Screening for adolescent alcohol and drug use in pediatric health-care settings: predictors and implications for practice and policy

Young people in foster care and substance use

Adolescents are at high risk for using substances and for young people in foster care, substance use rates are estimated to be as high as 49 %. Adolescence is an important period for preventing substance use and SUD. Universal screening, brief interventions, and substance use treatment can be used to decrease substance use and substance use disorders among adolescents. Brief interventions often used with adolescents include motivational interviewing and contingency management. Of the many types of outpatient therapies utilized to treat adolescents with substance use disorder, some of the most established include cognitive behavioral therapy, family-based therapy, and a combination of different types of interventions. Medication treatment is less frequently offered to adolescents due to buprenorphine being the only drug FDA approved for youth under the age of 18. Residential treatment is also an option if lower levels of care are not adequate to safely support youth. Lastly, limited research has looked at the effectiveness of continuing care options to support youth in maintaining treatment results.

Standard Versus Family-Based Screening, Brief Intervention, and Referral to Treatment for Adolescent Substance Use in Primary Care: Protocol for a Multisite Randomized Effectiveness Trial

BACKGROUND

Screening, brief intervention, and referral to treatment for adolescents (SBIRT-A) is widely recommended to promote detection and early intervention for alcohol and other drug (AOD) use in pediatric primary care. Existing SBIRT-A procedures rely almost exclusively on adolescents alone, despite the recognition of caregivers as critical protective factors in adolescent development and AOD use. Moreover, controlled SBIRT-A studies conducted in primary care have yielded inconsistent findings about implementation feasibility and effects on AOD outcomes and overall developmental functioning. There is urgent need to investigate the value of systematically incorporating caregivers in SBIRT-A procedures.

OBJECTIVE

This randomized effectiveness trial will advance research and scope on SBIRT-A in primary care by conducting a head-to-head test of 2 conceptually grounded, evidence-informed approaches: a standard adolescent-only approach (SBIRT-A-Standard) versus a more expansive family-based approach (SBIRT-A-Family). The SBIRT-A-Family approach enhances the procedures of the SBIRT-A-Standard approach by screening for AOD risk with both adolescents and caregivers; leveraging multidomain, multireporter AOD risk and protection data to inform case identification and risk categorization; and directly involving caregivers in brief intervention and referral to treatment activities.

METHODS

The study will include 2300 adolescents (aged 12-17 y) and their caregivers attending 1 of 3 hospital-affiliated pediatric settings serving diverse patient populations in major urban areas. Study recruitment, screening, randomization, and all SBIRT-A activities will occur during a single pediatric visit. SBIRT-A procedures will be delivered digitally on handheld tablets using patient-facing and provider-facing programming. Primary outcomes (AOD use, co-occurring behavior problems, and parent-adolescent communication about AOD use) and secondary outcomes (adolescent quality of life, adolescent risk factors, and therapy attendance) will be assessed at screening and initial assessment and 3-, 6-, 9-, and 12-month follow-ups. The study is well powered to conduct all planned main and moderator (age, sex, race, ethnicity, and youth AOD risk status) analyses.

RESULTS

This study will be conducted over a 5-year period. Provider training was initiated in year 1 (December 2023). Participant recruitment and follow-up data collection began in year 2 (March 2024). We expect the results from this study to be published in early 2027.

CONCLUSIONS

SBIRT-A is widely endorsed but currently underused in pediatric primary care settings, and questions remain about optimal approaches and overall effectiveness. In particular, referral to treatment procedures in primary care remains virtually untested among youth. In addition, whereas research strongly supports involving families in interventions for adolescent AOD, SBIRT-A effectiveness trial testing approaches that actively engage family members in primary care are absent. This trial is designed to help fill these research gaps to inform the critical health decision of whether and how to include caregivers in SBIRT-A activities conducted in pediatric primary care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05964010; https://www.clinicaltrials.gov/study/NCT05964010.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/54486.

Efficacy of a Digital Health Preventive Intervention for Adolescents With HIV or Sexually Transmitted Infections and Substance Use Disorder: Protocol for a Randomized Controlled Trial

BACKGROUND

HIV or sexually transmitted infections remain a significant public health concern in the United States, with adolescents affected disproportionately. Adolescents engage in HIV/STI risk behaviors, including drug use and condomless sex, which increase the risk for HIV/STIs. At-risk adolescents, many of whom are racial minorities, experience HIV/STI disparities. Although at-risk adolescents are disproportionately affected by HIV/STI risk behaviors and infections and although the Centers for Disease Control and Prevention recommends routine HIV/STI testing for adolescents, relatively few adolescents report having ever been tested for HIV/STI. With expected increases in health clinic visits as a result of the Affordable Care Act combined with technological advances, health clinics and mobile health (mHealth), including apps, provide innovative contexts and tools to engage at-risk adolescents in HIV/STI prevention programs. Yet, there is a dearth of efficacious mHealth interventions in health clinics to prevent and reduce both condomless sex and drug use and increase HIV/STI testing for at-risk adolescents.

OBJECTIVE

To address this gap in knowledge, we developed a theory-driven, culturally congruent mHealth intervention (hereon referred to as S4E [Storytelling 4 Empowerment]) that has demonstrated feasibility and acceptability in a clinical setting. The next step is to examine the preliminary efficacy of S4E on adolescent HIV/STI testing and risk behaviors. This goal will be accomplished by 2 aims: the first aim is to develop a cross-platform and universal version of S4E. The cross-platform and universal version of S4E will be compatible with both iOS and Android operating systems and multiple mobile devices, aimed at providing adolescents with ongoing access to the intervention once they leave the clinic, and the second aim is to evaluate the preliminary efficacy of S4E, relative to usual care control condition, in preventing or reducing drug use and condomless sex and increasing HIV/STI testing in a clinical sample of at-risk adolescents aged 14-21 years living in Southeast Michigan.

METHODS

In this study, 100 adolescents recruited from a youth-centered community health clinic will be randomized via blocked randomization with random sequences of block sizes to one of the 2 conditions: S4E mHealth intervention or usual care. Theory-driven and culturally congruent, S4E is an mHealth adaptation of face-to-face storytelling for empowerment, which is registered with the Substance Abuse and Mental Health Services Administration's National Registry of Evidence-Based Programs and Practices.

RESULTS

This paper describes the protocol of our study. The recruitment began on May 1, 2018. This study was registered on December 11, 2017, in ClinicalTrials.gov. All participants have been recruited. Data analysis will be complete by the end of March 2024, with study findings available by December 2024.

CONCLUSIONS

This study has the potential to improve public health by preventing HIV/STI and substance use disorders.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03368456; https://clinicaltrials.gov/study/NCT03368456.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/47216.

Sexually Transmitted Infection Diagnoses at Children's Hospitals During COVID-19

OBJECTIVES

COVID-19 mitigation strategies resulted in changes in health care access and utilization, which could negatively impact adolescents at risk for sexually transmitted infections (STIs). We evaluated changes in STI diagnoses during adolescent visits at children's hospitals during COVID-19.

METHODS

We conducted a retrospective cohort study using the Pediatric Health Information System database comparing adolescent (11-18 years) hospital visits with an STI diagnosis by International Classification of Diseases, 10th revision, code during COVID-19 (2020) to pre-COVID-19 (2017-2019). Data were divided into spring (March 15-May 31), summer (June 1-August 31), and fall (September 1-December 31). Median weekly visits and patient characteristics were compared using median regression.

RESULTS

Of 2 747 135 adolescent encounters, there were 10 941 encounters with an STI diagnosis from 44 children's hospitals in 2020. There was a decrease in overall median weekly visits for STIs in spring during COVID-19 (n = -18.6%, P = .001) and an increase in overall visits in summer (11%, P = .002) during COVID-19. There were significant increases in inpatient median weekly visits for STIs in summer (30%, P = .001) and fall (27%, P = .003) during COVID-19. We found increases in Neisseria gonorrhoeae (50%, P < .001) and other STI diagnoses (defined as other or unspecified STI by International Classification of Diseases, 10th revision, code; 38%, P = .040) in fall COVID-19 (2020), and a decrease in pelvic inflammatory disease (-28%, P = .032) in spring COVID-19 (2020).

CONCLUSIONS

We found increases in median weekly adolescent inpatient visits with an STI diagnosis in summer and fall COVID-19 (2020). These findings were likely partially driven by changes in behaviors or health care access. Further work is needed to improve STI care and thus potentially improve related health outcomes.

Association of Adolescents' Body Mass Index Classification With Preventive Clinical Care Receipt

PURPOSE

To examine differences in screening and advising for modifiable risk behaviors during well-visits based on adolescents' body mass index categories.

METHODS

Retrospective analyses were conducted with the National Institute of Health's NEXT Generation Health Study data, a nationally representative cohort of 10th graders. In wave 1 (2010), adolescents were classified as being underweight (<4.99th percentile), normal-weight (5-84.99th percentile), overweight (85-94.99th percentile), or with obesity (≥95th percentile) based on the body mass index categories described by the Centers for Disease Control and Prevention. In wave 2 (2011), adolescents were asked by their provider about smoking, alcohol use, use of other drugs, sexual activity, nutrition, and exercise, and whether they were advised about risks associated with these behaviors.

RESULTS

The sample consisted of 1,639 eligible participants as follows: 57.8% females, 63.3% 16-year-olds, 47.8% non-Hispanic Whites, 41.5% living in the South, 75.4% with health insurance, and 29.8% with low family affluence. Screening rates for overweight compared to normal-weight males were 51% reduced for smoking, 46% for alcohol use, 47% for other drug use, 57% for nutrition, and 47% for exercise. Screening rates were 40% reduced for other drug use for males with obesity, and 89% reduced for alcohol use for underweight males compared to normal-weight males. Advice receipt for females with obesity compared to normal-weight females was 90% increased for nutrition and 78% increased for exercise.

DISCUSSION

Overweight male adolescents reported being less likely to be screened across almost all preventive service topics representing missed opportunities for care delivery.

Identifying Game-Based Digital Biomarkers of Cognitive Risk for Adolescent Substance Misuse: Protocol for a Proof-of-Concept Study

BACKGROUND

Adolescents at risk for substance misuse are rarely identified early due to existing barriers to screening that include the lack of time and privacy in clinic settings. Games can be used for screening and thus mitigate these barriers. Performance in a game is influenced by cognitive processes such as working memory and inhibitory control. Deficits in these cognitive processes can increase the risk of substance use. Further, substance misuse affects these cognitive processes and may influence game performance, captured by in-game metrics such as reaction time or time for task completion. Digital biomarkers are measures generated from digital tools that explain underlying health processes and can be used to predict, identify, and monitor health outcomes. As such, in-game performance metrics may represent digital biomarkers of cognitive processes that can offer an objective method for assessing underlying risk for substance misuse.

OBJECTIVE

This is a protocol for a proof-of-concept study to investigate the utility of in-game performance metrics as digital biomarkers of cognitive processes implicated in the development of substance misuse.

METHODS

This study has 2 aims. In aim 1, using previously collected data from 166 adolescents aged 11-14 years, we extracted in-game performance metrics from a video game and are using machine learning methods to determine whether these metrics predict substance misuse. The extraction of in-game performance metrics was guided by literature review of in-game performance metrics and gameplay guidebooks provided by the game developers. In aim 2, using data from a new sample of 30 adolescents playing the same video game, we will test if metrics identified in aim 1 correlate with cognitive processes. Our hypothesis is that in-game performance metrics that are predictive of substance misuse in aim 1 will correlate with poor cognitive function in our second sample.

RESULTS

This study was funded by National Institute on Drug Abuse through the Center for Technology and Behavioral Health Pilot Core in May 2022. To date, we have extracted 285 in-game performance metrics. We obtained institutional review board approval on October 11, 2022. Data collection for aim 2 is ongoing and projected to end in February 2024. Currently, we have enrolled 12 participants. Data analysis for aim 2 will begin once data collection is completed. The results from both aims will be reported in a subsequent publication, expected to be published in late 2024.

CONCLUSIONS

Screening adolescents for substance use is not consistently done due to barriers that include the lack of time. Using games that provide an objective measure to identify adolescents at risk for substance misuse can increase screening rates, early identification, and intervention. The results will inform the utility of in-game performance metrics as digital biomarkers for identifying adolescents at high risk for substance misuse.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/46990.

Neonatal Abstinence Syndrome: An Insight Over Impact of Maternal Substance Use

Neonatal abstinence syndrome (NAS) highlights the intricate interplay between maternal substance use during pregnancy and the challenges neonates face from the distressing global opioid crisis. This comprehensive review captures the multilayered landscape of NAS, encircling its underlying mechanisms, epidemiology, diagnostic intricacies, clinical manifestations, continuing developmental impacts, treatment paradigms, and the crucial role of multidisciplinary care. The core pathophysiology of NAS involves the transplacental passage of addictive substances, activating chemical dependence in the maturing fetus, which is characterized by neurotransmitter dysregulation, neuroadaptations, and receptor sensitization. A diverse clinical presentation ranges from central nervous system hyperactivity and autonomic dysregulation to gastrointestinal manifestations, necessitating homogenous assessment tools such as the Finnegan Neonatal Abstinence Scoring System. The demand for a multilayered approach is essential for comprehensive management, involving pharmacological interventions like morphine or methadone and non-pharmacological strategies such as swaddling. The complications of NAS are not only limited to but are also well beyond infancy, leading to behavioral, longstanding cognitive, and socioemotional consequences. Addressing these developmental arcs demands decisive longitudinal monitoring and early interventions. NAS management is fundamentally multidisciplinary, requiring the teamwork of nurses, social workers, psychologists, pediatricians, and neonatologists. Apart from the clinical realm, managing the psychosocial needs of families traversing NAS requires resources and empathy. A crucial comprehensive approach is essential to confront the challenges and limitations of NAS. From early identification and prevention to longstanding support through pharmacological, non-pharmacological, and psychological channels, it creates a holistic structure that emerges as the basis for understanding the complicated relationship between maternal substance use and its impact on neonates. An amalgamation of community engagement, society, policy initiatives, and medical expertise is essential to mitigate the repercussions of NAS and adopt healthier outcomes for affected infants.

Implementation of substance use screening in rural federally-qualified health center clinics identified high rates of unhealthy alcohol and cannabis use among adult primary care patients

BACKGROUND

Screening for substance use in rural primary care clinics faces unique challenges due to limited resources, high patient volumes, and multiple demands on providers. To explore the potential for electronic health record (EHR)-integrated screening in this context, we conducted an implementation feasibility study with a rural federally-qualified health center (FQHC) in Maine. This was an ancillary study to a NIDA Clinical Trials Network study of screening in urban primary care clinics (CTN-0062).

METHODS

Researchers worked with stakeholders from three FQHC clinics to define and implement their optimal screening approach. Clinics used the Tobacco, Alcohol, Prescription Medication, and Other Substance (TAPS) Tool, completed on tablet computers in the waiting room, and results were immediately recorded in the EHR. Adult patients presenting for annual preventive care visits, but not those with other visit types, were eligible for screening. Data were analyzed for the first 12 months following implementation at each clinic to assess screening rates and prevalence of reported unhealthy substance use, and documentation of counseling using an EHR-integrated clinical decision support tool, for patients screening positive for moderate-high risk alcohol or drug use.

RESULTS

Screening was completed by 3749 patients, representing 93.4% of those with screening-eligible annual preventive care visits, and 18.5% of adult patients presenting for any type of primary care visit. Screening was self-administered in 92.9% of cases. The prevalence of moderate-high risk substance use detected on screening was 14.6% for tobacco, 30.4% for alcohol, 10.8% for cannabis, 0.3% for illicit drugs, and 0.6% for non-medical use of prescription drugs. Brief substance use counseling was documented for 17.4% of patients with any moderate-high risk alcohol or drug use.

CONCLUSIONS

Self-administered EHR-integrated screening was feasible to implement, and detected substantial alcohol, cannabis, and tobacco use in rural FQHC clinics. Counseling was documented for a minority of patients with moderate-high risk use, possibly indicating a need for better support of primary care providers in addressing substance use. There is potential to broaden the reach of screening by offering it at routine medical visits rather than restricting to annual preventive care visits, within these and other rural primary care clinics.

Cross-sectional online survey of clinicians' knowledge, attitudes and challenges to screening and counselling adolescents and young adults for substance use

OBJECTIVE

To examine adolescent healthcare clinicians' self-reported screening practices as well as their knowledge, attitudes, comfort level and challenges with screening and counselling adolescents and young adults (AYA) for cigarette, e-cigarette, alcohol, marijuana, hookah and blunt use.

DESIGN

A 2016 cross-sectional survey.

SETTING

Academic departments and community-based internal medicine, family medicine and paediatrics practices.

PARTICIPANTS

Adolescent healthcare clinicians (N=771) from 12 US medical schools and respondents to national surveys. Of the participants, 36% indicated male, 64% female, mean age was 44 years (SD=12.3); 12.3% of participants identified as Asian, 73.7% as white, 4.8% as black, 4.2% as Hispanic and 3.8% as other.

PRIMARY AND SECONDARY OUTCOME MEASURES

Survey items queried clinicians about knowledge, attitudes, comfort level, self-efficacy and challenges with screening and counselling AYA patients about marijuana, blunts, cigarettes, e-cigarettes, hookah and alcohol.

RESULTS

Participants were asked what percentage of their 10-17 years old patients they screened for substance use. The median number of physicians reported screening 100% of their patients for cigarette (1st, 3rd quartiles; 80, 100) and alcohol use (75, 100) and 99.5% for marijuana use (50,100); for e-cigarettes, participants reported screening half of their patients and 0.0% (0, 50), (0, 75)) reported screening for hookah and blunts, respectively. On average (median), clinicians estimated that 15.0% of all 10-17 years old patients smoked cigarettes, 10.0% used e-cigarettes, 20.0% used marijuana, 25.0% drank alcohol and 5.0% used hookah or blunts, respectively; yet they estimated lower than national rates of use of each product for their own patients. Clinicians reported greater comfort discussing cigarettes and alcohol with patients and less comfort discussing e-cigarettes, hookah, marijuana and blunts.

CONCLUSIONS

This study identified low rates of screening and counselling AYA patients for use of e-cigarettes, hookahs and blunts by adolescent healthcare clinicians and points to potential missed opportunities to improve prevention efforts.

Screening Adolescents for Sensitive Health Topics in Primary Care: A Scoping Review

We sought to aggregate common barriers and facilitators to screening adolescents for sensitive health topics (e.g., depression, chlamydia) in primary care, as well as those that are unique to a given health topic. We conducted a literature search of three databases (PsycInfo, MEDLINE, and CINAHL) and reference lists of included articles. Studies focused on barriers and facilitators to screening adolescents (ages 12-17 years) for sensitive health topics in primary care that are recommended by national guidelines. Articles were peer-reviewed, presented empirical data, and were published in English in 2006-2021. We coded barriers and facilitators using the Consolidated Framework for Implementation Research, a well-established framework within implementation science. In total, 39 studies met inclusion criteria and spanned several health topics: depression, suicide, substance use, HIV, and chlamydia. We found common barriers and facilitators to screening across health topics, with most relating to characteristics of the primary care clinics (e.g., time constraints). Other factors relevant to screening implementation ranged from confidentiality concerns to clinician knowledge. Barriers and facilitators specific to certain health topics, such as the availability of on-site laboratories for HIV screening, were also noted. Findings can guide refinements to screening implementation.

Leveraging technology to address unhealthy drug use in primary care: Effectiveness of the Substance use Screening and Intervention Tool (SUSIT)

Background: Screening for unhealthy drug use is now recommended for adult primary care patients, but primary care providers (PCPs) generally lack the time and knowledge required to screen and deliver an intervention during the medical visit. To address these barriers, we developed a tablet computer-based 'Substance Use Screening and Intervention Tool (SUSIT)'. Using the SUSIT, patients self-administer screening questionnaires prior to the medical visit, and results are presented to the PCP at the point of care, paired with clinical decision support (CDS) that guides them in providing a brief intervention (BI) for unhealthy drug use. Methods: PCPs and their patients with moderate-risk drug use were recruited from primary care and HIV clinics. A pre-post design compared a control 'screening only' (SO) period to an intervention 'SUSIT' period. Unique patients were enrolled in each period. In both conditions, patients completed screening and identified their drug of most concern (DOMC) before the visit, and completed a questionnaire about BI delivery by the PCP after the visit. In the SUSIT condition only, PCPs received the tablet with the patient's screening results and CDS. Multilevel models with random intercepts and patients nested within PCPs examined the effect of the SUSIT intervention on PCP delivery of BI. Results: 20 PCPs and 79 patients (42 SO, 37 SUSIT) participated. Most patients had moderate-risk marijuana use (92.4%), and selected marijuana as the DOMC (68.4%). Moderate-risk use of drugs other than marijuana included cocaine (15.2%), hallucinogens (12.7%), and sedatives (12.7%). Compared to the SO condition, patients in SUSIT had higher odds of receiving any BI for drug use, with an adjusted odds ratio of 11.59 (95% confidence interval: 3.39, 39.25), and received more elements of BI for drug use. Conclusions: The SUSIT significantly increased delivery of BI for drug use by PCPs during routine primary care encounters.

Addressing Barriers to Primary Care Screening and Referral to Prevention for Youth Risky Health Behaviors: Evidence Regarding Potential Cost-Savings and Provider Concerns

Despite growing evidence and support for co-locating behavioral services in primary care to prevent risky health behaviors, implementation of these services has been limited due to a lack of reimbursement for services and negative perceptions among providers. We investigated potential to overcome these barriers based on new developments in healthcare funding and screening and referral to prevention (SRP) in primary care based on the Consolidated Framework for Implementation Research (CFIR), which could guide future SRP implementation strategies. To investigate the economic need for healthcare-based SRP, we quantified hospital charges to healthcare payors for services arising from adolescent risky behaviors (e.g., substance use, risky sex). Annual North Carolina (NC) hospital charges for these services exceeded $327 M (2019 dollars), suggesting high potential for cost savings if SRP can curb hospital services associated with risky behaviors. To investigate provider barriers and facilitators, we surveyed 151 NC pediatricians and 230 NC family therapists about their attitudes regarding a recently developed well-child visit SRP with family-based prevention. Both sets of professionals reported widespread need for and interest in the SRP but cited barriers of lack of reimbursement, training, and referrals to/from each other. Physicians, but not family therapists, reported concerns with poor patient or parent compliance. Many barriers could be resolved by co-locating family therapists in pediatric clinics to conduct well-child SRP. Our results support further research to develop business models for payor-funded SRP and CFIR-guided research to develop implementation strategies for primary care SRP to prevent adolescent risky health behaviors.

State of the Art in Substance Use Prevention and Early Intervention: Applications to Pediatric Primary Care Settings

With changes to drug-related policies and increased availability of many drugs, we currently face a public health crisis related to substance use and associated health consequences. Substance use and substance use disorders (SU/SUDs) are complex developmental disorders with etiologies that emerge through the intergenerational transmission of biological, familial, and environmental factors. The family ecosystem both influences and is influenced by SU/SUDs, particularly in children and adolescents. Family dynamics and parent functioning and behaviors can represent either risk or protective factors for the development of SU/SUDs in children. Primary care providers who provide care for children, adolescents, and families are in an ideal position to deliver prevention messages and to intervene early in the development of substance misuse and SUD among their patients. Despite recommendations from the American Academy of Pediatrics, few pediatric primary care providers provide anticipatory guidance to prevent or screen for substance misuse. Many barriers to those practices can be overcome through the integration and application of findings from the field of prevention science and the many lessons learned from the implementation of evidence-based interventions. Consideration of the implications of prevention science findings would help clarify the relevant roles and responsibilities of the primary care clinician, and the benefit of referral to and consultation from addiction specialists. Additionally, the past decade has seen the development and validation of a continuum of evidence-based prevention and early SU/SUD intervention activities that can be adapted for use in primary care settings making wide-spread implementation of prevention feasible. We propose a paradigm shift away from a model based on diagnosis and pathology to one upstream, that of family-focused prevention and early intervention. Adapting and scaling out empirically based prevention and early SU/SUD interventions to primary care settings and removing barriers to collaborative care across primary care, addiction medicine, and mental health providers offer the potential to meaningfully impact intergenerational transmission of SU/SUD — addressing a leading health problem facing our nation.

The CAMP study: feasibility and clinical correlates of standardized assessments of substance use in a youth psychiatric inpatient sample

BACKGROUND

To determine: (a) the feasibility and acceptability of administering a standardized electronic assessment of substance use and other mental health concerns to youth admitted to an inpatient psychiatric unit, and (b) the prevalence and clinical correlates of substance use in this sample.

METHODS

The sample included 100 youth between the ages of 13 to 17 years admitted to an inpatient psychiatric unit in Ontario, Canada between September and November 2019 (78% response rate). Youth data were comprised of electronic self-reported assessments (during hospitalization and 6-months following) and chart reviews (99% consented; historical and prospective). Frontline staff completed a self-report survey assessing their perceptions of the need for standardized substance use assessments, training, and interventions on the unit (n = 38 Registered Nurses and Child and Youth Workers; 86% response rate). Analyses included descriptive statistics, correlations, regression, and qualitative content analysis.

RESULTS

Feasibility of standardized youth self-reported mental health and substance use assessments was evident by high response rates, little missing data, and variability in responses. 79% of youth had used at least one substance in their lifetime; 69% reported use in the last 3 months. Substance use was positively correlated with severity of psychiatric symptoms (τb 0.17 to 0.45) and number of psychiatric diagnoses (τb 0.17 to 0.54) at index. Based on prospective and retrospective data, substance use was also positively related to mental health symptom severity at follow-up and repeat mental health related hospital visits. Frontline staff reported a need for standardized assessment, training, and interventions on the unit, indicative of acceptability.

CONCLUSIONS

This study demonstrated the feasibility, acceptability and clinical importance of administering a standardized mental health and substance use assessment among youth experiencing psychiatric hospitalization.

Implementation of a Universal Screening Process for Substance Use in Pregnancy

OBJECTIVE

To implement a standardized universal substance use screening process in an outpatient prenatal clinic at an urban tertiary care hospital.

METHODS

Using a quality-improvement framework that involved process modeling, stakeholder analyses, and plan-do-study-act cycles, we implemented universal substance use screening for prenatal patients using a modified 5Ps screening tool (Parents, Peers, Partner, Past, Present). Implementation included an operational workflow based on the SBIRT (Screening, Brief Intervention, Referral to Treatment) model. The primary outcome measure was percentage of patients who were screened for substance use, with a goal of 90% screened. Secondary outcome measures were percentage who screened positive and percentage of the time a positive screen resulted in documentation of a brief intervention by a health care practitioner.

RESULTS

Over a 19-month implementation period, 733 patient encounters were sampled. A substance use screen was completed in 618 (84%). We exceeded our goal of screening 90% of eligible patients for the final 6 months of data collection. Of the 618 completed screens, 124 (20%) screened positive. Health care practitioner documentation of brief interventions for patients with a positive screen reached 80% in the final phase of implementation, but then declined to 50% by the completion of the study period.

CONCLUSION

A sustainable and generalizable process to carry out substance use screening within a large prenatal practice is feasible, and assisted with identification of patients not known to be at risk. Further efforts are needed to evaluate how to sustain health care practitioner documentation of intervention in response to positive screens.

Creative Approaches for Assessing Long-term Outcomes in Children

Advances in new technologies, when incorporated into routine health screening, have tremendous promise to benefit children. The number of health screening tests, many of which have been developed with machine learning or genomics, has exploded. To assess efficacy of health screening, ideally, randomized trials of screening in youth would be conducted; however, these can take years to conduct and may not be feasible. Thus, innovative methods to evaluate the long-term outcomes of screening are needed to help clinicians and policymakers make informed decisions. These methods include using longitudinal and linked-data systems to evaluate screening in clinical and community settings, school data, simulation modeling approaches, and methods that take advantage of data available in the digital and genomic age. Future research is needed to evaluate how longitudinal and linked-data systems drawing on community and clinical settings can enable robust evaluations of the effects of screening on changes in health status. Additionally, future studies are needed to benchmark participating individuals and communities against similar counterparts and to link big data with natural experiments related to variation in screening policies. These novel approaches have great potential for identifying and addressing differences in access to screening and effectiveness of screening across population groups and communities.

Adolescent SBIRT Practices Among Pediatricians in Massachusetts

OBJECTIVES

Adolescent Screening, Brief Intervention, and Referral to Treatment (SBIRT) in primary care is a key strategy to prevent, identify, and respond to substance use problems and disorders, including opioid and other drug addictions. Despite substantial investment in recent years to increase its implementation, few studies have reported on recent levels of SBIRT implementation among pediatricians. We aimed to assess self-reported use of the SBIRT framework with adolescent patients among Massachusetts pediatricians, and describe trends since an earlier survey.

METHODS

We analyzed responses to a cross-sectional survey mailed in 2017 to a representative sample of pediatricians in Massachusetts. We computed response frequencies for all SBIRT practice questions. We used the chi-square test to compare current data to data collected in 2014, as we found no demographic differences between the 2 samples.

RESULTS

Nearly all pediatricians in the 2017 sample (n = 160) reported annual screening of their adolescent patients (99%). The majority reported giving positive reinforcement (87%), brief advice (92%), counseling (90%), and referral to treatment (66%) in response to screen results. Compared with 2014, a significantly higher proportion of pediatricians in 2017 referred patients who screened positively for problematic alcohol use, but perceived barriers to screening and follow-up remain, such as insufficient time to screen and patient refusal to return.

CONCLUSIONS

Among respondents to a Massachusetts pediatrician survey, we found high rates of delivering SBIRT in accordance with published guidelines, though barriers remain. Whether the content of the counseling adheres to guidelines is unknown.

Self-reported and Documented Substance Use Among Adolescents in the Pediatric Hospital

BACKGROUND AND OBJECTIVES

Adolescent substance use is associated with numerous adverse health outcomes. A hospitalization represents an opportunity to identify and address substance use. We sought to describe self-reported and documented substance use among hospitalized adolescents.

METHODS

We conducted a cross-sectional survey of adolescents aged 14 to 18 years old admitted to two pediatric hospitals between August 2019 and March 2020. Using previously validated questions, we assessed the proportion of adolescents reporting ever, monthly, and weekly use of alcohol, marijuana, tobacco, electronic cigarettes, and other illicit drugs and nonmedical use of prescription medications. We reviewed medical records for substance use documentation.

RESULTS

Among 306 respondents, 57% were older (16-18 years old), 53% were female, and 55% were of non-Hispanic white race and ethnicity. The most frequently reported substances ever used were alcohol (39%), marijuana (33%), and electronic cigarettes (31%); 104 (34%) respondents reported ever use of >1 substance. Compared with younger adolescents, those aged 16 to 18 years were more likely to report ever use of alcohol (29% vs 46%; P = .002), marijuana (22% vs 41%; P < .001), and ≥2 drugs (26% vs 40%; P = .009). A positive substance use history was rarely documented (11% of records reviewed), and concordance between documented and self-reported substance use was also rare.

CONCLUSIONS

In this study of hospitalized adolescents, the most commonly reported substances used were alcohol, marijuana, and electronic cigarettes. Positive substance use documentation was rare and often discordant with self-reported substance use. Efforts to improve systematic screening for substance use and interventions for prevention and cessation in hospitalized adolescents are critically needed.

Comparison of Methods for Alcohol and Drug Screening in Primary Care Clinics

IMPORTANCE

Guidelines recommend that adult patients receive screening for alcohol and drug use during primary care visits, but the adoption of screening in routine practice remains low. Clinics frequently struggle to choose a screening approach that is best suited to their resources, workflows, and patient populations.

OBJECTIVE

To evaluate how to best implement electronic health record (EHR)-integrated screening for substance use by comparing commonly used screening methods and examining their association with implementation outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This article presents the outcomes of phases 3 and 4 of a 4-phase quality improvement, implementation feasibility study in which researchers worked with stakeholders at 6 primary care clinics in 2 large urban academic health care systems to define and implement their optimal screening approach. Site A was located in New York City and comprised 2 clinics, and site B was located in Boston, Massachusetts, and comprised 4 clinics. Clinics initiated screening between January 2017 and October 2018, and 93 114 patients were eligible for screening for alcohol and drug use. Data used in the analysis were collected between January 2017 and October 2019, and analysis was performed from July 13, 2018, to March 23, 2021.

INTERVENTIONS

Clinics integrated validated screening questions and a brief counseling script into the EHR, with implementation supported by the use of clinical champions (ie, clinicians who advocate for change, motivate others, and use their expertise to facilitate the adoption of an intervention) and the training of clinic staff. Clinics varied in their screening approaches, including the type of visit targeted for screening (any visit vs annual examinations only), the mode of administration (staff-administered vs self-administered by the patient), and the extent to which they used practice facilitation and EHR usability testing.

MAIN OUTCOMES AND MEASURES

Data from the EHRs were extracted quarterly for 12 months to measure implementation outcomes. The primary outcome was screening rate for alcohol and drug use. Secondary outcomes were the prevalence of unhealthy alcohol and drug use detected via screening, and clinician adoption of a brief counseling script.

RESULTS

Patients of the 6 clinics had a mean (SD) age ranging from 48.9 (17.3) years at clinic B2 to 59.1 (16.7) years at clinic B3, were predominantly female (52.4% at clinic A1 to 64.6% at clinic A2), and were English speaking. Racial diversity varied by location. Of the 93,114 patients with primary care visits, 71.8% received screening for alcohol use, and 70.5% received screening for drug use. Screening at any visit (implemented at site A) in comparison with screening at annual examinations only (implemented at site B) was associated with higher screening rates for alcohol use (90.3%-94.7% vs 24.2%-72.0%, respectively) and drug use (89.6%-93.9% vs 24.6%-69.8%). The 5 clinics that used a self-administered screening approach had a higher detection rate for moderate- to high-risk alcohol use (14.7%-36.6%) compared with the 1 clinic that used a staff-administered screening approach (1.6%). The detection of moderate- to high-risk drug use was low across all clinics (0.5%-1.0%). Clinics with more robust practice facilitation and EHR usability testing had somewhat greater adoption of the counseling script for patients with moderate-high risk alcohol or drug use (1.4%-12.5% vs 0.1%-1.1%).

CONCLUSIONS AND RELEVANCE

In this quality improvement study, EHR-integrated screening was feasible to implement in all clinics and unhealthy alcohol use was detected more frequently when self-administered screening was used at any primary care visit. The detection of drug use was low at all clinics, as was clinician adoption of counseling. These findings can be used to inform the decision-making of health care systems that are seeking to implement screening for substance use.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02963948.

"People Don't Just Start Shooting Heroin on Their 18th Birthday": A Qualitative Study of Community Stakeholders' Perspectives on Adolescent Opioid Use and Opportunities for Intervention in Baltimore, Maryland

Initiation of non-medical prescription opioid use (NMPO) during early adolescence is tightly linked to heroin and other drug use disorders and related sequelae in later adolescence and young adulthood. Few studies explore stakeholders’ perspectives on the burden and determinants of youth opioid use and barriers and facilitators to engaging youth in opioid use prevention and treatment services in urban settings with longstanding opioid epidemics. In-depth interviews were conducted with 22 stakeholders representing health and social service agencies in Baltimore, Maryland from May 2018- February 2019, to examine their perspectives on the burden and context of adolescent opioid use and identify barriers and facilitators to preventing and responding to adolescent opioid use. Transcripts were analyzed using the constant comparison method to identify themes. Most respondents described a recent uptick in opioid use independently, and in combination with other substances. As compared to heroin, NMPO was perceived to be more frequently used and less stigmatized among youth. Stakeholders perceived the process of transitioning from using NMPO to heroin as more common among White vs. Black youth and was perceived as occurring faster among White vs. Black youth. Some stakeholders believed racial differences in internal stigma against heroin use, and differential health service use among Black youth and White youth may have influenced these differences. Trauma and poverty were noted determinants of youth opioid use. Barriers to service provision included youth cognitive development, stigma and structural factors (e.g., disinvestment, lack of youth-centered and integrated services). Stakeholders perceive prevalent NMPO among Baltimore youth and identify multilevel barriers to delivering prevention, treatment and harm reduction services to this population. These findings encourage further investigation of determinants and consequences of opioid use among diverse racial/ethnic groups of youth in urban settings, and development of multilevel, youth-driven and youth-centered approaches to prevention and treatment.

Electronic Health Risk Behavior Screening With Integrated Feedback Among Adolescents in Primary Care: Randomized Controlled Trial

BACKGROUND

Health risk behaviors are the most common sources of morbidity among adolescents. Adolescent health guidelines (Guidelines for Preventive Services by the AMA and Bright Futures by the Maternal Child Health Bureau) recommend screening and counseling, but the implementation is inconsistent.

OBJECTIVE

This study aims to test the efficacy of electronic risk behavior screening with integrated patient-facing feedback on the delivery of adolescent-reported clinician counseling and risk behaviors over time.

METHODS

This was a randomized controlled trial comparing an electronic tool to usual care in five pediatric clinics in the Pacific Northwest. A total of 300 participants aged 13-18 years who attended a well-care visit between September 30, 2016, and January 12, 2018, were included. Adolescents were randomized after consent by employing a 1:1 balanced age, sex, and clinic stratified schema with 150 adolescents in the intervention group and 150 in the control group. Intervention adolescents received electronic screening with integrated feedback, and the clinicians received a summary report of the results. Control adolescents received usual care. Outcomes, assessed via online survey methods, included adolescent-reported receipt of counseling during the visit (measured a day after the visit) and health risk behavior change (measured at 3 and 6 months after the visit).

RESULTS

Of the original 300 participants, 94% (n=282), 94.3% (n=283), and 94.6% (n=284) completed follow-up surveys at 1 day, 3 months, and 6 months, respectively, with similar levels of attrition across study arms. The mean risk behavior score at baseline was 2.86 (SD 2.33) for intervention adolescents and 3.10 (SD 2.52) for control adolescents (score potential range 0-21). After adjusting for age, gender, and random effect of the clinic, intervention adolescents were 36% more likely to report having received counseling for endorsed risk behaviors than control adolescents (adjusted rate ratio 1.36, 95% CI 1.04 to 1.78) 1 day after the well-care visit. Both the intervention and control groups reported decreased risk behaviors at the 3- and 6-month follow-up assessments, with no significant group differences in risk behavior scores at either time point (3-month group difference: β=-.15, 95% CI -0.57 to -0.01, P=.05; 6-month group difference: β=-.12, 95% CI -0.29 to 0.52, P=.57).

CONCLUSIONS

Although electronic health screening with integrated feedback improves the delivery of counseling by clinicians, the impact on risk behaviors is modest and, in this study, not significantly different from usual care. More research is needed to identify effective strategies to reduce risk in the context of well-care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02882919; https://clinicaltrials.gov/ct2/show/NCT02882919.

Organizational Acceptability of Implementing SBIRT for Adolescents in Primary Care

Adolescent illicit drug, tobacco, and alcohol use can result in sudden and long-term negative health consequences. Primary care environments present the optimal opportunity for screening and brief interventions that target prevention and curtailing use. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a service delivery method that could potentially be well-integrated into primary care settings and used to serve a high volume of adolescents. Methods: This qualitative analysis of clinic staff interviews (N = 20), collected during a large cluster-randomized trial to implement two models of adolescent SBIRT, examined barriers and facilitating factors to overall acceptability of SBIRT. This study was conducted in a large, urban Federally Qualified Health Center (FQHC) at 7 sites throughout Baltimore City, Maryland, USA. Participants from each clinic included a range of various roles and responsibilities including: medical assistants (n = 3), nurses (n = 3), primary care providers (n = 4), behavioral health counselors (n = 4), and administrators (n = 6). Results: Results indicate both barriers and facilitating factors for acceptability of SBIRT in terms of (1) universal screening, (2) provider time demands, (3) behavioral health collaboration, and (4) behavioral health caseloads. Discussion: Universal screening was acceptable to participants across organizational roles, but brief interventions and referrals to treatment were found substantially less acceptable.

Early implementation of screening for substance use in rural primary care: A rapid analytic qualitative study

Background: Few primary care patients are screened for substance use. As part of a phased feasibility study examining the implementation of electronic health record-integrated screening with the Tobacco, Alcohol, and Prescription Medication Screening (TAPS) Tool and clinical decision support (CDS) in rural primary care clinics, focus groups were conducted to identify early indicators of success and challenges to screening implementation. Method: Focus groups (n = 6) were conducted with medical assistants (MAs: n = 3: 19 participants) and primary care providers (PCPs: n = 3: 13 participants) approximately one month following screening implementation in three Federally Qualified Health Centers in Maine. Rapid analysis and matrix analysis using Proctor's Taxonomy of Implementation Outcomes were used to explore implementation outcomes. Results: There was consensus that screening is being used, but use of the CDS was lower, in part due to limited positive screens. Fidelity was high among MAs, though discomfort with the CDS surfaced among PCPs, impacting adoption and fidelity. The TAPS Tool's content, credibility and ease of workflow integration were favorably assessed. Challenges include screening solely at annual visits and self-administered screening for certain patients. Conclusions: Results reveal indicators of implementation success and strategies to address challenges to screening for substance use in primary care.

Insights Provided by Depression Screening Regarding Pain, Anxiety, and Substance use in a Veteran Population

Objective:

We sought to quantify the extent to which a depression screening instrument commonly used in primary care settings provides additional information regarding pain interference symptoms, anxiety, and substance use.

Methods:

Veterans Aging Cohort Study (VACS) data collected from 2003 through 2015 was used to calculate odds ratios (OR) for associations between positive depression screening result cutoffs and clustering conditions. We assessed the test performance characteristics (likelihood ratio value, positive predictive value, and the percentage of individuals correctly classified) of a positive Patient Health Questionnaire (PHQ-9 & PHQ-2) depression screen for the identification of pain interference symptoms, anxiety, and substance use.

Results:

A total 7731 participants were included in the analyses. The median age was 50 years. The PHQ-9 threshold of ≥20 was strongly associated with pain interference symptoms (OR 21.6, 95% CI 17.5-26.7) and anxiety (OR 72.1, 95% CI 52.8-99.0) and yielded likelihood ratio values of 7.5 for pain interference symptoms and 21.8 for anxiety and positive predictive values (PPV) of 84% and 95%, respectively. A PHQ-9 score of ≥10 still showed significant associations with pain interference symptoms (OR 6.1, 95% CI 5.4-6.9) and symptoms of anxiety (OR 11.3, 95% CI 9.7-13.1) and yet yielded lower likelihood ratio values (4.36 & 8.24, respectively). The PHQ-9 was less strongly associated with various forms of substance use.

Conclusion:

Depression screening provides substantial additional information regarding the likelihood of pain interference symptoms and anxiety and should trigger diagnostic assessments for these other conditions.

A chart review of substance use screening and related documentation among adolescents in outpatient pediatric clinics: implications for practice

Background

Despite recent reductions, youth substance use continues to be a concern in the United States. Structured primary care substance use screening among adolescents is recommended, but not widely implemented. The purpose of this study was to describe the distribution and characteristics of adolescent substance use screening in outpatient clinics in a large academic medical center and assess related factors (i.e., patient age, race/ethnicity, gender, and insurance type) to inform and improve the quality of substance use screening in practice.

Methods

We abstracted a random sample of 127 records of patients aged 12–17 and coded clinical notes (e.g., converted open-ended notes to discrete values) to describe screening cases and related characteristics (e.g., which substances screened, how screened). We then analyzed descriptive patterns within the data to calculate screening rates, characteristics of screening, and used multiple logistic regression to identify related factors.

Results

Among 127 records, rates of screening by providers were 72% (each) for common substances (alcohol, marijuana, tobacco). The primary method of screening was use of clinical mnemonic cues rather than standardized screening tools. A total of 6% of patients reported substance use during screening. Older age and racial/ethnic minority status were associated with provider screening in multiple logistic regression models.

Conclusions

Despite recommendations, low rates of structured screening in primary care persist. Failure to use a standardized screening tool may contribute to low screening rates and biased screening. These findings may be used to inform implementation of standardized and structured screening in the clinical environment.

Clinical trial registration

not applicable.

Substance Use Screening, Brief Intervention, and Referral to Treatment in Pediatric Practice: A Quality Improvement Project in the Maryland Adolescent and Young Adult Health Collaborative Improvement and Innovation Network

The American Academy of Pediatrics recommends pediatric providers routinely screen for, assess, and treat substance use and substance use disorders among adolescents, a process called "Screening, Brief Intervention, and Referral to Treatment," or "SBIRT." Because there are limited data on how Maryland pediatric practices have adopted SBIRT, a quality improvement initiative was developed within the Maryland Adolescent and Young Adult Health Collaborative Improvement and Innovation Network using a "Plan/Do/Study/Act" approach. A 2-part provider training was conducted regarding screening and motivational interviewing, and the "CRAFFT" screening tool was integrated into the practice's electronic medical record. Results from evaluation demonstrated significant improvements in provider knowledge, attitudes, and screening behavior. The association between substance use and sexual behavior suggests a need for further expansion of this model with inclusion of sexual health screening. Overall, this study demonstrates that SBIRT implementation into a general pediatric practice is highly feasible, acceptable, and shows preliminary effectiveness.

Adolescent Vulnerability to Alcohol Use Disorder: Neurophysiological Mechanisms from Preclinical Studies

Adolescent alcohol use in human populations dramatically increases the likelihood of adult alcohol use disorder. This adolescent vulnerability is recapitulated in preclinical models which provide important opportunities to understand basic neurobiological mechanisms. We provide here an overview of GABAergic and glutamatergic neurotransmission and our current understanding of the sensitivity of these systems to adolescent ethanol exposure. As a whole, the preclinical literature suggests that adolescent vulnerability may be directly related to region-specific neurobiological processes that continue to develop during adolescence. These processes include the activity of intrinsic circuits within diverse brain regions (primarily represented by GABAergic neurotransmission) and activity-dependent regulation of synaptic strength at glutamatergic synapses. Furthermore, GABAergic and glutamatergic neurotransmission within regions/circuits that regulate cognitive function, emotion, and their integration appears to be the most vulnerable to adolescent ethanol exposure. Finally, using documented behavioral differences between adolescents and adults with respect to acute ethanol, we highlight additional circuits and regions for future study.

Reliability and Validity of the Newton Screen for Alcohol and Cannabis Misuse in a Pediatric Emergency Department Sample

OBJECTIVES

To determine the test-retest reliability, concurrent, convergent, and discriminant validity of a recently devised screen (the Newton screen) for alcohol and cannabis use/misuse, and its predictive validity at follow-up.

STUDY DESIGN

Adolescents, 12-17 years old (n = 4898), treated in 1 of 16 participating pediatric emergency departments across the US were enrolled in a study as part of a larger study within the Pediatric Emergency Care Applied Research Network. Concurrent and predictive validity (at 1, 2, and 3 years of follow-up) were assessed in a random subsample with a structured Diagnostic and Statistical Manual of Mental Disorders-based interview. Convergent validity was assessed with the Alcohol Use Disorders Identification, a widely used alcohol screening measure.

RESULTS

The sensitivity of the Newton screen for alcohol use disorder at baseline was 78.3% with a specificity of 93.0%. The cannabis use question had a baseline sensitivity of 93.1% and specificity of 93.5% for cannabis use disorder. Predictive validity analyses at 1, 2, and 3 years revealed high specificity but low sensitivity for alcohol and high specificity and moderate sensitivity for cannabis.

CONCLUSIONS

The Newton screening instrument may be an appropriate brief screening tool for use in the busy clinical environment. Specificity was high for both alcohol and cannabis, but sensitivity was higher for cannabis than alcohol. Like other brief screens, more detailed follow-up questions may be necessary to definitively assess substance misuse risk and the need for referral to treatment.

Identifying Problematic Substance Use in a National Sample of Adolescents Using Frequency Questions

BACKGROUND

Brief substance use screening questions for tobacco, alcohol, cannabis, and other drugs need further validation in adolescents. In particular, optimal age-specific screening cut-points are not known, and no study has been large enough to evaluate screening questions for noncannabis illicit drug use.

METHODS

Adolescent respondents to an annual national household survey were included (2008 to 2014; n = 169,986). Days of tobacco use in the past month, and days of alcohol, cannabis, other illicit drug use in the past year, were assessed as brief screens for tobacco dependence and DSM-IV alcohol (AUD), cannabis (CUD), and other illicit drug use disorders (DUD). Areas under receiver operating characteristics curves (AUCs), sensitivity and specificity were estimated separately by age group (12-15-, 16-17-, and 18-20-year-olds) and cut-points that maximized combined values of sensitivity and specificity were considered optimal.

RESULTS

The prevalence of tobacco dependence, AUD, CUD, and DUD was 5.8%, 7.1%, 4.5%, and 2.0%, respectively. AUCs ranged 0.84 to 0.99. The optimal cut-points for screening for tobacco dependence and DUDs was the same for all age groups: ≥1 day. The optimal cut-points for alcohol and cannabis varied by age: ≥3 days for 12-15-year-olds and ≥12 days for older adolescents.

CONCLUSIONS

Brief measures of past-year use, or past-month use for tobacco, accurately identified adolescents with problematic substance use. However, health systems should use age-specific screening cut-points for alcohol and cannabis to optimize screening performance.

Adaptation of the Drug and Drug Problems Perception Questionnaire to assess healthcare provider attitudes toward adolescent substance use

Although preventive screening, brief intervention and referral to treatment for adolescent substance use is recommended by the American Academy of Pediatrics, primary care providers inconsistently address substance use with their pediatric patients (AAP Committee on Practice and Ambulatory Medicine and AAP Bright Futures Periodicity Schedule Workgroup, 2017). Further research on provider perceptions about addressing adolescent substance use may help identify and address some barriers to screening. However, there are few validated measures of provider perceptions toward patient substance, and none are specific to pediatric patients. This study (conducted in Maryland, 2015-2017) examines the internal consistency and factor structure of an adapted measure to assess perceptions of adolescent substance use. Internal consistency was assessed using responses from a sample of 276 healthcare practitioners (87.7% women, 12.3% men). Their professions included the following: Certified Medical Assistants (10.9%), Registered Nurses (17.8%), Nurse Practitioners (8.3%), Physician Assistants (3.6%), Medical Doctors (13.8%), Clinical Therapists (10.9%) and Other (21.0%). A four-factor solution was identified and initial evidence suggests the adapted measure is appropriate for use with health care providers. A subsample of 181 participants who reported direct interaction with adolescent patients in a provider role was also used to assess convergent validity with self-reported screening practices and effectiveness. Provider-reported frequency of alcohol and drug use assessment for pediatric patients was significantly related to positive perceptions about adolescent substance use on all subscales. The adapted measure could prove useful for assessing provider readiness to receive adolescent substance use screening training and could be further adapted to include items unique to adolescent care, including parental involvement.

Effect of Electronic Screening With Personalized Feedback on Adolescent Health Risk Behaviors in a Primary Care Setting: A Randomized Clinical Trial

IMPORTANCE

Health risk behaviors are a leading cause of morbidity during adolescence. Screening and counseling for health risk behaviors are recommended but infrequently performed.

OBJECTIVE

To test the effect of an electronic screening and feedback tool on clinician counseling and adolescent-reported health risk behaviors.

DESIGN, SETTING, AND PARTICIPANTS

A randomized clinical trial compared electronic screening and feedback on an intention-to-treat basis with usual care among 300 youths 13 to 18 years of age at 5 pediatric clinics in the Pacific Northwest. Outcomes were assessed via electronic survey at 1 day and 3 months after the initial visit. Study data collection occurred from March 13, 2015, to November 29, 2016, and statistical analysis was conducted between February 6, 2017, and June 20, 2018.

INTERVENTIONS

Youths in the intervention group (n = 147) received electronic screening and personalized feedback with clinician clinical decision support. Youths in the control group (n = 153) received standard screening and counseling as provided by their clinic.

MAIN OUTCOMES AND MEASURES

Youths' report of receipt of counseling during the visit and risk behaviors at 3 months.

RESULTS

In the final study sample of 300 youths (intervention group, 75 girls and 72 boys; mean [SD] age, 14.5 [1.4 years]; and control group, 80 girls and 73 boys; mean [SD] age, 14.5 [1.4] years), 234 (78.0%) were aged 13 to 15 years. After adjusting for age, sex, and random effect of clinic, youths in the intervention group were more likely to receive counseling for each of their reported risk behaviors than were youths in the control group (adjusted rate ratio, 1.32; 95% CI, 1.07-1.63). Youths in the intervention group had a significantly greater reduction (β = -0.48; 95% CI, -0.89 to -0.02; P = .02) in their risk behavior scores at 3 months when compared with youths in the control group.

CONCLUSIONS AND RELEVANCE

Electronic screening of health risk behavior with clinical decision support and motivational feedback to teens can improve care delivery and outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02360410.

Adolescent Experiences of Clinician-Patient HIV/STI Communication in Primary Care

Effective clinician-patient communication is linked to positive patient health outcomes in adults, yet the research on adolescent populations remains limited. We describe adolescent experiences of clinician-patient HIV/STI communication through qualitative interviews with predominantly African-American adolescent women from a youth-centered primary care clinic. Participants described acknowledging clinicians are professionals, the importance of confidentiality to foster clinician-adolescent communication, and calling for clinician-initiated HIV/STI communication. Adolescents expressed the necessity for clinicians to engage youth in these challenging conversations through an open and understanding approach. Additionally, adolescents described experiences of perceived judgment and uncomfortableness from clinicians, and non-disclosure of HIV/STI risk behaviors to their clinician. Findings underscore the adolescents' desire to engage in HIV/STI communication with healthcare providers, while highlighting important strategies for clinicians. Results can inform health communication research and practice, and the development of interventions aimed at increasing clinician-adolescent HIV/STI communication.

Implementing SBIRT for adolescents within community mental health organizations: A mixed methods study

OBJECTIVE

Many adolescents with substance use problems remain untreated, leading to increased risk for the development of substance use disorders. One response is Screening, Brief Intervention, and Referral to Treatment (SBIRT)-an evidence-based, early intervention that can be tailored for adolescents. This mixed methods study examined the implementation of SBIRT across 27 community mental health organizations (CMHOs) serving adolescents.

METHODS

Organizations completed surveys on the adoption of SBIRT and implementation barriers during the study period. Quantitative data were analyzed to examine the frequency of screening, brief intervention, and referrals. Qualitative data were coded using an iterative process that focused on barriers categorized according to the Conceptual Framework for Implementation Research (CFIR) constructs.

RESULTS

A total of 2873 adolescents were screened for alcohol and drug use with 1517 (52.8%) receiving a positive drug or alcohol screen. Positive screens that received brief intervention (BI)/referral to treatment (RT) had a significantly greater mean drug score and overall scores at baseline. The most salient implementation barriers were adaptability and complexity of SBIRT, policies related to funding and licensing, staff turnover, and implementation climate.

DISCUSSION

Nearly half of the adolescents scored positive for problematic substance use demonstrating the unmet need among this population. Future implementation efforts should focus on coordinating program demands, securing funding, integrating SBIRT into clinical workflows, retaining staff, and improving referral to treatment processes.

Using marijuana, drinking alcohol or a combination of both: the association of marijuana, alcohol and sexual risk behaviour among adolescents

Background Although the association between alcohol use and sexual risk behaviour has been well-documented, there is little understanding of whether marijuana use alone or combining marijuana with alcohol use contributes to sexual risk behaviour among adolescents.

METHODS

A diverse sample of sexually active adolescents (n = 616) aged 12-18 years (50.32% Hispanic; 31.17% Black) completed a survey on alcohol use, marijuana use and sexual risk behaviour during a visit to a primary care clinic.

RESULTS

Adolescents were more likely to report having had two or more sexual partners in the past 3 months if they reported using both alcohol and marijuana (OR=3.90, P<0.0001), alcohol alone (OR=2.51, P<0.0001) or marijuana alone (OR=1.89, P<0.001) compared with adolescents who reported no use during the past month. Adolescents were more likely to report having both two or more partners and condomless sex if they used both alcohol and marijuana (OR=3.19, P<0.001) or alcohol alone (OR=3.41, P<0.01) in the past month compared with adolescents who reported using marijuana alone or had no use of either.

CONCLUSIONS

Providers should screen for both alcohol and marijuana use among adolescents and discuss how use of alcohol or alcohol in conjunction with marijuana may be associated with sexual risk behaviours.

Barriers and facilitators affecting the implementation of substance use screening in primary care clinics: a qualitative study of patients, providers, and staff

Background

Alcohol and drug use are leading causes of morbidity and mortality that frequently go unidentified in medical settings. As part of a multi-phase study to implement electronic health record-integrated substance use screening in primary care clinics, we interviewed key clinical stakeholders to identify current substance use screening practices, barriers to screening, and recommendations for its implementation.

Methods

Focus groups and individual interviews were conducted with 67 stakeholders, including patients, primary care providers (faculty and resident physicians), nurses, and medical assistants, in two urban academic health systems. Themes were identified using an inductive approach, revised through an iterative process, and mapped to the Knowledge to Action (KTA) framework, which guides the implementation of new clinical practices (Graham et al. in J Contin Educ Health Prof 26(1):13–24, 2006).

Results

Factors affecting implementation based on KTA elements were identified from participant narratives. Identifying the problem: Participants consistently agreed that having knowledge of a patient’s substance use is important because of its impacts on health and medical care, that substance use is not properly identified in medical settings currently, and that universal screening is the best approach. Assessing barriers: Patients expressed concerns about consequences of disclosing substance use, confidentiality, and the individual’s own reluctance to acknowledge a substance use problem. Barriers identified by providers included individual-level factors such as lack of clinical knowledge and training, as well as systems-level factors including time pressure, resources, lack of space, and difficulty accessing addiction treatment. Adapting to the local context: Most patients and providers stated that the primary care provider should play a key role in substance use screening and interventions. Opinions diverged regarding the optimal approach to delivering screening, although most preferred a patient self-administered approach. Many providers reported that taking effective action once unhealthy substance use is identified is crucial.

Conclusions

Participants expressed support for substance use screening as a valuable part of medical care, and identified individual-level as well as systems-level barriers to its implementation. These findings suggest that screening programs should clearly communicate the goals of screening to patients and proactively counteract stigma, address staff concerns regarding time and workflow, and provide education as well as treatment resources to primary care providers.

Electronic supplementary material

The online version of this article (10.1186/s13722-018-0110-8) contains supplementary material, which is available to authorized users.

Pediatrician and Behavioral Clinician-Delivered Screening, Brief Intervention and Referral to Treatment: Substance Use and Depression Outcomes

PURPOSE

Early intervention for adolescent substance use and mental health problems may mitigate potential harm. We examined patient outcomes from a pragmatic trial of two modalities of delivering screening, brief intervention, and referral to treatment (SBIRT) and usual care (UC) in pediatric primary care.

METHODS

All clinic pediatricians (n = 52) were randomized to three arms: (1) pediatrician-only, in which pediatricians were trained to deliver SBIRT; (2) embedded behavioral clinician (BC), in which pediatricians were trained to refer eligible adolescents to a BC who administered SBIRT; and (3) UC. Using electronic health record data, changes in past year substance use and depression symptoms between the index visit and next screening visit were examined across treatment arms.

RESULTS

Among patients who endorsed substance use and/or depression symptoms or were eligible for further assessments, brief interventions, and referrals based on clinician assessment at the index visit, 648 patients (mean age = 15.2 [standard deviation = 1.2]) were rescreened at a follow-up visit between 6 months and 2 years later. Among all patients, self-reported substance use rates did not differ over time or across arms, and depression symptoms increased over time. The embedded BC arm had lower odds of having depression symptoms at follow-up than the physician-only arm, and lower odds than the UC arm although not significant; we found no differences between the pediatrician-only and UC arms.

CONCLUSIONS

The increase in depression symptoms over time highlights this population's vulnerability and the importance of developing appropriate interventions. An embedded BC in pediatric primary care trained in SBIRT may benefit patients with depression symptoms.

Screening adolescents for substance use: The role of NPs in school settings

NPs have a key role in screening for adolescent substance use in school settings. This article provides evidence-based information on the prevalence and consequences of adolescent substance use, discusses standardized substance use screening and brief interventions using the CRAFFT tool, and suggests relevant practice and policy implications.

The Adolescent Champion Model: Primary Care Becomes Adolescent-Centered via Targeted Quality Improvement

OBJECTIVE

To evaluate the effects of implementing the Adolescent Champion model, a novel quality improvement program targeted at helping primary care sites become more adolescent-centered.

STUDY DESIGN

Nine primary care sites from pediatrics, family medicine, and medicine-pediatrics implemented the Adolescent Champion model. Each site identified a multidisciplinary champion team to undergo training on adolescent-centered care, deliver prepackaged trainings to other staff and providers, make youth-friendly site changes, implement a standardized flow to confidentially screen for risky behaviors, and complete a quality improvement project regarding confidentiality practices. Adolescent patients, staff, and providers were surveyed at baseline, year-end, and 1-year follow-up to assess changes.

RESULTS

Adolescent patients' experiences with both their provider and the site overall significantly improved (P values from <.0001 to .004, N = 474 baseline, 386 year-end). Staff perceived an improvement in clinic practices relating to adolescents and in their ability to make institutional and personal change (P < .0001, N = 121 baseline, 109 year-end). The majority of changes were sustained 1-year postintervention. Frequently noted site improvements included: (1) initiating a method to gather feedback from adolescent patients; (2) adding trainings on confidentiality, cultural humility, and using a nonjudgmental approach; (3) updating immunizations at every visit; and (4) training providers in long acting reversible contraception via implant training.

CONCLUSIONS

Implementing the Adolescent Champion model successfully helped primary care sites become more adolescent-centered. Further studies are needed to evaluate the effects of this model on patient outcomes.

Influence of mental health and alcohol or other drug use risk on adolescent reported care received in primary care settings

Background

To describe patterns of alcohol and other drug (AOD) use risk and adolescent reported primary care (PC) screening and intervention, and examine associations of AOD risk and mental health with reported care received.

Methods

We analyzed data from cross-sectional surveys collected from April 3, 2013 to November 24, 2015 from 1279 diverse adolescents ages 12–18 who reported visiting a doctor at least once in the past year. Key measures were AOD risk using the Personal Experience Screening Questionnaire; mental health using the 5-item Mental Health Inventory; binary measures of adolescent-reported screening and intervention.

Results

Half (49.2%) of the adolescents reported past year AOD use. Of the 769 (60.1%) of adolescents that reported being asked by a medical provider in PC about AOD use, only 37.2% reported receiving screening/intervention. The odds of reported screening/intervention were significantly higher for adolescents with higher AOD risk and lower mental health scores.

Conclusions

Adolescents at risk for AOD use and poor mental health are most likely to benefit from brief intervention. These findings suggest that strategies are needed to facilitate medical providers identification of need for counseling of both AOD and mental health care for at risk youth.

Trials registration

clinicaltrials.gov, Identifier: NCT01797835, March 2013.

Use of web-based screening and brief intervention for unhealthy alcohol use by older adults

BACKGROUND

While the number of older adults who engage in unhealthy drinking is increasing, few studies have examined the role of online alcohol screening and intervention tools for this population. The objective of this study was to describe characteristics of drinking behaviors among older adults who visited an alcohol screening and intervention website, and compare them to younger adults.

METHODS

We analyzed the responses of visitors to Alcoholscreening.org in 2013 (n=94,221). The prevalence of unhealthy alcohol use, behavioral change characteristics, and barriers to changing drinking were reported by age group (ages 21-49, 50-65, 66-80). Logistic regression models were used to identify characteristics associated with receiving a plan to either help cut back or quit drinking.

RESULTS

Of the entire study sample, 83% of respondents reported unhealthy drinking (exceeding daily or weekly recommended limits) with 84% among 21-49year olds, 79% among 50-65year olds, and 85% among adults over 65. Older adults reported fewer negative aspects of drinking, lower importance to change, highest confidence and fewer barriers to change, compared to younger adults. In the adjusted model, females (AOR=1.45, p<0.001) and older adults (AOR=1.55, p<0.002) were more likely to receive a plan to change drinking behaviors.

DISCUSSION

An online screening and intervention tool identified many older adults with unhealthy alcohol use behaviors and most were receptive to change. Web-based screening and interventions for alcohol use have the potential to be widely used among older adults.

Specialty addiction and psychiatry treatment initiation and engagement: Results from an SBIRT randomized trial in pediatrics

OBJECTIVE

Many adolescents needing specialty addiction or psychiatry treatment never access care. We examined initiation and engagement with addiction and/or psychiatry treatment among adolescents referred to treatment from a trial comparing two different modalities of delivering Screening, Brief Intervention and Referral to Treatment (SBIRT) to Usual Care in pediatric primary care. We hypothesized that both intervention arms would have higher initiation and engagement rates than usual care.

METHODS

We randomized all pediatricians (n=52) in a pediatric primary care clinic to three arms: 1) pediatrician-only arm, in which pediatricians were trained to deliver SBIRT for substance use and/or mental health problems; 2) embedded-behavioral health clinician (embedded-BHC arm), in which pediatricians referred adolescents who endorsed substance use and/or mental health problems to a BHC; and 3) Usual Care (UC). We used electronic health record (EHR) data to examine specialty addiction and psychiatry treatment initiation and engagement rates after referral.

RESULTS

Among patients who screened positive for substance use and/or mental health problems and were referred to specialty addiction and/or psychiatry (n=333), those in the embedded-BHC arm had almost four times higher odds of initiating treatment than those in the pediatrician-only arm, OR=3.99, 95% CI=[1.99-8.00]. Compared to UC, those in the pediatrician-only arm had lower odds of treatment initiation (OR=0.53, 95% CI=[0.28-0.99]), while patients in the embedded-BHC arm had marginally higher odds (OR=1.83, 95% CI=[0.99-3.38]). Black patients and those with other/unknown race/ethnicity had lower odds of treatment initiation compared with white adolescents; there were no gender or age differences. We found no differences in treatment engagement across the three arms.

CONCLUSIONS

Embedded BHCs can have a significant positive impact on facilitating treatment initiation for pediatric primary care adolescents referred to addiction and/or psychiatry services.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov #NCT02408952.

The concurrent validity of the Problem Oriented Screening Instrument for Teenagers (POSIT) substance use/abuse subscale in adolescent patients in an urban federally qualified health center

BACKGROUND

The Problem Oriented Screening Instrument for Teenagers (POSIT) substance use/abuse subscale has been validated with high school students, adolescents with criminal justice involvement, and adolescent substance use treatment samples using the Diagnostic and Statistical Manual of Mental Disorders (DSM)-III-R and DSM-IV. This study examines the concurrent validity of the POSIT's standard 17-item substance use/abuse subscale and a revised, shorter 11-item version using DSM-5 substance use disorder diagnoses.

METHODS

Adolescents (N = 525; 93% African American, 55% female) 12-17 years of age awaiting primary care appointments at a Federally Qualified Health Center in Baltimore, Maryland completed the 17-item POSIT substance use/abuse subscale and items from a modified World Mental Health Composite International Diagnostic Interview corresponding to DSM-5 alcohol use disorder (AUD) and cannabis use disorder (CUD). Receiver operating characteristic curves, sensitivities, and specificities were examined with DSM-5 AUD, CUD, and a diagnosis of either or both disorders for the standard and revised subscales using risk cutoffs of either 1 or 2 POSIT "yes" responses.

RESULTS

For the 17-item subscale, sensitivities were generally high using either cutoff (range: 0.79-1.00), although a cutoff of 1 was superior (sensitivities were 1.00 for AUD, CUD, and for either disorder). Specificities were also high using either cutoff (range: 0.81-0.95) but were higher using a cutoff of 2. For the 11-item subscale, a cutoff of 1 yielded higher sensitivities than a cutoff of 2 (ranges for 1 and 2: 0.96-1.00 and 0.79-0.86, respectively). Specificities for this subscale were higher using a cutoff of 2 (ranges for 1 and 2: 0.82-0.89 and 0.89-0.96, respectively).

CONCLUSIONS

Findings suggest that the POSIT's substance use/abuse subscale is a potentially useful tool for screening adolescents in primary care for AUD or CUD using a cutoff of 1 or 2. The briefer, revised subscale may be preferable to the standard subscale in busy pediatric practices.

Comparison of the Substance Use Brief Screen (SUBS) to the AUDIT-C and ASSIST for detecting unhealthy alcohol and drug use in a population of hospitalized smokers

Hospitalized patients have high rates of unhealthy substance use, which has important impacts on health both during and after hospitalization, but is infrequently identified in the absence of screening. The Substance Use Brief Screen (SUBS) was developed as a brief, self-administered instrument to identify use of tobacco, alcohol, illicit drugs, and non-medical use of prescription drugs, and was previously validated in primary care patients. This study assessed the diagnostic accuracy of the SUBS in comparison to longer screening instruments to identify unhealthy and high-risk alcohol and drug use in hospitalized current smokers. Participants were 439 patients, aged 18 and older, who were admitted to either two urban safety-net hospitals in New York City and enrolled in a smoking cessation trial. We measured the performance of the SUBS for identifying illicit drug and non-medical use of prescription drugs in comparison to a modified Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) and its performance for identifying excessive alcohol use in comparison to the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C). At the standard cutoff (response other than 'never' indicates a positive screen), the SUBS had a sensitivity of 98% (95% CI 95-100%) and specificity of 61% (95% CI 55-67%) for unhealthy alcohol use, a sensitivity of 85% (95% CI 80-90%) and specificity of 75% (95% CI 78-87%) for illicit drug use, and a sensitivity of 73% (95% CI 61-83%) and specificity of 83% (95% CI 78-87%) for prescription drug non-medical use. For identifying high-risk use, a higher cutoff (response of '3 or more days' of use indicates a positive screen), the SUBS retained high sensitivity (77-90%), and specificity was 62-88%. The SUBS can be considered as an alternative to longer screening instruments, which may fit more easily into busy inpatient settings. Further study is needed to evaluate its validity using gold standard measures in hospitalized populations.

Alcohol screening among young people: a prospective study from the Swiss Sentinel Surveillance System (Sentinella) of physicians' a priori opinions

BACKGROUND

Systematic screening for excessive alcohol use among young people is recommended but rarely implemented. Family practitioners tend to select patients for screening, based on their preliminary subjective opinions, which may be biased.

OBJECTIVE

To evaluate the ability of family practitioners to identify excessive alcohol use among young people prior to screening them.

METHODS

This prospective study was conducted through Sentinella, an epidemiological network involving 150 family practitioners across Switzerland. All patients aged 10-24 years old, consulting participating physicians between January 1 and December 31, 2014 were eligible. First, physicians were asked to give their a priori opinion about patients' potential alcohol use. Subsequently, they asked two screening questions: (i) 'Do you drink alcohol?' and (ii) 'How many times have you had 5 (4 for girls) or more standard drinks in one day over the past year?'. Excessive alcohol use was defined as ≥1 episode of binge drinking a month. Physicians' a priori opinions were regarded as a screening test and were compared with patients' answers.

RESULTS

7723 patients were eligible for analysis. Their mean age (SD) was 17.3(4.0) years. The two screening questions identified 3559 (46.1%) and 509 (6.6%) patients who consumed alcohol occasionally and regularly, respectively. 406 patients (5.3%) reported excessive alcohol use. Physicians' a priori opinions had a sensitivity of 26.4% and a positive predictive value of 35.5% for the identification of excessive alcohol use.

CONCLUSION

The systematic use of a screening tool should be preferred over family practitioners' subjective opinions to identify excessive alcohol use in young people.

Is HEADS in our heads? Health risk behavior is not routinely discussed with young people with chronic conditions

BACKGROUND

Outpatient clinic visits are a window of opportunity to address health risk behaviors and promote a healthier lifestyle among young people. The HEADS (Home, Education, Eating, Activities, Drugs [i.e. substance use including tobacco, alcohol, and illegal drugs], Sexuality [including contraception], Safety, Self-harm) interview is a feasible way of exploring health risk behaviors and resilience.

OBJECTIVE

The purpose of this study was to evaluate how often HEADS topics were addressed according to young patients and staff in pediatric and adult outpatient clinics.

METHODS

We conducted a questionnaire survey among young patients and health care professionals at a tertiary university hospital. Young patients reported on their cumulative experience and staff reported on their usual practice.

RESULTS

A total of 290 young patients aged 12-22 years (78% having a chronic condition) and 97 health care professionals participated. We found only small reported differences between staff and young patients regarding whether home, education, and activity were addressed. However, staff reported twice the rate of addressing smoking, alcohol, illegal drugs, sexuality, and contraception compared to young patients. Young patients reported that smoking, alcohol, illegal drugs, sexuality, and contraception were addressed significantly more at adult clinics in comparison to pediatric clinics. After controlling for age, gender and duration of illness, according to young patients, adjusted odds ratios for addressing smoking at adult vs. pediatric clinics was 2.47 (95% confidence interval [CI]: 1.26-4.83), alcohol 2.84 (95% CI:1.45-5.57), illegal drugs 4.20 (95% CI:1.69-10.44), sexuality 3.54 (95% CI: 1.67-7.50), contraception 3.68 (95% CI:1.61-8.41), and any of the above 2.95 (95% CI: 1.47-5.91).

CONCLUSION

According to young patients, smoking, alcohol, illegal drugs, sexuality, and contraception were not routinely addressed at a tertiary hospital, and especially at paediatric clinics, these issues were seldom addressed.

Use of the 5 As for Teen Alcohol Use

Clinical guidelines recommend addressing adolescent alcohol use in primary care; the 5 As (Ask, Advise, Assess, Assist, Arrange) may be a useful model for intervention. We audio-recorded 540 visits with 49 physicians and adolescents, compared alcohol disclosure rates in the encounter with those in a survey, and analyzed conversations for use of the 5 As and their relation to adolescent reports of drinking 3 months after the encounter. When physicians asked clear, nonleading questions, drinkers were more likely to disclose alcohol use ( P = .004). In 64% of visits in which alcohol was discussed, physicians used one or more of the 5 As, most frequently "Ask." No physician used all 5 As. Among drinkers, there was no association between physicians' partial use of the 5 As and adolescent alcohol consumption at 3 months. Physicians can learn more effective ways to "Ask" about alcohol use to increase disclosure of drinking and to be more comprehensive in their counseling.

The Juvenile Justice Behavioral Health Services Cascade: A new framework for measuring unmet substance use treatment services needs among adolescent offenders

OVERVIEW

Substance use and substance use disorders are highly prevalent among youth under juvenile justice (JJ) supervision, and related to delinquency, psychopathology, social problems, risky sex and sexually transmitted infections, and health problems. However, numerous gaps exist in the identification of behavioral health (BH) problems and in the subsequent referral, initiation and retention in treatment for youth in community justice settings. This reflects both organizational and systems factors, including coordination between justice and BH agencies.

METHODS AND RESULTS

This paper presents a new framework, the Juvenile Justice Behavioral Health Services Cascade ("Cascade"), for measuring unmet substance use treatment needs to illustrate how the cascade approach can be useful in understanding service delivery issues and identifying strategies to improve treatment engagement and outcomes for youth under community JJ supervision. We discuss the organizational and systems barriers for linking delinquent youth to BH services, and explain how the Cascade can help understand and address these barriers. We provide a detailed description of the sequential steps and measures of the Cascade, and then offer an example of its application from the Juvenile Justice - Translational Research on Interventions for Adolescents in the Legal System project (JJ-TRIALS), a multi-site research cooperative funded by the National Institute on Drug Abuse.

CONCLUSION

As illustrated with substance abuse treatment, the Cascade has potential for informing and guiding efforts to improve behavioral health service linkages for adolescent offenders, developing and testing interventions and policies to improve interagency and cross-systems coordination, and informing the development of measures and interventions for improving the implementation of treatment in complex multisystem service settings. Clinical Trials Registration number - NCT02672150.