Correction: Computer-Facilitated Screening and Brief Intervention for Alcohol Use Risk in Adolescent Patients of Pediatric Primary Care Offices: Protocol for a Cluster Randomized Controlled Trial.

[This corrects the article DOI: 10.2196/55039.].

Standard Versus Family-Based Screening, Brief Intervention, and Referral to Treatment for Adolescent Substance Use in Primary Care: Protocol for a Multisite Randomized Effectiveness Trial.

BACKGROUND: Screening, brief intervention, and referral to treatment for adolescents (SBIRT-A) is widely recommended to promote detection and early intervention for alcohol and other drug (AOD) use in pediatric primary care. Existing SBIRT-A procedures rely almost exclusively on adolescents alone, despite the recognition of caregivers as critical protective factors in adolescent development and AOD use. Moreover, controlled SBIRT-A studies conducted in primary care have yielded inconsistent findings about implementation feasibility and effects on AOD outcomes and overall developmental functioning. There is urgent need to investigate the value of systematically incorporating caregivers in SBIRT-A procedures. OBJECTIVE: This randomized effectiveness trial will advance research and scope on SBIRT-A in primary care by conducting a head-to-head test of 2 conceptually grounded, evidence-informed approaches: a standard adolescent-only approach (SBIRT-A-Standard) versus a more expansive family-based approach (SBIRT-A-Family). The SBIRT-A-Family approach enhances the procedures of the SBIRT-A-Standard approach by screening for AOD risk with both adolescents and caregivers; leveraging multidomain, multireporter AOD risk and protection data to inform case identification and risk categorization; and directly involving caregivers in brief intervention and referral to treatment activities. METHODS: The study will include 2300 adolescents (aged 12-17 y) and their caregivers attending 1 of 3 hospital-affiliated pediatric settings serving diverse patient populations in major urban areas. Study recruitment, screening, randomization, and all SBIRT-A activities will occur during a single pediatric visit. SBIRT-A procedures will be delivered digitally on handheld tablets using patient-facing and provider-facing programming. Primary outcomes (AOD use, co-occurring behavior problems, and parent-adolescent communication about AOD use) and secondary outcomes (adolescent quality of life, adolescent risk factors, and therapy attendance) will be assessed at screening and initial assessment and 3-, 6-, 9-, and 12-month follow-ups. The study is well powered to conduct all planned main and moderator (age, sex, race, ethnicity, and youth AOD risk status) analyses. RESULTS: This study will be conducted over a 5-year period. Provider training was initiated in year 1 (December 2023). Participant recruitment and follow-up data collection began in year 2 (March 2024). We expect the results from this study to be published in early 2027. CONCLUSIONS: SBIRT-A is widely endorsed but currently underused in pediatric primary care settings, and questions remain about optimal approaches and overall effectiveness. In particular, referral to treatment procedures in primary care remains virtually untested among youth. In addition, whereas research strongly supports involving families in interventions for adolescent AOD, SBIRT-A effectiveness trial testing approaches that actively engage family members in primary care are absent. This trial is designed to help fill these research gaps to inform the critical health decision of whether and how to include caregivers in SBIRT-A activities conducted in pediatric primary care. TRIAL REGISTRATION: ClinicalTrials.gov NCT05964010; https://www.clinicaltrials.gov/study/NCT05964010. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/54486.

Computer-Facilitated Screening and Brief Intervention for Alcohol Use Risk in Adolescent Patients of Pediatric Primary Care Offices: Protocol for a Cluster Randomized Controlled Trial.

BACKGROUND: Alcohol and other substance use disorders usually begin with substance use in adolescence. Pediatric primary care offices, where most adolescents receive health care, are a promising venue for early identification of substance use and for brief intervention to prevent associated problems and the development of substance use disorder. OBJECTIVE: This study tests the effects of a computer-facilitated screening and brief intervention (cSBI) system (the CRAFFT [Car, Relax, Alone, Forget, Family/Friends, Trouble] Interactive System [CRAFFT-IS]) on heavy episodic drinking, riding with a driver who is substance impaired, or driving while substance impaired among adolescents aged 14 to 17 years presenting for a well visit at pediatric primary care practices. METHODS: We are conducting a cluster randomized controlled trial of the CRAFFT-IS versus usual care and recruiting up to 40 primary care clinicians at up to 20 pediatric primary care practices within the American Academy of Pediatrics (AAP) Pediatric Research in Office Settings network. Clinicians are randomized 1:1 within each practice to implement the CRAFFT-IS or usual care with a target sample size of 1300 adolescent patients aged 14 to 17 years. At study start, intervention clinicians complete web-based modules, trainer-led live sessions, and mock sessions to establish baseline competency with intervention counseling. Adolescents receive mailed recruitment materials that invite adolescents to complete an eligibility survey. Eligible and interested adolescents provide informed assent (parental permission requirement has been waived). Before their visit, enrolled adolescents seeing intervention clinicians complete a self-administered web-based CRAFFT screening questionnaire and view brief psychoeducational content illustrating substance use-associated health risks. During the visit, intervention clinicians access a computerized summary of the patient's screening results and a tailored counseling script to deliver a motivational interviewing-based brief intervention. All participants complete previsit, postvisit, and 12-month follow-up study assessments. Primary outcomes include past 90-day heavy episodic drinking and riding with a driver who is substance impaired at 3-, 6-, 9-, and 12-month follow-ups. Multiple logistic regression modeling with generalized estimating equations and mixed effects modeling will be used in outcomes analyses. Exploratory aims include examining other substance use outcomes (eg, cannabis and nicotine vaping), potential mediators of intervention effect (eg, self-efficacy not to drink), and effect moderation by baseline risk level and sociodemographic characteristics. RESULTS: The AAP Institutional Review Board approved this study. The first practice and clinicians were enrolled in August 2022; as of July 2023, a total of 6 practices (23 clinicians) had enrolled. Recruitment is expected to continue until late 2024 or early 2025. Data collection will be completed in 2025 or 2026. CONCLUSIONS: Findings from this study will inform the promotion of high-quality screening and brief intervention efforts in pediatric primary care with the aim of reducing alcohol-related morbidity and mortality during adolescence and beyond. TRIAL REGISTRATION: ClinicalTrials.gov NCT04450966; https://www.clinicaltrials.gov/study/NCT04450966. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/55039.

Pediatric Primary Care Provider Perspectives on a Computer-Facilitated Screening and Brief Intervention System for Adolescent Substance Use.

PURPOSE: This study aimed to elicit pediatric primary care providers' (PCPs) feedback on the acceptability and feasibility of implementing a tablet computer-facilitated Screening and Brief Intervention (cSBI) system for adolescent substance use in their practices. METHODS: We trained PCPs at five Boston area practices and enrolled their 12- to 18-year-old patients in a pilot randomized trial of cSBI versus usual care. PCPs completed an 18-item poststudy questionnaire. We computed frequencies and thematically coded open-ended responses. RESULTS: The analysis sample included 49 of 54 participating PCPs (90.7%). Overall, 89.8% of participants agreed the cSBI system was useful, and 81.6% reported increased confidence in providing brief counseling. Most useful were the immediate availability of screen results, talking points on substance use risks, and counseling prompts. Challenges included time and unfamiliarity with tablet computers. Many suggested electronic health record integration of cSBI to improve efficiency. CONCLUSIONS: cSBI showed high acceptability and increased confidence among pediatric PCPs. Feasibility could be enhanced by electronic health record integration.

Digital recovery networks: Characterizing user participation, engagement, and outcomes of a novel recovery social network smartphone application.

BACKGROUND: Recovery support services, including in vivo (i.e., face to face) peer-based supports and social networks, are associated with positive effects on substance use disorder recovery outcomes. The translation of in vivo supports to digital platforms is a recent development that is mostly unexamined. The types of users and their engagement patterns of digital recovery support services (D-RSS), and the utility of objective and self-report data in predicting future recovery outcomes require further study to move the recovery support field forward. METHODS: De-identified individual user data from Sober Grid, a recovery social network site (R-SNS) smartphone application, for the years 2015-2018 was analyzed to identify the demographics, engagement patterns, and recovery outcomes of active users. Analysis of variance (ANOVA) tests were used to examine between generational group differences on activity variables and recovery outcomes. Logistic and linear regressions were used to identify significant predictors of sobriety length and relapse among users. RESULTS: The most active tercile of users (n = 1273; mAge = 39 years; 62% male) had average sobriety lengths of 195.5 days and had experienced 4.4 relapses on average since sign-up. Users have over 33,000 unilateral and nearly 14,000 bilateral connections. Users generated over 120,000 unique posts, 507,000 comments, 1617,000 likes, 12,900 check-ins, and 593,000 chats during the period of analysis. Recovery outcomes did not vary between generations, though user activity was significantly different between Generations (Millennials, Generation X, and Baby Boomers), with baby boomers and generation X having higher levels of engagement and connection among all activity markers. Logistic regression results revealed gender (female) was associated with a lower likelihood of reporting loneliness or sexual feelings as an emotional trigger. Linear regressions revealed generation, number of unilateral connections, and number of check-ins was associated with sobriety length, while generation and number of check-ins was associated with number of relapses. CONCLUSIONS: Active users of Sober Grid engage in several platform features that provide objective data that can supplement self-report data for analysis of recovery outcomes. Most commonly uses features are those similar to features readily available in open-ecosystem social network sites (e.g., Facebook). Prediction model results suggest that demographic factors (e.g., age, gender) and activity factors (e.g., number of check-ins) may be useful in deploying just-in-time interventions to prevent relapse or offer additional social support. Further empirical examination is needed to identify the utility of such interventions, as well as the mechanisms of support that accompany feature use or engagement with the D-RSS.

Effect of Computer-Based Substance Use Screening and Brief Behavioral Counseling vs Usual Care for Youths in Pediatric Primary Care: A Pilot Randomized Clinical Trial.

Importance: Annual preventive health visits provide an opportunity to screen youths for unhealthy substance use and intervene before serious harm results. Objectives: To assess the feasibility and acceptability and estimate the efficacy of a primary care computer-facilitated screening and practitioner-delivered brief intervention (CSBI) system compared with usual care (UC) for youth substance use and associated risk of riding with an impaired driver. Design, Setting, and Participants: An intent-to-treat pilot randomized clinical trial compared CSBI with UC among 965 youths aged 12 to 18 years at 5 pediatric primary care offices and 54 practitioners. Patients were randomized to CSBI (n = 628) or usual care (n = 243) groups within practitioner with 12 months of follow-up. Data were collected from February 1, 2015, to December 31, 2017. Data analysis was performed January 1, 2018, to March 30, 2019. Interventions: Patients self-administered a computer-facilitated substance use screening questionnaire before their annual preventive health visits. Immediately after completing the screening, they received their score and level of risk and viewed 10 pages of scientific information and true-life vignettes illustrating health risks associated with substance use. Trained practitioners received the screening results, patients' risk levels, talking points designed to prompt brief counseling, and recommended follow-up plans. Main Outcomes and Measures: Feasibility and acceptability were assessed using adolescents' postvisit ratings. Days of alcohol use, cannabis use, and heavy episodic drinking were assessed at baseline and 3-, 6-, 9-, and 12-month follow-ups using Timeline Followback, and riding in the past 3 months with a driver who was impaired by use of alcohol or other drugs was assessed using 2 self-report items. The primary outcome was the intervention effect among at-risk youths who reported using alcohol or other drugs in the past 12 months or riding with an impaired driver in the past 3 months at baseline. The secondary outcome was the prevention effect among those with no prior use or risk. Results: Among 871 youths screened, 869 completed the baseline assessment; 211 of the 869 reported alcohol or cannabis use in the past 12 months at baseline (mean [SD] age, 16.4 [1.3] years; 114 [54.1%] female; 105 [49.8%] non-Hispanic white). Of the 211 youths, 148 (70.1%) were assigned to the CSBI group and 63 (29.9%) were assigned to the UC group. Among youths in the CSBI group, 105 (70.9%) reported receiving counseling about alcohol, 122 (82.4%) reported receiving counseling about cannabis, and 129 (87.2%) reported receiving counseling about not riding with an impaired driver. Adjusted hazard ratios for time to first postvisit use of alcohol or other drugs for CSBI vs UC were as follows: alcohol use, 0.69 (95% CI, 0.47-1.02); heavy episodic drinking, 0.66 (95% CI, 0.40-1.10); and cannabis use, 0.62 (95% CI, 0.41-0.94). At 12-month follow-ups among 99 youths who reported having ridden in the past 3 months at baseline with an impaired driver (64 in the CSBI group; 35 in the UC group), adjusted relative risk ratio of riding in the past 3 months with an impaired driver for CSBI vs UC groups was 0.58 (95% CI, 0.37-0.91). No intervention effect was observed among youths who reported no prior use of alcohol or other drugs (n = 658) or not having ridden with an impaired driver (n = 769) at baseline. Conclusions and Relevance: The CSBI system is a feasible and acceptable option for screening youths in primary care practice for use of alcohol and other drugs and for risk of riding with an impaired driver, and the estimated efficacy in this sample warrants further testing in larger samples. Trial Registration: ClinicalTrials.gov identifier: NCT00227877.

Screening and Brief Advice to Reduce Adolescents' Risk of Riding With Substance-Using Drivers.

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.

Computer-Facilitated Screening and Brief Advice to Reduce Adolescents' Heavy Episodic Drinking: A Study in Two Countries.

PURPOSE: A computer-facilitated screening and brief advice (cSBA) intervention was previously shown to reduce drinking among U.S. adolescents but not among Czech youth. The purpose of this study was to assess cSBA effect on heavy episodic drinking (HED). METHODS: Participants were 12- to 18-year-olds at nine U.S. primary care offices (N = 2,096) and 10 Czech pediatrician-generalist offices (N = 589) who completed measurements only during an 18-month treatment-as-usual (TAU) phase. We then initiated the cSBA protocol for all participants and recruited the 18-month cSBA phase. Generalized Estimating Equations logistic regression compared past-90-day HED for cSBA versus TAU at 3- and 12-months, controlling for baseline HED and other covariates. RESULTS: Baseline past-90-day HED rates were 11% for U.S. and 28% for Czech youth. At 3 months, among Czech baseline non-HED, the adjusted relative risk ratio for cSBA versus TAU was .52 (95% confidence interval .29, .92). The effect dissipated by 12 months. CONCLUSIONS: cSBA shows promise for short-term prevention of adolescent HED.

Association Between Substance Use Diagnoses and Psychiatric Disorders in an Adolescent and Young Adult Clinic-Based Population.

PURPOSE: Adolescents with substance use disorders are more likely to have a current psychiatric disorder. However, when compared with the adult literature, there is relatively limited information regarding the specific co-occurrence of certain mental health diagnoses and substance use disorders in adolescents. The objectives of this study were to build on the previous literature regarding mental health diagnoses and different types of substance use disorders in adolescents, as well as explore the differences, if any, between groupings of mental health diagnosis and type of substance used. METHODS: Data were extracted from the clinical records of 483 individuals aged 11-24 years referred for an evaluation at the Adolescent Substance Abuse Program at Boston Children's Hospital. According to DSM-IV-Text Revision criteria, individuals received diagnoses of substance abuse or dependence and any additional psychiatric disorders. Problematic use was included within the sample for greater power analysis. A multivariable logistic regression model estimated the association between psychiatric diagnosis and substance use while adjusting for covariates including age and gender. RESULTS: Multiple significant associations were found, including having any anxiety-related diagnosis and opioid use (odds ratio [OR] = 2.23, p < .001), generalized anxiety disorder and opioids (OR = 3.42, p = .008), cocaine and post-traumatic stress disorder (OR = 3.61, p = .01), and marijuana and externalizing behavior disorders (OR = 2.10, p = .024). CONCLUSIONS: Our study found multiple significant associations between specific substances and certain co-occurring psychiatric disorders. The use of office screening systems to efficiently identify these youths should be a part of routine medical and psychiatric care.

Putting Adolescents at Risk: Riding With Drinking Drivers Who Are Adults in the Home.

OBJECTIVE: Alcohol-related car crashes are a leading cause of adolescent death, and one in five U.S. adolescents reports recent riding in a car with a drinking driver. How often the driver is an adult in the home (e.g., parent) is unknown. Pediatric visits offer an opportunity to counsel families to reduce this risk. Our study aim was to determine the prevalence of recent riding with a drinking driver (RWDD) who was an adult in the home among adolescent primary care patients and to identify the demographic and environmental (substance use among family members) profiles of those at increased risk. METHOD: We recruited 12- to 18-year-olds arriving for routine medical care between 11/2005 and 10/2008 from nine practices in New England. Computer self-administered questionnaires assessed demographics, past-3-month RWDD, driver characteristics, and parent/sibling substance use. We computed adjusted relative risk ratios using multiple logistic regression modeling. RESULTS: Among 2,096 adolescents (86% participation rate; mean age = 15.8 years, SD = 2.0; 58% girls; 65% White non-Hispanic), 8.2% reported past-3-month RWDD who was an adult in the home (36.6% of those reporting any past-3-month RWDD). Risk was higher for girls, younger adolescents (<17 year olds), White non-Hispanic and Hispanic versus Black youth, those with non-college-graduate parents, and those with substance-involved parents. CONCLUSIONS: For a substantial proportion of adolescent primary care patients RWDD, the driver is a parent or other household adult, suggesting an important target for screening and counseling.

Concurrent Validity of Caffeine Problems and Diagnostic Criteria for Substance Use Disorders.

Background: The DSM-5 proposes caffeine use disorder (CUD) as a condition for further study. The objective of this study was to report on the prevalence of CUD and rates of endorsement for each substance use disorder (SUD) criterion in relation to caffeine compared to alcohol and marijuana in a sample of adolescents presenting for medical care in the primary, adolescent, and substance use clinics at an academic medical center. Methods: A convenience sample of patients (N = 213; 66.7% female) aged 12-17 presenting for medical care completed the Composite Diagnostic Interview-Substance Abuse Module questionnaire, with questions regarding use of caffeine, alcohol, and marijuana. Descriptive analyses were used to determine prevalence of CUD and frequency of each endorsed SUD criterion as applied to caffeine versus alcohol or marijuana. Comparative Fit Index (CFI) and Tucker-Lewis Index (TLI) were used to determine psychometric properties for CUD. Results: The majority of subjects (N = 153) reported past 30-day caffeine use and of these, six (4%) met criteria for CUD. All six also met criteria for either alcohol and/or marijuana use disorders. Of the three essential CUD criteria (failure to quit, use despite harm, and withdrawal), both harm and withdrawal were endorsed significantly more often in relation to caffeine versus alcohol. Descriptive fit indices for the CUD model were excellent (CFI = 0.994, TLI = 0.991). Conclusions: In our sample, the proportion of adolescents that met proposed CUD criteria was low, suggesting that the proposed criteria would not lead to overdiagnosis of CUD. CUD was highly correlated with other SUDs.

Adolescent substance use screening in primary care: Validity of computer self-administered versus clinician-administered screening.

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.

Symptoms Attributed to Consumption of Caffeinated Beverages in Adolescents.

Purpose: Pediatric caffeine use has become increasingly prevalent. The American Academy of Pediatrics discourages caffeine use by children and adolescents due to its adverse impact on sleep and blood pressure. The objective of this study was to measure prevalence of physical and emotional symptoms related to caffeine consumption among adolescents receiving primary care. Methods: A convenience sample of patients (N = 179; 73% female) aged 12-17 presenting for routine primary care completed the Composite International Diagnostic Interview Substance Abuse Module questionnaire, which included questions regarding use of caffeine. Descriptive statistics were used to summarize prevalence of caffeine use and caffeine-related symptoms. Associations of number of caffeine-related symptoms with age, gender, and race/ethnicity were also analyzed. Results: Sixty-seven percent of participants (n = 120) reported past 30-day caffeinated beverage consumption. Of those, 68% (n = 82) reported at least one symptom or problem attributed to caffeine use or withdrawal, including caffeine cravings, 24% (n = 29); frequent urination, 21% (n = 25); difficulty falling asleep, 18% (n = 22); and feeling anxious, 3.3% (n = 4). Conclusions: In our sample, caffeinated beverage consumption by adolescents was frequently associated with physical and emotional symptoms, as well as problems attributed to use.

A group therapy program for opioid-dependent adolescents and their parents.

BACKGROUND: Opioid dependence is a significant problem for adolescents in the United States. Psychosocial treatment for adolescents with opioid use disorders may be effective, although it has not been well studied. METHODS: This paper describes a 13-week psychoeducational group therapy program with parallel tracks for adolescents with opioid use disorders and their parents attending an outpatient substance use program in a children's hospital. In addition to group therapy, participating adolescents received medical care, including medication-assisted treatment for opioid dependence, drug testing, medical follow-up, psychopharmacology, individual counseling, and parent guidance. Data were collected as part of a quality improvement project for the program. Forty-two adolescents and 72 parents attended the group program between 2006 and 2009. Frequencies were computed and a weighted kappa was used to assess agreement between adolescent and parent reports of use and driving risk. RESULTS: Of the 42 adolescents participating in the 13-week group program, 36 (86%) completed 3 or more group sessions, and 24 (57%) completed 10 or more sessions. Twenty-two (52%) adolescent participants reported abstinence from all substances on each of their weekly evaluations. Adolescent-parent agreement for substance use was good to very good: weighted kappa (95% confidence interval) .76 (.60, .87), but poor for driving risk, weighted kappa .11 (-.20, .40). CONCLUSIONS: Completion rates and self-report of outcomes from this group program indicate promise and warrant further testing.

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.

Do risky friends change the efficacy of a primary care brief intervention for adolescent alcohol 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.

Computer-facilitated substance use screening and brief advice for teens in primary care: an international trial.

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.

Acceptability of drug testing in an outpatient substance abuse program for adolescents.

BACKGROUND: Laboratory drug testing programs may be effective in reducing substance use by adolescents, but developmentally appropriate programs have not been described, and it is unknown if adolescents would be willing to participate in drug testing. OBJECTIVE: To describe a drug testing protocol for adolescents and report on acceptance rate by patients participating in an outpatient adolescent substance abuse program. METHODS: Eligible adolescents participating in an outpatient substance abuse treatment program were offered a random laboratory drug testing program that is described in detail in this manuscript. We recorded whether they accepted and, if not, the reason for refusal. RESULTS: Of the first 114 eligible patients, 67 (59%) agreed to participate in a drug testing program (PDT). CONCLUSIONS: A majority of adolescents participating in an outpatient drug treatment program agreed to participate in a drug testing program that requires frequent urine specimens and reports results to parents. Future studies should determine how this program affects treatment outcomes and whether this program is feasible in primary care.

Alcohol policy enforcement and changes in student drinking rates in a statewide public college system: a follow-up study.

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.

Screening adolescents for substance use-related high-risk sexual behaviors.

PURPOSE: This analysis was undertaken to determine whether adolescents who screened positive for high-risk substance use with the CRAFFT questions were also more likely to engage in risky sexual behaviors than their peers, and to determine the test-retest reliability of a substance use-related sexual risk behaviors inventory. METHODS: Clinic patients 12-18 years old completed a multi-part questionnaire that included eight demographic items, the CRAFFT substance use screen, and a 14-item scale assessing sexual behaviors associated with substance use. Participants were invited to return 1 week later to complete an identical assessment battery. RESULTS: Of the 305 study participants, 49 (16.1%) had a positive CRAFFT screen result (score of 2 or greater, indicating high risk for substance abuse/dependence) and 101 (33.9%) reported sexual contact during the past 90 days. After controlling for gender, age, race/ethnicity, and number of parents in household, adolescents with a positive CRAFFT screen had significantly greater odds of having sexual contact after using alcohol or other drugs, of having a sexual partner who used alcohol or other drugs, of having sex without a condom, and of having multiple sexual partners within the past year, compared to their CRAFFT negative peers. The substance use-related sexual risk behaviors inventory has acceptable test-retest reliability, and the 10 frequency questions have scale-like properties with acceptable internal consistency (standardized Cronbach's alpha=.79). CONCLUSION: Clinicians should pay special attention to counseling CRAFFT-positive adolescents regarding use of condoms and the risks associated with sexual activity with multiple partners, while intoxicated, or with an intoxicated partner.