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Substance Abuse Screening, Brief Intervention and Referral to Treatment (SBIRT)

Billie Jo Smith, MS, LPC

4/21/2023

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This presentation was prepared for the Central East Addiction Technology Transfer Center (Central East ATTC) Network under a cooperative agreement from the Substance Abuse and Mental Health Services Administration (SAMHSA). All material appearing in this publication, except that taken directly from copyrighted sources, is in the public domain and may be reproduced or copied without permission from SAMHSA or the authors. Citation of the source is appreciated. Do not reproduce or distribute this publication for a fee without specific, written authorization from Central East ATTC. For more information on obtaining copies of this publication, email webinars@danyainstitute.org.�

At the time of this publication, Miriam E. Delphin-Rittmon, Ph.D, served as Assistant Secretary for Mental Health and Substance Use in the U.S. Department of Health and Human Services and the Administrator of the Substance Abuse and Mental Health Services Administration.

The opinions expressed herein are the view of TTC Network and do not reflect the official position of the Department of Health and Human Services (DHHS), SAMHSA. No official support or endorsement of DHHS, SAMHSA, for the opinions described in this document is intended or should be inferred.

This work is supported by grants 1H79TI080210 from the Department of Health and Human Services, Substance Abuse and Mental Health Services Administration.

Presented 2023

�Acknowledgment

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Objectives

Identify the moving components of SBIRT

Discuss the need to address substance use from a public health model

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Module 1 - Re-conceptualizing Our Understanding of Substance Use Problems

T

R

I

B

S

Quick assessment of severity

Screening

Collaborative conversation to enhance motivation

Intervention

Specialty care

Outpatient

Withdrawal Management

Residential

Community Support Group

Treatment

Short conversation to increase awareness

Brief

Connecting a person to someone who can assist

Referral

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A Systems Change Initiative

Substance use screening, brief intervention, and referral to treatment (SBIRT) is a systems change initiative. As such, we are required to shift our view toward a new paradigm, and;

Re-conceptualize how we understand substance use problems.

Re-define how we identify substance use problems.

Re-design how we treat substance use problems.

SBIRT isn’t just a new service added to an old system. The system itself must change to accommodate a new approach to providing substance use services. The current system focuses on primary prevention for youth intended to preclude or delay onset of use. There are no lifelong prevention activities for substance use (as opposed to those for obesity, heart disease, cancer, diabetes, etc). Once prevention activities are provided to youth the system is designed to wait until individuals have a substance use disorder prior to providing services (and services are structured and reimbursed in such a way that only individuals with a diagnosis are able to access or pay for services).

By changing how we understand, identify, and treat substance use problems we can expand the continuum of care to more appropriately provide services to those who are at risk for psycho-social and health care problems related to their substance use choices as well as those who are substance dependent. Because SBIRT approaches substance use from a different perspective from that used in the past it requires us to change our understanding as well as the system that supports it. In general, SBIRT asks us to re-conceptualize how we understand substance use problems, re-define how we identify substance use problems and re-design how we treat substance use problems.

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Learning from Public Health

The public health system of care routinely screens for potential medical problems (cancer, diabetes, hypertension, tuberculosis, vitamin deficiencies, renal function), provides preventative services prior to the onset of acute symptoms, and delays or precludes the development of chronic conditions.

SBIRT mirrors what the health care system has always done by seeking to identify potential problems via screening for them before they are acute or chronic (and become more difficult and more expensive to treat). This allows us to intervene earlier. Examples from health care include getting your blood pressure checked (screening for hypertension), getting a Mammogram (screening for breast cancer), getting your blood drawn (screening for vitamin deficiencies, etc.) Note that these screenings do not provide a diagnosis (if a problem is suspected based on the screening results more tests may be necessary, i.e., referral to a specialist to assess and diagnose). Since we understand substance use as public health problem it follows that we would model what the health care system does. We want to provide universal screening to identify potential substance use problems, intervene prior to the onset of anything acute, and as a result delay or preclude a chronic problem.

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The Current Model�A Continuum of Substance Use

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Abstinence

Addiction

Responsible Use

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The SBIRT Model�A Continuum of Substance Use

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Abstinence

Experimental Use

Social Use

Binge Use

Abuse

Substance Use Disorder

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Module 2 – Screening

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Screening Does Not Provide

A Diagnosis

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Screening Does Provide

Immediate rule-out of low/no risk users.
Immediate identification of level of risk.
A context for a discussion of substance use.
Information on the level of involvement in substance use.
Insight into areas where substance use may be problematic.
Identification of patients who are most likely to benefit from brief

intervention.

Identification of patients who are most likely in need of referral

for further assessment.

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Two Levels of Screening

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Provided to all adult patients.
Serves to rule-out patients who are at low or no-risk.
Can (should) be done at intake or triage.
Positive universal screen = proceed with full screen.

Universal:

Provided to specific patients (alcohol on breath, positive BAL, suspected alcohol/drug related health problems)
Provided to patients who score positive on the universal screen.

Targeted:

In the healthcare setting, screening are common and used in many ways (weight, blood pressure, temperature). These screens are done as a way to identify those who may be at a greater risk for illness.

Screening for alcohol use has been around since the 80s and the World Health Organization found that “the rewards from screening and early intervention for alcohol problems are considerable, more so than for treating advanced dependence or disability” – WHO 1987

As we have learned in our previous module, approximately 75% of the adult population will identify as having no problem, it is advantageous to provide a simple universal screen (generally 1 to 4 questions) to rule out individuals who are low to no risk.

Once those individuals are ruled out the focus can shift to the remaining 25% who are likely at risk for a psycho-social or health care problem related to their current substance use choices.

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NIAAA Definitions

Low Risk:

Healthy Men < 65

≤ 4 drinks per day → AND NOT MORE THAN 14 drinks per week

Healthy Women & Men ≥ 65

≤ 3 drinks per day → AND NOT MORE THAN 7 drinks per week

Hazardous:

Pattern that increases risk for adverse consequences.

Harmful:

Negative consequences have already occurred.

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National Institute of Alcohol Abuse and Alcoholism. (2015). Rethinking drinking: Alcohol and your health. Retrieved from http://pubs.niaaa.nih.gov/publications/RethinkingDrinking/Rethinking_Drinking.pdf.

Babor, T.F. & Higgins-Biddle, J.C. (2001). Brief intervention for hazardous and harmful drinking: a manual for use in primary care. World Health Organization. Retrieved from http://apps.who.int/iris/bitstream/10665/67210/1/WHO_MSD_MSB_01.6b.pdf.

So what constitutes being at risk? The National Institute of Alcohol Abuse and Alcoholism defines low risk for healthy men under 65 as less than or equal to 4 drinks per day (acute measure) AND not more than 14 drinks per week (chronic measure). For healthy women and men 65 and older, the cutoff is less than or equal to 3 drinks per day AND not more than 7 drinks per week. Drinking over these amounts places the individual at risk for psycho-social or health care problem related to their current substance use choices. In addition to being at risk for psycho-social or health care problems SBIRT also recognizes levels of risk (hazardous) and use that is already resulting in problems (DUI, etc.)These are the agreed upon standards for low risk (non-excessive) use. Any use above this amount (and all illicit drug use or use of Rx drugs other than prescribed) constitutes risk. If negative consequences have yet to be experienced the use is hazardous. If negative consequences are occurring the use is harmful.

Reference: National Institute of Alcohol Abuse and Alcoholism. (2015). Rethinking drinking: Alcohol and your health. Retrieved from http://pubs.niaaa.nih.gov/publications/RethinkingDrinking/Rethinking_Drinking.pdf.

Reference: Babor, T.F. & Higgins-Biddle, J.C. (2001). Brief intervention for hazardous and harmful drinking: a manual for use in primary care. World Health Organization. Retrieved from http://apps.who.int/iris/bitstream/10665/67210/1/WHO_MSD_MSB_01.6b.pdf.

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A Standard Drink

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National Institute of Alcohol Abuse and Alcoholism. (2015). Rethinking drinking: Alcohol and your health. Retrieved from http://pubs.niaaa.nih.gov/publications/RethinkingDrinking/Rethinking_Drinking.pdf.

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The SBIRT Concept

SBIRT uses a public health approach to universal screening for substance use problems.

SBIRT provides:

Immediate rule out of non-problem users;
Identification of levels of risk;
Identification of patients who would benefit from brief advice;
Identification of patients who would benefit from further assessment, and;
Progressive levels of clinical interventions based on need and motivation for change.

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Validated Screening Tools

AUDIT: Alcohol Use Disorder Identification Test. World Health Organization. (1982). The Alcohol Use Disorders Identification Test.
DAST: Drug Abuse Screening Test. The Addiction Research Foundation. (1982) The Drug Abuse Screening Test.
CRAFFT: Car, Relax, Alone, Forget, Family or Friends, Trouble (for adolescents). Knight, J.R., Sherritt, L., Shrier, L. A., Harris, S. K., & Chang, G. (2002). Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Archives of Pediatrics & Adolescent Medicine, 156(6), 607-614.
ASSIST: Alcohol, Smoking, and Substance Abuse Involvement Screening Test. World Health Organization. (2002). The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): development, reliability and feasibility. Addiction, 97(9), 1183-94.
CAGE-AID: Cut Down, Annoyed, Guilty, Eye-Opener, Hinkin CH, Castellon SA, Dickson-Fuhrman E, Daum G, Jaffe J, Jarvik L. Screening for drug and alcohol abuse among older adults using a modified version of the CAGE. Am J Addict. 2001;10:319-26.

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Module 3 - Brief Intervention

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What is a Brief Intervention (BI)?

A Brief Intervention is a time limited, individual counseling session.

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What is Your Role?

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Provide

Provide feedback about the screening results.

Offer

Offer information on low-risk substance use, the link between substance use and other lifestyle or healthcare related problems.

Understand

Understand the client’s viewpoint regarding their substance use.

Explore

Explore a menu of options for change.

Assist

Assist the individual in making new decisions regarding their substance use.

Support

Support the individual in making changes in their substance use behavior.

Give

Give advice if requested.

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The Feedback Sandwich�

Ask Permission

Offer Feedback/Information/Advice

Ask for Response

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Offer a Menu of Options

Manage drinking/use (cut down to low-risk limits)
Eliminate your drinking/drug use (quit)
Never drink and drive (reduce harm)
Utterly nothing (no change)
Seek help (refer to treatment)

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Module 4 - Referral to Treatment �for Patients at Risk for Substance Use Disorder

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Referral to Treatment

Approximately 5% of patients screened will require referral to substance use evaluation and treatment.
A patient may be appropriate for referral when:

Assessment of the patient’s responses to the screening reveals serious medical, social, legal, or interpersonal consequences associated with their substance use.

These high-risk patients will receive a brief intervention followed by referral.

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Referral to Treatment

Always:

Follow appropriate confidentiality (42, CFR-Part 2) and HIPAA regulations when sharing information.
Establish a relationship with your community provider(s) and ensure you have a referral agreement.
Maintain a list of providers, support services, and other information that may be helpful to patients.
Reduce barriers and build bridges.

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“Warm hand-off” �Approach to Referrals

Describe

Describe treatment options to patients based on available services

Develop

Develop relationships between health centers, who do screening, and local treatment centers

Facilitate

Facilitate hand-off by:

Calling to make appointment for patient/student
Providing directions and clinic hours to patient/student
Coordinating transportation when needed

In order to help patients initiate treatment for substance use disorders, clinicians need to take an active role in the referral process. By “warm hand-off” we mean that clinicians make the transition to the treatment facility as smooth as possible for the patient.

Bullet 1. When we discuss options for specialty care with patients, we need to describe what treatment entails and the types of available resources in the community.

Bullet 2. To be able to do this, we need to get to know some of the local treatment facilities in our area so that we can describe what treatment entails. We also need to have the treatment facilities’ contact information and address on hand when we make referrals.

Bullet 3. There are several things we can do to facilitate the hand-off:

Bullet 4. call around to find a facility with availability, call to make the appointment for the patient before he or she leaves your office,

Bullet 5. give the patient directions to the facility, and

Bullet 6. help the patient with transportation if needed. Some treatment facilities offer transportation, so this is something to inquire about when meeting with treatment facility staff.

Ask the audience if they know of other referral strategies that are helpful.

Source: Pacific Southwest ATTC (2011). SBIRT Curriculum, retrieved September 24, 2013 from http://www.attcnetwork.org/regcenters/productdetails.asp?prodID=784&rcID=11

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What if the person does not want a referral?

Encourage follow-up – at the point of contact

At follow-up visit:

Inquire about use
Review goals and progress
Reinforce and motivate
Review tips for progress

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Evaluation

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Accelerate the adoption and implementation of evidence-based and promising addiction treatment and recovery-oriented practices and services;
Heighten the awareness, knowledge, and skills of the workforce that addresses the needs of people with substance use or other behavioral health disorders; and
Foster regional and national alliances among culturally diverse practitioners, researchers, policy makers, funders, and the recovery community.