BETHESDA, MD. – Screening, brief intervention, and referral to treatment programs in large-volume general medical settings captured a range of patients at risk for alcohol, tobacco, and other drug use disorders that otherwise might not have been detected, findings in an evaluation of data from a cohort of centers that implemented the program show.
Emergency/trauma centers, in particular, are effective as screening, brief intervention, and referral to treatment (SBIRT) venues, because they serve high proportions of at-risk individuals, Francis K. Del Boca, Ph.D., reported at the annual conference of the Association for Medical Education and Research in Substance Abuse.
Forty-five percent of patients who screened positive for tobacco or at-risk alcohol use also reported using an illicit drug, said Dr. Del Boca of the University of Connecticut Health Center in Farmington. She noted that those who screened positive “often had ancillary physical, medical, and mental health issues that required consideration in the treatment referral process” and that being able to do so at an earlier stage could have an impact on patient outcomes.
The centers in the current analysis were based in California, Illinois, New Mexico, Pennsylvania, Texas, Washington State, and Cook Inlet in Alaska–together referred to as cohort 1 in the analysis. The cohort members had received funding from the Substance Abuse and Mental Health Services Administration in 2003 to set up SBIRT services in several diverse settings.
Other centers have since received funding as well, but the current analysis was based on data from the first cohort.
The researchers sought to establish the effectiveness, availability, and efficiency of the program by reviewing documents from the centers and conducting site visits that included interviewing and observing program providers and administrators.
There were three service delivery models–in-house generalist, in-house specialist, or contracted specialist–and when the researchers broke down the services into the categories of prescreening, screening, brief intervention (BI), or brief treatment (BT), the contracted specialist model seemed to work well across all of the categories, especially for screening, BI, and BT.
Providers in the hospital-outpatient setting recommended screening and feedback to 87% of patients, but BI, BT, and referral to treatment (RT) to only 8%, 3%, and 3% of patients, respectively. Likewise, federally qualified community health center providers recommended screening to most patients (85%), but their rates for BI, BT, and RT were also notably lower–11%, 3%, and 1%, respectively. By comparison, although only 70% of emergency/trauma patients were recommended for screening and feedback, the corresponding percentages for BI, BT, and RT recommendations were 18, 5, and 8. In the hospital-inpatient setting, only 65% of patients were recommended for screening, but the rates for BI, BT, and RT were 23%, 6%, and 7%.
The researchers found that the SBIRT programs could be implemented successfully and that both patients and medical staff found the programs acceptable. In fact, most patients were willing to participate in SBIRT after screening, with 86% proceeding to BI, 93% to BT, and 93% to RT.
Over time, most SBIRT facilitators found that the programs needed to be adapted to real-world settings, and the researchers noted a migration from early service delivery models, settings, and implementation models, Dr. Del Boca said. Delivery models migrated from full-length screening to shorter prescreening; traditional substance abuse treatment to on-site delivery of treatment; and from a focus on alcohol and drug risk factors to a focus on tobacco, comorbid psychiatric disorders, and other health risk factors.
In addition, hospital and emergency/trauma settings supplanted clinic settings, and a shift was seen away from the early in-house generalist model to contracted specialist model.
The effects of these migrations resulted in an overall shift in program emphasis from treatment to prevention, from alcoholism to heavy drinking, addiction to recreational drug use, disease conditions to risk factors, and from a focus on the individual to a broader public health perspective, said Thomas Babor, Ph.D., also of University of Connecticut Health Center, and who copresented with Dr. Del Boca at the meeting, which was also sponsored by Brown Medical School.
Another presenter, Jeremy Bray, Ph.D., of the nonprofit research and development organization, RTI International, reported on the costs and financing of SBIRT. Among the components that the researchers examined were the cost per patient of screening, and the cost of a BI or BT in a medical care setting, compared with a specialty care setting.
In regard to screening, they found that support activities took as much time as–or sometimes more time than–services activities, with the total screen and service time ranging from about 4 to 14 minutes at a per patient cost of $1.50 to $6.00. For BI, service and support activities took about the same amount of time–from 12 to 22 minutes, with cost ranging from $4.50 to $9.00.