A number of standardized screening instruments are available that have been validated in a range of clinical care settings for opioid and substance use disorders, including the 2-item Screen of Drug Use, Rapid Opioid Dependence Screen (RODS), Severity of Dependence Scale (SDS), Cutdown, Annoyed, Guilt, Eye-opener Adapted to Include Drugs (CAGE-AID), Drug Abuse Screening Test (DAST), and Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST).
However, provider-level barriers, including time constraints, the need for extensive training and certification to administer such tools, and the requirement to calculate overall scores have been cited as impediments to the uptake of these screening tools. Moreover, many of these tools are clinician-rated only and are subcomponents of larger instruments that screen for multiple substances or other disorders (e.g., opioids, alcohol, cocaine, or psychiatric disorders).106
This guideline endorses universal substance use screening, using the 2-item Screen of Drug Use (see below). A positive screen should prompt an in-depth discussion of substance use patterns and a diagnostic interview using the DSM-5 criteria for OUD, as outlined below.
2-item Screen of Drug Use
A simplified screening tool for substance use disorders may circumvent the reported barriers to screening. The 2-item Screen of Drug Use tool was developed and validated to identify substance use disorders other than alcohol use disorder in primary care settings. Patients are asked to estimate their drug use in the previous 12 months.
The first question asks: “How many days in the past 12 months have you used drugs other than alcohol?” Any response of 7 or more days is considered a positive screen result. If the answer is 6 or fewer days, the administrator should proceed to the second question.
The second question asks: “How many days in the past 12 months have you used drugs more than you meant to?” Any response greater than 2 days is considered a positive screen result.107
The 2-item Screen of Drug Use has been validated to identify opioid use disorder in primary care settings. Using patients who screened positive for OUD by the MINI as the criterion measure, the 2-item Screen of Drug Use demonstrated 100% sensitivity (95% CI: 89.9–100), 86.3% specificity (95% CI: 84.3–88.1), 7.3 positive likelihood ratio (95% CI: 6.4–8.4), and 0 negative likelihood ratio. These results are comparable to the sensitivity and specificity of other frequently used substance use disorder screening tools in primary care settings107
While the 2-item Screen of Drug Use was developed to screen for substance use disorders, clinicians may also find it useful to identify patients who use substances, including opioids, but do not meet criteria for substance or opioid use disorders.108 Clinicians should consider offering harm reduction education and supplies or referrals to other support services to patients who respond to the screening questions with numbers greater than 1 but less than the criteria for a positive screen.
Rapid Opioid Dependence Screen
The Rapid Opioid Dependence Screen (RODS) is an 8-item instrument to assess the risk of opioid dependence. Based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), criteria, the RODS was developed for use in both clinical and research settings and allows for quick, targeted screening. The RODS may be administered as a stand-alone screening tool or as a component of a larger comprehensive interview. The RODS consists of a series of questions that assesses lifetime use of opioids, and the physiological, behavioural, and cognitive factors that are associated with opioid dependence. Each positive response to a question receives 1 point. Patients may have a total possible score of 8, and a score of 3 or greater is considered a positive screen result for opioid dependence.106
In the initial validation study in a population of newly incarcerated, HIV-positive individuals, the RODS demonstrated 97% sensitivity, 76% specificity, 69% positive predictive value, and 98% negative predictive value. Psychometric analysis showed a strong internal consistency (α=0.92) and inter-item correlations (0.66–0.87).106
Similar to the 2-item Screen of Drug Use instrument, the RODS may help health care providers identify patients who use opioids but are not opioid dependent (i.e., those with a score of less than 3). Health care providers should offer patients who fall into this category counselling, harm reduction education and supplies, or referrals to other support services.
References
- Wickersham JA, Azar MM, Cannon CM, Altice FL, Springer SA. Validation of a Brief Measure of Opioid Dependence: The Rapid Opioid Dependence Screen (RODS). J Correct Health Care. Jan 2015;21(1):12-26. doi:10.1177/1078345814557513