Asking about stuff is only the first step

Today I wrote about how docs ask about guns in the home because that’s how prevention works. Asking about sensitive topics is important. Here’s a great example – “An Electronic Screen for Triaging Adolescent Substance Use by Risk Levels“:

Importance: Screening adolescents for substance use and intervening immediately can reduce the burden of addiction and substance-related morbidity. Several screening tools have been developed to identify problem substance use for adolescents, but none have been calibrated to triage adolescents into clinically relevant risk categories to guide interventions.

Objective: To describe the psychometric properties of an electronic screen and brief assessment tool that triages adolescents into 4 actionable categories regarding their experience with nontobacco substance use.

Design, Setting, and Participants: Adolescent patients (age range, 12-17 years) arriving for routine medical care at 2 outpatient primary care centers and 1 outpatient center for substance use treatment at a pediatric hospital completed an electronic screening tool from June 1, 2012, through March 31, 2013, that consisted of a question on the frequency of using 8 types of drugs in the past year (Screening to Brief Intervention). Additional questions assessed severity of any past-year substance use. Patients completed a structured diagnostic interview (Composite International Diagnostic Interview–Substance Abuse Module), yielding Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) substance use diagnoses.

Main Outcomes and Measures: For the entire screen and the Screening to Brief Intervention, sensitivity and specificity for identifying nontobacco substance use, substance use disorders, severe substance use disorders, and tobacco dependence were calculated using the Composite International Diagnostic Interview–Substance Abuse Module as the criterion standard.

Results: Of 340 patients invited to participate, 216 (63.5%) enrolled in the study. Sensitivity and specificity were 100% and 84% (95% CI, 76%-89%) for identifying nontobacco substance use, 90% (95% CI, 77%-96%) and 94% (95% CI, 89%-96%) for substance use disorders, 100% and 94% (95% CI, 90%-96%) for severe substance use disorders, and 75% (95% CI, 52%-89%) and 98% (95% CI, 95%-100%) for nicotine dependence. No significant differences were found in sensitivity or specificity between the full tool and the Screening to Brief Intervention.

Conclusions and Relevance: A single screening question assessing past-year frequency use for 8 commonly misused categories of substances appears to be a valid method for discriminating among clinically relevant risk categories of adolescent substance use.

The gist of this study is that asking adolescents a single question about substance use uncovers a ton of disorders, including severe disorders. That’s why we ask the question, even when it’s uncomfortable.

But an accompanying editorial is equally important. It makes the following point:

To date, no clinical trials have reported the efficacy of brief (or extended) interventions for alcohol, cannabis, or other prescription medication misuse in pediatric settings. As a result, the US Preventive Services Task Force has issued an “I” (for insufficient) recommendation for screening and interventions for adolescents with illicit drug use, alcohol misuse, or nonmedical pharmaceutical use.

It’s great that we can find the problem. We also need to do something about it. Too often, we lack research in those areas. That’s because such research is time consuming and expensive. We still need to do such work, though. Recent pushes to focus on more “patient-centered” outcomes are a step in the right direction.

I feel this way about obesity, too. It’s also true for guns. I’m sure one of the complaints that people will level at my NYT piece is that there’s no evidence that finding out that guns are in the home and encouraging parents to store them more safely actually prevents injuries. That’s true. It’s because almost no research gets done with respect to guns and injuries at all. Please fund it. I know tons of health services researchers who would love to do that work.

It’s not fair to cause ignorance, or refuse to combat it, and then use it as excuse to do nothing.


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