New VA, DoD Model Offers Intervention Before Drinking Becomes Out of Control

by U.S. Medicine

December 13, 2012

By Sandra Basu

Vladimir Nacev, PhD

WASHINGTON – In the past, healthcare systems typically waited until a drinker sought help for alcohol dependence before intervening. Now, a newer model encourages clinicians to engage with their patients about alcohol use before it becomes an out-of-control problem.

The method known as the screening, brief intervention and referral to treatment model (SBIRT) is a system-level approach to identify and treat those with drinking problems.

Authors of a recent Institute of Medicine (IoM) report are encouraging greater use of SBIRT in the military. The report, Substance Use Disorders in the U.S. Armed Forces, alleged the military has not stayed up-to-date on its approaches to combat substance abuse. The report also pointed out that medical protocols for SBIRT “have not been implemented in military primary care programs,” where screening for behavioral health problems routinely occurs.

“Evidence-based approaches of brief advice, early intervention, and referral to treatment when needed through models commonly known as screening, brief intervention, and referral to treatment (SBIRT) should be a focus of the full continuum of care,” the report stated.

That report pointed out that VA, in contrast, “routinely screens for alcohol use problems and offers brief intervention and referral to further treatment if needed.”

Treating Patients

Earlier this year, DoD and VA officials told clinicians during a webinar how the use of SBIRT can help to reach troops and veterans who might be struggling with dangerous levels of drinking, especially with alcohol abuse becoming an increasing problem in this population. A 2008 study showed that rates of heavy alcohol use among troops increased from 15% in 1998 to 20% a decade later.

“Research has demonstrated that SBIRT is effective in identifying persons at risk of developing serious alcohol problems, reducing the frequency or severity of alcohol use and increasing the percentage of patients who enter specialized alcohol treatment,” said Vladimir Nacev, PhD, moderator of a DCoE webinar earlier this year about addressing alcohol misuse among troops.

Under the SBIRT model, all patients undergo a quick screening to assess their alcohol use. Patients at risk of developing a serious alcohol problem receive a brief intervention. Patients who need more extensive help receive referrals to specialty care. The primary goal of SBIRT is not to identify those who are alcohol dependent but to identify those who are at moderate or high risk for psychosocial or healthcare problems related to their substance-use choices.

“This model says we can identify people quickly, and we can provide them a very time- limited, cost-limited intervention form of treatment at that moment and assist them in making changes in their substance-use choices,” said Stephen O’Neil, MA, director of Georgia BASICS Project Division of Addictive Diseases in a presentation during the webinar.

O’Neil explained that, historically, substance-use services focused on two areas: primary prevention in which delaying the onset of substance use is the focus and then treatment of those with serious substance-abuse disorders.

“It focuses initially on trying to stop use before it starts, or at least delaying its onset, and then it sort of disappears and then waits until people are chronically or acutely ill with a substance-use disorder,” he said.

In addition, O’Neil said, a traditional model focuses services on those who have a diagnosed substance-use problem, versus those who do not meet the criteria for having a substance-use disorder. As a result, those who do not fit the criteria of being alcohol dependent receive no intervention.

“What we have said is that you are either substance dependent, or you are not. You have a problem or do not,” he said.

The problem with this model is that about 25% of the population is not alcohol dependent but drinks excess amounts and suffer from related problems, O’ Neil explained. These individuals are not reached with intervention messages, and many do not know they are at risk.

The SBIRT model provides a way of reaching all types of drinkers with an intervention, he added.

Alcohol Screening in the VA

While making sure no segment of the population is overlooked in alcohol screening is crucial, how that screening is administered also appears to be important, according to Katharine Bradley, MD, MPH. She said at the webinar that, since 2006, the VA has required use of the Audit C questionnaire, which asks three questions:

• How often did you have a drink containing alcohol in the past year?

• How many drinks did you have on a typical day when you were drinking in the past year?

• How often did you have six or more drinks on one occasion in the past year?


Bradley said a national study at the VA comparing Audit C screening by providers, versus on the VA’s patient satisfaction survey, found that 61% of patients who screened positive on the alcohol screening through the survey were negative when screened as part of clinical care in the VA.

That led to a further study examining how the Audit C was being used by clinicians in VA at nine sites. What the researchers found was that “screening was happening in all kinds of ways,” she said.

The researchers found that there appears to be discomfort on the part of clinicians to “not own” the questions, Bradley said.

“For instance, rather than asking them straightforward, they would say, ‘VA has some questions for you,’ or ‘This is a reminder we have to ask,’ or ‘They want to know about your alcohol use.’ So one of the things was this disowning the process of alcohol screening,” she said.

Bradley also noted that responses were sometimes presumed by interviewers, if the patients’ response did not fit the written options, or the questions were not asked verbatim. “These were all clinicians trying to do the right thing, but they didn’t understand. … So, it is very essential to not just train primary-care providers in screening and brief intervention, but, if their medical assistants or health techs or nurses are doing screening, it is essential that everybody understands the rationale behind it,” she said.

Best practices also were observed during screening, the study showed.

“We concluded that the best is if you can give the patient a private way to answer the questions themselves,” she said. “We observed clinics that were using paper-based screening. It can be mailed prior to the appointment; it can be self-administered in the waiting room. Another is a laminated questionnaire that, during intake and blood-pressure intake, can be handed to the patient. The patient can tell [the clinician] the number of the response for [the questions].”

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