USPSTF Draft Recommendation

More Study Needed on Illicit Drug Use Counseling in Youth

October 22, 2019 08:50 am Chris Crawford

On Oct. 1, the U.S. Preventive Services Task Force posted a draft recommendation statement(www.uspreventiveservicestaskforce.org) and draft evidence review(www.uspreventiveservicestaskforce.org) on primary care-based prevention of illicit drug use in young people.

[physician talking to teenage patient]

The USPSTF concluded that current evidence is insufficient to assess the benefits and harms of primary care-based behavioral counseling interventions to prevent or reduce illicit drug use, including nonmedical use of prescription drugs, in children, adolescents and young adults. This is an "I" statement.(www.uspreventiveservicestaskforce.org)  

The task force defined illicit drugs as illegal drugs or prescription medications or household products that are used in a way that isn't recommended.

The USPSTF noted that by the time adolescents graduate from high school, about half of them have used an illicit drug.

"We know that using illicit drugs at a young age can lead to many poor social and health outcomes, including lower academic performance or developing a drug dependency," said USPSTF member Michael Silverstein, M.D., M.P.H., in a news release.(www.uspreventiveservicestaskforce.org) "Therefore, it is critical to find effective ways for clinicians to keep children and teens from starting to use drugs in the first place."

Story Highlights
  • The U.S. Preventive Services Task Force concluded that current evidence is insufficient to assess the benefits and harms of primary care-based behavioral counseling interventions to prevent or reduce illicit drug use in children, adolescents and young adults.
  • This draft statement is generally consistent with the USPSTF's 2014 final recommendation on the topic but expanded the population considered in its evidence review to include adults between ages 18 and 25.
  • On Aug. 13, the task force posted another draft recommendation on screening for illicit drug use and concluded that evidence was insufficient to assess the balance of benefits and harms of screening for illicit drug use in adolescents.

The task force reviewed evidence on how clinicians can prevent drug use in young patients who have never used drugs or who have only rarely used them by providing behavioral interventions, including through approaches such as one-on-one counseling, group sessions, print materials and computer-based tools.

"Unfortunately, while some studies on how primary care clinicians can prevent drug use in young people showed promising results, others did not," said USPSTF member Martha Kubik, Ph.D., R.N., in the release. "More research is needed to identify how clinicians in primary care settings can make a difference in preventing drug use and its negative effects on young patients."

Clinicians should continue to rely on their judgment on how best to address this issue in young patients who are not using drugs, the task force concluded.

Comparison With Other Recommendations

This draft recommendation statement is generally consistent with the USPSTF's 2014 final recommendation(www.uspreventiveservicestaskforce.org) on the same topic, although it expanded the population considered in its evidence review to include adults between ages 18 and 25.

On Aug. 13, the task force posted a draft recommendation on screening for illicit drug use,(www.uspreventiveservicestaskforce.org) which also concluded that evidence was insufficient to assess the balance of benefits and harms of screening for illicit drug use in adolescents -- an "I" statement. At this time, the AAFP continues to support a similar final recommendation statement(www.uspreventiveservicestaskforce.org) the USPSTF released in 2008.

About the Current Draft Recommendation

The USPSTF commissioned a systematic evidence review to update its 2014 recommendation statement on interventions to prevent illicit drug use in children, adolescents and young adults.

The task force reviewed 28 studies on interventions to prevent illicit drug use. Ten studies targeted middle school students (ages 10-14) and two targeted young adults (ages 17-24). The remaining studies focused on youth in high school or of high school age.

Twenty-one of the studies were conducted in the United States; race/ethnicity data were not reported in all studies, but 10 studies included a majority of black and Hispanic youth, three were limited to Native American females and one was limited to Asian American females.

Nearly half of the interventions studied consisted of individual counseling sessions (in person or by phone), 18% were group sessions or a combination of group and individual sessions, and 36% were exclusively computer-based. Most interventions -- 67% -- involved the youth alone; 24% involved the youth and the parent.

Trials in middle school-age youth tended to be more intensive, with an average of seven to 12 sessions, compared with one to three sessions in older groups.

According to the draft recommendation, common components of interventions targeted to youth were

  • education about illicit drugs and/or other substances;
  • correction of normative thoughts or beliefs; and
  • development of social skills, stress management skills, positive peer relationships, refusal skills and self-esteem.

Interventions targeted to parents included information on youth development, communication, monitoring, establishing rules and positive parenting.

And although alcohol and tobacco are both psychoactive drugs, they were not the focus of this recommendation; the USPSTF has made separate recommendations on screening and interventions for alcohol use(www.uspreventiveservicestaskforce.org) (final) and interventions for tobacco use(www.uspreventiveservicestaskforce.org) (draft) in adolescents.

Family Physician Expert's Perspective

Robert "Chuck" Rich, M.D., of Bladenboro, N.C., who represents the AAFP on the AMA Task Force to Reduce Opioid Abuse, told AAFP News that substance use of all types in adolescents has been linked to increased risk of death from vehicular accidents, accidental overdose, suicide and homicide.

Additionally, research has suggested that use of drugs as adolescents is linked with increased incidence of substance abuse as adults compared with those who never used drugs in adolescence.

"Finally, there is evidence that suggests use of cannabis in adolescence is associated with decreased academic performance; decreased academic advancement; increased anxiety; and poorer learning, attention and thinking compared to nonuser adolescents," Rich said.

Based on current research, Rich recommends family physicians routinely begin conversations about illicit drugs with patients at age 12 and start those conversations even earlier if the preteen is at particular risk for earlier exposure to drugs or alcohol.

"If these conversations reveal possible substance use or abuse, interventions begin with advising the adolescent to reduce and discontinue use and, subsequently, praising and offering encouragement for positive changes noted in follow-up visits," he said. "Family physicians will need to see at-risk adolescents more frequently to monitor for such behavior changes."

For adolescents using and/or abusing drugs or alcohol, interventions include definitive advice to reduce and discontinue use, including asking them to help develop the plan to accomplish those behavior changes and eliciting the assistance of parents and other adults, such as teachers, to assist in those plans.

Rich noted that the USPSTF's draft recommendation doesn't recommend for or against specific interventions to help adolescents avoid substance use.

For adolescent patients at risk of injury and death, interventions include arranging for referral for substance abuse treatment and even immediate hospitalization for adolescents at greatest risk, he said.

As for parents, Rich said they should be aware of their own use of alcohol and drug use, because adolescents' behavior may easily be modeled after their own.

"It's also important to point out that the most common source for misused prescription drugs by adolescents is the home medicine cabinet, so any prescription pain medication or benzodiazepine should be stored in a lockable storage device or box away from ready access by adolescents or their friends," he said. "Similarly, encourage neighbors that your adolescent may visit to practice similar behaviors."

Finally, Rich said parents should be reminded to maintain an open, supportive dialogue with adolescents, encouraging them to discuss issues such as drug and alcohol use and offering positive encouragement when they do engage in those discussions.

"Along with the supportive parent, the supportive family physician who is sensitive to the issue of adolescent substance use and who is ready to ask those screening questions of their adolescent patient can positively impact the patient at risk and intervene before death, injury or other negative behavior occurs," Rich concluded.

Commenting Opportunity

The USPSTF is accepting comments on the draft recommendation statement(www.uspreventiveservicestaskforce.org) and draft evidence review(www.uspreventiveservicestaskforce.org) until 8 p.m. EDT on Oct. 28. All comments received will be considered as the task force prepares its final recommendation.

The AAFP will review the USPSTF's draft recommendation statement and supporting evidence and will provide comments to the task force. The Academy will release its own recommendations on the topic after the task force finalizes its guidance.

Related AAFP News Coverage
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Prevalence Varies by Age, Presence of Medical Condition

(10/16/2019)

AAFP Releases Marijuana, Cannabinoids Position Paper
Research Into Safety, Health Effects Sorely Needed, Says FP Expert

(9/20/2019)

USPSTF Recommends Screening Adults for Illicit Drug Use
Evidence Remains Insufficient to Recommend Screening in Adolescents

(8/27/2019)