SBIRT (Screening, Brief Intervention, Referral to Treatment) is an innovative, evidence-based approach to addressing drug and alcohol use with adolescents.

Its core components include :

• Regular, de-stigmatized, and universal screening for substance use using validated tools;
• Consideration of substance use as a continuum rather than a dichotomous “addicted versus not addicted” judgment;
• Use of motivational interviewing-based, patient-centered talk versus directive, prescriptive talk;
• Broad understanding of “referral to treatment,” to include traditional treatment as well as support and anticipatory guidance for all levels of use or abstinence, including harm reduction methods when appropriate;
• Facilitation of smooth, bidirectional transitions among primary care, behavioral health, and specialty addiction treatment when indicated.

SBIRT is widely recommended by health organizations, including the American Medical Association², the American Academy of Pediatrics³, Bright Futures^{4, 5}, the U.S. Surgeon General⁶, the World Health Organization^{7, 8}, NIAAA⁸, and the National Institute on Drug Abuse (NIDA)⁹. Nonetheless, it remains underimplemented.^{10, 11, 12, 13} Common perceived barriers include limited time during the patient visit, lack of knowledge and training, fearing negative patient reactions, and feeling uncomfortable discussing substance use. This toolkit includes information and tools designed to counter these barriers.

To see a video demonstration of the SBIRT process in a school-based health center, see the video below.

Adolescent substance use is common. More than half of high school seniors in the United States have used alcohol in the last year; more than a third have used marijuana, and 15% of high school students report having ever used select illicit or injection drugs^{14, 15}. When school-based health centers implement SBIRT, they are addressing a behavior common among teenage students, as adolescents use substances for a variety of reasons. The adolescent brain is oriented to favor new experiences and engage in risky behaviors, meaning drug use may coincide with these normal developmental urges. In addition, adolescents may use substances as they seek to find out who they are as individuals, try to deal with problems, do better in school, or react to social pressure from friends.¹⁶

Adolescent substance use can result in negative consequences. A number of negative safety and legal consequences are more likely to occur when adolescents use substances like alcohol and marijuana^{17, 18}. Moreover, substance use can impact adolescents’ brain development, affecting memory, attention, and information processing.¹⁹ Like primary care and pediatric health settings, school-based health centers play an important role in conveying clear and consistent messaging about the potential outcomes of using substances during adolescence.

Adolescence is a critical time to prevent later addiction. When health professionals implement the SBIRT model with adolescent patients, they are acting to 1) help delay initiation of use with teens who have not tried substances; 2) increase the motivation of teens who do use to cut back or abstain; and, 3) help teens experiencing a substance use disorder get help through specialized treatment. Because the large majority of Americans experiencing a substance use disorder started using before the age of 18²⁰, health professionals can play an important role in preventing addiction later in life.

Screening tools work. Screening instruments such as the CRAFFT, the S2BI, and others* are validated specifically with adolescents, take little time to complete, and are feasible for routine use in health care settings. These screening tools can be administered verbally by a health professional or self-administered by an adolescent patient, either on paper or in electronic format. By scoring answers to just a few questions, health professionals can quickly learn how often an adolescent uses substances, which substances are used, and what consequences the adolescent is experiencing associated with use. These tools also indicate to the health professional what response is most appropriate.

*SBHA recommends using the most recent version of any validated tool.

Brief interventions are well suited for adolescents. Short conversations that employ principles of motivational interviewing can increase the likelihood that an adolescent will cut back or abstain from substance use²¹. Motivational interviewing is a technique well suited for adolescents because of their desire for autonomy and resistance to authority²². Health care professional can learn how to perform effective brief interventions by participating in a short training session.

Most teens who would benefit from treatment do not receive it. There is a large gap between the number of adolescents who could benefit from specialized treatment and the percentage of those who actually obtain it²³. By identifying these students and proactively connecting them to further assessment, health professionals increase access to critical services. Several types of treatment are available specifically for adolescents, and studies show they can produce outcomes such as decreased use, decreased criminal-legal system involvement, and improved psychological adjustment and school performance.

There’s room for improvement. Many health care professionals do not routinely address substance use with adolescent patients. In one study, 82% of 10^th graders reported seeing a doctor in the past year, but only half of them were asked about drinking alcohol²⁴. Of those who were frequent drinkers, only 25% were asked. Meanwhile, only 27% of marijuana users were advised to reduce or quit by a doctor. Failing to ask about substance use is a missed opportunity to provide important care. By implementing a standardized SBIRT workflow, SBHCs can help ensure all patients are responded to with the appropriate positive reinforcement, anticipatory guidance/brief advice, brief intervention, or referral to treatment.

SBHCs are uniquely positioned to support adolescent substance use prevention. Students are 21 times more likely to visit an SBHC for behavioral health care than they are to visit a community clinic²⁵. Students with access to behavioral health services at SBHCs report lower frequencies of cigarette, marijuana, and unauthorized prescription drug use²⁶. SBHC providers who have relationships with teens may be better situated to identify and respond to substance use in their adolescent patients.

The video below describes the rationale for and potential benefits of SBIRT in SBHCs.

Resources:

• Improving Adolescent Health: Facilitating Change for Excellence in SBIRT
• The Evidence for School-Based SBIRT
• AAP Policy Statement: Substance Use Screening, Brief Intervention, and Referral to Treatment
• AAP Clinical Report: Substance Use Screening, Brief Intervention, and Referral to Treatment
• School-Based Health Clinics: Critical Access Points For Confronting The Addiction Epidemic
• Alcohol Use Screening and Behavioral Counseling with Adolescents in Primary Care: A Call to Action
• Who’s Doing What? The Epidemiology of Adolescent Substance Use
• The Impact of Substance Use on the Developing Adolescent Brain
• Evaluation of Youth Substance Use Prevention – Abt Associates

References:

1. Abt Associates. The Impact of the COVID-19 Pandemic on School SBIRT Programs: Issues and Solutions. https://www.abtassociates.com/insights/publications/report/the-impact-of-the-covid-19-pandemic-on-school-based-substance-use. Published 2021.
2. Levy SJ, Williams JF, AAP Committee on Substance Use and Prevention. Substance Use Screening, Brief Intervention,and Referral to Treatment. Pediatrics 2016;138(1).
3. Committee on Substance Abuse. Substance Use Screening, Brief Intervention, and Referral to Treatment for Pediatricians. American Academy of Pediatrics. 2011;128(5):e1330-e1340.
4. American Academy of Pediatrics Committee on Substance Abuse. Policy Statement -Alcohol Use by Youth and Adolescents: A Pediatric Concern. Pediatrics. 2010;125(5):1078-1087.
5. S. DHHS. The Surgeon General’s call to action to prevent and reduce underage drinking. In: Office of the Surgeon General, ed. Washington, DC: US Department of
6. Health and Human Services; 2007.
7. Babor TF, McRee BG, Kassebaum PA, Grimaldi PL, Ahmed K, Bray J. Screening, Brief Intervention, and Referral to Treatment (SBIRT) toward a public health approach to the management of substance abuse. Substance abuse. 2007;28(3):7-30.
8. National Institute on Alcohol Abuse and Alcoholism. Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide. Bethesda, MD: US Dept of Health and Human Services; 2011.
9. National Institute on Drug Abuse. Principles of Adolescent Substance Use Disorder Treatment: A Research-based Guide. NIDA;2014. NIH Publication Number 14-7953.
10. National Institute on Alcohol Abuse and Alcoholism. Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide. Bethesda, MD: US Dept of Health and Human Services; 2011.
11. Harris BR, Shaw BA, Sherman BR, Lawson HA. Screening, brief intervention, and referral to treatment for adolescents: Attitudes, perceptions, and practice of New York school-based health center providers. Subst Abus. 2016;37(1):161-167.
12. Harris SK, Herr-Zaya K, Weinstein Z, et al. Results of a statewide survey of adolescent substance use screening rates and practices in primary care. Subst Abus. 2012;33(4):321-326.
13. Lunstead J, Weitzman ER, Kaye D, Levy S. Screening and brief intervention in high schools: School nurses’ practices and attitudes in Massachusetts. Subst Abus. 2017;38(3):257-260.
14. Monitoring the Future: 2020 Survey Results. National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services. https://www.drugabuse.gov/drug-topics/related-topics/trends-statistics/infographics/monitoring-future-2020-survey-results Updated December 17, 2020. Accessed December 2, 2021.
15. CDC. Youth Risk Behavior Surveillance—United States, 2019. MMWR Suppl 2020;69(1):1-83.
16. NIDA. Why do adolescents take drugs?. National Institute on Drug Abuse website. https://www.drugabuse.gov/publications/principles-adolescent-substance-use-disorder-treatment-research-based-guide/frequently-asked-questions/why-do-adolescents-take-drugs. Updated May 24, 2020. Accessed July 12, 2021.
17. NIDA. Alcohol. National Institute on Drug Abuse website. https://teens.drugabuse.gov/drug-facts/alcohol. Updated June 25, 2021. Accessed July 12, 2021.
18. NIDA. Marijuana. National Institute on Drug Abuse website. https://teens.drugabuse.gov/drug-facts/marijuana. Updated June 25, 2021. Accessed July 12, 2021.
19. Squeglia LM, Jacobus J, Tapert SF. The influence of substance use on adolescent brain development. Clinical EEG and neuroscience. 2009;40(1):31-38.
20. The TEDS Report: Age of Substance Use Initiation among Treatment Admissions Aged 19 to 30. Substance Abuse and Mental Health Services Administration. http://www.samhsa.gov/data/sites/default/files/WebFiles_TEDS_SR142_AgeatInit_07-10-14/TEDS-SR142-AgeatInit-2014.htm. Published July 14, 2014. Accessed December 2, 2021.
21. Levy S, Williams J; Committee on Substance Use and Prevention. Substance Use Screening, Brief Intervention, and Referral to Treatment. Pediatrics. 2016; 138(1): 2016-1210. DOI: 10.1542/peds.2016-1210.
22. Silvers JA, Squeglia LM, Rømer Thomsen K, et al. Hunting for what works: Adolescents in addiction treatment. Alcoholism: Clinical and Experimental Research. 2019; 43(4): 578-592.
23. Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings. Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/data/sites/default/files/NSDUHresults2012/NSDUHresults2012.pdf. Published September, 2013. Accessed December 2, 2021.
24. Hingson RW, Wenxing Z, Iannotti RJ, Simons-Morton B. Physician Advice to Adolescents About Drinking and Other Health Behaviors. Pediatrics. 2013;131: 249.
25. Juszcack L, Melinkovich P, Kaplan D. Use of health and mental health services by adolescents across multiple delivery sites. Journal of Adolescent Health. 2003; 32(6 Suppl): 108-118.
26. Paschall MJ, Bersamin, M. School-based mental health services, suicide risk, and substance use among at-risk adolescents in Oregon. Preventive Medicine. 2018; 106: 209-215.
27. Hanes M. Effects and Consequences of Underage Drinking. Juvenile Justice Bulletin. 2012.