Improve and Expand Screening and Testing for Misuse and Dependency

 

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Introductory Paragraph

One of the keys for helping people get off the road of developing dependence and OUD is to do screening to detect the risks so that people who might be more likely to misuse are not prescribed opioids at all -- or if they are, with added precautions. In other cases, some types of screening or testing can help identify people who are in the early stages of misusing opioids so they can get the type of intervention that will be most helpful before they develop an addiction. Doing more screening and better screening should be an important part of a comprehensive strategy.

Key Information

Screening for Risk Factors can Minimize People Misusing Opioids

Prescribing physicians or other medical professionals "should evaluate for mental health issues that can make patients vulnerable to addiction, says Hilary Connery, M.D., Ph.D., assistant professor of psychiatry at Harvard Medical School. “If you ignore screening for trauma, self-harm, and suicide,” she says, “you’re missing a crucial opportunity for prevention.”

A 2016 article in Health Psychology Open states that "Comprehensive screening and risk stratification are associated with decreased costs for patients, providers, and insurers as those prescribing are able to make increasingly well-informed decisions when treatment-planning regarding what to prescribe and how to best monitor patients for safety based on individual risk profiles."

Screening tools that provide risk stratification that can aid decisions on when additional toxicology testing, such as urine drug testing (UDT) is appropriate.  

Risk Factor Screening Tools
There are a variety of risk factor screening tools that are appropriate for different scenarios.

Key Benefits of Toxicology Testing for Misuse
When done well, toxicology testing for misuse can contribute to addressing the opioid crisis in several ways:

• It provides prescribing physicians with insights to reduce or eliminate prescriptions of opioids in situations where the risk of misuse is high.
• It quickly detects if opioids are being overused so steps to stop misuse can begin earlier.
• It detects if opioids are being underused and potentially diverted to illegal use (being sold or given away) or left around for possible theft.
• It enhances accountability and discourages people from misusing or diverting opioids because such behavior will be detected

Recommended Testing for People on Chronic Opioid Therapy
Researchers estimate that 9.6–11.5 million adults, or approximately 3%–4% of the adult U.S. population, were prescribed long-term opioid therapy in 2005. 

These people on chronic opioid therapy are at significant risk for developing Opioid Use Disorder, with one review of studies showing that an average of between 3% and 19% of people on chronic opioid therapy develop an addiction. The following are recommended practices when people are on chronic opioid therapy:

• All patients should be assessed for risk factors, and then classified and stratified to optimize the testing protocols used.
• All patients on chronic opioid therapy should have a detailed treatment agreement in the form of a contract signed by both the patient and physician that clearly identifies risks and the terms under which opioids may be prescribed.
• Physicians must review PDMP data before prescribing opioids to identify possible risks or evidence of misuse or redirection.
• Drug screening (or preferably, toxicology testing) prior to the initiation of opioid therapy.
• Pill counts
• Screening to potentially make referrals to mental health providers or social service providers.

Current Status of Testing and Following Recommended Protocols
Very few (statistics and source needed) physicians follow the recommended guidelines when giving prescriptions for people on chronic opioid therapy.
Only 11 states make it mandatory for physicians to randomly test patients if they are writing multiple controlled substances prescriptions.
Carol Falkowski, CEO of Drug Abuse Dialogs emphasized the need to expand testing and screening in doctors’ offices at the 2016 Saving Lives Opioid Conference in Minneapolis.

Falkowski said that less than 5% of the referrals to treatment come from doctors’ offices, but they should be a huge source of referrals.
 

Types of Screenings

Urine Drug Testing
There are two categories of urine drug testing: screening and confirmatory.
 

Saliva Drug Screening– For multiple reasons, a saliva sample should be chosen over the more common urine sample to test for drugs present in the system. Unlike urine, saliva tests cannot be adulterated, it can be administered rapidly, it has the ability to test for many things, it shows the metabolite drug and is cost-effective in the long run. Some healthcare systems may consider cost an issue, but saliva tests are billed to the same code. 
Contact: John Cribbs (john@nodrugsneeded.com)

Biobot Labs- Biobot Labs has built a robot which analyzes human waste to determine where drugs are being abused most in a particular city or town. They analyze human waste flowing through the sewers at various points throughout the system, testing for metabolized traces of various substances to pinpoint where the highest concentrations of opioid users -- or cocaine users, alcohol users-- are located. The goal is to shift data collection and response away from overdose and death,and move it in the direction of early detection and overdose prevention.

SBIRT
Screening is the first step to recognizing whether a person may have a substance use disorder. It is important to take clinical care a step further and get everyone the help they need. See the SBIRT Program wiki page for more information. More information on Expanding SBIRT Programs

 

Relevant Research

Screening for Alcohol Problems in Primary Care: A Systematic Review- A review of role of Primary Care in assessing and screening for SUD. 

Impactful Federal, State, and Local Policies

SAFE Solutions is an ever-growing platform. Currently limited information is readily available for this section. SAFE Project is dedicated to providing communities with the most relevant and innovative materials. We will continue to regularly monitor and make updates accordingly with community input and subject matter expert collaboration. Please check back soon.

Available Tools and Resources

National Center for Substance Abuse & Child Welfare/SAMHSA- Sample Screening and Assessment Tools for Substance Use Disorders 

Promising Practices

SAFE Solutions is an ever-growing platform. Currently limited information is readily available for this section. SAFE Project is dedicated to providing communities with the most relevant and innovative materials. We will continue to regularly monitor and make updates accordingly with community input and subject matter expert collaboration. Please check back soon.