What Every Social Worker Needs To Know About Screening, Brief Intervention, and Referral to Treatment (SBIRT)

by Shelley Steenrod, Ph.D., LICSW

     A social worker visits Mr. Henry, an older African American man who is attending a community-based day program for senior citizens. He is very insistent that the program social worker ask his doctor to refill a prescription for pain medication. The social worker is concerned that his medication-seeking behavior may indicate a substance abuse problem.

     Yolanda, an 18-year-old Latina college freshman, is taken to a local hospital emergency room by ambulance. She is accompanied by her frightened roommate, who reports that Yolanda has passed out after consuming a “huge” amount of alcohol while playing a drinking game at a party.

     Denise, a 33-year-old pregnant White woman meets with a social worker in an early intervention (EI) program to discuss her 3-year-old child who receives EI services. TheEarly Intervention Program social worker screens Denise for alcohol, tobacco, and drug use with the ASSIST. The screen reveals that Denise is abusing tobacco, alcohol, and methamphetamine.

     The cases above illustrate how social workers are often on the front line when it comes to interacting with individuals with substance use disorders. Unfortunately, social workers often feel under-prepared or untrained to intervene in cases in which substance abuse is present. The Office of National Drug Control Policy (ONDCP) and the Substance Abuse and Mental Health Services Administration (SAMHSA) have put forth a public health model to identify and provide treatment services to individuals with substance disorders. This approach, called SBIRT, is an acronym for Screening, Brief Intervention, and Referral to Treatment.    

     Why is the federal government interested in a screening program for substance disorders? Consider the following: One in every four deaths is the result of alcohol, illegal drugs, or tobacco use (National Institute of Drug Abuse, 2012). In addition, the economic cost of alcohol and illegal drug use in the United States is a whopping $426 billion per year (Substance Abuse and Mental Health Services Administration, 2012; National Drug Intelligence Center, 2011). SBIRT is grounded in the belief that early identification of problematic alcohol or drug use can save lives and reduce costs related to health care and behavioral health care, crime and incarceration, and overall loss of productivity.

What is SBIRT?    

     Screening is the first step in the SBIRT process. Screening is a universal process, meaning that an entire population group is screened for an illness or disease. For example, in the field of medicine, all female patients are instructed to begin regular mammography screening at the age of 40, all pregnant women are screened for gestational diabetes with a glucose tolerance test, and men and women alike are routinely screened for high cholesterol through laboratory tests.    

     It’s important to note that screening is different from assessment. Screening is brief, time limited, and intended to simply identify clients with problem alcohol or drug use. In contrast, assessment is a deeper, more thorough process that may take several sessions. Assessment interviews are conducted by substance abuse specialists who consider multiple domains of a client’s alcohol or drug use, including risk for withdrawal, medical complications, emotional/behavioral complications, stage of change, relapse potential, recovery environment, legal complications, family system, and employment history.    

     In the SBIRT framework, screening for substance use is conducted on every client who is seen in a particular program or agency. Settings may include emergency rooms, trauma centers, psychiatric crisis units, health centers, doctors’ offices, child protection settings, and other medical or behavioral health environments.    

     A social worker or other clinician begins screening with the use of a standardized instrument. (See Table 1.) Some frequently used tools include the AUDIT (Alcohol Use Disorders Identification Test), the DAST (Drug Abuse Screening Test), the ASSIST (Alcohol, Smoking, Substance Involvement, Screening Test), the CAGE (Cut Down, Annoyed, Guilty, Eye-Opener), and the CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble). The result of the screening dictates one of three clinical responses: no intervention, brief intervention, or referral to treatment (See Figure 1).

Potential Outcomes of SBIRT    

     No Intervention: A screening interview with negative results requires no further action specific to substance abuse intervention or treatment. For example, after screening Mr. Henry for alcohol and drug use with an instrument targeted for older clients (MAST-G), the social worker is relieved to learn that he is not abusing his prescription medication as a way to manage his pain. However, she believes that Mr. Henry could benefit from a more holistic approach to pain management and makes a note to speak with Mr. Henry’s physician about a referral to a pain management center that employs mind-body approaches to pain control.    

     Brief Intervention: A screening interview that indicates moderate risk requires a brief intervention, or “a discussion aimed at raising an individual’s awareness of their risky behavior and motivating them to change their behavior” (Substance Abuse and Mental Health Services Administration, 2007). Brief interventions are conducted in the community sector, often at the same time and by the same clinician who conducted the screening interview.    

     There are several reasons why client behavior can change as the result of a brief intervention. A key component of brief interventions is to educate clients on safe drinking behavior, as well as the physical, social, and familial consequences of alcohol and drug abuse. Next, brief interventions require a treatment plan to be implemented to reduce or eliminate substance use. Third, scheduled follow-up appointments hold clients accountable for problem use and provide an opportunity for clinicians to recommend higher levels of treatment, if needed.    

     In Yolanda’s case, once she is medically stable, Yolanda meets with a hospital social worker who interviews her using the CRAFFT, a screening tool for adolescents. The screen indicates that Yolanda rarely uses alcohol and never uses drugs. Her roommate corroborates these facts. However, because the consequences of this isolated incident are so serious, the social worker conducts a brief intervention to educate Yolanda on the consequences of alcohol misuse.    To this end, the social worker uses motivational interviewing practices to build rapport and set goals with Yolanda. Yolanda states that her goal is to continue to attend college parties, but not become so intoxicated that she embarrasses herself or gets sick. The social worker provides Yolanda with an overview of the dangers of binge drinking and some data on the number of deaths that are attributed to excess alcohol use each year. She also offers Yolanda strategies to avoid consuming large amounts of alcohol in short periods of time. For example, she advises Yolanda to consistently snack at parties where alcohol is present and to alternate alcoholic drinks with non-alcoholic drinks. The social worker also educates Yolanda on what a standard drink is (1 ounce of liquor, 4 ounces of wine, and 8 ounces of beer), so she can quantify the amount of alcohol she ingests. Finally, the social worker helps Yolanda and her roommate establish a contract around when to exit campus parties. Yolanda leaves the emergency room armed with knowledge and strategies to avoid future binge drinking emergencies. The social worker follows up after two weeks and reports that Yolanda is utilizing the strategies that they discussed.    

     Referral to Treatment: A screening interview that indicates severe risk of dependence requires a referral to a specialized alcohol and drug treatment program for comprehensive assessment and treatment. In this instance, the referral process should be as “air tight” as possible. It is insufficient to simply give a client the name and number of an alcohol and drug treatment program. Instead, it is best for social workers to make an appointment with the client at hand and follow up to be sure the client follows through. Recommendations from a substance abuse assessment may include one or more of the following interventions: detoxification, short-term residential treatment, long-term residential treatment (such as a half-way house or therapeutic community), outpatient treatment, day or evening treatment, medications, and/or group treatment.    

     In Denise’s case, the screening social worker identifies a substance abuse treatment agency with expertise in substance abuse treatment for pregnant women and arranges for an assessment appointment later that afternoon. The EI social worker is careful to ask Denise for written permission to communicate with the alcohol and drug program, so she can stay involved and informed. Assessment results indicate that Denise requires a medically supervised detoxification program, followed by a residential program for pregnant and parenting women. The EI social worker will have ongoing contact with Denise and her children through the provision of early intervention services.

Conclusion    

     The SBIRT model has several advantages. It matches clients with the appropriate type and amount of services they require, avoiding under- or over-treatment. It also offers social workers a framework for how community-based services can interface with specialty alcohol and drug treatment programs. SBIRT has been identified as an “evidence based practice” by the Substance Abuse and Mental Health Services Administration with promising efficacy. Finally, SBIRT has been approved by the American Medical Association and the Centers for Medicare and Medicaid Services as a reimbursable service, meaning that social workers and agencies can be reimbursed for providing SBIRT services.    

     Please visit the following websites for more information on SBIRT:

http://www.integration.samhsa.gov/clinical-practice/sbirt

http://www.bu.edu/bniart/

http://www.nida.nih.gov/nidamed/resguide/

References

National Drug Intelligence Center. (2011). The economic impact of illicit drug use on American society. Washington D.C.: United States Department of Justice. Retrieved online at http://www.justice.gov/ndic on October 7, 2013.

National Institute on Drug Abuse. (2012). Medical consequences of drug abuse. Retrieved online at http://www.drugabuse.gov/related-topics/medical-consequences-drug-abuse/mortality on October 15, 2013.

Substance Abuse and Mental Health Services Administration. (2007). SBIRT glossary. Retrieved from http://sbirt.samhsa.gov/glossary.htm on February 3, 2007.

Substance Abuse and Mental Health Services Administration. (2012). Results from the 2011 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-44, HHS Publication No. (SMA) 12-4713. Rockville, MD: Substance Abuse and Mental Health Services Administration.

Shelley Steenrod, Ph.D., LICSW, is an associate professor of social work at Salem State University in Salem, Massachusetts. She received her Master of Social Work from Boston University and her Ph.D. from the Heller School at Brandeis University. Dr. Steenrod specializes in the treatment of substance use disorders.