Improve and Expand Screening and Testing for Misuse and Dependency
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.
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.
Opioid Abuse Risk Screener (OARS) was developed as a comprehensive self-administered measure of potential risk that includes a wide range of critical elements noted in the literature to be relevant to opioid risk. This 43-question assessment is administered using an iPad (tablet) and takes about 10 - 12 minutes to complete. It is HIPAA compliant, EMR supported, and has high reliability, validity and predictability scores. The assessment is instantly scored, and a report is available to the prescribing physician that provides a summary opioid risk profile and a multidimensional assessment of risk factors. The OARS also provides depression and anxiety scores that can be used for SBIRT assessments and wellness visits, including scores for the PHQ-9 and the GAD-7. All information is provided in a compressive easy to read report which clearly identifies aberrant behavior and risk factors for follow-up by the provider with the patient during the visit.
The OARS is reimbursable with an average rate of $40/screening. Providers can get reimbursed in most cases with the CPT Code 96103 or the SBIRT codes while taking important steps to identify individuals that may be at risk for opioid misuse or abuse.
InteraSolutions, the company that developed OARS, received a 2018 recipient of the State of Ohio's Opioid Science Challenge that seeks to identify and support scientific breakthroughs that help to address the opioid crisis. The OARS screening tool was recognized as one of those important breakthroughs.
WellScreen integrates technology-based screening tools with the SBIRT model.
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 .
A review of 26 studies by Cochrane in 2010 concluded that well-screened patients receiving long-term opioid treatment were at very low risk of developing an addiction (< 1%) , but it should be considered that the studies they were reviewing may have been the ones funded by pharma companies trying to prove that long-term opioid treatment was safe, and the screening they used may have contributed to fewer instances of people becoming addicted--which itself could support the benefits of effective screening in reducing the risks of people becoming addicted.
Prescriptions for this category of patients is a major contributor to the number of opioids in the U.S. (statistics and citation needed). 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 (firstname.lastname@example.org)
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.
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
Screening for Alcohol Problems in Primary Care: A Systematic Review- A review of role of Primary Care in assessing and screening for SUD. 
Evidence for Screening and Assessment Tools - Evidence based study for review of screening of alcohol use and overuse. 
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 
GuideMed - This organization utilizes a software program to develop network standards of care for people receiving long-term opioid therapy for pain management, including:
- Monitoring protocols
- Treatment recommendations
- Risk assessments