CDS Connect: Alcohol and Other Substance Use Screening Using the National Institute on Drug Abuse Quick Screen (NIDA QS) and USAUDIT (Alcohol Use Disorders Identification Test, Adapted for Use in the United States)

Alcohol and Other Substance Use Screening Using the National Institute on Drug Abuse Quick Screen (NIDA QS) and USAUDIT (Alcohol Use Disorders Identification Test, Adapted for Use in the United States)

Description

This CDS artifact facilitates evidence-based substance use screening with the NIDA QS and the USAUDIT to identify adults using alcoholic beverages. The logic includes progression from the NIDA QS (which screens for alcohol, tobacco, illicit drug and non-medical prescription drug use), to an alcohol prescreen question (i.e., Do you sometimes drink beer, wine or other alcoholic beverages?) to the full USAUDIT, when indicated.

Artifact Type
Creation Date
Version
1.0
Status
Experimental
True

Artifact Creation and Usage

Contributors

This artifact was developed by MITRE software engineers and clinical informaticists in collaboration with clinical subject matter experts and leaders from the Centers for Disease Control and Prevention (CDC) National Center on Birth Defects and Developmental Disabilities (NCBDDD).

License
IP Attestation The author asserts that this artifact has been developed in compliance with the intellectual property rights attributed to the source material.
Copyrights

© 2020 The MITRE Corporation. All Rights Reserved. Approved for Public Release: 20-1504. Distribution and Use of Artifacts and Associated Documentation Unlimited.

Implementation Details
Engineering Details

The CDS flow diagram pictured here provides a high level overview of the screening flow and some of the decision points specified in the CDS logic.

The semi-structured (i.e., human readable, Level 2) representation of the artifact is available in Appendix A of the implementation guide for this artifact. The structured (i.e., coded) CDS logic is attached to this artifact in the Logic File field. The code is expressed using Clinical Quality Language (CQL) and the Fast Healthcare Interoperability Resources (FHIR) Release 4 (R4) data model. All value sets referenced in the logic are published on the Value Set Authority Center (VSAC). Additional details about these resources can be accessed via the following URLs:

Open source resources associated with this CDS are available on GitHub here. The resources include:

  • asbi-intervention-app: a SMART on FHIR application that provides CDS interventions based on alcohol screening scores and patient information to assist clinicians with caring for patients based on their alcohol use
  • asbi-screening-app: a SMART on FHIR application that provides multiple alcohol screening instruments for assessing a patient's alcohol use
  • questionnaire-to-survey: a library for incorporating FHIR Questionnaires into SurveyJS
  • asbi-testing-server: a node-based FHIR server to be used for testing alcohol screening and brief intervention CDS 
Repository Information
Approval Date
Publication Date
Last Review Date
Knowledge Level

Structured code that is interpretable by a computer (includes data elements, value sets, logic)

Purpose and Usage
Purpose

This CDS identifies adults for whom substance use screening is indicated. It delivers four screening questions that assess the patient's use of alcohol, tobacco, illicit drugs and prescription drugs used for non-medical purposes (i.e., the NIDA QS). If the NIDA QS is positive for "heavy alcohol" intake or the patient states that they sometimes drink alcoholic beverages, the CDS delivers the full USAUDIT to further evaluate the patient's use of alcohol. The resulting USAUDIT score can then guide a clinician in discussing alcohol use with the patient.

Intended Population

This CDS is intended for adults (i.e., individuals 18 years old and older).

Usage

This artifact is intended for use by healthcare personnel working in primary healthcare settings who care for adults. This audience includes, "physicians, general practitioners, community health workers, behavioral health workers, health educators, nurses, social workers, psychologists, psychiatrists, obstetricians and midwives" (Babor, Higgins-Biddle, Robiana 2018).

Cautions
Consider the value of implementing a multi-substance screening questionnaire that evaluates a full spectrum of a patient's use of alcohol:
Healthcare organizations that have not implemented a multi-substance screening questionnaire in their health information technology [IT] system, or have implemented a brief alcohol screening questionnaire (e.g., the Single Alcohol Screening Question [SASQ]) as a “stand alone” alcohol screening assessment are encouraged to consider implementing either 1) this CDS artifact, which flows from evaluation of a patient's use of alcohol, tobacco, illicit drugs, and prescription drugs taken for non-medical reasons via the NIDA QS into the USAUDIT if the patient tests "positive" for alcohol use, or 2) either version of the full AUDIT questionnaire (to further evaluate the full spectrum of a patient’s alcohol use) if the patient screens positive on a brief screening questionnaire. Integration of the Alcohol Screening Using the WHO AUDIT artifact or the Alcohol Screening Using the USAUDIT artifact with a brief alcohol screening assessment can provide additional, valuable insight into the patient’s alcohol consumption, which in turn can inform more appropriate patient-centered brief interventions and care. 
This artifact does not include care recommendations (e.g., brief interventions): The CDS Development Team and CDC sponsors of this work took a modular approach to developing alcohol screening and brief intervention (ASBI) CDS artifacts to 1) lessen the complexity of each artifact and 2) enable organizations to only integrate portions of logic that they really need (e.g., are not already present in their health IT system). A modular approach allows for personalized implementation choices without the need to edit CDS code. The Brief Behavioral Counseling Interventions for Unhealthy Alcohol Use with Optional Referral to Treatment and Facilitating Shared Decision Making For People Who Drink Alcohol: A Patient Decision Aid artifacts (also available on the CDS Connect Repository) are integral companion CDS modules to this artifact if a healthcare organization does not have ASBI care recommendations implemented in their health IT system. 
This artifact aligns with USAUDIT guidelines, as opposed to World Health Organization (WHO) AUDIT guidelines, to provide a full spectrum assessment of a patient's alcohol use: The USAUDIT was created to "identify individuals with risky patterns of alcohol consumption, as defined by the U.S. standard drink (14 grams) and recommended drinking limits, and those who may have an alcohol use disorder" (Babor, Higgins-Biddle & Robiana, 2018) . The WHO AUDIT assumes a standard drink size of 10 grams (Babor et al., 2001). As such, the responses to questions 1, 2 and 3, and the wording of question 3, vary between each questionnaire, as does the scoring and a few other specifics. Prior to implementing this CDS, it is important to consider which version of the AUDIT is most appropriate for the country where this CDS may be utilized since the types and amounts of alcoholic drinks will vary according to culture and custom (Babor et al., 2001). 
This artifact does not provide in-depth screening to further evaluate the patient's use of tobacco products, prescription drugs for non-medical reasons or illegal drugs if they test "positive" on the NIDA QS. Organizations implementing this artifact may elect to integrate other screening instruments with this CDS to enhance understanding of the patient's substance use (e.g., NIDA-Modified ASSIST). 
All care provided to the patient should be subject to clinical judgement: Clinicians are encouraged to consider the patient's medical condition, family history of alcohol problems and perceived honesty in responding to the AUDIT questions prior to making care decisions related to the patient's alcohol use (Babor et al. 2001).
Implementation Note: This artifact is not “standalone”. It is not intended to be completely plug-and-play (i.e., healthcare systems will need to integrate the artifact with components of their health IT system for the artifact to work). Implementers should conduct extensive testing, including clinical testing in real-life workflows. It is expected that artifacts will be customized and adapted to local clinical and IT environments.
Test Patients
Supporting Evidence
Source Description

The development of this artifact was informed by the evidence-based references listed below.

References

National Institute on Drug Abuse. (2009). Screening for Drug Use in General Medical Settings: A Resource Guide for Providers. Accessed at: https://www.drugabuse.gov/publications/resource-guide-screening-drug-use-in-general-medical-settings/nida-quick-screen/. 

Babor, T. F., Higgins-Biddle, J. C., & Robaina, K. (2017). The Alcohol Use Disorders Identification Test, Adapted for Use in the United States: A Guide for Primary Care Practitioners, 24. Retrieved from https://www.ct.gov/dmhas/lib/dmhas/publications/USAUDIT-2017.pdf

Babor, T. F., Higgins-Biddle, J. C., Saunders, J. B., & Monteiro, M. G. (2001). The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Care. Retrieved from https://www.who.int/substance_abuse/publications/audit/en/

Curry, S. J., Krist, A. H., Owens, D. K., Barry, M. J., Caughey, A. B., Davidson, K. W., … Wong, J. B. (2018). Screening and Behavioral Counseling Interventions to Reduce Unhealthy Alcohol Use in Adolescents and Adults: US Preventive Services Task Force Recommendation Statement. JAMA - Journal of the American Medical Association, 320(18), 1899–1909. https://doi.org/10.1001/jama.2018.16789

Centers for Disease Control and Prevention. (2014). Planning and Implementing Screening and Brief Intervention for Risky Alcohol Use A Step-by-Step Guide for Primary Care Practices. Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities. Retrieved from https://www.cdc.gov/ncbddd/fasd/documents/AlcoholSBIImplementationGuide.pdf

Artifact Decision Notes

Decisions made while developing this CDS are outlined in Appendix A of the accompanying implementation guide for this artifact.

Artifact Representation
Logic Files
Testing Experience
Pilot Experience

As of June 4, 2020, this CDS is in draft status and has not been tested in a clinical setting.