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Lead Author(s): Jennifer McNeely , MD, MS, Leah K. Hamilton , PhD, and Susan D. Whitley , MD. Writing Group: Timothy J. Wiegand , MD, FACMT, FAACT, DFASAM, Sharon L. Stancliff , MD, Brianna L. Norton , DO, MPH, Charles J. Gonzalez , MD, and Christopher J. Hoffman , MD, MPH, MSc, FACP; on behalf of Substance Use Guidelines Committee .
Baltimore (MD): Johns Hopkins University ; 2024 May .Copyright © Johns Hopkins University Clinical Guidelines Program 2000-2024. The Clinical Guidelines Program, a collaborative effort of the NYSDOH AI and the Johns Hopkins University School of Medicine, Division of Infectious Diseases, encourages the use, reproduction, and distribution of original documents and related graphics from this program website accompanied by a full citation of source that includes: Author(s). Committee. Title. Date of publication. Full URL. Date accessed. Links to pages on this Clinical Guidelines Program website are also encouraged and may be created without seeking permission. Requests to adapt material, i.e., to change or alter in any way material from this website for inclusion in another publication, should be sent to aiguidelines@jhmi.edu. Please include detailed information about the intended use and desired adaptations.
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Updates, Authorship, and Related Guidelines
Developer and funding source
New York State Department of Health AIDS Institute (NYSDOH AI)
Primary care clinicians and care providers in other adult outpatient care settings in New York State
Rated recommendations added in Patient Engagement and Interventions section SIS-C (Single-Item Screen-Cannabis) added in Screening Tools section Resources, citations, and references updated throughout this guidelineAuthor and writing group conflict of interest disclosures
See Conflict of Interest statement *
Related NYSDOH AI guidelines
NYSDOH AI Guidance
Date of current publication: May 30, 2024 Lead authors: Jennifer McNeely, MD, MS; Leah K. Hamilton, PhD; Susan D. Whitley, MD Writing group: Timothy J. Wiegand, MD, FACMT, FAACT, DFASAM; Sharon L. Stancliff, MD; Brianna L. Norton, DO, MPH; Charles J. Gonzalez, MD; Christopher J. Hoffmann, MD, MPH, MSc, FACP Committee: Substance Use Guidelines Committee Date of original publication: October 21, 2020
This guideline on screening and risk assessment for substance use in adults (≥18 years old) was developed by the New York State Department of Health AIDS Institute (NYSDOH AI) for use by primary care clinicians and in other adult outpatient care settings in New York State to achieve the following goals:
Increase the identification of unhealthy substance use among New York State residents and increase access to evidence-based interventions for appropriate patients. “Unhealthy substance use” refers to a spectrum of use that increases the risk of health consequences and ranges from hazardous or risky patterns of use to severe substance use disorder (SUD).
Increase the number of clinicians in New York State who perform substance use screening and risk assessment as an integral part of primary care.
Provide clinicians with guidance on selecting validated substance use screening and risk assessment tools and on providing or referring for evidence-based interventions.
Promote a harm reduction approach to the identification and treatment of substance use and SUDs, which involves practical strategies and ideas aimed at reducing the negative consequences associated with substance use.
Rationale: In the United States, the use of tobacco, alcohol, and drugs (illicitly manufactured and nonmedical prescription) are among the top 10 leading causes of preventable death, accounting for more than 500,000 deaths per year [White, et al. 2020; GBD 2018]. Alcohol-related deaths have doubled in the past 2 decades; in 2019, there were more than 140,000 alcohol-related deaths in the United States [CDC 2022]. Surging rates of drug overdose deaths (often opioid-related) are a public health crisis across the country. In the United States, drug overdose contributed to 1 in 22 deaths in 2021, and there were more than 100,000 drug overdose deaths in the 12 months ending August 2023 [CDC 2024; Gomes, et al. 2023].
Patient visits to healthcare settings are an opportunity for clinicians to identify substance use and related problems, offer timely interventions, and provide or link patients to treatment when indicated. Screening and treatment for tobacco use have been widely adopted as core clinical quality measures for primary care [CMS 2013], but alcohol and drug use screening is not as widely performed, and use is substantially under-recognized [Hallgren, et al. 2020; WHO 2016; Venkatesh and Davis 2000]. Screening for alcohol use has been a recommended practice in adult primary care since 1996 [Curry, et al. 2018]. In a study of 13 states and the District of Columbia in 2017, 81.4% of patients reported being asked about any alcohol use by a healthcare professional; however, only 37.8% reported being asked about binge drinking behavior [McKnight-Eily, et al. 2020].
Screening for substance use in primary care is generally well accepted by patients as a marker of quality care [Simonetti, et al. 2015; Miller, et al. 2006]. However, thoughtful implementation, with sensitivity to stigma and privacy concerns, is essential for patients and clinicians to be comfortable [Bradley, et al. 2020; McNeely, et al. 2018].
The goals of screening for and assessing substance use risk in primary care vary by practice setting and resources and may include:
Informing medical care: Substance use is an important aspect of medical history because it can significantly affect disease processes, response to treatment, and exposure to health risks. Knowledge of a patient’s substance use informs a clinician’s diagnosis of other medical and psychiatric conditions and alerts them to associated health risks (e.g., overdose, liver disease) and common comorbid conditions (e.g., depression). Similar to knowledge about a patient’s past medical history, family history, or social determinants of health, knowledge about a patient’s substance use helps clinicians formulate effective patient-centered treatment plans.
Identifying the need for intervention: A second goal is to identify patients who would benefit from interventions to limit harms related to use and/or reduce their consumption (see guideline section Patient Engagement and Interventions) or patients for whom treatment may be appropriate (see guideline section Diagnosis of Substance Use Disorder). Evidence-based interventions are available, including brief interventions for moderate-risk alcohol use, pharmacotherapy for opioid and alcohol use disorders, and treatment for smoking cessation [Patnode, et al. 2021; Patnode, et al. 2020; USPSTF(c) 2020; Curry, et al. 2018; Jonas, et al. 2014; Mattick, et al. 2014]. Such treatments can be delivered effectively in a primary care setting, but they remain underused.
Engaging patients: Another goal is opening the conversation and engaging patients in discussion about substance use. If approached sensitively, a nonjudgmental discussion of a patient’s substance use may reduce perceived stigma, improve the clinical relationship, and facilitate behavior change. Initiating such a discussion communicates to patients that substance use is a health issue that the clinician is concerned about and can offer help for.
Definitions of the terms used throughout this guideline are detailed below.
Unhealthy substance use: Unhealthy substance use refers to a spectrum of use that increases the risk of health consequences and ranges from hazardous or risky patterns of use to severe substance use disorder. As defined in this guideline, unhealthy alcohol use is use that exceeds U.S. Department of Health and Human Services and Department of Agriculture 2015-2020 Dietary Guideline For illicitly manufactured drugs, less information is available about dosage and health risks of specific substances and preparations, and any use is considered potentially unhealthy. For prescription medications with potential for misuse, any nonmedical use (use of prescribed medication at increased dose or frequency or for reasons other than prescribed) or use of medications that were not prescribed is considered unhealthy.
Screening: Screening entails asking patients brief questions (or a single question) about substance use and can quickly identify patients with potentially unhealthy substance use. Many of these patients will not have substance use-related clinical signs or symptoms [Saitz(b), et al. 2014; Gordon, et al. 2013].
Risk assessment: Risk assessment entails asking patients additional questions on the extent, duration, and pattern of substance use to determine the clinical significance and severity of use. Assessment tools determine the level of risk (i.e., low, moderate, or high) and thus the potential for negative consequences; see Box 1, below. As shown in Figure 1: Substance Use Screening, Risk Assessment, Diagnosis, and Interventions, risk level and other individual patient factors guide clinicians in recommending appropriate interventions and informing patients about the potential consequences of their substance use [McNeely(a), et al. 2016; Saitz 2005].
Low risk: Patient is abstinent or uses substances in a way that is not currently associated with negative health consequences or other problems (e.g., alcohol consumption that does not exceed levels recommended by U.S. Department of Health and Human Services and Department of Agriculture 2015-2020 Dietary Guidelines or occasional low-dose cannabis use).
Moderate risk: Patient is at risk of and may already be experiencing negative health consequences or other problems, such as elevated blood pressure related to alcohol use, atypical chest pain related to cocaine use, or family problems or poor work performance related to opioid use.
High risk: Patient likely has a substance use disorder, is likely experiencing substance-related health or other types of problems (e.g., alcohol use-related cirrhosis or consequences such as separation from family or loss of employment), and is engaging in continued or escalating use despite negative consequences.
Other drug use (B3), and when unhealthy use is identified, assess the level of risk to the patient. (A3)
For information on the Child Abuse Prevention and Treatment Act (CAPTA) in New York State, see Plans of Safe Care for Infants and their Caregivers.
Prescribing medication(s) that have adverse interactions with alcohol or drugs. (A2)A patient has symptoms or medical conditions that could be caused or exacerbated by substance use. (A3)
Substance Use Screening, Risk Assessment, Diagnosis, and Interventions. Abbreviations: DSM-5-TR, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision; MI, motivational interviewing; SUD, substance use disorder. Notes:
In primary care settings, clinicians should screen all adult patients ≥18 years old for alcohol use. A large body of evidence indicates that screening tools can accurately identify unhealthy alcohol use (see Table 1: Recommended Validated Tools for Use in Medical Settings to Screen for Alcohol and Drug Use in Adults) and that brief counseling interventions can reduce alcohol use, improve health, and be cost-effective [Patnode, et al. 2020; Kaner, et al. 2018; O'Connor, et al. 2018; O'Donnell, et al. 2014; McNeely, et al. 2008; Solberg, et al. 2008; Maciosek, et al. 2006]. The National Committee on Quality Assurance adopted alcohol screening and brief intervention as a quality indicator in 2018 and incorporated it into the widely used Healthcare Effectiveness Data and Information Set performance measures.
In the absence of systematic screening, unhealthy alcohol use typically goes unidentified [Hallgren, et al. 2022; McKnight-Eily, et al. 2020] or is identified by clinicians only when an individual has developed a severe alcohol use disorder or alcohol-related health problems, such as alcohol-related cirrhosis or pancreatitis.
Ask patients about substance use during the initial visit and follow-up visits because patterns of use may change over time. Annual screening may be most appropriate, and most validated alcohol and drug screening questionnaires ask about use in the past year.
Inform patients that information about their substance use is protected by the same privacy laws that apply to all other information in their medical records.
Clinicians should screen all patients for all types of tobacco use, and when use is identified, provide counseling, assessment, and treatment [Patnode, et al. 2021; USPSTF 2021]. Every visit with a care provider allows for identifying a patient’s tobacco use and offering effective cessation interventions. Screening for tobacco use is often accomplished with 1 question: “Have you ever smoked cigarettes or used any other kind of tobacco?” Patients who answer “yes” should be asked about frequency and level of use in the past 30 days (e.g., number of cigarettes smoked per day) [DHHS 2008]. Despite concern about increasing rates of e-cigarette use, screening for electronic nicotine delivery systems is not currently a recommended practice [Krist, et al. 2021; USPSTF 2021].
Based on clinical experience and expertise and federal recommendations [USPSTF(b) 2020], this committee recommends that clinicians screen for drug use other than alcohol and tobacco in adult patients ≥18 years old who present for primary care. Screening should be performed in settings where treatment or counseling resources are available on-site or by referral and should identify a patient’s use of illicitly manufactured drugs and nonmedical use of prescription drugs that can be misused (e.g., opioids, benzodiazepines, and stimulants).
Evidence supports the accuracy of validated screening questionnaires in adults [Patnode, et al. 2020] and the benefits of pharmacologic treatment for opioid use disorder (OUD), which can be delivered effectively in primary care settings [Wartko, et al. 2023] and no longer requires a waiver for prescribing buprenorphine [Stringfellow, et al. 2021]. However, data on the effectiveness of drug screening plus brief intervention to reduce drug use and associated health consequences are currently limited, and this is an area of ongoing research. Randomized controlled clinical trials have generated mixed results regarding the efficacy of brief interventions in reducing drug use [Sahker, et al. 2022; Patnode, et al. 2020; Gelberg, et al. 2015; Roy-Byrne, et al. 2014; Saitz(a), et al. 2014; Humeniuk, et al. 2012]. Evidence supporting drug interventions delivered in primary care has primarily come from treatment-seeking populations, rather than patients identified only through screening [Saitz 2020; USPSTF(a) 2020].
No currently published studies demonstrate harms directly associated with screening adult primary care patients for drug use, although the potential for harm does exist [Saitz 2020]. For some patients, especially those who are pregnant or planning to conceive, positive results from a drug screening test could pose social or legal consequences, such as required reporting and the potential for involvement of child protective services (see discussion below). It is essential to respect the sensitivity of any substance use information documented in patients’ health records and ensure that patients understand privacy protections for their health information.
Rationale for drug use screening: This committee’s rationale for recommending drug use screening in adult patients, even with the potential for harm in some specific circumstances, is based on the following:
Stigma is a significant barrier to identifying and treating unhealthy drug use or substance use disorders (SUDs). The exclusion of routine screening for drug use may perpetuate the perception that discussion of drug use with healthcare providers is taboo. This is especially the case if alcohol and tobacco use are discussed openly but drug use is not mentioned. Routine, matter-of-fact, nonjudgmental screening for drug use may help reduce stigma by normalizing this discussion.
The social history that clinicians currently perform typically includes questions about alcohol, tobacco, and drug use but may not collect this information in a systematic and clinically useful manner. It is important that clinicians screen for drug use consistently, in a nonbiased manner, and use standardized, evidence-based screening tools.
Fatal and non-fatal opioid overdose deaths can be reduced through increased identification of unhealthy opioid use and, when indicated, effective treatment with medications for OUD [Watts, et al. 2022; Wakeman, et al. 2020; Sordo, et al. 2017; Cousins, et al. 2016].
Identifying and addressing unhealthy drug use, including drug use disorders, may positively affect other patient outcomes. For instance, identification of benzodiazepine use in a patient receiving opioids for chronic pain could inform overdose prevention counseling, opioid prescribing, and provision of naloxone to reduce the patient’s overdose risk.
Knowledge of a patient’s drug use is essential for accurate diagnosis and treatment. For example, in a patient who uses cocaine, chest pain could be the result of drug use rather than a blocked coronary artery, but without knowledge of the drug use, the clinician will not have the information necessary to perform the appropriate diagnostic workup. In addition, knowledge of drug use may be essential for an accurate diagnosis of psychiatric disorders, and knowledge of injection drug use can help guide screening for infections.
Urine toxicology, measures of blood alcohol level, and other laboratory tests should not be relied on for identifying unhealthy drug use.
Drug use screening in individuals who are pregnant or planning to conceive: Because there are potential legal and social consequences of a positive drug use screening result in individuals who are pregnant or planning to conceive, this committee urges caution when performing drug use screening. It is essential to engage patients in shared and informed decision-making before screening is performed. Fully informed consent includes clear discussion and confirmed patient understanding of the benefits, potential harms, and consequences of screening. For patients who are pregnant or planning to conceive, the informed consent discussion should include:
Description of drug screening processes and procedures Potential benefits of drug screening for the patient Discussion of how results are interpreted and likely next steps if the screening result is positive Confirmation of confidentiality of the patient’s medical information Discussion of the risk of being reported to child protective servicesDiscussion of the patient’s ability to refuse drug screening without repercussions, except in cases in which screening is mandated by an employer or by the court
Psychosocial support and counseling about the potential harms of drugs and treatment options for SUD, if patients decline to be screened for other drugs
Screening is recommended for patients who use medications that have adverse interactions with alcohol or drugs. Iatrogenic harm is possible if a patient’s substance use is not identified, including adverse effects resulting from drug-medication interactions, overdose from combining prescribed medications with illicitly manufactured drugs, and withdrawal syndromes when a patient’s drug use is undisclosed and they are unable to use, such as during hospitalization [Lindsey, et al. 2012; CDC 2007; Antoniou and Tseng 2002]. Patients taking prescription opioids or benzodiazepines should be screened for use of alcohol and for illicitly manufactured or nonmedical use of other sedating drugs (including other opioids or benzodiazepines) that can increase the risk of overdose. Patients taking any controlled substances should be assessed for co-occurring substance use that may increase the probability of engaging in risky use of prescribed medications or of having or developing an SUD.
Clinicians should be aware of potential interactions between alcohol or drugs and medications, such as antiretroviral, pain management, or neurologic medications (e.g., gabapentin and pregabalin) [Gomes, et al. 2017; Lyndon, et al. 2017; Lindsey, et al. 2012; Bruce, et al. 2008; Saitz 2005; Antoniou and Tseng 2002].
When counseling patients who use substances about drug-medication interactions, clinicians should be clear about the safety of their prescribed medications and be certain to encourage adherence to all critical medications, such as antiretroviral treatment [Kalichman, et al. 2015].
See the following resources for checking drug-drug interactions:
Clinicians should also perform substance use screening in patients who have symptoms or other medical conditions that could be caused or exacerbated by substance use, such as chest pain, liver disease, or mood disorders [NIAAA 2024; Ries, et al. 2018; Kim, et al. 2017; Edelman and Fiellin 2016; Mertens, et al. 2005; Lock and Kaner 2004].
Who to screen: All adults seen by primary care clinicians should be screened for substance use. Some specific patient populations may have higher rates of unhealthy substance use [SAMHSA 2019; Schulden, et al. 2009], but no specific demographic characteristics reliably predict such use.
How often to screen: Because substance use behavior changes over time, clinicians should repeat screening at regular intervals. However, evidence is lacking about the optimal frequency of screening [Moyer 2013]. Annual screening may strike the best balance between the need for frequent repetition of screening and time and resource constraints and has been recommended by an expert panel convened by the National Council for Behavioral Health and Substance Abuse and Mental Health Services Administration (SBIRT Change Guide 1.0, February 2018) [McNeely, et al. 2021].
Who should perform screening: Most of the screening instruments discussed in Table 1: Recommended Validated Tools for Use in Medical Settings to Screen for Alcohol and Drug Use in Adults can be administered verbally by trained staff or can be self-administered by patients on paper or electronically. Primary care practices must choose the format that is most appropriate for their clinical workflow and patient population. Generally, self-administered screening facilitates more accurate reporting of stigmatized behavior, such as substance use [Wight, et al. 2000; Tourangeau and Smith 1996]. A self-administered approach may lead to higher rates of detected substance use by ensuring fidelity of administration [McNeely, et al. 2021; Williams, et al. 2015; Bradley, et al. 2011], increasing patient comfort [McNeely, et al. 2018; Spear, et al. 2016], and reducing staff burden. Electronic screening tools that can be self-administered can be completed online through a patient portal or an app made available with a tablet computer or kiosk in the clinic, with results uploaded to a patient’s electronic health record.
How to introduce substance use screening to patients: Explain the reasons for screening, the type of screening that will be performed, the potential benefits, and any potential harms. Make sure that patients understand how results will be interpreted and the likely response to screening results. Remind them of the privacy protections for the information being collected, including who will see the information; acknowledge the potential sensitivity of the information; and avoid judgmental or stigmatizing language [NIDA 2011].
National Institute on Drug Abuse: Implementing Drug and Alcohol Screening in Primary CareClinicians should use standardized and validated questionnaires for substance use screening (see Table 1: Recommended Validated Tools for Use in Medical Settings to Screen for Alcohol and Drug Use in Adults). (A3)
Successful substance use screening relies on accurate patient self-report. Although urine toxicology, measures of blood alcohol level, or other laboratory testing may detect the presence of substances used very recently (typically hours or ≤4 days after the last use), these tests are not appropriate for identifying unhealthy use, which may be intermittent and occur over time [Bosker and Huestis 2009; Cone and Huestis 2007; Verstraete 2004]. Laboratory screening tests for alcohol and drugs do not provide information about the severity or consequences of use and thus provide less information than questionnaires.
No reliable biomarker with sufficient sensitivity and specificity identifies the range of drinking behaviors that constitute unhealthy alcohol use [Afshar, et al. 2017; Jarvis, et al. 2017; Jatlow, et al. 2014; Stewart, et al. 2014; Verstraete 2004; Neumann and Spies 2003]. For drug use, urine, saliva, and blood testing are not recommended as replacements for questionnaire-based screening because laboratory tests have a brief window of detection (typically 1 to 4 days) [Bosker and Huestis 2009; Cone and Huestis 2007; Verstraete 2004]. Although hair testing has a more extended detection period, the cost and lack of reliability for detecting occasional drug use decrease its utility in primary care [Verstraete 2004].
