Location: North Platte, Nebraska
Type of practice: Pediatric group practice

Great Plains Pediatrics is a pediatric primary care practice that includes 2 licensed behavioral health practitioners. The practice is part of Great Plains Health, a regional hospital and specialty clinic. Great Plains Health serves a mostly rural community in western Nebraska, northern Colorado and northern Kansas — a coverage area of 67,832 square miles, or about the size of Pennsylvania. About 85 percent of patients are covered by Medicaid.

Screening, Brief Intervention and Referral to Treatment (SBIRT) Implementation Strategies

Great Plains Pediatrics participated in the Practice Improvement to Address Adolescent Substance Use initiative (PIAASU) Phase 2, beginning in 2019. The PIAASU project aimed to increase use of the SBIRT approach to address adolescent substance use in pediatric practices.

To screen for substance use, the practice uses the CRAFFT (Car, Relax, Alone, Forget, Friends/Family, Trouble) and a modified S2BI (Screening to Brief Intervention). Patients also complete a PHQ-9 depression screen, which often identifies adolescents who are later found to have substance use problems not detected by the CRAFFT and S2BI screens.

At Great Plains Pediatrics, patients who screen negative for substance use receive Brief Intervention from a pediatrician to reinforce their healthy choices, encourage them to continue to abstain and to educate them about consequences. Adolescents with mild to moderate substance use receive Brief Intervention, including Motivational Interviewing, to help them weigh the risks vs. perceived benefits of continued use. Vaping and THC are the most common types of substance use identified by the screens at Great Plains Pediatrics and are widespread in the community and schools.

For more frequent substance use, physicians consult with the 2 behavioral health practitioners on staff to determine next steps. This often includes an evaluation by specialists outside the practice. Those with occasional substance use and with underlying concerns such as anxiety or depression typically receive behavioral health care treatment within the practice; more serious substance use problems require referrals to an outside specialist. The practice maintains a detailed list of nearby providers to facilitate referrals, but inpatient services, if needed, are several hours away, in Denver or Omaha.

Within the practice it’s not uncommon for a practitioner treating a patient for a behavioral health issue to uncover substance use that was not detected by the CRAFFT or modified S2B1 screens. Substance use often is secondary to behavioral problems, and patients experiencing anxiety, depression or trauma may be self-medicating with alcohol, marijuana or other substances. Depending on the severity, those patients also may be referred to outside providers.

Challenges and Adaptations

To capture specific substance use, the practice developed a modified version of the S2BI screen. The S2BI screens for frequency of use of seven types of substances (alcohol, tobacco, marijuana, prescription drugs, illegal drugs — such as cocaine or ecstasy — inhalants and herbal or synthetic drugs). The modified version lists 25 drugs and also captures e-cigarette/vaping and sexual activity. Besides being more specific, the expanded checklist has elicited more positive responses according to the practice.

Lessons Learned


  • Mental health and substance use concerns often are co-occurring. Mental health screening conducted at health supervision visits often identifies underlying trauma, anxiety or depression. A behavioral health practitioner treating those conditions often determines that the patient also is smoking, drinking or using other drugs.
  • To build a rapport with patients, it helps to know which substances are currently popular and to stay abreast of the lingo. For example, instead of asking a teen if they vape THC, a behavioral health practitioner may ask if they’ve ever “greened out” — a term for the sweating, dizziness, nausea and paranoia that comes from consuming too much cannabis.