Christina Lightbourn knows drinking is a touchy subject for many people. Her job is to push them to discuss it, which requires a fair amount of tact.
"I'm not here to make the patient feel bad about the choices they're making," says Lightbourn, health educator at UW Health's Northeast Family Medical Center. "I'm here to help the patient see that the alcohol or substance abuse could be having an impact on their life in a negative way and suggest changes they could make."
Lightbourn is the clinic's point person for SBIRT (www.sbirt.samhsa.gov), pronounced ESS-burt. The acronym stands for Screening, Brief Intervention and Referral to Treatment.
In 2006, the Wisconsin Department of Health Services began receiving a five-year, $12.6 million grant from the U.S. Substance Abuse and Mental Services Health Administration to implement the SBIRT program throughout Wisconsin. The UW School of Medicine and Public Health is helping carry out the program, now available at 20 sites throughout the state, including the Northeast Family Medical Center and Dean East Clinic in Madison.
SBIRT gives patients a questionnaire when they check in for an appointment, asking about drug and alcohol use. Professionals like Lightbourn review these responses for red flags that may indicate problems. They also check to see if there is a family history of substance abuse and any medical conditions like hypertension, high cholesterol or diabetes that might be exacerbated by drug or alcohol use.
Armed with this knowledge, Lightbourn initiates a discussion with the patient. She asks open-ended questions to help place the patients' use of substances into one of four categories: low risk, at risk, harmful use and likely dependent.
Advice is given sparingly, and patients are not told what to do. As Lightbourn puts it, "The patient is driving the bus, and the decision is up to them to decide if they would like to make a change in their alcohol and drug use."
Wisconsin is one of 11 states participating in the SBIRT program. From March 2007 through mid-November 2009, 76,414 brief screenings were completed statewide in participating clinics, leading to 14,179 brief interventions, 315 referrals to treatment and 114 patients who have received treatment.
According to the Wisconsin Initiative to Promote Healthy Lifestyles (WIPHL), which coordinates the SBIRT program, Wisconsin leads the country in binge drinking and drunk-driving violations. Almost 6,000 motor vehicle accidents per year are attributed to drinking, and more than 126,000 state arrests are made annually because of alcohol abuse. More than half of all Wisconsin motor vehicle fatalities are alcohol-related.
The UW Population Health Institute estimates that more than a half-million Wisconsin residents suffer from alcohol or drug dependence or abuse. Alcoholism is the fourth-leading cause of death in Wisconsin and is linked to over 2,000 state deaths annually. The economic toll of such cases - through health care, social services and criminal justice systems - tops $5 billion a year.
But screening can make a difference. WIPHL research shows a 20% decrease in binge drinking, a 50% decrease in motor vehicle accidents and a 46% decrease in arrests involving alcohol among program participants. And that saves money as well as lives.
"By treating the patients before a problem begins, the long-term health of the patient is improved," says WIPHL clinical director Dr. Richard L. Brown, an associate professor of family medicine at the UW School of Medicine. "SBIRT prevents hospital admissions, ER visits, motor vehicle crashes and injuries that arise from drinking and drug use."
The Wisconsin SBIRT grant, which runs through 2011, provides $2.5 million annually to cover program expenses, including 20 health educators located in urban and rural settings. About 15% of the funding goes to cover the cost of treatment for people who can't afford it.
Brown, a national leader in the SBIRT approach, is working to continue the program beyond 2011. The goal is to pass the cost of screening services on to third-party payers, who save money by catching substance-abuse problems early on.
Currently a dozen major health plans are covering the services. Beginning in January, SBIRT will be covered by Medicaid and BadgerCare Plus, which will create a platform to extend access to SBIRT throughout Wisconsin. And proposed parity legislation would expand coverage for mental health and substance-abuse problems.
"SBIRT is increasingly being seen as a standard of care," says Brown. "Just as a patient would expect to have their blood pressure taken during a clinic visit, they would also expect to be asked about their drinking and drug use."
Ultimately, he hopes to expand the program to include screening for tobacco usage, obesity, depression and inactivity.
The Northeast clinic, where Lightbourn works, uses a team approach. Each of its 26 providers screens patients with SBIRT, then Lightbourn steps in.
"When you consider that a doctor only spends 15 minutes with a patient who might have a list of medical concerns to discuss, it leaves little time to discuss substance-abuse issues," says Kathy Oriel, a family physician at the clinic. "That's why Christina's job is so important. She's able to take time with the patient and really get to know them. Patients open up with her as they feel comfortable with her."
Lightbourn tells of one 48-year-old patient who drank four to six beers three to four days a week. Twice per month, the patient - who has heart issues and was not taking prescribed meds - would also use crack.
After a recent physical, the doctor arranged for the patient to meet with Lightbourn, who conducted a brief intervention. The patient agreed to participate in residential treatment at Tellurian and has successfully completed treatment and follow-up.
Lightbourn has also helped many patients lessen their drinking by explaining what constitutes a standard drink. This is defined as a 12-ounce beer or wine cooler; a 1.5-ounce shot of whiskey, gin, vodka or other spirits; or a 5-ounce glass of wine.
"Most people think they are drinking within what a standard drink is," she says, "but in reality they are drinking much more alcohol, especially if they are drinking doubles."
Brown says screening for substance abuse is 'increasingly being seen as a standard of care.'
How much is too much?
According to the National Institute on Alcohol Abuse and Alcoholism, these are the recommended alcohol limits for men ages 21-64: no more than 14 drinks per week or more than four drinks in a day or evening.
- Women ages 21-64 (who are not pregnant): No more than seven drinks per week or three drinks in a day or evening.
- Men and women 65 and older: No more than seven drinks per week or one drink in a day or evening.
- People who should never drink: women who are pregnant or trying to become pregnant; people who are about to drive or do anything that needs attention and skill; people who take certain medications or who have medical conditions made worse by drinking; and people under age 21.
For more information and screening questions, see www.wiphl.com.