Expand SBIRT Program

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Introductory Paragraph

SBIRT is a popular model because all patients are screened regardless of an identified disorder. This allows healthcare professionals to reach a wider range of people - not just those who are seeking treatment for substance use disorder (SUD) or behavioral health. This is especially critical for those who may be at risk for substance use disorder but may not meet established criteria.  Additionally, SBIRT screens for all types of substance use, not just dependencies.

This evidence-based, public health approach is a paradigm shift in substance-use treatment. Routine screening helps identify and intervene with patients whose use puts them at risk for health issues.
Georgia Council on Substance Abuse Illustration

SBIRT places risky substance use where it belongs—in the realm of healthcare. It focuses on identifying risky substance use to help prevent the onset of the more costly disease of addiction. Similar to preventive screenings for chronic diseases such as cancer, diabetes, and hypertension, SBIRT is an effective tool for identifying risk levels related to substance use and for providing the appropriate intervention[1]. By expanding the use of SBIRT and improving SBIRT practices, it can provide critical pathways for people to access treatment earlier.    

Key Information

The 6 Characteristics of a Behavioral Health SBIRT Model

SAMHSA supports a research-based comprehensive behavioral health SBIRT model which reflects the six following characteristics[2]:

1. It is brief. The initial screening is accomplished quickly (about 5-10 minutes) and the intervention and treatment components indicated by the screening results are completed in significantly less time than traditional substance abuse specialty care. 

2. Screening is universal. The patients, clients, students, or other target populations are all screened as part of the standard intake process.

3. One or more specific behaviors are targeted. The screening tool addresses a specific behavioral characteristic deemed to be problematic, or pre-conditional to substance dependence or other diagnoses. 

4. The services occur in a public health, or other non-substance use treatment setting.  

5. It is comprehensive. The program includes a seamless transition between brief universal screening, brief intervention and/or brief treatment, and referral to care. 

6. Strong research or substantial experiential evidence supports the model. At a minimum, programmatic outcomes demonstrate a successful approach.    

SBIRT Related Training

General Training

How can communities expand Screening and SBIRT tools? One way is to increase public awareness of the SBIRT approach and the value of identifying people who are at high risk or might be using substances. 

The NORC is a public policy and social research organization affiliated with the University of Chicago.  They provide hosted Webinars on Screening, Brief Intervention, and Referral to Treatment (SBIRT) training includes resources for professionals, adolescent SBIRT, workplace/EAP, community stakeholders, and other addiction or behavioral professionals. [3]  NORC provides SBIRT education both in on-demand and live webinars.

The SBIRT Process

Screening

The very first step of the SBIRT process is screening. Ideally, it is used universally -- whether at an annual physical or other regularly occurring appointments with a provider or healthcare specialist. It uses a quick and simple method of identifying patients who use alcohol or other substances at at-risk levels, identifies use or experimenting, can help identify individuals who use substances at at-risk levels, as well as those who are already experiencing substance use-related issues.

Brief Intervention and Referral to Treatment

After an initial screening, the individual may be referred for a Brief Intervention (BI)[4], where a healthcare professional engages a patient showing risky substance use behaviors in a short conversation, providing feedback and advice.

According to SAMHSA, commonly used models for brief interventions treatment include:

  • Cognitive-Behavioral Therapy (CBT)
  • Motivational Enhancement Therapy
  • Community Reinforcement Approach
  • Solution-focused Therapy

Models for brief treatment recommended by SAMHSA[3] include:

  • Brief Negotiated Interview
  • Brief Counseling
  • Feedback, Responsibility, Menu of options, Empathy, Self-efficacy (FRAMES)
  • Motivational Interviewing (MI) techniques

If the patient requires additional services, the healthcare professional may recommend a Referral to Treatment (RT)[5] — brief therapy or treatment to patients who screen showing they need additional services. SAMHSA recommends that referral to treatment is a critical component of the SBIRT process. It involves establishing a clear method of follow-up with patients that have been identified as having a possible dependency on a substance or in need of specialized treatment. The referral to treatment process consists of assisting a patient with accessing specialized treatment, selecting treatment facilities, and helping navigate any barriers such as treatment cost or lack of transportation that could hinder treatment in a specialty setting.   

Integrate SBIRT into Other Settings  

Besides typical healthcare settings, there are many other places where professionals come into contact with people who may be at risk of substance use disorder.   

Hospitals and Emergency Rooms

Individuals with SUDs or just occasional use regularly access emergency care.  Utilizing the SBIRT approach with individuals seeking care can be beneficial. A 2018 study [6] examined an SBIRT program in Allegheny County, Pennsylvania emergency rooms. It concluding that SBIRT had the potential to reduce healthcare costs and utilization, as measured by Medicaid claims data and that SBIRT use in the emergency department can be readily incorporated into existing practice settings.

Dentists and Oral Surgeons

Dentists and oral surgeons can play an important role in SBIRT. In fact, a study in the Journal of the American Dental Association (JADA) [7] showed that in the late 90s, dentists were the top specialty providers of immediate-release opioids, accounting for 15.5% of those prescriptions. The American Dental Association recommends dentists and oral surgeons incorporate NIDA's "Screening for Substance Use in the Dental Setting"[8]  to help dental professionals recognize the signs of risky substance use and addiction.

Community Health Centers and Clinics

Community health providers offer excellent opportunities for early intervention with at-risk substance users and intervention for persons with SUDs and mental health issues. The state of New Hampshire[9] was an early adopter of SBIRT in a community setting. By incorporating SBIRT, New Hampshire found that universal screening lowers the barriers to early intervention and treatment, integrated care, and increased positive outcomes for patients.

Schools

An estimated 310,000 adolescents (aged 12-17)[10] misused prescription pain relievers for the first time in 2018 - that's 850 teens every day.  Many states have moved forward to expand SBIRT in school settings. In fact, schools offer a prime opportunity to identify, support, and redirect students in middle school and high school. Massachusetts was one of the first states to require SBIRT in a school setting and is considered a model for school-based SBIRT [11]. Other states now incorporating SBIRT in schools include New York, Pennsylvania, California, Florida, and Texas.

A 2017 study [12] found that universal delivery of school-based SBIRT to all students -- not just substance-using students -- actually provides 2 types of prevention. First, it can prevent the onset of substance use by motivating abstinent students to remain abstinent. Second, it can reduce substance use among users by providing education on the consequences of substance use and brainstorming strategies to cut down or quit if the student wishes to do so.

The School-Based Health is currently testing and refining the adaptation of  school-based SBIRT into 17 health care settings in seven states.[13]

 

Integrate SBIRT into Electronic Health Records

One way to enhance the impact of SBIRT is to integrate information from the process into the Electronic Health Record (EHR)[14]. 

   

Relevant Research

A growing body of evidence demonstrates SBIRT’s effectiveness in creating positive outcomes for those with substance use disorder. A  2017 report[16] studied eleven multi-site programs of SAMHSA grant recipients each funded for 5 years to promote the use and  implementation of SBIRT. They screened more than 1 million people and reviewed five years of SBIRT research, concluding that its implementation was associated with improvements in treatment system equity, efficiency, and economy, including:

  • Greater intervention intensity was associated with larger decreases in substance use.
  • Brief intervention and treatment had positive outcomes- brief intervention was more cost-effective for most substances.

Key Findings about SBIRT:

  • Adapted successfully to the needs of early identification efforts for harmful use of alcohol and illicit drugs
  • Integrates management of substance use disorders into primary care and general medicine
  • Improves treatment system equity, efficiency, and economy   

   

Available Tools and Resources

For Adolesents[17]

  • SBIRT FOR ADOLESENTS - Sharon Levy, MD, MPH is a board-certified Developmental-Behavioral Pediatrician and has recorded a webinar with valuable information about screening and brief intervention to prevent or reduce substance use in youth.[18].
  • SBIRT OREGON - workflow, screening forms, clinical tools, curriculum, and video demonstrations



 

Promising Practices

How can communities expand SBIRT?  According to SAMHSA, one of the benefits of the SBIRT approach is that it is easy to learn relative to other behavioral treatment techniques that may require lengthy specialized training. As such, it can be implemented by diverse health professionals who work in busy medical settings such as physicians, nurses, social workers, health educators, and paraprofessionals.

Accordingly, if a community wants to expand SBIRT it may require training of a large number of people. One cost-effective option to accomplish this is through the use of technology.

  • Kognito offers accredited technology-based training[19] on Screening and Brief Intervention for youth using innovative simulations to provide training and evaluate the skills of those taking the training. The program was developed in collaboration with NORC at the University of Chicago and adopted by more than 40 schools of health professions and state agencies.  Additionally, the Kognito Conversation Platform[20] has an innovative behavior change model that integrates several evidence-based models and techniques, game mechanics, and learning principles. Kognito is listed in the National Registry of Evidence-based Programs and Practices (NREPP).
  • IRETA (The Institute for Research, Education, and Training in Addiction) provides online training for both professionals and the public, as well as free webinars and on-site prescriber education[21].
  • SAMHSA offers a wide list of general resources for SBIRT with links to technical assistance, online apps, and other research.[22]

Communities can also enhance SBIRT by incorporating technology through new screening tools. These tools make it easier for health professions to expand initial screenings while opening up a new avenue to engage patients and individuals. Screening tools may include phone apps, tablet-based screening, computer-administered screening (available in Spanish), interactive voice response, web-based or even text-based.

  • SBIRT Oregon App[23]:  The Department of Family Medicine at Oregon Health and Science University designed online resources and an SBIRT app for primary care and emergency medicine settings in Oregon and the U.S. The patient uses a web-based screening app for tablet, phone, or desktop, which quickly screens and assesses patients for substance use and depression, converts answers into chart-ready notes, reads questions out loud for patients with low literacy, and delivers screening tools in English or Spanish.
  • Screen for Opioid Abuse Risk (SOAR in Ohio, also known as OARS)[24]  was developed as a comprehensive self-administered measure of potential risk that includes a wide range of critical elements noted in the literature to be relevant to opioid risk.[2] This 43-question assessment is administered using a tablet and takes about 10 - 12 minutes to complete.  The assessment is instantly scored and a report is available to the prescribing physician that provides a summary opioid risk profile and a multidimensional assessment of risk factors. SOAR also provides depression and anxiety scores that can be used for SBIRT assessments and wellness visits.


Sources

  1. ↑ https://www.integration.samhsa.gov/clinical-practice/sbirt/SBIRT_Colorado_WhySBIRT.pdf
  2. ↑ https://www.samhsa.gov/sites/default/files/sbirtwhitepaper_0.pdf
  3. ↑ https://www.sbirteducation.com/
  4. ↑ https://www.integration.samhsa.gov/clinical-practice/sbirt/brief-interventions
  5. ↑ https://www.integration.samhsa.gov/clinical-practice/sbirt/referral-to-treatment
  6. ↑ https://warmhandoff.org/wp-content/uploads/2019/07/Safe-Landing-ED.pdf
  7. ↑ https://jada.ada.org/article/S0002-8177(18)30419-7/pdf
  8. ↑ https://www.drugabuse.gov/nidamed-medical-health-professionals/science-to-medicine/screening-substance-use/in-dental-setting
  9. ↑ http://sbirtnh.org/wp-content/uploads/2016/05/The-Power-of-Best-Practices-Launching-SBIRT-in-a-Community-Health-Center.pdf
  10. ↑ https://www.samhsa.gov/data/report/2018-nsduh-annual-national-report
  11. ↑ https://www.communitycatalyst.org/resources/publications/document/Massachusetts-Provides-a-Model-for-Addressing-Students-Risky-Substance-Use-7_6_18.pdf
  12. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5753915/
  13. ↑ http://www.sbh4all.org/current_initiatives/sbirt-in-sbhcs/
  14. ↑ https://www.indianasbirt.org/ehr-modification
  15. ↑ https://ireta.org/resources/electronic-health-record-toolkit/
  16. ↑ https://onlinelibrary.wiley.com/doi/epdf/10.1111/add.13675
  17. ↑ https://www.sbirt.care/resources.aspx
  18. ↑ https://www.youtube.com/watch?v=JtCd4jATtFw
  19. ↑ https://kognito.com/products/sbi-with-adolescents
  20. ↑ https://kognito.com/approach
  21. ↑ https://ireta.org/training/overview/
  22. ↑ https://www.integration.samhsa.gov/clinical-practice/sbirt
  23. ↑ http://www.sbirtoregon.org/screening-app/
  24. ↑ https://intera.solutions/soar-ohio-screen-opioid-abuse-risk/
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