In 2013, the Conrad N. Hilton Foundation launched a national strategic initiative to transform how substance use by young people is identified and addressed. Historically, youth substance use has been viewed through the lens of either preventing initiation or providing specialty substance use treatment when problems had become severe. At that point, little work had been done to develop approaches to identify and engage youth who use alcohol or other drugs but who do not yet meet criteria for needing intensive services. Although the concept of early intervention had been advanced in the mental health field, it had not really caught on in the substance use field. This despite a multiyear investment by the Substance Abuse and Mental Health Services Administration in advancing an early intervention framework developed for adults referred to as Screening, Brief Intervention and Referral to Treatment or SBIRT. SBIRT is a public health approach to the delivery of early intervention and treatment to people with substance use disorders (SUD) and those at risk of developing these disorders. Screening quickly assesses the severity of substance use and identifies the appropriate level of treatment using evidence-based instruments. Brief Intervention focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change. Referral to Treatment provides those identified as needing more extensive treatment with information about specialty care.
Although some of the Substance Abuse and Mental Health Services Administration funding had been used by states to explore providing SBIRT for young people, like in New Mexico where SBIRT was provided in school-based health centers, in general, there was not an emphasis on youth as a primary population of focus for the funding. Meanwhile, several health systems, including Boston Children's Hospital and Kaiser Permanente in Northern California, were pioneering learning about how to use SBIRT with young people. Based in part on this early work, in 2011 the American Academy of Pediatrics issued its first policy statement in support of providing SBIRT as part of routine care in pediatric settings.
The Hilton Foundation had a long history of investing in substance use prevention for youth dating back to the 1980s and was interested in charting a new direction for their funding. After a lengthy research, analysis, and strategy development process the Board of Directors approved a 5-year plan to invest in advancing SBIRT and other early intervention approaches for youth. They were motivated to focus on SBIRT by several important developments in the substance use field such as the ongoing effort to address substance use as a health issue as opposed to a criminal justice or moral issue. Interviews with key leaders in the field expressed enthusiasm for the idea that SBIRT could be adapted and developmentally tailored to serve youth. Finally, there was growing recognition of the need to bridge the gap between prevention and treatment, particularly for youth, to ensure young people who were using alcohol or other drugs but not in need of clinical services were receiving the support needed to make healthy and safe decisions.
Ultimately, during the course of the 6-year investment the Foundation awarded over $81 million to fund the work of 56 grantees. Through the investment, diverse types of organizations came together to try new ideas, develop and share learning, and change the way their organizations addressed early and risky substance use in youth. Although SBIRT had been primarily viewed through a health systems lens, the Foundation implemented its strategy with the intent of also serving youth in non–healthcare settings, such as community-based organizations, schools, juvenile justice programs, and community behavioral health organizations. In broadening the scope beyond traditional healthcare settings, the Foundation wanted to acknowledge the racial disparities that exist around access to health care for young people of color by emphasizing the importance of including other settings in the community that serve large numbers of youth of color. It also provided an important opportunity to follow best practice in youth services of “meeting youth where they are.”
The papers presented in this supplement address the critical issues and research findings pertaining to the implementation and effectiveness of SBIRT for youth and young adults. The authors highlight what we know and do not know about the effectiveness of adolescent SBIRT across a diverse set of developmentally appropriate outcomes, including substance use initiation, substance use quantity and frequency, treatment initiation and engagement, comorbid mental and physical health conditions, healthcare and other services utilization, connection to social supports, youth experience of SBIRT, and education and job placement. The papers provide insights on expanding the definition of brief intervention, describe variability in intervention messages, and implementation across different settings.
In addition to the outcomes discussed in this supplement, several key recommendations emerged from the strategic initiative to help shape the future of substance use care for young people:
Provide education and training to health professionals and other youth-serving providers to normalize conversations about substance use as part of overall adolescent health and well-being. The lack of education within health professional training programs about substance use and SUDs is well-documented. This challenge is often cited as a barrier to providing substance use services in healthcare settings. This limited education and training often leads to low self-efficacy about addressing these concerns and resistance from providers who feel substance use prevention and early intervention is a “social issue” outside of their purview and skill set, and not a priority in busy healthcare practices.
Many of the organizations that participated in the strategic initiative indicated that the SBIRT framework provided a valuable opportunity to initiate education and training for providers about substance use as part of the health continuum. This included important information about how people who develop SUDs typically initiate use during adolescence and therefore why it is critically important to intervene to address youth substance use during this period. In addition, it gave providers new language and a set of tools to talk to young people and their parents/caregivers about substance use, the same way they would any other health issue, without judgment or shame. Similarly, in other settings like schools and workforce development programs, education and training of staff provided a critical opportunity to reframe what had traditionally been a punitive perspective or disciplinary issue as something that instead should be addressed with nonpunitive supportive and therapeutic interventions.
Include early intervention in the continuum of care for youth to address substance use before crisis occurs. The strategic initiative explored the opportunity to build out the middle of the continuum of substance use problems that exists between primary prevention and clinical specialty treatment services. Early intervention is a relatively new concept in the substance use field that has not benefited from a great deal of research and program and model development. Similar to harm reduction philosophy, early intervention approaches, including SBIRT, provide an opportunity to engage young people who may be using alcohol or drugs in a patient-centered way, with their goals for their health and well-being front and center. Rather than lecturing about the dangers of drugs using the “Just Say No” tagline, or ignoring the substance use all together, early intervention provides an opportunity to understand why the young person is engaging in substance use and a process for identifying strategies to address those needs. Brief intervention uses evidence-based motivational interviewing techniques to meet young people where they are and explore ambivalence about substance use. In addition, partners indicated that the approach is complementary to best practice in tailoring programs to adolescent development research. It builds on adolescents' growth of autonomy and sense of self-direction during this important developmental time.
Involve youth and peers in the development of programs to improve the likelihood that the approaches and models resonate with young people and are culturally appropriate. SBIRT was initially developed for adults in emergency departments and primary care settings. The Foundation's investment in adolescent SBIRT provided an opportunity to elevate youth voices in developing intervention messaging and framing, testing peer-based interventions delivered by youth with the lived experience of being in recovery from an SUD and engaging racially and culturally diverse groups of adolescents in research and strategy development to inform appropriate adaptions. Research shows that providing culturally appropriate care can improve access to care and outcomes for young people of color, those who identify as LGBTQ, and other marginalized groups with distinct needs based on religion, disability, geographic location, and so on.
In closing, a quote from a provider involved in the strategic initiative summarizes an overarching key finding: “Providers have found the SBIRT process to be beneficial in that it has facilitated a dialog about substance use/misuse and has often opened the door to conversations that would not have happened otherwise.” This quote underscores a key goal of the initiative: to fill a gap in the evidence and service continuum with important ramifications for the current and long-term health and well-being of young people by addressing substance use before SUD develops. Ultimately, the organizations that participated in the initiative developed deep learning and knowledge about youth early intervention that continues to ripple through the field and inform current and future policy and practice related to youth substance use.
Conflicts of interest: The author has no conflicts of interest to disclose.
Disclaimer: This article was published as part of a supplement supported by the Conrad N. Hilton Foundation through a grant to Abt Associates. The opinions or views expressed in this article are those of the authors and do not necessarily represent the official position of the funder.
© 2021 Society for Adolescent Health and Medicine. Published by Elsevier Inc.