Drug Screen for Primary Care Patients

描述(由申请人提供)： 背景/理由：目前的指南建议对药物使用障碍进行筛查，并建议将药物使用障碍患者转至物质使用障碍(SUD)专科治疗(SAMHSA，2005；Sullivan&Fleming，1997；退伍军人/国防部循证临床实践指南工作组，2001；退伍军人健康管理局，2005)。然而，目前的指南没有推荐特定的工具，因为没有适合于此目的的工具(Berman等人，2005年；McPherson&Hersch，2000年；Tiet等人，2008年)。没有一种工具适合于药物筛选的目的，它适用于退伍军人初级保健患者，而且足够简单并已得到验证(McPherson&Hersch，2000；Tiet et al.，2008)。目的：本研究有三个主要目的：目标1是修订、缩短和检验现有的6种药物筛选工具在初级保健(PC)环境中的敏感性和特异性，并提供6种修订、更短、更实用的用于PC环境的药物筛选工具。修订后的仪器将根据它们对(A)与药物有关的障碍和(B)与药物有关的后果和问题的检测情况进行检查，这些患者可能不符合药物使用障碍的诊断标准。目标2是通过组合现有仪器的项目来开发一种新的仪器，并通过比较修订后的、缩短的现有仪器和新构建的仪器来确定具有最佳切入点(考虑假阳性和假阴性的相对数量)的最佳仪器。目的3是检查6个修订的药物筛选工具和1个新开发的药物筛选工具在检测患有和不患有创伤后应激障碍(PTSD)的PC患者的药物使用障碍和药物相关问题方面的表现。方法：患者将从VA Palo Alto HCS的PC诊所招募，为期24个月。六个现有的筛查者将被修改、缩短并检查他们的心理测量特性，一个新的工具将通过选择和比较现有工具的项目而开发出来。最好的工具将通过比较六个修订的、缩短的、现有的工具和新开发的工具的心理测量特性来确定。当研究小组进行的结构化诊断访谈(CIDI，WHO，1990)发现药物使用诊断时，将认为存在药物使用障碍的标准衡量标准(“黄金标准”)。药物使用后果清单(INDEC；Tonigan&Miller，2002)将被用作第二个标准(“黄金标准”)，用于衡量可能不符合药物相关诊断诊断标准的PC患者的药物相关问题。将使用接收器工作特性(ROC)、多变量Logistic回归分析和ROC曲线下面积(AUC)分析技术进行基于树的信号检测，以确定最佳筛查工具。影响：一种简单实用的药物筛查仪器将对患有或不患有创伤后应激障碍的PC患者产生广泛的好处。早期发现和干预与更好的创伤后应激障碍和药物相关的结果以及降低VHA的医疗费用有关。一个经过验证的筛查器将成为未来研究的基础，以确定哪些患者需要不同强度的干预措施来告知临床实践。拟议研究的长远潜在影响是可导致制定退伍军人管理局实务指南，以筛选和管理个人电脑系统中与药物相关的障碍或问题的患者，并将检测、评估、治疗和转介有药物相关问题的创伤后应激障碍患者作为退伍军人管理局治疗系统的组成部分。

DESCRIPTION (provided by applicant): Background/Rationale: Current guidelines recommend screening for drug use disorders, and referral of patients with drug disorders to substance use disorder (SUD) specialty treatment (SAMHSA, 2005; Sullivan & Fleming, 1997; VA/DoD Evidence-based Clinical Practice Guideline Working Group, 2001; Veterans Health Administration, 2005). However, current guidelines do not recommend a specific instrument because no instrument is appropriate for this purpose (Berman et al., 2005; McPherson & Hersch, 2000; Tiet et al., 2008). There is no instrument that is appropriate for drug-screening purposes that is suitable for VA primary care patients that is brief enough and has been validated (McPherson & Hersch, 2000; Tiet et al., 2008). Objectives: There are three primary aims for this study: Aim 1 is to revise, shorten, and examine the sensitivity and specificity of six existing drug screening instruments for patients in the primary care (PC) settings and to provide six revised, shorter, and more practical drug screening instruments to be used in PC settings. .The revised instruments will be examined against how well they detect (a) drug-related disorders, and (b) drug- related consequences and problems in patients who may not meet diagnostic criteria for a drug use disorder. Aim 2 is to develop a new instrument from combining items across the existing instruments, and the best instrument with the optimal cut-point (considering the relative number of false positives and false negatives) will be identified from comparing the six revised, shortened, existing instruments and the newly constructed instrument. Aim 3 is to examine how well the six revised and one newly developed drug screening instruments perform in detecting drug use disorders and drug-related problems among PC patients with and without Post- Traumatic Stress Disorder (PTSD). Methods: Patients will be recruited from PC clinics at the VA Palo Alto HCS over a 24-month period. Six existing screeners will be revised, shortened, and examined for their psychometric properties, and a new instrument will be developed from choosing and comparing items across existing instruments. The best instrument will be identified from comparing psychometric properties of the six revised, shortened, existing instruments and the newly developed instrument. The criterion measure ("gold standard") for a drug use disorder will be considered present when a drug use diagnosis is detected by a structured diagnostic interview (CIDI, WHO, 1990) conducted by the study team. The Inventory of Drug Use Consequences (InDUC; Tonigan & Miller, 2002) will be used as the second criterion ("gold standard") for measuring drug-related problems for PC patients who may not meet diagnostic criteria for a drug related diagnosis. Tree based signal detection using the receiver operating characteristic (ROC), multivariate logistic regression analyses, and area under the ROC curve (AUC) analytical techniques will be conducted to identify the best screening instrument. Impact: A brief and practical drug screening instrument will have wide-ranging benefits to PC patients with or without PTSD. Early detection and intervention are associated with better PTSD and drug-related outcomes, and reduction of health care cost for the VHA. A validated screener will be the foundation for future studies to identify patients who need differential intensities of interventions to inform clinical practice. Long-term potential impact of the proposed study is information that can lead to the development of VA practice guidelines for screening and managing patients with drug-related disorders or problems in the PC system, and to make detection, assessment, treatment and management or referral for treatment of PTSD patients with drug-related problems an integral part of the treatment system in the VA.