Abstract
Onset of nicotine and tobacco, alcohol, and cannabis use is most likely to occur during adolescence. Effective, evidence-based interventions to prevent or reduce substance use for adolescents are not widely available. This paper reviews the existing literature on the delivery of the Brief Negotiated Interview (BNI) during routine medical visits to reduce substance use, with evidence of effectiveness for adolescents in general and for those at increased risk due to other social factors (e.g., foster care). BNI typically takes 5–15 min to deliver, making it highly versatile for use across medical, school-based, and other community settings that work with adolescents. BNI significantly decreases substance use in the short term (e.g., 1–2 months post-intervention), although long-term effects are minimal. The brief effects of reduced substance use, however, cannot be overlooked as part of a larger programmatic focus on reducing adolescent substance use. Policy implications, including the importance of the United States Preventive Services Task Force and of billing and reimbursement policies for behavioral health services, are discussed.
Social Media
5–15 min substance use prevention interventions in medical exams for adolescents are linked to lower alcohol, nicotine/tobacco, and cannabis use among adolescents in the short term. Protect USPSTF to ensure universal access to brief preventive interventions.
Key Points
When adolescents receive screening, brief intervention, and referral to treatment (SBIRT) during medical visits, their substance use declines
Adolescents who receive brief intervention via the Brief Negotiated Interview temporarily reduce their substance use, but the effects wear off
Repeated intervention, or SBIRT combined with other programming, may lead to more sustained declines in substance use.
Even short-term declines in substance use are important for adolescent health.
The United States Preventive Services Task Force must be supported to continue reviewing and recommending evidence-based prevention in healthcare settings.
With evidence, brief interventions could be more widely available at no cost to adolescent patients.
Substance use and associated comorbidities account for 1 in 4 deaths in the United States. (US; McGinnis & Foege, 1999). Eliminating the detrimental impact of substance use in the US is estimated to save $428 billion annually (Miller & Hendrie, 2009). The bulk of efforts to prevent problematic substance use and related negative consequences (including substance use disorders, SUD) must begin in childhood and adolescence, when substance use initiation is most likely to occur (Volkow et al., 2021). For the majority of adolescents, this effort is focused on delaying substance use initiation (primary prevention) or reducing and stopping use once adolescents engage in substance use (secondary prevention) before adolescents progress to demonstrating signs of SUD (Han et al., 2017). While family and school systems are important for substance use prevention, pediatric healthcare providers also play a critical role in screening for, monitoring, and intervening upon substance use behavior to prevent SUD (Young et al., 2014). The pediatric healthcare system provides adolescents with a confidential and supportive environment where they can learn about the benefits of avoiding substance use, safely disclose substance use, and receive secondary prevention support. Screening practices in pediatric healthcare services are recommended because of the robust evidence of safety and effectiveness (US Preventive Services Task Force, 2020b); as a result of US Preventive Services Task Force (USPSTF) recommendations, screening efforts in pediatric primary care settings have increased (Pilowsky & Wu, 2013) and are more likely to be reimbursed by insurance providers (Lesser et al., 2011).
While screening for substance use is important, it is insufficient to change behavior. Rather, adolescent behavior is most likely to shift when behavior modification is aligned with adolescents’ identities and future goals (Kaminer et al., 2018; Spinola et al., 2017). These are critical components of the brief negotiated interview (BNI; D’Onofrio et al., 2005), which draws on motivational interviewing techniques to identify adolescents’ goals and self-identities, create dissonance between the goals adolescents have for themselves and their substance use behaviors, and support reduction in use or other harm reduction strategies (Kaner et al., 2011). BNI can be delivered once or repeated, and a single dose of intervention often takes 15 min or less to deliver. While there is some evidence of effectiveness of the BNI and similar brief interventions (Mitchell et al., 2022), results overall in adolescence are mixed, and recommendations are currently under review by the USPSTF. As a result of this gap, brief interventions after substance use screening are less consistently delivered in pediatric healthcare settings, and are also less likely to be reimbursed (Reif et al., 2022a), leading to challenges with sustained implementation.
Elevated Substance use Risk for Specific Subgroups of Adolescents
Adolescents with Mental Health Concerns
The co-occurrence of substance use with other mental health concerns, including internalizing diagnoses like depression and externalizing diagnoses like attention deficit hyperactivity disorder (ADHD), is well documented (Whitesell et al., 2013). Understanding the contribution of mental health disorders to risk for substance use, where adolescents may be using substances as a form of treatment (e.g., self-medication hypothesis; Costanzo et al., 2023) and, simultaneously, adolescents may experience worsening mental health symptoms as a result of their substance use (Hansen et al., 2025), is important. Evidence of both directions (substance use contributing to worse mental health, mental health contributing to worse substance use) indicates a strong bidirectional pattern between substance use and mental health concerns in adolescence (Beal et al., 2013). Addressing both mental health concerns and substance use in adolescence is therefore essential to prevent substance use and SUD. This can be accomplished by combining interventions to address substance use with interventions for specific mental health concerns (Brewer et al., 2017; Teesson et al., 2020). In the absence of addressing mental health concerns alongside substance use, brief interventions may be less effective (Dunn et al., 2026).
Adolescents Exposed to Social Stress
Adolescent exposure to maltreatment, adversity, and other social stressors also increases the risk for adolescent substance use (Whitesell et al., 2013). This can include abuse and neglect directed at children, witnessing or being a target of violence, bullying, and other forms of aggression, and other social strains within the home or community settings where adolescents live and interact socially. Importantly, while all of these factors are associated with increased risk for adolescent substance use, interventions often do not consider these social factors when addressing substance use in healthcare settings. Combining and adapting interventions that target social stressors (e.g., Murry et al., 2018) and selecting alternative interventions that prevent substance use initiation (Carney & Myers, 2012) might be maximally effective for young people to prevent and reduce substance use over the long-term.
Adolescents in Foster Care
Primary and secondary prevention of substance use among adolescents in foster care is especially important, in part because of the elevated and earlier onset of substance use behaviors among adolescents in foster care (Beal et al., 2023) and because of the lack of effective interventions that reduce substance use once initiation has occurred (Title IV-E Prevention Services Clearinghouse, 2024). As adolescents enter foster care, they are required to receive healthcare (at the time of entry and regularly thereafter), and this is audited for compliance by the Administration for Children and Families. This places healthcare systems in the unique position of being able to both screen for and deliver brief interventions to prevent or reduce substance use for adolescents in foster care (e.g., Greiner et al., 2024), if effective interventions are identified and can be sustained through billing and reimbursement (Reif et al., 2022a). Therefore, in addition to the need for more research demonstrating the effectiveness of BNI for reducing substance use generally, evidence of effectiveness with youth in foster care is also needed.
The Efficacy and Effectiveness of BNI
Studies of BNI as part of substance use screening, brief intervention, and referral to treatment have had mixed results (Mitchell et al., 2022; Young et al., 2014). This is in part due to variability in intervention locations, follow-up duration, and target populations (Calihan & Levy, 2023). When focusing more specifically on delivery to adolescents as part of healthcare settings, a slightly clearer picture of the effects of BNI on adolescent substance use emerges. Specifically, as reported in a recent scoping review (Gette et al., 2023), the effects of brief intervention in healthcare settings are significant, as measured by reductions in the number of days of use during the first 30–60 days post-intervention. Beyond that point (e.g., 3 months or longer), the effectiveness of BNI on cannabis (Gette et al., 2023) and alcohol (McGinnes et al., 2016) outcomes wanes, and findings are inconsistent. This is also observed for young people in foster care (Beal et al., 2026), including those with mental health concerns (Dunn et al., 2026). Further, there is some evidence from literature reviews (e.g., McGinnes et al., 2016; Schizer et al., 2020) that more intense substance use behavior may be more responsive to BNI—a context where adolescents may also benefit from additional screening and referral to treatment for SUD. While some have concluded that BNI is ineffective because of the lack of sustained improvement (e.g., Mitchell et al., 2022), there are benefits to adolescent health and safety with even a temporary reduction in substance use (Irwin, 2022). The reduction in substance use in the first 1–2 months following BNI may also make it possible for adolescents to engage in other behavioral interventions that would sustain reductions in substance use over the longer term (for review, see Tinner et al., 2022).
Funding
A significant barrier to delivering BNI in pediatric healthcare settings is the reimbursement rate for screening and BNI services (Reif et al., 2022b). Screening and brief intervention are often sustained in school and healthcare settings by grants and other programmatic funding that covers the cost for specific periods of time (e.g., 1–5 years). This requires programs to secure funding to sustain programmatic delivery that is intended to improve individual adolescent health outcomes. This is a stark contrast from other prevention efforts to improve adolescent health that often can be sustained with billable service codes (Hodgkin et al., 2023).
Summary
BNI administration in primary care (5–15 min) contributes to significant reductions in nicotine and tobacco use, cannabis use, and alcohol use. Importantly, the effects of BNI have been observed in the short-term (e.g., 2 months after a single dose of the intervention) for all substances (e.g., Beal et al., 2026). This effect is achieved even among adolescents who are at higher risk for substance use and SUD (e.g., adolescents in foster care; Beal et al., 2023; Moss et al., 2020). Sustaining reductions in substance use may require interventions with longer duration (60 or more hours of intervention), the inclusion of both a caregiver and the adolescent (Haggerty et al., 2023; Kim & Leve, 2011), and targeting subgroups of the adolescent population (girls, early adolescents). Among higher-risk youth, more intensive interventions have broadly not been directly effective in preventing or reducing substance use (Krishnapillai et al., 2025), although indirect effects (e.g., through reduced association with deviant peers) have significantly impacted substance use prevention over the long term (2–3 years; Kim & Leve, 2011). A combination of short-term benefits from BNI and longer-term benefits from other programs may be the right combination of services to address concerns about adolescent substance use before problems progress to SUD.
Policy Implications
Ensuring Effective, Universally Delivered, and Flexible Primary and Secondary Substance Use Prevention Delivered via Healthcare for Adolescents. There is a dearth of evidence-based interventions to prevent initiation of substance use (primary prevention) or prevent and reduce continued substance use (secondary prevention) for adolescents that can be delivered across a variety of settings. The evidence supporting SBIRT broadly and BNI specifically is promising (US Preventive Services Task Force, 2020a). This review further highlights the potential for BNI's short-term effectiveness. Cross-agency collaboration within Health and Human Services (e.g., from the Administration for Children and Families (ACF), Substance Abuse and Mental Health Services Administration (SAMHSA), National Institutes of Health (NIH)) to support rigorous implementation and evaluation of BNI in combination with other interventions (via randomized clinical trials and similar causal designs) tested in real-world healthcare settings is a gap that remains. The opportunities to design those studies are significantly limited by the unique priorities of each funding source—SAMHSA, for example, is focused on universal implementation and dissemination of SBIRT, while ACF is looking for randomized clinical trials in reviewing levels of evidence for interventions that can be supported by federal funding, and NIH is looking for new and innovative interventions that generate important new scientific knowledge. Shared initiatives that will meet the goals of all three agencies for specific gaps, like substance use prevention, could be considered for priority funding across agencies within HHS to solve these larger, persistent problems for adolescents.
Timely Updates to Reviews of Evidence that Drive Healthcare Policy. Federal investment in research has resulted in a quickly changing landscape with respect to evidence-based services for primary and secondary substance use prevention. The USPSTF was established in 1984 as one group responsible for the timely review of scientific evidence with recommendations for changes in practice and care delivery that should be universally available for primary and secondary prevention (Woolf & Atkins, 2001). The work of USPSTF supports access to important health-promoting interventions in primary care. Healthcare systems often change practices to provide recommended healthcare services because USPSTF recommendations are evidence-based and more likely to be reimbursed (Reif et al., 2022a). In 2024, USPSTF assembled a panel of experts to review the science on BNI and similar brief interventions that prevent or reduce substance use among adolescents. HHS paused the work of USPSTF in March of 2025 (Henderson et al., 2026). As a result, the review of evidence and updated recommendations around primary and secondary prevention for adolescents have not been released. HHS should allow this expert panel reviewing the literature on brief interventions to prevent or reduce substance use among adolescents to complete their work, ensuring that the most recent evidence is available to practitioners and that insurers cover evidence-based interventions and make them available to adolescent patients who will benefit from them.
Supporting the Sustainability of Preventive Interventions through Existing Funding Streams. While the endorsement of prevention practices by USPSTF is an important step to ensuring funding within healthcare systems (and similarly, ACF's evidence-based clearinghouse is helpful for Title IV-E funding), it does not guarantee that funding will be sufficient to cover the cost of service delivery (i.e., sustainability) (Reif et al., 2022a), nor does it universally allow for the use of a diverse trained workforce (e.g., community health workers, psychology and social work, nursing) to deliver those interventions. The costs associated with the delivery of BNI, for example, will vary depending on whether a post-baccalaureate-trained individual (e.g., registered nurse, community health worker), a behavioral health provider (e.g., clinical psychology, social work), or a physician is delivering the service. While higher reimbursement based on level of training is reasonable, the cost of having a post-baccalaureate or similarly trained role should also account for the opportunity cost associated with not having a higher-trained professional (e.g., pediatrician, psychologist, therapist) available to address higher-acuity needs that someone with lower levels of training could not cover. This is a significant issue across prevention, where workforce sustainability and effectiveness can be achieved using non-clinically licensed individuals who have appropriate training and supervision, but where clinically licensed individuals instead deliver prevention because reimbursement rates are higher—leading to shortages for medical and behavioral healthcare (Axelson, 2019; Bazemore et al., 2025). In line with USPSTF recommendations, alternative payment structures, including bundled payments for prevention services and support for preventive interventions from managed care organizations, could also be explored.
Footnotes
Abbreviations
ORCID iDs
Funding
This team was supported by the Substance Abuse and Mental Health Services Administration (SAMHSA) under grant 1H79TI084035 (Greiner, PI).
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Role of Funder/Sponsor (if any)
SAMHSA had no role in the design and conduct of the study.