Adolescence is a time of dramatic physical, mental and emotional growth and development but also a time when significant risks exist. Adolescence is the time when many youth begin to experiment with alcohol and other drugs (AOD). Research has shown the brain is still developing until age 25 and is more vulnerable to the harmful effects of alcohol and other drugs. Cognitive functioning of the brain can be permanently impaired even if the adolescent stops using (Schweer, 2009). It is important to prevent and/or delay as long as possible the onset of AOD use as individuals are four times more likely to develop alcohol dependence if they begin drinking before the age of 14 compared to those who wait until age 21. The data is similar for early onset of regular marijuana smoking (Hingson, 2006).
Substance use is a major contributor to the three leading causes of death among adolescents: motor vehicle accidents, homicides and suicides. (American Academy of Pediatrics, 2010). 32.5% of New York State (NYS) high school students, grades 9-12 are current drinkers (reported drinking in the last 30 days), 21.4 % current marijuana smokers (reported smoking marijuana in the last 30 days) and 18.4% report binge drinking (five or more drinks of alcohol in a row in past 30 days) (2013 NYS YRBS). Binge drinking results in increased risk for: riding with a driver who had been drinking; smoking cigarettes or cigars; being a victim of dating violence and using illicit drugs. Teens that use alcohol, marijuana or other drugs are more likely to be sexually active, to engage in risky sexual behavior and to experience the negative consequences of risky sex e.g. unintended pregnancy or contracting a sexually transmitted disease, compared to those who do not use substances. Adolescent substance users are also twice as likely to have poor grades and drop out of high school. (Bryant, 2003). Lastly, the costs of underage drinking, (youth violence, youth traffic crashes, high risk sex, youth property crime, youth injury, poisoning and psychoses, FAS (mothers age 15-20) and youth alcohol treatment) in NYS are substantial with underage drinking costs estimated in 2010 to be $3.3 billion annually. (Pacific Institute for Research and Evaluation, 2011).
Overview of SBIRT
Fortunately, there is an evidence based healthcare intervention called Screening, Brief Intervention and Referral to Treatment (SBIRT) that can provide early intervention services to adolescents who have begun to use AOD. SBIRT can be provided in a variety of healthcare settings e.g. emergency rooms, primary health clinics, college campus health centers, school-based health centers (SBHCs) etc. Individuals undergo Screening, using a valid and reliable screening instrument to assess their level of alcohol and drug use. If they’re determined by the screen to be at risk, they receive a Brief Intervention that focuses on raising their awareness of their substance use, identifying existing or potential consequences of their use and motivating them to change their behavior. Individuals who need more extensive treatment receive Referrals to Treatment. SBIRT is ranked among the top five most beneficial and cost-effective preventive health services by the US Preventive Services Task Force (Solberg, 2008). SBIRT is rated higher than screening for high blood pressure, high cholesterol, breast, colon, or cervical cancer, and osteoporosis. SBIRT has been shown to reduce both alcohol and other drug use and the consequences associated with both. Research shows a savings of $4.30 for every $1 spent on SBIRT. Center for Substance Abuse Treatment (CSAT) has the goal to help integrate SBIRT throughout the entire health care system.
Effectiveness of SBIRT with Adolescents
SBIRT is a good fit for adolescents as they tend to not have a long history of AOD abuse, many times are ambivalent regarding changing their substance use, desire autonomy, and often resist authority. The self-guided structure of SBIRT does not force adolescents to admit having a problem. This approach avoids confrontation and instead allows adolescents to develop their own goals. Abstinence from alcohol and other drugs may not necessarily be the initial goal, but by taking on a more flexible approach toward goal attainment, adolescent clients appear more receptive to the change process.
Most of the research on the effectiveness of SBIRT has been conducted with adults but more studies are being done on SBIRT with adolescents and show similar positive results. Studies show lower past 90-day alcohol and other drug use comparing SBIRT to usual care (Harris, 2010), decreased marijuana use after 3 months, (Grenard, 2007), and reduced risk of drinking and driving (Knight, 2005).
SBIRT in School Based Health Centers (SBHCs)
The American Academy of Pediatrics’ Bright Futures and the American Medical Association’s Guidelines for Adolescent Preventive Services both recommend that youth aged 11 years and older should be screened for AOD use at each annual preventive health visit. Unfortunately, pediatricians rarely screen for alcohol and other drugs as a part of routine adolescent healthcare visits and relatively few pediatricians who do screen do so according to guidelines or use evidence-based screening tools (American Academy of Pediatrics, 2002.). Even if youth screen positive, intervention and/or referral to specialty care are not common (Bethell, 2001). The most common reasons given for pediatricians’ failure to routinely screen and intervene were: time constraints; adolescent confidentiality policies and regulations; belief that patients would not tell the truth and uncertainty regarding whether treatment was effective (Sterling, 2012).
In contrast, SBHCs provide a convenient location where SBIRT services can be delivered and services can reach a large number of at-risk students statewide. SBHCs can help address the unique needs of adolescents, including enhancing access to behavioral health services (Weinstein, 2006). Visits at SBHCs were twenty-one times more likely to be initiated for behavioral health reasons than at other healthcare facilities. Adolescents and their families have been found to be receptive to screening and intervention in SBHC settings, and in fact perceive the quality of care to be higher when AOD is addressed (Yoast, 2007). Students receiving behavioral health care in SBHCs had significantly lower total health and behavioral health costs than students outside of SBHC care. [Guo, 2008].
Providing SBIRT in SBHCs provides the convenience of the school with the confidentiality of healthcare clinics. In NYS, parents sign an enrollment form for the SBHC that gives permission for the SBHC to provide “Health education and counseling for the prevention of risk-taking behaviors such as: drug, alcohol and smoking abuse…”. This policy has encouraged students in SBHCs to be willing to discuss substance use with their healthcare provider and students reported not feeling judged (Grenard, 2007).
There are 227 SBHCs in New York, the largest SBHC network in the country. There are 104 SBHCs that serve middle and high school students. In the 2011-2012 school year, there were 212,620 students attending the schools with an SBHC; 80% of these students (170,096) were enrolled in an SBHC. A large proportion of these students are minority, uninsured or insured by Medicaid. SBHCs offer an environment where SBIRT services can be delivered to a large number of youth.
OASAS Experience with SBIRT in SBHCs
In New York State the billing codes for SBIRT have been activated for Medicaid allowing SBHCs to bill Medicaid for SBIRT services. With the belief that SBIRT could be effectively delivered in SBHCs, and with the added incentive of having the services reimbursed, the NYS Department of Health, NYS Department of Education, NYS Office of Alcoholism and Substance Abuse Services (OASAS), NYC Department of Health and Mental Hygiene (NYC DOHMH) and the NYC Department of Education all supported a pilot to implement SBIRT in selected SBHCs.
In 2012 OASAS, in cooperation with NYC DOHMH, began an SBIRT pilot project at five sites in two SBHCs, Winthrop University Health Center located on Long Island and Morris Heights Health Center, located in the Bronx. The CRAFFT, a valid and reliable screening tool for adolescents, was selected as the screening instrument. Training was provided onsite to staffs from the two SBHCs. Between January and May of 2012, 401 screens were conducted among 388 unique students. Of those, 140 (35%) reported alcohol or drug use in the past 12 months: 113 (28%) reported alcohol use, and 64 (16%) reported marijuana use. Fifty-seven, or 14% screened positive based on score of 2 or more on CRAFFT. 21 received a brief intervention, and 8 received both a brief intervention and a referral to treatment.
Lessons learned from that pilot were used to help inform the planning and implementation of an upstate demonstration project with 3 SBHCs at 6 sites in 2013-2014. Two of the SBHCs were located in Rochester and the third in the Cooperstown area. Site visits were conducted at each site to meet the staffs and to understand the patient flow. Meetings were arranged between staffs from the SBHCs and regional substance abuse providers. The purpose of the meetings was to have staff from the SBHCs and substance abuse programs meet each other, learn about each other’s services, and to facilitate the referral process between the SBHC and substance abuse program. Monthly conference calls were held with the three upstate SBHC directors to discuss successes challenges, possible solutions, and establish an environment where the 3 SBHCs could learn from each other. A focus group was conducted in June of 2014 (and other focus groups to be scheduled) with staff from one SBHC to identify lessons learned and identify improvement opportunities that OASAS can utilize in future implementation SBIRT efforts.
Between October 2013 and June 2014, screens were conducted and data entry forms were submitted for 316 students. Of those, 39 (12%) reported alcohol or drug use in the past 12 months: 25 (8%) reported alcohol use, and 32 (10%) reported marijuana use. Twenty-seven, (9%) screened positive (based on score of 2 or more on CRAFFT). 24 received a brief intervention, and 9 received a referral to the on-site mental health staff.
The percentage of positive screens for the upstate SBHCs was lower than expected and significantly lower than those for the downstate SBHCs. There were varying opinions why this was the case, e.g. adolescents screened were looking to “give the right answers” in the school setting, but further analysis would be needed to confirm the causes.
Successes and Challenges
In speaking with staff from the various SBHCs there were consistent positive results. The SBIRT screenings and interventions were not found to be time consuming. SBIRT had been well integrated into Well Child Checks, sports physicals and annual check-ups. There was the belief, even with the low numbers upstate, that by using the CRAFFT standardized screening tool more students would be identified with potential substance abuse problems. SBIRT was well-received by students, there was an increased number of referrals to in-house mental health staff, and delivering SBIRT services provided the opportunity for the SBHCs to bill and be paid for SBIRT services.
Challenges/improvement opportunities included billing and receiving payment for SBIRT services. SBHCs also considered the data collection and reporting to OASAS for the purpose of this demonstration project to be a burden to their staff so not all of the data was completely reported.
In conclusion, SBHCs provide a convenient location where healthcare services are already being provided to large numbers of youth and adolescences. This unique opportunity to deliver SBIRT services should reduce the level of use of AOD for students and the accompanying negative consequences and benefit the school, the SBHCs and most importantly, the students who receive SBIRT services.