FAQ

This library provides an opportunity for staff to efficiently review multiple validated screening tools and identify those that are most appropriate for their settings. Each tool fact sheet includes information including substance(s) covered, audiences, mode of delivery, and evidence base to help HIV service delivery settings integrate substance use screening into their practice. 

This library is for clinical staff, program managers, case managers, medical assistants, and others in an HIV service delivery setting who have direct contact with clients. The library includes screening tools that both clinical and non-clinical staff can administer after receiving the appropriate training.

Screening provides a valid and reliable snapshot of a client’s substance use. Screening for substance use with a validated instrument is an evidence-based practice that facilitates identification of clients who are likely to benefit from additional conversation and resources related to substance use. When HIV care providers discuss substance use with patients, it increases the likelihood that they will enter substance use treatment.³ In turn, substance use treatment has been associated with greater retention in HIV care.⁴

The acronym, S·BI·RT – Screening, Brief Intervention and Referral to Treatment – refers to an approach to systematic universal screening for problematic alcohol and drug use and the routine steps taken in response to the screening results.⁵ This library includes validated tools that can be used during the screening portion of S·BI·RT.  

Brief interventions encompass a number of steps that may follow screening. Generally, staff engage in conversation with the client to understand the level of risk indicated by the results of the screening, the client’s readiness to change a behavior, their specific needs and life circumstances, and the need for follow-up to facilitate positive results as defined by the client.³

Additional information is available from the HIV Provider Reference Series - Screening, Brief Intervention, and Referral to Treatment: Addressing Substance Abuse in HIV Care Settings.  

Many tools included in this library screen for multiple substances, including opioids. This ensures that screening is comprehensive, since individuals may use more than one substance at once (known as  “polysubstance use”). Only one tool screens for opioid use exclusively: the Rapid Opioid Dependence Screen (RODS). It was originally developed to assess whether an individual leaving a correctional setting should be offered medication for opioid use disorder and can be used as a stand-alone screening tool, or as part of a more comprehensive screening process.

Single question screening tools may be appropriate for some settings, such as primary care offices and emergency departments. These settings use a single question screening tool as a form of triage. Examples of single question screening tools include: NIDA Quick Screen, Single-Question Alcohol Screening Test, and Single-Question Screening Test for Drug Use. A positive result on a single question screening tool requires further screening using one of the tools included in this library.

Wakeman (2020) has suggested utilization of a single question screener for primary care settings looking to quickly determine candidates for medication for opioid use. She recommends following the question by asking the individual patient which drug(s) they used.⁶

There are many considerations when integrating substance use screening tools into an HIV service delivery setting. Timing is important. Organizations should offer screenings at preset intervals but allow both clinical and non-clinical staff working with a client to use judgment as to when to use a tool. Administering a tool when staff have not established trust with the client or the client does not trust the system, when the client is not ready or willing to discuss their substance use, or for whom reducing substance use is not a top priority, could push the person out of care, rather than foster a supportive conversation.  

Screening tools should be brief, informative, and easily interpretable. Additionally, managers and administrators should consider the following to minimize disruptions in workflow when implementing substance use screening tools:¹⁰ 

1. Before implementation of new screening procedures, identify potential strategies and interventions to respond to a positive substance use screening result. 
   • Ensure frontline staff have input in the development of interventions.
   • Provide staff with appropriate training and support to implement screening tools while maintaining an open and respectful relationship with clients.
      
2. Use a validated, self-report substance use screening tool for all clients at the first appointment and determine a preset interval for screening at follow-up appointments.
   • While further research is needed to determine the optimal frequency of screening for substance use, screening at least annually is currently considered good practice.¹¹
   • Clients may be more likely to disclose substance use after developing a trusting relationship with staff. Allow frontline staff to conduct repeat screening when indicated.
      
3. Consider characteristics (i.e., average administration time, sensitivity, specificity, population for which the tool has been validated) when identifying potential screening tools to use in the HIV service setting.
    
4. Identify staff responsible for screening tool administration. 
    
5. When possible, use electronic or web-based platforms to reduce potential under-reporting, provide real-time results to providers on screening results, and facilitate recording of screening responses within medical record systems.
    
6. Share screening results with clients.
    
7. Provide consistent follow-up for clients with past positive screenings for substance use.
    
8. Preserve confidentiality in every step of the screening process. Establish screening protocols to protect confidentiality by considering the following questions: a.    
   • In what private space will staff complete the screening tool with clients? 
   • Where is the screening information saved in the EHR?
   • If tools are administered on paper, how will you dispose of the tools once completed?

Clients can self-administer many screening tools using paper or electronic methods. Individuals who complete self-administered surveys may be more willing to share sensitive information, such as drug use.¹² It is recommended that the staff person who initiates the screening process with a client maintain contact with the client to establish trust and remove redundancy. 

If your organization elects to conduct screening verbally, it is important to consider: 

• The tool must have an evidence base for verbal administration.
• Questions must be asked exactly as written, with no deviation.
• Staff such as care coordinators, case managers, medical assistants, nurses, and physicians must be trained in the best practices of verbally administering the tool to receive consistent results.
• There will be costs of staff time for both administration and regular booster training to maintain efficacy.³

Take the following actions to help operationalize screening in your setting:⁴

• Determine if any tools have been built and are available for your electronic health record (EHR) or case management system. These tools may be available at a reduced cost in a shorter time frame.
   
• If administering screening tools via electronic methods is not feasible, complete a paper version. Be sure to account for staff time required to enter information into the EHR or case management system and maintain confidentiality with all hard copies.
  • A creative solution to implementing paper screening tools is to laminate the screening tool and use dry-erase markers. Once the information has been entered into the case file in a confidential manner, wipe the laminate clean.

Some screening tools have been translated into various languages; however, it is important to remember that the translation of a tool does not necessarily ensure a culturally responsive approach to screening. Consider the following guidelines:¹³

• Reflect empathy, curiosity, and respect, which are fundamental to successful cross-cultural encounters.
• Demonstrate knowledge about cultural groups but recognize that each group is heterogeneous.
• Understand each client’s expectations of the medical experience and what an illness may mean, including cause, severity, and prognosis; expected treatment; and how it affects the person’s life.¹⁴
• Accommodate client’s language preference.
• Increase focus on social context and support.
• Provide appropriate education to match a client’s health literacy level.
• Cultivate diversity in the care setting workforce.
• Incorporate members of the community in the design and implementation of cross-cultural initiatives and programs.
• Adopt a family-centered approach when appropriate, ensuring proper release of confidential information with 42 CFR Part 2.
• Integrate traditional practices and spirituality when appropriate.
• Use motivational interviewing techniques to determine substance use referral options in line with the client’s goals.

It is important to intervene based on the results of each client’s screening. Positive reinforcement, brief advice, brief intervention, and referral to treatment are all potential next steps when the screening process is complete. Reinforce client autonomy when making referrals. Provide a menu of available options to clients and be clear that you support whatever option, if any, the client chooses. Explicitly emphasize that continued access to your services is not contingent on follow-up with a substance use referral; otherwise, clients may assume they have no choice but to accept the referral. Additional information is available from the HIV Provider Reference Series - Screening, Brief Intervention, and Referral to Treatment: Addressing Substance Abuse in HIV Care Settings.