By Katherine Garcia, MA, LAC, MAC, Clinical Services Manager, Peer Health Assistance Programs
From the Fall 2018 Journal of the Colorado Dental Association
During the CDA annual session in June 2018, Peer Assistance Services, Inc. (PAS) and Dr. Brett Kessler presented a lunch and learn session focused on Screening Brief Intervention and Referral to Treatment (SBIRT). SBIRT is an evidence-based practice used to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs. Dentists see a broad proportion of the population and have regular contact with individuals who may not see a medical provider as frequently during adolescence, which is a critical time of rapid change; therefore, they have a unique opportunity to screen for substance use and educate patients on the impacts that alcohol and other drugs can have on oral and physical health. Addressing substance use in multiple healthcare settings can help prevent a wide range of illnesses and decrease healthcare costs.
Questions regarding the utilization of screening of adolescent patients for substance use arose during the session, as pediatric dentists are placed in a unique role dynamic consisting of their patient and the patient’s parent. The questions and discussion in this session provided an opportunity for PAS to provide further information and clarification on screening an adolescent patient for substance use.
- Adolescent confidentiality: It is critical to ensure confidentiality when implementing SBIRT with adolescents. PAS heard this key point emphasized clearly when we participated in focus groups with adolescents to gather feedback on how to make conversations about substance use in healthcare settings comfortable and effective. The adolescents in those focus groups also understood that there are limits to confidentiality. So, the bottom line is to communicate clearly that the conversation about alcohol or drug use is confidential unless the healthcare professional identifies that the adolescent is at-risk of harm to themselves or to another person or that someone may be abusing them. The information should be communicated verbally by the professional and conveyed in writing on a screening form and potentially also through a sign on the wall of the clinic. An example of possible language is: “The information you share with me today and our conversation is private, and I would only share it with other people if I find that you are thinking of hurting yourself or another person, or I learn that someone is abusing you. Do you have any questions about this?” It is also important to note that screening results (answers to screening questions) about alcohol or drug use are part of a person’s regular medical record and not stored in a separate, private record. Once a person enters substance use treatment services the privacy of substance use treatment information takes effect.
- Involving parents: There is no obligation for health professionals to share screening results or conversations with parents. In fact, the threat of doing so may threaten the relationship between the health professional and adolescent and is not consistent with the spirit of motivational interviewing (motivational interviewing is a patient/client-centered approach to conversations about change with an emphasis on demonstrating empathy to help a person identify their own best reasons and approaches to making changes to improve their health and other areas of their life) because it could amount to manipulation or intimidation. Rather, when adolescents raise fears about their parents being informed it is much more helpful to emphasize that their health and overall safety are the most important goals. Then you can focus the conversation on evoking change. Talk to help them move in the direction of being ready to change substance use or commit to harm reduction if they are not willing to completely abstain. It would also be appropriate to encourage the adolescent to seek opportunities to discuss the substance use issue with other trusted health professionals that they may see more often than their dentist. For example, their primary care doctor or nurse, a school nurse or counselor. The dentist could help facilitate communication with the primary care provider. At the same time, (in some cases) it eventually becomes clear that for an adolescent to receive the care and help that he/she needs, a parent or guardian needs to get involved. For example, to arrange for follow-through substance use treatment or due to communications that may need happen with insurance plans (such as written EOBs that are sent by mail). Adolescent SBIRT training emphasizes that it is critical for the health professional to negotiate parental involvement and disclosure of information with the adolescent before it happens and involve the adolescent at every step of the process.
- Minor consent for substance use disorder treatment: In Colorado, adolescents may self-refer for substance use treatment at any age and must sign for release of substance use treatment records to another entity. The age of consent for reproductive healthcare is also any age. The age for mental health services it is 15. Following is a reference chart that outlines the minor consent laws in Colorado:
For further information and training on SBIRT, visit sbirtcolorado.org. For information on the Dental Peer Health Assistance Program, visit phap.squarespace.com.
Acknowledgement: Many thanks to Carolyn Swenson, MSPH, MSN, RN, SBIRT Consultant, Peer Assistance Services, Inc. for her extensive work on this article.