Good afternoon, everyone. My name is Sejal Patel. I work for American Psychiatric Association's Division of Research, and I'm project manager for MNET, Addiction Medicine Practice-Based Research Network. As you know, MNET is a network of office-based addiction medicine prescribers working to address the opioid epidemic and in-patient outcomes. For today's webinar, we are joining by Dr. Jennifer McNeely. She is associate professor at Department of Population Health and Department of Medicine at NYU School of Medicine. Before we get started, I will quickly go through some housekeeping details. So thank you, Dr. McNeely. So please unmute your microphone by clicking microphone icon. Also, make sure you are not using both your computer audio and calling in by phone as it causes feedback noise. Please raise your hand by clicking on participants and find the raise hand button. Type any questions you have in the question box, and we are monitoring the chat box. We'll take up your questions, you know, once the presentation is over. And the last thing I want to mention is that by participating in this webinar, you can earn CME credit. After the webinar is over, within 24 hours, you will receive a link. And by following that link and taking some questions, you will be able to earn CME credit provided by APA. So to that end, Dr. McNeely, the floor is yours. Great, thank you. So it's great to be with all of you today, virtually. And I just to lead off, I want to note I have no disclosures, no conflicts of interest, and all the work that I'm talking about today has been funded by NIH. So I am an addiction medicine physician and primary care provider who does research really focused broadly on integrating identification and interventions for substance use, mostly drugs, but also including alcohol into general medical settings. And much of my work has been in primary care and screening has been, you know, centered in a lot of that work. And that's the subject of what the talk is about today. This is what I'm hoping to cover. First to review the current screening guidelines and evidence behind them. Then jump into screening instruments, not an exhaustive review, but calling out a couple of instruments that can be used in medical settings. And then thinking about implementation. So the talk is going to be divided about equally between these content areas. My own work on screening started early in my career, actually, with support of a NIDA K23 Career Development Award. And I often start a talk like this with acknowledging the people who have mentored and supported me over the years. And today, I'm especially acknowledging Rich Bates, who was a real leader in the field of screening and how to address substance use in medical settings. Rich, unfortunately, passed away very much before his time last week from pancreatic cancer. And I, like many, many others in the field really feel the loss of an important colleague and mentor, as well as a friend who's had a great influence on me, particularly around this work on screening. And so, you know, Rich's work, I encountered first around this article on unhealthy alcohol use in the New England Journal. I remember I was a resident in medicine and I came across this, which really helped to solidify my thinking about how we really can do this, especially in primary care. And then he led the work around developing and then validating single-item screening questions for alcohol and drug use, which showed that it was feasible to screen in a brief way. And then, you know, he kept a very clear and unrelenting eye on the evidence behind screening and intervention to address drug use. And while he and I sometimes disagreed on what we should be doing in the face of that evidence, he was my most trusted colleague in this area. And I will really miss having the opportunities to, you know, check in with him and to talk about. So, the field will miss him. I will miss him. I just want to acknowledge that. You know very well about the health consequences, generally, of substance use. But I think it's always helpful to remember that when we begin to talk about screening and interventions in medical care settings. So, you know, tobacco, alcohol, and drug use are all among the top 10 preventable causes of death in the U.S. And that was true even before the current overdose crisis and is now even more so with over 100,000 overdose deaths in the past year. So, we know also that in medical settings, we see a lot of patients who have unhealthy alcohol and drug use. And in fact, the prevalence is a little higher in medical settings, even in primary care, than in the general population with, you know, depending on the specific environment and location, but around a quarter of patients would have some type of risky substance use and 5 to 10% of patients having a substance use disorder in most primary care settings. And then in inpatient care settings, in inpatient settings, and then in the hospital, and certainly in the emergency department, the severity tends to skew even higher with about 17% and sometimes, you know, 20% of patients having a substance use disorder. So, you know, this population, particularly people with substance use disorder, tend to have a high utilization of acute care, emergency room, hospital, and many touches, actually, with our healthcare system. And those are all opportunities to identify the substance use and to provide help with it. But those opportunities are often missed. And one sort of fundamental reason, though not the only reason, is that healthcare providers are often unaware of their patients' substance use. And that's when screening enters into the picture. So, when the United States Preventive Services Task Force, or USPSTF, is really the main arbiter of what happens for preventive care, and especially screening in primary care settings. And they have looked at the evidence and made recommendations for alcohol and drugs. You know, the alcohol recommendation, which is for screening for unhealthy alcohol use in primary care in adults and offering brief counseling interventions, has been a recommendation on the books for about two decades now, though it's not still widely implemented. The drug screening recommendation is more recent, came about in 2020, when the task force changed from an insufficient evidence recommendation to a grade B recommendation. And you'll note that the statements, the recommendation statements, are slightly different. But in both cases, it's for screening adults in primary care. And for drugs, the qualifier is that screening should be implemented when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred. And it clarifies that screening means asking questions, not doing toxicology testing. So, I want to walk through sort of where these guidelines come from very briefly next. And we'll talk about the difference between the alcohol and the drug screening guidelines in that context. So, when the USTF-TS sets up the question about screening, this is generally how they look at it. So, with this and for other conditions as well, often starting with, you know, does screening itself lead to reduced morbidity and mortality? And with the alcohol screening, which we're looking at first, and with most sort of screening for preventive care, the answer is no. Maybe the only exception, I think, to that rule I've ever been able to come up with is maybe colonoscopy, where you can actually screen and remove a polyp that could directly have an effect on morbidity. But usually, what we're looking at is does screening, you know, can you accurately detect the condition with screening? And then, does that allow you to offer interventions that can then lead to, you know, reduced alcohol use, leading to reduced risk behaviors and and improve social outcomes, thereby leading to reduced morbidity and mortality? And for alcohol, we check all these boxes. We have screening tools that can detect unhealthy use accurately. And when use is detected, we have, you know, feasible brief interventions, as well as alcohol use disorder treatments that can reduce consumption and go down this path. And in fact, the evidence base for alcohol screening and brief intervention is quite strong. The benefit is modest, and that's the source of the grade B recommendation by the task force. But the evidence base is quite robust, that it does reduce hazardous and harmful alcohol use, can decrease healthcare utilization, and it is ranked as among the five most effective clinical preventive services in the U.S. Quality matters, and the best quality, at least the best evidence, is from doing this in primary care. The drug screening recommendation, so we're going to walk through this in the same way. The setup for how the USPSTF looks at that question is essentially the same as with alcohol. And starting with, you know, the screening itself, reduced morbidity and mortality, and the answer is no. And then we get to, you know, the rest of the pathway. So, screening, do we have screening tools that are feasible to use and that can accurately detect drug use? The answer is yes. And that was actually sort of a change that led in this latest recommendation in favor of screening, was in part based on a better development, you know, development of better screening tools that were more accurate. And the answer is yes. Accurate and more feasible. But then we get into the rest of the pathway, which is, you know, by screening, do we have interventions that we can offer to a population that's detected through screening, not a treatment-seeking population, that can reduce, you know, drug use and improve risk behaviors and down the line reduce morbidity and mortality. And this is where the evidence base for drugs is weaker than for alcohol, is that we know that we have, you know, treatment interventions that can work for people, especially for people with drug use disorders. And the treatment of opioid use disorder in primary care is probably the prime example of a highly effective intervention. But we don't have great evidence for, you know, a population that's detected only on screening, who didn't walk in the door looking for treatment, being able to start them on that pathway. And so that's the evidence gap that's created a fair amount of controversy in the drug screening recommendation, which is also a grade B recommendation from USPSDS. And this is where, you know, frankly, more work and more research is needed. So, the other aspects of the recommendation, so it is restricted to adults, but, you know, special populations, including pregnant women, are included in that recommendation. And screening is to be by, through questionnaires, the self-reported, not toxicology testing. And this qualifier, that screening should be done when services for accurate diagnosis, treatment, and appropriate care can be offered or referred. So, I would argue that essentially any medical setting should be able to meet that condition. I also think it's useful to, you know, take a step back from how the USPSDS frames the question and to think about what is the value as clinicians from screening. And here it's a bit broader. So, you know, certainly screening, we can reduce a consumption of alcohol or drugs through the interventions that are targeting the substance use itself. But also screening is important for knowing about alcohol and drug use is important for delivering clinical care, that there are patient safety issues like drug medication interactions or, you know, what will happen to my patient who's getting admitted to the hospital for elective surgery if they go into alcohol withdrawal that I wasn't expecting. There are issues around making an accurate diagnosis of conditions that we see really commonly, you know, hypertension, depression, almost anything is highly affected by unhealthy substance use. We also know that it affects treatment outcomes, for example, through impacting adherence to medications or other treatments and prevention that we screen differently for things like HIV or hepatitis or sexually transmitted infections. Based on a risk profile that substance use is part of. And also, and I think important for your group as well is, you know, we need to know about prevalence in the populations that we're taking care of in order to, you know, inform service design and to know, you know, really what's happening in our, that's directly affecting our population that we may be able to impact through the services that we're giving. And if we don't have information, we kind of don't know where to start. And that's also an argument for doing some systematic screening in medical settings. And finally, yeah, it's important for bringing this into the medical conversation and reducing the stigma around unhealthy alcohol and drug use. We can't expect patients to walk in and bring this up themselves. Sometimes patients do, which is incredibly impressive to me when I'm in clinic and a patient walks in and brings this up before I do. But most of the time it's something that's embarrassing, that patients don't feel like they are free to talk about or to ask for help with until things are quite severe. And so, for sort of normalizing the conversation, bringing this into the overall context of regular healthcare, I think we have to systematically forget any habits or have systems that just incorporate asking about alcohol and drug use routinely for patients. So, that's sort of the background that I wanted to start with to lead into talking about screening tools that can be used in medical settings. And there's a whole host of screening instruments. You may be familiar with many of them. And I'm just going to focus in on a couple that are well-suited and really were developed for brief screening in medical settings. So, for thinking about doing this, I think it's helpful to remember that substance use exists on a continuum. And you're progressing from low risk use to risky use to use is causing problems up to substance use disorders. And as use as consumption goes up, the consequences of use tend to go up. And when we're screening, generally what we're looking to identify is any unhealthy use, so anything other than low risk use. But. Yeah, there may be settings where maybe you only want to identify substance use disorders. So in a addiction treatment setting, for example, where you're trying to really target interventions, maybe there you only want to identify the higher severity substance use. But in general, for preventive care and early intervention, we want to identify this whole top of the pyramid, starting with risky use. And the prevalence in general in the population, if you think about alcohol and drug use combined is about a third of the population should exist in this unhealthy use part of the pyramid. And if we're implementing screening in a high quality way, that's what we would more or less expect to detect. In thinking about how to organize choices around screening tools, I think about it on a spectrum as well of tools that are for pretty much universal screening. Asking a question, is there any use, yes or no, to sort your population to know then who needs further assessment? And those screening tools should take very few resources to deliver because you need to deliver them to a lot of people. And then for those going down the line, for people who screen positive, ideally you would want to have tools that could assess the level of risk and maybe tell you what types of substances someone was using, which can help to guide clinical care. And then sort of the highest resource type of assessment in this process is making a diagnosis of a substance use disorder. And typically that requires a trained clinician. So some folks have started to work with patient administered checklists, but that's the most intensive part. We're going to focus today on the first two steps of screening and brief assessment. The screening tools I'll talk about are the TAPS tool, which can be used for screening and for brief assessment. And then we'll touch on the single item screening questions and the audit and Audit C. I'm going to spend most of the time on the TAPS tool because in some ways this is the newer instrument. So at this point it's been around for a number of years. And this was the one that I've done the most work with in a study led by Robert Schwartz where we developed and validated the TAPS tool in a large primary care population. The TAPS tool is an integrated screening and brief assessment instrument. It starts with a four item screener that asks about past year use of tobacco, alcohol, non-medical use of prescription drugs, and any use of illicit drugs. And then a positive response to one of those four substance classes would then lead you into the corresponding items on the TAPS tool, which is a modified and shortened version of the longer WHO assist instrument. And that covers seven substance classes, asks about current use, so use in the past three months, and gathers information about problems related to use in just a couple of questions. And the TAPS was intentionally developed in two formats and validated that way as a self-administered version that can be done by patients themselves on an iPad or something similar, and an interviewer-administered version. And this is the study that Robert led that we conducted in the NIDA clinical trials network. Five primary care clinics participated with 2,000 adult primary care patients in the study, and they completed the TAPS tool in both versions, the interviewer and the self-administered, and were randomized to which one they completed first, whether they did self-administered first or second. The reference standard measure was the CD, which allowed us to identify DSM-5 diagnostic criteria, and the comparisons were for looking at TAPS detecting problem use and substance use disorder. This is from our study, an example of what the TAPS looked like. So this is from the TAPS-1, the initial screener, asks in the past year, how often have you used? This is the prescription medication item, and it gives these categories ranging from never to daily or almost daily, but basically any response other than never is considered a positive screen on the TAPS-1. And if you answered yes to that question about prescription medication, then you would, in the TAPS-2, receive these substance more specific items about use in the past three months of first, prescription opioids, second, sedatives, and third, prescription stimulants. And if you were to answer yes to use in the past three months of one of those, you would get two follow-up questions about really problems related to use that would generate your score. So this is the validation study. So the scores for any, these are the substance classes that we looked at. I'm just noting that prescription stimulants are not in this table because we didn't have a large enough sample to get reliable estimates of sensitivity and specificity in the general adult primary care population where the study was done. So scores can range from one, from zero to three, up to four for alcohol. And this, a score of one or greater was what we were looking at for this problem of, for identifying problem use. So what the table is showing is the sensitivity and specificity of the TAPs for identifying problem use on the self-administered version. And in general, with these screening tools, what we're looking for is the sensitivity of 70 percent or greater, sensitivity being how good is the instrument at picking up unhealthy use when it's present. And then specificity is how good is the tool at ruling out unhealthy use when it's not present. So how good is it at avoiding false positives. And there for specificity, generally we're looking for 80 percent or greater. And what we see is with this cutoff in the validation study, the TAP performs well for tobacco, alcohol, marijuana, cocaine, and heroin, the most commonly used substances and the most commonly used illicit substances for cocaine and heroin. And then for the prescription medications, less well. So unfortunately, this is comparable to other screening tools that have tried to identify non-medical use of prescription drugs. We can take questions about it at the end, but it's just it's a tricky thing for multiple reasons to identify on a screener. The specificity for all substances was high. So that's for problem use. And the interviewer-administered version had a really very similar findings, no substantial difference. So looking at validity for detecting substance use disorder, this is measured using the CD and using the higher cutoff of a TAP score of two or greater. So the higher cutoff, what we what we see is pretty good sensitivity for identifying the three substances that are most commonly used in primary care populations, which are tobacco, alcohol, and marijuana. And then it drops off for the other drugs and prescription medication. Specificity is high across the board. So essentially, if you have a positive TAP score with two or greater for any of these substances, it's likely to, there's a high likelihood of substance use disorder, but the sensitivity is low enough that you wouldn't want to rely on a negative screen, a negative TAP score with not having a score of two or greater to rule out use of drugs other than marijuana. And so the recommendation is to do some assessment of patients who have a TAP score of one for any drug, but for tobacco, alcohol, marijuana, you can be quite, have a good degree of certainty that with a TAP score of two or greater, you're dealing with higher risk use or substance use disorder. Just a reminder that the TAP is a two-part instrument, so the four-item screener followed by what we were just looking at are the full results, including the TAP two. But if you used only the TAP one, which is four items, you can use that alone to screen for a past year unhealthy use of those four classes. And this is an analysis led by Jen Brzezinski of data from the same TAP tool study, which found that you have very good sensitivity and specificity for each of those four drug classes if you wanted to identify unhealthy use in the past year. As I said, along with the validation study, we did collect some information about feasibility of administering the TAP to this adult primary care population. And this is a paper presenting some of that information. And basically, one of the big concerns is how long is it going to take, especially when we're talking about asking more than one or two questions. And what we found is that for the self-administered version, it took on average about four and a half minutes. For interviewer-administered, it took on average about two and a half minutes, so a little bit faster. But the vast majority of the population was able to complete it in an amount of time that would be reasonable in primary care. And particularly with the self-administered version, since you're not taking up staff time and asking the question, an average time of four and a half minutes is workable in most clinical workflows. And we asked patients how they liked it, if they felt comfortable with it. The vast majority said that they were comfortable with the questions themselves and that they would be comfortable sharing the results with their doctor, though we know that that's a complicated decision, actually, that patients make about sharing information about substance use with their clinical provider. And there wasn't a strong preference for the interviewer or IPAD. Most had no preference for the mode of administration, but among those who did, there's just a slight preference for the self-administered, but overall, good acceptance really of either self-administered or interviewer version. And there's a nice website that NIDA built to help clinical providers and others to use the TAPs, and this is the URL here. And this allows you to go through and just administer the electronic version of the TAPs, and then it has guidance at the end on interpretation of the scores for providers. So I encourage you to take a look and to use that if it makes sense for you. And just one extension of the TAPs study that's worth talking about for you all is that there was a use of it to it's always interest in better identifying opioid use disorder or problem opioid use among patients who are receiving chronic opioid therapy. And so this was recently published where they decided to use the prescription opioid items from the TAPs combined with a DSM checklist for those who screen positive on those items. And that has not been validated as sort of a set, but it seems like a sensible approach and a way of adapting an instrument like the TAPs for a specific population, a specific use. There are also a host of other screening instruments, and the NIDA Clinical Trials Network has compiled kind of a selected group of them that both have good validation data and are short enough to be feasible for use in medical settings. And they're indexed here at this Common Data Elements site. To touch very briefly on a couple of them, so the single item screening questions, one question for alcohol, this is the NIAAA screening question of how many times in the past year have you had for men five or more drinks, for women four or more drinks in a day. And then the sort of nearing question for drug use, how many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons. And these have now been validated both for interviewer administration and for self-administration and have good sensitivity for alcohol and drugs as well as good specificity. And so that's an alternative approach that can be used if you want to identify just sort of the whole class of drugs with one question, but it doesn't sort out what types of drug use you might be dealing with, that takes more questioning. The other one that's really an industry standard is the audit or the Audit C. The audit, the 10-item instrument developed by the World Health Organization, and the Audit C being just the first three items of that, the three items that are asking about consumption, that's where the C comes from, and that those can be used to identify both unhealthy use and higher risk use that's a likely alcohol use disorder and have also been validated for interviewer and self-administered versions. The ranges you'll note are a little bit broader in terms of their sensitivity and specificity, which is really kind of reflecting the multitude of studies that have been done with the Audit and Audit C, some with better quality or better fidelity of screenings than others. But these are, if you just wanted to identify alcohol use, these would be your go-to screening tools for identifying both unhealthy use and severity of use. And these are, the VA is the largest system that's adopted these into regular practice. So the last piece that I wanted to move into today is talking about implementation of screening and medical settings, and I'm going to focus mostly on primary care, that's the context that I work in and where most of the screening recommendations focus. And this is important, you know, I think for your group especially because, you know, implementation, you can't implement it, you're not going to see any data related to screening outcomes where you won't be able to collect data about substance use. And the quality with which it's implemented, you know, impacts the availability of data and also the quality of the data, how much you can trust the findings about severity of substance use or prevalence. So there has been a large literature on barriers to implementing screening with or without brief intervention into primary care settings. And there are logistical barriers around time and workflow. And then there are sort of harder to tackle barriers around provider knowledge and attitudes and discomfort really on the part of patients and providers alike with talking about substance use. And so those barriers are, those take a thoughtful implementation approach and there's work to do. But yeah, I think when we're faced with them and we're thinking about choosing screening tools, the tools themselves should facilitate, they should be brief, they should be accurate, they should capture that whole range of severity of unhealthy use that we're interested in for clinical care. They should also be able to be easily integrated with electronic health records and the screening tools should fit into the existing clinical workflows, not that you have to make up a whole new workflow around the screening tool. And my work in this area has focused a lot on self-administered screening as a way of addressing many of these barriers, both because it relieves staff from having to administer the screener, but also because patients tend to be more comfortable reporting stigmatized behavior on a self-administered form than saying it to someone, their face-to-face. That's true even when they know that the results are going to their medical provider, someone will see the results. But also, it can be easier if you do electronic self-administered screening, can be easier and more immediately integrated into electronic health records. And there's potential to modify it better for specific patients, like to offer different language versions. This was a study that we had just recently completed in the NIDA Clinical Trials Network that was looking at the process of implementation of EHR-integrated screening tools and implementation outcomes. And this was a phased implementation study that we conducted in two large health systems, one in New York, one in Boston, in a total of six primary care clinics. And the screening tools that they used were the single-item screening questions for alcohol and drugs, followed by the Audit C for brief assessment of alcohol and DAS-10 for brief assessment of drugs. And this was, we did not add in resources to the clinics to help them do screening. The task of the study was to do some practice facilitation to help the clinics use their existing resources to deliver it better. And none of the clinics were screening systematically for alcohol or drugs at the time we did this study. So in the first year of screening, once it went live, across the clinic, 72% of patients were screened, which is a good screening rate in comparison to other similar efforts. And what we see though is that, one thing is that alcohol and drug screening rates are almost the same, and that's because the screeners were administered together. So patients. And there's variability in the screening rates. So 95% was the highest and about 24% was the lowest. And when we looked at, again, this is not a randomized trial. When we just sort of looked at the things, the characteristics of the clinics that had higher versus lower screening rates, the thing that's most striking was what visits they targeted for screening. So the clinics that said they did screening once a year, but they offered it regardless of the type of visit that a patient was presenting for. So any type of primary care encounter, they could be screened. Those are the ones that had screening rates in the 90% range. And for other clinics we're targeting just the designated annual preventive care visit. And those were the ones that had lower screening rates. So there was still a variation among them with some good screening rates of 70 to 72% at one of the clinics, even with that strategy. The other thing that was really striking were differences in how well unhealthy alcohol use was detected, depending on whether the choice was to do staff-administered screening, which was chosen by one clinic versus self-administered screening, which was chosen by the other five. And so the gold and red bars are showing you detection of moderate risk alcohol use on screening and in red, high risk alcohol use on screening. And what we see is rates of about 2% unhealthy alcohol use in the clinics that use the staff-administered approach versus rates from around 20 to 30 plus percent with self-administered screening. Remember that in the population in general, we would expect to see rates about a third of the population screen positive with gold or red area risk. And so the detection rate is in the, about a third of patients screening positive at some of the clinics that use self-administered is actually exceptionally good for a clinical setting where patients know that their results are going to be seen, integrated into the electronic health record and seen directly by their primary care provider. I'll note also the staff-administered screening, we did a lot to try to ensure the quality of screening of the staff-administered approach. So there were multiple training sessions with the medical assistants who are delivering it with booster training sessions. There was some observation to see if they were actually saying the questions correctly. So this was pretty high quality staff-administered screening and still it fell far short from being successful in detecting realistic rates of unhealthy alcohol use. For drug use, again, this is with the single item screening question in the DAS-10 assessment, which does not differentiate between types of drugs. So cannabis use would be lumped in with all the other types of drug use here. And here we just, we had low rates of detection regardless of whether it was staff or self-administered. We have just last week finalized a online resource for clinics to help them make a plan for implementing screening, really drawing from what's been learned from this study and from other similar studies in the field. So this is, I gave the URL here that you can take a look at, and I'm gonna walk you through it. Before I do that, I'm gonna note one more thing because it does come up in this online resource as well. The low rate of detection of unhealthy drug use in this study was not good enough for recommending this as a useful approach for screening. We did an ancillary study in an additional three clinics where they use the TAP tool, which allows you to identify whether the drug you're using is cannabis or cocaine or heroin or prescription medication. And in those sites, which were done in a state where cannabis was legal for recreational use, the rate of detection was 10%. So 10% of the population screened positive for drug use versus about 1% here. And I think that that is driven by the, in large part by the selection of the screening tool because patient, and that's based on what patients told us in focus groups and interviews, is that patients particularly who are using cannabis and don't consider that to be like other types of drug use will screen negative, they'll answer no to whether they have used drugs in the past year, unless you give them an opportunity to say what type of drug they used. So that study will have funding out from that one soon, but just wanted to note that since we're talking about the TAP tool. So this is, in the website, just to give you a really quick orientation, you're free to check this out, is that it goes through, it gets a little bit of information about the clinical setting, and then walks you through sort of choices to be made in planning an approach to screening implementation, and then give some guidelines for how to monitor the success of that approach. And it generates, when you go through, it only takes a few minutes, but you go through, answer the questions and make selections about these points, like what screening instrument do we want to use? How frequently do we wanna screen? What types of visits do we wanna target? It'll collect that information and generate a report for you at the end. Similarly with the monitoring part, if you choose like who's going to monitor the success of the screening program, what types of information, how are the reports gonna be done, that gets collected too. So that's meant to be a resource for folks who are thinking about either implementing or improving their alcohol or drug screening process in clinics. So that's the end of the material that I was hoping to cover. But just to summarize, I will continue to make a strong case that identifying substance use in medical settings is important for clinical care and for informing the types of services that we should be providing. That existing screening tools, we have tools that can be used, they're feasible and they can be recommended for use in regular practice. And choosing the right screening tool and being thoughtful for how you implement it will impact the success of screening and the quality of the results that you get. But that it is doable. I collected some resources among the many that are available. So those will be available with the slide. And I'll close by giving, again, a really hearty thank you for all the mentors and collaborators who have worked with me over the years or allowed me to work with them over these years, as well as my own research team and the sources of support for this work. So we do have some time for questions now. I haven't been able to monitor the Q&A or chat while I was showing slides, but I'm going to take a look at that now, but also just invite anyone to unmute yourself or to, and speak up preferably. And I'm gonna take a look at the couple of questions in the Q&A. I'm gonna take the first question that I see. Well, the first question is, will the slides be available? And yes, I hope so. I'm happy to share them. And then the next question is, how does the TAPS compare to the NIDA quick screen? Which is a great question. So they're almost the same. The origin of the two was a little bit different, but essentially the NIDA quick screen, like you point out here, was four items covering the same substance classes. The TAPS one is essentially the same with maybe some subtle wording differences that we used based on validated screening tools and then cognitive interviewing that we did as part of the development process for the TAPS tool. So I would say the TAPS one has been, has a little bit more rigor behind it and its validation is very similar to the NIDA quick screen. And from Robert Schwartz, how often do we recommend repeating screening? That's a great question. And one that there still isn't a great answer for. So the USPSTS includes that in their review also and concluded that they didn't, there wasn't enough evidence on it. In reality, like in practicality, usually I will recommend in most medical settings like primary care, screening once a year, which is not too burdensome in terms of taking up a lot of time with screening, not too repetitive for patients who get tired of answering screening questions every time they come in, but also, yes, are frequent enough to catch real changes in use, which can happen, yes, certainly over the time the patient's in care. So usually what I recommend and what most health systems have done is once a year, but there's no great evidence-based answer for that. And then there's a question, do you use your screener in any of the NYU emergency rooms? Yes, NYU as a system has adopted the TAPS tool. And so they're using the TAPS in the emergency room as well as in the inpatient side. And it's funny to me because they adopted it without my involvement, which is great, which I'm very happy about. And that I check in from time to time and hear that it's gone well, that the providers are happy with the TAPS. And then Robert Schwartz asking, if we do urine drug testing, is there a benefit to doing self-reported screening? I say, yes, multiple benefits. One is that just the window of most toxicologies is so short. It's getting used in the past couple of days of drug use for most drugs. And you want to know, especially for people who have less severe use or not using daily, it's really easy to miss that even though it's clinically meaningful use. But also I will say, I think having the conversation like doing some self-reported screening, getting patients used to sort of answering questions about it, reporting their use is helpful just for helping to destigmatize and kind of normalize the conversation. Even if it's done, even if patients are like filling it out on a form or on a computer, it's a different type of action. And it's more, it's voluntary. It's involving the patient. It's starting conversation instead of sort of feeling to patients like a gotcha game, which I think our toxicology testing often. These are great questions. Let's see if there's anything else here. Okay, we're right at time at two o'clock. So I'm going to turn it back to you, Sajal, to wrap up. Absolutely. First of all, thank you so much for this wonderful presentation. We had an amazing audience and some great questions. I would like to tell participants that if you have any additional questions for Dr. McNeely or about MNED, please forward it to MNED at psych.org, P-S-Y-C-H dot O-R-G. I'll be happy to answer as many as I can and I'll forward the relevant questions to Dr. McNeely for response. I will also forward the slides whoever has asked for with Dr. McNeely's permission. And with that, thank you so much for joining the webinar and very active participation. Thank you so much. Thank you, Dr. McNeely. It was amazing. Thank you for having me. Thank you all for joining. Thank you. Bye-bye. Bye, everyone.

Dr. Jennifer McNeely

NYU School of Medicine

substance use screening

TAPS tool

NIAAA screening question

NIDA quick screen

primary care settings

self-administered screening

clinic screening programs