Alcohol, drug and other substance use is a key concern for providers of adolescent medical and behavioral health care in the United States (US). Despite overall reductions in youth substance use over the past 5 years, opioids, marijuana and binged alcohol continue to see sustained use in adolescent and young adult populations.(1) Cigarette smoking continues to decline among adolescents in recent years, however e-cigarette use or vaping of nicotine, marijuana and/or flavorings has increased dramatically.(1) By 12th grade, 48% of teens have tried an illicit drug.(1) Marijuana remains the most heavily used drug, with 30% of all 8th -12th graders having tried it in their lifetime and 6% of 12th graders reporting daily use. However, of all substances overall, alcohol remains the most commonly used in the teenage population. As early as 8th grade, 24% of students have tried alcohol. By the end of high school, 60% have tried alcohol, and 40% have been drunk; 18% of 12th graders report having been drunk in the last 30 days. Binge drinking is common with 14% of 12th graders having consumed > 5 alcoholic beverages at one time in the prior 2 weeks.
Teens who use drugs or alcohol are susceptible to negative consequences. Substance use is associated with risky teen behavior and related morbidity including teenage pregnancy, sexually transmitted infections, and domestic violence,(2) as well as social and legal issues related to substance abuse including criminal behavior, school failure, and family problems.(3) Furthermore, the leading cause of mortality between youth aged 10–24 years old is unintentional injury, and substance use increases this risk.(4)
Beyond the immediate implications of adolescent substance use, early drug use is a predictor of future addiction.(5, 6) While undergoing crucial periods of development, the adolescent brain is particularly vulnerable to developing substance use disorders.(7) In addition, substances of abuse have the potential to trigger long-term neurocognitive changes. Marijuana and alcohol use during developmental years have been shown to impair learning, negatively affect functional brain activity, and can even lead to permanent IQ loss.(8, 9) The area of the brain that is responsible for assessing situations and controlling impulses, the prefrontal cortex, is not fully mature until the mid-20 s.(7) While this makes teens more susceptible to substance use disorders, it also provides a critical time frame for impactful guidance. Given the numerous medical, social, and cognitive effects of early initiation of substance use, pediatricians are in the unique position to intervene on a pattern of behavior that could affect their patients’ lives beyond just adolescence.
To help guide pediatricians through this intervention process, the American Academy of Pediatrics (AAP) issued a policy statement in 2011 (revised in 2016) detailing the pediatrician’s role in decreasing the burden of substance use among adolescents.(10, 11) The statement endorses the use of Substance Use Screening, Brief Intervention, and Referral to Treatment (SBIRT) as a method to systematically address teen drug and alcohol use.(10, 11) The Substance Abuse and Mental Health Services Administration (SAMHSA) in the US defines SBIRT as “an evidence-based practice used to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs.”(12) Substance use is measured along a range of abstinence, to limited use, to problematic use, and finally to development of a use disorder.(10) Screening is not intended to make a diagnosis, but rather to delineate level of risk.(10) The importance of screening for all adolescents is supported by the fact that most substance related consequences during adolescence do not occur as a result of addiction, but rather due to the fact that any degree of substance use comes with risks in this population.(11) By determining where a patient falls on the spectrum of misuse, a clinician can appropriately direct the next steps in care. Although a variable range of between 50–86% of pediatricians report screening for substance use,(11) they often use psychosocial screening mnemonic tools such as the HEEADSSS (home, education/employment, eating, activities, drugs, sexuality, suicide/depression, safety from injury/violence) or SSHADESS (strengths, school, home, activities, drugs/substance use, emotions/eating/depression, sexuality, safety) instead of a structured screening tool.(13) However, prior research suggests that clinician perception alone is not accurate in determining the level of substance use, and the use of a standardized and validated screening protocol results in higher detection rates.(3, 14) The AAP policy statement endorses the importance of utilizing a validated and age-appropriate screening tool, such as the CRAFFT, Screening to Brief Intervention (S2BI) or Brief Screener for Tobacco, Alcohol and Other Drugs (BSTAD).(10, 11) The level of use reported via these screeners may then trigger a brief intervention, a screening outcome-responsive conversation that focuses on raises awareness and encourages a patient to consider behavior change.(10)
Despite AAP recommendation and the evidence base for SBIRT, this method is not widely implemented in adolescent primary care. Patient factors that may impede screening include level of comfort to discuss sensitive topics(15) and concern about confidentiality.(16) For providers, barriers include time constraints, feeling less capable of making a diagnosis, disagreements on who should implement screening tools, perception of difficulty in discussing substance use, and doubt regarding effectiveness of intervention.(17, 18) Evidence suggests that pediatric primary care providers who reported feeling prepared to diagnose substance use disorders have higher levels of screening(19) and additional training and resource support may help providers implement brief intervention with or without referral to treatment.(11, 17)
In adults, SBIRT has been shown to be effective in reducing alcohol and drug use(20, 21) and is backed by the U.S. Preventative Services Task Force (USPSTF) for this purpose.(22) In the adolescent population, the base of evidence is still evolving. Not only is SBIRT difficult to study in the teen population, given changing and variable developmental stages, but results for the efficacy of intervention are mixed.(23, 24) Some studies have shown efficacy of brief motivational interviewing to decrease subsequent substance use,(25) whereas others have not.(26) Recently, the USPSTF released draft recommendations promoting brief interventions and educational messages as effective at preventing tobacco use in adolescents.(27) However, the USPSTF has cited insufficient evidence for the clinical utility of substance use screening and intervention when applied widely in pediatric primary care environments.(22) Nevertheless, SAMHSA, AAP and other professional groups continue to advocate for universal screening and intervention.(2, 11, 28) Reductions in even mild to moderate adolescent substance use have considerable potential to reduce long-term sequelae; however, further research on SBIRT is necessary to help substantiate the use of the model in the adolescent population.
The purpose of this study was to describe substance use screening among adolescents in the outpatient clinics of a large academic medical center in the Midwest (i.e., frequency of screened, diagnosis, referral), to assess factors associated with screening, and evaluate the documentation of screening in the medical records to inform integration of SBIRT into the routine practice.