The enormous public health impact of adolescent substance use and its preventable morbidity and mortality highlight the need for the health care sector, including pediatricians and the medical home, to increase its capacity regarding adolescent substance use screening, brief intervention, and referral to treatment.
Using SBIRT, which stands for Screening, Brief Intervention, and Referral to Treatment, is an evidence-based practice used to help identify when problems exist, according to Dr. Louise Stanger, who specializes in Parent Coaching at Paradigm Treatment Centers.
“Adolescence is a time of change, searching and often experimentation,” Dr. Stanger noted. “One of our best allies to help behavioral health professionals, such as myself, and to help parents in terms of screening for substance abuse and other problems is a family’s pediatrician. Most schools require a yearly physical and when your teen is ill they are the go-to person.”
In Dr. Stanger’s own family, “my children never wanted to stop seeing their pediatrician. He was helpful in identifying medical issues, such as thyroid disease substance use within my family, and helped us with treatment when one of our daughters was experimenting with substance abuse.”
The following research article offers, in part, how helpful it is for physicians to use this in their practices, “and it is good for parents to know such a helpful early intervention screening exists,” Dr. Stanger said.
Screening is a procedure applied to populations to identify individuals or groups at risk of or with a disease, condition, or symptoms. Screening is conducted so that the results can form the basis for a corresponding care plan. The best screening tools are those containing the lowest number of succinct validated questions that can elicit accurate and reliable responses. Comprehensive bio-psychosocial screening, including substance use screening, is a recommended component of routine adolescent health care.
The SBIRT screening goal is to define experience with substance use along a spectrum ranging from abstinence to addiction so that this information can be used to guide the next steps of the related clinical approach, or intervention. Screening results broadly inform clinical care: for example, alcohol and drug use may be the source of a presenting symptom or may interfere with prescribed medications and test results. The management of inattentiveness would be different if the physician learned that the patient used marijuana (a possible cause) or a stimulant drug (a prescribing risk). Awareness about the range of possible screening results allows the pediatrician to be prepared to address the range of potential patient responses.
Brief intervention is a conversation that focuses on encouraging healthy choices so that the risk behaviors are prevented, reduced, or stopped. In the context of SBIRT, regardless of which substance use screening tools are used, the brief intervention strategy is identical, because it is a direct response to the reported substance use severity. Brief intervention encompasses a spectrum of potential pediatrician responses, including positive reinforcement for adolescents reporting no substance use; brief, medically based advice for those reporting use but showing no evidence of a substance use disorder; brief motivational interventions when a mild or moderate substance use disorder is revealed; and referral to treatment of those with a severe substance use disorder. Using motivation-enhancing principles is compatible with all brief intervention dialogue regarding any level of substance use and risk.
Referral to Treatment
Referral to treatment describes the facilitative process through which patients identified as needing more extensive evaluation and treatment are able to access the appropriate services. Historically, medical encounters have been notably poor in identifying adolescents who have severe substance use disorders and connecting them with treatment. The Substance Abuse and Mental Health Services Administration has estimated that fewer than 10% of adolescents in need of specialty substance use treatment receive it, and the majority of referrals are from the justice system.
Deciding where to refer an adolescent in need of treatment is often complicated by limited treatment availability, insurance coverage complexities, and preferences of the adolescent and family. In most cases, pediatricians will refer adolescents with substance use disorders to a mental health or addiction specialist to conduct a comprehensive bio-psychosocial assessment and to determine the appropriate level of care from the treatment spectrum, ranging from outpatient substance use counseling to long-term residential treatment programs.
Optimal Standards for a Substance Use Disorder Treatment Program
The following were adapted from the Substance Abuse and Mental Health Services Administration and Center for Substance Abuse Treatment standards into optimal goals for inpatient or outpatient substance use disorder treatment programs serving the pediatric population. The program will:
- View drug and alcohol use disorders as a primary disease rather than a symptom.
- Include a comprehensive patient evaluation and a developmentally appropriate management and treatment referral plan for associated medical, emotional, and behavioral problems identified.
- Maintain rapport with the patient’s pediatrician to facilitate seamless after-care and primary care follow-up.
- Adhere to an abstinence philosophy and consider continued drug use as an indication for more treatment rather than for discharge. Substance use disorder is a chronic disease, and a drug-free environment is essential. Tobacco use should be prohibited, and nicotine cessation treatment should be provided as part of the overall treatment plan. The continued use of tobacco, alcohol, or other drugs should be viewed as a need for more treatment rather than discharge or refusal to treat.
- Maintain a low patient-to-staff ratio.
- Use treatment professionals who are knowledgeable in both addiction treatment and child and adolescent behavior and development.
- Maintain separate treatment groups for individuals at varying developmental levels (adolescents, young adults, and older adults).
- Involve the entire family in the treatment and relate to the patients and their families with compassion and concern. Programs located as close to home as possible are preferable to facilitate family involvement, even though separation of the adolescent from the family may be indicated initially.
- Offer patients an opportunity to continue academic and vocational education and assistance with restructuring family, school, and social life. Consider formal academic and cognitive skills assessment, because unidentified weaknesses may contribute to emotional factors contributing to the substance use.
- Keep the family apprised of costs and financial arrangements for inpatient and outpatient care and facilitate communication with managed-care organizations.
- Ensure that follow-up and continuing care are integral parts of the program.
If you are worried about your teen and want help, call Dr. Stanger at 619-507-1699.