InSight
into Screening,
Brief Intervention,
Referral, and
Treatment
IOM Recommendations Providers
• Organizations should (Chapter 4):
– Increase use of valid and reliable
patient questionnaires
– Use measures of process and quality
to continuously improve the quality of
care they provide
What is Screening?
Screening is performed using a distinct
valid brief questionnaire (AUDIT, DAST,
ASSIST)
• Method of identifying individuals at-risk.
• Determine level of risk.
• Provides an opportunity for feedback.
What is Brief Intervention?
• A 15 to 45 minute facilitated interaction
– Express concern
– Provide feedback
– Explore the issue
– Promotes change
Brief Intervention Evidence
• World Health Organization (Am J Pub Health 1996)
 Multinational study of heavy drinkers
 Simple advice, brief & extended counseling
compared to control group (N = 1,260)
Consumption decreased:
21% with 5 minutes of advice
27% with 15 minutes of advice
7% among controls
Efficacy and Cost of Advice
At 4 years…
Control
Intervention
Hospital Days (p<0.05)
663
420
ED Visits (p<0.08)
376
302
Risky Drinking* (p<0.001)
35%
23%
Cost of intervention: $166 per patient (includes patient costs)
Net benefit: $546 in medical costs,
$7780 if societal costs included (mainly motor vehicle)
*36 months. >20 drinks (men), >13 drinks (women) per week - Fleming MF et al., 2002.
Intervention in Trauma Patients
• Gentilello et al. (Ann Surg 1999)
– Admitted trauma patients 46% screened positive for
alcohol problem – 30’ intervention psychologist
– Intervention ~50% decrease in trauma and
subsequent hospitalization
American College of Surgeons Level I Trauma
Center Verification process now requires
Screening and Brief Intervention
Brief Intervention and Drug Use
• Meta Analysis of 5 studies
– Moderate decrease in drug use
– Large effect on social outcomes
• Review of 17 trials
– 14 of 17 with positive results
– Increased treatment involvement
– Increased abstinence
– Reduced drug-related problems
Mesa Grande
• 361 controlled studies
– evaluated at least one treatment for AUD
– compared it with an alternative condition
– used a procedure designed to create
equivalent groups before treatment
– reported at least 1 outcome measure of
drinking or alcohol-related consequences
Miller, WR Addiction 2002 97(3)
Mesa Grande
• Methodological quality of studies was significantly but
modestly correlated with the reporting of a specific
effect of treatment
• The strongest evidence of efficacy was found for BI,
social skills training, the community reinforcement
approach, behavior contracting, behavioral marital
therapy and case management
• Most strongly supported approaches included: opiate
antagonists (naltrexone, nalmefene) and
acamprosate
• Least supported were methods designed to educate,
confront, shock or foster insight regarding the nature
and causes of alcoholism
Miller, WR Addiction 2002 97(3)
Brief motivational feedback better than InternetBarnett et al. 2004 based educational intervention to motivate
Trends in SBI:
Lessons from the Field
students enter counseling
Borsari and Carey
2005
Brief individual motivational sessions reduced
consumption more at 3 months and 6 months
than did standard alcohol education
Small-group feedback sessions were effective
McNally and Palfai
at reducing alcohol use among heavy-drinking
2003
students at 4-week follow-ups.
Reductions in drinking with mailed motivational
Murphy et al. 2004 feedback and in-person feedback interviews
Neighbors et al.
2004a
Reduced use at 3- and 6-month follow-ups with
computerized feedback compared with an
assessment-only control group
White et al., 2006
Students in brief motivational interview (BMI)
intervention and a written feedback-only (WF)
intervention reduced alcohol, cigarette and
marijuana use, and problems related to use
Brief Review of the Evidence
Screening can identify people drinking risky
amounts, problems or alcohol use disorders
Screening followed by a brief (nonjudgmental)
intervention can result in reduced drinking
Evidence varies by setting
For drug use and related problems/disorders
evidence for efficacy is more limited
For adolescents there is limited data
Request For Applications –
SAMHSA/CSAT
• Expand the State’s continuum of care to include
screening, brief intervention, referral, and brief
treatment (SBIRT) in general medical and other
community settings
• Identify systems and policy changes to increase
access to treatment in generalist and specialist
settings
SBIRT GPRA SUMMARY*
AREA
TARGET TO
DATE
ACTUAL TO
DATE
PERCENTAGE
SCREENING
171,876
305898
178%
BRIEF
INTERVENTION
42,926
56,432
131%
BRIEF
TREATMENT
6,604
9,443
143%
REFERRAL TO
TREATMENT
6,094
10,883
178%
*SBIRT GPRA Summary as of 5/15/06
Anecdotal Observations
• Adoption slow
• Time considerations with resistant
versus receptive patients
• System-wide approaches – eligibility
criteria?
• Little consensus on favorable outcome
Future Directions - Research
• Outcomes & costs for system-wide SBI
• Public versus Private
• When treatment of dependence included
• Line item versus billable service
•
•
•
•
Long-term effectiveness
Dosing (number and length of sessions)
Differences adults and adolescents
Multiple lifestyle interventions