Last year, I saw a teenager in the emergency department (ED). He was 15, and his mother brought him in after finding a vape in his backpack. She wanted him screened for substance use, but he wanted no part of it.

I asked him a few questions anyway. He gave short answers and stared at the ceiling while his mother watched from the doorway. No one in the room felt comfortable. I left thinking we were handling this the wrong way.

The realities of emergency department substance screening

That experience was one reason I decided to study this issue. My team recently published a national survey of 548 adolescents and 544 caregivers about their views on substance use screening in the pediatric ED. The results were eye-opening.

Less than half supported universal screening. To be specific, 43.8 percent of adolescents and 42.6 percent of caregivers thought it should be a routine part of every ED visit. About one in five adolescents were strongly against it.

Privacy was the biggest concern. Three out of four adolescents said it was a barrier, and two out of three caregivers agreed. The next worry was legal trouble. Over 60 percent of adolescents feared a positive screen could get them in trouble. More than half also said they did not trust health care staff.

These concerns are real and reflect how teenagers actually feel in the ED. The ED is busy, noisy, and unfamiliar. Staff come and go, and there is no real relationship. For a teenager, being asked about drug use in that setting, in front of a parent, by someone they do not know, can feel more like a trap than health care.

Building trust and clear communication

The data also revealed something more helpful: what actually makes a difference.

Adolescents who understood that screening was happening, and why, felt much more comfortable and were more likely to say the process helped them understand the risks of substance use. Those who felt respected during screening were also more likely to take part. Supportive health care staff and clear communication were named as key factors by 70 percent of adolescents and 74 percent of caregivers.

We can do this right now. It does not need a new protocol or extra funding. It just takes a simple sentence: “I ask all my teenage patients a few questions about drugs and alcohol. It’s part of how we look out for your health. Everything you tell me stays between us unless I’m worried about your safety.”

That one sentence covers privacy, makes the process feel normal, and starts to build trust in just a minute.

Modernizing the screening approach

There are a few more findings to mention. Adolescents preferred digital follow-up tools over brochures. An app with information about drug use and treatment options was supported by 58 percent of adolescents and 57 percent of caregivers. Brochures were the least popular. If we are still giving teenagers pamphlets, we are already behind.

Adolescents also wanted a chance to talk to a doctor alone. Not every teenager can be honest with a parent in the room. Even a short private moment during the visit, before or after the caregiver is present, can change what teenagers are willing to share.

There is a gap in care that the ED is in a unique position to fill. Many adolescents we see are not connected to primary care. They do not have a pediatrician asking these questions at regular visits. The ED might be our only chance to reach them.

The conversation does not have to be long. It just needs to be respectful, private, and clearly explained. Most adolescents will not bring up their substance use on their own. But if we ask in the right way, most will tell us the truth.

The full study is published in the Journal of the American College of Emergency Physicians (JACEP) Open.

Stephen M. Sandelich is a pediatric emergency physician.