Draft Recommendation Statement
Illicit Drug Use, Including Nonmedical Use of Prescription Drugs: Screening
This opportunity for public comment expired on September 9, 2019 at 8:00 PM EST
Note: This is a Draft Recommendation Statement. This draft is distributed solely for the purpose of receiving public input. It has not been disseminated otherwise by the USPSTF. The final Recommendation Statement will be developed after careful consideration of the feedback received and will include both the Research Plan and Evidence Review as a basis.
Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
Draft: Recommendation Summary
|Adults age 18 years or older|
The USPSTF recommends screening for illicit drug use in adults age 18 years or older. Screening should be implemented when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred.
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for illicit drug use in adolescents.
See the Practice Considerations for suggestions for practice regarding the I statement.
The U.S. Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific preventive care services for patients without obvious related signs or symptoms.
It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment.
The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decisionmaking to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms.
Many Americans experience problems related to illicit drug use, defined in this recommendation statement as the use of illegal drugs and the nonmedical use of prescription psychoactive medications (i.e., use for reasons, for duration, in amounts, or with frequency other than prescribed or use by persons other than the prescribed individual). In 2017, an estimated 11.5% of Americans age 18 years or older reported current illicit drug use in a national survey .1 Illicit drug use is more commonly reported in young adults ages 18 to 25 years (24.2%) than in older adults (9.5%) or in adolescents ages 12 to 17 years (7.9%). In 2017, an estimated 8.5% of pregnant persons ages 18 to 44 years reported drug use in the last month. Among survey respondents age 12 years and older who reported illicit drug use in the last month, 85.3% reported using cannabis and 19.5% reported nonmedical use of psychotherapeutic drugs, including opioids, pain relievers, or other drugs. Less than 8% reported using cocaine, hallucinogens, or inhalants.
An estimated 7.5 million persons age 12 years and older were classified as having a diagnosis of dependence on or abuse of illicit drugs in the past year.1 Illicit drug use is among the most common causes of preventable death, injuries, and disability.2, 3 In 2017, illicit drug use caused more than 70,000 fatal overdoses.4 Illicit drug use can cause many serious health effects that vary by drug type, administration mode, amount, and frequency of use, as well as pregnancy status.5 Opioid use can cause drowsiness, slowed breathing, constipation, coma, and fatal overdose. Stimulants such as cocaine can cause arrhythmias, myocardial infarction, seizures, and other complications. Marijuana use is associated with slowed reaction time; problems with balance, coordination, learning, and memory; and chronic cough and frequent respiratory infections. Injection drug use may result in blood borne viral and bacterial infections.2, 5 Illicit drug use during pregnancy can increase risk of obstetric complications such as placental abruption, preeclampsia, and third trimester bleeding, as well as adverse fetal and infant outcomes such as spontaneous abortion, abnormal brain growth, preterm delivery, low birth weight, and neonatal abstinence syndrome.6 Illicit drug use is also associated with violence, criminal activity, incarceration, impaired school and work performance, interpersonal dysfunction, and other social and legal problems.7
Draft: USPSTF Assessment of Magnitude of Net Benefit
Adults Age 18 Years and Older
The USPSTF concludes with moderate certainty that screening for illicit drug use in adults has moderate net benefit when services for accurate diagnosis of unhealthy drug use or drug use disorders, effective treatment, and appropriate care can be offered or referred.
No studies provide direct evidence on the benefits and harms of screening. The USPSTF found adequate evidence that available screening tools can detect illicit drug use.
The USPSTF found adequate evidence that three opioid pharmacotherapy agents (naltrexone, buprenorphine, and methadone) approved by the U.S. Food and Drug Administration (FDA) have moderate benefits for reducing relapse and increasing retention in treatment in adults with opioid use disorder.
The USPSTF found adequate evidence that psychosocial interventions have moderate benefits for increasing abstinence from or reducing illicit drug use; effects may be greater for intensive psychosocial interventions and for cannabis use.
The USPSTF found limited direct evidence on the harms of screening.
The USPSTF bounds the magnitude of the harms of screening and pharmacotherapy and intensive psychosocial interventions as no greater than small based on lack of evidence that these interventions cause serious adverse events and evidence that buprenorphine is associated with only minor side effects (such as constipation).
Adolescents Ages 12 to 17 Years
Because of the lack of evidence, the USPSTF concludes that the benefits and harms of screening for any type of illicit drug use in adolescents are uncertain and that the balance of benefits and harms cannot be determined.
The USPSTF found inadequate evidence for the accuracy of screening tools for detecting use of most types of illicit drugs.
The USPSTF found inadequate evidence that opioid pharmacotherapy is effective for reducing relapse or increasing retention in treatment or that psychosocial interventions are effective for increasing abstinence from or reducing the use of illicit drugs.
The USPSTF found inadequate evidence to determine the harms of screening or any type of intervention for illicit drug use disorders.
See the Table for more information on the USPSTF recommendation rationale and assessment.
For more details on the methods the USPSTF uses to determine the net benefit, see the USPSTF Procedure Manual.8
Draft: Practice Considerations
Patient Population Under Consideration
This recommendation statement applies to adults age 18 years or older, including pregnant and postpartum persons, and adolescents ages 12 to 17 years in primary care settings. This statement does not apply to adolescents or adults who have a currently diagnosed drug use disorder or are currently undergoing or have been referred for drug use treatment.
Definitions of Illicit Drug Use, Including Nonmedical Use of Prescription Drugs
“Illicit drug use” is defined as the use of substances (not including alcohol or tobacco products) that are illegally obtained or involve nonmedical use of prescription psychoactive medications; that is, use for reasons, for duration, in amounts, or with frequency other than prescribed or use by persons other than the prescribed individual. These substances are ingested, inhaled, injected, or administered using other methods to affect cognition, affect, or other mental processes; to “get high”; or for other nonmedical reasons.
Assessment of Risk
The USPSTF recommends screening in all adults age 18 years or older regardless of risk factors for illicit drug use. However, some factors are associated with a higher prevalence of illicit drug use. These include being age 18 to 25 years; being male; or having a mental health condition, personality or mood disorder, nicotine or alcohol dependence; a history of physical or sexual abuse, parental neglect, or other adversity in childhood; or drug or alcohol addiction in a first-degree relative.1, 9 Factors associated with misuse of prescription drugs include history of other illicit drug use, mental illness, pain, and greater access to prescription drugs.10 Factors associated with prenatal use of illicit drugs include a mental health disorder, interpersonal violence, and family history of substance use.11
Several tools have reasonable accuracy for detecting one or more classes of illicit drug use, the frequency or severity of use, or drug-related health, social, or legal consequences that characterize unhealthy use or illicit drug use disorders. Interviewer-administered tools and self-administered tools appear to have similar accuracy.12
Primary care practices may consider several factors when selecting screening tools. Brief tools (e.g., the six-question BSTAD [Brief Screener for Tobacco, Alcohol, and Other Drugs]), may be more feasible in busy primary care settings, but longer tools (e.g., the eight-item ASSIST [Alcohol, Smoking and Substance Involvement Screening Test] risk assessment–based tool) that assess risks associated with illicit drug use or comorbid conditions may reveal information signaling the need for prompt diagnostic assessment. Tools with questions on nonmedical use of prescription drugs (e.g., TAPS [Tobacco, Alcohol, Prescription Medication, and Other Substance Use]) may be useful when clinicians are concerned about prescription misuse. One study reported that the PRO (Prenatal Risk Overview) risk assessment tool was reasonably accurate for detecting drug abuse or dependence in pregnant women. Some tools that indirectly estimate a patient’s illicit drug use (by asking about the patient’s alcohol or tobacco use or a partner’s illicit drug use) may be useful when clinicians are concerned about patient underreporting of illicit drug use.12
Screening tools are not meant to diagnose drug dependence, abuse, addiction, or use disorders. Patients with positive screening results may therefore need to be offered or referred for diagnostic assessment.
There is little evidence about the optimal time to start screening or the optimal screening interval for adults older than age 18 years. A pragmatic approach based on recommendations of the Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Institute on Drug Abuse (NIDA) is to rescreen young adults every time they seek medical services and when clinicians are concerned about risk behaviors for illicit drug use and comorbidities such as accidents, injuries, and depression.13, 14
Treatment for illicit drug use disorders is based on the type of drug used, the severity of drug use, and the type of use disorder.15 Many drug use disorders are chronic, relapsing conditions and many persons who start treatment do not complete treatment. Therefore, treatment must often be repeated to stabilize current drug use, reduce relapse, and achieve abstinence or other treatment goals.15 Some patients, such as those who are pregnant, nursing, or caring for ill or healthy neonates, may require specialized treatment settings.6
Pharmacotherapy, which is often provided with individual or group counseling, is the standard for treatment of opioid use disorders involving heroin or prescription opioid use in adults and pregnant and postpartum women.13, 15-19 Illicit drug use disorders involving nonopioid drugs, such as cannabis, stimulants, and some prescription drugs, are generally treated with various psychosocial interventions that usually involve multiple sessions of cognitive behavioral therapy, motivational interventions, contingency management, relapse prevention, community reinforcement, family behavioral therapy, 12-step facilitation therapy, or other behavioral approaches.13, 15, 16 Intensive interventions usually involve several in-person sessions over several weeks or months.
The management of patients who screen positive is usually accompanied by other interventions, including testing for blood borne pathogens; assessment of misuse, abuse, or dependence on alcohol or tobacco; assessment of potentially coexisting mental health disorders; and pain management for patients with pain who are abusing opioids.15, 16
In practice, the benefits and harms of screening may vary due to several health, social, and legal issues. In many communities, affordable, accessible, and timely services for diagnostic assessment and treatment for patients with positive screening results are in limited supply or unaffordable. Providers should be aware of any state requirements for mandatory screening or reporting of screening results to medicolegal authorities and understand the positive and negative implications of reporting.13, 20-23
Additional Tools and Resources
Several tools may help clinicians implement this screening recommendation.
- NIDA. Screening and Assessment Tools Chart. https://www.drugabuse.gov/nidamed-medical-health-professionals/screening-tools-resources/chart-screening-tools
- SAMHSA-Health Resources and Services Administration Center for Integrated Health Solutions. Substance Use Disorder and Pregnancy. https://www.integration.samhsa.gov/about-us/integration-edge/substance-use-disorder-and-pregnancy
- NIDA. Screening for Drug Use in General Medical Settings: A Resource Guide for Providers. https://www.drugabuse.gov/sites/default/files/resource_guide.pdf
- Center for Substance Abuse Treatment. A Guide to Substance Abuse Services for Primary Care Clinicians. https://www.ncbi.nlm.nih.gov/books/NBK64820
- SAMHSA. Finding Quality Treatment for Substance Use Disorders. https://store.samhsa.gov/system/files/pep18-treatment-loc.pdf
Suggestions for Practice Regarding the I Statement for Adolescents Aged 12 to 17 Years
Potential Preventable Burden
Based on a national survey in 2017, 7.9% of adolescents ages 12 to 17 years reported illicit drug use in the last month. Among youth reporting such drug use, the most commonly used substances were marijuana, inhalants, prescription psychotherapeutic drugs, and hallucinogens.1 An estimated 3% met diagnostic criteria for substance use disorders1 and the vast majority presented with concurrent mental health diagnoses.24 Risk factors for illicit drug use in youth include aggressive childhood behavior, lack of parental supervision, poor social skills, access to drugs at school, and community poverty.25
Adolescent substance use, including use of heroin and misuse of prescription opioids, is associated with the leading causes of death: suicide, overdose, unintentional injury, and violence.24 Substance use during this period of rapid brain development can also harm neurocognitive development and endocrine function that, in turn, can impair academic, occupational, and social functioning.25-27 Adolescents with drug use disorders are also at increased risk of sexually transmitted infections, other physical health problems, unintended pregnancies, criminal involvement, and school truancy.24
Potential Harms of Screening and Treatment
Although there is limited evidence on harms, adolescents may experience potential harms from screening for illicit drug use such as labeling and stigmatization. Because of concerns that long-term use of opioid agonists may harm development of the brain and endocrine system and induce prolonged physical dependence, the FDA restricts approval for buprenorphine to youth age 16 years or older, and the U.S. Department of Health and Human Services restricts admission to methadone programs to youth younger than age 18 years who continue to use opioids after at least two rounds of drug-free detoxification and psychosocial interventions.27
About 50% to 86% of pediatricians report routinely screening for substance use and most screen using their clinical impressions rather than a validated screening tool.23
Other Related USPSTF Recommendations
The USPSTF has issued recommendation statements on these related topics:
- Interventions to prevent illicit and nonmedical drug use in children, adolescents, and young adults28
- Screening and behavioral counseling interventions for reducing unhealthy alcohol use in adolescents and adults29
- Interventions for tobacco smoking cessation in adults, including pregnant women30
- Primary care interventions to prevent tobacco use in children and adolescents31
- Screening for depression in adults32
- Screening for depression in children and adolescents33
- Screening for suicide risk in adolescents and adults34
Draft: Update of Previous USPSTF Recommendation
When final, this recommendation statement will replace the 2008 USPSTF recommendation, which concluded that the evidence at that time was insufficient to assess the balance of benefits and harms of screening for illicit drug use in adolescents and adults, including those who were pregnant or postpartum.35 This updated statement incorporates new evidence since 2008 about screening tool accuracy and the benefits and harms of treatment of unhealthy drug use or drug use disorders. This new evidence supports the updated recommendation that primary care clinicians offer screening to adults age 18 years and older, including those who are pregnant or postpartum, when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred. The USPSTF continues to conclude that evidence is insufficient to assess the balance of benefits and harms of screening for illicit drug use in adolescents.
Draft: Supporting Evidence
Scope of Review
The USPSTF commissioned two systematic evidence reviews in support of this updated recommendation statement. These reviews evaluated evidence on the accuracy and harms of screening for illicit drug use12 and the benefits and harms of pharmacotherapy for opioid use disorders and psychosocial interventions for any type of illicit drug use.36
Accuracy of Screening Tools
The USPSTF identified 30 different screening tools that were evaluated in adults, pregnant or postpartum women, or adolescents. Many tools had sensitivity of 75% or more for detecting one or more measures of illicit drug use, unhealthy drug use, drug abuse or dependence, or illicit drug use disorders. Most screening studies used structured clinical or diagnostic interviews that used varied definitions for unhealthy use, abuse, dependence, and use disorders as the reference standard. Few studies used biologic reference standards such as testing of hair or urine specimens.12
The Task Force reviewed 12 studies that assessed the accuracy of 15 different screening tools in nonpregnant adults recruited from primary care settings, an emergency department, or a specialty clinic for attention deficit disorder, or used data from a representative sample of U.S. adults.12 There was considerable variation in sample size (139 to 2,057, not including the large U.S.-based national sample of 42,923); proportion of females (4.7% to 94%), and mean age (25.2 to 62.0 years). All but two studies were conducted in the United States. The use and severity of use of any drug or specific drugs varied widely across study populations. Several screening tools directly addressed the frequency of drug use (single-item drug frequency; SUBS [Substance Use Brief Screen]; TAPS-1 [Tobacco, Alcohol, Prescription Medication, and Other Substance Use-1]) or the frequency of drug use and risks associated with drug use (ASSIST; ASSIST-Drug; CAST [Cannabis Abuse Screening Test]; 2-, 10- and 28-DAST [Drug-Abuse Screening Test]; PDUQp [Prescription Drug Use Questionnaire-Patient Version]; PSQ [Parent Screening Questionnaire]; SoDU [Screen of Drug Use]; TAPS [Tobacco, Alcohol, Prescription Medication, and Other Substance Use]; TICS [Two-Item Conjoint Screen]) (examples of “direct tools”). One tool indirectly assessed illicit drug use by asking questions about alcohol or tobacco use (single-item heavy episode drinking frequency) (an example of an “indirect tool”).12
For detecting unhealthy use of “any drug” (including illegal drugs and nonmedical use of prescription drugs) in the past month or year, the sensitivity of direct tools ranged from 0.71 to 0.94 (95% CI range, 0.62 to 0.97) and specificity ranged from 0.87 to 0.97 (95% CI range, 0.83 to 0.98). For detecting abuse or dependence or a use disorder related to “any drug”, direct tool sensitivity ranged from 0.85 to 1.00 (95% CI, 0.67 to 1.00) and specificity ranged from 0.67 to 0.93 (95% CI range, 0.58 to 0.95). Screening tools had higher sensitivity for detecting unhealthy use and drug use disorders related to “any drug” (most of which was cannabis), cannabis, heroin, and stimulants than for detecting unhealthy use or use disorders related to nonmedical use of prescription opioids or sedatives (range, 0.38 to 0.89 [95% CI range, 0.29 to 0.94], but specificity was comparable; range, 0.79 to 0.99 [95% CI range, 0.71 to 0.99]).12
Four studies assessed the accuracy of direct tools (the frequency-based ASSIST-2 tool and the risk assessment based DAST-10, PRO, Wayne Indirect Drug Use Screener (WIDUS)/ASSIST-2 [modified tool]) or an indirect tool (WIDUS) for detecting illicit drug use or drug use disorders (not including alcohol) in women recruited during prenatal care visits or shortly after delivery. The prevalence of any prenatal drug use varied from 1.2% to 41% across these four studies. Three of these studies used biologic reference standards. For detecting any prenatal use of illicit drugs using direct tools, sensitivity ranged from 0.37 to 0.76 (95% CI range, 0.24 to 0.86) and specificity ranged from 0.68 to 0.83 (95% CI range, 0.55 to 0.91). For detecting any drug abuse or dependence, one study of the PRO risk assessment–based tool (in a population in which 7% met diagnostic criteria for drug abuse, dependence, or both) reported sensitivity of 0.88 (95% CI, 0.77 to 0.95) and specificity of 0.74 (95% CI, 0.71 to 0.77). The only indirect tool that reported on any prenatal use of illicit drugs (not including alcohol) (WIDUS/ASSIST-2) had lower sensitivity (0.68 [95% CI, 0.53 to 0.80]) and specificity (0.69 [95% CI, 0.57 to 0.80]). An additional study of the indirect tool Parents Partner Past Pregnancy reported high sensitivity (0.87 [95% CI, 0.71 to 0.95) and high specificity (0.76 [95% CI, 0.70 to 0.82]) for detecting the combined outcome of any prenatal use of illicit drugs or alcohol, but did not assess the outcome of prenatal use of illicit drugs alone.12
The evidence on accuracy of tools in adolescents was limited. Most studies focused on the detection of cannabis use; no studies provided information specifically on opioid use or other drug classes. Few tools that assessed cannabis use were evaluated in more than one study. The available studies evaluated the Brief Screener for Tobacco, Alcohol, and Other Drugs; a single item assessing cannabis use; ASSIST; ASSIST-Lite; CAST; CPQ-A-S (Cannabis Problems Questionnaire for Adolescents-Shortened); or CRAFFT (Car Relax Alone Forget Family/Friends Trouble) tools against a diagnostic interview. For detecting any cannabis use or unhealthy cannabis use, sensitivity of these direct tools ranged from 0.68 to 0.98 (95% CI, 0.64 to 0.99) and specificity ranged from 0.82 to 1.00 (95% CI, 0.80 to 1.00). Given the limited numbers of studies on individual tools and the lack of information on accuracy of tools on drugs other than cannabis, the Task Force determined the evidence to be inadequate on accuracy of screening in adolescents.12
Benefits of Screening and Treatment
No studies directly addressed the benefits of screening on reducing illicit drug use or drug-related health, social, or legal outcomes in any population.
Several trials found that use of FDA-approved pharmacotherapy had benefits for nonpregnant adults with opioid use disorders who had sought or were referred for treatment. Adults assigned to pharmacotherapy generally had lower rates of relapse and increased retention in treatment than adults assigned to placebo or no treatment.36
Nineteen trials evaluated naltrexone (opioid antagonist), buprenorphine (partial opioid agonist), or methadone (opioid agonist) (usually provided with individual or group counseling) in adults with opioid use disorder primarily related to heroin. None assessed the effects of pharmacotherapy in adults whose opioid use disorder was related only to prescription opioids or was detected through primary care screening. Trials recruited participants from inpatient settings, drug treatment programs, and criminal justice systems. Most trials were conducted outside the United States and several used naltrexone formulations not available in the United States. Most participants were adult males younger than age 30 years. No trials specifically enrolled women who were pregnant or postpartum or adolescents. However, women of reproductive age comprised 25% to 46% of participants who received methadone or buprenorphine and 0% to 28% of participants who received naltrexone.36
Thirteen trials evaluated the effects of oral, injectable, or implantable naltrexone. Outcomes were assessed during the course of treatment in 11 trials (2 to 9 months after start of treatment) or after treatment completion in two trials (6 to 10 months after completion). Sample sizes ranged from 31 to 301 (total N=1,718 participants). Retention in treatment varied considerably in persons assigned to naltrexone (range, 7% to 60%) and persons assigned to placebo or no treatment (range, 6% to 56%). Use of naltrexone was associated with a significant decrease in illicit drug use relapse (pooled relative risk [RR], 0.73 [95% CI, 0.62 to 0.85]) and increased retention in treatment (pooled RR, 1.71 [95% CI, 1.13 to 2.49]). The few naltrexone trials that reported on mortality, global functioning, quality of life, anxiety, depression, or legal or employment outcomes had inconsistent findings regarding these outcomes, but mortality was rare.36
Seven trials assessed the opioid agonist methadone, the partial opioid agonist buprenorphine, or both. During the course of ongoing treatment with one of these two opioid agonists (monitored for 4 to 12 months), use of methadone and sublingual or implantable buprenorphine was significantly associated with a decrease in relapse (pooled RR, 0.75 [95% CI, 0.59 to 0.82]) and increased retention in treatment (pooled RR, 2.58 [95% CI, 1.78 to 4.59]). Findings from five trials that assessed the effects of opioid agonists on health, social, and legal outcomes were mixed and did not show clear treatment benefits. A few trials found that buprenorphine was associated with better self-reported scores on quality of life, well-being, and life satisfaction. No deaths were reported in trials that reported this outcome.36
Adults. Psychosocial interventions were associated with increased likelihood of abstinence from drug use versus control conditions at 3 to 4 months (15 trials; RR, 1.60 [95% CI, 1.24 to 2.13]) and at 6 to 12 months (14 trials; RR, 1.52 [95% CI, 1.14 to 2.04]) after interventions started based on meta-analyses of the subset of 23 trials with poolable data (of which 21 enrolled a majority of participants who were age 18 years or older).36
Approximately half of the psychosocial intervention trials enrolled persons who had sought or were referred for drug treatment. Sample sizes ranged from 34 to 1,175 (total N=15,659). Most trials were conducted in the United States and included participants who were primarily male, nonwhite, and had lower socioeconomic status. The severity of illicit drug use in trial participants varied greatly. Interventions were categorized as intensive (defined as more than two sessions or two sessions lasting more than an hour each) or brief (defined as one to two sessions each lasting an hour or less). Interventions were generally based on established behavioral approaches and were administered by phone or in person by researchers or were self-administered by computer. Intensive interventions commonly used face-to-face cognitive behavioral therapy, motivational interviewing, and contingency management approaches. Most brief interventions consisted of a single, personalized counseling session with in-person or computer-based feedback, with or without a telephone or in-person booster session. Followup ranged from 3 to 4 months to 12 or more months after the start of interventions. From 38% to 98% of participants completed assessments at designated followup points. Meta-analyses and sensitivity analyses included only the subset of trials with poolable data and combined trials that evaluated nonpregnant adults, pregnant or postpartum adults, or adolescents; any type of illicit drug use; and either brief or intensive interventions.36
In sensitivity analyses, effects on abstinence were greater at 3 to 4 months in trials of treatment-seeking populations (7 trials; RR, 2.08 [95% CI, 1.51 to 3.07]) than in trials of screen-detected populations (8 trials; RR, 1.28 [95% CI, 0.97 to 1.84]; p=0.05 for interaction). Effects on abstinence were smaller in trials of brief interventions than in trials of intensive interventions, but the differences were not statistically significant. Effects were statistically significant for abstinence from cannabis use (7 trials; RR, 2.08 [95% CI, 1.51 to 3.07], at 3 to 4 months and 4 trials; RR, 1.58 [95% CI, 1.17 to 3.06], at 6 to 12 months), but not for abstinence from stimulant or mixed drug use. Results of meta-analyses on the association of psychosocial interventions and other outcomes, including number of days using drugs and drug use severity, were mixed. Evidence on the association between psychosocial interventions and health, social, or legal outcomes related to use of cannabis, stimulants, opioids, “any drug,” or mixed drugs in adults was sparse and showed no or limited effectiveness.36
Five trials specifically assessed intensive or brief interventions exclusively in pregnant women or postpartum women compared with attention control groups or information and advice from obstetricians or nurses. None reported significant effects on illicit drug use or health, social, or legal outcomes of illicit drug use at 3 to 6 months after the start of the interventions.12
Adolescents. There were few trials on psychosocial interventions that focused on adolescents ages 12 to 17 years. Evidence was limited and results were inconclusive.12, 36 These studies did not report the effect of psychosocial interventions on illicit drugs other than cannabis.
Harms of Screening and Treatment
No studies addressed the harms of screening in any population.12
Eleven naltrexone trials and four buprenorphine trials assessed potential harms, including suicide, overdose, or study withdrawal due to serious adverse events, but no methadone trials assessed harms. Few harms or serious adverse events were reported. The risk of adverse events were generally similar in persons assigned to pharmacotherapy and control groups, including risks estimated in pooled analysis of three naltrexone trials (pooled RR, 2.65 [95% CI, 0.50-14.10]) and three buprenorphine trials (pooled RR, 0.73 [95% CI, 0.19 to 2.78]). Constipation was significantly more common in buprenorphine users than in control groups. No trials reported on harms of pharmacotherapy in adolescents or in pregnant or postpartum women.36
None of the four trials that reported on harms or adverse events of brief psychosocial interventions identified harms or adverse events. These included two trials in college students targeting cannabis use and two trials in postpartum women who received brief interventions after delivery. None of the other psychosocial intervention trials reported on harms or adverse events in adults.36
Draft: Research Needs and Gaps
The USPSTF identified important gaps related to screening for illicit drug use. To fill these gaps, the USPSTF needs more evidence from well-designed studies that further evaluate the following:
- The effectiveness of screening and interventions for illicit drug use in adolescents
- The optimal screening interval for detecting illicit drug use
- The accuracy of screening tools for detecting nonmedical use of prescription drugs, including opioids
- The relative accuracy of screening tools administered within the same population by primary care providers
- Strategies to improve access to pharmacotherapy and psychosocial interventions for persons with various types of illicit drug use disorders
- The benefits and harms of providing prophylactic prescriptions for naloxone “rescue therapy” to patients in whom opioid misuse or opioid use disorders are detected after primary care screening
Draft: Recommendations of Others
Several organizations have issued statements about screening for illicit drugs that vary by patient subpopulation. SAMHSA recommends universal screening for substance use (including alcohol), brief intervention, and/or referral to treatment (known as SBIRT) as part of routine health care.12 The U.S. Departments of Defense and Veterans Affairs16 and the American Academy of Family Physicians37 have adopted the 2008 USPSTF recommendation statement (I statement) indicating that evidence is insufficient to recommend routine screening for illicit drug use. The American Academy of Pediatrics recommends screening adolescents through their early 20s for substance use (including tobacco and alcohol) at every annual physical examination as well as screening adolescents who present to emergency departments or urgent care centers; report cigarette smoking; have depression, anxiety, or other mental health conditions associated with substance abuse; or exhibit school, legal, or social problems or other behavioral changes.38 It provides a list of screening tools that have been validated for use in adolescents through their early 20s.23 The Bright Futures initiative includes a recommendation that all adolescents (including those ages 18 to 21 years) should be screened for substance use (including tobacco and alcohol) as part of an overall psychosocial history.39 The American College of Obstetricians and Gynecologists specifically advises screening women annually for nonmedical use of prescription drugs.40 It also recommends screening women ages 18 to 26 years for illicit drug use as part of preventive care;41 universal screening of women before pregnancy and early in pregnancy;42-44 and screening postpartum women as indicated (such as during the uniquely vulnerable postpartum period, which may increase risk of drug use disorders).45
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2. GBD 2016 Alcohol and Drug Use Collaborators. The global burden of disease attributable to alcohol and drug use in 195 countries and territories, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Psychiatry. 2018;5(12):987-1012.
3. Murray CJ, Lopez AD. Measuring the global burden of disease. N Engl J Med. 2013;369(5):448-457.
4. Centers for Disease Control and Prevention. Drug Overdose Deaths. 2018. https://www.cdc.gov/drugoverdose/data/statedeaths.html. Accessed June 26, 2019.
5. National Institute on Drug Abuse. Commonly Abused Drugs Charts. 2018. https://www.drugabuse.gov/drugs-abuse/commonly-abused-drugs-charts. Accessed June 26, 2019.
6. Forray A, Foster D. Substance use in the perinatal period. Curr Psychiatry Rep. 2015;17(11):91.
7. Horgan CM. Substance Abuse: The Nation's Number One Health Problem. Princeton, NJ: Robert Wood Johnson Foundation; 2001.
8. U.S. Preventive Services Task Force. Procedure Manual. https://www.uspreventiveservicestaskforce.org/Page/Name/procedure-manual. Accessed June 28, 2019.
9. Harrington M, Robinson J, Bolton S, Sareen J, Bolton J. A longitudinal study of risk factors for incident drug use in adults: findings from a representative sample of the US population. Can J Psychiatry. 2011;56(11):686-695.
10. Substance Abuse and Mental Health Services Administration. Preventing Prescription Drug Misuse: Understanding Who Is at Risk. 2016. https://www.michigan.gov/documents/mdhhs/UnderstandingWhoIsAtRisk_547024_7.pdf. Accessed June 26, 2019.
11. Cook JL, Green CR, de la Ronde S, et al. Epidemiology and effects of substance in pregnancy. J Obstet Gynaecol Can. 2017;39(10):906-915.
12. Patnode CD, Perdue LA, Rushkin M, O’Connor EA. Screening for Drug Use in Primary Care in Adolescents and Adults, Including Pregnant Women: An Updated Systematic Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 186. AHRQ Publication No. 19-05255-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2019.
13. Substance Abuse and Mental Health Services Administration. A Guide to Substance Abuse Services for Primary Care Clinicians. 1997. https://www.ncbi.nlm.nih.gov/books/NBK64827/. Accessed June 26, 2019.
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Draft: Table. Summary of USPSTF Rationale
|Rationale||Adults age 18 years and older||Adolescents ages 12 to 17 years|
|Detection||Adequate evidence that available screening tools can detect illicit drug use.||Inadequate evidence that available screening tools can detect use of most types of illicit drug use.|
|Benefits of Early Detection and Intervention and Treatment||
|Harms of Early Detection and Intervention and Treatment||
|USPSTF Assessment||Moderate certainty that screening for illicit drug use has a moderate net benefit when services for accurate diagnosis of unhealthy drug use or drug use disorders, effective treatment, and appropriate care can be offered or referred.||Benefits and harms of screening for any type of illicit drug use are uncertain and the balance of benefits and harms cannot be determined.|
Internet Citation: Draft Recommendation Statement: Illicit Drug Use, Including Nonmedical Use of Prescription Drugs: Screening. U.S. Preventive Services Task Force. August 2019.