A Rapid Teen Substance Use Screening Tool for Clinicians

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“In the past year, on how many days…

  • Have you had more than a few sips of beer, wine, or any drink containing alcohol?
  • Have you smoked cigarettes or used other tobacco products?
  • Did you use marijuana?”

The answers to these questions can help a busy health care provider flag a teen’s problematic use of these substances, say NIDA-supported researchers.

The three questions are part of the Brief Screener for Tobacco, Alcohol, and other Drugs (BSTAD). In a recent study, BSTAD developers Dr. Sharon Kelly and colleagues at the Friends Research Institute (FRI) in Baltimore examined the frequencies of use at which a teen is likely to qualify for a diagnosis of an alcohol use disorder (AUD), nicotine use disorder (NUD), or cannabis use disorder (CUD). The frequencies turned out to be surprisingly low.


For the study, Dr. Kelly and colleagues recruited 525 teens (46 percent boys, 54 percent girls) who were awaiting primary care at three health center sites in Baltimore. The participants were 12 to 17 years old, and 93 percent of them were African American. The researchers administered two instruments to the teens: the modified Composite International Diagnostic Interview-2 Substance Abuse Module (CIDI-2) and the BSTAD. The modified CIDI-2 is a structured interview that identifies substance use disorders (SUDs) according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).

The teens’ BSTAD responses revealed that 22 percent had used alcohol in the past year, 16 percent had used marijuana, 10 percent had used tobacco, and 3 percent had used at least one illicit substance other than marijuana. The DSM-5 criteria for an AUD, NUD, and a CUD were met by 4.0 percent, 4.5 percent, and 10.7 percent of the teens, respectively.

The FRI researchers compared the teens’ responses on the two instruments to see which BSTAD responses were associated with meeting the DSM-5 criteria as determined by the modified CIDI-2. Their analysis showed that almost all teens who reported on the BSTAD that they had consumed an alcoholic beverage on 2 or more days during the past year had an AUD. Conversely, teens who reported drinking on fewer than 2 days were unlikely to have this disorder. The corresponding BSTAD cut points for an NUD was nicotine use on 6 or more days during the past year and for a CUD was marijuana use on 2 or more days.

Using these cut points, the researchers found that the BSTAD was highly sensitive. Ninety-six percent of teens with an AUD, 95 percent with an NUD, and 80 percent with a CUD identified with the modified CIDI-2 reported use at or above the respective cut points, and so would be flagged as likely in need of further assessment for a brief intervention or referral to treatment. BSTAD’s specificity was also high: 85 percent of teens without an AUD, 97 percent without an NUD, and 93 percent without a CUD reported use below the cut points, and so would be correctly classified.

“Very low substance use frequencies were found to be optimal in identifying these disorders,” Dr. Kelly comments. The BSTAD does not distinguish the severities of the disorders, she notes, so when it flags a teen, providers need to follow up with questions to determine appropriate interventions or referrals to treatment.

Furthermore, Dr. Kelly says, “Health care providers should have a one-on-one discussion with teens who indicate any substance use to assess level of risk, provide brief advice, and, if necessary, recommend further assessment for a treatment intervention.” Providers also should rescreen teens regularly, because onset of substance use can occur abruptly during adolescence.

An Obstacle Addressed

Both the World Health Organization and the American Academy of Pediatrics recommend screening all adolescent patients for substance use. Despite the high prevalence of substance use among teens (see In Nationwide Survey, More Students Use Marijuana, Fewer Use Other Drugs), many providers do not regularly screen their patients for such use. This lapse is concerning, because later problem use or SUDs often are seeded in this life stage.

“Providers are extremely busy and need a quick and valid screening measure for identifying teens who use substances,” says Dr. Kelly. She and colleagues developed the BSTAD in response to a NIDA call for new tools to fill this need (see also Electronic Questionnaire Quickly Rates Teens’ Substance Use).

To create the BSTAD, Dr. Kelly and colleagues added the questions about tobacco and marijuana to the widely disseminated National Institute on Alcohol Abuse and Alcoholism screen for youth alcohol use. In the validation study, the FRI research team administered the BSTAD in person to half of the participants, and the rest of the participants self-administered the instrument on an iPad. The teens reported a strong preference for the iPad. The iPad version offers the potential extra convenience that results can be automatically transferred into a teen’s electronic medical record.

This study was supported by NIH grant DA026003.


Kelly, S.M.; Gryczynski, J.; Mitchell, S.G. et al. Validity of brief screening instrument for adolescent tobacco, alcohol, and drug use. Pediatrics (133)5:819-826, 2014. Full text

Note: Wording in the opening paragraph of this article was revised on October 8, 2015.