Traci L. Brooks, MD, and John R. Knight, MD
103
INTRODUCTION
Substance use is one of the greatest health threats faced by American teenagers. Several professional societies recommend that clinicians ask all adolescents yearly about drug and alcohol use as part of routine health care. The goals for primary care can be summarized as screening, brief intervention and referral to treatment.
SCREENING FOR USE
Clinicians should begin asking adolescents about substance use as soon as the young person is old enough to be interviewed without the parent present, typically between ages 11 and 13 years. After meeting with the parent and patient together, the clinician should ask the parent to leave the room so he or she can ask the adolescent personal questions and emphasize that the details discussed will remain confidential unless he or she has safety concerns about the patient or others. Reassure the adolescent that if it is necessary to inform a parent of a safety issue, the clinician will notify the adolescent of the disclosure prior to telling a parent. For younger children, it may be helpful to lead into the screening with a very simple question about friends’ use (“During the past 12 months, did any of your friends drink alcohol or use drugs?”).
To maximize the sensitivity of the question, the interviewer should begin the question with “During the past 12 months, did you drink any alcohol? (Do not count sips of alcohol taken during family or religious events.).” The interviewer should avoid ambiguous questions, such as “Do you drink/smoke?,” as answers to these questions may be interpreted differently by patient and clinician (full screen available at http://www.ceasar.org/CRAFFT/pdf/CRAFFT_English.pdf).
Adolescents who report complete abstinence from alcohol and drugs should be asked the CAR question (below) only and then given praise and encouragement regarding the good decisions they have made. Any adolescent who reports having used alcohol or drugs should be asked all six CRAFFT questions or be screened with another developmentally appropriate screener.Clinicians tend to underestimate adolescents’ substance use severity when relying on clinical impressions alone.
SCREENING FOR RISKS AND PROBLEMS
CRAFFT is a mnemonic acronym designed to assess the prior 12 months:
1. Have you ever ridden in a Car driven by someone, including yourself, who was high or had been using alcohol or drugs?
2. Do you ever use alcohol or drugs to Relax, feel better about yourself, or fit in?
3. Do you ever use alcohol or drugs while you are by yourself, Alone?
4. Do you ever Forget things you did while using alcohol or drugs?
5. Had your Family or Friends tell you that you should cut down on your drinking or drug use?
6. Gotten into Trouble while you were using alcohol or drugs?
Each “yes” response is scored 1 point. A score of 2 or greater is a positive screen and indicates that the adolescent is at high risk for having an alcohol- or drug-related disorder.
SCREEN-SPECIFIC STRATEGIES
Physician Brief Advice
Brief advice is a 2-to 3-minute statement from the provider that reinforces the choice of the adolescent who is not actively using alcohol or drugs by conveying that use can be harmful. Examples of brief advice statements are provided in Table 103-1.
TABLE 103-1. BRIEF ADVICE SAMPLE STATEMENTS
No Use: Praise and Encouragement
For adolescents that have been abstinent from alcohol and drugs and who have never ridden with an intoxicated driver, the clinician may say, “It sounds as if you have made smart choices by not using drugs or alcohol. If that ever changes, I hope you will feel comfortable enough to talk to me about it.” Such a message keeps the door open for future communication.
Physician Assessment
Medium Risk: No Use/Car +
All adolescents who have ridden with an intoxicated driver should receive risk reduction advice. They can be given the “Contract for Life” document developed by Students Against Destructive Decisions (available at http://sadd.org/pdf/05SADD_CFL_FS_2.pdf) that asks adolescents to commit to never ride with a driver who has been drinking or using other drugs and also asks parents to promise to provide transportation home without any questions if their child is in need.
Medium Risk: +Use/-Car/CRAFFT Negative
Adolescents who report alcohol or other drug use but screen negative (i.e., 0 or 1 on the CRAFFT) are at medium risk for a substance use disorder. These teens should receive brief advice to stop using, such as “My advice is for you to stop using alcohol or drugs at all, because these pose a serious risk to your health.” The clinician may also give specific information related to the health effects of the drug that the teen is using. The clinician may ask the patients to try a time-limited trial of abstinence (e.g., 1 week to 3 months) and ask them to come for a return visit to discuss how it went.
High Risk: CRAFFT 2 or Above
A brief assessment should begin with assessing the patients for acute risk of harm to themselves or others. Clinicians may need to break confidentiality if they deem ongoing acute danger. Referrals to individual and/or family therapy should be considered to treat these and other underlying problems that are likely contributors to the substance use. For patients who are not drug dependent, a statement such as “Your CRAFFT score indicates that you are at high risk. I am very worried about you. I’d like you to make an appointment for next week so we can continue to discuss this.” Ask the patient to agree to no alcohol or drug use until the return visit, but clarify this statement with “Even if you do use, I would still like for you to follow up next week. We can discuss why it was so difficult for you to abstain.”
Strategies for Interviewing Adolescents
For any patient, a nonjudgmental, empathetic interviewing style that accepts the patient’s point of view encourages more information sharing than does an interrogative style. The interviewer should use open-ended questions to begin the conversation, with an emphasis on the pattern of drug use over time, including whether use has increased in quantity or frequency, whether the teen has made attempts at discontinuing use, and why and whether attempts have been successful. Information about the pattern of use and associated problems is more important in making a diagnosis of a substance-related disorder than the absolute quantity or frequency. At times, cues from the clinician may help the adolescent make connections between drug use and consequences. Statements such as “It seems that your grades started to fall at the same time that you started using more marijuana” may help the adolescent associate the two occurrences.
Substance Use History
Substance of Choice
The clinician should begin with an open-ended question, such as “Tell me about your history of alcohol use.” Cue adolescents to discuss general trends in their substance use (“Has your use been increasing over time?”), and obtain an estimate of the current level of use (“About how often do you use now?”). The clinician should ask whether adolescents have had any problems related to their use of substances. If the teen denies experiencing problems, the clinician may ask specifically about tension with parents, school problems, decrease in grades or sports performance, suspensions or expulsions from school or sports teams, physical fights, arguments with friends while intoxicated, medical problems (i.e., overdose or becoming sick), unwanted sexual contact, or legal problems/arrests. The clinician can also ask patients whether they have ever tried to quit, and if so, why. Adolescents’ reasons for previous quitting attempts provide insight into perceived negative consequences of substance abuse and can be very helpful in personalizing advice.
Review of Other Substances
After completing the history for the substance of choice, the clinician should review whether the adolescent has used other substances. If the substance of choice is not alcohol or marijuana, the clinician may ask detailed questions (as earlier) about these substances, as it is unusual for an adolescent to have used other illicit drugs without ever using alcohol or marijuana.
Collateral History
At times, substance use by an adolescent will present to a clinician as a report by a parent, from a school, or from another adult. In these cases, the clinician should take a careful collateral history. If a parent suspects drug use but the child denies using substances, the clinician should have the parent carefully list his or her observations. Substance use often presents with nonspecific complaints, such as staying out late, moodiness, breaking house rules, drop in grades, loss of interest in hobbies, or developing a new group of friends, and these symptoms should always be investigated further, particularly if more than one is present. Lying, stealing, appearing intoxicated, and possessing drugs or paraphernalia are more specific signs of drug use and should raise suspicion whenever present. In some cases, parents will report having caught their child using alcohol or other drugs. If consent is properly obtained, it is often useful to obtain additional history from patients’ significant others, siblings or other extended family, teachers and other school administrators, and any mental health providers who may already be involved with the adolescent.
Physical Exam
Adolescents who have a positive screen for high-risk substance use should have a physical exam to look for signs of acute intoxication or chronic drug use.
Laboratory Testing
Laboratory testing is discussed in detail in (Chapter 19, “Laboratory Diagnosis”). Ethical and confidentiality issues as these relate to drug testing in adolescents are reviewed elsewhere in this text.
SUBSTANCE USE SPECTRUM
The goal of brief assessment is to triage adolescents who screen positive for high-risk substance use to the appropriate level of intervention. Based on the information from the clinical interview, the clinician can conceptualize the adolescents’ substance use on a spectrum that varies from primary abstinence to substance dependence.
Adolescents whose use is nonproblematic should be advised similarly to other low-risk teens, including brief advice to stop and specific information regarding the health consequences of substance use.
FOLLOW-UP AND REFERRAL TO TREATMENT
Problematic Use
Adolescents with problem use of any substance should receive a targeted brief intervention, aimed at reducing substance use and related harm. In this chapter, we define “brief intervention” as a small number (i.e., one to three) of individual counseling sessions with an allied mental health provider, such as a psychologist or social worker. Motivational enhancement therapy is particularly suited to this type of intervention though other counseling techniques, such as family-based therapies, are also effective. If the adolescent continues to use substances, a referral to more intensive treatment should be considered.
Abuse
Adolescents who meet diagnostic criteria for alcohol or marijuana abuse should be referred for a brief intervention and followed up closely for signs of behavioral change. If substance use continues despite intervention, more intensive treatment may be required.
Adolescents who meet diagnostic criteria for abuse of more than one substance or of a substance other than alcohol and marijuana should be referred to a mental health specialist or a substance abuse specialty program for a detailed assessment and further treatment.
Dependence
All adolescents who meet dependence criteria for any substance should be referred to a mental health or substance abuse specialist for treatment.
KEY POINTS
1. Easily implemented substance use screens can quickly and reliably determine which teens are at high risk of having a substance use disorder.
2. Teens at low risk can be effectively counseled in a primary care setting using just a few minutes of clinician advice.
3. For teens with more serious substance use disorders, experienced clinicians can follow up a positive screen with a brief assessment to determine the appropriate level of care and make appropriate referrals.
REVIEW QUESTIONS
1. All adolescents should be asked at every primary care visit:
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