Substance Screening, Brief Intervention, and Referral to Treatment in Rural Primary Care

Abstract

Problem: Providers in a small, rural primary care practice in rural Maryland reported higher rates of alcohol or drug use disorders over the past several years, consistent with county-level data. The lack of screening tools and referral resources was identified as a need (Carroll County Sheriff Office, 2017). Purpose: SBIRT is a comprehensive early intervention approach that includes universal substance screening (S), and depending on problem severity, providing either brief interventions (BI) or referrals to treatment (RT) (SAMHSA, 2019). Methods: Medical assistants (MA) conducted a pre-screen using the first 3 items of the Alcohol Use Disorders Identification Test (AUDIT) and the National Institute on Drug Abuse (NIDA) single item drug screen. For those with positive pre-screens, medical providers completed full screens, using the remaining 7 items of the AUDIT, and the Readiness Ruler to assess for use of other substances and readiness to change. Results: Of 290 eligible patients seen over 10 weeks, 68.6% received a pre-screen. Reasons for missed pre-screens were “too busy” (27.4%); high patient census that day (29.6%) or no MA on duty (42.8%). N=38 patients (19.1%) had a positive pre-screen; all scoring >8 on the full AUDIT received a BI for alcohol misuse (n=6, 15.7%) or an RT for probable alcohol dependence (n=1, 2.6%). All with a positive drug screen (n=4, 2.0 %) received a BI. Low rates of screening may be due to short duration of implementation; low patient census; staffing issues, and possibly, patient under-reporting of substance use. Conclusions: Organizational leadership and physician involvement is necessary for SBIRT implementation. Primary care practices adapting SBIRT into their workflow should implement universal screening with validated, standardized substance use screening tools. SBIRT implementation should be conducted as a team approach. To help alleviate potential time constraints, medical assistants can be utilized to conduct SBIRT screening. SBIRT implementation can help primary care staff increase their knowledge of alcohol and drug use in their patient population and help to reduce the associated stigma.