To increase much-needed early identification and treatment of adolescent substance use – and prevent the onset of substance use disorder – the Massachusetts Child Psychiatry Access Program and the Adolescent Substance Use and Addiction Program at Boston Children’s Hospital partnered to offer readily available consultation services to the state’s primary care providers and their adolescent patients with substance use needs.
Early intervention in adolescent substance use has the potential to promote healthy development, facilitate more integrated care to address related behavioral health concerns, and reduce development of a substance use disorder (SUD), resulting in significant cost savings to states. But many primary care providers (PCPs) report they are not comfortable managing the substance use needs of their adolescent patients and only 10 percent of adolescent patients who need SUD treatment receive it. The Massachusetts model provides an easily accessible expert resource to bolster access, early intervention, and primary care provider capacity to respond to this health care need.
Substance use among adolescents is common. In 2019, 29 percent of US adolescents reported current use of alcohol with 13.7 percent reporting binge drinking within the past 30 days. During this same timeframe, approximately 22 percent of adolescents reported using marijuana. Among adolescents who have used substances at any point in their lifetime, 37 percent reported using marijuana and 14.3 percent reported misusing prescription opioids.
While most adolescents who try substances, such as alcohol or marijuana, do not develop an SUD, substance use at an early age can be an important predictor of later life SUDs. The majority of those with SUDs started using substances before age 18 and developed a disorder by age 20. This risk is greatest for those who begin use in their early teens. In total, SUDs cost state Medicaid programs approximately $7 billion annually. Even brief substance use that does not meet criteria for an SUD can affect normal adolescent brain development and key social transitions, resulting in potential long-term consequences., Despite the prevalence and well-documented effects of adolescent substance use, only 10 percent of 12- to 17-year-olds in need of substance use treatment actually receive services.
As states explore opportunities to increase access to substance use services for adolescents, there is growing interest in the integration of behavioral health into primary care settings. This case study focuses on the Massachusetts Child Psychiatry Access Program’s partnership with the Adolescent Substance Use and Addiction Program to strengthen the identification and treatment of adolescent substance use within primary care settings.
Massachusetts Child Psychiatry Access Program
In 2003, Massachusetts launched a pilot program, the Massachusetts Child Psychiatry Access Program (MCPAP), to assist primary care providers managing the mental health needs of their patients. Originally developed by the University of Massachusetts Medical School under a grant from the Centers for Medicare & Medicaid Services and MassHealth (the state Medicaid program), MCPAP expanded statewide in 2004 under the Massachusetts Behavioral Health Partnership.,  MCPAP is a public health model that emphasizes universal screening, supports access to services in the appropriate setting based on need, and mitigates gaps in child psychiatry resources by building provider capacity. Similar child psychiatry access programs (CPAPs) exist in at least 30 states and Washington, DC.
MCPAP has seven regional children’s behavioral health consultation sites staffed by pediatric psychiatrists, licensed behavioral health providers, and care coordinators. These teams provide free, ongoing consultation and education to primary care providers serving children with mental health conditions. While PCPs must enroll in MCPAP, they can request a telephone consultation with MCPAP for any child, regardless of the child’s insurance status. Requests to MCPAP can include:
- Questions about diagnosis and treatment options;
- Use of medications and screening tools;
- Available community resources; and
- Requests that MCPAP staff provide diagnostic face-to-face or telehealth consultations with the youth/family.
MCPAP is financed by state general revenue funds (totaling $3.87 million in fiscal year 2019) under the Massachusetts Department of Mental Health, which covers operational costs under MCPAP, including staff salaries and administrative expenses.  While MassHealth does not currently claim Medicaid reimbursement for MCPAP consultation services provided to eligible enrollees, in-person visits provided under the program are eligible for Medicaid reimbursement. For children with commercial insurance served by MCPAP (representing 60 percent of consultations), insurers reimburse the state for their members’ portion of MCPAP costs under a formula used by the state’s Pediatric Immunization Program Assessment.,
Available outcome data on MCPAP suggests promising results, particularly relating to the perceived competency of participating providers. Among the PCPs enrolled in MCPAP, 77 percent reported feeling comfortable treating attention-deficit hyperactivity disorder (ADHD) and 68 percent and 67 percent reported feeling comfortable treating depression and anxiety, respectively. However, fewer than 15 percent of these providers reported feeling comfort treating adolescent SUDs, suggesting a need for enhanced support.
In 2019, MCPAP entered into a partnership with the Adolescent and Substance Use and Addiction Program (ASAP). Based at the Boston Children’s Hospital, ASAP is a specialty clinic that provides adolescent substance use services, including in-person comprehensive evaluation, diagnostic assessments, and treatment services (e.g., therapy and medication-assisted treatment). Using a team-based approach, ASAP staff include developmental-behavioral trained pediatricians, addiction medicine specialists, licensed social workers, and child and adolescent psychiatrists who are uniquely equipped to serve adolescents with a full range of substance use problems and disorders.
The ASAP-MCPAP partnership operates using the existing MCPAP structure, in which PCPs enrolled in MCPAP submit consultation requests to their regional MCPAP team via telephone. Substance use-specific requests are then routed to an ASAP clinician for additional information and education. Similar to MCPAP, consultation services under ASAP are available to all adolescents regardless of their insurance status.
Depending on the nature of the request, ASAP clinicians consult on a variety of care management activities, such as brief intervention tools and behavioral contracting, medications to curb withdrawal and drug testing programs, and referrals to behavioral health services, including the ASAP clinic. The partnership with ASAP costs $70,000 annually and is funded using available state funds appropriated to support MCPAP. These appropriated funds cover a portion of ASAP clinicians’ time, allowing them to provide consultation services under MCPAP.
Massachusetts Child Psychiatry Access Program and Adolescent and Substance Use and Addiction Program Partnership Model
Since the ASAP-MCPAP partnership launched in October 2019, requests for substance use-specific consultation have steadily increased. While some incoming calls to ASAP are critical (e.g., a recent overdose), most questions relate to more routine adolescent substance use problems (e.g. excessive marijuana use) and requests for referrals. These initial utilization trends mirror those seen when MCPAP first launched. Drawing from the lessons learned from MCPAP’s early years, ASAP and MCPAP are using these initial consultation requests as an opportunity to promote stronger primary care management. For example, ASAP clinicians often begin by assisting a provider with a referral or obtaining a buprenorphine waiver for medication-assisted treatment for an opioid use disorder. As PCPs continue to submit requests, ASAP clinicians will gradually empower them to manage their adolescent patients’ substance use needs independently. While building primary care providers’ clinical competency and capacity takes time, this approach has the effect of sustainably improving access to adolescent substance use treatment services over the long-term.
As the ASAP-MCPAP partnership continues to evolve and telehealth becomes more widely accepted due, in part, to COVID-19, ASAP-MCPAP is piloting a program in which PCPs connect adolescents to SUD counselling by calling the ASAP-MCPAP. Under this pilot, an ASAP clinician submits third-party reimbursement claims for any counselling rendered, with MCPAP providing supplemental funds to offset the ASAP clinician’s downtime. By offering telephonic substance use treatment under the ASAP-MCPAP, there may be additional consultation requests, and thus, more opportunities to strengthen providers’ capacity to manage adolescent substance use needs in primary care.
In an effort to increase access to substance use services for adolescents, Massachusetts successfully expanded MCPAP through a partnership ASAP to strengthen the identification and treatment of adolescent substance use by building the capacity of PCPs. With child psychiatry access programs (CPAPs) in at least 30 states and Washington, DC, Massachusetts’s partnership model can inform other states’ efforts to augment their CPAP to better support adolescent substance use needs.
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 Mark, T., et al., Insurance financing increased for mental health conditions, but not for substance use disorders, 1986-2014. Health Affairs, June 2016. https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2016.0002
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 Massachusetts Behavioral Health Partnership is the state’s contracted Medicaid mental health and substance abuse provider.
 “Overview, Vision, and History,” Massachusetts Child Psychiatry Access Program. Accessed October 1, 2020. https://www.mcpap.com/About/OverviewVisionHistory.aspx
 “Overview, Vision, and History,” Massachusetts Child Psychiatry Access Program
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 “Budget Summary FY2019, Child and Adolescent Mental Health Services,” Office of the Governor. Accessed October 2, 2020. https://budget.digital.mass.gov/bb/gaa/fy2019/app_19/act_19/h50425000.htm
 John Straus. (Massachusetts Child Psychiatry Access Program Founding Director) Email. September 22, 2020.
 Code of Massachusetts Regulations: 104 CMR 30.08, “Massachusetts Child Psychiatry Access Program Assessment,” February 8, 2019. https://www.mass.gov/files/documents/2019/02/11/jud-lib-104cmr30.pdf
 John Straus, Sharon Levy, “Stopping Behavioral Health and Substance Use Disorders Before They Start: Prevention and Treatment in Adolescence,” Aspen Institute, May 2020. https://ascend.aspeninstitute.org/webinar-stopping-behavioral-health-and-substance-use-disorders-where-they-start-prevention-and-treatment-in-adolescence/
 “Overview: Adolescent and Substance Use Program,” Boston Children’s Hospital. Accessed October 2, 2020. http://www.acaam.org/wp-content/uploads/2017/04/Pharmacologic-Treatment-in-Pediatric-PC_FINAL-LEVY-AMFDA_LiveLink_2017_04_03-003CBS-first.pdf
 Straus and Levy, Stopping Behavioral Health and Substance Use Disorders Before They Start: Prevention and Treatment in Adolescence
 John Straus. (Massachusetts Child Psychiatry Access Program Founding Director) Email. September 22, 2020.
Acknowledgements: This case study is a publication of the National Academy for State Health Policy (NASHP). This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under the Supporting Maternal and Child Health Innovation in States Grant No. U1XMC31658; $398,953. The information, content, and conclusions are those of the authors’ and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the US government.