Alcohol, drug and other substance use is a key concern for providers of adolescent medical and behavioral health care in the United States (US). Despite overall reductions in youth substance use over the past 5 years, opioids, marijuana and binged alcohol continue to see sustained use in adolescent and young adult populations [1]. In addition, while cigarette smoking continues to decline among adolescents in recent years, e-cigarette use or vaping of nicotine, marijuana and/or flavorings has increased dramatically [1]. This is a particular concern because compared to other age groups, adolescents are at particularly high risk for substance use-related health problems [2]. Substance use among teens is associated with other risk behavior and related morbidity, including teenage pregnancy, sexually transmitted infections, and domestic violence, [3] as well as social and legal issues related to substance abuse including criminal behavior, school failure, and family problems [4]. Furthermore, the leading cause of mortality between youth aged 10–24 years old is unintentional injury, and substance use increases this risk [5]. Beyond the immediate implications of adolescent substance use, early drug use is a predictor of future addiction as well as long-term sequalae [6, 7]. While undergoing crucial periods of development, the adolescent brain is particularly vulnerable to developing substance use disorders [8] and substance abuse has the potential to trigger long-term neurocognitive changes in adolescents.

Because of the unique vulnerability of adolescents and the numerous medical, social, and cognitive effects of early initiation of substance use, pediatricians are in the unique position to intervene on a pattern of behavior that could affect their patients’ lives beyond adolescence. For example, most adolescents are seen in primary care once a year, may have an on-going and trusting relationship with their provider, and often view their provider as knowledgeable on substance use and other sensitive issues, all of which provide opportunity for intervention [2].

Screening for substance use is often the first step in identifying substance use problems in adolescents. Screening is the process of asking structured questions (not just asking about substance use informally) that objectively identify those patients who are at the highest risk of substance misuse and dependence. Prior research suggests that clinician perception alone is not accurate in determining the level of substance use, and that the use of a standardized and validated screening protocol results in higher detection rates [4, 9]. Furthermore, prior research suggests that relying on provider impressions, rather than a structured screening tool, may also lead to biased screening. For example, evidence suggest physicians are more likely to screen boys than girls, and screen older adolescents versus younger adolescents [10]. To provide guidance on screening for substance use in primary care, the American Academy of Pediatrics (AAP) issued a policy statement in 2011 (revised in 2016) detailing the pediatrician’s role in decreasing the burden of substance use among adolescents [2, 11]. The AAP endorses the use of Substance Use Screening, Brief Intervention, and Referral to Treatment (SBIRT) as a method to systematically address teen drug and alcohol use [2, 11].. In adults, SBIRT has been shown to be effective in reducing alcohol and drug use [12, 13] and is backed by the U.S. Preventative Services Task Force (USPSTF) for this purpose [14]. In the adolescent population, the base of evidence is still evolving and thus, an important area for further research.

In practice, between 50 and 86% [2] of pediatricians report screening adolescent patients for substance use and often use psychosocial mnemonic tools such as the HEEADSSS (home, education/employment, eating, activities, drugs, sexuality, suicide/depression, safety from injury/violence) or SSHADESS (strengths, school, home, activities, drugs/substance use, emotions/eating/depression, sexuality, safety) as a primary framework [15]. In these mnemonics, the “D” (i.e., “drugs” or “drugs/substance use”) is a cue to the physician to ask about substance use, with a question such as “Do you use tobacco? Alcohol? Other Drugs?” [16] If an adolescent answers in the affirmative, additional structured tools should be used to assess the quantity, frequency and potential problem behavior associated with use of each substance [17]. The AAP endorses the use of a validated and age-appropriate screening tool, such as the CRAFFT, Screening to Brief Intervention (S2BI) or Brief Screener for Tobacco, Alcohol and Other Drugs (BSTAD) [2, 11]. By determining where a patient falls on the spectrum of misuse, a clinician can appropriately direct the next steps in care. For example, for patients who are not using substances, this offers an opportunity to reinforce healthy behavior. For those with low or intermittent use reported via these screeners, the provider may use a brief intervention, a screening outcome-responsive conversation that focuses on raising awareness of negative effects, a plan to reduce or stop us, and encouragements of strengths to support behavior change. For those with moderate to high and/or more frequent use, a referral to more intensive services may be needed [11].

Despite AAP recommendations and the evidence base for screening and intervention, the use of standardized screening tools is still not widely implemented in adolescent primary care. Patient factors that may impede screening include level of comfort to discuss sensitive topics [18] and concern about confidentiality [19]. For providers, barriers include time constraints, feeling less capable of making a diagnosis, disagreements on who should implement screening tools, perception of difficulty in discussing substance use, and doubt regarding effectiveness of intervention [20, 21]. Evidence suggests that pediatric primary care providers who reported feeling prepared to diagnose substance use disorders have higher levels of screening [22]. Additional training and resource support may help providers implement brief interventions with or without referral to treatment [2, 20].

The purpose of this study was to describe the distribution and characteristics of substance use screening among adolescents in the outpatient clinics of a large academic medical center in the Midwest (i.e., e.g., which substances screened, how screened) as the first step in the process of identify and addressing substance use problems, to assess patient factors that may be associated with screening (i.e., patient age, race/ethnicity, gender, and insurance type), and evaluate the documentation of screening in the medical records to inform integration of high quality screening into the routine practice.