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Screening and Intervention for Illicit Drug Abuse
A National Survey of Primary Care Physicians and Psychiatrists
Peter D. Friedmann, MD, MPH;
Deirdre McCullough, MS;
Richard Saitz, MD, MPH
Arch Intern Med. 2001;161:248-251.
ABSTRACT
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Background Illicit drug abuse causes much morbidity and mortality, yet little is
known about physicians' screening and intervention practices regarding illicit
drug abuse.
Methods We mailed a survey to a national sample of 2000 practicing general internists,
family physicians, obstetricians and gynecologists, and psychiatrists to assess
their screening and intervention practices for illicit drug abuse.
Results Of 1082 respondents (adjusted response rate, 57%), 68% reported that
they regularly ask new outpatients about drug use. For diagnosed illicit drug
abuse, 55% reported that they routinely offer formal treatment referral, but
15% reported that they do not intervene. In multivariate logistic regression
models, more optimal screening and intervention practices were associated
with psychiatry specialty, confidence in obtaining the history of drug use,
optimism about the effectiveness of therapy, less concern that patients will
object, and fewer perceived time constraints.
Conclusions Most physicians reported that they ask patients about illicit drug use,
but a substantial minority inadequately intervene in diagnosed drug abuse.
Initiatives to promote physician involvement in illicit drug abuse should
include strategies to increase physicians' confidence in managing drug problems,
engender optimism about the benefits of treatment, dispel concerns about patients'
sensitivity regarding substance use, and address perceived time limitations.
INTRODUCTION
ILLICIT DRUG ABUSE causes much morbidity and mortality,1
and primary care physicians and psychiatrists are well positioned to identify
and treat it.2 Few studies have examined physician
screening for illicit drug abuse, but much research supports health benefits
from substance abuse screening and intervention for alcohol or tobacco abuse3; these benefits are likely to extrapolate to illicit
drug abuse. In addition, the Substance Abuse Coverage Study4
suggested that decreased criminal justice involvement would have the individual
and societal benefit of greater recognition of and treatment referral for
illicit drug abuse. Some professional and governmental organizations5, 6, 7, 8 recommend
screening for drug abuse, while others9 equivocate,
in large part because of the low prevalence of drug abuse in primary care
settings and insufficient direct evidence of the benefits of screening. Although
physicians adopt some screening and intervention practices despite a lack
of consensus, little is known about such practices regarding illicit drug
abuse. Thus, we conducted a national survey of primary care physicians and
psychiatrists to examine screening and intervention practices for illicit
drug abuse and the barriers to their implementation.10
METHODS
As previously reported,11 we mailed a
survey to a national systematic sample of family physicians, general internists,
obstetricians and gynecologists, and psychiatrists, from September 15, 1997,
to March 15, 1998. The institutional review board of the University of Chicago,
Chicago, Ill, approved this research.
DEPENDENT VARIABLES: ILLICIT DRUG PRACTICES
Using 5-point Likert scales, with responses from "never" to "always,"
the survey assessed how often the physician asked new adult outpatients about
illicit drug use and how often they used 4 interventions in cases of diagnosed
illicit drug abuse. The 4 interventions were recommending a 12-step program,
offering referral to a mental health professional, offering referral to a
chemical dependency treatment program, and counseling the patient without
other consultation or referral. Dichotomous variables created from these questions
indicated whether the physician usually or always offered any of the interventions
for illicit drug abuse.
EXPLANATORY VARIABLES: CONFIDENCE, ATTITUDES, AND BARRIERS
On 5-point Likert scales, the survey assessed physicians' confidence
in obtaining patients' history of drug use, their interest in caring for drug-using
patients, and the importance of 8 barriers to screening for substance abuse.
The brief Substance Abuse Attitude Survey12, 13
evaluated physician attitudes toward substance-abusing patients. Five subscales
(permissiveness, nonmoralism, nonstereotyping, optimism in the effectiveness
of treatment, and treatment intervention) are standardized along a 10-point
continuum, with 10 representing the most positive attitudes. The questionnaire
also inquired about the outpatient practice setting, including the percentage
of outpatients who are women, Hispanic, black, uninsured, Medicaid insured,
or aged older than 50 years or have a history of substance abuse.
STUDY POPULATION
We drew a self-weighted, national, systematic sample of 500 family physicians,
500 general internists, 500 obstetricians and gynecologists, and 500 psychiatrists
with greater than 50% clinical practice time from the AMA (American Medical
Association) Physician Masterfile,14 a listing
of all licensed physicians. Of the 2000 mailings, 107 could not be delivered.
The remaining 1893 included 856 eligible and 226 ineligible (retired or nonpracticing)
respondents and 811 nonrespondents, yielding an adjusted response rate of
57%.15 Sex, geographic location, and age of
respondents were similar to those listed in the AMA Physician Masterfile.
The 3 mailing waves revealed similar rates of illicit drug screening, making
response bias unlikely.16
STATISTICAL ANALYSIS
We entered the explanatory variables (P .25)
into stepwise multivariate logistic regression models to determine correlates
(P.05, 2-tailed) of whether the physician reported
that they usually or always ask about drug use or offer any intervention for
diagnosed illicit drug abuse. Models controlled for the physicians' specialty,
sex, age, and board certification. Statistical analysis was performed using
SAS statistical software (version 6.12; SAS Institute, Cary, NC).
RESULTS
Of the 856 eligible respondents, 243 (28%) were family physicians; 195
(23%), internists; 222 (26%), obstetricians and gynecologists; and 196 (23%),
psychiatrists. The mean ± SD age and length of practice were 46 ±
12 years and 19 ± 13 years, respectively; 29% were women, and 62% were
board certified. There were 23% from the Northeast, 24% from the Midwest,
30% from the South, and 22% from the West. Twenty-six percent practiced in
a group; 29%, hospital; 22%, solo; 4%, academic setting; 0.1%, health maintenance
organization; and 19%, unclassified or other.
Most physicians (68%) reported that they usually or always ask new outpatients
about illicit drug abuse. This reported inquiry was associated with psychiatry
or obstetrics and gynecology compared with family medicine, younger physician
age, lack of board certification, greater confidence in obtaining the patient's
history of drug use, greater optimism in the effectiveness of therapy, less
agreement with the statement, "patients don't want to be asked about substance
use," fewer perceived time constraints, and a practice with fewer older but
more black patients (Table 1). There was a trend toward an association between more screening and the percentage
of patients who are current or past alcohol or drug abusers (P = .05).
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Factors Associated With Screening and Intervention Practices for Illicit
Drug Abuse*
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For patients with diagnosed illicit drug abuse, 55% of physicians reported
that they usually or always offer referral to a chemical dependency treatment
program and 61% reported that they recommend a 12-step program. A similar
proportion reported that they offer referral to a social worker or mental
health professional, and few physicians reported that they counsel the patient
without referral. Of the specialties, psychiatrists were most likely to recommend
a 12-step program, while family physicians were slightly more likely to offer
referral to a formal treatment program (Figure
1). Although most physicians reported that they offer more than
1 of these interventions, 15% reported that they do not routinely offer any
intervention. Psychiatrists, female, and board-certified physicians were more
likely to intervene, while obstetricians and gynecologists were least likely
(Table 1). Greater confidence
in obtaining the patient's history of drug use, fewer perceived time constraints,
and fewer patients with a history of substance abuse were also associated
with a greater propensity to intervene.
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By specialty, percentage of physicians who reported that they usually
or always recommend a 12-step program, such as Narcotics Anonymous, offer
referral to a mental health professional or social worker, offer referral
to a chemical dependency treatment program, or counsel the patient without
other consultation or referral for diagnosed illicit drug abuse. Error bars
indicate SE.
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COMMENT
In this national survey, 32% of primary care physicians and psychiatrists
reported that they do not inquire routinely about illicit drug use. This finding
is not surprising given the lack of brief, well-validated screening tools
for illicit drug abuse, the dearth of evidence for benefits of screening,
and conflicting recommendations.5, 6, 7, 8, 9
Only 55% of physicians reported that they routinely recommend formal addiction
treatment to drug-abusing patients, and a substantial minority reported that
they do not regularly intervene at all, despite a consensus favoring referral
of drug-abusing patients to specialized treatment.9
Psychiatrists were most likely to intervene but, like many of their primary
care colleagues, were more likely to refer drug-abusing patients to a 12-step
program than to a formal treatment program. This practice pattern is contrary
to the available evidence, which provides strong support for formal addiction
treatment, especially the use of methadone maintenance, but few data regarding
the effectiveness of 12-step programs for drug abuse.4
Psychiatrists and obstetricians and gynecologists were most likely to
screen for drug use, but obstetricians and gynecologists were least likely
to intervene. This cross-sectional study cannot discern whether differences
in training or stigmatizing attitudes mediated the influence of specialty.
In distinction to prior research, stigmatizing attitudes contributed little
to inadequate screening and intervention practices toward substance-abusing
patients.13, 17 The exception was
in physicians who are optimistic about the effectiveness of treatment, a trait
that increased screening. Expectations about treatment have been previously
found to be related to drug abuse screening and intervention.18, 19, 20, 21
This finding highlights the need for research demonstrating downstream benefits
from such screening.
Younger age, which is highly correlated with more recent medical school
graduation, was also associated with screening.20
Curiously, board certification was correlated with less propensity to screen
for illicit drug abuse but more propensity to intervene. We can only speculate
that board-certified physicians do not screen because of conflicting recommendations
but are more likely to follow the solid consensus favoring intervention.9
A correct perception of the lower prevalence of illicit drug abuse in
the older population might underlie decreased screening for illicit drug abuse
among physicians who treat older patients. Greater screening among physicians
who treat more black patients might reflect the negligible increased prevalence
of drug use among the black population (7.5% of black individuals vs 6.4%
of white individuals).22 Alternatively, it
might indicate prejudice regarding susceptibility to drug abuse.
Physicians' confidence in obtaining the patient's history of drug use
was correlated with both screening and intervention. Self-efficacy has been
previously associated with substance abuse practices.11, 20
Development of brief, accurate screening tools might further augment confidence
in obtaining the history of drug use. Concern that patients do not want to
be asked about drug use implies a lack of familiarity with reports that patients
willingly disclose sensitive information to physicians.23, 24
The association between screening and intervention and perceived time constraints
suggests the need for prescreening questionnaires or chart prompts and the
need for training physicians and other staff in brief therapeutic strategies,
to facilitate screening and intervention in busy clinical settings. We cannot
determine the direction of the trend association between more substance-abusing
patients in the physician's practice and a greater propensity to screen. One
can speculate that patients with easily recognized histories of substance
abuse might have more severe addictive disorders and that prior treatment
failures might have left the physician skeptical about intervention.
These findings require validation in other physician samples. A major
limitation of this study is its reliance on reported, not actual, practices.
Also, social desirability may have biased respondents' reports of their screening
and intervention practices. This study's strengths are national representation
and a response rate comparable to other physician surveys.25
The findings suggest that initiatives to promote physician involvement with
illicit drug abuse should include strategies to increase physicians' confidence
in managing these problems, to engender optimism about the benefits of addiction
treatment, to dispel physician concerns about patients' sensitivity about
substance issues, and to address perceived, rather than actual, time constraints.
AUTHOR INFORMATION
Accepted for publication June 16, 2000.
This research was funded by a grant from the Home Health Care Research
Program and the summer research program of the Pritzker School of Medicine
(Ms McCullough), the University of Chicago, Chicago, Ill; Generalist Physician
Faculty Scholar awards from the Robert Wood Johnson Foundation, Princeton,
NJ (Drs Friedmann and Saitz); Mentored Clinical Scientist Career Development
Award K08-DA00320 (Dr Friedmann), and grant R01-DA10019 (Dr Saitz) from the
National Institute on Drug Abuse, and grant R01-AA10870 from the National
Institute on Alcohol Abuse and Alcoholism (Dr Saitz), Bethesda, Md; and faculty
development grant T26-SP08355 from the Center for Substance Abuse Prevention,
Rockville, Md (Dr Saitz).
We thank the participating physicians.
From the Division of General Internal Medicine, Rhode Island Hospital,
Brown University School of Medicine, Providence (Dr Friedmann); the Pritzker
School of Medicine, University of Chicago, Chicago, Ill (Ms McCullough); and
the Clinical Addiction Research and Education Unit, Section of General Internal
Medicine, Department of Medicine, Boston Medical Center, Boston University
School of Medicine, Boston, Mass (Dr Saitz).
Corresponding author: Peter D. Friedmann, MD, MPH, Division of General
Internal Medicine, Rhode Island Hospital, 593 Eddy St, Providence, RI 02906
(e-mail: pfriedmann{at}lifespan.org).
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