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

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.

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