Primary care clinicians should screen all adults for illicit drug use, including nonmedical prescription drug use, according to a draft recommendation from the U.S. Preventive Services Task Force (USPSTF).1
“If everyone is asked, it means we start to destigmatize illicit drug use,” says USPSTF Vice Chair Karina Davidson, PhD, MASc. “We found substantial new evidence that showed that many more patient-reported adult screening measures had been validated and found to be accurate.”
Also, more behavioral counseling and treatment services showed evidence of benefit. “We are really encouraging clinicians to first understand the needs of their patient population and connect the patients with services,” Davidson explains.
Clinicians are encouraged to consider the recommendations in light of what they know about each patient. “That always has to be prioritized,” Davidson stresses.
Nevertheless, at this point, illicit drug use is one of the most common causes of preventable injuries and death. “There are many patients out there who could be helped if the conversation is started by their clinician,” Davidson offers.
There’s no question that screening for illicit drug use among all adult patients “is the right thing to do,” argues Lydia Dugdale, MD, MAR (ethics), associate director of clinical ethics at Columbia University Medical Center. As a primary care doctor, Dugdale has been screening her patients for illicit drug use for decades. “There exists within medical training a long tradition of screening for a variety of factors that can affect a patient’s health,” Dugdale observes.
To complete the “social history” component of a patient’s history of present illness, medical students are trained to ask patients about their occupation, sexual practices, smoking, drinking, and drug use. “All of these items and more have potential to cause health problems,” Dugdale says.
No harm can result from this kind of screening, Dugdale adds. In fact, it may identify large numbers of people who could benefit from interventions to decrease drug use or identify and treat conditions such as hepatitis C that may result from illicit drug use.
“Working toward the good of our patients and toward eliminating harm to our patients are ethical principles at the core of patient care,” Dugdale says.
However, there remains an important caveat for primary care doctors, according to Dugdale. It is not uncommon for primary care doctors to have only 10 or 20 minutes to address a patient’s medical concerns. What happens if a patient screens positive for illicit drug use, but a doctor (for whatever reason) fails to address it? “Here, we have the possibility of inadvertently harming our patients through an act of omission,” Dugdale says.
The USPSTF recommendation specifies that screening should be implemented when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred. Dugdale says primary care practices are morally obligated to help patients when substance use disorders are identified. Some practices employ social workers or mental health practitioners who follow up with patients.
“Primary care doctors carry a tremendous burden of responsibility for all of a patient’s general medical concerns, from substance use to diabetes to marriage problems and everything in between,” Dugdale notes.
It is not uncommon for patients to withhold or underreport sensitive information. Often, time constraints demand that doctors must focus on the pressing issue of the day (such as dangerously high blood pressure) and put off other issues (such as a substance use problem) until they become problematic.
“This is the unfortunate reality of how the American healthcare system has chosen to value and, thus, pay for primary care,” Dugdale observes. “There is simply never enough time with patients.”