SBIRT Implementation for Adolescents in Urban Federally Qualified Health Centers

Patterns of substance use among adolescents in and out of foster care: An analysis of linked health and child welfare administrative data

BACKGROUND

Young adults with a history of foster care have higher risk for substance use disorders. Social systems can deliver substance use prevention to youth; however, the timing of intervention delivery and how needs differ for youth in foster care are unclear.

OBJECTIVE

To compare initiation and rates of substance use among adolescents in foster care to demographically similar adolescents never in foster care as identified by the healthcare system, and identify factors associated with increased substance use.

PARTICIPANTS AND SETTING

Youth in foster care (n = 2787, ages 10-20, inclusive) and demographically matched youth never in foster care (n = 2787) were identified using linked child welfare and electronic health records from a single pediatric children's hospital and county over a five-year period (2012-2017).

METHODS

All healthcare encounters were reviewed and coded for substance use by type (alcohol, tobacco, cannabis, other). Age of first reported or documented substance use was also captured. Demographic and child welfare information was extracted from administrative records. Survival and logistic regression models were estimated.

RESULTS

In adjusted models, youth in foster care initiated substance use at earlier ages (HR = 2.50, p < .01) and had higher odds of engaging in use (AOR = 1.54; p < .01) than youth never in care. By age 12, substance use initiation was more likely while youth were in foster care than when they were not in foster care (HR = 1.42, p < .01). Placement stability and family care settings reduced odds of lifetime substance use.

CONCLUSIONS

Foster care placement is associated with substance use. Screening may be important for prevention.

Readiness to implement screening, brief intervention, and referral to treatment in school-based health centers

The purpose of this study was to evaluate the readiness of a university-based school-based health center (SBHC) program to implement the screening, brief intervention, and referral to treatment (SBIRT) model. We completed preimplementation surveys and interviews with providers, staff, and administrators at participating SBHCs (N = 19) to measure current protocols for and barriers to addressing adolescent substance use and barriers and facilitators to implementing SBIRT. We used the R = MC² heuristic (readiness equals motivation, general organizational capacity, and innovation-specific capacity) to interpret findings from the data. Using the R = MC² heuristic, we identified factors that may aid implementation, including the prioritization of substance use and a supportive organizational culture, as well as potential barriers, including competing high-priority health issues and a lack of resources for innovation. This study contributes to the emerging literature on the implementation of the SBIRT model with adolescents and in SBHCs and demonstrates the practical applicability of the R = MC² heuristic for assessing implementation readiness. SBHCs are ideal locations for addressing substance use but SBHC providers also face unique challenges when implementing the SBIRT model.

Sexual Health and Relationship Abuse Interventions in Pediatric Primary Care: A Systematic Review

PURPOSE

Supporting adolescents in developing healthy relationships and promoting sexual and reproductive health (SRH) is an important responsibility of pediatric primary care providers. Less is known about evidence-based interventions in pediatric settings focused on healthy relationships and SRH.

METHODS

We conducted a systematic review to describe SRH and healthy relationship/adolescent relationship abuse (ARA) interventions for pediatric primary care over the past 20 years. Eligible articles were original research on an SRH-focused or ARA-focused intervention, conducted in-person within pediatric primary care or school-based health centers specifically for middle or high school-aged adolescents. Data abstracted from included articles included intervention description, content, delivery, evaluation design, and effectiveness of primary outcomes. Heterogeneous outcomes and evidence levels made conducting a meta-analysis infeasible.

RESULTS

Nineteen studies described 17 interventions targeting a variety of SRH and ARA topics (e.g., sexually transmitted infections, contraception, ARA). Interventions largely focused on screening/counseling adolescents (89%). Interventions generally were reported as being effective in changing adolescent health or practice-level outcomes.

DISCUSSION

This review provides preliminary evidence that SRH and ARA interventions in pediatric primary care settings can be effective in promoting adolescent health. Future work should consider ARA-specific prevention interventions, including parents in interventions, and strategies for implementation, dissemination, and scaling.

Implications for a System of Care in Hawai'i for Youth Involved in the Justice System and Substance Use

The shift from punitive responses to restorative public health approaches to tackle the problem of youth substance use and justice system involvement follow a nationwide trend. Hawai'i has made significant strides towards transforming the justice system and developing effective substance abuse programs. However, these efforts require changes in policies, practices, and paradigms to be fully and permanently realized. Such a philosophical shift requires a major reallocation of resources from downstream, high-cost punitive modalities, such as incarceration, to upstream solutions that allow adolescents to heal past trauma and grow the understanding and tools to lead a healthy and meaningful life. Research and evaluation to support ongoing learning and system improvement will also be required. Most critically, taking an approach to work with youth so they can overcome the root problems they face holds the most promise of ending the cycle of justice involvement and substance use that the state has witnessed for far too long.

Pediatric Subspecialist Alcohol Screening Rates and Concerns About Alcohol and Cannabis Use Among Their Adolescent Patients

PURPOSE

Pediatric specialty care provides an opportunity to screen for and address patient substance use; however, little is known about providers' screening rates, their opinions regarding substance use harms, or the potential marijuana to be used as a medication.

METHODS

We surveyed national convenience samples of pediatric endocrinologists (N = 142) and rheumatologists (N = 83) and used descriptive statistics and multivariate logistic regression to examine alcohol screening rates, barriers, and for medical use of marijuana, differences between subspecialist concerns.

RESULTS

In all, 36.4% of providers reported screening adolescent patients annually or more, and a majority expressed concerns about impacts on disease management (80.0%/80.0%) and symptom management (69.3%/53.3%) from alcohol and marijuana, respectively. Nearly equal proportions disagreed (30.2%), were neutral (34.7%), or agreed (35.1%) that some patients would benefit from medical marijuana, although majorities were not comfortable recommending marijuana (62.7%) and did not believe marijuana is standardized enough to be used as medication (57.8%).

DISCUSSION

Fewer than half of the subspecialists in our study routinely screen their adolescent patients for substance use, although many have concerns regarding the impacts of alcohol and marijuana use on their patients. Education and training on best practice could help to increase screening rates. There is agreement that marijuana is not standardized enough to be used as a medication. There is also a broad range of opinions regarding the pharmaceutical potential of marijuana and concerns about the impact of marijuana on underlying chronic medical conditions, which should be considered as marijuana policy continues to evolve.

Costs and Implementation Effectiveness of Generalist Versus Specialist Models for Adolescent Screening and Brief Intervention in Primary Care

OBJECTIVE

This study analyzed the marginal service and program costs, and conducted a cost-effectiveness analysis (CEA) of two models of implementation of adolescent substance screening, brief intervention, and referral to treatment (SBIRT).

METHOD

SBIRT was implemented at seven clinics in a multisite, cluster-randomized trial, through a Specialist model (behavioral health counselor-delivered brief intervention), and a Generalist model (primary care provider-delivered brief intervention). The CEA calculated marginal costs using an activity-based costing methodology for direct SBIRT services, and effectiveness was measured by the proportion of brief interventions delivered among patients who screened positive for alcohol, tobacco, or other drugs. Site-level program costs comprised start-up and maintenance (training and technical assistance). Costs were estimated in 2017 U.S. dollars.

RESULTS

The marginal cost of SBIRT per patient with a positive screen for brief intervention was $6.72 in the Specialist model and $6.05 in the Generalist model. Implementation effectiveness was 7.2% (SE = 2.9%) in the Specialist model and 37.7% (SE = 5.6%) in the Generalist model. The program costs to provide SBIRT for 1 year per site were $13,548 for the Specialist site and $12,081 for the Generalist.

CONCLUSIONS

The Generalist model was more effective in implementing brief intervention and less expensive than the Specialist model. Results were robust to sensitivity analysis. Brief intervention delivered by primary care providers rather than by handoff to a behavioral health counselor may ensure greater penetration and a lower cost of these services in primary care settings.

Costs and Implementation Effectiveness of Generalist Versus Specialist Models for Adolescent Screening and Brief Intervention in Primary Care

OBJECTIVE

This study analyzed the marginal service and program costs, and conducted a cost-effectiveness analysis (CEA) of two models of implementation of adolescent substance screening, brief intervention, and referral to treatment (SBIRT).

METHOD

SBIRT was implemented at seven clinics in a multisite, cluster-randomized trial, through a Specialist model (behavioral health counselor-delivered brief intervention), and a Generalist model (primary care provider-delivered brief intervention). The CEA calculated marginal costs using an activity-based costing methodology for direct SBIRT services, and effectiveness was measured by the proportion of brief interventions delivered among patients who screened positive for alcohol, tobacco, or other drugs. Site-level program costs comprised start-up and maintenance (training and technical assistance). Costs were estimated in 2017 U.S. dollars.

RESULTS

The marginal cost of SBIRT per patient with a positive screen for brief intervention was $6.72 in the Specialist model and $6.05 in the Generalist model. Implementation effectiveness was 7.2% (SE = 2.9%) in the Specialist model and 37.7% (SE = 5.6%) in the Generalist model. The program costs to provide SBIRT for 1 year per site were $13,548 for the Specialist site and $12,081 for the Generalist.

CONCLUSIONS

The Generalist model was more effective in implementing brief intervention and less expensive than the Specialist model. Results were robust to sensitivity analysis. Brief intervention delivered by primary care providers rather than by handoff to a behavioral health counselor may ensure greater penetration and a lower cost of these services in primary care settings.

Addressing adolescent substance use in an urban pediatric federally qualified health center

OBJECTIVE

Screening, brief intervention, and referral to treatment (SBIRT) is a systematic approach to identification and intervention for individuals at risk for substance use disorders. Prior research indicates that SBIRT is underutilized in pediatric primary care. Yet few studies have examined procedures for identifying and addressing substance use in clinics that serve publicly insured adolescents (i.e., federally qualified health centers [FQHC]). This descriptive, multi-method study assessed adolescent substance use frequency and provider perspectives to inform SBIRT implementation in an urban pediatric FQHC in California.

METHODS

A medical record review assessed substance use frequency and correlates among publicly insured adolescents aged 12-17 years who completed a well-child visit in pediatric primary care between 2014 and 2017 (N = 2252). Data on substance use (i.e., alcohol, illicit drugs, and tobacco) were from a health assessment tool mandated by Medicaid. Semi-structured interviews with 12 providers (i.e., pediatricians, nurse practitioners, behavioral health clinicians) elicited information about the current clinic workflow for adolescent substance use and barriers and facilitators to SBIRT implementation.

RESULTS

Of 1588 adolescents who completed the assessment (70.5%), 6.8% reported current substance use. Self-reported use was highest among non-Hispanic Black (15.2%) adolescents and those with co-occurring depressive symptoms (14.4%). Provider-reported challenges to implementing SBIRT included a lack of space for confidential screening and a lack of referral options. Providers favored implementing technology-based tools such as tablets for adolescent pre-visit screening and electronic medical record-based decision support to facilitate brief intervention and treatment referrals.

CONCLUSIONS

This study fills a substantial research gap by examining factors that impede and support SBIRT implementation in pediatric FQHC settings. Successful SBIRT implementation in these settings could significantly reduce the unmet need for substance use treatment among uninsured and publicly insured adolescents. Pediatric primary care and urgent care providers perceived SBIRT to be feasible, and health information and digital technologies may facilitate the integration of SBIRT into clinic workflows. Ensuring confidentiality for screening and expanding referral options for adolescents in need of community-based addiction treatment are also critical to increasing SBIRT uptake.

Implementing adolescent SBIRT: Findings from the FaCES project

BACKGROUND

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based approach to early intervention of substance misuse. Methods: This mixed-methods evaluation assessed the implementation of an adolescent SBIRT change package across 13 primary care clinics. These clinics participated in an 18-month learning collaborative, during which they received training and technical assistance on SBIRT practices. Results: Six major themes emerged around the implementation of the change package: operational readiness of the sites, training of staff members, factors around the screening process, factors around intervention delivery, the referral process, and the adaptation and utilization of the electronic health record (EHR). Conclusions: Through the guidance of the change package and the associated training and technical assistance, the participating primary care clinics were able to implement SBIRT practices within their existing workflows. There was also an observed reduction in reported substance use among the at-risk adolescents served by these clinics.

Provider and Practice Characteristics and Perceived Barriers Associated With Different Levels of Adolescent SBIRT Implementation Among a National Sample of US Pediatricians

Pediatrician Screening, Brief Intervention, and Referral to Treatment (SBIRT) practices vary widely, though little is known about the correlates of SBIRT implementation. Using data from a national sample of US pediatricians who treat adolescents (n = 250), we characterized self-reported utilization rates of SBIRT among US pediatricians and identified provider- and practice-level characteristics and barriers associated with SBIRT utilization. All participants completed an electronic survey querying the demographics, practice patterns, and perceived barriers related to SBIRT practices. Our results showed that 88% of respondents reported screening for substance use annually, but only 26% used structured/validated screening instruments. Furthermore, 40% of respondents provided evidence-based brief interventions, and only 11% implemented all core SBIRT practices. Common barriers (eg, confidentiality and insufficient time) and unique provider- and setting-specific barriers to implementation were identified. These findings indicate that although most pediatricians deliver some SBIRT components in their practice, few implement the full SBIRT model, and barriers persist.

Organizational Acceptability of Implementing SBIRT for Adolescents in Primary Care

Adolescent illicit drug, tobacco, and alcohol use can result in sudden and long-term negative health consequences. Primary care environments present the optimal opportunity for screening and brief interventions that target prevention and curtailing use. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a service delivery method that could potentially be well-integrated into primary care settings and used to serve a high volume of adolescents. Methods: This qualitative analysis of clinic staff interviews (N = 20), collected during a large cluster-randomized trial to implement two models of adolescent SBIRT, examined barriers and facilitating factors to overall acceptability of SBIRT. This study was conducted in a large, urban Federally Qualified Health Center (FQHC) at 7 sites throughout Baltimore City, Maryland, USA. Participants from each clinic included a range of various roles and responsibilities including: medical assistants (n = 3), nurses (n = 3), primary care providers (n = 4), behavioral health counselors (n = 4), and administrators (n = 6). Results: Results indicate both barriers and facilitating factors for acceptability of SBIRT in terms of (1) universal screening, (2) provider time demands, (3) behavioral health collaboration, and (4) behavioral health caseloads. Discussion: Universal screening was acceptable to participants across organizational roles, but brief interventions and referrals to treatment were found substantially less acceptable.

Management of Opioid Misuse and Opioid Use Disorders Among Youth

In response to the growing impact of the current opioid public health crisis in the United States on adolescents and young adults, pediatricians have an expanding role in identifying opioid use early, preventing escalation of risky use, reducing opioid-related harms, and delivering effective therapies. Research and expert consensus suggest the use of brief interventions focused on reducing risks associated with ongoing opioid use and using motivational interviewing strategies to engage youth in treatment. Because fatal opioid overdose remains a major cause of opioid-related mortality among youth, delivering overdose education as part of any visit in which a youth endorses opioid use is one evidence-based strategy to decrease the burden of opioid-related mortality. For youth that are injecting opioids, safe injection practices and linkage to needle or syringe exchanges should be considered to reduce complications from injection drug use. It is crucial that youth be offered treatment at the time of diagnosis of an opioid use disorder (OUD), including medications, behavioral interventions, and/or referral to mutual support groups. The 2 medications commonly used for office-based OUD treatment in adolescents are extended-release naltrexone (opioid antagonist) and buprenorphine (partial opioid agonist), although there is a significant treatment gap in prescribing these medications to youth, especially adolescents <18 years of age. Addiction is a pediatric disease that pediatricians and adolescent medicine physicians are uniquely poised to manage, given their expertise in longitudinal, preventive, and family- and patient-centered care. Growing evidence supports the need for integration of OUD treatment into primary care.

Adolescent SBIRT implementation: Generalist vs. Specialist models of service delivery in primary care

BACKGROUND

Drug, alcohol, and tobacco use among adolescents pose significant short- and long-term health consequences and are associated with more severe use as adults. Screening, brief intervention, and referral to treatment in primary care settings has the potential to deliver preventive interventions to a diverse range of adolescents, but optimal implementation of these services needs to be determined. The purpose of this study was to compare implementation of two different SBIRT service delivery models in primary care settings.

METHODS

This cluster-randomized trial assigned 7 primary care clinics of a federally qualified health center to implement brief interventions (BI) using a Generalist model (4 sites), in which BIs were delivered by the primary care provider (PCP), or a Specialist model (3 sites), in which BIs were delivered by a behavioral health counselor (BHC) for adolescent patients ages 12-17 years. Implementation was tracked through the clinic's electronic health record, spanning 9639 clinic visits over 20 months. Multilevel logistic regression modeling was used to compare Generalist and Specialist strategies on penetration of BI for patients scoring ≥2 on the CRAFFT substance use screen, delivered by the PCP in the Generalist sites, and via warm hand-off to a BHC in the Specialist sites.

RESULTS

Approximately 62% of adolescent patient visits were screened with the CRAFFT (with <4% screening positive with a CRAFFT score ≥ 2). The Generalist Condition had significantly higher self-reported penetration of BI delivery than the Specialist Condition (38% vs. 8%; Adjusted Odds Ratio = 6.53; p = .005).

DISCUSSION

Despite having co-located behavioral health services at all sites, a Specialist approach to providing BI was less effectively implemented than a Generalist approach in this FQHC. BI delivered by PCPs rather than by hand-off to a BHC may ensure greater penetration of these services in primary care settings. Both implementation models provided a framework for identifying and intervening with adolescent primary care patients whose substance use might have otherwise gone undetected.

Does increased implementation support improve community clinics' guideline-concordant care? Results of a mixed methods, pragmatic comparative effectiveness trial

Background

Disseminating care guidelines into clinical practice remains challenging, partly due to inadequate evidence on how best to help clinics incorporate new guidelines into routine care. This is particularly true in safety net community health centers (CHCs).

Methods

This pragmatic comparative effectiveness trial used a parallel mixed methods design. Twenty-nine CHC clinics were randomized to receive increasingly intensive implementation support (implementation toolkit (arm 1); toolkit + in-person training + training webinars (arm 2); toolkit + training + webinars + offered practice facilitation (arm 3)) targeting uptake of electronic health record (EHR) tools focused on guideline-concordant cardioprotective prescribing for patients with diabetes. Outcomes were compared across study arms, to test whether increased support yielded additive improvements, and with 137 non-study CHCs that share the same EHR as the study clinics. Quantitative data from the CHCs’ EHR were used to compare the magnitude of change in guideline-concordant ACE/ARB and statin prescribing, using adjusted Poisson regressions. Qualitative data collected using diverse methods (e.g., interviews, observations) identified factors influencing the quantitative outcomes.

Results

Outcomes at CHCs receiving higher-intensity support did not improve in an additive pattern. ACE/ARB prescribing did not improve in any CHC group. Statin prescribing improved overall and was significantly greater only in the arm 1 and arm 2 CHCs compared with the non-study CHCs. Factors influencing the finding of no additive impact included: aspects of the EHR tools that reduced their utility, barriers to providing the intended implementation support, and study design elements, e.g., inability to adapt the provided support. Factors influencing overall improvements in statin outcomes likely included a secular trend in awareness of statin prescribing guidelines, selection bias where motivated clinics volunteered for the study, and study participation focusing clinic staff on the targeted outcomes.

Conclusions

Efforts to implement care guidelines should: ensure adaptability when providing implementation support and conduct formative evaluations to determine the optimal form of such support for a given clinic; consider how study data collection influences adoption; and consider barriers to clinics’ ability to use/accept implementation support as planned. More research is needed on supporting change implementation in under-resourced settings like CHCs.

Trial registration

ClinicalTrials.gov, NCT02325531. Registered 15 December 2014.

A framework for integrating young peers in recovery into adolescent substance use prevention and early intervention

Substance use among adolescents is associated with a range of negative outcomes and risk-taking behaviors. Identifying and intervening early is essential to reducing associated risks in adolescence and adulthood. New approaches are needed to equip youth-serving systems with tools to identify and respond to substance use. Screening, Brief Intervention, and Referral to Treatment (SBIRT) has emerged as a promising public health framework and there is a growing research interest in effective adaptations for its use with adolescents. However, healthcare settings, schools, and other community-based settings are slow to adapt SBIRT, citing gaps in knowledge and capacity to deliver evidence-based substance use prevention and early intervention. Further, these settings and the surrounding communities often lack the treatment and other prevention and recovery support resources needed for youth who screen as high-risk. Integrating young adult peers with personal lived experience of substance use recovery may meet this practical need. By drawing upon their shared experiences and skills developed in recovery, young adult peers can provide developmentally appropriate screening and intervention support to youth - while also providing urgently needed skills and time to under resourced settings. This article describes the value of young adult peer roles in expanding youth substance use prevention and early intervention, and features Project Amp as an example. Project Amp was designed as an extended, four-session brief intervention for low to moderate risk adolescents, delivered by trained young adult peers. Project Amp draws on best practices from peer recovery support and prevention and early intervention approaches such as SBIRT.

Implementation of a screening, brief intervention and referral to treatment programme for risky substance use in South African emergency centres: A mixed methods evaluation study

BACKGROUND

Screening, brief intervention, and referral to treatment (SBIRT) for risky substance use is infrequently included in routine healthcare in low-resourced settings. A SBIRT programme, adopted by the Western Cape provincial government within an alcohol harm reduction strategy, employed various implementation strategies executed by a diverse team to translate an evidence-based intervention into services at three demonstration sites before broader programme scale-up. This paper evaluates the implementation of this programme delivered by facility-based counsellors in South African emergency centres.

METHOD

Guided by the Consolidated Framework for Implementation Research, this mixed methods study evaluated the feasibility, acceptability, appropriateness and adoption of this task-shared SBIRT programme. Quantitative data were extracted from routinely collected health information. Qualitative interviews were conducted with 40 stakeholders in the programme's second year.

RESULTS

In the first year, 13 136 patients were screened and 4 847 (37%) patients met criteria for risky substance use. Of these patients, 83% received the intervention, indicating programme feasibility. The programme was adopted into routine services and found to be acceptable and appropriate, particularly by stakeholders familiar with the emergency environment. These stakeholders highlighted the burden of substance-related harm in emergency centres and favourable patient responses to SBIRT. However, some stakeholders expressed scepticism of the behaviour change approach and programme compatibility with emergency centre operations. Furthermore, adoption was both facilitated and hampered by a top-down directive from provincial leadership to implement SBIRT, while rapid implementation limited effective engagement with a diverse stakeholder group.

CONCLUSION

This is one of the first studies to address SBIRT implementation in low-resourced settings. The results show that SBIRT implementation and adoption was largely successful, and provide valuable insights that should be considered prior to implementation scale-up. Recommendations include ensuring ongoing monitoring and evaluation, and early stakeholder engagement to improve implementation readiness and programme compatibility in the emergency setting.

A Comparison of Screening Practices for Adolescents in Primary Care After Implementation of Screening, Brief Intervention, and Referral to Treatment

PURPOSE

The American Academy of Pediatrics recommends screening adolescents for substance use at all well-child and appropriate acute-care visits. However, many pediatric practices aim for such screenings annually at well-child visits.

METHODS

As part of a larger study, 7 urban Federally Qualified Health Center clinics implemented universal screening for risky alcohol and drug use using the Car, Relax, Alone, Forget, Friends, Trouble (CRAFFT) screening tool. The present study compared uptake of screening and screening results at well-child versus acute-care visits.

RESULTS

Over a period of 13 months for which encounter-level electronic medical records data were available, there were 6,346 clinic visits by 3,475 unique patients aged 12-17 years, at which 76.6% (n = 4,865) of visits had a screening for problematic substance use conducted. Rates of screening were 95.1% (2,750/2,891 involving 2,629 unique adolescents) for well-child visits and 61.2% (2,115/3,455 involving 1,535 unique adolescents) for acute-care visits. Rates of positive screening results were 9.0% (248/2,750 involving 245 unique adolescents) for well-child visits and 7.8% (164/2,115 involving 126 unique adolescents) for acute-care visits. Of the 469 unique adolescents screened only during an acute-care visit during that same period, 40 unique adolescents had positive screening results for a positive screening rate of 8.5%.

CONCLUSIONS

Nearly 10% of adolescent patients screened only at acute-care visits would not have been screened if screening was implemented solely at well-child visits, and 40 adolescents reporting substance use would have been missed. The findings highlight the benefits of screening adolescents at every primary care visit to better detect and intervene in adolescents' substance use.

An Overlapping Systems Conceptual Framework to Evaluate Implementation of a Behavioral Health Intervention for Justice-Involved Youth

Background:

Nearly 65% of justice–involved youth have a substance use and/or mental health disorder. Although evidence–based practices have been established for adolescents with co–occurring mental health and substance use disorders, these practices are not widely used in juvenile justice agencies due to environmental and organizational complexities.

Methods:

Our study builds on Juvenile Justice—Translational Research on Interventions for Adolescents in the Legal System (JJ–TRIALS), a multi–site cooperative research initiative of juvenile justice and partnering behavioral health agencies. We also integrate state and county–level data to support broader assessment of key drivers of implementation success.

Results:

We present an economics/systems conceptual model describing how the environmental context, systems organization, and economic costs of implementation can affect implementation outcomes. Comparison of intervention condition (Core vs Enhanced) and pre–implementation costs (High vs Low) found differences in insurance reimbursements and types, as well as agency staffing characteristics.

Discussion:

Implementing new procedures or policies at a systems level must consider implementation outcomes in a broad context. Factors such as population demographics, primary care and behavioral health treatment capacity, unemployment rates, and public funding for treatment and other services are important in determining intervention success and sustainability.

Application of System Dynamics to Inform a Model of Adolescent SBIRT Implementation in Primary Care Settings

System dynamics (SD) modeling is used to compare and contrast strategies for effective implementation of an evidence-based adolescent behavioral health treatment in primary care settings. With qualitative and quantitative data from an on-going cluster-randomized trial in 7 federally qualified health center sites, two implementation conditions were compared: generalist vs. specialist. In the generalist approach, the primary care provider (PCP) delivered brief intervention (BI) for substance misuse (n = 4 clinics). In the specialist approach, BIs were delivered by behavioral health counselors (BHCs) (n = 3 clinics). The resultant SD model compared 'basecase' dynamics to strategic approaches to deploying continuous technical assistance (TA) and performance feedback reporting (PFR). The basecase effectively represented the SBIRT intervention, which reflected actual monthly volume of adolescent primary care visits (N = 9639), screenings (N = 5937), positive screenings (N = 246), and brief interventions (BIs; N = 50) over the 20-month implementation period. Insights gained suggest that implementation outcomes are sensitive to frequency of PFR, with bimonthly events generating the most rapid and sustained screening results. Simulated trends indicated that availability of the BHC directly impacts success of the specialist model. Similarly, understanding PCPs' perception of severity of need for intervention is key to outcomes in either condition.

Substance use screening and brief intervention: Evaluation of patient and implementation differences between primary care and emergency department settings

RATIONALE, AIMS, AND OBJECTIVES

There are well-documented barriers that have limited widespread, sustained adoption of screening and brief intervention for risky substance use in health care settings. In order to better inform implementation efforts, this study evaluates whether patient characteristics, screening results, and implementation success indicators differed between two clinical setting types: primary care and emergency.

METHODS

Patients presenting to an emergency or primary care setting were screened for risky substance use (n = 41 567). Patients with a positive screen were further assessed for psychosocial, health, and substance use problems (n = 1604). Differences in patient characteristics between primary care and emergency settings were examined using chi-square and t tests. Multilevel logistic regression was used to examine whether setting type predicted screening results. Site-level indicators of implementation success were calculated (percentage prescreens completed, percentage full screens completed, and percentage refused services) for all patient visits (n = 78 656).

RESULTS

As compared with primary care patients, emergency patients had more severe substance use patterns and screening scores, were more likely to use a variety of illicit drugs, and reported more psychosocial issues. In logistic regression models, setting type did not predict whether patients screened positive; however, it did predict screening into a higher vs lower risk category such that emergency patients were more likely to be in a higher risk category. Emergency settings had lower indicators of implementation success (eg, 14% lower prescreen completion rate) as compared with primary care settings on some implementation measures.

CONCLUSIONS

This evaluation found important differences in patient characteristics and screening and implementation results between primary care and emergency settings. Health care organizations and administrators implementing screening and brief intervention should attend to setting differences that could affect implementation and clinical care.

Disclosure of Adolescent Substance Use in Primary Care: Comparison of Routine Clinical Screening and Anonymous Research Interviews

PURPOSE

The American Academy of Pediatrics recommends substance use screening in adolescent primary care. Many studies of substance use prevalence and screening tool validation are conducted under research protocols that differ from routine clinical screening in context, consequences, and privacy implications.

METHODS

This study is a secondary analysis drawing from two projects focused on adolescent primary care patients, aged 12-17, conducted nearly contemporaneously in a Federally Qualified Health Center system. The first project conducted anonymous research interviews with patients (N = 525), while the other tracked routine clinical screening as part of a larger service implementation project (N = 5,971). Both projects assessed substance use with the CRAFFT screening tool.

RESULTS

Rates of substance use disclosure and substance use problems were over three and four times higher, respectively, in the anonymous research interview sample compared to rates found in routine clinical screening (p values < .001).

CONCLUSIONS

Routine clinical screening may underestimate substance use among adolescents.

Implementing SBIRT for adolescents within community mental health organizations: A mixed methods study

OBJECTIVE

Many adolescents with substance use problems remain untreated, leading to increased risk for the development of substance use disorders. One response is Screening, Brief Intervention, and Referral to Treatment (SBIRT)-an evidence-based, early intervention that can be tailored for adolescents. This mixed methods study examined the implementation of SBIRT across 27 community mental health organizations (CMHOs) serving adolescents.

METHODS

Organizations completed surveys on the adoption of SBIRT and implementation barriers during the study period. Quantitative data were analyzed to examine the frequency of screening, brief intervention, and referrals. Qualitative data were coded using an iterative process that focused on barriers categorized according to the Conceptual Framework for Implementation Research (CFIR) constructs.

RESULTS

A total of 2873 adolescents were screened for alcohol and drug use with 1517 (52.8%) receiving a positive drug or alcohol screen. Positive screens that received brief intervention (BI)/referral to treatment (RT) had a significantly greater mean drug score and overall scores at baseline. The most salient implementation barriers were adaptability and complexity of SBIRT, policies related to funding and licensing, staff turnover, and implementation climate.

DISCUSSION

Nearly half of the adolescents scored positive for problematic substance use demonstrating the unmet need among this population. Future implementation efforts should focus on coordinating program demands, securing funding, integrating SBIRT into clinical workflows, retaining staff, and improving referral to treatment processes.

Start-Up Costs of SBIRT Implementation for Adolescents in Urban U.S. Federally Qualified Health Centers

OBJECTIVE

Understanding the costs to implement Screening, Brief Intervention, and Referral to Treatment (SBIRT) for adolescent substance use in primary care settings is important for providers in planning for services and for decision makers considering dissemination and widespread implementation of SBIRT. We estimated the start-up costs of two models of SBIRT for adolescents in a multisite U.S. Federally Qualified Health Center (FQHC). In both models, screening was performed by a medical assistant, but models differed on delivery of brief intervention, with brief intervention delivered by a primary care provider in the generalist model and a behavioral health specialist in the specialist model.

METHOD

SBIRT was implemented at seven clinics in a multisite, cluster randomized trial. SBIRT implementation costs were calculated using an activity-based costing methodology. Start-up activities were defined as (a) planning activities (e.g., changing existing electronic medical record system and tailoring service delivery protocols); and (b) initial staff training. Data collection instruments were developed to collect staff time spent in start-up activities and quantity of nonlabor resources used.

RESULTS

The estimated average costs to implement SBIRT were $5,182 for the specialist model and $3,920 for the generalist model. Planning activities had the greatest impact on costs for both models. Overall, more resources were devoted to planning and training activities in specialist sites, making the specialist model costlier to implement.

CONCLUSIONS

The initial investment required to implement SBIRT should not be neglected. The level of resources necessary for initial implementation depends on the delivery model and its integration into current practice.

A Pilot Study for Linking Adolescent Patients to an Interactive Tobacco Prevention Program

CONTEXT

The American Academy of Pediatrics and professional guidelines recommend intervening with adolescents about avoiding tobacco use in the health-care setting. Barriers in the clinical setting limit consistent provision of this critical service.

OBJECTIVES

This pilot study compared 2 approaches for referring adolescents to an evidence-based tobacco prevention and cessation program in the outpatient setting. Secondary aims assessed tobacco use, knowledge, and program evaluation.

DESIGN SETTING AND PARTICIPANTS

The study setting was a medical and dental clinic. Participants aged 13 to 18 received tobacco advice and instructions to work through "A Smoking Prevention Interactive Experience." The program addresses health concerns of adolescents about tobacco use and is founded on behavioral change theories. The link to access it is featured on the website of the National Cancer Institute's Research-Tested Interventions. Participants (N = 197) were randomized to 1 of 2 approaches (ie, a program link via e-mail or referral by a printed card).

RESULTS

The program was accessed by 57% (112 of 197) of participants. Both referral approaches were equally effective. Non-Hispanics were twice as likely to access the program as Hispanics (adjusted odds ratio = 2.1, 95% confidence interval = 1.2-3.8, P < .05). Over 95% of participants identified themselves as nonusers of tobacco and evaluated the program as beneficial in increasing knowledge and motivation to remain tobacco-free.

CONCLUSION

Linking adolescent patients to an evidence-based tobacco prevention/cessation program at a community health clinic was highly promising and feasible. We present conclusions for future research.

Screening, Brief Intervention, and Referral to Treatment

Screening, Brief Intervention, and Referral to Treatment is a quick, effective technique with which to manage substance use in adolescents and young adults. Use of a validated measure for detecting substance use and abuse is significantly more effective than unvalidated tools or provider intuition. There are a variety of validated tools available to use in the adolescent/young adult population, and there are opportunities to increase the efficiency and scalability of screening by using computerized questionnaires. This area continues to evolve rapidly.

The future of screening, brief intervention and referral to treatment in adolescent primary care: research directions and dissemination challenges

PURPOSE OF REVIEW

Screening, brief intervention and referral to treatment (SBIRT) offers a practical, integrated model for addressing substance use in primary care settings. This review provides an update of the research on SBIRT for adolescents in primary care, examines current dissemination challenges and suggests future research directions.

RECENT FINDINGS

A number of brief screening tools for adolescents have been developed and tested relative to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) substance use disorders. Computerized previsit screening promotes standardization and is a more time-efficient alternative to provider interview. The adolescent brief intervention literature is growing, particularly with respect to technology-based tools, but is still limited, with evidence greatest for alcohol, and for motivational enhancement therapy interventions. Increasing SBIRT implementation in pediatric primary care remains a challenge. Using nonphysician behavioral health providers to deliver SBIRT, and embedding a screener and decision support tool in electronic medical record systems are strategies being investigated to promote SBIRT implementation.

SUMMARY

Substance use begins in adolescence, and pediatric SBIRT could help to achieve a population-level reduction of substance use-related harms. With a growing number of available tools, adolescent SBIRT effectiveness and feasibility are increasing, but more studies are needed to grow its evidence base, and elucidate strategies to increase implementation.

Addressing substance misuse in adolescents: a review of the literature on the screening, brief intervention, and referral to treatment model

PURPOSE OF REVIEW

Adolescent substance use is a major public health concern in the United States. Pediatricians are in a unique position via the medical home to address this issue. Screening, brief intervention, and referral to treatment (SBIRT) is a comprehensive approach that aims to prevent, identify, and reduce substance use. SBIRT has been heavily studied in adults, but research with adolescents is still ongoing. This review examines the SBIRT model and highlights recent applicable research.

RECENT FINDINGS

This research indicates that alcohol and drug use has a negative impact on the developing brain. In 2011, the American Academy of Pediatrics (AAP) released a policy statement recommending the use of SBIRT. An adolescent SBIRT algorithm can be used clinically. Recent studies focus on individual components of SBIRT; however, there have been no studies that examine all three components together in adolescents. Nevertheless, research indicates that SBIRT is an important tool to assess and intervene regarding adolescent substance use.

SUMMARY

SBIRT is recommended by the AAP as a way to address adolescent substance use. Pediatricians should be screening adolescents for substance use at every well exam, and acute care visits when possible, with a validated tool. Although more research is needed, SBIRT is an effective method to address adolescent substance use.

SBIRT-A: Adapting SBIRT to Maximize Developmental Fit for Adolescents in Primary Care

The Screening, Brief Intervention and Referral to Treatment (SBIRT) model is widely recommended as part of routine visits in pediatric primary care despite a dearth of evidence on its effectiveness, feasibility, and developmental appropriateness for adolescents in this setting. The purpose of this article is to explicate ways that SBIRT may be tailored to better serve adolescents in primary care under a set of recommended adaptations that we refer to collectively as SBIRT-A or Screening, Brief Intervention, and Referral to Treatment for Adolescents. Each component of the SBIRT-A framework incorporates recommendations to optimize developmental fit with adolescents based on extant empirical research, developmental theory, and well-documented barriers to service delivery in primary care. Commonalities across proposed adaptations include reliance upon proactive methods to identify and engage youth; innovation in service delivery aimed at improving the consistency and reach of interventions; and a family-focused approach to engagement, assessment, and intervention. Specific recommendations include taking advantage of every clinical encounter with the family to screen, involving caregivers in assessments and brief interventions, leveraging technology to administer brief interventions and booster sessions, and patient- and family-centered procedures for treatment referral and engagement. The adaptations proposed in this article have the potential to enhance the detection of adolescents with SU problems in primary care, the consistency of intervention provision, and engagement of this typically recalcitrant population into appropriate treatment.

Introduction to the Special Issue on the Studies on the Implementation of Integrated Models of Alcohol, Tobacco, and/or Drug Use Interventions and Medical Care

National efforts are underway to integrate medical care and behavioral health treatment. This special issue of the Journal of Substance Abuse Treatment presents 13 papers that examine the integration of substance use interventions and medical care. In this introduction, the guest editors first describe the need to examine the integration of substance use treatment into medical care settings. Next, an overview of the emerging field of implementation science and its applicability to substance use intervention integration is presented. Preview summaries of each of the articles included in this special issue are given. Articles include empirical studies of various integration models, study protocol papers that describe currently funded implementation research, and one review/commentary piece that discusses federal research priorities, integration support activities and remaining research gaps. These articles provide important information about how to guide future health system integration efforts to treat the millions of medical patients with substance use problems.