National guidelines recommend the implementation of the SBIRT model in general medical settings, but low adherence to these guidelines creates barriers to adolescent SUD treatment.
Nearly 75% of adolescents visit a primary care physician each year (Newacheck et al., 1999), and studies have shown that adolescents want to talk about their substance use with physicians but often fail to do so (Klein & Wilson, 2002; Stern et al., 2007). Primary care clinicians and other health care providers have enormous potential to screen adolescents for SUDs, engage in brief office-based interventions, and make appropriate referrals to treatment (SBIRT). However, the available evidence suggests that many opportunities for intervention are missed (Levy & Knight, 2008).
Clinicians often fail to routinely implement the SBIRT model during health care visits, despite recommendations for universal screening in the American Medical Associations Guidelines for Adolescent Preventive Services (Elster & Kuznets, 1994). A national survey found that less than 20% of physicians provide alcohol screening and education to all of their adolescent patients (Marcell et al., 2002). Physicians in a California health maintenance organization reported higher universal screening, with about 40% of physicians screening all of their adolescent patients (Halpern-Felsher et al., 2000). Even in emergency departments where substance use is often implicated in traumatic injury, implementation of screening is low, with one study documenting that just 13% of adolescents hospitalized for traumatic injury were screened for alcohol use (Mader et al., 2001).
This low rate of routine screening is particularly disappointing because researchers have developed and validated brief standardized screening tools (Winters & Kaminer, 2008). One validated tool, known as the CRAFFT, has been tested in a variety of primary care settings. Researchers found that nearly 15% of adolescents presenting for a routine medical visit screened positive for substance abuse (Knight et al., 2007), pointing to a need for additional assessment and brief intervention or referral to treatment.
Use of standardized screening tools is particularly important because clinicians often miss SUDs when they rely solely on their clinical impressions. One study found that clinicians only successfully identified 10% of adolescents who met formal criteria for SUDs (Wilson et al., 2004). Given increasing demands to reduce the length of office visits, technological innovations such as personal digital assistants (PDAs) can be used to screen youths, with adolescents completing the screening questions before meeting with the physician. PDA-based screening tools have been shown to significantly increase the percentage of office visits in which teens discuss substance use with their physicians (Olson et al., 2009).
Diagnosis of an SUD by a physician does not guarantee referral to treatment services. Pediatricians are two times more likely to ask an adolescent with an SUD to return to their own office for an additional visit than to make a referral to a mental health counselor (Hassan et al., 2009). A recent review of medical charts of 400 adolescents with SUDs found that just 16% of medical charts included a written documentation of referral to SUD treatment; about 30% of medical charts had a written referral to mental health treatment (Scott et al., 2004). Taken together, these findings suggest that primary care clinicians need to be prepared to help adolescents with SUDs. More tools and training resources may be necessary in order to adequately prepare the primary care workforce to routinely implement the SBIRT model.