How high are the stakes when it comes to adolescent substance use?
On one hand, most people with substance use disorders recover on their own. So maybe the hysteria about how many Americans are addicted to opioids or alcohol is a bit misplaced. Most of those folks will, over time, reduce or cease their use.
On the other hand, almost 50,000 people died of drug overdoses in 2014, and about 14,000 of those people were under the age of 35. We now have firm evidence that substance use during adolescence can cause long-term brain changes. And we know that almost everyone who struggles with addiction began using substances before the age of 18.
So, again, how high are the stakes when it comes to adolescent substance use? And as a community, what should we do to prevent or reduce it? I’m not entirely sure. But one thing is clear as day: We really need to talk with youth about substance use. We need to talk about it, and then we need to keep talking about it.
There are a few reasons it’s so important to keep the conversation going. For one thing, there’s always new knowledge to share. We learn more every day about adolescent brain development and the neurobiology of addiction.
Our understanding of effective treatment modalities and harm-reduction strategies keeps changing, too. For teens, trends and availability change rapidly. Weird synthetic drugs invented in secret chemistry labs appear out of nowhere at freeway gas stations. Celebs secure new alcohol endorsements, glamorize new ways to party.
We also need to keep talking about substance use because an individual’s motivation to change isn’t fixed; it’s fluid. Motivation can be planted and watered and over time, it can grow. If the 96 percent of Americans who meet the criteria for a substance use disorder but don’t think they need treatment were unreachable, we’d best give up and not bother. But addiction counselors, primary care physicians, parole officers and many others know it’s possible to generate and support an individual’s desire to change over time. Ongoing conversation offers this opportunity.
The question is how to institutionalize this ongoing conversation. The most effective way to establish a culture of openness and learning about substance use is the widespread use of Screening, Brief Intervention and Referral to Treatment (SBIRT) for youth in a variety of settings.
The components of SBIRT are universal screening (that is to say, engaging everyone in a given setting in a conversation about substance use), a brief intervention for individuals whose use may be risky, and a referral to treatment resources for those who appear to have substance use disorders. SBIRT for youth has been implemented in all sorts of locations, including school-based health centers, job training programs and primary care offices.
SBIRT is certainly not the only way to create dialogue about substance use. Family dinner conversations are important. Guidance from mentors and community role models is essential. But SBIRT is a systematic approach to addressing substance use that will afford the greatest number of youth an opportunity to share and learn about substance use and the way it affects their lives.
Another strength is that SBIRT incorporates an evidence-based approach to motivation-building called Motivational Interviewing, which is known to work well with young people. Motivational Interviewing is a therapeutic strategy that elucidates the issues that matter most to people and determines how behavior change could improve the outcomes they care about. Let’s be honest: Most people don’t make changes so they can be less of a drain on the health care system. They change because they want to meet their own goals and feel close to the people they care about. This is true of adolescents and adults alike.
SBIRT also supports health literacy. I’m delighted that kids don’t respond to Just Say No. Why should they? And why should we dole out advice that condones ignorance? There’s plenty of actual information to be shared, like: Substance use has a more powerful and long-lasting effect on adolescent brains compared to adult brains. Or, we know there’s a strong genetic component to addiction. And of course, there’s information about what we don’t know, like, some people outgrow unhealthy substance use patterns and some people don’t. We don’t know why.
Just say no and other finger-wagging approaches to substance-use prevention also obliterate the opportunity to ask important questions, such as: How many times in the last year have you used alcohol or a medication that wasn’t prescribed to you? Do you know the difference between using other people’s medication and your own? Do you know that mixing alcohol and pills can make overdose more likely? And, what benefits do you get from drinking alcohol?”
As with diet, exercise and other health behaviors, reducing risky substance use is about hearts and minds. (It’s also about effective policies to keep alcohol and tobacco companies out of our communities — but that’s another column.) Using SBIRT means accepting that we don’t get to make these decisions for other people, including adolescents. But that we have a duty to ask, talk and listen.
Jessica Williams is the director of communication and health promotion at the Institute for Research, Education and Training in Addictions (IRETA) in Pittsburgh, Pennsylvania. IRETA is a federally designated training and technical assistance center to advance the use of SBIRT.
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