A Brief Self-administered Substance Use Screening Tool for Primary Care: Two-site validation study...
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A Brief Self-administered A Brief Self-administered Substance Use Screening Tool for Substance Use Screening Tool for Primary Care: Two-site validation Primary Care: Two-site validation study of the Substance Use Brief study of the Substance Use Brief
Screen (SUBS) Screen (SUBS)
Jennifer McNeely, Shiela M. Strauss, Charles M. Cleland, Richard Saitz, Joseph J. Palamar, John Rotrosen, Marc N. Gourevitch
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No relevant financial relationships to disclose
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ObjectivesObjectives1. Discuss potential advantages of a self-
administered screening approach2. Describe development of the Substance Use
Brief Screen (SUBS)3. Present results of a validation study in primary
care 3. Discuss feasibility and application
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Self-administered Self-administered screening approachscreening approach
1. Efficiency
2.Fidelity
3. Patient comfort
Sterling, Addict Med Clin Pract 2012Friedmann, J Gen Int Med 2000Friedmann, Arch Int Med 2001Anderson, Alcohol Alcoholism 2004McCormick, J Gen Int Med 2006
Bradley, JGIM, 2011Williams, ASCP, 2013
Tourangeau, Pub Op Quart, 1996Wight, AIDS Educ Prev, 2000
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Substance Use Brief Screen (SUBS)Substance Use Brief Screen (SUBS)
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Instrument development Instrument development processprocess
Pilot Study Modify computer interface
Inform feasibility, acceptability
Focus Groups
Test-retest Reliability Excellent agreement
Validation: comparison to reference standard
measures
McNeely, et al., INEBRIA 2011; AMERSA 2011McNeely et al., SGIM 2012McNeely et al., Substance Abuse, in pressSpear, Shedlin, McNeely, AHSR 2013McNeely et al., J Sub Abuse Treat, under review
Cognitive Interviews Select language and format
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Overview of Study Overview of Study ProceduresProcedures
Screening (computer) Validation Measures (interviewer)
ReferralsIncentive
• ASSIST• Timeline Follow
Back• MINI-Plus• Fagerstrom• REALM• Demographics
Oral fluid tests
Second Consent
• SUBS• SISQ-alcohol, SISQ-drug
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Reference standard Reference standard measuresmeasures
ASSIST TLFB (30 days)
MINI-Plus Fagerstr
om Test*
Nic-Alert oral fluid *
Intercept oral fluid*
Tobacco – unhealthy use + + +
Tobacco - disorder +
Alcohol – unhealthy use + + +
Alcohol - disorder + Illicit drug – unhealthy use + + + +
Illicit drug - disorder +
Rx drug – unhealthy use + + + +
Rx drug – disorder +
* Collected at Site A only
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Statistical AnalysisStatistical Analysis1. Comparison of SUBS item to
composite reference standards 2. Examine site differences3. Calculate sensitivity, specificity, AUC:oTobacco oAlcoholo Illicit drugsoPrescription drugs
4. Subgroup analysesAny drugs
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Study Sites and Study Sites and RecruitmentRecruitment
• 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
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Participant RecruitmentScreened: N = 3063
Eligible: N = 1198
1865 were excludedLanguage: 972Age: 439Not a patient: 229Other: 225
Completed interview: N = 586Site A: 390*Site B: 196
610 declinedNo time: 499Other: 111
2 had lost data
*348 (89%) Site A participants agreed to saliva test
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Characteristics of the 586 Characteristics of the 586 participantsparticipants
Age (years) Mean = 46, SD = 12Range = 21-65
Sex (%) MaleFemaleTransgender
49.849.80.4
Race/Ethnicity (%) Black/African American HispanicWhite/Caucasian Other
50.221.718.79.4
Country of Birth (%)
United StatesOutside of United States
66.433.6
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Education and Health LiteracyEducation and Health Literacy Highest Level of Education Health Literacy Level
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Prevalence of substance usePrevalence of substance use
Substance Lifetime use %
Current use%
Tobacco 64 37Alcohol 85 56Any Drug 62 26
Illicit 59 23Prescription 24 9
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Unhealthy useUnhealthy useSubstance + on SUBS
N (%)
+ on Reference
N (%)
Sensitivity
%(95% CI)
Specificity
%(95% CI)
AUC
(95% CI)
Tobacco 144 (37) 136 (35) 98 (94-100) 96 (92-98) .97(.95-100)
Alcohol 252 (43) 189 (32) 85 (79-90) 77 (73-81) .81 (.78-.84)
Illicit Drugs 133 (23) 148 (26) 81 (74-87) 97 (95-98) .89 (.86-.92)
Rx Drugs 74 (13) 54 (9) 56 (41-69) 92 (89-94) .74 (.67-.80)
Any Drugs 169 (29) 160 (28) 83 (76-88) 91 (88-94) .87 (.84-.90)
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Unhealthy use: saliva test Unhealthy use: saliva test resultsresults
(n=390)(n=390)Substance + on SUBS
N (%)
+ on Reference
N (%)
Sensitivity
% (95% CI)
Specificity
%(95% CI)
AUC
Tobacco 144 (37) 121 (31) 99(96-100)
91(87-94)
.951
Alcohol 167 (43) 67 (17) 94(85-98)
68(62-73)
.809
Illicit Drugs 77 (20) 83 (21) 80(69-88)
96(94-98)
.879
Rx Drugs 45 (12) 25 (6) 56(35-76)
91(88-94)
.737
Any Drugs 108 (28) 85 (22) 86(76-92)
89(85-92)
.874
NC NC
77 92
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Substance Use Disorder Substance Use Disorder
Substance + on SUBS
N (%)
+ on Reference
N (%)
Sensitivity
%(95% CI)
Specificity
%(95% CI)
AUC
(95% CI)
Tobacco 144 (37) 49 (13) 100 (93-100) 72 (67-77) .86 (.84-.89)
Alcohol 252 (43) 77 (13) 94 (86-98) 65 (60-69) .79 (.76-.83)
Illicit Drugs 133 (23) 95 (16) 82 (73-89) 89 (86-91) .85 (.81-.90)
Rx Drugs 74 (13) 27 (5) 59 (39-78) 89 (86-92) .74 (.65-.84)
Any Drugs 171 (30) 98 (17) 86 (77-92) 82 (78-85) .84 (.80-.88)
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Subgroup AnalysisSubgroup AnalysisSubgroups 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
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Subgroup AnalysisSubgroup Analysis• Lower sensitivity for unhealthy drug use in
females (p<0.01)
• Higher sensitivity for tobacco use in Hispanics (p<0.01)
Sensitivity SpecificityFemale 70.9 (51.7, 82.4) 94.3 (90.5, 97.0)
Male 88.6 (80.9, 94.0) 87.0 (81.2, 91.5)
Sensitivity SpecificityHispanic 100.0 (96.2,
100.0)94.6 (90.3, 97.4)
Non-Hispanic 92.7 (80.1, 98.5) 98.5 (91.8, 100.0)
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LimitationsLimitations• Safety net primary care populations• English speaking only• Tested in research context, with
assurance of confidentiality• Low prevalence of prescription drug
misuse
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ConclusionsConclusions• Substance Use Brief Screen (SUBS)
accurately identified unhealthy substance us in primary care patients
• Additional assessments may be needed for prescription drug misuse
• Computerized self-administered approach has potential to ease implementation barriers to substance use screening in primary care
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AcknowledgementsAcknowledgementsFunding:• K23 Career Development
Award NIDA K23 DA030395• NYU-HHC CTSI Translational
Pilot GrantNIH/NCATS UL1 TR000038 • The MITRE Corporation
(contract from ONC and SAMHSA)
Staff and others:•Julianne Cameron•Arianne Ramautar•Derek Nelsen•Linnea Russell•Seville Meli•Jacqueline German•Ritika Batajoo•Catherine Federowicz•Marshall Gillette•Charlie Jose•Emily Maple•Keshia Toussaint•Study participants