Validation of self-administered single item screening questions (SISQs) for unhealthy alcohol and other drug use in primary care patients at two sites Jennifer McNeely, Charles M. Cleland, Shiela M. Strauss, Joseph J. Palamar, John Rotrosen, Marc N. Gourevitch, Richard Saitz

No relevant financial relationships to disclose

Objectives

1. Describe the need for a self-administered approach to substance use screening 2. Single Item Screening Questions (SISQs) for alcohol and drug use 3. Present results of a validation study in primary care 4. Discuss feasibility and application

Screening for substance use in primary care

• • Medical providers fail to identify clinically relevant substance use D’Amico, Medical Care 2005 Barriers to screening: o o o o o

Time Workflow

Knowledge/Training Discomfort Attitudes Sterling, Addict Med Clin Pract 2012 Friedmann, J Gen Int Med 2000 Friedmann, Arch Int Med 2001 Anderson, Alcohol Alcoholism 2004 McCormick, J Gen Int Med 2006

Self-administered screening is a more feasible approach

Screening

SISQ-alcohol and SISQ-drug

+ Assessment Low Risk Education Monitoring Moderate Risk Office-based counseling High Risk or Dependence Treatment

Single Item Screening Questions

• SISQ-alcohol

How many times in the past year have you had X or more drinks in a day?

(X=5 for men, and X=4 for women) • SISQ-drug

How many times in the past year have you used an illegal drug or used a prescription medication for non medical reasons (for example, because of the experience or feeling it caused?

Prior validation of SISQs

• • • • • Adult primary care patients (N=286) Single site, urban safety net medical center Good sensitivity and specificity for detection of unhealthy use SISQ-alcohol: Sensitivity 82%, Specificity 79% SISQ-drug: Sensitivity 85%, Specificity 96% Smith et al., JGIM 2009 Smith et al., Arch Int Med 2010

Current Study

Screening (computer) • • SUBS

SISQ-alcohol, SISQ-drug

Validation Measures (interviewer) • • • • • Timeline Follow Back SIP-A and SIP-D MINI-Plus REALM Demographics Referrals Incentive Second Consent Saliva drug screen

Reference standard measures

Alcohol Drugs Unhealthy use Disorder Unhealthy use Disorder

Timeline follow back (30d)

+ +

SIP-A

+

SIP-D

+

MINI-Plus screening MINI-Plus abuse or dep Intercept oral fluid test*

+ + + + + * Collected at Site A only

Statistical Analysis

1. Comparison of SISQs to composite reference standards 2. Examined site differences 3. Calculate sensitivity, specificity, AUC: o Unhealthy use o Substance use disorder 4. Subgroup analyses

Study Sites and Recruitment

• • • • Adult primary care clinics 2 urban safety net hospitals Patients presenting for medical visits Consecutive recruitment • • • • Eligibility Criteria: Age 21-65 Current clinic patient Fluent in English No disability preventing computer use

Participant Recruitment

Screened: N = 2131 Eligible: N = 915 1216 were excluded Language: 679 Age: 306 Not a patient: 168 Other: 115 453 declined No time: 363 Other: 90 1 lost data Completed interview: N = 459 Site A: 265* Site B: 194 *230 (87%) Site A participants agreed to saliva test

Characteristics of the 459 participants Age (years) Sex (%) Race/Ethnicity (%) Mean = 46, SD = 12 Range = 21-65 Male Female Transgender Black/African American Hispanic White/Caucasian Other Country of Birth (%) United States Outside of United States 48.4

51.2

0.4

51.8

20.2

19.1

8.6

64.6

35.3

Education and Health Literacy

Highest Level of Education 14% 25% 61% Less than high school High school diploma/GED College degree 59% Health Literacy Level 41% < High school High school or higher

Prevalence of substance use

Substance Past year use (MINI) Alcohol Drugs Specific drug categories Illicit drugs Marijuana N (%)

103 (22.3) 114 (24.7) 108 (23.4) --

Cocaine Heroin

- --

Hallucinogens

- Prescription drugs (non-medical use) 21(4.6)

Opioids Benzodiazepines Stimulants

- - - a c

Past month use (TLFB) N (%)

89 (19.3) b 73 (15.8) c 5 3 2 58 (12.6) 12 (2.6) 10 (2.2) 1

Unhealthy use

Substance + on SISQ

Alcohol

N (%)

155 (34)

+ on Reference N (%)

146 (32) Drugs 107 (23) 122 (27)

Sensitivity % (95% CI)

73.3 (65.3, 80.3)

Specificity AUC % (95% CI)

84.7 (80.2, 88.5)

(95% CI)

0.79 (0.75, 0.83) 71.3 (62.4, 79.1) 94.3 (91.3, 96.6) 0.83 (0.79, 0.87) Oral fluid test results: 8 tested positive, all reported use on SISQ  No change to results

Substance use disorder

Substance + on SISQ

Alcohol

N (%)

155 (34)

+ on Reference N (%)

60 (13) Drugs 107 (23) 74 (16)

Sensitivity % (95% CI)

86.7 (75.4, 94.1)

Specificity AUC % (95% CI)

74.2 (69.6, 78.4)

(95% CI)

0.80 (0.76, 0.85) 85.1 (75.0, 92.3) 88.6 (85.0, 91.6) 0.87 (0.83, 0.91)

Subgroup Analysis

• • • • • • Subgroups anticipated to have greater difficulty with self-administered screening: Male Age greater than 50 Hispanic/Latino Primary language other than English Born outside US Education or health literacy lower than high school level

Subgroup Analysis

• • No differences for SISQ-alcohol Lower sensitivity of SISQ-drug among: Primary language other than English (p<0.01) English Non-English Sensitivity 74.3 (65.1, 82.2) 46.2 (19.2, 74.9) Specificity 94.4 (90.7, 96.9) 94.3 (87.1, 98.1) Less than high school education (p<0.01) Sensitivity Specificity High school 79.0 (66.8, 88.3) 95.2 (91.0, 97.8) < High school 63.3 (49.9, 75.4) 93.3 (88.0, 96.7)

50% 40% 30% 20% 10% 0%

Site A

Required assistance Other Computer-related Comprehension/ reading

Site B

Limitations

• • • Safety net primary care populations English speaking only Tested in research context, with assurance of confidentiality

Conclusions

• SISQs accurately identified unhealthy substance us in primary care patients • Lower sensitivity and specificity than interviewer-administered versions • Efficiency, fidelity, and patient comfort may be advantages to self-administered approach

Acknowledgements

• • • Funding: K23 Career Development Award NIDA K23 DA030395 NYU-HHC CTSI Pilot Grant NIH/NCATS UL1 TR000038 The MITRE Corporation (contract from ONC and SAMHSA) • • • • • • • • • • • • • Staff and others: Seville Meli Jacqueline German Ritika Batajoo Catherine Federowicz Marshall Gillette Charlie Jose Emily Maple Keshia Toussaint Julianne Cameron Arianne Ramautar Derek Nelsen Linnea Russell Study participants