Screening and Brief Intervention for Substance Abuse: Overview of

Practical and Conceptual Issues

Thomas Babor, PhD, MPH

Objectives

• Discuss SBIRT programs in relation to a public health approach to substance abuse

• Describe progress made in the past two decades in the development of concepts, screening tools, intervention techniques, and implementation for SBIRT

• Discuss implications for traffic safety

Basic Elements of SBIRT

• Screening—How, Who, and When?• Treatment matching linked to screening results

• Brief intervention

• Brief treatment

• Referral to standardized assessment and more intensive treatment

• Continued monitoring

Conceptual Overview of SBIRT Screening, Brief Intervention, and Referral to Treatment

Raise the IssueConduct Screening

No/Low RiskNegative Screen

Positive Screen

High-Risk or Risky

Substance Use

Motivational Counseling

Brief Intervention

Brief Treatment

Risk ReducedRisk Reduced

Follow-up Follow-up

Referral to Treatment

Specialist Treatment

Risk Reduced

Follow-up

Individual screening scores

determined to assess level of

risk

Risk Continues

Risk ContinuesRisk

Continues

Spurt – a sudden burst of energy or activityA Brief History of SBIRT

• Phase I (1980’s) Development of screening tests • Phase II (1985-current) Clinical trials of brief

intervention with risky drinkers and drug users• Phase III (1990-current) Feasibility research on barriers

to implementation of SBIRT• Phase IV (2000-current) Development and evaluation of

national plans for alcohol SBIRT program initiatives in health care systems in both developed and developing countries

Distinctions / Dichotomies

• Treatment vs. prevention

• Alcoholism vs. heavy drinking;

• Addiction vs. recreational drug use

• Disease conditions vs. risk factors

• Individual vs. public health perspectives

• Adequate definition of problem and operational criteria for diagnosis

• Natural history of problem understood, as well as risk factors and populations at risk

• Screening tests available: brief, easy to administer, reliable, valid

• Effective intervention and treatment methods available

Preconditions for a Public Health Approach to Screening and Early Intervention

Evaluating a SBIRT ProgramEfficacy Can it work?

Effectiveness Does it work?

Availability and Reach Is it reaching those who need it?

Efficiency Is it worth doing compared to other uses of the same resources?

Key Terms and DefinitionsDependence Syndrome A cluster of cognitive,

behavioral, and physiological symptoms

Harmful Use A pattern of substance use that has already caused damage to health

Hazardous Use A pattern of substance use carrying with it a risk of harmful consequences to the user

Dependent Drinkers

At-Risk Drinkers

Responsible Drinkers

Abstainers

The Drinkers’ Pyramid

Illicit drug abuse requiringformal treatment

Current illicit drug use

No illicit drug use

Note: Figures based on Connecticut 1996 adult household telephone surveys and 2000 US census of adults age 18 to 39.

3%(24,912)

14%

(104,653)

83%(619,313)

Illicit Drug Use PyramidConnecticut Adults Age 18 to 39

Goals of Screening

• Identify both hazardous/harmful drinking or drug use and those likely to be dependent

• Use as little patient/staff time as possible

• Create a professional, helping atmosphere

• Provide the patient information needed for an appropriate intervention

Common Self-Report Screening Assessments

• Alcohol– AUDIT, CAGE, TWEAK, et. al.

• Drugs– DAST

• Combined Substances (Tobacco, Alcohol, Other Drugs)– ASSIST, CAGE-AID, SASSI

A Short History of SBIRT: Phase IIAlcohol Brief Intervention Trials

• Malmo Study (1982)

• WHO AMETHYST Project (1985-1996).

• Other trials (Wallace et al., Fleming et al.)

• Meta-analyses and review papers

Sequence of Study and Procedures Associated with Each Condition

Screening

Recruitment

WHO Composite Interview Schedule

Stratified Random Assignment

GROUP IControl group

GROUP IISimple Advice

•Review interview results•Explain Sensible Drinking Leaflet (5 min)

GROUP IIIBrief counsellingReview interview resultsExplain Sensible Drinking leaflet (5 min)Introduce Problem Solving Manual (15 min)Mention Diary cards and identify a helper

Mention six-month follow-up interviewAsk patient to fill out Health and Daily Living Questionnaires

Six month follow-up

Alcohol Brief Intervention Trials, Results of Meta-analyses

• Brief interventions (BI) can reduce risky alcohol use by about 20% for at least 12 months

• Approach is effective with younger and older adults, men and women.

• Results mixed on longer-term health care utilization and reduction of alcohol-related harm.

• Results consistent across providers (professional/nonprofessional), settings (PHC, ED, Trauma, hospitals), and cultural groups

Subsequent Brief Intervention Trials and Other SBIRT Research

• Brief intervention trials with at-risk drug users

• Combined health behavior risk factor brief intervention research

• Brief treatment trials with substance users• Motivational Enhancement Therapy (NIAAA-

funded Project MATCH)• Brief Marijuana Treatment (SAMHSA-CSAT-

funded MTP study)

A Multi-site Study of the Effectivenessof Brief Treatment for Cannabis Dependence

A Cooperative Agreement funded by

SAMHSA-CSAT

MTPMarijuana Treatment Project

D e la y e dT r e a tm e nt C o ntr o l

(D T C )

F o llo w -up E v a lua t io n4 , 9 , a nd 1 5 m o nths

B r ie fT r e a tm e nt

(B T )

E xte nd e dT r e a tm e nt

(E T )

R a nd o m A ss ig nm e nt

B a se line A sse ssm e nt

E nr o llm e nta nd

Info r m e d C o nse nt

S c r e e n ing fo r E lig ib ility

R e c r ut im e nt o f 4 5 0 c hr o n ic m a r ijua na use r s thr o ug ha d v e r t is ing a nd r e fe r r a l

Study Design

0

10

20

30

40

50

60

70

80

90

100

Baseline 4 Months 9 Months 15 Months

% D

ays

of M

arij

uana

Use

Delayed Treatment 2-Session Treatment 9-Session Treatment

Outcomes: Baseline, 4, 9 & 15-months% of Days Smoked Marijuana

A Short History of SBIRT:Time for Implementation Efforts

• Brief interventions and brief treatments are effective with smokers, drinkers and results are promising with marijuana users.

• SBIRT poised for implementation • Two decades of clinical research, program development• Effective screening tests, brief intervention and brief

treatment protocols available• Training programs developed

• There is general agreement on the need to “broaden the base” of treatment (expand treatment and early intervention services to less severe cases and populations at risk)

SBIRT Implementation Trials –

• R.A. Senft et al., primary care, 1997

• Prescription for Health Initiative, RWJ/AHRQ

(2002 – present)

• Vital Signs, UConn, dental clinics (2002–2004)

• Cutting Back, RWJ, 2002-2005

What is being learned from implementation research?

• It can be done, but it’s not easy

• Staff participation in planning is critical

• Training does change beliefs and builds capacities; practice reinforces change

• Many factors contribute to success & problems

• Outcomes may be somewhat less than in tightly managed trials

• Costs are low compared to many services

Phase IV: The Future Has ArrivedUSA Policy Implications

• Expert committee reports

• Standards and practices

• National alcohol screening day

• SBIRT National demonstration program

US Preventative Services Task Force Recommends that Primary Care Clinicians Screen and Counsel Adults to Prevent Misuse of

Alcohol AHRQ, April, 2004

• Primary care clinicians should screen all adults and pregnant women for alcohol misuse and refer them for counseling if necessary

• Women who drink more than 7 drinks per week or more than 3 drinks per occasion and men who drink more than 14 drinks per week or more than 4 drinks per occasion are considered to be risky or hazardous drinkers

• The term alcohol misuse includes risky drinking as well as harmful drinking

• Effective counseling sessions for risky drinkers should include advice to reduce current drinking; feedback about current drinking patterns; explicit goal-setting, usually for moderation; assistance in achieving the goal; and followup through telephone calls, repeat visits, and repeat monitoring.

Standards and Practices

• Insurance policy legislation can restrict or facilitate SBIRT

• American College of Surgeons, Committee on Trauma, recommends new standards requiring Level 1 and level 2 trauma centers to "include identification and intervention for problem drinkers."

National Alcohol Screening Day

• The largest and most visible SBIRT activity in the USA

• Established in 1999• Three objectives:

– Administer free and anonymous alcohol screening in an accessible setting

– Provide referrals for treatment– Provide public education about the impact of

alcohol on health

World Health Report 2002

• Burden due to major risks

• Cost-effectiveness of relevant interventions

• Policy implications

High MortalityDeveloping Countries

Low MortalityDeveloping Countries

= Major NCD risk factors

1 Underweight Alcohol Tobacco 2 Unsafe sex Blood pressure Blood pressure

3 Unsafe water Tobacco Alcohol 4 Indoor smoke Underweight Cholesterol 5 Zinc deficiencyBody mass index Body mass index 6 Iron deficiency Cholesterol Low fruit & veg. intake 7 Vitamin A deficiency Low fruit & veg intake Physical inactivity 8 Blood pressure Indoor smoke - solid fuels Illicit drugs 9 Tobacco Iron deficiency Unsafe sex 10 Cholesterol Unsafe water Iron deficiency 11 Alcohol Unsafe sex Lead exposure 12 Low fruit & veg intake Lead exposure Childhood sexual abuse

DevelopedCountries

Leading 12 selected risk factors as causes of disease burden

From: Chisholm, D., Rehm, J., Van Ommeren, M. & Monteiro, M. (2004) Reducing the global burden of hazardous alcohol use: A comparative cost-effectiveness Analysis. Journal of the Studies on Alcohol 65:782-793.

Cost Effectiveness of Brief Intervention with Risky Drinkers

Implications and Applications of SBIRT for DUI Countermeasures

• Driver education programs – early intervention

• DUI specific SBI, e.g., screening items, intervention techniques

• Referral to alcohol assessment

• Referral to treatment

POLICY AND CLINICAL IMPLICATIONS

• A successful example of translational research• Meets requirements of a public health approach to secondary

prevention, but needs to focus on high risk groups in high volume settings for maximum effect

• Consistent with IOM vision of “Broadening the Base” of treatment, and SAMSHA/CSAT Access To Recovery Initiative

• Could serve as a major feeder to treatment system, AND an additional secondary prevention component

• Alcohol SBI as a Trojan Horse to drug SBI• Direct and indirect applications to drink-driving

countermeasures