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The 2009 National Survey on Drug Use and Health (NSDUH) reported that 21.8 million, or 8%, of Americans over age 12 were users of illicit substances in the past month, 23.7% (59.6 million) reported binge drinking, and 6.8% (17.1 million) reported regular heavy drinking.1 These findings make substance abuse one of the most common medical disorders in the United States as compared to cardiovascular diseases at 81 million,2 chronic obstructive pulmonary disease at 24 million,2 or diabetes at 25.8 million. 3 NSDUH data indicate that the rising numbers are largely driven by increase in the abuse of prescription pain relievers. The number of prescription analgesic abusers is estimated at 5.3 million; an increase of 20% from 2002. Further, Drug Abuse Warning Network findings for 2009 show 2.1 million emergency department visits attributable to drug abuse with the most frequently reported drugs being oxycodone and hydrocodone combinations, drugs to treat insomnia, and drugs to treat anxiety—including benzodiazepines and antidepressants.4 Concurrent alcohol use was present in 31.8% of these events.
Although the most recent statistics indicate that more than 21 million are in need of substance abuse treatment, the actual numbers receiving treatment are 2.6 million.1 The population of individuals engaging in “at risk” use is even larger,1 and may go undetected until a full blown substance use disorder develops or serious harm occurs. An important question becomes how we train medical professionals to identify patients in need, and to provide this essential care—including those substance abuse problems arising from inappropriately used or prescribed medications.
Screening, Brief Intervention, Referral and Treatment (SBIRT) is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance use disorders or who are at risk. Primary care centers, emergency rooms, trauma centers, and other community health settings provide opportunities for early intervention with at-risk substance users before more severe consequences occur.5 Screening quickly assesses the severity of substance use and identifies the appropriate level of treatment. A single question screener, “In the past year, have you had any times when you had 5 (for women, 4) or more drinks at one sitting?” has been shown to be 84% sensitive and 78% specific for hazardous alcohol use, and 88% sensitive and 66% specific for detection of current alcohol use disorders.6 Research to develop similar types of screening questions for misuse of other illicit substances, including prescription medications, is ongoing. Brief intervention focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change. Referral to treatment provides those identified as needing more extensive treatment with access to specialty care assisted by their primary care providers.
SBIRT for both alcohol and illicit drug use across a range of clinical settings and in diverse populations appears efficacious.7 In a study of over 499,000 patients, screening identified 22.7% as hazardous users or having a current substance use disorder. Most were offered a brief intervention (15.9%), with the remainder receiving either brief treatment (3.2%) or referral to specialty treatment (3.7%). Significant declines in heavy alcohol use (38.6% lower) and illicit drug use (67.7% lower) were reported at 6-month follow-up. Those receiving specialty care reported significant improvements in general health, mental health, employment, housing status, and criminal behavior.
The Center for Substance Abuse Treatment/Substance Abuse and Mental Health Services Administration has launched a 17 site, medical residency training program to promote core SBIRT clinical skills for physicians, and to identify innovations supporting SBIRT implementation. The overarching goal is to bring one of the most common medical disorders into the mainstream of medicine by placing it on par with other medical problems currently addressed by primary care providers. By successfully placing these services in primary care, SBIRT becomes a routine component of primary care medicine and will be a major advancement in the effective treatment of patients. In addition to identifying and treating the substance use disorder, regular drug and alcohol screening will help to decrease the number of inaccurate diagnoses (and subsequent prescribed treatments) made when clinicians incorrectly attribute signs and symptoms of substance use disorders to other medical problems.
As health care reform progresses in the United States and larger numbers enter the medical system, we can expect that those needing interventions for substance abuse issues will increase. Innovative care delivery models such as the patient-centered medical home have acknowledged the need for behavioral health integration and workforce training.8 SBIRT offers a streamlined mechanism for routine screening for these problems, an efficient, short-term intervention that will meet the needs of most in assisting them with reducing or stopping hazardous use, knowledge of approved pharmacotherapies for substance use disorders that can be implemented in primary care, and resources for obtaining specialty care when needed. SBIRT is well suited to collaborative, multidisciplinary approaches and could include screenings initiated by nursing staff and/or ongoing substance abuse treatment delivered by onsite behavioral health providers. It is essential that physicians and other primary care providers not abdicate their role in the identification, brief intervention, and referrals for substance abuse problems in the patients they serve. As clinicians, team leaders, and, oftentimes, the health professional most acquainted with the patient, primary care providers are ideally situated to have maximum impact on a patient’s substance use behaviors. The data on substance-related morbidity and mortality should place SBIRT on par or in even higher priority to many currently accepted primary care tasks.
Some have argued that there is a lack of data for implementation of SBIRT for illicit drug use, and have called for clinical trials to show efficacy.9 We agree with the need for additional clinical trials, although evidence is beginning to accumulate.7 We would also argue that the benefits of teaching SBIRT and implementing regular care for substance use problems, be it alcohol or other drug use, in settings where patients are likely to access medical care, such as in primary care clinics, makes good clinical sense for a disease affecting such large numbers of Americans.
Supported by Grant # U79 TI020295 from CSAT/ SAMHSA, Bethesda, MD (Dr. Satterfield), and grant K24 DA 023359 from NIH/NIDA, Rockville, MD (Dr. McCance-Katz).