Although Not Evidence-based, the USPSTF Recommends Screening Adults for Drug Use

Previously, the US Preventive Services Task Force (USPSTF) has found the evidence to be insufficient to recommend screening for unhealthy drug use,* although US health agencies have sponsored such screening programs. The USPSTF recently published a new recommendation.

• “The USPSTF recommends screening by asking questions about unhealthy drug use in adults 18 years or older. Screening should be implemented when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred.” This is a grade B recommendation, which means that “the USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.”
• The USPSTF also concluded that that “the current evidence is insufficient to assess the balance of benefits and harms of screening” adolescents.
• The evidence review found that brief screening tools are valid, and treatment for drug use disorder (e.g., pharmacotherapy for opioid use disorder) has efficacy in people who seek it.
• However, among those identified by screening, brief counseling lacked efficacy for reducing drug use or increasing treatment entry.

* Defined as “the use of substances (not including alcohol or tobacco products) that are illegally obtained or the nonmedical use of prescription psychoactive medications.”

Comments: The USPSTF’s recommendation represents a stunning departure from its decades of strict reliance on evidence of a preventive service’s efficacy. Clearly there are reasons to identify unhealthy drug use: to diagnose and treat symptoms that could be caused by use; to prescribe medications; to better know one’s patient; and to demonstrate to patients, clinicians, and policy-makers that drug use is a medical issue. But clinicians should be aware of the potential risks of documenting illegal behavior in the medical record (e.g., in some states, drug use by pregnant women is deemed criminal child abuse), and they should not expect patients to reduce their use or link to specialized care as a result of their brief advice.

Richard Saitz, MD, MPH.

References: US Preventive Services Task Force. Screening for unhealthy drug use: US Preventive Services Task Force recommendation statement. JAMA. 2020;323(22):2301–2309.

Patnode CD, Perdue LA, 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.

Saitz R. Screening for unhealthy drug use: neither an unreasonable idea nor an evidence-based practice. JAMA. 2020;323(22):2263–2265.

Bradley KA, Lapham GT, Lee AK. Screening for drug use in primary care: practical implications of the new USPSTF recommendation. JAMA Intern Med. 2020 [Epub ahead of print]. doi:10.1001/jamainternmed.2019.7335.