Babor, Thomas F. PhD, MPH; Kadden, Ronald M. PhD
Substance use problems involve a broad spectrum of social, medical, and psychologic disabilities that affect a significant proportion of the adult and adolescent U.S. population.1 The people most visibly affected are those who have developed a syndrome of substance dependence—a psychiatric disorder characterized by impaired control over substance use, neuroadaptation (tolerance and withdrawal), and increased salience of drug seeking.2 Less prominent but far more numerous are people who excessively use psychoactive substances (illegal drugs, prescribed pain medications, and alcohol or tobacco) but who are not dependent on alcohol or drugs. Essentially, there are two “worlds” of substance use disorders. One is characterized by dependence and frequent substance-related consequences; the other is characterized by intermittent use with occasional consequences. Each requires different approaches to screening, diagnosis, and clinical management.
Before recommending that screening, early intervention, and routine treatment procedures be routinely applied in health care settings, at least four conditions should be met: the target disorder should have sufficient conceptual clarity to permit reliable measurement; the natural history of the target disorder, along with risk factors and populations at risk, should be fairly well understood; the screening test used should be reliable, valid, inexpensive, easy to administer, and acceptable to both providers and the target population; and appropriate treatments (or brief interventions) should exist so that the treatment of persons identified can be managed effectively.3,4 Furthermore, the delivery mechanism for the intervention should be feasible.
The scientific basis for these conditions is described in the remainder of this article. We conclude that the four conditions have indeed been met. By assessing the implications of our findings as they relate to the unique needs of trauma centers, we explore whether taking a public health approach to early intervention for psychoactive substance use disorders is feasible. The public health approach includes early intervention efforts designed to identify and manage populations at risk of developing substance use disorders. These efforts should be based on a careful definition of the target condition and the use of population screening procedures followed by appropriate interventions.
SCREENING APPROACHES: UNDERSTANDING THE TARGET DISORDER
Any discussion of screening for substance use disorders or risk of these disorders is complicated because a wide variety of substances can be classified as psychoactive agents. These agents include illegal drugs (i.e., crack cocaine, heroin, and marijuana); legal substances (i.e., alcohol and tobacco); and prescribed pain medications such as OxyContin that have high abuse potential.
Screening is a preliminary procedure used to determine the likelihood that an individual has a particular disease or condition or is at increased risk of developing health or social problems. Screening assesses risk factors, which can be genetic, behavioral, or environmental. Screening also helps distinguish between those who could benefit from a minimal intervention and others who may require further diagnostic assessment or possible treatment. When screening is used to identify persons at risk, it is called screening for risk factors. When the aim of screening is to identify cases that warrant a formal diagnosis, it is called case finding. The distinction between these two concepts lies in the type of intervention that follows the screening process.
Screening for Risk Factors
If the risk factors for psychoactive substance disorders can be identified early, screening efforts can focus on those who have not yet developed dependence or serious substance-related problems. The purpose of screening is either to prevent substance-related disabilities in persons at risk or to prevent further harm among those in the early stage of substance use. Initial screening may be followed by brief educational and motivational interventions designed to minimize harm and reduce substance use.
Case finding identifies those who already have a substance-related health condition or problem that warrants a formal diagnosis for treatment. Treatment is designed to prevent the progression of dependence or the onset of additional substance-related problems.
A World Health Organization memorandum5 defines hazardous use as a level of substance use likely to result in harm. In contrast, harmful use is defined as use that has already resulted in adverse mental or physical effects. This terminology provides clinicians and researchers with guidelines to identify individuals at risk who do not meet formal criteria for psychoactive substance dependence.2 Hazardous and harmful use should be the primary targets of early intervention programs. Such programs usually cost less than full-scale treatment for alcohol or drug dependence and may even preclude the need for subsequent treatment. We believe that substance use disorders can be defined with sufficient clarity to serve as targets for screening and early intervention programs. It follows that the conceptual clarity permits reliable measurement.
SUBSTANCE USE: POPULATIONS AT RISK, RISK FACTORS, AND NATURAL HISTORY
Since the l970s, school surveys have consistently shown that substance use begins and rises dramatically during early adolescence, with the risk of developing diagnosable substance dependence reaching a peak between the ages of 15 and 25.6 Substance use varies considerably according to gender, socioeconomic status, ethnic group membership, and urbanicity.7 A variety of personality factors are also involved in initiating and maintaining substance use, and some of these personality factors are related to the types of medical consequences that come to the attention of health care providers. For example, Jonah et al.8 found that college students who scored high on the personality measure sensation seeking engaged in more driving-related risky behaviors, drank more frequently, were more likely to drive after drinking, and believed they could drink more before becoming impaired.
Babor et al.9 found a strong association between sociopathy and alcohol-related trauma. Sociopathy is a general personality trait characterized by strong tendencies to seek stimulation, a diminished capacity to inhibit ongoing behavior, and an inability to learn from punishing experience. These data suggest there may be greater risk of traumatic injury among heavy drinkers and drug users who have personality characteristics associated with risk taking, sociopathy, or sensation seeking. The association of these vulnerabilities with both the early development of substance use disorders and the progression along a more severe course are important factors in screening, diagnosis, and treatment planning.
Epidemiologic research has also identified the consequences of using substances likely to be encountered in medical settings. Two general types of consequences can be distinguished. The first, short-term consequences, is associated with the effects of acute intoxication and include acute panic reactions, traumatic injuries, and changes in interpersonal behavior (e.g.. aggression). The second, long-term consequences, emerges after chronic ingestion of psychoactive substances. Long-term consequences include physical health problems and impaired psychosocial development caused by interference with important developmental tasks—such as education, emotional development, peer socialization, or identity formation.10,11 Regular use of a psychoactive substance is closely associated with the development of pharmacologic dependence and may also increase the risk of other substance use.7
Much has been learned in recent years about the natural history of substance use disorders: substance use disorders are broadly distributed throughout the population, but they are particularly prevalent among young adults. Prevalence rates are driven disproportionately by users with less severe disorders. These users are typically uninterested in or are found inappropriate for formal, specialized treatment services. Alcohol and marijuana are the most commonly used substances. The same personality factors that predispose one to substance use disorders may increase the likelihood of traumatic injuries.
These findings provide a sound empirical basis for designing screening and brief intervention programs that take into account the diverse nature of psychoactive substances and of the users themselves. Research also suggests that trauma centers and emergency departments may be particularly appropriate medical settings for early identification of psychoactive substance users because of the demographic and personal characteristics of patients encountered in these settings.
SCREENING TESTS: SELF-REPORT AND BIOLOGICAL
An important prerequisite for a public health approach to screening is the availability of one or more screening procedures that can be used with different population groups in a variety of settings. In this section, we review the current status of two types of screening procedures: self-report and biological. The primary focus is on screening tests supported by research that demonstrates acceptable sensitivity and specificity; feasibility in terms of time to administer and score; applicability to critical target populations; and appropriateness for trauma centers and emergency departments.
Alcohol screening has gained popularity in health care settings, not only because of the extent of problem drinking and its impact on health but also because of the development of new screening technologies, encouraging research, expert committee recommendations, and mandates to conduct routine alcohol screening.12,13 One of the first alcohol screening tests, the Michigan Alcoholism Screening Test (MAST),14 consists of 24 yes or no questions about the signs and symptoms of severe alcohol dependence. The MAST has been criticized because of its length, its potential for falsification, and its focus on screening for alcohol dependence rather than for early identification of risk factors. A shorter, 12-question version of MAST15 and the four-question CAGE screening test16 increase the feasibility of screening but still focus on identifying active alcohol dependence. A disguised screening test based on the patient's history of traumatic injury17 was developed to deal with the falsification problem, but this was done at the expense of sensitivity and specificity. A number of alcohol screening tests have been developed for special populations, including women18,19 and the elderly.20 The World Health Organization developed the Alcohol Use Disorders Identification Test (AUDIT),21 which focuses on both hazardous drinking and alcohol use disorders.22
Although not recommended for routine screening, several biological markers have been useful adjuncts to alcohol screening in emergency medicine and criminal justice settings: blood alcohol concentration, gamma-glutamyltransferase (a liver enzyme), and carbohydrate-deficient transferrin. Blood alcohol concentration has a short half-life and does not provide information about risk behavior other than to estimate the extent of recent drinking. Gamma-glutamyltransferase and carbohydrate-deficient transferrin have not been found to be sensitive or specific enough for use in general medical settings.23
A number of different approaches have been developed to screen for illegal drug use using self-report and biological screening tests.24–26 Given the different needs and substance use patterns of adults and adolescents, self-report screening tests have generally been designed and validated for one or the other of these populations.
Screening Tests for Adults
There are two different types of self-report screening tests for adults. The Drug Abuse Screening Test (DAST),27,28 modeled after the Michigan Alcoholism Screening Test,14 consists of 10 direct questions that yield a quantitative index of problems associated with drug use. Originally, the DAST comprised 28 questions; following an initial validation study, the number of questions was reduced to 20, and then DAST was further revised to produce a highly reliable 10-question scale.
In contrast to screening tests that ask direct questions about substance use and related problems, a second type of test has been developed to correlate or measure risk factors that suggest an actual or potential substance use disorder. One such example, the revised version of the Minnesota Multiphasic Personality Inventory (MMPI-2), contains two scales to assess alcohol and drug problems: the Addiction Acknowledgment Scale (AAS) assesses willingness to acknowledge problems with alcohol or other drugs; and the Addiction Potential Scale (APS) identifies individuals with a potential for developing alcohol or other drug problems. APS has no items that address substance use directly, whereas AAS is a collection of items that directly assess open acknowledgment of problems. Both AAS and APS have performed well in validation research.29
Screening Tests for Alcohol and Drugs—Adolescents
Until recently, there have been few adolescent-specific screening instruments. Recognizing the need for this type of comprehensive, multidimensional screening instrument, the U.S. National Institute on Drug Abuse developed the Problem-Oriented Screening Instrument for Teenagers (POSIT).30 This 139-item screening questionnaire was designed as the first stage in a sequential assessment system intended to improve the evaluation and referral of substance-involved youth. The POSIT indicates whether a problem may exist in 10 functional areas: substance use and misuse; mental health status; physical health status; aggressive behavior and delinquency; social skills; family relations; educational status; vocational status; peer relations; and leisure and recreation. After screening, a more comprehensive diagnostic assessment can be given in those areas where the POSIT indicates a potential problem. Among adolescents referred to an assessment service, McLaney et al.31 found the test reliable and valid for evaluating substance use disorders.
In contrast to the comprehensive, multidimensional screening included in the POSIT, several shorter screening instruments have been developed specifically for substance use among adolescents. The Personal Experience Screening Questionnaire (PESQ)32 is a 38-item instrument that focuses on substance use and resultant problems. The PESQ has acceptable reliability and validity in detecting individuals with different histories of substance use.33 The Substance Abuse Subtle Screening Inventory (SASSI)34 is a 78-item self-report that classifies adolescents as chemically dependent. Although designed to prevent faking by using indirect questions, the SASSI has not produced consistently accurate results.35 The Drug and Alcohol Problem (DAP) Quick Screen36 was developed for use by pediatricians. This questionnaire focuses on substance use and related behaviors. The DAP Quick Screen originally had 42 questions; it has been revised to 30 questions that yield acceptable validity data.37
Multiple Risk-Factor Screening
Despite advances in developing accurate and feasible self-report screening tests for a variety of psychoactive substances, considerably less attention has been paid to developing multiple risk-factor screening tests. Such tests would screen for a variety of health risk factors and thereby serve to embed questions about drug use in the context of a broader health survey.
Depending on the demographic characteristics of a given population and the expected prevalence rates for specific types of substance use disorders, one approach would be to “mix and match” existing screening tests. For example, Davis and Bush38 developed a screening program for female patients that focused on past-year smoking, drinking, other drug use, and psychiatric disorders. The survey contained items from a variety of standardized screening tests. This approach may be efficient for a small number of risk behaviors, but combining questions from various tests could be confusing for both patients and clinic staff because of different questioning procedures and response formats.
Another approach would be to develop a combined screening test with instructions, time frames, risk behaviors, response formats, and scoring procedures that are comprehensive, integrated, and systematic. For example, the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)39 was developed to screen for at-risk use of psychoactive substance use and related problems, such as traumatic injuries. The ASSIST screens for 11 psychoactive substances, including injection drug use. Its format provides a way of estimating the relative importance of different risk behaviors so that counseling interventions can be prioritized.
Screening for multiple substances could result in a significant provider burden. A relatively simple procedure that addresses this problem is a screening test called CAGE (a mnemonic title that refers to the four-item test) or the CAGE-AID test—the version “adapted to include drugs.” A study of primary care patients found the CAGE-AID test more sensitive, but less specific, for substance use disorders than the CAGE test.40
Biological Screening Methods
Drug screening through urinalysis, hair testing, and saliva tests is often favored because the results are more objective, although not necessarily more accurate than self-report measures.41 Currently, urinalysis is the preferred drug-screening method. Urinalysis is less invasive than blood testing, and drugs or drug metabolites tend to be present in relatively high concentrations in urine. Recently self-contained, easy-to-use urine testing kits have become available. These kits do provide rapid test results. However, information indicating the quantity, frequency, or time of drug ingestion is limited to drug use only over the previous few days. Test results also include a risk of false-positives (caused by passive drug exposure or ingestion of foodstuffs) and false-negatives (caused by the use of adulterants).
Evaluating Screening Tests
A number of important issues associated with biological and self-report screening tests must be addressed in the design of any early intervention program that is based on population screening in medical settings (e.g., trauma centers and emergency departments), as follows:
* Reliability. Most of these tests have been evaluated under research conditions, which tend to increase the likelihood of reliability (i.e., the extent to which results are consistent across time, conditions, and types of administration). However, random error is likely to reduce the accuracy of screening tests in clinical settings.
* Construct validity. Most self-report screening tests correlate well with other measures of the same construct (e.g., problem severity).
* Cost and efficiency. Self-report tests are free or inexpensive, but they require time for administration and scoring. Biological tests are more costly to use on a routine basis.41
* Cultural sensitivity and generalizability. Although research has not been extensive, there is no evidence suggesting that the reliability or validity of self-report tests varies across different ethnic groups.22,24
* Susceptibility to response bias. A self-report test can be deliberately faked or distorted by subtle influences, such as presenting oneself in a socially desirable way. Even so, self-report measures of substance use tend to be valid and reliable under most circumstances. Accuracy depends on a variety of conditions, including the social context of the data-gathering situation and the motivation, cognitive impairment status, and other personal characteristics of the respondent.42
* Target groups. Most screening tests have been designed for case finding rather than to identify risk factors for drug abuse. Although subtle or disguised screening tests may be useful in screening for risk factors, they do not appear to be sufficiently sensitive or specific for identifying active cases. Comprehensive screening tests like the POSIT and ASSIST are capable of identifying both active cases and risk factors, but they require more time to administer and score.
* Biological Tests. Problems also exist with respect to biological screening methods.41 The handling of body fluids is a major limitation, in addition to their cost, invasiveness, and lack of sensitivity.
The U.S. Preventive Health Services Task Force43 concludes there is sufficient evidence to warrant routine alcohol screening for all adult and adolescent patients in medical settings. In contrast, the Task Force concludes there is insufficient evidence to recommend for or against routine drug screening—self-report tests may be inaccurate and biological tests may be insensitive. Nevertheless, because of the prevalence of drug abuse and the resultant serious consequences, the Task Force suggests that health professionals ask questions about drugs when taking patient histories from adolescents or adults.
The fourth prerequisite of a public health approach to early intervention for substance use disorders is its potential for linkage with appropriate treatment or early intervention services. If intervention does not exist or is not feasible, why screen?
The term “intervention” includes any effort made to provide information or advice, to increase motivation to stop, to teach skills consistent with cessation of substance use, or to provide more intensive therapy. Among the least expensive interventions are brief motivational conversations between a substance user and a physician or other person with counseling skills. These interventions generally involve 1 to 3 sessions of relatively short duration, whereas brief treatment involves 3 to 15 therapy sessions by a trained provider. Brief treatment is not given detailed consideration in the section that follows. Instead, we emphasize studies of various brief interventions for alcohol and drug use disorders.
Evaluating the Effectiveness of Brief Alcohol Interventions
Bien et al. evaluated 32 controlled studies involving over 6,000 patients.44 It was concluded that the course of harmful alcohol use can be effectively altered by relatively brief interventions in primary health care or employee assistance program settings. Kahan et al. reviewed 11 trials of brief intervention, concluding that brief alcohol interventions are effective and have considerable potential to impact public health.45 Wilk et al. reviewed 12 randomized controlled trials, concluding that brief intervention in outpatient settings is a low-cost, effective preventive measure for heavy drinkers.46 Moyer et al. reviewed studies comparing brief intervention both to untreated control groups and to groups receiving more extended treatments.47 They found “further positive evidence” for the effectiveness of brief interventions, especially among patients with less severe problems. Moreover, brief interventions are shown to be a cost-effective way of reducing alcohol consumption and associated problems.48,49 In an extensive review of the literature for the U.S. Preventive Services Task Force, Whitlock et al. concluded that alcohol counseling interventions among primary care patients are feasible and potentially highly effective components of an overall public health approach to reducing alcohol misuse.50
Most of these studies have been conducted in primary care settings where the prevalence of alcohol abuse and dependence tends to be lower than that found in emergency and trauma centers. Emergency departments and trauma centers have been identified as high-yield settings for alcohol screening,51–53 but structural and attitudinal barriers may impede a systematic response in these settings. Nevertheless, a large randomized trial of brief interventions in a trauma center found that a brief motivational intervention was associated with decreased alcohol consumption and a reduced risk of trauma recidivism.54
Evaluating the Effectiveness of Drug-Disorder Interventions
In contrast to alcohol literature, and despite numerous studies of brief treatment for persons with drug dependence, there are few studies of brief interventions for hazardous drug use. The majority of published studies on brief interventions have been for marijuana use disorders. Although some studies have used behavioral or cognitive-behavioral approaches, most interventions are based on a motivational approach. Motivational Interventions (MI) typically include feedback about the relative severity of drug use compared with national norms. This type of intervention includes discussion of the negative and positive aspects of continued use and examines factors contributing to use. Behavioral interventions generally reinforce achieving and maintaining abstinence. Cognitive-behavioral interventions typically focus on identifying both the trigger situations and training in the behavioral skills needed to cope with those situations. What follows is a brief review of studies that have applied these methods in the form of brief interventions for drug use disorders.
In adults, one or two sessions of MI were found to be more efficacious than no treatment at all.55–57 In two of the studies, longer interventions had greater efficacy than one or two brief MI sessions. When combined with training in cognitive-behavioral strategies, Lang et al. found that a single assessment reduced both the quantity and frequency of marijuana use.58 However, because there was no control group, it is not possible to conclude that reductions in quantity or frequency were attributable to the intervention. In contrast, Baker et al.59 found that a single motivational session with psychiatric inpatients had only a modest impact on substance use, with marijuana use remaining at a high level throughout a 1-year follow-up period. All of these studies were conducted among adults who were chronic or heavy users of marijuana, most of whom met the diagnostic criteria for cannabis dependence.
Using two intervention groups and a control group, Baker et al.60 compared the use of a self-help booklet for amphetamine abusers to the use of interventions consisting of one MI session combined with either one or three additional sessions of cognitive-behavioral therapy. Amphetamine use fell significantly for the sample as a whole, with no observable differences between the control group and two intervention groups. At the 6-month follow-up, the two intervention groups demonstrated greater abstinence than the control group.
Cormack et al.61 studied the effect of letters sent by general practitioners to patients who were long-term benzodiazepine users. The letter significantly reduced benzodiazepine use, as compared with a control group. The addition of a monthly information sheet did not enhance the effect of the initial letter. Compared with a control group, Bashir et al.62 found that a single consultation with a general practitioner, supplemented by a self-help booklet, reduced benzodiazepine prescriptions. The reductions in benzodiazepine use did not result in psychological harm or increased consultation with a general practitioner.
Assessing the Effectiveness of Brief Interventions
Brief interventions for risky drinking and alcohol abuse are well supported in terms of their effectiveness and feasibility in primary health care and other medical settings.50 Regarding brief interventions for drug abuse, one or two brief motivational interventions are superior to providing no treatment but may be less effective than longer interventions. In general, brief motivational interventions among marijuana users appear particularly efficacious, but it is difficult to compare these results with those of other drugs because of methodological differences across studies. Based on a very small number of studies, behavioral and cognitive-behavioral brief interventions for drug-use disorders do not appear as promising as brief motivational approaches.
When assessing studies on brief interventions for drug use disorders, an important consideration is that most involve persons with diagnosed substance dependence rather than persons with patterns of nondependent but hazardous substance use. As a result, little is known about the effectiveness of brief interventions among less severe drug users. The fact that brief interventions appear to be effective for those who use marijuana heavily suggests that this approach may also be useful for those who use marijuana only casually.
THE PUBLIC HEALTH APPROACH WITH TRAUMA PATIENTS
Many trauma surgeons recognize that psychoactive substance use is a major concern in diagnosing and treating trauma patients. However, because most trauma surgeons are not familiar with effective screening tests and brief intervention techniques, progress has been slow in identifying substance-related risks.63 Given the prevalence rates of alcohol abuse and other substance use disorders in trauma centers, surgeons need an early intervention strategy that is feasible, efficient, credible, and effective in preventing future injuries. From previous experience, only a very brief screening and intervention procedure (from 10–40 minutes duration) is likely feasible in trauma settings because of time constraints and other contingencies.51
There are at least three reasons why the trauma center is an opportune setting for brief interventions. First, for many of these patients, particularly young adults and others lacking access to primary care, trauma centers and emergency departments are their only contact with the health care system. Consequently, interventions in these settings may be the only opportunity for some patients to obtain preventive services. Moreover, these are the main settings where patients are encountered during a “teachable moment” after a traumatic injury. Although primary care patients with substance use disorders have received the most research attention, trauma patients often mirror the demographic and personality characteristics of the population most at risk. This is particularly true of young male subjects who have personality traits such as sensation seeking, aggression, or sociopathy.
Second, brief interventions should be effective for many trauma patients who use psychoactive substances—particularly alcohol. The literature indicates that young adults respond as well as other age groups to brief interventions, with no evidence that effectiveness varies by type of provider or the setting where screening, brief intervention, and referral are conducted.50 As noted previously, there is greater scientific support for alcohol screening and brief intervention than for drug screening and brief intervention. Still, there is no reason why trauma patients with drug-related injuries should not also receive appropriate screening tests, brief interventions, or referrals for further evaluation. Most trauma patients who are drug users, use marijuana. This type of drug use appears to respond well to brief interventions.
Third, screening and brief interventions are likely feasible, even in busy trauma center conditions, provided that procedures are adapted to the situation so that the delivery mechanism is in place. For example, Rhodes et al.64 evaluated a computer-assisted procedure for screening and health promotion in the emergency department. They found that the majority of patients disclosed important health risk information (including problem drinking and drug use) and were more likely than a control group to remember receiving advice on what they could do to improve their health. It was concluded that computer-assisted screening could easily be used in the emergency room while patients wait for treatment as a way to promote good health and identify at-risk patients for specific interventions. Other feasibility research65 indicates that screening for alcohol and other substances can be either conducted with equal effectiveness by on-site personnel or outsourced to health educators, depending on the needs and demands of the health care provider.
Trauma centers present a unique opportunity to implement screening and brief interventions. The prevalence of substance use disorders among trauma patients is high. The elements of a public health approach are available in this medical setting and, if applied, can lead to improved prevention services for these patients. The target disorders have sufficient conceptual clarity to allow reliable measurement. Moreover, the natural history of the target disorder and the underlying risk factors and populations at risk are well understood. Existing screening tests can be implemented through trauma centers at an opportune time—when the patient's medical consequences evoke a teachable moment. Screening tests are reliable, inexpensive, and easy to administer, and brief interventions are available, effective, and feasible within the trauma environment.
We thank the Centers for Disease Control and Prevention and the Center for Substance Abuse Treatment, part of the Substance Abuse and Mental Health Services Administration (SAMHSA), for their support in the preparation of this article.
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