Universal screening in primary care does not appear to increase new OUD diagnoses

Key takeaways:

• Practices that adopted universal screening did not see a significant increase in the number of OUD diagnoses.
• Researchers said this can be due to the clinic’s underlying prevalence of OUD and stigma.

Screening for opioid use disorder, or OUD, in primary care clinics did not increase the percentage of new OUD diagnoses, according to results from a cluster randomized trial published in the Annals of Internal Medicine.

John C. Fortney, PhD, a professor in the department of psychiatry at the University of Washington, and colleagues initially hypothesized that universal screening would in fact lead to an increase in OUD diagnoses, contrary to the study’s results.

“Because screening for depression, anxiety and alcohol use disorder is so effective at identifying patients with undiagnosed disorders, we expected OUD screening would also be effective,” they told Healio in a shared response by email.

Currently, the U.S. Preventive Services Task Force recommends screening for substance use in adults during routine care if accurate services for diagnosis, effective treatment and appropriate care are available.

The researchers had conducted the cluster randomized trial to determine the change in the number of new OUD diagnoses in 20 diverse primary care clinics 6 months after universal screening was implemented compared with the previous 6 months.

Of 167,710 patients who had a unique visit in the 6 months after universal screening had been adopted, 1,656 had OUD diagnoses, including 177 with new diagnoses.

Overall, the median change in patients with a new OUD diagnosis was 0.03% (95% CI, –0.08% to 0.38%), and the median increase in the number of patients with a new OUD diagnosis was 1.5 per clinic (95% CI, –4 to 17) after universal screening had been implemented.

Fortney and colleagues suggested several possible reasons that OUD diagnoses did not increase, including “delays in follow-up diagnostic assessments; generally low prevalence of OUD, resulting in few true positives and more false positives; stigma associated with OUD, with patients having trepidation about answering the screening questions candidly; and/or less congruence between screen sensitivity observed in psychometric studies and screen sensitivity observed in routine care.”

The researchers added that screening for OUD may be effective at reducing mortality — even with the lack of new diagnoses — and its cost-benefit may be may be advantageous to clinics with a high prevalence of OUD and where stigma is less of a concern.

“Therefore, we recommend that each clinic consider the underlying prevalence of OUD in their patient population, the expected sensitivity of the screening instrument given the levels of stigma in their clinic and their community, and their own clinical priorities,” they said.

References:

• Fortney J, et al. Ann Intern Med. 2023;doi:10.7326/M23-1369.
• USPSTF. JAMA. 2020;doi:10.1001/jama.2020.8020.