Expand SBIRT in Maternity Care Clinics

Introductory Paragraph

SBIRT (Screening, Brief Intervention, Referral to Treatment) is "a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance use disorders, as well as those who are at risk of developing these disorders" and has been widely acknowledged as an evidenced-based practice. It helps identify the level of risk associated with alcohol or substance use.

Key Information

Early identification of substance use allows for early intervention and treatment which minimizes potential harms to the mother and her pregnancy. Selective screening based on “risk factors” perpetuates stigma and misses most women with problematic use.

The goals of SBIRT include:

• Educate people about the risks of alcohol and other drugs
• Make people aware of their use and whether it may be creating health risks for them
• Decrease general use so as to reduce the societal risk and burden of the effects of overuse
• Identify individuals who have dependence and provide rapid access to care

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), 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 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) — 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 examined an SBIRT program in Allegheny County, Pennsylvania emergency rooms. It concludes 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.

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 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.

• Use non-judgmental and caring tone - Patients are usually not offended by questions about substance use if asked in caring and nonjudgmental manner.
• Normalize questions – Embed them in other health behavior question and preface questions by stating that all patients are asked about substance use
• Ask permission – “Is it OK if I ask you some questions about smoking, alcohol and other drugs?"
• Avoid closed-ended questions – “You don’t smoke or use drugs, do you?”

Relevant Research

This SAMHSA White Paper discusses the evidence supporting the effectiveness of SBIRT as a comprehensive approach and individual components of SBIRT for different non-medical behavioral health conditions. The report includes a literature review and addresses the question of what a model SBIRT program is, compared to programs which include or adapt components of the comprehensive SBIRT approach.

NIDA Study. The National Institute on Drug Abuse funded research on SUMMIT (Substance Use, Motivation, Medication and Integrated Treatment). It looked at ways to implement MAT and behavioral treatment for patients with opioid and alcohol use disorders in a community health clinic. The project helped the clinic implement SBIRT and evaluated whether integrated collaborative care helped patients get the care they needed. The manual titled, “SUMMIT Study Protocol: Step-by-Step Procedures for Providing Screening, Brief Intervention, and Treatment Services to Primary Care Patients with Opioid or Alcohol Use Disorders,” is useful for researchers, primary care clinics, and policymakers providing treatment in primary care settings. The introduction provides a general overview of the study for readers, and the remainder of the manual is presented in the step-by-step instructional format used during the study.

Impactful Federal, State, and Local Policies

SAFE Solutions is an ever-growing platform. Currently limited information is readily available for this section. SAFE Project is dedicated to providing communities with the most relevant and innovative materials. We will continue to regularly monitor and make updates accordingly with community input and subject matter expert collaboration. Please check back soon.

Available Tools & Resources

National Association of Addiction Professionals (NAADAC) provides a webinar that outline a plan on how to work collaboratively with clinics in rural settings to build a SBIRT practice.

Massachusetts Toolkit. This is a step-by-step guide for implementing SBIRT.

SAFE Project has a more detailed wiki page titled "Expanding SBIRT Program" with additional tools and resources.

Promising Practices

Increase Uptake of SBIRT

• Embed it in standard of care
  • Staff-wide trainings
  • EMR
  • Routine part of QA Evaluation
• Don't rely exclusively on physicians
  • Physicians (especially primary care physicians) are overburdened by time and an increasing load of screenings
  • Think creatively about staff, screening and brief interventions
• Expand types of screening
  • Patient completed
  • Nurse/staff administered
  • Computer-assisted
• Expand types of intervention
  • Computer-based
  • Peer-based
  • Other staff

Promising Programs

Ultrasound Feedback

One study showed that real-time ultrasound feedback focused on the potential effects of smoking on the fetus may be an effective treatment adjunct to improve smoking outcomes. This could be adapted and used to treat women with other types of SUDs as well.

Educating Medical Students

A 2012 study of medical students in an obstetrics and gynecology rotation found that when students are placed in a residential treatment center for pregnant women (i.e. specialized training) they showed greater comfort in assessing and educating patients about substance abuse during pregnancy compared to those in a regular rotation.

 

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