Focus on Adolescent Use of Club Drugs and "Other" Substances.

Club drugs and "other" abusable substances are briefly overviewed as a reminder about the wide variety of known and unknown substances used by adolescents, the high potential for direct and interactive substance use effects to manifest acutely and chronically, and the vigilance needed to anticipate and recognize the new effects and drug-drug interactions arising as novel substances continue to be custom "designed," manufactured, and marketed to meet substance use trends. This article discusses dextromethorphan, flunitrazepam (Rohypnol), gamma-hydroxybutyrate, inhalants, ketamine, lysergic acid diethylamide, methylenedioxymethamphetamine, phencyclidine, Salvia divinorum (salvia), synthetic cannabinoids, and synthetic cathinones (bath salts).

Fetal Alcohol Research Caring for Patients with Prenatal Alcohol Exposure: A Needs Assessment.

BACKGROUND: Prenatal alcohol exposure (PAE) is the United States' most common preventable cause of birth defects and intellectual and developmental disabilities collectively referred to as Fetal Alcohol Spectrum Disorders (FASD). OBJECTIVES: This study was designed to identify gaps in pediatric providers' knowledge and practices regarding FASD patient identification, diagnosis, management and referral, and to inform needs-based FASD resource development. METHODS: Pediatric providers (pediatricians, trainees, nurse practitioners) were exposed to survey links embedded in newsletters electronically distributed to the membership of two national professional societies. Survey responses were compiled and analyzed using descriptive statistics. RESULTS: Of the 436 respondents, 71% were pediatricians and 88.2% suspected that a child in their practice could have an FASD. Only 29.2% of respondents felt "very comfortable" diagnosing or referring an individual with suspected FASD. Merely 11.5% were satisfied with their current FASD knowledge base and practice behaviour. Most respondents (89.6%) indicated online continuing education courses as preferred learning method and suggested their knowledge and practices would be best enhanced through FASD-specific diagnostic and referral checklists or algorithms, and patient education brochures and fact sheets. CONCLUSIONS: This study showed that few respondents were satisfied with their current FASD knowledge or practice behaviours. Continuing FASD education, particularly through online courses, was strongly desired. To maximize FASD recognition and optimize care for patients with FASDs, pediatric care providers must ensure that their FASD knowledge base, practice skills and provision of medical home care remain current.

Substance Use Screening, Brief Intervention, and Referral to Treatment.

The enormous public health impact of adolescent substance use and its preventable morbidity and mortality highlight the need for the health care sector, including pediatricians and the medical home, to increase its capacity regarding adolescent substance use screening, brief intervention, and referral to treatment (SBIRT). The American Academy of Pediatrics first published a policy statement on SBIRT and adolescents in 2011 to introduce SBIRT concepts and terminology and to offer clinical guidance about available substance use screening tools and intervention procedures. This clinical report provides a simplified adolescent SBIRT clinical approach that, in combination with the accompanying updated policy statement, guides pediatricians in implementing substance use prevention, detection, assessment, and intervention practices across the varied clinical settings in which adolescents receive health care.

Fetal Alcohol Spectrum Disorders.

Prenatal exposure to alcohol can damage the developing fetus and is the leading preventable cause of birth defects and intellectual and neurodevelopmental disabilities. In 1973, fetal alcohol syndrome was first described as a specific cluster of birth defects resulting from alcohol exposure in utero. Subsequently, research unequivocally revealed that prenatal alcohol exposure causes a broad range of adverse developmental effects. Fetal alcohol spectrum disorder (FASD) is the general term that encompasses the range of adverse effects associated with prenatal alcohol exposure. The diagnostic criteria for fetal alcohol syndrome are specific, and comprehensive efforts are ongoing to establish definitive criteria for diagnosing the other FASDs. A large and growing body of research has led to evidence-based FASD education of professionals and the public, broader prevention initiatives, and recommended treatment approaches based on the following premises:▪ Alcohol-related birth defects and developmental disabilities are completely preventable when pregnant women abstain from alcohol use.▪ Neurocognitive and behavioral problems resulting from prenatal alcohol exposure are lifelong.▪ Early recognition, diagnosis, and therapy for any condition along the FASD continuum can result in improved outcomes.▪ During pregnancy:◦no amount of alcohol intake should be considered safe;◦there is no safe trimester to drink alcohol;◦all forms of alcohol, such as beer, wine, and liquor, pose similar risk; and◦binge drinking poses dose-related risk to the developing fetus.

South Texas Residency Screening, Brief Intervention, and Referral to Treatment (SBIRT) Training: 12-Month Outcomes.

BACKGROUND: Screening, brief intervention, and referral to treatment (SBIRT) is an efficacious and cost-effective skill set when implemented in primary care settings regarding hazardous alcohol use. This study assesses the impact of medical resident SBIRT training across 3 specialties and identifies predictors of change in trainee behavior, attitudes, and knowledge over 12 months. METHODS: This program's substance use SBIRT training was developed and tailored to fit diverse curricular objectives and settings across an array of medical residency programs in South Texas. The 329 residents training in pediatrics, family medicine, and internal medicine during 2009-2012 constituted the trainee group reported in this analysis. Surveys assessing SBIRT-related knowledge, current practice, confidence, role responsibility, attitudes, beliefs, and readiness to change were completed by 234 (71%) trainees at 3 time points: pre-training, then 30 days and 12 months post-initial training. RESULTS: SBIRT-related knowledge, confidence, and practice increased from pre-training to 12-month follow-up. Residents who reported the least amount of pre-training clinical and/or prior academic exposure to substance use reported the greatest SBIRT practice increases. When controlling for demographic and prior exposure variables, the largest contributor to variance in SBIRT practice was attributed to residents' confidence in their SBIRT skills. CONCLUSIONS: SBIRT training that employs diverse educational methodologies as part of customizing the training to residency specialties can similarly enhance SBIRT-related knowledge, confidence, and practice. Trainee report of limited prior clinical or academic exposure to substance use and/or low confidence regarding SBIRT skills and their professional role responsibilities related to substance use predicted trainee success and sustained SBIRT strategy application. When customizing SBIRT training, curriculum developers should consider leveraging and capacity building related to those factors predicting continued use of SBIRT practices.

The role of the parent in adolescent substance use.

The overall goal of adolescent development is personal emancipation through individuation. The parent is considered an adolescent's most powerful formative influence and role model regarding health attitudes, behavioral norms, and social boundaries. For adolescents, engaging in risk-taking behaviors can be a normal maturational "rewarding" response or a strategy to cope with perceived stress and express emotions. Effective stress management is an important skill set for the developing adolescent who may experiment with a range of unhealthy strategies for coping or personal expression despite their high potential for hazardous consequences. Parenting the adolescent poses the immense challenge of promoting the adolescent's development of life skills while enabling stimulating healthy opportunities during a time of increased access and vulnerability to risky choices, including substance use. Effective parenting includes consistency, communication, respect and safety-based boundaries as well as monitoring the adolescents' friends and activities, particularly media use. Not only are parents important in deterring, suspecting, and at times detecting their adolescents' substance use, they can facilitate the evaluation or interventions that may be needed to stop substance use, start recovery, and sustain it. The role of parents is to guide adolescents in developing strengths and resilience, and fulfilling their fullest life potential.

Adolescent substance use: the role of the medical home.

Given the continued high rates of substance use by adolescents and young adults, it should be among the topics addressed at every health care visit in the medical home. Primary care physicians should counsel and refer parents for substance use assessment, counseling, and cessation management when pediatric or adolescent patients are environmentally exposed to substances and substance use. The role of the medical home includes providing parents, children, and adolescents with anticipatory guidance, drug use screening, health advice, brief intervention, and referral for further assessment and treatment when an SUD is suspected. Clinical and technical reports, policy statements, and educational materials provided by national institutes and health professional societies assist those caring for children and adolescents by assuring best practices in detailed guidance and developmentally appropriate strategies related to alcohol, tobacco, and other substance use across the pediatric age range.

A university system's approach to enhancing the educational mission of health science schools and institutions: the University of Texas Academy of Health Science Education.

BACKGROUND: The academy movement developed in the United States as an important approach to enhance the educational mission and facilitate the recognition and work of educators at medical schools and health science institutions. OBJECTIVES: Academies initially formed at individual medical schools. Educators and leaders in The University of Texas System (the UT System, UTS) recognized the academy movement as a means both to address special challenges and pursue opportunities for advancing the educational mission of academic health sciences institutions. METHODS: The UTS academy process was started by the appointment of a Chancellor's Health Fellow for Education in 2004. Subsequently, the University of Texas Academy of Health Science Education (UTAHSE) was formed by bringing together esteemed faculty educators from the six UTS health science institutions. RESULTS: Currently, the UTAHSE has 132 voting members who were selected through a rigorous, system-wide peer review and who represent multiple professional backgrounds and all six campuses. With support from the UTS, the UTAHSE has developed and sustained an annual Innovations in Health Science Education conference, a small grants program and an Innovations in Health Science Education Award, among other UTS health science educational activities. The UTAHSE represents one university system's innovative approach to enhancing its educational mission through multi- and interdisciplinary as well as inter-institutional collaboration. CONCLUSIONS: The UTAHSE is presented as a model for the development of other consortia-type academies that could involve several components of a university system or coalitions of several institutions.

A transition strategy for becoming a baby-friendly hospital: exploring the costs, benefits, and challenges.

The objectives of this study were to provide an economic assessment as well as a calculated projection of the costs that typical U.S. tertiary-care hospitals would incur through policy reconfiguration and implementation to achieve the UNICEF/World Health Organization Baby-Friendly® Hospital designation and to examine the associated challenges and benefits of becoming a Baby-Friendly Hospital. We analyzed hospital resource utilization, focusing on formula use and staffing profiles at one U.S. urban tertiary-care teaching hospital, as well as conducted an online survey and telephone interviews with a selection of Baby-Friendly Hospitals to obtain their perspective on costs, challenges, and benefits. Findings indicate that added costs for a new Baby-Friendly Hospital will approximate $148 per birth, but these costs sharply decrease over time as breastfeeding rates increase in a Baby-Friendly environment.

Cost comparison of baby friendly and non-baby friendly hospitals in the United States.

OBJECTIVES: The objectives of this study were to provide an economic assessment of the incremental costs associated with obtaining the World Health Organization and United Nations International Children's Emergency Fund designation as a Infant-Friendly hospital. We hypothesized that baby-friendly hospitals will have higher costs than similar non-baby-friendly hospitals. METHODS: Data from the 2007 American Hospital Association and the 2007 Centers for Medicare and Medicaid Cost Reports were used to compare labor and delivery costs in baby-friendly and non-baby-friendly hospitals. Operational costs per delivery were calculated using a matched-pairs analysis of a sample of baby-friendly and non-baby-friendly hospitals in the United States. Costs associated with labor-and-delivery diagnosis-related codes were analyzed for each baby-friendly hospital and compared with the mean and median costs incurred by non-baby-friendly hospitals. RESULTS: Nursery plus labor-and-delivery costs for the baby-friendly sites were $2205 per delivery, compared with $2170 for the non-baby-friendly matched pair. Baby-friendly facilities have slightly higher costs than non-baby-friendly facilities, ranging from 1.6% to 5%, but these costs were not statistically significant (P > .05). CONCLUSIONS: These results suggest that becoming baby-friendly is relatively cost-neutral for a typical acute care hospital. Although the overall expense of providing baby-friendly hospital nursery services is greater than nursery service costs of non-baby-friendly hospitals, the cost difference was not statistically significant. Additional research is needed to compare the economic impact of maternal and infant health benefits from breastfeeding versus the incremental expenses of becoming a baby-friendly hospital.

Inhalant abuse.

Inhalant abuse is the intentional inhalation of a volatile substance for the purpose of achieving an altered mental state. As an important, yet-underrecognized form of substance abuse, inhalant abuse crosses all demographic, ethnic, and socioeconomic boundaries, causing significant morbidity and mortality in school-aged and older children. This clinical report reviews key aspects of inhalant abuse, emphasizes the need for greater awareness, and offers advice regarding the pediatrician's role in the prevention and management of this substance abuse problem.

Abuse of proprietary (over-the-counter) drugs.

A predominantly overlooked type of substance abuse by adolescents and young adults in the United States and around the world is the abuse of medications and other products sold without a prescription, or over-the-counter (OTC), to the public. OTC substance abuse causes significant morbidity and mortality, and there are concerns that some types of OTC substance abuse are increasing. Regular office screening for inhalant abuse and other substance abuse and health risk behaviors must be part of standard pediatric care. This article discusses what is known about the extent and clinical impact of OTC substance abuse and reviews key points about recognition, detection, and management.

Prevalence and risk factors for hepatitis C virus infection among adolescents in detention.

OBJECTIVE: To assess the prevalence and correlates of hepatitis C virus infection in a sample of detained adolescents. DESIGN/SETTING/PARTICIPANTS: Cross-sectional prevalence study with 10- to 18-year-old adolescents who were consecutively admitted to a juvenile detention center in San Antonio, Tex. MAIN OUTCOME MEASURES: The prevalence of hepatitis C virus infection and associated risk factors. RESULTS: Of the 1002 participants, 75% were Hispanic and the mean age was 15 years. Twenty adolescents had laboratory data consistent with hepatitis C virus infection, giving an overall prevalence of 2.0% (95% confidence interval, 1.2-3.1). All adolescents infected with hepatitis C virus were Hispanic (13 boys and 7 girls). Although a high proportion of the participants reported having had intranasal drug use (55.6%), tattooing (50.5%), or body piercing (25.3%), the only factor significantly associated with hepatitis C virus infection was having a history of injection drug use. Injection drug use was reported by 5.3% of the participants but by 95% (19/20) of those infected with the hepatitis C virus. CONCLUSIONS: This study indicates that injection drug use was linked with the majority of hepatitis C virus infections in this population of detained adolescents, similar to findings in adults. These adolescents reported a high frequency of other behaviors that could potentially pose a risk for contracting bloodborne infections. Effective prevention and awareness programs in a detention setting need to be comprehensive and include screening, hepatitis A and B immunizations, and risk-reduction counseling.