SBIRT:
Addressing unhealthy substance
use in primary care
Christine Pace, MD, MSc
Assistant Professor of Medicine, Boston University School of Medicine
Lee Ellenberg, LICSW
Training Manager, MASBIRT Training and Technical Assistance (TTA)
April 3, 2014
Outline
Outline
• Impact and spectrum of unhealthy
substance use in primary care
• Screening, brief intervention and referral to
treatment (SBIRT)
– Approach
– Effectiveness
• Implementation opportunities & resources
Unhealthy substance use in
primary care
• Spectrum of use that risks health consequences
– Cardiovascular disease, cancer, trauma, infection, more
– Alcohol = 3rd leading preventable cause of death in US1
• Costly:
– Societal costs of $416.5 billion annually2
• Underdiagnosed
– 16% of patients ever discussed alcohol with provider3
• Undertreated
– 14% with substance use disorders (SUD) in MA get
treatment4
1 http://www.prevent.org/National-Commission-on-Prevention-Priorities/Rankings-of-Preventive-Services-forthe-US-Population.aspx ;2 Bouchery, Am J Prev Med 2011:41;516-524; 3. CDC Vital Signs Report 2013
http://www.cdc.gov/vitalsigns/ ; 4. Brolin, MA Health Policy Forum 2005
New concept
Addiction:
Historical
Perspective
Unhealthy
SUD
use
Risky use:
For alcohol—
• Men < 65: >4
Risky
drinks/occasion or
use
>14 drinks/wk
• Women & >65: >3
drinks/occasion or
>7 drinks/wk
No Problem
Low
risk use or For drugs*--ANY use
Problem
no use
http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/guide.pdf
What is SBIRT?
A low intensity, low cost, public health approach to
identify and intervene with people with unhealthy
substance use.
 Screening: Universal, brief questionnaire that
identifies unhealthy substance use
 If positive: Additional questions to determine
severity and consequences of use
 Brief Intervention: Brief conversation to raise
awareness of risks & build motivation to change
 Referral to Treatment: For those with more
serious problems, when appropriate
Why is SBIRT important?
 Patients often don’t understand impact of alcohol
and drug use on health
 Particularly unaware of drinking guidelines
 Clinician suspicion of alcohol problems has poor
sensitivity (27%) for identifying patients with (+)
screen for unhealthy alcohol use1
 Lack of confidence in substance use assessment
and intervention is associated with lower MD
satisfaction in working with patients with SUD2
1
Vinson, D, Annals of Fam Med. 2013; 2 Saitz, R, J Gen Intern Med. 2002.
The key to SBIRT: Brief intervention
….a brief, non-judgmental, nonconfrontational, directive conversation,
using Motivational Interviewing (MI)
principles & techniques to enhance a
patients’ motivation to change their use
of alcohol and other drugs.
Brief intervention
Brief intervention
 Feedback: provide personalized feedback
based on screening results; state concern
regarding medical risks/consequences of use
 Advice: ask permission; then, make explicit
recommendation for change in behavior;
discuss patient’s reaction
 Seal the Deal: enhance motivation for
behavior change; elicit ideas & negotiate plan
with patient, schedule follow-up
WhySBIRT
is SBIRT
important?
effectiveness
 SBIRT has been found to:
 Help patients reduce alcohol use1,2,
 Increase proportion with SUD who get treatment3
 Reduce healthcare costs4,5:
 Alcohol SBI in primary care reduces ED visits and inpatient days,
and saves $3 for every healthcare dollar spent.6
 Most effective for lower severity alcohol use in primary care 7,8
 Ongoing research: Drugs, other settings & severities, teens
 USPSTF recommends alcohol SBI (grade B)
1 Babor, T Sub Abuse 2007; 2 Mertens, J Alc Clin Exp Res 2005; 3 Krupski, A Drug Alc Dep 2010; 4 Solberg, L,
Am J Prev Med, 2008; 5 Estee, S Medical Care 2010; 6 Fleming, M, Medical Care. 2000; 7 Kaner, E Drug Alc Review
2009; 8 Saitz, R Ann Intern Med 2007; USPSTF=US Preventive Services Task Force
Rankings of 25 Preventive Services
Recommended by USPSTF
#
Service
Public Benefit
ROI
1
Childhood immunizations
5
5
1
Smoking cessation
5
5
1
Aspirin in high risk patients to prevent
heart attack & stroke
5
5
2
Alcohol screening & intervention
4
5
Ranked higher than:
• Screening for high BP or cholesterol
• Screening for breast, cervical, or colon cancer
• Adult flu, pneumonia, or tetanus immunization
Maciosek, Am J Prev Med, 2006; Solberg, Am J Prev Med 2008;
http://www.prevent.org/content/view/43/71
Adapted from Partners in Integrated Care
10
1 = lowest; 5 = highest
Implementing
SBIRT:
SBIRT
implementation
Challenges
opportunities
challengesand
& opportunities
Challenges
• Limited reimbursement
Opportunities
• New payment models
• Workflow challenges
• Team-based care
• Training gaps
• Broad-based behavioral
health integration efforts
(enhance training
opportunities, access)
• Poor access to specialty
substance use treatment
SBIRT in action:
BMC Primary Care
• Front desk: Gives screen to patient
– Single-item alcohol and drug questions
– PHQ-2 for depression
• Medical assistant: Scores screen, gives
follow-up tool for any (+) response
– AUDIT, DAST-10 and/or or PHQ-9
• Provider: Scores any follow-up tool; as
needed, conducts BI and/or places
referral.
MASBIRT
Training & Technical Assistance (TTA)
(www.masbirt.org)
Supported by MA DPH: Bureau of Substance Abuse
Services (BSAS) to build statewide SBIRT awareness and
capacity to
–
–
implement and integrate SBIRT into diverse settings and
organizations,
and promote clinician SBIRT skills and competency.
www.maclearinghouse.com
Conclusions
Conclusions
• SBIRT is an evidence-based, cost-saving
intervention to reduce unhealthy substance use
among primary care patients
• SBIRT training and implementation should
emphasize brief intervention
• Healthcare reform and behavioral health
integration efforts present opportunities for broad
implementation of SBIRT
• MASBIRT TTA is a resource to support
implementation (www.masbirt.org)