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Guest Editorial Leading specialists review current developments in pediatrics.

A dolescent substance use has been called the number one public health threat in the Unit-

ed States.1 In 2011, a nationally repre- sentative household survey found that adults rated drug abuse as the number one health concern for youth (tied with obesity) among a list of 23 health issues.2 The federal government also recognizes the public health burden and included 21 policy and prevention goals for substance use in Healthy People 2020, the current 10-year national objectives established by the US Department of Health and Hu- man Services to improve the health of all Americans.3

Concerns about the consequences of adolescent substance use are well founded. Alcohol, the substance most commonly used by teens, is involved in more than one-third of the deaths from unintentional injury, homicide, and suicide, which together account for three-fourths of mortality in the 15- to 19-year age group.4 Marijuana use has risen sharply over the past several years; currently, one in ten teens uses mari- juana nearly every day—an increase of 60% from rates of use in 2008.5 Likely fueled by changing marijuana policy, continued declines in the proportion of adolescents who perceive great risk of harm associated with marijuana use6 suggest that these rates will continue to climb in the foreseeable future. De- clines in tobacco use by high school

students have plateaued since 2007; nearly one-half (44.7%) of 9th through 12th graders report having tried ciga- rettes, and nearly one-quarter (23.4%) report current (past 30 days) use of tobacco in any form.7 Newer products such as hookah and electronic or e-cig- arettes, which deliver nicotine via va- por, and newer marketing methods, in- cluding personalized ads presented via social media, threaten to attract increas- ing numbers of youth to using nicotine with flavors such as cotton candy and bubble gum. In addition to acute harms and medical complications associated with substance use, early initiation of use during adolescence is associated with an increased likelihood of devel- oping a severe substance use disor- der—a chronic neurological condition resulting from disruption of neurons in the nucleus accumbens, sometimes re- ferred to as the brain’s reward center.

New health care models demand that medical homes increase their capacity to identify and address mental and be- havioral health problems. Preventing, identifying, and addressing substance use in childhood and adolescence offers perhaps the great promise in reducing associated morbidity and mortality. Pe- diatricians and other primary care pro- viders who care for children and adoles- cents are ideally positioned to provide anticipatory guidance to families. Pri- mary care providers can assure parents

that it is never too early to start talking about substance use in a developmen- tally appropriate manner and that there is no such thing as too much discussion of this topic. Particularly as children en- ter adolescence, parents can be coached on both the importance of role modeling and how to teach their children to man- age strong emotions and stress without substances. Clinicians can also provide guidance to children and their parents on navigating the complex landscape of social media. This landscape is par- ticularly challenging for many families because the current generation of par- ents are raising the first generation of digital natives and cannot count on their own childhood experiences to guide them. Evidence-based, meaningful sug- gestions from a professional may help children and families to avert the hidden dangers of this new frontier.

Beyond advice and guidance, pri- mary care clinicians are tasked with screening each adolescent patient for substance use and intervening to pre- vent, delay, or reduce substance use, a strategy referred to as Screening, Brief Intervention, Referral to Treatment—or SBIRT. According to the 2014 National Drug Control Strategy, “early detec- tion and treatment of a substance use problem by a doctor, nurse, or other health care professional is much more effective and less costly than dealing with the consequences of addiction or

Adolescent Substance Use Sharon Levy, MD, MPH

PEDIATRIC ANNALS • Vol. 43, No. 10, 2014 407

Guest Editorial

Sharon Levy, MD, MPH, is a board-certified Developmental- Behavioral Pediatrician and an Assistant Professor of Pediatrics at Harvard Medical School; she also has a master’s degree from the Harvard School of Public Health. She is the Director of the Adolescent Substance Abuse Pro- gram in the Division of Develop- mental Medicine at Boston Chil- dren’s Hospital, where she has evaluated and treated hundreds of adolescents with substance use disorders. She has published ex- tensively on the outpatient man- agement of substance use dis- orders in adolescents, including screening and brief advice in pri- mary care, the use of drug testing, and the outpatient management of opioid-dependent adolescents. She is the PI of the SAMHSA- funded adolescent SBIRT project and an NIAAA-funded study vali- dating the youth alcohol screening tool in a population of youth with chronic medial illness. Dr. Levy currently serves as the chair of the American Academy of Pediatrics Committee on Substance Abuse.

Address correspondence to Sharon Levy, MD, MPH, via email: [email protected]. edu.

About the Guest Editor criminal justice involvement later on.”8 To achieve the goals of this mandate, SBIRT must be delivered in ways that optimize both efficiency and efficacy, including the use of validated algo- rithms, targeted clinician guidance, and structured interventions that can be re- liably administered with fidelity.

This issue provides a review and practical recommendations for primary care clinicians to address these impor- tant issues related to adolescent sub- stance use. The first article describes positive guidance as a technique that clinicians can teach to parents to help them prevent and manage substance use in their children. The second article in- cludes a review of the potential risks of social media use, particularly in regard to substance use. Although there has been little research in this field, the ar- ticle offers summary recommendations based on what is known about patterns of adolescent use of this media. Finally, the third article presents a new, simpli- fied algorithm for conducting screening and brief intervention based on newer screening tools and nascent literature on behavioral interventions. A func- tional knowledge base in these three areas should allow clinicians to compe- tently address these important aspects of primary care for adolescents.

REFERENCES 1. Adolescent Substance Use: America’s #1

Public Health Problem. The National Cen- ter on Addiction and Substance Abuse at Co- lumbia University. CASAColumbia website. http://www.casacolumbia.org/addiction-

research/reports/adolescent-substance-use. Published June 29, 2011. Accessed Septem- ber 8, 2014.

2. Drug abuse now equals childhood obesity as top health concern for kids. University of Michigan C.S. Mott Children’s Hospi- tal. http://mottnpch.org/sites/default/files/ documents/081511toptenreport.pdf. Pub- lished August 15, 2011. Accessed September 8, 2014.

3. Substance abuse. US Department of Health and Human Services. HealthyPeople. gov website. http://www.healthypeople. gov/2020/topicsobjectives2020/overview. aspx?topicid=40. Accessed September 8, 2014.

4. Kann L, Kinchen S, Shanklin S, et al. Youth Risk Behavior Surveillance—United States 2013. MMWR. 2014;63(SS04):1- 168. http://www.cdc.gov/mmwr/pdf/ s s / s s 6 3 0 4 . p d f ? u t m _ s o u r c e = r s s & u t m _ m e d i u m = r s s & u t m _ c a m p a i g n = y o u t h - risk-behavior-surveillance-united-states- 2013-pdf. Accessed September 8, 2014.

5. 2012 Partnership Attitude Tracking Study: Teens and Parents. Partnership for Drug-Free Kids. http://www.drugfree.org/wp-content/ uploads/2013/04/PATS-2012-FULL-RE- PORT2.pdf. Published April 23, 2013. Ac- cessed September 8, 2014.

6. Johnston LD, O’Malley PM, Miech RA, Bachman JG, Schulenberg JE. Monitoring the Future: National Results on Drug Use— 2013 Overview: Key Findings on Adoles- cent Drug Use. The University of Michigan Institute for Social Research. http://www. monitoringthefuture.org/pubs/monographs/ mtf-overview2013.pdf. Published February 2014. Accessed September 8, 2014.

7. Eaton DK, Kann L, Kinchen S, et al. Youth Risk Behavior Surveillance—United States 2011. MMWR. 2012;61(SS04):1-162. http:// www.cdc.gov/mmwr/preview/mmwrhtml/ ss6104a1.htm. Accessed September 8, 2014.

8. Office of National Drug Control Policy. Na- tional Drug Control Strategy; 2013. http:// www.whitehouse.gov/ondcp/drugpolicyre- form. Accessed September 18, 2014.

doi: 10.3928/00904481-20140924-06

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