Am Fam Physician. 2015;91(5):online
Summary of Recommendation and Evidence
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary care–based behavioral interventions to prevent or reduce illicit drug or nonmedical pharmaceutical use in children and adolescents. This recommendation applies to children and adolescents who have not already been diagnosed with a substance use disorder (Table 1). I statement.
|Population||Children and adolescents younger than age 18 years who have not already been diagnosed with a substance use disorder|
|Grade: I statement|
|Behavioral interventions||While the evidence is insufficient to recommend specific interventions in the primary care setting, those that have been studied include face-to-face counseling, videos, print materials, and interactive computer-based tools. Studies on these interventions were limited and findings on whether interventions significantly improved health outcomes were inconsistent.|
|Balance of benefits and harms||The evidence regarding primary care–based behavioral interventions to prevent or reduce illicit drug and nonmedical pharmaceutical use in children and adolescents is insufficient, and the balance of benefits and harms cannot be determined.|
|Other relevant USPSTF recommendations||The USPSTF has made recommendations on screening for and interventions to decrease the unhealthy use of other substances, including alcohol and tobacco. These recommendations are available at http://www.uspreventiveservicestaskforce.org.|
According to the National Survey on Drug Use and Health (NSDUH), more than 4,300 adolescents aged 12 to 17 years use drugs for the first time each day in the United States.1 (note: The NSDUH collected data on use of illicit drugs and nonmedical use of prescription drugs but not over-the-counter drugs; thus, actual drug use [illicit and non-medical use of all pharmaceuticals] rates may be greater.) Approximately 9.5% of youths aged 12 to 17 years report drug use in the past month.1 In addition, in 2012, 4.4% of eighth-, tenth-, and twelfth-grade students reported using over-the-counter cough or cold medicine in the past year for non-medical reasons.2 Drug use is associated with many negative health, social, and economic consequences and is a significant contributor to 3 of the leading causes of death among adolescents—motor vehicle accidents, homicide, and suicide. Consequences not only arise from frequent and heavy drug use, but use increases risk-taking behaviors while intoxicated, such as driving under the influence, unsafe sexual activity, and violence. In 2011, more than 150,000 adolescents were treated in emergency departments for complications of illicit drug and nonmedical pharmaceutical use.3
BENEFITS OF BEHAVIORAL INTERVENTIONS
The USPSTF found inadequate evidence about the effect of behavioral interventions to reduce drug use on health outcomes in adolescents. It also found inadequate evidence about the effect of behavioral interventions to reduce initiation of drug use in adolescents. The Task Force found no evidence about behavioral interventions for children younger than age 11 years.
HARMS OF BEHAVIORAL INTERVENTIONS
The USPSTF found no studies about the magnitude of the harms of behavioral interventions to prevent or reduce drug use. Although the USPSTF recognizes that theoretical harms, such as the potential to increase drug initiation through a false sense of security, may exist, it concludes that the harms of behavioral interventions are probably small to none.
The USPSTF concludes that the evidence about primary care–based behavioral interventions to prevent or reduce illicit drug and nonmedical pharmaceutical use in children and adolescents is insufficient, and the balance of benefits and harms cannot be determined.
PATIENT POPULATION UNDER CONSIDERATION
This recommendation applies to children and adolescents younger than age 18 years. It does not apply to children and adolescents who have been diagnosed with a substance use disorder. All persons with a substance use disorder should receive appropriate treatment. Although this statement does not include a recommendation on screening for drug use, further information on screening tests is provided in the Discussion section.
The USPSTF recognizes that various definitions have been applied to the terms drug use, misuse, and abuse. For the purpose of this recommendation statement, “drug use” encompasses the general concepts of “illicit drug use” and “nonmedical use of pharmaceuticals” (prescription and over-the-counter drugs). “Illicit drug use” specifies use of illegal drugs (such as cocaine and heroin) and inhalants (such as aerosols, glue, and gasoline). “Nonmedical use of pharmaceuticals” includes the use of prescribed medications for a purpose other than prescribed (or by a person not prescribed the medication) or the use of over-the-counter drugs for a purpose other than medically indicated. To be consistent with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, “substance use disorder” is used instead of “substance abuse” and “substance dependence” unless describing previously collected study or survey results that reported findings using the terms abuse and dependence.
Although the evidence to recommend specific interventions in the primary care setting is insufficient, interventions that have been studied include face-to-face counseling, videos, print materials, and interactive computer-based tools. Studies on these interventions provide little to no evidence of significant improvements in health outcomes.
SUGGESTIONS FOR PRACTICE REGARDING THE I STATEMENT
In deciding whether to provide behavioral interventions to prevent or reduce illicit drug and nonmedical pharmaceutical use for children and adolescents, primary care providers should consider the following.
Potential Preventable Burden. According to the NSDUH, nearly 1 in 10 American adolescents uses drugs.1 In 2011, the Drug Abuse Warning Network estimated that more than 75,000 emergency department visits by children and adolescents involved illicit drugs, and more than 75,000 visits involved the nonmedical use of pharmaceuticals.3 The consequences of drug use include risk for progression to a substance use disorder, an increase in risk-taking behaviors while under the influence, and lower educational achievement and attainment. Persons who initiate marijuana use at younger ages are more likely to progress to drug abuse and dependence as adults compared with those who initiate use after age 18 years.1
Costs. The costs associated with primary care–based behavioral interventions vary substantially and are similar to costs of interventions for tobacco and alcohol reduction. Health systems and providers should account for the staff time associated with any intervention, which may range from distributing educational materials to a series of office-based, 1-on-1 counseling sessions. Computer-based interactive tools linked to an adolescent's personal health record may require less ongoing staff time to administer. There are also potential costs for families, especially for interventions that require significant participation from parents as well as adolescents.
Potential Harms. Potential harms associated with behavioral interventions include anxiety, interference with the clinician–patient relationship, opportunity costs (that is, time spent on these interventions that could be used for other, more effective interventions), unintended increases in other risky behaviors, and even paradoxical increases in drug use or initiation. Although evidence is limited, no direct harms were identified.
Current Practice. Most clinicians who care for children and adolescents in the United States do not provide behavioral interventions to reduce drug use. Given the lack of evidence of effective primary care–based interventions, this is not surprising. It is important to recognize that this recommendation does not address screening for drug use. Screening adolescents who are not suspected to be using drugs may identify some who meet criteria for a substance use disorder and for whom treatment is available. The Task Force did not find effective interventions to reduce future drug use in adolescents who have tried illicit drugs.
The USPSTF has made recommendations on screening for and interventions to decrease the unhealthy use of other substances, including alcohol and tobacco. These recommendations are available on the USPSTF Web site (http://www.uspreventiveservicestaskforce.org).
This recommendation statement was first published in Ann Intern Med. 2014;160(9):634–639.
The “Other Considerations,” “Discussion,” “Update of Previous USPSTF Recommendation,” and “Recommendations of Others” sections of this recommendation statement are available at http://www.uspreventiveservicestaskforce.org/Page/Topic/recommendation-summary/drug-use-illicit-primary-care-interventions-for-children-and-adolescents.
The USPSTF recommendations are independent of the U.S. government. They do not represent the views of the Agency for Healthcare Research and Quality, the U.S. Department of Health and Human Services, or the U.S. Public Health Service.