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Anxiety disorders are the most common psychiatric conditions in children and adolescents, affecting nearly 1 in 12 children and 1 in 4 adolescents. Anxiety disorders include specific phobias, social anxiety disorder, separation anxiety disorder, agoraphobia, panic disorder, and generalized anxiety disorder. Risk factors include parental history of anxiety disorders, socioeconomic stressors, exposure to violence, and trauma. The U.S. Preventive Services Task Force recommends screening for anxiety disorders in children eight years and older; there is insufficient evidence to support screening in children younger than eight years. Symptoms of anxiety disorders in children and adolescents are similar to those in adults and can include physical and behavioral symptoms such as diaphoresis, palpitations, and tantrums. Care should be taken to distinguish symptoms of a disorder from normal developmental fears and behaviors, such as separation anxiety in infants and toddlers. Several validated screening measures are useful for initial assessment and ongoing monitoring. Cognitive behavior therapy and selective serotonin reuptake inhibitors are the mainstay of treatment and may be used as monotherapies or in combination. Prognosis is improved with early intervention, caretaker support, and professional collaboration.

Background: Patients with substance use disorders (SUDs) are more likely to experience serious health problems, high healthcare utilization, and premature death. However, little is known about the contribution of SUDs to medical 30-day readmission risk. We examined the association between SUDs and 30-day all cause readmission among non-pregnant adult in-patients in the US. Methods: We conducted a retrospective study using 2010–2014 data from the Nationwide Readmissions Database. Our primary focus was on opioid use compared to stimulant use (cocaine and amphetamine) identified by ICD-9-CM diagnosis codes in index hospitalizations. Multivariable logistic regression models were used to estimate adjusted odds ratios and 95% CI representing the association between substance use and 30-day readmission, overall and stratified by the principal reason for the index hospitalization. Results: Nearly 118 million index hospitalizations were included in the study, 4% were associated with opioid or stimulant use disorder. Readmission rates for users (19.5%) were higher than for nonusers (15.7%), with slight variation by the type of substance used: cocaine (21.8%), opioid (19.0%), and amphetamine (17.5%). After adjusting for key demographic, socioeconomic, clinical, and health system characteristics, SUDs and stimulant use disorders increased the odds of 30-day all-cause readmission by 20%. Conclusions: Reducing the frequency of inpatient readmission is an important goal for improving the quality of care and ensuring proper transition to residential/outpatient care among patients with SUDs. Differences between groups may suggest directions for further investigation into the distinct needs and challenges of hospitalized opioid- and other drug-exposed patients.

Objective: The objective of this chapter is to summarize evidence-based strategies for working with adolescent patients in primary care toward making healthy decisions around substance use. Background: Substance use that progresses to substance use disorder (SUD) most often begins in adolescence and early adulthood. Although alcohol use in adolescence continues to decline, cannabis use is on the rise, as is nicotine use via e-cigarettes as well as rates of opioid-related overdose. Primary care clinicians are uniquely positioned to engage adolescent patients in substance use prevention and early intervention. Main Ideas: When discussing substance use with adolescent patients, clinicians should speak with the adolescent without their parent or guardian present and delineate the confidentiality parameters of the conversation up front. All adolescent patients, ages 12–21, should be screened annually with evidence-based screening instruments for substance use. Brief, 5–15-min interventions based on motivational interviewing principles delivered by the primary care clinician or behaviorist are effective in helping adolescents using substances who have not yet developed a SUD to make healthier choices around their substance use, for example, to cut back or quit. Adolescents screening positive for SUD should be referred to evidence-based treatment when such SUD treatment is not available within the primary care practice. Family involvement in the adolescent's SUD treatment is nearly always essential to their long-term recovery. Conclusion: Screening, brief intervention, and referral to treatment, or SBIRT, is an evidence-based model to effectively address adolescent substance use in the primary care setting.

Opioid misuse, including the use of heroin and the overprescribing, misuse, and diversion of opioid pain medications, has reached epidemic proportions in the United States. As a result, there has been a dramatic increase in opioid use disorder and associated overdoses and deaths. Addiction is a chronic brain disease with a genetic component that affects motivation, inhibition, and cognition. Patient characteristics associated with successful buprenorphine maintenance treatment include stable or controlled medical or psychiatric comorbidities and a safe, substance-free environment. As a partial opioid agonist, buprenorphine has a ceiling effect that limits respiratory depression and adds to its safety in accidental or intentional overdose. Buprenorphine and combinations of buprenorphine and naloxone are generally well tolerated; adverse effects include anxiety, constipation, dizziness, drowsiness, headache, nausea, and sedation. Family physicians who meet specific requirements can obtain a Drug Addiction Treatment Act of 2000 waiver by notifying the Substance Abuse and Mental Health Services Administration of their intent to begin dispensing and/or prescribing buprenorphine. Medication-assisted treatment with buprenorphine is as effective as methadone in terms of treatment retention and decreased opioid use when prescribed at fixed dosages of at least 7 mg per day; dosages of 16 mg per day are clearly superior to placebo. Sporadic opioid use is not uncommon in the first few months of medication-assisted treatment and should be addressed by increased visit frequency and more intensive engagement with behavioral therapies. Follow-up visits should include documentation of any relapses, reemergence of cravings or withdrawal, random urine drug testing, pill or wrapper counts, and checks of state prescription drug database records.

Background The Baylor College of Medicine SBIRT Medical Residency Training Program is a multilevel project that trains residents and faculty in evidenced-based screening, brief intervention, and referral to treatment methods for alcohol and substance use problems. Methods This paper describes the training program created for pediatric residents and provides an evaluation of the program. Ninety-five first-year pediatric residents participated in the training program. They were assessed on satisfaction with the program, self-rated skills, observed competency, and implementation into clinical practice. Results The program was successfully incorporated into the residency curricula in two pediatric residencies. Evaluations indicate a high degree of satisfaction with the program, self-reported improvement in SBIRT skills, observed proficiency in SBIRT skills, and utilization of SBIRT skills in clinical practice. Conclusions SBIRT skills training can be incorporated into pediatric residency training, and residents are able to learn and implement the skills in clinical practice.

Introduction Alcohol and tobacco use are common among U.S. women, yet if used during pregnancy these substances present significant preventable risks to prenatal and perinatal health. Because use of alcohol and tobacco often continue into the first trimester and beyond, especially among women with unintended pregnancies, effective evidence-based approaches are needed to decrease these risk behaviors. This study was designed to test the efficacy of CHOICES Plus, a preconception intervention for reducing the risk of alcohol- and tobacco-exposed pregnancies (AEPs and TEPs). Study design RCT with two intervention groups: CHOICES Plus (n=131) versus Brief Advice (n=130). Data collected April 2011 to October 2013. Data analysis finalized February 2016. Setting/participants Settings were 12 primary care clinics in a large Texas public healthcare system. Participants were women who were non-sterile, non-pregnant, aged 18–44 years, drinking more than three drinks per day or more than seven drinks per week, sexually active, and not using effective contraception (N=261). Forty-five percent were smokers. Intervention Interventions were two CHOICES Plus sessions and a contraceptive visit or Brief Advice and referral to community resources. Main outcome measures Primary outcomes were reduced risk of AEP and TEP through 9-month follow-up. Results In intention-to-treat analyses across 9 months, the CHOICES Plus group was more likely than the Brief Advice group to reduce risk of AEP with an incidence rate ratio of 0.620 (95% CI=0.511, 0.757) and absolute risk reduction of –0.233 (95% CI=–0.239, –0.226). CHOICES Plus group members at risk for both exposures were more likely to reduce TEP risk (incidence rate ratio, 0.597; 95% CI=0.424, 0.840 and absolute risk reduction, –0.233; 95% CI=–0.019, –0.521). Conclusions CHOICES Plus significantly reduced AEP and TEP risk. Addressing these commonly co-occurring risk factors in a single preconception program proved both feasible and efficacious in a low-income primary care population. Intervening with women before they become pregnant could shift the focus in clinical practice from treatment of substance-exposed pregnancies to prevention of a costly public health concern. Trial registration This study is registered at clinicaltrials.gov NCT01032772.

Background: Screening, brief intervention, and referral to treatment (SBIRT) is shown to be effective in identifying, intervening with, and making appropriate referrals for patients with unhealthy alcohol use. SBIRT training consists of knowledge-based and skill-based components and has increased the use of screening and intervention skills in clinical settings. This article reports on the development and evaluation of 2 SBIRT proficiency checklists for use across institutions to assess SBIRT skills in both simulated and clinical encounters. Methods: A national panel of 16 experts identified 137 discrete SBIRT skills items for the checklists. From this final list, 2 proficiency checklists were derived: the SBIRT Proficiency Checklist (SPC), composed of 22 questions for videotaped interviews, and the Clinical SBIRT Proficiency Checklist (CSPC), composed of 13 questions for direct clinical observation. An evaluation was conducted to test the reliability of the SPC and to assess the utility of the CSPC. Results: Two checklists for assessing SBIRT proficiency were developed by a collaborative workgroup. Fleiss’ kappa analyses indicated moderate agreement. In addition, faculty recorded satisfaction with the CSPC for assessing residents on their SBIRT performance during clinical encounters. Conclusions: The SPC and the CSPC are practical tools for assessing competence with SBIRT and are easily integrated as standard instruments in a wide range of training settings. Future advancements to the checklists and their evaluation include modification of the SPC rating scale to be consistent with the CSPC, developing a training program for using the checklists, and further testing to improve interrater reliability.

The Baylor College of Medicine SBIRT Medical Residency Training Program is a multilevel project that trains residents and faculty in evidenced-based screening, brief intervention, and referral to treatment (SBIRT) methods for alcohol and substance use problems. This paper describes the training program and provides initial evaluation after the first year of the project. The program was successfully incorporated into the residency curricula in family medicine, internal medicine, and psychiatry. Initial evaluations indicate a high degree of satisfaction with the program and, despite a slight decrease in satisfaction scores, participants remained satisfied with the program after 30 days. Implementation barriers, solutions, and future directions of the program are discussed.

Background The Screening, Brief Intervention and Referral to Treatment (SBIRT) service for unhealthy alcohol use has been shown to be one of the most cost-effective medical preventive services and has been associated with long-term reductions in alcohol use and health care utilization. Recent studies also indicate that SBIRT reduces illicit drug use. In 2008 and 2009, the Substance Abuse Mental Health Service Administration funded 17 grantees to develop and implement medical residency training programs that teach residents how to provide SBIRT services for individuals with alcohol and drug misuse conditions. This paper presents the curricular activities associated with this initiative. Methods We used an online survey delivery application (Qualtrics) to e-mail a survey instrument developed by the project directors of 4 SBIRT residency programs to each residency grantee's director. The survey included both quantitative and qualitative data. Results All 17 (100%) grantees responded. Respondents encompassed residency programs in emergency medicine, family medicine, pediatrics, obstetrics-gynecology, psychiatry, surgery, and preventive medicine. Thirteen of 17 (76%) grantee programs used both online and in-person approaches to deliver the curriculum. All 17 grantees incorporated motivational interviewing and validated screening instruments in the curriculum. As of June 2011, 2867 residents had been trained, and project directors reported all residents were incorporating SBIRT into their practices. Consistently mentioned challenges in implementing an SBIRT curriculum included finding time in residents' schedules for the modules and the need for trained faculty to verify resident competence. Conclusions The SBIRT initiative has resulted in rapid development of educational programs and a cohort of residents who utilize SBIRT in practice. Skills verification, program dissemination, and sustainability after grant funding ends remain ongoing challenges.