Hello, everyone. Thank you for joining. My name is Andrew Saxon, and on behalf of the American Psychiatric Association, welcome to today's webinar, Screening for Substance Use in Primary Care, Screening Tools and Guidance for Implementation. Today's activity is presented on behalf of the SAMHSA-funded Providers Clinical Support System, a program operated collaboratively by 19 medical specialty organizations, including the APA. Please note that following today's presentation, you will receive a follow-up email within one hour of the webinar. This email will contain the instructions to claim your one credit hour for attending. This activity offers CE credit for physicians, nurses, nurse practitioners, pharmacists, physician assistants, and social workers. Next slide, please. Please feel free to submit your questions throughout the presentation by typing them into the question area found in the attendee control panel. We'll reserve 10 to 15 minutes at the end of the presentation for Q&A. Next, please. Now, I'd like to introduce you to our faculty for today's webinar, Dr. Jennifer McNeely. Dr. McNeely is a clinician investigator at NYU School of Medicine in the Department of Population Health and Department of Medicine. Her research focuses on substance use for individuals and health systems and on improving the identification and treatment of addiction in general medical settings. I'm really looking forward to hearing what Dr. McNeely has to say, and I welcome you to today's session. Dr. McNeely, thank you for leading today's webinar. Thank you. Thank you, Dr. Saxon, and thanks to all of you for joining today. I'm speaking to you today as a primary care physician who has felt strongly throughout my career that substance use should be addressed as part of general medical care. The work that I'm talking about today really began as I was finishing my medical training and starting to ask the question, why don't we talk about substance use as part of the care that we provide in primary care clinics, but also in the hospital or the emergency department? Of course, the answers that I got to that question were multiple layers of reasons, but a fundamental thing as a starting point was that we just don't know about how our patients are using alcohol and drugs until it becomes a crisis. My early work started working on solving that problem and then has grown from there. We're talking about screening today, and I have no disclosures. Really, everything that I'm going to present to you has been supported by NIDA through studies in the Clinical Trials Network, as well as my Career Development Award early on. I'm really thrilled to be talking with you as other healthcare providers. Just a reminder here that the goal of PCSS and of this session is to train professionals in evidence-based practices for the prevention and treatment of opioid use disorders, prescribing medication, as well as prevention and treatment of substance use disorders. Our focus is really on the prevention side today. Happy Valentine's Day. This is not a particularly romantic topic, but I have a great love for it, which I hope you will catch some of. Just acknowledging that we all hopefully have some love for what we do and for the patients that we take care of. My goals today are to... This is a three-part talk. First, we'll be focusing really on the background and the screening guidelines and current state of the evidence, then talking about specific screening tools that you could use in your clinic, and then focusing in on implementation issues. We know, especially this audience, that substance use is an important driver of poor health in the U.S. population. It leads to more death and morbidity than any other preventable condition. That was true before the opioid crisis and even more so now. For decades, since we first started to look at it, we've known that tobacco, alcohol, and drug use are all in the top 10 preventable causes of death. In fact, with overdose deaths, they now drive all-cause mortality in younger populations. This is not abating. What has also been true for a long time is that most people with substance use disorders, alcohol or other drugs, are not engaged in treatment. The prevalence is high. It's close to that of diabetes. Despite the pervasiveness of the problem, it's been true that between 10 and 12 percent of people in any given year who have a substance use disorder will be engaged in formal treatments. What's also true and maybe less focused on is that most people with substance use disorders have an encounter with primary care. In fact, people with substance use disorders have a lot of health care contacts, all of which are potential points to identify and to provide interventions that could improve their health. Medical populations have been known for a while to be enriched with patients who have unhealthy substance use. About a third of patients in primary care have some type of either risky use or substance use disorder. In hospitals and emergency departments, the prevalence is high and tends to be more severe. Oftentimes, this is treated as a problem that people with substance use disorders have are high utilizers of acute care. I would suggest that we should be flipping that and saying we have a lot of opportunities to reach patients, but oftentimes those opportunities are lost. Like the question that launched me on this path, the first reason that they're lost is because providers may be unaware. With that background, the US Preventive Services Task Force, USPSTF, that is really the main arbiter of what types of preventive care gets offered in primary care settings, and they take a very hard-nosed look at the evidence. They have now recommended screening for alcohol and for drugs. The alcohol recommendation has been in place for decades. It's a grade B recommendation, and both it and the drug recommendation are limited to adults in primary care, so still not extending into adolescents, but largely because of insufficient evidence in that area. The drug screening recommendation is a more recent change in 2020. I think it's helpful for particularly because of the recent change in the drug screening recommendation, which came after screening had actually not been recommended on a prior review because of insufficient evidence. I think it's helpful just to understand how the USPSTF asks the question. This is generally how they would set up the evidence review. For any condition, the goal is to reduce morbidity and mortality, the goal of preventive care. The first question is, does screening itself reduce death and disease? For almost every condition, the answer to that is no. Maybe I'm always looking for exceptions to that rule, and I think possibly screening colonoscopy where you can actually remove a polyp that would develop into cancer, maybe that's one example, but in general, screening itself is not directly impacting that. By screening, we can identify people who have unhealthy use, offer interventions, and we have interventions to offer that can reduce their consumption, reduce risk behaviors, and improve social outcomes, and through those mechanisms, reducing morbidity and mortality. Alcohol, there have been many studies that check all of these boxes for the benefit of screening. In fact, there's a robust body of evidence that screening followed by a brief counseling intervention focused on motivational intervention can reduce hazardous and harmful alcohol consumption in adult primary care patients, some evidence that can decrease inappropriate healthcare utilization, and in fact, it's ranked as one of the five most effective clinical preventive services. When we look at the USPSTF recommendation around drug screening, what we see is, again, it's a question set up the same way. First is, does screening itself reduce death and disease? There's no evidence for that here, as with alcohol. Then, does screening accurately detect unhealthy drug use? The answer there is yes. We now have screening tools that can accomplish this, and that's what we're going to focus on in the next part of the talk. Then, where the question mark is, and before we do that, we also know that we have interventions, including interventions that can be delivered in primary care, such as buprenorphine treatment for opioid use disorder, that reduce drug use, improve risk behaviors, and reduce morbidity and mortality. The question mark here in what makes the drug screening recommendation different from alcohol is that there's not enough studies looking at whether in a non-treatment-seeking population, so people who are coming in for regular primary care who are identified through screening, if we can deliver those interventions to them and still have these same effects. This is where the fine print of the screening recommendation is important. It's a grade B recommendation for drug screening, meaning moderate evidence, moderate certainty, and many of the things that we do every day in primary care have that level of recommendation and are an accepted part of practice. As I said, it's restricted to adults 18 and over, and it's specific that we're talking about screening by asking questions about drug use. It's not about doing toxicologies. Then there's this part of the recommendation that says, we should screen when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred. That's related to this question mark around how we treat what the evidence is for treatment of non-treatment seekers. Many smart people have pointed out that we do lack evidence in that connector area, including my colleague and friend, the late Rich Sates. There has been controversy around the screening recommendation, but ultimately, the USPSTF did review the evidence rigorously and weighed in that it was a recommended practice. Coming back into my clinical perspective, that there are many reasons why identifying substance use is important and of value, particularly in clinical settings. I think the USPSTF review focuses largely on this top box of, can we screen, intervene, and reduce drug use? Then there's a whole set of clinical reasons, including you need to know about a patient's alcohol and drug use for patient safety reasons. For example, a patient coming in for an elective surgery who then goes into alcohol withdrawal in the hospital. That's preventable, but only if you know about their alcohol use beforehand. Screening is important for making accurate diagnoses of pretty much any condition that you would encounter in primary care, everything from chest pain to gastritis to depression. Substance use is associated with treatment outcomes, often mediated through adherence to treatment plans. It's important to know for prevention that maybe you would change your frequency of screening, say, for infectious diseases in light of a patient's substance use behavior. Those are all clinical reasons for wanting and needing this information. There's also, for health systems or from a public health perspective, how do you know really what type of care is needed? How to design services if you don't know about the characteristics of the population. There's another reason that's worth talking about in terms of thinking about the value or potential value of screening. It's about bringing it into regular medical visits, into practice, normalizing asking about substance use as a health behavior as it is. In this respect, universal screening approaches where patients don't feel singled out. This is one example of a phrase that we will often use. We ask everyone because this information is an important part of your health picture. Screening implemented poorly will not reduce stigma, but screening done well is an opportunity to do that. Done well means really focusing on the role of the health care provider in asking these questions because of us wanting and needing to work with you on your health and prevention. It's important that we say how we can help, that that's why we're asking about this and respecting privacy in doing so. We're going to turn back a little bit at the end of the talk to that component. The next section, though, is to now, I'm hoping that I've gotten your buy-in, at least in large part, for thinking that screening is a valuable thing to do as part of care. Now I want to turn into specific screening tools that could practically and feasibly be used in medical settings. There is a large body of potential tools to choose from. I'm not going to do a lightning review of all of them, but to focus in on some of the ones that are most used and I think most valuable in this context. Before jumping into that, it's worth just remembering that when we're talking about identifying unhealthy substance use, it exists on a continuum. This pyramid I love as a way of showing this, that about a third of the population, it's not exactly to scale, but about a third of the population in a primary care setting would be expected to have unhealthy use. The unhealthy use is a range of severity from risky use to problematic to a substance use disorder. As the level of consumption goes up, the consequences go up and the severity of the condition increases. So a tool that identifies, say a diagnostic instrument for identifying moderate to severe substance use disorder isn't gonna be well-suited to identify these people who are lower down with risky use. But the folks at the top of the pyramid are also a small percentage of the entire population who has some risk because of their unhealthy use. So when I think about the world of screening tools, this is how I think of them, is that there's screening which should take few resources to deliver. And it's asking a simple question, is there unhealthy use, yes or no? And that's a question that you would need to ask of pretty much everyone, which is why it's important that it's quick and doesn't take a lot of resources to do that. Then for someone who would screen positive, a brief assessment is asking, what is their level of risk and what are they using? So the assessment is beginning to guide clinical care. And that takes a bit more resources to do that. And then finally, if someone is say high risk on assessment to know how to deliver treatment to them, then you would need to make a diagnosis. And that is the highest resource activity, but it's a minority of the people who would be screened. So the tools that I'm going to focus in on for the talk today are the ones shown on the screen. So on the low resource side, single item screening questions and the TAPS tool, which is in two parts, a brief screener followed by a brief assessment. Other instruments that go into this category would be the audit and the audit C. We're going to touch on each of these, but I'm going to start in on the TAPS tool and spend the most time here. TAPS tool is sort of the newer screener on the block in terms of some of the other ones that have been used for some time, but it was developed and published in 2016 through a large trial in the NIDA clinical trials network. And what the tool is, is it was intentionally developed to meet these needs for screening and brief assessment in very busy medical settings. And it starts with a four item screener asking about any past year use of tobacco, unhealthy alcohol use, which is a binge drinking question, non-medical use of prescription drugs or any use of illicit drugs. And then a positive screen on any of these four categories triggers a short set of follow-up questions to identify past three months use, so current use of up to seven classes of substances and to give a score that shows sort of the level of problems related to use. And it was developed to be either self-administered by patients on an iPad or interviewer administered, and it was validated in both of those formats. This is the primary study from the validation of the TAPS tool. And like I said, it was done in the clinical trials network with 2000 adult primary care patients from five primary care clinics. They completed both versions and then for validation, the responses were compared against the CD, which identifies both past year unhealthy use and a level of substance use disorder and problem use. This just to give you a flavor for it, if you haven't seen the TAPS, this is what it looked like when delivered on the iPads that were used in the study. So the first, the TAPS one question is about use in the past year. It ranges from never to daily or almost daily, but really any response other than never is just treated as a positive screen in that way that I was talking about, where it's sort of a quick yes, no to unhealthy use type of way. And then if that was positive, so the screening question was about, was there any past year non-medical use of prescription medications? And this is the follow-up question from the brief assessment that then asked, is there current use and of what medications? So breaking it down to sedatives, opioids, and then stimulants. When we examined its validity in this population of 2000 adults, we looked first at the TAPS tool for identifying any problem use. So this, we chose a cutoff of a total score of one or higher. The score ranges depending on the substance use category, either zero to three or for alcohol, zero to four. And what we, a couple of things to notice here is that this is a general primary care population. The most prevalent substances are tobacco, alcohol, and cannabis. And then, but then we did have a good smattering of these other types of substance use in the group. In general with screeners, the kind of rule of thumb is that we like to see sensitivity of 70% or higher and specificity of 80% or higher. So sensitivity is how good is it at identifying a condition, where the condition exists. And then specificity is how good is it at not identifying the condition in a healthy population. So high specificity is lower rates of false positives. And what we see here for the TAPS is that your sensitivity is very high for tobacco and above 70% for all of the illicit drugs. It drops off some for the prescription medications. And that unfortunately is true for any screening tool out there right now. And then specificity across the board is very high, well above the 80% mark. And then when we looked at the validity of the TAPS tool for identifying substance use disorder, we looked at applying a higher score. So looking to see if the tool can discriminate between higher use with a higher score essentially. And what we see here is that the prevalence is lower. So fewer people meeting that target. And then sensitivity is about 70% or above for the most commonly used substances in primary care populations. So tobacco, alcohol, and cannabis. And then lower for the other drugs. Specificity is still very high across the board. And so the recommendation in using the TAPS is that a score of one indicates unhealthy use for likely for all of the substance classes. Though noting that it may not be perfectly sensitive for prescription opioids and sedatives. With a score of two or higher, that is sensitive for identifying a substance use disorder for tobacco, alcohol, and marijuana. If there's a score of one or higher for the other drugs, you'd want to do some clinical assessment to identify substance use disorder because the sensitivity with the cutoff of two may be missing some people who you would be able to identify through a clinical assessment. However, if you get a patient in primary care who had a score of two on the TAPS because specificity is high, and in fact, the likelihood of them having a unhealthy use or a substance use disorder is very high, you would certainly prioritize people with the higher TAPS score for assessment if you weren't able to assess everyone. And we can talk about that more in the Q&A. It's also addressed in the papers on the TAPS and how to interpret this. There was an additional study in the same population that looked at, so what if we only had time to do the first part of the TAPS? That's the four-item screener. And there we see for the groups of substance classes, very high sensitivity and specificity for each of them, and certainly could be recommended as a quick general screen for unhealthy use. As the study was going on, we examined its feasibility and acceptability to patients, and that's published in this paper. And a couple of things to note here is that the median time to complete was about four minutes for the self-administered and about two minutes for the interviewer-administered. And so interesting that the self-administered does take longer, but when you think about a clinical workflow, that may be less problematic because you're not taking up a staff person's time for doing that with them. Over 90% of people completed the TAPS in less than three minutes for the interviewer format and less than seven minutes for the self-administered. We asked participants how they felt about the questions, and overall they felt very comfortable answering the TAPS questions, said they would be comfortable sharing the results with their provider. I think that you have to kind of, there are a lot of qualifiers on that depending on the situation and the provider that I'll touch on a bit later when we focus more on implementation. And there was no strong preference for the interviewer versus the iPad. If you want to try the TAPS out or look more in depth into it, NIDA built out a nice website. This is the URL here. You can find it just by searching NIDA TAPS tool. So I do want to touch on alternatives to the TAPS tool also that are widely used and valid approaches to screening. One of which may be the main one of which are the single item screening questions, one for alcohol and one for drugs. The language of the screening questions is shown here. And each of them is asking about any past year unhealthy use. And even though it asks how many days, how many times in the past year, it essentially anything other than zero is treated as a positive screen. And these have also been validated for interviewer administered and self-administered approaches and shown to have good sensitivity and specificity and certainly can be recommended for use in practice and are used. When the single item screening question for drugs was validated, legalization of recreational or even medical use of cannabis was not common. And things have really changed since that time. And so many have noticed that when screening it for drugs is implemented that there is either confusion or a failure to identify cannabis because the question asks about illegal drug use. And so Tessa Mattson developed and validated more recently a cannabis specific single item screener. So you could imagine using this along with the more general question about drug use in the past year. And it's phrased slightly differently but essentially capturing the same idea of anything other than never could be treated as a positive screen. And this is a recent paper in JAMA Network Open showing that as long as you set the cutoff as not more than a monthly use, you get good sensitivity and specificity with the cannabis specific screener. And then finally, really the most used substance use screening tool is the audit or the shorter version, the Audit C which are the first three items of the audit asking about consumption. These have been widely adopted, used around the world for identifying unhealthy use and likely alcohol use disorder with good sensitivity and specificity with good sensitivity and specificity. There's a broader range of results here just because this instrument has been tested and validated in so many different studies and populations but overall it's accepted to work very well for identifying alcohol. In the final part of the talk, I'm going to hone in on implementation issues. So really taking the road that we now have screening tools that can work that are valid at least in research settings and let's see how they function in the real world and how do we go about getting them used in clinical settings. So if you are spending any time in clinical practice you know that there are multiple barriers to screening especially in strapped primary care settings and all of these barriers have been well researched and characterized, time is a huge one but also in workflow and then lack of knowledge on the part of providers about what to do with a positive screen, negative attitudes towards substance use certainly persist and discomfort and stigma on the part of patients as well as their providers. And so given that all of that exists I think a screening tool can't solve all of those barriers but given that they're there the screening should be as easy as possible. So we should be using and trying to implement tools that are brief, as accurate as they can be that capture that sort of full range of severity of substance use that we saw in the pyramid that we care about in taking care of patients. And in today's world it needs to be integrated with the electronic health record and the screener needs to fit existing workflows not making new workflows just to be able to use the screener. The NIDA CTN has compiled sort of a short list of screening instruments including the ones that I talked about today but some others as well that can be feasibly implemented and this is just a good reference if you're looking for a screener that you might wanna use. That led to a study and implementation feasibility study that we conducted in the CTN looking at taking screening tools off of that list and implementing them integrated with the EHR in primary care. So this was a four phase non-randomized implementation study involving six clinics and two health systems. And this study launched before the TAPS tool validation was completed. And we used the single item screening questions followed up with the Audit C or DAS-10 for brief assessment. And then there was an ancillary study in rural FQHCs that used the TAPS tool. And what we saw, so the norm is when you look for a screening results in the EHR with using validated screening tools, normally you find almost nothing. And so we were very happy to see that with kind of thoughtful implementation of these screening tools, overall 72% of patients were screened in the first year after it was implemented. And it did, however, vary depending on the clinic, which you can see better in the figure here. So one of the main differences, remember we had six clinics. One of the main differences between them is that one health system targeted annual visits. So annual visits for preventive care when you're kind of reviewing everything makes a lot of sense clinically as a place to do this, but it had much lower screening rates than the clinic that would try to screen at any type of primary care visit. They would still only trigger it once a year, but you could be coming in for any type of a follow-up or even an urgent visit if it was with the primary care provider and get screened. So that generated screening rates 90% and higher. The other finding that's really worth highlighting here is that we were looking for how much unhealthy alcohol use is detected on screening. And we had one clinic that used a staff-administered approach. These were medical assistants delivering the screening while they're doing vitals, a pretty typical workflow for screening implementation and primary care. And these were very well-trained, well-prepared staff who were doing it and got a positive screening rate of about 2%, which is much lower than what we believe the actual population prevalence to be. Those that use a self-administered approach had overall a 26% positive screen rate. And some of the clinics that was even higher, about a third of patients with unhealthy use. And so it does appear, even though it's a non-randomized study, it really does appear that the mode of administration has a lot to do with driving the detection rates. And it makes sense. This is a stigmatized behavior. And patients, even if the person asking the question is doing it the right way, using the right language and welcoming sort of body language, even with that, patients just may not be comfortable reporting this behavior face-to-face. But also worth noting here, patients were very aware that their results were going to their primary care provider. So this was not presented to them as confidential screening. It was just self-administered. The other thing that we know, so this is now looking at results from the ancillary study as well as in that parent study, ancillary study using the TAPS tool, parent using the single item screening question, and just looking at how the screeners performed for drug use. So remember the single item screener kind of lumps together all types of drug use and doesn't ask separately about cannabis or any other drug, whereas the TAPS tool separates it out. And what we saw was 10% screening rate, screening positive for unhealthy use with this more categorized approach that allows patients to say, yes, I use cannabis, but no, I don't use heroin as compared to the more standard approach where we had a 1% screen positive rate. And this is all with self-administered screening. Just to touch quickly before we finish up about some best practices around the quality of screening and some implementation considerations. So it really is important to use validated screening tools. Remember, this is not like a biologic measure and the words themselves are the test. The calibration will be off if it's not a validated tool and if it's not delivered using the validated language. It's important when introducing a screening program to an individual patient or in a new clinic overall to communicate that the reason we're asking about this is because we want to improve your health. This is not an enforcement or a punitive approach but it's an important part of your health. Ensuring privacy is important in communicating to patients what happens with their information. I did a lot of interviews and focus groups around these issues of screening with patients and it's kind of incredible what patients, the degree of access that they kind of might assume that others have to their health information and to this information. And it's important to clarify who gets to see not just this information but any of their health information from the medical record as part of introducing a screening program. And I think there are many reasons, both practical and quality-wise to use a self-administered screening approach and I would always recommend that. If self-administered is not feasible, then trying to normalize the screening as much as possible, delivering it alongside other screeners, making sure it's in a private setting. So certainly not in the waiting room or in places where patients feel like someone might overhear it. And patients are pretty clear that they are more comfortable, they sort of understand that this information is needed say by their provider, but they're reluctant to share it with people who are not interested with their healthcare. And that can include a medical assistant if they don't think that they have any influence on what happens with their care or their health. And certainly for receptionists or other non-clinical staff will not get the same responses on a screener. So in summary, the guidelines recommend screening adult primary care patients for alcohol and for drug use. The importance of screening is there in informing clinical care as well as the design of services and understanding the needs of the patient population. There are screening tools that can be recommended for use in medical settings. And it's important to choose the right tool for the job and to think about how it's going to be delivered to overcome some of the common implementation barriers. And screening should always be thought of and delivered alongside education, focus on counseling with a motivational approach and offers of treatments. And in fact, that will help the quality and the amount of reporting on the screening as well as help taking those results from screening and improving patient health. Beyond the scope of this talk to go into all of it, but screening is one component of addressing substance use in primary care and medical settings. There is a tool developed by the NIDA Clinical Trials Network that's available at this URL that can help with the decision points around implementing screening in your clinical setting. And this is just a screenshot of the homepage but to give you a quick preview of what's in there. It asks some questions about the clinic and then walks through how you might design and plan an approach to implementation and then monitor the success of that approach. So I encourage you to check this out and to make use of it. This is another sort of an example of what this looks like. It presents choices to you and some pros and cons of those choices. And then it includes a long list of resources, examples. So you don't have to feel like you need to create materials from scratch if you're looking to implement this in practice. This is a short list of resources of some of the items that I showed. And I'll just close up by saying a huge thank you to all the people who've collaborated and mentored me throughout this work which really was the start of my career as a clinician investigator. And in particular, wanting to note the contributions of the NIDA Clinical Trials Network supporting this work and this idea of introducing screening into healthcare settings. And I think we can spend the rest of our time with questions. Okay. Thank you very much, Dr. McNeely for the informative presentation. I think you took what is an exceedingly complicated topic and you presented it in a way that really made it very understandable and practical for all of us listeners. We have a number of really interesting questions. We won't get to all of them but we'll get to some that we can. So Glenn Hebel put in the question, we are looking at implementing screening for SUD in our emergency department, smaller typical community ED. What do you recommend for an ED with the time pressures and concern for get them in, get them out? Have you seen any one of the tools successfully implemented ED for general screening? And then he had a follow-up question about, is there some way to get the patients to do it self-administered in the ED? Yeah, great question. And so I think any of these tools can be used in the ED. There aren't specific validation studies in the ED with them, but I think there's no practical reason to think that the findings in primary care patients wouldn't translate to the ED. I think the key is around implementation. So I think in the ED, which is rarely a private setting, having it be self-administered is really key. And I have seen good examples of this using tablets though it can be done on paper too if the tablet is too heavy of a lift. But oftentimes patients are in the ED with a lot of waiting time and there's good experience with using tablets to do screening, even to do a little bit of education with patients there. I think that aspect of it also kind of relieves a little bit of the time pressure. So you said that you're interested in identifying patients with substance use disorder, which means doing the quick screen of is there unhealthy use, yes or no, followed up by some assessment, at least to know who's at a higher level of risk so that when the person who is offering treatment, the medical provider steps in, they're only stepping in with those patients who are your priority for being able to treat or they're spending their time reserved for those patients. So I would say using a self-administered approach and using a tool that kind of goes the distance, so to speak. So the TAPS tool would be one example that could do that and generate patients with a higher risk score would be the ones that you would then wanna do some clinical assessment of substance use disorder for. And the last consideration is to, in the ED to lead with, we have resources for treatment and that will help patients feel like it's something that they should disclose that they might benefit from disclosing. Thank you, Dr. McNeely. Harry House had some questions about, why are we not screening under 18? But another question, since sensitivity is somewhat low and there are no validated screens for people under 18, why not simply do urine drug screens as a way to detect people with substance use disorder? Yeah, so I am an adult primary care provider and I know some of the literature, but I don't know it in as much depth with respect to adolescents. But I'll tell you that the reason that the USPSTF doesn't recommend using toxicology for screening is that the short window of detection just makes it not that useful. Most drugs are gonna be detected within a couple of days of use. And what you're seeing with adolescents is infrequent use, you're really trying to catch it early in order to intervene and so a toxicology may just provide a false sense of security actually and not be able to identify actually at risk where the exact same patients who you probably have the best chances of doing an effective intervention with and changing their trajectory. Thank you, that's a great answer. And this is gonna be the last question. Sorry, we couldn't get to them all, but Tanya Harris asks, what will be the plan for services once usage was detected? Would this be a place or endpoint for intervention? What services would they be referred to if needed? So great question and requires way more time than we have to answer. I think the reality is that services are different depending on your practice setting, but that there is, I think any primary care practice with a little bit of work could identify people to refer patients who have substance use disorders that cannot be treated in that practice. But I would say we provide motivational intervention to patients for a huge range of conditions in primary care, obesity, smoking. We need to be exercising that muscle here with respect to alcohol and drug use too. And there are resources on the tool that I showed you has some resources for thinking about how to take the next step of acting on a positive screen. I know PCSS has other materials out there as does SAMHSA. Thank you, Dr. McNeely. Let's move to the next slide. Please visit www.pcssnow.org and see the variety of helpful resources that are offered as Dr. McNeely just mentioned, including the free PCSS Mentor Program, which offers general information to clinicians about evidence-based clinical practices in prescribing medications for opioid use disorder. Next. We also have a PCSS Discussion Forum. PCSS mentors have expertise in medication for substance use treatment and clinical education. You can also find the PCSS Discussion Forum, a simple and direct way to receive an answer related to medication for substance use treatment. Next. Today's activity was presented on behalf of the SAMHSA-funded Providers Clinical Support System, a program operated collaboratively by 19 medical specialty organizations, including the American Psychiatric Association. Next. Again, thank you for joining today. We hope to see you soon at future webinars. And also once again, a great thanks to Dr. McNeely for her fabulous presentation. Have a good day, everyone. Thank you.

Dr. Jennifer McNeely

webinar

screening

substance use

primary care

SAMHSA

Providers Clinical Support System

TAPS tool

screening tools