Stacy Sterling, DrPH, MSW, MPH Legal Action Center September 27, 2017

1. What is the current state of the evidence for adolescent screening, brief intervention and referral to treatment? Stacy Sterling, DrPH, MSW, MPH Legal Action Center September 27, 2017

2. Overview What does the literature say about the efficacy and effectiveness of adolescent SBI in primary care, emergency departments, non-medical settings? What do we know about the effectiveness of RT? What do systematic reviews and meta-analyses tell us? Current guidelines Future Directions for Adolescent SBIRT

3. Richard Saitz, MD, Boston Medical Center, Boston University School of Medicine: “Screening and Brief Intervention has the most promise in adolescents” September 14, 2017, International Network of Brief Interventions for Alcohol & Other Drugs annual meeting

4. Adolescent SBIRT in Primary Care – Efficacy & Effectiveness Trial comparing screening and “priming” prior to well-visit to screening, priming + provider prompting to usual care – found that intervention arm teens were more likely to report binge drinking than usual care controls at 6 and 12 months (Boekeloo, 2004); A small, randomized pilot study found that BIs were associated with less, and less frequent, cannabis use (D’Amico, 2008); A Brazilian pediatric primary care RCT found less substance use among users and reduced initiation among non-users in the BI group(De Micheli, 2004); Large, quasi-experimental study of brief, tablet-based substance use education and physician advice (Harris, 2012) found: • In U.S. sample: less of any SU at 3 and 12 months, reductions in alcohol use and more drinking cessation (among drinkers) and less alcohol use initiation (among non-drinkers), • In the Czech sample: less cannabis use, more cannabis use cessation (among users) and lower cannabis initiation (among non-users)

5. Adolescent SBIRT in Primary Care – Efficacy & Effectiveness cont. Two related RCTs (Walton, 2013, 2014) of computerized and therapist-delivered BIs versus usual care found: • reductions in cannabis initiation, consequences, DUI and other drug use in cannabis-naïve teens, and • lower rates and frequency of use among cannabis-using teens, compared to controls. A pragmatic RCT in pediatric primary care compared pediatrician-delivered to embedded-behavioral health clinician-delivered SBIRT and usual care. At 6 months, found no differences in self-reported substance use, but found that the BH clinician model resulted in less depression symptoms – an important precursor to substance use (Sterling, under review).

6. Adolescent SBIRT – Emergency Department Majority of Teen SBIRT studies in medical settings have been conducted in Emergency Departments. Many found mixed or no main effects of BIs on AOD use (Yuma-Guerrero review, 2012). Several found BIs to be effective on other important adolescent outcomes, including: • Drinking and driving, alcohol-related injuries and problems (Monti, 1999; Neighbors, 2010); • Emotional health, hazardous use (Tait, 2004, 2005); • Experiences of violence, attitudes about alcohol and violence, self-efficacy in dealing with alcohol and violence, consequences (Cunningham, 2009 & 2012; Walton, 2010) • Thinking about quitting, attempts to quit, cut back, or to be careful when drinking (Bernstein, 2010) • Abstinence from cannabis, attempts to quit use, fighting (Bernstein, 2009) • Drinking frequency and binge drinking among more severe subgroups (Spirito, 2004; Maio, 2005)

7. Adolescent SBIRT – Specialty Treatment Initiation and Engagement Referral to Treatment has been the least well-studied component of SBIRT: Among adolescents presenting to the emergency department for alcohol-related problems – at the 4- and 12-month folloups, those who received a brief intervention which included facilitated referral (help navigating specialty treatment system, making appointments, reminder calls) were more likely to have attended specialty treatment (Tait, 2004, 2005). Adolescents who received SBIRT from an embedded-behavioral health clinician, including facilitated referral, were 4 times as likely to start specialty behavioral health treatment than those in the pediatrician only arm. African-American teens were less likely to initiate specialty treatment, compared to whites. (Sterling, 2017)

8. Adolescent SBIRT – Non-Medical Settings A trial comparing adolescents with AOD problems assigned to receive one of two therapist-delivered brief interventions or a control condition, found that those in the BI arms had better 6 month outcomes months (fewer days of alcohol use, binge drinking, and illicit drug use, and fewer negative consequences than the controls (Winters, 2007). A school-based trial comparing: 1) a 2-session, adolescent-only MI-based intervention with 2) the same intervention and a parent session, and 3) no intervention control – both interventions produced better (Winters, 2012) A single-session brief motivational intervention delivered in a secondary school setting, reduced alcohol, marijuana, and tobacco use among 16- to 20-year olds, but effects deteriorated over time (McCambridge, 2004).

9. Adolescent SBIRT – Non-Medical Settings A small Thai study which examined brief intervention for high-school students with methamphetamine disorders found short-term decreases in quantity and frequency of use compared to the control condition (Srisurapanont, 2007). Suzuki et al. found promising results for brief interventions conducted in a high school, but they had a small sample size with no control condition (Suzuki, 2003). A counselor-delivered brief intervention with homeless adolescents produced reductions in drug use other than marijuana among the intervention group compared to controls at 1-month, but no effect on alcohol or marijuana (Peterson, 2006).

10. Adolescent SBIRT – Reviews Tanner-Smith & Lipsey, 2014 – Systematic review and meta-analysis of alcohol brief interventions  Moderate but significant improvements in alcohol consumption and related problems, across settings and populations, effects persisted for up to 1 year. • Brief interventions which incorporated motivational interviewing, decisional balance and goal-setting components found to be associated with larger effects. Tanner-Smith et al., 2015 –Meta-analysis  Brief interventions which target both alcohol and drugs are effective in reducing use of both substance, but those targeting alcohol use alone do not reduce illicit drug use. Steinka-Fry et al., 2015 – Systematic Review and Meta-analysis  Brief alcohol interventions were associated with reduced drinking and driving and related consequences. Tanner-Smith & Risser, 2016 – Meta-analysis  While the beneficial effects from brief interventions may vary depending on outcome measures, but that significant effects were found across measures.

11. Adolescent SBIRT – Reviews cont. Carney & Myers, 2012 – Systematic review and meta-analysis of studies examining both drinking outcomes and behavioral outcomes  Early interventions are effective for reducing adolescent substance use and can also impact other behavioral outcomes. Mitchell et al., 2013 – Literature review  Brief interventions may be effective, but there are a number of gaps in the literature Das et al., 2016 –Review of reviews  • school-based alcohol prevention interventions associated with reduced frequency of drinking • family-based interventions have a small , persistent effect on alcohol misuse • school-based drug interventions combining social competence and social influence show protective effects against drugs and cannabis use • evidence from Internet-based interventions, policy initiatives, and incentives is mixed and needs further research • various delivery platforms, such as digital platforms show potential to improve substance abuse outcomes but need more research

12. Other SBIRT Literature Effectiveness of BIs on older adolescents/college students on a range of outcomes: • AOD use, binge drinking, driving & drinking, smoking, AOD consequences, and ER utilization. (Fleming, 2010; Schaus, 2009; Marlatt, 1998; Martin, 2005; Lawendowski, 1998). There is an extensive evidence base on the efficacy, effectiveness and cost-effectiveness of alcohol SBIRT for adults, in a variety of settings (Bien, 1993; Bertholet, 2005; Fleming, 2002) The evidence for the effectiveness of SBIRT for adults to address drug use is mixed, but weak (Saitz, 2014; Gelberg, 2015, 2017)

13. What about the U.S. Preventive Services Task Force Ratings?!?

14. Alcohol Misuse: Screening and Behavioral Counseling Interventions in Primary Care for Adolescents – “I” Rating – Insufficient Evidence “The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening and behavioral counseling interventions in primary care settings to reduce alcohol misuse in adolescents.” Drug Use, Illicit: Primary Care Interventions for Children and Adolescents for Children and Adolescents without a Substance Use Disorder – “I” Rating – Insufficient Evidence “The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary care–based behavioral interventions to prevent or reduce illicit drug or nonmedical pharmaceutical use in children and adolescents. This recommendation applies to children and adolescents who have not already been diagnosed with a substance use disorder.”

15. USPSTF Rating – Alcohol Alcohol Misuse: Screening and Behavioral Counseling Interventions in Primary Care Systematic Review and Meta-Analysis looked at studies of intervention in all adults, young adults/college age, pregnant women, and adolescents (Jonas, et al., 2012) Inclusion criteria: Randomized, controlled trialsonly. Primary care only. Required at least 6-month follow-up. Total number of references examined = 6,265. 23 studies included, 0 studies of adolescents met criteria. Out of a list of 666 excluded studies, only 38 dealt with adolescents. “Alcohol misuse among adolescents is an important public health problem. Limited evidence is available to assess the effects of screening and behavioral counseling in adolescents, and high-quality studies specifically addressing this population are needed.” Current review (in process) exclusions: Interventions to prevent initiation of use among nonusers; comparators with a reasonable expectation of affecting change in alcohol consumption – rules out comparative effectiveness studies; Attitudes, knowledge, and beliefs related to alcohol use; Intention to change behavior; Alcohol use initiation; persons presenting in an emergency setting for alcohol-related issues

16. USPSTF – Drugs Drug Use, Illicit: Primary Care Interventions for Children and Adolescents Systematic Literature Review (Patnode et al., 2014) of randomized, controlled trials or controlled (nonrandomized) clinical trials designed to prevent or reduce drug use in children and adolescents Inclusion criteria: studies with at least 6-month follow-up; only trials with minimal or no-treatment control groups; children and adolescents without a substance use disorder; studies in health care settings or applicable to health care settings. Excluded: studies in school, treatment programs, employment, juvenile justice settings. 2,253 abstracts reviewed  144 full papers read  5 studies included “Four of the 5 studies that measured marijuana use before and after the intervention found greater benefit in the intervention youths than in the control youths. None of the studies found benefit of the intervention on health, social, and legal outcomes at 6 months or later, which is not surprising given that the interventions focused on samples of children and adolescents who reported low levels of drug use in general.”

17. AAP 2016 Policy Statement: “Despite this early conclusion (the USPSTF rating), the low cost of SBIRT, minimal potential for harm, and emerging study results together support the tremendous potential for a population-level benefit from even small reductions in substance use and provide sufficient basis for the incorporation of SBIRT practices into the medical care standards for adolescents.” Surgeon General’s 2016 Report: “Populations who should receive early intervention: Of particular concern are the 1.4 million binge drinkers aged 12 to 17, who may be at higher risk for future substance use disorders because of their young age.”

18. Why would we expect the same old SBIRT model to work for middle-aged adults and teenagers?

19. Patients

20. “Lewis,” 15-year-old, Caucasian, 9th grader Lives in the family home with his mother and maternal grandfather, father not involved. Referred to MPower by our Child and Family Psychiatry when family failed to attend an intake appointment. History of depression and anxiety symptoms, substance use. Uses marijuana usually 2-6x/week, 20 days/month, started at 13 The family joined MPower, randomized into Group arm, attended all 4 sessions.  Following the group, the mother and the interventionist remained in close contact, given her concern about his substance use.  Within a month, the mother decided to enroll the teen in Kaiser’s Addiction treatment program after the teen was caught with marijuana at school. The mother shared her appreciation of the support and encouragement provided through MPower, which had enabled her to make this decision.

21. “Alesia,” 17-year-old, African-American, 12th grader Alesia lives in the family home with her mother, father, older brother, adopted sister, aunt, two cousins, and grandmother.  Referred by her pediatrician due to mood symptoms and substance use.  Randomized into the Individual arm.  During the BI, she disclosed her experience of stress and feelings of depression.  Methods of coping for the teen included listening to music, watching Netflix, and "partying,"drinking alcohol and smoking marijuana to relax.  She declined referral to Child and Family Psychiatry, but remained in contact with the MPower clinician following the single session BI, and ultimately accepted a referral to the Psychiatry department after several weeks, “so I can work on how I feel and why I need to smoke.”

22. Next Steps for the Field 1) We need to expand our idea of SBIRT beyond simply 1 or 2 sessions of M.I.-based brief advice or brief intervention. Promising approaches that need to be tried, evaluated and studied: • Expanded SBIRT – 1-2 sessions is likely not enough, even for less severe kids – multi-session, boosters • In primary care – look beyond pediatricians, to take advantage of care teams, integration • Family-inclusive • Addressing underlying causes – comorbidity, ACEs/trauma exposure • Technology • Linguistically-, culturally-tailored

23. Teen MPower RCT– Conrad N. Hilton Foundation - Kaiser Permanente NCal Site Kaiser Oakland, San Leandro Richmond and Hayward Adolescents at risk for substance use or other behavioral health problems Referred to MPower by Pediatrician • Curriculum • Motivational Interviewing • Decisional balance • Risk-taking • Stressors • Coping • Cognitive distortions • Mindfulness • Healthy choices/pro-social behaviors • Navigating resources • Adolescent brain development • Communication Teen Single-session Brief Intervention referral to treatment as needed vs. Parent Teen Teen & Parent Spanish Language Version

24. Adolescent SBI – Technology RCT of web-based screening and brief motivational intervention for substance use among at-risk 16-18 year-old adolescents in four European countries. Assessment-only control group. At 3 months, BI group had lower rates of self-reported past-month drinking, drinking frequency, and frequency of binge drinking, compared to the control group. No differences in illegal drug use and polydruguse (Arnaud et al., 2016).

25. Next Steps for the Field 2) We need to include a broader range of relevant, developmentally-appropriate outcomes in studies, program development and evaluations Outcomes: • Substance use prevention or delay – initiation or non-progression of use, cutting back and harm reduction • Risky behaviors – driving, biking, skateboarding, sex • RT  Treatment initiation and engagement • Comorbidity – depression, anxiety, suicidality • Academic outcomes, family functioning • Short- (e.g., 1 and 3 month) and longer-term outcomes

26. Next Steps for the Field 3) More research is clearly needed – across interventions, populations and settings AND we need to think about how policy recommendations and practice guidelines are developed, disseminated, digested and understood by providers, policymakers and others.

27. Thank you!stacy.a.sterling@kp.org