Final Recommendation Statement
Illicit Drug Use in Children, Adolescents, and Young Adults: Primary Care-Based Interventions
May 26, 2020
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.
|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 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.||I|
Clinician SummaryExpand All
|What does the USPSTF recommend?||For children, adolescents, and young adults: I statement
The USPSTF found that the evidence is insufficient to assess the balance of benefits and harms of primary care–based behavioral counseling interventions to prevent illicit drug use in children, adolescents, and young adults. More research is needed.
|To whom does this recommendation apply?||Children (younger than 11 years), adolescents (aged 12 to 17 years), and young adults (aged 18 to 25 years), including pregnant persons.
It does not apply to persons who have a history of regular or harmful illicit drug use or who have been diagnosed with a substance use disorder.
|What’s new?||This recommendation is consistent with the 2014 USPSTF statement.|
|How to implement this recommendation?||There is insufficient evidence to recommend for or against behavioral counseling interventions to prevent illicit drug use. Clinicians should remain alert to the signs and/or symptoms of illicit drug use and treat as appropriate.|
|What are other relevant USPSTF recommendations?||The USPSTF has issued other recommendation statements about substance use at www.uspreventiveservicestaskforce.org, including:
|Where to read the full recommendation statement?||Visit the USPSTF website (https://www.uspreventiveservicestaskforce.org) to read the full recommendation statement. This includes more details on the rationale of the recommendation, including benefits and harms; supporting evidence; and recommendations of others.|
|Table of Contents||PDF Version and JAMA Link||Archived Versions|
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.
In 2017, an estimated 7.9% of persons aged 12 to 17 years reported illicit drug use in the past month,1 and an estimated 50% of adolescents in the US had used an illicit drug by the time they graduated from high school.2 Young adults aged 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 3 of the leading causes of death among young persons (aged 10 to 24 years): unintentional injuries including motor vehicle crashes, suicide, and homicide.3
Because of limited and inadequate evidence, the US Preventive Services Task Force (USPSTF) concludes that the benefits and harms of primary care–based interventions to prevent 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
Patient Population Under Consideration
This recommendation applies to children (11 years and younger), adolescents (aged 12-17 years), and young adults (aged 18-25 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 (aged 12-17 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 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 of illicit drugs that can be provided or referred from 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 inconsistent evidence on the net benefit to behavioral outcomes (drug abstinence or reduced frequency or quantity of illicit drug use) or health outcomes (morbidity, mortality, educational, or legal outcomes).
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 18 years and older (B recommendation) and in adolescents aged 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 18 years and older (B recommendation) and adolescents aged 12 to 17 years (I statement).6 In addition, 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 190,000 emergency department visits by persons aged 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 aged 12 to 25 years.9 In 2015, drug overdose (both intentional and unintentional) accounted for 9.7 deaths per 100,000 persons aged 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 aged 10 to 24 years in the US resulted from 3 causes: unintentional injuries, including motor vehicle crashes (41.1%); suicide (17.3%); and homicide (14.9%).3 Among the leading health risk behaviors, 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 (ie, dropping out of high school or not obtaining a college degree).13-15 Persistent illicit drug use starting in adolescence has been associated with negative psychosocial and neurocognitive effects, including increased anxiety and impaired abstract thinking, attention, learning, and psychomotor functioning.16,17
The USPSTF found inconsistent evidence on potential benefits associated with interventions. There was a small, statistically significant improvement in cannabis use specifically. However, other drug use outcomes (such as any illicit drug use and the number of times used in the last 3 months) failed to demonstrate statistically significant improvement. There was little evidence that interventions to prevent illicit drug use improve health outcomes such as mortality, educational attainment, or legal outcomes.
The USPSTF found limited evidence on potential harms associated with interventions. Only 1 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.
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.22,23 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. Interventions included in the review were either conducted in a primary care setting or judged to be generalizable to a primary care setting.
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.6,24
Benefits of Interventions
The USPSTF reviewed 29 studies (N = 18,353) of interventions to prevent illicit drug use.22,23 The review included 26 general prevention trials and 3 trials of the Family Spirit program, an intensive home visitation program that targeted pregnant Native American/Alaska Native youth.18,25,26 Ten of the studies targeted middle school–aged students (aged 10-14 years) and 2 targeted young adults (aged 17-24 years). The remaining studies focused on high school–aged youth or covered an age range inclusive of high school–aged youth. Most (22) of the studies were conducted in the US. Race/ethnicity data were not reported in all studies, although 10 studies included a majority of black and Hispanic youth, 3 were limited to Native American women or girls, and 1 was limited to Asian American women or girls.
Half of the interventions (50%) were individual counseling sessions (in person or by telephone), 21% were group sessions or a combination of group and individual sessions, and 35% were primarily computer based. Trials in middle school–aged youth tended to be more intensive, with an average of 7 to 12 sessions, compared with 1 to 3 sessions in older groups. Most interventions involved the youth alone (68%) or the youth and the parent (23%). Common components of interventions targeted to youth were education about illicit drugs, other substances, or both; 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.22,23
The majority of trials addressed outcomes in addition to illicit drug use, with 9 trials focusing broadly on substance use (including alcohol, tobacco, or both). Other outcomes included family functioning (8 trials), risky sexual behavior (5 trials), mental health and emotional well-being (6 trials), truancy and delinquent behaviors (1 trial), and breastfeeding and infant care (3 trials).22,23 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.
Findings were inconsistent for illicit drug use outcomes across all studies. For the general prevention trials (ie, those other than the Family Spirit trials), the pooled effect of interventions on illicit drug use (including any drug use and number of times used) was not statistically significant (pooled standard mean difference, –0.08 [95% CI, –0.16 to 0.0001]; 24 trials; n = 12,801; I2 = 57.0%).22 The pooled odds ratio for using any illicit drug was also nonstatistically significant (0.82 [95% CI, 0.67 to 1.04]; 12 trials; n = 9031; I2 = 38.2%); however, there was a statistically significant improvement in cannabis use specifically (pooled odds ratio, 0.78 [95% CI, 0.64 to 0.95]; 7 trials; n = 6520; I2 = 1.3%).22,23 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 = 3651; I2 = 51.0%).22,23 Only 4 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 follow-up.21 Although some interventions reported positive findings at 1 or more follow-ups, nearly half of the trials reported no clear benefit, and 2 trials reported statistically significant increases in illicit drug use for at least 1 drug use outcome in the intervention group compared with the control group.22
For the Family Spirit home visitation trials, only 1 found statistically significant reductions in illicit drug use, although only at the final time point (38-month follow-up).22,23 Other behavioral outcomes, including delinquent behavior, risky sexual behavior, and unsafe driving, were not reported.22,23
Nineteen studies (n = 9042) (16 of the general prevention trials and all 3 of the Family Spirit trials) reported on health or related outcomes.18,19,25-41 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 (5 trials), depression symptoms (7 trials), externalizing (3 trials), internalizing (1 trial), and anxiety symptoms (1 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 5 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.22,23 Other reported health or related outcomes, such as consequences of illicit drug use (3 trials), health-related quality of life (1 trial), and arrests (1 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.25,26,29,34,40,42,43
Response to Public Comment
A draft version of this Recommendation Statement was posted for public comment on the USPSTF website from October 1 through October 28, 2019. Several comments noted that the term “prevent or reduce” could be interpreted as applying only to persons who have never used illicit drugs or only to those currently using drugs. The primary focus of this recommendation is the prevention of illicit drug use in children, adolescents, and young adults who are not regular drug users (defined as drug use less than 1 time per week). This includes persons who have never used drugs as well as those with early or experimental use. Changes were made to clarify this point.
Comments also suggested that research on interventions that can be carried out in schools should be included. These comments also noted that the term “primary care–based” is confusing, since many of the reviewed interventions were not carried out in a clinical setting. The USPSTF makes recommendations on interventions that can be conducted in or referred from a clinical setting. As such, only studies that are conducted in or are judged to be generalizable to a primary care setting were included in the review. Language was added to clarify this. The USPSTF wishes to emphasize that screening for drug use in adolescents and young adults is covered in a separate recommendation. As such, evidence on screening interventions was not reviewed in this recommendation. In addition, the USPSTF updated the recommendation to include data from a recent trial44 that evaluated the effect of a computer-based intervention for the prevention of youth substance use and associated risky behaviors.
The USPSTF identified several gaps in the evidence where more research is needed:
- There was promising evidence that interventions could be effective in preventing cannabis use specifically; however, the benefit to harm ratio could not be determined because of a lack of studies reporting harms. Future research on cannabis prevention that deliberately addresses both benefits and harms 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 10 years and limited evidence in young adults (aged 18-25 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.
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.45 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.46 For patients reporting no substance use, it recommends positive reinforcement. The Canadian Paediatric Society recommends screening and education for risky behaviors, including substance use.47 The UK 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.48
The US Preventive Services Task Force (USPSTF) members include the following individuals: Alex H. Krist, MD, MPH (Fairfax Family Practice Residency, Fairfax, Virginia, and Virginia Commonwealth University, Richmond); Karina W. Davidson, PhD, MASc (Feinstein Institutes for Medical Research at Northwell Health, Manhasset, New York); Carol M. Mangione, MD, MSPH (University of California, Los Angeles); Michael J. Barry, MD (Harvard Medical School, Boston, Massachusetts); Michael Cabana, MD, MA, MPH (University of California, San Francisco); Aaron B. Caughey, MD, PhD (Oregon Health & Science University, Portland); Katrina Donahue, MD, MPH (University of North Carolina at Chapel Hill); Chyke A. Doubeni, MD, MPH (Mayo Clinic, Rochester, MN); John W. Epling Jr, MD, MSEd (Virginia Tech Carilion School of Medicine, Roanoke); Martha Kubik, PhD, RN (Temple University, Philadelphia, Pennsylvania); Gbenga Ogedegbe, MD, MPH (New York University, New York, New York); Lori Pbert, PhD (University of Massachusetts Medical School, Worcester); Michael Silverstein, MD, MPH (Boston University, Boston, Massachusetts); Melissa A. Simon, MD, MPH (Northwestern University, Evanston, Illinois); Chien-Wen Tseng, MD, MPH, MSEE (University of Hawaii, Honolulu); John B. Wong, MD (Tufts University School of Medicine, Boston, Massachusetts).
Conflict of Interest Disclosures: Authors followed the policy regarding conflicts of interest described at https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/conflict-interest-disclosures. All members of the USPSTF receive travel reimbursement and an honorarium for participating in USPSTF meetings. Dr Barry reported receiving grants and personal fees from Healthwise.
Funding/Support: The USPSTF is an independent, voluntary body. The US Congress mandates that the Agency for Healthcare Research and Quality (AHRQ) support the operations of the USPSTF.
Disclaimer: Recommendations made by the USPSTF are independent of the US government. They should not be construed as an official position of AHRQ or the US Department of Health and Human Services.
Additional Information: The USPSTF makes recommendations about the effectiveness of specific preventive care services for patients without obvious related signs or symptoms. It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment. The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision-making to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms.
Copyright Notice: USPSTF recommendations are based on a rigorous review of existing peer-reviewed evidence and are intended to help primary care clinicians and patients decide together whether a preventive service is right for a patient's needs. To encourage widespread discussion, consideration, adoption, and implementation of USPSTF recommendations, AHRQ permits members of the public to reproduce, redistribute, publicly display, and incorporate USPSTF work into other materials provided that it is reproduced without any changes to the work of portions thereof, except as permitted as fair use under the US Copyright Act.
AHRQ and the US Department of Health and Human Services cannot endorse, or appear to endorse, derivative or excerpted materials, and they cannot be held liable for the content or use of adapted products that are incorporated on other Web sites. Any adaptations of these electronic documents and resources must include a disclaimer to this effect. Advertising or implied endorsement for any commercial products or services is strictly prohibited.
This work may not be reproduced, reprinted, or redistributed for a fee, nor may the work be sold for profit or incorporated into a profit-making venture without the express written permission of AHRQ. This work is subject to the restrictions of Section 1140 of the Social Security Act, 42 U.S.C. §320b-10. When parts of a recommendation statement are used or quoted, the USPSTF Web page should be cited as the source.
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|Benefits of intervention||
|Harms of intervention||Inadequate evidence to determine the harms of interventions to prevent or reduce illicit drug use, with only 1 study reporting harms and 2 studies reporting an increase in illicit drug use after drug prevention interventions|
|USPSTF assessment||Evidence on the benefits and harms of primary care–based interventions to prevent or reduce illicit drug use are insufficient and the balance of benefits and harms cannot be determined|
Abbreviation: USPSTF, US Preventive Services Task Force.