Week 7 Part 3-Literature Review and Critical Appraisal

Substance abuse refers to the hazardous and harmful use of psychoactive substances, including illicit drugs and alcohol. Substance abuse is also defined as the sporadic or persistent use of drugs that are not in line with or are unrelated to the accepted use of medication. More than 1.3 million adolescents aged 12 years to 17 years are diagnosed with substance use disorder in the United States (Coleman, 2018). Tobacco initiation often occurs in the adolescent stages of life. There is also an increased acceptance of the use of alcohol in social settings. The impact of substance use and abuse among adolescents includes involvement in risky behaviors such as crime, unprotected sex, and driving under drug influence. The health of adolescents using drugs is also affected, where they may have changes in cognitive ability and brain development. Memory problems and suicide are high among adolescents who use and abuse drugs. Therefore, substance abuse is associated with reduced life expectancy, suicides, accidents, mental disorders, unemployment, and poor health (Das et al., 2016). Hence, there is a need to take approaches and initiatives which reduce the negative effects and prevalence of substance abuse among adolescents. The purpose of this work is to evaluate the use of the CRAFFT tool as a method to improve the screening of adolescents in a rural care setting.

Problem Statement

Substance abuse among adolescents is a major public health concern not only in urban cities but in rural areas as well. Primary care nurses in rural areas lack the skills and knowledge in substance abuse screening (Lynch, 2020). Early screening and subsequent detection of the possible use of drugs and alcohol helps in directing patients to access the right healthcare services (Levy & Williams, 2016). Adolescence is a challenging time for most persons in this age category, and this can be further complicated by substance abuse (Radel et al., 2018). When healthcare providers are left to their discretion on screening for substance abuse, they will often fail to do so (Lynch, 2020). Screening does not take place as often as it ought to be done despite the recommendations by professional guidelines for substance abuse screening (D’Amico et al., 2016). In the current research, education for nurses on the use of the CRAFFT screening tool and how the tool is applied in clinical practice for adolescent populations will be the focus.

The research has the potential to impact the nursing practice through empowering nurses, as stated earlier. Pre-licensure nurses are inadequately prepared for effective patient substance abuse screening. Most academic programs have a 1–5-hour session of instruction that focuses on substance abuse in patients with infrequent teaching of skills necessary for addressing patient substance abuse (Knopf-Amelung et al., 2018). Therefore, nurses, upon graduating, are ill-equipped, and this calls for researches such as this that seek to empower RNs. When RNs gain important and valuable information and also understand the need and their role to help reduce the frequency of substance abuse among adolescents, then the war against this epidemic will be fast won.

The research seeks to fill the gap created by practice settings in rural areas where adolescent patients are not screened for substance abuse because of the nurses’ failure to do so. Several factors have been identified as contributing to the existence of this gap, and these include lack of referral places; inadequate training; refusing or assuming to discuss the issue of substance abuse that is, denial of its existence; and time constraints, among others (D’Amico et al., 2016). When nurses lack the necessary training on substance abuse, their understanding and confidence is greatly hindered as to how they can integrate into their daily practice, drug and alcohol abuse screening (KnopfAmelung et al., 2018).

Project Purpose Statement

The purpose of the project is to evaluate a method or tool to improve the screening of adolescents using and abusing drugs in a rural care setting. The project’s objective is to assess nurses’ knowledge and the screening efficiency of substance use adolescents before and after implementation or use of the CRAFFT screening tool.

Background and Significance

In the United States, about 9.4 % of the adolescent population use and abuse drugs (Coleman, 2018). The trend shows that the number of adolescents using marijuana, alcohol, and stimulants such as methamphetamine, cocaine, heroin, and hallucinogens increases each year (Coleman, 2018). Substance abuse is associated with reduced life expectancy, suicides, accidents, mental disorders, unemployment, and poor health (Das et al., 2016). Substance abuse among adolescents increases both societal and healthcare costs. A lot of money is spent on the treatment of addicts and on controlling illicit drugs. The United States uses more than $740 billion each year to deal with drugs and substance abuse (Coleman, 2018). The trends in substance use and abuse among youth are a concern, especially in the rural areas, which seem to be neglected. The involvement of nurses is essential in dealing with the problem of drugs and substance abuse among adolescents. Adolescents should be screened for substance use at least once a year for proper intervention to be implemented to deal with the problem.

The CRAFFT tool is one of the tools that can be used to screen substance abuse in adolescents. CRAFFT, as a screening tool, stands for C-car, R-relax, A-alone, F-forget, F-friends, and T-trouble (Coleman, 2018). The tool has been tested in the primary care setting, where it was more effective in identifying adolescents on substance use than other tools (Coleman, 2018). The tool uses short questions, is cheap, and is also flexible. Using the CRAFFT screening tool can increase the number of adolescents identified using drugs for necessary action (Coleman, 2018). The project is innovative in that it identified a tool that saves time for adolescents, something most adolescents prefer. The tool also offers privacy as it can be used electronically or in the form of paper. The tool is also evidence-based as there is enough evidence on the use of the tool. The project will help in coming up with the best substance abuse screening tool and the best way to implement the tool to improve the outcomes.

PICOt formatted Clinical Project Question

The target population will be rural nurses who will implement the use of the CRAFFT tool as the nursing intervention. The implementation of the CRAFFT tool will be compared to its prior implementation. The outcome that will be used to evaluate the tool is the improvement of nurses’ knowledge and the screening efficiency among adolescents. The time frame for the study will be six months. The PICOT question is: Among rural nurses (P), does the implementation of the CRAFFT tool (I) at a rural health care setting, compared to prior to the implementation of the tool (C) improve the nurses’ knowledge (O), as well as increase screening efficiency among adolescents over a six-month period (T)?

Literature Review

The purpose of the research was to evaluate a method or tool to improve the screening of adolescents using and abusing drugs in a rural care setting. To find the literature related to the topic, keywords were first developed, which helped in searching for evidence-based articles related to the topic. The keywords established included adolescent health, drug abuse, substance use, substance use disorders, substance use screening, nursing intervention, and CRAFFT screening tool. The keywords were keyed in the Pub Med search engine to give related articles. The number of bolded keywords in the heading, and the content of the articles determined the article to be used for literature review. Articles with the highest number of bolded key words in the headings and content were selected. The years of the article were filtered to an article within the last five years. Therefore the research used the latest information. The articles also had to be scholarly articles.

The search engine generated 20 articles related to the topic, but five articles were selected. Number of key words in the article, publication year, and academic field of the article guided in selection of five articles. Articles with most key words, published within the last five years and published within the nursing or medical field were selected. The five articles acknowledged that substance abuse among the youth is a problem that can be addressed through proper screening methods. CRAFFT screening tool was mentioned as one of the best tools for screening substance abuse among adolescents to develop the best interventions for preventing drugs and substance abuse.

Article one: Adolescent Substance Abuse Screening

Lynch (2020), in his work, focused on how nurses could implement the CRAFFT tool to detect and screen substance use among adolescents early. The research was done in rural Ohio, where primary nurses were used as participants (Lynch, 2020). The research was both qualitative and quantitative with a pretest-posttest design. 7 nurses working in a rural psychiatry unit were used in the study. Training or education on the CRAFFT tool was done before subjecting the nurse to pretest and posttest evaluation (Lynch, 2020). The study found that training on the CRAFFT tool improved pretest and posttest scores when screening adolescents (Lynch, 2020). However, the results of the study are not reliable since only a small sample of seven nurses was used, which cannot represent other areas.

Article two: The best way to identify youths at risk for substance use

D’Amico et al. 2016 in their study compared various screeners used to screen youths for marijuana and alcohol abuse. The researchers compared 4 screeners, which included the CRAFFT tool, the Alcohol Use Disorders Identification Test, the National Institute on Alcohol Abuse and Alcoholism Screening Guide, and the Personal Experience Screening Questionnaire Problem Severity Scale (D’Amico et al., 2016). The study used youth aged between 12 and 18 years, where 1573 Hispanic and black youths were used. The researchers found out that the Personal Experience Screening Questionnaire Problem Severity Scale and CRAFFT tool correctly identified more youths at risk for abusing marijuana and alcohol (D’Amico et al., 2016). The results were valid as they focused on specific populations. Using a large sample of both Hispanics and blacks made the results reliable as they can be applied in other areas.

Article Three: Use of the CRAFFT tool in screening substance use

The purpose of the article by Coleman (2018) was to evaluate the effectiveness of the CRAFFT tool when used to assess substance use among the pediatric population in a care setting. CRAFFT screening tool was used to improve practice where documentation was used to review the outcomes before administration of the tool and after use of the tool (Coleman, 2018). The study was descriptive, where electrical medical records were reviewed in pre-phase and post-phase. 200 records were reviewed, 100 in the pre-phase and 100 in the post-phase. It was found that implementation of the CRAFFT tool improved screening, as seen from the review of records (Coleman, 2018). The research is both valid and reliable as it reviewed existing records in the healthcare facility.

Article Four: Implementation of the CRAFFT Cannabis Screening Tool

The article focused on the implementation of the CRAFFT tool along with DSM-IV’s diagnostic procedure in screening. The study was descriptive, where 10 healthcare providers were used as evidence for the implementation of the CRAFFT tool (Loeprich, 2018). The study found that providers preferred to use the CRAFFT tool to assess substance use disorder. The use of only 10 participants made the research unreliable as it cannot be used to represent other areas (Loeprich, 2018). Participants were aware of the intended outcomes, making them change their responses during the research, which altered the validity of the research.

Article Five: Substance use screening and rates of treatment referral among justice-involved youth

The rate of substance abuse is high among youth, and therefore need to solve substance abuse-related problems. According to Yurasek et al. (2021), early screening is essential in dealing with the problem of substance abuse (Yurasek et al., 2021). The study was descriptive where it used 348 youths who received CRAFFT screening and MAYSI-2 alcohol or drug use subscale (Yurasek et al., 2021). The study found that the CRAFFT tool was more accurate in identifying youths at risk of drug abuse. The results were not valid as the study was prone to biases. The treatment referral in the research was low, making the result unreliable.

Critical Appraisal of Literature

Strengths and Weaknesses

The strength of the first article by Lynch (2020) is that it gives one of the best interventions for implementing the CRAFFT tool, which is the education and training of nurses. The weakness is that it uses only 7 participants; hence, it cannot be used to make conclusions in other areas. The strength of the second article is that it compares the CRAFFT tool with other tools to identify the best tool. Its weakness, however, is that it focused only on a specific age group of youth, leaving out the other population. The third article’s strength was that it evaluated the effectiveness of the CRAFFT tool when used to screen youth. However, the article only focused on documentation which can be altered instead of focusing on the real practice. The fourth article analyzed the use of the CRAFFT tool by medical practitioners, which is important. The low number of participants was the weakness of the article. In the fifth article, the researchers tried to compare two tools to identify the best which is good for the selection of the best tool. Using only two tools for comparison could not give valid results for using the CRAFFT tool as the best screening tool.

Knowledge Gained from Review

Substance abuse among youth is increasing, leading to the need to come up with interventions to reduce the rate of substance abuse. Early screening and detection of substance abuse are essential in dealing with the issue. The CRAFFT tool is one of the best tools for screening adolescents at risk of abusing drugs. Other interventions should be implemented together with the CRAFFT tool. Staff training and education on the use of CRAFFT tools lead to desired outcomes. Proper documentation is also essential in evaluating the success of using the CRAFFT tool.

Gaps in Knowledge

There are some gaps in existing evidence on the use of the CRAFFT tool to screen substance abuse. One of the gaps is that most of the research on screening methods are shallow. Studies use a small number of participants, making it hard to draw general conclusions using the results. Most studies also compare a few tools. Research studies should be comprehensive and should use participants in various parts of the country or healthcare facilities. Studies should also ensure that participants do not alter their behaviors or responses by using a longitudinal research design.

Conclusion

There is enough evidence indicating the use of the CRAFFT tool in screening substance abuse. Literature on substance abuse indicates that early detection of those at risk helps to solve the problem of drug abuse by implementing early interventions. The CRAFFT tool, compared to other methods, leads to better outcomes when used to screen youth at risk of abusing drugs. However, other interventions, such as education, should accompany the implementation of the CRAFFT tool based on existing evidence. Early detection of youth at risk of substance abuse using the CRAFFT tool helps to reduce the effects of substance abuse among youths.

References

Coleman, L. (2018). Evaluation of the CRAFFT Substance Use Screening Tool in Primary Care.

D’Amico, E. J., Parast, L., Meredith, L. S., Ewing, B. A., Shadel, W. G., & Stein, B. D. (2016). Screening in primary care: what is the best way to identify at-risk youth for substance use?. Pediatrics, 138(6).

Das, J. K., Salam, R. A., Arshad, A., Finkelstein, Y., & Bhutta, Z. A. (2016). Interventions for adolescent substance abuse: An overview of systematic reviews. Journal of Adolescent Health, 59(4), S61-S75.

Knopf-Amelung, S., Gotham, H., Kuofie, A., Young, P., Stinson, R. M., Lynn, J., … & Hildreth, J. (2018). Comparison of instructional methods for screening, brief intervention, and referral to treatment for substance use in nursing education. Nurse Educator, 43(3), 123.

Levy, S. J., & Williams, J. F. (2016). Substance use screening, brief intervention, and referral to treatment. Pediatrics, 138(1).

Loeprich, B. L. (2018). Implementation of the CRAFFT Cannabis Screening Tool (Doctoral dissertation, Walden University).

Lynch, W. (2020). Adolescent Substance Abuse Screening(Doctoral dissertation, Walden University).

Radel, L., Baldwin, M., Crouse, G., Ghertner, R., & Waters, A. (2018). Substance use, the opioid epidemic, and the child welfare system: Key findings from a mixed methods study. Office of the Assistant Secretary for Planning and Evaluation, 1-9.

Yurasek, A. M., Kemp, K., Otero, J., & Tolou-Shams, M. (2021). Substance use screening and rates of treatment referral among justice-involved youth. Addictive behaviors, 122, 107036.