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AAP Committee on Substance Use and Prevention

May 3, 2016

PamGonzalez2By Pamela Gonzalez, MD

The AAP Committee on Substance Abuse (COSA) has officially changed its name to Committee on Substance Use and Prevention (COSUP). This is great news for many reasons, including the elimination of pejorative language (“abuse”).

“The Committee on Substance Use and Prevention (COSUP) produces guidance for pediatricians, state and federal government, and other stakeholders to reduce harm from substance use. This is where your key role in prevention, screening, and early intervention comes in.

 

Screening

I know substance use screening can sound like just another time thief in your already busy, overbooked schedules. Please allow me to put you at ease about how little time this usually actually takes, and the pay-off for that child/future adult whom you may identify as struggling.

The most likely outcome of a substance use screen is negative and is an opportunity to provide positive reinforcement for healthy behavior. Mind you, screening should occur in all adolescents, not just the kids pediatricians think might be using. Research shows physicians are notoriously bad at guessing who has used and who has not.

The second most common scenario is the youth that has tried a substance, but has not developed a substance use problem, injury, or other negative sequelae…yet. Unfortunately, more than half of kids will try alcohol — more than just sips — before their senior year. Pediatricians should educate themselves and prepare to educate kids about the downsides of underage drinking. This includes understanding that yes, tobacco and cannabis use by minors not only lead to their own substance use disorders, but are markers of current and other substance use. For example, a 14-year-old kid who’s smoking cannabis is absolutely at increased risk for “recreational” Percocet use.

The smallest, but very concerning group is the kids that have developed some degree of substance use disorder (SUD). I was recently told, “They likely aren’t going to change their behavior in that 10-minute encounter, so what would be a reasonable goal?” I love that, and it’s absolutely true. Even if a kid comes to see me, or goes to “treatment,” he/she doesn’t magically stop using. Unfortunately, once a kid has been funneled into the largely un-vetted “CD treatment” world, they are frequently cut off from their medical home, and receive no or substandard care for co-occurring psychiatric symptoms/diagnoses.

A huge concern to me is the separation of substance use and mental health screening and care. Brain health is poorly integrated into medical care as it is, and further cleaving SUD creates yet another silo. Kids who have developed substance use problems benefit most from trusting, continuity relationships like pediatricians provide.

Almost as a rule, the folks with the most severe SUD started the youngest. This means their use started right under our noses. We don’t yet fully know what impact we can have by addressing these issues in the pediatric office, but we definitely know that overlooking the problem means many will die from overdose; suffer injury, assault, infectious disease, unprotected sex and unintended pregnancy; underachieve academically and vocationally; and if they’re lucky, end up seeing someone like me as a young adult (or older) after more years of addictive use and problems.

Ask Users about Methods and Frequency

On a final note, don’t fall for clickbait! Routes of drug use come in and out of vogue. Marijuana “dabbing” is not new; it has been around for decades, and gone by other names such as “knife hits.” Similarly, while vaporizing pens represent relatively novel devices, countless apparatuses/setups have been used to deliver drugs. So, while the media and sometimes providers become excited about “new” ways youth use drugs, there are other relevant, timeless features that are more important for pediatrician awareness.

Methods/routes of drug use speak more to amount of drug used, potency, and speed of delivery to the brain. All of these factors contribute to acute toxicity, and development/presence of SUD. Key important questions to ask a young person who is using cannabis or other drugs is frequency (monthly, weekly, daily), route of use (PO, snorting, smoking, IV), consequences, and other drugs being used.

Please remember to screen for psychiatric symptoms at the same time. Even when you make subspecialty referrals, please help preserve these kids’ medical homes; don’t lose them to the “rehab” silo.
Have questions for me? Drop me a line: pamel003@umn.edu

Resources:

www.teensubstancescreening.org/
Introduction to adolescent Screening, Brief Intervention and Referral to Treatment (SBIRT), which is recommended for all adolescents in primary care

www.aap.org/en-us/about-the-aap/Committees-Councils-Sections/substance-use/Pages/home.aspx
AAP Committee on Substance Use and Prevention (COSUP)

 

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