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US Public Health Service. Office of Disease Prevention and Health Promotion. Clinician's Handbook of Preventive Services. 2nd edition. Washington (DC): Department of Health and Human Services (US); 1999.

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

Cover of Clinician's Handbook of Preventive Services

Clinician's Handbook of Preventive Services. 2nd edition.

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18Alcohol and Other Drug Abuse

Abuse of alcohol and other drugs is a major health problem for older children and adolescents. Accidental injuries are the leading cause of death for adolescents, and approximately 40% of such injuries are related to alcohol use. Alcohol use has also been implicated in a significant percentage of adolescent homicides and suicides -- the second and third leading causes of death in this age group. Cocaine use leads to increased cardiovascular morbidity and mortality in adolescents and young adults and indirectly contributes to the number of violent deaths of young people that are related to illegal drug activities. Use of illegal drugs is also related to poor school performance, social withdrawal, and family dysfunction.

Drug abuse affects children in all cultural and socioeconomic groups, not only minorities, the poor, and the undereducated. A 1990 survey of high school seniors found that the percentage of white youths reporting use of alcohol, marijuana, and cocaine in the month prior to the survey was higher than that of African-American youths (alcohol: 62.2% versus 32.9%; marijuana: 15.6% versus 5.2%; cocaine: 1.8% versus 0.5%). In this same study, alcohol and marijuana use were found to be directly related to parental educational levels. Higher parental educational levels were associated with greater drug use by the child. In general, the prevalence of alcohol and other drug abuse among females is lower than that among males.

See chapter 53 for information on counseling adults about abuse of alcohol and other drugs. See chapters 24 and 60 for information on counseling about tobacco use and smoking cessation.

Recommendations of Major Authorities

  • American Academy of Family Physicians --
  • Recommends counseling about accidental injury prevention with regard to impaired driving.
  • American Academy of Pediatrics --
  • Clinicians should condemn the nontherapeutic use of all psychoactive drugs, including alcohol and nicotine, by children and adolescents. All providers of adolescent health care should discuss the hazards of alcohol and other drug use with their patients as a routine part of risk behavior assessment. Providers should reinforce abstinent behaviors and assess current use with a nonjudgmental approach. Special attention should be paid to the discussion of this issue when risk factors for problem drinking, such as family history of alcoholism, are present. Preventive child health care visits provide an opportunity to inquire about a family history of alcoholism and parental attitudes about alcohol use.
  • American Medical Association --
  • Clinicians should counsel all adolescents on the dangers of substance use and strategies to refrain from use. This approach should be complemented by counseling parents to monitor adolescents' social behaviors. Clinicians should screen adolescents for use of alcohol and other drugs. Previsit questionnaires may be used to determine risk for substance abuse, with direct questioning about actual use during a clinical interview. Once use is identified, a positive response to any of the following questions should alert the health care provider to possible abuse and prompt a referral: Does the adolescent ever use drugs when alone?Does the adolescent ever use alcohol when alone?Does the adolescent ever get drunk or high at social events or have friends who do?Does the adolescent ever consume alcohol on school grounds?Does the adolescent ever miss school because of drinking or hangovers?When truant, does the adolescent ever go drinking or get high on drugs?
  • All adolescent males who participate in high school athletic programs should be asked about their knowledge and use of anabolic steroids. Particular attention should be given to those who participate in sports that require weight and strength, such as football, track and field, and weight-lifting.
  • Bright Futures --
  • Child and adolescent health supervision visits should include interview questions, developmental surveillance questions, and anticipatory guidance that address alcohol and other drug abuse, as well as tobacco use.
  • Canadian Task Force on the Periodic Health Examination --
  • Routine active case-finding of problem drinking among patients in medical practices is highly recommended on the basis of the high prevalence of this problem, its association with adverse consequences before the stage of dependency is reached, and its amenability to a counseling intervention by clinicians. Active case-finding should be performed through structured interviews and questionnaires. Clinicians should be sensitive to the possibility of alcohol-related stressors in offspring of alcoholic or alcohol-abusing parents and in some high-risk groups, particularly children hospitalized for injury. Primary health care providers are in an excellent position to prevent children's injuries by identifying, evaluating, and assisting families in recovery from the effects of family alcoholism.
  • US Preventive Services Task Force --
  • Screening to detect problem drinking is recommended for all adult and adolescent patients. Screening should involve a careful history of alcohol use and /or the use of standardized screening questionnaires. Routine measurement of biochemical markers is not recommended in asymptomatic persons. Pregnant women should be advised to limit or cease drinking during pregnancy. Although there is insufficient evidence to prove or disprove harms from light drinking in pregnancy, recommendations that women abstain from alcohol during pregnancy may be made on other grounds. All persons who use alcohol should be counseled about the dangers of operating a motor vehicle or performing other potentially dangerous activities after drinking alcohol.
  • There is insufficient evidence to recommend for or against routine screening for drug abuse with standardized questionnaires or biologic assays. Including questions about drug use and drug-related problems when taking a history from all adolescents and adult patients may be recommended on other grounds, including the prevalence of drug use and the serious consequences of drug abuse and dependence. All pregnant women should be advised of the potential adverse effects of drug use on the development of the fetus. Clinicians should be alert to the signs and symptoms of drug abuse in patients and refer drug-abusing patients to specialized treatment facilities where available.

Basics of Alcohol and Other Drug Abuse Counseling

1.

Begin educational discussions with children and parents during the preteen years. Sample questions for discussing drug use with children in this age group are listed in Table 18.1. Similar questions can be used to discuss alcohol use. Inform all children and adolescents of the dangers of alcohol and drug use. Emphasize the dangers of operating a motor vehicle while under the influence of alcohol or drugs. Explain the potential risk for exposure to hepatitis B, HIV, and other STDs and the risk of unintended pregnancies from sexual encounters while under the influence of alcohol or other drugs.

2.

Ask parents about their own use of alcohol and other drugs and whether they discuss the use of alcohol and other drugs with their children. Assess whether a family history of alcoholism or other drug use exists and whether family stress places the child at increased risk. See chapter 53 for information on counseling adults about abuse of alcohol and other drugs.

3.

Establish a caring and confidential relationship with adolescent patients. Inform both the parents and the adolescent of the limits of this confidentiality. Such limits can be summarized as follows: absolute confidentiality is not possible if the provider judges the adolescent's actions to be of immediate and serious danger to him/herself or to others. There is a duty to disclose to protect the adolescent from him/herself (eg, suicidality), a duty to warn others of imminent or likely harm (eg, homicidality), and also a duty to report (eg, sexually transmitted diseases and abuse or neglect). Discussions about confidentiality should assure the teen that in all other situations, information will not be shared with parents or others without the teen's permission. Clinicians should reinforce the limits of confidentiality at each visit. Using one or more examples as illustration is also helpful.

4.

Begin by asking children and adolescents about alcohol and drug use in their environment -- at home, school (including use of drugs to enhance athletic ability), or work. This may be less threatening than first asking about their personal use. A set of questions using this indirect approach is listed in Table 18.2.

5.

If a history of alcohol or other drug use is elicited, ask the adolescent in a nonjudgmental manner about the type of drugs used, the quantity and frequency of use, and the setting of use.

6.

Evaluate the extent to which alcohol or other drug use is adversely affecting important aspects of the patient's life, such as school performance, peer relationships, family relationships, work performance, and sexual relationships. "Drinking and You," in The Adolescent Drinking Index, is an evaluation tool designed and tested with adolescents ( see Provider Resources).

7.

Counsel patients at increased risk for hepatitis B, HIV, and other STDs about the importance of screening for these conditions and receiving hepatitis B vaccination.

8.

Remain alert for signs and symptoms of physiologic dependence or withdrawal, such as craving, compulsive alcohol- or drug-seeking behavior, tremulousness, agitation, weight loss, headaches, and changes in mental status.

9.

The presence of significant psychosocial impairment or physiological dependence attributable to alcohol or other drug abuse suggests the need for early referral of the patient for comprehensive evaluation and possible inpatient, outpatient, or day treatment. Be familiar with the range of referral and treatment options in your community. Examples of types of community resources may include behavioral health centers, community mental health centers, alcohol and drug treatment centers specializing in adolescent care, child and adolescent guidance centers (in some states these are part of local public health clinics), and school health centers. The primary care provider may counsel patients who are not seriously impaired.

10.

Chapter 53 discusses basic principles of substance abuse counseling, including:

  • Establishing a therapeutic relationship
  • Making the medical office or clinic off-limits for substance abuse
  • Presenting information about negative health consequences
  • Involving family and other support
  • Setting goals
  • Becoming familiar with community treatment services
  • Providing follow-up

Table 18.1. Sample Questions Concerning Drugs for School-aged Children.

Table

Table 18.1. Sample Questions Concerning Drugs for School-aged Children.

Table 18.2. Sample Questions Concerning Drug Use for Adolescents.

Table

Table 18.2. Sample Questions Concerning Drug Use for Adolescents.

Patient Resources

  • Anabolic Steroids and Athletes. American College of Sports Medicine, PO Box 1440, Indianapolis, IN 46206-1440; (317)637-9200. Internet address: http://www.acsm.org/sportsmed
  • Alcohol: What to Do If It's a Problem for You. American Academy of Family Physicians, 8880 Ward Parkway, Kansas City, MO 64114-2797; (800)944-0000. Internet address: http://www.aafp.org
  • Alcohol: Your Child and Drugs; Cocaine: Your Child and Drugs; Marijuana: Your Child and Drugs; Teens Who Drink and Drive: Reducing the Death Toll; Inhalent Abuse: Your Child and Drugs. American Academy of Pediatrics, PO Box 927, Elk Grove Village, IL 60009-0927; (800)433-9016. Internet address: http://www.aap.org
  • Let's Talk Facts about Substance Abuse. American Psychiatric Association, 1400 K Street, NW, Washington, DC 20005; (800)368-5777. Internet address: http://www.psych.org
  • National Clearinghouse for Alcohol and Drug Information. Information about numerous publications available in both English and Spanish. (800)729-6686.

Provider Resources

  • The Adolescent Drinking Index. Manual and 25 test booklets (cost $55). Available from Psychological Assessment Resources, Inc, PO Box 998, Odessa, FL 33556; (800)331-TEST.
  • Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents; Bright Futures Pocket Guide; Bright Futures Anticipatory Guidance Cards. Available from the National Center for Education in Maternal and Child Health, 2000 15th Street North, Suite 701, Arlington, VA 22201-2617; (703)524-7802. Internet address: http://www.brightfutures.org

Selected References

  1. American Academy of Family Physicians. Summary of Policy Recommendations for Periodic Health Examination. Kansas City, Mo: American Academy of Family Physicians; 1997.
  2. American Academy of Pediatrics, American Academy of Family Physicians, American College of Obstetricians and Gynecologists, NAACOG — The Organization for Obstetric, Gynecologic, and Neonatal Nurses, National Medical Association (joint policy statement). Confidentiality in adolescent health care. In: Policy Reference Guide: A Comprehensive Guide to AAP Policy Statements Published through December 1996. Elk Grove Village, Ill: American Academy of Pediatrics; 1997:129.
  3. American Academy of Pediatrics, Committee on Adolescence, Committee on Substance Abuse. Marijuana: A continuing concern for pediatricians. Pediatrics. . 1991; 88:1070–1072. [PubMed: 1945617]
  4. American Academy of Pediatrics. Committee on Substance Abuse and Committee on Native American Child Health. Inhalent Abuse. Pediatrics. . 1996; 97:420–423. [PubMed: 8604284]
  5. American Academy of Pediatrics, Committee on Substance Abuse. Alcohol use and abuse: a pediatric concern. Pediatrics. . 1995; 95:439–442. [PubMed: 7862490]
  6. American Academy of Pediatrics, Committee on Substance Abuse. Role of the pediatrician in prevention and management of substance abuse. Pediatrics. . 1993; 91:1010–1013. [PubMed: 8474792]
  7. American Academy of Pediatrics, Committee on Substance Abuse. The role of schools in combatting substance abuse. Pediatrics. . 1995; 95:784–785. [PubMed: 7724327]
  8. American Medical Association. Use of alcohol, drugs, and steroids. In: AMA Guidelines for Adolescent Preventive Services (GAPS): Recommendations and Rationale. Chicago, Ill: American Medical Association; 1994.
  9. Canadian Task Force on the Periodic Health Examination. Children of alcoholics. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 41.
  10. Canadian Task Force on the Periodic Health Examination. Early detection and counseling of problem drinking. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 42.
  11. Green M, ed. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Arlington, Va: National Center for Education in Maternal and Child Health; 1994.
  12. National Center for Health Statistics. Health, United States, 1991 Prevention Profile. Hyattsville, Md: Public Health Service; 1992. US Department of Health and Human Services publication PHS 92-1232.
  13. Schonberg KS, ed. Substance Abuse: A Guide for Health Professionals. Elk Grove Village, Ill: American Academy of Pediatrics; 1988.
  14. US Preventive Services Task Force. Screening for drug abuse.In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 53.
  15. US Preventive Services Task Force. Screening for problem drinking.In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 52.
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