It is undoubtedly a critical time in this country to address the complexities of how to effectively prevent, treat, and help people recover from substance use disorders. As many parts of the country struggle to reduce the impact of the current opioid epidemic and help people rebuild their lives, others are contending with the new reality of cannabis legalization and the possible implications for youth.
Meanwhile, others are calling attention to rising rates of alcohol use, high-risk drinking, and alcohol use disorders, particularly among women, older adults, racial/ethnic minorities, and the socioeconomically disadvantaged. These trends are occurring against the backdrop of progress in driving down all areas of youth illicit substance misuse except marijuana. One example is underage drinking, which is at the lowest rate ever recorded in the annual national study of students that is funded by the National Institute on Drug Abuse. (See the Monitoring the Future study for more details.)
This is the time to double down on prevention investments. We know that 90 percent of people who develop a substance use disorder started with use during the adolescent years, and the earlier they start, the more likely it is that they will develop a problem. Fortunately, progress has occurred over the past thirty years in developing and implementing evidence-based prevention approaches.
Now a new frontier in prevention is emerging, focused on developing early intervention approaches by health care practitioners and other service providers to address risky substance use among young people before serious problems develop. While these conversations can be an opportunity to deliver preventative messages and link those in need to clinical treatment services, the primary target for early intervention approaches is young people who have started to use alcohol or other drugs and perhaps have even begun to experience negative effects, but don’t yet need specialty substance use disorder treatment services. These early intervention approaches are delivered as part of a comprehensive public health framework, most commonly referred to as Screening, Brief Intervention, and Referral to Treatment (SBIRT), and they provide promise for engaging and empowering young people to lead healthy, full lives unhampered by substance misuse.
SBIRT provides strategies to engage young people in conversations that build upon the sense of autonomy that is often a hallmark of adolescence. By using motivational interviewing, an evidence-based practice, brief intervention approaches focus on helping young people to strengthen their motivation for, and commitment to, change. Like adults, many young people use alcohol and other drugs to cope with stress, violence, or other adversities, or to manage mental health conditions such as anxiety and depression.
Early identification and intervention approaches like SBIRT can help providers understand and respond to the root causes that are driving the substance use. For young people, school-based health clinics (SBHCs) are one setting in which to provide these potentially life-saving interventions.
As part of its new Substance Use Prevention strategic initiative launched in 2013, the Conrad N. Hilton Foundation invests approximately $11 million a year in testing various screening and early intervention approaches to find better ways of addressing substance use early on, before it reaches a crisis level.
Until recently, there had been little emphasis on supporting the role of school health clinics in providing substance use services to youth. To address this gap, the Hilton Foundation has partnered with funders including Interact for Health and the California Community Foundation to invest in SBHCs for implementation of screening and early intervention approaches like SBIRT in several communities in Ohio and in several student health and wellness centers in Los Angeles. Partnerships have also been developed with the School-Based Health Alliance and the University of New Mexico (UNM) to strengthen implementation and learn more about how to build better collaboration between schools, SBHCs, community providers, and youth to address alcohol and other drug use as part of routine school health care.
Findings From Substance Use Prevention In SBHCs
A number of compelling findings have emerged from the first phase of work. We have learned that with support and encouragement, SBHCs can and will incorporate SBIRT into practice. Providers that have implemented SBIRT indicate that it has been valuable in increasing their awareness of substance use and other mental health issues in schools where they work.
Some schools have successfully used SBIRT as an alternative to discipline, by directing staff to send students with behavioral health and substance use concerns to the SBHC for assistance. Fortunately, there is a growing sense of urgency about implementing SBIRT-type approaches in school-based health programs. Sixty-nine percent of SBHCs provide some type of substance use screening, but just 10 percent have a trained alcohol and drug counselor on staff. A recent survey of SBHC providers in New Mexico shows that the vast majority of such providers feel a sense of responsibility for providing substance use care. However, experience tells us that screening does not occur universally in health care settings that serve youth, including SBHCs, nor do providers use validated screening tools. Universal screening and use of validated screening tools are essential components of an evidence-based approach.
Providers often lack confidence in talking to young people about alcohol and drugs because they do not receive training about substance use disorder prevention, treatment, or recovery as part of their medical education. As a result, most do not ask because they may not know what to do with the answer! Training regarding SBIRT best practices is critical to addressing these issues.
Strengths Of The SBHC Model
The SBHC model has a number of unique strengths that make SBIRT adoption a realistic goal. Because SBHCs are located on school grounds but are not actually part of the school, students have the convenience to their school with the added benefit of being able to engage in confidential health services outside of the jurisdiction of the school. The promise of confidentiality allows students to be more open and forthcoming about topics such as substance use and related issues like home and school problems, depression or anxiety, thoughts of self-harm or suicide, and sexual health questions. Confidentiality helps build trust, which is especially important for engaging adolescents in conversations about sensitive health issues.
In rural states such as New Mexico, where the Hilton Foundation has been investing in SBIRT through a grant to UNM, SBHCs provide access to otherwise very limited primary care and behavioral health services for adolescents. This is particularly important for vulnerable youth, who may be low income, uninsured (for example, undocumented immigrants), racial and ethnic minorities, or LGBTQ.
LGBTQ youth in New Mexico who use SBHCs reported receiving patient-centered care as often as did their straight peers, an important measure that suggests that SBHCs may be important access points for sexual minority youth, who tend to have higher rates of substance misuse. New Mexico’s data show that the majority of students who received services from the SBHCs reported those services included behavioral health care. These data underscore the importance of SBHCs in providing substance use services and the need to continue to support and prepare SBHC providers to address substance use as part of routine adolescent health care.
In collaboration with our partners, we are working to provide training and technical assistance to providers, change policy, and build the evidence base needed to ensure that screening and early intervention approaches—like SBIRT—become part of routine care in SBHCs.
“School-Based Health Centers: A Funder’s View Of Effective Grant Making,” by Susan M. Sprigg, Francie Wolgin, Jennifer Chubinski, and Kathryn Keller, GrantWatch section, Health Affairs, April 2017 issue.