Screening, Brief Intervention, and Referral to Treatment ... a Public Health Ap… · Mental Health...

Screening, Brief Intervention,and Referral to Treatment (SBIRT):Toward a Public Health Approach

to the Management of Substance Abuse

Thomas F. Babor, PhD, MPHBonnie G. McRee, MPH

Patricia A. Kassebaum, MAPaul L. Grimaldi, PhD

Kazi Ahmed, PhDJeremy Bray, PhD

SUMMARY. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a comprehen-sive and integrated approach to the delivery of early intervention and treatment services throughuniversal screening for persons with substance use disorders and those at risk. This paper describesresearch on the components of SBIRT conducted during the past 25 years, including the develop-ment of screening tests, clinical trials of brief interventions and implementation research. Begin-ning in the 1980s, concerted efforts were made in the US and at the World Health Organization toprovide an evidence base for alcohol screening and brief intervention in primary health care set-tings. With the development of reliable and accurate screening tests for alcohol, more than a hun-dred clinical trials were conducted to evaluate the efficacy and cost effectiveness of alcoholscreening and brief intervention in primary care, emergency departments and trauma centers. Withthe accumulation of positive evidence, implementation research on alcohol SBI was begun in the1990s, followed by trials of similar methods for other substances (e.g., illicit drugs, tobacco, pre-scription drugs) and by national demonstration programs in the US and other countries. The resultsof these efforts demonstrate the cumulative benefit of translational research on health care deliverysystems and substance abuse policy. That SBIRT yields short-term improvements in individuals’health is irrefutable; long-term effects on population health have not yet been demonstrated, butsimulation models suggest that the benefits could be substantial. doi:10.1300/J465v28n03_03 [Arti-cle copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mailaddress: <[email protected]> Website: <http://www.HaworthPress.com> © 2007 by TheHaworth Press, Inc. All rights reserved.]

Thomas F. Babor and Bonnie G. McRee are affiliated with the University of Connecticut School of Medicine.Patricia A. Kassebaum, Paul L. Grimaldi, and Kazi Ahmed are affiliated with JBS International, Inc., Silver

Spring, MD.Jeremy Bray is affiliated with RTI International, Research Triangle Park, NC.Address correspondence to: Thomas F. Babor, The University of Connecticut School of Medicine, 263

Farmington Avenue, Farmington, CT 06030 (E-mail: [email protected]).The writing of this paper was supported by the Center for Substance Abuse Treatment, Substance Abuse and

Mental Health Services Administration [SBIRT Contract No. is 270-03-1000 and the Task Order No. is270-03-1007].

[Haworth co-indexing entry note]: “Screening, Brief Intervention, and Referral to Treatment (SBIRT): Toward a Public Health Approach tothe Management of Substance Abuse.” Babor, Thomas F. et al. Co-published simultaneously in Substance Abuse (The Haworth Medical Press, animprint of The Haworth Press, Inc.) Vol. 28, No. 3, 2007, pp. 7-30; and: Alcohol/Drug Screening and Brief Intervention: Advances in Evi-dence-Based Practice (ed: Richard Saitz, and Marc Galanter) The Haworth Medical Press, an imprint of The Haworth Press, Inc., 2007, pp. 7-30.Single or multiple copies of this article are available for a fee from The Haworth Document Delivery Service [1-800-HAWORTH, 9:00 a.m. - 5:00p.m. (EST). E-mail address: [email protected]].

Available online at http://suba.haworthpress.com© 2007 by The Haworth Press, Inc. All rights reserved.

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KEYWORDS. Alcohol, screening, substance abuse, brief intervention, SBIRT, drugs

INTRODUCTION

Screening, Brief Intervention, and ReferraltoTreatment(SBIRT)isacomprehensive, inte-grated,publichealthapproach to thedeliveryofearly intervention and treatment services forpersons with substance use disorders, as well asthose who are at risk of developing them.SBIRT is based on public health principles andprocedures, and is designed to reduce the bur-den of injury, disease and disability associatedwith the misuse of psychoactive substances,particularlyalcohol, illicitdrugs, tobaccoprod-ucts, and prescription medications with highabuse potential. The aims of this review are tosummarize the research base and state ofknowledge on SBIRT. For the purposes of thisreview, the following are considered core com-ponents of SBIRT:

• Screening: SBIRT begins with the intro-duction of systematic screening into thenormal routine at medical facilities andother community settings where personswith substance use disorders are likely tobe found. Screening is by definition a pre-liminary procedure to evaluate the likeli-hood that an individual has a substanceuse disorder or is at risk of negative conse-quences from use of alcohol or otherdrugs. Whereas screening tests were ini-tially developed to identify active cases ofalcohol and drug dependence, in recentyears the aim has been expanded to coverthe full spectrum ranging from risky sub-stance use to alcohol or drug dependence.Because the population of persons withrisk factors is much larger than the popu-lation of dependence cases (1), SBIRTprograms focusing on early interventionhave generally adopted a broad definitionof screening.

• Brief intervention: The term brief inter-vention refers to any time-limited effort(e.g., 1-2 conversations or meetings) toprovide information or advice, increasemotivation to avoid substance use, or toteach behavior change skills that will re-duce substance use as well as the chancesof negative consequences. Brief interven-

tions are typically delivered to those indi-viduals at low to moderate risk. Amongthe most cost-effective and time efficientinterventions are brief motivational con-versations between a health care profes-sional and a substance user.

• Brief treatment: Brief treatment refers tothe delivery of time-limited, structured(or specific) therapy for a substance usedisorder by a trained clinician and is typi-cally delivered to those at higher risk or inthe early stages of dependence. It generallyinvolves 2-6 sessions of cognitive-behav-ioral or motivational enhancement ther-apy with clients who are seeking help.Brief treatment may also include the on-going management of substance use dis-orders in primary care settings, especiallywith theuseofnewpharmaceuticalagents.

• Referral to treatment: Screening oftenidentifies those who already have a sub-stance-related health condition or a sus-pected substance use disorder that warrantsa formal diagnosis and possible referral totreatment. The referral process facilitatesaccess to care (including brief treatment)for those individuals who have more seri-ous signs of substance dependenceand re-quire a level of care outside the scope ofbrief services.

• Integration and coordination activities:In many communities screening and briefintervention services are nonexistent, di-agnostic and referral services are frag-mented and inconsistent, and specializedtreatment services operate independentlyof the larger health care system. A key as-pect of SBIRT is the integration and coor-dination of these four components into asystem of services linking the specializedtreatment programs in a community witha network of early intervention and refer-ral activities that are conducted in medicaland social service settings.

As shown in Figure 1, SBIRT can be de-scribed as a set of inter-related services linkedbydecisionrules thatdetermine theappropriatecourseofactionforagivenpatient.Whenrisk is

8 ALCOHOL/DRUG SCREENING AND BRIEF INTERVENTION

elevated but in the low range, brief interventionis the recommended course. Evidence is lack-ing regarding an exact cutoff for moderate risk,but several screening tests such as the AUDIT(2) have defined a mid-range of risk scoreswhere furtherassessment,monitoringandbrieftreatment are warranted. Conceptually, anyonewith elevated risk is eligible to begin with briefintervention even if the intent of the clinician isto delivera referral to treatmentor providebrieftreatment. And in some cases, screening canlead directly to referral without feedback andadvice. For those at low/moderate risk, the ini-tial clinical procedure is brief intervention. For

those at moderate or high risk, or with depend-ence, the goal would be a brief intervention thatencourages entry into brief treatment or spe-cialty treatment, respectively. Clearly manypeople at higher risk identified by screeningwill not receive specialty treatment. Follow-upovals include arrows pointing back to the riskovals in order to stress the need for continuedmonitoring and referral to further treatment ifnecessary.

The model for SBIRT is based in part on theInstitute of Medicine (3) report that recom-mends the development of integrated servicesystems linking community-based screening

Overview 9

FIGURE 1. SBIRT logic model

and brief intervention with assessment and re-ferral activities. One important function ofSBIRT is to fill the gap between primary pre-vention efforts and more intensive treatmentfor persons with serious substance use disor-ders. From a public health perspective, the goalof SBIRT is to improve the health of a commu-nity by reducing the prevalence of adverse con-sequences of substance misuse, including butnot limited to diagnosable abuse or depend-ence, through the coordination of early inter-vention and referral to specialized treatment.When all components are functioning effec-tively in health care and social service agenciesthroughout a community, SBIRT programsshould be capable of reaching a significantproportion of the population using psychoac-tive substances.

A BRIEF HISTORY OF SBIRT

Although some SBIRT components dateback as far as the early 18th century (4), it wasnot until the development of effective screen-ing tests for alcohol and drug use in the 1980sthat SBIRT emerged as a viable public healthapproach to addressing substance misuse.Screening instruments such as the MAST, theCAGE and the DAST were first developed toidentify active cases of alcohol and drug de-pendence for referral to treatment (5). In the1980s a seminal study by Russell et al. (6)showed how brief physician advice was capa-ble of motivatingsmall but significantnumbersof patients to stop smoking. Subsequent re-search in Malmo, Sweden (7) indicated thatsystematic screening combined with brief in-terventions delivered in primary care settingswere capable of reaching large numbers ofat-risk drinkers, many of whom reduced theiralcohol consumption in response to the pro-gram. The public health implications of theMalmo study for the prevention of alcoholproblems led the World Health Organization(WHO) to initiate a program of clinical and ap-plied research on the development of an inter-national screening test and the evaluation ofbrief interventions for at-risk drinkers (8). Thatprogram,begunin1981, led to thedevelopmentof the Alcohol Use Disorders IdentificationTest (9) as well as the first cross-national clini-

cal trial of the effectiveness of brief interventionsin health care settings (10). The WHO programwas expanded to include a consortium of re-searchers investigating ways to implementscreening and brief intervention technologiesin primary care settings, as well as the develop-ment of national plans to integrate SBIRT ac-tivities into the health care systems of both de-velopedanddevelopingcountries (8).Arelatedprogram was initiated in 1997 to develop ascreening test and brief interventions for illicitdrugsaswellasalcoholandtobacco(11).Theseprojects have been conducted during a 25-yearperiod when there has been a dramatic increasein clinical and health services research onscreeningandbrief interventionforalcoholandother substances. This research has been con-ducted primarily in the United States, Australiaand European countries and has been accompa-nied by evaluations of training packages, im-plementation models, program costs and sys-temschangesnecessarytofacilitate theadoptionof SBIRT programs (2).

Perhaps the most significant development inthis evidence-based movement to test and dis-seminate new screening and intervention tech-nologies in theUSis theSubstanceAbuseMen-tal Health Services Administration’s SBIRTinitiative,which consists of a variety of demon-stration programs operating in 11 states. Otherlargescaleprogramshavebeen implementedinBrazil, South Africa and the European Union.In the remainder of this review, we will criti-cally evaluate the literature supporting the vari-ous components of SBIRT, summarizing thisevidence in terms of its practical applicationsfor program planners, administrators, andpolicymakers.

SCREENING

An important prerequisite for the SBIRT ap-proachis theaccurate identificationofpeopleatrisk as well as active cases of substance abuseand dependence. Screening for alcohol, to-bacco and other drugs has been gaining popu-larity in health care settings because of newtechnologies, expert committee recommenda-tions and encouraging research findings aboutthe effectiveness of early intervention (5,12,13).Table 1 provides a compendium of 25 self-re-


port screening tests for alcohol and other sub-stance use, abuse and dependence. The testswere identified in an extensive review of the lit-erature published in peer reviewed journalscovered in Index Medicus. For each screeningtest, the compendium lists the item content, tar-get population, administration mode, numberof items, scoring time, and the time frame ofmeasurement. In this section, we update anevaluation of screening tests initially con-ducted by Babor and Kadden (5). Screeningtests for alcohol and drugs are reviewed sepa-rately, and in both types of substances we fur-ther distinguish between self-report screeningtests and biological tests that are conducted onsamples of body fluids.

Alcoholscreeningtests:Oneof thefirstalco-hol screening procedures, the Michigan Alco-holism Screening Test (MAST, 14), consists of24 yes-no questions that list signs and symp-toms of chronic alcoholism. The MAST hasbeen criticized because of its length, its poten-tial for falsification, and its focus on findingcases of alcohol dependence rather than earlyidentification of risk factors. The shorter12-item MAST (15) and the four-item CAGEscreening test (16) increase the feasibility ofscreening but still maintain a focus on identify-ingactivealcoholics.Anaddeddisadvantageofthese screening tests is their use of questionsmeasuring “lifetime” symptoms (“have youever . . .”), which can produce false positiveswhen the alcohol problems occurred in the pastbut have since remitted. A disguised screeningtest based on the patient’s history of traumaticinjury (17) was developed to deal with the falsi-fication problem, but this was done at theexpense of sensitivity and specificity.

A number of alcohol screening tests havebeendevelopedfor specialpopulations, includ-ing women (18,19) and the elderly (20). TheWorld Health Organization developed theAlcohol Use Disorders Identification Test(AUDIT) (9,2) in order to maximize culturaland linguistic generalizability of screening re-sults. The AUDIT focuses on both hazardousdrinking as well as alcohol use disorders. TheAUDIT has been well validated across differ-ent cultural groups in a variety of countries, andseveral shorter adaptations have been devel-oped, including the AUDIT-PC, the AUDIT-FAST, and the AUDIT-C, all of which focus

mainly on the quantity, frequency and patternof drinking (21,22). Finally, several single itemscreening tests have been developed and vali-dated. Williams and Vinson (23) found that asingle question about the last episode of heavydrinking has good sensitivity and specificity indetecting hazardous drinking and alcohol usedisorders. O’Brien et al. (24) found that by ask-ing “How many days do you get drunk?” in atypical week, they could identify college stu-dents who are at higher risk of alcohol-relatedinjury. To the extent that very short screeningtests may motivate clinicians to screen moreoften, these tests may have value (see, for ex-ample, 25). Nevertheless, the value of longertests is that the patient’s responses to questionsabout drinking and alcohol problems can be theimmediate point of departure for a briefintervention, which typically begin with adiscussion of specific screening results.

Although not recommended for routinescreening, several biological markers havebeen useful adjuncts to alcohol screening inemergency medicine and criminal justice set-tings, such as the breath alcohol concentration(BAC), gamma-glutamyltransferase (GGT, aliver enzyme), and carbohydrate-deficient trans-ferrin(CDT).BAChasashorthalf-lifeanddoesnot provide information about risk behaviorother than to estimate theextentof recentdrink-ing. GGT and CDT have not been found to besensitiveorspecificenoughtodetectheavyepi-sodic drinking (26).

Other psychoactive substances: Given thedifferent needs and substance use patterns ofadults and adolescents, self-report drug screen-ing tests have generallybeen designed and vali-dated for one or the other of these populations.Two types of self-report tests have been devel-oped for adults. The first, exemplified by theDrug Abuse Screening Test (DAST; 27), con-sists of direct obvious or face valid questionsabout drug use and related problems that yieldsa quantitative score reflecting the severity ofdrug abuse. A later version of the DAST re-duced the number of items from 28 to 10 with-outcompromisingreliability(28). Incontrast toscreeningtests thataskdirectlyaboutsubstanceuse, several tests have been developed to mea-sure risk factors that are associated with actualor potential substance use disorders. However,tests of this type tend be quite long. For exam-

Overview 11

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ple, some of these tests are embedded in theMinnesota Multiphasic Personality Inventory,which contains over 500 items, and thus maynot be appropriate to use in health care settingswhere there is limited time to administer andscore the screening test (29).

Recognizing the need for a comprehensivescreening and referral test for adolescents, theNational Institute on Drug Abuse (NIDA) de-veloped the Problem-Oriented Screening In-strument for Teenagers (POSIT) (30). ThePOSIT consists of 139 items that generatescores indicating problems in ten functional ar-eas that are related directly or indirectly to sub-stance use disorders: Substance Use/Abuse,Mental Health Status, Physical Health Status,AggressiveBehavior/Delinquency,SocialSkills,Family Relations, Educational Status, Voca-tional Status, Peer Relations and Leisure andRecreation. The test has demonstrated good re-liability and validity in adolescents referred toan assessment service for evaluation of sub-stance use problems (31), but is too long toserve as a brief screening test. One option is touse only the Substance Use/Abuse part of thetest, which would make it more efficient forscreening in general health care settings.

In addition to the multidimensional screen-ingapproachused in thePOSIT, several shorterinstrumentshavebeendeveloped toscreenspe-cifically for substance use among adolescents.The Personal Experience Screening Question-naire (PESQ) (32) focuses primarily on druguse and related problems, but also collects in-formation on other areas of concern, such aspsychopathology. Reliability and validity ofthis 38-item test have been demonstrated in thedetection of individuals with different historiesof substance use (33). Another adolescentscreening test that has been used at adolescenttreatment programs is the Substance AbuseSubtle Screening Inventory (SASSI, 34), a78-item self-report instrument that classifiesadolescents as chemically dependent. Al-though the SASSI was designed to prevent de-liberate falsification by using indirect ques-tions, it has not been found to be very accurate(35,36). Other screening tests have been de-signed for more specific populations, such asthe 42-item Drug and Alcohol Problem (DAP)Quick Screen, which was developed for use bypediatricians (37). Validity data have been re-

ported for the 30-item revision of this test (38).Finally, the CRAFFT (Car, Relax, Alone,Friends, Forget, Trouble) is brief (6 items) andhas been validated with adolescents in primarycare settings (39). Because of its brevity, it ismore likely to be used than the longer instru-ments described above.

Combined screening tests: Despite ad-vances in the development of self-reportscreening tests for specific types of psychoac-tive substances, there has been considerablyless attention to instruments that screen formultiple substances. To address this deficiency,the Alcohol, Smoking and Substance Involve-ment Screening Test (ASSIST; 11) was devel-oped to screen for at-risk use of psychoactivesubstances as well as related problems. The testuses a common format to screen for 11 psycho-active substances as well as injection drug use.The scoring procedure estimates the relativeimportance of these different risk behaviors forthepurposeofprioritizingcounseling interven-tions. Although the ASSIST is not able to iden-tify people who exceed risky drinking limitsbased on quantities of alcohol consumed, thesequestions can easily be added to obtain coun-try-specific alcohol risk levels.

A major challenge to combined screeningfor specific substances is provider burden,which refers to the skills and time demanded ofthe screening agent. A relatively simple proce-dure that addresses this problem is the CAGEtest adapted to include drugs (CAGE-AID).The CAGE-AID was found to be more sensi-tive but less specific than the CAGE (40). Thiseasy-to-use four-item test nevertheless re-quires further questioning if the patient scorespositive. Thus, efficiency comes at the price ofspecificity, and screening questions using alifetime (ever) approach can result in highnumbers of false positives.

Biological Screening Methods for Drugs: Avariety of biological procedures have been de-veloped to detect recent drug use through uri-nalysis, hair testing, and saliva tests. Thesemethods are not capable of detecting sub-stance-related problems or even substance usebeyond a narrow time window (41). Urinescreening tends to be the preferred method be-cause it is less invasive than blood testing andthe drugs or their metabolites are present in rel-atively high concentrations in urine. A recent


innovation that facilitates biological screeningis the commercial availabilityof self-containedurine testingkits. These tests are easy to use andprovide rapid access to test results, but they canonly indicate drug use over the previous fewdays. Other problems include a risk of falsepositives by passive drug exposure or ingestionof foodstuffs, and false negatives due to the useof adulterants.

Summary: There are a number of importantissues associated with screening instrumentsthat should be taken into account in the designof an integrated SBIRT program intended toserve the needs of a defined population. First,the accuracy of most of the self-report tests hasbeen evaluated under research conditions,which tend to maximize the likelihood of goodperformance. Although most screening testshave been found to be valid, performance islikely to diminish in routine clinical settings. Amajor concern is the extent to which the resultsof a self-report test can be deliberately faked ordistorted inanattemptby thepatient topreservea respectableself-image in thehealthcareor so-cial service setting. Although self-report mea-sures of substance use tend to be valid and reli-able in the aggregate under most circumstances,accuracy in clinical settings depends on the de-gree of perceived threat in the data gatheringsituation, the cognitive processes (such asmemory) that are required to produce answersto the questions, and the motivation and otherpersonal characteristics of the respondent (42).A second consideration is cost and efficiency.Self-report tests are free or inexpensive, andthey can be administered and scored quickly.Nevertheless, medical staff sometimes vieweven a small addition to their routine as an un-necessary burden. Although some screeningtests are relatively brief (e.g., CAGE andAUDIT-C) and can be administered in one ortwo minutes, others require more time and ad-ministration skills. Biological tests can becostly to use on a routine basis and require evenmore time to administer and score. Neverthe-less, they are often seen as being more consis-tent with routine medical practice, and this mayaffect their acceptability to both patients andstaff. A third issue is cultural sensitivity. Al-though research has not been extensive, there isno evidence to suggest that the reliability or va-lidity of self-report tests varies across different

ethnic groups (9,11). A final issue is the targetgroup of the screening program. Many of theadult screening tests described in Table 1 havebeen designed for finding active cases of alco-hol or drug dependence, not to identify risk fac-tors for drug or alcohol abuse. These tests (e.g.,the DAST) typically avoid direct questionsabout use of specific drugs, focusing instead onthe problems associatedwith any substance usein the past. Subtle or disguised screening tests(e.g., the SASSI) do not appear to be suffi-ciently sensitive or specific to identify activecases, but may be useful in screening for riskfactors. Comprehensive screening tests like thePOSIT and ASSIST are capable of identifyingboth “caseness” and risk factors, but they takemore time to administer and score. Even singleitem or very brief screening tests like theAUDIT-C require further questioning once thepatient screens positive, so screening tests withskip-out instructions like the AUDIT andASSIST may save considerable time becausemost patients need not be screened further afternegative responses to the first few questions.

BRIEF INTERVENTIONS

A key component of the SBIRT approach isthe linking of screening results with appropri-ate early intervention services or referral totreatment. If interventiondoesnotexistor isnotfeasible or effective, it is not useful to conductscreening. Among the least expensive inter-ventions are brief motivational conversationsbetween the substance user and a concernedphysician, a nurse, a physician assistant or a so-cial worker. In this section we review efficacystudies of brief interventions for excessive al-coholordruguse.Given thevolumeof researchliteratureon this topic foralcohol,wewill focusprimarily on key studies and the results ofmeta-analyses of the cumulative literature.Brief interventions for drug use and abuse havebeenstudiedconsiderably less, so this literatureis reviewed in terms of its preliminary findingsand its deficiencies.

Brief interventions for alcohol abuse andat-risk drinking: In the first systematic reviewof research on this subject, Bien et al. (43) eval-uated32controlledstudies involvingover6000patients studied prior to 1992. Brief interven-

Overview 15

tionswithproblemdrinkerswereoftenfound tobe as effective as more extensive treatments. Itwas concluded that the course of harmful alco-hol use can be effectively altered by relativelybrief contacts in contexts such as primaryhealth care settings and employee assistanceprograms. Kahan et al. (44) reviewed 11 trialsof physician-based brief intervention in medi-cal settings and concluded that brief alcohol in-terventionsareeffective,andtheirpublichealthimpact is potentially enormous. Twelve ran-domized controlled trials were reviewed byWilk et al. (45), who concluded that brief inter-vention is a low-cost, effectivepreventivemea-sure for heavy drinkers in outpatient settings.Additional support for these conclusions,based on new analyses of many of the samestudies summarized in previous reviews, hasbeen reported by Ballesteros et al. (46). Moyeret al. (47) reviewed studies comparing brief in-tervention both to untreated control groups andto more extended treatments. They found “fur-ther positive evidence” for the effectiveness ofbrief interventions, especially among patientswith less severe problems. In an extensive re-view of the literature for the U.S. PreventiveServices Task Force, Whitlock et al. (13) con-cluded that behavioral counseling interven-tions for alcohol misuse among nondependentprimary care patients identified by screeningare feasible and potentially effective compo-nents of an overall public health approach to re-ducing alcohol misuse.

Most of the studies cited in these reviewswere conducted in primary care settings, wherethe prevalence of alcohol abuse and depend-ence tends to be lower than what is found inemergency and trauma centers. Emergency de-partments and trauma centers have been identi-fied as high-yield settings for alcohol screening(12,48,49). A large randomized trial of brief in-terventions in a trauma center (50) found that abrief motivational intervention was associatedwith decreased alcohol consumption and areduced risk of trauma recidivism.

In the course of investigating the efficacy ofbrief interventions with at-risk drinkers, re-search has also evaluated the extent to whichbehavior change is related to individual differ-ences among drinkers, the professional train-ing, ethnicity and gender of the interventionprovider, and the nature of the intervention it-

self (13). In general, behavior change is not de-pendent on provider training or characteristics,but the dependence severity of the drinker doesseem to be an important correlate of low re-sponse to brief intervention. Regarding the na-ture of the intervention, skills training, simpleadvice,andmotivationalapproachesseemtobeequally effective. In addition, the interventionsseem to be equally effective with adolescents,adults, older adults, and pregnant women.

Despite the general preponderance of posi-tive findings, some studies have shown no dif-ferences between intervention and controlgroups, and many studies report significant re-ductions incontrolgroupdrinkingthatarecom-parable to those of the intervention group (51).Oneexplanationfor thisphenomenonis that thescreening procedure itself has a motivationaleffect, although one study found no evidencethat assessment alone was responsible forchanges in the control group (51). The other ex-planationis“regressiontothemean,”whichde-scribesastatistical tendencyforextremevaluessuch as heavy drinking to return to the groupaverage over time.

Brief intervention for drug use and abuse: Incontrast to the alcohol literature, there havebeen few studies of brief interventions for drugabuse. Bernstein et al. (52) found that brief in-tervention in a clinical setting can reduce co-caine and heroin use. Brief intervention ap-peared to facilitateabstinenceat6months,evenin the absence of meaningful contact with thetreatment system. Baker et al. (53) found thatboth the provision of a self-help booklet and asingle session of motivational interviewingwere associated with reduced amphetamineconsumptionamongregularusers. Twostudies(54,55) have found that general practitionerscan reduce excessive benzodiazepine use intheir patients using brief interventions such asletters or consultations. Despite these promis-ing findings from controlled studies, and simi-lar positive results from research describedbelow under Brief Treatment, several investi-gators have reported negative findings frombrief interventions with drug users. Marsden etal. (56) evaluated the effect of a stimulant-fo-cused brief motivational interview (relative tothe provision of health risk information aboutstimulants) among adolescent and young adultstimulant users. No significant differences be-


tween groups were found for ecstasy, powdercocaine, crack or alcohol. Other research (53)with psychiatric inpatients showed similar lackof effectiveness.

Summary: Research on brief interventionsfor alcohol and other substance users has accu-mulated rapidly during the past two decades.Not only are the procedures generally effectivewith a variety of population groups, they can bedelivered with equal effect by a variety ofhealth care providers. Less evidence is avail-able regarding the brief interventions for drugusers, but several studies show positive effects.An important question that requires further re-search is the extent to which brief interventionscan be made more effective when combinedwith stepped care strategies that increase the in-tensity of the intervention for patients who donot respond initially. Among the options arebrief treatment and referral to specializedprograms serving persons with alcohol or drugdependence.

BRIEF TREATMENT

Brief treatment (BT) refers to the provisionof as few as two sessions of therapy by a trainedcounselor, social worker, psychologist or psy-chiatrist. While brief interventions focus onmotivating clients to change their substanceuse, brief treatment helps clients develop theskills and resources to change. BTs are oftenbased on motivational approaches (e.g., Moti-vational Enhancement Therapy) or behavioralapproaches (e.g., Cognitive-Behavioral Ther-apy) or a combination of the two. BT typicallyincludes a standardized assessment procedure,goal-setting, and rapid implementation ofchange strategies. BT should be characterizedas a self-contained modality, rather than fewersessionsof longer termor traditionaltherapy,oras more sessions of BI. The goals of BT differfrom those of both longer term, traditional ther-apy and of BI. BT tends to focus on the presentsituation and emphasizes the use of effectivetherapeutic tools to make specific behavioralchanges in a shorter period of time.

Studies have compared BT to more inten-sive, traditional treatment approaches and to BIapproaches. Many have incorporated wait-listed control groups in the experimental de-

sign. Stephens, Roffman and Curtin (57) com-pared a brief, two-session individual treatmentwith 14 sessions of cognitive behavioral skillstraining. Both treatments produced substantialreductions in marijuana use relative to the de-layed treatment control condition with treat-ment gains maintained at 16-month follow-up.The Marijuana Treatment Project (MTP) com-pared two treatment therapies with a delayedtreatment control condition (58). One of thetherapies consisted of nine individual counsel-ing sessions delivered over a 12-week period.The other consisted of two motivational en-hancement therapy sessions delivered over aone-month period. The nine-session interven-tion produced significantly greater reductionsin marijuana use and associated consequencesthan the two-session intervention, and at eachfollow-up point over a 12-month period bothtreatments produced outcomes superior to thefour-month delayed treatment control condi-tion. The results indicate that even a brieftwo-session treatment is associated with sub-stantial reductions in marijuana use and relatedproblems in chronic marijuana users.

Several studies have demonstrated promis-ing evidence that BT is often as effectiveas lon-ger term, traditional therapies for substance usedisorders (59-61). Moyer et al. (47) found posi-tive evidence for the effectiveness of brief ther-apies, especially among patients with less se-vereproblems.Forclientswithgreaterproblemseverity, Berglund et al. (62) noted that betterresults were observed with more treatment. Al-though studies show that patients who receivemore outpatient mental health care tend tohave better short-term substance use outcomes(63-65), there isgrowingevidencethatdurationand continuity of care is more important thanthe amount or intensity of care (66-69). Thefinding that duration of treatment (rather thanamount of treatment) for alcohol and drug usedisorders is more closely related to outcomesuggests that more resources should be de-voted to interventions such as brief treatmentsthat are linked to other continuity of care op-tions (70).

Summary: BT models are consistent with apublic health approach in which large numbersof individuals at risk of developing serious al-cohol or other drug problems may be identifiedthrough primary care screening or through

Overview 17

court-mandated treatment (e.g., stemming fromDUI arrests). The BT target population has tra-ditionally been those individuals with less se-vere substance use disorders. However, there isagrowingbodyofevidence tosuggest thatbrieftreatments are effective with a wide range ofclients, including persons with mild to moder-ate alcohol dependence and regular marijuanausers. BT may also be appropriate for some pa-tients when previous attempts using traditionaltreatment approaches have failed, when thereare insufficientresources(e.g.,client timeor in-surance coverage) available for longer-termtherapy, or when there are long waiting lists forspecialized treatment. There is no question thatBT is more effective than being on a waiting listand could benefit large numbers of clients whoare seeking and waiting for longer term care(71).

MEDICATION-ASSISTED TREATMENTIN HEALTHCARE SETTINGS

Recent advances in pharmacological treat-ment for alcohol and opioid dependence pro-vide significant opportunities to integrate themanagement of substance use disorders intoprimary health care. After screening and briefintervention, pharmacotherapy can be initiatedin health care settings to assist patients under-going BT or to facilitate the transition totraditional substance abuse treatment.

Medications for alcohol disorders: FourFDA-approved medications are available thatphysicianscanprescribe todampencraving, re-duce heavy drinking, and/or promote absti-nence. These are: naltrexone, a μ (mu)-opiatereceptor antagonist; depot naltrexone, an ex-tended-release form of naltrexone that is in-jected monthly; acamprosate calcium de-layed-release tablets; and disulfiram (undersupervised administration).These medicationscan be helpful to patients who are struggling tomaintain sobriety and for preventing relapseafter referral to treatment.

Of particular interest to SBIRT, one recentstudy looked at whether general internists andprimary care physicians could treat alcohol-de-pendentpatientsaseffectivelyasaddictionspe-cialists, using naltrexone (72). Results indi-cated that primary care counseling with

naltrexone pharmacotherapy is a promising ap-proach that canbe effective in selectedpatients.In addition, the long acting, injectable form ofnaltrexone that is now available may enhanceits use in primary care settings (73).

With the newer medications now available,there is increasing interest in whether alco-hol-dependent individuals can be treated suc-cessfully with FDA-approved medications bytheir primary care physicians in routine medi-cal practice. The comprehensive COMBINEclinical trial at 11 sites with nearly 1,400 pa-tients explored a variety of treatment methods–alone and in combination–within the context ofmedical management (74). Alcohol consump-tion decreased by 80 percent over a 4-monthtreatment period, which suggests that medicalmanagement by primary physicians in routinepractice can be of benefit in treating alcohol de-pendence (75). However, the medical manage-mentused in theCOMBINE trialwas relativelyintensive (nine 20-minute sessions), so theminimal level of contact with primary carephysicians necessary to manage alcohol-de-pendent patients has not yet been determined.

The COMBINE Study also found thatnaltrexone in combination with a brief behav-ioral therapy delivered by licensed health careprofessionals ismoreeffectivethanmore inten-sive behavioral therapy delivered by licensedbehavioral health specialists (74).

Medications fordrugdependence:TheDrugAddiction Treatment Act of 2000 established anew paradigm for the medication-assistedtreatment of opioid dependence. Qualifyingphysicians in a medical office or other appro-priate settings may now apply to the SubstanceAbuseandMentalHealthServicesAdministra-tion (SAMHSA) to prescribe and/or dispenseopioid medications for treating opioid addic-tion.Twosublingual formulationsofbuprenor-phine, a long-acting partial agonist of mu-opioid receptors, have been approved by theFDA for this purpose.

The decision to allow office based treatmentof buprenorphine was based on a large body ofclinicalexperiencefromothercountriesandtheUnited States (76-78). A Cochrane Reviewmeta-analysis of 13 randomized clinical trialsconcluded that buprenorphine is an effectiveintervention for use in the maintenance treat-ment of heroin dependence (79).


REFERRAL TO ASSESSMENTAND SPECIALIZED SUBSTANCE

ABUSE TREATMENT

Research suggests that brief interventionalonemay not be sufficient therapy for severelydependent drinkers (80). Because many briefintervention trials specifically exclude peopledependent on alcohol or drugs, it is not knownwhether this population may be helped by briefinterventions alone. Thus, for patients with se-vereconditions,SBIRTprogramsneedtomakereferrals to more intensive treatmentand to mu-tual support groups such as Alcoholics Anony-mous (AA), Narcotics Anonymous (NA), andCocaine Anonymous (CA).

Researchdemonstrates thathospitalpatientsidentified as substance dependent during medi-cal screening (most of whom are not seekingtreatment) can be effectively referred and en-gaged in specialized treatment at rates muchgreater than controls (81-85). In these individ-ual program studies, brief interventions haveincreased the percent of patients who show upfor their first clinic appointment from 5 percentamongcontrols to from50to65percent,withasmany as 50 percent of patients reporting thatthey continue to be involved in some kind ofsubstance abuse treatment or 12-step meetingson follow-up (81-83).

Information is limited about the prognosisfor alcohol- and drug-dependent patients seenand referred in other medical settings, wherepatients are highly heterogeneous in terms oftype, stage,andseverityofsubstanceproblems,with many of these patients not motivated tostart treatment (86). Prognosis appears to bestrongly related to the patient’s motivation toenter treatment, as well as to change drinking ordrug-using behavior (85).

The literature provides little informationabout the specific referral processes used byvarious SBIRT programs. However, existingevidence suggests that brief motivational inter-ventions have positive benefit on patients’ par-ticipation in substance abuse treatment and re-tention in treatment. For example, when onehospital replaced staff referrals with motiva-tional interview techniques done by alcoholspecialists, the percent of referred patients whocompleted treatment increased from 40 to 88percent (85). In another study, 65 percent of pa-

tients who received a brief motivational inter-vention kept their initial interview at an alcoholclinic, compared to 5.4 percent of the controlgroup (83).

These findings indicate that SBIRT referralmethods need to address the patient’s motiva-tion to be treated,with the added intentionof re-ducing the risk of drop-out and assisting the pa-tient’s adherence to treatment. Based on theavailable literature, it is not possible to saywhich brief intervention approaches, in whichsettings, and with which patients will be mosteffective for promoting entry and engagementinto specialized alcohol or drug treatment. Theresearch shows that the earlier substance-de-pendent patients engage in treatment or mu-tual-help groups, the better the outcomes(87,88).

IMPLEMENTATION, INTEGRATIONAND COORDINATION ACTIVITIES

A major challenge to the public health im-pact of SBIRT is the difficulties involved in in-tegrating its components into relevant parts ofthe health care system.

Screening: As noted above, progress hasbeenmade in thedevelopmentofavarietyofef-fective screening procedures. Nevertheless, anumberofpracticalandlogistical issuesneedtobe resolved before a screening program can beimplemented. These issues relate not only towho does the screening, but when, where, howoften and who pays for it. Given the simplicityof most self-report screening tests, they are ca-pable of being administered in variety of differ-ent settings and modalities, such as interview,questionnaire, and computer. Dyches et al. (89)describe an interactive telephone technologyfor screening with primary care patients. Bothpatients and practitioners had rated the proce-dure positively. Under some circumstances,impersonal procedures, such as paper and pen-cil questionnaires and computer-assisted tele-phone interviews, may be more effective thanface-to-face interviews with physicians. Saitzet al. (90) report 50,000 visits a year for screen-ing at an internet web site where positive casesreceived advice and information, suggestingthat an accessible web site can attract high riskdrinkers for screening and brief intervention.

Overview 19

In theabsenceof routinescreeningwithstan-dardized instruments, physicians do not sys-tematicallyapplyNIAAAguidelinesregardinghazardous drinking levels (91) and may be se-lective in whom they screen. One study (92)found that physicians were least likely to initi-ate discussions about drinking with patientswho are white, female and widows. A Danishstudy of screening by general practitioners (93)reported that physicians did not think all pa-tients should be screened. The major barrierswere lack of time and financial incentives, andskepticismthatpatientswantedtobescreened.

Some investigators (94) have argued thatprimary health care is not an effective or effi-cient place to conduct alcohol screening. Oth-ers have suggested alternative sites for screen-ing and professionals who can conduct it.Anderson et al. (95) identified the clergy as po-tential providers of screening and brief inter-vention. Hungerford et al. (96) report thatscreening in an emergency departmentcan pro-duce high rates of acceptance of counselingabout alcohol use. In a rural university emer-gency department (12), only 3% of the patientsscreened or counseled were uncooperative;70% thought the emergency department was agood place to help patients with alcohol prob-lems. Another potential setting for screeningprogramsis traumacenters.Schermeretal. (97)found that 70% of trauma patients were suc-cessfully screened, with less than 1% refusing.Nevertheless, a survey (98) of 50 insurancecommissioners indicated 38 states where thereare concerns about the possibility that screen-ing will affect insurance payments, which canbe denied in many states if the patient has beendrinking.

Brief intervention: According to Roche andFreeman (99), physician-based secondary pre-vention efforts based on brief interventions forhazardous drinking have failed at the imple-mentation stage. Barriers to implementationinclude lack of time, poor diagnostic skills,negative attitudes, and perceptions of role in-compatibility (100). In a survey of 711 traumasurgeons (97), 83% agreed that the trauma cen-ter was an appropriate setting but only 25%used formal screening questionnaires and lessthan one half of problem patients are addressedin their hospital stay. Barriers included cost,

time, confidentiality and threats to insurancecoverage.

To overcome some of these barriers, otherdelivery agents (e.g., nurses) have been consid-ered. D’Onofrio and Degutis (101) describe theuse of non-physician health promotion advo-cates (HPAs) to do SBI and referrals in theemergency department.

Another way to expand the use of brief inter-ventions is through internet applications. A re-view of the small number of web-based inter-ventions (102) found that a demand does seemto exist for this kind of service and the potentialimpact could be considerable. As noted above,Saitz et al. (90) recorded 50,000 screening vis-its a year at an internet web site. Positive casesreceived advice and information, suggestingthat an accessible web site can attract high-riskdrinkers for brief interventions.

Another barrier to brief intervention is com-petition for the provider’s time once a patientscreens positive. Saitz et al. (103) showed thatthe very act of screening can prompt physiciansto increase discussions and provide advice.Brady et al. (104) found that prompting of pro-viders using other means doubled the rate ofbrief intervention. In a study by Kaner et al.(105), patient and practitioner characteristicspredicted who got a brief intervention afterscreening: males, the unemployed, and techni-cally trained workers were more likely to re-ceive an intervention than females and em-ployed persons. In addition, practitioners withmore training and longer practice experiencewere more likely to deliver interventions.Babor et al. (106,107) compared two differentimplementation strategies for Cutting Back, aprimary care alcohol screening and brief inter-vention program for hazardous and harmfuldrinkers. In one model, medical providers wereresponsible for delivering interventions. In an-other model mid-level professionals (usuallynurses) acted as the clinic specialists to providethat service. In a sample of 10 health clinics, themid-level professionals screened a higher per-centage of patients than did the medical provid-ers during the best month of program operation(50% vs. 44%) and over allmonths of operation(24% vs. 19%). Of those patients who screenedpositive, more patients screened by the mid-level professionals received an interventionthan in the provider model (73.1% vs. 57.1%).


The abilityof clinics to conduct SBI was signif-icantly correlated with both staffing character-istics and organizational factors (e.g., prior ex-perience, organizational stability, number ofclinicians trained and the quality of the coordi-nator’s work). Lack of time, staff turnover andcompetingprioritiescorrelatednegativelywithSBIRT implementation.

In summary, the primary obstacles to the useof SBIRT in applied settings are: (1) lack oftime for overburdened health care workers;(2) training and motivation of professionals toadminister screeningand intervention toat-riskdrinkers; and (3) organizational factors includ-ing administrative support and competing pri-orities. Successful implementation of the tech-nology tends to occur at those sites whereclinicians are reimbursed for their services andare well trained for the task. In addition, the ex-tent to which a given delivery model is likely towork best within a managed care organizationdepends on complex provider and organiza-tional characteristics.

Brief treatment: Although there are insuffi-cient data to determine which populationsmight benefit most from Brief Treatment, agrowing literature suggests that BT is effectivewith a wide range of substance abusing clients.Further, the majority of clients receiving sub-stance abuse treatment stay in therapy for rela-tively short periods of time (between 6 and 20one-hour sessions). Although this statistic ar-gues for a greater use of structured BT ap-proaches in current clinical practice, DHHS(71) found that many therapists trained in tradi-tional approaches were resistant to using struc-turedBTmodels.A relatedproblemis thatbrieftreatment is typically developed, evaluated anddelivered in an individual therapy format,whereas traditional treatment tends to be offeredingroupformatbecauseofcostconsiderations.

The demonstration of several efficaciousbrief treatment interventions, especially formarijuana dependence, raises questions abouthow best to engage chronic marijuana users intreatment and how best to maintain improve-ments following treatment. Unfortunately,very little research has been conducted in theseareas. A pilot study was conducted to evaluateaprogram designed to offer a guided self-assess-ment(butnot treatment) topersons interestedinchanging their marijuana use. It successfully

used a variety of recruitment strategies to at-tract participants, including posters, radio andnewspaper ads, and outreach at various com-munityevents (108).Thecheck-upprogramof-fered a useful method for reaching non-treat-ment-seeking heavy marijuana users, and atfollow-up program participants reported a sig-nificant reduction in the frequency of mari-juana use when compared to those who just gotinformation. These results suggest that stand-alone programs that provide discrete treatmentto regular marijuana users may be feasible andcan reach large numbers of clients if they areproperly designed and advertised.

Training and technology transfer: Trainingin how to conduct screening and brief inter-ventions is clearly a vital component in assur-ing effective implementation of SBIRT com-ponents. Introducing new screening andprevention activities into primary care prac-tices and other settings presents significantchallenges to professional training and contin-uing education. Medical schools and residencyprograms devote limited faculty resources andcurriculumtime tosubstanceabuse (109-111)andmany professionals feel inadequately trainedwhen faced with patients who have sub-stance-related problems (112,113). Barriers toadequate coverage of alcohol and drug-relatedproblems in both medical schools and continu-ing professional education include traditionalattitudes about the moral culpability of chronicalcoholics, confusion as to whether problemdrinking is a medical or psychiatric concern,lack of faculty role models, lack of trainingmaterials, and role ambiguity regarding who isresponsible for screening and intervention(114,115). Research on medical education hasshown that training can be effective in im-proving students’ and physicians’ knowledgeand skills in addressing alcohol issues (106,116-118), but changes in knowledge may beeasier to produce than changes in attitudes andbehavior (119). A review of the componentsand outcomes of medical education in sub-stance-related disorders concluded that the se-lection of a combined didactic and interactiveeducational strategy may be the most cost-ef-fective learning strategy, but there is little em-piricalevidencetosupport thisapproach(119).

Although some progress has been made inthe development of SBIRT for medical practi-

Overview 21

tioners, medical students, and health care orga-nizations (1,120,121), a necessary step towarddissemination is the development of successfultraining packages that include program imple-mentation procedures. Babor et al. (106) foundthat following a relatively short (3-hour) work-shop and subsequent supervision, physiciansexperienced an increased sense of confidencein performing screening procedures. In addi-tion, non-physician clinicians perceived fewerobstacles to screening patients after receivingthe training. When delivered in the context of acomprehensive SBIRT implementation pro-gram, training was effective in changing pro-viders’ knowledge, attitudes, self-efficacy andpracticeof screeningandbrief interventionsforat-risk drinking. The results are consistent withother studies of provider behavior (116,122,123) which show that health care providerstrained to deliver a brief alcohol interventionwill counsel their at-risk patients when cued todo so and when supported by a primary care of-fice system. Adams et al. (123) found that a2.5-hour training doubled the rate of alcohol in-terventions in high-risk primary care patients.Wilk and Jensen (124) used standardized pa-tients (i.e., actors who play the role of symp-tomatic patients) to train residents to useSBI. After training more residents conductedscreening and brief interventions. Gomel et al.(125) compared three strategies to market andtrain primary care physicians. Tele-marketingwas more cost-effective than academic detail-ing and direct mail in promoting uptake of anSBI package. Roche et al. (117) compared twoeducationalprogramsto trainmedicalstudents;interactive training was no more effective thantraditional didactic lectures in developingknowledge and skills. These studies suggestthat SBIRT training can be effective in provid-ing skills, increasing self-efficacy, and chang-ing provider behavior.

In summary, training programs have beendeveloped and adapted to specialty settings(e.g., physicians in primary care clinics). Edu-cational materials for use with problem drink-ers have also been developed. Manuals, pam-phlets,andbookshavebeenwrittentohelptrainprofessionals in the process of SBI. Researchon all of these training packages suggests thatthey increase knowledge about drug misuse,but they vary in their ability to change provider

behavior. More research is needed on how in-creased knowledge translates into behaviorchanges and what factors help to sustain thosebehavior changes.

ECONOMIC CONSIDERATIONS

There are several important economic issuesto consider in relation to implementing SBIRT.Providers, financial managers, and decisionmakers need accurate information about thecosts of screening and brief interventions andestimates of the revenue potential. Decisionmakers also need to know the cost-effective-ness of various SBIRT models in order tochoose between lower cost/less effective mod-els and highercost/moreeffectivemodels.Costbenefit estimates are needed to assess the netcosts to health plans or to society of divertingresources toSBIRTactivities.In thissectionwesummarize research on each of these issues.

Cost: SBIRT costs will vary, depending onthe perspective from which costs are calcu-lated, e.g., the provider’s, the payer’s, the pa-tient’s, or society’s perspective. For financialmanagementpurposes, the totalcostsofSBIRTservices can be broken down into their compo-nents, e.g., screenings, information packets,counseling sessions, and case management.From the provider’s perspective the cost ofbrief interventionsdependsprimarilyonthena-ture and severity of the client’s alcohol or drugproblems, thenumberof sessions thatcomprisetheinterventions, thepersonneldeliveringbriefinterventions, the resources to produce and de-liver interventions (and treatments) and the set-tings in which brief interventions are provided.Providersmustalsoconsider theone-timecostsof developing and starting the service plus anyon-going continuing costs such as continuingeducation of staff. From the client’s perspec-tive, the cost of SBIRT includes the amount theclient pays for the intervention beyond the pre-miums for health insurance, as well as time andtransportation costs to the site where interven-tions are furnished. From a payer’s perspec-tive, the cost of brief interventions might be de-fined as the amount paid for the service minusany financial benefit that may accrue from thereduction of future costs resulting from the ser-vice. From society’s perspective, the cost of


brief interventions is expressed in terms of themarketvalueof thebestalternativeuse towhichlabor, capital, and other resources may be put(i.e., economic or opportunity costs).

Given the various perspectives that could beused, it is not surprising that published esti-mates of the costs of SBIRT vary considerably.For example, Zarkin et al. (126) estimatedscreening costs at $0.42 per patient for a 2-min-ute screen versus $16 per patient by Gentilelloet al. (127) and $497 per patient by Kunz et al.(128). Given the fact that fewer than 30 percentof patients screened are referred for brief inter-ventions, efforts to reduce the initial screeningcostscansignificantlyreducetheoverallcostofprovidingalcoholSBI.There is alsobroadvari-ability in the costing methodology used in theliterature. For example, brief intervention costshave been reported at $2.59 per patient (126),$135 per brief intervention session (128), and$0.59 median per member per month (insur-ance premium cost) (129). Obviously, the un-derlyingvariabilityof theSBIprogramsisapri-mary cause for the variation in cost estimates,but the lack of a consistent costing methodol-ogy contributes to the variability and limits theusefulness of cross-program comparisons.

Furthermore, current SBI cost-effectivenessandcost-benefit researchoftenpresentscost re-sults without a detailed description of the cost-ing methods used. Many of these studies do notadequately address how and what was actuallycosted (e.g., 130). Authors often take nationalwage averages and estimate the amount of timefor services (e.g., 127). The most thorough costestimate comes from the Cutting Back study(126), which used activity-based costing toseparate start-up costs from ongoing imple-mentation costs, a distinction overlooked byprevious studies. CuttingBack is the only studyto compare costs across providers and is alsothe first tocostdifferentmodelsof implementa-tion. However, the SBI models studied byZarkin et al. (126) were implemented exclu-sively for the Cutting Back research project,and therefore the authors were forced to makejudgments as to which costs would likely beretained in a non-research setting.

Cost effectiveness analysis: Cost effective-nessanalysis (CEA)enablesdecisionmakers tocompare the economic merits of alternativetypes of service, such as brief interventions and

standardcare,whichrepresents thecare thatcli-ents would ordinarily receive. Kunz et al. (128)found cost-effectiveness ratios for brief inter-ventions administered in a hospital emergencydepartment of $258 for a one unit reduction inthe follow-up AUDIT score, $219 for a de-crease of one drink per week, and $61 for a onepercentage point decline in the follow-up prob-abilityofheavydrinking. Inastudy thatappliedestimates from published studies to Australia,Wutzke et al. (130) found that brief physicianadvice to at-risk drinkers resulted in additionalyears of life from fewer accidents. Dividing thecost of the intervention by the number oflife-years saved yielded a cost of approxi-mately Aus $1,873 per life-year saved. CEAdoes not, however, provide definitive recom-mendations on which program should beadopted. Rather, it provides decision makerswith evidence on the relative benefits and costsof one program compared to another. For thisreason,CEAalone isoftennotenough to justifyadoption of a new program.

Cost benefit analysis: Unlike CEA, CBAplaces a dollar value on all outcomes and di-rectly compares to the dollar value of a pro-gram’s outcomes to the dollar value of its costs.As a result, CBA often provides definitive an-swers on which programs should be adopted.The program with the largest dollar benefit af-ter accounting for costs should unambiguouslybe adopted. There are various methods withwhich to compare the benefits of a program toits costs, including: net benefit measures inwhichcostsaresubtractedfrombenefits; returnon investment in which the benefits are ex-pressed as a percentage return to the investmentrepresentedby theprogram costs; and thebene-fit cost ratio inwhichbenefits areexpressedasaratioof thecosts.ThechoiceofCBAmeasure islargely determined by the audience, with returnon investmentoftenappealingmore tobusinessor corporate audiences and net benefit or bene-fit-cost ratiosappealingmore toacademicaudi-ences.

The CBA evidence on SBIRT is generallyvery favorable. In a randomized trialof brief in-terventions administered in physician offices,Fleming and colleagues (131) found that agroup receiving a brief intervention not onlyhad significant reductions in alcohol use, theyalso had fewer hospital days and fewer emer-

Overview 23

gency department visits. The intervention cost$205 per person ($166 from the clinic perspec-tive and $39 from the client’s perspective) andsaved$712inhealthcarecosts.Thebenefitcostratio of 4.3 suggests a $43,000 savings in futurehealth care costs for every $10,000 spent forearly intervention. The benefit cost ratio in-creased to 39:1 after factoring fewer motorvehicle and legal events into the analysis.

In a CBA using published sources, Gentilelloet al. (127) estimated that the screening andbrief alcohol interventions provided to injuredpatients treated in an emergency department oradmitted to a hospital together cost $54 per pa-tient, or $16 plus $38, respectively.The net costsavings from the screening and interventionwas estimated at $89 per patient, or $330 foreach patient receiving an intervention (27 per-cent had a positive screen). The benefit, in theformof reduceddirecthealthcosts, resulted inasavings of $3.81 for every $1.00 spent onscreeningand intervention, forabenefitcost ra-tio of 3.8:1. If interventions were routinely of-fered to injured adult patients nationwide, itwas estimated that the potential net savingsmight approach $1.82 billion annually.

In a retrospective study of admissions to theNaval Medical Center in Portsmouth, Virginia,Storer (132) estimated that intervention pa-tients had significantly lower hospital readmis-sion rates than other patients. The lower read-mission rate for intervention patients alonegenerated an estimated savings of $606,400,for a total cost of $31,500 (benefit cost ratio of19:1), for an average cost of $154 for 205 briefinterventions.

Summary:Although the findingssupport theuse of certain SBIRT components on economicgrounds, the studies should be used cautiously.The cost effectiveness of SBIRT may vary con-siderably, depending on how the technology isapplied. If a program is aimed at a selected,high-risk portion of the population (e.g., emer-gency room patients with injury or trauma), ahigher rate of risky drinkers will be identifiedthan in a “population approach” (e.g., all mem-bers of an HMO), where a cross-section of theentire population is screened (133). This issuewill affect the rate at which people receive anSBIRT service and the economic efficiency ofany such operation. Similarly, the potential forcost savings is much greater among a higher

risk portion of the population. The labor cost ofpersonnel designated to screen and conductbrief intervention, and whether SBIRT is theirsole function or is incorporated into other func-tions will affect cost effective calculations.Additionally, the extent of the intervention–whether one five-minute session at the time ofthe screening, or multiple sessions of longerduration on different days–will significantlyaffect both treatment costs and costs incurredby patients.

CONCLUSION:TRANSLATING RESEARCH

INTO PRACTICE

In the parlance of contemporary medical sci-ence, “translation” has three inter-relatedmeanings: (1) applying what we have learnedfrom research to practical settings; (2) makingscientific knowledge accessible and relevant topractitioners; and (3) improving the health ofthe populationby broad disseminationof effec-tive medical and health promotion technolo-gies. Translation from research to practice canbe consideredat two levels: (1) from the labora-tory “bench” to the patient’s “bedside”; and(2) frombedside to theentirecommunity. In theformer (called T1 translation), basic science re-search leads to new clinical investigation andinterventions.ExamplesofT1benchtobedsideapplications from the 25 years of SBIRT re-searchconsideredin this reviewincludethedis-covery of biomarkers for alcohol and drugscreening, theuseofpsychometric theory tode-velop new self-report screening tests, and thedevelopmentof new medications to dampen al-cohol craving, reduce heavy drinking, and/orpromote abstinence. Examples of the secondform of translation, where clinical investiga-tion leads to improved medical practice and en-hanced population health (called T2 transla-tion), are studies of SBIRT training, programimplementation and cost effectiveness. Al-though much work needs to be done at both T1and T2 levels, the findings of this reviewindicate that significant progress has beenmade in translating research into practice. Forexample, since 1980:


• Several hundred empirical studies onscreening, brief intervention, referral andintegration of SBIRT into health care set-tings have been conducted.

• Over 25 screening tests have been devel-oped and validated.

• Scores of randomized controlled trials ofbrief intervention have been conducted ina wide range of countries.

• 15 or more integrative reviews of theSBIRT literature have been published.

• A growing literature on provider training,SBIRT implementation, and new applica-tions is now available.

Based on the results of this review, the fol-lowing conclusions seem warranted about thevarious components of SBIRT:

• Self-report screening tests are reliableandvalid under most clinical conditions, butthe use of screening tests depends on pro-vider and patient characteristics.

• Self-report response bias can be pre-dicted, detected and minimized.

• Brief Interventions (BI) can reduce alco-hol use for at least 12 months in non-de-pendent heavy drinkers.

• The approach is acceptable to both gen-ders and to adolescents and adults.

• Cost-effectiveness has been demonstratedin several countries.

• Brief interventions are effective withsmokers and risky drinkers, and there issome evidence that they work well withmarijuana users.

• Brief treatments are effective with per-sons who are dependent on alcohol, mari-juana or other drugs.

• SBIRT risk reduction materials exist indiverse formats.

After two decades of clinical research, pro-gram development and evaluation studies,SBIRT is poised for the next step in dissemina-tion. There is general agreement on the need to“broaden the base” of treatment by expandingSBIRTservices to lessseverecasesandpopula-tions at risk. In order for this to happen, the tra-ditional, acute care model of curative medicinewillhave tobeexpanded to includeanew popu-lation-based healthcare management perspec-

tive in which persons experiencing or at risk ofsubstance use disorders are provided with arangeofpreventive,curative,andrehabilitativeservices. These services should be designed tofit the needs of defined populations, with pro-viders organized into networks that attempt toshift utilization to lower cost settings or mostappropriate levelofcare. Implementationmod-els are currently inadequate to achieve suffi-cient population reach unless routine screen-ing, which is the linchpin of SBIRT, isorganized throughout the health care and socialservice systems. Contractual models forscreening, brief intervention, and referral maywork better in settings where there are limitedresources or staff resistance. In all cases, it isimportant to fit theSBIRTprogramto thepopu-lation, rather thanrequiringthatpatientssuit theneeds of the providers. It is clear from the find-ings of this review as well as other research(134) that population-wide measures to imple-ment the various SBIRT components couldhave a significant effect on reducing the burdenof illness associated with substance use disor-ders.

Nevertheless, thereare still gaps in the litera-ture, which suggest the need for further re-search. Little research has been devoted to thepotential role thatSBIRT could play to increaseaccess to treatment for people with alcohol anddrug dependence. Additional research is neededto evaluate screening and brief interventionmethods for illicitdrugusers ingeneralmedicalsettings.To theextent thatSBIRTprogramsarepart of a broader network of specialized andgeneral health care services, research is need todetermine how best to implement SBIRT pro-grams, how to evaluate their impact on indica-tors of population health (such as alcohol-re-lated morbidity and drunk driving rates), andwhat are the costs and benefits to society.

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Overview 25

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