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Continued Decline in Youth Substance Abuse

Current illicit drug use among teens is continuing to decline, according to a new report by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) released today. The study also shows positive signs that teens are seeing the dangers of abusing prescription drugs and methamphetamine and are pushing back. Among youth ages 12-17, the 2007 National Survey on Drug Use and Health (NSDUH), the Nation's largest substance use survey, shows that the significant decline in overall past month illicit drug use that began in 2002 continued through 2007, from 11.6 percent to 9.5 percent.

The survey, released at the start of the 19th Annual National Alcohol and Drug Addiction Recovery Month, shows that the reductions in youth drug use occurred for nearly every type of illicit drug including marijuana, cocaine, hallucinogens, LSD, and Ecstasy. The survey also shows dramatic declines in meth use, down by 67 percent (from 0.3% to 0.1%) and prescription drug abuse among teens, which declined overall by 18 percent, from 4 percent to 3.3 percent between 2002-2007.

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The Clinician-Patient E-mail Dilemma

Columns - On the Web

Monday, 30 September 2002

Early one morning, you check your email to find this message from a longtime patient: I'm sorry I missed our last appointment. I relapsed last month after almost six months. I'm clean now - back at my meetings - and I'd like to reschedule an appointment.

This message contains basic information that we would record if we had heard it orally from the patient in the office. He missed an appointment, relapsed, and states that he is now clean and attending AA again. I don't think any of us have a problem printing out the message and placing it into the medical record. Imagine that in the same e-mail session, you find this message: I slipped again. I haven't slept in days and with all the cocaine I've been doing, you know how I feel now. I was doing so well, but when the fellow downstairs, you know the guy - John Smith, got a new shipment in, I just couldn't stop myself. I got some money over at the Shell station and was back before I knew it. I know I need help but I just can't stop.

This time, the e-mail implicates the patient in several ways. By his own statement, he has been using cocaine, an illegal activity. We generally record a patient's use of cocaine, but in our words, not his. This fellow also obtained money at the Shell station. How? Was there an ATM there? Or did he steal it? If there was a crime committed at the Shell station that night, and if your patient was responsible, should you be the route by which he becomes a suspect? If you keep the e-mail, it may eventually come to light during routine copying for insurers, or perhaps as the result of a court order. Does it alter the likelihood that patients will be forthcoming with their clinicians if we save every word they say or write? How does this differ from audiotaping each patient session and saving the tape with the medical record? As an aside, John Smith is also implicated as being a cocaine dealer. Here in your small town, John Smith may somehow find out that your patient fingered him no matter how cautious you are with the record. Is placing the e-mail into the medical record worth the possible repercussions? What would you do?

There has been healthy discussion within most professional organizations regarding clinician-patient e-mail. The New York Times has even run a feature story detailing some of the pros and cons of such communication. At its meeting this June, the American Medical Association passed new wording altering its recommendations to physicians as to how they should handle e-mail with patients.

Within the first AMA policy for clinician-patient e-mail, written over two years ago, one recommendation read that each e-mail message "may be included as part of the medical record, at the discretion of the physician." This policy had been worded quite specifically for a number of reasons. It was felt that most people treat email as an informal communication more comparable to a hallway discussion than a certified letter. It was known that e-mails tend to stray from the topic at hand to include anything that comes to mind during the composition. It was pointed out in the development of the original policy that patients often included information irrelevant to the clinical question, to the diagnosis, or to the treatment. From a privacy standpoint, it was therefore felt that the decision as to whether to keep the e-mail message as part of the medical record should lie with the counselor/physician, already charged to protect the patient's privacy.

Shortly after the policy was passed, two important events took place. The first was the trial involving Microsoft, which turned on occasion with the finding of various e-mails that had been kept on a hard drive much to Microsoft's chagrin. This led some to assume that all e-mails between individuals can be recovered, not realizing that the vast majority of e-mails between two people disappear from all storage devices within a matter of weeks. The second event was a more chronic one, the rapidly worsening liability crisis in which jury awards for malpractice findings have risen so fast that some physicians are no longer able to afford or even find malpractice liability coverage. It was recognized that virtual copies or printouts of e-mail communications might be obtained by either party, or might have been saved by either party. Given that a patient might be obtaining or retaining such copies, it was felt that the treatment professional could reduce potential liability by retaining copies as well.

Within this environment, the AMA's Council on Medical Service put forward a report, passed by the AMA in 2001, which altered the e-mail policy to read that, "Whenever possible, electronic and/or paper copies of patient e-mails and corresponding responses will be retained as part of the patient's medical record." Advocates for the new wording successfully argued that the phrase, "Whenever possible," gave physicians the right to exclude inappropriate material. Opponents had argued that phrase would simply refer to potential technological limitations. That is, if the technology existed to print an e-mail, it was clearly possible to include that e-mail within the record.

Six months later, the AMA was offered replacement wording: At the physician's discretion, electronic and/or paper copies of patient e-mails and corresponding responses will be retained or summarized as part of the medical record. This essentially returned discretion clearly to the physician, but eliminated the possibility of excluding all signs of any one e-mail. At the least, each e-mail was to be summarized, much as phone calls have to be summarized within the record. The AMA did not pass this new wording, instead choosing for the entire affair to be referred to the AMA's Board of Trustees for a decision. This decision would then be returned to the AMA House of Delegates for a vote.

Finally, this June, the AMA passed the new wording brought them by the Trustees, a compromise between the two sides: Whenever possible and appropriate, physicians should retain electronic and/or paper copies of e-mail communications with patients. This new language allows physicians to retain some discretion with respect to whether to retain each e-mail.

As counselors, let me know if the new AMA policy will alter your plans as to what to do with e-mails you receive from patients. Do you think the new policy is appropriate to apply to allied healthcare professionals as well? What would you do with an e-mail such as the second one in this column?

Stuart Gitlow, MD, MPH, is the author of Substance Use Disorders: A Practical Guide, from Lippincott Williams & Wilkins. He is Vice-Chair of the American Medical Association's eMedicine Advisory Committee. He writes and speaks frequently on both topics.