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According to the National Survey on Drug Use and Health (NSDUH), among persons 17 and older, one in eleven or 8.6% of the population has been diagnosed with a substance use disorder (Center for Behavioral Health Statistics and Quality [CBHSQ], 2013). Screening, Brief Intervention and Referral to Treatment (SBIRT) is a comprehensive and integrated public health approach to the delivery of early intervention and treatment services for persons with, and at risk of developing, substance use disorders (Substance Abuse and Mental Health Services Administration [SAMHSA], 2015). The use of screening and brief intervention for alcohol use, specifically SBIRT, has been well established in the literature as a primary means in helping individuals recognize and change unhealthy patterns of use (SAMHSA, 2015). This article will suggest ways that SBIRT training can be integrated into the curriculum of social work classroom and field education.
The SBIRT Model
Screening, Brief Intervention and Referral to Treatment (SBIRT) is an evidence-based approach to identifying risky levels of alcohol and other drug use, with the goal of reducing and preventing related health consequences, disease, accidents, and injury (SAMHSA, 2015). Identifying at-risk substance use helps prevent the more serious disease of addiction, similar to other preventive screenings found in health care such as cancer, diabetes, or hypertension (National Institute on Alcohol Abuse and Alcoholism [NIAAA], 2005). Both SAMHSA and the Council on Social Work Education (CSWE) encourage social workers to adopt the SBIRT framework, supporting its long-term system change (SAMHSA, 2015).
The SBIRT process is comprised of three primary areas. First, pre-screening for alcohol and other drug use is completed as part of typical intake and routine assessment forms. The screening process is intended to assess the severity of substance use and identify the appropriate level of care. Screening can be completed in various community settings and requires limited experience or training. If the screening indicates moderate risk behaviors, the second step is to complete a brief intervention. Based in motivational interviewing (MI) techniques, the brief intervention aims to increase insight and awareness regarding substance use and motivation for change. This step usually takes about fifteen minutes to complete and assumes some training in MI techniques and foundational knowledge of substance use. Finally, if screening results indicate high-risk behaviors, a referral to treatment or more intensive specialty care is recommended (NIAAA, 2005).
There are three ways to address the challenges in integrating SBIRT into field education: 1) accessing models of SBIRT training for students, faculty and field instructors; 2) promoting the SBIRT model in classroom and field within the school of social work; and 3) gaining acceptance for the SBIRT model within field agencies.
Accessing SBIRT models
Research has found that few health care professionals, including social workers, consistently provide alcohol screening or intervention in practice (Pringle, Kowalchuk, Meyers, & Seale, 2012). However, a wealth of stakeholders exists to support the implementation of SBIRT including SAMHSA (http://www.samhsa.gov/sbirt) and the NIAAA (http://pubs.niaaa.nih.gov/publications/arh28-2/55-56.htm). The Addiction Technology Transfer Center Network (ATTC) has developed a National SBIRT ATTC which offers a multitude of sources including consultation, a training registry, technical assistance, and monthly webinars (http://attcnetwork.org/national-focus-areas/?rc=sbirt). The free eight-part SBIRT Webinar series covers topics such as implementing SBIRT and the use of SBIRT with specific populations including older adults, veterans, and the LGBTQ populations (http://attcnetwork.org/national-focus-areas/content.aspx?rc=sbirt&content=DISTCUSTOM1). The National SBIRT ATTC also offers the ability to connect geographic regions virtually and in-person with other nearby institutions engaged in SBIRT. In addition, an SBIRT App has been developed by Baylor College of Medicine (https://itunes.apple.com/us/app/sbirt/id877624835?mt=8).
Integrating SBIRT into the Social Work Curriculum
Russett and Williams (2014) have shown that social work programs offer limited formal education on substance use, possibly because there is a paucity of faculty trained in substance abuse education. The importance of substance abuse education can be brought to the attention of faculty and administration in several ways. Though the CSWE Educational Policy and Accreditation Standards (EPAS) presents no specific standards addressing requirements for generalist practitioners with regard to substance abuse education or training at the bachelor’s or master’s degree level (CSWE, 2008a), CSWE did publish a guide for “Advanced Social Work Practice in the Prevention of Substance Use Disorders” conceptually linking the content to the 2008 EPAS for use in developing a concentration area of practice (http://www.cswe.org/File.aspx?id=22249). This document emphasizes alcohol, tobacco, and other drug problems are relevant to all facets of social work practice. The Council has published a list of nine universities with faculty research and teaching related to SBIRT (CSWE, 2008b).
Training social work students in SBIRT occurs in tandem in the classroom and in field by both field instructors and faculty. Educational materials related to SBIRT can be intentionally infused into existing curriculum and complement CSWE competencies. In the classroom, SBIRT can be used in case studies, (for example a fictitious client who is concerned about their alcohol use), to illustrate the process at various stages in the planned change process. Often raising the topic of substance use can be uncomfortable, but by relating it to the skills in engagement (such as asking questions, using active listening, and providing feedback), students are provided opportunities to learn how to talk with clients about a sensitive topic while practicing foundational social work skills. Similarly, alcohol and drug screenings instruments can easily be integrated into teaching the stages of assessment or exploration. Reliable instruments related to SBIRT include the CAGE or AUDIT (http://www.integration.samhsa.gov/clinical-practice/sbirt/screening-page), which are generally short questionnaires with ten or fewer questions. In the field, students are often responsible for completing intake assessment and documentation for their agency. The screening tools used in SBIRT could easily be incorporated in this task. Finally, brief intervention allows students to practice giving feedback to their client while practicing skills at this stage and learning how and when to make appropriate referrals. Other steps used in SBIRT that match social work competencies and values include: making ethical decisions such as practicing within individual competency related to substance use; using supervision to guide decisions around brief intervention; and developing knowledge of community resources for referrals. SBIRT can be used to support teaching cultural competency. For example, individuals in the LGBTQ community are at higher risk for substance use (CBHSQ, 2013). Practicing SBIRT with minority case examples allows students to use compatible language and become comfortable talking to clients no matter their background or behavior.
Integrating SBIRT Training in Field Instruction
Field instructors’ comfort with supervising interns in the SBIRT model may depend on their own training in the model. Field instructors can gain informal and formal trainings on SBIRT during field education meetings held annually or semi-annually by social work programs. If more formal training on SBIRT is held on-site, it may be possible to offer continuing education credits (CEUs) as incentives for field instructors to participate. In addition to teaching foundational SBIRT strategies, field instructors can provide critical supervision and opportunities for students to integrate SBIRT into practice. This parallel process allows students to learn the skills in the classroom and practice them in field. Supervisors provide an excellent means of modeling this process for students. They may also ask students open ended questions in supervision, similar to the motivational interviewing strategies used in SBIRT, such as “What do you think was going on with that client?” or “What would make you feel more confident in using SBIRT?” Another area of supervision to explore is asking students about barriers in addressing substance use when engaging with clients or educating them on community resources used for referrals. While SBIRT is grounded in MI, faculty and field supervisors do not have to be experts in this perspective to integrate some key concepts of SBIRT into their practice and teaching. However, gaining further knowledge and experience in MI will make full implementation more effective (Kamya, 2010).
Field instructors may encounter resistance to teaching SBIRT to interns in their agencies. The agencies may not be interested in substance abuse education, may use another preferred model, or may be loath to have field instructors take time away from their work to learn new skills. In addition to the supports described above, (including close advising and CEU’s), field faculty can help field instructors advocate for the implementation of SBIRT. First, they can point out the ubiquity of substance abuse in all populations served by social work agencies. For example, agencies working with youth need to know that more than a third of young adults report binge drinking in the last month, one fifth have used illicit drugs, and 5.2% of younger adolescents were found to have a substance abuse disorder (CBHSQ, 2013). Substance abuse is high among many clients served by social workers: veterans, LGBT populations, people experiencing homelessness and individuals involved with the criminal justice system (CBHSQ, 2013).
Second, there are ample data to show the effectiveness of SBIRT. SAMHSA (2015) identified SBIRT as an evidence-based practice applicable to all levels of social work practice, not specific to settings specializing in substance abuse disorders. Several key organizations have adopted the SBIRT framework, considering it a necessary practice and appropriate for all consumers in a variety of clinical settings. In 2011, The American Academy of Pediatrics began recommending screening all adolescents for substance use, with specific use of SBIRT guidelines (Wiley Periodicals Inc., 2011) and the Joint Commission for the Accreditation of Health Care Organizations created performance standards for hospitals that directly identify SBIRT procedures as data to be tracked (Wiley Periodicals Inc., 2011).
The adoption of SBIRT in so many arenas reflects the cost-effectiveness and accuracy of the model. The National Commission on Prevention Priorities states that alcohol screening and prevention provides the fourth greatest return on medical investment, behind aspirin, childhood immunizations and tobacco cessation (SBIRT Colorado, n.d.). Although there are still restrictions, financial reimbursement has been approved for screening and brief intervention through private insurance, Medicare, and Medicaid (SAMHSA, 2015). As similar policies and procedures aligned with the aims of the Affordable Care Act gain an increasing foothold in medical and clinical settings across the nation, the implementation of SBIRT will likely increase.
Conclusion
In summary, the SBIRT model has been proven effective in early intervention and treatment of substance abuse. The model can be successfully integrated into social work education, both in classroom and in field. This integration depends on access to training sites, understanding of how SBIRT skills complement the EPAS competencies for social workers, and support of field instructors (and their agencies) in supervising interns using SBIRT.
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