Gaps in Screening Recommendations Must Be Addressed to Protect Youth and Adults from Substance Use-Related Harm.

Background: In June 2020, the U.S. Preventive Services Task Force (USPSTF) issued a final recommendation on screening for unhealthy drug use in adults and adolescents. It assigned a "B" rating on a recommendation for screening in primary care for adults when services for accurate diagnosis, effective treatment, and appropriate care can be provided or referred, but declined to recommend the same for adolescents, concluding that current evidence is insufficient to assess the balance of benefits and harms. Objectives: To examine and provide recommendations to address gaps in the USP ST recommendation on screening for unhealthy drug use. Results: The lack of recommendation to screen adolescents represents a critical gap and highlights the need for research on adolescent substance use screening. While research is limited, available evidence shows short-term benefits from youth screening and early intervention and no evidence of harm. The lack of recommendation for youth leaves practitioners without guidance and incentive to intervene with youth who use substances, discourages expansion/support of youth screening, and reinforces treatment barriers. The statement also lacks guidance to address barriers to implementing screening in adults. Despite promotion of the practice, implementation in primary care is sporadic. Providers should be made aware of implementation barriers and the clinical guides and training available to facilitate implementation. Conclusions/Importance: Screening and intervention are vital for addressing the addiction crisis, and USPSTF recommendations are critical for making preventive health care services accessible and affordable. These gaps must be addressed for the recommendation statement to reach its full life-saving potential.

Keywords: Substance use disorder; drug use; adolescent; screening; early intervention; U.S. Preventive Services Task Force; prevention; addiction; implementation

The U.S. Preventive Services Task Force (USPSTF) is an independent, volunteer panel of national experts in prevention and primary care that makes evidence-based recommendations about clinical preventive services. The USPSTF assigns each recommendation a letter grade (A, B, C, or D, or an I statement) based on the strength of the evidence and the balance of the benefits and harms of a preventive service. The Affordable Care Act (ACA) requires health plans to cover preventive services that receive an "A" or "B" rating from the USPSTF without cost-sharing, meaning they are free to most patients who have health insurance (Public Health Service Act, [23]).

In June 2020, the USPSTF issued a final recommendation statement on screening for unhealthy drug use for adults and adolescents (United States Preventive Services Task Force, [25]). It determined that the existing research on screening adults for unhealthy drug use demonstrates a moderate net benefit and limited evidence of harm. At the same time, the USPSTF concluded that current evidence is insufficient to assess the balance of benefits and harms of screening for unhealthy drug use in adolescents. Therefore, it assigned a "B" rating on a recommendation for screening in primary care for unhealthy drug use in adults age 18 or older, including pregnant women, "when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred," but declined to recommend the same screening for adolescents.

Screening and intervention are critical tools to help effectively address our nation's addiction crisis. Unfortunately, gaps in the USPSTF's recommendation statement limit the potential impact on both screening for substance misuse and reducing the negative consequences of drug use in both adolescents and adults. First, the recommendation statement does not adequately address barriers and practice considerations necessary for health care providers to properly implement the recommendation to screen adults for unhealthy drug use. Second, the USPSTF allowed lack of research to dictate its decision not to recommend screening among adolescents rather than weigh the admittedly limited available evidence that screening can benefit at-risk youth against the evidence showing no harm.

The implementation section of the recommendation statement offers an incomplete discussion of barriers and resources to assist providers with implementation. Implementation of screening for substance use by primary care providers is sporadic at best, despite state and federal government promotion of the practice, availability of numerous implementation and clinical guides, and widespread training efforts (McNeely et al., [12]). Even when health care settings offer screening procedures, many factors limit the number of patients screened or contribute to disparities in those who are screened (Bachhuber et al., [2]; O'Grady et al., [19]). Barriers to screening include: competing priorities for providers, including the need to focus on more medically urgent issues; inadequate referral sources; time constraints; staff turnover; stigma and negative provider attitudes; lack of training and provider discomfort addressing substance use problems; lack of standardized screening tools; difficulties incorporating a new practice into existing clinical systems; lack of organizational or leadership support; cost and reimbursement issues; and limited knowledge and resources to support implementation (Bachhuber et al., [2]; O'Grady et al., [19]; Vendetti et al., [26]).

While studies have found that formal training is effective at facilitating use of screening as well as brief intervention, additional efforts are needed for screening to become routine practice (McNeely et al., [12]; Vendetti et al., [26]). Providers and health systems will need to make a number of changes to support implementation of screening, including integrating screening tools into electronic health records, having clear staff roles and protocols, carefully building screening and resulting clinical practices into the practice workflow, gaining leadership and organizational support, having practice champions to promote screening, and holding ongoing staff training.

Our organization has created a number of tools and resources to facilitate implementation. In partnership with Northwell Health, New York State's largest health care provider, we created the Screening and Brief Intervention and Referral to Treatment (SBIRT) for Health Professionals app to provide a standardized and streamlined set of questions for providers to use with patients to identify problematic substance use, guide providers in conversations with patients about their readiness to make lifestyle changes and set goals, and support providers in discussions with patients about treatment referral (Center on Addiction and Northwell Health, [4]; Center on Addiction and Northwell Health, [5]; Northwell Health, [16]; O'Grady et al., [18]). We encourage the use of practice change methods to effectively implement screening and to monitor its success, and we have created an implementation manual to assist practitioners (National Center on Addiction and Substance Abuse at Columbia University, [14]).

While there are additional barriers unique to adolescents, such as sensitivities about how to include parents while maintaining confidentiality, many of the same implementation barriers that limit screening for adults also apply to adolescent screening (Derges et al., [6]; Palmer et al., [21]). There are tools and resources designed specifically for implementing adolescent screening (see Addiction Technology Transfer Center Network, [1]). For example, both the American Academy of Pediatrics and National Institute on Alcohol Abuse and Alcoholism offer guidance on these practices for physicians, and medical residency programs have begun to provide formal training in screening adolescents in pediatric care. Moreover, emerging models for screening adolescents offer proactive, assertive, and family-focused strategies for addressing the clinical needs of adolescents with substance use problems that are otherwise likely to go unnoticed during routine pediatric encounters (Ozechowski et al., [20]). Comprehensive, developmentally-informed identification and intervention engagement strategies for adolescents at risk for substance use disorder (SUD) are essential for meaningfully reducing the gap between those who need intervention services and those who receive them.

The USPSTF recommendation statement should provide a comprehensive explanation of implementation barriers as well as tools and resources to assist providers with overcoming those barriers and implementing effective screening protocols.

Preventing youth substance use and intervening early with those who use are key to reducing the many consequences of risky substance use, including addiction. As documented consistently in the literature on neurodevelopment of adolescent risky behavior (for a summary, see National Center on Addiction and Substance Abuse at Columbia University, [13]), adolescence is the critical period both for starting to smoke, drink, and use other drugs and for experiencing more harmful consequences as a result. Because it is still developing, the teen brain is primed to take risks, including experimenting with these substances, and is more vulnerable to the negative impact of addictive substances, further impairing judgment, interfering with brain development, and increasing the risk of addiction. Alcohol and other drugs are associated with the three leading causes of death among adolescents—accidents, homicides, and suicides. Young people who use nicotine, alcohol, and other drugs are at significantly increased risk of addiction, and the earlier a person initiates substance use, the greater the lifetime likelihood of developing this disease. Nine out of 10 people with a substance use disorder began using an addictive substance before age 18.

Despite the reasonable assumption that screening can benefit youth at risk, the USPSTF concluded that there is insufficient evidence to assess the balance of benefits and harms of screening for unhealthy drug use in adolescents. Although research supporting screening for drug use among youth continues to be limited, there is virtually no research that points to the harms of these practices. The available evidence does show short-term benefits from youth screening and early intervention and no evidence of harm (O'Connor et al., [17]; Patnode et al., [22]).

Youth screening, combined with brief intervention, has been studied in a variety of settings, including schools, primary care settings, and emergency departments. This research has yielded some positive results in terms of reducing alcohol and drug use and related consequences (Bernstein et al., [3]; Gibson et al., [7]; Knight et al., [9]; Maslowsky et al., [11]; Spirito et al., [24]). Furthermore, the USPSTF's systematic review highlights short-term benefits (at one to three months) of screening youth for drug use. The USPSTF review also highlights that school-based interventions to prevent illicit and nonmedical drug use have been effective in reducing illicit drug use and could be implemented in health care settings. Scientific reviews of screening and brief interventions acknowledge the enormous potential benefits of these practices for adolescents, and several major behavioral health organizations, including the American Academy of Pediatrics, American Medical Association, National Institute on Alcohol Abuse and Alcoholism, National Institute on Drug Abuse, and the Substance Abuse and Mental Health Services Administration, have championed its use among this population (Ozechowski et al., [20]).

The USPSTF cites concern that adolescents may be harmed by labeling and stigma associated with screening. This is not supported by research; to the contrary, research shows that training in SBIRT helps to reduce stigma among health care providers against patients with SUD (Mahmoud et al., [10]). Screenings also help to normalize conversations about substance use between adolescents and their providers (National Institute on Drug Abuse (NIDA), [15]). Existing research on screening youth shows no evidence of harm. The USPSTF should promote screening among adolescents to encourage health professionals to address substance use as a preventable and treatable health condition and a health concern within their professional purview to address.

Excluding adolescents from the screening recommendation statement, and also failing to recommend interventions to prevent SUD in this critical population, leaves practitioners without the guidance and incentive to intervene with youth who engage in substance use. It may further discourage the expansion and support of youth screening and reinforce barriers to needed services and treatment. The USPSTF should revisit the growing body of evidence soon to examine emerging research and highlight the benefits and lack of harm of youth screening currently demonstrated by existing evidence, as well as screening tools and brief intervention approaches that have shown promising results.

The obstacle to allowing the USPSTF to recommend these practices is not evidence against their use, but rather an insufficient base of valid studies to support their use. Therefore, researchers must step up their efforts to conduct efficacy and effectiveness studies of SBIRT in adolescents, and funders need to prioritize this type of research to help ensure that it is conducted. We desperately need research examining the nuances around the effectiveness of SBIRT for youth, such as for which sub-populations and under what conditions the model works best. Numerous screening tools (e.g. ASSIST, CRAFFT, and PESQ-PS) have been developed and established as powerful indicators of current and future problematic substance use. There are also evidence-based interventions for adolescent substance use that should be made accessible to youth who screen positive and their families (Hogue et al., [8]). Primary care practitioners should be encouraged to use these promising intervention practices to facilitate development of a stronger evidence base.

Recommendations from the USPSTF are critical for making preventive health care services more accessible and affordable. If properly implemented, the USPSTF recommendation to screen adults for unhealthy drug use will reduce morbidity and mortality as more people are properly screened for substance misuse and connected with appropriate care. We encourage policymakers and providers to work together to effectively implement screening and ensure that the new designation is used to its full potential.

The lack of recommendations for adolescent screening, brief intervention, and referral to treatment in primary care demonstrates a vital need for more research. The insufficient evidence for the recommendation is not due to research showing these interventions do not work, but rather due to a dearth of quality studies attesting to their effectiveness. It is imperative that we expand research in this area so that we include the adolescent population in screening and intervention services to prevent the health consequences of risky substance use, including addiction.

Addressing these critical gaps in the USPSTF's recommendation statement would help ensure that practitioners, advocates, and elected officials understand the intuitive and practical benefits of these practices and support their implementation. Screening and early intervention are critical tools in addressing our nation's addiction crisis. As with any chronic disease, catching addiction early will improve outcomes and save lives.

The authors declare that they have no conflict of interest. The authors alone are responsible for the content and writing of the article.