Disclosure of Adolescent Substance Use in Primary Care: Comparison of Routine Clinical Screening and Anonymous Research Interviews

Initial Validation of a Computerized Adaptive Test for Substance Use Disorder Identification in Adolescents

PURPOSE

Computerized adaptive tests (CATs) are highly efficient assessment tools that couple low patient and clinician time burden with high diagnostic accuracy. A CAT for substance use disorders (CAT-SUD-E) has been validated in adult populations but has yet to be tested in adolescents. The purpose of this study was to perform initial evaluation of the K-CAT-SUD-E (i.e., Kiddy-CAT-SUD-E) in an adolescent sample compared to a gold-standard diagnostic interview.

METHODS

Adolescents (N = 156; aged 11-17) with diverse substance use histories completed the K-CAT-SUD-E electronically and the substance related disorders portion of a clinician-conducted diagnostic interview (K-SADS) via tele-videoconferencing platform. The K-CAT-SUD-E assessed both current and lifetime overall SUD and substance-specific diagnoses for nine substance classes.

RESULTS

Using the K-CAT-SUD-E continuous severity score and diagnoses to predict the presence of any K-SADS SUD diagnosis, the classification accuracy ranged from excellent for current SUD (AUC = 0.89, 95% CI = 0.81, 0.95) to outstanding (AUC = 0.93, 95% CI = 0.82, 0.97) for lifetime SUD. Regarding current substance-specific diagnoses, the classification accuracy was excellent for alcohol (AUC = 0.82), cannabis (AUC = 0.83) and nicotine/tobacco (AUC = 0.90). For lifetime substance-specific diagnoses, the classification accuracy ranged from excellent (e.g., opioids, AUC = 0.84) to outstanding (e.g., stimulants, AUC = 0.96). K-CAT-SUD-E median completion time was 4 min 22 s compared to 45 min for the K-SADS.

CONCLUSIONS

This study provides initial support for the K-CAT-SUD-E as a feasible accurate diagnostic tool for assessing SUDs in adolescents. Future studies should further validate the K-CAT-SUD-E in a larger sample of adolescents and examine its acceptability, feasibility, and scalability in youth-serving settings.

Patterns of substance use among adolescents in and out of foster care: An analysis of linked health and child welfare administrative data

BACKGROUND

Young adults with a history of foster care have higher risk for substance use disorders. Social systems can deliver substance use prevention to youth; however, the timing of intervention delivery and how needs differ for youth in foster care are unclear.

OBJECTIVE

To compare initiation and rates of substance use among adolescents in foster care to demographically similar adolescents never in foster care as identified by the healthcare system, and identify factors associated with increased substance use.

PARTICIPANTS AND SETTING

Youth in foster care (n = 2787, ages 10-20, inclusive) and demographically matched youth never in foster care (n = 2787) were identified using linked child welfare and electronic health records from a single pediatric children's hospital and county over a five-year period (2012-2017).

METHODS

All healthcare encounters were reviewed and coded for substance use by type (alcohol, tobacco, cannabis, other). Age of first reported or documented substance use was also captured. Demographic and child welfare information was extracted from administrative records. Survival and logistic regression models were estimated.

RESULTS

In adjusted models, youth in foster care initiated substance use at earlier ages (HR = 2.50, p < .01) and had higher odds of engaging in use (AOR = 1.54; p < .01) than youth never in care. By age 12, substance use initiation was more likely while youth were in foster care than when they were not in foster care (HR = 1.42, p < .01). Placement stability and family care settings reduced odds of lifetime substance use.

CONCLUSIONS

Foster care placement is associated with substance use. Screening may be important for prevention.

Veterans Health Administration Screening for Military Sexual Trauma May Not Capture Over Half of Cases Among Midlife Women Veterans

BACKGROUND

Approximately 1 in 3 women veterans endorse military sexual trauma (MST) during Veterans Health Administration (VHA) screening. Higher rates have been reported in anonymous surveys.

OBJECTIVE

We compared MST identified by VHA screening to survey-reported MST within the same sample and identified participant characteristics associated with discordant responses.

METHODS

Cross-sectional data were drawn from an observational study of women veterans aged 45-64 enrolled in VHA care in Northern California, with data from mail- and web-based surveys linked to VHA electronic health records (EHRs). Between March 2019 and May 2020, participants reported sociodemographic characteristics, current depressive (Patient Health Questionnaire-9) and posttraumatic stress (PTSD checklist for DSM-5) symptoms, and MST (using standard VHA screening questions) in a survey; depression and posttraumatic stress disorder diagnoses (ICD-10 codes) and documented MST were identified from EHRs. Associations between sociodemographic characteristics, mental health symptoms and diagnoses, and discordant MST reports (EHR-documented MST vs. MST reported on survey, not in EHR) were examined with multivariable logistic regression.

RESULTS

In this sample of midlife women veterans (n = 202; mean age 56, SD = 5), 40% had EHR-documented MST, and 74% reported MST on the survey. Sociodemographic characteristics, mental health symptoms, and diagnosed depression were not associated with discordant MST responses. Women with an EHR-documented PTSD diagnosis had fivefold higher odds of having EHR-documented MST (vs. survey only; odds ratio 5.2; 95% confidence interval 2.3-11.9).

CONCLUSIONS

VHA screening may not capture more than half of women who reported MST on the survey. VHA screening may underestimate true rates of MST, which could lead to a gap in recognition and care for women veterans.

Rates and predictors of substance use in pediatric primary care clinics

Background: Screening for substance use within pediatric primary care provides a unique opportunity to identify adolescents in need of intervention. Methods: This study analyzed screening data collected across 13 Federally Qualified Health Centers over the course of an 18-month project designed to implement Screening Brief Intervention Referral to Treatment (SBIRT) for adolescents aged 12-21. A mixed-effects modeling strategy was used to describe associations between demographic, procedural, and clinical factors and adolescent reports of substance use. Results: In total, 10,813 adolescents were screened between December 2017 and May 2019, with 17% reporting past year use, including 11% at lower risk and 6% at high risk of a substance use disorder. Females, Hispanic, Black/African American, heterosexual, non-primary English speakers, and patients who did not have a co-occurring mental health disorder were all less likely to report past year substance use. While rates of disclosing any past year substance use were equivalent between patients screened by a staff member and those who completed self-administered screens, patients who were screened by a staff member were associated with reporting overall greater frequencies of use. Patients who were screened by a staff member with a parent present were less likely to disclose any past year substance use. Conclusion: While overall rates of disclosure of any past year substance use (17.2%) were lower than reported in research settings, a substantial proportion (6.3%) had screen results indicating a high risk for substance use disorder.

Development and preliminary evaluation of the Conventional Medicine Disclosure Index

BACKGROUND

Non-disclosure of conventional medicine use to complementary medicine health professionals may result in patient harm. Currently, no standardised validated instrument is available to measure reasons for conventional medicine disclosure or non-disclosure.

OBJECTIVE

The aim of this study was to develop and evaluate a multidimensional index for identifying reasons for conventional medicine disclosure and non-disclosure by patients.

METHODS

Drawing upon a sub-sample of the Complementary and Alternative Medicine Use Health Literacy Disclosure Study (N = 520), a formative measurement approach was used to develop a Conventional Medicine Disclosure Index (CONMED-DI). Variance-based structural equation modelling employing partial least squares evaluated multicollinearity, significance and relevance of the formative indicators to their associated primary constructs.

RESULTS

The CONMED-DI demonstrated adequate construct validity suggesting the CONMED-DI is a pragmatic measure to determine the reasons why people choose to disclose (or not) their conventional medicine use. The CONMED-DI contains 2 second-order measurement models, both with three sub-domains.

CONCLUSION

The CONMED-DI serves as a preliminary instrument primarily of value to researchers interested in exploring the complementary medicine clinical encounter. The development of targeted interventions that promote disclosure of conventional medicine can be facilitated through understanding patients' reasons for disclosure and non-disclosure and optimise patients' safe use of medicines.

Adolescent SBIRT implementation: Generalist vs. Specialist models of service delivery in primary care

BACKGROUND

Drug, alcohol, and tobacco use among adolescents pose significant short- and long-term health consequences and are associated with more severe use as adults. Screening, brief intervention, and referral to treatment in primary care settings has the potential to deliver preventive interventions to a diverse range of adolescents, but optimal implementation of these services needs to be determined. The purpose of this study was to compare implementation of two different SBIRT service delivery models in primary care settings.

METHODS

This cluster-randomized trial assigned 7 primary care clinics of a federally qualified health center to implement brief interventions (BI) using a Generalist model (4 sites), in which BIs were delivered by the primary care provider (PCP), or a Specialist model (3 sites), in which BIs were delivered by a behavioral health counselor (BHC) for adolescent patients ages 12-17 years. Implementation was tracked through the clinic's electronic health record, spanning 9639 clinic visits over 20 months. Multilevel logistic regression modeling was used to compare Generalist and Specialist strategies on penetration of BI for patients scoring ≥2 on the CRAFFT substance use screen, delivered by the PCP in the Generalist sites, and via warm hand-off to a BHC in the Specialist sites.

RESULTS

Approximately 62% of adolescent patient visits were screened with the CRAFFT (with <4% screening positive with a CRAFFT score ≥ 2). The Generalist Condition had significantly higher self-reported penetration of BI delivery than the Specialist Condition (38% vs. 8%; Adjusted Odds Ratio = 6.53; p = .005).

DISCUSSION

Despite having co-located behavioral health services at all sites, a Specialist approach to providing BI was less effectively implemented than a Generalist approach in this FQHC. BI delivered by PCPs rather than by hand-off to a BHC may ensure greater penetration of these services in primary care settings. Both implementation models provided a framework for identifying and intervening with adolescent primary care patients whose substance use might have otherwise gone undetected.

Excessive substance use screening to encourage behaviour change among young people in primary care: Pilot study in preparation for a randomized trial

INTRODUCTION

Alcohol, cannabis and other substance use affects young people's health. Primary care physicians are encouraged to screen and provide brief interventions for substance use in this population, but implementation is often limited. Pre-consultation self-administered screening may decrease at-risk substance use and could have population-level benefits. A randomized controlled trial is planned to test this hypothesis. The present pilot study's objective was to assess the feasibility of methods for the future trial.

METHODS

The parallel-group randomized controlled pilot trial was undertaken in 6 primary care practices in Geneva, Switzerland, over 2 months. 29 patients aged 15-24 years consulting for any reason were randomly assigned to intervention (substance use screening, n = 14) or control (physical activity questionnaire, n = 15) using computer-generated random number tables. Outcomes were assessed one month later by telephone questionnaire. Physicians, practice staff and outcome assessors were blinded to allocation. The primary outcomes were feasibility of procedures and acceptability to participants, primary care physicians and practice staff.

RESULTS

Of 16 participants reached at follow-up, 3 reported excessive substance use. Methods were acceptable to all participants, especially regarding confidentiality. Three participants were lost due to technical difficulties with the consent form. No major problems with study methods were reported in the practices. 4 practices did not meet recruitment targets.

CONCLUSION

The study procedures proved to be feasible in primary care practices and acceptable to young people who were readily available to participate. The main challenge for the future full-sized trial will be to ensure that recruitment targets can be met.