Organization of Drug Prevention Services in the Health Care Delivery System

Literature Review
July, 1998

- Author's Notes
- Executive Summary
- Introduction and Background
- Methods and Conceptual Framework
- Findings
   - General Primary Care
   - Pediatric Health Care
   - Obstetrical-Gynecological Practice
   - Psychiatry
   - Occupational Health Care
- Conclusions and Future Directions
- References

Author's Notes

In the course of developing this paper, I made several modifications to the original outline and approach. First, I made personal and telephone contacts with a number of key informants, some of whom were suggested by the NIDA reviewer. The topic is an emerging area, and a good deal of pertinent information is not yet published in the literature. The three personal communications cited in the text include Nancy Kennedy, Director, Office of Managed Care, Center for Substance Abuse Prevention; Dennis McCarthy, Ph.D., Research Professor, Director of Substance Abuse Research at the Institute for Health Policy, Heller Graduate School, Brandeis University; and Marguerite Pappaioanou, D.V.M., Ph.D., Chief, Community Preventive Services Guide Development Activity, Division of Prevention Research and Analytic Methods, Epidemiology Program Office, Centers for Disease Control and Prevention.

A second author has been added to the report. Kim Watson is a Research Analyst at the Heller Institute for Social Research at Brandeis who works with me on a number of prevention projects. She has been invaluable in carrying out this literature review and deserves recognition for her contribution.

In developing the paper, I adapted the outline somewhat in order to better present the material. This was in partial response to comments from internal reviewers who suggested organizing the paper by health care setting and then type of prevention, rather than vice versa. I tried several different structures and decided the present one worked best.

Sections

Executive Summary

This paper summarizes an extensive review of the literature to explore the current amount and type of drug abuse prevention services within the health care system, the barriers to fuller participation, and promising models for improving prevention activities. Research studies as well as clinical and policy papers, gleaned from an extensive electronic search, are reviewed. The report concludes with implications for practice as well as suggestions for future directions.

The review organizes reports on prevention by the different types of settings in which health care is provided and for which information was found. These include general primary care, pediatrics, obstetrics/gynecology, psychiatry, and workplace settings. Within each of these categories, reports are further sorted by the type of prevention services provided: universal, selective, or indicated. Papers that provide primary analysis of data from research studies are further analyzed to assess strength of evidence. Information on the research questions, methods, sample selection, findings, and limitations for these research studies is outlined in attached tables to supplement the text.

Although professional organizations and clinical journals advise health care practitioners to screen their clients routinely for drug abuse, only a small fraction comply. The review provides insight into the formidable barriers: the nature of health care environments that are structured for brief visits with many patients; the lack of research to support screening for drug abuse; the lack of validated screening tools; the reticence of patients and clinicians to discuss drug use because of social stigma and workplace or legal repercussions; and the lack of resources for assessment and treatment when a problem is identified. Despite these barriers, the literature shows the promise of and need for health care involvement. Innovative advances are highlighted.

Sections

Introduction and Background

Most current drug prevention programs are delivered outside of the health care system, primarily in educational, social, and criminal justice settings (Haaga & Reuter, 1995). Historically, major federal appropriations for prevention have been allocated through the following agencies:

• Department of Education
• Department of Housing and Urban Development
• Department of Justice
• Department of Health and Human Services (HHS)
• Centers for Disease Control and Prevention (CDC)
• National Institute on Alcohol Abuse and Alcoholism (NIAAA)
• National Institute on Drug Abuse (NIDA)
• National Institute of Mental Health (NIMH)
• Substance Abuse and Mental Health Services Administration (SAMHSA)

 The 1981 Omnibus Budget Reconciliation Act consolidated all drug, alcohol, and mental health categorical programs into block grants to be handled by a single state agency, and required states to spend at least 20% of their total drug and alcohol program grants on prevention activities. These block grants are now the largest source of prevention funding for programs outside of the schools; but little if any of the funding appears to be allocated for services within the health care system (Haaga & Reuter, 1995; D. McCarty, personal communication, August 9, 1997).

A summary of the most recent budget allocations for federal drug control initiatives confirms that the health care system continues to be on the sidelines for prevention funding (Office of National Drug Control Policy, 1997). Prevention efforts currently focus on a national media campaign about illegal drug consumption by youth, increased Safe and Drug Free School spending, increased National Institute on Drug Abuse (NIDA) funding for basic drug prevention and treatment research, and State Incentive Grants for youth prevention initiatives. Health professionals are seen only in treatment roles except with regard to the poor, for whom they are encouraged (but not funded) to integrate "drug prevention and assessment programs in prenatal, pediatric, and adolescent medical practices or clinics" (p. 48).

The health care system, however, could have a more important role in drug abuse prevention. Increasing its role requires more research on the effectiveness and cost-effectiveness of different approaches to prevention, and the elimination of barriers to fuller participation. Several federal programs have attempted to address these barriers. For instance, NIDA and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) have supported a Health Education Program to fund the improvement of medical and nursing school curricula in early diagnosis and treatment of substance abuse (Ungerleider, Siegel, & Virshup, 1995). The Center for Substance Abuse Prevention (CSAP) funds medical school curriculum and faculty development demonstration projects in substance abuse education. CSAP also supports the National Clearinghouse for Alcohol and Drug Information (NCADI), which publishes and distributes free health information about substances of abuse to the public. Recently, CSAP hosted a Prevention in Managed Care Working Group to encourage alcohol and other drug (AOD) prevention services within managed health care organizations (N. Kennedy, personal communication, September 4, 1997).

The Office of Disease Prevention and Health Promotion publishes a Guide to Clinical Preventive Services (U.S. Preventive Services Task Force, 1996) that includes a chapter on drug abuse. The Guide offers screening recommendations based on reports of professional medical associations and a rigorous review of the literature. The U.S. Public Health Service is currently developing a complementary Guide to Community Preventive Services, summarizing what is known about the effectiveness — and cost-effectiveness, where data exist — of population-based prevention and control interventions. A section on "Changing Risk Behaviors" is planned with separate chapters addressing tobacco, alcohol, and other addictive drugs (M. Pappaioanou, personal communication, July 9, 1997).

In addition, professional associations have provided training, certification, and practice guidelines in substance abuse treatment and prevention (American Academy of Child and Adolescent Psychiatry, 1996; Committee on Substance Abuse, 1996). Yet, clearly, education alone will not change practice patterns. Despite the efforts described, only about 25% of primary care providers report that they inquire about clients’ use of drugs and alcohol (National Center for Health Statistics [NCHS], 1996).

A major barrier to changing practice patterns is that clinicians traditionally have been reimbursed only for treatment. Prevention efforts have not been financially rewarded. Managed care presents a new opportunity over fee-for-service insurance, as HMOs investigate new ways to save money beyond reducing hospital stays. Prevention services, and particularly behavioral interventions, represent the next great frontier in lowering expensive health care utilization. Administrative structures, not needed or possible in fee-for-service structures, have been widely implemented in HMOs to monitor practice patterns and outcomes. This combination of risk and ability to monitor in managed care sets the stage to test prevention services on a broad scale.

This paper summarizes an extensive review of the literature in order to explore the current amount and type of drug abuse prevention services within the health care system, the barriers to fuller participation, and promising models for improving prevention activities. Research studies as well as clinical and policy papers, gleaned from an extensive electronic search, are reviewed. The report concludes with policy and practice implications as well as critical future research directions.

Sections

Methods and Conceptual Framework

Three electronic databases were searched for reports about drug abuse prevention in health care: ArticlesFirst, MEDLINE, and HealthSTAR. ArticlesFirst, produced by the Online Computer Library Center and available via the First search engine, is updated daily and draws citations from over 12,000 journals. MEDLINE, produced by the U.S. National Library of Medicine and covering all areas of medicine with a focus on biomedical subjects, is updated monthly, drawing from over 3,500 journals. HealthSTAR, produced jointly by the U.S. National Library of Medicine and the American Hospital Association, focuses on both clinical and nonclinical aspects of health care delivery. A professional librarian assisted with the HealthSTAR search. Each search was limited to English language documents from 1987 to the present. Various keyword strategies were used for a comprehensive search of the literature.

Out of over 2,000 titles and abstracts reviewed, 94 were deemed potentially relevant to drug abuse prevention because they were conducted in the traditional health care system (clinics, doctors' offices, hospitals), or by doctors or nurses in school or workplace settings. Of these, 33 were dropped after more extensive review. Publications that addressed the prevention of alcohol abuse or the use of tobacco were excluded unless drug abuse prevention was also addressed. Articles reviewed for the 1996 Guide to Clinical Preventive Services were also dropped; instead, recommendations from the Guide are provided at the beginning of each section. Additional sources of publications, besides the electronic search, included the authors' personal library, citations gleaned from search publications, and references from colleagues.

The review organizes reports on drug abuse prevention by the different types of settings in which health care is provided. These include general primary care, pediatrics and school settings, obstetric/gynecology, psychiatry, and workplace settings. Within each of these categories, reports are further sorted by the type of drug abuse prevention services provided: universal, selective, or indicated (Mrazek & Haggerty, 1994). Papers that provide primary analysis of data from research studies were further analyzed to assess strength of evidence. Information on the research questions, methods, sample selection, findings, and limitations for these research studies is outlined in tables (see Attachments 1-4) to supplement the text.

Sections

Findings

General Primary Care

Universal preventive interventions are targeted to the general public or a whole population group that has not been identified on the basis of individual risk (adapted from Institute of Medicine, Reducing Risks for Mental Disorders, 1994, p. 24). The most common universal drug abuse prevention measure discussed in the health care literature is routine screening. A comprehensive review on drug screening in the latest edition of the Guide to Clinical Preventive Services (1996) concludes:

Many Americans face substantial risks from illicit drugs and the nonmedical use of other drugs, but questions remain about appropriate methods for screening for drug abuse among asymptomatic patients. The routine use of screening instruments or laboratory tests has not yet proven effective in reducing harmful drug use. . . . Clinicians should be alert to signs and symptoms of drug abuse and ask about the use of illicit drugs and legal drugs of abuse (e.g., sedatives, stimulants); use of inhalants should be considered in older children, adolescents, and young adults. (pp. 589-590)

The U.S. Preventive Services Task Force used a standard rating procedure for all preventive services included in their report. They rated routine screening for drug abuse with standardized questionnaires or biologic assays as a "C" (i.e., there is insufficient evidence to recommend for or against the inclusion of the condition in a periodic health examination, but recommendations may be made on other grounds). They rated the quality of evidence with a "III" (i.e., opinions of respected authorities, based on clinical experience; descriptive studies and case reports; or reports of expert committees). These ratings are in contrast to a higher endorsement for alcohol screening, which received a "B" (there is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination), along with a "I" (evidence obtained from at least one properly randomized controlled trial) and "II-2" (evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group).

SAMHSA recently developed A Guide to Substance Abuse Services for Primary Care Clinicians Treatment Improvement Protocol (TIP) (1997) through a Consensus Panel commissioned by the Center for Substance Abuse Treatment (CSAT). The TIP recommends that clinicians should "periodically and routinely screen all patients for substance abuse disorders" (p. 13). The apparent discrepancy between the Guide to Clinical Preventive Services and the TIP is, in part, because TIP recommendations bundle alcohol and drug abuse together, whereas the Guide considers research evidence for each of them separately.

The TIP does note that research evidence is much stronger for alcohol screening and that the prevalence of problem use is three to four times greater than that of illicit drug use. Unlike the U.S. Preventive Services Task Force, the Consensus Panel recommends that primary care clinicians periodically and routinely screen all patients for substance use disorders, including drug use, because, "Deciding to screen some patients and not others opens the door for cultural, racial, gender, and age biases that result in missed opportunities to intervene with or prevent the development of alcohol- or drug-related problems" (p. 13).

In terms of testing for drug abuse, the TIP reports that the CAGE-AID is the only tool that has been tested with primary care patients, citing a single study published in the Wisconsin Medical Journal (Brown & Rounds, 1995). The CAGE-AID is adapted from the CAGE questionnaire, an alcohol screening instrument that has been tested extensively in primary care settings. In regard to the CAGE-AID, the TIP advises:

While those patients who are drug dependent may screen positive, adolescents and those who have not yet experienced negative consequences as a result of their drug use may not. For this reason, the Consensus Panel recommends asking patients, "Have you used street drugs more than five times in your life?" In Panelists’ experience, a positive answer indicates that drugs may be a problem and suggests the need for in-depth screening and possibly assessment. (p. 17)

Other professional medical groups also have recommended regular screening.

The American Medical Association (AMA) and the American Academy of Family Physicians (AAFP) advise physicians to include an in-depth history of substance abuse as part of a complete health examination for all patients. (Guide to Clinical Preventive Services (1996), p. 589)

Neither professional association recommends routine biological screening in the absence of clinical indications.

No similar professional nursing groups’ recommendations on regular screening were found, but a review article in Nurse Practitioner (Caulker-Burnett, 1994) stressed that primary care providers currently do not deal with substance abuse as a chronic disease, although it is a common comorbidity in both hospitalized and ambulatory patients. The article outlined physical signs, results of laboratory tests, and other indications clinicians should watch for, and suggested that primary care providers should recognize addicted patients and motivate them to seek treatment.

Healthy People 2000 provides a national prevention strategy for improving Americans' health (NCHS, 1996). Its three broad goals are to increase the span of healthy life, reduce health disparities among groups, and achieve access to preventive services for all. Substance abuse is one of 22 priority areas, and regular drug screening is listed as an objective:

4.19: Increase to at least 75% the proportion of primary care providers who screen for alcohol and other drug use problems and provide counseling and referral as needed. (p. 62)

In 1992, primary care providers were surveyed to find out how close they were to this screening target (NCHS, 1996). Asked if they inquire of 81-100% of patients 12 years old and over about illegal drug use, only 28% of pediatricians, 43% of nurse practitioners, 32% of obstetrician-gynecologists, 34% of internists, and 23% of family physicians responded positively. The first three groups reported similar patterns for alcohol, but more internists (63%) and family physicians (39%) responded positively to doing alcohol screening than to drug screening.

Several reports explain or describe barriers contributing to the disparity between drug abuse prevention objectives and practice. An important barrier is the lack of procedure codes to bill for drug abuse prevention services (Kunnes et al., 1993). Third-party payer policies vary on coverage of substance abuse services, based on overall benefit, practice type and setting, and coding efficiency and accuracy. For the provider, detecting and assessing a chemical dependency problem and developing a treatment plan can lengthen a visit from 15 to 45 minutes, although the payment remains the same. The opportunity to see and bill for two additional patients is lost. Managed care physicians also face financial disincentives if they see fewer patients. In addition to financial pressures, primary care physicians lack assessment skills and information about resources; substance abuse issues occupy a low status in primary health care practice. Support for payer coverage is not likely to improve until clear practice guidelines are developed and the cost-effectiveness of drug abuse prevention services is shown.

Almost every report alluded to primary care clinicians' lack of education about substance abuse and on providing appropriate services to their clients. A Public Health Service Policy Report of the Physician Consortium on Substance Abuse Education (1991) described a consensus that substance abuse education and training for all levels of medical education is markedly deficient. Although some medical education curricula focusing on substance abuse exist, few are widely used. Faculty need to be trained to educate, supervise, and serve as role models. The minimal substance abuse training that takes place fails to address the special problems and needs of minorities. Further, questions remain about how to translate increasing general knowledge of substance abuse into definitively altered practice behavior. Finally, Consortium members also agreed that physician prejudice regarding substance abusers, including the belief that abusers have a poor prognosis, must be overcome; and that physicians' uncertainty about who has ultimate responsibility for substance abuse intervention must be addressed.

The Consortium findings were echoed in an essay describing a model education program (Durfee, Warren, & Sdao-Jarvie, 1994). Stressing that substance abuse is a chronic disease that must be managed using a biopsychosocial model of care, the authors note that most physicians, educated under a strict biological model of disease, are not comfortable assessing social and psychological problems. Two research studies evaluated training for doctors and nurses in general practice. The first, a longitudinal study of medical students, assessed physician attitudes and intentions to provide services (Scott, Neighbor, & Brock, 1992; see Attachment 1). Primary care physicians were found to be more amenable to providing preventive care services than the specialists. The second study evaluated a continuing education conference for nurses on substance abuse primary prevention skills. Attendees reported that the biggest obstacle to prevention was a lack of time and opportunity during brief inpatient or outpatient visits (Beebe, 1992; see Attachment 1).

Additional papers have addressed ways to encourage behavioral assessment in general practice. In the first, the authors argue that the three barriers to effective recognition and treatment are patient factors (e.g., reluctance to discuss, fear of stigma, financial concerns); the nature of the health care system (e.g., a generalist provides care for large numbers in a short time; reimbursement policies provide few incentives to treat mental disorders); and physician-related issues (e.g., negative attitudes, deficient technique, prior negative experiences with psychiatrists, lack of available psychiatric consultation, and cost factors associated with such consultation) (Pincus et al., 1995). Under the sponsorship of NIMH, physician groups and psychiatrists developed the DSM-IV-PC, a guide for primary care physicians to diagnose common psychiatric disorders including problematic substance use. This guide is considered a first step in promoting educational, clinical, and research collaboration among psychiatrists and primary care physicians. The second paper, a research study, addressed the clinical significance of subthreshold psychiatric symptoms in primary care practice (Olfson et al., 1996; see Attachment 1). Among other behavioral health symptoms, patients in an HMO were screened for subthreshold symptoms of legal or illegal drug abuse. Patients who met criteria for these symptoms were likely to have other clinical disorders, such as alcohol dependence or major depression. The authors recommend fuller psychiatric assessment when subthreshold symptoms are found, but do not address how or if general practitioners should regularly screen for subthreshold symptoms.

A report in the managed care literature describes another approach to integrating behavioral health and primary care (Strosahl et al., 1994). Group Health Cooperative of Puget Sound places chemical dependency (CD) counselors in primary care clinics to assist physician teams in identifying and referring CD patients. The Group’s Alcohol and Drug Abuse Program of Treatment sponsors continuing medical education, provides discharge summaries and progress notes, and sponsors joint staff meetings and visits to primary care clinics on a regular basis. Quantifiable outcome measures assure that collaboration occurs. The program is particularly interesting because it brings specialty resources directly into primary care.

Managed care organizations typically receive capitated payments for their enrolled members. Capitation is a funding mechanism that provides a standard monthly rate of payment per enrolled member, whether or not the member uses services. The rate may be adjusted up or down, depending on the member’s age or medical condition, or the richness of the benefit package. If the membership is stable, capitation should provide incentives for activities that have been proven to prevent illness or injury, since over time these activities will reduce total cost. If the membership is not stable (e.g., if there is intense competition among HMOs and if disenrollment from the HMO is a frequent occurrence), then this incentive may not be salient. Instead, HMOs can be expected to provide services that will attract and maintain members who incur the lowest costs and/or provide the highest capitation rate.

Capitation has other related implications for prevention services. Because capitation puts managed care organizations at risk for the costs of providing comprehensive services to members, it encourages scrutiny of inefficient service provision. For instance, primary care physicians have become "gatekeepers" who allow or block access to specialty services based on their assessment of member need. The TIP comments on the implications of this gatekeeping role as follows:

In this era of managed care, the primary care clinician’s responsibility is expanding. As the gatekeeper charged with ensuring the provision of comprehensive care, the primary care clinician will almost certainly provide some type of alcohol- or other drug-related service. Basic skills in identifying and diagnosing patients who are chemically dependent will become essential. Clinicians in areas with limited substance abuse resources may be responsible for assessments, whereas those trained in addiction medicine may be providing a range of treatment services. Regardless of how extensively involved clinicians become, those who are familiar with the medical complications of substance abuse and are able to relate them to other comorbid illnesses will be better equipped to deliver adequate care. (p. 2)

Financial risk also encourages organizations to monitor the behavior of their physicians and to develop information systems that support practice patterns deemed necessary and/or effective. An example of how this can enhance prevention services is cited in the TIP:

Computerized reminder systems are used in some large staff-model health maintenance organizations (HMOs) (Balas et al., 1996). Each time a patient visits his or her physician, the computer generates an individualized, updated health screen report that is placed on the front of the chart before the patient arrives. The report lists several health screen procedures, the frequency with which such tests should be performed based on medical research and decisions by the leadership of the HMO, and the last date on which the patient was screened in these areas. The frequency standard that has been applied to alcohol use history is to review it at every new patient’s initial health assessment and during periodic health reviews thereafter. When such a review is due, the computer places an asterisk next to the "Alcohol Use" category on the health screen report. (pp. 72-73)

Another way to encourage regular screening is by developing quality standards and assessing managed care and primary care group practices for evidence of desired services. An example is the "report card" ratings used by regulators to monitor quality and provide information to consumers and payers for comparing managed care organizations. By far the most influential of these report card systems is the Health Plan Employer Data and Information Set (HEDIS) sponsored by the National Committee for Quality Assurance (Corrigan & Nielsen, 1993; Druss & Rosenheck, 1997). HEDIS has been criticized, however, for the paucity of behavioral health indicators, such as those involving substance abuse (Peck, 1994). Other planned uses for HEDIS include testing for the effectiveness of care, such as substance counseling for adolescents and screening for chemical dependency (HEDIS, 1997).

Health care organizations also have participated in universal prevention strategies in other ways, besides screening. Health care organizations have become partners in community prevention coalitions, such as Fighting Back (Saxe et al., 1997). In Vallejo, California, for example, Kaiser Permanente has been a highly involved partner, donating volunteer time and in-kind contributions and participating in the leadership of the Vallejo Fighting Back Partnership (see Hallfors, Reber, Watson, Spath, & Cohen, 1998). Fallon Health Care System staff were members of the Public Awareness Task Force of Worcester (Massachusetts) Fights Back and also participated in efforts to reach elders who may have alcohol or prescription drug abuse problems. Blue Cross/Blue Shield participated in the planning of a pilot program to provide health education/screening services to community residents through school- and church-based sites in the target area (Newark Fighting Back Partnership, 1994 Workplan).

Selective preventive interventions are targeted to individuals or a subgroup of the population whose risk of developing substance abuse or dependence is significantly higher than average (adapted from Institute of Medicine, Reducing Risks for Mental Disorders, 1994, p. 24). Persons requiring emergency room (ER) care make up one such group, because of the link between substance use and injury. Two anecdotal reports of screening and assessment programs geared toward ER patients were found. The first described a system that allows ER doctors to request substance abuse follow-up for patients (Strosahl et al., 1994). By filling out a name, medical record number, and phone number on a form, the Kaiser Alcohol and Drug Abuse Program follows up with enrolled patients, calling them and requesting they come in for an evaluation. In acute situations, the patient can be evaluated while in the ER.

The second program evolved from a community coalition in Santa Barbara funded by the Robert Wood Johnson Foundation, called Fighting Back (Jellinek & Hearn, 1991). The program began as an attempt to educate physicians and nurses on AOD issues. In response to the high rates of AOD involvement in ER visits, the program evolved into an Emergency Psychiatric Service, providing 24-hour assessment and referral services for chemical dependency and dual diagnosis (Smith, 1997). The coalition provided seed money for the program, but the hospital eventually covered all costs.

Indicated prevention interventions are targeted to high-risk individuals who are identified as having minimal but detectable signs or symptoms foreshadowing substance abuse or dependency, or biological markers indicating a predisposition for substance abuse or dependency, but who currently do not meet DSM-III-R diagnostic levels (adapted from Institute of Medicine, Reducing Risks for Mental Disorders, 1994, p. 25). The Guide to Clinical Preventive Services (1996) notes:

The quantity, frequency, patterns of consumption, and adverse consequences of drug use (e.g., interference with school or work, evidence of dependence) should be assessed for all patients who report drug use. Clinicians should establish a trusting relationship with patients, approach discussion of drug use in a nonjudgmental manner, and respect the patient's concerns about the confidentiality of disclosed information. (p. 590)

No research studies were found that addressed indicated drug abuse prevention in general medical practice. However, the TIP recommends brief intervention by primary care providers as an appropriate indicated prevention method, based on evidence from alcohol research. The TIP notes that clinical trials and research studies in this country and abroad over the past 15 years have demonstrated the feasibility and effectiveness of brief intervention with selected patients identified as heavy drinkers. It further states: "Though few studies have included illicit drug users, the Panel believes that brief intervention has the potential to stop or curb some patients’ drug use also" (p. 27). The TIP notes that patients may be appropriate candidates for a brief intervention if they have positive but low scores on screening tests such as the CAGE-AID, occasional use of marijuana (e.g., five or more episodes in a lifetime), or questionable use of mood-altering prescription medications.

Sections

Pediatric Health Care

Numerous articles in the current literature advise physicians and nurses to provide drug abuse prevention services routinely to their young patients. The Guide to Clinical Preventive Services (1996) summarizes physician groups' guidelines on drug abuse prevention services with pediatric patients:

The AAFP, AMA Guidelines for Adolescent Preventive Services (GAPS), Bright Futures recommendations, and American Academy of Pediatrics suggest that clinicians discuss the dangers of drug use with all children and adolescents and include questions about substance abuse as a part of routine adolescent visits. (p. 589)

Although this and other reports show unanimity among professional groups and clinical writers about providing universal preventive services to young people, it should be noted again that only 28% of pediatricians and 23% of family practitioners report that they inquire about drug use (NCHS, 1996). Many of the reasons for this disparity are similar to those discussed in the previous section, but several issues are specific to pediatric practice.

The first of these is confidentiality. Most reports stress developing a strong alliance with the young client and conducting confidential inquiries into drug use (Committee on Substance Abuse, 1996; Faigel, 1996; Fuller & Cavanaugh, 1995; Johnson, Stands, & Strothers, 1994; Stevens & Lyle, 1994). None of the reviewed reports, however, suggest what clinicians should do if they uncover use and clients refuse to share this information with parents or guardians. Klein, Slap, Elster, and Cohn (1993) note that whereas adolescents want disclosures to be confidential, physicians are uncomfortable with family negotiations concerning independent care and decision making. No articles were found that addressed the legal and ethical issues for physicians of not disclosing information about use to the parents of minors, particularly in the event of accidents or other negative sequelae involving substance use.

The second issue is the differences in philosophy about the causes and course of substance abuse. Most reviewed articles advocate using a biopsychosocial model, which considers the physiological, genetic, cultural, social, intrapsychic, and other influences on substance use. Physicians and nurses are advised to assess the young person and provide counseling and anticipatory guidance on developmental tasks (e.g., development of friendships and intimate relationships, school achievement, and separation from family) using an instrument such as HEADS or HEADSFIRST (Fuller & Cavanaugh, 1995; Muramoto & Leshan, 1993). Other articles, however, espouse a disease model of substance abuse and postulate that adolescents experience a more rapid progression of addiction than adults, with more entrenched and delusional denial (Morrison, 1990). Clinicians are given little advice about early intervention except to be diligently watchful and aggressive in screening (Hicks, Morales, & Soldin, 1990; see Attachment 2).

A related issue, then, is the appropriate education of pediatricians and other clinicians who routinely provide health care to children and youth. The two studies found on this topic both suggest that training can increase awareness and change attitudes among medical students. The first was a case study of three second-year medical students who developed and implemented a middle school alcohol, tobacco, and other drug (ATOD) abuse prevention curriculum (Davis et al., 1994; see Attachment 2). By the end of the project, the medical students could identify prevention strategies that were most appealing to adolescents; at 8-month follow-up, they reported a sense of increased competence in working with adolescents. Involving medical students with adolescents outside of the clinical setting makes this program particularly innovative.

The second study evaluated a model AOD use curriculum for pediatric residents along more traditional lines (Kokotailo, Fleming, & Koscik, 1995; see Attachment 2). The curriculum was partially funded by a NIDA/NIAAA faculty development grant for training about alcohol and drug abuse. Residents who participated in the program showed significant pre- to posttest gains in general knowledge, knowledge and use of screening techniques, and clinical management skills when compared with a control group. Authors report that the curriculum was "well received by students and continuing with strong faculty support" (p. 497).

An additional issue in this literature is the best method for screening adolescents for substance use. Professional groups and physician guidelines generally advocate face-to-face interviews. Stevens and Lyle (1994), reviewing the GAPS guidelines, noted that although there is some evidence of the importance of physician interviews in obtaining histories of adolescent substance use, these interviews expose less than 5% of self-reported drug use and have been found to give less information than standard questionnaires. Nonetheless, GAPS notes, "Health professionals generally agree that although questionnaires may promote screening for sensitive information, they should not substitute for a face-to-face interview" (p. 424).

A few articles suggest alternatives. One recommends that, after conducting a physical examination during a routine visit, the physician leave the adolescent with a simple paper and pencil questionnaire to fill out in private (Fuller & Cavanaugh, 1995). This becomes a "door opener" for further discussion of sensitive information. An even more promising screening approach is the use of computers for eliciting information about substance use. A study of three randomly assigned groups found that adolescents reported the regular use of marijuana, alcohol, and tobacco at much higher rates when using a computer than when using an identical written questionnaire (Paperny, Aono, Lehman, Hammar, & Risser, 1991; see Attachment 2). The computer screen was particularly useful in identifying males who are heavy marijuana users. Total confidentiality did not alter the results: the group that was told the printout would be shared with physicians responded at similar rates to the group that was told their responses would not.

Biological drug screening of adolescents is controversial. The GAPS states: "Use of urine toxicology for the routine screening of adolescents is not recommended" (Stevens & Lyle, 1994, p. 428). Other authors have recommended that urine drug screens may be useful and necessary to uncover use, confront denial, diagnose abuse or overdose, or ensure abstinence (Hicks et al., 1990; Morrison, 1990; Muramoto & Leshan, 1993). The American Academy of Pediatrics (AAP) provides guidance as follows:

The AAP does not object to diagnostic testing for the purpose of drug abuse treatment. Testing should be approached in a fashion similar to diagnostic testing for other diseases, which includes obtaining informed consent from individuals with decisional capacity. Involuntary testing would be justified only if the adolescent were at risk of serious harm that could be averted only if the specific drug were identified. If the treatment and therapy would not be changed by testing, involuntary testing would not be justified.

Because serious legal consequences may result from a positive drug screen, it is a minimal requirement that there be a candid discussion regarding confidentiality and the need for informed consent from a competent individual. If confidentiality issues are adequately addressed, a competent adolescent may consent to testing and counseling without the knowledge of parents, police, or school administrators.

Voluntary screening may be a deceptive term, in that there often are negative consequences for those who decline to volunteer. Parental permission is not sufficient for involuntary screening of the older, competent adolescent, and the AAP opposes such involuntary screening. Consent from the older adolescent may be waived when there is reason to doubt competency or in those circumstances in which information gained by history or physical examination strongly suggests that the young person is at high risk of substance abuse. (Committee on Substance Abuse, 1996, pp. 306-307)

Another major issue is the paucity of resources for clinicians who identify a problem (Riggin, 1993). In the evaluation of community coalitions funded by the Robert Wood Johnson Foundation program, Fighting Back, many communities identified a lack of identification, intervention, and treatment services for adolescents (Smith, 1997). One site developed an initiative called Insure the Children in order to get substance abuse services to this population (Smith, 1997).

Besides problems accessing AOD treatment, adolescents also receive less primary health care and prevention services than any age group in the United States (Klein et al., 1993). Fewer than 15% of all adolescent visits to office-based physician providers are for health supervision or preventive care; as many as 69% of visits do not include health counseling or guidance. Many adolescents are also underinsured, with health insurance that does not include preventive care, counseling, substance abuse treatment, or other needed services. And youth living at or below the poverty line are only about half as likely to identify a source of health care as those of higher economic status.

School-based clinics have met some of these needs for some youth (Dryfoos, 1994; Klein et al., 1993). School nurses are actively involved in prevention and screening activities and participate in developing school policies for identification and intervention (Cromwell & LeMoine, 1992; Jack, 1992; Riggin, 1993). Despite their importance and potential for delivering prevention services, however, schools are not feasible as sole sources of health care: access to services is limited to the school calendar, and the approximately 500 school clinics that are thought to exist (Klein et al., 1993) represent only a small fraction of the nation's schools.

Access to drug abuse prevention and treatment might improve if more were known about cost-effectiveness. One study attempted to assess the costs of clinical interventions for risk behaviors among adolescents, including substance abuse, and to compare them with the cost of regular prevention services (Gans, Alexander, Chu, & Elster, 1995; see Attachment 2). Unfortunately, the cost-effectiveness of prevention services is not known, so no link to cost offsets can yet be made. The authors note that a capitated system has more "system-level" incentives to provide preventive care than an indemnity system, and they conclude that high-quality data collection on efficacy, effectiveness, and costs associated with clinical adolescent preventive services is critically needed.

Although examples were not found in the literature, there is a further opportunity for health care organizations to provide universal prevention programs for youth. Several science-based drug prevention programs have been described in the NIDA (1997) document Preventing Drug Use Among Children and Adolescents: A Research-Based Guide. These universal programs typically have been developed for schools, but they also could be incorporated as part of a managed care benefit package or as a way for pediatricians or organizations to collaborate with school health programs. Examples include the Life Skills Training Program (Bovin, Baker, Dusenbury, Botvin, & Diaz, 1995; Botvin, Baker, Filazzola, & Botvin, 1990; Botvin, Schinke, et al., 1995) and Preparing for the Drug Free Years (Hawkins, Catalano, & Miller, 1992). The latter program has been adapted for group implementation for families in a variety of settings including health care or behavioral health care sites.

Two reviewed reports discuss the potential for selective drug abuse prevention services in pediatric practice. A third, dealing with adolescent psychiatric inpatients, is discussed in a subsequent section on psychiatry.

The first, a research study, analyzed data from a retrospective chart review to see if adolescent use of regular primary care services reduced the likelihood of more expensive care in an HMO (Joshi, O’Mara, Hendershott, Vose, & Straus, 1993; see Attachment 2). Adolescents admitted for trauma or mental health services were matched to a comparison group with no such utilization. The trauma/mental health group had equal rates of primary care utilization, but episodic outpatient care was much higher. Substance abuse was also analyzed for the two groups, but was hampered by high rates of missing data. The authors believe that an increase in episodic care visits should alert providers to impending crises in their teen patients and prompt them to explore teens' psychosocial status, including substance use, which was rarely noted in the chart.

The second paper discussed the special needs of homeless children, a population that may be uniquely vulnerable for early initiation and sustained use of substances (Wagner, Melragon, & Menke, 1993). According to the author, nurses in health care clinics serving the homeless may be well suited to implementing drug abuse prevention programs that focus on underlying factors, such as fostering personal competency and self-worth, the ability to form lasting interpersonal relationships, and a commitment to developing meaningful goals. Health professionals are urged to work with the parents of young children to increase the child's chances of experiencing consistent, empathetic, sensitive parenting and opportunities for prosocial activity.

No studies were found of selective pediatric prevention programs within the health care system. However, science-based programs do exist and could be implemented as part of comprehensive care. One example is the Strengthening Families Program (Kumpfer, Molraard, & Spoth, 1996), which includes parent training to improve parenting skills and reduce substance abuse by parents, children’s skills training to decrease negative behaviors and increase socially acceptable behaviors, and family skills behavior to improve the family environment (NIDA, 1997). Another promising program is Focus on Families (Catalano, Haggerty, Fleming, & Brewer, in press), which targets parents on methadone treatment and their children. Session topics include family goal setting, relapse prevention, family communications, creating family expectations about alcohol and other drugs, and helping children succeed in school. Booster sessions and case-management services are part of this program.

Two reviewed reports described indicated prevention programs for substance-using college and high school youth. The first of these, the Impaired Student Assistance Program (ISAP), was developed to help identify college students with substance abuse problems (Steenbarger, Coyne, Baird, & O’Brian, 1995). Besides the universal components of education, outreach, and alcohol-free social options for students, the ISAP seeks to link college counseling and health services for identifying, assessing, and referring students who are themselves in health training programs.

The second, a research study, analyzed adolescents’ use of school health clinic services in relation to the traditional health care system. During a 38-month period, 3,318 high school students made at least one visit to the school health clinic. This represented 63% of students enrolled in the clinic and approximately 42% of the total school population. Of these students, 25% visited a mental health counselor and 8% visited a substance abuse counselor (Anglin et al., 1996; see Attachment 2). The authors reported that there was little published literature about corresponding services for adolescents in the traditional health care system; such visits were too few to be included in the National Ambulatory Medical Care Survey. The authors believe that clinics have several advantages as a provider of AOD preventive care: students in school tend to have less severe substance abuse problems than dropouts; counselors can find them for follow-up; and student assistance programs provide an incentive to comply rather than face suspension.

Although not found in the health care literature, one additional example of an indicated program for youth is worth mentioning. Reconnecting Youth (Eggert, Thompson, Herting, & Nicholas, 1994, 1995) is a research-based program found to be effective in reducing drug involvement and mental health problems and improving school performance among targeted youth. The program was developed as a school-based program for young people in grades 9 through 12 who showed signs of poor school achievement and potential for dropping out of high school. The personal growth class potentially could be adapted for the health care setting, for youth who are experimenting with substances.

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Obstetrical-Gynecological Practice

Education and guidance about avoiding drug use is particularly important for pregnant women because of the potential negative effects of substance use on the developing fetus. The Guide to Clinical Preventive Services (1996) notes the following:

All pregnant women should be advised about the potential risks to the fetus of drug use during pregnancy and the potential to transmit drugs to infants through breastfeeding. Routine drug testing of urine or other body fluids is not recommended as the primary method of detecting drug use in pregnant women or other asymptomatic adults. (p. 583)

The American College of Obstetricians and Gynecologists recommends that clinicians take a thorough history of substance use and abuse in all obstetric patients, and remain alert to signs of substance abuse in all women. (p. 589)

Despite these guidelines for universal prevention services, only 32-43% of obstetrical-gynecological clinicians report routinely inquiring about drug use (Horton, Cruess, & Pearse, 1993; NCHS, 1996; see Attachment 3). Female physicians inquire at considerably higher rates than their male counterparts, with 68% versus 38% reporting they routinely ask about alcohol and other drugs. One third or more women receive no advice from any health professional on ceasing ATOD use (Kogan, Kotelchuck, Alexander, & Johnson, 1994).

As with pediatric care, particular issues appear to conspire against preventive ATOD health care services for women. First, health care providers lack training and often think they are unable to help the abusing patient (Campinha-Bacote & Bragg, 1993). Second, substance abuse by women carries more stigma, so women are less likely to divulge information and clinicians are less likely to ask about use (Hughes & Fox, 1993). Third, discovering illegal drug use by pregnant women can carry considerable legal and ethical dilemmas, since some states require clinicians to report women with a positive drug screen to authorities for child abuse (Moseley & Bell, 1991).

ATOD use is quite common among women, including pregnant women. The four relevant studies in this review show a wide range of prevalence reports of illegal drug use, depending on the geographic area and when the client was screened. At a Maryland health clinic, Marques and McKnight (1991; see Attachment 3) found that 20% of pregnant adolescents and 31% of pregnant women 21 years and older were either current users or at high risk for use. Another study, based in Alabama and using urine screens during clinic visits, found that 11% of pregnant women and almost 16% of nonpregnant women tested positive for drugs (George, Price, Hauth, Barnette, & Preston, 1991; see Attachment 3). In a third study, less than 4% of California women had positive urine drug screens at the time of delivery, although this varied widely by ethnic group (Noble et al., 1997; see Attachment 3). In a fourth study, 7% of Iowa women, also tested with urine drug screens at delivery, were positive for cocaine (Reddin, Schlimmer, & Mitchell, 1991; see Attachment 3) .

The method of testing can account for considerable variation in use rates. For cocaine, a good correlation between self-report, maternal urine, and meconium was found, with approximately 3.4% testing positive at delivery (Bibb, Stewart, Walker, Cook, & Wagener, 1995; see Attachment 3). This was not true for tetrahydrocannabinol (THC) (5.7% by self-report, 2.5% in urine, 1% in meconium). Newborn urine was not as reliable as other methods, with much lower rates of identification than the other three biological methods. As with adolescents, screening by computer yielded much higher reported rates of use than written questionnaires, and clients liked using the computer (Lapham, Kring, & Skipper, 1991; see Attachment 3).

One anecdotal report of a promising managed care program was found for screening and referring pregnant women (Butynski, 1996). In the Kaiser Permanente Early Start Program, all prenatal patients complete a standardized questionnaire and are given information about the health consequences of using ATOD. Those with any level of risk are referred to an on-site prenatal substance abuse specialist for immediate assessment and intervention. The physician walks the patient down the hall for a face-to-face introduction to the specialist, which is considered an essential component of the process. Without leaving the office, the patient works with a trained specialist, while the physician is freed up to continue with normal primary care. Begun in Oakland, California, in 1994, the program now operates at 10 sites throughout the region and serves approximately 10,000 pregnant women annually.

The Guide to Clinical Preventive Services (1996) notes:

Selective use of urine testing during pregnancy may be appropriate when the possibility of drug use is suggested by clinical signs and symptoms (e.g., growth retardation, inadequate weight gain, inadequate prenatal care). Patients should give consent prior to drug testing and be informed of any legal obligations on the part of the clinician to report drug use to child protective agencies or other authorities. Both positive and negative results should be interpreted with understanding of the kinetics of drug metabolism and the limitations of testing methods, and positive screening tests should be confirmed by more reliable methods. (p. 591)

Most hospitals use selective screening techniques for identifying illicit drug use by pregnant women (Birchfield, Scully, & Handler, 1995; see Attachment 3), although universal screens identify use at much higher rates (Hansen, Evans, Gillogley, Hughes, & Krener, 1992; see Attachment 3). Whether and how pregnant women and their infants should be biologically screened for illicit drugs remains controversial. Some advocate universal screening as the most effective way to eliminate discriminatory testing and the inconsistencies and bias that can lead to discriminatory reporting. Others advocate selective screening because of concerns about government involvement, testing costs, and overloading of social agencies with cases. The preferred option may be to remove legal sanctions and other adverse consequences, since they only inhibit women from seeking prenatal care (Moseley & Bell, 1991).

Indicated prevention includes services to women who are known to use substances in order to stop or limit the use, thus preventing dependence and the harms to the woman and fetus related to drug use. The Guide to Clinical Preventive Services notes:

Periodic testing can also help monitor and encourage abstinence in women who have used drugs. Pregnant women who abuse drugs should be advised of the importance of regular prenatal care and be referred for treatment where available. (p. 591)

Three reviewed reports addressed indicated drug abuse prevention services. The first report described a model state prevention and treatment program for pregnant and parenting women (Brindis, Berkowitz, Clayson, & Lamb, 1997; see Attachment 3). Prevention services were to include substance abuse screening during prenatal care visits, counseling to deter escalation of use for women who are early in their substance abuse careers, and biopsychosocial support during pregnancy and the postpartum period. The model was then compared to current services in California. Service providers indicated that there were too few AOD treatment slots for pregnant and parenting women. Child care and transportation, as well as weekend and evening aftercare programs, were lacking.

Although the previously mentioned Early Start Program (Butynski, 1996) reported high participation rates among substance-using pregnant women, other studies report poor or mixed results. Van-Amerongen (1996; see Attachment 3) described a program that identified cocaine use through urine screen and invited women to participate in a comprehensive program aimed at improving outcomes. Despite initial consent, none of the women continued past the first meeting.

Alemi and Stephens (1996; see Attachment 3) recruited volunteers in a program designed to complement chemical dependency treatment and high-risk pregnancy management by reducing feelings of social isolation and increasing health information. Both study group and comparison group patients showed lower use of alcohol and drugs; the addition of telephone-based computer services did not further improve these outcomes.

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Psychiatry

Just as general practice implies a primarily universal approach to prevention, the screening of psychiatric clients implies a selective approach to prevention. Four reviewed studies focused on ways to screen psychiatric clients and underlined the high rates of substance abuse comorbidity in this population.

The first study found that 56% of persons entering an inpatient psychiatric hospital were substance abusers, but only half of these persons received treatment for the disorder (Kanwischer & Hundley, 1990; see Attachment 4). The authors recommend conducting substance abuse screening for all hospital admissions with particular attention paid to adult forensic and child and adolescent patients; developing training protocols for identifying, assessing, treating, and managing mentally ill substance abusers; and developing and implementing hospital- and community-based treatment programs for patients with dual diagnosis.

A second study found that physicians ordered drug screens on about half of psychiatric ER patients, and 28% were positive (Dhossche & Rubinstein, 1996; see Attachment 4). Clinical correlates of cocaine use included suicidality in males and paranoid ideation in black males. Carey, Cocco, and Simons (1996; see Attachment 4) tested the ability of outpatient therapists (social workers, psychiatric nurses, and psychologists) to accurately assess psychiatric outpatients' substance use, abuse, and dependence. The author concluded that clinical rating scales could be useful in determining the need for further in-depth assessment and monitoring.

The Substance Abuse Subtle Screening Inventory (SASSI), which was tested in screening adolescent psychiatric inpatients, had high rates of agreement with a diagnostic interview by a trained chemical dependency counselor (Piazza, 1996; see Attachment 4). The high co-occurrence of psychiatric disorders with substance use disorders (41%) supported inclusion of a screen such as the SASSI for substance use disorders in adolescent psychiatric treatment programs' standard intake and assessment protocols.

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Occupational Health Care

Papers on drug abuse prevention services in work settings were also reviewed. The Guide to Clinical Preventive Services (1996) summarizes medical recommendations for workplace-related prevention efforts:

The AMA supports drug testing (in conjunction with rehabilitation and treatment) as part of preemployment examinations for jobs affecting the health and safety of others. The AMA and most other medical organizations endorse urine testing when there is a reasonable suspicion of drug abuse. (p. 589)

As noted, urine drug testing is a major strategy for deterring drug use in employment settings. An American Management Association survey found that 50% of U.S. companies test either job applicants or current employees (random testing or on reasonable suspicion of drug use), a jump of over 100% in 4 years (Platman, 1990). The increase stems from President Reagan's 1986 Executive Order mandating a drug-free federal workplace to serve as a model for all American businesses. The federal mandate limits tested drugs to marijuana, cocaine, opiates, amphetamines, and phencyclidine (PCP).

The physician's role in workplace substance abuse prevention is typically as a medical review officer (MRO) who determines the urine drug screen results (Platman, 1990). The MRO plays a highly technical, almost neutral role, a "decidedly forensic function" (Clark, 1990). The MRO's role was written into the federal order to protect employees against false-positive results. The MRO informs an affected worker of positive urine screen results and may then conduct a medical interview and reorder the test. If the MRO determines the screen to be a true positive, the worker may face discharge or referral to an employee assistance program (EAP) for mandatory treatment; a prospective employee will not be hired.

Although drug testing may identify and even deter use, employee assistance programs (EAPs) provide the opportunity to provide further prevention and treatment services. EAPs have developed from alcohol assessment and referral centers to specialized behavioral health programs, defined by six major components: identification of problems based on job performance, consultation with supervisors, constructive confrontation, evaluation and referral, liaison with treatment providers, and substance abuse expertise (White, McDuff, Schwartz, Tiegel, & Judge, 1996). Short-term counseling, evaluation, and referral by EAPs also have been used by employers as a way to control health care costs. Some employers have elected to use the EAP as a gatekeeper and case manager for mental health and substance abuse benefits (White et al., 1996).

Bray, French, Bowland, & Dunlap (1996) identified six typical EAP services provided in worksites:

• 24-hour telephone hotline access to the EAP staff
• In person assessment of the employee’s presenting problem and referral to treatment as needed
• Short-term counseling with up to five follow-up visits
• Long-term counseling if more than five visits are needed
• Supervisor and/or employee training to recognize problems and to use the EAP effectively
• Health promotion and/or wellness programs, including literature, presentations, and other activities to promote health and increase awareness of health risks

Thus, indicated prevention services, such as assessment and short-term counseling, could be provided if employee drug use was identified, either through a drug screening program or through job performance. Health and wellness programs also could be used as universal prevention measures.

A recent study found that EAPs are becoming an increasingly popular adjunct to primary health care services, even at small worksites (Hartwell et al., 1996). EAPs are more likely to be found in larger worksites, however, and in the communications, utilities, and transportation industries. Approximately 33% of all private, nonagricultural worksites with 50 or more full-time employees currently offer EAP services to their employees, an 8.9% increase over 1985. Administratively, EAPs can be affiliated with the medical, human resources, or other department of a company and function either as an internal administrative unit or as an external contractor (Hartwell et al., 1996).

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Conclusions and Future Directions

Although clinicians' professional organizations and journals advise them to provide drug abuse prevention services, only a small fraction comply. This review of the recent literature describes the many structural reasons that conspire against implementation of the recommendations. Public health programs have historically stood on the sidelines when federal dollars were distributed for drug abuse prevention. Health care reimbursement mechanisms have not supported the provision of drug abuse prevention services in most indemnity or managed care programs. Physicians' and nurses' work environments are geared for very brief visits with many patients, and opportunity costs are high when new prevention services are added. Cost-effectiveness research on drug abuse prevention is in its infancy, and little has been done yet to test tools for screening or the outcomes of drug prevention in primary care.

Moreover, most clinicians have not received training in substance abuse prevention through their educational programs. Medical training, traditionally disease oriented, has not provided clinicians with skills in assessing or guiding clients when they are having psychosocial problems. Substance abuse prevention has suffered from low status in primary care, and health care providers are reluctant to raise issues that carry stigma and engender denial in their patients. Clinicians who detect problems face legal and ethical dilemmas, such as the legal requirement to report pregnant women who use illegal drugs. Referral and treatment options are few, particularly for the poor and for women, youth, and ethnic minorities.

Thus, there are two parts to achieving the goal of incorporating drug abuse prevention services into the health care system. The first is to demonstrate that specific drug prevention activities are effective and can be implemented in an efficient manner. Second, the tested tools and procedures must be disseminated to primary care clinicians in a way that ensures that they will be regularly and appropriately adopted.

This paper considers several different health care settings, each of which could test promising methods of regular screening and/or services. For instance, the TIP recommends that primary care clinicians should ask one simple question (Have you used street drugs more than 5 times in your life?) to identify potential problems and the need for more in-depth screening. A research protocol could be set up to assess the rates of affirmative answers to this question and whether screening in this manner uncovers problem drug use. If it does, can a brief intervention protocol, similar to ones found successful with alcohol use, also be effective with drug use?

Both the TIP and the Guide comment on the lack of this basic level of clinical research. To do even this much requires the testing of three discrete pieces, each with its own set of research questions. These are (a) asking a screening question (Should it be face to face? As part of a comprehensive screening instrument? Are rates of positive answers at expected levels?); (b) following up on a positive response (What protocol should be used for further screening?); and (c) the brief intervention (What intervention works and for whom?). The alcohol research literature should provide a useful guide for conducting this type of research, since considerable work has already been done in brief interventions with alcohol.

Managed care organizations provide good potential for doing this research because they are relatively closed systems where all patient service utilization and costs can be tracked. Participation in HEDIS offers even greater potential to compare the effectiveness of different models of prevention services, since participating organizations could be randomly assigned to implement different models. The above-mentioned research study could be tested in general medical practice and perhaps also tried in pediatrics and obstetrical practice. Emergency room programs, similar to those reviewed in this paper, also could be tested through a carefully designed demonstration program to determine the rate at which problems with drug abuse can be uncovered in this setting, whether follow-up is conducted successfully, and what happens to clients after this type of intervention. Selective prevention programs, such as Strengthening Families, is another important area that could be demonstrated and tested in health care settings.

For adolescents, the way to screen is an important area for research. The randomized controlled trial on computer versus paper and pencil screens is most intriguing and should be tested further. Research questions might include the following: How do physicians and nurses respond to these "door openers," and how should they respond in order to discourage use and encourage substance-free development? What adjunct services are needed? (Mental health services appear to be extremely important, given that 50% of adolescents who made substance abuse visits at a school clinic were also making mental health visits [Anglin, 1996].) How should physicians and nurses involve parents when minors report illegal drug use? Screening through school health clinics was not discussed, but also may be an important use for computer-based tools. Methods of follow-up, the handling of confidentiality, and student and peer perceptions about school personnel involvement could be explored. In addition, demonstrations of indicated prevention programs, such as Reconnecting Youth, could be implemented and evaluated both in the school setting and within HMOs.

The Kaiser Permanente Early Start Program shows promise in reaching pregnant women and merits further review. Other reports describe less successful prevention attempts with women known to be using illegal drugs. The use of computers for screening sounds promising with this population as well as for adolescents and should be explored further. Development and evaluation of programs are critically needed, since there is clearly a lack of services for pregnant women. These findings are corroborated by our own evaluation of the Fighting Back program.

Confidentiality appears to be a significant problem for this population, and the threat of legal sanctions for child abuse may deter women from seeking prenatal care. Moseley and Bell (1991) argue convincingly that the use of illegal drugs has no greater predictive harm to the fetus than the heavy use of alcohol or tobacco, or the lack of a nutritious diet. If screening is a disincentive to prenatal care, then this public policy may be more injurious to the fetus than therapeutic. Much more information is needed about how to reach this population and how truly to prevent harm to mothers and their children.

Further research in the screening of psychiatric patients seems warranted, given the high incidence of abuse found in this population. The study by Olfson and colleagues (1996) also points to the link between any illicit drug use and other psychiatric disorders. Cost-effectiveness studies may support regular behavioral screening in primary care and may show a further link between drug use and high medical utilization.

Evaluation of the effectiveness of both urine screens and EAPs as prevention tools is needed. Both have been described in the literature in terms of the extent of their use, the process of use, and the cost of use. But no information was found in this search about whether either method should be considered an effective prevention service.

Once there are strong research-based programs for preventing drug abuse in the health care system, organizations can adopt and disseminate them. As noted in several of the reviewed papers, education of physicians and other clinicians has been a stumbling block. Problems in incorporating prevention activities in primary care are not unique to drug abuse, however. The TIP cites two excellent studies of clinician education and practice change strategies that could also be used in incorporating drug abuse prevention in health care. Davis, Thomson, Oxman, & Haynes (1995) found that the least effective continuing medical education (CME) technique was the most common: the formal CME conference or lecture. The most effective strategies were clinician reminders, patient-mediated interventions (e.g., patient educational materials and patient reminders), outreach visits to clinicians by peers (academic detailing), use of local opinion leaders, and use of multifaceted strategies (combining two or more of these effective strategies). Similarly, Yano, Fink, Hirsh, Robbins, and Rubenstein (1995) found that computer-generated reminders, audits with personal feedback to clinicians, academic detailing, and shifting specific activities to multidisciplinary team members were the most effective ways to improve practice performance in primary care settings. These techniques could be tested specifically for their effectiveness in implementing chosen drug abuse prevention strategies in the clinical setting.

This literature review, although not exhaustive, provides a comprehensive overview of drug abuse prevention in the health care system. Program development and research are both in very primitive stages, but appear to be poised for growth as managed care organizations struggle to find new ways to improve care while cutting costs.

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References

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