53.  Screening for Drug Abuse

RECOMMENDATION

There is insufficient evidence to recommend for or against routine screening for drug abuse with

standardized questionnaires or biologic assays. Including questions about drug use and drug-related

problems when taking a history from all adolescent and adult patients may be recommended on

other grounds (see Clinical Intervention). All pregnant women should be advised of the potential

adverse effects of drug use on the development of the fetus. Clinicians should be alert to signs and

symptoms of drug abuse in patients and refer drug abusing patients to specialized treatment

facilities where available.

Burden of Suffering

The abuse of both illicit and legal drugs remains an important medical problem in the U.S.

Although casual (i.e., occasional) use of illicit drugs declined steadily in the general population

from 1979 to 1992, drug use appears to be increasing since then, especially among teenagers and

young adults.1,2 Moreover, there has been little improvement in the numbers of persons using

drugs on a regular basis.3,4 In a 1991 survey of over 8,000 persons aged 15-54 years, 3.6%

met diagnostic criteria for drug dependence or drug abuse in the past year,5 and drug-related

emergency visits in the U.S. reached all-time highs in 1993.6 An estimated 5.5 million

Americans, half of whom are in the criminal justice system, are affected by drug abuse or

dependence.7

In a national household survey in 1993, 14% of adults ages 18-25 and 3% of those over 35

reported using illicit drugs within the last month.2 Occasional use of marijuana accounts for a

large proportion of reported drug use, but many drug users used other illicit drugs (cocaine,

heroin, phencyclidine, methaqualone, hallucinogens, etc.), legal drugs not prescribed by a

physician (e.g., amphetamines, benzodiazepines, barbiturates, and 

anabolic steroids), or inhalants (amyl and butyl nitrite, gasoline, nitrous oxide, glue, and other

solvents). An estimated 5 million Americans smoke marijuana regularly (at least once a week),

almost 500,000 use cocaine weekly, and over 500,000 used heroin or other injectable drug in

the past year.2 Others have estimated that up to 500,000 Americans are addicted to heroin and 1-

1.6 million currently use injection drugs.8 Drug use is more common among men, the

unemployed, adults who have not 

completed high school, and urban residents. The overall prevalence of drug use does not differ

greatly among white, African American, and Hispanic populations, but patterns of drug use may

differ.4

Adverse effects of drug use are greatest in heavy users and those dependent on drugs, but some can

occur from even occasional drug use. Cocaine can produce acute cardiovascular complications (e.g.,

arrhythmias, myocardial infarction, cerebral hemorrhage, and seizures), nasal and sinus disease,

and respiratory problems (when smoked).9,10 Dependence on cocaine produces diminished

motivation, psychomotor retardation, irregular sleep patterns, and other symptoms of

depression.11 "Crack," a popular and cheaper smokeable form of cocaine, is also highly addictive.

Mortality among injection drug users (IDUs) is high from overdose, suicide, violence, and medical

complications from injecting contaminated materials (e.g., human immunodeficiency virus [HIV]

infection, hepatitis, bacterial endocarditis, chronic glomerulonephritis, and pulmonary emboli);

in some cities, up to 40% of IDUs are infected with HIV.12 Although the extent of adverse effects of

marijuana use is controversial, chronic use may be associated with respiratory complications or

amotivational syndrome.13,14 In a 1991 survey, 8% of cocaine users and 21% of marijuana

users reported daily use for 2 weeks or more.15

The indirect medical and social consequences of drug use are equally important: criminal activities

related to illegal drugs take a tremendous toll in many communities, use of injection drugs and

crack are major factors in the spread of HIV infection16,17 (see Chapter 28), and drugs play a

role in many homicides, suicides, and motor vehicle injuries (see Chapters 50, 57, and 59).

Nearly half of all users of cocaine or marijuana reported having driven a car shortly after using

drugs.13,15

Drug Use During Pregnancy.  A national probability sample of 2,613 women giving birth in

1992-1993 estimated that 5.5% used some illicit drug during pregnancy: the most frequently

used drugs were marijuana (2.9%) and cocaine (1.1%).18 Anonymous urine testing of nearly

30,000 women giving birth in California in 1992 detected illicit drugs in 5.2%: marijuana

(1.9%), opiates (1.5%), and cocaine (1.1%) were the most frequently detected substances.19

Prevalence of drug use is generally higher among mothers who smoke or drink, are unmarried,

are not working, have public or no insurance, live in urban areas, or receive late or no prenatal

care.18-20 Anonymous urine testing detected cocaine use in 7-15% of pregnant women from

high-risk, urban communities21,22 and in 0.2-1.5% of mothers in private clinics and rural

areas.23,24 The most important forms of substance abuse during pregnancy are the use of alcohol

and tobacco, however (see Chapters 52 and 54).25

Drug use during pregnancy has been associated with a variety of adverse outcomes, but problems

associated with drug use (e.g., use of alcohol or cigarettes, poverty, poor nutrition, and inadequate

prenatal care) may be more important than the direct effects of drugs.26,27 Regular use of

cocaine and opiates is associated with poor weight gain among pregnant women, impaired fetal

growth, and increased risk of premature birth; cocaine appears to increase the risk of abruptio

placentae.28 The effects of social use of cocaine in the first trimester are uncertain.29,30 Cocaine

has been blamed for some congenital defects,27 but the teratogenic potential of cocaine has not

been definitively established. Infants exposed to drugs in utero may exhibit withdrawal symptoms

due to opiates, or increased tremors, hyperexcitability, and hypertonicity due to cocaine.27,31

Possible long-term neurologic effects of drug exposure are difficult to separate from the effects of

other factors that influence development among disadvantaged children.27,32,33 The effects of

marijuana on the fetus remain controversial.34-36

Drug Use in Children and Adolescents.  Drug use and abuse remain important problems among

adolescents.37 After more than 10 years of decreasing trends, drug use among high school students

increased in 1993 and 1994.1,38 Use of illicit drugs may interfere with school, increase the

risk of injuries, contribute to unsafe sex, and progress to more harmful drug use. Among high

school seniors in 1994, 22% reported using an illicit drug in the past month: marijuana (19%),

stimulants (4%), inhalants (3%), and hallucinogens (3%) were more common than cocaine

(1.5%) or heroin (0.3%).1 Abuse of inhalants is a leading drug problem in younger adolescents1

and can cause asphyxiation or neurologic damage with chronic abuse.39 Abuse of anabolic steroids

in adolescent boys and young men can cause psychiatric symptoms and has been associated with

hepatic, endocrine, and cardiovascular problems.

Accuracy of Screening Tests

The diagnostic standard for drug abuse and dependence is the careful diagnostic interview.40

Important information from the patient history includes the quantity, frequency, and pattern of

drug use; adverse effects of drugs on work, health, and social relationships; and any symptoms of

dependence.41 Clinicians often have trouble accurately identifying drug use and drug abuse among

their patients in routine clinical encounters, however. Time may be too limited to take a careful

history, some patients may not acknowledge drug problems due to denial, and many others are

reluctant to admit to using drugs, for fear of discrimination by health care providers or concerns

about confidentiality. It is common for adolescents to distrust authority figures such as clinicians,

and young persons may be especially concerned about their drug use becoming known to family

members, school officials, or the police.42

There are few data to determine whether or not the use of standardized screening questionnaires

can increase the detection of potential drug problems among patients. Brief alcohol screening

instruments such as the CAGE or MAST (see Chapter 52) can be modified to assess the

consequences of drug use in a standardized manner,41,43 but these instruments have not been

compared to routine history or clinician assessment. Questionnaires which include items about

personal problems, outlook, and high-risk behaviors can identify adolescents at increased risk for

drug use, but they have not been validated in prospective studies.44 Other instruments such as the

Addiction Severity Index45 are useful for evaluating treatment needs but are too long for

screening.

Toxicologic tests can provide objective evidence of drug use. The most common tests employ

radioimmunoassays (RIA), enzymatic immunoassay (EIA), fluorescence polarization immunoassay

(FPI), or thin-layer chromatography (TLC) to measure concentrations of specific drugs and their

metabolites in urine specimens.46 Sensitivity of these tests is generally above 99% compared

with reference standards;47 sensitivity for detecting drug use in individuals, however, depends

directly on timing of drug use and the urinary excretion of drug metabolites. Marijuana may be

detected for up to 14 days after repeated use, but evidence of cocaine, opiates, amphetamines, and

barbiturates is present for only 2-4 days after use. Various techniques may be employed by drug

users who wish to avoid detection that further reduce the sensitivity of urine testing: water

loading, diuretic use, ingestion of interfering substances, or adulterating urine samples. Most

importantly, toxicologic tests do not distinguish between occasional users and individuals who are

dependent on or otherwise impaired by drug use.

False-positive results from urine drug screening are possible due to cross-reaction with other

medications or naturally occurring compounds in foods.48 To prevent falsely implicating persons

as users of illegal drugs, screen-positive samples are usually confirmed with more specific (and

expensive) techniques such as gas chromatography-mass spectroscopy (GC-MS). These

procedures reduce, but do not eliminate, the possibility of false-positive results due to

cross-reactions, contamination, or mislabeled specimens. Proficiency testing of nearly 1,500

urine specimens sent to 31 U.S. laboratories produced no false-positive results and 3%

false-negative results.49 A similar study of 120 clinical laboratories in the U.K. demonstrated

higher error rates (4% false-positive, 8% false-negative), largely due to laboratories that did

not use confirmatory tests.50

Screening Pregnant Women and Newborn Infants.  A careful history taken by trusted clinicians

remains the most sensitive means of detecting drug use and abuse,51,52 but many pregnant

women conceal use of illicit drugs, since it may provide grounds for action by child welfare

agencies. Clinicians often selectively screen for drug use, based on preconceptions of the typical

drug-using mother. Studies using sensitive toxicologic tests suggest that only one in four pregnant

women who have used opiates, cocaine, or marijuana are identified as drug users in the medical

record.51 Patient history identified only 40-60% of pregnant women with urine tests positive

for illicit drugs.21,53 Detection of drug use is increased by use of a standard protocol for

assessing drug use in patients, rather than screening based on the discretion of the

clinician.54,55

Testing of newborn specimens can identify infants exposed to drugs in utero. Assays of infant urine

are most common but are not sensitive for drug use early in pregnancy. Among mothers admitting

drug use during pregnancy, RIA of infant urine had a sensitivity of 52%, versus 88% for RIA of

meconium.51 Among 39 women who used cocaine, RIA of infant hair was more sensitive (78%)

than RIA of infant urine (38%) or meconium (52%).52 These more sensitive tests are not widely

available, however, and have not yet been sufficiently validated for screening purposes.56

Moreover, clinical history may be more useful than toxicologic testing for identifying newborns at

risk: among drug-exposed infants identified by meconium testing, adverse outcomes were limited

to infants born to mothers who admitted to drug use.51

Adverse Effects of Screening.  Drug testing is frequently performed without informed consent in

the clinical setting on the grounds that it is a diagnostic test intended to improve the care of the

patient. Because of the significance of a positive drug screen for the patient, however, the rights of

patients to autonomy and privacy have important implications for screening of asymptomatic

persons.57 If confidentiality is not ensured, test results may affect a patient's employment,

insurance coverage, or personal relationships.58 Testing during pregnancy is especially

problematic, because clinicians may be required by state laws to report evidence of potentially

harmful drug or alcohol use in pregnant patients.

Effectiveness of Early Detection

Early intervention has the potential to avert some of the serious consequences of drug abuse,

including injuries, legal problems, and medical complications. Although various treatments have

been proven effective in drug-dependent patients (see below), they have largely been studied in

patients who have already developed medical, social, or legal problems due to their drug use. There

is much less evidence that systematic screening and earlier intervention is effective in improving

clinical outcomes among asymptomatic persons, who may be less motivated to undergo treatment

than more severely impaired drug users.

The evidence supporting the effectiveness of treatment for drug abuse and dependence was reviewed

in 1990 by the Institute of Medicine.7 The most consistent evidence supports the clinical benefits

of methadone maintenance in persons addicted to heroin. Several studies, including two randomized

controlled trials, have shown that heroin addicts who remain in methadone maintenance programs

have reduced heroin consumption, lower rates of HIV infection, decreased criminality and

unemployment, and lower mortality than subjects who are not treated or treated for only short

periods.7,59 Over the short term, methadone treatment is associated with a 95% reduction in

self-reported heroin use and a 57-68% reduction in self-reported cocaine use,60 but some

persons switch from heroin to other drugs while on treatment.61 Moreover, results may be biased

due to reliance on patient self-report and loss to follow-up of patients who drop out of

treatment.62

Drug abusers are frequently enrolled in residential treatment programs, often as part of a court

order related to drug offenses. Patients entering such programs experience lower rates of drug

use, imprisonment, and unemployment than drug users who do not enroll.7 Longer programs seem

to be more effective than short (<3 months) programs.63 However, attrition rates from

residential programs can reach 75%,64 and selection bias may contribute to the improved

outcomes in subjects who complete programs.65 Less intensive outpatient programs also seem to

be effective for drug users, but the wide variation in interventions used limits the conclusions

that can be drawn. Attrition is highest in outpatient, nonresidential programs.7 There are fewer

data on long-term (>1 year) outcomes  of drug treatment; recidivism is high and many patients

suffer from other problems (psychiatric disorders, unemployment, homelessness) which

reinforce drug use and are often not addressed by drug treatment.7

Treatment of adolescent substance abusers has been recently reviewed for nearly 1,500

primarily middle-class adolescents aged 12-19 years who entered inpatient or residential

treatment programs.66 Compared to use before treatment, there was a significant reduction in

regular drug use (weekly or more) 1 year after treatment (85% vs. 29%), and 50% of teens had

been abstinent for 6 months. Increasing parental participation in treatment was associated with

greater levels of abstinence. High school primary prevention programs which emphasize "life

skills" have reduced tobacco or alcohol use over the short term (1 year),67 but long-term effects

on illicit drug use have not been well studied. In a 6-year randomized trial among 3,597 high

school students, a prevention curriculum delivered in grades 7-9 significantly reduced smoking

and alcohol use, but not marijuana use, in high school seniors; a subgroup of students who received

a more complete intervention were less likely to use marijuana regularly (5% vs. 9%).68

Treatment of Pregnant Drug Abusers. There are few controlled trials of interventions for pregnant

women who use illicit drugs. Women who use crack and other forms of cocaine account for the

largest group of pregnancies at risk from illicit drugs, but optimal treatment for cocaine users is

uncertain. In two observational studies, risk of low birth weight decreased substantially with

increasing number of prenatal visits.69,70 Women who reduced use of cocaine during pregnancy,

or used cocaine infrequently, had outcomes similar to nonusers in several studies.30,34

Methadone maintenance is the usual treatment for pregnant women addicted to opiates: withdrawal

during pregnancy is dangerous, and the regular contact required for methadone treatment may

encourage women to receive regular prenatal care.27 Methadone can be safely withdrawn after

delivery but it prolongs withdrawal in the infant. Because the most seriously impaired drug users

often present late for care, if at all, options for improving the course of drug-exposed pregnancies

are often limited.

Recommendations of Other Groups

The American Medical Association (AMA)71 and the American Academy of Family Physicians

(AAFP)72 advise physicians to include an in-depth history of substance abuse as part of a

complete health examination for all patients. The AAFP,72 AMA Guidelines for Adolescent

Preventive Services (GAPS),73 Bright Futures recommendations,74 and American Academy of

Pediatrics75,76 suggest that clinicians discuss the dangers of drug use with all children and

adolescents and include questions about substance abuse as a part of routine adolescent visits. The

American College of Obstetricians and Gynecologists recommends that clinicians take a thorough

history of substance use and abuse in all obstetric patients, and remain alert to signs of substance

abuse in all women.77,78

The AMA supports drug testing (in conjunction with rehabilitation and treatment) as part of

preemployment examinations for jobs affecting the health and safety of others.71 The AMA and

most other medical organizations endorse urine testing when there is reasonable suspicion of

substance abuse, but none of these groups recommends routine drug screening in the absence of

clinical indications.

Discussion

Many Americans face substantial health risks from illicit drugs and the nonmedical use of other

drugs, but questions remain about appropriate methods for screening for drug abuse among

asymptomatic patients. The routine use of screening instruments or laboratory tests has not yet

been proven effective in reducing harmful drug use. Nonetheless, information about drug use is an

important component of the medical interview, especially for adolescents and young adults, and a

careful history remains the best way to identify those who need treatment. Despite frequent

treatment failures, the medical and social benefits of treating drug abuse are substantial for

patients who achieve long-term abstinence. Reducing drug use is also likely to have important

benefits to society in reducing criminal activity and the spread of HIV.7

Urine testing is sensitive and specific for recent drug use but has many limitations as a routine

screening test: it does not distinguish occasional use from drug abuse or dependence; sensitivity

and specificity vary with timing of drug use; and the effectiveness of early intervention has not

been examined in asymptomatic drug users detected by toxicologic screening.79 Routine screening

in asymptomatic individuals also poses important risks: testing without informed consent may

violate patient autonomy; the predictive value of positive test results may be low in populations

with a low prevalence of drug use; and patients may be discriminated against if confidentiality of

results is not ensured.

Efforts to screen for drug use in pregnancy have been prompted by concern about the adverse

effects on the developing fetus, the impact of parental drug use on child safety and welfare, and the

realization that many drug-using mothers go undetected by routine patient history. Use of

standardized clinical assessment in all pregnant women can increase the identification of drug use,

but there is little evidence that routine urine screening in asymptomatic women reduces drug use

during pregnancy or results in better perinatal outcomes. Treatment services for pregnant,

drug-abusing women are often scarce, testing may not identify those pregnancies at highest risk,

and positive tests have direct legal and social consequences for the mother and child.80 Where

clinicians must report drug use in pregnancy, routine testing may lead some women to avoid

needed prenatal care.

CLINICAL INTERVENTION

There is insufficient evidence to recommend for or against routine screening for drug abuse with

standardized questionnaires or biologic assays ("C" recommendation). Including questions about

drug use when taking a history from adolescent and adult patients may be recommended on other

grounds, including the prevalence of drug use and the serious consequences of drug abuse and

dependence. Clinicians should be alert to signs and symptoms of drug abuse and ask about the use of

illicit drugs and legal drugs of abuse (e.g., sedatives, stimulants); use of inhalants should be

considered in older children, adolescents, and young adults. The quantity, frequency, patterns of

consumption, and adverse consequences of drug use (e.g., interference with school or work,

evidence of dependence) should be assessed for all patients who report drug use. Clinicians should

establish a trusting relationship with patients, approach discussion of drug use in a nonjudgmental

manner, and respect the patient's concerns about the confidentiality of disclosed information.

All pregnant women should be advised about the potential risks to the fetus of drug use during

pregnancy and the potential to transmit drugs to infants through breastfeeding. Routine drug

testing of urine or other body fluids is not recommended as the primary method of detecting drug

use in pregnant women or other asymptomatic adults. Selective use of urine testing during

pregnancy may be appropriate when the possibility of drug use is suggested by clinical signs and

symptoms (e.g., growth retardation, inadequate weight gain, inadequate prenatal care); periodic

testing can also help monitor and encourage abstinence in women who have used drugs. Pregnant

women who abuse drugs should be advised of the importance of regular prenatal care and be

referred for treatment, where available.

Patients should give consent prior to drug testing and be informed of any legal obligations on the

part of the clinician to report drug use to child protective agencies or other authorities. Both

positive and negative results should be interpreted with understanding of the kinetics of drug

metabolism and the limitations of testing methods, and positive screening tests should be

confirmed by more reliable methods.

All patients who report potentially harmful use of drugs should be informed of the risks associated

with their drug use and advised to cut down or stop. Decisions about treatment should be based on

evidence of drug abuse or drug dependence obtained through careful patient interview, including

discussion with friends or family members where appropriate. A treatment plan should be

developed for the patient and family that is tailored to the drug of abuse and the needs of the

patient. Patients with evidence of drug dependence should be referred to appropriate

drug-treatment providers and community programs specializing in the treatment of drug

dependencies. Persons who continue to inject drugs should be screened periodically for HIV

infection and advised of measures that may reduce the risk of infections due to drug use: use a new

sterile syringe with each use, never share or re-use injection equipment, use clean (sterile, if

possible) water to prepare drugs, clean the injection site with alcohol prior to injection, and

safely dispose of syringes after use (see Chapters 28 and 62). Drug-using patients should be

informed of available resources for sterile injection equipment.

The draft update of this chapter was prepared for the U.S. Preventive Services Task Force by David

Atkins, MD, MPH.

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