The United States is grappling with two severe health crises: the COVID-19 pandemic and an opioid epidemic that appears to be worsening as more people deal with stress and isolation as they face increased barriers to medical care. Preliminary numbers for 2020 show that overdose deaths were outpacing the record-setting number of more than 71,000 fatalities in 2019.
More than ever, it is key to connect patients with opioid use disorder (OUD) to treatment as early as possible. Primary care offices can be among the most promising places to make this connection because they typically see patients over long periods of time. And a model for confronting substance use disorder, including OUD, that was pioneered by the National Academy of Medicine can help. This approach, which has been around for decades, has a long name—screening, brief intervention, and referral to treatment—that is usually shortened to SBIRT.
SBIRT is used in health care settings to screen patients for substance misuse. Based on an initial assessment, providers can start an intervention, provide treatment, or refer patients to specialty care. Although most research on the use of SBIRT is for alcohol misuse, a growing number of studies indicate that the approach may be effective in reducing misuse of other substances as well.
One reason for that is so many Americans routinely visit their doctors. Just more than three-quarters of U.S. adults surveyed in 2018 reported visiting or consulting a primary care physician at least once a year. And a three-year study that concluded in 2016 found the prevalence of OUD among primary care patients as high as 1.4%, higher than the prevalence of OUD among U.S. adults generally (0.8%) during the last year of the analysis. Still, these rates may not fully capture the amount of OUD because many physicians do not generally assess or document the illness. Broader use of SBIRT assessments could ensure that they do.
Primary Care Providers Can Routinely Screen for Opioid Use Disorder
To follow the SBIRT approach, clinicians can take the following steps and ask these sample questions during standard checkups and office visits.
Step 1: Screening
Clinician uses an evidence-based questionnaire to assess possible severity of patient substance use and identifies the appropriate level of intervention.
“How many times in the past year have you used an illegal drug or prescription medication for nonmedical reasons?”
Step 2: Brief Intervention
When needed, the clinician provides patients with feedback on their assessments, discusses risks, enhances their motivation to change, and discusses individualized goals.
“On a scale from 0-10, how ready are you to change any aspect of your drug use?”
“On a scale from 0-10, how confident do you feel to make these changes?”
Step 3: Referral to Treatment
Patients identified as needing more intensive care are referred to specialty treatment.
Source: The U.S. Department of Health and Human Services’ Substance Abuse and Mental Health Services Administration
Evidence of SBIRT’s effectiveness
Peer-reviewed research indicates that SBIRT may be effective in reducing drug misuse in a variety of medical and community settings. A 2017 study of 11 programs serving over 1 million in total people found an 80% reduction in self-reported illicit substance use, including opioid use, following intervention. For example, Washington state’s SBIRT program found that 84% of those who had been assessed using the process reported a reduction in days of drug use six months later. The program also saw an increase—from 55% to 71%—in the number of people reporting abstinence from illicit drugs in the past month. And in a randomized controlled trial in 2005 at an urban teaching hospital, researchers found that use of heroin and cocaine each declined by 29% following SBIRT interventions by peer educators.
But some of these outcomes are based on self-reported data, and other studies suggest no difference in outcomes for some who received SBIRT. That means additional research is needed to fully assess how effective the intervention is in identifying, intervening, and facilitating treatment for people with OUD.
Federal policymakers can support SBIRT implementation and evaluation through grant awards to states. These efforts should focus on evaluating outcomes broken down by setting and substance being misused. States interested in implementing SBIRT programs for OUD should monitor federal funding availability and the evolving research.
Further, state Medicaid program administrators should opt to cover SBIRT so providers can get reimbursed for these services, which can be done by activating Medicaid SBIRT billing codes already authorized by the federal government and assigning reimbursement amounts. This process varies by state, but would encourage a more sustainable funding mechanism for this approach to OUD in the absence of specific grants. In addition, states may need to take further steps to ensure implementation of this practice, such as offering incentives for providing SBIRT services—because Medicaid reimbursement rates can be low—and expanding the list of providers permitted to apply for reimbursement.
Primary care settings are uniquely positioned to identify patients who may be at risk of OUD. With proper education, resources, and funding, many more offices could use the SBIRT approach to help their patients. In this time of great need, such approaches can offer clinicians more opportunities to link people with OUD to lifesaving treatment.
Beth Connolly is a director and Vanessa Baaklini is an associate for Pew’s substance use prevention and treatment initiative.