Why Screen?

question-mark

The majority of patients express concern that their health care provider is neither involved with their substance abuse- or addiction-related issues nor capable of detecting addiction or substance use issues when they are present.

In particular:

  • 54.8 percent of patients believed that physicians do not know how to detect addictions
  • 53.7 percent of patients said their primary care physician did nothing about their substance abuse
  • 74.1 percent of patients said their primary care physician was not involved in their decision to seek treatment

These numbers are a cause for concern and patients’ perceptions are not entirely unfounded nor do they fail to represent physicians’ own perceptions of their involvement with patents’ substance use.

  • 94 percent of primary care physicians missed or misdiagnosed alcohol-abusing patients
  • 88 percent of physicians said they asked new outpatients whether they drank alcohol, but only 13 percent used a formal alcohol screening tool
  • Only 19.9 percent of primary care physicians considered themselves “very prepared” to identify “alcoholism”

answerThe answer to the question “why screen for substance use,” then, is because if we do not, then we are missing valuable opportunities to help our patients, and to do so with a minimum of time and effort.

Screening tools are validated, quantifiable, and reproducible. They provide us key data to augment and move beyond our own intuition and “hunches” regarding who among our patients may or may not be using substances.

In turn, the processes enabled by the use of screening–the repeated asking and tracking of standardized substance use questions and answers–should, over time, address both patients’ and physicians’ perceptions about physicians’ ability to detect or identify substance use, misuse, abuse, or addiction.

In short, where these statistics suggest a problem, a gap in our performance, the regular and systematic use of screening tools with each and every one of our patients represents a means of scientifically closing that gap while simultaneously offering the possible of improve patient outcomes.

question-markThe majority of patients express concern that their health care provider is neither involved with their substance abuse- or addiction-related issues nor capable of detecting addiction or substance use issues when they are present.  In particular:

  • 54.8 percent of patients believed that physicians do not know how to detect addictions
  • 53.7 percent of patients said their primary care physician did nothing about their substance abuse
  • 74.1 percent of patients said their primary care physician was not involved in their decision to seek treatment

These numbers are a cause for concern and patients’ perceptions are not entirely unfounded nor do they fail to represent physicians’ own perceptions of their involvement with patents’ substance use.

  • 94 percent of primary care physicians missed or misdiagnosed alcohol-abusing patients
  • 88 percent of physicians said they asked new outpatients whether they drank alcohol, but only 13 percent used a formal alcohol screening tool
  • Only 19.9 percent of primary care physicians considered themselves “very prepared” to identify “alcoholism”

answerThe answer to the question “why screen for substance use,” then, is because if we do not, then we are missing valuable opportunities to help our patients, and to do so with a minimum of time and effort.

Screening tools are validated, quantifiable, and reproducible. They provide us key data to augment and move beyond our own intuition and “hunches” regarding who among our patients may or may not be using substances.

In turn, the processes enabled by the use of screening–the repeated asking and tracking of standardized substance use questions and answers–should, over time, address both patients’ and physicians’ perceptions about physicians’ ability to detect or identify substance use, misuse, abuse, or addiction.

In short, where these statistics suggest a problem, a gap in our performance, the regular and systematic use of screening tools with each and every one of our patients represents a means of scientifically closing that gap while simultaneously offering the possible of improve patient outcomes.

question-markWhy screen for substance use? Screening for a variety of disorders is common in pediatric practice. In the case of substance use, screening can actually open up discussions that reveal more than just usage history and patterns. Let’s look further at some of the reasons for routine substance use screening of pre-adolescents and adolescents.

We Routinely Screen for Common Conditions

When you think about screening, what disorders come to mind? The purpose of screening is to detect common diseases and disorders in the populations we care for. As it turns out, substance use disorders are among our most common conditions in any patient age category. Data from the National Institute on Drug Abuse’s 36th annual Monitoring the Future Survey revealed that in 2010, 48% of U.S. 12th graders surveyed had reported at use in their lifetime of at least one illicit substance. Of those, nearly half had used in the past month (23.8% of respondents).

The consequences of early alcohol and drug use can be far-reaching. Substance use before age 18 has been associated with an eightfold greater likelihood of developing substance dependence in adulthood. Adults who began to use alcohol before age 15 are five times more likely to report previous-year alcohol dependence or abuse than those who began alcohol use at age 21 or older.

answerSo given the frequency of adolescent alcohol and drug use and the potential for significant future adverse health outcomes, it makes sense to screen just from a “numbers” standpoint.

Patients Want a Chance to Talk

Part of the difficulty in screening for substance use among adolescents comes from a sensitivity regarding patient privacy and a desire to establish trust. It may be difficult or impossible to discuss these issues in front of a parent or ask to interview the patient alone. However, studies do show that patients do not mind being asked about their substance use. In some cases, patients genuinely want to discuss these issues with their primary care physician. A survey of adolescent females in the U.S. revealed that though only 35 percent of adolescents reported discussing substance use with their primary care physicians, 65 percent of the sample said they wanted to.

Screening Tools Are A Reliable, Efficient Way to Identify Problems

Have you ever been shocked to learn a patient was using an illicit substance? It turns out that, as physicians, we do a terrible job of judging a book by its cover. Physical signs, mode of speech, dress and manner provide very poor clues about which patients are engaging in risky substance use behaviors, particularly in the experimental and early regular use phases of adolescent substance use.

Screening tools are validated, quantifiable, and reproducible. The adolescent population has been well-studied in terms of what screening tools do and don’t “work.” These screening tools have been shown to provide us reliable data to augment and move beyond our own intuition and “hunches” regarding who among our patients may or may not be using substances. Plus, they only take a few minutes to administer by healthcare personnel. Some screening tools have been validated for self-administration, allowing for even greater time efficiency.

Screening can lead to prevention

Screening can open the subject of substance use with the adolescent patient. A negative result on a screening test can provide an opportunity for the pediatrician to focus on the individual’s beliefs about and experience with substance use in their lives.

For adolescents, a complex interplay of individual, family, peer, school and community characteristics can put them at greater risk of beginning or continuing substance use. Within all these “domains” of influence also lie factors, which can prevent the individual from engaging in experimental or regular substance use. The grid below outlines the relationship between the risk and protective factors that the pediatrician can use to tip the balance in the favor of safe behaviors.

The table below is adapted from Tobacco, Alcohol, and Other Drugs: The Role of the Pediatrician in Prevention, Identification, and Management of Substance Abuse (Kulig, JW, Pediatrics2005;115;816-821) and outlines the interplay of these factors within the domains of influence. The pediatrician can use this knowledge to leverage their influence upon protective factors in the adolescent’s life.

Domain Risk Factor Protective Factor
Individual Early initiation of substance use Late initiation of substance use
Attitude favorable to substance use Perceived risk of substance use
Low self-esteem or poor coping skills Positive sense of self, assertiveness, social competence
Attention-deficit/hyperactivity disorder Pharmacotherapy for attention-deficit/hyperactivity disorder
Sensation seeking, impulsivity, distractibility Resilient temperament
Low intensity of religious beliefs and observance High intensity of religious beliefs and observance
Rebelliousness and alienation from the dominant values of society and conventional norms Positive social orientation, adoption of conventional norms about substance use
Family Permissive or authoritarian parenting Authoritative parenting, parental monitoring of activities
Parental and older sibling use of alcohol, tobacco, or other drugs Clearly communicated parental expectation of nonuse and clear rules of conduct consistently enforced
Family history of alcoholism Parent in recovery
High levels of family conflict Positive, supportive relationships with family
Parental divorce during adolescence Open communication with parents
Child abuse and neglect or sexual abuse Supportive relationships with pro-social adults
Peers Friends who drink, smoke, or use other drugs Friends not engaged in substance use
School Perceived peer drug use Peer disapproval of substance use
Poor academic achievement and school failure Good academic achievement and school success
Low interest in school and achievement High academic aspirations
Community Disorganization in the community or neighborhood Less acculturation and higher ethnic identification
Availability of tobacco and alcohol Increased legal smoking and drinking ages
Marketing of tobacco and alcohol Increased excise taxes on tobacco and alcohol
Availability of licit and illicit drugs Strict law enforcement
Sociocultural Media portrayal of substance use Media literacy
Advertising licit substances Comprehensive, theory-based antidrug education programs

Don’t Miss Opportunities to Open the Door!

The answer to the question “why screen for substance use,” then, is because if we do not, then we are missing valuable opportunities to help our patients, and to do so with a minimum of time and effort.

 

question-markWhy screen for substance use? Screening for a variety of disorders is common in pediatric practice. In the case of substance use, screening can actually open up discussions that reveal more than just usage history and patterns. Let’s look further at some of the reasons for routine substance use screening of pre-adolescents and adolescents.

We Routinely Screen for Common Conditions

When you think about screening, what disorders come to mind? The purpose of screening is to detect common diseases and disorders in the populations we care for. As it turns out, substance use disorders are among our most common conditions in any patient age category. Data from the National Institute on Drug Abuse’s 36th annual Monitoring the Future Survey revealed that in 2010, 48% of U.S. 12th graders surveyed had reported at use in their lifetime of at least one illicit substance. Of those, nearly half had used in the past month (23.8% of respondents).

The consequences of early alcohol and drug use can be far-reaching. Substance use before age 18 has been associated with an eightfold greater likelihood of developing substance dependence in adulthood. Adults who began to use alcohol before age 15 are five times more likely to report previous-year alcohol dependence or abuse than those who began alcohol use at age 21 or older.

answerSo given the frequency of adolescent alcohol and drug use and the potential for significant future adverse health outcomes, it makes sense to screen just from a “numbers” standpoint.

Patients Want a Chance to Talk

Part of the difficulty in screening for substance use among adolescents comes from a sensitivity regarding patient privacy and a desire to establish trust. It may be difficult or impossible to discuss these issues in front of a parent or ask to interview the patient alone. However, studies do show that patients do not mind being asked about their substance use. In some cases, patients genuinely want to discuss these issues with their primary care physician. A survey of adolescent females in the U.S. revealed that though only 35 percent of adolescents reported discussing substance use with their primary care physicians, 65 percent of the sample said they wanted to.

Screening Tools Are A Reliable, Efficient Way to Identify Problems

Have you ever been shocked to learn a patient was using an illicit substance? It turns out that, as physicians, we do a terrible job of judging a book by its cover. Physical signs, mode of speech, dress and manner provide very poor clues about which patients are engaging in risky substance use behaviors, particularly in the experimental and early regular use phases of adolescent substance use.

Screening tools are validated, quantifiable, and reproducible. The adolescent population has been well-studied in terms of what screening tools do and don’t “work.” These screening tools have been shown to provide us reliable data to augment and move beyond our own intuition and “hunches” regarding who among our patients may or may not be using substances. Plus, they only take a few minutes to administer by healthcare personnel. Some screening tools have been validated for self-administration, allowing for even greater time efficiency.

Screening can lead to prevention

Screening can open the subject of substance use with the adolescent patient. A negative result on a screening test can provide an opportunity for the pediatrician to focus on the individual’s beliefs about and experience with substance use in their lives.

For adolescents, a complex interplay of individual, family, peer, school and community characteristics can put them at greater risk of beginning or continuing substance use. Within all these “domains” of influence also lie factors, which can prevent the individual from engaging in experimental or regular substance use. The grid below outlines the relationship between the risk and protective factors that the pediatrician can use to tip the balance in the favor of safe behaviors.

The table below is adapted from Tobacco, Alcohol, and Other Drugs: The Role of the Pediatrician in Prevention, Identification, and Management of Substance Abuse (Kulig, JW, Pediatrics2005;115;816-821) and outlines the interplay of these factors within the domains of influence. The pediatrician can use this knowledge to leverage their influence upon protective factors in the adolescent’s life.

Domain Risk Factor Protective Factor
Individual Early initiation of substance use Late initiation of substance use
Attitude favorable to substance use Perceived risk of substance use
Low self-esteem or poor coping skills Positive sense of self, assertiveness, social competence
Attention-deficit/hyperactivity disorder Pharmacotherapy for attention-deficit/hyperactivity disorder
Sensation seeking, impulsivity, distractibility Resilient temperament
Low intensity of religious beliefs and observance High intensity of religious beliefs and observance
Rebelliousness and alienation from the dominant values of society and conventional norms Positive social orientation, adoption of conventional norms about substance use
Family Permissive or authoritarian parenting Authoritative parenting, parental monitoring of activities
Parental and older sibling use of alcohol, tobacco, or other drugs Clearly communicated parental expectation of nonuse and clear rules of conduct consistently enforced
Family history of alcoholism Parent in recovery
High levels of family conflict Positive, supportive relationships with family
Parental divorce during adolescence Open communication with parents
Child abuse and neglect or sexual abuse Supportive relationships with pro-social adults
Peers Friends who drink, smoke, or use other drugs Friends not engaged in substance use
School Perceived peer drug use Peer disapproval of substance use
Poor academic achievement and school failure Good academic achievement and school success
Low interest in school and achievement High academic aspirations
Community Disorganization in the community or neighborhood Less acculturation and higher ethnic identification
Availability of tobacco and alcohol Increased legal smoking and drinking ages
Marketing of tobacco and alcohol Increased excise taxes on tobacco and alcohol
Availability of licit and illicit drugs Strict law enforcement
Sociocultural Media portrayal of substance use Media literacy
Advertising licit substances Comprehensive, theory-based antidrug education programs

Don’t Miss Opportunities to Open the Door!

The answer to the question “why screen for substance use,” then, is because if we do not, then we are missing valuable opportunities to help our patients, and to do so with a minimum of time and effort.

Screening can help identify those at risk, and screening takes very little time. For alcohol, for example, 25% of the population will score an 8 or above on the AUDIT, a brief screening tool for alcohol use and abuse.

SBIRT_Drinkers_Pyramid