How Pediatricians Can Foster Healthy Conversations about Substance Use
Picture this: You’re 14 years old, and you have an appointment to see your pediatrician for an annual physical before starting ninth grade. You don’t want to spend a precious summer afternoon in the doctor’s office when you could be hanging out with your friends, but it’s an annual requirement.
Your mother is with you because you don’t have a driver’s license or your own health insurance. You sit next to her in the waiting room while the time passes … excruciatingly slowly. When the medical assistant calls your name, your mother follows you into the exam room. You take a seat under the bright lights and the exam table paper crinkling under your weight, reminding you that this is not a comfortable position to be in.
The pediatrician enters and before you know it, she’s asking if you would answer a few questions about alcohol use and sexual activity. The last few summer months flash before your eyes. There definitely are some things you could report. You see your mother concerned and awaiting your response.
If you were in the patient’s shoes, how honest would you be? Would you disclose your risky behaviors? Highly unlikely, and we don’t blame you.
Changing the Conversation
Similar scenarios play out in primary care offices all over the country every day, and it takes a skilled practitioner to navigate the tricky dynamics at play to create an environment where adolescents feel safe providing information about substance use.
But it doesn’t have to be awkward for patients or providers. When pediatricians are properly trained, primary care is an ideal setting for the prevention of adolescent substance use. That’s because providers have ongoing and consistent visits with this population, and they have experience addressing health concerns.
Family First Health in York, Pa., participated in a National Council for Behavioral Health-led (National Council) learning community to develop the skills necessary to implement efforts to screen for and intervene early in adolescent substance use. So, when a pediatrician at the clinic encountered a 14-year old patient who, in the presence of her parents, declined to answer screening questions, they knew what to do.
The pediatrician tactfully asked the parents to step out of the exam room. When the patient was alone with the provider, she openly discussed her marijuana use and sexual activity. Having that information allowed the provider to address the patient’s marijuana use and offer reproductive health options, all while maintaining patient confidentiality.
The training that providers at Family First Health received was grounded in Screening, Brief Intervention and Referral to Treatment (SBIRT), an evidence-based approach to identify, treat and prevent risky substance use. The National Council, with support from the Conrad N. Hilton Foundation, developed Improving Adolescent Health: Facilitating Change for Excellence in SBIRT, an adolescent SBIRT implementation guide that addresses both clinical and operational change management concepts. The goal of the training is to implement SBIRT in accordance with this guide, the first comprehensive resource of its kind.
Improving Adolescent Health recommends using the Screening to Brief Intervention (S2BI) screening tool, which has been validated for use with adolescents. Unlike other screening tools, it is very brief yet highly effective, making it an ideal option for busy primary care practices. The implementation guide pairs the S2BI with practical tips to help providers effectively use the screener, including scripts for navigating patient confidentiality and parental involvement.
Adolescent Substance Use: A Continually Evolving Problem
This new implementation guide helps providers address an old, yet constantly evolving problem – adolescent substance use. When asked in the right way, adolescents may appreciate discussing substance use with their provider, and recent trends underscore the importance of having these conversations. New data shows that marijuana vaping has rapidly become a national medical crisis – the number of teens in 12th grade who vaped marijuana in any month nearly doubled in one year (increasing from 7.5% in 2018 to 14% in 2019), according to a new report released December 19, 2019, by the National Institute on Drug Abuse, a component of the National Institutes of Health.
As if this isn’t alarming enough, the recent American Academy of Family Physicians Vaping Survey, revealed that nearly nine in 10 youth who answered the survey got facts wrong and had misconceptions about health risks. For example, 60% of respondents (ages 16 to 30) said secondhand vapor is harmless, though there is no medical evidence to support that claim. This paints a particularly concerning picture: skyrocketing vaping rates paired with youth who are misinformed about the potential health effects.
And if you’re wondering whether alcohol use remains a problem, the Centers for Disease Control and Prevention (CDC) reports that by 12th grade, about two-thirds of students have tried alcohol.
As adolescent substance use continues to be a concern, primary care providers face challenges discussing, identifying and treating adolescents with substance use issues, whether they are identified as having a low-, moderate- or high-risk substance use disorder.
Federally qualified health centers that participated in the National Council’s learning community reported that using the S2BI helped them encourage adolescents to open up about their substance use. At Pillars Community Health in La Grange, Ill., an adolescent who previously reported no use on the screener, requested that the pediatrician administer the screener during a subsequent visit so she could report use. This example demonstrates that even if an adolescent does not immediately share information about their use, administering the S2BI sets the stage for continued conversations.
Jordan Valley Community Health in Springfield, Mo., encouraged an adolescent who used tobacco to participate in a program to reduce and quit smoking, demonstrating that sites not only screened, but also appropriately intervened and connected patients to much-needed services.
New Resources for a New, Comprehensive Approach
Publication and distribution of Improving Adolescent Health comes as SBIRT earns greater acceptance throughout the primary care community. But not all primary care providers are well-versed and trained at screening, so the new resource provides, among many other things, sample scripts for pediatricians and primary care providers to engage with their young patients on the subject of substance use.
Understanding substance use among adolescents is as important as understanding a young patient’s blood pressure or other vital signs and is inextricably linked to overall health. Alcohol or other drug use can lead to disease exacerbation and serious complications among adolescents with a chronic illness and may expose them to other risks that generally worsen health such as inadequate sleep, skipped meals, exposure to smoke and unprotected sex (Levy, et al., 2016; Wisk, et al., 2018).
The National Council’s resources help providers integrate SBIRT seamlessly into the delivery of care.
In addition to Improving Adolescent Health, the National Council website provides general information about SBIRT. A recent webinar provides a detailed discussion of SBIRT by primary care providers and those who helped develop the change package.