SBIRT PROTOCOL
WHY SUBSTANCE USE SCREENING?
Adolescence is a period marked by risk-taking and experimentation. Nearly 70% of adolescents have tried
alcohol, half will have taken an illegal drug, nearly 40 percent will have smoked a cigarette, and more than 20
percent will have used a prescription drug for a nonmedical purpose.
The earlier that someone starts using substances, the greater the likelihood of their developing a substance
use disorder. Adolescents with a mental health disorder, or who have been exposed to trauma, are
particularly vulnerable.
Bill Wilson Center serves at-risk populations and has the opportunity to change the trajectory of the lives of its
clients through the use of SBIRT.
WHAT IS SBIRT?
Screening, Brief Intervention and Referral Treatment (SBIRT) is an evidence-based practice aimed at reducing
the negative consequences of substance use. It has demonstrated significant, positive outcomes, when used
by physicians with adults in primary care settings. It shows great promise, when used to address substance
use among adolescents.
Screening to identify individuals at risk for developing substance use disorders.
Brief Intervention to raise awareness of risks and consequences, internal motivation for change and help set
healthy lifestyles goals.
Referral to Treatment to facilitate access to specialized treatment services and coordinate care between
systems for patients with higher risk and/or dependence.
SBIRT is not looking for addiction but for individuals with unhealthy substance use patterns. It is most effective
as a prevention and early intervention tool. Screening serves to identify whether or not an individual should
receive a brief intervention or a referral to treatment. Bill Wilson Center uses the CRAFFT as its screening tool.
What is the CRAFFT Screening Tool?
The CRAFFT is a simple instrument specifically designed to be used by non-specialists in a variety of settings.
It is recommended by the American Academy of Pediatrics' Committee on Substance Abuse for use with
adolescents. It consists of a series of 6 questions developed to screen adolescents for high risk alcohol and
other drug use. It is a short, effective screening tool meant to assess whether a longer conversation about the
context of use, frequency, and other risks and consequences of alcohol and other drug use is warranted.
CRAFFT is a mnemonic acronym of first letters of key words in the six screening questions. The questions
should be asked exactly as written.
C - Have you ever ridden in a CAR driven by someone (including yourself) who was "high" or had been using
alcohol or drugs?
R - Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?
A - Do you ever use alcohol/drugs while you are by yourself, ALONE?
F - Do you ever FORGET things you did while using alcohol or drugs?
F - Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use?
T - Have you gotten into TROUBLE while you were using alcohol or drugs?
One or more positive answer: provide brief intervention
Two of more positive answers: provide brief intervention and consider referral to treatment
TRAINING
Before starting to use SBIRT, all clinicians should, at a minimum, complete two Relias Learning training
courses:
1) Adolescent Substance Use Disorder Clinical Pathways
2) Motivational Interviewing
Additional training may be provided by the training manager and support is available from your clinical
supervisor.
A list of on-line SBIRT resources, including videos of clinicians using motivational interviewing is available on
the BWC website in the staff portal.
Other questions about SBIRT can be addressed to Stephen Betts, Director, Behavioral Health Integration:
extension 6137.
PROTOCOL:
To be used with any client aged twelve or older (Clinicians have the discretion to use it with younger clients,
if they deem it clinically appropriate):
PRE-SCREEN
It is important that clinicians establish rapport with their client, since this will increase the likelihood of more
accurate answers and give clinicians useful information that they can come back to when enhancing
motivation.
Begin by telling the individual that you would like to ask them some questions to better get to know their
health habits and have the most complete picture possible in order to make the time most efficient and
effective. Then telling him/her "Your answers will be kept confidential"; asking if they have any questions and
if they are willing to proceed. Start with other health screening questions – tobacco use, exercise, stress
management, etc. Then ask three opening questions:
During the past twelve months, did you:
1. Drink any alcohol (more than a few sips)? Do not count sips of alcohol taken during family or religious
events
2. Use any marijuana or hashish?
3. Use anything else to get high? -“Anything else” includes illegal drugs, over the counter and prescription
drugs, and things that you sniff or huff.
If all answers are “no,” just ask the CAR question (in the CRAFFT screening tool).
If any questions are answered with “yes,” complete the RASAI CRAFFT screening form (see attachment).
Information collected on the RASAI CRAFFT SCREENING sheet should be entered into AWARDS
BRIEF INTERVENTION
BRIEF INTERVENTION is the process of sharing information, offering advice and engaging individuals in the
management of their clinical issues to achieve their personal health goals.
1. RAISE THE SUBJECT
a. Ask Permission: “Thank you for answering these questions. I’d like to take a few minutes to
review the results, is this ok with you?
b. Elicit the pros and cons: “What are good things about ______? What are the not so good things
about _______?
2. PROVIDE FEEDBACK
Elicit: (e.g. “What have you heard about marijuana?”)
Advise: (e.g. “I’d like to share with you some additional information, would that be ok?”)
Elicit: (e.g. “So where does this leave you?”)
3. ENHANCE MOTIVATION
Use OARS:
Open-ended inquiry
(e.g. “Tell me more about the pressure you’re feeling.)
Affirmations
(e.g. “You’ve been very diligent about getting your grades up.”)
Reflections
(e.g. “Being the first in your family to go to college is important to you.”)
Summarizing
(e.g. “Here’s what I’ve heard so far… Is that an accurate summary?)
Readiness/confidence and/or importance: “on a scale of 0 to 10, how important is it for you to change?”
“On a scale of 0 to 10, how confident are you that you can make a change?
4. DEVELOP A PLAN
 Elicit the individual’s own ideas (e.g. “There’s a party this weekend, what are your options?)
 Details and troubleshooting (e.g. “What will you say when your friend calls?” “You think she will be
mad.”)
 Arrange follow-up: (e.g. “I’d like to check back in with you to see how things are going.”)
REFERRAL TO TREATMENT
If screening results indicate that a client might benefit from a referral to treatment, it is essential to use
motivational techniques to build the client’s confidence and willingness to enter treatment. Ask the client
about any concerns that he/she may have about being referred to a treatment program. Provide corrective
information. Ask the client to identify any potential obstacles and discuss ways to address them. If the client
agrees to the referral, make the referral with the client present and have him/her sign releases so that there
can be a two-way exchange of information between you and the provider.
REFERRAL OPTIONS
We have two referral options: to a Seven Challenges group at BWC or a referral to the County’s publiclyfunded substance use disorder services (SUDS) systems of care.
The Seven Challenges is an evidence-based model designed specifically for youth. It focusses on decisionmaking skills and is particularly suitable for youth in a pre-contemplative stage of change, who are not willing
or ready to participate in the County’s system of care.
County’s Systems of Care: Youth 21 and younger should be referred to the Youth System of Care (YSOC).
Entry into YSOC is made by referring a client to a central intake number: 408 272 6518. An intake coordinator
will attempt to match the client with a provider, who can best meet the needs of the client, based on such
factors as: language need and proximity to school or home. This referral is more suitable for a client who is a
contemplative, or higher stage of change, or for a client with a parent or responsible adult, who can ensure
participation in the program.
Individuals over the age of 21 should be referred to the Adult System of Care (ASOC) through their intake
system “Gateway:” 1-800-488-9919.
We know that outcomes are improved when an individual with co-occurring mental health and substance use
problems receives concurrent treatment for both, so we strongly encourage clinicians to maintain on-going
communication with the substance use disorders services (SUDS) provider to coordinate care. For example,
through a weekly telephone consultation. To facilitate communication, it is essential that the clinician have
their client sign a consent form to share information.
USE SBIRT AGAIN AFTER THREE MONTHS
Since circumstances in the lives of youth can change in a relatively short time, it is important to repeat the
SBIRT process every three months. Also, since some youth may be very guarded, and not be completely
forthcoming, when new to treatment, they may be more open at a later point after building trust and rapport.
RASAI CRAFFT Screening Form
The RASAI screen is comprised of three components: an alcohol use scale (items 1-3), a drug use scale (item 4), and
the original CRAFFT screening instrument (items 5-10), Below are suggested cut-off scores for brief intervention and
referral to treatment. This guidance was developed by the RASAI team, based on advice from the tool’s developers and
subject matter experts. Please keep in mind that screens merely provide an indication of whether or not an individual
appears at risk for a given condition. Screens are inappropriate for use as treatment intake tools and insufficient for
determining diagnoses. The guidance below should not, in any way, override your clinical judgment.
Alcohol Scale
1. How often do you have a drink containing alcohol?
(0) Never
(1) Monthly or less
(3) 2 to 3 times a week
(2) 2 to 4 times a month
(4) 4 or more times a week
2. How many drinks containing alcohol do you have on a typical day when you are drinking?
(0) 1 or 2
(1) 3 or 4
(3) 7, 8, or 9
(2) 5 or 6
(4) 10 or more
3. How often do you have five or more drinks on one occasion?
(0) Never
(1) Less than monthly (3) Weekly
(2) Monthly
(4) Daily or almost daily
Total Alcohol Screen Score
Consider Brief Intervention
Consider Referral to Treatment
Under 21: If total score = 1+
Over 21: If scores on items 2 or 3 = 2+
If item 1 + item 2 = 4+
If female and score on Item 2= 1+
All:
If total score = 10+
If item 1 score = 2+ and item 2 score = 1+
marijuana, any other drug, or prescription medication to get high?
(0) Never
(1) Monthly or less
(3) 2 to 3 times a week
(2) 2 to 4 times a month (4) 4 or more times a week
Total Drug Use Screen Score
Consider Brief Intervention
Consider Referral to Treatment
CRAFFT Screen
Under 21: If total score = 1+
Over 21: If total score = 2+
All: If total score = 3+
Drug
Use
Scale
4. How
often
do you
use
Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or
drugs?
(1) Yes
(0) No
Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?
(1) Yes
(0) No
Do you ever use alcohol or drugs while you are by yourself, or ALONE?
(1) Yes
(0) No
Do you ever FORGET things you did while using alcohol or drugs?
(1) Yes
(0) No
Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking or drug use?
(1) Yes
(0) No
Have you ever gotten into TROUBLE while you were using alcohol or drugs?
(1) Yes
(0) No
CRAFFT Score
Consider Brief Intervention
If CRAFFT Score is 1
Consider Referral to Treatment
If CRAFFT Score is 2+