Michael Bogenschutz, Dennis Donovan, Cameron Crandall, Robert Lindblad, Raul Mandler, Harold Perl, Alyssa Forcehimes 1 Screening Procedures to Identify Problematic Substance Users in Medical Emergency Departments

Goals for This Presentation Describe and provide rationale for screening procedures used in the NIDA CTN SMART-ED study Describe characteristics of sample screened and recruited to date using these procedures

Screening for Study vs. Clinical Screening The purpose of screening in this study is to define a population of patients who are likely to have problematic drug use, abuse, or dependence for inclusion in the study, and to do so with minimal interaction (to minimize assessment reactivity). Priority is high positive predictive value (probability of the disorder given positive test). Clinical screening instruments are designed to have high sensitivity (probability of a positive test given the disorder). 3

Recruitment Total proposed N is 1285 randomized participants. 6 sites will recruit an average of 215 participants. Site recruitment target is 6 participants per week. We estimated that 5% of screened patients would qualify for the study. Therefore, 120 patients would need to be screened per week at each site to achieve the recruitment target. 4

Screening Screened sample must be broadly representative of ED population, but does not need to be a random sample. RAs screen patients out of the ED flow by identifying potentially eligible participants in the ED log. Brief Information Tool (BIT) records basic demographics and presenting complaint for all patients for whom screening is attempted. 5

Screening, cont. After triage, before or during ED treatment, RA approaches ED patient and invites him/her to participate in anonymous screening for possible study participation. Screening proceeds following verbal informed consent. 6

Screening Instrument Screening instrument is called the TAD (for Tobacco, Alcohol, and Drug). Administered using tablet PC. Includes a total of 20 questions: – Heavy Smoking Index (4 items) – AUDIT-C (3 items on quantity/frequency of alcohol) – Drug Abuse Screening Test (DAST-10) – Primary substance, days of use of primary substance in past 30 days, and substance- relatedness of the ED visit. 7

Screening, cont. Screening continues for participants who have DAST-10 score of 3 or greater and report at least 1 day of use of the self- identified primary problem substance in the past 30 days. RA then administers Secondary Prescreening Form (SPF) to assess additional exclusion criteria. Participants who pass are invited to proceed to written informed consent for the study. 8

Completion of screening prior to randomization Before participant can be randomized the RA must complete – Demographics – Locator Information Form – Hair sample (objective measure of substance use) – Enrollment Forms A and B 9

Screening and Randomization Through Sept 20, 2011 Site# BITs# TADs# Randomized % BITs Randomized % TADs Randomized %7% %13% %4% %5% %7% %35% Overall %9% 10

Substance use among those completing the TAD 11 2,855 participants endorsed past-30d drug use (25% of TADs). Of these, 955 have been randomized (33% of drug users). Most of those not randomized were excluded because they did not meet DAST ≥ 3 criterion.

Drug use by primary substance Primary Drug 30-day drug users from TAD Randomized participants % users randomized # users %days use # users %days use Cannabis166658% %1824% Cocaine50818%924926%1249% Street Op.36113% %2152% Prescr. Op.1666%13536%1832% Methamph.813%7435%1153% Sedatives351%14131%2037% Hallucin.221%37 332% Amphet.161%630%719% 12

Primary Substance by site Site CannabisCocaineStreet opioids Prescr. opioids Meth.SedativeHalluci- nogens Amphet- amine 117% 43%8%16%1%0% 249%30%14%5%---1% %25%14%6%1%4%3% %34%9%2%3%1%---1% 576%8%5%10%---2%---1% 635%48%11%3%---2%1%--- Total41%26%20%6%5%1% 0% 13

Demographics (n = 343, primarily from two wave-1 sites) 64% male mean age 39 ± 12 54% non-White, 26% Hispanic 2% were college graduates 9% were married 10% had full-time jobs 79% had household incomes under $15,

Conclusions 6% of those selected for screening, and 9% of those screened, were enrolled in the study. 25% of those screened endorsed past- month drug use. Sites differ in prevalence of various classes of drugs and overall rates of drug use. 15

Conclusions, continued These screening procedures are identifying heavy users of several types of drugs, as well as a larger number of drug users who do not meet severity criteria for the study. These procedures would likely need some modification for practical clinical use. 16