Opinion: It's Time To Screen Teenagers At School For Risky Substance Use

Hearings are being held in the Massachusetts State House on a bill that would enable public school nurses to screen teens for the risk of substance use. This practice is strongly supported by the Children’s Mental Health Campaign and the Addiction Free Future Project, and part of a mission in five states to promote screening for teenagers at risk of substance use problems.

We favor broad screening as a way to reduce death and disability due to substance use that typically starts in the teen years. We understand that this screening will be totally confidential — like all substance use screening and discussions between teens and health care providers. However, parents are free to oppose the screening of their children just as they may prevent their children from receiving vaccinations.

The downside to screening raised by some is that it will bring additional costs to the state, including extra time for training and to administer the tests. In addition, some kids may feel discomfort being asked sensitive questions. However, the overall reduced costs of treatment are great. And most kids really are open to talking about substance use in a confidential setting.

There are certainly some people who do not feel school is a place for screening of any kind. But after looking at research on substance use disorder prevention, professionals at The MGH Clay Center for Young Healthy Minds, The MGH Recovery Research Institute and the Massachusetts Children’s Mental Health Campaign feel that the benefits of early screening far outweigh the financial cost and time factors involved. The risks of excessive substance use in teenage years is very dangerous to brain development and social functioning.

A new blog post by screening advocates John F. Kelly, Ph.D., founder and director of the Recovery Research Institute and associate director of the Center for Addiction Medicine at Massachusetts General Hospital, and Courtney Chelo, behavioral health project manager at the Massachusetts Society for the Prevention of Cruelty to Children (MSPCC) lays out the details:

Massachusetts is in the midst of a crisis: opiate overdoses in the Commonwealth rose by 90% between 2000 and 2012, and since then, there’s been another 33% increase in opiate-related deaths. In fact, overdoses killed twice as many people in 2013 as motor vehicle accidents. People are using substances at higher rates—and they’re starting at an earlier age.

It isn’t just opiates that are the problem. Massachusetts has the second highest rate of high school students reporting current marijuana use, and 40% of this age group reports having had alcohol in the last month. We also know that the decisions teens make around substance use are fraught with danger, given their sensitivity to peer pressure and greater impulsivity compared to adults. In the 2012 National Survey of American Attitudes on Substance Abuse, high school students identified drugs, alcohol, and tobacco as the most important problem they face, beating out the second- and third-place contenders of social and academic pressure by a wide margin.

The younger teens are when they experiment with alcohol or drugs, the more likely they are to struggle with addiction later in life. That’s because the adolescent brain is a work in progress, with full maturation occurring around age 25. During the teen years, the parts of the brain that control emotion, motivation and impulsive behavior are rapidly evolving, leading key executive functions, such as judgment and reasoning, to be particularly impaired if exposed to alcohol or other drugs. These impairments, in turn, can give way to risky behavior, as rationality is essentially overridden by emotionally-charged reactions. Not only do these impairments cause accidents, injuries, and deaths during teenage years, but can have life-long ramifications for cognition and emotion regulation and increase risk for addiction. Studies show that anywhere from 40-50% of teens who start drinking before the age of 15 will struggle with alcohol or other significant drug problems later in life.

While addiction is without a question a complicated disease, it is, thankfully, both treatable and preventable. Therefore, the Children’s Mental Health Campaign, a statewide coalition of families, advocates, healthcare providers, educators and parents dedicated to the comprehensive reform of the children’s mental health system, has launched the Addiction Free Futures Project in Massachusetts to help combat youth substance use by expanding access to Screening, Brief Intervention, and Referral to Treatment (SBIRT).

SBIRT is a simple, low-cost, evidence-based public health approach to addressing teenage substance use. It’s geared to adolescents ages 14-22, is easy to administer, and, most importantly, is effective in identifying youth at risk (Harris et al, 2014; Mitchell et al, 2012; Winters and Leiten, 2007), and guiding them toward counseling and treatment if a problem exists. Through SBIRT, we can begin to have frank, sensitive discussions with adolescents at a time when they may be more receptive and amenable to change. And, when we’re able to have honest conversations with young people about alcohol and drugs, we can help them stay on the path to a bright future—or get back on track if they’re in need of help.

Research has shown that brief interventions to reduce risky alcohol use by adults are extremely effective, and save an estimated $6.00 for every $1.00 spent (Fleming et al, 2000; Quanbeck et al, 2010). The savings may be even greater for teens—not just in terms of dollars saved, but in terms of the number of lives saved. Alcohol and other drug use among youth 15-24 years old accounts for the vast majority of life-years lost due to disease, disability, and premature mortality (Gore et al, 2011). Practically the only thing a young person will get sick or die from during this age is from alcohol or other drugs. Early detection through SBIRT can save lives, reduce suffering, and makes sound financial sense.

The Addiction Free Futures Project is part of the five-state “TRUE TALK: POWER OF PREVENTION” initiative run by Community Catalyst, a national nonprofit advocacy organization based in Boston, and supported by grants from the Conrad N. Hilton Foundation and The Peter and Elizabeth C. Tower Foundation. Dedicated to expanding access to SBIRT for youth and young adults, the project has authored a piece of legislation (H. 1796 An Act relative to preventing adolescent substance abuse by expanding SBIRT) that, if passed, would add screening for substance use to the list of health screenings conducted in public schools. The bill builds on an existing program developed by the Massachusetts Department of Public Health that has trained school nurses and other school health personnel to utilize evidence-based, cost-effective strategies to universally screen for risky substance use and guide appropriate follow-up in eight school districts to date.

(A version of this piece first ran on The MGH Clay Center for Young Healthy Minds website.)

Eugene Beresin, M.D. is executive director of The MGH Clay Center for Young Healthy Minds and professor of psychiatry at Harvard Medical School.