Screening, brief intervention, and referral to treatment (SBIRT) is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services. It is used for persons with substance use disorders and higher levels of risk. Primary care centers, hospitals, and other community settings provide quick access for early intervention for persons with substance use disorders.
What is SBIRT?
An intervention based on “motivational interviewing” strategies for:
- Utilization of universal screening allows for quick access for patients presenting with a severity of alcohol use; illicit drugs; and prescription drug use, misuse, and abuse.
- Brief Interventions provide the patient with brief intrinsic motivation and awareness – raising intervention given to risky or problematic substance users.
- Referral to Treatment: Referrals to specialty care for patients with substance use disorders.
Screening
The AUDIT-C can help identify individuals who are hazardous drinkers or who have alcohol use disorders (including alcohol abuse or dependence). The AUDIT-C is a 3-item alcohol screen and is a modified version of the 10-question AUDIT screening instrument. The instrument has clinical utility in reliably identifying patients who are hazardous drinkers or who have alcohol use disorders (Bush, K., Kivlahan, D., McDonell, M., et al., 1998). Frequently asked questions guide to using the AUDIT-C can be found on the VA/DOD Clinical Practice Guidelines site. Unfortunately, alcohol and substance abuse contribute to trauma exposure and the victims as they try to find ways to cope with the wounded memories. Both the AUDIT-C and the CAGE-AID screens/questionnaires are brief. However, they are reliable and can identify patients who are hazardous drinkers or have active alcohol use disorders. The AUDIT-C has been scientifically validated for primary care screening.
The Questions are as follows:
1) How often did you have a drink containing alcohol? never (0), monthly (1), weekly (2), some days each week (3), most days each week (4)
2) How many drinks did you have on a typical day when you were drinking? 1or2 (0), 3 or 4 (1), 5 or 6 (2), 7-9 (3), more than 10 (4)
3) How often did you have six or more drinks on one occasion? never (0), <monthly (1), monthly (2), some days a week (3), most days each week (4)
Treatment
Current approaches to understanding the treatment of substance use and co-occurring disorders are driven by empirical advances in neuroscience and behavioral research rather than by theories alone. There is now good evidence that both biological factors and psychosocial experiences may occur at home, work, and in the community, and a stressor or risk factor may have a small or profound effect, depending on individual differences.
Below is an overview of motivational interviewing (MI), motivational enhancement therapy (MET), and cognitive–behavioral therapy (CBT) provides context for the treatment sessions.
MI is an effective, evidence-based method for helping patients with a variety of health and behavioral concerns. These approaches were developed by William Miller and Stephen Rollnick (2012), seeking to foster the intrinsic drive people have for healing, positive change, and self- development.
MET is a structured intervention approach that uses MI techniques. MET interventions typically involve both a specific feedback discussion following a screening and assessment and goal-setting interactions. Motivation enhancement is achieved by building rapport through reflective discussions, helping patients understand the pros and cons of use, and helping to establish collaborative goals based on the patient’s needs. Motivational enhancement strategies assess and increase the patient’s readiness, willingness, and ability to change. In CBT, substance use is viewed as an intrapersonal and interpersonal issue, a relapsing and habitual disorder that can be successfully treated.
The clinician must further assess the trauma-exposed coping skills in this area that too many times will make the patient vulnerable to substance abuse. Several studies have found that substance abuse developed following trauma exposure (25%–76%) or the onset of PTSD (14%–59%) in a high proportion of teens with substance abuse disorders. Research suggests that traumatic stress or PTSD may make it more difficult for adolescents to stop using substances, as exposure to reminders of the traumatic event have been shown to increase drug cravings in people with co-occurring trauma and substance abuse (Sadalin, M. E., et al. , 2003).
Treatment approach:
- Expressing concern (unhealthiness of use)
- Feedback (linking use to health issues)
- Education and recommended drinking limits (How much is okay and how much is not okay for patient’s health)
- Offer of explicit advice (to cut down or abstain)
- Follow-up (return visit to assess client’s response to intervention)
- Referral (for more specialized SA services such as BHC, AA/NA, CSB, inpatient detox)
Referral
When a patient needs more specialized services referrals take place in collaboration with specialized substance abuse services such as; BHC, AA/NA, CSB, or inpatient detox. Usually, the local Community Service Board (CSB) will have programs to address substance abuse issues and usually have a psychiatrist available to help with any needed medications. Services such as substance abuse group therapies and case management services can be established at the CSB. Inpatient treatment and detox may be needed to begin recovery in a supportive environment while being addressed medically. Local support groups and alternative therapies, such as massage therapy and acupuncture could be added to a comprehensive care management plan. Also, at times there may be a need for methadone/suboxone treatments. Therefore, a referral to a Methadone/Suboxone Clinic may be necessary.
Alcohol and other drug abuse/addictions are medical conditions. Substance abuse services can be effectively provided in a health care setting. SBIRT codes now provide financial support to health care settings using behavioral health care. Screenings, interventions, and referrals are the tools used for integrative substance abuse services. Co-occurring disorders are more effectively treated with integrative health care services. Ultimately, the patients’ care and treatment experience are enhanced in a patient-centered, integrated primary care clinic.
Bill McFeature, Ph.D.
Cinthia McFeature, Ph.D.
References
Bush, K. Kivlahan, D. R., McDonell, M. B. et al. The AUDIT Alcohol Consumption Questions (AUDIT-C): An effective brief screening test for problem drinking. Arch Internal Med. 1998 (3): 1789-1795.
Drugs, Brains, and Behavior: The Science of Addiction, NIH Pub No. 08-5605, printed April 2007, reprinted February 2008.
Drug Facts: Shatter the Myths, NIH Pub No. 10-7589, printed October 2010. www.nida.nih.gov/
McFeature, B. & Herron-McFeature, C. (2017). Integrated health – HeartPath practitioner assessment and intervention for the trauma-exposed patient. Melbourne, FL: Motivational Press.
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