Screening, Brief Intervention and
Referral to Treatment (SBIRT) in the
Primary Care Setting
Sarah T. Melton, PharmD,BCACP,
BCPP,CGP,FASCP
16th Annual Primary Care Conference
Monday , March 26, 2012
Millennium Centre, Johnson City, TN
Objectives
At the completion of this presentation, the participant will be able to:
1. Describe the steps involved in proper screening,
brief intervention, and referral to treatment (SBIRT)
for substance abuse in the primary care setting.
2. Select the appropriate tools to screen for alcohol
and drug abuse in the primary care setting.
3. Apply the principle of motivational interviewing and
stages of change in the SBIRT process.
4. Examine principles of coding, billing and
reimbursement for SBIRT in the primary care
setting.
What is SBIRT?
SBIRT is a comprehensive, integrated, public
health approach to the delivery of early
intervention and treatment services
For persons with substance use disorders
Those who are at risk of developing these
disorders
Primary care centers, trauma centers, and other
community settings provide opportunities for
early intervention with at-risk substance users
Before more severe consequences occur
SBIRT: Core Clinical Components
Screening: Very brief screening that identifies
substance-related problems
Brief Intervention: Raises awareness of risks and
motivates patient toward acknowledgement of
problem
Brief Treatment: Cognitive behavioral work with
patients who acknowledge risks and are seeking
help
Referral: Referral of those patients with more
serious addictions for outpatient or inpatient
treatment
Nationwide Movement Toward Standard of Care
US Preventive Services Task Force
The Patient Protection and Affordable Care Act 2010
$240 million in federal SBIRT funding to states and
residency training programs (ETSU!)
NIH funding
JACHO – proposed standard
Reimbursement codes - Centers for Medicare &
Medicaid Services; the AMA (CPT codes) and E&M
codes
Evidence to Support SBIRT in Primary Care
Systematic review of 22 randomized controlled
trials (RCT) of brief alcohol interventions in primary
care settings
 15 minutes or less
 At least one follow-up
Average number of drinks/week reduced by 4
drinks over controls
10-19% more participants drinking at moderate or
safe levels than controls
One study showed maintenance of improved
drinking for up to 48 months
Whitlock EP, Polen MR, Green CA, et al. Annals Int Med 2004;104(7):557-580.
Kaner EF, Dickinson HO, Beyer F, et al. Drug Alcohol Rev 2009; 28(3):301-23.
Evidence to Support SBIRT in Primary Care
 A meta-analysis suggests an overall reduction of 56% in
number of drinks consumed per week
 The effect size for a brief motivational intervention of all types
ranged from 0.25 to 0.57, with participants followed from 3 to 24
months
 Research has shown brief interventions can reduce alcohol use
for at least 12 months in patients who are not alcohol
dependent
 10-30% of patients can be expected to change their drinking
behaviors as a result of a brief intervention
Burke BL, Arowitz H, Menchola M.Consult Clin Psychol 2003;71(5):843-6;
Babor TF, Higgins-Biddle JC. Addiction 2000;95(5):677-86.
Fleming M, Manwell LB. Alcohol Res Health 1999;23(2):128-37.
SBIRT Prospective Cohort Study
 6 clinical sites
 459,599 patients
screened
 Hazardous use or
current substance
abuse disorder: 22.7%
 At 6-month follow up
 Drug use 67.7% ↓
 Alcohol use 38.6% ↓
 Self reported
improvement in general
health, mental health,
employment, housing
status and criminal
behavior
16%
14%
70%
Brief Intervention
Brief Treatment
Madras BK, Compton WM, Avula D, et al., Drug Alcohol Depend 2009;99:280-95.
Specialty Treatment
Major Impact on Public Health?
 Stem progression to dependence
 Improve medical conditions exacerbated by substance
abuse
 Prevent medical conditions resulting from substance abuse
or dependence
 Reduce drug-related infections and infectious diseases
 Improve response to medications
 Identify those at higher risk of abusing prescription drugs
 Identify abusers of prescription drugs or OTC drugs
 Have positive influence on social function
Characteristics of a Good Screening Tool
Brief (10 or fewer questions)
Flexible
Easy to administer, easy for patient
Addresses alcohol & other drugs
Indicates need for further assessment or
intervention
Has good sensitivity and specificity
Sensitivity and specificity
Sensitivity refers to the ability of a test to
correctly identify those people who actually have
a problem, e.g., “true positives”
Specificity is a test’s ability to identify people
who do not have a problem, e.g., “true
negatives”
Good screening tools maximize sensitivity and
reduce “false positives”
SBIRT Goals
Increase access to care for persons with
substance use disorders and those at risk of
substance use disorders
Foster a continuum of care by integrating
prevention, intervention, and treatment services
Improve linkages between health care services
and alcohol/drug treatment services
Poll the Audience
What percentage of your primary care
patients would be classified with alcohol
abuse or dependence?
What percentage would be classified as
“at risk” drinkers?
What percentage of your primary care
patients have used illicit drugs in the past
month?
Compare Demographics
How did your answers compare with statistics
for the general population?
 Percent with alcohol abuse or dependence
• 7% or about 1 in 14
 Percent “at risk” drinkers
• 23% or nearly 1 in 4!
 Percent using illicit drug
• 8% or about 1 in 12
SAMHSA, National Survey on Drug Use and Health, 2008
Ages 12+ in the United States
Why Screen?
SCREENING WIDENS THE NET
ABSTAINERS &
LOW RISK USE
AT-RISK
ALCOHOL & DRUG
USE
ABUSE/
DEPENDENCE
Specialized Treatment
Brief Intervention
Primary Prevention
Annual Screen
 Description
 One question regarding alcohol use
 One question regarding drug use
 Method
 Written form given once a year by front office at
check-in
 Verbally once a year at triage or by nursing when
patient is being roomed
 Pre-screens are NOT reimbursable
 Purpose
 Quickly identify patients at risk of misusing alcohol or
drug and warrant further screening
Annual Screening
Once a year, all our patients are asked to complete this form because drug
use, alcohol use, and mood can affect your health as well as medications you
may take. Please help us provide you with the best medical care by answering
the questions below.
Full Screen
 Description
 The AUDIT (Alcohol Disorder Identification Tool) is a 10-item
questionnaire for alcohol use
 The DAST-10 (Drug Abuse Screening Tool) is a 10-item
questionnaire for drugs
 Method
 Given to patients who are positive on annual screen
 Written form(s) given when patient is taken into exam room by
nursing
 Purpose
 Stratify patients into zones of substance use and informing the
clinician who does a brief intervention
The AUDIT
• Developed by World
Health Organization
• Accurate measure of risk
across gender, age, &
cultures
• 3 domains of drinking
• Scores 8 > indicate risky
drinking
• Scores 20 > may indicate
need of treatment
The AUDIT
Advantages:
Validated on primary health care patients
in six countries
Identifies hazardous and harmful alcohol
use as well as possible dependence
Brief, rapid, and flexible
Can be administered as questionnaire or
interview
The AUDIT
Limitations:
Limited to alcohol screening
May be too lengthy for some situations
(e.g. emergency department)
Not enough research has been completed
to determine precise cut-off points
DAST-10
DAST-10
Advantages:
Brief and inexpensive
Provides a quantitative index of the extent
of problems related to drug abuse
Can be administered to adults as well as
adolescents
Can be administered as questionnaire or
interview
DAST-10
Limitations:
Does not screen for alcohol use/abuse
Clients may “fake” results
Scores may be misinterpreted
Should NOT be administered to persons
actively under the influence of drugs or
who are undergoing drug withdrawal
reaction
Scoring the DAST-10
For questions 1 & 2, score “1” for every
“YES” response
For question 3, score “1” for a “NO”
response
For questions 4-10, score “1” for every
“YES” response
Scoring the DAST-10
Score
0
1-2
3-5
6-8
9-10
Degree of Problem
None Reported
Low Level
Moderate Level
Substantial Level
Severe Level
DAST Interpretation Guide
Score
0
1-2
3-5
6-8
9-10
Action
ASAM
Monitor
Brief Counseling
Outpatient
Intensive
Intensive
None
Level I
Level I or II
Level II or III
Level III or IV
ASAM = American Society of Addiction Medicine level/category
Brief Intervention
 Description
 Evidence-based and can be performed in as little as 3
minutes, typically 5-15 minutes
 Based on motivational interviewing
 Method
 Delivered by the clinician after the full screen has
been scored
 Purpose
 Motivate patients to reduce their use, abstain, or
accept a referral to treatment
Effectiveness of Brief Intervention
 32 controlled studies found brief interventions often as
effective as more extensive treatments
 Reduction in the following as a result of brief intervention:
 Alcohol and other substance consumption/use
 Harmful physical consequences
 Social consequences
 Sick days, missed work
 Hospitalizations
 Trauma/accidents/injuries
Fleming M, Manwell LB. Alcohol Res Health 1999;23(2):128-37.
What is Motivational Interviewing?
Helps identify and encourage behavior change
Increase patient’s awareness of problems,
consequences, and risks related to behavior
Assists patient to explore and resolve
ambivalence toward behavior and increase
motivation to change
Motivation to change is elicited from the person,
not mandated from the outside
Principles of Motivational Interviewing
Express empathy
Develop discrepancy
Roll with resistance
Support self-efficacy
Four Components of Brief Intervention
Raise the subject
Provide feedback
Enhance motivation
Negotiate and advise
Raising the Subject
1. Build rapport
Would you mind taking a few minutes to
talk about your [X] use? Before we go
further, I’d like to learn a little more
about you.
What is a typical day like for you?
Where does your [X] use fit in?
2. Ask about Pros &
Cons
Help me understand through your eyes
the good things about using [X]?
What are some of the not so good things
about using [X]?
Summarize
So on the one hand you said <PROS>, and
on the other hand <CONS>.
Providing Feedback
3. Feedback
Ask permission
Give information
Elicit reaction
I have some information on low-risk
guidelines for drinking, would you mind
if I shared them with you?
We know that drinking
• 4 or more (F)/ 5 or more (M) drinks in 2
hours
• more than 7(F)/14(M) drink in a week
• use of illicit drugs
can put you at risk for illness and injury.
It can also cause health problems like
[insert medical information].
What are your thoughts on that?
Assessing Readiness to Change
4. Readiness to Change
Readiness ruler
Reinforce positives
This Readiness Ruler is like the Pain Scale
we use to measure pain levels. On a
scale from 1-10, with one being not
ready at all and 10 being completely
ready, how ready are you to change your
[X] use?
You marked ___. That’s great. That
means you’re ___% ready to make a
change.
Why did you choose that number and not
a lower one like a 1 or 2?
SBIRT READINESS RULER
Categories of drinking
Low-risk
drinking limits
IV Dependent: 5%
Harmful: 8%
III
Drinks
Per week
Drinks
Per day
Men
14
4
II
Women
7
3
I
All age
>65
7
3
Low risk or
Abstain: 78%
0cm 1 2 3 4 5 6 7 8 9 10
I Low risk/Abstain
AUDIT: 0–7 DAST: 0
II Risky
III Harmful
9%
Very
IV Dependent
AUDIT: 8–15 DAST: 1-2 AUDIT: 16-19 DAST: 3-5 AUDIT: 20+ DAST: 6+
Raise the
subject
• “If it’s okay with you, let’s take a minute to talk about the
annual screening form you’ve filled out today.”
Provide
feedback
• “As your doctor, I can tell you that drinking (drug use) at this
level can be harmful to your health and possibly responsible
for the health problem you came in for today.”
Enhance
motivation
“On a scale of 0-10, how ready are you to cut back your use?”
• If >0: “Why that number and not a ____ (lower one)?”
• If 0: “Have you ever done anything while drinking (using
drugs) that you later regretted?”
Negotiate
plan
• “What steps can you take to cut back your use?”
• “How would your drinking (drug use) have to impact your life
in order for you to start thinking about cutting back?”
SAMHSA Referral Helpline
1-800-662-HELP
Not
at all
Risky:
Stages of Change
Prochaska & DiClemente
Creating an Action Plan
Create action plan
What are some options/steps that will
work for you? What do you think you can
do to stay healthy and safe?
Identify strengths
& supports
Tell me about a time when you overcame
challenges in the past. What kinds of
resources did you call upon then? Which
of those are available to you now?
5. Prescription for
Change
Write down action
plan
You have some great ideas, would you
mind if we wrote them down on to keep
with you as a reminder? Will you
summarize the steps you will take to
change your [X] use?
How does it all fit together?
Feedback
Setting the stage
Tell screening results
Explore Pros and Cons
Listen &
Understand
Explain Importance
Assess readiness to change
Options
Explored
Discuss change
options
Follow up
Video Demonstration
http://www.sbirtnc.org/
Brief Intervention and Referral
 Description
 Clinician advises further assessment and treatment
from a specialized facility or resource
 Method
 Referrals can be advised as part of the intervention
 Clinic staff will actively facilitate the referral
 Purpose
 Motivate and engage patients to see further
assessment and/or treatment as part of the brief
intervention.
Does Treatment Work?
Providers sometimes feel discouraged about referring patients
for substance abuse treatment. Sometimes it seems like it just
isn’t worth the effort. But relapse rates are really no different
than other chronic diseases:
http://www.nida.nih.gov/PODAT/faqs.html#Comparison
Referral to Treatment Guidelines
 To maximize the likelihood of success, assess level of
care needed
 Determine if patient is drug or alcohol dependent (and
needs medical withdrawal) (inpatient) or is a
substance abuser (outpatient unless has other risk
factors)
 Determine if patient has other risk factors that would
make them better candidates for inpatient treatment
than outpatient treatment:
• Co-occurring mental illness (may need a psychiatry
consult)
• Polysubstance use and dependence on multiple
substances
• Serious medical illnesses that may be exacerbated
when substance use changes
Other Factors to Consider
Insurance coverage
 Private: must check with insurer to determine
what kind of treatment and what facilities they
will pay for
 Public assistance (VA vs. TN Medicaid)
Language ability/cultural competence
Treatment history (have they failed outpatient
treatment in past?)
Location/transportation: can the patient and their
family easily access the treatment facility?
Other Factors to Consider
Family support
Can the facility treat both substance use disorders
and mental illness?
Can the facility treat both substance use disorders
and medical illness?
Does the facility offer/support pharmacotherapy
for maintenance of abstinence?
Does the facility have a good record of keeping
referring medical staff informed of patient
progress and ongoing needs?
Common Roadblocks/Mishandling
 PCP rushes into “action” and makes referral when the
patient has no interest
 PCP refers to an program unable to accept patient due to
capacity or doesn’t take the patient’s insurance
 Patient feels unheard and frustrated
 PCP doesn’t create a referral “package”
 Other strategies/programs patient can try while they are
on a program
 PCP doesn’t consider pharmacotherapy to reduce cravings
and/or reduce suffering
 PCP gets frustrated and sees the patient as “resistant” or
“self-sabotaging”
 Versus having a difficult chronic disease
What could you do to avoid each of these mistakes?
How will you assess your success?
Key Points for Billing
Pre-screen
 Front desk personnel, triage nurses, etc.
 Not reimbursable SBIRT services
Full Screen
 Physicians, physician assistant, nurse
practitioner
 Licensed behavioral health care practitioner
• Clinical social worker
• Psychologist
• Professional counselor
Key Points for Billing - Scenario
 PCP sees a new patient with a chief complaint relating to
physical health
 Primary care office administers pre-screen for drug and
alcohol abuse
 Negative – document negative pre-screen and do not
pursue further SBIRT services; no SBIRT billing
 Positive – may conduct Full Screen and Brief
Intervention Service
• Bill under regular E&M code for the primary
complaint
• SBIRT service code either 99408 or 99409,
depending on time
Key Points for Billing - Scenario
 If Full Screen is negative
 May choose not to pursue further SBIRT services
• No billing would occur
• Billing for services would be under E&M billing
codes, depending on time and complexity of
primary health service
 May choose to provide general feedback, prevention
counseling, discuss risky lifestyle choices, selfmanagement
• Bill under SBIRT codes
– 99408 (15-30 minutes)
– 99409 (greater than 30 minutes)
Key Points for Billing - Scenario
If Full Screen is positive
 May provide more complete screening
and brief intervention services
• Billing under SBIRT codes may occur
AND
• Billing for primary health services
under E&M codes may occur
Key Points for Billing - Scenario
If SBIRT service experience indicates need for
specialized alcohol and drug abuse services
 Provide services from internal behavioral
health/addiction specialist OR
 Refer patient to outside addiction specialist
 SBIRT codes may NOT be used since
services are beyond scope of Brief
Intervention Services authorized
Coding for SBIRT Reimbursement
Payer
Code
Description
Fee Schedule
CPT 99408
Alcohol and/or substance abuse
structured screening and brief
intervention services; 15 to 30
minutes
$33.41
CPT 99409
Alcohol and/or substance abuse
structured screening and brief
intervention services; greater
than 30 minutes
$65.51
G0396
Alcohol and/or substance abuse
structured screening and brief
intervention services; 15 to 30
minutes
$29.42
G0397
Alcohol and/or substance abuse
structured screening and brief
intervention services; greater
than 30 minutes
$57.69
H0049
Alcohol and/or drug screening
$24.00
H0050
Alcohol and/or drug service,
brief intervention, per 15 minutes
$48.00
Commercial
Insurance
Medicare
Medicaid
http://www.samhsa.gov/prevention/sbirt/coding.aspx
Helpful Resources
SBIRT Training : Skills Training for Primary Care
Providers
 http://www.sbirttraining.com/
SAMHSA’s Motivational Interviewing Training
Website
 http://www.motivationalinterview.org/index.html
SAMHSA’S Screening, Brief Intervention and Referral
to Treatment website
 http://www.samhsa.gov/prevention/sbirt/
Helpful Resources
Substance Abuse Screening, Brief Intervention and Referral
to Treatment North Carolina
 http://www.sbirtnc.org/
Resource documents (screening tools, presentations,
publications) at the University of Texas Health Sciences
Center School of Medicine
 http://familymed.uthscsa.edu/sstart/resourcesOPEN.asp
SAMHSA Mental Health Services Locator
 http://store.samhsa.gov/mhlocator
Helpful Resources
Institute of Substance Abuse Treatment Evaluation:
Tennessee Outcomes for Alcohol and Drug Services
(TOADS)
 http://www.isate.memphis.edu/treatment.html
Substance Use Screening, Brief Intervention, and
Referral to Treatment for Pediatricians
 http://pediatrics.aappublications.org/content/128/
5/e1330.full.html
Screening, Brief Intervention and
Referral to Treatment (SBIRT) in the
Primary Care Setting
Sarah T. Melton, PharmD,BCACP,
BCPP,CGP,FASCP
16th Annual Primary Care Conference
Monday , March 26, 2012
Millennium Centre, Johnson City, TN