Introduction to SBIRT: The Problem and a Solution
Patients use, misuse, and abuse alcohol and other substances.
These patients can be helped. They often aren’t. They often aren’t, because they simply are not asked.
Substance use, misuse and abuse affect a very large number of people, including adolescents. They can substantially damage people’s mental, physical, personal, and professional lives. No matter the specialty you choose to practice, you will encounter patients who are affected by their own or a significant other’s substance abuse. Often, their abuse will affect the management of some other medical issue about which you are concerned. As a pediatrician, you will be in a position to advise parents and your young and adolescent patients about the serious consequences of early substance use.
No matter how long you practice and how experienced you are, you cannot tell just by looking or talking to a patient what their pattern or frequency of substance use is. You have to ask and you have to be specific.
Do I have to tell parents?
A minor who voluntarily seeks treatment for alcoholism, alcohol abuse, or drug abuse may receive treatment without notification of consent of the parents/guardians (IC 12-23-12-1) BUT Parental notification of minors who seek care for substance abuse is at the discretion of the clinician (IC 12-23-12-2).
You don’t have to, but you can, and if you can get the minor to agree that it is a good idea, then that is the best outcome. A Motivational Interviewing (MI) approach, discussed later in this course, can help!
How Can a Physician Address These Issues?
Like most chronic diseases, substance use must be identified before it can be treated and managed. Like the developmental delays and disabilities for which you regularly screen your patients, substance use must be identified before it can be treated and managed. Screening for and intervening on these substance use issues can be done in many ways: a 2-question screening tool, a single-sentence advice statement, a comprehensive formal screening tool or in-depth counseling session.
Screening, Brief Intervention and Referral for Treatment (SBIRT) is a simple method that any physician can adopt to help identify and briefly intervene to help their patients with substance use issues. And, as you will see, these small interventions can have a big impact.
The primary goal of SBIRT efforts is to identify and respond to patients who use substances, including alcohol, in a hazardous, risky, or harmful manner. A secondary benefit of SBIRT is that patients with substance use disorders (i.e. abuse, dependency) are recognized too and may be referred for additional assessment and/or specialty addiction treatment.
In this course, “substances” includes alcohol, as well as illicit drugs, prescription medications, and tobacco.
We also use the terms use, misuse, and abuse, somewhat interchangeably, although they have, especially abuse, clinical differences which are discussed later.
Any substance use can have negative consequences. In terms of illicit use, or tobacco, substance use of any kind can be detrimental. For alcohol and prescription medications, use may be okay but misuse, that is hazardous drinking, overuse, or use without a prescription, is a problem.
Regardless of the substance and the terms used to describe use, many of your patients will be affected adversely by substance use. By using SBIRT with each and every one of your patients, each and every visit, you can play a significant role in reducing these adverse effects.
Thus, the much larger population of patients seen in primary care who screen positive for hazardous and/or harmful substance use are the target group for SBIRT.
Thus, in pediatric practice, the main target groups of SBIRT are those “non-users” who may benefit from brief advice to maintain abstinence and those non-dependent early users who may benefit from early intervention such as brief counseling.
A considerably smaller sub-set will be detected who have a clinical condition (i.e. substance use disorder), and these patients should be appropriately referred for more specialized assessment and treatment. That is, for a typical substance user pyramid, SBIRT specifically targets the often overlooked middle of the pyramid and also has the benefit of frequently identifying those at the top end as well.
Will you help?