Behavioral Health - Key Activity 9D


Screen Adults for Unhealthy Substance Use


This key activity involves the following elements of person-centered population-based care: operationalize clinical guidelines; behavioral health integration.


Annual universal screening for unhealthy substance use for adults aged 18 and above.

Alcohol and other drug use is one of the most common causes of preventable death, injuries, and disability in the United States; in 2017, more than 70,000 individuals died as a consequence of overdose. Serious health effects, such as overdose, arrhythmias, seizures, impairment while driving, difficulty with learning and memory impairment, greater risk of infections, and obstetric complications are associated with drug use and vary by drug type, administration mode, amount, frequency of use, and pregnancy status. In addition to serious health effects, unhealthy drug use is also associated with violence, criminal activity, incarceration, impaired school and work performance, interpersonal dysfunction, and social and legal problems.

Substance Abuse and Mental Health Services Administration (SAMHSA), American College of Obstetricians and Gynecologists (ACOG), American Academy of Pediatrics (AAP) and Bright Futures all recommend universal annual screening for unhealthy substance use, including alcohol, tobacco, marijuana and opiates.

Note: The U.S. Departments of Defense and Veterans Affairs and the American Academy of Family Physicians (AAFP) have adopted the 2008 USPSTF recommendation indicating that evidence is insufficient to recommend routine screening for illicit drug use.[1] Concerns center on the potential harms of screening, including labeling, stigmatization, and medicolegal consequences. Finally, current treatment options are limited.

Due to implicit racial bias, in the absence of universal screening, minority populations are screened and found to be positive for unhealthy drug use at greater rates than white populations. This raises grave concerns for equitable outcomes, especially when considering the medicolegal consequences of positive screens.[2] Research suggests that, while all populations underutilize drug treatment, there are variable consequences of unhealthy substance use, such as the fact that Hispanic and African American men are more likely to die from cirrhosis than are white men.[3]

Universal screening for unhealthy substance use, when paired with referral to treatment, may result in support for the entire family system. As noted previously, unhealthy substance use is associated with physical, emotional and social consequences that potentially have ramifications for the family as a whole.

Technology can support screening for unhealthy substance use by delivering structured guidelines, protocols, and clinical decision support to care team members responsible for carrying out assessments. It can also help by incorporating standardized screening tools into EHRs and care management and care coordination applications. These screening tools can also be made available directly to patients through patient outreach and screening technologies.

Understanding the prevalence of behavioral health conditions assists in program and resource development to track impact on health outcomes and to incorporate into risk stratification. Health information technologies used to track referrals are also important in care management.

Action steps and roles

1. Review current recommendations.

Suggested team member(s) responsible: Representatives and leaders from medical and behavioral health teams, QI staff.


2. Select a validated tool appropriate for the local context.

Suggested team member(s) responsible: Representatives and leaders from medical and behavioral health teams, QI staff.

Currently, there is a lack of consensus about specific validated tools to use to screen for alcohol, marijuana and other drug use. While SAMHSA endorses using a combination of the Alcohol Use Disorders Identification Test (AUDIT) and CAGE questionnaire tools, USPSTF encourages the use of a one- to three-item screener and suggests the AUDIT or Single Alcohol Screening Question (SASQ), with additional tools focusing on specific populations, such as pregnant people, older adults, children and adolescents. Recent evidence suggests that the SBIRT tool is effective at screening for unhealthy alcohol use, but there is an absence of evidence suggesting effectiveness for other nonmedical drug use.[4] At this time, we encourage integrated teams to choose and consistently use a validated tool with considerations for clinic setting, preferences and populations served.

3. Decide frequency of tool administration and when in the visit flow screens will be conducted.

Suggested team member(s) responsible: Representatives and leaders from medical and behavioral health teams, QI staff.

4. Train staff in administering tools with workflows for low, medium and high acuity.

Suggested team member(s) responsible: QI leads, nursing or rooming staff.

As with any screening effort, it is appropriate for staff to ask permission before proceeding with screening and respect the patient’s preferences to forego screening at a given visit. This is most often done by the staff administering the screening (e.g., rooming staff, such as medical assistants, nursing staff, etc.) and is true for all screens. This is especially important in the area of substance use, where individuals may feel singled out or stigmatized.

5. Conduct training with all staff and providers to enhance the effectiveness of screening and assessment.

Suggested team member(s) responsible: Clinic director, CBHO, CMO.

There is a high degree of patient concealment about the use of alcohol and other drugs, likely due to societal stigma and a potential history of judgment from healthcare providers. Screening is only useful if patients feel comfortable answering honestly. Training all patient-facing staff on the medical field's history of harm to people with addictive disorders, education about addictive disorders, anti-stigma communication skills, and evidenced-based empathic communication is crucial for screening to be effective.


  1. Coles, S., & Vosooney, A. (2021). Evidence lacking to support universal unhealthy drug use screening. American Family Physician, 103(2), 72–73. 
  2. Roberts, S. C., & Nuru-Jeter, A. (2012). Universal screening for alcohol and drug use and racial disparities in child protective services reporting. The journal of behavioral health services & research, 39(1), 3–16. 
  3. Manuel, J. K., Satre, D. D., Tsoh, J., Moreno-John, G., Ramos, J. S., McCance-Katz, E. F., & Satterfield, J. M. (2015). Adapting Screening, Brief Intervention, and Referral to Treatment for Alcohol and Drugs to Culturally Diverse Clinical Populations. Journal of addiction medicine, 9(5), 343–351. 
  4. Young, M.M., Stevens, A., Galipeau, J. et al. Effectiveness of brief interventions as part of the Screening, Brief Intervention and Referral to Treatment (SBIRT) model for reducing the nonmedical use of psychoactive substances: a systematic review. Syst Rev 3, 50 (2014).