Barriers and Facilitators to Implementation of SUD Screening in Primary Care

• Alcohol and drug use are leading causes of illness and death in the U.S., yet substance use disorders (SUDs) are greatly under-recognized in medical settings.
• Many studies have examined barriers to implementing screening for substance use in primary care, however, most of the research documenting those barriers has been conducted with primary care physicians, despite the fact current primary care practices emphasize a team-based approach with patient-centered care.
• Because a successful screening approach typically involves other members of the care team performing the screening, the perspectives of non-physician clinical staff and patients are critical to developing effective implementation strategies.

This study sought to gain an understanding of SUD screening from a range of clinical stakeholders, as part of the NIDA Clinical Trials Network study CTN-0062-Ot, which aims to implement substance use screening in primary care clinics using the NIDA CTN Common Data Elements (CDEs).

Focus groups and individual interviews were conducted with 67 stakeholders, including patients, primary care providers, nurses, and medical assistants, in two urban academic health systems. Factors affecting implementation were identified from participant narratives and included:

Identifying the problem: Participants consistently agreed that having knowledge of a patient’s substance use is important, that it is not currently being properly identified in medical settings, and that universal screening is the best approach.
 

Assessing barriers: Patients expressed concerns about consequences related to disclosing their substance use to primary care providers, confidentiality, and their own reluctance to acknowledge their substance use was a problem. Barriers identified by providers included individual-level factors such as lack of clinical knowledge and training, as well as systems-level factors like time pressure, lack of resources, lack of space, and difficulty accessing specialty SUD treatment.
 

Adapting to the local context: Most patients and providers felt that primary care providers should play a key role in screening and interventions for substance use disorders. Opinions diverged regarding the optimal approach, however most preferred a patient self-administered approach.

Conclusions: These findings provide general guidance regarding key elements of a screening implementation approach for primary care settings, something both patient and providers agreed was a valuable part of medical care. Screening programs should clearly communicate the goals of screening to patients, proactively work to counteract stigma, consider and address staff concerns related to time and workflow, and provide education as well as treatment resources to primary care providers.

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