Drug (Illicit) and Nonmedical Pharmaceutical Use: Primary Care Behavioral Interventions -- Children and Adolescents


General

Grade: I The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.

Specific Recommendations

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.

Frequency of Service

No information available.

Risk Factor Information

No information available.


Clinical

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.

Definitions

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.

Behavioral Interventions

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 use drugs. 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. 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.

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.

Useful Resources

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 (www.uspreventiveservicestaskforce.org).

Other Considerations

Research Needs and Gaps

Illicit drug and nonmedical pharmaceutical use in adolescents is an important public health problem. Evidence to assess the effects of behavioral interventions in adolescents is limited, and high-quality studies that focus on the role of primary care professionals in preventing initiation of drug use and reducing use among those who have experimented are needed. Research on brief interventions; interventions that link screening with tailored interventions; and social media, cell phone, and Internet-based interventions is needed and may identify novel, effective risk-reduction strategies. Research should continue to study diverse populations and the effects of interventions on children and adolescents with different risks, as well as which interventions work best in these subpopulations. Research should continue to examine the effectiveness of behavioral interventions with and without parental involvement. Additional high-quality studies that evaluate interventions and address drug use in the context of other substances, including tobacco and alcohol, are also needed. Research to develop and validate tools to measure current and past substance use is needed. Attention should be given to the standardization of research outcomes to improve the ability of future systematic reviews to move the field forward.

Rationale

No information available.


Others

The American Academy of Pediatrics recommends that all adolescents be screened for alcohol and drug use and that, based on the results, clinicians conduct further assessment, provide guidance and brief counseling interventions, and, if appropriate, refer for treatment. The American Academy of Family Physicians' recommendation on interventions to address drug use in children and adolescents is currently under review.


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