Background: Substance abuse is associated with many adolescent health problems such as depression, unplanned sexual activity, and conduct disorder. It is also associated with the leading causes of death among teenagers in the United States: accidents, homicide, and suicide. By the end of high school, one half of adolescents have used an illicit drug, and about 80 percent have started drinking. The American Medical Association and the American Academy of Pediatrics recommend substance abuse screening during the annual well-child care visit. Adherence to this recommendation among primary care practices has been low, with physicians citing inadequate time to perform this screening. Knight and colleagues studied the prevalence of positive substance abuse screenings among adolescents at routine outpatient medical visits.
The Study: The authors prospectively evaluated adolescents 12 to 18 years of age across a wide range of primary care practices in New England, including rural and urban settings and high school-based health centers. Participants were enrolled at well-child and acute care visits. Adolescents were asked to complete a survey during their visit that included the CRAFFT questionnaire, a six-question substance abuse screening tool that has high reliability and validity for identifying substance-related disorders in this population (see accompanying table). A score of two or more on the CRAFFT questionnaire was considered to be a positive screening result.
|C||Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or who had been using alcohol or drugs?|
|R||Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?|
|A||Do you ever use alcohol or drugs while you are by yourself, ALONE?|
|F||Do you ever FORGET things you did while using alcohol or drugs?|
|F||Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use?|
|T||Have you ever gotten into TROUBLE while you were using alcohol or drugs?|
Results: Ninety-three percent of the 2,301 invited adolescents agreed to complete the screening, for a total of 2,133 participants. The mean age of participants was 15.7 years. In the sample, 56.3 percent of respondents were female and 48.6 percent were non-Hispanic white adolescents. Two thirds of visits were for routine well-child care. Overall, 43.5 percent of respondents reported using alcohol or drugs at some point during their life, and 14.8 percent screened positive on the CRAFFT questionnaire for possible substance abuse. Significantly higher rates of positive CRAFFT results were seen among adolescents presenting for sick visits compared with well-child care visits (23.2 versus 11.4 percent, respectively), but this did not remain significant after adjusting for demographics including age, ethnicity, and practice location. Highest rates of CRAFFT-positive screening were seen in school clinics and rural family medicine practices (29.5 and 24.2 percent, respectively).
Conclusion: Given the high positive screen rates at acute care visits, the authors concluded that screening adolescents for substance abuse should be performed whenever there is an opportunity rather than waiting until annual well-child care visits. More research is needed on efficient methods for screening, although in this study the CRAFFT questionnaire was used effectively.