Confidentiality Among Adolescents

Confidentiality is especially important when treating adolescents, as they are more likely to be honest during medical treatment if they know their privacy will be respected. This assurance also makes them more likely to seek treatment in the first place. In addition, when adolescents are allowed their privacy when making health decisions, it helps them establish autonomy (Carlisle et al., 2006).

Medical associations that support confidential health care for adolescents include the:

  • American Medical Association,
  • Society for Adolescent Medicine, and
  • American Academy of Pediatrics (Weddle & Kokotailo, 2002).

Obtaining consent from a minor is the same process as obtaining consent from an adult (Weddle & Kokotailo, 2002). The safety of a minor outweighs his or her right to privacy (Weisleder, 2004) and it is your job to determine whether the minor is capable of providing informed consent or if parental involvement is required, as well as how that parental involvement might impact treatment (Weddle & Kokotailo, 2002).

State Level

Most states protect the adolescent's confidentiality related to treatment for substance use disorders (Weisleder, 2004). Because these laws can vary by location, you should become familiar with the laws of the state in which you practice.

Practice Tip

Be sure to review current federal and laws regarding the treatment of adolescents.

View ReferencesHide References
Carlisle J, Shickle D, Cork M, McDonagh A. Concerns over confidentiality may deter adolescents from consulting their doctors. A qualitative exploration.. Journal of Medical Ethics. 2006; 32(3): 301-315. Available at: Accessed on: 2013-10-24.
Weddle M, Kokotailo P. Adolescent substance abuse. Confidentiality and consent.. The Pediatric Clinics of North America. 2002; 49(2): 301-315. Available at: Accessed on: 2013-10-24.
Weisleder P. The right of minors to confidentiality and informed consent. Journal of Child Neurology. 2004; 19(2): 145-148. Available at: Accessed on: 2013-10-24.
The Health Insurance Portability and Accountability Act (HIPAA)

In 1996, the first HIPAA regulations were enacted (Feld, 2005). They were set forth to standardize electronic data communication, thereby improving health care efficiency. The Standards For Privacy of Individually Identifiable Health Information, referred to as the Privacy Rule, was added in 2003. It protects any identifiable health information about an individual, including:

  • Photographs,
  • Birth dates,
  • Social security numbers
  • Phone numbers

Following the requirements of this rule, health care providers must obtain patient authorization before disclosing "protected health information" (PHI), apart from the following exceptions:

  • Disclosures required to public health officials and law enforcement officials (only in certain lifethreatening circumstances and certain other serious circumstances).
  • Disclosures to family or others involved in the patient's medical treatment unless the patient specifically objects
  • Operations (eg: quality improvement, notification of appointments)
  • Treatment
  • Payment
Implications for Substance Use Programs

As patients are receiving treatment for substance abuse, they must share very personal information, which may make them wary. To alleviate this concern, federal regulations (Title 42, Section 290dd-3 and ee-3 of the U.S. Code) mandate strict confidentiality for information about patients being treated for substance use disorders. Disclosure of this information is prohibited without the written consent of the patient. The HIPAA laws also provide privacy protection for patients with psychiatric disorders, which are often comorbid with substance use disorders (Kleber et al., 2006).

Privacy Issues in Multidisciplinary Care

Maintaining privacy while treating patients for substance use disorders can get complicated when coordinating care with multiple providers. Review SAMHSA's frequently asked questions document on Applying the Substance Abuse Confidentiality Regulations to Health Information Exchange (HIE) for more on the topic.

View ReferencesHide References
Feld A. The health insurance portability and accountability act (HIPAA): its broad effect on practice. . American Journal of Gastroenterology.. 2005; 100(7): 1440-1443. Available at: Accessed on: 2013-10-24.
Kleber HD, Weiss RD, Anton RF, et al. Treatment of patients with substance use disorders, second edition. American Psychiatic Association. Am J Psychiatry. 2006; 163(8 Suppl): 5-82. Available at: Accessed on: 2013-10-24.
Legal Information Institute. 42 CFR Part 2 - Confidentiality of alcohol and drug abuse patient records. Cornell University Law School. 2003. Available at: Accessed on: 2015-06-18.
Legal Information Institute. 42 U.S. Code § 290dd–2 - Confidentiality of records. Cornell University Law School. 2003. Available at: Accessed on: 2015-06-18.

Investigating potential treatment providers. Ask about:

  • Services offered
  • Philosophy toward treatment
  • Insurance accepted or if there are publicly funded programs

Establishing office protocol for referrals. Have a clear, standard, complete protocol in place for referral and make all staff aware of it. It should include the following:

  • How the referral is made
  • Who makes the referral call
  • When and where in the appointment flow is the referral call made
  • How the need for a referral is communicated to the person making the call
  • If referral calls are delegated to staff, what training they must have
  • What type of follow-up is needed with both the potential provider and patient, who will do it, and when

Contacting potential treatment provider. When contacting a potential provider, there are multiple options:

  • The provider or a staff member can make the initial call for the patient in the patient's presence.
  • The provider may ask the patient to come into the provider's office, following the examination, to discuss the referral and make the referral call.
  • To start the patient taking self-responsibility, the patient can be asked to make the phone call while still in the clinic.
  • Alternatively, staff may be trained in working with the patient to contact the potential treatment provider. Training must include information on potential treatment providers, how to make the referral, and how to follow-up. The patient encounter record used to communicate with staff should clearly identify the need for the referral.

Making the call immediately takes advantage of the momentum of the motivational interviewing and provides the opportunity to support the patient.

Referral letter. Send a referral letter to the specialist before the patient's first visit.

Follow-up communications. Request that the treating party communicate with the referring provider after the patient's assessment, or if the patient misses the appointment. Follow-up with the patient to make sure that they follow through with the referral.

(CSAT & SAMHSA, 1997)

View ReferencesHide References
Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA). TIP 24: A Guide to Substance Abuse Services for Primary Care Clinicians. Rockville, MD. Center for Substance Abuse Treatment. 1997. Available at: Accessed on: 2010-06-15.

The following dialogue is an example of how to give a patient a warm referral, which makes sure that she goes from the connection you have built up to a direct connection with another individual at the treating institution, with no intervening time period with a lack of support.

With the severity of your alcohol use disorder, and use of sedatives complicating things, I feel it's time for specialty treatment. Can we talk about that possibility?

I agree I'm addicted to alcohol, and I need help, but I just can't afford to be away from my job right now.

The intensive outpatient treatment fits with your situation. I think you'll benefit from the support they provide. You may have to adjust your work schedule somewhat, but with the support you have from your family, that may work out. The important thing is to get the treatment you need.

All right. I'm ready to do what is needed.

I know of a treatment facility close to your home that takes your insurance. I'd be happy to set up an appointment and introduce you to them to see if they are a good match for your needs. [Warm-Referral] How does that sound?

I'd like to hear more about it.

Talking Points

Some patients will resist discussing, or deny having, substance use problems. However, if you suspect substance use disorders and referral to addiction treatment is warranted, then you must discuss the issues with the patient. Explain to patients and their significant others that:

  • Addiction is a treatable chronic disease
  • You want to give them the best treatment and so you are referring them to a specialist much like you would for other chronic diseases
  • When stabilized, patients may return to the primary care provider for on-going care, while the addiction specialist can continue to provide the addiction treatment

Skillful, empathetic interviewing is key. Sensitive approaches can reduce resistance.

Interview Techniques
  • Use the "Ask-Tell-Ask" approach:
    1. Ask permission to discuss something with them
    2. Tell them your concerns
    3. Ask what they thought about what you said
  • Explain that you need to discuss tobacco/alcohol/drug use because you are concerned about their health and explain why you are recommending a referral. Point out the direct relationship between their substance use and health/social consequences.
  • Provide as much information as possible about the provider/clinic where you are referring the patient. If you speak with confidence and knowledge about the treatment center, patients are more likely to respond positively.
  • Maintain the patient's privacy. Conduct the interview in private and do not bring up the substance use disorder or referral around others without the patient's permission.
Using "Warm" Techniques for Referral

A "warm hand-off" or "warm referral" is a referral strategy in which the primary care provider directly introduces the patient to the substance abuse treatment provider that they will be working with. This process can further help build rapport and trust between the primary care provider and patient, by establishing the presence of prior communications and relationships between the provider and treatment center.

Introducing patients personally, or via telephone, to their treatment provider can also increase the likelihood that appointments will be met by patients (IBHP, 2007).

View ReferencesHide References
IBHP. Warm hand-off referrals by the primary care provider to the behavioralist . California Metal Health Services Authority . 2007. Available at: Accessed on: 2015-06-11.

(Storie, 2011)
Problems viewing videos? Click on View References below to access the video link to YouTube.

The video shows a provider talking with a client who is in the high-risk category but only in the preparation stage, meaning he knows he has a problem but needs help finding treatment. He needs a referral for treatment. The provider completes the following steps:

  1. Explains the significance of the patient's test results, and elicits his response to hearing these results, and responds with reflective listening.
  2. Assesses and labels the patient's stage of change.
  3. Explains to the patient that he needs treatment and offers to make a referral
View ReferencesHide References
Storie M. SBIRT Brief Intervention for Preparation Stage, High Risk Client. Colorado SBIRT. Youtube. 2011. Available at: Accessed on: 2015-05-19.
Motivating the Patient to Follow Through
  1. Schedule the appointment immediately. If possible, schedule referral appointments to specialists and programs while the patient is in the office. Asking them to make the appointment themselves, in your presence, encourages the patient to start taking responsibility while at the same time provides support. Support the patient by providing the name and phone number, and a phone if necessary. Easing the patient's ability to request specialized treatment will increase their likelihood of following through with a referral.

  2. Provide encouragement. It is important to encourage patients to comply with treatment, especially when referring them to other treatment facilities, in order to raise the likelihood that the patient will follow through with the intended treatment plan.

  3. Provide information about the treatment program. Being informed about the prospective treatment program is likely to reduce a patient's anxiety about it. Let them know what to expect. For instance, among self-help group referrals, providing both extensive information about the group and having contact information for a volunteer mentor available improves both attendance and treatment outcomes (Timko & DeBenedetti, 2007).

  4. Follow up and repeat referrals as needed. It is important to follow-up with the patient to make sure the referral was successful. The patient may require multiple referrals to find a treatment format with which they feel comfortable. For instance, comfort with a particular psychosocial approach may vary with psychiatric stability, polysubstance abuse, co-morbid medical disorders, age, and pregnancy status.
Practice Tip

To ease a referred patient's anxiety about what to expect in a treatment program, provide some patient education materials about topics such as:

  • Substance abuse treatment
  • Information about how a particular treatment works
  • What treatment entails
  • Benefits of treatment and recovery
View ReferencesHide References
Timko C, DeBenedetti A. A randomized controlled trial of intensive referral to 12-step self-help groups: one-year outcomes. Drug and Alcohol Dependence. 2007; 90(2-3): 270-279. Available at: Accessed on: 2013-10-24.
Referral to Addiction Treatment

Treatment facility locations can be found online for resources such as employee assistance programs, behavioral health programs, local health departments, hospitals, and support group programs, such as 12 step programs. Some of the details that may be provided and that should be considered when selecting a treatment facility for a referral include the following:

  • Type of treatment
  • Patient age
  • Location
  • Hours
  • Accessibility to public transportation
  • Eligibility criteria
  • Cost/insurance accepted
  • Staff complement and qualifications
  • Language proficiency
  • Any religious orientation

If you need to compile a list yourself, the following resources are good first steps:

  • Substance Abuse Treatment Facility Locator - maintained by SAMHSA's Center for Substance Abuse Treatment
  • AlcoholAnswers' Treatment Provider Locator - to find alcohol treatment specialists in your area
  • American Society of Addiction Medicine Member Directory - Find ASAM certified providers in your area via their website.
  • Support Groups - Keep a current list of various support groups meeting locations and times that can be given to the patient, such as 12 Step Groups. These can be obtained from local meeting sites or online.

Links to the above resources and more are provided in the Related Resources section on this page and at the end of the module. Also, you can get referral information from employee assistance programs, local health departments, behavioral health program counselors, and local hospitals.

Treatment Locator Tools, such as the SAMHSA Locator Tool, can help you find addiction treatment providers in your area. Mentors are also available for consultation through NIDA's Physician Clinical Support System.

Practice Tips

Clinics and hospitals should maintain a list of local treatment providers where they can refer patients when a substance use problem is identified or suspected.

If you use the same local referral resource repeatedly, you will develop a positive working relationship, enhancing communication. You can visit the treatment source, personalizing the experience. This will also improve the likelihood of your patient coming back to your practice after treatment.


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