Development of this Treatment Improvement Protocol (TIP) was motivated by the Center for Substance Abuse Treatment's (CSAT's) recognition that simple instruments are needed to screen for alcohol and other drug (AOD) abuse problems and infectious diseases. Because these two conditions can occur together with high prevalence in some populations, workers in each of these fields need to be knowledgeable about how to screen their clients for the disorders and problems of the other.
AOD abuse treatment personnel, especially screeners and intake staff, need to be able to recognize risk factors for infectious diseases in the individuals with whom they come into contact. Similarly, outreach workers and other health care personnel working with people at risk for infectious diseases need to be alerted to signs of possible AOD problems in their clientele.
The screening instruments presented in this document were designed for use by AOD and infectious-disease workers to screen for disorders with which they may have limited familiarity. The AOD instrument is intended for use primarily by infectious-disease personnel, whereas the infectious-disease screening instrument is designed for use primarily by AOD workers. The use of these instruments in this manner can enhance the detection of these often comorbid conditions and can promote communication between referral agencies to foster the development of a network of treatment programs and other resources for clients.
Many, if not most, of the factors that place an individual at high risk for either substance use disorders or infectious diseases also place them at risk for the other of these two problems. For instance, injecting drug users, in addition to being highly likely to have an addiction problem, are also at high risk for infection with human immunodeficiency virus (HIV) because of the practice of sharing needles that is common among these individuals. Similarly, an individual with sexually transmitted diseases (STDs) may also be likely to have a drug problem, owing to the sexual disinhibition that is often produced by AOD abuse and that may have led to high-risk sexual encounters.
Outreach and other health care personnel who provide services to high-risk individuals, such as the homeless, pregnant adolescents, and criminal offenders, should therefore consider screening for both substance use disorders and infectious diseases because of the relatively high likelihood that an individual being screened for one of these problems also has the other. In addition to identifying more individuals with one or both of these problems, data on the comorbidity of these conditions will also be useful to program planners and managers in developing resources to treat these individuals.
Ultimately, it is hoped that screening for both AOD abuse and infectious diseases concomitantly will facilitate access to health care for at-risk individuals by promoting early identification of these problems. In addition, the appropriateness and specificity of treatment placement can be improved when a comorbid client is accurately screened. For example, individuals with infectious diseases of major health importance can receive appropriate intervention, such as preventive therapy for potential latent tuberculosis (TB) infection in HIV-infected patients, in the AOD abuse treatment center. Another alternative would be to refer these individuals for appropriate treatment of the infectious condition. The risk of illness and spread of disease to other member of the community could thus be reduced.
Substance abuse and infectious diseases of public health importance, both of which are preventable causes of illness and death, are two of the 10 leading causes of death in the United States. The prevalence of both problems remains high in certain populations.
Despite indications that AOD abuse is declining in the United States, it is still an integral part of our culture. During any given month in the last 20 years, at least 14 million individuals in the United States consumed some type of illicit drug. A recent report by the Institute of Medicine estimated that on a typical day in 1987-1988, 5.5 million individuals needed treatment for AOD abuse (Institute of Medicine, 1990).
The incidence and prevalence of infectious diseases among AOD abusers, as well as among other high-risk individuals, have increased substantially. The risk for contracting infectious diseases is greater in individuals with AOD abuse problems than in non-AOD users for three major reasons:
They are more likely to be involved in drug-related activities, such as needle sharing, that place them at risk.
They may be more likely, because of the sexual disinhibition associated with AOD use, to engage in sexual behaviors that confer an increased risk.
The social networks of some AOD abusers may overlap with those of individuals with STDs and TB.
People with AOD abuse problems account for a significant proportion of the increasing rate of STDs, HIV infection and acquired immunodeficiency syndrome (AIDS), TB, and hepatitis B and C. In recognition of these factors, AOD treatment programs are becoming sensitized to the medical needs of their clients who are at increased risk for infectious diseases.
Syphilis and gonorrhea occur more frequently in individuals with AOD abuse problems than in the general population. Higher rates of STDs have long been noted in injecting drug users. The syphilis epidemic of the late 1980s, which resulted in the highest rate of syphilis in 40 years, and the increased prevalence of antibiotic-resistant strains of gonorrhea have led to an increased incidence of STDs in persons who abuse drugs. Abuse of cocaine, especially crack, for example, has been associated with sex-for-drugs prostitution, which, in turn, places individuals at increased risk for STDs.
TB has been seen with increased frequency in chronic alcohol abusers and, recently, in injecting drug users as well. Because AOD abusers typically have low compliance with treatment, and because the incidence of both drug-sensitive and multiple-drug-resistant TB is on the rise, the detection of this disease has become a public health imperative. The low socioeconomic status of many individuals with STDs or TB makes it unlikely that they will receive adequate diagnostic and treatment services, contributing to the further transmission of these diseases.
HIV has had a tremendous impact on populations in which AOD abuse and infectious diseases are prevalent. People who abuse drugs are at high risk for contracting HIV infection due to behavioral risk factors, such as needle sharing by injecting drug users and high-risk sexual behaviors resulting from AOD-related sexual disinhibition. The presence of STDs along with the AOD abuse further increases the risk of HIV transmission for physiological as well as behavioral reasons. Studies have shown that the transmission efficiency of HIV is greatly increased in patients with STDs, particularly herpes, syphilis, gonorrhea, and chlamydia (Kirby et al., 1991; Wasserheit, 1992). Conversely, HIV infection lowers an individual's resistance to other infecting organisms, thereby increasing susceptibility to STDs.
In addition, HIV infection alters the clinical course of many diseases, especially TB, increasing both its severity and its potential for transmission. The increase in cases of TB since 1985 has been almost entirely due to the impact of HIV on both the transmissibility of and susceptibility to the disease. TB is much more easily transmitted to others from an individual who also has HIV infection than from someone with TB alone, due to the greatly increased number of bacteria produced per cough by the HIV-infected TB patient. Conversely, being infected with HIV makes a person much more susceptible to TB because of the lowered immune response caused by the virus.
In turn, many individuals treated for infectious diseases also have AOD problems. Left untreated, these substance use disorders may have adverse consequences for the successful treatment of infectious diseases and the prevention of transmitting these diseases to others. AOD abuse often results in behaviors that, in addition to increasing the risks of contracting HIV infection and other infectious diseases, also adversely affect an individual's ability to successfully complete therapy for infectious diseases. These behaviors can also impede the success of interventions intended to change risk-associated behaviors that contribute to the transmission of these diseases.
The relationships between AOD abuse and infectious diseases are becoming clearer. Patients with AOD abuse problems are at higher risk for infectious diseases of all kinds. Conversely, patients with diagnosed STDs or TB are at higher risk for AOD abuse. Recognition of this potential for comorbidity, and screening for both of these problems, can increase the likelihood of early detection, and, thereby, the success of preventive and rehabilitative measures.
Screening is a broad term that may be defined as a range of evaluation procedures and techniques.
The screening process, however, is distinguishable from comprehensive assessment procedures in several ways. It is important to understand this distinction so that the limitations of the screening instruments are recognized, thereby increasing the likelihood that they will be used appropriately and effectively.
A screening instrument does not enable a clinical diagnosis to be made, but rather merely indicates whether there is a probability that the condition looked for is present. Screening is a preliminary assessment or evaluation that attempts to measure whether key or critical features of the target problem area are present in an individual. A comprehensive assessment, on the other hand, is a thorough evaluation whose purpose is to establish definitively the presence or absence of a diagnosable disorder or disease. Accomplishing this goal entails evaluating other problems that may be related to the individual's disorder. A screening procedure typically involves a single event. A comprehensive assessment, in contrast, necessarily encompasses multiple procedures and sources of information.
The options arising from the results of screening should be limited to the following:
The individual is likely to benefit from a referral for a comprehensive assessment,
More assessment is not warranted at this time, or
The screening will be repeated at a later time.
In contrast, the decision options resulting from a comprehensive assessment have to do with the provision of treatment or referral for treatment and for other specialized assessments.
In addition to ascertaining the presence of AOD abuse or infectious disease, a comprehensive assessment is also aimed at identifying problems that may be related to the condition being identified. These ancillary problems include residential or employment instability, physical and mental health problems, and difficulties with interpersonal relationships. On the basis of the information obtained through a comprehensive assessment, a service provider can develop a treatment plan and determine a client's need for additional social services and other health-related referrals.
A CSAT-sponsored consensus panel, attended by expert clinicians and researchers, was held in order to conceptualize and develop instruments for screening for AOD abuse and infectious diseases. (See page vii for a list of panel members.) This document describes the considerations and deliberations of the consensus panel and the process used to develop the instruments. The screening instruments themselves, along with guidelines for their use in field tests, are presented in Chapters 2 and 3.
The development of the screening instruments for AOD abuse and infectious diseases was guided by a number of critical goals:
The instruments must be designed for use in both adolescents and adults.
The AOD instrument must be designed to address all substances of abuse.
The instruments must be able to be rapidly administered (in no more than 10-15 minutes); relatively simple to read, administer, score, and interpret; and must be user friendly to a diverse group of outreach workers, paraprofessionals, and professionals in the fields of both AOD abuse and infectious diseases.
The instruments and related training guidelines and materials must be designed to facilitate their use by AOD abuse and infectious-disease personnel without specific background or training in the field; in other words, the infectious-disease instrument should be easily implemented by AOD service providers, and the AOD abuse instrument should be easily implemented by infectious-disease health care personnel.
Both screening instruments should be flexible and broadly applicable to diverse populations that vary in ethnic and cultural background, age, gender, socioeconomic status, literacy level, and sexual orientation. They should be designed for use by a wide range of service providers with various skills and backgrounds and to promote collaboration among agencies without compromising objectivity and accuracy.
The instruments' measurement scope should be limited to screening for potential problems, not establishing a diagnosis. Thus, the clinical decision for individuals who score positive on the instrument would be referral for a more comprehensive assessment or for a complete diagnostic evaluation. Additionally, since screening is not diagnosis, reporting of infectious diseases, which is mandated by local statutes for STDs, TB, and, in some cases, HIV, is not required when positive results are scored for these items.
The instruments' validity and practical utility should be evaluated across a wide range of settings, representing diverse clients and problem profiles.
It is expected that appropriate training for interested service providers will occur at the community level and that community agencies serving populations for whom the instruments are intended will strive to use them consistently. Agreement on such issues will help ensure that agencies efficiently and objectively serve the best interests of their clients.
The consensus panel was divided into two smaller workgroups, one of which was charged with developing the AOD instrument, and the other, the infectious-disease instrument. Each of these two workgroups comprised experts in the field represented by the assigned screening instrument: the group responsible for the infectious-disease instrument was made up of infectious-disease clinicians and physicians, and the workgroup developing the AOD instrument was composed of AOD health care professionals. The rationale behind the workgroup assignments was that experts in each field would best understand what questions needed to be asked in order to screen effectively for the problem with which they had familiarity and expertise.
The process of developing the content and format of the screening instruments began with lengthy discussions among members of each workgroup. General decisions about how to organize the content were made. For example, the groups decided to focus on factors reflecting the continuum of abuse and dependence in the AOD instrument and the signs and symptoms of infectious diseases in the infectious-disease instrument. In the latter workgroup, it was decided to focus on behavioral and social risk factors because the infectious diseases being screened for by the instrument are often asymptomatic.
Both groups decided to design the instruments in the form of questions requiring a simple response of either "yes" or "no." It was felt by both groups that this format would facilitate scoring and interpretation and would minimalize subjective interpretation of open-ended questions.
After the preliminary instruments were completed, review of each instrument by the other workgroup provided feedback from the other's perspective that was used subsequently to modify it. In some instances, the wording of a question was changed to simplify it, to make it appropriate for all drugs or all infectious diseases, or to increase its applicability to a diverse population. Each group also developed a glossary of terms pertinent to its screening instrument to aid understanding by workers less familiar with its field of expertise.
The AOD workgroup compiled a general list of more than a dozen areas believed to be relevant to the identification of AOD abuse problems. These areas, termed "content domains" (see Chapter 2), were discussed at length and eventually were narrowed and edited for redundancy, resulting in five primary domains.
Noting that the substance abuse field contains many popular and well-researched screening instruments, the AOD workgroup also agreed that no screening tool existed that pertained to all forms of substances of abuse and that was appropriate for both adolescents and adults. The group therefore decided to review well-known screening instruments that were intended for use in adult and adolescent audiences and from which items could be selected to satisfy the need for broader coverage.
Items selected from these existing instruments were then assigned to the relevant content domains that had been decided upon earlier, and the items were placed in a preliminary order. A number of observational items relating to physical signs and symptoms of AOD abuse were also developed to supplement (or replace, in cases in which the resulting instrument would be used with a nonverbal client) the screening questions. These observational items, which are presumed to be relatively specific indicators of drug abuse, appear at the end of the AOD abuse screening instrument (Chapter 2).
In the infectious-disease workgroup, each member composed a list of questions he or she felt to be the most important and effective in screening for infectious diseases. The questions focused on diseases that are prevalent in AOD-abusing populations. These lists were then combined, and overlapping and redundant areas were eliminated. Discussion of the larger list that resulted eventually led to agreement among the workgroup members as to the questions deemed to be most useful and relevant. The indications, or recommended actions to be taken in response to a positive result, along with the risk factors conferred by a positive result, were then listed for each question.
Because there are far fewer existing screening tools for infectious diseases, the infectious-disease workgroup then devised a brief commentary for each question, explaining the rationale for its inclusion and the implications of an affirmative answer to that question. These notes appear at the end of the screening instrument for infectious diseases (Chapter 3).
The screening instruments for AOD abuse and infectious diseases were designed for use by a wide variety of service providers in a broad range of populations, service agencies, and settings. These providers may be nurses or nurses practitioners, physicians or physician extenders in treatment clinics (treatment specialists), or mental health workers (psychologists and psychiatrists, case managers, social workers, and paraprofessionals).
Ideally, all agencies and providers that have contact with individuals with AOD abuse problems and/or infectious diseases should be using both instruments with their clients and patients on a routine basis. These groups include, but may not be limited to, the following:
Outreach workers and screening staff in AOD and infectious-disease facilities
Public health physicians and nurses
AOD and medical personnel who have contact with patients in health care institutions
School nurses
Criminal justice personnel (police, AOD workers in prisons, and probation officers).
The primary audiences for the screening instruments are populations considered to be at risk for having AOD abuse problems of infectious diseases. Such at-risk populations include the following:
Individuals who inject illicit drugs
HIV-infected individuals
Individuals who engage in unsafe sex practices (including sexually active adolescents, gay and bisexual men, heterosexuals, and sex partners of those at risk for or infected with HIV or STDs)
Immigrant and migrant populations
Homeless individuals
Pregnant women with AOD abuse problems
People with multiple diagnoses (comorbidities such as AOD abuse, chronic physical or psychological disorders, and/or infectious diseases)
Sex workers.
Settings in which the instruments can be used include outpatient and inpatient programs for AOD abuse; service organizations and clinics for HIV infection and AIDS, STDs, and TB; and needle-exchange programs. A screening instrument for AOD abuse and infectious diseases that focused only on clients and patients in existing programs for these problems, however, would undoubtedly miss a significant proportion of those at risk. Many individuals who are at risk for both AOD abuse problems and infectious diseases can be found in settings where they are not always perceived to be at risk for these problems.
For example, shelters for battered women or homeless individuals may house people who have AOD problems and who are also at risk for infectious diseases. Because these individuals are usually primarily identified in terms of their needs for shelter, food and clothing, however, the risk or presence of AOD abuse or infectious diseases often goes unrecognized. It is important to identify such "hidden" populations who are at risk for, or who already have, these two problems. Such potential clients may be found in the following settings:
Primary-care health centers, mental health centers, and mobile health units
Outreach and health programs for adolescents, and college- and school-based health clinics
Hospital emergency rooms
Drop-in community social service centers
Public housing and transitional living homes
Senior service and recreational facilities
Programs and shelters for battered women and the homeless
Child welfare and child protective agencies
Family planning programs and clinics
Rape crisis centers
Community health centers for medically underserved populations, including illegal aliens, refugees, and migrant workers
Community-based organizations for homosexual and bisexual men and women
Both of the instruments in this document rely on the self-report method, in which results are based on the respondent's answers rather than on direct observation or other objective findings of the person administering the test. The self-report method can be a valid strategy when investigating AOD abuse or risks for infectious diseases, but its limitations are important to consider when using the screening instrument.
Because of the social stigma that has long been attached to substance use disorders and the resulting reluctance by AOD abusers to admit their substance use, the self-report method is notoriously problematic when screening for these disorders. Its limitations are not confined to AOD abuse, however; screening for risk factors for infectious diseases is attended by similar problems. The factors that place a person at risk for these diseases also have to do with behaviors, most notably of sexual habits, that carry similar social stigma.
For example, some people who have AOD problems may give negative responses despite observational evidence of AOD abuse. Others may not admit to behaviors that place them at risk for infectious diseases. In addition, some individuals may answer affirmatively to some of the screening questions for AOD abuse or infectious diseases, such as adverse consequences of substance use or physical symptoms of disease, and yet still deny that they have an AOD problem or that they have engaged in high-risk behaviors. Others may deny that they have an AOD problem or an infectious disease when asked this directly, but will nevertheless answer other, indirect questions affirmatively.
The problems and limitations of self-reporting were taken into account in developing the screening instruments. As a result, most of the questions regarding substance use or risk-taking behaviors are worded indirectly. Screeners need to exercise sensitivity and patience in administering the instruments and to be aware of the possibility that people being screened may deny or minimize their problems.
Recommendations to use results from screening instruments are driven by four epidemiologic criteria. These four criteria are based on the four categories into which test results are divided: two types of positive results (true positives and false positives) and two types of negative results (true negatives and false negatives).
A positive result may be obtained from a test for one of two reasons: 1) either the individual actually has the condition being looked for (a true-positive result), or 2) the individual does not actually have the disorder, and the positive result occurred for some other reason, usually having to do with the test itself (a false-positive result). The same applies to negative results: a true-negative result is one in which the individual actually does not have the disorder, whereas a false-negative result is a negative result obtained when the individual is, in reality, positive for the disorder.
Sensitivity is a measure of the percentage of false-negative results that can be expected to be obtained from a test. Looked at another way, measuring a test's sensitivity attempts to determine how many individuals who actually have the disorder in question will be missed by the test. The question attempted to be answered by determining an instrument's sensitivity is: What percentage of individuals who are actually positive will turn up with a negative (that is, a false-negative) result? Sensitivity is defined as follows:
Positive test results/(true positives + false negatives [i.e., all positives]).
For example, a test that is 99 percent sensitive will be positive for 99 of 100 individuals who are known to have the disease or condition. One of those 100 individuals, who is actually positive for the condition, will be identified as negative (i.e., false negative) by such a test.
On the other hand, specificity is a measure of false-positive results. Measuring a test's specificity attempts to determine how many individuals who in reality do not have the disorder in question will be identified by the test as having the disorder. Determining the specificity of a test, in other words, is an attempt to answer the question: What percentage of individuals who are actually negative will be identified as positive by the test? Specificity is defined as:
Negative test results/(true negatives + false positives [i.e., all negatives]).
A test that is 90 percent specific will therefore be negative for 90 of 100 individuals who are known not have the disease or condition. Ten of the 100 individuals who are actually negative for the condition will be identified as positive (i.e., false positive) by such a test.
Measuring the sensitivity and specificity of the screening instruments presented in this document is fundamental to determining their accuracy - that is, to finding out how often they accurately identify individuals with AOD abuse problems or infectious diseases and how well they rule out those who do not have these problems. One way of determining the accuracy of the screening instruments would be to determine whether a client who is referred on the basis of screening responses actually has an infectious disease or substance abuse disorder. To accurately determine the sensitivity of these screening instruments, however, they must be tested on large numbers of people known to be at risk for infectious diseases or AOD abuse. These individuals include those identified through street outreach efforts, interviewed in intake settings, and monitored through followup procedures.
In general, it is desirable for screening instruments to have very high sensitivity, even at the expense of specificity. Therefore, false-positive results are expected to occur and must be addressed through subsequent, more confirmatory tests or assessments. The results obtained from the instruments, therefore, should not be overly relied upon as definitively indicating the presence of AOD problems or infectious diseases in the individuals screened.
Measurements of sensitivity and specificity are used to determine a test's positive and negative predictive value. Positive predictive value is an epidemiologic concept that evaluates the likelihood that a positive test result is truly positive - that the disease or condition is actually present. Negative predictive value is the converse concept - that a negative test truly represents the absence of the disease or condition.
Positive and negative predictive values are determined by a test's sensitivity and specificity, as well as by the prevalence of the condition in the population being evaluated. For example, the predictive value of a positive HIV test is higher in a population of injecting drug users (where HIV seroprevalence is high) than in volunteer blood donors (where HIV seroprevalence is low).
For any screening instrument to be effectively used, an evaluation of its predictive value is critical. Such an evaluation should assess the scope and limitations of the instrument and should be carried out in the same manner as that used with clinical tests. One way to determine an instrument's sensitivity, specificity, effectiveness, and facility of use is through field testing, which should take into account the prevalence of AOD abuse and infectious diseases in the populations being tested. Field testing should also include an assessment of the ease with which clients are referred and can gain access to services.
A formal scoring system for the screening instruments cannot be defined until their accuracy is determined. Until a scoring system for the instruments is defined, workers should use the screening results only as general guidelines.
In addition to this introductory chapter, this TIP has four major chapters. Chapters 2 and 3, Development of the Simple Screening Instrument for AOD Abuse and Development of the Simple Screening Instrument for Infectious Diseases, describe the procedures used to develop the instruments. The conceptual background that formed the basis on which the workgroup's decisions were based and items were selected is elaborated in these chapters. Also included is a discussion of issues pertaining to administration, scoring, and interpretation of the instruments. Each of these two chapters also contains the instruments constructed by the groups.
Chapter 4, "Training and Implementation," provides a training guide for individual service providers and agencies wishing to implement the screening instruments. Chapter 5, "Ethical and Legal Issues in Screening for AOD Abuse and Infectious Diseases," describes the legal and ethical issues relating to screening for these problems.
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