Clinical Consult | Overview
Researching the value of substance abuse screening for adolescents during pediatrician visits
There aren't enough data available to prove that doctor-led interventions are useful in reducing substance use in adolescents, according to the U.S. Preventive Services Task Force (USPSTF). The results of their findings were recently published in Annals of Internal Medicine.
Task Force members, comprised of an independent panel of experts in prevention and evidence-based medicine, systematically reviewed published research on the benefits and harms of interventions that pediatric primary care physicians (PCPs) use to prevent or reduce drug use among their adolescent patients. In their research, they found only six good- or fair-quality studies on the topic, with various findings. Given the small evidence base—and lack of consistent findings among them—the Task Force determined that there currently is insufficient evidence to say whether or not these interventions are effective.
But it's important to note that the "insufficient" label doesn't mean the USPSTF is implying that these interventions don't work—it simply indicates there aren't enough data available to make a definitive statement one way or the other.
It's a sentiment the Task Force went out of its way to note in a statement released in conjunction with the report: "This does not mean that the Task Force is recommending against primary care professionals speaking with their young patients about drug use," it reads. "When there is a lack of evidence, doctors must use their clinical experience and judgment, and many clinicians may choose to talk with an adolescent to prevent or discourage risky behaviors, such as drug use.”
A call for more research
Sion Kim Harris, PhD, co-director of the Boston Children's Hospital's Center for Adolescent Substance Abuse Research (CeASAR) who has spent the past several years researching the effectiveness of behavioral intervention on adolescent substance use in the primary care setting, wasn't dismayed by the Task Force's findings. In fact, she welcomes the importance it places on future study of the topic.
"There's plenty of research demonstrating the effectiveness of PCPs using behavioral interventions to reduce problem drinking in adults, but research documenting its effectiveness in pediatrics only dates back to 2002," Harris says. "Given the limited data available, I don't think the 'insufficient' statement is surprising, nor is it a condemnation—it's a call for more research."
To that end, Harris and her colleagues have done much work to determine the important role PCPs play in combating teen substance abuse. One such study, published in Pediatrics, demonstrated that adolescents who completed a five-minute computerized screening and feedback program before the visit, followed by a two- to three-minute discussion with their PCP based on the results, were almost 50 percent less likely to drink three months after their visit than teenagers who didn’t complete the program.
Likewise, Jennifer Louis-Jacques, MD, MPH, then a fellow in Boston Children’s Division of Adolescent/Young Adult Medicine, published a study in Journal of Adolescent Health showing that this computerized screening and PCP brief-advice intervention was successful in reducing underage drinking even in adolescents at risk for the behavior (i.e., those whose friends drink or approve of drinking.)
For many PCPs, however, the biggest barrier to addressing substance abuse with their adolescent patients isn't a lack of data proving its worth—it's a lack of time during well visits to broach the subject, or insufficient training in what to do if screening indicates that a particular child or teen has a problem.
Both issues present legitimate challenges, Harris acknowledges, but notes that new technology can be used to make screening techniques more streamlined—providing the clinician with important information and the patient with valuable education—without adding substantial time to the visit.
"The most feasible way to integrate screening and brief interventions into the primary care environment is through the use of computerized technology," she says. "Having patients undergo screenings online while they're waiting for the doctor, so the results are available by the time the examination starts, is an excellent way to make more efficient use of time for both the physician and patient."
As for addressing doctors' fears that they may not know exactly what to do if screening uncovers problematic drug and alcohol use in their patients, Harris says using a proven screening method that prompts the physician with instruction on how to counsel patients based on their answers can be very effective. In cases where the clinician believes more than well-visit counseling is warranted, she says having access to trusted behavioral therapists, to whom to refer the patients, is crucial.
Until enough data have been collected to clearly demonstrate which screening methods work best, there will be inconsistency in how PCPs choose to address the issue in their own practice. Considering that 90 percent of adult addicts started using in adolescence, determining exactly which prevention therapies are most effective should be a high priority for researchers.
"If we can halt addiction's progression by identifying children at risk and intervening early, we can save a lot of lives, as well as a lot of health care costs," Harris says. "With many people in the field working towards that end, we're definitely heading in the right direction."