2. prepared for
Michigan Primary Care Association

3. Peer Assistance Services, Inc.
Dedicated to quality, accessible prevention and
intervention services in workplaces and
communities, focusing on substance abuse and
related issues.
Incorporated in 1984

4. Programs
• Peer Health Assistance Programs (Dental, Pharmacy, Nursing,
and other professions)
• Colorado TASC (Treatment Accountability for Safer
Communities)
• Workplace Prevention Services (WPS)
• Prescription Drug Abuse Prevention Program
• SBIRT (Screening, Brief Intervention, and Referral to
Treatment)

5. Acknowledgements

6. Objectives
• Discuss evidence that supports SBIRT
• Identify core components of SBIRT
• Describe lessons learned from SBIRT Colorado
• Review solutions to commonly perceived barriers

7. Why SBIRT?

11. “The administration will continue to promote the integration of
SBIRT in to mainstream health care, disseminate information
about SBIRT to a wide variety of health care settings, highlight
model programs that are using SBIRT, and encourage training
opportunities for the allied health professions.”
-2012 National Drug Control Strategy

12. Support for SBIRT
• The Joint Commission
• The American College of Surgeons Committee on Trauma
• The U.S. Preventive Services Task Force
• The American Congress of Obstetricians and Gynecology
• The Emergency Nurses Association
• The Office of National Drug Control Policy
• The Centers for Medicare and Medicaid Services
• The Center for Substance Abuse Treatment
• Health Resources and Services Administration
• National Institute on Alcohol Abuse and Alcoholism
• National Institute on Drug Abuse

13. Prevention Priorities

14. Billing Codes
Payer Code Description Fee
Commercial CPT 99408 Alcohol and/or substance abuse structured $33.41
screening and brief intervention services; 15 to
30 minutes
CPT 99409 Alcohol and/or substance abuse structured
screening and brief intervention services; $65.51
greater than 30 minutes
Medicare G0396 Alcohol and/or substance abuse structured $29.42
screening and brief intervention services; 15 to
30 minutes
G0397 Alcohol and/or substance abuse structured
screening and brief intervention services; $57.69
greater than 30 minutes
Medicaid H0049 Alcohol and/or drug screening $24.00
H0050 Alcohol and/or drug service, brief intervention, $48.00
per 15 minutes

15. SBIRT Colorado

16. History of SBIRT in Colorado

17. County Population Density 2000

18. Brief
Intervention
35%
Screening only
60%
Brief Therapy
2%
Referral to
Treatment
3%

19. 16
14
12
10
8 Alcohol
6 Marijuana
4 Illicit drugs
2
0
Intake 6 mth follow-
up

20. Screening, Brief Intervention
and Referral to Treatment

23. The SBIRT Process
• Introducing SBIRT
• Brief Screen
• Screening
• Brief Intervention
• Referral to Treatment and Follow-Up

24. Introduction and Consent

25. Purpose of Screening

27. Brief Screen
1. How many drinks do you have per week?
2. When was the last time you had 4/5 or more drinks in
one day?
3. In the past year, have you used or experimented with an
illegal drug or prescription drug for nonmedical
reasons?
4. Do you currently smoke or use any form of tobacco
products?

28. Moderate Drinking Guidelines

29. What is a standard drink?

30. Screening Instruments
Use for follow-up in those who test positive on
the brief screen:
• ASSIST: Alcohol, Smoking, and Substance Involvement
Screening Test
• AUDIT: Alcohol Use Disorders Identification Test
• DAST-10: Drug Screening Test (not including alcohol)
• CRAFFT: Adolescent drug and alcohol screening

31. Brief Intervention

32. What is Brief Intervention?
• A brief motivational conversation
• Single 3-5 minute to multiple 15-30 minute sessions
have led to decreased use
• Most effective with at-risk clients who are not
addicted
• Educating clients about the health risks of their
substance use has led to behavior change
• BIs are low cost, quick, client friendly, easy to do

33. Motivational Interviewing
William Miller and Steven Rollnick
Ambivalence as central construct
Persuasion elicits resistance
Alternative to direct persuasion and it works!
Source: William Miller (2002)

34. Examples of MI Strategies
Open-ended questions
Affirmation
Reflective listening
Summarizing
Goal is to elicit change talk!!!

35. Don’t Assume
• Patient ought to change
• Patient wants to change
• Patient’s health motivates him/her
• Now is the right time for patient to change
• Tough approach is best

36. Brief Intervention
Step 1: Raise the Subject
Step 2: Provide Feedback
Step 3: Enhance Motivation
Step 4: Negotiate and Advise

37. Step 1: Raise the Subject
Raise the subject of substance use
“Would you mind taking a few minutes to
talk with me about your substance use?”

38. Step 2: Provide Feedback
Discuss health risks of alcohol and other
substances
“At this level of consumption, you are at increased
risk for health and other consequences such as…”
Review drinking guidelines
“The recommended guidelines for healthy
women/men are…

39. Step 3: Enhance Motivation
Pre-Contemplation
Contemplation
Maintenance
Preparation
Action

40. Step 4: Negotiate and Advise
Elicit response: “What are some of your thoughts regarding
our discussion?
Negotiate a goal: “Why are you a 5 and not a 7?” and “What
are some steps you could take?”
Assist in developing a plan: “What will be challenging for
you to meet this goal? What is your plan for overcoming
these challenges?”
Summarize: “What I heard you say is…”

41. Closing the Intervention
Show appreciation to your client
Affirm positive behaviors
Respect client’s decisions
Offer information
Arrange for follow up

42. Referral to Brief Therapy and
Treatment
• If patient scores high on assessment
• What is brief therapy?
• Know your resources!

43. Sustainability
• Identify an internal champion
• Flexibility in how SBI can be implemented
• Best to combine with other health screening and education to
enhance integrated care
• Involve the entire team
• Train nursing students and residents to establish SBI as a routine
practice

44. References
• The National Center on Addiction and Substance Abuse at Columbia University. The Cost of Substance Abuse to America’s Health
Care System. Report 2: Medicare Hospital Costs. May 1994. Available at http://www.casacolumbia.org/articlefiles/379-
Cost%20of%20Substance%20Abuse%20Report%202.pdf.
• Mokdad A, Marks J, Stroup D, Gerberding J. Actual causes of death in the United States, 2000. JAMA 2004;291:1238--45.
• Substance Abuse and Mental Health Services Administration. (2006) Results from the 2005 National Survey on Drug Use and
Health: National findings Rockville (MD): Office of Applied Studies.
• Maciosek, MV, Coffield, AB, Edwards, MS, et al. Priorities Among Effective Clinical Preventive Services. Results of a Systematic
Review and Analysis. Am J Prev Med 2006; 31 (1) 52-61. Available at
http://www.prevent.org/data/files/initiatives/prioritiesamongeffectiveclinicalpreventivesvcsresultsofreviewandanalysis.pdf.
• D’Onofrio G, Pantalon MV, Degutis LC, et al. The Yale Brief Negotiated Interview Manual. Yale University School of Medicine.
2005. Available at http://www.ihs.gov/nonmedicalprograms/nc4/documents/appendix_a_yale_bni_manual.pdf.
• William Miller, Rollnick Steven. Motivational Interviewing, Second Edition: Preparing People for Change. 2002.

45. www.improvinghealthcolorado.org
www.healthteamworks.org