The rising rates of opioid deaths and the legalization of marijuana sale and use for adults have made substance use a prominent topic from local governments to presidential politics. As illustrated by numerous articles in Health Affairs’ June 2016 theme issue on behavioral health, substance use policy debates are now focused as never before on prevention and treatment. At the same time, the Affordable Care Act (ACA) has begun creating momentum to incorporate behavioral health initiatives into primary care, calling upon primary care physicians to expand counseling and advice about substance use, detect patients with substance use disorders, and link them with treatment.
Responding to these developments, the American Academy of Pediatrics (AAP) has recently reaffirmed recommendations for universal screening, brief intervention, and referral to treatment—an approach commonly referred to as SBIRT—to prevent, delay, or decrease substance use by adolescents. The AAP also released clinical guidelines that reaffirm its position that abstinence is the best medical advice for teens, and that addressing substance use is an important part of routine health care for adolescents. In the update, clinical recommendations have been simplified to promote implementation of good practice.
Alcohol and other drug use account for the vast majority of life-years lost due to disease, disability, and premature death among those aged 15-24. In addition to being susceptible to acute harms, the growing adolescent brain is also especially vulnerable to developing the neurological changes of addiction. Marijuana use in adolescence in particular is associated with more than a threefold increase in risk of subsequent opioid addiction. Indeed, over 90 percent of the more than 20 million Americans with a substance use disorder initiated use before age 18. Preventing adolescent substance use may be one of our best strategies for both improving adolescent health and addressing the current epidemic of opiate addiction in adults.
There is evidence that pediatricians are heeding the call to discuss substance use with their adolescent patients and this relatively new venue for substance use prevention presents tremendous opportunity. Well implemented, brief health advice from a physician has the potential to address one of the most important modifiable behaviors that contributes to poor health outcomes in adolescents. Simple, clear messages about the health benefits of abstinence for adolescents hold the promise of producing long-lasting prevention of substance use disorders. Indeed, rates of alcohol and traditional cigarette use have fallen sharply in recent decades, likely attributable at least in part to strong public health efforts that have informed the population of the harms of using these substances.
Alcohol and marijuana use by adolescents is often perceived as a developmental milestone rather than a modifiable behavior, and consequently advice to limit use or to choose one substance as a safer alternative to another is common. Yet an approach that advises teens to use these substances “carefully” or “in moderation” may inadvertently encourage substance use, as these messages can easily be misinterpreted as a green light to use.
The definition of moderation is a prime example. While five drinks is the definition of a binge according to the National Institute on Alcoholism and Alcohol Abuse, 90 percent of all alcohol consumed by underage drinkers is consumed in volumes above this threshold. Consequently for many youth, limiting an evening to five drinks is moderation. Advice that may seem reasonable and practical to physicians and other adults may have the unintended consequence of encouraging the behavior it is attempting to extinguish.
Concerns that advice to adolescents to abstain is unrealistic or off-putting may stem from provider experiences with a small number of memorable teens with heavy substance use. But a broader, epidemiological approach shows that expectations that substance use is inevitable is incorrect.
For example, at its peak in 1997, 37 percent of 12th graders used tobacco products in the past 30 days. After decades of public health messaging about the health harms of tobacco use, the current rate is 11 percent. The same pattern is true for alcohol — the prevalence of past two-week binge drinking (consuming five or more drinks on one occasion) peaked at 41 percent among 12th graders in 1979. In 2015, binge drinking has fallen to 17 percent. The declines suggest that youth are very responsive to cultural messages, and particularly those that focus on health, and are in fact willing to abstain from substances that they perceive to be health harming.
Yet not all signs are positive. As we are seeing declines in alcohol and tobacco, use of new products such as electronic cigarettes and edible marijuana has grown. Today, youth who do initiate drug use enter a vast landscape of more potent products, synthetic alternatives, and new delivery methods that are far more addictive than psychoactive substances that were available to teens a generation ago, further underscoring the importance of the decision not to use any substances at all. It is important for adults to conceptualize youth substance use as a single decision from a health point of view (as opposed to a series of decisions about individual substances or specific levels of use or specific settings in which use can occur). This shift may help break the cycle of one substance losing popularity only to be replaced by another.
Ultimately, the American Academy of Pediatrics is encouraging primary health care providers to embrace and routinely deliver to their adolescent patients a message that says that their health is best served by not using any alcohol, tobacco, marijuana, or other drugs. What is more, a clear message to abstain does not conflict with substantive education on the topic; the AAP guidelines recognize that some adolescents reject abstinence, and suggests strategies for discussions about minimizing risks, but only after delivering a clear abstinence message.
What Can Policymakers Do?
Substance use advice and counseling by pediatricians can be supported by local and federal governments in the form of policies that recognize and reward the value of this activity. Primary care clinicians have a uniquely credible voice in the much larger cacophony because of their commitment to youth health and their long-standing health-focused relationships with their young patients. Developmentally appropriate health advice delivered during routine contacts is unlikely to be entirely drowned out by the multitude of messages that daily surround youth.
A cooperative public health approach that takes advantage of touch points wherever they occur—in schools, sports leagues, community centers, on social media, and perhaps most importantly through parentS—and that stays on a single no-use for health message has the greatest potential for impact. By embracing this approach and evaluating policy decisions through this lens politicians can advance the goals of reducing adolescent substance use and improving the health of the nation.
The author gratefully acknowledges pre-publication feedback on this post from Bob Dupont.