Grade: I recommendation
The AAFP concludes that the evidence is insufficient to assess the benefits and harms for screening adolescents and adults for unhealthy drug use. This statement does not include screening for opioid use disorder.
The AAFP emphasizes the importance of early diagnosis, treatment, and referral of individuals with substance use disorder (SUD). The AAFP recognizes that SUDs are complex health issues that have significant impacts on individuals, families, and communities. Family physicians play a key role in the diagnosis, treatment, and prevention of substance use disorders. The AAFP strongly urges its members to be knowledgeable of and utilize evidence-based strategies to diagnose and treat substance use disorders in the primary care setting.
The AAFP has reviewed the United States Preventive Services Task Force’s (USPSTF) recommendation on unhealthy drug use screening for adolescents and adults. Screening in this setting refers to asking patients who are asymptomatic questions about unhealthy use of illegal drugs and the nonmedical use of prescription psychoactive medications. The AAFP agrees with the USPSTF that there is insufficient evidence to assess the balance of benefits and harms for screening of unhealthy drug use in adolescents. However, the AAFP disagrees with the USPSTF regarding screening for unhealthy drug use in adults age 18 years or older and has found that the evidence presented by the USPSTF does not support a "B" level recommendation. The AAFP has issued a separate recommendation for screening for opioid use disorder.
The primary evidence report utilized by the USPSTF found that screening tools have acceptable sensitivity and specificity to identify drug use and substance use disorders in primary care.1There were no direct studies on the benefits or harms of screening for unhealthy drug use. Further, a second systematic review showed that psychosocial interventions and pharmacotherapy were only effective at improving opioid use outcomes for treatment-seeking populations, but not effective in screen detected populations.
The AAFP has concerns that there is an overreliance on indirect evidence to support the universal screening for all substance use, particularly on the use of medication assisted treatment (MAT) for opioid use disorders. The studies included evaluated the use of medication assisted therapies in treatment seeking populations, predominantly recruited from inpatient settings, drug treatment programs, and the criminal justice system. MAT for opioid use disorders is effective at reducing drug use, reducing risk of relapse, and increasing the likelihood of retention in treatment.2 Substance use disorders are a heterogenous group of disorders and evidence for treatment outcomes with one substance use disorder may not be generalizable to all substance use disorders.
Many individuals who screen positive for substance use may not have a substance use disorder. The AAFP is concerned about the potential for overdiagnosis and exposure to harms without beneficial interventions. Harms include stigmatization and medicolegal consequences of labeling patients, particularly those who are pregnant. The AAFP issues a strong call for more research on this topic, in addition to the reduction of administrative complexity and other barriers faced by patients to access treatment for unhealthy drug use.
Screening programs should only be implemented if services for accurate diagnosis, effective treatment, and psychosocial supports can be offered or referred.
These guidelines are provided only as assistance for physicians making clinical decisions regarding the care of their patients. As such, they cannot substitute the individual judgment brought to each clinical situation by the patient’s family physician. As with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations. These guidelines are only one element in the complex process of improving the health of America. To be effective, the guidelines must be implemented.