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PURPOSE: To identify barriers to adolescent substance abuse screening in primary care. METHODS: Focus groups were held at six primary care sites with a total of 38 providers. Providers brainstormed a list of barriers, collectively grouped similar barriers, and voted to produce a final ranked list. Two investigators qualitatively analyzed field notes and transcripts to triangulate findings, ranked the barriers across all sites by the number of groups identifying the barrier, then calculated a mean ranking (MR) for each. RESULTS: The most commonly identified barrier was insufficient time (MR 1.8). Lack of training in how to manage a positive screen was ranked second (MR 1.7), but was linked to the first. Providers reported they had enough time to administer a short screen, but insufficient time to manage a positive result during the well care visit. The need to triage competing problems (MR 3.0), lack of treatment resources (MR 3.3), tenacious parents who would not leave the room for a confidential discussion (MR 2.5), and unfamiliarity with screening tools (MR 3.0) were also noted by more than one group. CONCLUSIONS: Insufficient time and lack of training in how to manage positive screens are the greatest barriers to screening adolescents for substance abuse. This suggests that some providers might differentially avoid screening youth who they suspect will screen positive, yet these patients would benefit most from early recognition. More research is needed on effective ways to manage positive substance abuse screens in primary care. [ABSTRACT FROM AUTHOR]

Abstract Background Heavy alcohol use among U.S. college students is a major contributor to young adult morbidity and mortality. The aim of this study was to examine whether college alcohol policy enforcement levels predict changes in student drinking and related behaviors in a state system of public colleges and universities, following a system-wide change to a stricter policy. Methods Students and administrators at 11 Massachusetts public colleges/universities completed surveys in 1999 (N of students = 1252), one year after the policy change, and again in 2001 (N = 1074). We calculated policy enforcement scores for each school based on the reports of deans of students, campus security chiefs, and students, and examined the correlations between perceived enforcement levels and the change in student drinking rates over the subsequent two year period, after weighting the 2001 data to adjust for demographic changes in the student body. Results Overall rates of any past-30-days drinking, heavy episodic drinking, and usual heavy drinking among past-30-days drinkers were all lower in 2001 compared to 1999. School-level analyses (N = 11) found deans' baseline reports of stricter enforcement were strongly correlated with subsequent declines in heavy episodic drinking (Pearson's r = -0.73, p = 0.011). Moreover, consistently high enforcement levels across time, as reported by deans, were associated with greater declines in heavy episodic drinking. Such relationships were not found for students' and security chiefs' reports of enforcement. Marijuana use did not rise during this period of decline in heavy drinking. Conclusions Study findings suggest that stronger enforcement of a stricter alcohol policy may be associated with reductions in student heavy drinking rates over time. An aggressive enforcement stance by deans may be an important element of an effective college alcohol policy.

Background: Until local healthcare infrastructure is strengthened, cardiac surgical care in low- and middle-income countries is often provided by non-governmental organizations by way of visiting healthcare teams. This is generally considered to be a cost-effective alternative to transporting patients to high income countries for surgical care, but the costs of cardiac surgery consumables under this model are poorly understood. Our objective was to identify the per-patient cost of cardiac surgery consumables used in single and double valve replacements performed by a non-governmental organization in Rwanda., Methods: Financial data from 2020 were collected from Team Heart, a non-governmental organization that supports cardiac surgical care in Rwanda. A comprehensive list of consumables was generated, including surgical, perfusion, anesthesia, and inpatient supplies and medications. Acknowledging the variability in perioperative needs, the quantities of consumables were calculated from an average of six patients who underwent single or double-valve replacement in 2020. Total costs were calculated by multiplying purchasing price by average quantity per patient. Costs absorbed by the local hospital were excluded from the calculations., Results: The total cost per patient was estimated at $9,450. Surgical supplies comprised the majority of costs ($6,140 per patient), with the most substantial cost being that of replacement valves ($3,500 per valve), followed by surgical supplies ($1,590 per patient)., Conclusions: This preliminary analysis identifies a cost of just over $9,000 per patient for consumables used in cardiac valve surgery in Rwanda, which is lower than the estimated costs of transporting patients to centers in high income countries. This work highlights the relative cost effectiveness of cardiac surgical care in low- and middle- income countries under this model and will be instrumental in guiding the allocation of local and international resources in the future., (© 2024. The Author(s).)

Objective: Alcohol- and drug-related car crashes are a leading cause of death for adolescents in the United States. This analysis tested the effects of a computer-facilitated Screening and Brief Advice (cSBA) system for primary care on adolescents' reports of driving after drinking or drug use (driving) and riding with substance-using drivers (riding)., Method: Twelve- to 18-year-old patients (N = 2,096) at nine New England pediatric offices completed assessments only during the initial 18-month treatment-as-usual (TAU) phase. Subsequently, the 18-month cSBA intervention phase began with a 1-hour provider training and implementation of the cSBA system at all sites. cSBA included a notebook-computer with self-administered screener, immediate scoring and feedback, and 10 pages of scientific information and true-life stories illustrating substance-related harms. Providers received screening results, "talking points" for 2 to 3 minutes of counseling, and a Contract for Life handout. Logistic regression with generalized estimating equations generated adjusted relative risk ratios (aRRR) for past-90-day driving and riding risk at 3- and 12-month follow-ups, controlling for significant covariates., Results: We found no significant effects on driving outcomes. At 3 months, cSBA youth were less likely than TAU to report riding with a drinking driver (aRRR = 0.70, 95% CI [0.49, 1.00]), and less likely to report riding with a driver who had used cannabis or other drugs (aRRR = 0.46, 95% CI [0.29, 0.74]). The effect was even greater (aRRR = 0.34, 95% CI [0.16, 0.71]) for riding with drinking drivers who were adult family members. All effects dissipated by 12-month follow-up., Conclusions: Screening and pediatrician brief advice shows promise for reducing adolescents' risk of riding with substance-using drivers.

Background: Computer self-administration may help busy pediatricians' offices increase adolescent substance use screening rates efficiently and effectively, if proven to yield valid responses. The CRAFFT screening protocol for adolescents has demonstrated validity as an interview, but a computer self-entry approach needs validity testing. The aim of this study was to evaluate the criterion validity and time efficiency of a computerized adolescent substance use screening protocol implemented by self-administration or clinician-administration., Methods: Twelve- to 17-year-old patients coming for routine care at 3 primary care clinics completed the computerized screen by both self-administration and clinician-administration during their visit. To account for order effects, we randomly assigned participants to self-administer the screen either before or after seeing their clinician. Both were conducted using a tablet computer and included identical items (any past-12-month use of tobacco, alcohol, drugs; past-3-month frequency of each; and 6 CRAFFT items). The criterion measure for substance use was the Timeline Follow-Back, and for alcohol/drug use disorder, the Adolescent Diagnostic Interview, both conducted by confidential research assistant interview after the visit. Tobacco dependence risk was assessed with the self-administered Hooked on Nicotine Checklist (HONC). Analyses accounted for the multisite cluster sampling design., Results: Among 136 participants, mean age was 15.0 ± 1.5 years, 54% were girls, 53% were black or Hispanic, and 67% had ≥3 prior visits with their clinician. Twenty-seven percent reported any substance use (including tobacco) in the past 12 months, 7% met criteria for an alcohol or cannabis use disorder, and 4% were HONC positive. Sensitivity/specificity of the screener were high for detecting past-12-month use or disorder and did not differ between computer and clinician. Mean completion time was 49 seconds (95% confidence interval [CI]: 44-54) for computer and 74 seconds (95% CI: 68-87) for clinician (paired comparison, P < .001)., Conclusions: Substance use screening by computer self-entry is a valid and time-efficient alternative to clinician-administered screening.

Background: Screening, brief intervention, and referral to treatment (SBIRT) is recommended as part of routine health care for adolescents as well as adults. In an effort to promote universal SBIRT, the Substance Abuse and Mental Health Services Administration awarded funding to residency programs to develop and implement SBIRT education and training. Our project focused on creating scientifically based, developmentally appropriate strategies and teaching materials for the adolescent age range. This paper describes curriculum development and implementation and presents evaluation data., Methods: Pediatric and child psychiatry residents were trained. The training consisted of 4 activities: (1) case-based teaching modules, (2) role-play of motivational interviewing and brief interventions, (3) mock interviews with trained adolescents, and (4) supervised "hands-on" screening and brief interventions. Main outcome measures included trainee satisfaction, and SBIRT knowledge, perceived self-efficacy, and self- and observer report of use of the SBIRT algorithm., Results: Among 150 total participants completing the SBIRT training modules, nearly all (92.3%) were satisfied/very satisfied with the training modules. Knowledge accuracy immediately post training was high, but declined significantly by the end of the first residency year, with little change across subsequent years of residency. Confidence ratings also declined over time. Use of the SBIRT algorithm during the Adolescent Medicine rotation was high according to trainee self- and faculty observer report., Conclusions: We found evidence of training satisfaction, increased confidence in talking to adolescents about substance use, and widespread use of recommended practices immediately following training. Use of a highly structured algorithm to guide practice, and simple, highly structured brief interventions was a successful training approach, as residents self-reported accurate use of the SBIRT algorithm immediately after training. Knowledge and self-confidence declined over time. It is possible that "booster" sessions and ongoing opportunities to review materials could help residents retain knowledge and skills.

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.

Purpose: To determine if peer risk (having friends who drink or approve of drinking) modifies the effects of a computer-facilitated screening and provider brief advice (cSBA) intervention on adolescent alcohol use., Methods: We assessed the intervention effect using logistic regression modeling with generalized estimating equations on a sample of 2,092 adolescents. Effect modification by peer risk was analyzed separately for alcohol initiation (drinking at follow-up in baseline nondrinkers) and cessation (no drinking at follow-up in baseline drinkers) by testing an interaction term (treatment condition by peer risk). Interpretation of the interaction effect was further clarified by subsequent stratification by peer risk., Results: The intervention effect on alcohol cessation was significantly greater among those with peer risk (adjusted relative risk ratios; risk 1.44, 1.18-1.76 vs. no risk .98, .41-2.36) at 3 months' follow-up. There was no such finding for alcohol initiation., Conclusions: Alcohol screening and brief provider counseling may differentially benefit adolescent drinkers with drinking friends., (Copyright © 2014 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: Primary care providers need effective strategies for substance use screening and brief counseling of adolescents. We examined the effects of a new computer-facilitated screening and provider brief advice (cSBA) system., Methods: We used a quasi-experimental, asynchronous study design in which each site served as its own control. From 2005 to 2008, 12- to 18-year-olds arriving for routine care at 9 medical offices in New England (n = 2096, 58% females) and 10 in Prague, Czech Republic (n = 589, 47% females) were recruited. Patients completed measurements only during the initial treatment-as-usual study phase. We then conducted 1-hour provider training, and initiated the cSBA phase. Before seeing the provider, all cSBA participants completed a computerized screen, and then viewed screening results, scientific information, and true-life stories illustrating substance use harms. Providers received screening results and "talking points" designed to prompt 2 to 3 minutes of brief advice. We examined alcohol and cannabis use, initiation, and cessation rates over the past 90 days at 3-month follow-up, and over the past 12 months at 12-month follow-up., Results: Compared with treatment as usual, cSBA patients reported less alcohol use at follow-up in New England (3-month rates 15.5% vs 22.9%, adjusted relative risk ratio [aRRR] = 0.54, 95% confidence interval 0.38-0.77; 12-month rates 29.3% vs 37.5%, aRRR = 0.73, 0.57-0.92), and less cannabis use in Prague (3-month rates 5.5% vs 9.8%, aRRR = 0.37, 0.17-0.77; 12-month rates 17.0% vs 28.7%, aRRR = 0.47, 0.32-0.71)., Conclusions: Computer-facilitated screening and provider brief advice appears promising for reducing substance use among adolescent primary care patients.

Objective: To assess adolescents' preferences for substance abuse screening in primary medical care settings., Design/methods: Twelve- to 18-year-old patients (N = 2133) arriving for routine care at a network of primary care sites completed an interview that included demographic items, the CRAFFT screen, and a questionnaire assessing preferences for screening method (paper questionnaire, computer, oral interview by nurse or doctor). A subgroup (n = 222) completed the CRAFFT directly on the computer., Results: Across the entire sample, paper was the screening administration method most preferred (mean rank (MR) = 2.92, 95%CI 2.87-2.96) vs. computer (MR = 2.38, 2.33-2.43), nurse (MR = 2.43, 2.39-2.47), and doctor (MR = 2.30, 2.25-2.35). Among the participants who received the screening on the computer, however, computer (MR = 3.08, 95%CI 2.42-2.52) was statistically tied with paper (MR = 2.88, 2.75-3.02) and both were ranked significantly higher than nurse (MR = 2.06, 1.94-2.17) and doctor (MR = 1.98, 1.82-2.14). The findings were similar for participants' reports of being "very likely" to be honest when answering substance abuse screening questions., Conclusions: Adolescents should ideally be screened for substance abuse using paper or computer questionnaires.

We developed and pilot tested a 2-session motivational interviewing intervention for substance use among 14- to 18-year-old medical patients. Recruitment and retention were more challenging than anticipated. A substantial number of completers reduced their use of substances and risk of driving after drinking during the 3-month follow-up period.

Objective: To review home drug-testing products and the Internet-based recommendations intended for parents., Methods: A qualitative review of drug-testing products and structured analysis of information presented on company Internet sites were conducted. Eight Internet sites that sold home drug-testing products and contained a "parent's section" were identified by Ixquick using the search term "home drug testing." Description and prices of products sold by each Internet site and recommended indications for testing, consent, collection procedures, and follow-up of positive and negative test results were researched., Results: A variety of drug-testing products were available, including breath and saliva tests for alcohol, a multidrug panel hair test, and a variety of laboratory and instant urine tests. Prices ranged from 2.75 dollars for a single alcohol test to 89.00 dollars for a multidrug combination urine/hair package. A total of 14 indications for home drug-testing were cited; all sites claimed that drug testing was a way to know with certainty whether a child has used drugs. Only 1 web site made a clear statement against testing an adolescent against his or her will. Little information was presented on valid specimen collection procedures and the risks of false-positive and false-negative tests. Only half of the sites recommended that parents consult a professional if a test is positive., Conclusions: Pediatricians should advise parents of the limitations and potential risks associated with home drug-testing products.

Objective: To assess the association between heavy drinking and alcohol policy enforcement following the institution of a new system-wide alcohol policy at Massachusetts public colleges and universities., Method: Students (N = 1,252: 59% women) at 11 study schools completed a questionnaire that assessed drinking behaviors and alcohol-associated problems. College deans and campus security officers completed questionnaires assessing policy implementation and enforcement. We compared heavy drinking rates among the 11 schools and measured the association between schools' heavy episodic drinking rates and enforcement index scores based on deans' and security officers' reports of policy enforcement., Results: Rates of heavy episodic drinking varied widely among the 11 schools (range: 36%-71%). The percentage of students reporting strict/very strict policy enforcement also varied widely (35%-90%). In this small sample of colleges, heavy drinking rates among students living on campus tended to be negatively associated with stricter alcohol policy enforcement reports by security officers (Pearson's r = -0.64. p < .05) and the association appeared to be linear. Heavy drinking was not associated with enforcement reports by deans (Pearson's r = 0.17, p = NS)., Conclusions: Within this single state system, stricter enforcement by campus security officers of policies that limit underage drinking tends to be associated with lower rates of heavy drinking by students.