Michael Bogenschutz, Dennis Donovan, Cameron Crandall, Robert Lindblad,

Raul Mandler, Harold Perl, Alyssa Forcehimes

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Screening Procedures to Identify Problematic

Substance Users in Medical Emergency Departments

Goals for This Presentation

Describe and provide rationale for screening procedures used in the NIDA CTN SMART-ED study

Describe characteristics of sample screened and recruited to date using these procedures

Screening for Study vs. Clinical Screening The purpose of screening in this study is to

define a population of patients who are likely to have problematic drug use, abuse, or dependence for inclusion in the study, and to do so with minimal interaction (to minimize assessment reactivity).

Priority is high positive predictive value (probability of the disorder given positive test).

Clinical screening instruments are designed to have high sensitivity (probability of a positive test given the disorder).

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Recruitment Total proposed N is 1285 randomized

participants. 6 sites will recruit an average of 215

participants. Site recruitment target is 6 participants

per week. We estimated that 5% of screened

patients would qualify for the study. Therefore, 120 patients would need to

be screened per week at each site to achieve the recruitment target.

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Screening

Screened sample must be broadly representative of ED population, but does not need to be a random sample.

RAs screen patients out of the ED flow by identifying potentially eligible participants in the ED log.

Brief Information Tool (BIT) records basic demographics and presenting complaint for all patients for whom screening is attempted.

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Screening, cont.

After triage, before or during ED treatment, RA approaches ED patient and invites him/her to participate in anonymous screening for possible study participation.

Screening proceeds following verbal informed consent.

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Screening Instrument Screening instrument is called the TAD

(for Tobacco, Alcohol, and Drug). Administered using tablet PC. Includes a total of 20 questions:– Heavy Smoking Index (4 items)– AUDIT-C (3 items on quantity/frequency of

alcohol)– Drug Abuse Screening Test (DAST-10)– Primary substance, days of use of primary

substance in past 30 days, and substance- relatedness of the ED visit.

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Screening, cont.

Screening continues for participants who have DAST-10 score of 3 or greater and report at least 1 day of use of the self-identified primary problem substance in the past 30 days.

RA then administers Secondary Prescreening Form (SPF) to assess additional exclusion criteria.

Participants who pass are invited to proceed to written informed consent for the study. 8

Completion of screening prior to randomization Before participant can be

randomized the RA must complete– Demographics– Locator Information Form– Hair sample (objective measure of

substance use)– Enrollment Forms A and B

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Screening and Randomization Through Sept 20, 2011

Site # BITs # TADs # Randomized

% BITs Randomized

% TADs Randomized

1 5636 3481 252 4% 7%

2 3226 2262 287 9% 13%

3 2096 1638 69 3% 4%

4 2576 1737 95 4% 5%

5 1881 1553 111 6% 7%

6 426 405 141 33% 35%

Overall 15841 11076 955 6% 9%

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Substance use among those completing the TAD

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2,855 participants endorsed past-30d drug use (25% of TADs).

Of these, 955 have been randomized (33% of drug users).

Most of those not randomized were excluded because they did not meet DAST ≥ 3 criterion.

Drug use by primary substance

PrimaryDrug

30-day drug users from TAD

Randomized participants

% users randomized

# users

% days use

# users

% days use

Cannabis 1666

58% 12 394 41% 18 24%

Cocaine 508 18% 9 249 26% 12 49%

Street Op. 361 13% 16 188 20% 21 52%

Prescr. Op.

166 6% 13 53 6% 18 32%

Methamph.

81 3% 7 43 5% 11 53%

Sedatives 35 1% 14 13 1% 20 37%

Hallucin. 22 1% 3 7 1% 3 32%

Amphet. 16 1% 6 3 0% 7 19%

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Primary Substance by site

Site Cannabis

Cocaine Street opioids

Prescr. opioids

Meth. Sedative

Halluci-nogens

Amphet-amine

1 17% 17% 43% 8% 16% 1% 0% 0%

2 49% 30% 14% 5% --- 1% 1% ---

3 46% 25% 14% 6% 1% 4% 3% ---

4 49% 34% 9% 2% 3% 1% --- 1%

5 76% 8% 5% 10% --- 2% --- 1%

6 35% 48% 11% 3% --- 2% 1% ---

Total 41% 26% 20% 6% 5% 1% 1% 0%

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Demographics (n = 343, primarily from two wave-1

sites) 64% male mean age 39 ± 12 54% non-White, 26% Hispanic 2% were college graduates 9% were married 10% had full-time jobs 79% had household incomes

under $15,000.

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Conclusions

6% of those selected for screening, and 9% of those screened, were enrolled in the study.

25% of those screened endorsed past-month drug use.

Sites differ in prevalence of various classes of drugs and overall rates of drug use.

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Conclusions, continued These screening procedures are

identifying heavy users of several types of drugs, as well as a larger number of drug users who do not meet severity criteria for the study.

These procedures would likely need some modification for practical clinical use.

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