Substance Use Screening, Risk Assessment, and Use Disorder Diagnosis in Adults

Jennifer McNeely; Leah K. Hamilton; Susan D. Whitley; Timothy J. Wiegand; Sharon L. Stancliff; Brianna L. Norton; Charles J. Gonzalez; Christopher J. Hoffman

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Substance Use Screening, Risk Assessment, and Use Disorder Diagnosis in Adults

Lead Author(s): Jennifer McNeely, MD, MS, Leah K. Hamilton, PhD, and Susan D. Whitley, MD. Writing Group: Timothy J. Wiegand, MD, FACMT, FAACT, DFASAM, Sharon L. Stancliff, MD, Brianna L. Norton, DO, MPH, Charles J. Gonzalez, MD, and Christopher J. Hoffman, MD, MPH, MSc, FACP; on behalf of Substance Use Guidelines Committee .

Baltimore (MD): Johns Hopkins University; 2024 May.

Updates, Authorship, and Related Guidelines
Developer and funding source	New York State Department of Health AIDS Institute (NYSDOH AI)
Intended users	Primary care clinicians and care providers in other adult outpatient care settings in New York State
Development	See Supplement: Guideline Development and Recommendation Ratings
Updates
May 30, 2024	Rated recommendations added in Patient Engagement and Interventions section SIS-C (Single-Item Screen-Cannabis) added in Screening Tools section Resources, citations, and references updated throughout this guideline
Author and writing group conflict of interest disclosures	See Conflict of Interest statement^*
Related NYSDOH AI guidelines	Substance Use Harm Reduction in Medical Care Treatment of Alcohol Use Disorder Treatment of Opioid Use Disorder NYSDOH AI Guidance Clinical Guidance: Stimulant Use

Purpose of This Guideline

Date of current publication: May 30, 2024 Lead authors: Jennifer McNeely, MD, MS; Leah K. Hamilton, PhD; Susan D. Whitley, MD Writing group: Timothy J. Wiegand, MD, FACMT, FAACT, DFASAM; Sharon L. Stancliff, MD; Brianna L. Norton, DO, MPH; Charles J. Gonzalez, MD; Christopher J. Hoffmann, MD, MPH, MSc, FACP Committee: Substance Use Guidelines Committee Date of original publication: October 21, 2020

This guideline on screening and risk assessment for substance use in adults (≥18 years old) was developed by the New York State Department of Health AIDS Institute (NYSDOH AI) for use by primary care clinicians and in other adult outpatient care settings in New York State to achieve the following goals:

Increase the identification of unhealthy substance use among New York State residents and increase access to evidence-based interventions for appropriate patients. “Unhealthy substance use” refers to a spectrum of use that increases the risk of health consequences and ranges from hazardous or risky patterns of use to severe substance use disorder (SUD).
Increase the number of clinicians in New York State who perform substance use screening and risk assessment as an integral part of primary care.
Provide clinicians with guidance on selecting validated substance use screening and risk assessment tools and on providing or referring for evidence-based interventions.
Promote a harm reduction approach to the identification and treatment of substance use and SUDs, which involves practical strategies and ideas aimed at reducing the negative consequences associated with substance use.

Rationale: In the United States, the use of tobacco, alcohol, and drugs (illicitly manufactured and nonmedical prescription) are among the top 10 leading causes of preventable death, accounting for more than 500,000 deaths per year [White, et al. 2020; GBD 2018]. Alcohol-related deaths have doubled in the past 2 decades; in 2019, there were more than 140,000 alcohol-related deaths in the United States [CDC 2022]. Surging rates of drug overdose deaths (often opioid-related) are a public health crisis across the country. In the United States, drug overdose contributed to 1 in 22 deaths in 2021, and there were more than 100,000 drug overdose deaths in the 12 months ending August 2023 [CDC 2024; Gomes, et al. 2023].

Patient visits to healthcare settings are an opportunity for clinicians to identify substance use and related problems, offer timely interventions, and provide or link patients to treatment when indicated. Screening and treatment for tobacco use have been widely adopted as core clinical quality measures for primary care [CMS 2013], but alcohol and drug use screening is not as widely performed, and use is substantially under-recognized [Hallgren, et al. 2020; WHO 2016; Venkatesh and Davis 2000]. Screening for alcohol use has been a recommended practice in adult primary care since 1996 [Curry, et al. 2018]. In a study of 13 states and the District of Columbia in 2017, 81.4% of patients reported being asked about any alcohol use by a healthcare professional; however, only 37.8% reported being asked about binge drinking behavior [McKnight-Eily, et al. 2020].

Screening for substance use in primary care is generally well accepted by patients as a marker of quality care [Simonetti, et al. 2015; Miller, et al. 2006]. However, thoughtful implementation, with sensitivity to stigma and privacy concerns, is essential for patients and clinicians to be comfortable [Bradley, et al. 2020; McNeely, et al. 2018].

Substance Use Screening and Risk Assessment: Goals and Definitions

The goals of screening for and assessing substance use risk in primary care vary by practice setting and resources and may include:

Informing medical care: Substance use is an important aspect of medical history because it can significantly affect disease processes, response to treatment, and exposure to health risks. Knowledge of a patient’s substance use informs a clinician’s diagnosis of other medical and psychiatric conditions and alerts them to associated health risks (e.g., overdose, liver disease) and common comorbid conditions (e.g., depression). Similar to knowledge about a patient’s past medical history, family history, or social determinants of health, knowledge about a patient’s substance use helps clinicians formulate effective patient-centered treatment plans.
Identifying the need for intervention: A second goal is to identify patients who would benefit from interventions to limit harms related to use and/or reduce their consumption (see guideline section Patient Engagement and Interventions) or patients for whom treatment may be appropriate (see guideline section Diagnosis of Substance Use Disorder). Evidence-based interventions are available, including brief interventions for moderate-risk alcohol use, pharmacotherapy for opioid and alcohol use disorders, and treatment for smoking cessation [Patnode, et al. 2021; Patnode, et al. 2020; USPSTF(c) 2020; Curry, et al. 2018; Jonas, et al. 2014; Mattick, et al. 2014]. Such treatments can be delivered effectively in a primary care setting, but they remain underused.
Engaging patients: Another goal is opening the conversation and engaging patients in discussion about substance use. If approached sensitively, a nonjudgmental discussion of a patient’s substance use may reduce perceived stigma, improve the clinical relationship, and facilitate behavior change. Initiating such a discussion communicates to patients that substance use is a health issue that the clinician is concerned about and can offer help for.

Definitions of the terms used throughout this guideline are detailed below.

Unhealthy substance use: Unhealthy substance use refers to a spectrum of use that increases the risk of health consequences and ranges from hazardous or risky patterns of use to severe substance use disorder. As defined in this guideline, unhealthy alcohol use is use that exceeds U.S. Department of Health and Human Services and Department of Agriculture 2015-2020 Dietary Guideline For illicitly manufactured drugs, less information is available about dosage and health risks of specific substances and preparations, and any use is considered potentially unhealthy. For prescription medications with potential for misuse, any nonmedical use (use of prescribed medication at increased dose or frequency or for reasons other than prescribed) or use of medications that were not prescribed is considered unhealthy.
Screening: Screening entails asking patients brief questions (or a single question) about substance use and can quickly identify patients with potentially unhealthy substance use. Many of these patients will not have substance use-related clinical signs or symptoms [Saitz(b), et al. 2014; Gordon, et al. 2013].
Risk assessment: Risk assessment entails asking patients additional questions on the extent, duration, and pattern of substance use to determine the clinical significance and severity of use. Assessment tools determine the level of risk (i.e., low, moderate, or high) and thus the potential for negative consequences; see Box 1, below. As shown in Figure 1: Substance Use Screening, Risk Assessment, Diagnosis, and Interventions, risk level and other individual patient factors guide clinicians in recommending appropriate interventions and informing patients about the potential consequences of their substance use [McNeely(a), et al. 2016; Saitz 2005].

Box 1: Substance Use Levels of Risk [a]

Low risk: Patient is abstinent or uses substances in a way that is not currently associated with negative health consequences or other problems (e.g., alcohol consumption that does not exceed levels recommended by U.S. Department of Health and Human Services and Department of Agriculture 2015-2020 Dietary Guidelines or occasional low-dose cannabis use).
Moderate risk: Patient is at risk of and may already be experiencing negative health consequences or other problems, such as elevated blood pressure related to alcohol use, atypical chest pain related to cocaine use, or family problems or poor work performance related to opioid use.
High risk: Patient likely has a substance use disorder, is likely experiencing substance-related health or other types of problems (e.g., alcohol use-related cirrhosis or consequences such as separation from family or loss of employment), and is engaging in continued or escalating use despite negative consequences.

: Note:
a: Adapted from [Saitz 2005].

Screening

RECOMMENDATIONS

Screening

During the initial visit and once per year thereafter, primary care clinicians should screen for the following in adults ≥18 years old:
- Alcohol use, and when unhealthy use is identified, assess the level of risk to the patient. (A1)
- Tobacco use, and when use is identified, provide assessment and counseling. (A1)
- Other drug use (B3), and when unhealthy use is identified, assess the level of risk to the patient. (A3)
- See guideline section Risk Assessment and Figure 1: Substance Use Screening, Risk Assessment, Diagnosis, and Interventions.
Before screening for substance use, clinicians should explain the benefits and risks of screening to all patients, especially those who are pregnant or planning to conceive; the discussion should include state reporting requirements and the potential for involvement of child protective services. (A3)
- For information on the Child Abuse Prevention and Treatment Act (CAPTA) in New York State, see Plans of Safe Care for Infants and their Caregivers.
Clinicians should also perform substance use screening to inform clinical care when:
- Prescribing medication(s) that have adverse interactions with alcohol or drugs. (A2)
- A patient has symptoms or medical conditions that could be caused or exacerbated by substance use. (A3)

Figure 1

Substance Use Screening, Risk Assessment, Diagnosis, and Interventions. Abbreviations: DSM-5-TR, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision; MI, motivational interviewing; SUD, substance use disorder. Notes:

Alcohol

In primary care settings, clinicians should screen all adult patients ≥18 years old for alcohol use. A large body of evidence indicates that screening tools can accurately identify unhealthy alcohol use (see Table 1: Recommended Validated Tools for Use in Medical Settings to Screen for Alcohol and Drug Use in Adults) and that brief counseling interventions can reduce alcohol use, improve health, and be cost-effective [Patnode, et al. 2020; Kaner, et al. 2018; O'Connor, et al. 2018; O'Donnell, et al. 2014; McNeely, et al. 2008; Solberg, et al. 2008; Maciosek, et al. 2006]. The National Committee on Quality Assurance adopted alcohol screening and brief intervention as a quality indicator in 2018 and incorporated it into the widely used Healthcare Effectiveness Data and Information Set performance measures.

In the absence of systematic screening, unhealthy alcohol use typically goes unidentified [Hallgren, et al. 2022; McKnight-Eily, et al. 2020] or is identified by clinicians only when an individual has developed a severe alcohol use disorder or alcohol-related health problems, such as alcohol-related cirrhosis or pancreatitis.

KEY POINTS

Ask patients about substance use during the initial visit and follow-up visits because patterns of use may change over time. Annual screening may be most appropriate, and most validated alcohol and drug screening questionnaires ask about use in the past year.
Inform patients that information about their substance use is protected by the same privacy laws that apply to all other information in their medical records.

Tobacco

Clinicians should screen all patients for all types of tobacco use, and when use is identified, provide counseling, assessment, and treatment [Patnode, et al. 2021; USPSTF 2021]. Every visit with a care provider allows for identifying a patient’s tobacco use and offering effective cessation interventions. Screening for tobacco use is often accomplished with 1 question: “Have you ever smoked cigarettes or used any other kind of tobacco?” Patients who answer “yes” should be asked about frequency and level of use in the past 30 days (e.g., number of cigarettes smoked per day) [DHHS 2008]. Despite concern about increasing rates of e-cigarette use, screening for electronic nicotine delivery systems is not currently a recommended practice [Krist, et al. 2021; USPSTF 2021].

Other Drugs

Based on clinical experience and expertise and federal recommendations [USPSTF(b) 2020], this committee recommends that clinicians screen for drug use other than alcohol and tobacco in adult patients ≥18 years old who present for primary care. Screening should be performed in settings where treatment or counseling resources are available on-site or by referral and should identify a patient’s use of illicitly manufactured drugs and nonmedical use of prescription drugs that can be misused (e.g., opioids, benzodiazepines, and stimulants).

Evidence supports the accuracy of validated screening questionnaires in adults [Patnode, et al. 2020] and the benefits of pharmacologic treatment for opioid use disorder (OUD), which can be delivered effectively in primary care settings [Wartko, et al. 2023] and no longer requires a waiver for prescribing buprenorphine [Stringfellow, et al. 2021]. However, data on the effectiveness of drug screening plus brief intervention to reduce drug use and associated health consequences are currently limited, and this is an area of ongoing research. Randomized controlled clinical trials have generated mixed results regarding the efficacy of brief interventions in reducing drug use [Sahker, et al. 2022; Patnode, et al. 2020; Gelberg, et al. 2015; Roy-Byrne, et al. 2014; Saitz(a), et al. 2014; Humeniuk, et al. 2012]. Evidence supporting drug interventions delivered in primary care has primarily come from treatment-seeking populations, rather than patients identified only through screening [Saitz 2020; USPSTF(a) 2020].

No currently published studies demonstrate harms directly associated with screening adult primary care patients for drug use, although the potential for harm does exist [Saitz 2020]. For some patients, especially those who are pregnant or planning to conceive, positive results from a drug screening test could pose social or legal consequences, such as required reporting and the potential for involvement of child protective services (see discussion below). It is essential to respect the sensitivity of any substance use information documented in patients’ health records and ensure that patients understand privacy protections for their health information.

Rationale for drug use screening: This committee’s rationale for recommending drug use screening in adult patients, even with the potential for harm in some specific circumstances, is based on the following:

Stigma is a significant barrier to identifying and treating unhealthy drug use or substance use disorders (SUDs). The exclusion of routine screening for drug use may perpetuate the perception that discussion of drug use with healthcare providers is taboo. This is especially the case if alcohol and tobacco use are discussed openly but drug use is not mentioned. Routine, matter-of-fact, nonjudgmental screening for drug use may help reduce stigma by normalizing this discussion.
The social history that clinicians currently perform typically includes questions about alcohol, tobacco, and drug use but may not collect this information in a systematic and clinically useful manner. It is important that clinicians screen for drug use consistently, in a nonbiased manner, and use standardized, evidence-based screening tools.
Fatal and non-fatal opioid overdose deaths can be reduced through increased identification of unhealthy opioid use and, when indicated, effective treatment with medications for OUD [Watts, et al. 2022; Wakeman, et al. 2020; Sordo, et al. 2017; Cousins, et al. 2016].
Identifying and addressing unhealthy drug use, including drug use disorders, may positively affect other patient outcomes. For instance, identification of benzodiazepine use in a patient receiving opioids for chronic pain could inform overdose prevention counseling, opioid prescribing, and provision of naloxone to reduce the patient’s overdose risk.
Knowledge of a patient’s drug use is essential for accurate diagnosis and treatment. For example, in a patient who uses cocaine, chest pain could be the result of drug use rather than a blocked coronary artery, but without knowledge of the drug use, the clinician will not have the information necessary to perform the appropriate diagnostic workup. In addition, knowledge of drug use may be essential for an accurate diagnosis of psychiatric disorders, and knowledge of injection drug use can help guide screening for infections.

KEY POINT
Urine toxicology, measures of blood alcohol level, and other laboratory tests should not be relied on for identifying unhealthy drug use.

Drug use screening in individuals who are pregnant or planning to conceive: Because there are potential legal and social consequences of a positive drug use screening result in individuals who are pregnant or planning to conceive, this committee urges caution when performing drug use screening. It is essential to engage patients in shared and informed decision-making before screening is performed. Fully informed consent includes clear discussion and confirmed patient understanding of the benefits, potential harms, and consequences of screening. For patients who are pregnant or planning to conceive, the informed consent discussion should include:

Description of drug screening processes and procedures
Potential benefits of drug screening for the patient
Discussion of how results are interpreted and likely next steps if the screening result is positive
Confirmation of confidentiality of the patient’s medical information
Discussion of the risk of being reported to child protective services
Discussion of the patient’s ability to refuse drug screening without repercussions, except in cases in which screening is mandated by an employer or by the court
Psychosocial support and counseling about the potential harms of drugs and treatment options for SUD, if patients decline to be screened for other drugs

Screening to Inform Clinical Care

Screening is recommended for patients who use medications that have adverse interactions with alcohol or drugs. Iatrogenic harm is possible if a patient’s substance use is not identified, including adverse effects resulting from drug-medication interactions, overdose from combining prescribed medications with illicitly manufactured drugs, and withdrawal syndromes when a patient’s drug use is undisclosed and they are unable to use, such as during hospitalization [Lindsey, et al. 2012; CDC 2007; Antoniou and Tseng 2002]. Patients taking prescription opioids or benzodiazepines should be screened for use of alcohol and for illicitly manufactured or nonmedical use of other sedating drugs (including other opioids or benzodiazepines) that can increase the risk of overdose. Patients taking any controlled substances should be assessed for co-occurring substance use that may increase the probability of engaging in risky use of prescribed medications or of having or developing an SUD.

Clinicians should be aware of potential interactions between alcohol or drugs and medications, such as antiretroviral, pain management, or neurologic medications (e.g., gabapentin and pregabalin) [Gomes, et al. 2017; Lyndon, et al. 2017; Lindsey, et al. 2012; Bruce, et al. 2008; Saitz 2005; Antoniou and Tseng 2002].

When counseling patients who use substances about drug-medication interactions, clinicians should be clear about the safety of their prescribed medications and be certain to encourage adherence to all critical medications, such as antiretroviral treatment [Kalichman, et al. 2015].

See the following resources for checking drug-drug interactions:

Clinicians should also perform substance use screening in patients who have symptoms or other medical conditions that could be caused or exacerbated by substance use, such as chest pain, liver disease, or mood disorders [NIAAA 2024; Ries, et al. 2018; Kim, et al. 2017; Edelman and Fiellin 2016; Mertens, et al. 2005; Lock and Kaner 2004].

Box 2: Implementing Substance Use Screening in Primary Care Settings

Who to screen: All adults seen by primary care clinicians should be screened for substance use. Some specific patient populations may have higher rates of unhealthy substance use [SAMHSA 2019; Schulden, et al. 2009], but no specific demographic characteristics reliably predict such use.
How often to screen: Because substance use behavior changes over time, clinicians should repeat screening at regular intervals. However, evidence is lacking about the optimal frequency of screening [Moyer 2013]. Annual screening may strike the best balance between the need for frequent repetition of screening and time and resource constraints and has been recommended by an expert panel convened by the National Council for Behavioral Health and Substance Abuse and Mental Health Services Administration (SBIRT Change Guide 1.0, February 2018) [McNeely, et al. 2021].
Who should perform screening: Most of the screening instruments discussed in Table 1: Recommended Validated Tools for Use in Medical Settings to Screen for Alcohol and Drug Use in Adults can be administered verbally by trained staff or can be self-administered by patients on paper or electronically. Primary care practices must choose the format that is most appropriate for their clinical workflow and patient population. Generally, self-administered screening facilitates more accurate reporting of stigmatized behavior, such as substance use [Wight, et al. 2000; Tourangeau and Smith 1996]. A self-administered approach may lead to higher rates of detected substance use by ensuring fidelity of administration [McNeely, et al. 2021; Williams, et al. 2015; Bradley, et al. 2011], increasing patient comfort [McNeely, et al. 2018; Spear, et al. 2016], and reducing staff burden. Electronic screening tools that can be self-administered can be completed online through a patient portal or an app made available with a tablet computer or kiosk in the clinic, with results uploaded to a patient’s electronic health record.
How to introduce substance use screening to patients: Explain the reasons for screening, the type of screening that will be performed, the potential benefits, and any potential harms. Make sure that patients understand how results will be interpreted and the likely response to screening results. Remind them of the privacy protections for the information being collected, including who will see the information; acknowledge the potential sensitivity of the information; and avoid judgmental or stigmatizing language [NIDA 2011].
Resources:
- National Institute on Drug Abuse: Implementing Drug and Alcohol Screening in Primary Care
- National Committee for Quality Assurance: Screening and Follow-Up for Unhealthy Alcohol Use: Quality Improvement Change Package for Health Plans

Screening Tools

RECOMMENDATIONS

Screening Tools

Clinicians should use standardized and validated questionnaires for substance use screening (see Table 1: Recommended Validated Tools for Use in Medical Settings to Screen for Alcohol and Drug Use in Adults). (A3)

Successful substance use screening relies on accurate patient self-report. Although urine toxicology, measures of blood alcohol level, or other laboratory testing may detect the presence of substances used very recently (typically hours or ≤4 days after the last use), these tests are not appropriate for identifying unhealthy use, which may be intermittent and occur over time [Bosker and Huestis 2009; Cone and Huestis 2007; Verstraete 2004]. Laboratory screening tests for alcohol and drugs do not provide information about the severity or consequences of use and thus provide less information than questionnaires.

No reliable biomarker with sufficient sensitivity and specificity identifies the range of drinking behaviors that constitute unhealthy alcohol use [Afshar, et al. 2017; Jarvis, et al. 2017; Jatlow, et al. 2014; Stewart, et al. 2014; Verstraete 2004; Neumann and Spies 2003]. For drug use, urine, saliva, and blood testing are not recommended as replacements for questionnaire-based screening because laboratory tests have a brief window of detection (typically 1 to 4 days) [Bosker and Huestis 2009; Cone and Huestis 2007; Verstraete 2004]. Although hair testing has a more extended detection period, the cost and lack of reliability for detecting occasional drug use decrease its utility in primary care [Verstraete 2004].

Table 1: Recommended Validated Tools for Use in Medical Settings to Screen for Alcohol and Drug Use in Adults [a]
Tool	Substance(s) Included	No. of Items, Approximate Time Required to Complete, and Format
AUDIT-C (Alcohol Use Disorders Identification Test-Concise) [Bradley, et al. 2007; Bush, et al. 1998] Available in languages other than English	Alcohol	3 items; 1 to 2 minutes Interviewer- or self-administered via electronic app or on paper
SISQ-Alc (Single-Item Screening Questions for Alcohol) [McNeely(c), et al. 2015; Smith, et al. 2009]	Alcohol	1 item; 1 minute Interviewer- or self-administered via electronic app or on paper
SIS-C (Single-Item Screen-Cannabis) [Matson, et al. 2022]	Cannabis	1 item; 1 minute Self-administered on paper
SISQ-Drug (Single-Item Screening Questions for Drug Use) [McNeely(c), et al. 2015; Smith, et al. 2010]	Prescription drugs, other drugs	1 item; 1 minute Interviewer– or self-administered via electronic app or on paper
TAPS-1 (Tobacco, Alcohol, Prescription Medication, and Other Substance Use) [Gryczynski, et al. 2017]	Tobacco, alcohol, prescription drugs, other drugs	4 items; 2 minutes Interviewer- or self-administered via electronic app
SUBS (Substance Use Brief Screen) [McNeely(b) and Saitz 2015]	Tobacco, alcohol, prescription drugs, other drugs	4 items; 2 minutes Interviewer- or self-administered via electronic app or on paper

: Note:
a: For information on the sensitivity and specificity of tools for drug screening, see U.S. Preventive Services Task Force: Unhealthy Drug Use: Screening; for information on the sensitivity and specificity of tools for alcohol screening, see Screening and Behavioral Counseling Interventions to Reduce Unhealthy Alcohol Use in Adolescents and Adults: An Updated Systematic Review.

KEY POINT

Whenever possible, it is best to have patients self-administer the screening and assessment questionnaires rather than having the clinician or staff ask the questions. In general, self-administered screening facilitates more accurate reporting of stigmatized behavior, such as substance use [McNeely, et al. 2021; Sayre, et al. 2020; McNeely, et al. 2018; Williams, et al. 2015; Tourangeau and Smith 1996].

An optimal screening instrument will quickly and accurately identify individuals with the full spectrum of unhealthy use, fit into the existing clinical workflow, and have flexible administration options (i.e., self- or interviewer-administered). To facilitate patient reports of substance use, the language used in any screening tool should be clear and nonjudgmental. Drug screening should capture nonmedical prescription drug use and illicitly manufactured drug use. Table 1, above, lists recommended substance use screening tools.

The briefest approach to screening may be to use the Single-Item Screening Questions (SISQ) for alcohol or drug use (SISQ-Alc and SISQ-Drug). SISQ tools are validated for interviewer administration or patient administration and have good sensitivity and specificity. A positive response on SISQ tools identifies unhealthy use in the past year but does not indicate the level of risk. Both the Substance Use Brief Screen (SUBS) tool and the first section of the Tobacco, Alcohol, Prescription Medication, and Other Substance Use (TAPS-1) tool elicit information about use of tobacco, alcohol, illicitly manufactured drugs, and nonmedical prescription drugs through a single 4-item instrument. Like the SISQ-Alc and SISQ-Drug, the SUBS and TAPS-1 tools screen for any use in the past year, and a positive response indicates unhealthy use but does not identify level of risk. In states such as New York where cannabis is legal, asking about its use separately from that of illicitly manufactured drugs or nonmedical use of prescribed drugs may be preferable, and the Single-Item Screen-Cannabis, a validated single-item screening tool, is now available for this purpose [Matson, et al. 2022; Sayre, et al. 2020].

Risk Assessment

RECOMMENDATIONS

Risk Assessment

Clinicians should assess the level of substance use risk in individuals who have a positive substance use screening result or a history of substance use disorder (SUD) or overdose. (A3)
Clinicians should use standardized and validated tools to assess the level of risk associated with substance use (see Table 2: Brief, Validated Risk Assessment Tools for Use in Medical Settings With Adults ≥18 Years Old). (A3)

Who to Assess

Clinicians should use validated tools to perform substance use assessments in individual patients who have any of the characteristics discussed below. The purpose of assessment is to identify the level of risk (low, moderate, or high) posed by a patient’s substance use to guide clinical decisions about intervention, treatment, and follow-up (see Figure 1: Substance Use Screening, Risk Assessment, Diagnosis, and Interventions). Clinicians experienced in assessing and treating SUD may elect to use the Diagnostic and Statistical Manual of Mental Disorders-5-TR criteria as the initial assessment tool.

Positive substance use screening test: Given current levels of substance use in the general population and the negative effects of unhealthy substance use, any positive screening test result should prompt an efficient and accurate risk assessment [McNeely(a), et al. 2015; McNeely(c), et al. 2015].

Known history of SUD or overdose: Polysubstance use is common in people with SUD [Ellis, et al. 2023; Karamouzian, et al. 2022; Lin, et al. 2021; John, et al. 2018; Falk, et al. 2006]. For patients with a history of SUD, identification of all substances used, including tobacco, and assessment of the associated levels of risk are indicated for early intervention and clinical decision-making. SUDs are chronic conditions, and even patients with long periods of abstinence remain vulnerable to resuming previous patterns of use [McLellan, et al. 2000]. Patients with a history of SUD may reduce or stop use of one substance but develop unhealthy use of a different substance (e.g., alcohol) [Lin, et al. 2021; Callaghan, et al. 2018; Wang, et al. 2017; Falk, et al. 2006; Earleywine and Newcomb 1997]. Overdose is frequently the result of polysubstance use, and use of fentanyl and stimulants (methamphetamine, cocaine) is driving unprecedented rates of overdose death [Ciccarone 2021; Cicero, et al. 2020]. The use of opioids in combination with alcohol or benzodiazepines also puts individuals at high risk of overdose [Tori, et al. 2020]. In patients with a history of nonfatal overdose, it is critically important to conduct an assessment and identify all of the substances being used; the results will guide education and treatment to reduce the risk of another overdose.

The level of risk of associated with substance use in individuals who are planning to become pregnant should guide clinician counseling, particularly in light of the risk of fetal alcohol spectrum disorder that occurs early in pregnancy [May, et al. 2018; Moyer 2013; Stade, et al. 2009; Floyd, et al. 2008; Floyd, et al. 2006; DHHS 2005; CDC 2003]. In addition, it is reasonable to perform a substance use assessment in patients with chronic diseases who have difficulty following through with treatment recommendations or are not responding as expected to treatment of their medical condition [Garin, et al. 2017; Daskalopoulou, et al. 2014].

Risk Assessment Tools

Substance use assessment tools are designed to collect information on the quantity, frequency, and duration of substance use and to indicate a risk level (see Table 2, below).

Table 2: Brief, Validated Risk Assessment Tools for Use in Medical Settings With Adults ≥18 Years Old [a]
Tool	Substance(s) Included	No. of Items, Approximate Time Required to Complete, and Format
ASSIST (Alcohol, Smoking, and Substance Involvement Screening Test) [Humeniuk, et al. 2008] Available in languages other than English	Tobacco, alcohol, prescription drugs, and other drugs; identifies specific drug classes	10 to 71 items; 5 to 15 minutes, depending on no. of substances used Interviewer-administered
TAPS-2 (Tobacco, Alcohol, Prescription Medication, and Other Substance Use) [b] [Adam, et al. 2019; McNeely(a), et al. 2016]	Tobacco, alcohol, prescription drugs, other drugs; identifies specific drug classes	4 to 25 items; 2 to 4 minutes, depending on no. of substances used Interviewer- or self-administered via electronic app on computer/tablet
ACASI-ASSIST (Audio Computer-Assisted Self-Interview-ASSIST) [Kumar, et al. 2016; McNeely(b), et al. 2016]	Tobacco, alcohol, prescription drugs, and other drugs; identifies specific drug classes	10 to 98 items; 5 to 15 minutes, depending on no. of substances used Self-administered via electronic app on computer/tablet
Alcohol Symptom Checklist [Hallgren, et al. 2022]	Alcohol	11 items; 5 minutes Self-administered on paper and documented in the electronic health record
AUDIT (Alcohol Use Disorders Identification Test) [c] [Reinert and Allen 2007] Available in languages other than English	Alcohol	10 items; 3 minutes Interviewer– or self-administered
DUDIT (Drug Use Disorders Identification Test) [Hildebrand 2015; Berman, et al. 2005] Available in languages other than English	All drugs; does not identify drug classes	11 items; 5 minutes Interviewer- or self-administered on paper
DAST-10 (Drug Abuse Screening Test) [Yudko, et al. 2007; Skinner 1982] Available in languages other than English	All drugs; does not identify drug classes	10 items; 10 minutes or less Interviewer- or self-administered on paper

: Notes:
a: Clinicians with experience in treating patients with substance use and substance use disorder may choose to use the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision criteria as the initial assessment tool.
b: An online version of the TAPS tool with clinical guidance on interpreting the scores and resources for intervention is available at National Institute on Drug Abuse TAPS.
c: The 3-item AUDIT-C performs as well as the full 10-item AUDIT for identifying risky use and problem use in primary care [Bradley, et al. 2007]. However, use of the full AUDIT provides expanded information about problems related to alcohol use that may be helpful for clinicians offering brief interventions or other alcohol counseling.

Patient Engagement and Interventions

RECOMMENDATIONS

Patient Engagement

Clinicians should discern patients’ perceptions of their substance use and adjust interventions using techniques informed by motivational interviewing. (A3)

Interventions

For patients with low-risk substance use, clinicians should:
- Provide positive reinforcement for minimizing risk. (B3)
- Repeat screening annually. (A3)
For patients with moderate-risk substance use, clinicians should further explore patients’ risk level (risk behaviors, pattern and quantity of use); if concern exists about high-risk use, perform or refer for SUD assessment with DSM-5-TR criteria. (A3)
For patients with high-risk substance use, clinicians should perform or refer for SUD assessment with DSM-5-TR criteria. (A2 for alcohol, A3 for other drugs).
For patients with moderate- or high-risk substance use not diagnosed as a use disorder, clinicians should:
- Offer brief advice on potential negative health consequences. (A3)
- Discuss harm reduction strategies, including reducing use. (A3)
- Provide or refer for a brief intervention informed by motivational interviewing. (A1 for alcohol, A3 for other drugs)
- Provide individualized follow-up. (A3)

: Abbreviations: DSM-5-TR, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision; SUD, substance use disorder.

Many individuals with unhealthy alcohol use or other substance use regularly interact with the healthcare system, and primary care providers are optimally positioned to offer prevention, risk reduction, and treatment interventions. Routine screening and annual rescreening provide structure and opportunity to identify at-risk individuals, monitor for significant changes, and revisit identified concerns.

The Screening, Brief Intervention, and Referral to Treatment (SBIRT) framework provides a comprehensive approach to the delivery of early intervention and treatment services for patients with unhealthy substance use of various degrees of severity. The key elements include:

Screening/risk assessment to quickly identify at-risk individuals
Brief intervention focused on increasing awareness and motivation toward behavioral change
Referral to treatment to facilitate access to care

For additional guidance on implementation and reimbursement based on this framework, see Substance Abuse and Mental Health Services Administration (SAMHSA): Screening, Brief Intervention, and Referral to Treatment (SBIRT) and Box 2: Implementing Substance Use Screening in Primary Care Settings.

Patient Engagement

A positive substance use screening result should trigger further risk assessment, including a detailed history and understanding of individual risk factors; see guideline section Risk Assessment. Assessment tools determine the level of risk (low-, moderate-, and high-risk use) and thus the potential for negative consequences and appropriate interventions. Figure 1: Substance Use Screening, Risk Assessment, Diagnosis, and Interventions outlines the sequence of steps for the clinician.

When administering a risk assessment tool or during patient evaluation after a self-administered risk assessment, clinicians should remain alert to the patient’s perception of their substance use and readiness to change behaviors. Based on clinical experience, this interaction is an important opportunity to build rapport, dispel misconceptions, and engage patients in a therapeutic relationship. Understanding a patient’s readiness to change and identifying internal motivators for change provide important building blocks to shape the intervention strategy.

Motivational interviewing: Interventions tailored to match a patient’s level of risk, perception of their substance use, and readiness to change can promote engagement and increase the probability of progress toward goals [VA/DoD 2015; SAMHSA 1997]. The principals of motivational interviewing (MI) provide a framework for this approach, and all clinicians can develop the skills to educate, advise, offer treatment, or refer patients for appropriate interventions [McLellan 2017; Edelman and Fiellin 2016]. The core skills of MI, as defined by Miller and Rollnick, can be remembered with the acronym OARS, which stands for: open-ended questioning, affirming, reflective listening, and summarizing [Miller and Rollnick 2013]. For more information, see Resources box, below.

Trauma-informed care: Individuals with SUD have a high prevalence of childhood trauma [Bartholow and Huffman 2023; Karsberg, et al. 2021; Zarse, et al. 2019], and substance use is a risk factor for repeated exposure to traumatic events [Aronowitz and Meisel 2022; Simon, et al. 2020]. Knowing that trauma contributes to challenges connecting to the healthcare system, clinicians and organizations with a trauma-informed approach can better overcome these barriers and improve outcomes. For more information on trauma-informed care, see the Resources box, below.

RESOURCES
SAMHSA: TIP 57: Trauma-Informed Care in Behavioral Health Services Centers for Disease Control and Prevention: 6 Guiding Principles to a Trauma-Informed Approach (infographic) New York State Trauma-Informed Network & Resource Center

Interventions

Positive reinforcement (for patients with low-risk substance use): For alcohol use, reinforce the benefits of staying below the U.S. Department of Health and Human Services and Department of Agriculture 2015-2020 Dietary Guidelines (1 drink or fewer per day for women and 2 drinks or fewer per day for men). Statements such as “The amount that you are drinking falls within a level that is considered safe for most healthy adults and is unlikely to have a negative impact on your health” and “In general, the less you drink, the better it is for your health” reinforce low-risk alcohol use. Be alert to pregnancy, older age (>65 years), and other health conditions that may warrant advice to drink less or not at all.

Brief advice (for patients with moderate- or high-risk substance use): Statements such as “As your healthcare provider, I am concerned about your alcohol (or substance) use and the potential impact on your health” and discussion of any related health effects (current or potential) should be integrated into the visit. This discussion can be supplemented by additional interventions as time and resources allow.

For individuals who use alcohol, clinicians can provide information on the recommended safe limits of use. Safe limits have not been established for older individuals or those with medical or psychiatric comorbidities. If a patient is hesitant, negotiate an individualized goal. Little information is available about the dose limits and associated health risks of cannabis and illicitly manufactured drugs.

Harm reduction strategies (for patients with moderate- or high-risk substance use): See the NYSDOH AI guideline Substance Use Harm Reduction in Medical Care for more information, including resources in New York State.

Overdose prevention strategies: Counsel patients to:

Assume all illicitly manufactured opioids will contain fentanyl or other high-potency synthetic opioids and that stimulants and counterfeit pills may contain these agents.
When possible, test drugs with fentanyl test strips or other drug-checking systems. Online sources include MATTERS (for New York State residents and programs, no charge), DanceSafe, and BTNX. Some NYS Authorized Syringe Exchange Sites may provide fentanyl test strips and other drug-checking systems.
Try to avoid using drugs alone, and if they have to use alone, arrange for someone to check in or use phone- and web-based apps (e.g., Never Use Alone Inc. at 800-484-3731).
When using any drug, start with a small amount.
Carry naloxone (NLX), learn how to use it to reverse an opioid overdose, and encourage friends and contacts to do the same. The 4 mg NLX nasal spray formulation is available at pharmacies, at NYSDOH-Registered Opioid Overdose Prevention Programs (no charge), and through online resources such as NEXT Distro. NLX is covered by NYS Medicaid and most private insurers.

Brief interventions (for patients with moderate-risk substance use or high-risk substance use not diagnosed as a use disorder): A brief intervention is a time-limited, patient-centered strategy that focuses on increasing insight and awareness about substance use and motivation toward behavioral change. Brief interventions can range from 5 to 20 minutes in duration, vary in frequency, and include a variety of components. Common elements of a brief intervention include discussion of the risks and rewards of substance use as perceived by the patient and individualized feedback about the level of risk.

Using these techniques, clinicians can encourage “change talk” by amplifying statements about a patient’s desire, ability, and reasons for change [Rollnick, et al. 2022]. The amount of time spent in change talk is correlated with improved outcomes; the more a patient verbalizes their desire and reasons for change, the more likely it is to happen.

Robust evidence supports the efficacy of brief advice and other brief interventions in the primary care setting for reducing alcohol use among individuals with unhealthy use who do not meet the criteria for alcohol use disorder [Curry, et al. 2018; Kaner, et al. 2018; O'Connor, et al. 2018]. However, the optimal timing, dose, and order of interventions is unknown. A systematic review of the literature on brief alcohol intervention implementation in medical settings was unable to identify specific interventions that were clearly associated with improved outcomes [Curry, et al. 2018]. The most common component was the use of personalized feedback in which participants were shown how their alcohol use compared with that of others. Personalized feedback was often combined with MI or other strategies, such as drinking diaries, action plans, or alcohol use “prescriptions.”

Randomized controlled clinical trials have generated mixed results regarding the efficacy of brief interventions in reducing drug use [Sahker, et al. 2022; Patnode, et al. 2020; Gelberg, et al. 2015; Roy-Byrne, et al. 2014; Saitz(a), et al. 2014; Humeniuk, et al. 2012]. Evidence supporting drug use interventions delivered in primary care has primarily come from treatment-seeking populations rather than patients identified only through screening [Saitz 2020; USPSTF(a) 2020]. However, brief interventions are recommended by SAMHSA and have been implemented in many healthcare settings with no evidence of harm [SAMHSA 2018].

In the absence of evidence to guide the choice of specific interventions, clinicians should engage in any strategies that are available and feasible. Clinician factors, including training and time restrictions, will guide strategy. Practice factors, including standard workflows, electronic health record decision support, and availability of integrated behavioral health specialists, can enhance the uptake and implementation of best practices [Loughran, et al. 2021].

Individualized Follow-Up

Because substance use behaviors can change over time, annual rescreening is recommended for individuals with low-risk substance use. For individuals with moderate- or high-risk substance use and those meeting criteria for an SUD, the frequency and type of follow-up will be individualized. As with other chronic diseases, the plan will vary based on the severity of the problem, presence of significant medical or psychiatric comorbidities, and the patient’s perception and goals. When indicated, the plan should include referral for specialty services.

Diagnosis of Substance Use Disorder

RECOMMENDATIONS

Diagnosis of SUD

Clinicians should use the DSM-5-TR criteria to diagnose an SUD and determine its severity. (A3)
If patients present with symptoms consistent with both an SUD and a mental health disorder, clinicians should assess for both types of disorder and refer for specialty behavioral healthcare when indicated. (A3)

Treatment

Clinicians should engage in shared decision-making with patients diagnosed with an SUD to develop an individualized treatment plan that includes pharmacologic and behavioral treatment as indicated and available [a]. (A3)

: Abbreviations: DSM-5-TR, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision; SUD, substance use disorder.
: Note:
a: See NYSDOH AI guidelines Treatment of Alcohol Use Disorder and Treatment of Opioid Use Disorder, NYSDOH AI Clinical Guidance: Stimulant Use, and U.S. Public Health Service: A Clinical Practice Guideline for Treating Tobacco Use and Dependence.

The diagnosis of an SUD and its severity is made by a clinical interview and based on DSM-5-TR diagnostic criteria (see Table 3, below) [APA 2022]. Diagnostic checklists incorporated into the health record can be helpful tools. Studies have confirmed that symptom checklists can reliably assess for alcohol use disorder criteria in patients who screen positive for high-risk drinking [Hallgren, et al. 2022]; a similar strategy may be useful for the diagnosis of other SUDs [Matson, et al. 2023].

Individuals with a diagnosis of SUD should be offered pharmacologic and behavioral treatment as indicated and available (see Note [a], above). Conversations about treatment options should be guided by precepts outlined in the guideline section Patient Engagement. When referral to specialty addiction treatment is necessary, primary care providers can support patients in selecting treatment resources, navigating potential barriers, and checking in about progress while continuing to address medical needs.

Patients often present with concurrent SUDs and mental health disorders [NIDA 2020]. Symptoms of one can mimic the other, making it challenging to arrive at a definitive diagnosis [SAMHSA 2019]. Clinicians should consider a diagnosis of SUD before establishing a primary psychiatric diagnosis (e.g., alcohol-induced depressive disorder vs. major depressive disorder). Symptoms of intoxication, such as mood changes or perceptual disturbances, and symptoms of withdrawal, such as depression, anxiety, irritability, and insomnia, can also mimic psychiatric disorders and should be carefully assessed. Care providers should consult with a mental health specialist when symptoms are severe and/or when a clear diagnosis is difficult to establish.

Table 3: DSM-5-TR Criteria for Diagnosing and Classifying Substance Use Disorders [a,b]
Criteria Type	Description
Impaired control over substance use (DSM-5-TR criteria 1 to 4)	Consuming the substance in larger amounts and for a longer amount of time than intended. Persistent desire to cut down or regulate use. The individual may have unsuccessfully tried to stop in the past. Spending a great deal of time obtaining, using, or recovering from the effects of substance use. Experiencing craving, a pressing desire to use the substance.
Social impairment (DSM-5-TR criteria 5 to 7)	Substance use impairs ability to fulfill major obligations at work, school, or home. Continued use of the substance despite it causing significant social or interpersonal problems. Reduction or discontinuation of recreational, social, or occupational activities because of substance use.
Risky use (DSM-5-TR criteria 8 and 9)	Recurrent substance use in physically unsafe environments. Persistent substance use despite knowledge that it may cause or exacerbate physical or psychological problems.
Pharmacologic (DSM-5-TR criteria 10 and 11)	Tolerance: Individual requires increasingly higher doses of the substance to achieve the desired effect, or the usual dose has a reduced effect; individuals may build tolerance to specific symptoms at different rates. Withdrawal: A collection of signs and symptoms that occurs when blood and tissue levels of the substance decrease. Individuals are likely to seek the substance to relieve symptoms. No documented withdrawal symptoms from hallucinogens, PCP, or inhalants. Note: Tolerance and withdrawal in the context of appropriate medical treatment (i.e., pain medication used as prescribed) do not count as criteria for an SUD.

: Abbreviations: DSM-5-TR, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision; SUD, substance use disorder.
: Notes:
a: Adapted from [APA 2022]. Please consult the DSM-5-TR criteria for substance-specific diagnostic information.
b: SUDs are classified as mild, moderate, or severe based on how many of the 11 criteria are fulfilled: mild, any 2 or 3 criteria; moderate, any 4 or 5 criteria; severe, any 6 or more criteria.

All Recommendations

RECOMMENDATIONS

Screening

During the initial visit and once per year thereafter, primary care clinicians should screen for the following in adults ≥18 years old:
- Alcohol use, and when unhealthy use is identified, assess the level of risk to the patient. (A1)
- Tobacco use, and when use is identified, provide assessment and counseling. (A1)
- Other drug use (B3), and when unhealthy use is identified, assess the level of risk to the patient. (A3)
- See guideline section Risk Assessment and Figure 1: Substance Use Screening, Risk Assessment, Diagnosis, and Interventions.
Before screening for substance use, clinicians should explain the benefits and risks of screening to all patients, especially those who are pregnant or planning to conceive; the discussion should include state reporting requirements and the potential for involvement of child protective services. (A3)
- For information on the Child Abuse Prevention and Treatment Act (CAPTA) in New York State, see Plans of Safe Care for Infants and their Caregivers.
Clinicians should also perform substance use screening to inform clinical care when:
- Prescribing medication(s) that have adverse interactions with alcohol or drugs. (A2)
- A patient has symptoms or medical conditions that could be caused or exacerbated by substance use. (A3)

Screening Tools

Clinicians should use standardized and validated questionnaires for substance use screening (see Table 1: Recommended Validated Tools for Use in Medical Settings to Screen for Alcohol and Drug Use in Adults). (A3)

Risk Assessment

Clinicians should assess the level of substance use risk in individuals who have a positive substance use screening result or a history of substance use disorder (SUD) or overdose. (A3)
Clinicians should use standardized and validated tools to assess the level of risk associated with substance use (see Table 2: Brief, Validated Risk Assessment Tools for Use in Medical Settings With Adults ≥18 Years Old). (A3)

Patient Engagement

Clinicians should discern patients’ perceptions of their substance use and adjust interventions using techniques informed by motivational interviewing. (A3)

Interventions

For patients with low-risk substance use, clinicians should:
- Provide positive reinforcement for minimizing risk. (B3)
- Repeat screening annually. (A3)
For patients with moderate-risk substance use, clinicians should further explore patients’ risk level (risk behaviors, pattern and quantity of use); if concern exists about high-risk use, perform or refer for SUD assessment with DSM-5-TR criteria. (A3)
For patients with high-risk substance use, clinicians should perform or refer for SUD assessment with DSM-5-TR criteria. (A2 for alcohol, A3 for other drugs).
For patients with moderate- or high-risk substance use not diagnosed as a use disorder, clinicians should:
- Offer brief advice on potential negative health consequences. (A3)
- Discuss harm reduction strategies, including reducing use. (A3)
- Provide or refer for a brief intervention informed by motivational interviewing. (A1 for alcohol, A3 for other drugs)
- Provide individualized follow-up. (A3)

Diagnosis of SUD

Clinicians should use the DSM-5-TR criteria to diagnose an SUD and determine its severity. (A3)
If patients present with symptoms consistent with both an SUD and a mental health disorder, clinicians should assess for both types of disorder and refer for specialty behavioral healthcare when indicated. (A3)

Treatment

Clinicians should engage in shared decision-making with patients diagnosed with an SUD to develop an individualized treatment plan that includes pharmacologic and behavioral treatment as indicated and available [a]. (A3)

: Abbreviations: DSM-5-TR, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision; SUD, substance use disorder.
: Note:
a: See NYSDOH AI guidelines Treatment of Alcohol Use Disorder and Treatment of Opioid Use Disorder, NYSDOH AI Clinical Guidance: Stimulant Use, and U.S. Public Health Service: A Clinical Practice Guideline for Treating Tobacco Use and Dependence.

References

Adam A., Schwartz R. P., Wu L. T., et al. Electronic self-administered screening for substance use in adult primary care patients: feasibility and acceptability of the tobacco, alcohol, prescription medication, and other substance use (myTAPS) screening tool. Addict Sci Clin Pract. 2019;14(1):39. [PMC free article: PMC6794766] [PubMed: 31615549]
Afshar M., Burnham E. L., Joyce C., et al. Cut-point levels of phosphatidylethanol to identify alcohol misuse in a mixed cohort including critically ill patients. Alcohol Clin Exp Res. 2017;41(10):1745–1753. [PMC free article: PMC5626634] [PubMed: 28792620]
Antoniou T., Tseng A. L. Interactions between recreational drugs and antiretroviral agents. Ann Pharmacother. 2002;36(10):1598–1613. [PubMed: 12243611]
APA. Diagnostic and statistical manual of mental disorders, fifth edition, text revision. 2022; Washington, DC. https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425787 .
Aronowitz S., Meisel Z. F. Addressing stigma to provide quality care to people who use drugs. JAMA Netw Open. 2022;5(2):e2146980. [PubMed: 35119465]
Bartholow L. A., Huffman R. T. The necessity of a trauma-informed paradigm in substance use disorder services. J Am Psychiatr Nurses Assoc. 2023;29(6):470–476. [PubMed: 34334012]
Berman, A. H.. Drug Use Disorders Identification Test (DUDIT). 2005. https://www.emcdda.europa.eu/drugs-library/drug-use-disorders-identification-test-dudit_en [accessed 2024 Mar 20]
Bosker W. M., Huestis M. A. Oral fluid testing for drugs of abuse. Clin Chem. 2009;55(11):1910–1931. [PMC free article: PMC3165054] [PubMed: 19745062]
Bradley K. A., DeBenedetti A. F., Volk R. J., et al. AUDIT-C as a brief screen for alcohol misuse in primary care. Alcohol Clin Exp Res. 2007;31(7):1208–1217. [PubMed: 17451397]
Bradley K. A., Lapham G. T., Hawkins E. J., et al. Quality concerns with routine alcohol screening in VA clinical settings. J Gen Intern Med. 2011;26(3):299–306. [PMC free article: PMC3043188] [PubMed: 20859699]
Bradley K. A., Lapham G. T., Lee A. K. Screening for drug use in primary care: practical implications of the new USPSTF recommendation. JAMA Intern Med. 2020;180(8):1050–1051. [PMC free article: PMC7817137] [PubMed: 32515790]
Bruce R. D., Altice F. L., Friedland G. H. Pharmacokinetic drug interactions between drugs of abuse and antiretroviral medications: implications and management for clinical practice. Expert Rev Clin Pharmacol. 2008;1(1):115–127. [PubMed: 24410515]
Bush K., Kivlahan D. R., McDonell M. B., et al. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med. 1998;158(16):1789–1795. [PubMed: 9738608]
Callaghan R. C., Gatley J. M., Sykes J., et al. The prominence of smoking-related mortality among individuals with alcohol- or drug-use disorders. Drug Alcohol Rev. 2018;37(1):97–105. [PubMed: 28009934]
CDC Motivational intervention to reduce alcohol-exposed pregnancies--Florida, Texas, and Virginia, 1997-2001. MMWR Morb Mortal Wkly Rep. 2003;52(19):441–444. [PubMed: 12807086]
CDC Unintentional poisoning deaths--United States, 1999-2004. MMWR Morb Mortal Wkly Rep. 2007;56(5):93–96. [PubMed: 17287712]
CDC. Alcohol-Related Disease Impact (ARDI) application. 2022. https://nccd.cdc.gov/DPH_ARDI/default/default.aspx [accessed 2024 Jan 16]
CDC. National Vital Statistics System: provisional drug overdose death counts. 2024. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm [accessed 2024 Jan 16]
Ciccarone D. The rise of illicit fentanyls, stimulants and the fourth wave of the opioid overdose crisis. Curr Opin Psychiatry. 2021;34(4):344–350. [PMC free article: PMC8154745] [PubMed: 33965972]
Cicero T. J., Ellis M. S., Kasper Z. A. Polysubstance use: a broader understanding of substance use during the opioid crisis. Am J Public Health. 2020;110(2):244–250. [PMC free article: PMC6951387] [PubMed: 31855487]
CMS. 2014 Clinical Quality Measures (CQMs): adult recommended core measures. 2013. https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/2014_CQM_AdultRecommend_CoreSetTable.pdf [accessed 2020 Mar 31]
Cone E. J., Huestis M. A. Interpretation of oral fluid tests for drugs of abuse. Ann N Y Acad Sci. 2007;1098:51–103. [PMC free article: PMC2700061] [PubMed: 17332074]
Cousins G., Boland F., Courtney B., et al. Risk of mortality on and off methadone substitution treatment in primary care: a national cohort study. Addiction. 2016;111(1):73–82. [PubMed: 26234389]
Curry S. J., Krist A. H., Owens D. K., et al. Screening and behavioral counseling interventions to reduce unhealthy alcohol use in adolescents and adults: US Preventive Services Task Force recommendation statement. JAMA. 2018;320(18):1899–1909. [PubMed: 30422199]
Daskalopoulou M., Rodger A., Phillips A. N., et al. Recreational drug use, polydrug use, and sexual behaviour in HIV-diagnosed men who have sex with men in the UK: results from the cross-sectional ASTRA study. Lancet HIV. 2014;1(1):e22–e31. [PubMed: 26423813]
DHHS. U.S. Surgeon General releases advisory on alcohol use in pregnancy. 2005. http://come-over.to/FAS/SurGenAdvisory.htm [accessed 2020 Mar 31]
DHHS. Helping smokers quit: a guide for clinicians. 2008. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/references/clinhlpsmkqt/clinhlpsmksqt.pdf [accessed 2020 Mar 31]
Earleywine M., Newcomb M. D. Concurrent versus simultaneous polydrug use: prevalence, correlates, discriminant validity, and prospective effects on health outcomes. Exp Clin Psychopharmacol. 1997;5(4):353–364. [PubMed: 9386962]
Edelman E. J., Fiellin D. A. In the clinic. Alcohol use. Ann Intern Med. 2016;164(1):ITC1–IT16. [PubMed: 26747315]
Ellis J. D., Rabinowitz J. A., Ware O. D., et al. Patterns of polysubstance use and clinical comorbidity among persons seeking substance use treatment: An observational study. J Subst Use Addict Treat. 2023;146:208932. [PMC free article: PMC10035066] [PubMed: 36880895]
Falk D. E., Yi H. Y., Hiller-Sturmhöfel S. An epidemiologic analysis of co-occurring alcohol and tobacco use and disorders: findings from the National Epidemiologic Survey on Alcohol and Related Conditions. Alcohol Res Health. 2006;29(3):162–171. [PMC free article: PMC6527037] [PubMed: 17373404]
Floyd R. L., Jack B. W., Cefalo R., et al. The clinical content of preconception care: alcohol, tobacco, and illicit drug exposures. Am J Obstet Gynecol. 2008;199(6 Suppl 2):s333–s339. [PubMed: 19081427]
Floyd R. L., O'Connor M. J., Bertrand J., et al. Reducing adverse outcomes from prenatal alcohol exposure: a clinical plan of action. Alcohol Clin Exp Res. 2006;30(8):1271–1275. [PubMed: 16899029]
Garin N., Zurita B., Velasco C., et al. Prevalence and clinical impact of recreational drug consumption in people living with HIV on treatment: a cross-sectional study. BMJ Open. 2017;7(1):e014105. [PMC free article: PMC5253545] [PubMed: 28100565]
GBD 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. [PMC free article: PMC6251968] [PubMed: 30392731]
Gelberg L., Andersen R. M., Afifi A. A., et al. Project QUIT (Quit Using Drugs Intervention Trial): a randomized controlled trial of a primary care-based multi-component brief intervention to reduce risky drug use. Addiction. 2015;110(11):1777–1790. [PMC free article: PMC4948983] [PubMed: 26471159]
Gomes T., Juurlink D. N., Antoniou T., et al. Gabapentin, opioids, and the risk of opioid-related death: a population-based nested case-control study. PLoS Med. 2017;14(10):e1002396. [PMC free article: PMC5626029] [PubMed: 28972983]
Gomes T., Ledlie S., Tadrous M., et al. Trends in opioid toxicity-related deaths in the US before and after the start of the COVID-19 pandemic, 2011-2021. JAMA Netw Open. 2023;6(7):e2322303. [PMC free article: PMC10329206] [PubMed: 37418260]
Gordon A. J., Bertholet N., McNeely J., et al. 2013 update in addiction medicine for the generalist. Addict Sci Clin Pract. 2013;8(1):18. [PMC free article: PMC3819258] [PubMed: 24499640]
Gryczynski J., McNeely J., Wu L. T., et al. Validation of the TAPS-1: a four-item screening tool to identify unhealthy substance use in primary care. J Gen Intern Med. 2017;32(9):990–996. [PMC free article: PMC5570743] [PubMed: 28550609]
Hallgren K. A., Matson T. E., Oliver M., et al. Practical assessment of DSM-5 alcohol use disorder criteria in routine care: high test-retest reliability of an alcohol symptom checklist. Alcohol Clin Exp Res. 2022;46(3):458–467. [PMC free article: PMC8962965] [PubMed: 35275415]
Hallgren K. A., Witwer E., West I., et al. Prevalence of documented alcohol and opioid use disorder diagnoses and treatments in a regional primary care practice-based research network. J Subst Abuse Treat. 2020;110:18–27. [PMC free article: PMC7255441] [PubMed: 31952624]
Hildebrand M. The psychometric properties of the Drug Use Disorders Identification Test (DUDIT): a review of recent research. J Subst Abuse Treat. 2015;53:52–59. [PubMed: 25682718]
Humeniuk R., Ali R., Babor T., et al. A randomized controlled trial of a brief intervention for illicit drugs linked to the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in clients recruited from primary health-care settings in four countries. Addiction. 2012;107(5):957–966. [PubMed: 22126102]
Humeniuk R., Ali R., Babor T. F., et al. Validation of the Alcohol, Smoking And Substance Involvement Screening Test (ASSIST). Addiction. 2008;103(6):1039–1047. [PubMed: 18373724]
Jarvis M., Williams J., Hurford M., et al. Appropriate use of drug testing in clinical addiction medicine. J Addict Med. 2017;11(3):163–173. [PubMed: 28557958]
Jatlow P. I., Agro A., Wu R., et al. Ethyl glucuronide and ethyl sulfate assays in clinical trials, interpretation, and limitations: results of a dose ranging alcohol challenge study and 2 clinical trials. Alcohol Clin Exp Res. 2014;38(7):2056–2065. [PMC free article: PMC4107122] [PubMed: 24773137]
John W. S., Zhu H., Mannelli P., et al. Prevalence, patterns, and correlates of multiple substance use disorders among adult primary care patients. Drug Alcohol Depend. 2018;187:79–87. [PMC free article: PMC5959766] [PubMed: 29635217]
Jonas D. E., Amick H. R., Feltner C., et al. Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. JAMA. 2014;311(18):1889–1900. [PubMed: 24825644]
Kalichman S. C., Kalichman M. O., Cherry C., et al. Intentional medication nonadherence because of interactive toxicity beliefs among HIV-positive active drug users. J Acquir Immune Defic Syndr. 2015;70(5):503–509. [PMC free article: PMC4648658] [PubMed: 26226250]
Kaner E. F., Beyer F. R., Muirhead C., et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev. 2018;2(2):CD004148. [PMC free article: PMC6491186] [PubMed: 29476653]
Karamouzian M., Pilarinos A., Hayashi K., et al. Latent patterns of polysubstance use among people who use opioids: a systematic review. Int J Drug Policy. 2022;102:103584. [PubMed: 35074608]
Karsberg S., Hesse M., Pedersen M. M., et al. The impact of poly-traumatization on treatment outcomes in young people with substance use disorders. BMC Psychiatry. 2021;21(1):140. [PMC free article: PMC7941934] [PubMed: 33685430]
Kim T. W., Bernstein J., Cheng D. M., et al. Receipt of addiction treatment as a consequence of a brief intervention for drug use in primary care: a randomized trial. Addiction. 2017;112(5):818–827. [PMC free article: PMC5382041] [PubMed: 27886657]
Krist A. H., Davidson K. W., Mangione C. M., et al. Interventions for tobacco smoking cessation in adults, including pregnant persons: US Preventive Services Task Force recommendation statement. JAMA. 2021;325(3):265–279. [PubMed: 33464343]
Kumar P. C., Cleland C. M., Gourevitch M. N., et al. Accuracy of the Audio Computer Assisted Self Interview version of the Alcohol, Smoking and Substance Involvement Screening Test (ACASI ASSIST) for identifying unhealthy substance use and substance use disorders in primary care patients. Drug Alcohol Depend. 2016;165:38–44. [PMC free article: PMC4962996] [PubMed: 27344194]
Lin L. A., Bohnert A. S., Blow F. C., et al. Polysubstance use and association with opioid use disorder treatment in the US Veterans Health Administration. Addiction. 2021;116(1):96–104. [PubMed: 32428386]
Lindsey W. T., Stewart D., Childress D. Drug interactions between common illicit drugs and prescription therapies. Am J Drug Alcohol Abuse. 2012;38(4):334–343. [PubMed: 22221229]
Lock C. A., Kaner E. F. Implementation of brief alcohol interventions by nurses in primary care: do non-clinical factors influence practice?. Fam Pract. 2004;21(3):270–275. [PubMed: 15128688]
Loughran T. A., Scharer J. L., Rodriguez L., et al. Brief alcohol interventions in U.S. medical settings: a systematic review of the implementation literature. J Subst Abuse Treat. 2021;131:108456. [PubMed: 34098287]
Lyndon A., Audrey S., Wells C., et al. Risk to heroin users of polydrug use of pregabalin or gabapentin. Addiction. 2017;112(9):1580–1589. [PMC free article: PMC5635829] [PubMed: 28493329]
Maciosek M. V., Coffield A. B., Edwards N. M., et al. Priorities among effective clinical preventive services: results of a systematic review and analysis. Am J Prev Med. 2006;31(1):52–61. [PubMed: 16777543]
Matson Theresa E., Hallgren Kevin A., Lapham Gwen T., et al. Psychometric performance of a substance use symptom checklist to help clinicians assess substance use disorder in primary pare. JAMA Network Open. 2023;6(5):e2316283. [PMC free article: PMC10220521] [PubMed: 37234003]
Matson T. E., Lapham G. T., Bobb J. F., et al. Validity of the Single-Item Screen-Cannabis (SIS-C) for cannabis use disorder screening in routine care. JAMA Netw Open. 2022;5(11):e2239772. [PMC free article: PMC9627408] [PubMed: 36318205]
Mattick R. P., Breen C., Kimber J., et al. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2014;2014(2):CD002207. [PMC free article: PMC10617756] [PubMed: 24500948]
May P. A., Chambers C. D., Kalberg W. O., et al. Prevalence of fetal alcohol spectrum disorders in 4 US communities. JAMA. 2018;319(5):474–482. [PMC free article: PMC5839298] [PubMed: 29411031]
McKnight-Eily L. R., Okoro C. A., Turay K., et al. Screening for alcohol use and brief counseling of adults - 13 states and the District of Columbia, 2017. MMWR Morb Mortal Wkly Rep. 2020;69(10):265–270. [PMC free article: PMC7075256] [PubMed: 32163383]
McLellan A. T. Substance misuse and substance use disorders: why do they matter in healthcare?. Trans Am Clin Climatol Assoc. 2017;128:112–130. [PMC free article: PMC5525418] [PubMed: 28790493]
McLellan A. T., Lewis D. C., O'Brien C. P., et al. Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA. 2000;284(13):1689–1695. [PubMed: 11015800]
McNeely J., Adam A., Rotrosen J., et al. Comparison of methods for alcohol and drug screening in primary care clinics. JAMA Netw Open. 2021;4(5):e2110721. [PMC free article: PMC8138691] [PubMed: 34014326]
McNeely J., Kumar P. C., Rieckmann T., et al. Barriers and facilitators affecting the implementation of substance use screening in primary care clinics: a qualitative study of patients, providers, and staff. Addict Sci Clin Pract. 2018;13(1):8. [PMC free article: PMC5890352] [PubMed: 29628018]
McNeely J., Windham B. G., Anderson D. E. Dietary sodium effects on heart rate variability in salt sensitivity of blood pressure. Psychophysiology. 2008;45(3):405–411. [PMC free article: PMC2399901] [PubMed: 18047481]
McNeely(a) J., Strauss S. M., Saitz R., et al. A brief patient self-administered substance use screening tool for primary care: two-site validation study of the Substance Use Brief Screen (SUBS). Am J Med. 2015;128(7):784.e9–784.19. [PMC free article: PMC4475501] [PubMed: 25770031]
McNeely(a) J., Wu L. T., Subramaniam G., et al. Performance of the Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) tool for substance use screening in primary care patients. Ann Intern Med. 2016;165(10):690–699. [PMC free article: PMC5291717] [PubMed: 27595276]
McNeely(b) J., Saitz R. Appropriate screening for substance use vs disorder. JAMA Intern Med. 2015;175(12):1997–1998. [PubMed: 26641355]
McNeely(b) J., Strauss S. M., Rotrosen J., et al. Validation of an Audio Computer-Assisted Self-Interview (ACASI) version of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in primary care patients. Addiction. 2016;111(2):233–244. [PMC free article: PMC4899945] [PubMed: 26360315]
McNeely(c) J., Cleland C. M., Strauss S. M., et al. Validation of Self-Administered Single-Item Screening Questions (SISQs) for unhealthy alcohol and drug use in primary care patients. J Gen Intern Med. 2015;30(12):1757–1764. [PMC free article: PMC4636560] [PubMed: 25986138]
Mertens J. R., Weisner C., Ray G. T., et al. Hazardous drinkers and drug users in HMO primary care: prevalence, medical conditions, and costs. Alcohol Clin Exp Res. 2005;29(6):989–998. [PubMed: 15976525]
Miller P. M., Thomas S. E., Mallin R. Patient attitudes towards self-report and biomarker alcohol screening by primary care physicians. Alcohol Alcohol. 2006;41(3):306–310. [PubMed: 16574672]
Miller W. R., Rollnick S. Motivational interviewing: helping people change. Guilford Press; 2013; New York (NY).
Moyer V. A. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;159(3):210–218. [PubMed: 23698791]
Neumann T., Spies C. Use of biomarkers for alcohol use disorders in clinical practice. Addiction. 2003;98 Suppl 2:81–91. [PubMed: 14984245]
NIAAA. The healthcare professional's core resource on alcohol. 2024. https://www.niaaa.nih.gov/health-professionals-communities/core-resource-on-alcohol [accessed 2024 Jan 16]
NIDA. Screening for drug use in general medical settings: quick reference guide. 2011. https://nida.nih.gov/sites/default/files/pdf/screening_qr.pdf [accessed 2020 Mar 31]
NIDA. Common comorbidities with substance use disorders research report. 2020. https://www.ncbi.nlm.nih.gov/books/NBK571451/ [accessed 2024 Feb 8] [PubMed: 34185444]
O'Connor E. A., Perdue L. A., Senger C. A., et al. Screening and behavioral counseling interventions to reduce unhealthy alcohol use in adolescents and adults: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2018;320(18):1910–1928. [PubMed: 30422198]
O'Donnell A., Anderson P., Newbury-Birch D., et al. The impact of brief alcohol interventions in primary healthcare: a systematic review of reviews. Alcohol Alcohol. 2014;49(1):66–78. [PMC free article: PMC3865817] [PubMed: 24232177]
Patnode C. D., Henderson J. T., Coppola E. L., et al. Interventions for tobacco cessation in adults, including pregnant persons: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2021;325(3):280–298. [PubMed: 33464342]
Patnode C. D., Perdue L. A., Rushkin M., et al. Screening for unhealthy drug use: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2020;323(22):2310–2328. [PubMed: 32515820]
Reinert D. F., Allen J. P. The Alcohol Use Disorders Identification Test: an update of research findings. Alcohol Clin Exp Res. 2007;31(2):185–199. [PubMed: 17250609]
Ries R. K., Fiellin D. A., Miller S. C., et al. The ASAM principles of addiction medicine. Wolters Kluwer; 2018; https://shop.lww.com/The-ASAM-Principles-of-Addiction-Medicine/p/9781496371010 .
Rollnick S., Miller W. R., Butler C. C. Motivational interviewing in health care: helping patients change behavior. Guilford Press; 2022; New York (NY).
Roy-Byrne P., Bumgardner K., Krupski A., et al. Brief intervention for problem drug use in safety-net primary care settings: a randomized clinical trial. JAMA. 2014;312(5):492–501. [PMC free article: PMC4599980] [PubMed: 25096689]
Sahker E., Luo Y., Sakata M., et al. Efficacy of brief intervention for unhealthy drug use in outpatient medical care: a systematic review and meta-analysis. J Gen Intern Med. 2022;37(8):2041–2049. [PMC free article: PMC9198157] [PubMed: 35419744]
Saitz R. Clinical practice. Unhealthy alcohol use. N Engl J Med. 2005;352(6):596–607. [PubMed: 15703424]
Saitz R. Screening for unhealthy drug use: neither an unreasonable idea nor an evidence-based practice. JAMA. 2020;323(22):2263–2265. [PubMed: 32515804]
Saitz(a) R., Palfai T. P., Cheng D. M., et al. Screening and brief intervention for drug use in primary care: the ASPIRE randomized clinical trial. JAMA. 2014;312(5):502–513. [PMC free article: PMC4667772] [PubMed: 25096690]
Saitz(b) R., Cheng D. M., Allensworth-Davies D., et al. The ability of single screening questions for unhealthy alcohol and other drug use to identify substance dependence in primary care. J Stud Alcohol Drugs. 2014;75(1):153–157. [PMC free article: PMC3893629] [PubMed: 24411807]
SAMHSA. A guide to substance abuse services for primary care clinicians. 1997. https://www.ncbi.nlm.nih.gov/books/NBK64827/ [accessed 2020 Mar 31] [PubMed: 22514830]
SAMHSA. Implementing care for alcohol & other drug use in medical settings: an extension of SBIRT. SBIRT change guide 1.0. 2018. https://www.thenationalcouncil.org/wp-content/uploads/2021/04/Implementing_Care_for_Alcohol_and_Other_Drug_Use_In_Medical_Settings_-_An_Extension_of_SBIRT.pdf [accessed 2020 Mar 31]
SAMHSA. Key substance use and mental health indicators in the United States: results from the 2018 National Survey on Drug Use and Health. 2019. https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHNationalFindingsReport2018/NSDUHNationalFindingsReport2018.pdf [accessed 2020 Jan 6]
Sayre M., Lapham G. T., Lee A. K., et al. Routine assessment of symptoms of substance use disorders in primary care: prevalence and severity of reported symptoms. J Gen Intern Med. 2020;35(4):1111–1119. [PMC free article: PMC7174482] [PubMed: 31974903]
Schulden J. D., Thomas Y. F., Compton W. M. Substance abuse in the United States: findings from recent epidemiologic studies. Curr Psychiatry Rep. 2009;11(5):353–359. [PMC free article: PMC3144502] [PubMed: 19785975]
Simon R., Snow R., Wakeman S. Understanding why patients with substance use disorders leave the hospital against medical advice: a qualitative study. Subst Abus. 2020;41(4):519–525. [PubMed: 31638862]
Simonetti J. A., Lapham G. T., Williams E. C. Association between receipt of brief alcohol intervention and quality of care among veteran outpatients with unhealthy alcohol use. J Gen Intern Med. 2015;30(8):1097–1104. [PMC free article: PMC4510248] [PubMed: 25691238]
Skinner H. A. The drug abuse screening test. Addict Behav. 1982;7(4):363–371. [PubMed: 7183189]
Smith P. C., Schmidt S. M., Allensworth-Davies D., et al. Primary care validation of a single-question alcohol screening test. J Gen Intern Med. 2009;24(7):783–788. [PMC free article: PMC2695521] [PubMed: 19247718]
Smith P. C., Schmidt S. M., Allensworth-Davies D., et al. A single-question screening test for drug use in primary care. Arch Intern Med. 2010;170(13):1155–1160. [PMC free article: PMC2911954] [PubMed: 20625025]
Solberg L. I., Maciosek M. V., Edwards N. M. Primary care intervention to reduce alcohol misuse ranking its health impact and cost effectiveness. Am J Prev Med. 2008;34(2):143–152. [PubMed: 18201645]
Sordo L., Barrio G., Bravo M. J., et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ. 2017;357:j1550. [PMC free article: PMC5421454] [PubMed: 28446428]
Spear S. E., Shedlin M., Gilberti B., et al. Feasibility and acceptability of an audio computer-assisted self-interview version of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in primary care patients. Subst Abus. 2016;37(2):299–305. [PMC free article: PMC4962999] [PubMed: 26158798]
Stade B. C., Bailey C., Dzendoletas D., et al. Psychological and/or educational interventions for reducing alcohol consumption in pregnant women and women planning pregnancy. Cochrane Database Syst Rev. 2009;2009(2):CD004228. [PMC free article: PMC4164939] [PubMed: 19370597]
Stewart S. H., Koch D. G., Willner I. R., et al. Validation of blood phosphatidylethanol as an alcohol consumption biomarker in patients with chronic liver disease. Alcohol Clin Exp Res. 2014;38(6):1706–1711. [PMC free article: PMC4409698] [PubMed: 24848614]
Stringfellow, E. J.. Removing the X-waiver is one small step toward increasing treatment of opioid use disorder, but great leaps are needed. 2021. https://www.healthaffairs.org/content/forefront/removing-x-waiver-one-small-step-toward-increasing-treatment-opioid-use-disorder-but [accessed 2024 Mar 20]
Tori M. E., Larochelle M. R., Naimi T. S. Alcohol or benzodiazepine co-involvement with opioid overdose deaths in the United States, 1999-2017. JAMA Netw Open. 2020;3(4):e202361. [PMC free article: PMC7146101] [PubMed: 32271389]
Tourangeau R., Smith T. W. Asking sensitive questions: the impact of data collection mode, question format, and question context. Publ Opin Q. 1996;60(2):275–304.
USPSTF. Final recommendation statement: tobacco smoking cessation in adults, including pregnant persons: interventions. 2021. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions [accessed 2024 Jan 16]
USPSTF(a). Final evidence summary: unhealthy drug use: screening. 2020. https://www.uspreventiveservicestaskforce.org/uspstf/document/final-evidence-summary/drug-use-illicit-screening [accessed 2024 Jan 16]
USPSTF(b). Final recommendation statement: unhealthy drug use: screening. 2020. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/drug-use-illicit-screening [accessed 2024 Jan 16]
USPSTF(c). Interventions for unhealthy drug use—supplemental report: a systematic review for the U.S. Preventive Services Task Force. 2020. https://www.ncbi.nlm.nih.gov/books/NBK558205/ [accessed 2020 Jan 7]
VA/DoD. Clinical practice guideline for the management of substance use disorders. 2015. https://www.healthquality.va.gov/guidelines/MH/sud/VADODSUDCPGRevised22216.pdf [accessed 2020 Mar 31]
Venkatesh V., Davis F. D. A theoretical extension of the technology acceptance model: four longitudinal field studies. Management Science. 2000;46(2):186–204.
Verstraete A. G. Detection times of drugs of abuse in blood, urine, and oral fluid. Ther Drug Monit. 2004;26(2):200–205. [PubMed: 15228165]
Wakeman S. E., Larochelle M. R., Ameli O., et al. Comparative effectiveness of different treatment pathways for opioid use disorder. JAMA Netw Open. 2020;3(2):e1920622. [PMC free article: PMC11143463] [PubMed: 32022884]
Wang L., Min J. E., Krebs E., et al. Polydrug use and its association with drug treatment outcomes among primary heroin, methamphetamine, and cocaine users. Int J Drug Policy. 2017;49:32–40. [PMC free article: PMC5681890] [PubMed: 28888099]
Wartko P. D., Bobb J. F., Boudreau D. M., et al. Nurse care management for opioid use disorder treatment: the PROUD cluster randomized clinical trial. JAMA Intern Med. 2023;183(12):1343–1354. [PMC free article: PMC10616772] [PubMed: 37902748]
Watts B. V., Gottlieb D. J., Riblet N. B., et al. Association of medication treatment for opioid use disorder with suicide mortality. Am J Psychiatry. 2022;179(4):298–304. [PubMed: 35360916]
White A. M., Castle I. P., Hingson R. W., et al. Using death certificates to explore changes in alcohol-related mortality in the United States, 1999 to 2017. Alcohol Clin Exp Res. 2020;44(1):178–187. [PubMed: 31912524]
WHO. The health and social effects of nonmedical cannabis use. 2016. https://www.who.int/publications/i/item/9789241510240 [accessed 2020 Mar 31]
Wight R. G., Rotheram-Borus M. J., Klosinski L., et al. Screening for transmission behaviors among HIV-infected adults. AIDS Educ Prev. 2000;12(5):431–441. [PubMed: 11063062]
Williams E. C., Achtmeyer C. E., Thomas R. M., et al. Factors underlying quality problems with alcohol screening prompted by a clinical reminder in primary care: a multi-site qualitative study. J Gen Intern Med. 2015;30(8):1125–1132. [PMC free article: PMC4510245] [PubMed: 25731916]
Yudko E., Lozhkina O., Fouts A. A comprehensive review of the psychometric properties of the Drug Abuse Screening Test. J Subst Abuse Treat. 2007;32(2):189–198. [PubMed: 17306727]
Zarse E. M., Neff M. R., Yoder R., et al. The adverse childhood experiences questionnaire: two decades of research on childhood trauma as a primary cause of adult mental illness, addiction, and medical diseases. Cogent Medicine. 2019;6(1):1581447.

Supplementary Material

Supplement: Guideline Development and Recommendation Ratings

Footnotes

: Conflict of Interest: There are no author or writing group conflict of interest disclosures.

Created: October 2020; Last Update: May 2024.

Copyright © Johns Hopkins University Clinical Guidelines Program 2000-2024. The Clinical Guidelines Program, a collaborative effort of the NYSDOH AI and the Johns Hopkins University School of Medicine, Division of Infectious Diseases, encourages the use, reproduction, and distribution of original documents and related graphics from this program website accompanied by a full citation of source that includes: Author(s). Committee. Title. Date of publication. Full URL. Date accessed. Links to pages on this Clinical Guidelines Program website are also encouraged and may be created without seeking permission. Requests to adapt material, i.e., to change or alter in any way material from this website for inclusion in another publication, should be sent to aiguidelines@jhmi.edu. Please include detailed information about the intended use and desired adaptations.

This book is licensed under the terms of the Attribution-NonCommercial-NoDerivs 3.0 Unported (CC BY-NC-ND 3.0).

Bookshelf ID: NBK565474PMID: 33332063

PubReader
Print View
Cite this Page
McNeely J, Hamilton LK, Whitley SD, et al. Substance Use Screening, Risk Assessment, and Use Disorder Diagnosis in Adults [Internet]. Baltimore (MD): Johns Hopkins University; 2024 May.
PDF version of this title (1.1M)

In this Page

Purpose of This Guideline
Substance Use Screening and Risk Assessment: Goals and Definitions
Screening
Screening Tools
Risk Assessment
Patient Engagement and Interventions
Diagnosis of Substance Use Disorder
All Recommendations
References
Supplementary Material

Other titles in this collection

New York State Department of Health AIDS Institute Clinical Guidelines

Related information

NLM Catalog
Related NLM Catalog Entries
PMC
PubMed Central citations
PubMed
Links to PubMed

Recent Activity

Clear Turn Off Turn On

Substance Use Screening, Risk Assessment, and Use Disorder Diagnosis in Adults
Substance Use Screening, Risk Assessment, and Use Disorder Diagnosis in Adults

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

Bookshelf

Substance Use Screening, Risk Assessment, and Use Disorder Diagnosis in Adults

Purpose of This Guideline

Substance Use Screening and Risk Assessment: Goals and Definitions

Screening

Figure 1

Alcohol

Tobacco

Other Drugs

Screening to Inform Clinical Care

Screening Tools

Risk Assessment

Who to Assess

Risk Assessment Tools

Patient Engagement and Interventions

Patient Engagement

Interventions

Individualized Follow-Up

Diagnosis of Substance Use Disorder

All Recommendations

References

Supplementary Material

Footnotes

Views

In this Page

Other titles in this collection

Related information

Recent Activity