By Beryl Lieff Benderly
To someone with an injury or sudden illness, a visit
to a hospital emergency room can seem an endless stretch
of anxiety and frustration punctuated by periods of boredom.
But to a health educator, the time a patient spends
waiting to see a doctor can be a prime "teachable
moment." In a hospital setting, patients are strongly
focused on their health and highly attuned to hearing
and acting on the advice they receive.
So powerful is the patient's receptivity within the
medical encounter that SAMHSA's Center for Substance
Abuse Treatment (CSAT) granted $108 million over 5 years
to six states and one tribal council so that they can
harness it to reduce drug and alcohol abuse.
Known as Screening, Brief Intervention, Referral, and
Treatment (SBIRT), this CSAT initiative shifts the emphasis
to alcohol and drug users whom the traditional system
has largely ignored—those who consume more than
the medically accepted limits but are not yet dependent.
Rejecting the notion that only people with serious levels
of abuse or dependency need targeted interventions, SBIRT
assumes that everyone, regardless of current level of
alcohol or drug consumption, can benefit from learning
the facts about safe alcohol consumption and knowing
how their own usage compares to accepted limits.
SBIRT further assumes that many people who consume amounts
above those limits do not understand the risks they face
but can and will change their behavior when they find
out. For that reason, providing education about the consequences
of substance abuse is a major part of the program.
The brief interventions made possible by the SBIRT grants
"can reorient many people away from behavior that,
unchecked, can lead to addiction," says SAMHSA Administrator
Charles G. Curie, M.A., A.C.S.W. Starting in 2003, the
seven jurisdictions received renewable grants to bring
SBIRT services to hospitals, clinics, and other general
medical settings. (See Current SBIRT
Projects.)
One of these programs, California SBIRT (CASBIRT), is
testing the model by integrating uniform alcohol and
drug abuse screening services into 16 emergency rooms,
trauma centers, and health clinics in San Diego County.
CASBIRT staffers conduct a private interview with every
patient who arrives at these facilities and provide each
person with an individualized intervention appropriate
to the level of risk for abuse.
They have screened more than 225,000 people since January
2004, with impressive results.
"More than half of the people who have that single
interaction change their alcohol consumption," and
months later they are still consuming less than before
contact with SBIRT, says Tom Stegbauer, M.B.A., a lead
public health analyst in the CSAT Division of Systems
Improvement.
Such results show that the medical encounter is "too
good an opportunity not to deliver a prevention message,"
says Linda Peek, Associate Director for Altam Associates,
the San Diego company that administers the CASBIRT program
under contract with the state of California.
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Adding Screening
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Norma Devonish, Assistant Operations
Manager for Altam Associates, informs Dr. Susan
Panah at North County Health Services about her
patient's high-risk alcohol and drug use and the
referral she just made for brief treatment services
with a CASBIRT counselor.
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SBIRT brings the same approach to alcohol and drug abuse
as is used with other chronic conditions, Mr. Stegbauer
says. "We want to catch people early on, talk to them
about their consumption of alcohol and drugs. Think of
what we do in treating diabetes or what we do with cardiology
patients. We don't wait for the third heart attack to tell
people they need to get the cholesterol out of their bloodstream.
We screen with cholesterol tests, then we talk to them
about diet. We talk to them about their consumption."
Screening for heart disease or diabetes risk, however,
is accepted medical practice. Systematic screening for
alcohol and drug abuse has not attained that status,
despite the drastic effects of such abuse on health.
In addition, physicians have been slow to adopt this
new service in their medical encounters with patients.
The most effective way of getting SBIRT services into
busy emergency rooms and clinics, Ms. Peek says, is to
add "a new member to the health care team"
who is exclusively dedicated to providing these services.
Known as a peer health educator, this new team member
"looks like everybody else" in the medical
setting, says J.R. Ayala, CASBIRT Operations Manager.
The secret to an effective SBIRT program is combining
the science that supports the screening and intervention
protocols used in the interviews with a strong ability
to build rapport with patients, Mr. Ayala adds.
Between arriving at an emergency room and receiving
treatment from a physician, "a stream of people"
come in contact with the patient, Ms. Peek explains.
"One of those individuals is a member of our [CASBIRT]
staff wearing the same surgical scrubs and hospital ID
as other emergency room personnel," she continues.
"This person is going to be friendly, engaging,
and empathetic to the patient."
The peer health educator is "well trained to be
non-judgmental and non-threatening," and "well
scripted" on how to conduct interactions that produce
accurate screening results and effective interventions,
Ms. Peek adds.
The notable friendliness is no accident, because no
part of the CASBIRT encounter is left to chance. "Intense
and specific" training guides peer health educators
on everything from facial expressions and body language
to responses to what patients say, Mr. Ayala states.
"The empathy that we provide within the scientifically
scripted forms" results in fewer than 1 percent
of patients who decline to undergo screening.
Top Image Caption: Maggie Robles, a Health Educator Supervisor, roleplays screening questions with "patient" Juana Aguilar.
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