AAFP Updates Unhealthy Drug Use, OUD Screening Guidance

Academy Recommendations Differ From Those of USPSTF

July 23, 2020, 04:33 pm Michael Devitt – After carefully reviewing the U.S. Preventive Services Task Force's recently published final recommendation statement on screening for unhealthy drug use in adults and adolescents, the AAFP has reached a conclusion that differs slightly from that of the task force.

The Academy concluded that the evidence is insufficient to assess the benefits and harms of screening adolescents and adults for unhealthy drug use. This is an "I" recommendation.

That's in contrast to the USPSTF's June final recommendation statement on screening these populations for unhealthy drug use, which concluded that

for patients 18 and older, screening by asking questions about unhealthy drug use is recommended, with the stipulation that screening should be implemented when services for accurate diagnosis, effective treatment and appropriate care can be offered (a "B" recommendation); and
for adolescents 12-17, the current evidence is insufficient to assess the balance of benefits and harms of screening (an "I" statement).

Notably, the AAFP issued a separate recommendation statement on screening adults for opioid use disorder, recommending that clinicians selectively screen and refer adults 18 and older to OUD treatment after weighing the benefits and harms of screening and treatment, including those relating to health, social and legal outcomes. The Academy further recommends that screening programs should only be implemented if services for accurate diagnosis, effective treatment and psychosocial support can be offered or referred. This is a "C" recommendation.

"Practicing evidence-based medicine is a core value for family physicians, and in this case the evidence doesn't support that screening all patients for substance use disorder has a meaningful effect on their behavior or outcomes," said Alexis ("Alex") Vosooney, M.D., of West St. Paul, Minn., a member of the Academy's Commission on Health of the Public and Science. "The benefits that were seen were more evident in studies of patients who were seeking treatment rather than in the general population."

STORY HIGHLIGHTS

It's worth noting that the USPSTF's previous recommendation statement on the topic, issued in January 2008, concluded that the evidence was insufficient to assess the balance of benefits and harms associated with screening adolescents, adults and pregnant women for illicit drug use. The AAFP supported the 2008 recommendation.

Weighing the Evidence

The AAFP stated in its review that "the evidence presented by the USPSTF does not support a 'B' level recommendation" to screen adults for unhealthy drug use and cited various factors to support that conclusion, including

a lack of direct studies on the benefits or harms of screening for unhealthy drug use;
findings from a systematic review that showed psychosocial and pharmacological interventions were effective in improving opioid use outcomes in populations that actively sought treatment but were not effective in screen-detected populations;
concerns that an overreliance on indirect evidence was used to support universal screening for all unhealthy drug use, which included illicit substances and misuse of prescription medications; and
concerns about the potential for overdiagnosis and exposure to harms without beneficial interventions.

Asked to provide more detail on the Academy's concerns about overdiagnosis and exposure to harms, Vosooney explained there was not much evidence on the harms of screening, noting that the USPSTF itself identified that evidence gap as an area that required more investigation.

"Pregnant women in particular may have significant legal or social implications as a result of screening," Vosooney said.

Overall, the AAFP called for more research on the topic, as well as for a reduction in barriers such as administrative complexity that prevent patients with substance use disorders from accessing the services they need.

Regarding OUD, the AAFP noted that one of the evidence reviews the task force examined included research indicating that for patients seeking treatment for the disorder, medication-assisted therapeutic regimens that utilized opioid-agonists and naltrexone decreased the risk of relapse and increased the likelihood of treatment retention. A separate evidence review found that available screening tools have acceptable sensitivity and specificity to identify drug use and substance use disorders in primary care.

Based on those and other studies, the AAFP concluded there was a "small" benefit to screening adults for OUD, resulting in the C-level recommendation.

The Academy also offered members guidance on how to implement the recommendation.

"Readiness for treatment is a key in successful treatment of substance use disorders," the Academy wrote. "When considering implementing a screening program for OUD, clinicians must consider potential harms such as stigmatization and medicolegal consequences of labeling.

"Clinicians must be careful not to participate in punitive screening programs, be aware of applicable state and federal laws, and implement strategies to reduce stigmatization of their patients."

The AAFP emphasized that its OUD recommendation pertains to adults, including those who are pregnant, but does not apply to adolescents. Vosooney told AAFP News that the Academy does not have a separate statement on screening adolescents for OUD at this time.

Resolving Differences

Although it occurs only rarely, the recommendations of the Academy and the USPSTF are not always in complete agreement, said Vosooney.

"In situations where the recommendations from USPSTF and AAFP differ, physicians are always able to review the rationale for and evidence behind the recommendations and decide which one they will use in their practice," she said. "If patients are being screened for unhealthy drug use, clinicians should ensure that they have the appropriate resources available to care for the patient, including managing or referring for treatment and supportive care, as well as being knowledgeable about local mandated reporting laws.

"Recommendations can and should be reevaluated as new evidence emerges," Vosooney added. "We owe it to our patients to offer them evidence-based recommendations that can positively affect their health outcomes."

Additional Comments

Vosooney told AAFP News that the long-term relationships FPs build with patients put them in a unique position to establish trust and rapport, and that may make patients more comfortable disclosing substance use or related concerns.

When patients are ready to have that conversation, said Vosooney, "we want to be able to counsel them and offer resources that can support them. Take the time to find out the resources in your county and state, including assessment services, treatment centers, programs and providers who offer medication-assisted treatment.

"Being able to quickly offer resources and information to a patient, just as we can do for family planning, health care directives or other topics, helps destigmatize seeking care for substance use disorder."

Other AAFP Resources

The Academy offers myriad resources on OUD and other substance use issues. The AAFP's substance use disorders policy addresses opioids as well as alcohol and other drugs such as marijuana, while American Family Physician has published numerous articles on opioids, substance abuse, tobacco abuse and dependence and alcohol use disorders.

FPs who attend this year's virtual FMX in October can also earn CME by registering for the Substance Use track, a group of interactive sessions that will allow attendees to take a comprehensive dive into this topic. Attendees who purchase the FMX On Demand upgrade will have additional opportunities to earn CME while learning about OUD, alcohol screening, new drugs of abuse and related topics.

Be sure to visit the FMX CME Opportunities page for more information as it becomes available.