Addressing Adolescent Substance Use Requires Establishing Consistent Procedures

Tara Haelle

October 26, 2020

In addition to screening adolescent patients at least once a year for substance use, it's important that pediatricians build relationships with other behavioral health providers and develop a strategy for ensuring that teens with substance use issues continue returning to your practice as their medical home, according to Lucien Gonzalez, MD, assistant professor of psychiatry and behavioral sciences at the University of Minnesota, Minneapolis.

Dr Lucien Gonzalez

In a presentation at the annual meeting of the American Academy of Pediatrics, held virtually this year, Gonzalez discussed some of the common challenges pediatricians face in appropriately screening, diagnosing, and managing or referring youth when it comes to substance use.

Substance Use Screening

One of these included picking the right assessment tool and frequency for screening patients for substance use. A number of validated tools are out there, including the Screening to Brief Intervention (S2BI) and CRAFFT Screening Tool for Adolescent Substance Abuse. Regardless of which screening tool providers choose, "the important thing is to use a tool that is validated in the pediatric population and ideally has frequency results in it," Gonzalez said.

In terms of frequency, screening young people at least once a year is fairly standard, but it may be necessary to screen adolescents more often or to screen them at acute visits.

"As many of you who work with adolescents know, you can't always rely on the yearly well child visit because after a certain age, you start to see drop-off," Gonzalez said. "They often aren't coming for well child visits, and they often are then only showing up for acute visits."

That means doctors need to think about how their clinics operate, how often they see their teen patients, and other factors – including how much can happen in a single year of adolescence – to ensure that screening captures these patients at least once a year, but more if that works within the practice.

Screening vs Diagnosis

Gonzalez also addressed the difference between screening and diagnosis, a very familiar distinction to physicians in other areas of medicine but often a source of confusion in the area of substance use.

"Screening is the presumptive identification of unrecognized disease in apparently healthy people who don't have symptoms, using assessments that can be used rapidly," Gonzalez said. "When we move into the diagnostic realm, these are people who present with symptoms or they have positive results on our screening test prompting further investigation."

Sonia Khan, MD, a pediatrician and the medical director of the substance use disorder counseling program in the department of health and human services in Fremont, Calif., who heard the talk, particularly appreciated this point about screening versus diagnosis.

"As soon as you get a hint that there's a problem with the kid, you're no longer screening. You're doing diagnostic investigation," Khan, also the human relations commissioner for the city of Fremont, Calif., said in an interview. "Screening is about the kids you don't know about. It seems like a small point to make a big deal out of, but it's not."

Sometimes a screening tool can serve as an introductory interview guide when beginning a clinical investigation with a patient who already shows symptoms, but that doesn't mean it's a screen.

Gonzalez emphasized the importance of not prescreening.

"A prescreener looks at a kid and decides whether or not they need to be screened," Gonzalez said. "We have research that demonstrates that that doesn't work. Physicians are not good at determining this by eyeballing it, and it's fraught with bias. Universal screening with a validated screening tool is what works."

Again, the idea of confronting one's own personal biases and how they could interfere with screening really resonated with Khan.

"When it comes to the prescreening, if you're only screening the ones you [think you] need to screen, you're introducing bias into your screening," she said. "It's usually judgmental. It's important to focus on really getting the bias out of what you're doing because it's a field fraught with bias and expectations."

Brief Interventions

Another area of confusion for many providers is what qualifies as a brief intervention and how to deliver it. The brief intervention needs to focus on increasing the patient's knowledge, insights, and awareness when it comes to their own substance use and how it affects others. It should also support motivation in the patient to make behavioral changes. "It is always given in a nonjudgmental, supportive manner," Gonzalez said.

Though motivational interviewing is often discussed as though it's a brief intervention, it is actually the mechanism for delivering the intervention – not the intervention itself.

Gonzalez highly recommended that providers seek motivational interviewing training if they haven't already. He went on to caution attendees about behavior goals in interventions: They should be the patient's change goals, not the provider's, and the provider is there to facilitate the teen's clarification of those goals.

"It's very important to use those listening skills that we have and honor their decision-making and listen to their language in establishing their own goals," he said. It's also important to keep cultural relevance and respect in mind when delivering the intervention. He shared a chart showing the dominant and nondominant groups along various demographic cultural influences, including age, disability status, faith, race/ethnicity, indigenous heritage, socioeconomic status, national origin, gender and sexuality.

For example, the dominant age groups are the young and middle-aged while the nondominant are children and elderly. The dominant faith in the United States is Christian or secular, and the dominant sexuality is heterosexual; the corresponding nondominant groups would be non-Christian and nonheterosexual. It's important for providers to consider the child's needs within that entire behavioral context to understand where they're coming from.

"Have you ever characterized a kid's situation with regard to substance use and diagnoses based on certain characteristics?" Gonzalez asked attendees. "We like to think that we don't, but research on diagnostic disparities indicates otherwise."

A way to help avoid this is to know who you are in the room and who you're with in terms of dominant and nondominant groups. "Oftentimes a kid's cultural make-up holds a big part of the answer to what they need," Gonzalez said. He provided the example of a patient who was witnessing domestic violence in the home. A key part to helping him meet his goal of reducing cannabis and alcohol use was understanding his relationship with his dad, his response to trauma, and his depression, all within his cultural and religious background.

Preserving the Medical Home

Finally, when it comes to referrals, consider what are you referring a patient for and whom are you referring them to because not all programs and all clinicians are created equal. Create, build, and maintain relationships with as many behavioral health clinicians and practices as you can, he advised.

Further, it's important to preserve the medical home, though that can require extra effort, particularly with children who have seen a lot of providers. Each physician will need to develop their own strategy for how to do this. Sometimes kids feel passed around and there's poor communication within programs, leaving kids and their families feeling unwelcome at your practice.

"No child is a hot potato," he said. Because they may feel like they're being bounced around among different providers, programs, emergency departments, facilities, and such, it's important to convey strongly that you want to continue to care for them.

"Whether we've been part of that or not, we become part of that," Gonzalez said. "They may think that you don't want to see them again. You want to keep them, and you might have to continue giving repeated messages. We sometimes we need to be very overt and repeat ourselves and say no, 'I really, really, really want you to come back. This is your home and I want you to come back.' "

Gonzalez and Khan have no disclosures.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

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