Screening and Brief Intervention for Cannabis Use in Primary Care in a Large Urban Healthcare System

Context & Objective. To describe the implementation of an Epic electronic health record (EHR) based screening, brief intervention, and referral to treatment (SBIRT) for cannabis use and to present preliminary findings on cannabis use among adult patients attending primary care (PC) clinics in Los Angeles, CA.

Study Design. We developed and implemented an automated, EHR integrated, self-administered, cannabis screening questionnaire for patients receiving PC at a large university-based healthcare system in Los Angeles, CA. We obtained input from key stakeholders by conducting key informant focus groups with patients, PC providers, physician informaticists, and health system leaders. The screener was based on a validated substance use questionnaire (ASSIST) and sent via the EHR patient portal to adults being seen at one of 60 PC clinics for an annual wellness or new patient visit. Questions included past 3-month frequency of cannabis use, mode, and reasons for cannabis use. The screener was launched in January 2021 and data for this analysis were collected between January 2021 and February 2022.

Analysis. Facilitators of SBIRT identified as part of the focus groups included: (1) minimal disruption to clinic workflow; (2) minimal to no staff effort required; (3) advisory message in the EHR, if patients screened as moderate/high risk for cannabis use disorder; and (4) ease of access to support resources (i.e., Smartsets) to deliver SBIRT. Among the 69,353 patients screened, 16% reported cannabis use in the past 3-months which was significantly higher than current tobacco use (7%). Among cannabis users (n=11,176), nearly half reported using cannabis weekly or more often, and 45% reported cannabis use for self-defined medical reasons, most commonly for sleep (55%), stress (50%), anxiety (27%), and pain (32%). Edibles surpassed smoking and vaping as the most common mode of use: 61% edibles, 51% smoking, and 28% vaping. Cannabis use resources and referral materials (Smartsets) were accessed by providers 80 times.

Conclusions. Implementation of an EHR-based cannabis screening in a large healthcare system was both feasible and acceptable. The prevalence of recent cannabis use among adults in PC was high with a substantial proportion citing medical reasons as the motivation for use. Strategies to improve provider uptake of brief intervention and referral to treatment are needed.