Screening, Brief Intervention,
and Referral to Treatment
April Velasco, PhD
Deputy Regional Health Administrator
US Dept of Health and Human Services,
Region II (NY, NJ, PR, USVI)
Recent CDC report – Jan. 2012
• One in six Americans binge drinks four times
per month
• Average number of drinks during binge is 8
• 40,000 deaths per year (binge-specific)
• 2006 - $167.7 billion alcohol-related costs
• Age group that binge drinks most often – 65+
• Income group with most binge drinkers - $75K+
CDC Morbidity & Morality Weekly Report, Jan. 10, 2012 Vol. 61
CDC Report continued – binge drinking
responsible for:
• Risk factor for motor vehicle accidents, violence, suicide,
hypertension, heart attack, STDs, unintended pregnancy, FAS,
SIDS
• 85% of all alcohol-impaired driving episodes involved binge
drinking (2010)
• Accounted for 50% of all alcohol consumed by adults; 90% of
youth
• Most binge drinkers are not dependent
CDC Morbidity & Morality Weekly Report, Jan. 10, 2012 Vol. 61
Focus of SBIRT
Dependent
Use
4%
Harmful or
Risky Use
Low Risk Use
or Abstention
Brief Intervention and
Referral to Treatment
Brief Intervention
25%
71%
No
Intervention
What exactly is SBIRT?
• SBIRT—Screening, Brief Intervention, and Referral to
Treatment
• Universal screening of patients within medical settings with
use of validated screening tools
• If screened positive – brief intervention (guided discussion)
with medical provider occurs
• If screening reveals dependence – referral to specialty
substance abuse treatment provider
SBIRT: Primary Care Context
• Takes advantage of the “teachable moment”
• Patients aren’t seeking treatment but screening opens
door for awareness & education
• Focus on addressing low/moderate risk usage as a
preventative approach before addiction occurs
SBIRT Ranked in top ten of prevention
services
1. Discuss daily use of aspirin
2. Childhood immunization Series
3. Tobacco use screening and brief intervention
4. Colorectal cancer screening
5. Hypertension screening
6. Influenza immunization
7. Pneumococcal immunization
8. Problem drinking screening & brief intervention
9. Vision screening – adults
10.Cervical cancer screening
(Partnership for Prevention – Priorities for America’s Health:
Capitalizing on Life-Saving, Cost Effective Prev Services, 2006)
SBIRT and ACA
• Taking a closer look at the potential newly
insured population post-ACA marketplace
enrollment
• Prevalence estimates and data
PREVALENCE OF ANY MENTAL ILLNESS
BY POPULATION
Any Mental Illness
35%
30.5%
Percent with Condition
30%
25%
21.3%
21.3%
21.1%
21.2%
Uninsured Adults
(8,938,373)
CI: 20.6-22.0%
Uninsured Adults
<133% FPL
(3,811,510)
CI: 20.3-22.4%
Uninsured Adults
133-<400% FPL
(4,066,602)
CI: 20.1-22.2%
Uninsured Adults
<400% FPL
(7,879,491)
CI: 20.5-21.9%
20%
15%
10%
5%
0%
CI = Confidence Interval
Sources: 2008 – 2011 National Survey of Drug Use and Health, 2011 American
Community Survey
Medicaid Adults
(6,598,793)
CI: 29.4-31.6%
PREVALENCE OF SUBSTANCE USE
DISORDER BY POPULATION
Substance Use Disorder
16%
14.4%
Percent with Condition
14%
13.6%
14.3%
13.9%
11.9%
12%
10%
8%
6%
4%
2%
0%
Uninsured Adults
(6,042,844)
CI: 13.8-14.9%
Uninsured Adults
<133% FPL
(2,433,640)
CI: 12.9-14.4%
Uninsured Adults
133-<400% FPL
(2,756,039)
CI: 13.5-15.1%
CI = Confidence Interval
Sources: 2008 – 2011 National Survey of Drug Use and Health, 2011 American
Community Survey
Uninsured Adults
<400% FPL
(5,166,270)
CI: 13.4-14.5%
Medicaid Adults
(2,574,611)
CI: 11.2-12.7%
PREVALENCE OF ANY MENTAL ILLNESS OR
SUBSTANCE USE DISORDER BY POPULATION
Any Mental Illness or Substance Use Disorder
40%
Percent with Condition
35%
30%
36.0%
30.2%
29.7%
29.9%
29.8%
Uninsured Adults
(12,673,186)
CI: 29.4-30.9%
Uninsured Adults
<133% FPL
(5,314,641)
CI: 28.6-30.9%
Uninsured Adults
133-<400% FPL
(5,762,626)
CI: 28.7-31.0%
Uninsured Adults
<400% FPL
(11,075,888)
CI: 29.0-30.6%
25%
20%
15%
10%
5%
0%
CI = Confidence Interval
Sources: 2008 – 2011 National Survey of Drug Use and Health, 2011 American
Community Survey
Medicaid Adults
(7,788,739)
CI: 34.8-37.2%
PREVALENCE OF ANY MENTAL ILLNESS AND
SUBSTANCE USE DISORDER BY POPULATION
Any Mental Illness and Substance Use Disorder
8%
6.5%
Percent with Condition
7%
6%
5.5%
5.2%
Uninsured Adults
(2,308,031)
CI: 5.1-5.8%
Uninsured Adults
<133% FPL
(930,510)
CI: 4.7-5.7%
5.5%
5.4%
5%
4%
3%
2%
1%
0%
Uninsured Adults
133-<400% FPL
(1,060,015)
CI: 5.0-6.0%
CI = Confidence Interval
Sources: 2008 – 2011 National Survey of Drug Use and Health, 2011 American
Community Survey
Uninsured Adults
<400% FPL
(2,007,040)
CI: 5.0-5.7%
Medicaid Adults
(1,406,300)
CI: 5.9-7.1%
SBIRT Implementation
• Implementation strategies
• Considerations
Universal Prescreen
• (-) Negative
Provide positive reinforcement
(+) Positive
Low risk: Provide
positive reinforcement
Further screening with
• ASSIST
• AUDIT
• CRAFFT
• DAST
Moderate risk: Provide
Brief Intervention
Moderate high-risk: Provide
Brief Therapy
High risk:
Refer to treatment
Effective Screening Program Typically
Yields…
• Approximately 25% of all
patients will screen positive for
some level of substance misuse
or abuse
• Of those, the approximately
70% will be “at-risk” drinkers
• Most will be open to addressing
their substance abuse problems
(if discussed in a nonjudgmental manner)
Brief Intervention Approach
• Uses “Motivational Interviewing” techniques
• Discuss healthy drinking levels for male/females (NIAAA
standards)
• Weigh pros/cons of cutting down or quitting
• Use “scaling” to assess for readiness (i.e – on a 1 to 10
scale….)
• Effects on quality of life and/or existing medical conditions
• Plan to talk about it more than once (at future doctor visits)
• Small, obtainable goals (let patient tell you want he/she can
handle)
Identify Referral Resources
Short-term and long-term residential treatment centers
Community agencies for referrals
Hospital inpatient and outpatient centers
State treatment centers
Key Considerations for Starting SBI
Program
• Identify target population and
location(s)
• Reimbursement strategy &
considerations
• Develop a Screening protocol
• Staff training needs and
supervision
• Develop a Brief Intervention
protocol
• Identify staff to monitor and
evaluate program (strong QI mgt
essential)
• Program “champions” and buy-in
from CEO/Admin staff
Additional Considerations
Who Will Do the Screening and Brief Intervention?
•
•
•
•
•
•
•
•
“SBIRT” counselors/health educator model
Social Workers
Registered Nurses
Psychologists
Physicians
Dedicated contracted personnel
Medical Assistants
Para-professionals
Challenges & Lessons Learned
• Buy-in issues from existing medical staff
• Funding for additional staffing (or train existing staff)
• Need for management to be supportive and influence
implementation
• Consistent training available for new staff
Useful Resources
• Numerous SBIRT grantee websites with training videos,
screening protocols, insurance/billing information, toolkits,
etc…
• Addiction Technology Transfer Centers (ATTC) – SAMHSA
funded trainings in SBIRT, MI, etc…
• Other non-fed funded organizations offering training,
resources, etc…
Questions/Discussion
For additional information and resources.
Contact:
April Velasco
212-264-2560
april.velasco@hhs.gov