Substance Use Disorder Screening in Adolescent Patients in Primary Care: Findings, Challenges, Lessons Learned

Context: Fatal drug overdoses among adolescents have increased due to the availability of fentanyl. Early identification and intervention of substance use disorders (SUD) could reduce morbidity and mortality. SUD screening is not universally done in primary care (PC). In our institution, screenings are completed for patients ≥15 years during well visits; those not presenting for well visits and under 15 may represent missed opportunities.

Objectives: To implement SUD screening in patients aged 12-17 seen for all visit types (well and sick visits) and to quantify the rate of substance misuse.

Design: Convenience survey design.

Setting: Three PC practices that routinely serve adolescents were selected: 2 urban practices (1 Family Medicine [FM] and 1 Pediatric [PED]) and 1 rural combined FM/PED practice. Study period for urban locations: Oct 2–Dec 29, 2023; for the rural location: Nov 1, 2023–Jan 31, 2024.

Population: All patients aged 12-17 seen in the 3 practices during a 3-month study period.

Intervention: The CRAFFT tool was self-administered during rooming. A score ≥2 constitutes a positive screen for possible substance misuse. Providers were alerted of positive screens by rooming staff to either assess further or refer to our Pediatric SUD Clinic to manage.

Outcomes: Percentages of positive CRAFFT screens in the 3 practices were calculated. For patients screened positive, chart reviews were conducted and the number of referrals to SUD Clinic was tracked.

Results: CRAFFT completion rate: 82/92 (89.1%) in the urban FM practice with 1 positive screen (1.2%); 126/139 (90.6%) in the urban PED practice with 4 positives (3.8%); 50/95 (52.6%) in the rural practice with 6 positives (14.6%). Of the 11 positive screens, 3 (27%) had substance use addressed by providers; 5 (45%) had mental health issues addressed without discussing substance use; 3 (27%) received neither mental health nor substance use assessments. No patients were referred to the SUD Clinic.

Conclusions: We found a larger positive CRAFFT rate in our rural site although this practice had a lower rate of questionnaire completion. Thus, the actual positive rate in this site may be higher. Despite alerts of positive screen, a substantial portion of patients did not have SUD-related issues addressed. The lack of SUD Clinic referral suggests that having specialty support alone may not suffice. Efforts to explore provider confidence and knowledge on adolescent SUD, and barriers to referral are ongoing.