(60) Substance Use Among Adolescents in Pediatric Primary Care

Background & Introduction: The American Academy of Pediatrics recommends substance use screening, brief intervention, and referral to treatment (SBIRT) for adolescents in all health care settings. Substantial research has documented the accuracy of recommended screening tools in identifying substance use disorders among youth who report substance use. However, the sensitivity discriminating between past year users versus non-users is unknown, and there is limited research on the prevalence of substance use among adolescents screened in primary care settings. The objective of this study was to determine the prevalence of past-year substance use reported by adolescents presenting for pediatric primary care on a validated screening tool, and compare this prevalence to national survey data that is collected anonymously.

Methods: Secondary analysis of the Screening to Brief Intervention (S2BI) clinical screen results collected from 34 pediatric primary care practices in Massachusetts. The S2BI includes questions on the past year frequency (none, once or twice, monthly, weekly or more) of tobacco/nicotine, alcohol, cannabis, and other drug use. Reporting monthly or weekly use of any substance is considered a “positive” screen (i.e., high risk of substance use disorder). Descriptive statistics were used to summarize patient characteristics (age, sex) and substance and frequency of use identified by S2BI. S2BI screening data were compiled to estimate the prevalence of past-year substance use, stratified by practice, age, and sex. To adjust for demographic distribution differences, we applied raking - re-weighting method - to match age and sex distributions. Weighted generalized estimating equations (GEE) with robust sandwich standard errors were used to account for clustering at the practice level and to estimate population-averaged probabilities of a positive S2BI screen across the 29 practices included in this analysis, adjusting for the Child Opportunity Index (COI) associated with each practice’s ZIP code. Adjusted results were compared to state-level prevalence estimates from the 2022-2023 National Survey on Drug Use and Health (NSDUH) for Massachusetts, with two-sided Wald z-tests (α=0.05).

Results: We collected a total of 85,914 S2BI screens from patients collected at 34 pediatric practices between January 2022 and February 2024. This analysis includes 56,057 patients aged 14-20 years old screened at 29 of these practices between January 2022 and December 2023 with complete data. Mean age was 17.2 years old (SD 1.9); 49.3% were male. Prevalence of past year substance use and frequency increased by age for all substances. Past year use of any substance was reported by 6.4%, 18.6%, and 51.8% of 14-15-, 16-17-, and 18–20-year-olds respectively. Cannabis was the substance most commonly reported by 14-15 year old youth (4.0%), followed by tobacco (3.2%) and alcohol (3.2%). Alcohol was the substance most commonly reported by older youth (13.4% and 45.9% for 16-17- and 18-20 year old youth respectively), followed by cannabis (10.8% and 29.3%), and tobacco (6.3% and 15.0%). Monthly or more use of any substance was reported by 2.3%, 7.8%, and 34.0% of 14-15-, 16-17-, and 18-20-year-olds respectively. Cannabis was the substance most likely to be used monthly or more by 14-17-year-olds; alcohol was the substance most likely to be used monthly or more by older youth. Nonmedical prescription medication use and illicit drug use was rare among all age groups. When comparing the model-derived population-averaged prevalence estimates from primary care S2BI screen results to the substance use prevalence estimates for NSDUH Massachusetts state data, the primary care prevalence estimates were lower across all age groups and for all substances (p < 0.05).

Conclusion & Discussion: Adolescents commonly reported substance use when screened in primary care practices in Massachusetts, demonstrating the importance of SBIRT in pediatric primary care. The substance use prevalence estimates from primary care were lower than those reported in state-level data. It is possible that substance use is less common among youth accessing primary care in general pediatric practices compared to other sources of primary care (school-based health clinics, adolescent medicine clinics, family practice) or those who do not access primary care at all. It is also possible that youth under report their substance use when using recommended tools in pediatric primary care, and it is likely that both factors contribute to the significant discrepancy between national survey and primary care data. Future research could explore methods to improve the sensitivity of identifying any substance use with validated substance use disorder screens.

References: 1. Levy SJL, Williams JF, COMMITTEE ON SUBSTANCE USE PREVENTION, et al. Substance Use Screening, Brief Intervention, and Referral to Treatment. Pediatrics. 2016;138(1)doi:10.1542/peds.2016-1211
2. Levy S, Brogna M, Minegishi M, et al. Assessment of Screening Tools to Identify Substance Use Disorders Among Adolescents. JAMA Network Open. 2023;6(5):e2314422-e2314422. doi:10.1001/jamanetworkopen.2023.14422
3. Levy S, Weiss R, Sherritt L, et al. An electronic screen for triaging adolescent substance use by risk levels. JAMA Pediatr. Sep 2014;168(9):822-8. doi:10.1001/jamapediatrics.2014.774
4. Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Behavioral Health Statistics and Quality (CBHSQ). NSDUH 2022–2023 (2-year, RD02YR) Data Analysis System (DAS): Alcohol, marijuana, and nicotine vaping use by age and sex, Massachusetts (STUSAB=MA). Accessed October 20–21, 2025.