Screening and Brief Intervention for Substance Abuse: Overview of Practical and Conceptual Issues

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Screening and Brief Intervention for Substance
Abuse Overview of Practical and Conceptual Issues

• Thomas Babor, PhD, MPH

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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

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Basic Elements of SBIRT

• ScreeningHow, Who, and When?
• Treatment matching linked to screening results
• Brief intervention
• Brief treatment
• Referral to standardized assessment and more
  intensive treatment
• Continued monitoring

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Brief History of SBIRT

• Phase I (1980s) 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

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Distinctions / Dichotomies

• Treatment vs. prevention
• Alcoholism vs. heavy drinking
• Addiction vs. recreational drug use
• Disease conditions vs. risk factors
• Individual vs. public health perspectives

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Preconditions for a Public Health Approach to
Screening and Early Intervention

• 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

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Evaluating a SBIRT Program
Efficacy 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?
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Key Terms and Definitions
Dependence 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
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The Drinkers Pyramid
Dependent Drinkers At-Risk
Drinkers Responsible Drinkers
Abstainers
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Illicit Drug Use PyramidConnecticut Adults
Age 18 to 39
Illicit drug abuse requiring formal treatment
3 (24,912)
14 (104,653)
Current illicit drug use
83 (619,313)
No illicit drug use
Note Figures based on Connecticut 1996 adult
household telephone surveys and 2000 US census
of adults age 18 to 39.
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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

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Common Self-Report Screening Assessments

• Alcohol
• AUDIT, CAGE, TWEAK, et. al.
• Drugs
• DAST
• Combined Substances (Tobacco, Alcohol, Other
  Drugs)
• ASSIST, CAGE-AID, SASSI

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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

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Sequence of Study and Procedures Associated with
Each Condition
Screening
Recruitment
WHO Composite Interview Schedule
Stratified Random Assignment
GROUP I Control group

• GROUP II
• Simple Advice
• Review interview results
• Explain Sensible Drinking
• Leaflet (5 min)

GROUP III Brief counselling Review interview
results Explain Sensible Drinking leaflet (5
min) Introduce Problem Solving Manual (15
min) Mention Diary cards and identify a helper
Mention six-month follow-up interview Ask patient
to fill out Health and Daily Living Questionnaires
Six month follow-up
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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

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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)

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MTPMarijuana Treatment Project
A Multi-site Study of the Effectiveness of Brief
Treatment for Cannabis Dependence A Cooperative
Agreement funded by SAMHSA-CSAT
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Study Design
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Outcomes Baseline, 4, 9 15-months of Days
Smoked Marijuana
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A Short History of SBIRTTime 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)

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SBIRT Implementation Trials

• R.A. Senft et al., primary care, 1997
• Prescription for Health Initiative, RWJ/AHRQ
  (2002 present)
• Vital Signs, UConn, dental clinics (20022004)
• Cutting Back, RWJ, 2002-2005

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What is being learned from implementation
research?

• It can be done, but its 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

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Phase IV The Future Has ArrivedUSA Policy
Implications

• Expert committee reports
• Standards and practices
• National alcohol screening day
• SBIRT National demonstration program

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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.

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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."

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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

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World Health Report 2002

• Burden due to major risks
• Cost-effectiveness of relevant interventions
• Policy implications

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Leading 12 selected risk factors as causes of
disease burden
Major NCD risk factors
High Mortality Developing Countries
Low Mortality Developing Countries
Developed Countries
1 Underweight Alcohol Tobacco 2
Unsafe sex Blood pressure Blood pressure 3
Unsafe water Tobacco Alcohol 4 Indoor
smoke Underweight Cholesterol 5 Zinc
deficiency Body mass index Body
mass index 6 Iron deficiency Cholesterol L
ow 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
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Cost Effectiveness of Brief Intervention with
Risky Drinkers
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 65782-793.
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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

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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