Response to commentaries


Drs Harris, Raistrick and Teesson raise important considerations about the integration of treatments for substance use disorders (SUD) into general medical settings. Recently enacted US legislation has the potential to transform interventions for drug use disorders [1, 2] and standardized and validated screening for SUD must be a part of electronic health records (EHR) [3]. Development of the EHR recommendations was needed—and needed urgently—if substance abusing patients are to be adequately served by medical practitioners [4]. Each of the commentaries points out important, yet challenging, issues that must be considered before implementing SUD standardized data collection, associated screening and brief intervention (SBI), and clinical quality measures on a large scale.

Maree Teesson cautions that the stigma of SUD, and the underfunding and poor coordination of treatment, will continue to hinder integration into general medical care [5]. Including SUD in EHR will only achieve its potential of improved access, safety and effectiveness of care when it is implemented in combination with clinical decision support and other needed improvements to care and the shift of certain SUD services to the general medical setting. For example, we would expect the stigma of SUD to dissipate with time once an increased number of patients are identified and treated in general medical settings. Confidentiality concerning drug treatment is already protected by US federal law and will be protected by built-in safeguards for trusted exchange of information in EHRs.

Duncan Raistrick points out the limitations of expert groups and favors a systematic literature review [6]. We do not fundamentally disagree, but believe there are sufficient systematic reviews already available—some of which were cited in the commentaries and were reviewed by our taskforce. While we recognize the utility and convenience of a package of measures, particularly for drug, alcohol and tobacco use, our taskforce was constrained in scope to drug use. We concur with Raistrick that validation of the proposed instruments is limited and expect further validation or alternatives to be identified as ongoing validation occurs and the science evolves.

Alex Harris notes the paucity of scientific evidence for screening and effectiveness of brief treatments for drug use disorder in general medical care [7]. We agree that empirically-demonstrated benefits are needed before wide implementation. Our article noted that pilot testing of these common data elements and accompanying clinical decision support in Screening, Brief Intervention and Referral to Treatment (SBIRT) within a Substance Abuse and Mental Health Services Administration (SAMHSA) EHR is being planned, and the results of that study, and others, are expected to add to published evidence needed to satisfy the Centers for Medicare and Medicaid Services EHR Meaningful Use criteria. Identifying suitable data elements is only a first step.

Our article was intended to continue and broaden the stakeholder feedback we have sought throughout the consensus-building process and we appreciate these very thoughtful comments.

Declarations of interest

Several authors are employees of the Center for the Clinical Trials Network of the National Institute on Drug Abuse, National Institutes of Health, the funding agency for the National Drug Abuse Treatment Clinical Trials Network. The opinions in this manuscript are those of the authors and do not represent the official position of the US Government.