Clinical Screening and Peer Interventions to Prevent Substance Use in At-Risk Adolescents

Adolescent substance use is a significant public health concern with self-reported use of drugs and/or alcohol remaining high in the United States. Data from the National Survey on Drug Use and Health show that adolescent initiation of alcohol and cannabis use in the past year was 9.1% and 5.4% respectively. Evidence suggests that earlier initiation of substance use is linked to higher rates of substance use disorder (SUD) in adulthood. The American Academy of Pediatrics (AAP) recommends substance use screening for adolescents beginning at age 11 at annual health supervision visits. The Substance Abuse and Mental Health Services Administration (SAMHSA) also provides recommendations on screening for adolescent substance use using validated screening tools. Validated tools for adolescent substance use screening are available to primary care providers (PCPs) to administer to patients at health supervision visits. To use these resources effectively, practices are encouraged to have a pathway for administering screening tools and addressing responses. The screening, brief intervention, and referral to treatment (SBIRT) model is recommended as the ideal clinician response to positive screening. Negative screens for substance use generally are addressed with motivational interviewing but might not be discussed during a busy health supervision visit if there are other concerns to address. Furthermore, PCP delivered brief interventions have been shown to have mixed results providing some benefit in decreasing heavy alcohol use, but not cannabis use or abstinence.

Several common mental health diagnoses are associated with increased risk of adolescent substance use including depression, anxiety, and attention deficit hyperactivity disorder (ADHD). Adolescents receiving treatment for these diagnoses from their PCP often have frequent office visits ranging from monthly to quarterly. Screening and assessment tools are often utilized to both diagnose and monitor response to treatment for these conditions. Commonly used tools include the Patient Health Questionnaire 9 (PHQ-9) modified for teens for depression, Generalized Anxiety Disorder 7 (GAD-7) for anxiety, and NICHQ Vanderbilt scales for ADHD. Currently, there are no recommendations to screen more frequently for substance use in adolescents with depression, anxiety and/or ADHD despite their increased risk of developing SUD.

Recent Interventions: Many interventions for adolescent substance use prevention have been developed and studied. A recent study found that computer-based screening of adolescents for alcohol and cannabis followed by a brief educational intervention decreased risk behaviors in those reporting current use, but no benefit in those reporting no use. This study provided adolescents with immediate calculation of their reported use followed by multiple pages of scientific data and vignettes, focusing on decreasing risky use and riding with an impaired driver. However, a recent meta-analysis of primary prevention programs including Life Skills Training and other models, have demonstrated variable results and benefits. Similarly, meta-analysis of school-based interventions for alcohol and cannabis use in adolescents provided low or very-low quality evidence of effectiveness. Brief interventions targeting adolescents with depression and anxiety have not shown clear benefits in decreasing substance use, in part due to variability of models and interventions evaluated. Each of these studies concluded more research was needed to determine effectiveness of individual models in decreasing risk behaviors or preventing substance use.

Peer-based interventions have shown utility for improving adolescent engagement and participation in their health care, including the Providers and Teens Communicating for Health (PATCH) program. Studies of similar programs provide supporting evidence. One study examined a peer support service for youth experiencing complex challenges with mental health, physical health and/or substance use to better understand key features and underlying mechanisms that lead to improved client outcomes, noting the importance of mechanisms related to 1) positive identity development through identification with peers, 2) enhanced social connections, 3) observational learning and 4) enhanced autonomy and empowerment. Another looked at the direct relation between positive peer affiliation and substance use, and whether positive peer affiliation moderated the relation between self-reported sensation-seeking, future orientation, self-regulation and substance use, finding that having friends who generally engage in positive activities is an important buffer against socioemotional risk factors. Building on previous research, another examined the relationship of positive peer influence with indices of substance use and compared abstinent adolescents and substance-using adolescents on positive peer influence, with the results identifying positive peer influence as a significant predictor of lower substance use behaviors in adolescents and with positive influence from close friends being the strongest predictor. These findings, while hopeful, have been shown to need more study in sub-group analysis, as results vary by gender and other characteristics.

Looking more specifically at studies that examine the impact of peer-based interventions on prevention of substance use in adolescents, a systematic review of the literature on prevention of substance initiation for ages 11-21 showed peer-led interventions were associated with benefit in relation to alcohol use (OR = 0.80, 95% CI = 0.65-0.99, P = 0.036), while three studies ( n = 976 students in 38 schools) suggested an association with lower odds of cannabis use (OR = 0.70, 0.50-0.97, P = 0.034)17. Additional studies confirmed the value of this approach, with sometimes mixed results in sub-group analysis.

Proposed Model: Clinical Screening and Peer Interventions to Prevent Substance Use in At-Risk Adolescents: The investigators propose trialing an intervention focused on prevention of substance use among adolescents aged 11-14 at increased risk due to depression, anxiety, or ADHD diagnoses and who have not initiated substance use. These at-risk patients are routinely scheduled for regular follow-up visits with their PCPs for management of their mental health diagnoses. With our model, they will be rescreened for substance use quarterly (rather than annually) to promote more frequent conversations about prevention with their providers. They will receive access to brief video modules about avoiding substance use made by local peers.

This model is based on the novel use of clinical screening to identify at-risk adolescents not using substances for peer-led interactions. The use of video modules for substance use prevention is well-supported in the literature, as are social media awareness campaigns and media literacy for adolescents. Recently, the American Psychological Association issued recommendations for skill training for adolescents "to ensure that youth have skills that will maximize the chances for balanced, safe and meaningful experiences" using social media. The proposed intervention provides more frequent screening for substance use initiation to promote more frequent conversations about prevention with their providers and access to brief video modules about avoiding substance use made by local peers.

The primary objective of this study is to develop and trial an intervention of peer-designed and peer-delivered videos focused on prevention of substance use for adolescents aged 11-14 who have diagnosed depression, anxiety, or ADHD and who have not initiated substance use.

The secondary objective is to obtain user feedback on the videos for later development in a larger study.