As early as 1990, the Institute of Medicine (1990) was calling for the use of screening to identify alcohol abuse, dependence, and associated problems in all healthcare settings. This call and the subsequent support for the use of screening, brief intervention, and referral to treatment (SBIRT) in non-drug and alcohol settings (e.g., ERs, primary care settings, health clinics, etc.) is backed by a wealth of research on the effectiveness of this evidence-based practice. Early screening by health professionals has been associated with reductions in alcohol use, health care utilization, criminal justice involvement, and societal costs (Cuijpers et al., 2004; Gentilello et al., 1999; Wells-Parker & Williams, 2002; Chudnofsky, 2007; Fleming et al., 2002, etc.). While SBIRT had focused mainly on detecting and assessing alcohol use, there are a growing number of studies testing these methods to address illicit and prescription drug misuse with promising results (Bernstein et al., 2005; Micheli et al., 2004; Toumbourou et al., 2007,  etc.).  

At the same time that science and addictions practitioners were recognizing the benefit that SBIRT delivered by a health professional could provide (e.g., identification and treatment for substance abuse before progression to dependence and earlier identification of dependence to make treatment more accessible for those who needed it), the addiction field was undergoing a paradigm shift. Specifically, addiction, traditionally treated as an acute illness requiring discrete episodes of care, was now being understood as a potentially chronic illness, addressed better over a continuum of prevention, intervention, treatment, and, for those in which the disease progressed to a chronic state, ongoing and even lifetime care with recovery supports throughout- similar to other chronic illnesses such as diabetes and heart disease (McLellan et al., 2000; Flaherty, 2006; White and McLellan, 2008; Saitz, 2008).  

Within this framework, SBIRT has the potential to expand and enhance the clinical continuum to address substance use in many significant ways. First, the use of SBIRT completes the continuum of care used so successfully in other chronic illness: i.e., prevention, intervention, treatment and recovery support, by providing prevention and, when needed, earlier intervention services. Second, the use of SBIRT lends credence to the impact that risky alcohol or other drug use can have on an individual by providing a highly specialized method, similar to other early detection methods, like PAP smears and tests for blood sugar levels, and addressing potential current and future health problems in a straightforward manner. Third, SBIRT integrates substance screening and intervention into a new setting (e.g., PCP office, health clinic, ER, jail, therapist’s office, pre-natal clinic, etc.) but one that may be a more comfortable environment for a patient to discuss such issues. Lastly, the use of SBIRT offers individuals more opportunities to address a problem before greater acuity, morbidity and true chronicity take hold.  

Within the chronic illness framework outlined above, SBIRT is not an isolated intervention but rather is part of an enhanced clinical framework encompassing the full continuum of care-the ultimate goal of which is to provide individuals with the best opportunity to achieve and maintain total wellness and recovery.  In this framework, traditional addiction providers become the “specialty system,” providing care only when earlier components within the system (i.e., screening and brief intervention) have not been available or have been unsuccessful.  

Framework:    

Prevention -------- Intervention -------- Treatment ------- Long Term Recovery/Care        

- references provided on request -   Mike Flaherty, Ph.D. (flahertym@ireta.org)