News Articles, AAP Clinical Report, AAP Policy, Adolescent Health/Medicine, Substance
Abuse
Use SBIRT approach to identify teens who need help for substance use
by Lori O'Keefe, Correspondent
In a pair of reports, the Academy has reaffirmed its recommendation to incorporate universal screening, brief
intervention and referral to treatment (SBIRT) practices for adolescent substance use into routine health care.
A revised policy statement has been simplified from a 2011 statement, and a new clinical report contains
updated guidance, including screening tools and intervention procedures. The policy and report from the
Committee on Substance Abuse, both titled Substance Use Screening, Brief Intervention and Referral to
Treatment, appear in the July issue of Pediatrics (see resources).
Need for screening
Dr. Levy " Substance use is one of the most important modifiable behaviors adolescents
engage in, and as guardians of children's health, it is critically important for us to keep talking about this topic
with them," said Sharon J. Levy, M.D., M.P.H., FAAP, a lead author of both document.
According to the clinical report, 28% of eighth-graders and more than 68% of 12th-graders have tried alcohol. In
addition, half of high school students reported ever using illicit drugs, and 41% have tried smoking cigarettes.
Any amount or type of substance use increases the potential for risky behaviors. Half of all adolescents visiting
the emergency department for trauma-related injury test positive for alcohol use compared to only 5% of
adolescents seeking emergency care for other reasons, according to the clinical report.
A survey of pediatricians found that approximately 50%-86% of respondents performed routine adolescent
substance use screening, but only a minority used validated screening tools, and most relied on clinical
impressions. A recent study found that only one-third of adolescents excessively using alcohol were detected
when pediatricians relied on clinical impressions.
Validated screening tools featured in the clinical report ask questions about frequency of use, which has been
found to be effective at predicting risk of developing or having a substance use disorder, Dr. Levy said.
Focus on healthy behaviors
Copyright © 2016 American Academy of Pediatrics
News Articles, AAP Clinical Report, AAP Policy, Adolescent Health/Medicine, Substance
Abuse
Regardless of the screening results, brief intervention is important. The clinical report describes "a type of
screening outcome-responsive dialogue that focuses on encouraging healthy choices and healthful behavior
regarding identified risk activities so that the risk behavior and effects are prevented, reduced or stopped."
If a parent suspects a child is using illicit substances but the patient denies it, speak to the patient alone and ask
why he or she thinks the parent is concerned. Patients who continue to deny use may have to be referred to a
counselor who can obtain further information, Dr. Levy said.
If patients are not an immediate risk to themselves or others, pediatricians may choose to "accept" their answers
and provide positive reinforcement similar to what is said to patients who do not use substances, said Janet F.
Williams, M.D., FAAP, co-author of the reports.
Dr. Williams " You can respond to them by telling them you are glad they are making healthy
choices and available if they ever have questions about using substances," Dr. Williams said. "Building their
confidence and causing them to realize discrepancy in their actions may prompt them to start questioning the
safety of their choices, motivating them to make healthier choices."
Informing patients ahead of the screening that their responses will be kept confidential may increase the
likelihood that they will answer honestly.
Patients who report partaking in substance use once or twice in the past year should be informed about potential
negative health effects and encouraged to decrease use. Substance use that is more frequent may be
considered a substance use disorder, and brief motivational intervention may be more effective at empowering
patients to change behavior than attempting to convince them to change.
Handling a severe disorder
When patients are found to be at immediate risk of harm and/or having a severe substance use disorder,
confidentiality may need to be broken. However, patients should be informed of this decision before disclosing
information to parents.
Copyright © 2016 American Academy of Pediatrics
News Articles, AAP Clinical Report, AAP Policy, Adolescent Health/Medicine, Substance
Abuse
Adolescents may be more concerned about implicating their friends or revealing where they obtained the
substances than admitting to substance use. However, Dr. Williams said pediatricians can reassure patients that
they do not have to share details that do not endanger them.
The clinical report includes a chart with the various levels of treatment care, including outpatient and
inpatient/residential care. Research reports that only 10% of adolescents requiring treatment receive services.
This can be attributed to patients who do not believe they have a problem and either deny use during screening
or do not recognize the need for treatment. In addition, a lack of understanding about treatment may contribute
to the low number.
The big picture
"When speaking to pediatricians, we learned that they often think treatment referral for a substance use disorder
means sending a patient to rehab," Dr. Levy said. "In reality, only a very small proportion of the population with
substance use disorders need that."
Dr. Levy said she hopes the policy and clinical report help pediatricians to think in broader terms about referring
patients for community-based counseling to treat underlying reasons that may have led them to start using
substances in the first place.
In addition to practicing SBIRT, the policy statement recommends pediatricians advocate for continued research
and adequate payment for SBIRT-related issues, as well as parity of access to mental health and substance use
disorder treatment.
Resources
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"Substance Use Screening, Brief Intervention and Referral to Treatment" policy
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"Substance Use Screening, Brief Intervention and Referral to Treatment" clinical report
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Coding information
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Alcohol Screening and Brief Intervention for Youth: A Practitioner's Guide
Copyright © 2016 American Academy of Pediatrics