Despite clear evidence of the public health burden of substance use disorders, difficulty in detecting these across the lifespan is likely to continue given the current legal and social milieu. Illicit substance use carries legal and occupational risks, which creates tension for patients who are motivated to continue using despite these risks due to addiction. Many require routine urine drug testing, such as those in the transportation industry or those requiring the use of heavy equipment, and positive tests for illicit substances may be grounds for dismissal. In addition, although tobacco smoking is legal, many organizations, particularly large organizations tasked with providing healthcare for employees, have begun to routinely monitor for tobacco use in order to incentivize cessation. Although beneficial from the perspective of motivating cessation, such policies also create incentives to avoid detection despite ongoing use, impairing clinicians’ ability to intervene appropriately. Social stigma provides an additional incentive to conceal substance use, and in the case of adolescents, fear of disciplinary intervention does as well. Thus, although individuals as well as private and public organizations all share an interest
