Despite declines over the past decade, alcohol and drug exposure remain common among adolescents and young adults (AYAs) in the US. By high school graduation, approximately 7 of 10 American students have tried alcohol, more than half of students have tried an illicit drug, and approximately one-fourth have tried an illicit drug other than marijuana. One-fourth of students try an illicit substance by the end of 8th grade.¹ Alcohol and drug use are related to the four leading causes of death in the adolescent age-group and therefore present a major public health problem. In addition, the likelihood of developing addiction is inversely correlated with age of initiation.²

Clinicians who provide primary care to youth are on the “front-lines”; they are ideally positioned to provide primary and secondary prevention to those who have not initiated nor developed a substance use disorder (SUD) and early intervention to those who have developed a mild or moderate SUD. They may also leverage their position as a knowledgeable professional to assist AYAs who have developed a SUD in engaging in appropriate treatment. The Substance Abuse and Mental Health Services Administration (SAMHSA) has coined the term “SBIRT,” which refers to the clinical framework of Screening, Brief Intervention, and Referral to Treatment. While a recent review by the US Preventive Services Task Force found that to date, there is insufficient evidence to evaluate the efficacy of brief interventions for substance use with adolescents in primary care,³ emerging research is promising, and SBIRT is low cost and not associated with known harms. The findings for adults 18 and older are different. The Brief Intervention approach is effective for reducing “risky” alcohol use in adults but the evidence also suggests this approach is not effective for reducing illicit drug use in adult patients. Notably, there are also no competing approaches to address substance use, a known health risk factor for AYAs, within primary care. Therefore, the American Academy of Pediatrics (AAP) and other professional organizations recommend annual confidential screening and brief intervention as part of routine health maintenance for AYAs. Beyond SBIRT, clinicians should be prepared to assess AYAs who present with concerns stemming from substance use. Drug testing may be helpful as part of an assessment or for monitoring, and clinicians should be prepared to use this procedure. Clinicians should be familiar with varying levels of treatment for SUDs and aware of local resources.

Regardless of the format used to assess drug and alcohol use, questions about these behaviors and other sensitive health topics should always be asked in private, without a parent or guardian present. Before beginning a discussion about alcohol and drugs, we recommend that clinicians review their guidelines regarding confidentiality with AYA patients, and, when present, with parents. In general, adolescents should be afforded confidentiality unless their behavior poses an acute safety concern to themselves or others. Determining whether a specific behavior presents a safety concern is a matter of clinical judgment; the patient’s age, other diagnoses, and social situation should be taken into account. Occasional use of alcohol or marijuana can usually be kept confidential. In all cases, adolescents should be assured that if confidentiality is to be broken, the health care provider and patient will review what will be said before speaking with parents, and only diagnostic and planning information will be shared; specific details generally need not be disclosed. For young adults over age 18, their medical information must remain confidential unless they have signed a release of information for a clinician to communicate with a parent. Regardless of a patient’s age, it is good clinical practice to ask patients with SUDs what parents already know regarding their substance use whenever parents play a supportive role (i.e., in the case of a young adult who lives at home or is supported at school by parents). In many situations, parents are already aware of adolescents’ high-risk behaviors by the time they reach a level that requires breach of confidentiality, though parents may underestimate frequency or severity. Young adults whose parents are aware of the substance use problem can be encouraged to include them in treatment planning, though ultimately information should not be shared without a specific signed consent. When parents are involved, the discuss on can focus on treatment recommendations. Adolescents who report a behavior to their physician, such as intravenous drug use, may be asking for help. In these cases, we recommend evaluating for possible abuse and/or neglect before speaking with parents and managing accordingly.

In all 50 states, 18 years is the age of majority at which a young person is officially recognized as an adult. While this age is a landmark, for many American youth the 18th birthday signifies the beginning of a transition to adulthood, with a continued tapering of reliance on parents, rather than full independence. Many individuals continue to live at home with parents or are supported by parents while they continue their education. In accordance with these current cultural standards, imaging studies have found that the brain, and in particular the frontal lobes to which “executive functioning” is attributed, continue to mature well into the mid-third decade of life.⁴ We recommend that clinicians treat the period
of “young adulthood” as a transition period—both respecting the growing need for independence as well as the continued benefit of parental involvement in most cases. The approaches and recommendations in this chapter vary only minimally when working with adolescents or young adults, though one important change is that young adults over the age of 18 must formally give consent to include parents in their treatment.

All AYAs are at risk of exposure to alcohol and drugs. Therefore, every AYA should be screened regardless of race, ethnicity, socioeconomic status, religion, or gender. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) recommends screening for alcohol use in children as young as 9 years of age, or the first time that the child is interviewed privately.⁵ The AAP recommends screening for drug use beginning at age 12.⁶

Screens may be self-administered electronically, in a paper-and pencil format, by a clinical assistant or by a clinician; research suggests that all of these methods yield reliable results. A number of screens have been validated to determine likelihood of an alcohol or SUD (see Table 68.1 for validated screening and assessment tools and Table 68.2 for DSM-5 criteria for a SUD). The NIAAA youth alcohol screening tool is particularly notable because it is very brief (two questions), empirically derived, and recommended for children starting at age nine. The two screening questions provide information about (1) current risk of an alcohol use disorder (frequency of past year drinking) and (2) future risk of an alcohol use disorder (friends’ drinking). Alcohol-only screening may be particularly useful with younger children, when time is very limited or when alcohol use is a particular concern. The NIAAA published accompanying resource material and a web-based training course to guide clinicians in using this tool (Table 68.1).

Recently, the National Institute on Drug Abuse funded the development of brief adolescent substance use screening tools that are compatible with electronic health records, which resulted in the development of two new tools: Brief Screener for Tobacco, Alcohol and other Drugs (BSTAD)⁷ and “Screening to Brief Intervention” (S2BI).⁸ Both have been validated for ages 12 to 18. The BSTAD tool is built upon the NIAAA screening tool with added questions for tobacco and “drugs.” The optimal cut points for identifying a SUD were ≥6 days of tobacco use (sensitivity = 0.95; specificity = 0.97); ≥2 days of alcohol use in the past year (sensitivity = 0.96; specificity = 0.85); and ≥2 days of marijuana use (sensitivity = 0.80; specificity = 0.93).⁷ The S2BI uses a comprehensive stem question to assess the frequency of past-year use (none, once or twice, monthly, weekly or more) for tobacco, alcohol, marijuana, and five other classes of substances commonly used by adolescents. In the initial validation study, this tool had high sensitivity and specificity for discriminating between clinically relevant risk categories of adolescent substance use: no use; substance use without a SUD, which correlated to a response of “once or twice:” mild or moderate SUD, which correlated to a response of “monthly:” and severe SUD, which correlated to a response of “weekly or more.”⁹ The ability to detect adolescents who already have developed a severe SUD (addiction) is important: SAMHSA estimates that less than 10% of teens in need of specialty substance use treatment receive it and the majority who do are referred from the justice system.¹⁰,¹¹ The primary care arena has been notably poor in identifying teens with severe SUDs and connecting this vulnerable group with treatment. Indeed, clinical impressions alone, even those of experienced physicians, significantly underestimate the severity of an adolescent’s substance-related problems.¹² It is therefore imperative that screening be done with a validated tool.

BSTAD and S2BI have been validated for ages 12 to 18. As young adults typically have patterns of substance use consumption much more similar to adolescents than older adults, these two tools likely would be the “off-label” tool of choice for this group as well. In addition to the very brief screening adolescent-specific screening tools, the AUDIT and DAST¹³ can be used both with adolescents and also with college students and young adults.

In the US, one in four AYAs has a chronic medical condition such as diabetes, asthma, or arthritis that requires long-term follow-up by a regular care team.¹⁴ AYAs or youth with chronic medical conditions (YCMC) are heterogeneous in terms of specific diagnoses, disease management, and treatment regimens. However, they share a number of attributes that may interact negatively with substance use, including the need to follow a medication regimen, participate in regular clinical monitoring, self-monitor/manage their condition, and manage sleep, diet/meals, and activity levels. Adverse effects of substance use on these issues and attendant risks for poor health outcomes are vital topics to discuss and may be anchor points for screening and brief intervention. Frequent interactions with a clinical care team to address underlying health issues may provide physicians with opportunities for SBIRT, leveraging the strong patient-provider bonds established by long-term clinical management of pediatric onset chronic illness.

Most AYAs who use alcohol and drugs can be managed effectively in the primary care setting, and even patients who will ultimately require referral to an addiction or mental health specialist may receive direct benefit, or be more likely to accept treatment recommendations after a brief office intervention.¹⁶ Brief interventions by health care providers, ranging in intensity from a few seconds up to several hours, can significantly reduce drug and alcohol use. In this chapter, we define brief advice as an intervention lasting seconds to minutes in which the health care provider gives general information to discourage substance use to a patient and brief motivational intervention as a very brief counseling session focused on details specific to the patient’s substance use.