journal

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Screening adolescents for substance use: The role of NPs in school settings

Abstract: NPs have a key role in screening for adolescent substance use in school settings.

This article provides evidence-based information on the prevalence and consequences

of adolescent substance use, discusses standardized substance use screening and brief

interventions using the CRAFFT tool, and suggests relevant practice and policy implications.

By Nour Alayan, MSN, RN and Lynn Shell, PhD, APN-BC, CARN-AP

S ubstance use in adolescents is a serious threat to health, social and economic welfare, families, and nations worldwide. Substance use preva-

lence among adolescents has dramatically increased dur- ing the past decade and continues to do so.1 However, the majority of adolescent substance users do not seek help.2

NPs practicing in schools are favorably positioned to identify early substance use in adolescents enrolled in schools.

However, few NPs are sufficiently trained to address this growing challenge.3 The purpose of this article is to: offer evidence-based information on the prevalence and conse- quences of adolescent substance use; discuss adolescent substance use Screening, Brief Interventions, and Referral for Treatment (SBIRT); and suggest relevant practice and policy implications related to substance use.

■ Substance use prevalence and trends An estimated 2.3 million adolescents between the ages of 12 and 17 years reported illicit drug use in 2014 in the United States. An additional 2.9 million adolescents reported alco- hol use in the past month.1 Although the majority of statis- tics provide information on substance use among students in grades 8 or above, evidence suggests that substance use typically begins as early as grade 7 during early adolescence.4

Results from the Monitoring the Future study (which sur- veyed 41,700 students in 389 secondary schools nationwide in year 2013 only) showed alarming rates of substance use

among 8th, 10th, and 12th graders despite a significant reduction in cigarette smoking.5

In 2013, up to 50% of students used an illicit drug before graduating from high school. Adolescent illicit drug use increased by 1.3% in 2013 alone for 8th, 10th, and 12th graders.5 The increase for any illicit drug use has been attrib- uted to the increase in marijuana use primarily by 8th and 10th graders, while the rate of marijuana use remains stable for 12th graders.5

The increase in marijuana use among younger adoles- cents may raise concerns for carefully monitoring the future consequences of recreational marijuana legalization. Alcohol remains the most widely used substance among teenagers and is responsible for higher mortality and morbidity in this age group than all other drugs combined.4,5 By the 12th grade, 80% of high school seniors report having used alco- hol, 62% report having gotten drunk, and 31% report heavy episodic alcohol use.4

The illicit use of opioid analgesics (such as hydrocodone bitartrate and acetaminophen [Vicodin] and oxycodone hydrochloride extended-release tablets [Oxycontin]) and psychotherapeutic drugs (such as dextroamphetamine sac- charate, amphetamine aspartate, dextroamphetamine sulfate and amphetamine sulfate [Adderall], and methylphenidate hydrochloride [Ritalin]) is also a worrisome public con- cern.5,6 Other drugs that may be less prevalent among ado- lescents are associated with more serious health risks, including heroin, stimulants (cocaine), club drugs (ecstasy),

Keywords: adolescents, brief interventions, CRAFFT, drugs and alcohol, SBIRT, screening, substance abuse, substance use

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Screening adolescents for substance use: The role of NPs in school settings

2.5% to 9% of substance users received treatment at a spe-dissociative drugs (ketamine), and hallucinogens (LSD).5 For more information on specific drugs, administration meth- ods, acute effects, and health effects, refer to the commonly abused drugs charts by the National Institute on Drug Abuse (NIDA).6

■ Short- and long-term consequences Substance abuse costs related to healthcare, loss of produc- tivity, and crime can be enormous. Although the direct costs of adolescent substance abuse alone are not known, the overall abuse of tobacco, alcohol, and illicit drugs costs the nation over $600 billion annually.7 An increase in sub- stance abuse health consequences is revealed in global reports of Disability Adjusted Life Years (DALYs): the total years lost due to premature death or lack of productivity resulting from physical or mental impairment.8

In 2010, illicit drug dependence was directly responsible for 20 million DALYs, accounting for 0.8% of global all- cause DALYs. This represents a 52% increase in fi gures from 1990.9 Particularly, drug dependence and disease burden were found to be the highest among men between the ages of 20 and 29.9 Although such an elevated disease burden may not be evident during adolescence, substance use in this age group is associated with an eightfold increase in the risk of substance dependence in adulthood.10

Substance use (which starts in adolescence) is likely to continue into adulthood and develop into substance depen- dence disorders with serious consequences, including declined school performance, increased criminal and risk- taking behavior, future unemployment, depression and suicidality, and other psychiatric comorbidities.2,11-13

In particular, substance abuse health consequences include premature mortality and disability related to cogni- tive deficits, irreversible brain damage, and physical injuries resulting from risky behavior.1 Moreover, evidence from national family support groups demonstrates that the neg- ative consequences of substance abuse are not limited to the individual but rather impact the entire family. Substance abuse in a young family member can be especially disruptive to both parents and siblings, who may suffer from deterio- rated psychological functioning, impaired relationships and family cohesion, and involvement in legal problems and substantial fi nancial consequences.13

■ The effectiveness of SBIRT Although research evidence shows that substance abuse treatment can be successful across ages, the majority of substance users do not seek treatment, and many drop out of treatment programs early.1,14 In recent years, only about

cialty facility and of those who entered treatment, approxi- mately 65% did not complete it.1,15,16

Although more data are needed on adolescent treat- ment seeking and retention trends, the overall rates sug- gest that the traditional model of waiting for substance users to seek treatment is not the best approach to sub- stance abuse treatment.12 This is especially true in adoles- cent populations where treatment-seeking rates may be even lower as a result of developmental crises and youth rebellion; however, universal screening using SBIRT has been studied extensively and shown to be effective in early detection and treatment engagement of adolescents involved with substance use.7,12,17

In an attempt to decrease the overall disease burden of substance use in both adolescents and adults, universal SBIRT has been recommended by the Substance Abuse and Mental Health Services Administration, NIDA, and the National Institute of Alcohol Abuse and Alcoholism.4,18,19

Although screening does not result in a formal diagnosis, it is a relatively brief and direct method to determine the adolescent’s risk level in using illicit drugs and a promising strategy for early detection and intervention in adolescents who use alcohol or drugs.

A multisite, randomized trial in primary care clinics showed an increase in detection rates of substance use among adolescents when structured screening protocols were used.13 Also, in a large study conducted by Agerwala and colleagues, the use of SBIRT resulted in a 68% decrease in drug use and 39% decrease in alcohol con- sumption among screened individuals who received an intervention.17

Recently, a feasibility study of computerized SBIRT in two New York public schools showed very promising results. The study included all 6th to 12th grade students who were offered web-based substance use screening and a structured counseling protocol. Of the 248 students screened, 42% reported substance use, and all of them showed acceptance of the brief interventions received except for one refusal.20

■ Standardized substance use screening for adolescents: The CRAFFT tool CRAFFT is the most widely used and thoroughly studied standardized instrument for screening substance use in youth under the age of 21. It is also the recommended screen- ing tool by the American Academy of Pediatrics for adoles- cents 14 years and older.12,21,22 The acronym CRAFFT stands for the fi rst letters of major keywords of the series of six questions in the tool, including “Car,” “Relax,” “Alone,”

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Screening adolescents for substance use: The role of NPs in school settings

■ Brief interventions and referral for treatment The CRAFFT screening interview21 according to risk level

Intervention is a normal step after screening in healthcare Part A:Three opening questions settings. The SBIRT method is an integrated public health

Begin: “I’m going to ask you a few questions that I approach that is recommended for use with substance-using ask all my patients. Please be honest. I will keep your adolescents by the American Academy of Pediatrics.23 SBIRT answers confidential.” is based on motivational interviewing (MI) techniques, During the PAST 12 MONTHS, did you: which have been effective in adolescents resolving the ambiv- 1. Drink any alcohol (more than a few sips)?

(Do not count a few sips of alcohol taken during fam- alence they often experience about the impact of substance

ily or religious events.) use on their lives.24

2. Smoke any marijuana or hashish? MI works by increasing intrinsic motivation to change

3. Use anything else to get high? (“Anything else” substance use behavior through stimulating the adolescent’s includes illegal drugs, synthetic marijuana, over-the- own reasons and advantages of changing the harmful behav- counter and prescription drugs, or things that you sniff or “huff.”)

ior.2,4,12 This approach is thought to be especially successful with adolescents in low-to-moderate-risk categories when

Part B: Six CRAFFT questions ambivalence about substance use is at its peak.

C Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been

An in-depth MI review is beyond the scope of this arti-

using alcohol or drugs? cle but is accessible through the classic text Motivational

R Do you ever use alcohol or drugs to RELAX, feel Interviewing by W.R. Miller and S. Rollnick.24 The level of

better about yourself, or fit in? intervention delivered usually depends on the risk level A Do you ever use alcohol or drugs while you are by identified during screening. Brief interventions by risk cat-

yourself or ALONE? egories are based on CRAFFT scores are suggested below; F Do you ever FORGET things you did while using however, the level of intervention is often a function of the

alcohol or drugs?

F Do your family or FRIENDS ever tell you that you NP’s clinical judgment.

should cut down on your drinking or drug use?

T Have you ever gotten into TROUBLE while you were ■ Adolescents at low risk using alcohol or drugs? Adolescents who deny using any substances during the last

Used with permission from Boston Children’s Hospital. 12 months and have never ridden in a car with an intoxi- cated friend are at low risk for substance use disorders. Studies show that adolescents in this category are likely to

“Forget,” “Friends,” and “Trouble.” Screening using the maintain their behavior with praise and encouragement. CRAFFT is a simple, two-step process, which can be admin- A 1-to-2-minute conversation acknowledging the adoles- istered in a short time (see The CRAFFT screening interview).21 cent’s healthy behavior and reinforcing knowledge of

The NP starts by asking three opening questions on the adverse reactions of substance use is recommended.4

use of alcohol or any other drug during the past 12 months. For example: Adolescents who deny the use of alcohol or any other type “Your decision to stay away from alcohol or other drugs of drugs may be considered as low risk for substance use has helped you stay safe and healthy. Do well at school and disorders and are only asked the “Car” question of the six work toward achieving your goals. Do you have any ques- CRAFFT questions. However, those who answer “yes” to any tions about drugs? If you have any questions about alcohol of the three opening questions are considered to be at mod- or other drugs, please come here and ask me. I’m happy to erate-to-high risk for substance use disorders. answer any questions.”

The six CRAFFT questions are asked to adolescents in Adolescents who report to have ridden in a car with a moderate-to-high-risk categories. The CRAFFT may be friend driving under the influence of a substance should be administered by the clinician or can be given to the ado- asked to sign a “Contract for Life” with the purpose of facil- lescent for completion in a private place. Safeguarding itating communication between the adolescent and his or privacy and confidentiality of the information is crucial for her parent or caregiver. By signing this contract, the adoles- building a trusting relationship and ensuring honest self- cent pledges to commit to the agreement to avoid making report by the adolescent (see Simplified CRAFFT algorithm decisions that jeopardizes his or her life, including driving for NPs).4,12,22 under the influence of alcohol/drugs or riding with an

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Screening adolescents for substance use: The role of NPs in school settings

[Reinforce and build upon his or her understanding]. “Thereimpaired driver, and to seek help from a parent or a respon- sible adult when in a situation that threatens his or her safety. The parent or caregiver also pledges to understand, effec- tively communicate, and protect the adolescent child.25 The Center on Adolescent Substance Abuse Research recom- mends that clinicians give the Contract for Life to all ado- lescents regardless of their risk level.21

■ Adolescents at moderate risk Adolescents who answer “yes” to one or more of the opening questions and score 0 to 1 on the CRAFFT are at moderate risk for substance use disorder. These adolescents are usually experimenting with substance use and may be ambivalent about quitting. They benefit from a clear recommendation to stop alcohol and other drug use and a 2- to 5-minute conversation on the adverse effects they are risking with substance use, at the same time recognizing personal strengths, which they risk losing if they maintain their sub- stance use behavior.4 For example:

“Thank you for telling me about your drug use. Have you noticed any changes since you started to use X?” [Fill in the blank with the drug he or she identifi ed]. If he or she responds yes, address the change and its connection to sub- stance use if appropriate. If he or she responds no: “Good. As your NP, I am concerned about your health. There are risks associated with drug use that you probably have already heard about in health class. What risks do you remember?”

are other risks too. Drugs can interfere with family, sports, and your school work, jeopardizing your future plans if you continue using.” [Express concern and bring up positive traits they have.] “You are smart. You’ve worked hard, earned the respect of teachers, peers, and me, and deserve a bright future. I would like to help you achieve your goals. How would you feel about stopping for two weeks and then check- ing back in with me to talk about how it’s going?” [If the answer is yes, offer help]. “Would you like me to help you develop some strategies to use during the next two weeks?” [If the answer is no, reassure him or her that you are there to help when he or she is ready to stop]. “If you change your mind, please come back and check in with me. I’d like to help you develop strategies to stop using X.”

■ Adolescents at high risk Adolescents who answer “yes” to one or more of the opening questions and score 2 or more on the CRAFFT are at high risk. These adolescents are more likely to develop (or have already developed) substance use disorders and require a more thorough assessment of the degree of substance abuse or dependence based on criteria from the American Psychi- atric Association’s Diagnostic and Statistical Manual of Men- tal Disorders, Fifth Edition (DSM-V).26 The use of MI techniques for a detailed assessment is recommended to encourage adolescents to talk about their experience with

Simplified CRAFFT algorithm for NPs21

A sk

3 o

p en

in g

q u

es ti

o n

s in

a p

ri va

te s

et ti

n g

3 Opening Questions CRAFFT Scores

Ask “Car” question only Answers “No” to all

questions Low Risk

CRAFFT score = 0–1

Moderate Risk

Answers “Yes” to 1 or more question

CRAFFT score ≥ 2

High Risk

*It is recommended that clinicians give the Contract for Life to ALL patients regardless of risk level. The algorithm was created by Nour Alayan, MSN, RN and Lynn Shell, PhD, APN-BC, CARN-AP.

Brief Intervention

If answers “Yes,” give Contract for Life

If answers “No,” offer praise and encourage to

maintain abstinence

Advise to stop using completely, focusing on

adverse reactions

Assess for substance abuse disorder and refer for

further intervention

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Screening adolescents for substance use: The role of NPs in school settings

substance use and elicit a heightened insight of negative Some primary care providers may not feel that behav- consequences resulting from substance use. Three recom- mended questions to ask include:4

• “Tell me about your alcohol/drug use. When did you begin using? What is your use like now?” • “Have you had any problems at school, at home, or with the law?” If yes, “Were you drinking or using drugs just before that happened?” • “Have you ever tried to quit? Why? How did it go? For how long did you stop? Then what happened?”

Although referral to a specialized provider is recom- mended in this case, MI may still be used before referral in an attempt to increase the adolescent’s intrinsic motivation to change substance abuse behavior and encourage him or her to comply with referral recommendation. Involving parents in their children’s care is recommended, preferably with the adolescent’s consent. The NP must refer to school district and state laws in the event the adolescent does not provide consent for parental involvement.

The legal aspect of parental involvement in the care of adolescents with substance abuse problems presents poten- tial red flags of substance dependence in minors, which may require the practitioner to break confidentiality and resort to immediate referral and parental involvement (see Red flags of substance abuse).18

■ Practice and policy implications: The role of NPs Universal substance abuse screening in adolescents is growing. The use of SBIRT has been established as effective in many patient populations, including adolescents; how- ever, many factors contribute to continuing missed oppor- tunities for screening adolescents in various healthcare settings. The lack of time, resources, and training may set primary care providers to miss screening adolescents for substance use.

Red flags of substance abuse19

• CRAFFT score of 5 or higher • CRAFFT score of 2 or higher in adolescents ≤14 years • Daily or near-daily alcohol or drug use • History of alcohol- or drug-related blackouts • History of a drug-related hospital visit to the ED • Reports of I.V. drug use • Combining sedatives, such as alcohol and

benzodiazepines • Consuming large volumes of alcohol (14 or more

drinks) • Driving or participating in risky behavior under the

influence of drugs

ioral problems, such as substance use, fall within their scope of practice. This may be partially due to certain attitudes toward substance use or the lack of confi dence in dealing with a high-risk problem.19 Poor treatment-seeking behav- ior of an adolescent paired with poor screening makes it more difficult for healthcare providers and governments to minimize or even control substance abuse.

NPs who screen adolescents for substance abuse may struggle with the complicated issue of disclosure to parents or guardians and the legal protection of the adolescent’s right to privacy and confidentiality. Family involvement can play an important role in treatment on a clinical level; how- ever, there may be circumstances in which parental notifi ca- tion may not be a good choice for the adolescent. The issue of disclosure is also complicated on a legal level. In addition to federal laws, each state and school district will have its own parental disclosure rules regarding substance abuse screening and counseling.27

Many states give adolescents the authority to consent to substance abuse disorder assessment and treatment without parental consent, while other states require parental involve- ment.27 The complex legal and ethical issues associated with this dilemma are beyond the scope of this article. It is recom- mended that each NP speak to their state Board of Nursing and obtain legal counsel from their school district to be aware of their rights and responsibilities as well as the rights of their patients.

Nonetheless, targeting adolescents in school settings remains a partial solution to enhance early detection and intervention in adolescents involved in substance use. Very few studies investigated school-based SBIRT pro- grams. However, a recent multisite repeated measures study of 629 adolescents in high schools in New Mexico supported the use of a school-based SBIRT protocol administered by trained behavioral health counselors.2

Taking into consideration the cost-effectiveness and sus- tainability of such programs, it is only logical to think of NPs as the gatekeepers for screening adolescents in school settings.

In an attempt to identify the number of school nurses and NPs in the United States, only basic statistics were avail- able from the 2013 national school survey conducted by the National Association of School Nurses (NASN). The survey reported on 6,841 school nurse respondents in all 50 states. The majority of school nurses worked in public schools, and approximately 28% held master’s degrees in nursing or other related fields. However, only 1.9% of respondents identifi ed themselves as APRNs.28

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Screening adolescents for substance use: The role of NPs in school settings

14. National Institute on Drug Abuse. Trends and Statistics. 2012. www.Although no information is currently available on the breadth of the current role of NPs in school settings, NASN’s position statement identifies health screening as a priority and the school nurse as the liaison between the school, other healthcare providers, the family, and the community.29 Pri- mary NPs practicing in school settings are well trained and well positioned to conduct substance abuse screening in adolescents. In view of the increasing prevalence of sub- stance use among teenagers and its detrimental conse- quences, it is prudent to call for more efforts in establishing systematic substance use screening protocols for use in school settings—a growing concern crying out for innova- tive strategies for early screening and intervention.

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5. Johnston LD, O’Malley PM, Miech RA, Bachman JG, Schulenberg JE. Monitoring the Future National Results on Drug Use: 1975-2013: Overview, Key Findings on Adolescent Drug Use. Ann Arbor, MI: Institute for Social Research, The University of Michigan; 2014.

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11. Goodman I, Peterson-Badali M, Henderson J. Understanding motivation for substance use treatment: the role of social pressure during the transition to adulthood. Addict Behav. 2011;36(6):660-668.

12. Mitchell SG, Gryczynski J, O’Grady KE, Schwartz RP. SBIRT for adolescent drug and alcohol use: current status and future directions. J Subst Abuse Treat. 2013;44(5):463-472.

13. Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Treatment Improvement Protocol (TIP) Series, No. 39. Rockville, MD: Substance Abuse and Mental Health Services Administration (US); 2004.

drugabuse.gov/related-topics/trends-statistics#costs.

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17. Agerwala SM, McCance-Katz EF. Integrating Screening, Brief Intervention, and Referral to Treatment (SBIRT) into clinical practice settings: a brief review. J Psychoactive Drugs. 2012;44(4): 307-17.

18. Levy SJ, Kokotailo PK. American Academy of Pediatrics, Committee on Substance Abuse. Substance use screening, brief intervention, and referral to treatment for pediatricians. Pediatrics. 2011;128(5):e1330-e1340.

19. Sterling S, Kline-Simon AH, Wibbelsman C, Wong A, Weisner C. Screening for adolescent alcohol and drug use in pediatric health-care settings: predictors and implications for practice and policy. Addict Sci Clin Pract. 2012;7:13.

20. Curtis BL, McLellan AT, Gabellini BN. Translating SBIRT to public school settings: an initial test of feasibility. J Subst Abuse Treat. 2014;46(1):15-21.

21. The Center for Adolescent Substance Abuse Research. The CRAFFT Screening Tool. 2009. www.ceasar.org/CRAFFT/index.php.

22. Pilowsky DJ, Wu LT. Screening instruments for substance use and brief interventions targeting adolescents in primary care: a literature review. Addict Behav. 2013;38(5):2146-2153.

23. American Academy of Pediatrics. AAP Recommends Substance Abuse Screening as Part of Routine Adolescent Care. 2011. https://www.aap.org/ en-us/about-the-aap/aap-press-room/pages/AAP-Recommends-Substance- Abuse-Screening-as-Part-of-Routine-Adolescent-Care.aspx#sthash. IMe108ch.dpuf.

24. Miller W, Rollnick S. Motivational Interviewing, Helping People Change. 3rd ed. New York: The Guilford Press; 2012.

25. Students Against Destructive Decisions. Contract for Life. http://sadd.org/ contract.htm.

26. American Psychological Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychological Association; 2013.

27. National District Attorneys. Minor Consent to Medical Treatment Laws. 2011. www.ndaa.org/pdf/Minor_Consent_to_Medical_Treatment_(2).pdf.

28. Maughan E, Mangena AS. The 2013 NASN school nurse survey: advancing school nursing practice. NASN Sch Nurse. 2014;29(2):76-83.

29. National Association of School Nurses. Position Statement: Role of the School Nurse. 2011. www.nasn.org/portals/0/positions/2011psrole.pdf.

Nour Alayan is a PhD Student and Teaching Fellow at Rutgers, The State University of New Jersey, Newark, N.J.

Lynn Shell is an assistant clinical professor at Rutgers, the State University of New Jersey, Newark, N.J.

The authors have disclosed that they have no financial relationships related to this article.

The authors would like to thank Dr. Kim Dupree Jones, Oregon Health & Science University, and Dr. Sarah Kelly, Rutgers University, for their critical input on this manuscript.

DOI-10.1097/01.NPR.0000482380.82853.c0

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/ENU (Use these settings to create PDF's if you are not downloading low Res ads from AdSpring.) >> >> setdistillerparams << /HWResolution [2400 2400] /PageSize [612.000 792.000] >> setpagedevice