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Addressing Substance Use in Adolescents: Screening, Brief Intervention, and Referral to Treatment
The Journal for Nurse Practitioners xxx (xxxx) xxx
Contents lists available at ScienceDirect
The Journal for Nurse Practitioners journal homepage: www.npjournal.org
Addressing Substance Use in Adolescents: Screening, Brief Intervention, and Referral to Treatment Dianna Inman, DNP, PMHNP-BC, Peggy El-Mallakh, PhD, PMHNP-BC, Lynne Jensen, PhD, ANP-BC, Julie Ossege, PhD, FNP-BC, Leslie Scott, PhD, PPCNP-BC a b s t r a c t Keywords: adolescent substance use brief intervention referral to treatment SBIRT screening
Adolescent substance use is a national public health crisis. The most commonly used substances among adolescents are nicotine, alcohol, and marijuana. Use of these substances during adolescence has serious adverse effects on brain development, with impairments that can endure into adulthood. Advanced practice nurses in primary care can address substance use in the adolescent population with the use of evidencebased interventions, such as Screening, Brief Intervention, and Referral to Treatment (SBIRT). This article describes trends in adolescent substance use and use of the SBIRT intervention for low, medium, and highrisk use in this population. © 2019 Elsevier Inc. All rights reserved.
Introduction Researchers, clinicians, and policymakers have identified adolescent substance use (SU) as a national public health crisis.1 The scope of the problem is illustrated in A Day in the Life of American Adolescents, which reports that on an average day, 881,684 adolescents smoke cigarettes, 646,702 use marijuana, and 457,672 drink alcohol.2 The purpose of this article is to report recent trends in adolescent SU and describe the Screening, Brief Intervention, and Referral to Treatment (SBIRT) intervention as a strategy to identify and intervene for at-risk SU in this population.
high risk for several negative social, behavioral, and emotional outcomes.4 These include school failure, legal problems due to illegal use and driving when intoxicated, impulsive high-risk behaviors, and increased risk for suicide and homicide. Alcohol use during adolescence is also linked to a predisposition to future risky behaviors, such as continued substance use, delinquency, and aggression.5 Mortality rates from underage drinking are costly to adolescents, families, and society. Underage drinking resulted in 4,300 deaths in 2010, with an estimated cost of $24 billion.6 Alcohol accounted for 189,000 emergency department visits by people under age 21 for injuries and other conditions.6
Overview Since 1991, the Centers for Disease Control and Prevention (CDC) has conducted biennial surveys among high school students to assess high-risk health behaviors, including SU, using the Youth Risk Behavior Surveillance Survey (YRBSS). There has been a steady increase of SU among teens. According to the most recent YRBSS report completed in 2017, the most commonly used substances among students in grades 9 through 12 are alcohol, nicotine, and marijuana.3 Alcohol Alcohol is the most frequently used substance among adolescents in the United States.3 The 2017 YRBSS reported that almost 30% of youth in grades 9 through 12 reported current alcohol use, defined as at least 1 drink on at least 1 day in the previous 30 days.3 Current use ranged from 18.8% of 9th graders to 40.8% of 12th graders. Early-onset alcohol consumption places adolescents at https://doi.org/10.1016/j.nurpra.2019.10.004 1555-4155/© 2019 Elsevier Inc. All rights reserved.
Nicotine Nicotine is a highly addictive substance7 with extensively documented adverse health effects.7,8 The YRBSS reported that in 2017, 19.5% of high school students reported current use of any tobacco product, such as cigarettes, electronic vapor products (EVPs), smokeless tobacco, or cigars.3 Traditional tobacco products are frequently used by high school students; up to 8.8% of high school students (1.4 million students) used cigarettes.9 EVPs are the most frequently used nicotine products in this age group; up to 13.2% of high school students (2.1 million students) used EVPs during 2017.9 Adolescents prefer EVPs for a variety of reasons, including ease of concealment, which enables use in places that typically ban tobacco products. Some EVPs have very high concentrations of nicotine in their delivery systems, which presents a serious risk that users can become rapidly addicted or experience nicotine poisoning.9
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Marijuana In 2017, 19.8% of high school students reported current use of marijuana, ranging from 13.1% of 9th graders to 25.7% of 12th graders.3 Adverse effects of marijuana use include increased risk of anxiety and depression.10 In addition, several physical health problems have been linked to marijuana use, including chronic bronchitis and increased risk for myocardial infarction and stroke during marijuana intoxication.10 Clinicians are increasingly aware of the potential for addiction to marijuana among chronic users. Almost 17% of people who start using marijuana as teenagers will develop an addiction to the drug, and risk of marijuana addiction increases to 25e50% among people who smoke marijuana daily.10 In addition, tetrahydrocannabinol (THC) has become increasingly potent in marijuana since 1995; this increase in potency is associated with a 100% increase in marijuanarelated emergency department visits between 2004 and 2011.10 Recent trends in marijuana availability and use present considerable challenges for health care professionals engaged in SU counseling for adolescents. Synthetic Cannabinoids Synthetic cannabinoids (SCBs) are a particularly harmful form of lab-created marijuana.11 The 2017 YRBSS reported that 6.9% of adolescents ever used SCBs, ranging from 5.5% of 9th graders to 7.6% of 12th graders.3 Use was highest in Hispanic adolescents (9.1%), compared with 6.3% in African American and 5.9% in Caucasian youth in 2017.3 SCBs are typically sold as herbal products and are readily available on the Internet.11 The Drug Enforcement Agency designated several forms of SCBs as Schedule I drugs between 2013 and 2015, making them illegal. However, manufacturers and dealers have circumvented this by rapidly developing and disseminating new forms of synthetic cannabinoids. These newly developed drugs are not detectable using drug toxicity testing. SCBs are more potent and toxic than the THC found in naturally grown marijuana, and their effects are unpredictable and severe.7,11 Adverse effects reported to poison control centers during 2015 included tachycardia, lethargy/drowsiness, agitation/irritability, vomiting, and confusion.12 Psychiatric effects include acute psychosis,11 such as hallucinations, delusions, and violent behavior. Other adverse effects include suicidal thoughts,7 hypertension, rhabdomyolysis, renal failure, and death.11,12 According to Law et al,12 poison centers across the United States reported a 229% increase in emergency calls related to the adverse effects of SCBs between 2014 and 2015.
alcohol’s neurotoxic effects.5 Alcohol consumption during adolescence is associated with alterations in structural brain development, including the cerebral cortex, hippocampus, and cerebellum. Impaired development in these brain regions due to alcohol use results in problems with attention, memory, information processing, visuospatial functioning, language ability, executive functioning, and inhibition.5 Similarly, smoking and vaping during adolescence are associated with several cognitive impairments and deficiencies in cognitive maturation, including problems with executive functioning, memory, attention, and prefrontal cortex activation.13 Marijuana use, particularly chronic and long-term use, is associated with several impairments in brain development among adolescents.10 Structural impairments in neural connectivity have been observed, including areas of the brain that regulate alertness, self-conscious awareness, executive functioning, and inhibitory control. Impairments in verbal learning and working memory have also been observed among adolescents who are heavy users of marijuana; these impairments are evident for up to 6 weeks after cessation of heavy use.17 Importantly, marijuana has been identified as a possible gateway drug, which may be due to the ability of THC to cause the brain to be more responsive to other drugs, which may increase the risk for other addictions later in life.10 Risk and Protective Factors Several risk and protective factors have been linked to SU among adolescents. Times of transition increase the risk of drug use for the adolescent. For example, at the move from elementary school to middle school, the early adolescent may be exposed to tobacco and alcohol for the first time. In high school, teens may have greater access to drugs by attending social activities where substances are present. Several factors put teens at higher risk for misusing alcohol and other substances, such as impulsiveness, aggressive behaviors, or conduct problems. Additional risk factors include a family history of substance use/mood disorders, poor parental supervision, household disruption, low academic achievement, untreated attention-deficit/hyperactivity disorder and other psychiatric disorders, and SU among peers.18 Protective factors include a stable and supportive home environment, involvement in church and community activities, and good academic performance.18 Other protective factors include having parents who set clear rules and enforce them, eating meals together as a family, parental guidance about SU, having a parent in recovery, and adequate community resources.18
Substance Use and the Developing Adolescent Brain
Screening, Brief Intervention, and Referral to Treatment
Adolescence is a time of rapid brain growth and development.13 Adolescents who use substances are vulnerable to the development of substance misuse and addiction, due to patterns of adolescent brain maturation.14 Adolescent brain development is “nonlinear”15; the prefrontal cortex is immature, resulting in limited executive functioning related to decision-making, impulse control, and judgment.16 However, the dopaminergic reward pathway, an anatomical structure responsible for the pleasurable effects of SU, matures at a much faster rate than the prefrontal cortex.16 SU is reinforced because the adolescent experiences rewarding effects in the dopamine pathway, while the prefrontal cortex is not yet mature enough to allow the adolescent to consider that SU is detrimental. Adolescent brain development is highly vulnerable to the adverse effects of environmental toxins, including SU.14,16 Alcohol is a neurotoxin, and the developing adolescent brain is sensitive to
SBIRT is an evidence-based approach to identify and intervene for people who are at risk for problems related to substance use.1 The SBIRT process is endorsed by leading professional associations and government agencies such as the American Academy of Pediatrics (AAP)19 policy statements, the American Medical Association, the Substance Abuse and Mental Health Services Administration (SAMHSA), the Centers for Medicare and Medicaid Services, and the National Institute on Alcohol Abuse and Alcoholism. Extensive research has examined the effectiveness of SBIRT for adolescents that address a variety of SU issues, including alcohol and marijuana. Mitchell and colleagues20 implemented SBIRT in a school-based program to address substance use among 629 adolescents in 13 schools. Findings indicated that adolescents who received the SBIRT intervention reported reductions in frequency of illicit drug use and reductions in drinking to intoxication between baseline and 6-month follow-up.
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Table 1 CRAFFT 2.1: Level of Risk and Clinical Action Risk Level
CRAFFT Score
Clinical Action
Low
No use in past 12 months and CRAFFT score of 0
Medium
No use in past 12 months and “yes” to “car” question only OR use in past 12 months and CRAFFT score <2
High
Use in past 12 months and CRAFFT score 2
Provide information about risks of substance use and substance useerelated riding/driving Offer praise and encouragement Provide information about risks of substance use and substance useerelated riding/driving Brief advice Possible follow-up visit Provide information about risks of substance use and substance useerelated riding/driving Brief advice Follow-up visit Possible referral to counseling/treatment
Adapted from the CRAFFT 2.1 Manual.25
Screening Screening is an essential initial step in identifying and intervening for risky patterns of substance use among adolescents. The AAP19 recommends screening with the use of the CRAFFT 2.0, a well-validated survey that assesses substance use disorder.21,22 Advantages of the use of the CRAFFT in a clinical setting include its brevity and its “ability to inform providers whether a longer conversation about drug or alcohol use is warranted” (p. 379).20 The CRAFFT screening tool should be completed in a private place without a parent or guardian present. Teens may be resistant to disclosing information about their substance use due to concerns that the provider will inform the parents. However, if confidentiality is discussed up front, adolescents are more likely to be honest and engage in the SBIRT discussion.23 It is imperative the setting’s confidentiality policy ensures adolescents that their responses will not be shared with parents or guardians unless there is a need to prevent imminent harm to self or others. During the screening process, adolescents may screen positive for behaviors that present a safety risk; it is recommended that the provider inform the adolescent about the exact information he or she intends to disclose to the parent/guardian. The CRAFFT 2.1 is an updated version of the CRAFFT screening tool. The CRAFFT 2.1 incorporates opening questions about the frequency of past 12 months use of alcohol and other substances. CRAFFT is an acronym related to high-risk behaviors, including riding in a car driven by someone (including self) who was “high” or had been using alcohol or drugs; use of alcohol or drugs to relax, feel better about self, or to fit in; use of alcohol alone; episodes of the adolescent forgetting things that happen when using alcohol or drugs; whether family or friends told the adolescent to cut back or stop alcohol or drug use; and whether the teen got into trouble when using alcohol or drugs. There are 2 versions of the CRAFFT 2.1: a clinical interview and a self-administered questionnaire. Adolescents have reported greater comfort and likelihood of honesty with self-administered questionnaires compared with face-to face interviews.24 The selfadministered method is recommended (The CRAFFT 2.1 Manual).25 CRAFFT þ Nicotine Screening for nicotine use is recommended beginning at age 11 by the AAP.26 The CRAFFT þ Nicotine begins the screening process by asking 1 additional question. During the past 12 months, on how many days did you: use tobacco or nicotine products (eg, cigarettes, e-cigarettes, hookahs, or smokeless tobacco)? If the adolescent endorses any use of tobacco, it is important to elicit the method used. For those that screen positive, the provider initiates smoking
behavior change counseling.27 The CRAFFT screening tools can be located at https://crafft.org. Brief Intervention The approach for the brief intervention depends on the level of risk identified by the CRAFFT 2.1. For adolescents with no to low risk, providers affirm their choice and encourage continued abstinence from SU. Medium risk can be met in either of 2 ways: 1) no use in the past 12 months but yes to the “car” question (riding in a car driven by someone, including self who was “high” or had been using alcohol or drugs); or 2) any use in the past 12 months and CRAFFT score of 0 or 1. Brief intervention to eliminate use is recommended. The adolescent is considered high risk if she or he reports any use in the past 12 months and has a CRAFFT total score of 2 more (Table 1). Principles of patient-centered care guide the delivery of the brief intervention for the adolescent. The provider emphasizes choice, strengths, exploration of options, and the benefits of the adolescent developing his or her personal goals for reducing SU based on realistic perceptions of the feasibility of changing SU behaviors. The brief intervention consists of 4 phases: 1) raising the subject, 2) providing feedback on the adolescent’s score on the CRAFFT, 3) enhancing motivation to change, and 4) negotiating a plan for change (see Figure). Raise the Subject and Provide Feedback When providers raise the subject of SU with the adolescent, they express appreciation of his or her completion of the CRAFFT and then ask permission from the adolescent to discuss the meaning of the score. If the adolescent agrees, the provider gives feedback by relating the score to risk of problems with SU. If the reason for the visit can be linked to the adolescent’s SU, the provider can discuss this and explore the adolescent’s response to this information. Enhance Motivation to Change Motivational Interviewing (MI), a behavioral change counseling approach, provides the theoretical framework for delivery of the brief intervention component of SBIRT. The provider uses MI strategies to enhance “change” talk and reduce sustaining or “resistance” talk that maintains current behaviors.28 The hallmarks of MI are empathy, collaboration, support for the adolescent’s autonomy in making a decision about whether to change SU behaviors, and development of a therapeutic alliance.29 The provider emphasizes that the adolescent knows himself or herself best and knows which strategies will be most effective in attempts to change SU behaviors. Confrontation, direction, or giving advice are avoided; these
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Figure. Screening, Brief Intervention, and Referral to Treatment (SBIRT) components.
approaches invoke adolescents’ resistance to change and tend to foster continued SU. SBIRT includes several strategies for the provider to assess the adolescent’s perceptions about substance use. When discussing importance, providers can ask adolescents to envision a scale of 0 to 10, where 0 is “not at all important” and 10 is “extremely important,” and ask them to rate their level of importance based on this scale. A similar 0e10 scale assess perceived confidence in the adolescent’s ability to make a change (0 ¼ “not at all confident”; 10 ¼ “extremely confident”).28 Pros and cons of continuing or reducing/stopping use are also discussed with the adolescent.28 Adolescents may state that they use substances because they like the feeling of being “high” or disinhibited, to fit in with their peers, or to cope with stress and anxiety. The provider’s task is to explore the negative consequences of SU with the adolescent. During the SBIRT intervention, the adolescent is faced with a choice between continuing or stopping use and may express ambivalence about change. The provider’s task is to express empathy and understanding of the teen’s dilemma about behavioral change.
Negotiate a Change Plan After discussing the pros and cons of and ambivalence toward change, the provider then uses another 1e10 scale to rate readiness to change: “On a scale of 0 to 10, with 0 being “not at all ready” and 10 being “extremely ready,” how ready are you to make a change in your substance use?” Even if the adolescent rates his readiness to change as a “1,” the provider can use this to develop a plan: “OK, it looks like you are ready to make a change, even if it is a small change. What are you willing to do right now to change your substance use?” At this point, the provider and adolescent can Table 2 Guidelines for Referring for Further Treatment
High-risk adolescents who do not respond to the brief intervention Poor school attendance Fighting/aggression Not completing homework Problems with classroom conduct Mental health issues/comorbidities Under age 14 Daily or near daily use of any substance Alcohol-related “blackout” or substance useerelated hospital visit Alcohol use with another sedative drug
jointly explore goals for reducing substance use along with specific strategies for accomplishing this. Referral to Treatment Almost 50% of adolescents are low-risk substance users.30 Those needing additional treatment can be referred to a counselor within the practice or community (Table 2). If intensive treatment is warranted, the SAMSHA referral locator is a resource for identifying local facilities (findtreatment.samhsa.gov). If referral to treatment is needed, enlisting the assistance of a trusted adult can help encourage the process. When an adolescent is willing to admit he or she needs help with an SU problem and is willing to involve a parent, the provider should support the adolescent by facilitating the conversation regarding substance use. Resources Treatment programs that address substance use among all patients, including adolescents, can be found at SAMHSA’s National Registry of Evidence-Based Programs and Practices. Examples of evidence-based programs include the Family Check-Up, Positive Parenting Prevents Drug Abuse, and the Strengthening Families Program for Youth 10 to 14.18 Conclusion Trends in SU among adolescents, along with the serious neurocognitive impairments and health, social, and legal risks associated with use, underscore the urgency of addressing this public health problem.31 Prevention is the best strategy for addressing SU and reducing the development of SU disorders in adolescents. It is critical that providers implement strategies for early identification and intervention for problematic use among adolescents18 with the use of evidence-based practices such as SBIRT. References 1. Levy SJ, Williams JF. and the American Academy of Pediatrics Committee on Substance use and Prevention. Substance use screening, brief intervention, and referral to treatment. Pediatrics. 2016;138(1):e20161211. 2. Lipari RN, Crane EH, Strashny A, Dean D. A Day in the Life of American Adolescents: Substance Use Facts Update. The CBHSQ Report. Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration; August 29, 2013.
D. Inman et al. / The Journal for Nurse Practitioners xxx (xxxx) xxx 3. Centers for Disease Control. Youth Risk Behavior SurveillancedUnited States, 2017. 2018a. https://www.cdc.gov/healthyyouth/data/yrbs/pdf/2017/ss6708. pdf. Accessed October 1, 2018. 4. Moss HB, Chen CM, Yi H. Early adolescent patterns of alcohol, cigarettes, and marijuana polysubstance use and young adult substance use outcomes in a nationally representative sample. Drug Alcohol Depend. 2014;136(1):51-62. doi.org/10.1016/j.drugalcdep.2013.12.011. 5. Jacobus J, Tapert SF. Neurotoxic effects of alcohol in adolescence. Ann Rev Clin Psychol. 2013;9. https://doi.org/10.1146/annurev-clinpsy-050212-185610. 6. Centers for Disease Control. Underage drinking. 2018b. https://www.cdc.gov/ alcohol/fact-sheets/underage-drinking.htm. Accessed January 21, 2019. 7. National Institute on Drug Abuse. Drug facts: cigarettes and other tobacco products. 2018. https://www.drugabuse.gov. Accessed January 17, 2019. 8. Centers for Disease Control and Prevention. Smoking and heart disease and stroke. 2018d. https://www.cdc.gov/tobacco/campaign/tips/diseases/heartdisease-stroke.html. Accessed October 11, 2018. 9. Centers for Disease Control and Prevention. Quick facts on the risks of E-cigarettes for kids, teens and young adults. 2018c. https://www.cdc.gov/tobacco/ basic_information/e-cigarettes/Quick-Facts-on-the-Risks-of-E-cigarettes-forKids-Teens-and-Young-Adults.html. Accessed October 5, 2018. 10. Volkow ND, Baler RD, Compton WM, Weiss SRB. Adverse health effects of marijuana use. New Engl J Med. 2014;370(23):2219-2227. 11. Mills B, Yepes A, Nugent K. Synthetic cannabinoids. Am J Med Sci. 2015;350(1): 59-62. 12. Law R, Schier J, Martin C, Chang A, Wolkin A. Notes from the field: increase in reported adverse health effects related to synthetic cannabinoid usedUnited States, JanuaryeMay 2015. Morb Mort Wkly Rep. 2015;64(22):618-619. 13. England LJ, Bunnell RE, Pechacek TF, Tong VT, McAfee TA. Nicotine and the developing brain: a neglected element in the electronic cigarette debate. Am J Prev Med. 2015;49(2):286-293. https://doi.org/10.1016/j.amepre.2015.01.015. 14. Meruelo AD, Castro N, Cota CI, Tapert SF. Cannabis and alcohol use, and the developing brain. Behav Brain Res. 2017;325:44-50. 15. Squeglia LM, Gray KM. Alcohol and drug use and the developing brain. Curr Psychiatry Rep. 2016;18(5):46. 16. Chadi N, Bagley SM, Hadland SE. Addressing adolescents’ and young adults’ substance use disorders. Med Clin North Am. 2018;102:603-620. 17. Schweinsburg AC, Brown SA, Tapert SF. The influence of marijuana use on neurocognitive functioning in adolescents. Curr Drug Abuse Rev. 2008;1(1):99-111. 18. National Institute on Drug Abuse. Principles of adolescent substance use disorder treatment: a research-based guide. 2014. https://www.drugabuse.gov/ publications/principles-adolescent-substance-disorder-treatment-researchbased-guide. Accessed January 21, 2019. 19. American Academy of Pediatrics. Substance use screening and brief intervention for youth. 2019. https://www.aap.org/en-us/advocacy-and-policy/ aap-health-initiatives/Pages/Substance-Use-Screening.aspx. Accessed January 21, 2019. 20. Mitchell SG, Gryczynski J, Gonzales A, et al. Screening, brief intervention, and referral to treatment (SBIRT) for substance use in a school-based program:
21.
22. 23.
24.
25. 26.
27.
28. 29.
30.
31.
5
Services and outcomes. Am J Addict. 2012;21(1):S5-S13. https://doi.org/ 10.1111/j.1521-0391.2012.00299.x. Knight JR, Sherritt LA, Harris SK, Change G. Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Arch Pediatr Adolesc Med. 2002;156(6):607-614. D’Amico, E. J, Parast, L, Meredith, L. S, Weing, B. A, Shadel, W. G, & Stein, B. D. (2016). Screening in primary care: What is the best way to identify at-risk youth Ford CA, Millstein SG, Halpern-Felsher BL, Irwin CE Jr. Influence of physician confidentiality assurances on adolescents’ willingness to disclose information and seek future health care: a randomized controlled trial. JAMA. 1997;278(12):1029-1034; pmid:9307357. Jasik CB, Berna M, Martin M, Ozer EM. Teen preferences for clinic-based behavior screens: who, where, when, and how? J Adolesc Health. 2016;59(6):722-724. The Center for Adolescent Substance Abuse Research. The CRAFFT 2.0 manual. Boston, MA: Boston Children’s Hospital; 2017. American Academy of Pediatrics. Clinical practice policy to protect children from tobacco, nicotine, and tobacco smoke. Pediatrics. 2015;136(5):1008-1017. https://doi.org/10.1542/peds.2015-3108. Pbert L, Farber H, Horn K, et al. State -of-the-art office-based interventions to eliminate youth tobacco use: the past decade. Pediatrics. 2015;135(4):734-747. https://doi.org/10.1542/peds.2014-2-37. Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change. 2nd ed. New York: Guilford Press; 2002. El-Mallakh P, Chlebowy DO, Wall MP, Myers JA, Cloud RN. Promoting nurse interventionist fidelity to motivational interviewing in a diabetes self-care intervention. Res Nurs Health. 2012;35:289-300. Agley J, Gassman RA, Jun M, Nowicke C, Samuel S. Statewide administration of the CRAFFT screening tool: highlighting the spectrum of substance use. Substance Use Misuse. 2015;50(13):1668-1677. Feinstein EC, Richter L, Harris SE. Addressing the critical health problem of adolescent substance use through health care, research, and public policy. J Adolesc Health. 2012;50:431-436.
Dianna Inman, DNP, CPNP-PC, PMHS, PMHNP-BC, is an assistant professor at the University of Kentucky, Lexington, KY. She can be contacted at dianna.inman@uky. edu. Peggy El-Mallakh, PhD, PMHNP-BC, is an associate professor at the University of Kentucky, Lexington, KY. Lynne Jensen, PhD, ANP-BC, is an associate professor at the University of Kentucky, Lexington, KY. Julie Ossege, PhD, FNP-BC, FNAP, FAANP, is an associate professor at the University of Kentucky, Lexington, KY. Leslie Scott, PhD, PPCNP-BC, CDE, MLDE, is an associate professor at the University of Kentucky, Lexington, KY. This work was supported by a grant from the Substance Abuse and Mental Health Service Administration (1HT79T1025936-01). In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest.
Contents lists available at ScienceDirect
The Journal for Nurse Practitioners journal homepage: www.npjournal.org
Addressing Substance Use in Adolescents: Screening, Brief Intervention, and Referral to Treatment Dianna Inman, DNP, PMHNP-BC, Peggy El-Mallakh, PhD, PMHNP-BC, Lynne Jensen, PhD, ANP-BC, Julie Ossege, PhD, FNP-BC, Leslie Scott, PhD, PPCNP-BC a b s t r a c t Keywords: adolescent substance use brief intervention referral to treatment SBIRT screening
Adolescent substance use is a national public health crisis. The most commonly used substances among adolescents are nicotine, alcohol, and marijuana. Use of these substances during adolescence has serious adverse effects on brain development, with impairments that can endure into adulthood. Advanced practice nurses in primary care can address substance use in the adolescent population with the use of evidencebased interventions, such as Screening, Brief Intervention, and Referral to Treatment (SBIRT). This article describes trends in adolescent substance use and use of the SBIRT intervention for low, medium, and highrisk use in this population. © 2019 Elsevier Inc. All rights reserved.
Introduction Researchers, clinicians, and policymakers have identified adolescent substance use (SU) as a national public health crisis.1 The scope of the problem is illustrated in A Day in the Life of American Adolescents, which reports that on an average day, 881,684 adolescents smoke cigarettes, 646,702 use marijuana, and 457,672 drink alcohol.2 The purpose of this article is to report recent trends in adolescent SU and describe the Screening, Brief Intervention, and Referral to Treatment (SBIRT) intervention as a strategy to identify and intervene for at-risk SU in this population.
high risk for several negative social, behavioral, and emotional outcomes.4 These include school failure, legal problems due to illegal use and driving when intoxicated, impulsive high-risk behaviors, and increased risk for suicide and homicide. Alcohol use during adolescence is also linked to a predisposition to future risky behaviors, such as continued substance use, delinquency, and aggression.5 Mortality rates from underage drinking are costly to adolescents, families, and society. Underage drinking resulted in 4,300 deaths in 2010, with an estimated cost of $24 billion.6 Alcohol accounted for 189,000 emergency department visits by people under age 21 for injuries and other conditions.6
Overview Since 1991, the Centers for Disease Control and Prevention (CDC) has conducted biennial surveys among high school students to assess high-risk health behaviors, including SU, using the Youth Risk Behavior Surveillance Survey (YRBSS). There has been a steady increase of SU among teens. According to the most recent YRBSS report completed in 2017, the most commonly used substances among students in grades 9 through 12 are alcohol, nicotine, and marijuana.3 Alcohol Alcohol is the most frequently used substance among adolescents in the United States.3 The 2017 YRBSS reported that almost 30% of youth in grades 9 through 12 reported current alcohol use, defined as at least 1 drink on at least 1 day in the previous 30 days.3 Current use ranged from 18.8% of 9th graders to 40.8% of 12th graders. Early-onset alcohol consumption places adolescents at https://doi.org/10.1016/j.nurpra.2019.10.004 1555-4155/© 2019 Elsevier Inc. All rights reserved.
Nicotine Nicotine is a highly addictive substance7 with extensively documented adverse health effects.7,8 The YRBSS reported that in 2017, 19.5% of high school students reported current use of any tobacco product, such as cigarettes, electronic vapor products (EVPs), smokeless tobacco, or cigars.3 Traditional tobacco products are frequently used by high school students; up to 8.8% of high school students (1.4 million students) used cigarettes.9 EVPs are the most frequently used nicotine products in this age group; up to 13.2% of high school students (2.1 million students) used EVPs during 2017.9 Adolescents prefer EVPs for a variety of reasons, including ease of concealment, which enables use in places that typically ban tobacco products. Some EVPs have very high concentrations of nicotine in their delivery systems, which presents a serious risk that users can become rapidly addicted or experience nicotine poisoning.9
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Marijuana In 2017, 19.8% of high school students reported current use of marijuana, ranging from 13.1% of 9th graders to 25.7% of 12th graders.3 Adverse effects of marijuana use include increased risk of anxiety and depression.10 In addition, several physical health problems have been linked to marijuana use, including chronic bronchitis and increased risk for myocardial infarction and stroke during marijuana intoxication.10 Clinicians are increasingly aware of the potential for addiction to marijuana among chronic users. Almost 17% of people who start using marijuana as teenagers will develop an addiction to the drug, and risk of marijuana addiction increases to 25e50% among people who smoke marijuana daily.10 In addition, tetrahydrocannabinol (THC) has become increasingly potent in marijuana since 1995; this increase in potency is associated with a 100% increase in marijuanarelated emergency department visits between 2004 and 2011.10 Recent trends in marijuana availability and use present considerable challenges for health care professionals engaged in SU counseling for adolescents. Synthetic Cannabinoids Synthetic cannabinoids (SCBs) are a particularly harmful form of lab-created marijuana.11 The 2017 YRBSS reported that 6.9% of adolescents ever used SCBs, ranging from 5.5% of 9th graders to 7.6% of 12th graders.3 Use was highest in Hispanic adolescents (9.1%), compared with 6.3% in African American and 5.9% in Caucasian youth in 2017.3 SCBs are typically sold as herbal products and are readily available on the Internet.11 The Drug Enforcement Agency designated several forms of SCBs as Schedule I drugs between 2013 and 2015, making them illegal. However, manufacturers and dealers have circumvented this by rapidly developing and disseminating new forms of synthetic cannabinoids. These newly developed drugs are not detectable using drug toxicity testing. SCBs are more potent and toxic than the THC found in naturally grown marijuana, and their effects are unpredictable and severe.7,11 Adverse effects reported to poison control centers during 2015 included tachycardia, lethargy/drowsiness, agitation/irritability, vomiting, and confusion.12 Psychiatric effects include acute psychosis,11 such as hallucinations, delusions, and violent behavior. Other adverse effects include suicidal thoughts,7 hypertension, rhabdomyolysis, renal failure, and death.11,12 According to Law et al,12 poison centers across the United States reported a 229% increase in emergency calls related to the adverse effects of SCBs between 2014 and 2015.
alcohol’s neurotoxic effects.5 Alcohol consumption during adolescence is associated with alterations in structural brain development, including the cerebral cortex, hippocampus, and cerebellum. Impaired development in these brain regions due to alcohol use results in problems with attention, memory, information processing, visuospatial functioning, language ability, executive functioning, and inhibition.5 Similarly, smoking and vaping during adolescence are associated with several cognitive impairments and deficiencies in cognitive maturation, including problems with executive functioning, memory, attention, and prefrontal cortex activation.13 Marijuana use, particularly chronic and long-term use, is associated with several impairments in brain development among adolescents.10 Structural impairments in neural connectivity have been observed, including areas of the brain that regulate alertness, self-conscious awareness, executive functioning, and inhibitory control. Impairments in verbal learning and working memory have also been observed among adolescents who are heavy users of marijuana; these impairments are evident for up to 6 weeks after cessation of heavy use.17 Importantly, marijuana has been identified as a possible gateway drug, which may be due to the ability of THC to cause the brain to be more responsive to other drugs, which may increase the risk for other addictions later in life.10 Risk and Protective Factors Several risk and protective factors have been linked to SU among adolescents. Times of transition increase the risk of drug use for the adolescent. For example, at the move from elementary school to middle school, the early adolescent may be exposed to tobacco and alcohol for the first time. In high school, teens may have greater access to drugs by attending social activities where substances are present. Several factors put teens at higher risk for misusing alcohol and other substances, such as impulsiveness, aggressive behaviors, or conduct problems. Additional risk factors include a family history of substance use/mood disorders, poor parental supervision, household disruption, low academic achievement, untreated attention-deficit/hyperactivity disorder and other psychiatric disorders, and SU among peers.18 Protective factors include a stable and supportive home environment, involvement in church and community activities, and good academic performance.18 Other protective factors include having parents who set clear rules and enforce them, eating meals together as a family, parental guidance about SU, having a parent in recovery, and adequate community resources.18
Substance Use and the Developing Adolescent Brain
Screening, Brief Intervention, and Referral to Treatment
Adolescence is a time of rapid brain growth and development.13 Adolescents who use substances are vulnerable to the development of substance misuse and addiction, due to patterns of adolescent brain maturation.14 Adolescent brain development is “nonlinear”15; the prefrontal cortex is immature, resulting in limited executive functioning related to decision-making, impulse control, and judgment.16 However, the dopaminergic reward pathway, an anatomical structure responsible for the pleasurable effects of SU, matures at a much faster rate than the prefrontal cortex.16 SU is reinforced because the adolescent experiences rewarding effects in the dopamine pathway, while the prefrontal cortex is not yet mature enough to allow the adolescent to consider that SU is detrimental. Adolescent brain development is highly vulnerable to the adverse effects of environmental toxins, including SU.14,16 Alcohol is a neurotoxin, and the developing adolescent brain is sensitive to
SBIRT is an evidence-based approach to identify and intervene for people who are at risk for problems related to substance use.1 The SBIRT process is endorsed by leading professional associations and government agencies such as the American Academy of Pediatrics (AAP)19 policy statements, the American Medical Association, the Substance Abuse and Mental Health Services Administration (SAMHSA), the Centers for Medicare and Medicaid Services, and the National Institute on Alcohol Abuse and Alcoholism. Extensive research has examined the effectiveness of SBIRT for adolescents that address a variety of SU issues, including alcohol and marijuana. Mitchell and colleagues20 implemented SBIRT in a school-based program to address substance use among 629 adolescents in 13 schools. Findings indicated that adolescents who received the SBIRT intervention reported reductions in frequency of illicit drug use and reductions in drinking to intoxication between baseline and 6-month follow-up.
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Table 1 CRAFFT 2.1: Level of Risk and Clinical Action Risk Level
CRAFFT Score
Clinical Action
Low
No use in past 12 months and CRAFFT score of 0
Medium
No use in past 12 months and “yes” to “car” question only OR use in past 12 months and CRAFFT score <2
High
Use in past 12 months and CRAFFT score 2
Provide information about risks of substance use and substance useerelated riding/driving Offer praise and encouragement Provide information about risks of substance use and substance useerelated riding/driving Brief advice Possible follow-up visit Provide information about risks of substance use and substance useerelated riding/driving Brief advice Follow-up visit Possible referral to counseling/treatment
Adapted from the CRAFFT 2.1 Manual.25
Screening Screening is an essential initial step in identifying and intervening for risky patterns of substance use among adolescents. The AAP19 recommends screening with the use of the CRAFFT 2.0, a well-validated survey that assesses substance use disorder.21,22 Advantages of the use of the CRAFFT in a clinical setting include its brevity and its “ability to inform providers whether a longer conversation about drug or alcohol use is warranted” (p. 379).20 The CRAFFT screening tool should be completed in a private place without a parent or guardian present. Teens may be resistant to disclosing information about their substance use due to concerns that the provider will inform the parents. However, if confidentiality is discussed up front, adolescents are more likely to be honest and engage in the SBIRT discussion.23 It is imperative the setting’s confidentiality policy ensures adolescents that their responses will not be shared with parents or guardians unless there is a need to prevent imminent harm to self or others. During the screening process, adolescents may screen positive for behaviors that present a safety risk; it is recommended that the provider inform the adolescent about the exact information he or she intends to disclose to the parent/guardian. The CRAFFT 2.1 is an updated version of the CRAFFT screening tool. The CRAFFT 2.1 incorporates opening questions about the frequency of past 12 months use of alcohol and other substances. CRAFFT is an acronym related to high-risk behaviors, including riding in a car driven by someone (including self) who was “high” or had been using alcohol or drugs; use of alcohol or drugs to relax, feel better about self, or to fit in; use of alcohol alone; episodes of the adolescent forgetting things that happen when using alcohol or drugs; whether family or friends told the adolescent to cut back or stop alcohol or drug use; and whether the teen got into trouble when using alcohol or drugs. There are 2 versions of the CRAFFT 2.1: a clinical interview and a self-administered questionnaire. Adolescents have reported greater comfort and likelihood of honesty with self-administered questionnaires compared with face-to face interviews.24 The selfadministered method is recommended (The CRAFFT 2.1 Manual).25 CRAFFT þ Nicotine Screening for nicotine use is recommended beginning at age 11 by the AAP.26 The CRAFFT þ Nicotine begins the screening process by asking 1 additional question. During the past 12 months, on how many days did you: use tobacco or nicotine products (eg, cigarettes, e-cigarettes, hookahs, or smokeless tobacco)? If the adolescent endorses any use of tobacco, it is important to elicit the method used. For those that screen positive, the provider initiates smoking
behavior change counseling.27 The CRAFFT screening tools can be located at https://crafft.org. Brief Intervention The approach for the brief intervention depends on the level of risk identified by the CRAFFT 2.1. For adolescents with no to low risk, providers affirm their choice and encourage continued abstinence from SU. Medium risk can be met in either of 2 ways: 1) no use in the past 12 months but yes to the “car” question (riding in a car driven by someone, including self who was “high” or had been using alcohol or drugs); or 2) any use in the past 12 months and CRAFFT score of 0 or 1. Brief intervention to eliminate use is recommended. The adolescent is considered high risk if she or he reports any use in the past 12 months and has a CRAFFT total score of 2 more (Table 1). Principles of patient-centered care guide the delivery of the brief intervention for the adolescent. The provider emphasizes choice, strengths, exploration of options, and the benefits of the adolescent developing his or her personal goals for reducing SU based on realistic perceptions of the feasibility of changing SU behaviors. The brief intervention consists of 4 phases: 1) raising the subject, 2) providing feedback on the adolescent’s score on the CRAFFT, 3) enhancing motivation to change, and 4) negotiating a plan for change (see Figure). Raise the Subject and Provide Feedback When providers raise the subject of SU with the adolescent, they express appreciation of his or her completion of the CRAFFT and then ask permission from the adolescent to discuss the meaning of the score. If the adolescent agrees, the provider gives feedback by relating the score to risk of problems with SU. If the reason for the visit can be linked to the adolescent’s SU, the provider can discuss this and explore the adolescent’s response to this information. Enhance Motivation to Change Motivational Interviewing (MI), a behavioral change counseling approach, provides the theoretical framework for delivery of the brief intervention component of SBIRT. The provider uses MI strategies to enhance “change” talk and reduce sustaining or “resistance” talk that maintains current behaviors.28 The hallmarks of MI are empathy, collaboration, support for the adolescent’s autonomy in making a decision about whether to change SU behaviors, and development of a therapeutic alliance.29 The provider emphasizes that the adolescent knows himself or herself best and knows which strategies will be most effective in attempts to change SU behaviors. Confrontation, direction, or giving advice are avoided; these
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Figure. Screening, Brief Intervention, and Referral to Treatment (SBIRT) components.
approaches invoke adolescents’ resistance to change and tend to foster continued SU. SBIRT includes several strategies for the provider to assess the adolescent’s perceptions about substance use. When discussing importance, providers can ask adolescents to envision a scale of 0 to 10, where 0 is “not at all important” and 10 is “extremely important,” and ask them to rate their level of importance based on this scale. A similar 0e10 scale assess perceived confidence in the adolescent’s ability to make a change (0 ¼ “not at all confident”; 10 ¼ “extremely confident”).28 Pros and cons of continuing or reducing/stopping use are also discussed with the adolescent.28 Adolescents may state that they use substances because they like the feeling of being “high” or disinhibited, to fit in with their peers, or to cope with stress and anxiety. The provider’s task is to explore the negative consequences of SU with the adolescent. During the SBIRT intervention, the adolescent is faced with a choice between continuing or stopping use and may express ambivalence about change. The provider’s task is to express empathy and understanding of the teen’s dilemma about behavioral change.
Negotiate a Change Plan After discussing the pros and cons of and ambivalence toward change, the provider then uses another 1e10 scale to rate readiness to change: “On a scale of 0 to 10, with 0 being “not at all ready” and 10 being “extremely ready,” how ready are you to make a change in your substance use?” Even if the adolescent rates his readiness to change as a “1,” the provider can use this to develop a plan: “OK, it looks like you are ready to make a change, even if it is a small change. What are you willing to do right now to change your substance use?” At this point, the provider and adolescent can Table 2 Guidelines for Referring for Further Treatment
High-risk adolescents who do not respond to the brief intervention Poor school attendance Fighting/aggression Not completing homework Problems with classroom conduct Mental health issues/comorbidities Under age 14 Daily or near daily use of any substance Alcohol-related “blackout” or substance useerelated hospital visit Alcohol use with another sedative drug
jointly explore goals for reducing substance use along with specific strategies for accomplishing this. Referral to Treatment Almost 50% of adolescents are low-risk substance users.30 Those needing additional treatment can be referred to a counselor within the practice or community (Table 2). If intensive treatment is warranted, the SAMSHA referral locator is a resource for identifying local facilities (findtreatment.samhsa.gov). If referral to treatment is needed, enlisting the assistance of a trusted adult can help encourage the process. When an adolescent is willing to admit he or she needs help with an SU problem and is willing to involve a parent, the provider should support the adolescent by facilitating the conversation regarding substance use. Resources Treatment programs that address substance use among all patients, including adolescents, can be found at SAMHSA’s National Registry of Evidence-Based Programs and Practices. Examples of evidence-based programs include the Family Check-Up, Positive Parenting Prevents Drug Abuse, and the Strengthening Families Program for Youth 10 to 14.18 Conclusion Trends in SU among adolescents, along with the serious neurocognitive impairments and health, social, and legal risks associated with use, underscore the urgency of addressing this public health problem.31 Prevention is the best strategy for addressing SU and reducing the development of SU disorders in adolescents. It is critical that providers implement strategies for early identification and intervention for problematic use among adolescents18 with the use of evidence-based practices such as SBIRT. References 1. Levy SJ, Williams JF. and the American Academy of Pediatrics Committee on Substance use and Prevention. Substance use screening, brief intervention, and referral to treatment. Pediatrics. 2016;138(1):e20161211. 2. Lipari RN, Crane EH, Strashny A, Dean D. A Day in the Life of American Adolescents: Substance Use Facts Update. The CBHSQ Report. Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration; August 29, 2013.
D. Inman et al. / The Journal for Nurse Practitioners xxx (xxxx) xxx 3. Centers for Disease Control. Youth Risk Behavior SurveillancedUnited States, 2017. 2018a. https://www.cdc.gov/healthyyouth/data/yrbs/pdf/2017/ss6708. pdf. Accessed October 1, 2018. 4. Moss HB, Chen CM, Yi H. Early adolescent patterns of alcohol, cigarettes, and marijuana polysubstance use and young adult substance use outcomes in a nationally representative sample. Drug Alcohol Depend. 2014;136(1):51-62. doi.org/10.1016/j.drugalcdep.2013.12.011. 5. Jacobus J, Tapert SF. Neurotoxic effects of alcohol in adolescence. Ann Rev Clin Psychol. 2013;9. https://doi.org/10.1146/annurev-clinpsy-050212-185610. 6. Centers for Disease Control. Underage drinking. 2018b. https://www.cdc.gov/ alcohol/fact-sheets/underage-drinking.htm. Accessed January 21, 2019. 7. National Institute on Drug Abuse. Drug facts: cigarettes and other tobacco products. 2018. https://www.drugabuse.gov. Accessed January 17, 2019. 8. Centers for Disease Control and Prevention. Smoking and heart disease and stroke. 2018d. https://www.cdc.gov/tobacco/campaign/tips/diseases/heartdisease-stroke.html. Accessed October 11, 2018. 9. Centers for Disease Control and Prevention. Quick facts on the risks of E-cigarettes for kids, teens and young adults. 2018c. https://www.cdc.gov/tobacco/ basic_information/e-cigarettes/Quick-Facts-on-the-Risks-of-E-cigarettes-forKids-Teens-and-Young-Adults.html. Accessed October 5, 2018. 10. Volkow ND, Baler RD, Compton WM, Weiss SRB. Adverse health effects of marijuana use. New Engl J Med. 2014;370(23):2219-2227. 11. Mills B, Yepes A, Nugent K. Synthetic cannabinoids. Am J Med Sci. 2015;350(1): 59-62. 12. Law R, Schier J, Martin C, Chang A, Wolkin A. Notes from the field: increase in reported adverse health effects related to synthetic cannabinoid usedUnited States, JanuaryeMay 2015. Morb Mort Wkly Rep. 2015;64(22):618-619. 13. England LJ, Bunnell RE, Pechacek TF, Tong VT, McAfee TA. Nicotine and the developing brain: a neglected element in the electronic cigarette debate. Am J Prev Med. 2015;49(2):286-293. https://doi.org/10.1016/j.amepre.2015.01.015. 14. Meruelo AD, Castro N, Cota CI, Tapert SF. Cannabis and alcohol use, and the developing brain. Behav Brain Res. 2017;325:44-50. 15. Squeglia LM, Gray KM. Alcohol and drug use and the developing brain. Curr Psychiatry Rep. 2016;18(5):46. 16. Chadi N, Bagley SM, Hadland SE. Addressing adolescents’ and young adults’ substance use disorders. Med Clin North Am. 2018;102:603-620. 17. Schweinsburg AC, Brown SA, Tapert SF. The influence of marijuana use on neurocognitive functioning in adolescents. Curr Drug Abuse Rev. 2008;1(1):99-111. 18. National Institute on Drug Abuse. Principles of adolescent substance use disorder treatment: a research-based guide. 2014. https://www.drugabuse.gov/ publications/principles-adolescent-substance-disorder-treatment-researchbased-guide. Accessed January 21, 2019. 19. American Academy of Pediatrics. Substance use screening and brief intervention for youth. 2019. https://www.aap.org/en-us/advocacy-and-policy/ aap-health-initiatives/Pages/Substance-Use-Screening.aspx. Accessed January 21, 2019. 20. Mitchell SG, Gryczynski J, Gonzales A, et al. Screening, brief intervention, and referral to treatment (SBIRT) for substance use in a school-based program:
21.
22. 23.
24.
25. 26.
27.
28. 29.
30.
31.
5
Services and outcomes. Am J Addict. 2012;21(1):S5-S13. https://doi.org/ 10.1111/j.1521-0391.2012.00299.x. Knight JR, Sherritt LA, Harris SK, Change G. Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Arch Pediatr Adolesc Med. 2002;156(6):607-614. D’Amico, E. J, Parast, L, Meredith, L. S, Weing, B. A, Shadel, W. G, & Stein, B. D. (2016). Screening in primary care: What is the best way to identify at-risk youth Ford CA, Millstein SG, Halpern-Felsher BL, Irwin CE Jr. Influence of physician confidentiality assurances on adolescents’ willingness to disclose information and seek future health care: a randomized controlled trial. JAMA. 1997;278(12):1029-1034; pmid:9307357. Jasik CB, Berna M, Martin M, Ozer EM. Teen preferences for clinic-based behavior screens: who, where, when, and how? J Adolesc Health. 2016;59(6):722-724. The Center for Adolescent Substance Abuse Research. The CRAFFT 2.0 manual. Boston, MA: Boston Children’s Hospital; 2017. American Academy of Pediatrics. Clinical practice policy to protect children from tobacco, nicotine, and tobacco smoke. Pediatrics. 2015;136(5):1008-1017. https://doi.org/10.1542/peds.2015-3108. Pbert L, Farber H, Horn K, et al. State -of-the-art office-based interventions to eliminate youth tobacco use: the past decade. Pediatrics. 2015;135(4):734-747. https://doi.org/10.1542/peds.2014-2-37. Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change. 2nd ed. New York: Guilford Press; 2002. El-Mallakh P, Chlebowy DO, Wall MP, Myers JA, Cloud RN. Promoting nurse interventionist fidelity to motivational interviewing in a diabetes self-care intervention. Res Nurs Health. 2012;35:289-300. Agley J, Gassman RA, Jun M, Nowicke C, Samuel S. Statewide administration of the CRAFFT screening tool: highlighting the spectrum of substance use. Substance Use Misuse. 2015;50(13):1668-1677. Feinstein EC, Richter L, Harris SE. Addressing the critical health problem of adolescent substance use through health care, research, and public policy. J Adolesc Health. 2012;50:431-436.
Dianna Inman, DNP, CPNP-PC, PMHS, PMHNP-BC, is an assistant professor at the University of Kentucky, Lexington, KY. She can be contacted at dianna.inman@uky. edu. Peggy El-Mallakh, PhD, PMHNP-BC, is an associate professor at the University of Kentucky, Lexington, KY. Lynne Jensen, PhD, ANP-BC, is an associate professor at the University of Kentucky, Lexington, KY. Julie Ossege, PhD, FNP-BC, FNAP, FAANP, is an associate professor at the University of Kentucky, Lexington, KY. Leslie Scott, PhD, PPCNP-BC, CDE, MLDE, is an associate professor at the University of Kentucky, Lexington, KY. This work was supported by a grant from the Substance Abuse and Mental Health Service Administration (1HT79T1025936-01). In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest.