Screening, brief intervention, and referral to treatment (SBIRT) for alcohol and other drug use among adolescents: evaluation of a pediatric residency curriculum

Substance Use Screening, Brief Intervention, and Referral to Treatment in Pediatric Primary Care, School-Based Health Clinics, and Mental Health Clinics

Adolescent cannabis use is a modifiable health behavior with potential adverse developmental, cognitive, psychological, and health effects. Over the last 2 decades, work to promote implementation of screening, brief intervention, and referral to treatment has improved screening, use of validated screening tools, and preventive messaging. Current intervention strategies for cannabis use are associated with modest, short-term effects, and referral to treatment is limited by availability of resources for adolescent substance use. This article provides an update on the evidence base for screening, brief intervention, referral to treatment, and the current state of implementation focused on management of cannabis use disorder.

Substance Use Screening, Brief Intervention, and Referral to Treatment in Pediatric Primary Care, School-Based Health Clinics, and Mental Health Clinics

Adolescent cannabis use is a modifiable health behavior with potential adverse developmental, cognitive, psychological, and health effects. Over the last 2 decades, work to promote implementation of screening, brief intervention, and referral to treatment has improved screening, use of validated screening tools, and preventive messaging. Current intervention strategies for cannabis use are associated with modest, short-term effects, and referral to treatment is limited by availability of resources for adolescent substance use. This article provides an update on the evidence base for screening, brief intervention, referral to treatment, and the current state of implementation focused on management of cannabis use disorder.

The Status of SBIRT Training in Health Professions Education: A Cross-Discipline Review and Evaluation of SBIRT Curricula and Educational Research

PURPOSE

To assess the quality of curricular research on the Screening Brief Intervention and Referral to Treatment (SBIRT) approach and determine the presence of useful training modalities, particularly motivational interviewing (MI) training, across health care training curricula.

METHOD

The authors conducted a systematic review of published, peer-reviewed studies in PubMed, ERIC, CINAHL, Ovid HealthSTAR, and PsycINFO databases through March 2021 for English-language studies describing SBIRT, a curriculum for health care trainees, and curricular intervention outcomes. After the records were independently assessed, data were extracted and 20% of the studies were double-coded for interrater reliability.

RESULTS

Of 1,856 studies, 95 were included in the review; 22 had overlapping samples and were consolidated into 10 nested studies, leaving 83 total. Interrater reliability ranged from moderate (κ = .74, P < .001) to strong (κ = .91, P < .001) agreement. SBIRT training was delivered to trainees across many professions, including nursing (n = 34, 41%), medical residency (n = 28, 34%), and social work (n = 24, 29%). Nearly every study described SBIRT training methods (n = 80, 96%), and most reported training in MI (n = 54, 65%). On average, studies reported 4.06 (SD = 1.64) different SBIRT training methods and 3.31 (SD = 1.59) MI training methods. Their mean design score was 1.92 (SD = 0.84) and mean measurement score was 1.89 (SD = 1.05). A minority of studies measured SBIRT/MI skill (n = 23, 28%), and 4 studies (5%) set a priori benchmarks for their curricula.

CONCLUSIONS

SBIRT training has been delivered to a wide range of health care trainees and often includes MI. Rigor scores for the studies were generally low due to limited research designs and infrequent use of objective skill measurement. Future work should include predefined training benchmarks and validated skills measurement.

The effects of screening brief intervention referral to treatment (SBIRT) training on health professional trainees' regard, attitudes, and beliefs toward patients who use substances

BACKGROUND

Screening Brief Intervention Referral to Treatment (SBIRT) was developed as an integrated and comprehensive public health approach that includes early screening and intervention to address substance use in a variety of health care settings. Research suggests that SBIRT is effective in reducing substance use in individuals whose use places them at higher risk for negative health and social consequences. However, less is known about how training in SBIRT modifies attitudes, regard, and beliefs toward people who use substances. Methods: Participants included 461 students from a variety of healthcare related disciplines (physician assistant, nurse practitioner, pharmacy, psychiatry and psychology, and medical students). Participants were evaluated using a pre-post design to assess changes in regard, attitudes, and beliefs by completing the Short Alcohol and Alcohol Problems Perception Questionnaire, the Drug Problem Perception Questionnaire, the Medical Condition Regard Scale, and the Short Understanding of Substance Abuse Scale before and after a 7-hour SBIRT training program. We hypothesized that trainees would have more positive regard, attitudes, and beliefs toward people who use substances following training in SBIRT relative to a baseline assessment and that there would be between program differences. Results: Results were consistent with hypotheses and suggested that trainees had significantly more positive regard and changes in attitudes and beliefs toward working with patients who use substances following training in SBIRT. Results also suggested significant differences by training group at baseline and at 30-day follow up. Conclusions: Overall, the findings suggest that an important additional benefit of SBIRT is the impact it has on mitigating healthcare professional trainees' negative regard and modifying attitudes and beliefs toward those who use substances.

A Brief Negotiation Interview Adherence Scale for Smoking Cessation: A psychometric evaluation

Practitioner adherence to the Brief Negotiation Interview (BNI) for high-risk alcohol consumption and opioid use disorder can be measured using the BNI Adherence Scale, for alcohol (BAS-A) and opioids (BAS-O), respectively. However, no psychometrically validated brief intervention adherence scale for smoking cessation has been reported in the literature. Our objective was to develop and examine the psychometric properties of a BAS for smoking cessation (BASS). In the context of a clinical trial of the BNI in an emergency department (ED)-which incorporates motivational interviewing (MI), feedback, and behavioral contracting-plus nicotine replacement therapy (NRT), and a Smokers' Quitline referral and brochure (BNI), compared with brochure-only (control), we developed and examined the psychometric properties of the BAS-S, a scale that requires raters to answer whether each critical action of the BNI was implemented. Three independent raters rated three hundred and eighty-eight audio-recorded BNI sessions. The results indicated that the BAS-S had excellent internal consistency, and discriminant validity, inter-rater reliability, and construct validity. The following 3-factor (10-item) solution accounted for 43% of the variance: factor 1, "Feedback,", factor 2, "NRT Motivation," and factor 3, "Plan Negotiation." The study found predictive validity for the Feedback factor, suggesting that patients who were provided feedback on the harms of their smoking were significantly less likely to achieve biologically confirmed 7-day tobacco abstinence at their 3-month follow-up than those who were not provided such feedback (p < 0.03). The BAS-S is a psychometrically valid measure of adherence to the BNI for smoking cessation.

Alcohol Use by Youth

Alcohol use continues to be a major concern from preadolescence through young adulthood in the United States. Results of recent neuroscience research have helped to elucidate neurobiological models of addiction, substantiated the deleterious effects of alcohol on adolescent brain development, and added additional evidence to support the call to prevent and reduce underage drinking. This technical report reviews the relevant literature and supports the accompanying policy statement in this issue of Pediatrics.

Evaluation of a Pediatric Resident Skills-Based Screening, Brief Intervention and Referral to Treatment (SBIRT) Curriculum for Substance Use

PURPOSE

To evaluate a screening, brief intervention and referral to treatment curriculum for alcohol and other substance use developed, implemented and integrated into a pediatric residency program.

METHODS

During a 1-month adolescent medicine rotation, pediatric, and medicine/pediatric residents in an urban teaching hospital completed a 2 1/2-hour formal curriculum including a didactic lecture, a 40-minute video describing the Brief Negotiation Interview (BNI), and a skill-based session practicing the BNI and receiving individualized feedback. Access to a website with didactic material was provided. Outcome measures were pre- and post-training knowledge, BNI performance measured with a standardized patient using a validated BNI adherence scale, satisfaction with training, and adoption of BNI into clinical practice.

RESULTS

Of the 106 residents trained, 92(87%) completed both pre- and post-test evaluations. Significant improvements were found in pre- versus post-test scores of knowledge, (20.0 [2.4 SD] vs. 24.1 [3.5 SD], p <.001) and BNI performance comparing pre- and post BNI adherence scale total scores, (5.14 [1.8 S.D.] vs. 11.5 [.96], p<.001). Residents reported high satisfaction with training, [1.4, SD .5, immediately and 1.6, SD .6, 30-days post training)with scores ranging from 1 to 5 with lower score=greater satisfaction. During the 12-month follow-up period, we received 83 responses from residents reporting a total of 129 BNIs in actual clinical settings.

CONCLUSIONS

A screening, brief intervention and referral to treatment curriculum was successfully integrated into an adolescent medicine elective in a pediatric residency program. Residents demonstrated significant improvements in knowledge and skills performing the BNI, with high satisfaction and adoption of the BNI into clinical practice.

A postgraduation follow-up of social work students trained in "SBIRT": Rates of usage and perceptions of effectiveness

Screening, brief intervention, and referral to treatment (SBIRT) is an evidence-based modality that can help social workers work with substance-using clients as part of an integrated health care approach. This study reports the findings of a post-graduation one-year follow-up survey of 193 master's and bachelor's social work students trained in SBIRT in practice courses at a Northeast urban college. Forty-three percent of the trainees who were practicing social work after graduation were using SBIRT. A content analysis of participants' comments found that the vast majority found SBIRT to be a valuable practice modality, with barriers to utilization of SBIRT identified.

An interventionist adherence scale for a specialized brief negotiation interview focused on treatment engagement for opioid use disorders

BACKGROUND

No psychometrically validated instrument for evaluating the extent to which interventionists correctly implement brief interventions designed to motivate treatment engagement for opioid use disorders has been reported in the literature. The objective of this study was to develop and examine the psychometric properties of the Brief Negotiation Interview (BNI) Adherence Scale for Opioid Use Disorders (BAS-O).

METHODS

In the context of a randomized controlled trial evaluating the efficacy of 3 models of emergency department care for opioid use disorders, the authors developed and subsequently examined the psychometric properties of the BAS-O, a 38-item scale that required raters to answer whether or not ("Yes" or "No") each of the critical actions of the BNI was correctly implemented by the research interventionist. BAS-O items pertained to the BNI's 4 steps: (1) Raise the Subject, (2) Provide Feedback, (3) Enhance Motivation, and (4) Negotiate and Advise. A total of 215 audio-recorded BNI and 88 control encounters were rated by 3 trained raters who were independent of the study team and blind to study hypotheses, treatment, and assignment.

RESULTS

The results indicated the BAS-O has fair to excellent psychometric properties, in terms of good internal consistency, excellent interrater reliability, discriminant validity, and construct validity, and fair predictive validity. A 13-item, 2-factor solution accounted for nearly 80% of the variance, where factor 1 addressed "Autonomy and Planning" (7 items) and factor 2 addressed "Motivation and Problems" (6 items). However, predictive validity was found for only one of the BAS-O factor items (i.e., Telling patients that treatment will address a range of issues related to their opioid use disorder).

CONCLUSIONS

This study suggests that the BAS-O is a psychometrically valid measure of adherence to the specialized BNI for motivating treatment engagement in patients with opioid use disorders, thus providing a brief (13-item), objective method of evaluating BNI skill performance.

Screening, Brief Intervention, and Referral to Treatment

Screening, Brief Intervention, and Referral to Treatment is a quick, effective technique with which to manage substance use in adolescents and young adults. Use of a validated measure for detecting substance use and abuse is significantly more effective than unvalidated tools or provider intuition. There are a variety of validated tools available to use in the adolescent/young adult population, and there are opportunities to increase the efficiency and scalability of screening by using computerized questionnaires. This area continues to evolve rapidly.

The future of screening, brief intervention and referral to treatment in adolescent primary care: research directions and dissemination challenges

PURPOSE OF REVIEW

Screening, brief intervention and referral to treatment (SBIRT) offers a practical, integrated model for addressing substance use in primary care settings. This review provides an update of the research on SBIRT for adolescents in primary care, examines current dissemination challenges and suggests future research directions.

RECENT FINDINGS

A number of brief screening tools for adolescents have been developed and tested relative to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) substance use disorders. Computerized previsit screening promotes standardization and is a more time-efficient alternative to provider interview. The adolescent brief intervention literature is growing, particularly with respect to technology-based tools, but is still limited, with evidence greatest for alcohol, and for motivational enhancement therapy interventions. Increasing SBIRT implementation in pediatric primary care remains a challenge. Using nonphysician behavioral health providers to deliver SBIRT, and embedding a screener and decision support tool in electronic medical record systems are strategies being investigated to promote SBIRT implementation.

SUMMARY

Substance use begins in adolescence, and pediatric SBIRT could help to achieve a population-level reduction of substance use-related harms. With a growing number of available tools, adolescent SBIRT effectiveness and feasibility are increasing, but more studies are needed to grow its evidence base, and elucidate strategies to increase implementation.

Screening and Brief Interventions for Illicit Drug Use and Alcohol Use in Methadone Maintained Opiate-Dependent Patients: Results of a Pilot Cluster Randomized Controlled Trial Feasibility Study

BACKGROUND AND OBJECTIVES

The present study evaluated the effectiveness of a single clinician delivered brief intervention (BI) to reduce problem alcohol use and illicit substance use in an opiate-dependent methadone maintained cohort of patients attending for treatment.

METHODS

Four addiction treatment centers were randomly assigned to either treatment as usual (TAU; control group) or BI (intervention group). Clinicians screened patients using the alcohol, smoking, and substance involvement screening test (ASSIST) screening tool at baseline and again at three-month follow up. Fidelity checks were performed to ensure that training was delivered effectively and uniformly across all study sites. Feasibility of administering a BI within daily practice was assessed through intervention fidelity checks, patient satisfaction questionnaires and process evaluation.

RESULTS

A total of 465 patients were screened (66% of the overall eligible population) with a total of 433 (93%) ASSIST positive cases. Randomization was effective, with no differences in the control versus the intervention arms at baseline for key demographic or clinical indicators including substance us. There was a statistically significant difference between global risk score for the intervention (x = 39.36, sd = 25.91) group and the control group (x = 45.27, SD = 27.52) at 3-month follow-up (t(341) = -2.07, p < .05).

CONCLUSIONS

This trial provides the first evidence that a single clinician delivered BI can result in a reduction in substance use within a methadone maintained opiate-dependent cohort, and this effect is sustained at three month follow up.

Screening, Brief Intervention, Referral to Treatment (SBIRT), and Motivational Interviewing for PGY-1 Medical Residents

BACKGROUND

Screening, brief intervention, and referral to treatment (SBIRT) for alcohol use in primary care-often using motivational interviewing (MI)-is an effective preventive service. Medical residency programs have begun offering training in these areas, but little research has been conducted to examine the impact of SBIRT/MI training length on residents' satisfaction, affect, and behavioral intentions.

OBJECTIVE

We measured residents' satisfaction with their training in addition to variables shown in previous research to predict medical professionals' intention to perform SBIRT.

METHODS

This study focused on 2 SBIRT/MI training structures: a 4- to 6-hour training using didactic, experiential, and interactive methods and a brief 1-hour session explaining the same principles in a noninteractive format. Immediately following each training intervention, participating residents from internal medicine (IM), pediatrics (PEDS), medicine-pediatrics (IM-PEDS), and emergency medicine (EM) programs completed a 22-item instrument derived from established questionnaires; responses to each item were dichotomized, and comparisons were conducted between the training groups using Fisher exact test.

RESULTS

Of 80 participating residents, 59 IM, PEDS, and IM-PEDS residents completed the longer training, and 21 EM residents completed the shorter training. All participating residents reported high levels of satisfaction, although EM residents were comparatively less satisfied with their shorter training session.

CONCLUSIONS

Both SBIRT/MI training structures were feasible and were accepted by learners, although the 2 groups' perceptions of the training differed. Future research into the underlying causes of these differences may be useful to the application of SBIRT/MI training during residency.

The link between substance use and reproductive health service utilization among young U.S. women

BACKGROUND

The authors sought to investigate associations between young women's use of alcohol and other substances and their sexual and reproductive health (SRH) service utilization.

METHODS

The authors used data from 4421 young women aged 15-24 years in the nationally representative study, National Survey of Family Growth, 2002-2008. The authors examined associations between frequency of tobacco, alcohol, marijuana, and illicit drug use and SRH service use in the past year using logistic regression.

RESULTS

Over half (59%) of the young women used SRH services, including contraception (48%), gynecological examination (47%), and sexually transmitted infection (STI) testing/treatment (17%) services. Proportions of SRH service use increased with higher frequencies of substance use (all P values <.001); service use was particularly common among daily substance users (range: 72% of daily marijuana users to 83% of daily binge drinkers). In multivariable analyses, associations between substance and SRH service use varied by substance and service type: weekly marijuana (odds ratio [OR] = 2.5, 95% confidence interval [95% CI] = 1.4, 4.3, P = .002) and alcohol (OR = 1.7, 95% CI = 1.1, 2.4, P = .01) use were positively associated with gynecological service use. All substances were positively associated with STI service use. However, daily smoking was negatively associated with contraceptive service use (OR = 0.6, 95% CI = 0.4, 0.8, P = .001).

CONCLUSION

SRH service use was common among women reporting frequent substance use. SRH settings provide an opportunity to deliver substance use screening and preventive care to young women.

Development of a scale to measure practitioner adherence to a brief intervention in the emergency department

Brief intervention (BI) can reduce harmful and hazardous drinking among emergency department patients. However, no psychometrically-validated instrument for evaluating the extent to which practitioners correctly implement BIs in clinical practice (e.g., adherence) exists. We developed and subsequently examined the psychometric properties of a scale that measures practitioner adherence to a BI, namely the Brief Negotiation Interview (BNI). Ratings of 342 audiotaped BIs in the emergency department demonstrated that the BNI Adherence Scale (BAS) has: (1) excellent internal consistency and discriminant validity; (2) good to excellent inter-rater reliability, and (3) good construct validity, with an eight-item, two-factor structure accounting for 62% of the variance, but (4) no predictive validity in this study. The BAS provides practitioners with a brief, objective method to evaluate their BNI skills and give feedback to them about their performance.