Study reveals bias in substance use screening for injured adolescents

Injured adolescents from marginalized groups treated at pediatric trauma centers are more likely to be tested for drugs and alcohol than white adolescents, even when accounting for injury severity, a study led by researchers at UCLA and Children's Hospital Los Angeles suggests.

The findings, to be published October 4 in the peer-reviewed JAMA Network Open, suggest that clinician biases could influence the selection of adolescents for biochemical substance use screening at pediatric trauma centers, said Dr. Jordan Rook, a general surgery resident at the David Geffen School of Medicine at UCLA and the study's lead author. These inequitable screening patterns may lead to stigmatization and perhaps even legal implications for some injured adolescents.

While screening can positively affect patients if it is followed by counseling and treatment, it can also lead to negative consequences. We believe that existing guidelines on substance use screening may be inadequate to achieve equitable high-quality screening in adolescent trauma care. Stricter guidance and oversight and/or the implementation of universal screening protocols and equitable utilization of support services may be needed."

Dr. Jordan Rook, general surgery resident, David Geffen School of Medicine at UCLA 

The researchers used data from the 2017-2021 ACS Trauma Quality Programs for 85,400 adolescent trauma patients ages 12 to 17 years-old from 121 pediatric trauma centers. Of those adolescents, 67% were white, 82% were non-Hispanic, 72% were male, and 51% had private insurance.

Of the total number of adolescents, 25% were tested for alcohol and 22% were tested for drugs. Overall, American Indian, Black, Hispanic, female, Medicaid-insured, and uninsured adolescents were more likely to be screened for both alcohol and drugs, the researchers found.

Among the findings:

• For Black adolescents, the odds of alcohol and drug screening were 8% and 13% higher, respectively, than for white adolescents.
• For American Indian adolescents, the odds of alcohol and drug screening were 117% and 75% higher, respectively, than for White adolescents.
• For Hispanic adolescents, the odds of alcohol and drug screening were 20% and 12% higher, respectively, than for White adolescents.
• For female adolescents, the odds of alcohol and drug screening were 32% and 28% higher, respectively, than for males.
• For adolescents insured by Medicaid, the odds of alcohol and drug screening were 15% and 28% higher, respectively, than for adolescents with private insurance.

The authors note that there are some limitations to the study. The data the authors used do not describe if the tests resulted in treatment or intervention, so it was unclear if the benefits of the screenings outweighed any potential harms. Additionally, the data includes only biochemical screening tests and not interview-based screenings, thus underestimating overall screening rates.

The researchers are conducting more studies expanding on these findings to identify potential solutions to the inequities, Rook said. Using national data, they are studying whether individual hospital practices decrease screening disparities, and they will also examine the accuracy and effectiveness of interview-based screening versus biochemical screening.

"These efforts all seek to equitably increase substance use screening and support services for all adolescents," Rook said.

The study senior author is Dr. Lorraine Kelley-Quon of Children's Hospital Los Angeles and the University of Southern California. Additional co-authors are Dr. Catherine Juillard of UCLA; Dr. Ryan Spurrier, Dr. Cathy Shin of Children's Hospital Los Angeles and the University of Southern California; Dr. Christopher Russell of Stanford University; and Dr. Steven Lee of Seattle Children's Hospital.

The study was funded by the VA Office of Academic Affiliations through the National Clinician Scholars Program Fellowship, the Association for Academic Surgery Clinical Outcomes and Health Services Research Award, and a National Center for Advancing Translational Sciences UCLA CTSI Grant (UL1TR001881).