Don’t Drift Downstream
Recently, a friend of mine told me a story about his uncle Mike, who loves to escape to his “man cave,” watch football, and have a few brews. One night, as Mike came downstairs from a visit to the bathroom, he lost his footing, stumbled down three stairs, and broke his leg. While Mike got a bit too tipsy and lost his balance, he may not meet the criteria for a substance use disorder and certainly doesn’t see himself as needing a specialty substance use treatment center. However, he is drinking in unhealthy ways, and it is having a detrimental impact on his health.
And Mike isn’t alone. Thirty-eight million adults in the United States drink moderate amounts of alcohol, above the low risk guidelines but not necessarily enough to be diagnosed with a substance use disorder. While you’re reading this, college students are smoking pot at parties, people with high cholesterol are taking a statin with their evening cocktail, and adolescents are looking through their grandparents’ medicine cabinets. If health care professionals screened for substance use and drilled a little bit deeper into the lives of these individuals, they might detect substance misuse, and deploy brief interventions that facilitate strategies for reducing use with their patients. Screening, Brief Intervention, and Referral to Treatment – or SBIRT – is an upstream and evidence-based clinical protocol that furnishes health care providers with the skills and tools they need to motivate individuals to change harmful substance use as a part of routine care.
But SBIRT is under fire. In June’s issue of Alcohol and Drug Abuse Weekly, an article entitled, “Another study debunks SBIRT as a route to treatment” highlights a meta-analysis of randomized controlled trials — recently published in Addiction Review — that assesses whether brief interventions are efficacious in increasing utilization of alcohol-related services for individuals with substance use disorders. The article asserts that SBIRT is not effective at helping people in primary care with substance use disorders enter and engage in specialty substance use treatment.
At first glance, a reader might think that SBIRT is supposed to be a route to specialty substance use treatment, and is obviously failing at it. But it is important to note that SBIRT was not designed for people with substance use disorders. Instead, SBIRT has been shown to be effective among those with mild to moderate alcohol use problems. As a prevention and early intervention protocol, SBIRT has a solid track record, as demonstrated by a number of peer-reviewed studies, acquiring support from the Substance Abuse and Mental Health Services Administration, Health Services Resources Administration, and the Centers for Disease Control and Prevention.
But it’s hard for treatment providers, who are increasingly adopting SBIRT, to replace their “identifying and treating disorders” lens with an “early intervention” lens. This is parallel to our health care system’s overall struggle with moving upstream, despite Affordable Care Act provisions and other policy and financing levers that make it easier for health care providers to engage in — and get reimbursed for — prevention and early intervention. Despite our best efforts, it can be hard for us to resist drifting back downstream, since many clinicians — myself included — are trained to be interventionists among people who are very sick.
SBIRT challenges us to engage people who use substances in unhealthy ways, which is important because many of the problems due to drinking and substance use happen to people who are drinking or using substances in ways that seem normal. SBIRT gives practitioners the skills to prevent or intervene earlier, hopefully averting the devastating impact of substance use disorders, and the exorbitant cost to our health care system when we do not intervene early. That’s why the National Council is heavily involved in the SBIRT space, implementing the Reducing Adolescent Substance Abuse Initiative funded by the Conrad N. Hilton Foundation, focused on training adolescent mental health treatment providers in SBIRT; launching a national SBIRT consulting line for health care providers; and providing SBIRT technical assistance through our SAMHSA-HRSA Center for Integrated Health Solutions.
We must resist the urge to drift downstream with SBIRT, deviating from SBIRT’s intention and evidence-base as a prevention and early intervention protocol. We need to use SBIRT for what it’s good for instead of making SBIRT the scapegoat for referrals that don’t work and continue to develop strategies to mitigate the personal, systemic, and community-level barriers that keep people from engaging in specialty substance use treatment. That’s why the National Council provides training and technical assistance to improve the referral process by helping organizations build strong bidirectional relationships, leverage health information technology (HIT) to increase communication and information sharing, utilize peer support and care coordination to support systems navigation, enhance clinical skills to motivate clients, and integrate and co-locate services.
But for those who don’t need referral to specialty substance use treatment — the Mikes of the world, the kid looking inquisitively in his grandmother’s medicine cabinet, the college marijuana user, and the person with uncontrolled cholesterol — they need health care professionals who won’t be blind to unhealthy use, and have the confidence to intervene early.