1. Screening and Brief Intervention for Substance Abuse: Overview of Practical and Conceptual Issues Thomas Babor, PhD, MPH

2. 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

3. Basic Elements of SBIRT Screening—How, Who, and When? Treatment matching linked to screening results Brief intervention Brief treatment Referral to standardized assessment and more intensive treatment Continued monitoring

5. Spurt – a sudden burst of energy or activity A Brief History of SBIRT Phase I (1980’s) 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

6. Distinctions / Dichotomies Treatment vs. prevention Alcoholism vs. heavy drinking; Addiction vs. recreational drug use Disease conditions vs. risk factors Individual vs. public health perspectives

7. 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 Preconditions for a Public Health Approach to Screening and Early Intervention

8. Evaluating a SBIRT Program EfficacyCan it work? EffectivenessDoes it work? Availability and ReachIs it reaching those who need it? EfficiencyIs it worth doing compared to other uses of the same resources?

9. Key Terms and Definitions Dependence SyndromeA cluster of cognitive, behavioral, and physiological symptoms Harmful UseA pattern of substance use that has already caused damage to health Hazardous UseA pattern of substance use carrying with it a risk of harmful consequences to the user

10. Dependent Drinkers At-Risk Drinkers Responsible Drinkers Abstainers The Drinkers’ Pyramid

11. Illicit drug abuse requiring formal treatment Current illicit drug use No illicit drug use Note: Figures based on Connecticut 1996 adult household telephone surveys and 2000 US census of adults age 18 to 39. 3% (24,912) 14% (104,653) 83% (619,313) Illicit Drug Use Pyramid Connecticut Adults Age 18 to 39

12. 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

13. Common Self-Report Screening Assessments Alcohol –AUDIT, CAGE, TWEAK, et. al. Drugs –DAST Combined Substances (Tobacco, Alcohol, Other Drugs) –ASSIST, CAGE-AID, SASSI

14. A Short History of SBIRT: Phase II Alcohol Brief Intervention Trials Malmo Study (1982) WHO AMETHYST Project (1985-1996). Other trials (Wallace et al., Fleming et al.) Meta-analyses and review papers

15. 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

16. 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

17. 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)

18. A Multi-site Study of the Effectiveness of Brief Treatment for Cannabis Dependence A Cooperative Agreement funded by SAMHSA-CSAT MTP Marijuana Treatment Project

19. Study Design

20. Outcomes: Baseline, 4, 9 & 15-months % of Days Smoked Marijuana

21. A Short History of SBIRT: Time 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)

22. SBIRT Implementation Trials – R.A. Senft et al., primary care, 1997 Prescription for Health Initiative, RWJ/AHRQ (2002 – present) Vital Signs, UConn, dental clinics (2002–2004) Cutting Back, RWJ, 2002-2005

23. What is being learned from implementation research? It can be done, but it’s 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

24. Phase IV: The Future Has Arrived USA Policy Implications Expert committee reports Standards and practices National alcohol screening day SBIRT National demonstration program

25. 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.

26. 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."

27. 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

28. World Health Report 2002 Burden due to major risks Cost-effectiveness of relevant interventions Policy implications

29. High Mortality Developing Countries Low Mortality Developing Countries = Major NCD risk factors 1 UnderweightAlcoholTobacco 2 Unsafe sexBlood pressure Blood pressure 3 Unsafe waterTobacco Alcohol 4 Indoor smokeUnderweightCholesterol 5 Zinc deficiencyBody mass index Body mass index 6 Iron deficiencyCholesterolLow fruit & veg. intake 7 Vitamin A deficiencyLow fruit & veg intake Physical inactivity 8 Blood pressureIndoor smoke - solid fuels Illicit drugs 9 TobaccoIron deficiency Unsafe sex 10 CholesterolUnsafe waterIron deficiency 11 AlcoholUnsafe sexLead exposure 12 Low fruit & veg intake Lead exposureChildhood sexual abuse Developed Countries Leading 12 selected risk factors as causes of disease burden

30. 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 65:782-793. Cost Effectiveness of Brief Intervention with Risky Drinkers

31. 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

32. 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