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SBIRT: Identifying Risk

By Sue Coyle, MSW

It is likely that the majority of people in today’s society will have at least one glass of alcohol in their lifetime. Many, despite the increasingly negative public opinion, will smoke a cigarette. And with or without legalization, many will try marijuana. Then, there are the numerous other substances available legally and illegally to willing users. Many will use one or all of these. Some will become addicted. Others will not, but that doesn’t mean their behaviors don’t have consequences and have risks.

“It’s not necessarily a diagnosable disorder,” says Holly Hagle, PhD, director of the National SBIRT (screening, brief intervention, and referral to treatment) Addiction Technology Transfer Center Network at the Institute for Research, Education & in Addictions. “It’s people using low-risk substances in a high-risk manner—drinking too much on occasion and suffering consequences like a drunk driving accident. People are more vulnerable to domestic violence or any act of violence [when alcohol is involved]. They might be mixing medications and alcohol. We don’t talk enough about the risks.”

However, in an effort to create more opportunity to talk about those risks, professionals across the country and across many fields have been researching, explaining, and implementing SBIRT.

What Is SBIRT?

To put it generally, “SBIRT is a population-based public health approach for identifying people with at-risk drinking or other substance use,” explains Paul Sacco, PhD, LCSW, an associate professor at the University of Maryland School of Social Work. “It’s basically a form of outreach and identification.”

Breaking down that definition into a bit more detail starts not with SBIRT but with the term public health approach or model. What aspect of the model places it in that category? “It’s a public health model because we’re trying to advocate that it happens in many sectors of society,” Hagle says. “We’re seeing people throughout their life span and we want to be continually talking to them about their levels of substance use, so they could either decrease or make their own changes in use.”

“Providers who use a more classical model approach would ask only a patient who has a suspected substance use disorder about his/her substance use,” adds Cassidy Smith, MPH, program director, SBIRT Colorado at Peer Assistance Services, Inc. “SBIRT is an intervention that involves asking every patient about their substance use in order to identify his or her risk of negative health effects associated with risky use.”

The rest of the definition is rather self-explanatory when you break down the acronym.

S is for screening. The practitioner does a brief screening of the client or patient using a validated screen, Hagle says. “Those are scientifically tested to be reliable and valid through statistical analysis,” she explains. “There are several [screens] that have been validated to be found reliable to represent somebody’s level of drinking or smoking or drug use.” Hagle further explains that there may, for example, be a one-question prescreen that, if answered affirmatively, leads to a full screen, “which is usually about 10 questions.”

Should the screen be positive, a brief intervention (B and I) is provided. “The brief interventions are 10 to 30 minutes long,” describes Karen Rossie, DDS, PhD, a
research scientist at Clinical Tools, “depending upon the time available.”
“If negative,” Sacco says of the screen, “[the client/patient] is provided with education and positive reinforcement.”

If necessary, there is a referral to treatment (RT) following the intervention, specifically a warm referral. This means that, “You don’t just hand them a list of AA meetings and say, ‘Go to these meetings,’” Sacco says, by way of example. Referrals have to be individually focused and delivered in a way that encourages follow through.

“If a patient has an alliance with you, that does transfer to the referral,” Hagle adds. “If you can say, ‘I have worked with this clinician before and they’re close by and they take your insurance,’ the patient is more likely to go. We always say that you have to make the referral meaningful and real.”

And that’s it; a model that is not only straightforward but quick and easy to use. But, does SBIRT work?

Research and Implementation

SBIRT has been around for some time. Hagle has been working on it since 2003, and “Since 2006, Peer Assistance Services, Inc. has implemented and managed the SBIRT Colorado initiative through funding from the Substance Abuse and Mental Health Services Administration (SAMHSA) statewide grant to the Colorado Office of Behavioral Health,” Smith says.

Over the course of those years, there have been many research initiatives aimed at determining its efficacy. At present, SBIRT is “recognized as an empirically validated intervention for alcohol,” Sacco says. He notes that there is less evidence for drug use and for adolescents, but that’s not because it doesn’t work. Rather, there’s just been less research focusing on those populations, but even that likely won’t be true for long.

“SBIRT in adolescents is a promising practice, and it is during adolescence when this preventive service is most likely to function as primary prevention—in other words, prevent a substance use disorder from developing since most people who develop a severe substance use disorder begin drinking or using drugs during their teenage years,” Smith explains.

One place where there has been research is hospitals. “There have been studies of patients in a hospital setting. The patients were receptive. They thought it was appropriate because health care providers should know about substance use so they can better care for [the patients],” Hagle says.

Additionally, Smith notes, “The United States Preventive Services Task Force is an independent committee that rigorously reviews prevention research and makes recommendations for services that should be routinely offered in primary care types of health care settings. They issued a grade B recommendation for SBIRT, which means that it is considered a feasible, effective service that should be routinely offered.”

Organizations like Clinical Tools have done research as well, often in an effort to create training tools. “We developed an online skills training activity called SBIRTTraining.com to train health care providers in SBIRT,” Rossie says. “In order to develop it, we conducted a needs analysis with the target audience of primary care providers and counselors to determine their specific needs. The website was then designed around these results.

“We evaluated the website with the target audience and showed significant improvement in their knowledge, clinical simulation quiz, self-efficacy, and intended behavior regarding SBIRT before and after the training activity and found significant improvement in all measurements,” she concludes.

In the Social Work Classroom

In addition to research, SAMHSA and other organizations have made great efforts in distributing grants. “Because SBIRT can take as little as 10 minutes, it can be combined with just about any other practice modality. SAMHSA recognizes this potential for SBIRT, and that is why they have supported training initiatives for a wide variety of health care professionals, including physician assistants, dentists, psychologists, pharmacists, nurses, social workers, counselors, and medical students and residents,” Rossie says.

One such recipient of a grant is the University of Maryland School of Social Work. The school and many others around the country are working to include SBIRT training in MSW curriculum. “This year we had a two-day stand-alone training, and we’re continuing to do that training,” Sacco says. “We also provide training to field instructors, and we trained a whole class of students in their foundation class. It’s not mandatory, but it’s part of the curriculum now. We made it a part of something that’s already mandatory.”

But mandating training doesn’t take away challenges. One of those challenges is the very reason why SBIRT is necessary: reluctance to ask. “We have students who say, ‘Well, I’m not working with substance users. I work with those with mental health problems, but they don’t have substance use problems,’ or, ‘I work in child welfare’,” Sacco says. “Getting people to understand that SBIRT is for people who don’t work with substance users is difficult. If you work for Hazelden, you don’t need to do SBIRT because they’re already there for substance treatment.”

Once a social worker or other practitioner gets past the belief that it’s not him/her that has to ask, he/she can pose the question. When that happens, Hagle says, “people will answer honestly.”

— Sue Coyle, MSW, is a freelance writer and social worker in the Philadelphia suburbs.