pediatrics
Drug and Substance Use in Adolescents
Screening for Substance Use Disorders in Adolescents
Clinical evaluation, including routine screening Screening questions and drug testing Some behaviors should prompt parents, teachers, or others involved with an adolescent to be concerned about a possible substance use disorder. Other behaviors are nonspecific, for example Erratic behavior Depression or mood swings A change in friends Declining school performance Loss of interest in hobbies Adolescents who exhibit any of these behaviors should have a full medical evaluation for mental health and substance use. Substance use disorders should be considered as possible causes of these behaviors even if screening is negative. Substance use disorders are diagnosed based on Diagnosis . Screening for use of tobacco, alcohol, and other drugs is a standard part of health maintenance. Adolescents and their parents can benefit from advice about safely using and monitoring over-the-counter and prescription drugs. Universal substance use screening can normalize discussions about substance use, reinforce healthy behaviors and choices, identify adolescents at risk of problematic substance use or of a substance use disorder, guide interventions, and identify adolescents in need of referral for treatment. There are a number of different validated screening tools. The National Institute on Drug Abuse (NIDA) has two such electronic screening tools available for use with patients ages 12 to 17, theBrief Screener for Tobacco, Alcohol, and other Drugs(BSTAD) tool and theScreening to Brief Intervention(S2BI) tool. Each screening tool may be either self-administered by the patient or administered by a health care professional. Self-administration is recommended because it is preferred by adolescents. The tools begin with questions about frequency of use of tobacco, alcohol, and cannabis in the past year. A positive answer prompts questions about additional types of substance use. The tools triage adolescents into one of three risk categories for a substance use disorder: no reported use, lower risk, and higher risk. Based on the results, the tools offer an action plan based on guidance derived from expert consensus. Although times may vary based on method of administration and number of follow-up questions, these tools can typically be completed in under 2 minutes. The CRAFFT questionnaire is an older, validated screening tool for alcohol and drug use. Because the original CRAFFT questionnaire does not screen for tobacco use, provide information on frequency of use, or discriminate between drug and alcohol use, it is no longer widely used and other screening tools have been developed, including the updated CRAFFT 2.1+N questionnaire, which does have a question about use of tobacco andnicotine. that suggests beginning with two screening questions. The questions and interpretation of answers vary by age (see table NIAAA Alcohol Screening Questions for Children and Adolescents ). For moderate- and highest-risk patients, ask about Drinking patterns: Usual and maximal consumption Problems caused by or risks taken due to drinking: Missing school, fights, injuries, car crashes Use of other substances: Any other things taken to get high The NIAAA guide also provides useful strategies to address problems that are discovered. Drug Testing may be useful to identify substance use but has significant limitations. When parents demand a drug test, they may create an atmosphere of confrontation that makes it difficult to obtain an accurate substance use history and form a therapeutic alliance with the adolescent. Screening tests (including at-home tests) are typically rapid qualitative urine immunoassays that are associated with a number of false-positive and false-negative results. Furthermore, testing cannot determine frequency and intensity of substance use and thus cannot distinguish casual users from those with more serious problems. Clinicians must use other measures (eg, thorough history, questionnaires) to identify the degree to which substance use has affected each adolescent's life. Given these concerns and limitations, it is often useful to consult with an expert in substance use disorders to help determine whether drug testing is warranted in a given situation. However, the decision not to drug test should not prematurely terminate assessment for a possible substance use disorder or a mental health disorder. Adolescents with nonspecific signs of a substance use disorder or a mental health disorder should be referred to a specialist for a complete evaluation. 