With a few simple questions, a new screening tool detects whether a teen is likely to have a mild-to-moderate or a severe substance use disorder (SUD). The tool, “Screening to Brief Intervention” (S2BI), enables pediatricians and other clinicians to rapidly match adolescents’ drug involvement to an appropriate type of brief intervention or referral, as recommended by the American Academy of Pediatrics (AAP).
Dr. Sharon Levy at Boston Children’s Hospital and Harvard Medical School and colleagues developed S2BI in response to a NIDA call for tools that time-pressed pediatricians and primary care clinicians can practically use to detect and respond to their adolescent patients’ drug use (see also A Rapid Teen Substance Use Screening Tool for Clinicians). The S2BI tool may be administered by a pediatrician or filled out by the teen on a computer or tablet. Participants in the study who validated the instrument completed the questionnaire in just a few seconds.
Three initial queries ask the teen to select, from four choices for each substance, the one that describes how often he or she has used tobacco products, alcohol, or marijuana during the past year (see Figure). Teens who disclose any use of any of the three substances are also asked the same multiple-choice frequency question about four additional classes of substances.
On the basis of their answers, S2BI sorts the teen into four categories: no substance use, “once or twice” substance use (likely no SUD), monthly use (likely mild-to-moderate SUD), or weekly or more substance use (likely severe SUD). Each of these classifications corresponds to an “actionable category” as distinguished by AAP, which recommends a distinct type of brief intervention for each one, including positive reinforcement, brief advice on the problems associated with substance use, brief intervention, and referral to counseling or treatment.
Figure. A Short Electronic Questionnaire Quickly Screens Teen for Substance Use The S2BI tool asks the teen how often in the past year he or she has used tobacco, alcohol, or marijuana. The teen chooses from four possible responses for each substance: “never,” “once or twice,” “monthly,” or “weekly.” Those teens who indicate any use of any of the three substances may be asked follow-up questions about their past-year use of four other substances. Each step up in the frequency of use indicated in a teen’s response places him or her into a higher risk category for the corresponding substance use disorder.© Boston Children’s Hospital 2014. All rights reserved. This work is licensed under a Creative Commons Attribution-Noncommercial 4.0 International License.
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The figure shows the Screening to Brief Intervention questions. It starts with “In the past year, how many times have you used,” which asks about the use of three substances: tobacco, alcohol, and marijuana. The next line reads “STOP if all ‘Never.’ Otherwise, continue.” A teen continuing the screen is asked four additional questions: “Prescription drugs that were not prescribed for you (such as pain medication or Adderall)? Illegal drugs (such as cocaine or Ecstasy)? Inhalants (such as nitrous oxide)? Herbs or synthetic drugs (such as salvia, ‘K2,’ or bath salts)?”
Short, Sensitive, Specific
To validate S2BI, Dr. Levy and colleagues administered both it and the Composite International Diagnostic Interview-Substance Abuse Module (CIDI-SAM) to 213 volunteers, age 12 to 17, and compared the results of the two instruments. They considered an S2BI result to be correct when it agreed with the CIDI-SAM, a definitive tool that has been validated against the Diagnostic and Statistical Manual of Mental Disorders (DSM).
The S2BI tool demonstrated high sensitivity: It accurately detected every instance of substance use, severe substance or alcohol use disorder, marijuana use, and severe marijuana use disorder; between 94 and 100 percent of alcohol use, marijuana use disorder, past-year tobacco use, and any SUD; 79 percent of alcohol use disorders; and 75 percent of cases of nicotine dependence.
S2BI was also highly specific: It misclassified only a small percentage of youth as having a more serious condition than they actually had, according to the CIDI-SAM “gold standard.” This was the case less than 10 percent of the time with respect to any or severe SUDs, alcohol use and alcohol use disorders, marijuana use and marijuana use disorders, and past-year tobacco use.
The youths who participated in the validation study answered the questions in a few seconds. S2BI worked equally well whether teens self-administered it or answered a health practitioner’s questions in a face-to-face interview.
From Screen to Intervention
Dr. Levy and her team are now focusing on how pediatricians might best use S2BI to design and implement interventions for teens whom the tool flags as using substances or as having an SUD.
Dr. Levy says, “The existing literature and consensus opinions provide good guidance for each of the four S2BI categories of substance use severity.” For example, she says, teens who report monthly substance use, and therefore are at risk for moderate SUDs, should receive an intervention that begins with a clinical interview to identify problems associated with their substance use. Teens whose screening results indicate weekly or more substance use should be referred to further treatment, which could include individual counseling, medication-assisted treatment programs, or specialized SUD treatment programs.
Dr. Lisa Onken, chief of NIDA’s Behavioral and Integrative Treatment Branch, says. “Dr. Levy’s results need to be replicated in other settings, but simple screens that practitioners can use easily and quickly are very much needed. The S2BI shows promise in doing the required job: Differentiating various levels of substance use and severity with a few simple questions. Brevity, ease of administration, and accuracy—what else would you need?”
This study was supported by NIH grants DA019570, DA15831, and DA022288.
Sources:
Levy, S.; Weiss, R.; Sherrit, L. et al. An electronic screen for triaging adolescent substance use by risk levels. JAMA Pediatrics 168(9):798-799, 2014. Full text