Chapter 11.Integrating Screening, Brief Intervention, and Referral to Treatment With Motivational Work

Substance use disorders are commonly encountered in nonspecialty settings and most patients with substance use problems do not present to a specialist. The role of the nonspecialist can be envisioned as a catalyst to increase the rate at which those who are at risk or have harmful substance use conditions are treated or moved from nonspecialty to specialty care. The process of identifying patients with a need for intervention or referral to treatment is often referred to as Screening, Brief Intervention, and Referral to Treatment (SBIRT). SBIRT principles are based on Motivational Interviewing and intervention practices and are designed to move an individual from the precontemplative stage to the action stage. Screening strategies for alcohol and drug use disorders often include instruments such as the CAGE questionnaire (CAGE being an acronym for questions about Cutting down, Annoyance by criticism, Guilty feelings, and Eye openers; Ewing 1984), the CAGE Adapted to Include Drugs questionnaire (CAGE-AID; Brown and Rounds 1995), the Alcohol Use Disorders Identification Test (AUDIT; Saunders et al. 1993), the Michigan Alcoholism Screening Test (MAST; Selzer 1971), and the Drug Abuse Screening Test (DAST; Skinner 1982; see also Staley and el-Guebaly 1990). These methods for screening for alcohol and drug problems each have differing sensitivities and specificities in primary care. For instance, the CAGE questionnaire is best used for the diagnosis of alcohol abuse and dependence in primary care, whereas the AUDIT is best used in this setting for diagnosing hazardous drinking (Brown and Rounds 1995). Hazardous drinking is defined as a quantity or pattern of alcohol consumption that puts a person at risk for health problems (Saunders et al. 1993). The National Institute on Alcohol Abuse and Alcoholism (2005) endorsed a single-item screening tool as the first step for patients seen in clinical settings: “How many times in the past year have you had X or more drinks in a day?” (X = 5 for men and 4 for women.) Once a patient is noted to have a positive screening result for unhealthy alcohol use, illicit drug use, or nonmedical use of prescription medications, the goal is to help move the patient toward healthier behavior and treatment using psychoeducational strategies.