More teens test positive for drugs, alcohol at sick care visits

Physicians may need to screen 12- to 18-year-olds for possible drug and alcohol abuse issues any time they present for care and not just at checkups, as recommended by many medical societies, including the American Medical Association. This concept was the take-home message of a study in the November Archives of Pediatrics & Adolescent Medicine.

Still, many physicians agree that although the reasons supporting such screening are clear, implementing it is easier said than done.

The study found that nearly 15% of teenagers coming to a primary care practice would test positive when assessed with the CRAFFT, a tool designed to detect drug and alcohol use in this age group, but these rates varied widely depending on the purpose of the visit. Notably, about 23% of those presenting for sick care screened positive, while only 11% did so in the context of a well-child visit.

"Screening should occur when ever there's an opportunity, not just at the well-child visits," said John Knight, MD, lead author and director of the Center for Adolescent Substance Abuse Research at Children's Hospital Boston. "The earlier we can recognize the problem, the more successful treatment is likely to be."

The type of clinic also made a difference. Nearly 30% of those seeking care at school-based health clinics screened positive along with approximately 24% receiving care in a rural setting. Only 8% in the pediatric setting were positive as were slightly more than 14% of those getting medical services from a health maintenance organization.

"There are quite a few kids who have significant problems with substance abuse. If we don't ask about it, we're not going to find out," said Tom Martinko, MD, medical director of N.C.-based Wilmington Health Access for Teens.

Experts suspect that so many tested positive during the sick visit because many adolescents don't receive regular checkups. Those who abuse drugs and alcohol are even less likely to. And young people who are using or abusing substances also are more likely to present for sick care, particularly with complaints that may be connected to drugs and alcohol.

"A lot of adolescents don't come in for well care. We've got to do this at sick visits," said Martha J. Wunsch, MD, a member of the American Academy of Pediatrics Committee on Substance Abuse and associate professor and chair of addiction medicine at the Virginia College of Osteopathic Medicine in Blacksburg.

School-based health centers, because they often offer family planning, also may care for those more at risk. The higher rates at rural clinics may be explained by the many studies that have documented that alcohol and drug abuse can be bigger problems in these locations.

But while many physicians think more frequent screening for adolescent substance abuse is a good idea, several studies have found it challenging to incorporate in well-child care. Making it a part of sick or urgent care is expected to be even more difficult.

"I agree with the study's findings, but the problem, of course, is that if you were to put into effect all the recommended screenings for every visit for everybody in primary care, you would never get out of the office," said Robert Mallin, MD, associate professor in the Dept. of Family Medicine at the Medical University of South Carolina in Charleston.

Follow-up also can be problematic. A positive screen is not a diagnosis but does indicate the need for additional questioning to determine the extent of the problem if there is one. Brief counseling from a physician may be all that is needed to address this issue in some patients, but others may need much more. More intensive services for this age group may not be that accessible.

"Physicians feel they don't have enough time. They may not be sure where to make the referrals for treatment, and they may not be comfortable when the screening is positive," Dr. Knight said. "But substance use in adolescence can be associated with fatalities. You may be able to say or do something in just a couple minutes that could save a life."

Researchers used predictive modeling and determined that in a primary care setting, just more than 11% of teens will actually turn out to have problems in this area. Another 7% will be abusing these substances, and 3.2% can be diagnosed as dependent.