Primary care physicians may screen adolescent patients for the use of alcohol and drugs. For those who do not use drugs or whose use is minimal, delivering a cautionary message may be sufficient. However, according to a study at a 2005 American Academy of Pediatrics meeting, fewer than half of pediatricians screen their adolescent patients for alcohol and drug use. Perhaps one of the reasons is the short time for a visit or graciously getting parents to leave the room so the physician may interview the patient. A questionnaire for screening is called the CRAFFT. This instrument has six orally administered questions, is widely accepted, easy-to-administer, and is free. According to a study by Knight et al. (2002), the CRAFFT is 80 percent sensitive with a specificity of 86 percent for abuse or dependence. Two or more answers of ''yes'' to the CRAFFT questions indicate a positive result, and points to a follow-up interview to discuss the substance abuse. The following are the CRAFFT screening questions for drug/alcohol abuse:

- C: Have you ever ridden in a CAR driven by someone (including you) who was high or had been using alcohol or drugs?

- R: Do you ever use alcohol to RELAX, feel better about yourself, or fit in?

- A: Do you ever use alcohol/drugs while you are by yourself, ALONE?

- F: Do you ever FORGET things you did while using alcohol or drugs?

- F: Do your FAMLY or FRIENDS ever tell you that you should cut down on your drinking or drug use?

- T: Have you ever gotten into TROUBLE while you were using alcohol or drugs?

When considering treatment for ADHD or SUD, the physician must consider that both of these conditions may have accompanying disorders or comorbidities. Half of all adolescents with SUD have ADHD, and pharmacotherapy is the best treatment. However, conduct disorder is even more common, and pharmacotherapy is not the best answer. For depression, which is comorbid with SUD, psychosocial intervention, behavioral therapy, family-based intervention, and medication are more effective.

When treating ADHD/SUD patients, it is best to first stabilize the SUD. If that is not feasible, pharmacotherapy for ADHD along with an emphasis on SUD may be used. Several principles guide the treating of ADHD/SUD combination:

- Because youth with ADHD may start using drugs earlier than other children, they should be educated about the dangers of substance abuse before age 11. Schools should have a role in this education, as well as parents.

- Physicians will generally try to stabilize the drug addiction before treating ADHD.

- Other conditions such as depression, conduct disorder, and anxiety must be taken into consideration when prescribing a drug for treatment. The agents such as stimulants, antidepressants, and antihypertensives are most commonly prescribed.

- Stimulants have been shown to be effective formore that 70 percent but must be watched carefully. Extended-release formulations have less potential for abuse.

- As the child grows into adolescence, substance use should be monitored closely. Counseling about the hazards of driving under the influence of drugs or alcohol is essential.

- Depending on the age of the child and the laws of the state, the child's consent may be required before screening. It is wise to get the child's consent except in cases of medical emergency. Also, the parents need to know what to do if tests are positive.

- For those who do not use drugs or whose use is minimal, a motivational counseling session is necessary. Those who cannot stop using drugs should be referred to professional counseling.

- Students who are bound for college must be warned against binge drinking; they must know that because of their ADHD, they are at risk for long-term use of alcohol or illegal drugs.

The potential for abuse of these medications is always present. The Upadhyaya et al. (2005) study of 300 college students found that those with 22 percent of those taking medications for ADHD said they had used the medication to get high, and 29 percent said they had given or sold their medication to someone else.

Bibliography:

1) Biederman, J. et al. 2006. Is cigarette smoking a gateway to alcohol and illicit drug use disorders? A study of youths with and without attention deficit hyperactive disorder. Biology Psychiatry 59:258-64.

2) Johnston, L. D. et al. ''Monitoring the Future: National Results on Adolescent Drug Use.'' 2006. Bethesda, MD: National Institute on Drug Abuse.

3) Lang, Susan. ''Study Suggests Link between Maternal Cocaine Use, Attention Dysfunction in Kids.'' June 15, 2000.

4) Knight, J. R. et al. 2002. Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Archives of Pediatric Adolescent Medicine 156:607-14.

5) Knight, J. R. et al. 2005. Barriers to Screening Teens for Substance Abuse in Primary Care. Poster presentation, Pediatric Academic Societies 2005 Annual Meeting, May 14, 2005, Washington, D.C

6) Kollins, ?S. H. et al. 2005. ADHD and smoking: From genes to behavior. Archives of General Psychiatry 62:1142-47.

7) Molina, B. S. et al. 2003. Childhood predictors of adolescent substance use in a longitudinal study of children with ADHD. Journal of Abnormal Psychology 112:497-507.

8) Upadhyaya, H. P. et al. 2005. Attention deficit/hyperactive disorder, medication treatment, and substance use among adolescents and young adults. Journal of Child Adolescent Psychopharmacology 15:799-809.

9) Wilens, T. 2004. Attention-deficit/hyperactive disorder and the substance abuse disorders: The nature of the relationship, subtypes at risk, and treatment issues. Psychiatric Clinic North America 27:283-301.

10) Wilens, T. E. et al. 2003. Does stimulant therapy of attention deficit/hyperactive disorder beget later substance abuse? A meta-analytic view of the literature. Pediatrics 111:179-85.

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