John R Knight

Body modification and substance use in adolescents: is there a link?

PURPOSE To describe the characteristics of body modification among adolescents and to determine whether adolescents who engage in body modification are more likely to screen positive for alcohol and other drug problems than those who do not. METHODS Adolescents aged 14 to 18 years presenting to an urban adolescent clinic for routine health care completed a questionnaire about body modification and a substance use assessment battery that included the 17-item Problem Oriented Screening Instrument for Teenagers Alcohol/Drug Use and Abuse Scale (POSIT-ADS). Body modification was defined as piercings (other than one pair of bilateral earlobe piercings in females), tattoos, scarification, and branding. Problem substance use was defined as a POSIT-ADS score > or =1. Data were analyzed using logistic regression to determine whether the presence of body modification was an independent predictor of problem substance use. RESULTS The 210 participants had a mean (+/- SD) age of 16.0 (+/- 1.4) years and 63% were female. One hundred adolescents (48%) reported at least one body modification; girls were more likely than boys to have body modification (59% vs. 28%, p < or = .0005). Ninety (42%) reported piercings, 22 (10%) tattoos, 9 (4%) scarification, and 1 (< 1%) branding; 21 (10%) had more than one type of body modification. These were in a variety of locations, most commonly the ear and the nose (piercings) or the extremities (tattoos). One-third of the sample (33%) screened positive for problem substance use on the POSIT-ADS questionnaire. Controlling for age, adolescents with body modification had 3.1 times greater odds of problem substance use than those without body modification (95% CI 1.7, 5.8). CONCLUSIONS Body modification was associated with self-reported problem alcohol and other drug use among middle adolescents presenting for primary care. More research is needed to determine the clinical and sociocultural significance of body modification and its relationship to substance use in this population.

Methadone Safety: A Clinical Practice Guideline From the American Pain Society and College on Problems of Drug Dependence, in Collaboration With the Heart Rhythm Society

UNLABELLED Methadone is used for the treatment of opioid addiction and for treatment of chronic pain. The safety of methadone has been called into question by data indicating a large increase in the number of methadone-associated overdose deaths in recent years that has occurred in parallel with a dramatic rise in the use of methadone for chronic pain. The American Pain Society and the College on Problems of Drug Dependence, in collaboration with the Heart Rhythm Society, commissioned an interdisciplinary expert panel to develop a clinical practice guideline on safer prescribing of methadone for treatment of opioid addiction and chronic pain. As part of the guideline development process, the American Pain Society commissioned a systematic review of various aspects related to safety of methadone. After a review of the available evidence, the expert panel concluded that measures can be taken to promote safer use of methadone. Specific recommendations include the need to educate and counsel patients on methadone safety, use of electrocardiography to identify persons at greater risk for methadone-associated arrhythmia, use of alternative opioids in patients at high risk of complications related to corrected electrocardiographic QTc interval prolongation, careful dose initiation and titration of methadone, and diligent monitoring and follow-up. Although these guidelines are based on a systematic review, the panel identified numerous research gaps, most recommendations were based on low-quality evidence, and no recommendations were based on high-quality evidence. PERSPECTIVE This guideline, based on a systematic review of the evidence on methadone safety, provides recommendations developed by a multidisciplinary expert panel. Safe use of methadone requires clinical skills and knowledge in use of methadone to mitigate potential risks, including serious risks related to risk of overdose and cardiac arrhythmias.

Computer-Facilitated Substance Use Screening and Brief Advice for Teens in Primary Care: An International Trial

OBJECTIVE: Primary care providers need effective strategies for substance use screening and brief counseling of adolescents. We examined the effects of a new computer-facilitated screening and provider brief advice (cSBA) system. METHODS: We used a quasi-experimental, asynchronous study design in which each site served as its own control. From 2005 to 2008, 12- to 18-year-olds arriving for routine care at 9 medical offices in New England (n = 2096, 58% females) and 10 in Prague, Czech Republic (n = 589, 47% females) were recruited. Patients completed measurements only during the initial treatment-as-usual study phase. We then conducted 1-hour provider training, and initiated the cSBA phase. Before seeing the provider, all cSBA participants completed a computerized screen, and then viewed screening results, scientific information, and true-life stories illustrating substance use harms. Providers received screening results and “talking points” designed to prompt 2 to 3 minutes of brief advice. We examined alcohol and cannabis use, initiation, and cessation rates over the past 90 days at 3-month follow-up, and over the past 12 months at 12-month follow-up. RESULTS: Compared with treatment as usual, cSBA patients reported less alcohol use at follow-up in New England (3-month rates 15.5% vs 22.9%, adjusted relative risk ratio [aRRR] = 0.54, 95% confidence interval 0.38–0.77; 12-month rates 29.3% vs 37.5%, aRRR = 0.73, 0.57–0.92), and less cannabis use in Prague (3-month rates 5.5% vs 9.8%, aRRR = 0.37, 0.17–0.77; 12-month rates 17.0% vs 28.7%, aRRR = 0.47, 0.32–0.71). CONCLUSIONS: Computer-facilitated screening and provider brief advice appears promising for reducing substance use among adolescent primary care patients.

Reliability of the Problem Oriented Screening Instrument for Teenagers (POSIT) in adolescent medical practice.

PURPOSE To determine the internal consistency and 1-week test-retest reliability of the Problem Oriented Screening Instrument for Teenagers (POSIT) among adolescent medical patients. METHODS A research assistant administered the POSIT to a consecutive sample of 15- to 18-year-old patients arriving for routine medical care at a hospital-based adolescent medical practice. Each subject returned for a retest 1 week later. Internal consistency for each scale on test and retest was calculated using Cronbach alpha, and 1-week test-retest reliability by the intraclass correlation coefficient (r) and the kappa coefficient (kappa). RESULTS The Substance Use/Abuse, Mental Health Status, Educational Status, and Aggressive Behavior/Delinquency scales had favorable alpha scores (>.70). Others, including Physical Health Status, had lower alpha scores. High intraclass correlation coefficients were found for all 10 POSIT scales (r =.72 to.88), although (r) was lower for males on two of the scales. Kappa coefficients for all scales indicated good reproducibility beyond chance (kappa =.42 to.73). CONCLUSIONS This study provided supportive evidence for the reliability of the POSIT in primary care medical settings, although some POSIT scales could likely be improved. The 20- to 30-min administration time is most practical in settings that are dedicated to adolescent medicine, and computerized administration and scoring are needed.

Factors associated with aggressive and delinquent behaviors among patients attending an adolescent medicine clinic

PURPOSE The purpose of this study was to examine the associations among delinquency/aggressiveness and alcohol or drug use, sexual risk behaviors, and other scales from the Problem-Oriented Screening Instrument for Teenagers (POSIT). METHOD A total of 173 15- to 18-year-olds attending adolescent medicine clinic completed a 183-item questionnaire. The questionnaire contained the POSIT, the CAGE questions, a 22-item alcohol and drug screen (AOD), and a human immunodeficiency virus and sexual risk behavior screen. The dependent variable was the Aggressive Behavior/Delinquency (ABD) scale from the POSIT. RESULTS There were no gender or racial differences in the ABD scale (p > 0.05). The ABD scale was significantly (p < or = 0.001) associated with the POSIT AOD scale (r = 0.46), the 22-item AOD drug screen (r = 0.57), the CAGE questions (r = 0.39), the sexual risk behavior scale (r = 0.39), and the POSIT physical health (r = 0.34), mental health (r = 0.51), family relations status (r = 0.37), peer relations (r = 0.57), educational status (r = 0.44), social skills (r = 0.31), and leisure/recreation (r = 0.16) scales. Multiple regression analysis indicated that the AOD screen and problems in the area of peer relations, family relations, and mental health accounted for 47.7% of the variation in the ABD scale (p < or = 0.00001). CONCLUSIONS These findings suggest that adolescents who engage in more aggressive and delinquent behaviors are more likely to use alcohol and other drugs, engage in sexual risk behaviors, report problems with peer and family relationships, and report more mental health symptoms.

Screening adolescents for substance use-related high-risk sexual behaviors

PURPOSE This analysis was undertaken to determine whether adolescents who screened positive for high-risk substance use with the CRAFFT questions were also more likely to engage in risky sexual behaviors than their peers, and to determine the test-retest reliability of a substance use-related sexual risk behaviors inventory. METHODS Clinic patients 12-18 years old completed a multi-part questionnaire that included eight demographic items, the CRAFFT substance use screen, and a 14-item scale assessing sexual behaviors associated with substance use. Participants were invited to return 1 week later to complete an identical assessment battery. RESULTS Of the 305 study participants, 49 (16.1%) had a positive CRAFFT screen result (score of 2 or greater, indicating high risk for substance abuse/dependence) and 101 (33.9%) reported sexual contact during the past 90 days. After controlling for gender, age, race/ethnicity, and number of parents in household, adolescents with a positive CRAFFT screen had significantly greater odds of having sexual contact after using alcohol or other drugs, of having a sexual partner who used alcohol or other drugs, of having sex without a condom, and of having multiple sexual partners within the past year, compared to their CRAFFT negative peers. The substance use-related sexual risk behaviors inventory has acceptable test-retest reliability, and the 10 frequency questions have scale-like properties with acceptable internal consistency (standardized Cronbachs alpha=.79). CONCLUSION Clinicians should pay special attention to counseling CRAFFT-positive adolescents regarding use of condoms and the risks associated with sexual activity with multiple partners, while intoxicated, or with an intoxicated partner.

Alcohol use and religiousness/spirituality among adolescents.

Background: Previous studies indicate that religiousness is associated with lower levels of substance use among adolescents, but less is known about the relationship between spirituality and substance use. The objective of this study was to determine the association between adolescents’ use of alcohol and specific aspects of religiousness and spirituality. Methods: Twelve- to 18-year-old patients coming for routine medical care at three primary care sites completed a modified Brief Multidimensional Measure of Religiousness/Spirituality; the Spiritual Connectedness Scale; and a past-90-days alcohol use Timeline Followback calendar. We used multiple logistic regression analysis to assess the association between each religiousness/spirituality measure and odds of any past-90-days alcohol use, controlling for age, gender, race/ethnicity, and clinic site. Timeline Followback data were dichotomized to indicate any past-90-days alcohol use and religiousness/spirituality scale scores were z-transformed for analysis. Results: Participants (n = 305) were 67% female, 74% Hispanic or black, and 45% from two-parent families. Mean ± SD age was 16.0 ± 1.8 years. Approximately 1/3 (34%) reported past-90-day alcohol use. After controlling for demographics and clinic site, Religiousness/Spirituality scales that were not significantly associated with alcohol use included: Commitment (OR = 0.81, 95% CI 0.36, 1.79), Organizational Religiousness (OR = 0.83, 95% CI 0.64, 1.07), Private Religious Practices (OR = 0.94, 95% CI 0.80, 1.10), and Religious and Spiritual Coping – Negative (OR = 1.07, 95% CI 0.91, 1.23). All of these are measures of religiousness, except for Religious and Spiritual Coping – Negative. Scales that were significantly and negatively associated with alcohol use included: Forgiveness (OR = 0.55, 95% CI 0.42–0.73), Religious and Spiritual Coping – Positive (OR = 0.67, 95% CI 0.51–0.84), Daily Spiritual Experiences (OR = 0.67, 95% CI 0.54–0.84), and Belief (OR = 0.76, 95% CI 0.68–0.83), which are all measures of spirituality. In a multivariable model that included all significant measures, however, only Forgiveness remained as a significant negative correlate of alcohol use (OR = 0.56, 95% CI 0.41, 0.74). Conclusions: Forgiveness is associated with a lowered risk of drinking during adolescence.

Office-based intervention for adolescent substance abuse.

Because substance use is highly prevalent among teens, primary care clinicians may not be able to refer all adolescents to drug counselors or mental health care professionals. Pediatricians may therefore find it useful to use the basic principles of office intervention and reserve referral for those patients with the most significant drug and alcohol problems. Brief interventions have proven effective in reducing problematic drinking among adults, and early work among adolescents is promising. Effective interventions include feedback on risks and problems, an emphasis on personal responsibility, a menu of alternatives for change, an empathetic approach, and reinforcement of patient self-efficacy. Motivational interviewing is an effective means of enhancing success in counseling. When a referral is necessary, motivational interviewing can be used to maximize adherence.

The role of parental consent in adolescent substance use research.

PURPOSE The objective of our study was to assess the effects of requiring parental consent upon study participation and self-reported substance-related problems among 14-18-year-olds. METHODS This was a secondary analysis of combined data from two similar studies of adolescent substance use that recruited participants from the same adolescent clinic at Childrens Hospital Boston. Study 1 waived parental consent, whereas Study 2 required parental consent. The combined dataset included demographic characteristics and Car, Relax, Alone, Forget, Friends, Trouble (CRAFFT) study screening test responses. The CRAFFT is an orally administered screen that yields a score from 0-6 and that has been shown to be a valid and reliable measure of risk for substance-related problems. RESULTS The participation refusal rate in Study 1, where consent was waived, was 19.7% (132 of 670 eligible individuals) and in Study 2 (243 of 411 eligible individuals), where consent was required, it was 59.1% (p < .0001). Participants did not differ significantly with respect to gender and age but did differ by self-identified race/ethnicity between the two studies. Because the CRAFFT score distributions were highly skewed, we used the nonparametric Mann-Whitney U test for differences in mean rank. The mean rank in Study 1 was significantly higher than in Study 2 (mean rank 362 vs. 325, p = .02). After controlling for age, gender, and race/ethnicity, the adjusted proportional odds ratio for a one-point increase in CRAFFT score was 1.47 (CI 1.03, 2.10) for Study 1 compared with Study 2. CONCLUSIONS The research requirement of parental consent may result in substantial self-selection bias towards a lower risk sample.

Outcomes of a Monitoring Program for Physicians with Mental and Behavioral Health Problems

Objective. Most states have programs that provide structured monitoring for physicians with substance use disorders (SUDs). In recent years, the Massachusetts Medical Societys Physician Health Services (PHS) program has used a similarly structured approach to monitor physicians with other mental and behavioral health (MBH) problems. The objective of this study was to determine the outcomes of the PHS monitoring programs for SUDs and MBH problems, compare their overall success rates, and identify correlates of success. Method. Data were extracted from the PHS administrative database for physicians presenting between January 1, 1993 and May 31, 2003. Variables included gender, age, specialty, type of monitoring contract (SUD vs MBH), and state licensing board involvement. Dates of contract openings and closings were used to categorize cases as successful completion, relapse, or other. Results. Of 58 physicians with MBH contracts, 43 (74%) completed successfully, 7 (12%) relapsed, and 8 (14%) did not complete for other reasons. Of 120 total physicians with SUD contracts, 90 (75%) completed successfully, 10 (8%) relapsed, and 20 (17%) did not complete for other reasons. Successful completion of SUD contracts was significantly associated with licensing board involvement (84% vs 66%, p = 0.04). Survival analysis indicated that time to relapse was significantly shorter for women compared to men on both MBH and SUD contracts (log rank test for equality of survival distribution p < 0.001 for MBH and p = 0.001 for SUD). Conclusion. This study suggests that physicians with MBH problems can be monitored in a similar fashion as physicians with SUDs, and with similarly positive outcomes. However, greater attention should be given to services for women in physician health monitoring programs.