1. Overview of the SBIRT Process
David P. Miller, MD, MS, FACP
Associate Professor
Internal Medicine and Public Health Sciences

2. 5 Basic Components of an SBIRT System
Prescreening (1-2 question screen)
Screening (AUDIT / DAST; CRAFFT)
Clinician Intervention for all screen-positive clients
Referral as appropriate for clients with higher levels of risk or possibly dependent
Follow-up assessment/reinforcement at future visits

3. STEP 1: Prescreen is routinely performed every 6-12 months
Tools: Single alcohol screening question (SASQ - NIAAA)
single drug screening question (NIDA)

4. Prescreening Questions
“Single Alcohol Screening Question” (NIAAA)
Do you sometimes drink beer, wine, or liquor?
How many times in the past year have you had more than (3 or 4) drinks in a day?
“Single-Item Drug Use” (NIDA)
How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?

5. STEP 2: Administer screening IF prescreen is positive
Tools: AUDIT (for alcohol)
DAST-10 (for drugs)

6. AUDIT (for + alcohol prescreen)
Adapted from World Health Organization
3 quantity & frequency questions (1-3)
3 questions probing signs of dependency (4-6)
4 questions about alcohol-related problems (7-10)
Score Range:

7. DRUG USE QUESTIONNAIRE (DAST -10)
These questions refer to the past 12 months only:
Circle Response
1. Have you used drugs other than those required for medical reasons?
Yes No
2. Do you abuse more than one drug at a time?
3. Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis,
convulsions, bleeding, etc.)?
4. Have you had “blackouts” or “flashbacks” as a result of drug use?
5. Do you ever feel bad or guilty about your drug use?
6. Does your spouse (or parent) ever complain about your involvement with drugs?
7. Have you neglected your family because of your use of drugs?
8. Have you engaged in illegal activities in order to obtain drugs?
9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?
10. Are you always able to stop using drugs when you want to?
DAST-10 score (add circled responses in left column)
See printed form (color?)
Southeastern Consortium for Substance Abuse Training © 2013

8. DAST-10 Advantages Short, self-administered Disadvantages
Is not drug-specific
Validation data is limited
Does not distinguish between active and inactive illicit drug use
Focuses on dependence
Southeastern Consortium for Substance Abuse Training © 2012

9. Sensitivity & specificity in the discrimination of drug use disorders
Risk Zones
AUDIT Score:
DAST Score:
High
Risk
At Risk
Low/No Risk
1-13
≥ 14
1-2
3-10
(No drug use)
Sensitivity & specificity in the discrimination of drug use disorders
with psych populations are optimized with a score of ≥3 (Maisto et al., 2000).
Sensitivity & specificity in the discrimination of drug use disorders
with psych populations are optimized with a score of ≥3 (Maisto et al., 2000)
Southeastern Consortium for Substance Abuse Training © 2012

10. Prescreening/Screening for Adolescents: CRAFFT
During the past 12 months, did you:
Drink any alcohol (more than a few sips)?
Smoke any marijuana or hashish?
Use anything else to get high?

11. Prescreening/Screening for Adolescents: CRAFFT
Ask everyone

12. Risk Zones High Risk At Risk Low/No Risk CRAFFT >2 0 or 1
(use alcohol or drugs)
Sensitivity & specificity in the discrimination of drug use disorders
with psych populations are optimized with a score of ≥3 (Maisto et al., 2000).
Southeastern Consortium for Substance Abuse Training © 2012

13. STEP 3: Administer Brief Intevention

14. Components of a Brief Intervention
Ask permission
Provide feedback
Enhance motivation
Provide advice
Discuss next steps
Close on good terms

15. Intervention Guide
Zone I: At Risk
AUDIT 1-13 (≥ 1 binge); DAST 1-2
Zone II: High Risk, Possibly Dependent
AUDIT ≥ 14; DAST 3-10
Rev. Mar 2012
Funded by:
Ask Permission
“I appreciate your answering our health questionnaire. Could we take a minute to discuss your results?”
Provide Feedback
Refer to pyramid & provide patient’s AUDIT/DAST score & risk level(s). [As your physician] “Drinking/using at this level can be harmful to your health and possibly responsible for the health problem for which you came in today. What do you make of that?”
Enhance Motivation & Elicit Change Talk
“What are the good things/not so good things about your alcohol/drug use?” (Decisional balance)
“On a scale of 0-10, how important is it that you cut back or quit your alcohol/drug use?”
If >0, “Why that number and not a lower one?” [Use rulers to also ask about confidence, readiness]
“Have you ever considered cutting back or quitting?” If so, “Why?” If not, “What would have to happen for you to
consider cutting back/quitting?”
Provide Advice
Refer to chart on front of card in providing advice to quit or cut down as per NIH guidelines (or offer advice to quit or cut back drug use).
Zone II Additional Steps:
Ask: “If you go a day or 2 without drinking/using do you ever get sick, shaky, have tremors/seizures/cramps, or see/hear things that are not there?”
Offer menu of options for more help:
► Medication (naltrexone, acamprosate,
disulfiram, methadone, Suboxone)
► Referral
•Counseling/Brief treatment
•Support group (e.g., AA, NA, Celebrate
Recovery)
•Treatment or substance abuse program
Discuss Next Steps
“If you were to make a change, what would be your first step?”
Close on Good Terms
Summarize, emphasize patient strengths, highlight change talk and decisions made. Arrange for follow-up as appropriate.
Intervention card adapted from Oregon Health & Sciences University SBIRT Primary Care Residency Initiative

16. STEP 4: Refer to Treatment (if indicated)

17. Local Treatment Resources
Detox
Inpatient
Outpatient
Faith-based
Long-term residential
Every site needs to develop their own resource list.

18. STEP 5: Follow-up
Reassess
Reinforce