In an editorial in the January 15th issue of American Family Physician, Drs. Sarah Coles and Alexis Vosooney, members of the AAFP's Commission on the Health of the Public and Science (Dr. Coles is the current Chair) explained their reasoning for disagreeing with the USPSTF. They noted that the originally commissioned USPSTF evidence report found that "for screen-identified populations, psychosocial interventions and pharmacotherapy do not improve drug use or the consequences." Although the USPSTF then requested a second report that found some effective interventions to reduce unhealthy drug use in treatment-seeking populations,
The AAFP believes that it was inappropriate to rely on this indirect evidence and to generalize the benefits of OUD treatment to screening and treatment of other substance use disorders [SUDs]. Readiness for treatment and availability of effective treatment modalities are key in the successful treatment of SUDs. These data prompted the AAFP to issue an insufficient evidence grade for screening for unhealthy drug use in adolescents and adults, except for OUD.
In an independent commentary that accompanied the publication of the USPSTF recommendation statement in JAMA, Dr. Richard Saltz made similar points in calling screening for unhealthy drug use "neither an unreasonable idea nor an evidence-based practice." Regarding the USPSTF's reliance on studies demonstrating benefits in treatment-seeking populations, he wrote:
Considering this latter set of studies that included patients seeking treatment for drug use is akin to considering studies of chemotherapy for patients seeking care for breast cancer or thrombolysis for symptomatic myocardial infarction as relevant to questions of cancer and cardiovascular disease screening efficacy; efficacious treatment is necessary but not sufficient for making a case for screening. ... Many patients identified with drug use by screening will not have any intention of changing their use of drugs and are not ready to begin treatment, whereas a patient seeking treatment is more ready for change and willing to begin treatment (the success of which relies on readiness and adherence).
Further, Dr. Saltz observed, "the applicability of both [USPSTF] reviews to primary care in the US ... may be limited because many studies were conducted in settings outside primary care; the good-quality studies in primary care settings were null." He also expressed concern that universal screening for unhealthy drug use in pregnant persons and documentation of such use, as the USPSTF advised, could cause considerable harm since nearly half of states consider drug use in pregnancy to be child abuse; in contrast, the only two studies of psychosocial counseling for unhealthy drug use in pregnancy found no benefits.
Lack of access to medication-assisted treatment with buprenorphine remains a significant problem for patients with OUD who desire it; a Graham Center One-Pager found that only 11% of psychiatrists and 2.4% of family physicians prescribed buprenorphine to Medicare beneficiaries between 2013 and 2016. In order to encourage more clinicians to treat OUD with evidence-based medications, the U.S. Department of Health and Human Services (HHS) recently announced that it would allow all outpatient physicians registered with the U.S. Drug Enforcement Administration, rather than only those with a Drug Addiction Treatment Act of 2000 or "X" waiver, to prescribe buprenorphine to up to 30 patients at one time. Unfortunately, the Biden administration decided against implementing the new guidelines due to concerns that HHS does not have the legal authority to override the act of Congress that established the "X" waiver process in the first place. For many communities devastated by the opioid overdose epidemic during the COVID-19 pandemic, the lack of accessible and affordable treatment for OUD will continue to be a substantial barrier to care.
This post first appeared on the AFP Community Blog.