(50) Evaluating Adolescent Medicine Providers’ Barriers to SUD Screening and Intervention

Background & Introduction: Over 750,000 people die each year in substance use-related deaths.1,2,3 Tobacco use disorder is the leading preventable cause of death in the United States,1 followed by alcohol use disorder.2 The majority of people with substance use disorders (SUDs) begin using substances in adolescence;4 thus, early identification and intervention is critical to reducing SUD morbidity and mortality. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based approach shown to effectively address youth substance use. Its core components—universal screening, brief motivational interventions, and linkage to care—make it a promising tool in Adolescent Medicine, yet its application among Adolescent Medicine providers remains underexplored. Research has primarily focused on pediatricians and general practitioners, highlighting screening practices and intervention outcomes in these groups.5 However, there is a notable gap in understanding how Adolescent Medicine specialists—who are uniquely positioned to address the nuanced needs of this population—utilize SBIRT in their clinical practice. This lack of data limits implementation strategies tailored to adolescent-focused care settings, where maximizing SBIRT’s potential is crucial to reducing substance use-related harms. This study aims to explore the practices, barriers, and facilitators of SBIRT implementation among Adolescent Medicine providers to inform future training, policy, and integration efforts.

Methods: A 26-question REDCap survey was designed to evaluate the knowledge, attitudes, practices, barriers, and perceived self-efficacy of Adolescent Medicine providers regarding SBIRT use. This survey collected data on providers’ current role, time in that role, location of practice (inpatient vs outpatient), and frequency of substance use screening, brief intervention, and referral to treatment. Likert scales were employed to measure levels of agreement with statements related to knowledge, attitudes, practices, barriers, and self-efficacy in addressing substance use and implementing SBIRT. The survey was distributed to all Adolescent Medicine attending physicians, fellows, and nurse practitioners at The Children’s Hospital of Philadelphia, one of the nation’s largest Adolescent Medicine Divisions. This survey was also distributed to the second-year pediatric residents who had completed their core four-week Adolescent Medicine rotation. This study was deemed IRB-exempt.

Results: Thirty-four participants completed this survey, including 19 Adolescent Medicine attendings (56%), five Adolescent Medicine fellows (15%), three Adolescent Medicine nurse practitioners (9%), and seven second-year pediatric residents (21%). Ten of the respondents (29%) had worked at their current role for 10 or more years, and 19 had worked at their current role for three years or fewer (56%). Twenty-eight respondents (82%) worked in the main hospital inpatient setting and 29 respondents (85%) worked in the Adolescent Specialty Clinic.

Knowledge: Twenty-six respondents (76%) agree or strongly agree with the statement that they know the validated substance use screening tools, while 23 (68%) agree or strongly agree that they know what to say when a patient screens positive and 20 (59%) know how to refer a patient to treatment when they screen positive.

Attitudes: Thirty respondents (88%) agreed or strongly agree that providers should talk to patients about substance use, even if it is not the reason for the visit. All respondents (100%) agree that providers should talk to patients who screen positively for substance use.

Practice: Eleven respondents (32%) talk to patients at every visit about substances and 9 (26%) talk to every patient about substance use. If patients screen positive for substance use, 12 respondents (35%) follow up with patients at intervals of 6 months or longer and 12 (35%) do not follow up at all. Only 3 respondents (9%) refer every patient who screens positive for a SUD to treatment.

Barriers: Thirty-four respondents (100%) noted lack of community resources, 33 (97%), noted lack of time, 32 (94%) noted lack of training on substance use screening, and 29 (85%) noted lack of training on the referral to treatment process.

Self-efficacy: Twenty-nine respondents (85%) reported that perceived lack of patient interest in discussing substance use deterred the provider from screening for substance use. Fourteen respondents (41%) reported that patients who use substances want help with treatment. However, 32 respondents (94%) reported that that clinician screening, intervention, and referral to treatment was helpful for patients with substance use and 17 (50%) reported that their advice influenced patients’ substance use behaviors.

Conclusion & Discussion: Despite high self-reported knowledge and helpfulness of SBIRT, only 32% of respondents discussed substance use at every patient visit, and only 9% referred all patients who screened positively for SUD to treatment. The largest barriers were lack of community resources (100%), time limitations (97%), and inadequate training (94%). Further, 85% of respondents perceived patient disinterest in discussing substance use, and only 41% agreed that patients who use substances desire treatment.

In addition to systemic barriers, such as the paucity of treatment facilities for adolescents, individual barriers contribute to the sizeable gap between Adolescent Medicine providers’ knowledge and practice. Perceived patient disinterest in discussing substance use and perceived patient disinterest in help may be sequelae of stigma. Focusing provider education on the psychosocial aspects of SUD can increase SBIRT utilization, especially because psychosocial development is a unique area of expertise for Adolescent Medicine providers. Lack of time and knowledge of referral processes can be mitigated through integration of adolescent-specific electronic medical record tools and substance use navigators. Interventions to improve education, maximize workflow efficiency, and integrate experts in treatment options can increase the SBIRT practice among Adolescent Medicine providers, helping engage adolescents in treatment and reduce the risk of SUD development.

References: 1. U.S. Department of Health and Human Services. The Health Consequences of Smoking - 50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

2. Garnett MF, Miniño AM. Drug overdose deaths in the United States, 2003–2023. NCHS Data Brief, no 522. Hyattsville, MD: National Center for Health Statistics. 2024.

3. Esser MB, Sherk A, Liu Y, Naimi TS. Deaths from Excessive Alcohol Use — United States, 2016–2021. MMWR Morb Mortal Wkly Rep 2024;73:154–161.

4. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. The TEDS report: age of substance use initiation among treatment admissions aged 18 to 30. https://www.samhsa.gov/data/sites/default/files/WebFiles_TEDS_SR142_AgeatInit_07-10-14/TEDS-SR142-AgeatInit-2014.htm.

5. Alinsky RH, Percy K, Adger H, Fertsch D, Trent M. Substance Use Screening, Brief Intervention, and Referral to Treatment in Pediatric Practice: A Quality Improvement Project in the Maryland Adolescent and Young Adult Health Collaborative Improvement and Innovation Network. Clinical Pediatrics. 2020;59(4-5):429-435.