Routine Assessment of Symptoms of Substance Use Disorders in Primary Care: Prevalence and Severity of Reported Symptoms

Abstract

BACKGROUND: Most patients with substance use disorders (SUDs) never receive treatment and SUDs are underrecognized in primary care (PC) where patients can be treated or linked to treatment. Asking PC patients to directly report SUD symptoms on questionnaires might help identify SUDs but to our knowledge, this approach is previously untested. OBJECTIVE: To describe the prevalence and severity of DSM-5 SUD symptoms reported by PC patients as part of routine care. DESIGN: Cross-sectional study using secondary data. PARTICIPANTS: A total of 241,265 adult patients who visited one of 25 PC sites in an integrated health system in Washington state and had alcohol, cannabis, or other drug use screening documented in their EHRs (March 2015-July 2018) were included in main analyses if they had a positive screen for high-risk substance use defined as AUDIT-C score 7-12 points, or report of past-year daily cannabis use or any other drug use. MAIN MEASURES:The main outcome was number of SUD symptoms based on Diagnostic and Statistical Manual, 5th edition (DSM-5), reported on Symptom Checklists (0-11) for alcohol or other drugs: 2-3 mild; 4-5 moderate; 6-11 severe. RESULTS: Of screened patients, 16,776 (5.7%) reported high-risk use of alcohol (2.4%), cannabis (3.9%), and/or other drugs (1.7%), and 65.0-69.9% of those completed Symptom Checklists. Of those with high-risk alcohol use, 52.5% (95% CI 50.9-54.0%) reported ≥ 2 symptoms consistent with mild-severe alcohol use disorders. Of those reporting daily cannabis use, 29.8% (28.6-30.9%) reported ≥ 2 symptoms consistent with mild-severe SUDs. Of those reporting any other drug use, 37.5% (35.7-39.3%) reported ≥ 2 symptoms consistent with mild-severe SUDs.CONCLUSIONS AND RELEVANCE: Many PC patients who screened positive for high-risk substance use reported symptoms consistent with DSM-5 SUDs on self-report Symptom Checklists. Use of SUD Symptom Checklists could support PC providers in making SUD diagnoses and initiating discussions of substance use.

Comparison of Methods for Alcohol and Drug Screening in Primary Care Clinics

“…Many previous studies have reported the challenges of implementing substance use screening and interventions in primary care settings. 26,29,44,46,69,70 The health care systems participating in the present study have maintained screening and are now adopting our EHR-integrated screening tools systemwide, which highlights the success of their implementation. However, more research is needed regarding beneficial interventions to address moderate-risk drug use during primary care visits, strategies for motivating clinicians to engage patients in discussions of substance use, and the resources required to do so.…”

“…The screening rates at site A (89.6%-94.7%) were slightly higher than those reported in a recent pragmatic clinical trial conducted at primary care practices in Washington state. 46 The site B clinics, which specifically targeted annual examinations for screening, had lower and more variable screening rates (24.2%-72.0%). Although it is typical for primary care practices to conduct screening only during a dedicated annual physical or preventive care visit, patients may miss appointments; therefore, offering screening during any type of visit provides more opportunities to detect substance use.…”

What do clinicians want? Understanding frontline addiction treatment clinicians’ preferences and priorities to improve the design of measurement-based care technology

“…Integrating MBC with existing technology systems (e.g., electronic health records) may also be critical to limiting burdensomeness. Previous studies have shown that incorporating assessments into electronic health record systems facilitates the adoption of MBC [ 28 ] and incompatibility with record systems is often cited as a reason for implementation failure [ 29 ].…”

Prevalence of Medical Cannabis Use and Associated Health Conditions Documented in Electronic Health Records Among Primary Care Patients in Washington State

“…Kaiser Permanente Washington screens primary care patients annually for cannabis use as part of integrated mental health care. 7 , 8 Data (obtained exclusively from KPWA’s Epic EHR and insurance claims) included patient demographic characteristics, diagnoses, cannabis screen results, medication fills, and EHR free-text documentation (eg, encounter notes). This study received approval and waivers of consent and Health Insurance Portability and Accountability Act authorization from the KPWA Health Research Institute Institutional Review Board.…”