John R. Knight
The Role of Primary Care Provider
Alcohol and drug use are common among American adolescents; by high school graduation approximately eight of ten American students have tried alcohol, more than half of students have tried an illicit drug, and approximately one third have tried an illicit drug other than marijuana. Almost one third of students try an illicit substance by the end of 8th grade. Alcohol and drug use are related to the four leading causes of death in the adolescent age-group and therefore present a major public health problem. The American Academy of Pediatrics and the Maternal and Child Health Bureau recommend that all adolescents be screened for substance use at each yearly physical examination. Primary care providers should ask every adolescent if they have tried tobacco, alcohol, and other drugs during each yearly health maintenance visit and screen all of those who have used with a validated tool such as the CRAFFT questions (Knight et al., 1999). In most general practices, most teens will report no use or low risk use, and will benefit from praise, encouragement, or brief advice that can be given in a few moments. Those teens who screen positive for high-risk substance use require further assessment and either a brief intervention or referral for more intensive services.
Asking about Drug and Alcohol Use
Large population surveys have demonstrated that all adolescents are at risk of exposure to drugs and alcohol (Centers for Disease Control, 2004). Therefore, every adolescent should be asked yearly about alcohol and drug use, regardless of race, ethnicity, socioeconomic status, religion, or gender.
Health care providers should ask questions regarding substance use in private, after explaining the rules of confidentiality. Adolescents should be afforded confidentiality unless their behavior poses an acute safety concern to themselves or others. Determining whether a specific behavior presents a safety concern is a matter of clinical judgment; the patient's age, other diagnoses, and social situation should be taken into account. Occasional use of alcohol or marijuana can usually be kept confidential. In all cases, adolescents should be assured that if confidentiality is to be broken, the health care provider and patient will review what will be said before speaking with parents, and only diagnostic and planning information will be shared; specific details need not be disclosed.
To avoid miscommunication, questions about substance use should be clear and concise, such as, “Have you ever drunk alcohol? Have you ever smoked marijuana? Have you ever used another drug?” Some health care providers prefer to begin with questions about peers and friends whereas others begin with more direct personal questions.
Substance use may present with nonspecific signs and symptoms, such as change in school performance, loss of interest in hobbies or extracurricular activities, excessive moodiness or irritability, or a change in friends. When a parent reports any of these changes, the health care provider should be particularly alert to the possibility of substance use. In addition, any concerns about use expressed by parents, school officials, coaches, or other adults should be taken seriously. Drug testing may be recommended when parents have reasonable concerns that their child is using drugs and yet the adolescent denies drug use (see Chapter 72).
All teens who report using alcohol or drugs should receive a structured screening to determine whether their use is of low or high risk. Recent research has demonstrated that reliance on impressions alone may cause even experienced health care providers to underestimate the severity of an adolescent's substance-related problems (Wilson et al., 2004). A number of tools have been created to screen adolescents for alcohol and drug use. These tools fall into two main categories—paper and pencil tools such as the Alcohol Use Disorders Identification Test (AUDIT) (Miles et al., 2001; Reinert and Allen, 2002) and the Problem Oriented Screening Instrument for Teenagers (POSIT) (Knight et al., 1996), and orally administered tools such as the CAGE (see
Chapter 69, Figure 69.1) (Crowe et al., 1997; Ewing, 1984) or CRAFFT (see below) questions (Knight et al., 1999). Written assessments can be self-administered; oral tools are generally administered as part of a routine history. Written tools may screen for a number of disorders simultaneously, but take longer to administer, score, and interpret. Orally administered screens generally require minimal training to use and can be administered very quickly.
The CAGE questions are both valid and reliable for detecting alcohol disorders among adults, but have poor psychometric properties when used with teens and are not recommended for screening adolescents. The CRAFFT questions were developed specifically to screen adolescents for drug and alcohol use disorders simultaneously. Research has demonstrated that CRAFFT is a valid and reliable tool for screening adolescents, with a sensitivity of 76%, specificity of 94%, positive predictive value of 83%, and a negative predictive value of 91% for identifying problem use, abuse, or dependence (Knight et al., 2002b); and its psychometric properties are favorable across age, gender, and race/ethnicity. CRAFFT is a mnemonic acronym created from the first letters of key words in the test's six questions:
During the last 12 months have you ever:
Each “yes” response is scored one point. A score of 2 or greater is a positive screen, and indicates that the adolescent is at high risk for having an alcohol or drug-related disorder.
All teens who screen positive require further assessment, beginning with a more detailed substance use history. A nonjudgmental, empathetic interviewing style that accepts the patient's point of view encourages more information sharing than an interrogative style. Health care providers should use open-ended questions whenever possible, with an emphasis on the pattern of drug use over time, including whether drug use has increased in quantity or frequency, whether the teen has made attempts at discontinuing drug use and why and whether attempts have been successful. Information about the pattern of drug use and associated problems is more important in making a diagnosis of a substance-related disorder than the absolute quantity or frequency used. A well-conducted history has therapeutic value because it encourages the patient to consider the consequences of drug use that she/he has already experienced.
After interviewing the adolescent about his/her drug of choice, the health care provider should ask about use of other drugs, because use of multiple substances puts an adolescent at higher risk than use of a single substance. This information may also guide treatment planning, particularly if drug testing will be used for monitoring, or if medications are indicated as part of therapeutic management. Table 73.1 lists drugs and classes
of drugs that should be included in an extended drug history. For each drug ask the teen:
The health care provider should ask about the seven criteria for a diagnosis of drug dependence (Table 73.2) for the drug of choice and each drug the teen has reported using with associated problems.
A physical examination should be performed as part of a complete assessment. Signs of chronic drug use are rare in teens, but should be noted if present. A list of physical findings associated with acute intoxication, withdrawal, and chronic drug use are presented in Table 73.3.
Drug testing may be a useful part of a comprehensive assessment, particularly if symptoms of drug use are present, or parents have specific concerns, yet the teen denies drug use. The use of drug testing as an assessment tool is described in greater detail in Chapter 72.
Substance Use Disorders
As with many disorders, substance use can be viewed as a spectrum varying from experimentation to drug dependence and addiction. Table 73.2 describes various stages within this spectrum. The Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) includes diagnostic criteria for substance abuse and substance dependence disorders. Other designations, while not formal diagnoses, are useful descriptions that can help the health care provider determine the appropriate level of intervention.
Many adolescents with substance-related disorders will have symptoms consistent with a co-occurring mental health disorder, and it may be difficult to determine clinically whether the symptoms are solely the result of drug use. In some circumstances, the question of a co-occurring diagnosis cannot be fully resolved until the adolescent has had a period of complete abstinence. However, severe symptoms, symptoms that antedate drug use, or positive family history of a similar disorder all suggest a co-occurring disorder, and warrant concurrent treatment. On the contrary, symptoms beginning after the onset of drug use may resolve completely with abstinence, and patients may be observed and reassessed as necessary. The diagnosis of attention-deficit hyperactivity disorder (ADHD) should not be made unless the adolescent had symptoms before age 10. Dual diagnosis and management is discussed further in Chapter 74.
Primary Care Management
Most adolescents who use alcohol and drugs can be managed effectively in the primary care setting, and even patients who will ultimately require referral to an addiction or mental health specialist may receive direct benefit, or be more likely to accept treatment recommendations, after a brief office intervention (Borowsky et al., 2003; Fleming et al., 2002;Knight et al., 2000). Research has shown that brief interventions by health care providers, ranging in intensity from a few seconds up to several hours, can significantly reduce drug and alcohol use. In this chapter, we define brief advice as an intervention lasting seconds to minutes in which the health care provider gives general information regarding substance use to a patient and brief intervention as an individual interactive counseling session focusing on details specific to the patient's substance use.
Abstinence (Positive Reinforcement)
Adolescents who abstain from alcohol and drugs, either primarily or secondarily, should receive praise and encouragement from their health care provider. Statements should be brief yet specific and encourage the adolescent to discuss drug use or ask questions in the future should the need arise. An example is, “It sounds as if you have made some really good decisions about drugs and alcohol. I hope you will come back to me if you ever have questions about drugs, if you are tempted, or even if you try them.”
Low Risk (Brief Advice)
Adolescents who have used drugs or alcohol but score 0 or 1 on the CRAFFT questions are “low risk” users, most likely in the experimentation or regular use stage (Knight et al., 2002a,b 2004). These patients may benefit from brief general advice pertinent to the drug they have used. Advice may be targeted at abstinence or risk reduction. Sample statements are listed in Table 73.4. Knowledge of the patient can help the health care provider select the most relevant piece of information to share.
Problem Use and Abuse (Brief Intervention)
Adolescents who have problems associated with drugs may benefit from a brief intervention. It is important for health care providers and parents to realize that behavior change is a process that occurs over time. Prochaska and DiClemente have conceptualized behavior change as occurring in a series of steps, described in Table 73.5. The goal of brief intervention is to encourage the patient to move in the direction of positive behavior change. An intervention that causes an adolescent to move from precontemplation to contemplation should be considered a success, although no observed behavior change will be noted at that time.
Motivational interviewing (MI) is an empathetic, patient focused, directive counseling style that seeks to create conditions necessary for positive change. It is particularly well suited for brief therapeutic encounters, either as a primary method for assisting patients to change their
alcohol/drug use, or as a means of encouraging them to accept a referral for more intensive treatment.
MI is based on two important assumptions. The first is that motivation is a product of interpersonal interaction, and not an innate character trait. What a health care provider does or says in counseling sessions can either help or hinder a patient in changing his/her behavior. Confrontation leads to resistance, while empathy and understanding lead to change.
A second assumption is that ambivalence toward change is normal and acceptable. According to this view, adolescents who use alcohol and drugs are in constant conflict, simultaneously experiencing both positive and negative feelings about their use. Their “decisional balance” can be viewed as an old-fashioned pan scale, with the pros and cons of substance use represented by the relative weights on the two sides.
In this model, the counselor is the facilitator while the adolescent presents the arguments for change. The counselor listens carefully for the ambivalence in the patient's own words, and helps the patient to use his or her own negative feelings regarding drug use as the fuel for behavior change by drawing out, repeating, and reinforcing the negative aspects of drug use and positive aspects of change. She/he also looks for opportunities to support self-efficacy, by pointing out strengths, previous successes (no matter how small), and acknowledging the difficulties of making behavioral changes. The counselor avoids resistance by refraining from lecturing or arguing with the patient.
MI techniques: A variety of tools are associated with MI; an exhaustive description is beyond the scope of this chapter (Miller and Rollnick, 2002). Table 73.6 describes several of the most common techniques and gives sample situations in which they may be helpful.
When an adolescent does decide to make a behavior change it is useful to make a specific written plan, detailing the change attempted (abstinence, use only on weekends, etc.) and a time frame (usually 30–90 days). This allows both the health care provider and patient to monitor progress, and serves as an excellent starting point at follow-up visits. A sample abstinence contract and controlled use trial (CUT) contract are included in Table 73.7. Sample drinking and driving contracts are available at the Students Against Destructive Decisions (SADD) Web site (http://sadd.org/contract.htm#cf1).
Most adolescents who meet criteria for substance dependence will need intensive services from an addiction or mental health specialist. Pharmacological treatment may be a useful adjuvant for patients with opioid or alcohol dependence. Intensive therapies are discussed in detail in Chapter 74.
The Role of Parents
Parents play a vital role in the prevention and treatment of adolescent substance abuse. Health care providers should encourage the parents of preteens to discuss drugs and alcohol, and to set clear family rules of no use. Health care providers should also encourage parents to set a good example by consuming alcohol only in moderation, never driving after drinking, and avoiding drug use. If parents have had drug or alcohol problems in the past they may decide to share honestly their experiences if their children ask, but do not need to volunteer information.
Some adolescents who are misusing drugs or alcohol will not engage in treatment. In these cases family or parent support counseling may be useful, even if the adolescent refuses to participate. Parents should be advised to set firm limits and avoid enabling substance use. Limit setting refers to consequences designed by the parents, such as the following:
Ultimately, the adolescent will decide whether to use drugs, but she/he will have to live with the consequences of the decision, including consequences set by parents.
Enabling refers to any activity that intentionally or unintentionally assists the adolescent in obtaining or using
drugs. Parents may unintentionally enable an adolescent's drug use by providing money, cell phones, E-mail accounts, or a car that teenager uses to obtain drugs. A review of sources of money, communication, and transportation may help parents identify enabling behaviors and eliminate them. If parents are unable to enforce their home rules they may seek assistance from the court system by filing a “Child in Need of Supervision (CHINS)” order with the police department and having a probation officer assigned to assist them.
In all cases, the patient and family should be told that they are welcome to return to the office to discuss drugs and alcohol whenever they are ready. Some patients need more time. A supportive word or two may stay with them, preparing them to ultimately return and engage in treatment.
Substance use is common among American teenagers. Primary care health supervision visits provide an excellent opportunity for assessment in a one-on-one setting. All teens should be asked confidentially about substance use at each primary care visit. Those who have ever used substances should be screened using the CRAFFT questions. Positive reinforcement for adolescents who have not used substances and brief intervention for those who have but screen negative for high-risk use takes just a few moments but may have significant clinical impact. Teens who screen positive for high-risk use may directly or be more willing to accept a treatment referral after a brief office-based intervention. Primary care visits also provide an opportunity to help parents reduce the likelihood of their child developing a substance use disorder, or to engage parents in the treatment of teens who have developed a substance use disorder.
American Academy of Pediatrics, Committee on Substance Abuse. Alcohol use and abuse: a pediatric concern. Pediatrics 2001;108:185.
American Academy of Pediatrics, Committee on Substance Abuse. Testing Your Teen for Illicit Drugs: Information for Parents. Patient education brochure available from the Academy through the AAP Web site (www.aap.org) or by calling (888/227–1770). Accessed 2007.
American Academy of Pediatrics. Substance abuse: a guide for health professionals, 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2002.
Kulig JW, Committee on Substance Abuse, American Academy of Pediatrics. Tobacco, alcohol, and other drugs. Pediatrics 2005;115(3):816.
Miller WR, Rollnick S. Motivational interviewing: preparing people for change, 2nd ed. New York, NY: Guilford Press; 2002.
http://www.health.org/. National Clearinghouse for Alcohol and Drug Information.
http://www.nida.nih.gov/. National Institute on Drug Abuse.
http://www.niaaa.nih.gov/. National Institute on Alcohol Abuse and Alcoholism.
http://www.samhsa.gov/. Substance Abuse and Mental Health Services Administration.
http://www.saddonline.com/. Students Against Destructive Decisions.
References and Additional Readings
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Breslin C, Li S, Sdao-Jarvie K, et al. Brief treatment for young substance abusers: a pilot study in an addiction treatment setting. Psychol Addict Behav 2002;16(1):10.
Centers for Disease Control. Youth risk behavior surveillance–United States, 2003. MMWR 2004;53(SS-5):1.
Crowe RR, Kramer JR, Hesselbrock V, et al. The utility of the brief MAST' and the CAGE' in identifying alcohol problems: results from national high-risk and community samples.Arch Fam Med 1997;6(5):477.
Dembo R, Schmeidler J, Brodern P, et al. Examination of the reliability of the Problem Oriented Screening Instrument for Teenagers (POSIT) among arrested youth entering a juvenile assessment center. Subst Use Misuse 1996;31(7):785.
Ewing J. Detecting alcoholism: the CAGE questionnaire. JAMA 1984;252(14):1906.
Fleming MF, Mundt MP, French MT, et al. Brief physician advice for problem drinkers: long-term efficacy and benefit-cost analysis. Alcohol Clin Exp Res 2002;26(1):36.
von Hook S, Harris SK, Brooks T, et al. The “Six T's”: barriers to screening teens for substance abuse in primary care. J Adolesc Health 2007;40:465.
Knight JR, Goodman E, Pulerwitz T, et al. Reliabilities of short substance abuse screening tests among adolescent medical patients. Pediatrics 2000;105(4):948.
Knight JR, Goodman E, Pulerwitz T, et al. Reliability of the Problem Oriented Screening Instrument for Teenagers (POSIT) in an adolescent medical clinic population. J Adolesc Health. 2001;29(2):125.
Knight JR, Sherritt L, Gates E, et al. Should the CRAFFT substance abuse screening test be shortened. J Clin Outcomes Mgmt 2004;11(1):19.
Knight JR, Sherritt L, Harris SK, et al. Validity of brief alcohol screening tests among adolescents: a comparison of the AUDIT, POSIT, CAGE and CRAFFT. Alcohol Clin Exp Res2002a; 27:67.
Knight JR, Sherritt L, Shrier LA, et al. Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Arch Pediatr Adolesc Med 2002b;156:607.
Knight JR, Shrier LA, Bravender TD, et al. A new brief screen for adolescent substance abuse. Arch Pediatr Adolesc Med 1999;153:591.
Levy S, Vaugh BL, Angulo M, et al. Buprenorphine replacement therapy for adolescents with opioid dependence: early experience from a children's hospital-based outpatient treatment program. J Adolesc Health 2007;40:477.
Miles H, Winstock A, Strang J. Identifying young people who drink too much: the clinical utility of the five-item Alcohol Use Disorders Identification Test (AUDIT). Drug Alcohol Rev 2001;20:9.
Miller WR, Rollnick S. Motivational Interviewing: preparing people for change, 2nd ed. New York, NY: Guilford Press; 2002. http://www.powertrain.com Problem Oriented Screening Instrument for Teenagers (POSIT Version 2). Landover, MD: PowerTrain; 1998.
Prochaska J, DiClemente C. Toward a comprehensive model of change. In: Miller WR, Heather N, eds. Treating addictive behavior: process of change. New York: Plenum Publishing; 1986:3.
Prochaska JO, DiClemente CC. Stages of change in the modification of problem behaviors. Prog Behav Modif 1992;28:183.
Reinert D, Allen J. The Alcohol Use Disorders Identification Test (AUDIT): A review of recent research. Alcohol Clin Exp Res 2002;26(2):272.
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Wilson CR, Sherritt L, Gates E, et al. Are clinical impressions of adolescent substance use accurate. Pediatrics 2004;114: e536.