The enormous public health impact of adolescent substance use and its preventable morbidity and mortality highlight the need for the health care sector, including pediatricians and the medical home, to increase its capacity regarding adolescent substance use screening, brief intervention, and referral to treatment (SBIRT). The American Academy of Pediatrics first published a policy statement on SBIRT and adolescents in 2011 to introduce SBIRT concepts and terminology and to offer clinical guidance about available substance use screening tools and intervention procedures. This clinical report provides a simplified adolescent SBIRT clinical approach that, in combination with the accompanying updated policy statement, guides pediatricians in implementing substance use prevention, detection, assessment, and intervention practices across the varied clinical settings in which adolescents receive health care.
Importance: Retention in care for individuals with opioid use disorder (OUD) is one of the single greatest predictors of reduced mortality. Although clinical trials support use of OUD medications among adolescents and young adults (“youth”), data on timely receipt of buprenorphine, naltrexone, and methadone and its association with retention in care in real-world treatment settings are lacking. Objective: To identify the proportion of youth who receive timely addiction treatment, and to determine whether timely receipt of OUD medications is associated with retention in care. Design: Retrospective cohort. Setting: Enrollment and complete health insurance claims of 2.4 million Medicaid-enrolled youth from 11 states, January 1, 2014 to December 31, 2015. Participants: Youth of age 13–22 years diagnosed with OUD. Exposures: Receipt of OUD medication (buprenorphine, naltrexone, or methadone) within three months of diagnosis, compared to receipt of behavioral health services alone. Main Outcome and Measures: Retention in care, with attrition defined as ≥60 days without any treatment-related claims. Results: Among 4,837 youth diagnosed with OUD, 56.9% were female and 76.0% were non-Hispanic white. Median age was 20 years (interquartile range [IQR], 19–22). Overall, 3,654 (75.5%) youth received any treatment within three months. Most received only behavioral health services (n=2,515; 52.0%), with fewer receiving OUD medications (n=1,139; 23.5%). Only 4.7% (95% confidence interval [CI], 3.1–6.2%) of adolescents <18 years and 24.7% (95% CI, 23.4–26.0%) of young adults ≥18 years received timely OUD medications. Median retention in care among youth who received timely buprenorphine, naltrexone, or methadone was 123 days (IQR, 33–434), 150 days (IQR, 50–670), and 324 days (IQR, 115–670), respectively, compared to 67 days (IQR, 14–206) among youth who received only behavioral health services. Timely receipt of buprenorphine (adjusted hazard ratio [aHR], 0.58; 95% CI, 0.52–0.64), naltrexone (aHR, 0.54; 95% CI, 0.43–0.69), and methadone (aHR, 0.32; 95% CI, 0.22–0.47) were each independently associated with lower attrition from treatment compared to receiving behavioral health services alone. Conclusions and Relevance: Timely receipt of buprenorphine, naltrexone, or methadone is associated with greater retention in care among youth with OUD. Strategies to address the underutilization of evidence-based medications for youth are urgently needed.
This technical report updates the 2004 American Academy of Pediatrics technical report on the legalization of marijuana. Current epidemiology of marijuana use is presented, as are definitions and biology of marijuana compounds, side effects of marijuana use, and effects of use on adolescent brain development. Issues concerning medical marijuana specifically are also addressed. Concerning legalization of marijuana, 4 different approaches in the United States are discussed: legalization of marijuana solely for medical purposes, decriminalization of recreational use of marijuana, legalization of recreational use of marijuana, and criminal prosecution of recreational (and medical) use of marijuana. These approaches are compared, and the latest available data are presented to aid in forming public policy. The effects on youth of criminal penalties for marijuana use and possession are also addressed, as are the effects or potential effects of the other 3 policy approaches on adolescent marijuana use. Recommendations are included in the accompanying policy statement.
IMPORTANCE Screening adolescents for substance use and intervening immediately can reduce the burden of addiction and substance-related morbidity. Several screening tools have been developed to identify problem substance use for adolescents, but none have been calibrated to triage adolescents into clinically relevant risk categories to guide interventions.OBJECTIVE To describe the psychometric properties of an electronic screen and brief assessment tool that triages adolescents into 4 actionable categories regarding their experience with nontobacco substance use. DESIGN, SETTING, AND PARTICIPANTS Adolescent patients (age range, 12-17 years) arriving for routine medical care at 2 outpatient primary care centers and 1 outpatient center for substance use treatment at a pediatric hospital completed an electronic screening tool from June 1, 2012, through March 31, 2013, that consisted of a question on the frequency of using 8 types of drugs in the past year (Screening to Brief Intervention). Additional questions assessed severity of any past-year substance use. Patients completed a structured diagnostic interview (Composite International Diagnostic Interview-Substance Abuse Module), yielding Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) substance use diagnoses. MAIN OUTCOMES AND MEASURESFor the entire screen and the Screening to Brief Intervention, sensitivity and specificity for identifying nontobacco substance use, substance use disorders, severe substance use disorders, and tobacco dependence were calculated using the Composite International Diagnostic Interview-Substance Abuse Module as the criterion standard. RESULTSOf 340 patients invited to participate, 216 (63.5%) enrolled in the study. Sensitivity and specificity were 100% and 84% (95% CI, 76%-89%) for identifying nontobacco substance use, 90% (95% CI, 77%-96%) and 94% (95% CI, 89%-96%) for substance use disorders, 100% and 94% (95% CI, 90%-96%) for severe substance use disorders, and 75% (95% CI, 52%-89%) and 98% (95% CI, 95%-100%) for nicotine dependence. No significant differences were found in sensitivity or specificity between the full tool and the Screening to Brief Intervention. CONCLUSIONS AND RELEVANCEA single screening question assessing past-year frequency use for 8 commonly misused categories of substances appears to be a valid method for discriminating among clinically relevant risk categories of adolescent substance use.
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