Joanna Quigley, M.D., Child & Adolescent Psychiatrist, University of Michigan

Substance-use-related morbidity and mortality continue to increase at an alarming rate. It is imperative to learn, understand, and practice prevention, screening, assessment, and management of youth at risk for substance use to stem this alarming rise in substance use and its sequelae in the pediatric population. 

Substance use often starts in late childhood and adolescence, so these age groups are particularly important targets for prevention and early risk mitigation efforts.

• The adolescent brain is still developing and adolescents can have variable levels of impulsivity, thoughtful planning, awareness of future risk, judgment, and risk-taking engagement.
• Among youth surveyed in the 12th grade, most commonly youth initiated alcohol use in the 9th grade, and more than half initiated cannabis use in the 9th or 10th grade.
• In addition to a rapid rise in alcohol and marijuana use, as well as the increased vaping and nicotine use, there are over 900,000 adolescents misusing opioids nationally.

Primary care can play a pivotal role in substance use prevention and promoting behavioral health interventions to mitigate the risk of substance use, as highlighted by professional associations like the American Academy of Pediatrics, the American Academy of Family Medicine, and the American Academy of Child and Adolescent Psychiatry. 

• Primary care providers have the unique advantage of establishing a trusting, long-term relationship with youth and families from early childhood through young adulthood and may be well positioned to observe changes in a child’s presentation suggest risk or progression of substance use.
• Primary care providers do not need to guess or intuit substance use in their patients, as several short, validated screeners and tools exist to screen and assess youth for substance use risk, including tools like the CRAFFT and the AUDIT.
• Specific recommendations have been made for primary care to routinely screen adolescents for substance use, conduct assessment for those that screen positive, provide brief evidence-based interventions, and refer to more intensive treatment or psychiatric care when needed.

Most youth will endorse no use of tobacco, alcohol, or marijuana, and the physician in those cases can play an important role by reinforcing that healthy choice and the benefits of never starting to use.

• If use is detected, the integrated approach of substance use screening, brief intervention, and referral to treatment (SBIRT) can be utilized. SBIRT is an evidence-based practice used across multiple settings and age groups.
• SBIRT allows clinicians to identify young people who are at risk for developing a substance use disorder and choose an appropriate and informed response.
• In some cases, a brief intervention may be needed, and in the minority of more serious cases, the adolescent patient can be referred to more intensive and/or specialized treatment.

The unique access and influence pediatricians have on health behaviors throughout the early stages of life make them an essential point of intervention for adolescent substance use.

Resources Mentioned in the Video

• Screening, Brief Intervention, and Referral to Treatment (SBIRT): https://www.samhsa.gov/sbirt 
• American Academy of Pediatrics Clinical Report on Substance Use Screening, Brief Intervention, and Referral to Treatment (clinical workflow) https://publications.aap.org/pediatrics/article/138/1/e20161211/52568/Substance-Use-Screening-Brief-Intervention-and
• Al-Anon family support: https://al-anon.org/ 
• Use of Buprenorphine for opioid use disorder: https://www.samhsa.gov/medications-substance-use-disorders/medications-counseling-related-conditions/buprenorphine
• American Academy of Pediatrics Training to Treat Opioid Use Disorder in Adolescents: https://www.aap.org/en/patient-care/substance-use-and-prevention/training-to-treat-opioid-use-disorder-in-adolescents/
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Screening Tools

• Substance use: Car, Relax, Alone, Forget, Friends, Trouble (CRAFFT): https://crafft.org/ 
• Substance use, including nicotine: CRAFFT 2.1 N+ https://crafft.org/wp-content/uploads/2021/07/CRAFFT_2.1N-HONC_Clinician_2021-07-03.pdf 
• Alcohol use: Alcohol Use Disorders Identification Test (AUDIT): https://auditscreen.org/ 
• Depression: Patient Health Questionnaire (PHQ-9): https://www.apa.org/depression-guideline/patient-health-questionnaire.pdf 
• Suicidality: Ask Suicide Screening Questionnaire (ASQ): https://www.nimh.nih.gov/sites/default/files/documents/research/research-conducted-at-nimh/asq-toolkit-materials/asq-tool/screening_tool_asq_nimh_toolkit.pdf 
• Substance use: Screening to Brief Intervention (S2BI): https://www.samhsa.gov/resource/ebp/screening-brief-intervention-s2bi
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Other Resources

• MC3 Recording:
  • Youth Substance Abuse, MC3 ECHO: Behavioral Health, by Joanna Quigley, M.D.
• Pediatric Meltdown Podcast Episode:
  • Substance Use Disorders and Childhood Exposures: What you need to know with Dr. Allek Scheele (Episode 5)

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Hammond CJ, Gray KM. Pharmacotherapy for substance use disorders in youths. J Child Adolesc Subst Abuse. 2016;25(4):292-316. https://doi.org/10.1080/1067828x.2015.1037517 

Levy SJL, Williams JF, Committee on Substance Use and Prevention, Ryan SA, Gonzalez PK, Patrick SW, Quigley J, et al. Substance use screening, brief intervention, and referral to treatment. The American Academy of Pediatrics. 2016;138(1):e20161211. https://doi.org/10.1542/peds.2016-1211 

Miech RA, Johnston LD, O’Malley PM, Bachman JG, Schulenberg JE. Monitoring the future national survey results on drug use, 1975-2015: Volume I, secondary school students. https://eric.ed.gov/?id=ED578604 

Miech RA, Johnston LD, O’Malley PM, Bachman JG, Schulenberg JE, Patrick ME. Monitoring the future national survey results on drug use, 1975-2017: volume I, secondary school students. https://monitoringthefuture.org/wp-content/uploads/2022/08/mtf-vol1_2017.pdf 

Schwee LH. Pediatric SBIRT: understanding the magnitude of the problem. J Trauma Nurs. 2009;16(3):142-147. https://doi.org/10.1097/jtn.0b013e3181b9e0ee 

Substance Abuse and Mental Health Services Administration. (2021). Key substance use and mental health indicators in the United States: results from the 2020 National Survey on Drug Use and Health (HHS Publication No. PEP21-07-003, NSDUH Series H-56). Rockville, MD:Center for Behavioral Statistics and Quality, Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/data/