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A Brief Patient Self-administered Substance Use Screening Tool for Primary Care: Two-site Validation Study of the Substance Use Brief Screen (SUBS)

      Abstract

      Background

      Substance use screening is widely encouraged in health care settings, but the lack of a screening approach that fits easily into clinical workflows has restricted its broad implementation. The Substance Use Brief Screen (SUBS) was developed as a brief, self-administered instrument to identify unhealthy use of tobacco, alcohol, illicit drugs, and prescription drugs. We evaluated the validity and test-retest reliability of the SUBS in adult primary care patients.

      Methods

      Adults aged 18-65 years were enrolled from urban safety net primary care clinics to self-administer the SUBS using touch-screen tablet computers for a test-retest reliability study (n = 54) and a 2-site validation study (n = 586). In the test-retest reliability study, the SUBS was administered twice within a 2-week period. In the validation study, the SUBS was compared with reference standard measures, including self-reported measures and oral fluid drug tests. We measured test-retest reliability and diagnostic accuracy of the SUBS for detection of unhealthy use and substance use disorder for tobacco, alcohol, and drugs (illicit and prescription drug misuse).

      Results

      Test-retest reliability was good or excellent for each substance class. For detection of unhealthy use, the SUBS had sensitivity and specificity of 97.8% (95% confidence interval [CI], 93.7-99.5) and 95.7% (95% CI, 92.4-97.8), respectively, for tobacco; and 85.2% (95% CI, 79.3-89.9) and 77.0% (95% CI, 72.6-81.1) for alcohol. For unhealthy use of illicit or prescription drugs, sensitivity was 82.5% (95% CI, 75.7-88.0) and specificity 91.1% (95% CI, 87.9-93.6). With respect to identifying a substance use disorder, the SUBS had sensitivity and specificity of 100.0% (95% CI, 92.7-100.0) and 72.1% (95% CI, 67.1-76.8) for tobacco; 93.5% (95% CI, 85.5-97.9) and 64.6% (95% CI, 60.2-68.7) for alcohol; and 85.7% (95% CI, 77.2-92.0) and 82.0% (95% CI, 78.2-85.3) for drugs. Analyses of area under the receiver operating curve (AUC) indicated good discrimination (AUC 0.74-0.97) for all substance classes. Assistance in completing the SUBS was requested by 11% of participants.

      Conclusions

      The SUBS was feasible for self-administration and generated valid results in a diverse primary care patient population. The 4-item SUBS can be recommended for primary care settings that are seeking to implement substance use screening.

      Keywords

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      References

        • Babor T.F.
        • Higgins-Biddle J.C.
        Alcohol screening and brief intervention: dissemination strategies for medical practice and public health.
        Addiction. 2000; 95: 677-686
        • Solberg L.I.
        • Maciosek M.V.
        • Edwards N.M.
        Primary care intervention to reduce alcohol misuse ranking its health impact and cost effectiveness.
        Am J Prev Med. 2008; 34: 143-152
        • Whitlock E.P.
        • Polen M.R.
        • Green C.A.
        • Orleans T.
        • Klein J.
        U.S. Preventive Services Task Force. Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the U.S. Preventive Services Task Force.
        Ann Intern Med. 2004; 140: 557-568
        • Maciosek M.V.
        • Coffield A.B.
        • Edwards N.M.
        • Flottemesch T.J.
        • Goodman M.J.
        • Solberg L.I.
        Priorities among effective clinical preventive services: results of a systematic review and analysis.
        Am J Prev Med. 2006; 31: 52-61
        • Moyer V.A.
        Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: U.S. Preventive Services Task Force recommendation statement.
        Ann Intern Med. 2013; 159: 210-218
        • Kaner E.F.
        • Dickinson H.O.
        • Beyer F.
        • et al.
        The effectiveness of brief alcohol interventions in primary care settings: a systematic review.
        Drug Alcohol Rev. 2009; 28: 301-323
        • O'Donnell A.
        • Anderson P.
        • Newbury-Birch D.
        • et al.
        The impact of brief alcohol interventions in primary healthcare: a systematic review of reviews.
        Alcohol Alcohol. 2014; 49: 66-78
      1. SAMHSA-HRSA Center for Integrated Health Solutions. SBIRT: Screening, Brief Intervention, and Referral to Treatment. 2014. Available at: http://www.integration.samhsa.gov/clinical-practice/SBIRT. Accessed October 13, 2014.

        • Babor T.F.
        • McRee B.G.
        • Kassebaum P.A.
        • Grimaldi P.L.
        • Ahmed K.
        • Bray J.
        Screening, Brief Intervention, and Referral to Treatment (SBIRT): toward a public health approach to the management of substance abuse.
        Subst Abus. 2007; 28: 7-30
        • Kaner E.
        Brief alcohol intervention: time for translational research.
        Addiction. 2010; 105 (discussion 964-965): 960-961
        • Nilsen P.
        Brief alcohol intervention—where to from here? Challenges remain for research and practice.
        Addiction. 2010; 105: 954-959
        • Fiore M.C.
        • Keller P.A.
        • Curry S.J.
        Health system changes to facilitate the delivery of tobacco-dependence treatment.
        Am J Prev Med. 2007; 33: S349-S356
        • Anderson P.
        Overview of interventions to enhance primary-care provider management of patients with substance-use disorders.
        Drug Alcohol Rev. 2009; 28: 567-574
        • Center on Addiction and Substance Abuse (CASA)
        Missed Opportunity: National Survey of Primary Care Physicians and Patients on Substance Abuse.
        The National Center on Addiction and Substance Abuse at Columbia University, New York2000
        • Friedmann P.D.
        • McCullough D.
        • Saitz R.
        Screening and intervention for illicit drug abuse: a national survey of primary care physicians and psychiatrists.
        Arch Intern Med. 2001; 161: 248-251
        • Sterling S.
        • Kline-Simon A.H.
        • Wibbelsman C.
        • Wong A.
        • Weisner C.
        Screening for adolescent alcohol and drug use in pediatric health-care settings: predictors and implications for practice and policy.
        Addict Sci Clin Pract. 2012; 7: 13
        • Anderson P.
        • Laurant M.
        • Kaner E.
        • Wensing M.
        • Grol R.
        Engaging general practitioners in the management of hazardous and harmful alcohol consumption: results of a meta-analysis.
        J Stud Alcohol. 2004; 65: 191-199
        • Friedmann P.D.
        • McCullough D.
        • Chin M.H.
        • Saitz R.
        Screening and intervention for alcohol problems. A national survey of primary care physicians and psychiatrists.
        J Gen Intern Med. 2000; 15: 84-91
        • Johnson M.
        • Jackson R.
        • Guillaume L.
        • Meier P.
        • Goyder E.
        Barriers and facilitators to implementing screening and brief intervention for alcohol misuse: a systematic review of qualitative evidence.
        J Public Health (Oxf). 2011; 33: 412-421
        • Yoast R.A.
        • Wilford B.B.
        • Hayashi S.W.
        Encouraging physicians to screen for and intervene in substance use disorders: obstacles and strategies for change.
        J Addict Dis. 2008; 27: 77-97
        • Smith P.C.
        • Schmidt S.M.
        • Allensworth-Davies D.
        • Saitz R.
        Primary care validation of a single-question alcohol screening test.
        J Gen Intern Med. 2009; 24: 783-788
        • Smith P.C.
        • Schmidt S.M.
        • Allensworth-Davies D.
        • Saitz R.
        A single-question screening test for drug use in primary care.
        Arch Intern Med. 2010; 170: 1155-1160
        • Bradley K.A.
        • Lapham G.T.
        • Hawkins E.J.
        • et al.
        Quality concerns with routine alcohol screening in VA clinical settings.
        J Gen Intern Med. 2011; 26: 299-306
        • Williams E.C.
        • Achtmeyer C.E.
        • Rittmueller S.E.
        • et al.
        Factors underlying quality problems with alcohol screening in routine care.
        Addict Sci Clin Pract. 2013; 8: A85
        • Wight R.G.
        • Rotheram-Borus M.J.
        • Klosinski L.
        • Ramos B.
        • Calabro M.
        • Smith R.
        Screening for transmission behaviors among HIV-infected adults.
        AIDS Educ Prev. 2000; 12: 431-441
        • Tourangeau R.
        • Smith T.W.
        Asking sensitive questions – the impact of data collection mode, question format, and question context.
        Public Opin Q. 1996; 60: 275-304
      2. National Institute on Drug Abuse (NIDA). Screening for drug use in medical settings. 2010. Available at: http://www.drugabuse.gov/sites/default/files/pdf/nmassist.pdf. Accessed March 29, 2015.

        • Substance Abuse and Mental Health Services Administration (SAMHSA)
        Results from the 2012 National Survey on Drug Use and Health: summary of national findings, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795.
        Substance Abuse and Mental Health Services Administration, Rockville, MD2013
      3. Agency for Healthcare Research and Quality (AHRQ). Health Literacy Measurement Tools–Rapid Estimate of Adult Literacy in Medicine-Short Form (REALM-SF). Available at: http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy/index.html. Accessed March 17, 2015.

        • American Psychiatric Association
        Diagnostic and Statistical Manual of Mental Disorders.
        5th edition. American Psychiatric Publishing, Arlington, VA2013
      4. Humeniuk R. Validation of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) and pilot brief intervention: a technical report of phase II findings of the WHO ASSIST Project. 2008. Available at: http://www.who.int/substance_abuse/activities/assist_technicalreport_phase2_final.pdf. Accessed February 5, 2010.

        • Sobell L.C.
        • Sobell M.B.
        Timeline follow-back.
        in: Litten R.Z. Allen J. Measuring Alcohol Consumption: Psychosocial and Biological Methods. Springer, Totowa, NJ1992: 41-72
        • Lecrubier Y.
        • Sheehan D.
        • Weiller E.
        • et al.
        The Mini International Neuropsychiatric Interview (MINI). A short diagnostic structured interview: reliability and validity according to the CIDI.
        Eur Psychiatry. 1997; 12: 224-231
        • Sheehan D.V.
        • Lecrubier Y.
        • Sheehan K.H.
        • et al.
        The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10.
        J Clin Psychiatry. 1998; 59: 22-33
        • Heatherton T.F.
        • Kozlowski L.T.
        • Frecker R.C.
        • Fagerstrom K.O.
        The Fagerstrom Test for Nicotine Dependence: a revision of the Fagerstrom Tolerance Questionnaire.
        Br J Addict. 1991; 86: 1119-1127
        • Cooke F.
        • Bullen C.
        • Whittaker R.
        • McRobbie H.
        • Chen M.H.
        • Walker N.
        Diagnostic accuracy of NicAlert cotinine test strips in saliva for verifying smoking status.
        Nicotine Tob Res. 2008; 10: 607-612
        • Heltsley R.
        • DePriest A.
        • Black D.L.
        • et al.
        Oral fluid drug testing of chronic pain patients. I. Positive prevalence rates of licit and illicit drugs.
        J Anal Toxicol. 2011; 35: 529-540
        • Cone E.J.
        • Presley L.
        • Lehrer M.
        • et al.
        Oral fluid testing for drugs of abuse: positive prevalence rates by Intercept immunoassay screening and GC-MS-MS confirmation and suggested cutoff concentrations.
        J Anal Toxicol. 2002; 26: 541-546
        • Bosker W.M.
        • Huestis M.A.
        Oral fluid testing for drugs of abuse.
        Clin Chem. 2009; 55: 1910-1931
        • Cone E.J.
        • Huestis M.A.
        Interpretation of oral fluid tests for drugs of abuse.
        Ann N Y Acad Sci. 2007; 1098: 51-103
        • Verstraete A.G.
        Detection times of drugs of abuse in blood, urine, and oral fluid.
        Ther Drug Monit. 2004; 26: 200-205
        • Alonzo T.A.
        • Pepe M.S.
        Using a combination of reference tests to assess the accuracy of a new diagnostic test.
        Stat Med. 1999; 18: 2987-3003
        • Simel D.L.
        • Samsa G.P.
        • Matchar D.B.
        Likelihood ratios with confidence: sample size estimation for diagnostic test studies.
        J Clin Epidemiol. 1991; 44: 763-770
        • Hanley J.A.
        • McNeil B.J.
        The meaning and use of the area under a receiver operating characteristic (ROC) curve.
        Radiology. 1982; 143: 29-36
        • Satre D.
        • Wolfe W.
        • Eisendrath S.
        • Weisner C.
        Computerized screening for alcohol and drug use among adults seeking outpatient psychiatric services.
        Psychiatr Serv. 2008; 59: 441-444
        • Butler S.F.C.E.
        • Bromberg J.I.
        • Budman S.H.
        • Buono D.P.
        Computer-assisted screening and intervention for alcohol problems in primary care.
        J Technol Hum Serv. 2003; 21: 1-19
        • Reichmann W.M.
        • Losina E.
        • Seage G.R.
        • et al.
        Does modality of survey administration impact data quality: audio computer assisted self interview (ACASI) versus self-administered pen and paper?.
        PLoS One. 2010; 5: e8728
      5. Seed P. DIAGT: Stata module to report summary statistics for diagnostic tests compared to true disease status. 2010. Available at: http://EconPapers.repec.org/RePEc:boc:bocode:s423401. Accessed August 21, 2014.

        • Roy-Byrne P.
        • Bumgardner K.
        • Krupski A.
        • et al.
        Brief intervention for problem drug use in safety-net primary care settings: a randomized clinical trial.
        JAMA. 2014; 312: 492-501
        • Saitz R.
        • Palfai T.P.
        • Cheng D.M.
        • et al.
        Screening and brief intervention for drug use in primary care: the ASPIRE randomized clinical trial.
        JAMA. 2014; 312: 502-513
        • Saitz R.
        • Alford D.P.
        • Bernstein J.
        • Cheng D.M.
        • Samet J.
        • Palfai T.
        Screening and brief intervention for unhealthy drug use in primary care settings: randomized clinical trials are needed.
        J Addict Med. 2010; 4: 123-130
      6. U.S. Preventive Services Task Force. Screening for illicit drug use: U.S. Preventive Services Task Force recommendation statement. 2008. Available at: http://www.uspreventiveservicestaskforce.org/uspstf08/druguse/drugrs.htm. Accessed August 21, 2014.

        • Danaei G.
        • Ding E.L.
        • Mozaffarian D.
        • et al.
        The preventable causes of death in the United States: comparative risk assessment of dietary, lifestyle, and metabolic risk factors.
        PLoS Med. 2009; 6: e1000058
        • Antoniou T.
        • Tseng A.L.
        Interactions between recreational drugs and antiretroviral agents.
        Ann Pharmacother. 2002; 36: 1598-1613
        • Lindsey W.T.
        • Stewart D.
        • Childress D.
        Drug interactions between common illicit drugs and prescription therapies.
        Am J Drug Alcohol Abuse. 2012; 38: 334-343
        • Malta M.
        • Strathdee S.A.
        • Magnanini M.M.
        • Bastos F.I.
        Adherence to antiretroviral therapy for human immunodeficiency virus/acquired immune deficiency syndrome among drug users: a systematic review.
        Addiction. 2008; 103: 1242-1257
        • Arnsten J.H.
        • Demas P.A.
        • Grant R.W.
        • et al.
        Impact of active drug use on antiretroviral therapy adherence and viral suppression in HIV-infected drug users.
        J Gen Intern Med. 2002; 17: 377-381
        • Centers for Disease Control and Prevention (CDC)
        Unintentional poisoning deaths—United States, 1999-2004.
        MMWR Morb Mortal Wkly Rep. 2007; 56: 93-96
        • Baumeister S.E.
        • Gelberg L.
        • Leake B.D.
        • Yacenda-Murphy J.
        • Vahidi M.
        • Andersen R.M.
        Effect of a primary care based brief intervention trial among risky drug users on health-related quality of life.
        Drug Alcohol Depend. 2014; 142: 254-261
        • Madras B.K.
        • Compton W.M.
        • Avula D.
        • Stegbauer T.
        • Stein J.B.
        • Clark H.W.
        Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: comparison at intake and 6 months later.
        Drug Alcohol Depend. 2009; 99: 280-295
        • Field C.A.
        • Klimas J.
        • Barry J.
        • et al.
        Alcohol screening and brief intervention among drug users in primary care: a discussion paper.
        Ir J Med Sci. 2012; 181: 165-170
        • Sullivan M.A.
        • Covey L.S.
        Current perspectives on smoking cessation among substance abusers.
        Curr Psychiatry Rep. 2002; 4: 388-396
        • McNeely J.
        • Lee J.D.
        • Grossman E.
        Other drug use.
        in: Saitz R. Addressing Unhealthy Alcohol Use in Primary Care. Springer, New York2013: 171-188
        • Brown R.L.
        • Leonard T.
        • Saunders L.A.
        • Papasouliotis O.
        A two-item screening test for alcohol and other drug problems.
        J Fam Pract. 1997; 44: 151-160
        • Brown R.L.
        • Leonard T.
        • Saunders L.A.
        • Papasouliotis O.
        A two-item conjoint screen for alcohol and other drug problems.
        J Am Board Fam Pract. 2001; 14: 95-106
        • Vinson D.C.
        • Kruse R.L.
        • Seale J.P.
        Simplifying alcohol assessment: two questions to identify alcohol use disorders.
        Alcohol Clin Exp Res. 2007; 31: 1392-1398
        • Bradley K.A.
        • DeBenedetti A.F.
        • Volk R.J.
        • Williams E.C.
        • Frank D.
        • Kivlahan D.R.
        AUDIT-C as a brief screen for alcohol misuse in primary care.
        Alcohol Clin Exp Res. 2007; 31: 1208-1217
        • Lee J.D.
        • Delbanco B.
        • Wu E.
        • Gourevitch M.N.
        Substance use prevalence and screening instrument comparisons in urban primary care.
        Subst Abus. 2011; 32: 128-134
        • McNeely J.
        • Halkitis P.N.
        • Horton A.
        • Khan R.
        • Gourevitch M.N.
        How patients understand the term ‘nonmedical use’ of prescription drugs: insights from cognitive interviews.
        Subst Abus. 2014; 35: 12-20
      7. National Institute on Alcohol Abuse and Alcoholism (NIAAA). Helping patients who drink too much: a clinician's guide, 2005 ed. Available at: http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/guide.pdf. Accessed May 28, 2013.

        • Substance Abuse and Mental Health Services Administration (SAMHSA)
        Results from the 2013 National Survey on Drug Use and Health: summary of national findings, NSDUH Series H-48, HHS Publication No. (SMA) 14-4863.
        Substance Abuse and Mental Health Services Administration, Rockville, MD2014
        • Babor T.F.
        • Brown J.
        • Del Boca F.K.
        Validity of self-reports in applied research on addictive behaviors: fact or fiction?.
        Behav Assess. 1990; : 5-31
        • Del Boca F.K.
        • Darkes J.
        The validity of self-reports of alcohol consumption: state of the science and challenges for research.
        Addiction. 2003; 98: 1-12
        • Hser Y.I.
        Self-reported drug use: results of selected empirical investigations of validity.
        NIDA Res Monogr. 1997; 167: 320-343
        • Secades-Villa R.
        • Fernandez-Hermida J.R.
        The validity of self-reports in a follow-up study with drug addicts.
        Addict Behav. 2003; 28: 1175-1182
        • Jatlow P.I.
        • Agro A.
        • Wu R.
        • et al.
        Ethyl glucuronide and ethyl sulfate assays in clinical trials, interpretation, and limitations: results of a dose ranging alcohol challenge study and 2 clinical trials.
        Alcohol Clin Exp Res. 2014; 38: 2056-2065
        • Neumann T.
        • Spies C.
        Use of biomarkers for alcohol use disorders in clinical practice.
        Addiction. 2003; 98: 81-91
        • Davis C.G.
        • Thake J.
        • Vilhena N.
        Social desirability biases in self-reported alcohol consumption and harms.
        Addict Behav. 2010; 35: 302-311