Three Minutes To Spot TroubleJanuary 19, 2017
2-3 minutes is about how much time the average pediatrician has in a typical checkup with a teenage patient to assess whether they're using drugs or alcohol, according to a leading screening expert. And half of all doctors don't ask at all. HRSA is trying to change that.
Three out of four people admitted into treatment for substance use disorders started using alcohol or drugs before the age of 17 – but fewer than half of all pediatricians are currently screening for substance abuse in their young patients, two Harvard researchers say.
Further underscoring the urgent need for health care providers to get better at spotting the warning signs, as many as seven out of ten adolescent deaths may be attributable to alcohol and drugs.
Busy pediatricians have only a matter of about 2-3 minutes in a typical 20-minute appointment with a teenager to make an evaluation, said Dr. John Rogers Knight, founder of the Center for Adolescent Substance Abuse Research at Boston Children's Hospital, in a recent webcast.
So finding ways of quickly eliciting information has long been a challenge in clinical practice, "but the only way we are going to really make headway over time" against addiction "is if we prevent people from starting," said Knight, a pioneer in screening protocols.
Now comes new research that shows young people can screen themselves using a digital tablet "just as well" as being interviewed by their doctor, reported Dr. Sion Kim Harris, co-director of the center, in a December talk hosted by HRSA's Maternal and Child Health Bureau.
Changing clinical practice: (From left), Drs. John Rogers Knight, Sion Kim Harris and Shannon McDevitt (BPHC) described changes needed in youth screening procedures to cut down the incidence of alcohol and substance use -- and teen deaths. HRSA recently invested $94 million in health centers to hire new staff and increase screening.
Knight added that on-screen surveys may also help get around the longstanding problem of parental intrusion in examination rooms – which can dampen doctor-patient communications. In any case, caregivers who "don't have a structured approach to screening (are) going to miss the kids that have problems" if they simply rely on clinical impressions.
The digital method -- Computerized Screening and Brief Advice (cSBA) -- is an alternative to the questionnaire method common in primary care settings to screen patients age 12 to 24.
Known as CRAFFT, for "Car, Relax, Alone, Forget, Friends, and Trouble," the standard method uses six questions authored by Knight to help determine whether a longer conversation about substance use is warranted.
Focus group studies have made clear that young patients want to hear factual information about alcohol and drugs. The message, Knight said, is "Just give us the facts and trust us to make the right decisions … adolescents are especially interested in neuroscience. They like hearing about how their brains develop."
Competing trends in adolescent substance use: While drinking, smoking and drug use have been in overall decline, Knight noted, illicit drugs have re-emerged as a public health threat -- and alcohol remains a stubborn adversary and the leading killer, often enabled by ill-informed parents.
That addiction is a pediatric disease is plain.
Some 40 percent of all US adolescent deaths are attributable to unintentional injuries, Knight reported. "Motor vehicle crashes are the number one cause of premature and preventable deaths in the U.S." When combined with mortality by homicide and suicide, substance misuse may be a factor in as many as 71 percent of all adolescent deaths.
For now, drinking is the biggest contributor.
"Alcohol actually accounts for more deaths among teenagers than all drugs put together" in the United States, Knight said.
That could well change soon, however, given the nation's opioid crisis.
In the meantime, parents and kids alike need accurate information about alcohol and other substance use.
"About a third of parents provide alcohol to their children around prom and graduation season, thinking - incorrectly - that they can somehow keep them safe if they take the keys away," Knight said. "They are still not safe."
Dr. Shannon McDevitt of the Bureau of Primary Health Care, said one in 10 adolescents get their primary care services through a community health center, making them ideal venues to address the problem.
Some 271 grants awarded last year, a $94 million investment, will expand substance use disorder services in Health Centers.
The funds will enable approximately 800 new providers to be hired and 124,000 additional patients to receive treatment, she said.
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