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Effect of Computer-Based Substance Use Screening and Brief Behavioral Counseling vs Usual Care for Youths in Pediatric Primary CareA Pilot Randomized Clinical Trial

Educational Objective To review if a computer-facilitated system for youth substance use screening and brief intervention (CSBI) feasible and acceptable compared with usual care (UC) in primary care.
1 Credit CME
Key Points

Question  Is a computer-facilitated system for youth substance use screening and brief intervention (CSBI) feasible and acceptable compared with usual care (UC) in primary care?

Findings  In this pilot randomized clinical trial, among 106 youths who reported cannabis use in the past 12 months at baseline, the CSBI group reported longer time to first postvisit cannabis use compared with the UC group. Among 99 youths who reported riding with an impaired driver in the past 3 months at baseline, the CSBI group reported a lower rate of having ridden with an impaired driver in the past 3 months compared with the UC group.

Meaning  The CSBI system is feasible and acceptable in clinical practice and should be further tested in larger samples.

Abstract

Importance  Annual preventive health visits provide an opportunity to screen youths for unhealthy substance use and intervene before serious harm results.

Objectives  To assess the feasibility and acceptability and estimate the efficacy of a primary care computer-facilitated screening and practitioner-delivered brief intervention (CSBI) system compared with usual care (UC) for youth substance use and associated risk of riding with an impaired driver.

Design, Setting, and Participants  An intent-to-treat pilot randomized clinical trial compared CSBI with UC among 965 youths aged 12 to 18 years at 5 pediatric primary care offices and 54 practitioners. Patients were randomized to CSBI (n = 628) or usual care (n = 243) groups within practitioner with 12 months of follow-up. Data were collected from February 1, 2015, to December 31, 2017. Data analysis was performed January 1, 2018, to March 30, 2019.

Interventions  Patients self-administered a computer-facilitated substance use screening questionnaire before their annual preventive health visits. Immediately after completing the screening, they received their score and level of risk and viewed 10 pages of scientific information and true-life vignettes illustrating health risks associated with substance use. Trained practitioners received the screening results, patients’ risk levels, talking points designed to prompt brief counseling, and recommended follow-up plans.

Main Outcomes and Measures  Feasibility and acceptability were assessed using adolescents’ postvisit ratings. Days of alcohol use, cannabis use, and heavy episodic drinking were assessed at baseline and 3-, 6-, 9-, and 12-month follow-ups using Timeline Followback, and riding in the past 3 months with a driver who was impaired by use of alcohol or other drugs was assessed using 2 self-report items. The primary outcome was the intervention effect among at-risk youths who reported using alcohol or other drugs in the past 12 months or riding with an impaired driver in the past 3 months at baseline. The secondary outcome was the prevention effect among those with no prior use or risk.

Results  Among 871 youths screened, 869 completed the baseline assessment; 211 of the 869 reported alcohol or cannabis use in the past 12 months at baseline (mean [SD] age, 16.4 [1.3] years; 114 [54.1%] female; 105 [49.8%] non-Hispanic white). Of the 211 youths, 148 (70.1%) were assigned to the CSBI group and 63 (29.9%) were assigned to the UC group. Among youths in the CSBI group, 105 (70.9%) reported receiving counseling about alcohol, 122 (82.4%) reported receiving counseling about cannabis, and 129 (87.2%) reported receiving counseling about not riding with an impaired driver. Adjusted hazard ratios for time to first postvisit use of alcohol or other drugs for CSBI vs UC were as follows: alcohol use, 0.69 (95% CI, 0.47-1.02); heavy episodic drinking, 0.66 (95% CI, 0.40-1.10); and cannabis use, 0.62 (95% CI, 0.41-0.94). At 12-month follow-ups among 99 youths who reported having ridden in the past 3 months at baseline with an impaired driver (64 in the CSBI group; 35 in the UC group), adjusted relative risk ratio of riding in the past 3 months with an impaired driver for CSBI vs UC groups was 0.58 (95% CI, 0.37-0.91). No intervention effect was observed among youths who reported no prior use of alcohol or other drugs (n = 658) or not having ridden with an impaired driver (n = 769) at baseline.

Conclusions and Relevance  The CSBI system is a feasible and acceptable option for screening youths in primary care practice for use of alcohol and other drugs and for risk of riding with an impaired driver, and the estimated efficacy in this sample warrants further testing in larger samples.

Trial Registration  ClinicalTrials.gov identifier: NCT00227877

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Article Information

Accepted for Publication: May 8, 2019.

Published: June 21, 2019. doi:10.1001/jamanetworkopen.2019.6258

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Knight JR et al. JAMA Network Open.

Corresponding Author: Sion Kim Harris, PhD, Division of Adolescent and Young Adult Medicine, Boston Children's Hospital, 300 Longwood Ave, Mailstop 3189, Boston, MA 02115 (sion.harris@childrens.harvard.edu).

Author Contributions: Drs Knight and Harris had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Knight, Sherritt, Harris.

Acquisition, analysis, or interpretation of data: Knight, Sherritt, Gibson, Levinson, Grubb, Samuels, Silva, Vernacchio, Wornham, Harris.

Drafting of the manuscript: Knight, Sherritt, Gibson, Levinson, Harris.

Critical revision of the manuscript for important intellectual content: Knight, Sherritt, Gibson, Grubb, Samuels, Silva, Vernacchio, Wornham, Harris.

Statistical analysis: Sherritt, Harris.

Obtained funding: Knight, Sherritt, Harris.

Administrative, technical, or material support: Sherritt, Gibson, Levinson.

Supervision: Knight, Sherritt, Gibson, Grubb, Samuels, Silva, Vernacchio, Wornham, Harris.

Conflict of Interest Disclosures: Dr Knight reported holding the copyright for the CRAFFT screening tool. Drs Knight and Harris and Mr Sherritt reported claiming the computer-facilitated brief intervention tool as their intellectual property but have not applied for nor received a patent or copyright. No other disclosures were reported.

Funding/Support: This study was supported by grants from the National Institute on Alcohol Abuse and Alcoholism. Other support was provided by the Leadership Education in Adolescent Health Training Program and a cooperative agreement from the Maternal and Child Health Bureau, US Department of Health and Human Services (Dr Harris).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: This information, or content, and conclusions are those of the authors and should not be construed as the official position or policy of nor should any endorsements be inferred by the Health Resources and Services Administration, US Department of Health and Human Services, or the US government.

Data Sharing Statement: See Supplement 3.

Additional Contributions: We thank East Boston Neighborhood Health Center, Lexington Pediatrics, Tufts Medical Center Floating Hospital for Children, Longwood Pediatrics, and Boston Children’s Primary Care at Longwood Children’s Hospital for providing recruitment access for this study through their clinics.

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