their implementation of screening and brief
intervention services.^216 Too often, state
policymakers or administrators of these
programs fail to understand how risky use and
addiction impede progress in achieving their
organizational goals.
The priorities of protecting patient
confidentiality and maintaining an amicable and
trusting doctor-patient relationship also may
impede health professionals’ implementation of
these practices.^217 While existing federal
regulations* protect the privacy of patients
receiving addiction-related services in settings
that are federally assisted and that are primary
providers of these services, the regulations do
not apply to other service venues.^218 These
ambiguous rules serve as a disincentive to health
professionals to offer screening and brief
intervention services and an incentive to keep
substance-related services divorced from
mainstream medicine.^219
Inadequate Screening Tools .........................................................................................
Another barrier to the effective implementation
of screening and brief intervention has been that
widely-used screening tools do not adequately
identify the full range of incidences of risky
use.† These tools also do not follow consistent
standards nor are they designed to be tailored to
the unique patterns, symptoms and
consequences of substance use of different age
groups, genders, races/ethnicities and cultures or
of individuals with co-occurring conditions, for
whom a lower level of use may constitute risk
relative to an average respondent.‡ 220 Further,
most screening instruments focus on specific
substances independently rather than identifying
risky use of all addictive substances or risk for
addiction as a unified disease. Reliance on
- Known as 42 CFR, Part 2 (Confidentiality of
Alcohol and Drug Abuse Patient Records).
† See Appendix H.
‡ For example, any use of addictive substances by
children, adolescents or pregnant women constitutes
risky use; risky alcohol use is defined differently for
women vs. men; and substance use by some
individuals with co-occurring health conditions poses
extreme risks even at levels that may be considered
relatively safe among those without such conditions.
instruments that screen only for one type of
substance increases the likelihood that risky use
will not be adequately detected or that
interventions will fail to reduce risky use across
the board.Only a few screening instruments have
undergone rigorous scientific examination to
determine their reliability, validity, sensitivity
and specificity--key elements determining the
effectiveness of such instruments.§ 221 Rather
than using objective and standardized measures
of risky use and risk for addiction, many of the
more commonly-used screening instruments
determine risk by relying on respondents’
subjective reports of their own reactions to their
use of addictive substances and the reactions of
those around them, or their experiences of
adverse social and health consequences
associated with such use. For example, while
risky alcohol use commonly is defined simply as
drinking in excess of the established dietary
guidelines of no more than one drink per day for
women and two drinks per day for men, the
CAGE Questionnaire simply asks four items
related to the respondent’s alcohol use--(1) Have
you ever felt you should Cut down on your
drinking? (2) Have people Annoyed you by
criticizing your drinking? (3) Have you ever felt
bad or Guilty about your drinking? (4) Have you
ever had a drink first thing in the morning to
steady your nerves or to get rid of a hangover
(Eye-opener)?^222 --none of which assesses
directly the quantity and/or frequency of use.Likewise, the CRAFFT, a six-item questionnaire
for screening adolescents for risky alcohol and
other drug use (excluding nicotine) asks: (1)
Have you ever ridden in a Car driven by§ See Appendix H. Reliability is whether the
instrument produces the same results under the same
conditions when taken on multiple occasions.
Validity is how accurately the instrument measures
what it is intended to measure. Sensitivity refers to
an instrument’s ability to identify correctly the
presence of a condition; the higher the sensitivity the
less likely the instrument is to produce false
positives. Specificity is an instrument’s ability to
identify correctly those without the condition; the
higher the specificity, the less likely the instrument is
to produce false negatives.