Screen All Adult Patients for Drug Abuse, National Panel Urges

By | August 13, 2019

A national panel of health experts recommended on Tuesday that doctors screen all adult patients for illicit drug use, including improper use of prescription medications. But the group, the United States Preventive Services Task Force, stopped short of endorsing such screening for teenagers, a position that puts them at odds with major adolescent health groups.

The panel, which is appointed by the federal Department of Health and Human Services but operates independently, said that its proposed guidelines are intended to combat alarmingly high rates of substance abuse in the United States. It cited a 2017 federal survey that found 1 in 10 Americans ages 18 and older said they were using illicit drugs or not using medications in ways that doctors intended.

The panel’s call for increased scrutiny by primary care doctors is an effort to slow the deadly use of opioids, including street fentanyl and heroin as well as prescription painkillers, perhaps the worst public health crisis in a generation. The experts hope that if front-line health professionals can detect patients’ burgeoning abuse of drugs early, they can help contain or reverse the problems.

The group’s guidelines are not binding on doctors but they carry weight: A provision in the Affordable Care Act says that services recommended by the task force must be covered by insurance with minimal or no co-payment.

The proposed new guidelines represent a major shift by the panel, which said in 2008 that it did not have sufficient evidence that screenings could helped people stop using drugs. But more recent research shows that screening can result in successful intervention, the panel said, so it is recommending that doctors or other health care providers ask patients about drug use either in brief written questionnaires or in private conversation during the office visit.

“We don’t want doctors and nurses to get hung up on one tool or another,” said Dr. Carol Mangione, an author of the proposals who is a professor of medicine and public health at the University of California Los Angeles. “Just that they do it.”

But the guidelines, which are open for public comment through Sept. 9, carry significant challenges for implementation.

Most doctors have no training in how to elicit honest answers from patients about such a stigmatizing behavior.

Additionally, medical practices must also be knowledgeable about state laws, some of which require them to report pregnant patients whom they even suspect of using illicit drugs.

And, the task force noted, screening can’t take place in a vacuum: Doctors must be able to offer referrals for further diagnosis and treatment.

Dr. Mangione, a primary care physician, said that doctors are becoming increasingly eager to learn about medication-assisted treatments for addiction, because such services can be hard to come by and require special training.

“It’s on all of us providers to understand the diagnostic and treatment sources in our communities and not to use our lack of knowledge as a reason not to treat people,” she said.

The thrust of the recommendations is directed at patients who appear asymptomatic; those in the throes of addiction will be more readily apparent. There is no upper age limit for screening, said Dr. Mangione. While some people may assume that patients struggling with substance use disorders will be younger adults, older patients need scrutiny too.

Careful screening could correct some problems, Dr. Mangione said. Since many older patients are prescribed medications from different doctors, some may be taking too many medicines for the same condition, unaware of drug interactions. And some could be sharing a friend’s pain medications.

When patients are pregnant, screening has obvious benefits and potential harms. According to the Guttmacher Institute, which researches reproductive health policy, 25 states and the District of Columbia mandate that health care professionals report suspected drug abuse by pregnant women. Reporting may not necessarily lead to criminal sanctions or the scrutiny of child protective services: Instead, a few states, including California, Connecticut and Maryland, direct these women to treatment. The task force urged providers to be aware of the implications of screening for patients, as well as understand the nuances of state mandates.

The American College of Obstetrics and Gynecology says that while screening should be part of routine prenatal care, urine drug testing itself — which is not included in the new guidelines — should be used with extreme caution, because it can be inaccurate and lead to dire consequences for mother and baby, said Dr. Mishka Terplan, an obstetrician-gynecologist and addiction medicine consultant for Virginia Medicaid.

“Those of us who work in this area are aware of how off-the-rails these cases can go,” he said.

While the task force did not recommend screening teenagers, ages 12 to 17, it did not advise against such a step either.

“We’re not telling people to screen and we’re not telling people not to screen,” Dr. Mangione said about teenagers.

The task force relies on academic research. Those researchers concluded that the few clinical trials looking at screening as an intervention for teenagers were small and largely focused on cannabis, and they did not have clear beneficial results. The panel, therefore, said it was calling for more research on adolescent screening.

Dr. Sharon Levy, an author of a policy report for the American Academy of Pediatrics that encourages such screening, found the panel’s reluctance to endorse it “unfortunate.”

Even if screenings may not reduce a patient’s drug use, she said, there are many reasons to fold in questions about substance use during routine office visits with teenagers.

“If a kid walks in with inattention, is that A.D.H.D., or marijuana or nicotine use?” said Dr. Levy, who directs a program on adolescent substance use and addiction at Boston Childrens Hospital. “Even if we could never get these screenings to work as interventions, that information is critical when we decide how to treat kids.”

Because there is so much fear and shame around substance use disorders, the way that doctors frame their screening questions will have an impact on a patient’s response, Dr. Mangione said.

Doctors must be sensitive to patients feeling singled out or discriminated against, she said. So the screening should be presented as something doctors now ask everyone on a uniform health checklist, along with questions about alcohol and tobacco use, and number of sexual partners.

“These are hard topics for patients to bring up,” she said, “but when the provider does, patients sometimes feel relieved. We tell them that we bring it up because we have treatments for it.”

And though doctors know that patients may not be candid, the questions nonetheless must be posed, she said.

“A patient may not be ready at the time we’re asking, but the fact that we ask often plants a seed for the next visit.”

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