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Clinical Pearls Video Series: Substance Use Disorders

Video Chapters

Click on the three lines in the upper left corner to see chapter information or reference the chapter table of contents below to navigate to specific chapters.

  • Assessment
    • When should I start asking youth about their use, and is there an easy way to do that? (0:09–2:17)
    • What screening tools can be used and how can they help identify risk? (2:18–4:55)
    • I have a busy practice and wonder if there are strategies I can use that are time-limited when I start to notice initial or escalating use of nicotine or vaping, cannabis, and alcohol. (4:56–8:43)
    • What if I identify youth with more significant substance use during the screening process? (8:43–10:00)
  • Management
    • What can I do in a busy practice to help prevent substance use disorders in youth? Is there a communication style or approach that can help facilitate discussions about substance use and its treatment? (10:00–12:14)
    • What does treatment look like and what type of therapies are provided? (12:15–13:28)
    • What is the role of medications in substance use treatment? (13:29–15:38)
  • Key Takeaways (15:39–16:38)

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 Tools

Other Resources

Agerwala SM, McCance-Katz EF. Integrating screening, brief intervention, and referral to treatment (SBIRT) into clinical practice settings: a brief review. J Psychoactive Drugs. 2012;44(4):307-317. https://doi.org/10.1080/02791072.2012.720169 

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/ 

Test your knowledge with an optional 5-question quiz below. (Note: If you wish to receive a certificate of completion for this MC3 Clinical Pearl, you must receive a passing score of 80%.)

/5

Substance Use Disorders Quiz

1. When should screening for substance use begin in youth in the primary care setting?

2. An adolescent presents for an annual sports physical. The parent pulls you aside and tells you they found vaping materials in the adolescent’s backpack and hopes you will discuss this with them. The parent smokes tobacco and doesn’t want the adolescent to develop the habit but states “kids experiment, right?” Which of the following statements is most accurate for this patient?

3. An adolescent you are treating for depression with sertraline asks you about the benefits of marijuana for sleep. The patient states that the sertraline has been helpful but they continue to have difficulties sleeping and says using marijuana “2 or 3 times a week helps”. The patient’s PHQ-9 score is 16 and the adolescent has some suicidal ideation but no previous attempts, and no plan. When asked about intent the patient says “I would never do that to my family.” Which of the following is the most important next step in the care of this patient?

4. A patient in late adolescence comes in for examination before going to college in the fall. You screen for depression, suicidal ideation, and substance use using the PHQ-9, the Ask Suicide Screening Questions (ASQ), and the CRAFFT.  The PHQ score is 5 and item 9 is negative, the ASQ is negative, and the CRAFFT is positive for occasional weekend alcohol use and intermittent cannabis use. What is the next best step in supporting this adolescent given the information provided by the screeners?

5. With the support of an MC3 Consulting Psychiatrist, which of the following agents can be helpful in addressing cravings for cannabis in youth struggling with a cannabis use disorder?

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