If we are going to address the public health consequences of alcohol use disorder in the United States, we are going to have to do more work in primary care.
SBIRT (pronounced ESS-BIRT) stands for Screening, Brief Intervention, and Referral to Treatment. It’s a standardized series of steps a person such as a doctor or counselor can take to identify and address any risky substance use. Simply put, SBIRT means talking to people about their substance use and then offering an opportunity to make positive change.
According to a report from the 2016 INEBRIA (International Network on Brief Interventions for Alcohol & Other Drugs) conference, SBIRT has many strengths, but has fallen short for people with moderate-to-severe alcohol use disorders.
“Addressing…moderate to severe alcohol use disorder…has been given too little attention in SBI; clinical and research attention needs to be given to better connecting people to needed care, and to not relying on referral as the only solution,” the report reads.
This verdict comes as no surprise: SBIRT has been shown to enable small reductions in alcohol use, but wasn’t originally designed for patients experiencing alcohol addiction.
Does that mean SBIRT is useless for those patients? Not necessarily.
A Common Theme
Below are three ways that SBIRT can be adapted for patients with alcohol use disorders. They share a theme: that substance use disorders need to be addressed in primary care settings.
Why can’t we just ship people off to rehab? Research on SBIRT has reliably shown that the “referral to treatment,” isn’t very effective. One big reason is that patients don’t necessarily want to abstain from alcohol altogether, which most specialty addiction treatment providers require. Another issue is that patients don’t recognize that alcohol use is affecting their health, or don’t feel much motivation to address it.
This is where primary care providers can help. A primary care provider can support changes in alcohol use without demanding abstinence. And over time, primary care providers can help build awareness and readiness to change.
So what does that look like?
The CHOICE Model
The CHOICE (Choosing Healthier drinking Options In primary CarE) model is designed for a specific population, US veterans. It was implemented in Department of Veterans Affairs (VA) facilities for patients seeking primary care who reported frequent heavy drinking during a universal screening, but who were not specifically seeking treatment for an alcohol use disorder. In other words, people who fall into that group of heavy alcohol user who are traditionally difficult to influence with SBIRT.
The CHOICE intervention lasted a year. Specialized nurse practitioners conversed with patients on-site about their alcohol use on many occasions, using multi-session brief intervention (BI) to match people with a treatment option, which could include self-monitoring, self-assessment, or medication.
One of the major preliminary takeaways from this experiment was the unreliable relationship between readiness to change and actual behavior change. Patients’ stated interest in reducing or eliminating alcohol consumption seemed to have little bearing on whether or not their drinking patterns actually shifted. For example, patients declaring no interest in changing alcohol usage sometimes stopped unexpectedly.
Speaking to a patient who seems unwilling to make a positive change for the sake of their health can frustrate clinicians. It feels pointless. From the early feedback on the CHOICE Model, we can posit that positive influences are a subtle thing. In its final form, the study may lend credence to repeated BI over the standard one-time intervention.
The “15-method” is designed for people with mild-to-moderate AUDs. Their lives are affected, but compared to people with severe AUDs, they maintain relatively stable social and professional lives and experience fewer physical health repercussions. This makes their rate of treatment (and AUD detection) lower.
That “15” refers to both its 15-minute brief interventions and the use of a Brief Intervention with patients who score over 15 on the AUDIT. That’s the cutoff for “higher risk” drinking.
This all sounds pretty par for the SBIRT course, but the 15-method has a strategy for addressing higher risk drinking while retaining people in primary care. Clinicians set the patients up with four structured Cognitive Behavioral Therapy/Motivational Interviewing sessions with themes such as “goal setting.” Medication (e.g., acamprosate, disulfiram) was also available.
Specialized addiction care is the right path for some, but SBIRT historically drops a lot of people in the gap between referral and the patient actually going to treatment. By integrating basic addiction treatment into primary care, the folks behind this method hope to address that common flaw. So rather than referring patients to treatment in a new setting, they focus on work within primary care.
Notably, this extra level of structured therapy and treatment options found in CHOICE and the 15-method, often called “extended BI,” has been explored elsewhere. Some studies offer promising outcomes in specific populations and settings while proof for other groups was lacking.
SBIRT + Recovery Management
Like CHOICE and the 15-method, SBIRT+RM is designed to give primary care settings a road map for managing SUDs without referring patients elsewhere.
Imagine that SBIRT is a plane taking off. The engine ignites (screening), the plane gains momentum on the runway (brief intervention) and lifts off (referral to treatment). SBIRT plus Recovery Management (SBIRT+RM) adds in the next step—keeping the plane in the air, directed toward a destination.
The SBIRT+RM model suggests that primary care providers have a responsibility to stay involved in SUD care for the long haul. A large part of this responsibility involves connecting the patient to services and providers. That requires building relationships with specialists and treatment programs who can help.
For example, primary care staff should make sure their patient has transportation to specialty addiction services and that the patient knows how to cover any costs. Primary care doctors should also provide support for a patient transitioning from addiction treatment back into his or her community. He or she should provide ongoing monitoring and support. That could mean checking in and providing encouragement, but also suggesting further treatment if necessary.
Most Americans Don’t Want Addiction Treatment
Ultimately, only 1 in 10 Americans who meet the criteria for an SUD will ever receive specialty addiction treatment. Why so few? In some cases, people don’t know how to access treatment and some can’t afford it, but the large majority don’t believe that they need treatment at all. If we are going to address the public health consequences of alcohol use disorder in the United States, we are going to have to do more work in primary care.
That said, the NIAAA has released a new treatment navigation tool to help patients and their primary care providers understand the range of services that are available for reducing or ceasing alcohol use. The tool emphasizes that no one path fits for everyone, and includes an assessment that can help individuals determine what type of medication and psychosocial support might best address their alcohol use.