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Best practice №2

Once substance use is identified, perform a brief intervention and referral to appropriate treatment (SBIRT)

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by Candy Stockton-Joreteg, Carrie Griffin

Last updated October 7th, 2020

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Overview

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a comprehensive, evidence-based approach to the identification and delivery of services for a variety of conditions including substance use disorder (SUD). Once substance use is identified, perform a brief intervention and refer to the treatment most appropriate for a patient’s needs.  A brief intervention is a patient-centered, structured conversation that utilizes the principles of Motivational Interviewing (refer to Best Practice #8), in order to motivate the person to progress through the stages of readiness toward concrete changes that address their SUD. Brief interventions have been shown to improve outcomes for patients with substance use, and formal treatment is required for those with a diagnosable SUD.

Why we are recommending this best practice

SBIRT is a validated process for addressing SUD.  Each facility should identify resources in their community to assist women who screen positive and include a warm hand-off to a care navigator to help connect them with appropriate resources. 

Strategies for implementation

  • Identify and train the appropriate staff in the use of screening and brief intervention techniques. This can include sample scripting for staff around screening itself and how to respond to positive screens ­– this is important for any type of screening completed. Refer to Best Practice 7 for more information on Trauma-Informed Care and how to avoid re-traumatization. 

  • Have a list of resources or informational packets available for each American Society of Addiction Medicine (ASAM) level of care to support women at all levels of risk. 

  • Establish a clear system and workflow for positive, validated screening and/or assessment tools. 

  • Please see the Resources section of this Best Practice for information on risk (“AIM Opioid Screening Tools”). 
    • Low risk patients can receive brief advice related to their identified substance. 
    • Moderate risk patients should have a brief intervention
    • As described in Best Practice # 1, after a positive screen for SUD, use a validated assessment tool to determine the presence and severity of the SUD followed by the identification of and referral to the appropriate level of care that matches the severity of the patient’s needs. The state of California mandates that all counties with Drug Medi-Cal Organized Delivery System (DMC-ODS) contracts use the ASAM criteria to determine the appropriate level of care for an individual with SUD. The ASAM Co-triage or the ASAM Continuum clinical decision supports are ideal assessment tools to meet that requirement.

  • Other than the Co-triage, which is designed as a ten-minute provisional evaluation tool, each assessment typically takes an hour to complete. Identifying clinic personnel who can be trained to effectively administer the chosen screen, assessment, and level of care evaluation prior to SBIRT implementation will streamline workflow.

  • Identify local options for each level of care, including the full spectrum of office-based treatment (level 1), methadone clinic management (level 1 OTP), intensive outpatient centers (levels 2.1 and 2.5), residential treatment centers (levels 3.1, 3.3, 3.5, and 3.7) and medically managed inpatient treatment (level 4). Please see the Resources section of this Best Practice for the SAMHSA treatment locator tool. For more on levels of care, please refer to the ASAM CONTINUUM in the Resources section of this Best Practice.

  • Referral sites may be any of the above depending on the level of care determined to be most appropriate.
Kayla

Kayla

Kayla’s screen is positive for risk of substance use disorder, and she has shared that she is using opioid pain medications for her back pain, marijuana for her anxiety, and smoking cigarettes. While you are talking, she takes a pack of cigarettes out of her purse and throws it in the trash. She tells you that she knows smoking isn’t good for her baby, and she is going to quit right now. She explains that she knows she should stop everything, but she needs the pain medication and marijuana to manage her back pain and anxiety, especially since pregnancy will probably make her back pain worse. 
 
The physician applauds Kayla’s desire to make healthy choices for herself and her baby. She explains that all medications women take during pregnancy may have some effects on the baby and that there are treatments available for women who have become dependent on opioids; these treatments not only help mom feel better but are safer for developing babies. She explains that abruptly stopping opioids suddenly can be dangerous for her baby. She asks if Kayla would like to meet with Hannah (a social worker), who can help her set up an appointment to talk about treatment, as well as assist with any other needs Kayla may have during her pregnancy.

Resources

References

  • Wright TE, Terplan M, Ondersma SJ, et al. The role of screening, brief intervention, and referral to treatment in the perinatal period. Am J Obstet Gynecol. 2016; 215(5):539-547. doi:10.1016/j.ajog.2016.06.038.

Candy Stockton-Joreteg

MD, FASAM

Dr. Stockton is Board Certified in both Family Medicine and Addiction Medicine. Candy’s passion is providing patient-centered care to pregnant and parenting women with addiction as well as addressing the upstream causes of addiction in her community. She is Chief Medical Officer at the Humboldt IPA, and is a practicing physician at their Priority Care Center. In her role at the IPA, she oversees the developing School Based Health Center Program and is the clinical champion for the Humboldt RISE Project (a county-wide Perinatal Substance Use Disorder project) and Humboldt County’s Jail MAT program. She serves as a consultant for the implementation of the Hub and Spoke project in Northern California and for California’s Opioid Response Network, based out of UCLA. 

Carrie Griffin

DO

Dr. Carrie Griffin is a family medicine physician who specializes in maternal, child and reproductive health and practices in Humboldt County. She completed her residency at Maine Dartmouth Family Medicine Residency and fellowship at the University of New Mexico. Perinatal substance use is her clinical area of interest and expertise; she currently serves as a mentor for CMQCC's Mother Baby Substance Exposure  initiative and the Humboldt RISE project, a community initiative to promote screening and case management services for women with substance use disorders in pregnancy.