Screening for Substance Use in Rural Primary Care: a Qualitative Study of Providers and Patients

  • Elizabeth C. SaundersEmail author
  • Sarah K. Moore
  • Trip Gardner
  • Sarah Farkas
  • Lisa A. Marsch
  • Bethany McLeman
  • Andrea Meier
  • Noah Nesin
  • John Rotrosen
  • Olivia Walsh
  • Jennifer McNeely
Original Research



Substance use frequently goes undetected in primary care. Though barriers to implementing systematic screening for alcohol and drug use have been examined in urban settings, less is known about screening in rural primary care.


To identify current screening practices, barriers, facilitators, and recommendations for the implementation of substance use screening in rural federally qualified health centers (FQHCs).


As part of a multi-phase study implementing electronic health record–integrated screening, focus groups (n = 60: all stakeholder groups) and individual interviews (n = 10 primary care providers (PCPs)) were conducted.


Three stakeholder groups (PCPs, medical assistants (MAs), and patients) at three rural FQHCs in Maine.


Focus groups and interviews were recorded, transcribed, and content analyzed. Themes surrounding current substance use screening practices, barriers to screening, and recommendations for implementation were identified and organized by the Knowledge to Action (KTA) Framework.

Key Results

Identifying the problem: Stakeholders unanimously agreed that screening is important, and that universal screening is preferred to targeted approaches. Adapting to the local context: PCPs and MAs agreed that screening should be done annually. Views were mixed regarding the delivery of screening; patients preferred self-administered, tablet-based screening, while MAs and PCPs were divided between self-administered and face-to-face approaches. Assessing barriers: For patients, barriers to screening centered around a perceived lack of rapport with providers, which contributed to concerns about trust, judgment, and privacy. For PCPs and MAs, barriers included lack of comfort, training, and preparedness to address screening results and offer treatment.


Though stakeholders agree on the importance of implementing universal screening, concerns about the patient-provider relationship, the consequences of disclosure, and privacy appear heightened by the rural context. Findings highlight that strong relationships with providers are critical for patients, while in-clinic resources and training are needed to increase provider comfort and preparedness to address substance use.


substance use disorder screening primary care rural 



The authors would like to thank Kimberly Clark, Alison Carter, and Seamus Higgins, patients, providers, and staff at Penobscot Community Health Center, Brewer Medical System, and Helen Hunt Health Center who participated in the research.


This research was financially supported by grants from the National Institute on Drug Abuse Treatment Clinical Trials Network (UG1DA013035 [PIs John Rotrosen and Edward Nunes], UG1DA040309 [PI Lisa Marsch]), and T32-DA037202 (PI Alan Budney).

Compliance with Ethical Standards

The study was approved by the Institutional Review Boards (IRBs) of New York University School of Medicine and Dartmouth College.

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Supplementary material

11606_2019_5232_MOESM1_ESM.docx (61 kb)
ESM 1 (DOCX 61 kb)


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Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Elizabeth C. Saunders
    • 1
    Email author
  • Sarah K. Moore
    • 2
  • Trip Gardner
    • 3
  • Sarah Farkas
    • 4
  • Lisa A. Marsch
    • 2
  • Bethany McLeman
    • 2
  • Andrea Meier
    • 2
  • Noah Nesin
    • 3
  • John Rotrosen
    • 4
  • Olivia Walsh
    • 2
  • Jennifer McNeely
    • 5
  1. 1.The Dartmouth Institute (TDI) for Health Policy and Clinical PracticeLebanonUSA
  2. 2.Center for Technology and Behavioral HealthGeisel School of Medicine at Dartmouth CollegeHanoverUSA
  3. 3.Penobscot Community Health Care (PCHC)BangorUSA
  4. 4.Department of PsychiatryNew York University School of MedicineNew YorkUSA
  5. 5.Department of Population HealthNew York University School of MedicineNew YorkUSA

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