Draft Recommendation Statement
Illicit Drug Use in Children, Adolescents, and Young Adults: Primary Care–Based Interventions
This opportunity for public comment expired on October 28, 2019 at 8:00 PM EST
Note: This is a Draft Recommendation Statement. This draft is distributed solely for the purpose of receiving public input. It has not been disseminated otherwise by the USPSTF. The final Recommendation Statement will be developed after careful consideration of the feedback received and will include both the Research Plan and Evidence Review as a basis.
Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
Draft: Recommendation Summary
|Children, adolescents, and young adults|
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary care–based behavioral counseling interventions to prevent or reduce illicit drug use, including nonmedical use of prescription drugs, in children, adolescents, and young adults.
See the Practice Considerations section for suggestions for practice regarding the I statement.
In 2017, 7.9% of persons ages 12 to 17 years reported illicit drug use in the past month,1 and an estimated 50% of adolescents in the United States had used an illicit drug by the time they left high school.2 Young adults ages 18 to 25 years have a higher rate of current illicit drug use, with an estimated 23.2% currently using illicit drugs. Similar to adolescents, the illicit drugs most commonly used by young adults are marijuana (20.8%) and prescription psychotherapeutics (4.6%).1 Illicit drug use is associated with many negative health, social, and economic consequences and is a significant contributor to three of the leading causes of death among young persons (ages 10 to 24 years): unintentional injuries, including motor vehicle accidents; suicide; and homicide.3
Draft: USPSTF Assessment of Magnitude of Net Benefit
Because of limited and inadequate evidence, the USPSTF concludes that the benefits and harms of primary care–based interventions to prevent or reduce illicit drug use in children, adolescents, and young adults are uncertain and that the evidence is insufficient to assess the balance of benefits and harms. More research is needed.
See the Table for more information on the USPSTF recommendation rationale and assessment. For more details on the methods the USPSTF uses to determine the net benefit, see the USPSTF Procedure Manual.4
Draft: Practice Considerations
This recommendation applies to children (age 12 years and younger), adolescents (ages 12 to 17 years), and young adults (ages 18 to 25 years), including pregnant persons. The purpose of this recommendation is to assess the evidence on interventions to prevent the initiation of illicit drug use, and thus does not apply to persons who already have a history of regular or harmful illicit drug use. Children, adolescents, and young persons who are regular users of illicit drugs (at least once per week) or have been diagnosed with a substance use disorder are outside the scope of this recommendation.
Screening for illicit drug use in adults and adolescents (ages 12 to 17 years) is covered in a separate recommendation statement.5
Definitions of Illicit Drug Use, Including Nonmedical Drug Use
The term “illicit drug use” is defined as the use of substances (not including alcohol or tobacco products) that are illegally obtained or involve nonmedical use of prescription psychotherapeutic medications; that is, drug use for reasons, for duration, in amounts, or with frequency other than prescribed, or use by persons other than the prescribed individual. Nonmedical drug use also includes the use of over-the-counter medications, such as cough suppressants. Other illicit drugs include household products such as glues, solvents, and gasoline. These substances are ingested, inhaled, injected, or administered using other methods to affect cognition, affect, or other mental processes; to “get high”; or for other nonmedical reasons.
The body of evidence to recommend specific interventions to prevent initiation or reduce use of illicit drugs in the primary care setting is insufficient. Studied interventions include face-to-face or group counseling, print materials, interactive computer-based tools designed for patient use, and clinician training and quality improvement programs. Studies on these interventions provide little to no evidence of significant improvements in behavioral outcomes (drug abstinence or reduced frequency or quantity of illicit drug use) or health outcomes (morbidity, mortality, educational, or legal outcomes).
Draft: Other Related USPSTF Recommendations
The USPSTF has several recommendations on substance use–related services for young persons. The USPSTF is currently updating its recommendations on screening for illicit drug use in adults age 18 years and older (B recommendation) and in adolescents ages 12 to 17 years (I statement).5 The USPSTF also has recommendations on screening and behavioral counseling interventions to reduce unhealthy alcohol use in adults ages 18 years and older (B recommendation) and adolescents ages 12 to 17 years (I statement).6 Finally, the USPSTF is currently updating its recommendations on education or brief counseling interventions to prevent initiation of tobacco use among school-aged children and adolescents (B recommendation) and interventions for the cessation of tobacco use among school-aged children and adolescents (I statement).7
Suggestions for Practice Regarding the I Statement
Potential Preventable Burden
Illicit drug use is associated with multiple negative health, social, and economic consequences. In 2011, the Drug Abuse Warning Network estimated that approximately 1.1 million emergency department visits by persons ages 0 to 21 years involved illicit drug use (not including alcohol),8 and more than 79,000 of those visits were related to nonmedical use of opioids in persons ages 12 to 25 years.9 In 2015, drug overdose (both intentional and unintentional) accounted for 9.7 deaths per 100,000 persons ages 15 to 24 years.10
Frequent and heavy illicit drug use is associated with increased risk-taking behaviors while intoxicated, such as driving under the influence, unsafe sexual activity, and violence. In 2016, 73.6% of all deaths in young persons ages 10 to 24 years in the United States resulted from three causes: unintentional injuries, including motor vehicle accidents (41.1%); suicide (17.3%); and homicide (14.9%).3 The use of alcohol and illicit drugs are the primary health risk behaviors that contribute to these causes of death.11
Illicit drug use can also have harmful long-term consequences. Children and adolescents who initiate marijuana use before age 17 years are more likely to progress to other drug use and drug abuse/dependence as adults compared with those who initiate use after age 18 years.12 Studies have linked use of cannabis to poorer academic performance and lower education attainment (i.e., dropping out of high school or obtaining a college degree).13-15 Long-term negative psychosocial and neurocognitive effects have been associated with adolescent illicit drug use, including increased anxiety and impaired abstract thinking, attention, learning, and psychomotor functioning.16, 17
The USPSTF found limited evidence on potential harms associated with interventions. Only one study reported nonspecific “adverse events,” with no difference between intervention and control groups.18 Potential harms include a paradoxical increase in illicit drug use.19, 20
The USPSTF found little evidence on the frequency of use of behavioral counseling in primary care to prevent initiation of illicit drug use among nonusers, or the escalation of use among persons who do not use illicit drugs regularly.
Draft: Update of Previous USPSTF Recommendation
This recommendation replaces the 2014 USPSTF recommendation, which was also an I statement.21 This recommendation statement incorporates new evidence since 2014 and now includes young adults (ages 18 to 25 years).
Draft: Supporting Evidence
Scope of Review
The USPSTF commissioned a systematic evidence review to evaluate the evidence on the potential benefits and harms of interventions to prevent illicit drug use in children, adolescents, and young adults.22 This review was used to update the 2014 USPSTF recommendation statement.
The USPSTF uses the term “illicit drug use” to reflect a spectrum of behaviors that range from abstinence to severe substance use disorder. The scope of this recommendation includes interventions designed to prevent illicit drug use in children, adolescents, and young persons who have never used illicit drugs as well as stopping illicit drug use among those with experimental or limited use. Children, adolescents, and young persons who are regular users of illicit drugs (at least once per week) or have been diagnosed with a substance use disorder are outside the scope of this recommendation.
Although alcohol and tobacco are both psychoactive drugs, they are not the focus of this recommendation. The USPSTF has made separate recommendations on screening and counseling for tobacco and alcohol use in adolescents.6, 23
Benefits of Interventions
The USPSTF reviewed 28 studies (n=17,482) of interventions to prevent illicit drug use.22 The review included 25 general prevention trials and three trials of the Family Spirit program, an intensive home visitation program that targeted pregnant Native American/Alaska Native youth.18, 24, 25 Ten of the studies targeted middle school students (ages 10 to 14 years) and two targeted young adults (ages 17 to 24 years). The remaining studies focused on high school–aged youth or covered an age range inclusive of high school–aged youth. Most of the studies (21) were conducted in the United States. Race/ethnicity data were not reported in all studies, although 10 studies included a majority of black and Hispanic youth, three were limited to Native American females, and one was limited to Asian American females.
Nearly half of the interventions (48%) were individual counseling sessions (in person or by phone), 18% were group sessions or a combination of group and individual sessions, and 36% were exclusively computer based. Trials in middle school–aged youth tended to be more intensive, with an average of seven to 12 sessions, compared with one to three sessions in older groups. Most interventions involved the youth alone (67%) or the youth and the parent (24%). Common components of interventions targeted to youth were education about illicit drugs and/or other substances; correction of normative thoughts or beliefs; and development of social skills, stress management skills, positive peer relationships, refusal skills, and self-esteem. Interventions targeted to parents included information on youth development, communication, monitoring, establishing rules, and positive parenting.22
The majority of trials addressed outcomes in addition to illicit drug use, with eight trials focusing broadly on substance use (including alcohol and/or tobacco). Other outcomes included family functioning (eight trials), risky sexual behavior (five trials), mental health and emotional well-being (six trials), truancy and delinquent behaviors (one trial), and breastfeeding and infant care (three trials).22
Behavioral outcomes included illicit drug use (either any illicit drug use or frequency of use), associated alcohol and tobacco use, delinquent behavior, risky sexual behavior, and unsafe driving. Across all studies, findings were inconsistent for the outcome of any illicit drug use. Although some interventions reported positive findings on a drug use outcome, including benefits across multiple time points or multiple outcomes, nearly half of the trials reported no clear improvement in outcomes, and two trials reported statistically significant increases in illicit drug use for at least one drug use outcome in the intervention group compared with the control group.
For the general prevention trials (i.e., those other than the Family Spirit trials), the pooled effect of interventions on illicit drug use (including any use and number of times used) was not statistically significant (pooled standard mean difference, -0.08 [95% CI, -0.16 to 0.01]; 23 trials; n=11,932; I2=58.2%).22 The pooled odds ratio for any illicit drug use or any cannabis use was 0.85 (95% CI, 0.67 to 1.07; 11 trials; n=8,162; I2=43.1%).22 For continuous outcomes (number of times used in the last 3 months), the pooled mean difference between groups was statistically nonsignificant (0.21 times fewer in the intervention group [95% CI, -0.44 to 0.02]; 11 trials; n=3,651; I2 =51.0%).22 Only four trials reported on outcomes specifically related to misuse of prescription medications. All were computer-based interventions and reported greater reductions of misuse, ranging from 0.1 to 11.3 times fewer over the previous 3 months and up to 24 months of followup.21
For the Family Spirit home visitation trials, only one found statistically significant reductions in illicit drug use, although only at the final time point (38-month followup).22 Other behavioral outcomes, including delinquent behavior, risky sexual behavior, and unsafe driving, were not reported.22
Nineteen studies (n=9,042) (16 of the general prevention trials and all three of the Family Spirit trials) reported on health or related outcomes.18, 19, 24-40 Mental health and family functioning were the most common type of outcomes reported, although no outcome was widely reported. Mental health outcomes were reported in 12 trials and included global mental health functioning (five trials), depression symptoms (seven trials), externalizing (three trials), internalizing (one trial), and anxiety symptoms (one trial). Most of the general prevention trials found no group-to-group differences on mental health symptom scales after 3 to 24 months, and results were mixed for the Family Spirit trials. Family functioning (family communication, parental monitoring, and maternal closeness) was reported in five trials. Three of these trials reported statistically significant improvements in family functioning (0.3 to 0.6 on a 5-point scale for up to 24 months), although the clinical significance of this finding is uncertain.22 Other reported health or related outcomes, such as consequences of illicit drug use (three trials), health-related quality of life (one trial), and arrests (one trial) failed to demonstrate consistent benefit. No trials reported mortality.
Evidence on Harms of Interventions
No studies directly reported harms related to interventions, although one trial reported no difference in “adverse events” between intervention and control groups.18 Two studies reported paradoxical and statistically significant increased illicit drug use in intervention groups compared with control groups.19, 20 Seven other studies reported statistically nonsignificant increases in illicit drug, alcohol, or tobacco use in intervention groups.24, 25, 28, 33, 39, 41, 42
Draft: Research Needs and Gaps
The USPSTF identified several gaps in the evidence where more research is needed:
- There was minimal reporting on health, social, or legal outcomes and significant heterogeneity in reporting on drug use outcomes. Standardization of outcome measurement across trials would greatly strengthen the evidence base and improve the ability to pool data.
- Several interventions such as the Familias Unidas program (a family-based intervention program focusing on Hispanic youth) and interventions that included clinician training, education, personal coaching, and continuous quality improvement components showed promise in reducing illicit drug use. More studies are needed that replicate and further refine these interventions.
- There was no evidence on preventing or reducing illicit drug use in children younger than age 10 years and limited evidence in young adults (ages 18 to 25 years). More data are needed on the benefits and harms of interventions in these age groups.
- Technology-based interventions such as text-based messaging, smartphone apps, games, web-based interventions, and social media have the potential for wide reach, although there are limited data about their effectiveness. More studies of implementation of these types of interventions is needed, specifically among families referred from primary care, to determine their uptake and effectiveness.
Draft: Recommendations of Others
The Substance Abuse and Mental Health Services Administration recommends that universal screening for substance use, brief intervention, and/or referral to treatment (SBIRT) be part of routine health care.43 In children and adolescents, “brief interventions” include a wide spectrum of actions intended to prevent, delay, or reduce substance use.22 The American Academy of Pediatrics recommends that all adolescents be screened for alcohol and illicit drug use and that, based on the results, clinicians conduct further assessment, provide guidance and brief counseling interventions, and, if appropriate, refer for treatment.44 For patients reporting no substance use, it recommends positive reinforcement. The Canadian Paediatric Society recommends screening and education for risky behaviors, including substance use.45 The U.K. National Institute for Health Care Excellence recommends that clinicians consider providing preventive drug misuse activities and assess persons at risk of illicit drug misuse. Clinicians should consider providing skills training to young persons who are assessed as vulnerable to illicit and nonmedical drug use.46
1. Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2016 National Survey on Drug Use and Health. https://www.samhsa.gov/data/report/key-substance-use-and-mental-health-indicators-united-states-results-2016-national-survey. Accessed August 26, 2019.
2. Johnston LD, Miech RA, O'Malley PM, et al. 2018 Overview: Key Findings on Adolescent Drug Use. http://www.monitoringthefuture.org/pubs/monographs/mtf-overview2018.pdf. Accessed August 26, 2019.
3. Heron M. Deaths: leading causes for 2016. Natl Vital Stat Rep. 2018;67(6):1-77.
4. U.S. Peventive Services Task Force. Procedure manual. https://www.uspreventiveservicestaskforce.org/Page/Name/procedure-manual. Accessed August 29, 2019.
5. U.S. Preventive Services Task Force. Screening for Illicit Drug Use, Including Nonmedical Use of Prescription Drugs: Draft Recommendation Statement. 2019. https://www.uspreventiveservicestaskforce.org/Page/Document/draft-recommendation-statement/drug-use-in-adolescents-and-adults-including-pregnant-women-screening. Accessed August 26, 2019.
6. U.S. Preventive Services Task Force. Screening and behavioral counseling interventions to reduce unhealthy alcohol use in adolescents and adults: US Preventive Services Task Force recommendation statement. JAMA. 2018;320(18):1899-1909.
7. U.S. Preventive Services Task Force. Primary Care Interventions for Prevention and Cessation of Tobacco Use in Children and Adolescents: Draft Recommendation Statement. 2019. https://www.uspreventiveservicestaskforce.org/Page/Document/draft-recommendation-statement/tobacco-and-nicotine-use-prevention-in-children-and-adolescents-primary-care-interventions. Accessed August 26, 2019.
8. Substance Abuse and Mental Health Services Administration. Drug Abuse Warning Network, 2011: National Estimates of Drug-Related Emergency Department Visits. https://www.samhsa.gov/data/sites/default/files/DAWN2k11ED/DAWN2k11ED/DAWN2k11ED.pdf. Accessed August 26, 2019.
9. Crane EH. Emergency Department Visits Involving Narcotic Pain Relievers. 2015. https://www.samhsa.gov/data/sites/default/files/report_2083/ShortReport-2083.pdf. Accessed August 26, 2019.
10. Hedegaard H, Miniño AM, Warner M. Drug overdose deaths in the United States, 1999-2017. NCHS Data Brief. 2018;(329):1-8.
11. Kann L, McManus T, Harris WA, et al. Youth Risk Behavior Surveillance - United States, 2015. MMWR Surveill Summ. 2018;67(8):1-114.
12. Lynskey MT, Heath AC, Bucholz KK, et al. Escalation of drug use in early onset cannabis users vs co-twin controls. JAMA. 2003(289):427-433.
13. Townsend L, Flisher AJ, King G. A systematic review of the relationship between high school dropout and substance use. Clin Child Fam Psychol Rev. 2007;10(4):295-317.
14. Green KM, Doherty EE, Ensminger ME. Long-term consequences of adolescent cannabis use: examining intermediary processes. Am J Drug Alcohol Abuse. 2017;43(5):567-575.
15. Nargiso JE, Ballard EL, Skeer MR. A systematic review of risk and protective factors associated with nonmedical use of prescription drugs among youth in the United States: a social ecological perspective. J Stud Alcohol Drugs. 2015;76(1):5-20.
16. Grant I, Gonzalez R, Carey CL, Natarajan L, Wolfson T. Non-acute (residual) neurocognitive effects of cannabis use: a meta-analytic study. J Int Neuropsychol Soc. 2003;9(5):679-689.
17. Schreiner AM, Dunn ME. Residual effects of cannabis use on neurocognitive performance after prolonged abstinence: a meta-analysis. Exp Clin Psychopharmacol. 2012;20(5):420-429.
18. Barlow A, Mullany B, Neault N, et al. Effect of a paraprofessional home-visiting intervention on American Indian teen mothers' and infants' behavioral risks: a randomized controlled trial. Am J Psychiatry. 2013;170(1):83-93.
19. Jalling C, Bodin M, Romelsjö A, et al. Parent programs for reducing adolescent's antisocial behavior and substance use: a randomized controlled trial. J Child Fam Stud. 2016;25(3):811-826.
20. Kerr JC, Valois RF, Farber NB, et al. Effects of promoting health among teens on dietary, physical activity and substance use knowledge and behaviors for African American adolescents. Am J Health Educ. 2013;44(4):191-202.
21. U.S. Preventive Services Task Force. Primary care behavioral interventions to reduce illicit drug and nonmedical pharmaceutical use in children and adolescents: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160(9):634-639.
22. O’Connor EA, Thomas R, Robalino S, et al. Interventions to Prevent Illicit and Nonmedical Drug Use in Children, Adolescents, and Young Adults: A Systematic Evidence Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 190. AHRQ Publication No. 19-05258-EF-1. Rockville, MD: Agency of Healthcare Research and Quality; 2019.
23. U.S. Preventive Services Task Force. Primary care interventions to prevent tobacco use in children and adolescents: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;159(8):552-557.
24. Walkup JT, Barlow A, Mullany BC, et al. Randomized controlled trial of a paraprofessional-delivered in-home intervention for young reservation-based American Indian mothers. J Am Acad Child Adolesc Psychiatry. 2009;48(6):591-601.
25. Barlow A, Varipatis-Baker E, Speakman K, et al. Home-visiting intervention to improve child care among American Indian adolescent mothers: a randomized trial. Arch Pediatr Adolesc Med. 2006;160(11):1101-1107.
26. Kim HK, Leve LD. Substance use and delinquency among middle school girls in foster care: a three-year follow-up of a randomized controlled trial. J Consult Clin Psychol. 2011;79(6):740-750.
27. Baldus C, Thomsen M, Sack PM, et al. Evaluation of a German version of the Strengthening Families Programme 10-14: a randomised controlled trial. Eur J Public Health. 2016;26(6):953-959.
28. Bannink R, Broeren S, Joosten-van Zwanenburg E, et al. Effectiveness of a web-based tailored intervention (E-health4Uth) and consultation to promote adolescents' health: randomized controlled trial. J Med Internet Res. 2014;16(5):e143.
29. D'Amico EJ, Parast L, Shadel WG, et al. Brief motivational interviewing intervention to reduce alcohol and marijuana use for at-risk adolescents in primary care. J Consult Clin Psychol. 2018;86(9):775-786.
30. Dembo R, Briones-Robinson R, Schmeidler J, et al. Brief intervention impact on truant youths' marijuana use: eighteen-month follow-up. J Child Adolesc Subst Abuse. 2016;25(1):18-32.
31. Estrada Y, Lee TK, Wagstaff R, et al. eHealth Familias Unidas: efficacy trial of an evidence-based intervention adapted for use on the internet with Hispanic families. Prev Sci. 2018;10:10.
32. Fang L, Schinke SP, Cole KC. Preventing substance use among early Asian-American adolescent girls: initial evaluation of a web-based, mother-daughter program. J Adolesc Health. 2010;47(5):529-532.
33. Foxcroft DR, Callen H, Davies EL, Okulicz-Kozaryn K. Effectiveness of the Strengthening Families Programme 10-14 in Poland: cluster randomized controlled trial. Eur J Public Health. 2017;27(3):494-500.
34. Lee CM, Neighbors C, Kilmer JR, Larimer ME. A brief, web-based personalized feedback selective intervention for college student marijuana use: a randomized clinical trial. Psychol Addict Behav. 2010;24(2):265-273.
35. Sanci L, Chondros P, Sawyer S, et al. Responding to young people's health risks in primary care: a cluster randomised trial of training clinicians in screening and motivational interviewing. PLoS One. 2015;10(9):e0137581.
36. Schinke SP, Fang L, Cole KC. Preventing substance use among adolescent girls: 1-year outcomes of a computerized, mother-daughter program. Addict Behav. 2009;34(12):1060-1064.
37. Schinke SP, Fang L, Cole KC. Computer-delivered, parent-involvement intervention to prevent substance use among adolescent girls. Prev Med. 2009;49(5):429-435.
38. Schwinn TM, Schinke SP, Hopkins J, Keller B, Liu X. An online drug abuse prevention program for adolescent girls: posttest and 1-year outcomes. J Youth Adolesc. 2018;47(3):490-500.
39. Walton MA, Bohnert K, Resko S, et al. Computer and therapist based brief interventions among cannabis-using adolescents presenting to primary care: one year outcomes. Drug Alcohol Depend. 2013.
40. Walton MA, Resko S, Barry KL, et al. A randomized controlled trial testing the efficacy of a brief cannabis universal prevention program among adolescents in primary care. Addiction. 2014;109(5):786-797.
41. Rhee H, Hollen PJ, Belyea MJ, Sutherland MA. Decision-making program for rural adolescents with asthma: a pilot study. J Pediatr Nurs. 2008;23(6):439-450.
42. Malmberg M, Kleinjan M, Overbeek G, et al. Effectiveness of the 'Healthy School and Drugs' prevention programme on adolescents' substance use: a randomized clustered trial. Addiction. 2014;109(6):1031-1040.
43. Substance Abuse and Mental Health Services Administration. Screening, brief intervention, and referral to treatment (SBIRT). https://www.samhsa.gov/sbirt. Accessed August 27, 2019.
44. AAP Committee on Substance Use and Prevention. Substance use screening, brief intervention, and referral to treatment. Pediatrics. 2016;138(1).
Draft: Table. Summary of USPSTF Rationale
|Benefits of Intervention||
|Harms of Intervention||
Internet Citation: Draft Recommendation Statement: Illicit Drug Use in Children, Adolescents, and Young Adults: Primary Care–Based Interventions. U.S. Preventive Services Task Force. October 2019.