Coverage Policy Manual
Policy #: 2011012
Category: PPACA Preventive
Initiated: September 2010
Last Review: November 2023
  PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: ALCOHOL AND DRUG MISUSE COUNSELING AND/OR SCREENING
Description:
The Federal Patient Protection and Preventive Care Act was passed by Congress and signed into law by the President in March 2010.  The preventive services component of the law became effective 23 September 2010. A component of the law was a requirement that all “non-grandfathered” health insurance plans are required to cover those preventive medicine services given an “A” or “B” recommendation by the U.S. Preventive Services Task Force and those preventive services recommended by the Health Resources and Services Administration (HSRA).    
 
Plans are not required to provide coverage for the preventive services if they are delivered by out-of-network providers.
 
Task Force recommendations are graded on a five-point scale (A-E), reflecting the strength of evidence in support of the intervention.  Grade A: There is good evidence to support the recommendation that the condition be specifically considered in a periodic health examination.  Grade B: There is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination.  Grade C: There is insufficient evidence to recommend for or against the inclusion of the condition in a periodic health examination, but recommendations may be made on other grounds.  Grade D: There is fair evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.  Grade E: There is good evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.
 
Those preventive medicine services listed as Grade A & B recommendations are covered without cost sharing (i.e., deductible, co-insurance, or co-pay) by Health Plans for appropriate preventive care services provided by an in-network provider.  If the primary purpose for the office visit is for other than Grade A or B USPSTF preventive care services, deductible, co-insurance, or copay may be applied.
 
The Health Resources and Services Administration (HRSA) Bright Futures program recommends initiating questioning regarding alcohol or drug use and if positive, to follow with an alcohol or drug screening tool.  
 
 
 
Policy/
Coverage:
Screening for unhealthy drug use, using risk screening questions, for adults aged 18 years or older in primary care settings is covered for members of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay) once per year. Screening refers to asking questions about unhealthy drug use, not testing biological specimens. (Effective November 1, 2020)
 
Screening and behavioral counseling interventions to reduce alcohol misuse in adults aged 18 years or older, including pregnant women, in primary care settings are covered for members of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay) once per year.
 
Screening for alcohol or drug use using risk screening questions is covered as part of the preventive health exam, and administration of alcohol and drug screening tools to those who test positive to the risk screening questions are covered for adolescents who are covered under "non-grandfathered" plans, without cost sharing (i.e., deductible, co-insurance, or co-pay) during the preventive health exam between the ages of 11-21.
 
The appropriate ICD-10 codes to report these services are: Z71.41, F10.10, F10.120 and F10.129.
 
The codes used to report this service are G0442, G0443, 99408 and 99409.  When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and the HRSA Bright Futures recommendations, and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’.  The correct coding as listed for both ICD-10 and CPT or HCPCS codes are also required.
 
Rationale:
The U.S. Preventive Services Task Force (USPSTF) recommends screening and behavioral counseling interventions to reduce alcohol misuse by adults, including pregnant women, in primary care settings. (Grade B recommendation).
 
The USPSTF found good evidence that screening in primary care settings can accurately identify patients whose levels or patterns of alcohol consumption do not meet criteria for alcohol dependence, but place them at risk for increased morbidity and mortality, and good evidence that brief behavioral counseling interventions with follow-up produce small to moderate reductions in alcohol consumption that are sustained over 6- to 12-month periods or longer. The USPSTF found some evidence that interventions lead to positive health outcomes 4 or more years post-intervention, but found limited evidence that screening and behavioral counseling reduce alcohol-related morbidity. The evidence on the effectiveness of counseling to reduce alcohol consumption during pregnancy is limited; however, studies in the general adult population show that behavioral counseling interventions are effective among women of childbearing age. The USPSTF concluded that the benefits of behavioral counseling interventions to reduce alcohol misuse by adults outweigh any potential harms.
 
The USPSTF recommendations include the following information:
 
      • Alcohol misuse includes "risky/hazardous" and "harmful" drinking that places individuals at risk for future problems. "Risky" or "hazardous" drinking has been defined in the United States as more than 7 drinks per week or more than 3 drinks per occasion for women, and more than 14 drinks per week or more than 4 drinks per occasion for men. "Harmful drinking" describes persons who are currently experiencing physical, social, or psychological harm from alcohol use but do not meet criteria for dependence.4,5 Alcohol abuse and dependence is associated with repeated negative physical, psychological, and social effects from alcohol.6 The USPSTF did not evaluate the effectiveness of interventions for alcohol dependence because the benefits of these interventions are well established and referral or specialty treatment is recommended for those meeting the diagnostic criteria for dependence.
      • Light to moderate alcohol consumption in middle-aged or older adults has been associated with some health benefits, such as reduced risk for coronary heart disease.7 Moderate drinking has been defined as 2 standard drinks (e.g., 12 ounces of beer) or less per day for men and 1 drink or less per day for women and persons older than 65,8 but recent data suggest comparable benefits from as little as 1 drink 3 to 4 times a week.9
      • The Alcohol Use Disorders Identification Test (AUDIT) is the most studied screening tool for detecting alcohol-related problems in primary care settings. It is sensitive for detecting alcohol misuse and abuse or dependence and can be used alone or embedded in broader health risk or lifestyle assessments.10,11 The 4-item CAGE (feeling the need to Cut down, Annoyed by criticism, Guilty about drinking, and need for an Eye-opener in the morning) is the most popular screening test for detecting alcohol abuse or dependence in primary care.12 The TWEAK, a 5-item scale, and the T-ACE are designed to screen pregnant women for alcohol misuse. They detect lower levels of alcohol consumption that may pose risks during pregnancy.13 Clinicians can choose screening strategies that are appropriate for their clinical population and setting.11,14-17 Screening tools are available at the National Institute on Alcohol Abuse and Alcoholism Web site: http://www.niaaa.nih.gov/Publications/AlcoholResearch/.
      • Effective interventions to reduce alcohol misuse include an initial counseling session of about 15 minutes, feedback, advice, and goal-setting. Most also include further assistance and follow-up. Multi-contact interventions for patients ranging widely in age (12-75 years) are shown to reduce mean alcohol consumption by 3 to 9 drinks per week, with effects lasting up to 6 to 12 months after the intervention. They can be delivered wholly or in part in the primary care setting, and by one or more members of the health care team, including physician and non-physician practitioners. Resources that help clinicians deliver effective interventions include brief provider training or access to specially trained primary care practitioners or health educators, and the presence of office-level systems supports (prompts, reminders, counseling algorithms, and patient education materials).
      • Primary care screening and behavioral counseling interventions for alcohol misuse can be described with reference to the 5 As behavioral counseling framework: assess alcohol consumption with a brief screening tool followed by clinical assessment as needed; advise patients to reduce alcohol consumption to moderate levels; agree on individual goals for reducing alcohol use or abstinence (if indicated); assist patients with acquiring the motivations, self-help skills, or supports needed for behavior change; and arrange follow-up support and repeated counseling, including referring dependent drinkers for specialty treatment.18 Common practices that complement this framework include motivational interviewing,19 the 5 Rs used to treat tobacco use,20 and assessing readiness to change.21
      •  The optimal interval for screening and intervention is unknown. Patients with past alcohol problems, young adults, and other high-risk groups (e.g., smokers) may benefit most from frequent screening.
      • All pregnant women and women contemplating pregnancy should be informed of the harmful effects of alcohol on the fetus. Safe levels of alcohol consumption during pregnancy are not known; therefore, pregnant women are advised to abstain from drinking alcohol. More research into the efficacy of primary care screening and behavioral intervention for alcohol misuse among pregnant women is needed.
      • The benefits of behavioral intervention for preventing or reducing alcohol misuse in adolescents are not known. The CRAFFT questionnaire was recently validated for screening adolescents for substance abuse in the primary care setting.22 The benefits of screening this population will need to be evaluated as more effective interventions become available in the primary care setting.
 
The Health Resources and Services Administration (HRSA) Bright Futures program recommends initiating questioning regarding alcohol or drug use and if positive, to follow with an alcohol or drug screening tool beginning at age 11 for adolescents who test positive on risk screening questions.
 
2020 Update
The U.S. Preventive Services Task Force (USPSTF) recommends screening and behavioral counseling interventions to reduce alcohol misuse by adults 18 years or older, including pregnant women, in primary care settings. (Grade B)
 
The USPSTF recommends screening by asking questions about unhealthy drug use in adults age 18 years or older. (Grade B)
 
Bright Futures recommends initiating questioning regarding alcohol or drug use and if positive, to follow with an alcohol or drug screening tool for adolescence between the ages of 11-21.
 
The USPSTF uses the term “unhealthy alcohol use” to define a spectrum of behaviors, from risky drinking to alcohol use disorder (AUD) (eg, harmful alcohol use, abuse, or dependence) (O’Connor, 2018). “Risky” or ”hazardous” alcohol use means drinking more than the recommended daily, weekly, or per-occasion amounts, resulting in increased risk for health consequences but not meeting criteria for AUD (NIAAA, 2005). The National Institute on Alcohol Abuse and Alcoholism (NIAAA) defines “risky use” as exceeding the recommended limits of 4 drinks per day (56 g/d based on the US standard of 14 g/drink) or 14 drinks per week (196 g/d) for healthy adult men aged 21 to 64 years or 3 drinks per day or 7 drinks per week (42 g/d or 98 g/week) for all adult women of any age and men 65 years or older (NIAAA, 2005).
 
A standard drink is defined as 12.0 oz of beer (5% alcohol), 5.0 oz of wine (12% alcohol), or 1.5 oz of liquor (40% alcohol) (NIAAA, 2005). The American Society of Addiction Medicine (ASAM) defines “hazardous use” as alcohol use that increases the risk of future negative health consequences (ASAM, 2013). The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) defines the severity of AUD (mild, moderate, or severe) based on the number of criteria met (American Psychiatric Association, 2013). Previous versions of the DSM-5 had separate diagnoses for alcohol abuse and alcohol dependence, but it no longer separates these diagnoses (O’Connor, 2018). Currently, there is no firm consensus worldwide regarding the definition of risky drinking. In addition, the definition of a standard drink differs by country (O’Connor, 2018). Any alcohol use is considered unhealthy in pregnant women and adolescents (O’Connor, 2018). In adolescents, the definition of moderate- or high-risk alcohol use varies by age, based on days of use per year (NIAAA, 2011).
 
Excessive alcohol use is one of the most common causes of premature mortality in the United States. From 2006 to 2010, an estimated 88,000 alcohol-attributable deaths occurred annually in the United States, caused by both acute conditions (eg, injuries from motor vehicle collisions) and chronic conditions (eg, alcoholic liver disease) (O’Connor, 2018; Stahre, 2014). Alcohol use during pregnancy is also one of the major preventable causes of birth defects and developmental disabilities (Ismail, 2010).
 
The USPSTF found adequate evidence that numerous brief screening instruments can detect unhealthy alcohol use with acceptable sensitivity and specificity in primary care settings.
 
The USPSTF found no studies that directly evaluated whether screening for unhealthy alcohol use in primary care settings in adolescents and adults, including pregnant women, leads to reduced unhealthy alcohol use; improved risky behaviors; or improved health, social, or legal outcomes.
 
The USPSTF found adequate evidence that brief behavioral counseling interventions in adults who screen positive are associated with reduced unhealthy alcohol use. There were reductions in both the odds of exceeding recommended drinking limits and heavy use episodes at 6- to 12-month follow-up. In pregnant women, brief counseling interventions increased the likelihood that women remained abstinent from alcohol use during pregnancy. The magnitude of these benefits is moderate. Epidemiologic literature links reductions in alcohol use with reductions in risk for morbidity and mortality and provides indirect support that reduced alcohol consumption may help improve some health outcomes (O’Connor, 2018; Roerecke, 2013).
 
The USPSTF found inadequate evidence that brief behavioral counseling interventions in adolescents were associated with reduced alcohol use.
 
The USPSTF bounds the harms of screening and brief behavioral counseling interventions for unhealthy alcohol use in adults, including pregnant women, as small to none, based on the likely minimal harms of the screening instruments, the noninvasive nature of the interventions, and the absence of reported harms in the evidence on behavioral interventions. When direct evidence is limited, absent, or restricted to select populations or clinical scenarios, the USPSTF may place conceptual upper or lower bounds on the magnitude of benefit or harms.
 
The USPSTF found inadequate evidence on the harms of screening and brief behavioral counseling interventions for alcohol use in adolescents.
 
The USPSTF concludes with moderate certainty that screening and brief behavioral counseling interventions for unhealthy alcohol use in the primary care setting in adults 18 years or older, including pregnant women, is of moderate net benefit.
 
The USPSTF concludes that the evidence is insufficient to determine the benefits and harms of screening for unhealthy alcohol use in the primary care setting in adolescents aged 12 to 17 years.
 
The USPSTF commissioned 2 systematic evidence reviews in support of the updated drug use recommendation statement. These reviews evaluated evidence on the benefits and harms of screening for drug use, accuracy of screening tools to detect drug use, and the benefits and harms of psychosocial interventions and pharmacotherapy (Patnode, 2020; Patnode, 2020; Chou, 2020).
 
The USPSTF identified 30 different screening tools that were evaluated in adults, pregnant or postpartum persons, or adolescents. Many tools had sensitivity of 75% or more for detecting unhealthy drug use, drug abuse or dependence, or drug use disorders. Most screening studies used structured clinical or diagnostic interviews that used varying definitions of drug use, abuse, dependence, and drug use disorders as the reference standard. Few studies used biologic reference standards such as testing of hair or urine specimens (Patnode, 2020; Patnode; 2020).
 
The USPSTF reviewed 12 studies that assessed the accuracy of 15 different screening tools in nonpregnant adults (Patnode, 2020; Patnode; 2020). There was considerable variation in sample size (139 to 2057, not including a large US-based national sample of 42,923), proportion of female participants (4.7% to 94%), and mean age (25.2 to 62.6 years). All but 2 studies were conducted in the US. The use and severity of use of any drug or specific drugs varied widely across study populations. The prevalence of unhealthy use of any drug ranged from 14.2% to 37.9% and the prevalence of use disorders due to any drug ranged from 1.8% to 16.7%, based on reference standards of clinical interviews (with or without confirmation of drug use by saliva testing).
 
Several screening tools directly addressed the frequency of drug use (single-item drug frequency; SUBS [Substance Use Brief Screen]; and TAPS-1) or the frequency of drug use and risks associated with drug use (ASSIST; ASSIST-Drug; CAST [Cannabis Abuse Screening Test]; 2-, 10-, and 28-DAST [Drug-Abuse Screening Test]; PDUQp [Prescription Drug Use Questionnaire-Patient Version]; PSQ [Parent Screening Questionnaire]; SoDU [Screen of Drug Use]; TAPS; and TICS [Two-Item Conjoint Screen], all of which are examples of “direct tools”). One tool indirectly assessed drug use by asking questions about alcohol or tobacco use (single-item heavy episode drinking frequency [an example of an “indirect tool”]) (Patnode, 2020).
 
The sensitivity of direct tools for detecting unhealthy use of “any drug” (including illegal drugs and nonmedical use of prescription drugs) in the past month or year ranged from 0.71 to 0.94 (95% CI, 0.62-0.97), and specificity ranged from 0.87 to 0.97 (95% CI, 0.83-0.98). Direct tool sensitivity for detecting abuse or dependence or a use disorder related to “any drug” ranged from 0.85 to 1.00 (95% CI, 0.75-1.00) and specificity ranged from 0.67 to 0.93 (95% CI, 0.58-0.95). Screening tools had higher sensitivity for detecting unhealthy drug use and drug use disorders related to “any drug” (most of which was cannabis), cannabis, heroin, and stimulants than for detecting unhealthy drug use or drug use disorders related to nonmedical use of prescription drugs, including opioids or sedatives (range, 0.38-0.96 [95% CI, 0.29-0.99]) but specificity was comparable (range, 0.79-1.00 [95% CI, 0.71-1.00]) (Patnode, 2020).
 
Four studies assessed the accuracy of direct tools (the frequency-based ASSIST-2 tool and the risk assessment–based DAST-10, PRO, and WIDUS [Wayne Indirect Drug Use Screener]/ASSIST-2 [modified tool]) or an indirect tool (WIDUS) for detecting drug use or drug use disorders (not including alcohol) in women recruited during prenatal care visits or shortly after delivery. The prevalence of any prenatal drug use varied from 1.2% to 41% across these 4 studies. Sensitivity for detecting any prenatal use of drugs using direct tools ranged from 0.37 to 0.76 (95% CI, 0.24-0.86) and specificity ranged from 0.68 to 0.83 (95% CI, 0.55-0.91). One study of the PRO risk assessment–based tool (in a population in which 7% met diagnostic criteria for drug abuse, dependence, or both) reported sensitivity for detecting any drug abuse or dependence of 0.89 (95% CI, 0.77-0.95) and specificity of 0.74 (95% CI, 0.71-0.77). The only indirect tool that reported on any prenatal use of drugs, not including alcohol (WIDUS/ASSIST-2), had lower sensitivity (0.68 [95% CI, 0.53-0.80]) and specificity (0.69 [95% CI, 0.57-0.80]). An additional study of the indirect tool Parents Partner Past Pregnancy reported high sensitivity (0.87 [95% CI, 0.71-0.95) and high specificity (0.76 [95% CI, 0.70-0.82]) for detecting the combined outcome of any prenatal use of drugs or alcohol but did not assess the outcome of prenatal use of drugs alone (Patnode, 2020).
 
The evidence on accuracy of screening tools in adolescents is limited. Most studies focus on the detection of cannabis use; no studies provide information specifically on opioid use or other drug classes. Few tools that assess cannabis use were evaluated in more than 1 study. The available studies evaluated direct tools—the Brief Screener for Tobacco, Alcohol, and Other Drugs; a single item assessing cannabis use; ASSIST; ASSIST-Lite; CAST; CPQ-A-S (Cannabis Problems Questionnaire for Adolescents-Shortened); CRAFFT (Car Relax Alone Forget Family/Friends Trouble); PESQ-PS (Personal Experience Screening Questionnaire-Problem Severity Scale); POSIT (Problem Oriented Screening Instrument for Teenagers); and SDS (Severity Dependence Scale)—against a diagnostic interview. Sensitivity of these direct tools for detecting any cannabis use or unhealthy use ranged from 0.68 to 0.98 (95% CI, 0.64-0.99) and specificity ranged from 0.82 to 1.00 (95% CI, 0.80-1.00). Sensitivity of these direct tools for detecting cannabis use disorders ranged from 0.71 to 0.98 (95% CI, 0.41-1.00) and specificity ranged from 0.79 to 0.95 (95% CI, 0.77-0.98). Given the limited number of studies on individual tools and the lack of information on the accuracy of tools for detecting use of drugs other than cannabis, the USPSTF determined the evidence on accuracy of screening in adolescents to be inadequate (Patnode, 2020).
 
No studies directly addressed the benefits of screening on reducing drug use or drug-related health, social, or legal outcomes in adults or adolescents.
 
Several trials found that use of FDA-approved pharmacotherapy had benefits for nonpregnant adults with opioid use disorders who had sought or were referred for treatment for symptoms, signs, or drug-related health, social, or legal problems (hereafter abbreviated as “treatment-seeking populations”). Adults assigned to pharmacotherapy generally had lower rates of relapse and increased retention in treatment than adults assigned to placebo or no treatment (Patnode, 2020; Chou, 2020).
 
Nineteen trials evaluated naltrexone (opioid antagonist), buprenorphine (partial opioid agonist), or methadone (opioid agonist) (usually provided with individual or group counseling) in adults with opioid use disorder primarily related to heroin. None assessed the effects of pharmacotherapy in adults whose opioid use disorder was related only to prescription opioids or was detected through primary care screening. Trials recruited participants from inpatient settings, drug treatment programs, and criminal justice systems. Most trials were conducted outside the US, and several used naltrexone formulations not available in the US. Most participants were adult males younger than 30 years. No trials specifically enrolled pregnant or postpartum persons or adolescents, although FDA-approved pharmacotherapy agents are available for these patient populations. However, women of reproductive age comprised 25% to 46% of trial participants who received methadone or buprenorphine and 0% to 28% of participants who received naltrexone (Patnode, 2020; Chou, 2020).
 
Thirteen trials evaluated the effects of oral, injectable, or implantable naltrexone. Outcomes were assessed during the course of treatment in 11 trials (2-9 months after start of treatment) or after treatment completion in 2 trials (6-10 months after completion). Sample sizes ranged from 31 to 306 (total N = 1718 participants). Retention in treatment varied considerably in persons assigned to naltrexone (range, 7%-60%) and persons assigned to placebo or no treatment (range, 6%-56%). Use of naltrexone was associated with a significant decrease in drug use relapse (pooled relative risk [RR], 0.73 [95% CI, 0.62-0.85]) and increased retention in treatment (pooled RR, 1.71 [95% CI, 1.13-2.49]). The few naltrexone trials that reported on mortality, global functioning, quality of life, anxiety, depression, or legal or employment outcomes had inconsistent findings regarding these outcomes, but mortality was rare (Patnode, 2020; Chou, 2020).
 
Seven trials assessed the opioid agonist methadone, the partial opioid agonist buprenorphine, or both. During the course of ongoing treatment with 1 of these 2 opioid agonists (monitored for 4-12 months), use of methadone and sublingual or implantable buprenorphine was significantly associated with a decrease in relapse (4 trials; pooled RR, 0.75 [95% CI, 0.59-0.82]) and increased retention in treatment (7 trials; pooled RR, 2.58 [95% CI, 1.78-4.59]). Findings from 5 trials that assessed the effects of opioid agonists on health, social, and legal outcomes were mixed and did not show clear treatment benefits. A few trials found that buprenorphine was associated with better self-reported scores on quality of life, well-being, and life satisfaction. No deaths were reported in trials that reported this outcome (Patnode, 2020; Chou, 2020).
 
Psychosocial interventions were associated with increased likelihood of abstaining from use of drugs vs control conditions at 3 to 4 months (15 trials; RR, 1.60 [95% CI, 1.24-2.13]) and at 6 to 12 months (14 trials; RR, 1.25 [95% CI, 1.11-1.52]) (Patnode, 2020; Chou, 2020).
 
Approximately one-half of the psychosocial intervention trials enrolled persons who had sought or were referred for drug treatment. Sample sizes ranged from 34 to 1175 (total N = 15,659). Most trials were conducted in the US and included participants who were primarily male, nonwhite, and had lower socioeconomic status. The severity of drug use in trial participants varied greatly. Interventions were categorized as intensive (defined as more than 2 sessions or 2 sessions lasting more than 1 hour each) or brief (defined as 1 to 2 sessions each lasting 1 hour or less). Interventions were generally based on established behavioral approaches and were administered by telephone or in person by researchers or were self-administered by computer. Intensive interventions commonly used face-to-face cognitive behavioral therapy, motivational interviewing, and contingency management approaches. Most brief interventions consisted of a single, personalized counseling session with in-person or computer-based feedback, with or without a telephone or in-person booster session. Follow-up ranged from 3 to 4 months to 12 or more months after the start of interventions. Thirty-eight percent to 98% of participants completed assessments at designated follow-up points. Meta-analyses and sensitivity analyses included only the subset of trials with data that could be pooled and combined trials that evaluated nonpregnant adults, pregnant or postpartum adults, or adolescents; any type of drug use; and either brief or intensive interventions (Chou, 2020).
 
In sensitivity analyses, effects on abstinence were greater at 3 to 4 months in trials of treatment-seeking populations (7 trials; RR, 2.08 [95% CI, 1.51-3.07]) than in trials of screen-detected populations (8 trials; RR, 1.28 [95% CI, 0.97-1.84]; P =0.05 for interaction). Effects on abstinence were smaller in trials of brief interventions than in trials of intensive interventions, but the differences were not statistically significant. Effects were statistically significant for abstinence from cannabis use (7 trials; RR, 2.08 [95% CI, 1.51-3.07] at 3 to 4 months and 4 trials; RR, 1.58 [95% CI, 1.17-3.06] at 6 to 12 months), but not for abstinence from stimulants or mixed drug use. Results of meta-analyses on the association of psychosocial interventions and other outcomes, including number of days using drugs and drug use severity, were mixed. Evidence on the association between psychosocial interventions and health, social, or legal outcomes related to use of cannabis, stimulants, opioids, “any drug,” or mixed drugs in adults was sparse and showed no or limited effectiveness (Chou, 2020).
 
Five trials specifically assessed intensive or brief interventions exclusively in pregnant or postpartum persons compared with attention control groups or information and advice from obstetricians or nurses. None reported significant effects on drug use or health, social, or legal outcomes of drug use at 3 to 6 months after the start of the interventions (Patnode, 2020).
 
There were few trials on psychosocial interventions that focused on adolescents aged 12 to 17 years. Evidence was limited and results were inconclusive (Patnode, 2020; Chou, 2020). These studies did not report the effect of psychosocial interventions on drugs other than cannabis.
 
No studies addressed the harms of screening in adults or adolescents (Patnode, 2020).
 
Eleven naltrexone trials and 4 buprenorphine trials assessed potential harms, including suicide, overdose, or study withdrawal due to serious adverse events, but no methadone trials assessed harms. Few harms or serious adverse events were reported. In pooled analyses, the risk of adverse events was generally similar in persons assigned to pharmacotherapy and control groups, including the risk of study discontinuation due to adverse events (3 trials; RR, 1.54 [95% CI, 0.35-8.31]) or serious adverse events (3 trials; RR, 1.24 [95% CI, 0.11-10.21]) in trials of naltrexone or the risk of serious adverse events (2 trials; RR, 0.32 [95% CI, 0.09-1.12]) in trials of buprenorphine. Constipation was significantly more common in buprenorphine users than in control groups. No trials reported on harms of pharmacotherapy in adolescents or in pregnant or postpartum persons (Chou, 2020).
 
None of the 4 trials that reported on harms or adverse events of brief psychosocial interventions identified harms or adverse events. These included 2 trials in college students targeting cannabis use and 2 trials in postpartum persons who received brief interventions after delivery. None of the other psychosocial intervention trials reported on harms or adverse events in adults (Chou, 2020).
 
A draft version of this recommendation statement was posted for public comment on the USPSTF website from August 13 to September 9, 2019. In response to public comments, the USPSTF clarified that “screening” means asking questions about unhealthy drug use (not testing biological specimens, such as blood or urine testing) and that the term “unhealthy drug use” is used to describe nonmedical use of prescription or nonprescription drugs, illegal drugs, or unregulated substances (other than alcohol or tobacco). A few comments requested more information about the USPSTF’s interpretation of the evidence. The USPSTF clarified in the Rationale section that screening in primary care settings for drug use can detect a spectrum of drug use and types of drug use. The USPSTF, therefore, considered evidence from treatment trials that may have included patients with more severe drug use disorders to be applicable to screening. Some comments noted that screening adults may have unintended harms, such as discouraging health care seeking in persons who do not want to be screened, medical and sociolegal consequences of reporting positive screening results, privacy issues, or diverting clinicians’ attention from patients with established drug use disorders. The USPSTF recognizes these as potential harms and provided more details on screening implementation considerations that may address these harms. In addition, the USPSTF clarified in the Practice Considerations section that the net benefit assessment for this recommendation does not apply to settings and populations for which treatment is not provided or the result of screening is punitive.
 
Some respondents commented that screening should be offered to adolescents, but the USPSTF did not find sufficient evidence to support routine screening in this age group.
 
Alcohol and substance use is associated with deaths, injuries, and health problems among US teenagers. Use is associated with leading causes of death, including unintentional injuries (eg, motor vehicle crashes), homicides, and suicides. More than 30% of all deaths from injuries can be directly linked to alcohol. Substance use also is associated with a wide range of non-lethal but serious health problems, including school failure, respiratory diseases, and high-risk sexual behaviors. Alcohol and substance use is common among adolescents. Studies show that 46% of adolescents have tried alcohol by eighth grade, and by senior year in high school 77% of adolescents have begun to drink. Moreover, 20% of eighth graders and 58% of seniors have been drunk. Adolescents have recently reported increasing misuse of prescription drugs, including psychostimulant medications and oral opioid analgesics. Two factors can predict increases in the prevalence of use of specific illicit drugs:
 
• An increase in the perceived availability of the drug
• A decrease in the perceived risk of harm associated with use of the drug
 
Misuse of alcohol and drugs is found among all demographic subgroups. Higher risk of misuse is associated with being male, white, and from middle to upper socioeconomic status families. Early age of first use of alcohol and drugs can increase the risk of developing a substance use disorder during later life. Recurrent drunkenness, recurrent cannabis use, or any use of drugs other than cannabis are not normative behaviors, and health care practitioners should always consider them serious risks. However, experimentation with alcohol or cannabis or getting drunk once can arguably be considered developmentally normative behaviors.
 
Bright Futures further states that substance use should be evaluated as part of an age-appropriate comprehensive history. Reviewing the adolescent’s environment can identify risk and protective factors for the development of alcohol or drug abuse.
 
Risk Factors
 
• A family history of substance abuse or mood disorders. One in 5 children grows up in a household where someone abuses alcohol or other drugs. Substance use by a family member is associated with higher rates of substance use in adolescents.
• Poor parental supervision and household disruption are associated with involvement in substance use and other risk behaviors.
• Low academic achievement and/or academic aspirations.
• Untreated attention-deficit disorder (ADD) and attention-deficit/hyperactivity disorder (ADHD).
• Perceived peer acceptance of substance use and substance use in peers.
CPT/HCPCS:
99408Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes
99409Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minutes
G0442Annual alcohol misuse screening, 5 to 15 minutes
G0443Brief face to face behavioral counseling for alcohol misuse, 15 minutes
References: American Psychiatric Association.(2013) Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.

American Society of Addiction Medicine (ASAM).(2013) Terminology Related to the Spectrum of Unhealthy Substance Use. ASAM website. https://www.asam.org/advocacy/find-a-policy-statement/view-policy-statement/public-policy-statements/2014/08/01/terminology-related-to-the-spectrum-of-unhealthy-substance-use. Published 2013. Accessed October 1, 2018.

Chou R, Dana T, Blazina I, Grusing S, Bougatsos C.(2020) Interventions for Drug Use—Supplemental Report: A Systematic Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 187. Agency for Healthcare Research and Quality; 2020. AHRQ publication 19-05255-EF-2.

Ismail S, Buckley S, Budacki R, Jabbar A, Gallicano GI.(2010) Screening, diagnosing and prevention of fetal alcohol syndrome: is this syndrome treatable? Dev Neurosci. 2010;32(2):91-100

National Institute on Alcohol Abuse and Alcoholism (NIAAA).(2011) Alcohol Screening and Brief Intervention for Youth: A Practitioner's Guide. NIAAA website. https://www.niaaa.nih.gov/publications/clinical-guides-and-manuals/alcohol-screening-and-brief-intervention-youth. Published 2011. Accessed October 1, 2018.

National Institute on Alcohol Abuse and Alcoholism (NIAAA).(2018) Helping Patients Who Drink Too Much: A Clinician’s Guide. NIAAA website. https://www.niaaa.nih.gov/guide. Published 2005. Accessed October 1, 2018.

O’Connor EA, Perdue LA, Senger CA, et al.(2018) Screening and Behavioral Counseling Interventions in Primary Care to Reduce Unhealthy Alcohol Use in Adolescents and Adults: Updated Systematic Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 171. AHRQ Publication No. 18-05242-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2018.

Patnode CD, Perdue LA, Rushkin M, et al.(2020) Screening for unhealthy drug use: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. Published June 9, 2020.

Patnode CD, Perdue LA, Rushkin M, O’Connor EA.(2020) Screening for Drug Use in Primary Care in Adolescents and Adults, Including Pregnant Women: An Updated Systematic Review for the U.S. Preventive Services Task Force: Evidence Synthesis No. 186. Agency for Healthcare Research and Quality; 2020. AHRQ publication 19-05255-EF-1

PPACA & HECRA: Public Laws 111-148 & 111-152. The Patient Protection and Affordable Care Act

Roerecke M, Gual A, Rehm J.(2013) Reduction of alcohol consumption and subsequent mortality in alcohol use disorders: systematic review and meta-analyses. J Clin Psychiatry. 2013;74(12):e1181-9.

Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse, Topic Page. April 2004. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsdrin.htm

Stahre M, Roeber J, Kanny D, Brewer RD, Zhang X.(2014) Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States. Prev Chronic Dis. 2014;11:E109.
Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
CPT Codes Copyright © 2024 American Medical Association.