No discussion of addiction treatment is complete without reviewing SBIRT, which stands for screening, brief intervention, and referral to treatment. SBIRT is a coordinated approach that gives busy providers tools to implement universal screening, and resources to manage positive screens that occur in an outpatient setting. It's a well-funded and well-researched initiatives through the Substance Abuse and Mental Health Services Administration, or SAMHSA. The process starts with implementing simple screening techniques, followed by a quick assessment to understand what's actually going on with the patient. Then depending on what's uncovered, providers can either perform a brief intervention, if the case is mild or moderate, or they can refer to specialized treatment if the case is more severe. Let's consider the example of the alcohol use spectrum, where brief interventions are most useful if a patient has at-risk use, but doesn't necessarily meet criteria for an alcohol use disorder. This can be illustrated by a pyramid, where bottom represents little to no use, and we focus on prevention messaging. The top of the pyramid represents an alcohol use disorder diagnosis. Only the very tip of the pyramid represents those people who are engaged in treatment. For those with the diagnosis not engaged in treatment, our job is to refer them to care. The middle portion of that pyramid represents those with at-risk use, where we recommend performing a brief intervention. Since we've covered screening in a previous lesson, and we'll discuss referral to treatment in upcoming lessons, let's dive deeper into what a brief intervention looks like. In this lesson, you will learn how to conduct a brief intervention by using a four-part template, and applying motivational interviewing tactics within each stage. Practicing brief interventions will be particularly useful for at-risk patients that might not require formal treatment, but who would benefit from brief counseling. Conducting brief interventions will be a critical skill in your toolkit, as one out of every five patients who exceeds the daily limits of alcohol intake, and one out of every two patients that exceed the daily and weekly limits go on to develop an alcohol use disorder. Brief interventions have been found to be effective at reducing alcohol intake among patients identified as having at risk drinking through screening in primary care settings. While the approach can be adapted for other substances, or for use to motivate patients with more severe disease to engage in specialty treatment, the main application is for at-risk alcohol use identified in primary care. The four parts of a brief intervention are rooted in motivational interviewing, which you learned about in the first module. Part one of a brief intervention is to raise the subject. You can start by asking, would you mind taking a few minutes to talk with me about your alcohol use? Remember, asking permission is very important. Asking permission formally let's the patient know that their wishes come first, and helps create a non-judgmental climate. Part 2 is to provide personalized feedback. You will want to contextualize the results of the screener. You can use the following script. From what I understand, you are drinking. X-amount. We know that drinking above certain levels can cause problems such as, insert the patient's reason for visit, or other negative consequences. Then follow up by saying, I am concerned about your drinking. From there, you will want to guide your patient to make a connection. You can ask, what connection if any do you see between your drinking and your reason for visit or other medical consequences? For example, a patient might say, "I am on my fifth blood pressure medication, and my blood pressure is still high. I'm sick of taking all these medicines." Keep in mind that the connection isn't always medical, it can be behavioral. For example, a patient may say, "Well, my husband keeps nagging me because I'm spending over $70 a week on wine." After making a connection, you can compare the patient's drinking patterns to national drinking guidelines. So if your patient is a 35-year-old woman, you would say, "You've told me that you really don't drink during the week, but you might drink between five to eight drinks on a Friday or Saturday." According to the National Institute on Alcohol Abuse and Alcoholism, we consider for women, drinking more than seven drinks per week, or three drinks per occasion, to put one at risk for illness or injury. I find that many of my patients are shocked by these national drinking guidelines. You can use this reaction to engage the patient in the discussion, and offer education related to specific patient issues. Part 3 of a brief intervention is to enhance motivation. A great technique to generate motivation is by using a motivation to change ruler. You start by asking the patient on a scale from 1-10, where one is not at all ready, and 10 is very ready. How ready are you to change any aspect of your drinking? When the patient gives you a number, you follow up and ask why they didn't choose a lower number. So in a case that a patient says oh, one you can pivot by asking them, What would make this a problem for you, or have you ever done anything you wished you hadn't while you are drinking? These questions help to develop discrepancy. No matter how the patient responds, use your reflective listening skills to restate what you think the patient meant by his or her statement. Part 4 is to negotiate and advice. This is the part where we start talking about action and making plans. Ask the patient, What's the next step for you? If the patient suggests a positive next step, like trying to keep track of their drinking, or trying to cut back, then reflect and affirm that decision. If they don't have a positive next step, you may want to suggest one. You can follow up with advice such as, if you can stay within the weekly or per occasion limits, you'll be less likely to experience the negative consequences we discussed today related to your alcohol use. You'll want to conclude the brief intervention with a summary. Summaries should try to recap the patient's reasons for change. For example, help with blood pressure or to spend less money on alcohol. Along with any of the specific goals the patient set out, such as keeping number of drinks below the limit. Also makes sure to ask your patient if you summarized appropriately. That brings the patient back into the conversation and signals that you are talking with them, and not talking at them. After all, patients are experts of their own lives, and are the key decision-makers. You will want to close the discussion by suggesting a follow-up visit, and earnestly thanking the patient for their time. So to recap the four parts of a brief intervention. First, raise the subject by establishing rapport and asking permission to discuss alcohol use. Second, provide personalized feedback by reviewing patterns of use. Making connections between alcohol use and negative consequences, and comparing use to the national norms. Third, enhance motivation using the motivation to change ruler to develop discrepancy. Fourth, negotiate a goal and give advice and conclude the intervention by summarizing the reasons for change and specific goals. SBIRT can be implemented in a top-down approach where all providers in a particular setting are trained to follow these processes, or it can be applied in a bottom-up approach where individuals take it upon themselves to be local champions and modify their own practice and influence others. No matter what your role is in the health care system, it's vital to understand the basics of screening, brief intervention, and referral to treatment. We shouldn't rely on Specialty Care to address patients at risk for alcohol use. Brief interventions are an effective tool to manage unhealthy alcohol use.
