Clinicians Apply SBIRT to Adolescents and Young Adults

John Knight, M.D.: "Primary care providers have an excellent opportunity. It's a teachable moment in a confidential relationship."

John Knight, M.D.: “Primary care providers have an excellent opportunity. It’s a teachable moment in a confidential relationship.”

John Knight, M.D., shared a rich history in research of new strategies for early identification and intervention in adolescent substance abuse during Saturday’s Symposium 9, “SBIRT—Adolescent and Young Adults in General Medical Settings: Scientific Updates and Clinical Implications.”

“If you look at the trajectory of drug and alcohol abuse in adolescents, it goes from close to 0 percent at age 12 all the way up to 70 percent age 18, so there is a steady march year to year,” said Dr. Knight, Associate Professor of Pediatrics, Harvard Medical School, Boston. “Primary care providers have an excellent opportunity. It’s a teachable moment in a confidential relationship.”

The American Academy of Family Physicians and the American Medical Association recommend an annual substance abuse screening of adolescents. However, primary care physician adherence to this screening is low, he says. Fewer than 50 percent of primary care physicians screen all adolescents for substance abuse, fewer than 25 percent screen for substance-abuse driving risks, and less than 12.5 percent use a structured screening tool.

Studies have found that barriers to primary care screening include time constraints, insufficient training, competing medical care demands, lack of treatment resources, dealing with tenacious parents, and screening tools that are unknown to them. To address with these issues, he developed the CRAFFT test a decade ago to help clinicians screen for substance abuse among adolescents. It asked patients about everything from riding in a car driven by someone who is high to forgetting things while using alcohol and drugs. The CRAFFT test has also withstood the test of time and has become a valuable tool in many SBIRT initiatives throughout the country.

Recently, such SBIRT initiatives merged with the computer technology in administering the CRAFFT test and have found adolescents are more willing to take a computer test than answer questions from a physician or nurse. He is currently involved in an international trial of computer-facilitated substance use screening and brief advice for teens in primary care settings.

“The advantage of primary care in pediatrics is that you see your patients every year,” Dr. Knight said. “You get another bite of the apple when they come back the following year.”

Constance Weisner, Dr.PH., M.S.W., described how SBIRT for youths with substance use programs can work within an integrated health care system. She is currently involved in research on the medical home model for adolescent substance use problems in her position as Professor, Division of Research, Kaiser Permanente Northern California, University of California, San Francisco

“For the screening and brief intervention, we are applying SBIRT screening and managing short behavioral interventions for the lower severity problems with pediatrics,” she said. “For the treatment component, we get those children to special needs care, getting them stabilized, and then importantly, getting them back to pediatrics and keeping the care coordinated. Our SBIRT study is conceptually framed within this larger medical home model.”

A current study at Kaiser Permanente Northern California randomizes primary care providers to different modalities of delivering SBIRT—primary care physician delivery versus behavioral medicine specialists. Investigators are seeking to learn which SBIRT model produces the best screening, brief intervention and referral rates.

“Based on the findings, we will work with clinicians, health plan administrators, and consult with federal-qualified health centers and other researchers and consultants to see how to adapt this again to do a regional roll-out or a larger implementation study,” Dr. Weisner. “We have found that of those children who have had regular primary care visits each year, their abstinence rates are higher than those who have not. Of those who have had relapse, they are likely to receive a substance use treatment re-admission. That’s how we complete this whole circle with the medical home.”

Drs. Knight and Weisner were among several speakers who addressed this National Institute on Drug Abuse-sponsored symposium.