Today's lecture is on Addressing Adolescent Substance Use, How to Recognize, Screen, and Communicate. My name is Dr. Marla Kushner. I'm a fellow in the American College of Osteopathic Family Physicians and certified through the American Society of Addiction Medicine. I have one disclosure, I'm in the Speaker's Bureau for Alkermes. At the end of this session, you'll be able to use screening tools and assessment procedures, establish trust and build rapport when talking with adolescents and parents, evaluate referral practices, devise follow-up strategies, and address adolescent substance use in your practice. And this comic says, if we passed a law to make education illegal for anyone under 21, we'd have the smartest teenagers in the world. When we're dealing with adolescents, we really need to think about how to approach them and the obstacles that we are going to come across. Let's now talk about the scope of adolescent substance use. Let's start with some adolescent substance abuse statistics. Monitoring the Future is an annual survey of 8th, 10th, and 12th graders conducted by researchers at the Institute for Social Research at the University of Michigan, Ann Arbor, under a grant from the National Institute of Drug Abuse, part of the National Institutes of Health. Since 1975, the surveys measured how teens report their drug and alcohol use and related attitudes in 12th graders nationwide. 8th and 10th graders were added to the survey in 1991. 47,703 students from 360 public and private schools participated in the 2017 survey. Research indicates that substance use begins at an early age, with alcohol and marijuana being very common. Past year misuse of Vicodin among 12th graders has dropped dramatically in the past 15 years, from 9.6% in 2002 to 2% in 2017, and so has misuse of all prescription opioids among 12th graders, despite high opioid overdose rates among adults. Past year misuse of prescription over-the-counter drugs among 12th graders were Adderall at 5.5%, tranquilizers 4.7%, opioids other than heroin 4.2%, cough cold medicines 3.2%, sedatives 2.9%, Ritalin 1.3%. Past year use of illicit drugs among 12th graders were marijuana and hash 37.1%, synthetic cannabinoids 3.7%, LSD 3.3%, cocaine 2.7%, MDMA, which is ecstasy or molly, 2.6%, inhalants 1.5%, and heroin 0.4%. Students report lowest rates since the start of the survey. Across all grades, past year use of heroin, methamphetamine, cigarettes, and synthetic cannabinoids are at the lowest by many measures. The percentage of high school seniors who use marijuana daily is rising and has been trending upward among 12th graders for the past 30 years. The percentage of high school seniors who use marijuana daily is rising and has been trending upward among 12th graders for the past 30 years. Since 1992, there has been a significant decline in daily cigarette use among 12th graders, while the rate of daily marijuana use has increased. In its peak year, which was 1997, daily cigarette use among 12th graders was 24.6% compared to a rate of 4.2% in 2017. In its lowest year of use, 1992, daily use of marijuana among 12th graders was 1.9% compared to a rate of 5.9% in 2017. Since 1992, binge drinking, which is considered five or more drinks in a row in the last two weeks, appears to have leveled off this year, but is significantly lower than peak years. Peak years for binge drinking for each grade, 8th grade was 1996 at 13.3%, 10th grade was the year 2000 at 24.1%, and 12th graders, 1998, 31.5%. In 2017, binge drinking rates for each grade, 8th grade was 3.7%, 10th grade 9.8%, and 12th graders was 16.6%. The past year, e-cigarettes, or vaping, has been increasing as well. The survey also asked students what they thought was in their e-vaporizers, mists, the last time that they smoked. These were their responses. Nicotine, 8th grade 25.1%, 10th grade 32.8%, 12th grade 11.1%, marijuana or hash oil, 8th grade was 8.9%, 10th grade 10.7%, and 12th grade 11.1%. Just flavoring, 8th graders was 74.8%, 10th grade 59.2%, 12th grade 51.8%, and other was in 8th graders, 0.2%, 10th grade 0.5%, and 12th grade 0.7%. And those that just didn't know what was in there, 8th graders, 6.1%, 10th grade 4.6%, and 12th grade 3.7%. Adolescents are vulnerable. Early substance use can equal a high rate of addiction, and adolescent immaturity during critical development periods can equal vulnerability. So impulsiveness and excitement seeking can happen, difficulty delaying gratification, and poor executive functioning and inhibitory control. The PET scan image shows human cortical development across the age range of 5 years to 20 years. The scans reveal that higher order association cortices mature fairly late in adolescence. It's all accelerators and no brakes. Teen propensity for risky behavior is high, 26% report they've ridden in a car with a driver who's drunk alcohol, 30% report texting while driving, 9% report drinking and driving themselves, and 86% report not wearing a helmet while riding a bike. The risk is real despite cultural minimization. Progression from experimentation to impairment and use disorder, exposure to progressively deviant peer group, so they think that everyone is doing it. Levels seen by teens as normal can definitely be associated with academic decline, falling off the growth curve of psychosocial functioning, psychiatric morbidity, which could be a worsening depression and anxiety over time, and although rare, psychosis rates double with marijuana use. One in five people between ages 13 to 18 years have had seriously debilitating mental disorders. Let's talk about screening and assessment. It's important before you begin to decide how you're going to be using the screening tools. One screening tool is not for everyone. It's not a full assessment. Apply your existing office practice to screening. So how do you use patient documentation, consent forms, confidentiality, HIPAA, storage, your flow for patients, establish relationships with other providers for referrals, and consider patient and parent reading level when providing educational support. Some sample language could be, to establish confidentiality and honesty, I want to talk to each of you separately and together. To the parents, they'll tell me stuff they might not tell you. I'll tell you on a need-to-know basis, but maybe not all the details. To the adolescent, I can't help if I don't know the whole story. This stays between us unless I'm concerned about your health and safety, nothing behind your back. And to both, trust me, I've done this before. So there are three screening options that we're going to take a look at today. The BSTAD, the S2BI, and the CRAFT. Let's start with the BSTAD brief screener, tobacco, alcohol, and drugs. The question is, in the past year, on how many days did you have more than a few sips of any drink containing alcohol, smoke, marijuana, use cigarettes, or other tobacco products? And to look at the answers, if the substance is alcohol, the cutoff point, so the number of use days per year, would be two, and the rate of use disorder in primary care clinic would be about 4%. For marijuana, the cut point is two, and the rate of use disorder in primary care is 11%. And for tobacco, the cut point is six, and the rate of use would be 5%. The next screening is screen to brief intervention. In the past year, how many times, or the frequency, have you used alcohol, marijuana, tobacco, et cetera? It's a pattern tool. There's a high sensitivity and specificity for severity, and it provides a range. So we're going to look at the frequency and the severity of DSM-5 substance use disorder. For none, there's no use. Once or twice, it's use without disorder. Monthly use would be mild, so two to three criteria, or moderate, four to five criteria. And weekly or more would be severe, or greater than six criteria. And then the last is the CRAFT. It's a qualitative approach. It asks questions. Have you ever ridden in a car driven by someone, including yourself, who was high or had been using alcohol or drugs? Do you ever use to relax, feel better about yourself, or fit in? Do you ever use while you are alone by yourself? Do you ever forget things you did while using? Do your family or friends ever tell you that you should cut down? And have you ever gotten in trouble while you were using? A score of greater or equal to two indicates a high risk. So when you're looking at these screeners, pick what's going to work for you. Each has empirical support, and none are perfect, but note how low the cut points are. It can be surprising. And remember that these are just screeners. If they screen positive, they need to be referred for further assessment. What are some of the clinical indicators in adolescents that they may have? Let's ascertain the severity. How bad is it? Many of these indicators suggest a referral if they have regular use, if we're seeing antisocial behaviors, major health effects, major consequences, social role impairment, or progressive use of substances, such as progressing to opioids. And how do we balance these priorities? It's one more thing that we need to do in an already tight window. And we want to get paid for this. Well, there are some codes for screening and brief intervention and referral to treatment. Note that each state and payer is different, so you may want to look these up. You want to look at ancillary staff strategies. Do you have nurse practitioners, PAs, health educators, medical students, or residents can help. Separate visit strategies, so not having to do everything all at once. And remember that not enough is better than none at all. Now let's focus on how do we communicate with the adolescent patient. Having a conversation about the screen. How do you debrief the screening test? Well, for those patients who are zero or low level, it's important to praise their behavior. Ask them about peers who may have progression or trouble. And for patients that are high risk, it's important that we proceed to further assessment. To do a brief intervention, we want to ask the pros and cons of use. And we want to do this in a nonjudgmental way with open-ended questions. What are the adolescent's view of impact and risk? Can we connect to any personal concerns and goals? And is there discrepancy between the behaviors and personal goals? So if they tell you that they want to play sports in college, but they're using alcohol or marijuana daily, we want to ask the adolescents how they feel about drugs and alcohol, what their views are. And how do we explore this further? How much do you think is too much? What do you know about the health risks of drugs or alcohol? If it were to become a problem in the future, how would you know? And how much do your parents think is too much, and why do they think that? We can agree to disagree, but value meaningful and truthful discourse. Continue the conversation. What are some of the action steps that we can take? We want to ask the adolescents if they would consider going without substances or cutting down. You might want to suggest urine drug testing. Consider a specialist referral. And get the patient to agree to return. Follow-up appointments are so important. Some action steps could be, will you agree to come back and continue this conversation? Even if you believe it's no problem, would it be hard to stop or cut down if you wanted to? Will you agree to see what it's like to go for a while with no use or less use? Or would you go and see a specialist? Get another opinion. It's important to talk about urine drug testing. Urine drug testing must be normalized as part of routine testing, just as you would do a urine to screen for blood sugar or a blood glucose test. Normalize it's an inflection point. When you say urine drug screen, the adolescent or the parents may become a little surprised. Medicalize the conversation. It's important that we refer to it as urine drug testing and that we refer to the results as positive or negative or expected or not expected. We don't want to talk about it, refer to it as a drop or dirty or clean. And practice your narrative around it. It's also important to have your office staff practice their narrative as well. Communication and disclosure is important. This is your private treatment. It stays between us unless I'm concerned about your health and safety. I can't help if I don't know the whole story. You can also suggest, let's bring in your parents, do it together, I'll run interference. They'll find out anyway better coming from you. And then look at medical decision making about risk and urgency. Is there imminent harm versus postponement for further discussion? And this can be based on the screening test. And you want to get them to yes. It's important to communicate with the parents and realize that this can be a little bit tricky. Confidentiality varies. It may vary from state to state, so look into state laws and family culture. Families come in all shapes and sizes. It's important to remember that. And family history can be really instructive. If you know that there's a family history of mental illness or there's a family history of substance abuse, that can play into this conversation as well. Education-only school programs have been largely ineffective. It's parental attitude and influence that really makes a difference. You may have seen the commercials that talk about parents as the anti-drug, and that has made a difference over the years. Some parents will minimize the impairment and may be over-permissive, but then there's also some parents that are alarmist, impunitive, and over-intrusive. You want parents to model how to talk to their kids. Have the conversations. When parents speak to their kids before they leave for college, it really does make a difference. Don't be surprised if they don't get it right away. Pick your battles. It's also important to address the supply. Monitor and secure medications in the home. Dispose of medications that are no longer in use. And coordinate with peers, friends, parents, grandparents. Many adolescents will say that the first time they used a substance was something they got from the medicine cabinet, either at parents' or grandparents' house. And what about parental use? This can be tricky territory. Not that this applies to you, but some families may use substances socially, and remind them that kids are mimics. It's important to refer and monitor. Know your cut point, marker of severity. You can find a health care professional on the ASAM website, AACAP, AAAP, AOAAM. Learn your local resources and develop your network. It's so important that you have your network before you need it, so you want to know in your community who will treat adolescents for substance use. Because if you're looking for it at the last minute when the patient is agreeing for help, it may be time consuming. You may lose them for follow-up. So try and get that information as much as you can beforehand. You want to assess the quality of what's available around you. And remember, if you can't find great, go for good or even okay. And promote reciprocal communication with the referral. You want to be talking back and forth. You let them know why you're referring, and then you want them to have the patient come back to you. And reassure, it's easy for them to jump to the worst case scenario. A simple evaluation is the first step. Some sample referrals that can be helpful are outpatient and inpatient services. There's different levels of care. There's intensive outpatient that's usually four hours a day, either in the morning or in the evening. There is a partial hospitalization program, PHP, that is a full day program, but then they come home. And there's inpatient services. There's also young people in recovery meetings. There's Alcoholics Anonymous and other 12-step programs. There may be programs through the public health department, community mental health center. And I would encourage working parents to check with their employee assistance programs at their jobs to see if there are any benefits through that program for their adolescent. Talking through the referral, use the motivational moment. Explore potential barriers. What is going to keep them from making this happen? Again, normalize the anxiety and ambivalence. Address the patient's resistance to seeking help. Consider using motivational interviewing strategies, validating their concerns with empathy, reflecting back the patient's concerns, talk through pros and cons. And then you want to convey the urgency to families for high severity. If somebody is in immediate danger of withdrawal or potential overdose, you want to get them as soon as possible to treatment. And administer a warm handoff. Recovery care provider introduces a patient to the new practitioner, walk them over, assist with the phone call, stay with them while the appointment's being made, and facilitate the establishment of trust. Patients with substance abuse problems who are transferred with a warm handoff have very high rates of treatment enrollment. And again, if the patient refuses, ask, will you at least come back to talk with me and schedule that follow-up appointment before they leave? There are many treatments available. Medication-assisted treatment is standard of care for patients who have substance use disorders. Not all are approved for adolescent patients. There are medications, naloxone, buprenorphine, and combination drugs. You want to be aware of labeling. Just know the drugs. You don't have to be an expert. Naloxone should be given to all patients with opioid use disorder or prescribed opioids. And you want to instruct the family members on how to use it. It is an opioid antagonist that will immediately reverse opioid overdose. Buprenorphine products are indicated for patients age 16 and up. It requires a certification to receive an XDEA number to prescribe. Initially, prescribers can prescribe for 30 patients. Then it can increase to 100 and then 275 patients over the next couple of years. It's important to do an induction of the buprenorphine into the patient's system. That's what's recommended, slowly introducing the buprenorphine orally into the patient's system and then maintaining it. Patients will become physically dependent on the medication, and it does require a slow tapering. Naltrexone short and long acting injectable is only approved for age 18 and up. There's no certification needed, and you must be 7 to 10 days opioid free before you can take the medication. So following up, again, is very important. Prepare your questions. Praise the positive behavior. Have they been able to stay away from substances? Have they been going to meetings or treatment? Have their behaviors been changing with school or work? Problem solve about concerns and barriers, and don't argue with the patient. Again, normalize the urine drug test. It's important to note that positive urine drug testing does not necessarily mean addiction, and negative urine drug testing doesn't necessarily mean that there's not a problem with substances. Remind the patient that it's a health-related issue, not a judgment on their character, and you will make recommendations multiple times before they will fully appreciate it. Reflect on improvement or progression. Ask how has it been going since your last visit? Any thoughts about what we talked about? Questions like, how many times have you blank since then? Or did you try to stop or cut down? How can we get help from your parents or guardians? Reflect on previous patient set thresholds. For example, I remember you said that if you ever used more than blank, that might be a problem. And let's talk about urine drug testing. It's also important to note that there are comorbidities associated with adolescent substance abuse. There's medical comorbidities, sexual risk behaviors and STIs, pregnancy prevention, smoking tobacco or marijuana, reactive airway disease, and injuries, also mental health issues, depression and anxiety, and being careful to monitor safe adherence to stimulant prescriptions for ADHD. Consider this, health care providers, especially primary care, have enormous impact on patients and families. Set a clear standard. Any intoxicant use is unhealthy for adolescents. On the other hand, it's a marathon, not a sprint. Encourage waiting. Every delay is impactful. Longitudinal follow-up holds up a mirror of dynamic change, positive and negative. Thank you very much.

Adolescent Substance Use

Screening Options

Open Communication

Referrals

Treatment Options

Healthcare Professionals