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    It is impossible to overstate the negative impact that substance abuse has on individuals, families, and society. Addiction is arguably the greatest public health threat that we face in the US. When training on substance use disorders (SUDs), I describe it as a unique and complex issue in that it is like an octopus that has its tentacles wrapped up in every societal problem. 

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Helping Adolescents Connect to Specialty Addiction and Mental Health Treatment

Feature Articles

Alcohol and other drug use can negatively affect adolescents’ physical and mental health. It is associated with the major causes of mortality and morbidity in this age group, and can seriously disrupt healthy development (Clingempeel, Henggeler, Pickrel, Brondino, & Randall, 2005; Grella, Hser, Joshi, & Rounds-Bryant, 2001; Mertens, Flisher, Fleming, & Weisner, 2007; Sterling & Weisner, 2005; Subramaniam & Volkow, 2014; Wu, Gersing, Burchett, Woody, & Blazer, 2011). For those with more severe alcohol and drug problems or significant mental health symptoms, specialty addiction or mental health treatment can improve outcomes (Godley, Godley, Dennis, Funk, & Passetti, 2002; Godley, Godley, Dennis, Funk, & Passetti, 2007; Liddle, 2016). However most teens who could benefit from specialty treatment do not receive it, even if they are referred; it is estimated that only about one third of adolescents in need of specialty treatment for mental health or alcohol and drug problems actually start treatment (Merikangas et al., 2011).

 

Screening, brief intervention, and referral to treatment (SBIRT) is a public health approach to early identification and intervention for alcohol and drug problems which includes referral to specialty care for those with serious enough problems to warrant additional assessment and treatment. SBIRT has been widely endorsed by pediatric medical organizations such as the American Academy of Pediatrics (AAP), the Substance Abuse and Mental Health Services Administration (SAMHSA), and the National Institutes of Health (NIH; Levy, Williams, & Committee on Substance Use and Prevention, 2016). Although referral to treatment is an essential component of SBIRT, most studies of brief interventions for adolescents have focused specifically on reducing alcohol and other drug use (Harris et al., 2012), delaying use initiation (Walton et al., 2014), or driving while intoxicated (Bernstein et al., 2010). 

 

However, a key goal of SBIRT is getting adolescents with severe problems to access specialty care and few studies have focused on this (Glass et al., 2015). It is important to understand the most effective ways to refer these patients to specialty treatment, where their emerging behavioral health problems can be addressed more thoroughly and effectively than in primary care. 

 

What Do We Know So Far? 

 

To date, few studies have focused on the effects of SBIRT on specialty addiction and mental health treatment initiation among adolescents. A randomized trial conducted in Australia examined the effects of a brief intervention on teens presenting in the emergency department for an alcohol-related event (Tait, Hulse, & Robertson, 2004). The intervention included a facilitated referral to specialty treatment which consisted of a supportive counselor who helped patients identify and overcome barriers to treatment, helped them to make initial treatment appointments, called to remind them of treatment intake appointments, and assisted with transportation. This facilitated referral model was compared to emergency department care as usual. Adolescents who received the intervetion were more likely to start addiction treatment, and those who did start treatment had better substance use and emotional outcomes than those who did not (Tait et al., 2004). To our knowledge, however, no studies have examined the effectiveness of different approaches to delivering SBIRT in pediatric primary care on facilitating specialty treatment initiation and engagement.

 

The challenges facing primary care providers trying to incorporate behavioral health screening and intervention during the course of regular visits are well documented. Competing clinical priorities pose a significant challenge to incorporating new activities into ever more packed clinical workflows. There are over 150 preventive health directives pediatricians are advised to provide during the course of adolescent well care, and shorter pediatric visit appointment times are associated with lower quality of care and less opportunity for preventive health screening, including psychosocial assessments and intervention (Belamarich, Gandica, Stein, & Racine, 2006). Training deficits pose another challenge; two-thirds of pediatricians report lack of training in treatment of children’s behavioral health needs (Horwitz et al., 2015).

 

Innovative approaches to delivering integrated pediatric behavioral health care need to be considered to address this challenge. Different models have been developed in recent years, from facilitating consultation by child and adolescent specialists to on-site care coordination to colocation of pediatric primary care and behavioral health services. Most new approaches in health care involve pediatric health teams, including primary care pediatricians, specialty health care services (such as dermatology), and specialty mental health care clinicians (Committee on Psychosocial Aspects of Child and Family Health, 2009). However, clinicians and health policy professionals need to know more about what is needed to expand the capacity of pediatricians to address common behavioral health risks by using such care team members. In this way, pediatricians will be allowed to more thoroughly address important competing health topics within the limited appointment window.

 

The current study compared the effectiveness of two different modalities of delivering SBIRT in pediatric primary care (delivered by a pediatrician or by a counselor embedded in the clinic) with usual care, and compared rates of specialty addiction and/or mental health treatment initiation among patients referred to specialty care for alcohol and drug and/or mental health problems. Differences between the counselor-delivered and pediatrician-delivered models were also examined. 

 

We examined both specialty addiction and mental health treatment. Our previous pilot experiences and anecdotal evidence from both patients and physicians suggested that many patients and families find the prospect of entering addiction treatment daunting. Trying mental health treatment first is often more palatable to families, perhaps due to the lingering stigma often associated with addiction treatment. Based on these findings, combined with the fact that substance use and mental health problems are frequently comorbid (Grella, Joshi, & Hser, 2004; Sterling & Weisner, 2005; Sterling et al., 2003), we considered endorsement of either substance use or mood symptoms, or pediatricians’ clinical judgment, as sufficient reason for SBIRT delivery. 

 

Setting and Participants

 

The study was conducted in Kaiser Permanente Northern California’s (KPNC) Oakland Pediatrics Clinic from 11/1/2011–10/31/2013. KPNC is a nonprofit integrated health care delivery system serving approximately four million members and provides specialty addiction and mental health services internally, which are covered benefits for the majority of members. KPNC’s Oakland Pediatrics Department treats a racially and socioeconomically diverse population (Sterling et al., 2015). 

 

All pediatricians in the clinic (n=52) were randomized to one of three study arms:

 

  1. Pediatrician arm: Pediatricians were trained to assess alcohol and drug use and mental health problems using evidence-based screening tools, deliver brief interventions (BIs), and refer patients to specialty treatment
  2. Counselor arm: Pediatricians were trained to refer adolescents who endorsed AOD use and/or mental health problems to a counselor, embedded in the clinic, who delivered brief interventions and referrals
  3. Usual care (UC): Care administered as usual. UC-arm pediatricians addressed patient-reported AOD use and/or mental health symptoms per their usual practice, which might have varied based on expertise, time, interest, and clinical presentation 

 

Patients aged twelve to eighteen were eligible for the study, and there were no exclusion criteria. Patients were not recruited to the study or informed of which study arm included their pediatrician. The study was approved by the institutional review boards of KPNC and University of California, San Francisco.

 

Training and Intervention Workflow

 

Pediatricians in both intervention arms were offered on-site continuing medical education trainings—three sixty-minute sessions in the pediatrician-only arm, and one sixty-minute session in the counselor arm—for which they received lunch and continuing education credit. In the pediatrician arm, 64 percent of pediatricians attended at least two trainings. In the counselor arm, 75 percent of pediatricians attended the training. Pediatricians in both arms received supplemental recordings and slides, and research staff was available for technical assistance. Performance feedback and discussion of SBIRT techniques were provided at quarterly meetings. 

 

Trainings in the pediatrician arm covered: 

 

  • Adolescent alcohol and drug use and mental health prevalence, comorbidity, and consequences
  • Assessment
  • Brief intervention strategies for substance use—motivational interviewing (MI) skills (Miller & Rollnick, 2012), decisional balance exercises, and goal-setting—and depression (e.g., empathic listening, psychoeducation, problem-solving, behavioral activation, stress reduction, exploration of challenges in interpersonal relationships; Stein, Zitner, & Jensen, 2006)
  • Protocols for referring patients to specialty addiction and mental health treatment

 

Pediatricians in the pediatrician and usual care arms, if they delivered SBIRT, incorporated all SBIRT components, including referral to specialty treatment services, into their regular clinical workflow and well-visit appointment times (typically fifteen to thirty minutes). 

 

Pediatrician training in the counselor arm covered similar elements, but focused less on intervention delivery and more on how to assess severity and refer patients to the embedded counselor. The counselor was a licensed clinical psychologist who received ten hours of MI-based SBIRT training, and had prior adolescent depression and alcohol and drug treatment experience. She provided brief cognitive-behavioral-therapy-based treatment and crisis management for substance and mood problems, and received weekly clinical supervision with the study intervention trainer, an experienced clinical psychologist. Pediatricians in the counselor arm were able to call her directly, and she was available during clinic hours, and could generally meet with patients immediately following their primary care appointment, or could schedule a future appointment if patients were unable to stay. 

 

Typically, the workflow consisted of the pediatrician calling the counselor, who would come to the exam room within several minutes. The pediatrician would introduce the counselor as a “lifestyle clinician” who was there to meet with the teen for a “brief healthy living check-up.” A confidential meeting between the counselor and teen would then occur within the pediatric exam room, unless the pediatrician required the room right away. If this occurred, the teen would be taken to the counselor’s private office, located within the same building as the pediatrician. Sessions typically lasted thirty to sixty minutes and consisted of SBIRT activities, with potential additional follow-up phone interactions to facilitate referrals to specialty programs. In the counselor arm, the counselor provided patients with information regarding the health system’s mental health and addiction treatment programs. The counselor was also available for additional follow-up phone interactions to facilitate referrals, as needed. 

 

The challenge of providing confidential alcohol and drug and other counseling services in real-world pediatric primary care is a frequently cited barrier to implementing SBIRT (Sterling, Kline-Simon, Wibbelsman, Wong, & Weisner, 2012), and hesitation on the part of parents and/or guardians about allowing their children to participate in the confidential brief intervention was anticipated. However, such fears were unwarranted as parental concerns appeared to be assuaged by the benign framing of the intervention (i.e., a “brief healthy living check-up”) as well as normalization of conversations about alcohol and drugs and mental health symptoms as being a regular and integral part of the child’s pediatric well-vist. No complaints or refusals were obtained.

 

Per the clinic’s regular clinical workflow, all adolescents presenting for well-visits completed the Teen Well Check Questionnaire (TWCQ), a comprehensive health screening instrument created by health system clinical leaders and based on the Bright Futures (Simon et al., 2014) screening guidance. TWCQ responses are entered into the patient’s electronic health record (EHR). The TWCQ includes items on past-year (Yes/No) alcohol, marijuana and other drug use, and recent depression symptoms. For example, “During the past few weeks, have you often felt sad, down, or hopeless?” and “Have you seriously thought about killing yourself, made a plan, or tried to kill yourself?” These five items served as the initial substance use and mental health risk screening questions, and endorsement of any of these items, or pediatrician clinical judgment, triggered further assessment of substance use-related problems using the six-item CRAFFT adolescent substance use problem screening instrument (Knight, Sherritt, Shrier, Harris, & Chang, 2002), also already embedded in the EHR, and brief intervention or referral to specialty addiction or mental health treatment, as needed. 

 

Measures and Data Sources 

 

Pediatrician age, gender, and years of experience, and patient age, sex, and race/ethnicity (Asian, black, Hispanic, white, and other/missing), as well as specialty treatment utilization, were extracted from the EHR. Manual review of clinical notes identified referrals to specialty treatment within KPNC.

 

Outcomes

 

The primary outcomes of specialty mental health and addiction treatment initiation and engagement were calculated among patients referred to treatment, and were defined as having at least one visit to either a mental health or addiction program within six months of the respective referral. We used this relatively long time window because it is common for families to delay treatment entry. We examined both types of treatment as appropriate referral destinations for either substance use or mental health problems because our previous experience in this system, noted previously, suggested that families and pediatricians often prefer to have the adolescent initially obtain care in mental health over addiction treatment, regardless of their symptoms. Specialty treatment engagement was calculated among patients who were referred to and initiated treatment, and was defined as having at least two visits to the same type of treatment (addiction or mental health) within thirty days. 

 

Statistical Methods

 

The primary outcome was initiation of specialty addiction or mental health treatment. Analyses included only those who were referred to specialty treatment, rather than including all patients who endorsed substance use or mental health problems, many of whom had only mild symptoms and thus were not appropriate for referral. ANOVA and chi-square tests examined bivariate treatment arm differences between continuous and categorical patient characteristics, respectively. Chi-square tests were also used to examine differences between treatment arms and treatment initiaton and engagment rates. Multivariate logistic models examined differences in initiation to specialty addiction or mental health treatment across the three arms (UC [reference]) and between the two intervention arms only (Pediatrician-only [reference]) adjusting for patient charactersitics. Due to sample size limitations, engagment could not be modeled using logistic regression and is only examined using chi-square analyses. A more detailed report of analyses are reported by Sterling et al. (2017). Analyses were performed using SAS statistical software, version 9.3; significance was defined at p<.05. 

 

Results

 

There were 1871 patients deemed eligible for further assessment based on endorsement of substance use or mental health problems on the screening questionnaire or pediatrician clinical judgment. Among these patients, 18 percent were referred to specialty addiction or mental health treatment. More females (61.3 percent vs. 54.6 percent, p=0.025) and younger patients (mean=15.6 SD=1.5 vs. mean=15.9 SD=1.5, p<.001) were referred to treatment; race/ethnicity did not differ between those referred and not. The counselor arm had fewer referrals (13.9 percent) than the pediatrician-only (21.6 percent) and UC arms (18.5 percent, p=0.002).

 

Patient Demographics

 

The counselor arm referred fewer Asian and white patients and more Hispanic patients compared with the pediatrician and UC arms. Gender and age of patients referred did not differ across the arms. 

 

Specialty Addiction or Mental Health Treatment Initiation

 

Among those referred, 27 percent initiated either addiction or mental health treatment. Patients in the counselor arm had almost four times higher odds of starting either addiction or mental health treatment than the pediatrician arm patients (OR=3.99, CI=1.99-8.00). The pediatrician arm had lower odds of starting addiction or mental health treatment compared with the UC arm (odds ratio [OR]=0.53, 95 percent confidence interval [CI]=0.28-0.99) while those in the counselor arm had higher odds of starting than those in UC, although the difference only approached significance (OR=1.83, CI=0.99-3.38). Black patients had lower odds of starting addiction or mental health treatment compared with white patients (OR=0.47, CI=0.23-0.95); there were no gender or age differences. Both black patients (OR=0.32, CI=0.13-0.81) and those with other or unknown race/ethnicity (OR=0.12, CI=0.02-0.69) had lower odds of starting treatment compared with whites in the intervention-only model. 

 

Specialty Addiction or Mental Health Treatment Engagement

 

Among those who were referred and started specialty addiction or mental health treatment, 92 percent engaged in treatment. No differences were found in treatment engagement across study arms: 95.2 percent pediatrician-only, 91.7 percent counselor, 90.6 percent UC, p=0.823. 

 

Discussion

 

The question of how effective referral to treatment (the “RT” in SBIRT) is for facilitating treatment initiation among patients whose substance use, or risk for use due to mental health problems, is serious enough to warrant specialty addiction or mental health services has rarely been examined in adolescents (Glass et al., 2015). Only one previous study examined the effects of referral to treatment among adolescents, and they found that those receiving the intervention had higher rates of starting specialty treatment than controls. However, that study was based in an emergency department (Tait et al., 2004). We examined specialty treatment initiation and engagement rates among adolescents who received SBIRT delivered by pediatricians, an embedded counselor, or who received UC. Results indicated that SBIRT can indeed be effective at increasing specialty treatment initiation, especially when delivered by a trained behavioral health clinician. 

 

Initiation rates of addiction or mental health treatment, among those referred to treatment, were almost four times higher in the counselor arm compared to the pediatrician arm. The lower rates in the pediatrician arm maybe be due to patients feeling that they had received enough services from their pediatrician, a known and trusted professional trained in brief intervention, such that they preferred not to enter specialty behavioral health treatment. Alternatively, they may have decided to schedule a return visit with their pediatrician for further discussion rather than starting specialty treatment. The odds of starting treatment in the counselor arm was also almost twice as high as in UC, though the difference was not statistically significant. This suggests that embedded counselors may be more effective than pediatricians in facilitating adolescent patient referrals to specialty treatment. 

 

The counselor arm had fewer referrals to specialty addiction or mental health treatment than either the pediatrician or the UC arms (Sterling et al., 2015), which could be explained by counselors having more time to address behavioral health problems in primary care, thus alleviating the need for referral to specialty treatment for those patients. 
[H1]Providing Time and Space in Pediatric Primary Care to Talk About Emotional Distress and Reduce Stigma
“Cyrus,” a seventeen-year-old, was referred by his pediatrician given his mother’s concern about his emotional distress and unhealthy strategies for coping with grief and trauma resulting from exposure to neighborhood violence. Cyrus had recently lost two close friends to gun violence. He met with the counselor and disclosed his tendency to keep private matters to himself: “My mom thinks that something is wrong because I don’t talk about it [the recent deaths]. But I know that I can’t do anything about what happened, so I just move forward.” The potential negative effects of remaining emotionally isolated were discussed, as were positive and negative coping strategies, and the benefits of seeking social support. While he declined a referral to mental health, Cyrus decided to try opening up and speaking more about his private grief with trusted friends and family members given, “I know that not sharing things can hurt me. So, I need to do it more.” 

 

The length and extent of this interaction was possible because the counselor had more time to talk to the patient than would have been available to his pediatrician during a typical visit. The lower rates of treatment initiation among patients in the pediatrician arm may also reflect the relatively limited time pediatricians have with their patients, and their relative lack of expertise with behavioral health problems, compared to counselors. With training in behavioral health and knowledge of health system and community mental health and alcohol and drug treatment resources, counselors may have greater capacity to effectively facilitate treatment referrals. For patients with more severe problems, counselors may have more knowledge of the appropriate clinical services, and more time to motivate patients and their families and help them navigate logistical and stigma-related barriers (e.g., helping to schedule and remind families of appointments, which may help facilitate treatment initiation). In fact, in this study the counselor often acted as an intermediary between the patient and/or family and specialty services: clarifying dates and times of appointments, directing the families to their appointment locations, and communicating between parties (i.e., patients, families, and specialty clinicians) if they were having difficulty connecting or if the patient did not follow through with the referral. A counselor in this role could be particularly advantageous in health care systems without integrated addiction and mental health services, in which access to treatment may be more challenging and pediatricians may be less familiar with specialty care services available in the community. 

 

Another potential advantage of the embedded-counselor approach in pediatric primary care is that alcohol and drug use may not always emerge during brief conversations with the pediatrician during the check-up, even when using screening tools. We found in our earlier studies that many teens may initially endorse only mood or anxiety symptoms, and only disclose alcohol or drug use later, in the course of a more in-depth assessment than is typically feasible during busy primary care visits (Sterling et al., 2012). 

 

“Anita,” a seventeen-year-old study participant, was referred by her pediatrician for endorsement of stress in the questionnaire that she filled out prior to seeing the pediatrician during an annual check-up. She had not endorsed any alcohol or drug use. Upon meeting with the counselor, Anita described feeling so overwhelmed by academic pressures that she had quit attending classes altogether. In addition, she had begun to use marijuana on a daily basis, to “help me chill out and relax.” Interestingly, in addition to not endorsing alcohol or drug use on  the previsit screening questionnaire, she had not divulged her substance use patterns to her physician during her check-up, and this information only emerged during the interview with the counselor. 

 

Primary care settings may offer a less stigmatizing environment to address challenges than traditional outpatient mental health and substance use treatment settings (Davis, Berry, & Shaw, 2008). Embedded counselors, in particular, might also serve to destigmatize mental health care. Seeing the counselor in the same exam room immediately during the course of the medical appointment may make the idea of counseling less threatening, particularly for individuals and families who have never interfaced with the mental health department. In this study, we found that black adolescents were less likely to initiate specialty addiction or mental health treatment compared to whites. This finding is consistent with the growing body of evidence suggesting that nonwhite ethnic groups are less likely to access needed specialty treatment even in integrated health systems without access problems (Campbell, Weisner, & Sterling, 2006; Satre, Campbell, Gordon, & Weisner, 2010). It may be the result of heightened stigma around mental health and substance use problems and treatment (Alegría, Carson, Goncalves, & Keefe, 2011; Gary, 2005; Knifton et al., 2010; Mulvaney-Day, DeAngelo, Chen, Cook, & Alegría, 2012; Rose, Joe, & Lindsey, 2011) or concerns these families may have about mental health or addiction treatment. Providers or health systems adopting SBIRT should consider whether families and patients of color may need additional support and encouragement to access needed specialty treatment (Manuel et al., 2015), and whether access to a counselor trained in substance use and mental health problems based in pediatric primary care may better meet their needs and preferences. Additionally, specialty treatment programs may need to assess whether current programming, treatment approaches and staffing are equipped to appeal to and meet the linguistic and cultural needs of increasingly diverse patient populations, and may need to do more outreach to these patient populations (Alegría, Alvarez, Ishikawa, DiMarzio, & McPeck, 2016).

 

We found no differences in engagement rates in specialty addiction or mental health treatment across the three arms, all of which were over 90 percent. This is noteworthy, and suggests that once adolescents initiated treatment, patient and specialty treatment providers or milieu factors may have had more influence on retention than how they were referred there. 

 

Limitations

 

There are a number of limitations to this study. It was conducted in an integrated health care delivery system with an insured population in which adolescent patients’ parents received insurance through employment, Medicaid, or individual health plans, and may not be generalizable to uninsured populations. KPNC has integrated mental health and addiction treatment programs and clinician practices, which may result in differences in treatment accessibility compared to other settings.

 

Because of the significant co-occurrence of substance use and mental health problems among adolescents, we opted to examine both substance use and mental health problems as an inclusive definition of substance use risk. This is consistent with current recommendations of SBIRT for the spectrum of risk, including “preventing or delaying the onset of substance use in lower-risk patients, discouraging ongoing use and reducing harm in intermediate-risk patients, and referring patients who have developed substance use disorders for potentially life-saving treatment” (Levy et al., 2016). Consequently, adolescents were deemed eligible for further assessment if they endorsed either substance use or mental health problems, and we examined both specialty addiction and mental health treatment utilization. Thus, some of the patients did not explicitly endorse substance use problems, and some of the patients initiating treatment in mental health may not have been at risk for development of a substance use problem. This inclusive approach is also one which may be more acceptable and efficient for health systems if they are going to provide a counselor, helping to maximize the utility of these professionals in primary care settings. 

 

It is possible that specialty treatment utilization was underestimated due to some patients seeking care outside of KPNC, which would not have been recorded in the EHR. However, since both mental health and addiction are covered benefits, we expect such outside utilization to have been minimal. Referral data also relied on the accuracy of provider documentation in the EHR, which likely varied both across pediatricians and between pediatricians and the counselor. 

 

Summary

 

This study contributes to the adolescent SBIRT literature by providing valuable information regarding the relative effectiveness of different approaches to SBIRT at facilitating treatment initiation among adolescents. Our findings suggest that SBIRT can be effective in helping patients initiate specialty treatment, but that pediatricians might benefit from the support of other clinicians with substance use and mental health assessment and brief treatment expertise. Health systems should consider the use of pediatric-primary-care-embedded counselors as a way to serve more adolescent patients with mild to moderate behavioral health problems in primary care (Sterling et al., 2015), and to facilitate initiation in appropriate specialty treatment for those with more severe problems.

 

Acknowledgements: This research was supported by a grant from the National Institutes of Health/National Institute on Alcohol Abuse and Alcoholism (R01AA016204). The authors have no conflicts of interest relevant to this article to disclose. We thank Agatha Hinman for editorial assistance with the manuscript. We thank the KPNC Adolescent Chemical Dependency Coordinating Committee, the KPNC Adolescent Medicine Specialists Committee, Anna O. Wong, PhD, Patricia Castaneda-Davis, MD, and Jennifer Mertens, PhD, for their guidance. We also thank David Bacchus, MD, and all the physicians, medical assistants, nurses, receptionists, managers, and especially the patients and parents of KPNC’s Oakland Pediatrics clinic, for their participation in the activities related to this study. 

 

 

 

 

 

 

 

 

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Editor’s Note: This article was adapted from an article by the same authors previously published in the Journal of Substance Abuse Treatment (JSAT). This article has been adapted as part of Counselor’s memorandum of agreement with JSAT. The following citation provides the original source of the article:

Sterling, S., Kline-Simon, A. H., Jones, A., Satre, D. D., Parthasarathy, S., & Weisner, C. M. (2017). Specialty addiction and psychiatry treatment initiation and engagement: Results from an SBIRT randomized trial in pediatrics. Journal of Substance Abuse Treatment, 82, 48–54.