Behavior Ask the Expert: Alcohol? Drugs? How can you know?

Q

When treating adolescents in a busy practice, what are some resources or tools that the pediatrician can use to differentiate between the experimental drinker, the habitual drinker, and the true alcoholic? Also, can you tell me if it is possible for a teenager to be physically dependent on alcohol? Last, can you suggest a way to involve the parents of a teenager when you suspect substance abuse and the teenager "doesn't want my parents to know"?

Douglas G. Olk, MD
Dubuque, Iowa

A Finding out if a teenager is an experimental, a habitual, or a dependent user of alcohol can be challenging in a busy office practice. You can focus your assessment by using CRAFFT, an easy-to-remember, validated, six-question screening tool designed specifically for interviewing adolescents about substance use. CRAFFT comprises the following questions:

C Have you ridden in a Car driven by someone (including yourself) under the influence of alcohol or drugs?

R Do you use alcohol to Relax or feel better about yourself?

A Do you ever use alcohol when you are Alone?

F Do you Forget things you have done while using alcohol?

F Do Family or Friends tell you to cut down on alcohol?

T Have you ever gotten into Trouble because of alcohol use?

Two affirmative responses let you know that further assessment is needed. (For more on the CRAFFT assessment tool, refer to "Getting into adolescent heads: An essential update" by John M. Goldenring, MD, MPH, and David S. Rosen, MD, MPH in the January 2004 issue of Contemporary Pediatrics.)

A more detailed screening tool is available in the implementation materials of the Guidelines for Adolescent Preventive Services (GAPS). You can access the materials at www.ama-assn.org/ama/pub/category/2280.html and download an age-appropriate questionnaire, which you can use to question the patient about medical history, health issues, violence and use of weapons, tobacco and alcohol use, drug use, relationships, and the patient's self-perceptions.

A major determinant of alcohol dependence is whether signs or symptoms of withdrawal develop when alcohol use is discontinued. Although teenagers can have withdrawal symptoms, this happens rarely because withdrawal typically occurs only after ingesting large quantities of alcohol over a long period. Most teenagers tend to be poly-substance users. They switch among substances depending on availability, social circumstances, and available funds.

When a substance-abuse problem (as indicated by negative consequences) reaches the level of requiring outside intervention, and parents truly are unaware that their teenager is using drugs or alcohol, you need to evaluate the larger family structure and interactive dynamic. If the teenager seems afraid of disclosure, be sure to investigate patterns of parental discipline to make sure that the teenager is safe from physical harm or sexual abuse. In a busy office practice, it may be more effective to identify general behavior problems, rather than substance use specifically, and refer the patient and family for counseling, during which the connections between behavior and substance use can come to light more easily than in your office.

Last, be sure to stay informed about referral resources in your community so that you know what help is available to your patients.

Martin Stein, MD
Lawrence Friedman, MD

DR. STEIN is professor of pediatrics at the University of California at San Diego School of Medicine.

DR. FRIEDMAN is professor of pediatrics and chief of the division of general academic pediatrics at the University of California at San Diego School of Medicine.