Part 1: Prevalence and Screening
As healthcare providers, we know that Native American populations, for a multitude of historical and social reasons, have a problematic history with substance use disorders. The goal of this newsletter series is to describe the prevalence and patterns of substance use among Native American youth, as well and identify methods to assess co-occurring mental health conditions associated with substance use in youth and summarize evidence-informed treatment options for those youth.
This topic matters because Native American youth have among the highest rates of early substance initiation in the United States and experience higher rates of substance use disorders than many peer groups. On average, Native American youth ages 12-17 have double the rates of alcohol use disorder, nicotine use disorder, cannabis use disorder and prescription drug misuse compared to the national average. Four out of 10 Native American youth have a lifetime prevalence of substance use problems.
Disparities reflect historical, structural, and social factors that are specific to this population. Individual and family risk factors include: adverse childhood experiences (ACEs), parental substance use, and concerns related to social determinants of health including housing problems and poverty. Community and systems level risk factors include: limited access to behavioral health services, geographic isolation, and historical trauma. Barriers to care include limited local treatment programs, mistrust of systems in general, limited culturally trained providers, and limited use of harm reduction strategies and over focus on abstinence-only programs.
Adolescence is a particularly high-risk period for developing a substance use problem. Adolescence is a normative period for risk taking, novelty seeking and impulsive actions. There is an increase in emotional range, partially related to puberty and hormonal changes. There is normal separation from parental influence and greater peer influence. It is typical for teens to have difficulty in considering negative outcomes to their actions. All of these factors contribute to the risk of developing a substance use problem in the teen years.
For screening for substance use, it is important to maintain a non-judgmental stance. Language matters so using broad, open-ended questions can be helpful, for example:
“What role does this substance play in your life?”. Focus on curiosity and connection before correction to build trust. Helpful screening tools include the CRAFTT and BSTAD (Brief Screener for Tobacco, Alcohol, and other Drugs). One could use more specific screening questions for specific drugs as well:
· Nicotine: “Any vaping in the last 30 days? How soon after waking up?”
· Cannabis: “Edibles or vape? How often? Any school impact?”
· Alcohol: “Any binge episodes (≥4/5 drinks)? Riding with intoxicated driver?”
· Pills: “Any non-prescribed pills or ‘from a friend’? Any pressed pills?”
· Safety: “Using alone? Blackouts? Naloxone in the home?”
Schools and the primary care setting can play vital roles in the screening process and early identification of a substance use problem. Schools can offer prevention programs and help connect students to services when there is a problem. Primary care settings have the advantage of longitudinal relationships and normalizing the screening process. Primary care providers can help with linkage to behavioral health when needed for co-occurring mental health concerns.
AUTHOR:
Charmi Patel Rao MD, DFAACAP
Medical Director, Vista Hill Foundation
Voluntary Assistant Clinical Professor, UCSD Department of Psychiatry