Alcohol and drug misuse in the United States are major public health problems that degrade the physical and psychological well-being of individuals, families, and communities.In recent years, the need for improved alcohol and drug use behavioral risk reduction strategies has led to the rise in popularity of brief interventions (BI) — time-limited, structured, goal-oriented interventions that typically last 30 minutes or less. In 2003, the Substance Abuse and Mental Health Services Administration (SAMHSA) began federal funding of Screening, Brief Intervention, and Referral to Treatment (SBIRT) demonstration programs. Unlike primary prevention that targets non- or low-risk users, or treatment services for people already dependent, SBIRT provides early intervention services targeted at ‘risky users’ – those individuals who misuse alcohol or illicit drugs, but who may have not yet developed dependence. SBIRT programs provide comprehensive screening and assessments, and deliver interventions of appropriate intensity (matched to risk level) to reduce risks related to alcohol and drug use.
Studies have suggested SBIRT’s effectiveness in emergency departments (EDs). The ED visit may present a “teachable moment” in which a patient may be more open to feedback and suggestions regarding their risky health-related behaviors. Within acute healthcare settings, specially trained health educators often deliver BIs. Although individual program frameworks vary, all SBIRT programs share two key components: screening and intervention. Screening is conducted using brief, standardized assessments that are sensitive enough to detect the presence and severity of alcohol or illicit drug use problems through a short series of questions. Individuals who screen positive for alcohol or drug problems are provided with an appropriate educational or therapeutic service. Most of those screening “positive” are categorized as relatively low risk and receive a BI, consisting of a time-limited motivational interview done in the ED that focuses on increasing patient awareness of the risks of substance abuse, feedback on normative use and safe limits, and eliciting motivation to change. Individuals at moderate to severe risk are provided brief intervention plus brief treatment (e.g., 6 face-to-face counseling sessions) or Referral to Specialty Treatment for more intensive support.
Public health approaches to drug control like SBIRT save lives, save money, and can reduce the significant burden our drug problem places on both health care and criminal justice systems,” said White House Office of National Drug Control Policy Director Gil Kerlikowske. “This program represents the future of drug policy in America, and I commend our partners in the medical community for working with us to implement smart approaches in health settings to reduce our Nation’s challenges with substance use. Law enforcement efforts will always remain a part of our work to protect communities from drug-related crime, but as someone who has spent my entire career in law enforcement, I know that we cannot simply arrest our way out of the drug problem.”
Given the promise of the SBIRT approach, what are the implications of the Affordable Care Act (ACA) for expansion and sustainability of SBIRT services? Well, there’s good news and there’s not-so-good news. Since October of 2011, Medicare covers screening and behavioral counseling related to alcohol misuse in primary care settings (some states are working to “activate” Medicaid codes for SBIRT reimbursement as well). The ACA’s Health Home Model, an option to states that would better meet the needs of individuals with chronic conditions, could also expand the use of SBIRT services to provide more comprehensive care. In addition, the ACA requires that states must include mental health and substance use disorder services equal with other medical care, prevention services, and rehabilitative services. However, states are allowed to determine their own extent of coverage—SBIRT may or may not be included across multiple heath care settings in all states.
Faculty at the School of Social Work have interests in implementing and testing SBIRT in various venues and with diverse populations, including adolescents, incarcerated individuals, and military personnel. SBIRT holds promise as a cost-effective public health approach to preventing alcohol and drug use problems before they escalate.
Dr. Susan Woodruff is Professor, School of Social Work at SDSU.