Adolescent alcohol and drug use is a public health concern and a major contributor to health problems among youth, including smoking, at-risk sexual behavior, impaired driving, depression, low academic achievement, delinquency, and violence.289, 290, 291, 292, 293, 294, 295 Adolescents who drink are at higher risk for developing substance abuse disorders later in life, with risk increasing as age of initiation of alcohol use decreases.293, 296, 297, 298, 299, 300, 301, 302, 303 The prevalence of adolescent SUDs is 8 percent,304 and more than double that, 19 percent, among adolescents who have ever used alcohol or drugs.269, 289 Some research indicates that alcohol SBI is effective as an early identification and prevention approach to reducing underage drinking294, 305, 306, 307, 308 and use of substance.309, 310, 311, 312 But studies are inconsistent and effect sizes are small.313 Over the last 15 years, national and international public health agencies and medical professional associations including the U.S. Surgeon General,293 the NIAAA,314 the WHO,133 the American Medical Association,315 the HRSA Maternal Child Health Bureau, Bright Futures,316 and the American Academy of Pediatrics292, 317 have called for adolescent health care providers to routinely screen adolescents for alcohol and drug use and to provide brief preventive and early intervention counseling. However, the USPSTF has so far concluded that the current evidence is insufficient to assess the balance of benefits and harms of SBI among adolescents in primary care.
Fewer than half of pediatricians systematically screen adolescents for alcohol or other drugs,240 citing as barriers lack of time, inadequate reimbursement, lack of training, and uncertainty about referral sources.240, 318 Few adolescents who already meet the criteria of a SUD or who use substances in high-risk manners are identified early or receive treatment they could benefit from. The National Survey on Drug Use and Health304 finds that only 7 percent of adolescents who could benefit from treatment for their SUDs actually get that care.
Using the five dimensions of the CFIR model, we systematically evaluated the research on integrating alcohol and drug screening, brief intervention, and treatment into primary care practice. Few studies of adolescent substance use SBI have been conducted in FQHCs. The previous CFIR analyses of barriers to and facilitators of adult SBI likely hold for adolescents, but some specifics will be highlighted.
The source of the innovation, the strength and quality of the evidence supporting it, the relative advantages the innovation provides, and its adaptability, trial-ability, complexity, design quality and packaging, and cost.
School-based health centers and other PCPs who treat adolescents are more likely to adopt SBI if the clinician perceives the intervention as: (a) having a strong theoretical foundation and clear conceptual basis for interpreting normative and non-normative patterns of adolescent development; (b) including strong research backing; (c) providing accurate knowledge regarding development, maintenance, and consequences of problem behaviors as well as developing adolescent skills and competencies that can replace targeted behaviors and protect students from their onset; (d) combining psycho-education and skill building; (e) optimizing timing, duration, frequency, and intensity of interventions, with early exposure prior to the onset of the target problem; (f) fitting into the education goals of schools or practice goals of health care providers; (g) maintaining fidelity through manualization and ongoing monitoring; (h) standardizing intervention delivery techniques for the staff; (i) involving teachers or primary care clinicians in adapting SBI to their unique environments; (j) designing materials and program components to engage youth; (k) using non-school personnel to facilitate acceptance and fit; and (l) ensuring that interventions are age-appropriate and developmental-stage-appropriate (i.e., abstinence for younger adolescents, binge drinking hazard reduction for older adolescents, and exclusively alcohol use for late adolescents and young adults).319, 320, 321
In school-based health centers319 and in rural322 and urban primary care practices,308 computer-assisted screeners and video game-style programs tailored to students' demographics and language preferences have successfully been used to engage students in SBI interventions and led to higher identification rates compared with self-report pen-and-paper tools. Interventions that alerted adolescents that their PCP check-up would include a discussion of substance use, and that prompted PCPs to bring up substance use with youth, facilitated better communication.323
Lack of adequate screening tools has also been identified as a barrier, although the CRAFFT tool is gaining acceptance generally. Other validated brief screening tools are available for use in primary care including the Global Appraisal of Individual Needed-Short Screener and the Adolescent Drinking Index. Electronic or computerized screening and integrating screening into EHRs may facilitate wider use of these tools and lessen workflow disruptions and the need for practice change in primary care settings including FQHCs.322, 324, 325 Lengthy screening questionnaires, whether written or online, will not be used.308, 326
The economic, political, and social contexts within which an organization resides (e.g., constrained funding, billing rules, and the influence of policies related to treatment and targeted populations).
Adolescents and their families may be ambivalent about SBI. Gordon and his colleagues322 found that parents, families, and PCPs who perceived social norms to be tolerant of adolescent substance use; a community culture of alcohol use and positive attitudes toward drinking; parental drinking and willingness to provide adolescents with access to alcohol; and the lack of non-drinking alternative programs and activities for adolescents inhibited the acceptance of adolescent SBI in rural communities.
States that foster state-community initiatives on adolescent substance use and that support connecting school and pediatric practices with community substance use programs increase the uptake of adolescent screening. Kuhlthau and colleagues327 suggest that a multiyear effort to forge relationships between BHPs and PCPs who treated adolescents in Massachusetts, in addition to PCPs' access to an enhanced array of adolescent behavioral health services (emergency services, mobile crisis teams with 72-hour follow-up support, intensive care coordination, in-home care teams, and behavioral health consultation teams) encouraged PCPs and pediatricians to screen their adolescent patients. State Medicaid mandates to use specific screening instruments increase provider screening and the rates of identifying youth with risky substance use and referring them to specialty services.327
Getting paid is key to adolescent SBI. The financial sustainability of SBI is a consistent problem in school-based health programs.319, 324 Clark and Moss's study of adolescent SBI across a wide array of settings308 found that even when payment is available, reimbursement rates and actual payments received for adolescent SBI services delivered are rarely sufficient to cover the skills and time required to deliver the services. Health insurance and Medicaid reimbursement for school or health center screening and treatment strongly predict uptake.319 In one project, despite Medicaid reimbursement rates that were adequate to sustain SBI counselors and a supervisor in a school-based health clinic, insurance requirements that parents/guardians be notified nearly defeated the program. The SBI program was successfully implemented because great attention was given to informing all stakeholders about it (the school board, teachers, parent organizations, individual parents), the offer to parents of an easy "opt-out" from screening, and a strong positive relationship between the school system and a local substance abuse treatment program that staffed the SBI program in the school health center; all were regarded as essential to successfully opening SBI in school health clinics. The absence of readily available referral sources for adolescents identified as needing specialty care is frequently cited as a barrier to implementing adolescent SBI programs.322, 328 Support from outside the school or health center, from parents, the government, or community organizations, may be essential for getting schools or PCPs to start SBI programs.320
The structural, political, and cultural contexts through which the implementation process will proceed.
Factors cited as the biggest barriers to implementing adolescent SBI include insufficient time and training; limited access to referral options; competing needs to triage youths' other medical conditions; privacy, including the inability to have conversations about substance use with parents/guardians in the room; and confidentiality policies and regulations including fear that documenting substance use in EHRs will adversely affect adolescent patients.319, 322, 325, 328
School-based health programs generally consider treatment to be beyond their scope of services. SBI implemented as prevention, or even counseling, is more acceptable and less disruptive than treating adolescents with SUDs. Care must be taken to minimize role conflicts, role overload, and ideological conflicts for the school staff who assist in implementing program components. Delivery of SBIRT services must not be seen as interfering with educational activities or school attendance; services should be delivered during non-academic periods and physically located in the school. Careful considerations should be made to ensure that confidentiality and privacy procedures are in place and customized to school settings and operations.319, 320, 329
Characteristics of Individuals
Knowledge and beliefs about the intervention, self-efficacy, individual readiness to change, individual identification with the organization, and other personal attributes.
Clinicians are unsure of how to screen and counsel adolescents about substance use. Nearly half of primary care clinicians who treat adolescent patients believe they are insufficiently trained to deal with patients' substance use.322 Many rely on informal screening for risky substance use rather than using validated screening tools. Compared with other health issues among their adolescent patients, providers report less knowledge about substance use treatment and less certainty about their skills and abilities to address their patients' substance use. Surveys of providers suggest that they are reluctant to ask about substance use because they are unsure about what to do with the information, they lack the skills to intervene with risky use, and they are unprepared to diagnose alcohol or drug use disorders.322, 324, 325, 326
On the other hand, providers are likely to implement teen SBI if they believe that routine screening for alcohol use should begin early, that adolescent alcohol consumption is a significant health problem, that treatment resources are available should their patients need them, and that primary care settings are good places for identifying risky use and counseling risk reduction.319, 322, 327
Encompasses the steps taken to introduce and sustain the innovation.
Planning SBI implementation to avoid disrupting patient flows and workflows and to minimize interference with classes or school operations is essential in school-based health SBI. Projects that prepare concise, specific guides for clinicians and workbooks for youth and that conduct focus groups to test the usefulness of manuals and processes see improved uptake and sustainability. Simple metrics for monitoring clinicians' delivery of SBI, feedback, and clinical supervision have been found useful. As with adult SBI implementation, practice management systems and electronic medical record systems that prompt providers to screen and manage adolescents' substance use and that automate billing facilitate SBI programs.319, 320