Psychometric Performance of a Substance Use Symptom Checklist to Help Clinicians Assess Substance Use Disorder in Primary Care

Abstract

ImportanceSubstance use disorders (SUDs) are underrecognized in primary care, where structured clinical interviews are often infeasible. A brief, standardized substance use symptom checklist could help clinicians assess SUD.ObjectiveTo evaluate the psychometric properties of the Substance Use Symptom Checklist (hereafter symptom checklist) used in primary care among patients reporting daily cannabis use and/or other drug use as part of population-based screening and assessment.Design, Setting, and ParticipantsThis cross-sectional study was conducted among adult primary care patients who completed the symptom checklist during routine care between March 1, 2015, and March 1, 2020, at an integrated health care system. Data analysis was conducted from June 1, 2021, to May 1, 2022.Main Outcomes and MeasuresThe symptom checklist included 11 items corresponding to SUD criteria in the Diagnostic and Statistical Manual for Mental Disorders (Fifth Edition) (DSM-5). Item response theory (IRT) analyses tested whether the symptom checklist was unidimensional and reflected a continuum of SUD severity and evaluated item characteristics (discrimination and severity). Differential item functioning analyses examined whether the symptom checklist performed similarly across age, sex, race, and ethnicity. Analyses were stratified by cannabis and/or other drug use.ResultsA total of 23 304 screens were included (mean [SD] age, 38.2 [5.6] years; 12 554 [53.9%] male patients; 17 439 [78.8%] White patients; 20 393 [87.5%] non-Hispanic patients). Overall, 16 140 patients reported daily cannabis use only, 4791 patients reported other drug use only, and 2373 patients reported both daily cannabis and other drug use. Among patients with daily cannabis use only, other drug use only, or both daily cannabis and other drug use, 4242 (26.3%), 1446 (30.2%), and 1229 (51.8%), respectively, endorsed 2 or more items on the symptom checklist, consistent with DSM-5 SUD. For all cannabis and drug subsamples, IRT models supported the unidimensionality of the symptom checklist, and all items discriminated between higher and lower levels of SUD severity. Differential item functioning was observed for some items across sociodemographic subgroups but did not result in meaningful change (<1 point difference) in the overall score (0-11).Conclusions and RelevanceIn this cross-sectional study, a symptom checklist, administered to primary care patients who reported daily cannabis and/or other drug use during routine screening, discriminated SUD severity as expected and performed well across subgroups. Findings support the clinical utility of the symptom checklist for standardized and more complete SUD symptom assessment to help clinicians make diagnostic and treatment decisions in primary care.

Prevalence of Cannabis Use Disorder and Reasons for Use Among Adults in a US State Where Recreational Cannabis Use Is Legal

“…Knowledge of patient use provides an opportunity to discuss risks and limited benefits of cannabis use and potentially safer treatment alternatives for those using cannabis for medical reasons . For patients with higher risk cannabis use (eg, daily), psychometrically valid brief assessments for DSM-5 symptoms of CUD can identify and gauge CUD severity . Such knowledge can support engagement around symptoms, shared decision-making, and offering of treatment if desired, especially for patients with moderate to severe CUD who may benefit most from treatment.…”

Tools to implement measurement-based care (MBC) in the treatment of opioid use disorder (OUD): toward a consensus

“…We chose to focus primarily on measures for routine clinical care, as opposed to the research users because researchers could and often need to include longer or additional measures not easily administered in routine care. Patient self-report measures of substance use symptoms and brief screens for SUD have demonstrated validity in primary care even when results are documented in the EHR [ 23 , 29 , 30 , 71 ]. Our concern was optimizing doses and obtaining accurate, practical, and timely assessment of treatment outcome, rather than achieving a complete understanding of all the obstacles to and opportunities for patient improvement.…”

Evidence-Based Assessment of Substance Use Disorder

“…Finally, the Alcohol Use Disorder symptom checklist was developed as a brief self-report instrument that has good reliability for assessment in primary care settings (Hallgren, Matson, Oliver, Caldeiro, et al, 2022; Hallgren, Matson, Oliver, Witkiewitz, et al, 2022). Initial validation on a Substance Use Disorder checklist for primary care was also recently completed (Matson et al, 2023).…”