InSight Project Research Group. SBIRT outcomes in Houston: final report on InSight, a hospital district-based program for patients at risk for alcohol or drug use problems

Substance Use and Mental Health Screening Within an Emergency Department-Based HIV Screening Program: Outcomes From 1 Year of Implementation

INTRODUCTION

The emergency department (ED) may be an optimal setting to screen for substance use disorders (SUDs) and co-occurring psychiatric disorders (CODs). We report on the frequency of problematic substance use and comorbid elevated mental health symptoms detected during a 1-year implementation period of an ED-based SUD/COD screening approach within an established ED HIV screening program.

METHODS

Patients (N = 1,924) were approached by dedicated HIV screening staff in an urban, Midwestern ED. Patients first completed measures assessing problematic alcohol (Alcohol Use Disorder Identification Test-Concise [AUDIT-C]) and substance use across 10 categories of substances (National Institute on Drug Abuse-Modified Alcohol, Smoking, and Substance Involvement Screening Test [NIDA-Modified ASSIST]). Patients with positive alcohol and/or substance use screens completed measures assessing symptoms of depression (Patient Health Questionnaire-9 [PHQ-9]), anxiety (Generalized Anxiety Disorder-7 [GAD-7]), and post-traumatic stress disorder (PTSD) (PTSD Checklist-Civilian [PCL-C]).

RESULTS

Patients were predominantly male (60.3%) with a mean age of 38.1 years (SD = 13.0); most identified as White (50.8%) or Black (44.8%). A majority (58.5%) had a positive screen for problematic alcohol and/or other substance use. Of those with a positive substance use screen (n = 1,126), 47.0% had a positive screen on one or more of the mental health measures with 32.1% endorsing elevated depressive symptoms, 29.6% endorsing elevated PTSD-related symptoms, and 28.5% endorsing elevated anxiety symptoms.

CONCLUSIONS

Among those receiving ED HIV screening, a majority endorsed problematic alcohol and/or other substance use and co-occurring elevated mental health symptoms. Substance use and mental health screening programs that can be integrated within other ED preventive services may enhance the identification of individuals in need of further assessment, referral, or linkage to substance use treatment services.

Alcohol Screening, Brief Intervention, and Referral to Treatment (SBIRT) for Girls and Women

Females ages 12 and older are the fastest growing segment of alcohol consumers in the United States, with the past decade showing a 16% increase in alcohol use per 12-month period and a 58% increase in high-risk drinking (i.e., > 3 drinks in a day and/or > 7 drinks in a week) per 12-month period. The increase in alcohol use and risk drinking poses unique and serious consequences for women. Women have a more rapid progression to alcohol-related problems and alcohol use disorders (AUD) than men, and if pregnant, women can potentially expose the fetus to alcohol. Screening, brief intervention, and referral to treatment (SBIRT) is an evidence-based, integrated public health approach used to identify and address risky alcohol use among women in a variety of health and social service settings. This article presents the current status of SBIRT among girls ages 12 and older, women of childbearing age, and older women. Screening instruments, brief interventions, and implementation issues specific to women of all ages are described. Through this review of the current literature, care providers can determine best practices for the prevention and treatment of risk drinking in women of all ages presenting in health care settings.

Screening, Brief Intervention, and Referral to Treatment in a Retail Pharmacy Setting: The Pharmacist's Role in Identifying and Addressing Risk of Substance Use Disorder

OBJECTIVE

This study determined the feasibility of interviewing and screening patients presenting to a retail pharmacy using Screening, Brief Intervention, and Referral to Treatment (SBIRT) interview protocols, and to compare SBIRT results to a risk score calculated from Prescription Drug Monitoring Program (PDMP) data.

METHODS

Using the NIDA Quick Screen and NIDA Modified-ASSIST (NM-ASSIST) and the Alcohol Use Disorder Identification Test (AUDIT), retail pharmacy customers were screened for substance and alcohol use disorder and tobacco use. PDMP reports were collected on subjects and a PDMP-risk score was calculated based on the numbers of Schedule II-V prescriptions and prescribers over the previous 12 months.

RESULTS

A total of 24 patients were included in this study (67% response rate). SBIRT screening revealed that 20.8% were at-risk for substance use disorder (SUD), 16.7% for alcohol use disorder, and 37.5% used tobacco. Overall, 33.3% of subjects were at-risk for SUD or alcohol use disorder. Fifty percent of subjects required education and/or brief intervention based on their responses, 37.5% of all subjects were deemed at-risk based on their PDMP-risk score, and 60% of patients who were risk-positive by SBIRT screening were also PDMP-risk positive.

CONCLUSIONS

This study demonstrates the feasibility of performing SBIRT-based screenings in a retail pharmacy setting and combining these with PDMP-risk analysis to screen patients for prescription and illicit drug misuse. Findings from this study will inform the design of larger multisite studies, which should validate these findings and include follow-up analysis to assess the efficacy of intervention on this patient population.

Study protocol testing toolkit versus usual care for implementation of screening, brief intervention, referral to treatment in hospitals: a phased cluster randomized approach

BACKGROUND

Alarming rates of unhealthy alcohol, non-prescription drug, and tobacco use highlight the preventable health risks of substance abuse and the urgent need to activate clinicians to recognize and treat risky use. Screening, brief intervention, and referral to treatment (SBIRT) is an efficacious and effective processes to identify, reduce and prevent risky use of substances. This paper describes a study protocol testing implementation of a toolkit to enhance use of SBIRT in acute care settings to recognize and address patient risky alcohol, drug, and tobacco use.

METHODS

This study uses a phased cluster randomized mixed method design to test nurse-led implementation of an SBIRT toolkit on one medical-surgical unit at 14 acute care hospitals (critical access, community and academic health centers). Medical surgical units will be randomly assigned to implement the SBIRT toolkit (engagement and communication, assessment, planning, training, and evaluation tools) or a wait-list usual care control group that begins implementation 6 months later. Primary endpoints are documentation of SBIRT delivery in randomly selected electronic medical records at baseline, 6 months and 12 months after group 1 implementation (61 records per unit per time period, N = 2562). Two surveys will be administered to unit nurses: smoking cessation activities will be assessed at baseline and SBIRT use will be assessed on randomly-selected days after implementation. In addition, site coordinators will complete a baseline capacity assessment, an implementation fidelity survey post-implementation, and a structured interview at the end of the study. Multilevel mixed-effects effects logistic and linear models will be used to analyze use of SBIRT and cost outcomes.

DISCUSSION

This study will guide subsequent SBIRT implementation, dissemination, and spread across rural, community and urban healthcare systems throughout the state and beyond. The long-term objective is to activate clinicians to recognize, intervene and refer people with risky substance use to improve health and decrease substance use disorders. Trial registration ClinicalTrials.gov NCT03560076.

Treatment and outcomes of patients presenting to an adult emergency department involuntarily with substance misuse

Alcohol and other drug (AOD) use is common in our society. The use of these substances flow throughout all areas of healthcare, and is especially prevalent in patients presenting to the emergency department with signs of mental illness. At the extreme end of these presentations patients present involuntarily with either police or ambulance officers. The aim of this study was to identify and describe the population presenting to the ED involuntarily with and without substance misuse as a precipitating factor. Quantitative descriptive analysis was used to describe this population between April and June 2015. In patients presenting to one large inner city emergency department involuntarily, 30% had alcohol or other drug misuse as a precipitating factor. Patients who involuntarily presented with alcohol and other misuse stay longer in the emergency department then others that do not have alcohol or other drug misuse. These patients represent frequently, with over 50% representing at 90 days however this was not associated with alcohol or other drug misuse. Almost all patients who present involuntarily are discharged home post review by a mental health team. Significant improvements in care can be made in this population if the opportunistic treatment of both mental illness and AOD misuse is completed in the emergency department.

Moving Away from the Tip of the Pyramid: Screening and Brief Intervention for Risky Alcohol and Opioid Use in Underserved Patients

PURPOSE

Rates of risky substance use and substance use disorders are high in primary-care practices, yet the adoption of universal screening and brief intervention (SBI) has been slow and uneven. This study aimed to describe SBI-related attitudes, practices, and perspectives regarding practice change among medical providers in a minority-majority state.

METHODS

We conducted a cross-sectional, on-line survey of a practice-based research network of medical providers serving predominantly Hispanic/Latinx and Native American patients in rural and urban settings. The main variables were clinician 1) perspectives on the need to address substance use problems in primary care, 2) current screening and intervention practices, and 3) satisfaction with and willingness to make changes to their practices.

RESULTS

Although providers endorsed alcohol and opiate misuse to be significant problems in their practices, only 25% conducted universal screening. Providers reported focusing most of their screening efforts on those with substance use dependence. In general, providers rated importance of and ability to make practice changes moderately high. There was high interest in practice coordination with the community followed by interest in a collaborative care approach.

CONCLUSIONS

Providers mainly focus efforts on the relatively few patients at the tip of the pyramid (substance use dependence) rather than on the majority of patients who comprise the middle of the pyramid (risky substance use). Practice change strategies are needed to increase universal screening with a focus on risky substance use, particularly in practices serving racial/ethnic communities.

Associated factors of readiness to change in young adult risky drinkers

BACKGROUND

Readiness to change alcohol use has been associated with a number of predictors including emotional distress, drinking severity, and consequence severity, as well as with static demographic factors such as gender and race/ethnicity.

OBJECTIVE

To examine the relationships among these variables and readiness to change alcohol use in young adults.

METHODS

Structural equation modeling was used to test pathways of readiness to change in 1,256 young adult patients (78% male/22% female) ages 18-29 who were provided screening, brief intervention and referral to treatment (SBIRT) as part of a Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Capacity Expansion Project.

RESULTS

The strongest relationships were between emotional distress, drinking severity, and consequence severity with readiness to change. Results indicated that participants with more severe alcohol problems demonstrated higher levels of readiness to change alcohol use and therefore, may be more amenable to behavior change. Additionally, females, Hispanic/Latino, and Black non-Hispanic (Black) participants demonstrated higher levels of readiness to change when compared to other groups.

CONCLUSION

These results lend support to the concept that young adults are using alcohol to modulate their emotions. Furthermore, resultant severity of consequences from drinking may play an important role in their readiness to change risky drinking. This may be especially true for females, who reported greater emotional distress, and for Hispanic/Latinos and Blacks, who reported greater drinking severity with greater emotional distress. Caregivers may be better equipped to address young adult alcohol use with this added understanding.

A randomized study of the use of screening, brief intervention, and referral to treatment (SBIRT) for drug and alcohol use with jail inmates

BACKGROUND

Screening, brief intervention, and referral to treatment (SBIRT) is an evidence-based practice that has been shown to reduce alcohol and drug use in healthcare, educational, and other settings, but research on the effectiveness of SBIRT with populations involved in the criminal justice system is limited. These populations have high rates of substance use but have limited access to interventions.

METHODS

The study randomized 732 jail inmates from a large urban jail to the SBIRT intervention or to the control group. Using the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST), the intervention assessed the risk level for drug and alcohol misuse by inmates and provided those who were at low or medium risk with a brief intervention in jail and referred those at high risk to community treatment following release, including the opportunity to participate in a brief treatment (eight sessions) protocol. Using interview and records data from a 12-month follow-up, analyses compared the two groups with respect to the primary study outcomes of reductions in drug and alcohol use and the secondary outcomes of participation in treatment, rearrest, reduction in HIV risk behaviors, and quality of life. In addition, the costs of delivering the SBIRT intervention were calculated.

RESULTS

When baseline differences were controlled, the groups did not differ at follow-up on any of the primary or secondary outcomes.

CONCLUSIONS

Future research should develop and evaluate SBIRT models that are specifically adapted to the characteristics and needs of the jail population. Until more favorable results emerge, attempts to use SBIRT with jail inmates should be implemented with caution, if at all.

TRIAL REGISTRATION NUMBER

NCT01683643.

Feasibility of a computer-assisted alcohol screening, brief intervention and referral to treatment program for DWI offenders

BACKGROUND

Alcohol use patterns that are hazardous for one's health is prevalent among DWI (driving while intoxicated) offenders and is a key predictor of recidivism. The aim of this program evaluation was to determine the feasibility and usability of implementing a computer-assisted screening, brief intervention and referral to treatment (SBIRT) program for DWI offenders to enable the identification of those in need of treatment services soon after arrest. Our treatment program consisted of a web-based, self-guided screening tool for assessing alcohol use patterns and generating a personalized feedback report that is then used to deliver a brief motivational intervention and if needed, a referral to treatment.

METHODS

Between August and November 2014, all DWI offenders attending orientation for pre-trial supervision were assessed for eligibility. Of the 129 eligible offenders, 53.5 percent enrolled and the first 50 were asked to complete a usability and satisfaction questionnaire.

RESULTS

The results demonstrated that the majority of those screened reported at-risk alcohol use patterns requiring referral to treatment. Clients reported high ratings of usability and satisfaction with the screening tool and personalized feedback report, which did not significantly differ depending on alcohol use patterns. There were relatively few technical difficulties, and the majority of clients reported high levels of satisfaction with the overall SBIRT program.

CONCLUSION

Results of this program evaluation suggest that computer-assisted SBIRT may be successfully implemented within the criminal justice system to DWI offenders soon after arrest; however, further research is required to examine its effects on treatment utilization and recidivism.

An Assessment of SBIRT Prescreening and Screening Outcomes by Medical Setting and Administration Methodology

BACKGROUND

Screening, brief intervention, and referral to treatment (SBIRT) is an efficacious prevention practice. However, little research has assessed differences in prescreening outcomes between inpatient and outpatient primary care or among different prescreening administration methods. This study tested whether administration method (self-administered vs interview) and setting (inpatient versus outpatient) predicted prescreening outcomes in a large sample of primary care patients. Then, among patients who prescreened positive, it tested whether full screening scores differed by administration method and setting.

METHODS

Researchers used binomial logistic regression to assess predicted prescreening outcomes and analysis of variance to assess differences in SBIRT screening scores across a total of 14 447 unique patient visits in 10 outpatient sites and 1 centrally located hospital.

RESULTS

Controlling for gender, depression, and other substance use, both medical setting and method of prescreening, predicted prescreening results. Among patients who prescreened positive for alcohol, setting also was associated with mean screening scores. However, outcomes were not uniform by substance (eg, alcohol vs other drugs).

CONCLUSION

The results support previous studies on this topic that had utilized cross-study comparison or that were not specific to SBIRT prescreening/screening mechanisms. At the same time, nuanced findings were observed that had not previously been reported and suggest the need for further research in this area.

METelemedicine: a pilot study with rural alcohol users on community supervision

PURPOSE

This pilot study examined a telemedicine-based intervention using motivational enhancement therapy (METelemedicine) to reduce alcohol use among a sample of at-risk, rural alcohol users.

METHODS

A total of 127 rural alcohol users were recruited from community supervision offices and engaged in brief intervention sessions using telemedicine. Analysis examined alcohol outcomes at 3 months postbaseline.

FINDINGS

Findings indicated that although there were no overall differences between comparison groups on alcohol outcomes, 3+ sessions of METelemedicine significantly reduced the likelihood of any alcohol use by 72% (P < .05). In addition, 3+ sessions of the intervention predicted fewer days of drinking in the follow-up period, fewer drinks per week, and fewer days experiencing alcohol problems.

CONCLUSIONS

Findings demonstrate that telemedicine may be a promising approach to deliver interventions with alcohol users who may not utilize formal treatment services. This method has potential to decrease some of the barriers to access and use of evidence-based treatment for populations in need of services.

Predictors of readiness to change young adult drug use in community health settings

This study evaluated readiness to change drug use in young adult patients aged 18-25 years who were provided screening and brief intervention as part of a Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Capacity Expansion Project. Non-treatment-seeking young adults at risk for drug problems (n = 1,560) were assessed for readiness to change. Structural equation modeling examined latent constructs: emotional distress, age, drug use severity, criminal behavior, gender, and race/ethnicity. Drug use severity fully mediated the relationship between emotional distress and readiness. In addition, females and young adults with more severe drug problems may be more amenable to behavior change.

Screening, brief intervention, and referral to treatment (SBIRT) for offenders: protocol for a pragmatic randomized trial

BACKGROUND

Although screening, brief intervention, and referral to treatment (SBIRT) is an evidence-based technique that, in some health-care settings, has been shown to cost-effectively reduce alcohol and drug use, research on the efficacy of SBIRT among criminal offender populations is limited. Such populations have a high prevalence of drug and alcohol use but limited access to intervention, and many are at risk for post-release relapse and recidivism. Thus, there exists a need for treatment options for drug-involved offenders of varying risk levels to reduce risky behaviors or enter treatment.

METHODS/DESIGN

This protocol describes an assessment of SBIRT feasibility and effectiveness in a criminal justice environment. Eight-hundred persons will be recruited from a large metropolitan jail, with the experimental group receiving an intervention depending on risk level and the control group receiving minimal intervention. The intervention will assess the risk level for drug and alcohol misuse by inmates, providing those at low or medium risk a brief intervention in the jail and referring those at high risk to community treatment following release. In addition, a brief treatment (eight-session) option will be available. Using data from a 12-month follow-up interview, the primary study outcomes are a reduction in drug and alcohol use, while secondary outcomes include participation in treatment, rearrest, quality of life, reduction in HIV risk behaviors, and costs of SBIRT.

EXPECTED VALUE

Individual reductions in alcohol and drug use can have significant effects on public health and safety when observed over a large population at risk for substance-use problems. With wider dissemination statewide or nationwide, a relatively low-cost intervention such as SBIRT could offer demonstrated benefits in this population.

TRIAL REGISTRATION

Clinical Trials Government Identifier, NCT01683643.

Evaluation of California's Alcohol and Drug Screening and Brief Intervention Project for Emergency Department Patients

INTRODUCTION

Visits to settings such as emergency departments (EDs) may present a "teachable moment" in that a patient may be more open to feedback and suggestions regarding their risky alcohol and illicit drug-use behaviors. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an 'opportunistic' public health approach that targets low-risk users, in addition to those already dependent on alcohol and/or drugs. SBIRT programs provide patients with comprehensive screening and assessments, and deliver interventions of appropriate intensity to reduce risks related to alcohol and drug use.

METHODS

This study used a single group pre-post test design to assess the effect of the California SBIRT service program (i.e., CASBIRT) on 6 substance-use outcomes (past-month prevalence and number of days of binge drinking, illegal drug use, and marijuana use). Trained bilingual/bicultural Health Educators attempted to screen all adult patients in 12 EDs/trauma centers (regardless of the reason for the patient's visit) using a short instrument, and then delivered a brief motivational intervention matched to the patient's risk level. A total of 2,436 randomly selected patients who screened positive for alcohol and/or drug use consented to be in a 6-month telephone follow-up interview. Because of the high loss to follow-up rate, we used an intention-to-treat approach for the data analysis.

RESULTS

RESULTS of generalized linear mixed models showed modest reductions in all 6 drug-and alcohol-use outcomes. Men (versus women), those at relatively higher risk status (versus lower risk), and those with only one substance of misuse (versus both alcohol and illicit drug misuse) tended to show more positive change.

CONCLUSION

These results suggest that SBIRT services provided in acute care settings are associated with modest changes in self-reported recent alcohol and illicit drug use.

Design of NIDA CTN Protocol 0047: screening, motivational assessment, referral, and treatment in emergency departments (SMART-ED)

BACKGROUND

Medical settings such as emergency departments (EDs) present an opportunity to identify and provide services for individuals with substance use problems who might otherwise never receive any form of assessment, referral, or intervention. Although screening, brief intervention, and referral to treatment models have been extensively studied and are considered effective for individuals with alcohol problems presenting in EDs and other medical settings, the efficacy of such interventions has not been established for drug users presenting in EDs.

OBJECTIVES

This article describes the design of a NIDA Clinical Trials Network protocol testing the efficacy of an screening, brief intervention, and referral to treatment model in medical EDs, highlighting considerations that are pertinent to the design of other studies targeting substance use behaviors in medical treatment settings.

METHODS

The protocol is described, and critical design decisions are discussed.

RESULTS

Design challenges included defining treatment conditions, study population, and site characteristics; developing the screening process; choosing the primary outcome; balancing brevity and comprehensiveness of assessment; and selecting the strategy for statistical analysis.

CONCLUSION

Many of the issues arising in the design of this study will be relevant to future studies of interventions for addictions in medical settings.

SCIENTIFIC SIGNIFICANCE

Optimal trial design is critical to determining how best to integrate substance abuse interventions into medical care.

The relationship between services delivered and substance use outcomes in New Mexico's Screening, Brief Intervention, Referral and Treatment (SBIRT) Initiative

BACKGROUND

Recent years have seen increased diffusion of Screening, Brief Intervention, Referral and Treatment (SBIRT) in healthcare environments. This study examined the relationship between substance use outcomes and service variables within the SBIRT model.

METHODS

Over 55,000 adult patients were screened for substance misuse at rural health clinics throughout New Mexico during the SBIRT Initiative. This naturalistic pre-post services study used administrative baseline, 6 month follow-up, and services data for adult participants in the New Mexico SBIRT evaluation (n=1208). Changes in self-reported frequency of illicit drug use, alcohol use, and alcohol intoxication were examined as a function of service level (brief intervention - BI vs. brief treatment/referral - BT/RT) and number of service sessions.

RESULTS

Participants reported decreased frequency of illicit drug use, alcohol use, and alcohol intoxication 6 months after receipt of SBIRT services (p<.001 for each). Compared to those who received BI, participants who received BT/RT had sharper reductions in frequency of drinking (IRR=.78; p<.05) and alcohol intoxication (IRR=.75; p<.05). Number of service sessions was associated with reduced frequency of alcohol use (IRR=.84; p<.01) and intoxication (IRR=.82; p<.05), but only among those who received BI.

CONCLUSIONS

Substance-using patients with disparate levels of use may benefit from SBIRT. In a real-world, multi-site rural SBIRT program, services of higher intensity and (within the BI modality) frequency were associated with greater magnitude of change in drinking behaviors. Reductions in illicit drug use, while substantial, did not differ significantly based on service variables. Future studies should identify the preferred service mix in the SBIRT model as it continues to expand.