Abstract:
Research on alcohol Screening, Brief Intervention and Referral to Treatment (SBIRT) suggests that while brief interventions are effective for reducing alcohol and other substance use in medical settings, effects are small and program implementation is difficult and costly. This article describes SBIRT-Plus, which is designed to expand effectiveness and population reach of traditional SBIRT programs. SBIRT-Plus focuses on systems-level issues like social marketing of SBIRT services and interventions via social media and community-based information sources. Older adults could benefit widely from SBIRT-Plus due to frequent healthcare services use and risk of alcohol-medication interactions. But access to such services needs to increase.
Key Words:
alcohol screening, brief intervention, referral to treatment, SBIRT, SBIRT-Plus, alcohol-medication interactions
Research on alcohol Screening, Brief Intervention and Referral to Treatment (SBIRT) suggests that while these interventions are effective in medical settings in reducing alcohol and other substance use, the average effects are small, and program implementation is difficult (Kaner, et al., 2018; Heather, 2012; McCambridge and Saitz, 2017).
SBIRT was developed and tested in unselected samples of medical patients, and, of particular interest to this article, there have been studies of subpopulations of older adults, adolescents, and college students, showing effectiveness (Kaner, et al., 2018). Nevertheless, little attention has be given to the adaptation of the SBIRT message and its delivery techniques to the needs of these different population groups, while the alcohol industry carefully crafts its “market” to design products and communicate tailored messages to specific population subgroups.
Segmentation and adaptation could extend the population reach of SBIRT if a public health approach is added to the typical programmatic and dissemination strategies. These often consist of a brief medical encounter using motivational interviewing to persuade the patient to avoid hazardous drinking (Babor, Robaina, and Noel, 2017). Using older adults as a critical market segment for SBIRT, this article describes how these programs can be adapted and expanded into SBIRT-Plus, a new concept designed to improve the effectiveness and population reach of traditional, clinician-based programs. A population approach would add a variety of support mechanisms designed to facilitate, extend, and reinforce the typical SBIRT patient encounter with environmental and population measures to complement the clinical intervention.
Older adults could be one of the most appropriate population subgroups for SBIRT-Plus. This cohort’s growing numbers in the U.S. population, the rising prevalence of hazardous drinking in this group, and its frequent contacts with medical providers speak to the need and to the opportunity to reduce morbidity. Although older adults in later life tend to reduce the average quantity of alcohol consumed per occasion, they are also more likely to increase the frequency of drinking as they age (Molander, Yonker, and Krahn, 2010). Health problems associated with both acute and chronic alcohol use are a major risk factor for older adults; in addition, elders are at high risk for alcohol-medication interaction effects (Breslow, Dong, and White, 2015).
As a public health approach, SBIRT-Plus focuses on systems-level issues such as social marketing of SBIRT services through mass media and the Internet. It promotes enhanced delivery mechanisms through the use of the electronic medical records, waiting room prompts, and self-assessment procedures for screening (Babor, Robaina, and Noel, 2017). These SBIRT-Plus innovations are designed to bring more people into SBIRT and to export SBIRT services from the clinic to the community.
Bringing More People into SBIRT
Increasing access to settings or media offering SBIRT services to older populations can increase the number of individuals screened, identified, and receiving an intervention or referral to more intensive services. Care settings for older adults include hospitals, primary care clinics, nursing homes, assisted living facilities, and retirement communities. SBIRT delivery has been successfully taught to a range of health workers employed in these settings.
Several enhancements can be incorporated into traditional SBIRT programs to make them more relevant to older adults. For example, the waiting room in a healthcare clinic has been described as an opportunity to prime patients, as well as healthcare providers, for discussing alcohol use during consultations (Boekeloo et al., 2003). Methods include posters, flyers, educational videos, and computerized screening tests (McCarthy et al., 2019).
One promising strategy to overcome cognitive barriers in older adults is to use visual communication techniques, such as infographics, to explain health information through images and simple text (Pratt and Searles, 2017). Visual communication aids can increase attention, recall, comprehension, and adherence to health information, particularly among individuals with cognitive impairment and low health literacy (Schubbe et al., 2020).
In addition to waiting room strategies, SBIRT can be incorporated into the electronic medical record (EMR) and upgraded to include the rapid identification of potential alcohol-medication interactions. One national study showed 78.6 percent of ages 65 and older U.S. adults using medications that interact with alcohol (Breslow, et al., 2015). Alcohol interacts negatively with many commonly prescribed medications, increasing the risk of falls, traffic accidents, alcohol poisoning, and liver pathology, and by neutralizing the therapeutic potential of medications. Commonly used interactive medications are prescribed for cardiovascular disease, allergies, flus, anxiety, depression, arthritis, cough, diabetes, hypertension, infections, pain, and sleep problems.
Optional modules developed for some EMRs include prompts for providers to discuss screening results with patients, as well as the need to abstain from alcohol or to minimize its use because of potential alcohol-medication interactions. By developing algorithms to rapidly identify currently used medications that are incompatible with reported levels of alcohol use in a screening test, large numbers of new patients could be added to the purview of an SBIRT program.
Bringing SBIRT to More People Beyond Healthcare Settings
Other strategies could extend the impact and reach of SBIRT programs beyond traditional medical settings to include the incorporation of SBIRT technologies and messages into eldercare facilities, community networks, and social media popular with older adults. The use of substitutes and surrogates such as nursing home personnel and other midlevel professionals has been suggested as a way to expand SBIRT, based upon evidence that they can be as effective and reach more patients than primary care physicians, who often are too busy to conduct systematic screening and brief interventions (Keurhorst et al., 2015; Babor et al., 2005).
An alternative to using healthcare personnel to deliver SBIRT services is to use Web-based or app-based screening technologies, which can provide feedback and patient education materials (Kypri et al., 2008). Some evidence has shown that these technologies can engage “at-risk “ drinkers in self-change efforts by linking them to Internet-based SBIRT interventions, or by using self-assessment results to motivate a discussion with their doctor or primary care provider (Cunningham et al., 2016;). Internet-based interventions can be expanded further by providing the equivalent of outpatient treatment and to improve referral to traditional treatment programs, if needed.
Using images and situations featuring older adults can reinforce messages for sticking to recommended amounts of alcohol.
Social marketing is another way to increase the number of individuals exposed to SBIRT messages and programs. Social marketing consists of advertising techniques designed to influence or enhance health behaviors. Such campaigns have significantly reduced alcohol consumption, binge drinking, alcohol-impaired driving, and alcohol-impaired driving accidents (Janssen, et al., 2013). While studies have yet to determine whether social marketing campaigns can increase SBIRT’s population reach and impact with older adults, there is encouraging evidence from related fields (Wei, et al., 2011; Henderson, Evans-Lacko, and Thornicroft, 2013).
Social marketing campaigns to increase SBIRT’s population reach could be modeled on methods used by the alcohol and pharmaceutical industries to increase demand for their products. The key advice communicated in most brief interventions programs is to drink within recommended drinking limits, which in the United States are no more than one drink per occasion for women and no more than two drinks for men. For adults older than age 65, the recommendation is only one drink daily for both men and women.
If social marketing messages could substitute those limits for the alcohol industry’s ambiguous “drink responsibly” messages, it could help to generate norms that complement SBIRT messages communicated in healthcare settings. Using images and special situations featuring older adults can reinforce the messages for sticking to recommended amounts.
Another approach is to market SBIRT services to consumers using direct-to-consumer advertising and “ask your doctor” campaigns, which have been found to increase patient inquiries and influence physician prescribing behavior (Gellad and Lyles, 2007).
Using community-based opinion leaders is a third social marketing strategy to support SBIRT’s low-risk drinking guidelines, alcohol abstention campaigns (e.g., “Dry January” programs), as well as opposition to hazardous drinking activities like wine and beer tasting events and COVID-19 happy hours in assisted living and nursing home settings. Influencer marketing, or social media marketing, is a hybrid of old and new tools that goes beyond celebrity endorsement to communicate a brand (e.g., a hospital-based SBIRT program) and a message (e.g., adhere to lower risk guidelines). Influencer marketing of SBIRT could involve doctors and providers in a range of disciplines, people in recovery, clergy, and community leaders. The alcohol industry recruits opinion leaders, often celebrities, to endorse, promote, and model the use of its products. Educating opinion leaders about the benefits of SBIRT and the availability of its services could be a potentially effective strategy.
Other strategies designed to extend the reach of SBIRT messages include:
- Dissemination of low risk drinking guidelines and related SBIRT messages at healthcare clinics, pharmacies, community organization newsletters, local newspaper articles, and public service announcements.
- Creation of a digital SBIRT capability using online screening, web-based behavior therapy, and referral to treatment information.
- Enlisting pharmacists and other health professionals to disseminate SBIRT messages.
- Distribution of evidence-based warning labels based on key SBIRT messages that define the lower risk limits of “responsible drinking,” the health benefits of not drinking, and the health risk for cancer and many other diseases of even low doses of alcohol. This approach has met with some success in Northern Canada (Zhao, et al., 2020).
Conclusion
This article explores opportunities for improving the effectiveness and population reach of SBIRT, expanding it into a multicomponent public health program aimed at disseminating SBIRT concepts and program components through electronic and social channels, EMRs, and Internet-based interventions, as well as nursing homes, retirement communities, and community organizations.
The population impact of SBIRT programs will continue to be limited for older adults and others unless better ways are found to increase the number of individuals who access SBIRT services (“bringing people to SBIRT”) and new program elements are added to bring SBIRT services out of the clinic and into the community (“bringing SBIRT to the people”).
With the pervasive use of medications that interact with alcohol, and the increasing risks of medical and non-medical cannabis use, there is a growing need to scale up a more population-oriented version of SBIRT in order to address the needs of older adults.
Thomas F. Babor, PhD, MPH, is a professor of Community Medicine and Public Health in the Department of Public Health Sciences at the University of Connecticut School of Medicine in Farmington, Connecticut.
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