Evidence Synthesis Number 186 Screening for Illicit Drug Use, Including Nonmedical Use of Prescription Drugs: An Updated Systematic Review for the U.S. Preventive Services Task Force Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 5600 Fishers Lane Rockville, MD 20857 www.ahrq.gov Contract No. HHSA-290-2015-00007-I-EPC5, Task Order No. 2 Prepared by: Kaiser Permanente Research Affiliates Evidence-based Practice Center Kaiser Permanente Center for Health Research Portland, OR Investigators: Carrie D. Patnode, PhD, MPH Leslie A. Perdue, MPH Megan Rushkin, MPH Elizabeth A. O’Connor, PhD AHRQ Publication No. 19-05255-EF-1 August 2019 This report is based on research conducted by the Kaiser Permanente Research Affiliates Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. HHSA-290-2015-00007-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents, and do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services. The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients. The final report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied. None of the investigators has any affiliations or financial involvement that conflicts with the material presented in this report. Acknowledgments The authors gratefully acknowledge the following individuals for their contributions to this project: Kathleen Irwin, MD, MPH, David Meyers, MD, MPH, Ernest Sullivent, MD, MPH, and Amanda Borsky, DrPH, MPP, at AHRQ; current and former members of the U.S. Preventive Services Task Force who contributed to topic deliberations; Richard Saitz, MD, MPH, at Boston University Schools of Medicine and Public Health for his content expertise and review of the draft report; Cheryl Arratoon, MSc, Sharon Levy, MD, MPH, Jennifer McNeely, MD, MS, Natalie Mercer, PhD, Steven Ondersma, PhD, MA, Brad Stein, MD, PhD, Adrienne Stevens, PhD, and Matthew Young, PhD, for providing expert review of the draft report; Christina Mikosz, MD, MPH, Jean Ko, PhD, and Rebecca DelCarmen-Wiggins, PhD, for providing federal review of the report; and Smyth Lai, MLS, and Katherine Essick, BS, at the Kaiser Permanente Center for Health Research for technical and editorial assistance. Screening for Illicit Drug Use ii Kaiser Permanente Research Affiliates EPC Structured Abstract Objective: We conducted this systematic review to support the U.S. Preventive Services Task Force in updating its 2008 recommendation on screening adolescents and adults, including pregnant women, for illicit drug use. Our review addressed 5 key questions (KQ): 1a. Does primary care screening for drug use in adolescents and adults, including pregnant women, reduce drug use or improve other risky behaviors? 1b. Does primary care screening for drug use in adolescents and adults, including pregnant women, reduce morbidity or mortality or improve other health, social, or legal outcomes? 2. What is the accuracy of drug use screening instruments? 3. What are the harms of primary care screening for drug use in adolescents and adults, including pregnant women? 4a. Do counseling interventions to reduce drug use, with or without referral, reduce drug use or improve other risky behaviors in screen-detected persons? 4b. Do counseling interventions to reduce drug use, with or without referral, reduce morbidity or mortality or improve other health, social, or legal outcomes in screen-detected persons? 5. What are the harms of interventions to reduce drug use in screen-detected persons? Data Sources: We performed a search of MEDLINE, PubMed Publisher-Supplied, PsycINFO, and the Cochrane Central Register of Controlled Trials for studies published through June 7, 2018. Studies included in three related USPSTF reviews were re-evaluated for potential inclusion. We supplemented searches by examining reference lists from related articles and expert recommendations and searched federal and international trial registries for ongoing trials. Study Selection: Two researchers reviewed 17,919 titles and abstracts and 271 full-text articles against prespecified inclusion criteria. For all KQs, we included studies among adolescents and adults aged 12 years and older, including pregnant women. Studies targeting illicit psychoactive drug use or nonmedical pharmaceutical drug use were included; those targeting nonpsychoactive drugs (e.g., laxatives, anabolic steroids) were excluded. For KQs 1 and 3, we included studies that compared individuals who received screening with those who received no screening or who received usual care, including randomized trials or nonrandomized controlled trials. For KQ 2, we included studies that reported the accuracy (sensitivity and specificity) of standardized screening instruments compared with structured clinical interviews or biologic verification and that took place in a setting that was applicable to primary care. For KQ 4 and 5 about counseling interventions, only randomized and nonrandomized trials among screen-detected persons were included. Trials among persons who sought drug treatment or were referred or mandated to receive drug treatment were excluded. Interventions could include any brief counseling approach designed to reduce drug use, with or without referral. Studies of medication-assisted therapy (i.e., the use of methadone, buprenorphine, or naltrexone plus counseling) to treat opioid use disorders were excluded given that use of this therapy limited to adults with a diagnosed opioid use disorder (typically severe and non-screen detected). We conducted dual, independent critical appraisal of all provisionally included studies and abstracted all important study details and results from all studies rated fair or good quality. Data were abstracted by one reviewer and confirmed by another. Data Analysis: We synthesized data separately for each KQ and subpopulation (i.e., adolescents, young adults and adults, and pregnant and postpartum women). The data for KQ 2 did not allow for quantitative pooling due to the limited number of contributing studies for each screening instrument and condition, so we synthesized the data qualitatively through tables and narrative Screening for Illicit Drug Use iii Kaiser Permanente Research Affiliates EPC synthesis. For drug use outcomes, we ran random effects meta-analyses using the DerSimonian and Laird method to calculate the pooled differences in mean changes in drug use days; data was too sparse to pool for binary data on drug abstinence. We examined statistical heterogeneity among the pooled studies using standard χ2 tests and estimated the proportion of total variability in point estimates using the I2 statistic. We graded the strength of the overall body of evidence based on the consistency and precision of the results, reporting bias, and study quality. Results: We found no evidence that addressed the benefits and harms of screening for drug use. Twenty-eight studies (n=65,720) addressed the accuracy of 30 drug use screening instruments; each specific screening instrument has not been studied more than once or twice. Studies among adolescents mainly focused on detecting cannabis use. They found that sensitivity for detecting any cannabis use or unhealthy cannabis use of frequency-based and risk assessment screen tools (all validated against structured clinical interview alone) ranged from 0.68 to 0.98 (95% CI range, 0.64 to 0.99) and specificity ranging from 0.82 to 1.00 (95% CI range, 0.80 to 1.00). Among adults, frequency-based and risk assessment drug screening tools (all but two validated against structured clinical interview alone) showed sensitivity for detecting unhealthy use of any drug ranging from 0.71 to 0.94 (95% CI range, 0.62 to 0.97) and specificity ranging from 0.87 to 0.97 (95% CI range, 0.83 to 0.98). For identifying drug use disorders among adults, sensitivity ranged from 0.85 to 1.00 (95% CI range, 0.67 to 1.00) and specificity ranged from 0.67 to 0.93 (95% CI, 0.58 to 0.95) when using the same cutoffs. Sensitivity for detecting any prenatal drug use using frequency-based and risk assessment (all validated against hair or urine analyses) was lower than the estimates for any drug use in non-pregnant adults (only rarely based on validation against biologic samples) and ranged from 0.37 to 0.76 (95% CI range, 0.24 to 0.86). Specificity was comparable and ranged from 0.68 to 0.83 (95% CI range, 0.55 to 0.91). We included 27 trials that addressed the effectiveness of a counseling intervention on changes in drug use or improved health, social, or legal outcomes among a screen-detected population. Across all 27 trials (n analyzed=8705), in general, there was no consistent effect of the interventions on rates of self-reported or biologically confirmed drug use at 3- to 12-month followup. Likewise, across 13 trials reporting the effects of the interventions on health, social, or legal outcomes (n- analyzed=4304), none of the trials found a statistically significant difference between intervention and control groups on any of these measures at 3- to 12-month followup.