A Brief Patient Self-administered Substance Use Screening Tool for Primary Care: Two-site Validation Study of the Substance Use Brief Screen (SUBS)

Abstract

Background Substance use screening is widely encouraged in healthcare settings, but the lack of a screening approach that fits easily into clinical workflows has restricted its broad implementation. The Substance Use Brief Screen (SUBS) was developed as a brief, self-administered instrument to identify unhealthy use of tobacco, alcohol, illicit drugs, and prescription drugs. We evaluated the validity and test-retest reliability of the SUBS in adult primary care patients. Methods Adults age 18-65 were enrolled from urban safety net primary care clinics to self-administer the SUBS using touch-screen tablet computers for a test-retest reliability study (n=54) and a two-site validation study (n=586). In the test-retest reliability study, the SUBS was administered twice within a 2-week period. In the validation study, the SUBS was compared to reference standard measures, including self-reported measures and saliva drug tests. We measured test-retest reliability and diagnostic accuracy of the SUBS for detection of unhealthy use and substance use disorder for tobacco, alcohol, and drugs (illicit and prescription drug misuse). Results Test-retest reliability was good or excellent for each substance class. For detection of unhealthy use, the SUBS had sensitivity and specificity of 97.8% (95% CI 93.7 to 99.5) and 95.7% (95% CI 92.4 to 97.8), respectively, for tobacco; and 85.2% (95% CI 79.3 to 89.9) and 77.0% (95% CI 72.6 to 81.1) for alcohol. For unhealthy use of illicit or prescription drugs, sensitivity was 82.5% (95% CI 75.7 to 88.0) and specificity 91.1% (95% CI 87.9 to 93.6). With respect to identifying a substance use disorder, the SUBS had sensitivity and specificity of 100.0% (95% CI 92.7 to 100.0) and 72.1% (95% CI 67.1 to 76.8) for tobacco; 93.5% (95% CI 85.5 to 97.9) and 64.6% (95% CI 60.2 to 68.7) for alcohol; and 85.7% (95% CI 77.2 to 92.0) and 82.0% (95% CI 78.2 to 85.3) for drugs. Analyses of area under the receiver operating curve (AUC) indicated good discrimination (AUC 0.74-0.97) for all substance classes. Assistance in completing the SUBS was requested by 11% of participants. Conclusions The SUBS was feasible for self-administration and generated valid results in a diverse primary care patient population. The 4-item SUBS can be recommended for primary care settings that are seeking to implement substance use screening.

Comparison of the Substance Use Brief Screen (SUBS) to the AUDIT-C and ASSIST for detecting unhealthy alcohol and drug use in a population of hospitalized smokers

“…Two scoring cutoffs were used in our analysis of the SUBS. First we applied the standard SUBS cutoff of “never” as a negative screen and any other response as a positive screen (McNeely et al, 2015). Second, we examined the results designating a higher SUBS cutoff of “three or more days” as a positive screen, and other responses as a negative screen.…”

“…The SUBS (McNeely et al, 2015) (Fig. 1) was developed as a brief, self-administered instrument to identify unhealthy use of tobacco, alcohol, illicit drugs, and non-medical use of prescription drugs (4 total questions), and has been validated in the primary care setting (McNeely et al, 2015; National Institute on Drug Abuse, NIDA, 2016).…”

“…1) was developed as a brief, self-administered instrument to identify unhealthy use of tobacco, alcohol, illicit drugs, and non-medical use of prescription drugs (4 total questions), and has been validated in the primary care setting (McNeely et al, 2015; National Institute on Drug Abuse, NIDA, 2016). It has three response categories (Never, One or two days, Three or more days), but is designed to be dichotomized into negative and positive screening results, with any response other than ‘Never’ considered a positive screen.…”

“…The advantage for SUBS is it generally takes 1–2 min to finish compared to commonly used screening instruments that can range from 2 to 15 min to complete (Babor, Higgins-Biddle, Saunders, & Monteiro, 2001; Mdege & Lang, 2011). In a two-site study, SUBS was feasible for self-administration, and had good sensitivity and specificity for detecting past-year unhealthy use of tobacco (sensitivity of 97.8% and specificity of 95.7%), alcohol (sensitivity of 85.2% and specificity of 77.0%), and drugs (sensitivity of 82.5% and specificity of 91.1%) compared with reference standard measures including an oral fluid drug test in the primary care setting for a diverse population of adult safety-net patients (McNeely et al, 2015). …”

Primary Care Patients with Drug Use Report Chronic Pain and Self-Medicate with Alcohol and Other Drugs

“…However, other studies over the past decade have shown a wide range (3-26 %) of reported drug use in primary care. 8,9 The prevalence and severity of chronic pain and painrelated dysfunction in patients who screen positive for the full spectrum (at-risk use to substance use disorders) of drug use (Illicit, prescription misuse) in primary care is unknown. Because alcohol, 10 many illicit drugs (e.g., heroin, marijuana) and prescription opioids have analgesic properties, it is possible that patients are using these drugs to self-medicate pain.…”