Doctors often miss teen substance abuse
Severe alcohol and drug abuse by teenagers may be easily missed during routine and urgent-care medical visits, particularly in girls.
In a study published in the November issue of Pediatrics, researchers highlighted not only how often clinicians fail to notice the chronic problem in routine examinations, but also how seldom they seem to ask teens structured questions to determine how frequently they take drugs or alcohol.
In 2002, examinations of 500 urban adolescents, ages 14 to 18, at Children’s Hospital Boston failed to detect use or recurrent abuse in about 40% of the more than 100 teens who were later determined to have serious problems. In the 60% of cases in which clinicians correctly identified some use of alcohol or other drugs, they vastly underestimated the severity: Only 10% of recurrent “abusers” were correctly identified while “dependence” was missed in all 36 cases later diagnosed.
Yet, when the teenagers were asked specific questions about drug-and-alcohol related behavior in separate interviews after their exams, they were likely to talk about their use of alcohol or drugs.
“While a structured screening tool won’t necessarily make the adolescent reveal the problem, it hopefully would give the provider a structured way to ask about it,” said lead author Dr. Celeste Wilson, a pediatrician and researcher at Children’s Hospital Boston.
Adolescent substance abuse is a chronic problem that contributes to automobile accidents, unwanted pregnancies, sexually transmitted diseases, suicide and crime, and can also be a symptom of underlying mental problems such as depression.
Some studies indicate that the majority of adolescents have tried alcohol or another drug by the time they reach 12th grade. Some studies estimate that about 1.4 million teens regularly abuse illicit drugs. As a result, the American Medical Assn. recommends that health care providers screen all adolescents for substance abuse during routine physical exams.
The authors of the study recommended that medical staff routinely ask teenagers five questions, which they developed into a mnemonic, CRAFFT:
C: Have you ever ridden in a car driven by you or someone else who was using alcohol or drugs?
R: Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in?
A: Do you ever use alcohol or drugs while you are alone?
F: Do you ever forget things you did while using drugs or alcohol?
F: Do your family or friends ever advise you to cut down on your drinking or drug use?
T: Have you gotten into trouble while you were using alcohol or drugs?
Funded by the Robert Wood Johnson Foundation, the study involved more than 100 physicians, residents, medical students and nurse practitioners who completed a form giving their clinical impressions about each teen’s degree of substance use (none, minimal, problem use, abuse, dependence) after a physical exam with the patient. (The residents were not told the purpose of the evaluation.)
Of the more than 100 teens who were later identified to have “problem use,” the providers correctly identified just 18. Of the 86 most serious abusers (who fell into the “abuse” or “dependence” categories), providers underestimated their problem, categorizing the teens as having no use (24%); minimal use (50%); problem use (15%); abuse (10.5%) and dependence (0%).
The problems were more likely to be identified in boys, perhaps because boys are more likely to abuse substances than girls and so clinicians may be more likely to suspect them to be substance abusers, while inaccurately giving the girls the benefit of the doubt.
Tests that detect the presence of drugs or alcohol in the blood or urine were not used, said Wilson, and she doesn’t recommend them for routine screening because they can be misleading. A negative test doesn’t necessarily mean that there isn’t a problem, just that the substance wasn’t used in the last several hours, she said.
“It’s much more important to understand and communicate what’s going on and to get at the root of the problem,” Wilson said.