Dec 29, 2015
Screening, Brief Intervention, and Referral to
TreatmentCDR Kellie Cosby &
CDR Erich Kleinschmidt
Recent CDC report – Jan. 2012
• One in six Americans binge drinks four times per month
• Average number of drinks during binge is 8• 40,000 deaths per year (binge-specific)• 2006 - $167.7 billion alcohol-related costs • Age group that binge drinks most often – 65+ • Income group with most binge drinkers - $75K+CDC Morbidity & Morality Weekly Report, Jan. 10, 2012 Vol. 61
CDC Report continued – binge drinking responsible for:
• Risk factor for motor vehicle accidents, violence, suicide, hypertension, heart attack, STDs, unintended pregnancy, FAS, SIDS
• 85% of all alcohol-impaired driving episodes involved binge drinking (2010)
• Accounted for 50% of all alcohol consumed by adults; 90% of youth
• Most binge drinkers are not dependentCDC Morbidity & Morality Weekly Report, Jan. 10, 2012 Vol. 61
Focus of SBIRT
Dependent Use
4%
25%
71%
Brief Intervention
Brief Intervention andReferral to Treatment
No Intervention
Harmful orRisky Use
Low Risk Useor Abstention
What exactly is SBIRT?
• SBIRT—Screening, Brief Intervention, and Referral to Treatment
• Universal screening of patients within medical settings with use of validated screening tools
• If screened positive – brief intervention (guided discussion) with medical provider occurs
• If screening reveals dependence – referral to specialty substance abuse treatment provider
SBIRT: Primary Care Context
• Takes advantage of the “teachable moment”
• Patients aren’t seeking treatment but screening opens door for awareness & education
• Focus on addressing low/moderate risk usage as a preventative approach before addiction occurs
Ranked in top ten of prevention services
1. Discuss daily use of aspirin 2. Childhood immunization Series3. Tobacco use screening and brief intervention4. Colorectal cancer screening5. Hypertension screening6. Influenza immunization7. Pneumococcal immunization8. Problem drinking screening & brief intervention9. Vision screening – adults10.Cervical cancer screening
(Partnership for Prevention – Priorities for America’s Health: Capitalizing on Life-Saving, Cost Effective Prev Services, 2006)
SBIRT “Patient Flow”
Screen
Identification of substance related
problems
Brief InterventionRaises awareness of risks and motivates
client toward concrete
goals/actions
Referral to Tx Referral of those with more serious
abuse/dependency
Brief Treatment Cognitive behavioral
treatment with multiple sessions
available
Universal Prescreen
Provide positive reinforcement
(+) Positive
Further screening with• ASSIST• AUDIT
• CRAFFT• DAST
Low risk: Provide positive reinforcement
Moderate risk: Provide Brief Intervention
Moderate high-risk: Provide Brief Therapy
High risk: Refer to treatment
• (-) Negative
Effective Screening Program Typically Yields…
• Approximately 25% of all patients will screen positive for some level of substance misuse or abuse
• Of those, the approximately 70% will be “at-risk” drinkers
• Most will be open to addressing their substance abuse problems (if discussed in a non-judgmental manner)
Brief Intervention Approach
• Uses “Motivational Interviewing” techniques • Discuss healthy drinking levels for male/females (NIAAA
standards) • Weigh pros/cons of cutting down or quitting• Use “scaling” to assess for readiness (i.e – on a 1 to 10
scale….)• Effects on quality of life and/or existing medical conditions• Plan to talk about it more than once (at future doctor visits) • Small, obtainable goals (let patient tell you want he/she can
handle)
Identify Referral Resources
Community agencies for referrals
Short-term and long-term residential treatment centers
Hospital inpatient and outpatient centers
State treatment centers
Has been implemented in many settings
• Thus far, SAMHSA has funded 21 states, 2 tribal organizations, and 12 colleges since 2003 (five year grants to states; 3 year to colleges)
• Clinical sites include: trauma centers, EDs, inpatient units, community health centers, FQHCs, tribal health centers, elder services agencies, adolescent care clinics, college health centers, VA clinics, rural, urban, suburban
• SBIRT training of resident physicians (17 grantees) since Sept ’08 (five year grants)
Other Fed Collaborations
• Dept of Labor – Youthbuild program – construction jobs training for at-risk young adults; pilot tested SBIRT in several sites in 2011; now plan to implement in all sites in US
• Dept of Navy – assisted with physician training in SBIRT; planning on implementing within medical home and readiness clinic at Bethesda, MD (National Military Medical Center)
• NIDA – integration of screenings within EHR systems
Possible Federal Initiatives
• Further expansion of SBIRT model into other health conditions related to behavioral change (ie – tobacco, depression, weight mgt, medication adherence, chronic illness mgt)
• Further workforce development necessary to prepare medical providers to address behavioral related medical conditions
Key Considerations for Starting SBI Program
• Identify target population and location(s)
• Develop a Screening protocol
• Develop a Brief Intervention protocol
• Identify staff to monitor and evaluate program (strong QI mgt essential)
• Reimbursement strategy & considerations
• Staff training needs and supervision
• Program “champions” and buy-in from CEO/Admin staff
Additional Considerations
Who Will Do the Screening and Brief Intervention?
• “SBIRT” counselors/health educator model• Social Workers• Registered Nurses• Psychologists• Physicians • Dedicated contracted personnel• Medical Assistants • Para-professionals
Challenges & Lessons Learned
• Buy-in issues from existing medical staff
• Funding for additional staffing (or train existing staff)
• Need for management to be supportive and influence implementation
• Consistent training available for new staff
Useful Resources
• Numerous SBIRT grantee websites with training videos, screening protocols, insurance/billing information, toolkits, etc…
• Addiction Technology Transfer Centers (ATTC) – SAMHSA funded trainings in SBIRT, MI, etc…
• Other non-fed funded organizations offering training, resources, etc…