The SASSI Institute | News & Reports

"The data from SBIRT is not merely impressive; within the framework of most medical interventions, the impact of SBIRT is astounding, knock-your-socks-off, nearly too good to be true . . . ."

Screening, Brief Intervention, and Referral to Treatment (SBIRT, pronounced “ess-burt”) is a set of procedures for identifying and working with people who are likely to have alcohol or drug problems. Any setting in which high risk individuals appear—emergency departments, trauma centers, public health clinics, primary care physician offices, college health clinics, employee assistance programs—are good venues for SBIRT. In most cases, Medicare, Medicaid, and commercial insurance will pay for this service.

The goals of SBIRT are to decrease the incidence of drug and alcohol problems, decrease the associated personal and societal costs, and to save lives.

Some advantages of using SASSI-3 and Spanish SASSI for adults or SASSI-A2 for adolescents:

SBIRT is quickly becoming a recommended best practice in a variety of settings, especially emergency departments and trauma centers. Billing for these services is becoming easier as more states activate billing codes that will allow for Medicaid, Medicare, Federal Employees Health Benefit Plans, Veterans Administration facilities, and private insurers to pay for SBIRT services (Ault, 2008 ). Specific codes and reimbursement rates are listed at http://www.samhsa.gov/prevention/SBIRT/coding.aspx.

Take Virginia, for example:³ both SASSI-3 and SASSI-A2 are specifically listed as approved screening tools. For Medicaid purposes, most mental health, addictions, and medical professionals can be reimbursed for screening and brief intervention activities (Virginia DBHDS, 2008).

Major insurers covering screening and brief intervention include the Federal Employee Health Benefits Program (Whyche, 2008) and the following private plans: Aetna (nationwide), CIGNA (nationwide), Anthem Blue Cross and Blue Shield (Colorado, Connecticut, Indiana, Kentucky, Ohio, Maine, Missouri, Nevada, New Hampshire, Virginia, and Wisconsin), Blue Cross of California, Blue Cross-Blue Shield in Georgia, Blue Cross-Blue Shield of Minnesota, Empire Blue Cross-Blue Shield in New York, and Independence Blue Cross HealthPlus (Michigan).

When SBIRT began, the focus was on alcohol use and problem drinking. More recently, SAMHSA has broadened its recommendations to include other drugs of abuse such as street drugs and misuse of prescription drugs.

Madras and her colleagues found that screening for both alcohol and illicit drugs was “clearly feasible and clinically appropriate in diverse healthcare settings and for various populations.” They also stated, “The prevalence of illicit drug abuse was clinically significant across a range of substances among the full population screened.” (Madras, Compton, Avula, Stegbauer, Stein, & Clark, 2008, p. 12)

SAMHSA’s experts concur. Speaking specifically about the screening phase in trauma center settings:

The SASSI instruments are validated screening questionnaires that (1) come in both adult and adolescent versions, (2) ask about both drug and alcohol use, and (3) ask about risk factors for addiction problems, such as family history (Babor, McRee, Kasselbaum, Grimaldi, Ahmed, & Bray, 2007). In addition, the Defensiveness scale and other SASSI validity scales help to identify probable minimization, distortion or denial of substance abuse. The U.S. Department of Labor recommends the SASSI for SBIRT in EAP settings.

According to the National Commission on Prevention Priorities (NCPP),⁴ SBIRT ranks 4th out of 25 in a list of prevention activities that medical personnel and health educators should encourage. This ranking takes into account both the “clinical prevention burden, or the disease, injury, and premature death that would be prevented if the service were delivered to all people in the target population” and “cost effectiveness, which is a standard measure for comparing services’ return on investment” (National Commission on Prevention Priorities, 2008).

Primary care physicians in Wisconsin, both urban and rural, participated in an SBIRT trial. Patients (774 in all) were assigned to either a brief intervention or control condition. The average per person benefit to the brief intervention participants, compared to control subjects, was $1,151, at an average cost of only $205 per patient. On a broader level, over $420,000 was saved, approximately equally split between (1) savings in emergency department and other hospital use and (2) avoided costs of crime and motor vehicle accidents (Fleming, Mundt, French, Manwell, Stauffacher, and Barry, 2000).

The U.S. Department of Labor recommends screening for both alcohol and drugs to identify, early on, potential and actual substance abusers. After describing six screening/assessment techniques (Michigan Alcoholism Screening Test (MAST), CAGE, Alcohol Use Inventory (AUI), SASSI, the Addiction Severity Index (ASI), and the Diagnostic Interview Schedule-IV (DIS-IV)), they conclude as follows:

Pregnant women who use alcohol or drugs put the next generation at risk for birth defects or being born with an addiction. Screening for alcohol and drugs in public health clinics and OB/GYN practices can encourage pregnant women to seek treatment, decrease substance use behaviors, and potentially increase fetal health and well-being. Horrigan and colleagues, in two studies, have found the SASSI to be more cost effective than urine screens for detecting drug and alcohol abuse in this population. (Horrigan, Piazza, & Weinstein, 1996; Horrigan & Piazza, 1999)

For information on integrating the SASSI into SBIRT programs, please contact the Clinical Help Line at (888) 297-2774.

Alcohol and Drug Abuse Institute Library (ADAI), 2009, University of Washington. Review of SASSI Instruments. Downloaded from http://bit.ly/SASSI_inst on 01/27/2010.

Babor, T. F., McRee, B.G., Kasselbaum, P.A., Grimaldi, P. L., Ahmed, K., & Bray, J. (2007). Screening, Brief Intervention, and Referral to Treatment (SBIRT): Toward a public health approach to the management of substance abuse. Substance Abuse, 28(3), 7-30. Abstract at http://www.ncbi.nlm.nih.gov/pubmed/18077300.

Fleming, M. F., Mundt, M. P., French, M.T., Manwell, L. B., Stauffacher, E. A., & Barry, K. L. (2000). Benefit-cost analysis of brief physician advice with problem drinkers in primary care settings. Medical Care, 38(1), 7-18. Abstract at http://www.ncbi.nlm.nih.gov/pubmed/10630716

Horrigan, Terrence J.; Piazza, Nick (1999). The Substance Abuse Subtle Screening Inventory minimizes the need for toxicology screening of prenatal patients. Journal of Substance Abuse Treatment, 17, 243-247.

Horrigan, T.J., Piazza, N.J., & Weinstein, L. (1996). The Substance Abuse Subtle Screening Inventory is more cost effective and has better selectivity than urine toxicology for the detection of substance abuse in pregnancy. Journal of Perinatology, (16)5, 326-330.

Madras, B. K., Compton, W.M., Avula, D., Stegbauer, T., Stein, J.B., & Clark, H.W. (2008). Screening, Brief Interventions, Referral to Treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: Comparison at intake and six months later. Drug and Alcohol Dependence. Downloaded 11/18/2009; DOI: 10.1016/j.drugalcdep.2008.08.003. A summary of this article is also available as a news release at http://www.samhsa.gov/newsroom/advisories/0810310048.aspx.

McPherson, T. L., Goplerud, E., Olufokunbi-Sam, D., Jacobus-Kantor, L., Lasby-Treber, K.A., & Walsh, T. (2009). Workplace alcohol Screening, Brief Intervention, and Referral to Treatment (SBIRT): A survey of employer and vender practices. Journal of Workplace Behavioral Health, 24(3), 285-306.

National Commission on Prevention Priorities (NCPP). (2008). Rankings of preventive services for the U.S. population, 2008. Partnership for Prevention, 1015 18th Street NW, Suite 300, Washington, DC 20036. Downloaded 11/30/2009 from http://www.prevent.org/content/view/43/71/.

Substance Abuse and Mental Health Services Administration (SAMHSA). (2007). Screening and Brief Intervention (SBI) for trauma patients. PDF downloaded 11/18/2009 from http://www.samhsa.gov , DHHS Publication No. (SMA) 07-4266.
SAMHSA, 2008: Medicaid Billing Codes, downloaded 01/22/2010 from http://sbirt.samhsa.gov/coding.htm

Virginia Department of Behavioral Health and Developmental Services (Virginia DBHDS). (2008). Substance use disorder and mental health screening instruments. Downloaded 11/18/2009 from http://www.dbhds.virginia.gov/Screeners.htm#instruments.

Whyche, S. Federal workers get coverage for substance abuse screening. May 16, 2008. Psychiatric News, 43(10), p. 4. Downloaded 01/28/2010 from http://pn.psychiatryonline.org/content/43/10/4.1

¹From CSAM News, Winter 2008, p.6. http://www.csam-asam.org/pdf/misc/CSAM_Winter_2008.pdf

²Alcohol and Drug Abuse Institute Library (ADAI), 2009. University of Washington. Review of SASSI Instruments. Downloaded from http://bit.ly/SASSI_inst on 1/27/2010.

³Professionals reimbursed for screening and brief intervention services, approved by the Department of Medical Assistance Services of Virginia; other states are likely to have similar lists: doctors, nurses, nurse practitioners, psychiatric clinical nurse specialists, licensed professional counselors, licensed clinical psychologists, licensed clinical social workers, licensed marriage and family therapists, licensed substance abuse treatment practitioners, all managed care organizations, and mental health/developmental disability agencies. (Virginia Department of Behavioral Health and Developmental Services, 2008)

⁴The National Commission on Prevention Priorities is a committee of academics, public health advocates, and insurance company leaders. It is a project of Partnership for Prevention.

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