Establishing successful addiction screening, brief intervention, and referral programs (SBIR) in primary-care settings requires good training, establishing effective liaisons between primary-care staff and addiction experts, and ensuring that you're adding as little as possible to the staff's existing workload.

But keeping SBIR programs going requires "buy-in" from primary-care partners, good outcomes data and, of course, money, according to experts at the recent Demand Treatment Lessons Learned summit in Chicago, Ill.

Screening and brief intervention are two separate skills that can be used together to reduce risky substance use. Screening involves asking questions about use; a "brief intervention" is a negotiated conversation between a health professional and a patient designed to reduce use.

Not everyone who is screened will need a brief intervention, and not everyone who needs a brief intervention requires treatment. The goals of screening and brief intervention are to reduce risky substance use before people become dependent or addicted.

Seven of Join Together's Demand Treatment communities are screening in emergency departments or hospitals. Ten are screening in the community, such as in physicians' offices, through citywide help lines, or via clergy.

Lessons from SBIR Projects in Indianapolis, Illinois

When the Indianapolis Demand Treatment initiative won a $135,000 grant from the Nina Mason Pulliam Charitable Trust for a SBIR project involving six primary-care clinics, project leaders' first step was to get the clinics to sign a memorandum of understanding committing them to the effort. Then, they linked each site with an addiction-treatment provider, which sent treatment professionals to train the medical staff at the hospital, county sexually transmitted disease (STD) clinic, and community health clinics taking part.

"This created a bond that we hoped would overcome the barrier of lack of trust that the referral would go anywhere," said Janet Arno, M.D., medical director of the Bell Flower STD Clinic and a Demand Treatment project leader. "The training started with '101' stuff -- addiction, stigma, etc. We then talked about the screening tools themselves -- their validity and how to use them."

"The theme for us is collaboration," added Arno. "Over time, every single clinician has become very, very committed to doing substance-abuse screening. The staff credits the feedback given by the matched treatment clinician; also, teaching them the chronic-disease model of addiction really helps."

Each Indianapolis site developed a protocol for how the medical staff would implement SBIR in their particular setting. "This worked best when there was a strong relationship with the matched addiction-treatment provider," said Arno. Still, she said, "It was time-consuming: about 8 months of prep time was needed even after the clinics signed on."

Jennifer Smith, M.D., is associate chief of the Division of General Medicine at Chicago's Rush University Medical Center and program director of the SBIR-focused Demand Treatment initiative in the Cook County Bureau of Health Services, established in 2001 with the goal of setting up SBIR in city health centers and in the Cook County Jail, and funded with $17.5 million from the Substance Abuse and Mental Health Services Administration in 2003.

Smith agreed that taking the time to carefully build a coalition is critical to establishing a successful SBIR program with primary-care partners. "Not all of our meetings were good, and not all of our strategies had tangible outcomes, and we became a rather small group over time," she said. "And yet, we were able to do something really fantastic for Cook County. So, stick with it," she advised other community leaders at the summit.

Critical Liaisons, Simple Protocols

Mark Smith, a licensed social worker for Wishard Health Services, one of the community health clinics participating in the Indianapolis Demand Treatment project, said the addiction professional who comes to his clinic twice a week (for about two hours at a time) not only acts as a resource for staff, but also can meet with clients directly. "You need to have that connection" in order to involve the clinic in the development of the SBIR program, rather than imposing a screening protocol from above, said Smith.

Keeping the SBIR protocols as simply and easy to implement as possible also goes a long way to getting clinical staff to support the program, Demand Treatment leaders said.

"In our preliminary trials, we found that it took about 30 seconds to 1.5 minutes to administer the screening tool; we found it was better to ask in person versus a paper-and-pencil survey," said Arno. "It's not terribly disruptive to the clinic setting."

Jennifer Smith said that in the first phase of the Chicago SBIR project, grant-funded staff agreed to take on the responsibility for screening. "We weren't asking doctors or nurses to do anything new, at least at first," she said. "They only had to move over: this created high acceptance in the medical setting." Only in the second phase of the project will physicians take responsibility for conducting screenings, Smith said.

Of course, to maintain support for SBIR, primary-care doctors and other staff need to be convinced that the effort will yield tangible dividends. Research conducted by the Bell Flower clinic demonstrated that of the 2,756 patients screened since mid-May of 2004, 15 percent were identified as having an addictive disorder. But leaders from both the Indianapolis and Illinois projects acknowledged the difficulty of getting SBIR patients who need help referred to and placed in treatment programs.

"People are equally referred to residential and to brief treatment, but we are learning that it's very important to get people to the door fast," said Jennifer Smith. "We are learning a lot about how hard it is to interface with the treatment system."

Added Arno, "So far, we have limited numbers to show follow up to actual engagement in treatment. Tracking patients is a very difficult thing to do, even with signed consents, because it relies on patient compliance" -- a particular challenge in an STD clinic.

"There is pressure in medical settings that makes SBIR for substance abuse a tough sell," said Chicago's Smith. "They ask: 'How can you spend all this time and money on people who are less sick (right now) when there are people who are real sick, now?' It's a real struggle to keep focus on the early part of the continuum -- that intervening now will save lives and money down the line."

Overcoming such practical and philosophical hurdles to make primary-care doctors advocates for SBIR, and to generate good outcomes data, may be the biggest challenge to getting primary-care providers to internalize (and fund) SBIR once grant funding for projects like those in Indianapolis and Chicago inevitably dries up.

"If you don't have data to show there is a value added to put [SBIR] in, you won't get the dollars from your local health system," said meeting attendee Frank Vocci, M.D., the lead treatment researcher at the federal National Institute on Drug Abuse. "You can get sustainability by showing effectiveness."