Validation of the TAPS-1: A Four-Item Screening Tool to Identify Unhealthy Substance Use in Primary Care
Validation of the TAPS-1: A Four-Item Screening Tool to Identify Unhealthy Substance Use in Primary Care
Jan Gryczynski 2
Geetha A. Subramaniam 6
Dace S. Svikis 5
Lauretta A. Cathers 5
Gaurav Sharma 4
Courtney D. Nordeck 2
Shannon G. Mitchell 2
Kevin E. O'Grady 3
Robert P. Schwartz 2
0 Duke University School of Medicine , Durham, NC , USA
1 New York University School of Medicine , New York, NY , USA
2 Friends Research Institute , Baltimore, MD , USA
3 University of Maryland , College Park, College Park, MD , USA
4 Emmes Corporation , Rockville, MD , USA
5 Virginia Commonwealth University , Richmond, VA , USA
6 Center for Clinical Trials Network, National Institute on Drug Abuse , North Bethesda, MD , USA
BACKGROUND: The Tobacco, Alcohol, Prescription Medication, and Other Substance use (TAPS) tool is a combined two-part screening and brief assessment developed for adult primary care patients. The tool's first-stage screening component (TAPS-1) consists of four items asking about past 12-month use for four substance categories, with response options of never, less than monthly, monthly, weekly, and daily or almost daily. OBJECTIVE: To validate the TAPS-1 in primary care patients. DESIGN: Participants completed the TAPS tool in selfand interviewer-administered formats, in random order. In this secondary analysis, the TAPS-1 was evaluated against DSM-5 substance use disorder (SUD) criteria to determine optimal cut-points for identifying unhealthy substance use at three severity levels (problem use, mild SUD, and moderate-to-severe SUD). PARTICIPANTS: Two thousand adult patients at five primary care sites. MAIN MEASURES: DSM-5 SUD criteria were determined via the modified Composite International Diagnostic Interview. Oral fluid was used as a biomarker of recent drug use. KEY RESULTS: Optimal frequency-of-use cut-points on the self-administered TAPS-1 for identifying SUDs were ≥ monthly use for tobacco and alcohol (sensitivity = 0.92 and 0.71, specificity = 0.80 and 0.85, AUC = 0.86 and 0.78, respectively) and any reported use for illicit drugs and prescription medication misuse (sensitivity = 0.93 and 0.89, specificity = 0.85 and 0.91, AUC = 0.89 and 0.90, respectively). The performance of the intervieweradministered format was similar. When administered first, the self-administered format yielded higher disclosure rates for past 12-month alcohol use, illicit drug use, and prescription medication misuse. Frequency of use alone did not provide sufficient information to discriminate between gradations of substance use problem
unhealthy substance use; substance use disorders; screening; primary care; J Gen Intern Med 32(9); 990-6 DOI; 10; 1007/s11606-017-4079-x © Society of General Internal Medicine 2017
severity. Among those who denied drug use on the
TAPS1, less than 4% had a drug-positive biomarker.
CONCLUSIONS: The TAPS-1 can identify unhealthy
substance use in primary care patients with a high level of
accuracy, and may have utility in primary care for rapid
Tobacco,1 alcohol,2 illicit drugs,3, 4 and non-medical
prescription medication use5 contribute substantially to morbidity,
mortality, and societal costs. Recent efforts have focused on
identifying and addressing unhealthy substance use (the
spectrum ranging from any drug use or alcohol consumption above
guideline-recommended levels, through more severe
substance use disorder [SUDs]) in primary care.6, 7
There are many reasons for clinicians to identify unhealthy
substance use in their patients, including formulating
differential diagnoses of psychiatric and medical disorders that can be
mimicked or worsened by substance use, informing preventive
care, and avoiding potentially serious medication interactions.8
Screening for unhealthy substance use can initiate a broader
conversation about behavioral health, and provides an
opportunity to deliver prevention messages to those who screen
negative. For those who screen positive, there is good evidence
supporting the effectiveness of brief counseling for tobacco9
and alcohol.10 The evidence for illicit drugs is more equivocal,
with some randomized studies showing promising results11–13
and others showing no effects in primary care patients.14, 15
For patients with SUDs, interventions can be delivered in
primary care or via referral to a specialist. There are Food and
Drug Administration (FDA)-approved medications for
treating SUDs for tobacco (nicotine replacement therapy,
bupropion, varenicline), alcohol (acamprosate, disulfiram,
naltrexone), and opioids (buprenorphine, methadone,
naltrexone). Opioid overdose has reached epidemic levels in
the United States,16, 17 and primary care clinicians are
uniquely suited to identify opioid risks and prevent overdose death.
Many individuals may access primary care before they seek
specialty addiction treatment. Thus, primary care offers an
opportunity to identify opioid use disorders early in their
progression, facilitate treatment, and reduce overdose risk
(e.g., by providing education and naloxone to patients and
Although there are a growing number of validated
substance use screening tools, different tools have unique
strengths and weaknesses. Many older substance use
screening tools (e.g., the CAGE and AUDIT for alcohol) are limited
by their focus on a single substance.18 Other validated tools,
such as the World Health Organization (WHO) Alcohol,
Smoking and Substance Involvement Screening Test
(ASSIST),19 may be too lengthy, given the extreme time
demands on primary care providers. Screening tools must be
brief, while providing accurate detection. Research indicates
that brief instruments can perform surprisingly well in
detecting SUDs.8, 15, 20–22 Single-item screeners querying frequency
of use in the past year can accurately identify patients with
unhealthy drug8 and alcohol use22 and DSM-IV-defined
alcohol or drug dependence.15 A recent study in US Veterans
Affairs clinics found that a two-item screener had high
sensitivity and specificity (0.92/0.93) for detecting SUD among a
sample of veterans (95% male) in primary care.21 However,
one limitation of these rapid screeners is that they do not
differentiate between illicit drug and prescription medication
misuse,8, 15, 21 a distinction that may be particularly important
in primary care settings.
McNeely and colleagues20 recently reported a two-site
validation study of the self-administered Substance Use Brief
Screen (SUBS), which asks patients about use of tobacco,
binge drinking (4 or more drinks in a day), illicit drug use,
and prescription medication misuse. The SUBS was able to
detect unhealthy use and SUDs for alcohol and any drugs
(sensitivity/specificity for alcohol and any drug SUD = 0.94/
0.65 and 0.86/0.82, respectively), but was less sensitive for
prescription drug use disorders alone (sensitivity/specificity
for SUD = 0.59/0.89).
The Tobacco, Alcohol, Prescription Medication, and Other
Substance use (TAPS) tool is a two-step screening and brief
assessment tool adapted from the NIDA Quick Screen24 and
ASSIST-Lite25 (an abbreviated version of the WHO
ASSIST).19 The TAPS tool consists of two parts: a rapid screener
(TAPS-1) and a brief assessment (TAPS-2) for those who
screen positive on TAPS-1 (e.g., analogous to using the
PHQ-2 followed by PHQ-9 for depression screening).23 The
TAPS tool, using this two-part approach, was recently
validated in primary care by the National Drug Abuse Treatment
Clinical Trials Network (NIDA CTN0059).26 The purpose of
the present study was to examine the ability of the TAPS-1, as
a standalone screener, to identify adult primary care patients
with unhealthy substance use.
This secondary analysis examined the performance of the
TAPS-1 in a geographically diverse sample of 2000 adult
primary care patients. Methodological details of the parent
study have been reported elsewhere27 and are summarized
Design and Setting
Recruitment took place from August 2014 to April 2015 at
five primary care clinics in four Eastern US cities: a Federally
Qualified Health Center in Baltimore, MD [n = 589]; a public
hospital-based clinic in New York, NY [n = 534]; a
universitybased health center in Richmond, VA [n = 211]; and two
private practices in Kannapolis, NC [n = 287 and 379].
Research assistants consecutively approached patients in
each clinic’s waiting area and invited them to participate in
an anonymous screening for a health study. Patients who
agreed met with the research assistant in a private office and
completed the TAPS tool in two formats sequentially
(selfadministered on an iPad, and interviewer-administered), with
administration order determined at random. After patients had
completed both formats, a battery of reference measures
assessing substance use and related problems was
administered by the research assistant.
Participants were paid $20 for completing the assessment,
after which they were asked to provide an oral fluid sample for
a drug test. Participants were paid an additional $10 if they
provided the sample. Participants were not told about the oral
fluid collection until all self-reported assessments were
completed. The study was approved by the institutional review
boards (IRBs) of Friends Research Institute and participating
academic institutions, with a waiver of written consent,
because this would be the only identifiable link to the data.
Participants were given an IRB-approved information sheet.
The study had the following inclusion criteria: 1) adult (age 18
or older) primary care patient, and 2) able to provide informed
consent. Participants were excluded if they 1) could not
comprehend spoken English, 2) could not operate an iPad due to
physical limitations, or 3) had previously enrolled during an
earlier visit. Participants were 43.7% male, with 11.7%
Hispanic ethnicity. Racial identification was 33.4% white and
55.6% black/African American. The average age was 46.0
years (SD = 14.7). With respect to education, 19.2% had not
completed high school, 28.9% had a high school diploma/
GED, 21.3% had some college (no degree), 11.2% had an
associate’s degree, 14.0% had a bachelor’s degree, and 5.5%
had a graduate/professional degree.
TAPS-1. The TAPS-1 is the screening component of the TAPS
tool, and consists of a single stem question with four items
covering frequency of past-12-month use of tobacco, alcohol,
and illicit drugs, and non-medical use of prescription
medications (Fig. 1). In this study, the TAPS-1 was administered as
part of the full TAPS tool26; the focus of the present analysis is
exclusively on the TAPS-1.
SUD Criteria. Diagnostic criteria for SUDs were assessed
using the modified World Mental Health Composite
International Diagnostic Interview (WMH-CIDI)28 items
mapping to the SUD criteria in the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition (DSM-5).29
Consistent with DSM-5, our scoring dropped the DSM-IV
criterion on legal problems and included the item on craving.
DSM-5 criteria were assessed separately for tobacco, alcohol,
marijuana, cocaine, methamphetamine, heroin, and
nonmedical use of prescription opioids, sedatives, and stimulants.
Because the WMH-CIDI does not include many of the DSM-5
tobacco use disorder criteria, tobacco use disorder was
assessed using the language from the WMH-CIDI drug
section. To facilitate direct comparison with the categories
queried by the TAPS-1, we calculated DSM-5 scores for (a)
tobacco, (b) alcohol, (c) any illicit drugs, and (d) any
prescription medications used non-medically. We examined unhealthy
substance use at sub-diagnostic Bproblem use^ (≥1 DSM-5
criteria), mild SUD (≥2 DSM-5 criteria) and
moderate-tosevere SUD (≥4 DSM-5 criteria) thresholds.
Oral Fluid. Oral fluid cheek swab specimens were tested for
recent drug use via enzyme-linked immunosorbent assay
(ELISA) screening with liquid chromatography-tandem mass
spectrometry (LC-MS/MS) confirmation for amphetamines;
methamphetamine including ecstasy/MDMA/MDA/MDEA;
cocaine/benzoylecgonine; cannabis (THC); opiates (morphine,
heroin metabolite, codeine, hydrocodone); oxycodone;
methadone; barbiturates; phencyclidine; and benzodiazepines. Oral
fluid rather than urine specimens were collected because oral
fluid could be more efficiently obtained and shipped, and has
been found to have adequate reliability.30 The package insert
noted good agreement with gas chromatography–mass
spectrometry (GC-MS) results (e.g., benzodiazepines, 88%; opiates, 90%;
cocaine, 93%; cannabis, 94%; methamphetamine, 98%). In this
analysis, morphine with heroin metabolite was classified as illicit
drug-positive; other opiates (including morphine alone) were
classified as prescription medications.
Methamphetamine/ecstasy/MDMA/MDA were classified as illicit drugs; amphetamines
alone were classified as prescription medications. Research
assistants collected information about prescription medications that
participants reported taking medically as prescribed; oral fluid
tests for those medications were not counted as positive. Of the
2000 participants, 1802 (90%) provided an oral fluid sample.
Given a short detection window for oral fluid testing (several
days), its comparison with self-reporting offers a conservative
estimate of non-disclosure by permitting disconfirmation of
selfreported abstinence on the TAPS-1.
The TAPS-1 was compared against reference standards of
problem use, mild SUD, and moderate-to-severe SUD for tobacco,
alcohol, illicit drugs, and non-medical use of prescription
medications, using receiver operating characteristic (ROC) analysis of
the area under the curve (AUC), sensitivity, specificity, positive
predictive value (PPV), and negative predictive value (NPV).
Optimal cut-points were determined by maximizing sensitivity
and specificity as measured by AUC and Youden’s J
(sensitivity + specificity − 1), which combines sensitivity and specificity
into a single performance index ranging from −1 to 1, with 1
indicating a Bperfect^ test.31 These measures of test performance
were examined for both self- and interviewer-administered
formats. We used χ2 tests of independence to compare disclosure
rates (i.e., any self-reported past 12-month use) based on format
Substance Use Prevalence
Table 1 shows prevalence, based on responses to the modified
CIDI, of problem use, mild SUD, and moderate-to-severe
SUD. Overall prevalence of DSM-5 SUD (≥2 criteria) was
25% for tobacco, 14% for alcohol, 13% for illicit drugs, and
3.5% for prescription medications. Among those meeting
SUD criteria for illicit drugs, 57% met criteria for cannabis,
42% for illicit stimulants (cocaine or methamphetamine), and
25% for heroin (some met criteria for multiple drug classes).
Among those meeting SUD criteria for prescription
medications, 69% met criteria for opioids, 40% for anxiety or sleep
Rx = prescription, SUD = substance use disorder
Note: Substance problem categories are mutually exclusive. Slight
sample size differences are due to missing data on the modified World
Mental Health Composite International Diagnostic Interview
medications, and 11% for stimulants (some met criteria for
multiple drug classes).
Performance of the TAPS-1
Table 2 shows the performance of the self-administered
TAPS1 for detecting unhealthy substance use at each severity
threshold. For all four substance categories, the optimal cut-point on
the TAPS-1 for detecting problem use was any use in the past
12 months (i.e., any response greater than ‘Never’). For
detecting any SUD (including mild or moderate-severe SUD),
optimal cut-points were monthly use for tobacco and alcohol,
and any use for illicit drugs and prescription medications.
These cut-points were also optimal for detecting
The analysis identified the same cut-points for the
interviewer- and self-administered formats, with similar
performance between the two formats (Online Appendix Table 1).
However, participants disclosed substance use at higher rates on
the self-administered format for all substances except tobacco.
The greatest discrepancy was for prescription medication
misuse, which was 50% higher on the self-administered than the
interviewer-administered format (12% vs. 8%).
Administration Order Effects
For the interviewer-administered TAPS-1, there were no
significant differences in past 12-month prevalence of tobacco,
alcohol, illicit drug, or prescription medication misuse based
on whether the test was delivered before or after the
selfadministered format (all ps > 0.05). Conversely, for the
selfadministered format, disclosure rates were significantly higher
for every substance category except tobacco when the
selfadministered format preceded the interviewer-administered
format. When the self-administered TAPS-1 was presented
before vs. after the interviewer-administered TAPS-1,
disclosure rates were higher for alcohol (48% vs. 37%; p <0 .001),
illicit drugs (27% vs. 22%; p = .03), and prescription
medications (16% vs. 8%; p < 0.001). On the self-administered
TAPS-1, analyses stratified by administration order showed
small differences in sensitivity/specificity for first vs. second
administration for tobacco (0.93/0.81 vs. 0.90/0.79) alcohol
(0.73/0.83 vs. 0.69/0.87), illicit drugs (0.91/0.84 vs. 0.95/
0.87), and prescription medication misuse (0.86/0.87 vs.
Disclosure Rates vs. Oral Fluid
Oral fluid testing provides a brief detection window of
approximately 1–3 days since last drug use. For the
intervieweradministered TAPS-1, 3.9% (54/1372) and 3.4% (57/1667) of
participants who reported no illicit drug use or prescription
medication misuse, respectively, had a positive oral fluid test.
For the self-administered TAPS-1, 3.8% (51/1359) and 3.7%
(58/1585) had a positive oral fluid test despite reporting no illicit
drug use or prescription medication misuse, respectively.
However, approximately 10% of the sample refused the oral fluid
Rx = prescription, SUD = substance use disorder, AUC = area under the curve
Note: Slight sample size differences are due to missing data on the modified World Mental Health Composite International Diagnostic Interview
test, which could be for various reasons (e.g., lack of time,
concerns about confidentiality, or lack of candor in self-report).
As a screening tool, the TAPS-1 is simple and brief. It asks
four direct questions about past 12-month use for all major
substance use categories: tobacco, alcohol, illicit drugs, and
non-medical use of prescription medications. The TAPS-1 was
able to accurately detect problem use and SUDs for broad
categories of substance use, and can be used as a standalone
tool for quick triage in primary care. When implemented as
part of the full TAPS tool, the TAPS-1 branches directly to
additional questions in the TAPS-2.26 Although adding the
TAPS-2 questions does not appear to provide greater
sensitivity for detecting unhealthy use of illicit or prescription
substances as broad categories, the TAPS-2 questions fill in more
granular details about specific substances used and related
problems, which may be important for guiding clinical care.
Both self- and interviewer-administered formats were
able to detect unhealthy substance use at various severity
thresholds, with test performance falling in the acceptable
to excellent range. A noteworthy difference between the
two formats is that disclosure rates for prescription
medication misuse were 50% higher with the self-administered
format. However, this advantage in disclosure was seen
only when this format was administered prior to the
interviewer-administered TAPS-1, and this ordering had
slightly lower sensitivity and specificity for illicit drugs
and prescription medication misuse (perhaps because the
reference standard itself was interviewer-administered). It
is possible that participants were more reluctant to disclose
substance use in a face-to-face interview than on a
computer tablet,32 but that having the interviewer-administered
questions first primed participants to subsequently reduce
their level of candor. Another possibility is that
interviewers clarified misunderstandings that could lead to false
positives, and participants remembered these clarifications
when taking the self-administered format. For the
interviewer-administered TAPS, interviewers read the
questions verbatim but were allowed to provide a brief
clarification and explanation if requested. For both formats,
participants responded under confidential research
conditions, with the knowledge that the results would not enter
their medical record. It is not known how patients’
willingness to disclose substance use might change under
realworld practice conditions.
This study adds to a growing body of literature supporting
the use of brief screening tools for identifying unhealthy
substance use, and builds upon prior research demonstrating
the validity of even single-item substance use questionnaires
in primary care.8, 15, 20, 22 What is unique to the TAPS-1 is that
it screens for four substance categories, is validated for both
interviewer- and self-administered formats, may be
administered as a standalone screener or paired with a brief assessment
(TAPS-2), and has high sensitivity and specificity for
identifying unhealthy use of illicit drugs and prescription
medications. This last feature is particularly important given the
current opioid epidemic and high rates of overdose deaths
related to prescription opioid use across the US.
This study demonstrated the validity of the TAPS-1 in
both interviewer- and self-administered formats. Either
format can be used in practice. An advantage of the
selfadministered version may be slightly higher disclosure of
substance use (particularly prescription medication
misuse), low staff burden, and the potential for seamless
integration of screening results into the electronic medical
record. Ultimately, the choice of which format to deploy
will depend on workflow considerations that are to some
extent unique to each primary care practice. However,
given its brevity (typically <1 min), we recommend that
the TAPS-1 be incorporated into routinized screening
protocols whenever possible, with subsequent assessment and
intervention by providers as needed.
As evidenced by different optimal cut-points, the
TAPS1 had some utility in discriminating between
subdiagnostic problem use and SUD for tobacco and alcohol,
but the same cut-points optimally identified unhealthy use
of illicit drugs and prescription medications at all severity
thresholds examined. Hence, although the TAPS-1 is likely
to be an excellent tool for initial triage in primary care,
frequency of use alone does not provide sufficient
information to accurately discriminate between gradations of
severity. As with any brief screener, it is important to ask
follow-up questions to better inform diagnoses and
treatment plans. While some practices may choose to use the
TAPS-1 as a standalone screening tool for initial triage, it is
recommended that screening be followed by a more
detailed assessment when unhealthy substance use is
identified. For this reason, it was originally intended that a
positive TAPS-1 screen would be followed by the
corresponding TAPS-2 questions (which cover more recent use
of specific substances and problems) to better inform
clinical care for patients with unhealthy substance use.
Strengths of this study include the large sample, evaluation
of both interviewer- and self-administered formats with
randomized order, and inclusion of a drug use biomarker. This
was a diverse sample with white, African American, and
Hispanic participants recruited from five primary care sites
across the Eastern United States. However, the extent to which
findings may be generalized to other US regions or other
countries is unknown. The TAPS-1 and reference standard
measures were asked by the same interviewers. We
determined unhealthy substance use via a structured interview with
items mapping to DSM-5 criteria. This is the appropriate
standard, but remains an imperfect way of capturing a
complex and nuanced phenomenon. The TAPS-1 groups
marijuana with illicit drugs; however, several states have
decriminalized or even legalized recreational marijuana use.
Finally, findings may not generalize to settings where
disclosure of substance use carries potential consequences (e.g.,
Disclosure of substance use at low levels can identify
patients with problem use and SUDs with a high level of
accuracy. No screening tool should be considered an end unto
itself, but rather a means to triage patients and inform a more
detailed clinical assessment. To that end, the TAPS-1
succeeds. The findings from the current study support the use of
the TAPS-1 for rapid patient triage.
Corresponding Author: Jan Gryczynski, PhD; Friends Research
Institute, 1040 Park Avenue, Suite 103, Baltimore, MD 21201, USA
Compliance with Ethical Standards:
Conflict of Interest: GA Subramaniam is an employee of the Center
for Clinical Trials Network (CCTN), National Institute on Drug Abuse
(NIDA), which is the funding agency for the National Drug Abuse
Treatment Clinical Trials Network; her participation in this publication arises
from her role as a project scientist under a cooperative agreement for
this study. All other authors declare that they do not have a conflict of
Funding Source: This study was supported by National Institute on
Drug Abuse cooperative agreements: 5 U01 DA 013034;
U10DA013727 and UG1DA040317; 3UG1DA013035. The content is
solely the responsibility of the authors and does not necessarily
represent the official views of the National Institute on Drug Abuse or the
National Institutes of Health.
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