Substance Use Screening, Brief Intervention, and Referral to Treatment

Background

Substance use has an enormous direct and indirect public health impact on children and teenagers, ranging from prenatal exposure and complicated pregnancy outcomes to significant morbidity and mortality among adolescents and, over time, contributing to the development of many other health problems and substance use disorders. Pediatricians play a vital longitudinal role in the lives of adolescents and are uniquely positioned to effect change in adolescent patients’ health knowledge, behaviors, and well-being. Guidance about substance use can be provided in many forms: preventing or delaying the onset of substance use in lower-risk patients, discouraging ongoing use and reducing harm in intermediate-risk patients, and referring patients who have developed substance use disorders for potentially life-saving treatment.

The recommendations in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents¹ highlight the pediatrician’s unique role in addressing health behavior problems throughout adolescence. Because most adolescents (83%) have contact with a physician annually, consider physicians an authoritative source of knowledge about alcohol and drugs, and are receptive to discussing substance use, medical care encounters are tremendous opportunities for addressing substance use.^2,3 The Substance Abuse and Mental Health Services Administration recommends universal screening for substance use, brief intervention, and/or referral to treatment (SBIRT) as part of routine health care.² Adolescents are the age group at greatest risk of experiencing substance use–related acute³ and chronic⁴ health consequences and, as such, also are most likely to derive the greatest benefit from universal SBIRT. Specific SBIRT screening tools and intervention strategies have well-documented efficacy for adult alcohol use, but fewer studies of SBIRT efficacy have been conducted in adolescents.^5–7 On the basis of a review of the limited research literature available in 2014, the US Preventive Services Task Force concluded that the evidence was insufficient to assess the efficacy of brief interventions to reduce adolescent substance use.^8,9 Despite this early conclusion, the low cost of SBIRT, minimal potential for harm, and emerging study results together support the tremendous potential for a population-level benefit from even small reductions in substance use and provide sufficient basis for the incorporation of SBIRT practices into the medical care standards for adolescents. The accompanying clinical report¹⁰ contains clinical guidance for pediatricians and other clinicians who provide health care for adolescents.

Recommendations

The American Academy of Pediatrics recommends that pediatricians:

• increase their capacity in substance use detection, assessment, and intervention; and

• become familiar with adolescent SBIRT practices and their potential to be incorporated into universal screening and comprehensive care of adolescents in the medical home.

The American Academy of Pediatrics advocates for:

• the strong support of continued research to determine the most effective brief intervention strategies applicable to adolescent health care,

• health insurance providers to:

  • promote and pay for standard screening and brief intervention practices incorporated into medical home health maintenance appointments; and

  • ensure a standard mechanism for payment for confidential follow-up care of adolescents to receive continuity of care for substance use disorders; and

• parity of access and services for adolescent mental health and substance use disorder treatment compared with general adolescent care and adult health care.

Lead Authors

Sharon J.L. Levy, MD, MPH, FAAP

Janet F. Williams, MD, FAAP

Committee on Substance Use Prevention, 2015–2016

Sheryl A. Ryan, MD, FAAP, Chairperson

Pamela K. Gonzalez, MD, MS, FAAP

Stephen W. Patrick, MD, MPH, MS, FAAP

Joanna Quigley, MD, FAAP

Lorena Siqueira, MD, MSPH, FAAP

Leslie R. Walker, MD, FAAP

Former Committee Members

Sharon J.L. Levy, MD, MPH, FAAP

Janet F. Williams, MD, FAAP

Liaisons

Vivian B. Faden, PhD – National Institute of Alcohol Abuse and Alcoholism

Gregory Tau, MD, PhD – American Academy of Child and Adolescent Psychiatry

Staff

Renee Jarrett, MPH