An introduction to SAMHSA's SBIRT program, its role in addressing problematic drug and alcohol use and a call for occupational therapy leadership in its implementation.

1. SBIRT: A Promising Approach to
Addressing Problematic Use of Alcohol
and Drugs
Allison F. Sullivan, OT, DOT, MS, OTR
Hannah Sullivan, MPH
October 26th, 2018
MAOT 2018

2. Learning Objectives
1. Define drug and alcohol abuse as a modern public health
disaster and the context in which SBIRT has been introduced.
2. Identify components of this evidence-based intervention for
identifying, reducing, & preventing problematic use, abuse &
dependence on alcohol & illicit drugs.
3. Recognize the critical need for more research related to
occupational therapy intervention and SBIRT, as well as
potential obstacles to implementation of SBIRT in treatment
settings & resources for continuing education on this topic.
2

3. Social Determinants of
Health
3

4. https://www.healthypeople.gov/2020/topics-
objectives/topic/social-determinants-of-
health
4
Social
Determinants
of Health

5. https://www.kff.org/disparities-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/
5

6. https://www.kff.org/disparities-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/
6
Social
Determinants
of Health

7. Modern Public Health
Disasters
7

8. What Constitutes a Public Health
Disaster?
● A situation becomes an emergency or
disaster when the magnitude of health
consequences has the potential to
overwhelm a community in situations not
routinely encountered.
● Disaster preparedness is an area of study
in public health that instructs the public
on how to prepare for disasters, both man-
made and natural. 8

9. Defining Addiction as a
Modern Public Health
Disaster
9

10. What is Addiction?
● Addiction is characterized by inability to consistently abstain,
impairment in behavioral control and diminished recognition of
problems with one’s behaviors & interpersonal relationships
● Addiction is a primary, chronic disease of brain reward, motivation,
memory and related circuitry which results in an individual
pathologically pursuing reward/relief by substance use.
● Addiction often involves cycles of relapse and remission.
● Without treatment or engagement in recovery activities, addiction is
progressive and can result in disability or premature death.
ASDM (2011)
10

11. Public Health Model of Addiction & Recovery
● Harm Reduction is a specific type of public health strategy
which accepts that it is not possible to eliminate addiction.
● Instead, the public health goal becomes reducing the harmful
effects of addiction.
11

12. Public Health Model of Addiction & Recovery
● Social Determinants of Health tells us that addiction affects
both individuals with addictions and their communities
● Harm reduction principles seek to reduce harm through any
means necessary.
● The goal is an overall improvement in public health.
12

13. Opioid Addiction
Statistics
13

14. 14

15. Number of Opioid‐Related Overdose Deaths by
County, MA Residents: 2000‐2017
15

16. Confirmed MA Opioid Deaths by Gender:
January 2018‐June 2018
16
Male 488
Female 169
Total 657

17. Confirmed
MA Opioid
Deaths by
Age:
January
2018‐June
2018
17
<15 15-24 25-34 35-44 45-54 55-64 65+ Unknown Total
All Deaths 174 205 628 736 1,419 3,265 23,715 4 30,146
Opioid-
Related
1 39 215 183 135 72 12 0 657

18. Defining SBIRT
18

19. What is SBIRT?
1. Screening
2. Brief
Intervention
3. Referral to
Treatment
19

20. What is SBIRT?
● SBIRT is an evidence-based intervention practice for
identifying, reducing & preventing problematic use, abuse &
dependence on alcohol & illicit drugs
● Emphasizes screening and early intervention for substance
use disorders
● Aims to help identify people at risk for developing
substance use disorders.
● SBIRT utilizes a combined effort of screening and treatment
services as part of a cooperative system of early intervention.
Madras BK, Compton WM, Avula, D et al., 2009
20

21. Historical Background of the SBIRT Initiative
In 2001, the Institute of Medicine’s Committee on the Quality of
Health Care in America released Crossing the Quality Chasm: A
New Health System for the 21st Century:
•Identified in this report was the need for community-based
screening for health risk behaviors including substance use
with appropriate assessment and referral activities
•The SBIRT model was specifically cited as a promising
practice in this report
Institute of Medicine, 2001
21

22. Goal of SBIRT Initiative
• Prevent the unhealthy
consequences of alcohol and
drug use among those
whose use may not have
reached the diagnostic level
of a substance use disorder
• Help those with the disease
of addiction enter and stay
with treatment.
SAMHSA-HRSA, nd
22

23. Where are SBIRT Programs?
● Typically, SBIRT is conducted in medical settings, including
community health centers
● SBIRT has been proven successful in hospitals, specialty
medical practices such as HIV/STD clinics, emergency
departments, and workplace wellness programs such as
Employee Assistance ProgramsSAMHSA-HRSA
23

24. Why SBIRT?
24

25. SBIRT Decreases Healthcare Costs
Substance misuse & abuse is a
significant factor in poor health
outcomes and preventable
healthcare costs
● Societal cost of $600 billion annually
● One study estimated the net value of
SBIRT adoption was $771 per employee
25

26. SBIRT Reduces Severity of Substance Misuse
● Screening and brief intervention
was the single most effective
treatment method of the more
than 40 treatment approaches
SAMHSA studied, particularly
among groups of people not
actively seeking treatment
26

27. SBIRT Diminishes Risk of Physical Trauma for
Patients without Specialized Substance Treatment
● Studies on brief intervention identified outcomes
such as patients’: reducing their alcohol intake,
successful referral to & participation in treatment
programs & decreases in repeat injuries and injury
hospitalizations
● Following a U.S. Preventive Services Task Force
recommendation, in 2011 Medicare began
reimbursing alcohol and drug screening &
counseling in the primary care setting
Open Cancer Network (2017); SBIRT (nd) 27

28. OTs Can Demonstrate Leadership in SBIRT programs
✓OT is intended to be a holistic, client-centered
practice which addresses the needs of the whole
client (Law, Baum & Dunn, 2005)
✓OT takes place in settings where SBIRT was
intended
✓As direct service providers, OT practitioners
occupy a place of trust in the patient care
continuum (Birkhauer, et al., 2017)
28

29. OTs Can Demonstrate Leadership in SBIRT programs
✓Occupational therapy practitioners possess mental
health skills and knowledge as core components of
their educational background
✓Occupational therapists are skillful evaluators of
patient needs, trained to collaborate with the client
for the development of meaningful goals & outcomes
of treatment
(Law, Baum & Dunn, 2005)
29

30. SBIRT
Resources
30

31. Free training in SBIRT from the SAMHSA website
follow the link to the training here:
http://www.integration.samhsa.gov/clinical-practice/SBIRT#bmb=1 …

32. Interactive simulation technology to increase clinical skills
32

33. 33

34. Use Apps like the OHN SBIRT app from Open Cancer Network

35. SBIRT Basics
Click on
“Review”:
This opens to a
menu of
SBIRT Basics,
including helpful
information on:
• The Epidemiology of Drug & Alcohol abuse
• Drugs of abuse
• Consequences of Drug & Alcohol Abuse
• A brief explanation of SBIRT & its value
• Graphic illustrations and information regarding risky use

36. Screening
If the patient answers yes to the one question screen, the assessment continues to
a more comprehensive tool, the 3-question AUDIT-C or 10-question AUDIT (for
alcohol use in adults), the DAST (for adult drug use) or the CRAFFT, which screens
for drug and alcohol use by adolescents

37. Brief Interventions
Brief interventions are typically provided to patients with less severe alcohol or
substance use problems who do NOT need a referral to additional treatment.
In addition to behavioral health professionals, medical personnel, including OTs
can conduct these interventions and need only minimal training

38. Referral to treatment
The referral to treatment process consists of helping patients access specialized
treatment, selecting treatment facilities, and facilitating the navigation of any
barriers that might prevent them from receiving treatment at a specialty setting

39. SBIRT Funding Available through CCBHCs
● Certified Community Behavioral Health Clinics or CCBHCs,
were created through Section 223 of the Protecting Access to
Medicare Act (PAMA)
● CCBHCs are responsible for directly providing (or
contracting with partner organizations to provide) nine
required types of services:
● Emphasis on the provision of 24-hour crisis care, SBIRT,
utilization of evidence-based practices, care coordination,
and integration with physical health care.
39

40. Obstacle 1: Barriers to Reimbursement
Coding and billing policies are essential to widespread use of
SBIRT.
● The good news is that reimbursement is available through
commercial insurance, Current Procedural Terminology (CPT)
codes, Medicare G codes, and Medicaid Healthcare Common
Procedure Coding System (HCPCS) codes
● The bad news is that while Medicare currently pays for
screening and brief intervention as preventive services in the
primary care setting, many states have not yet “activated”
Medicaid codes for SBIRT reimbursement.

41. Obstacle 2: Workflow
One common barrier to implementing SBIRT in primary care settings is the
additional time the practice will add to already short visits.
● Successful programs employ a multi-disciplinary change team to identify
which existing clinical and administrative staff will be responsible for
various SBIRT functions.
● The keys to successful implementation have included collaboration with
health staff to tailor SBIRT to existing infrastructure and resources,
ongoing training, data collection for quality monitoring, and process
revision based on results.
● Visit SAMHSA-HRSA Center for Integrated Health Solutions for
resources that address workflow issues (SAMHSA-HRSA)

42. YOUR TAKE AWAY TODAY: SBIRT NEEDS
YOU!
• There are currently NO studies to date on the use and
implementation of SBIRT by occupational therapists
• Nurses and social workers are once again gaining an edge in primary
care settings by providing another revenue-generating service for
their facilities
• Occupational therapists are missing out on an effective, evidence-
based preventive intervention that will make use of our mental
health skills and knowledge
42
There is a critical need for more research related to
occupational therapy intervention & SBIRT

43. Acknowledgements
● American International College School of Health Sciences
● Tulane University School of Public Health and Tropical
Medicine
● Behavioral Health Network Inc.
43

44. Contact Information
Allison F. Sullivan,
OT, DOT, MS,
OTR/L
Email: Allison.Sullivan@aic.edu
Website: www.allisulli.com
Twitter: @_Allisulli
Hannah L. Sullivan,
MPH
Email: Hannah.Sullivan@bhninc.org
Twitter: @HannahMPH
44

45. References
Centers for Disease Control and Prevention (2017). Opioid Overdose. Retrieved from <https://www.cdc.gov/drugoverdose/epidemic/index.html>.
ClinicalTools, Inc. (2015). About Us - SBIRT Training. Retrieved from <https://www.sbirttraining.com/>.
Joynt, M., Train, M. K., Robbins, B. W., Halterman, J. S., Caiola, E., & Fortuna, R. J. (2013, June 25). The Impact of Neighborhood Socioeconomic Status and
Race on the Prescribing of Opioids in Emergency Departments Throughout the United States. Retrieved December 01, 2017, from
https://link.springer.com/article/10.1007/s11606-013-2516-z.
Kaiser Family Foundation (2017). Opioid Overdose Death Rates. Retrieved from https://www.kff.org/other/state-indicator/opioid-overdose-death-
rates/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
Kaiser Family Foundation (2017). Opioid Overdose by Age Group. Retrieved from https://www.kff.org/other/state-indicator/opioid-overdose-deaths-by-age-
group/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
Loesche, D (2017). America has the Highest Drug Related Deaths in North America and in the World. Retrieved from
https://www.statista.com/chart/9973/drug-related-deaths-and-mortality-rate-worldwide/
Maxwell, J. (2014). Brief Report on the Current Epidemic of Drug Poisoning Death. Retrieved from
https://socialwork.utexas.edu/dl/files/cswr/institutes/ari/pdf/opioid-overdose-2014.pdf.
Matrix Global Advisors, LLC. (2015). Healthcare Costs from Opioid Abuse: A State-by State Analysis. Retrieved from https://drugfree.org/wp-
content/uploads/2015/04/Matrix_OpioidAbuse_040415.pdf.
Mukherjee (2017). These Opioids Are Killing an Increasing Number of American Teens. Retrieved from <http://fortune.com/2017/08/16/opioid-crisis-teen-
overdose-deaths/>
45

46. References
National Institute on Drug Abuse (2016). Misuse of Prescription Drugs. Retrieved from <https://www.drugabuse.gov/publications/research-reports/misuse-
prescription-drugs/what-scope-prescription-drug-misuse>
National Institute on Drug Abuse (2017). Opioid Overdose Crisis. Retrieved from https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-
crisis#five
Council on Recovery, The. (n.d). Fighting the Opioid Epidemic Using New Technology. Retrieved from https://www.councilonrecovery.org/fighting-opioid-
epidemic-using-new-technology/
U.S. Department of Health and Human Services (2017). Trump Administration Awards Grants to States to Combat Opioid Crisis. Retrieved from
<https://www.hhs.gov/about/news/2017/04/19/trump-administration-awards-grants-states-combat-opioid-crisis.html>.
Van Handel MM et al (2016). County-Level Vulnerability Assessment for Rapid Dissemination of HIV or HCV Infections Among Persons Who Inject
Drugs, United States. Retrieved from <http://opioid.AmfAR.org/TX>.
Van Zee A. The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy. Am J Public Health. 2009;99(2):221-227.
doi:10.2105/AJPH.2007.131714.
Vowles KE, McEntee ML, Julnes PS, Frohe T, Ney JP, van der Goes DN. Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review
and data synthesis. Pain. 2015;156(4):569-576. doi:10.1097/01.j.pain.0000460357.01998.f1.
World Health Organization (2014). Information sheet on opioid overdose. Retrieved from <http://www.who.int/substance_abuse/information-sheet/en/>
46

47. References
American Occupational Therapy Association (2010). Specialized knowledge and skills in mental health promotion, prevention, and intervention in
occupational therapy practice. American Journal of Occupational Therapy, 64:S30-S43
Birkhäuer, J., Gaab, J., Kossowsky, J., Hasler, S., Krummenacher, P., Werner, C. & Gerger, H. (2017) Trust in the health care professional and health outcome:
A meta-analysis. PLOS One. Retrieved from: https://doi.org/10.1371/journal.pone.0170988
George Washington University Medical Center. Ensuring Solutions to Alcohol Problems (2008). The promise of the new reimbursement codes. Retrieved
from: www.ensuringsolutions.org/moreresources/moreresources_show.htm?doc_id=67293
Law, M, Baum, C, & Dunn, W. (2005). Measuring occupational performance: Supporting best practice in occupational therapy. Thorofare, NJ: Slack,
Incorporated.
Madras BK, Compton WM, Avula D et al. (2009). Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple
healthcare sites: Comparison at intake and six months later. Drug and Alcohol Dependence; 280‐295.
Institute of Medicine (2001). Committee on Quality of Health Care in America (IOM). Crossing the quality chasm: A new health system for the 21st century.
Washington, DC.
OHN SBIRT. Open Cancer Network (2017). [Mobile application software]. Retrieved from http://itunes.apple.com
Quanbeck A, Lang K, Enami K, & Brown RL. (2010). A cost-benefit analysis of Wisconsin's screening, brief intervention, and referral to treatment
program: adding the employer's perspective. State Medical Society of Wisconsin, 109(1):9-14
SAMHSA-HRSA (n.d.) In SBIRT: Screening, brief intervention, and referral to treatment: Opportunities for implementation and points for consideration.
Retrieved from: https://www.integration.samhsa.gov/SBIRT_Issue_Brief.pdf
47

48. Questions?
48