A troubling trend of increasing substance use, including alcohol, amid the stress and isolation of the COVID-19 pandemic is occurring (Pfefferbaum & North, 2020). Mental health clinicians and healthcare systems have a role to play in the response. But what is the best way to lend a helping hand to those hospitalized with comorbid addiction, in a time of scarce resources?
A new study conducted by researchers at Wake Forest University School of Medicine and The University of North Carolina at Greensboro suggests a solution to effectively help hospitalized patients suffering from alcohol problems – while saving health systems money (McCall et al., 2022). The findings center around mental health counselors using an individualized intervention technique called SBIRT, which stands for Screening, Brief Intervention, and Referral to Treatment (Substance Abuse and Mental Health Services Administration, 2021). In the study, counselors administered SBIRT as members of powerful integrated teams, working alongside doctors, nurses, and other healthcare staff in trauma, burn, and general medicine units.
Research findings suggest that hospitalized patients with risky alcohol use or alcohol use disorders were 68% less likely to be hospitalized again or visit the Emergency Department (ED) after receiving SBIRT from a mental health counselor, compared to patients not seen by the counselors. If the patients who received SBIRT did end up needing the hospital or ED in the year following the intervention, the cost of their healthcare needs averaged $2,547 less than patients who did not receive SBIRT (McCall et al., 2022). Of note, the results were not significant for patients using illicit drugs and/or prescription medications or both alcohol and drugs.
The U.S. healthcare system is struggling to provide effective care for patients with alcohol and other substance use problems when costs are rising, and healthcare resources are increasingly strained. SBIRT conducted by counselors working on integrated care teams may be a critically needed solution.
The risky and disordered use of alcohol, illicit drugs, and prescription medications in the United States is a public health crisis with severe consequences, jeopardizing the health of millions of people each year (Degenhardt et al., 2018). Substance use disorder increases the risk of physical and mental health problems, poor medical outcomes, and mortality. The costs to society from substance-related crime, lost productivity, and injuries amount to approximately $520 billion annually (National Institute on Drug Abuse, 2020).
The scope of the problem is vast, with over 67 million US residents engaged in problematic alcohol use and 53 million misusing or abusing illicit drugs and prescription medications (Substance Abuse and Mental Health Services Administration [SAMHSA], 2019). Alcohol-related deaths surpass 95,000 annually (Esser, 2020), and drug overdoses account for more than 100,000 deaths per year, the majority of which are unintentional (Centers for Disease Control and Prevention [CDC], 2021; Olfson et al., 2019).
Despite the dire consequences, treatment options remain limited for individuals struggling with substance use. Many treatment programs are designed for individuals who already use substances at disordered levels, leaving people with potentially harmful use with few options (SAMHSA, 2017). Even for individuals with disordered substance use, only a small percentage receives treatment each year, with only 6.3% of people with alcohol use disorders and 13.4% of those with drug use disorders receiving treatment (Grant et al., 2015; Grant et al., 2016).
The stigma associated with problematic substance use is a major barrier to treatment-seeking (Tai & Volkow, 2013). People may deny their need for treatment or try to self-manage their substance problems (Substance Abuse and Mental Health Services Administration [SAMHSA], 2015). In a study of 4,000 adult health center patients, researchers found that disordered substance use was widespread but patients’ willingness to enter treatment was low, with only 7% of patients agreeing to be helped (Lebrun-Harris, Tomoyasu, & Ngo-Metzger, 2014).
Another barrier to treatment-seeking is the historical separation of medical care from mental health care. Treatment for substance-related physical problems occurs in hospitals and clinics, while treatment for substance use disorders takes place in specialty facilities (SAMHSA, 2017). This body-mind separation of care, along with strict federal privacy laws surrounding substance use disorder treatment that forestall open communication among providers, creates fragmentation of services and failure to coordinate treatment plans (Fornili, 2016). The absence of coordinated care may be a significant factor in relapse rates. Of people entering specialty treatment, 64% have done so at least once before (White & Kelly, 2011). The lifetime recovery rate from substance disorders is only 50-60% (White & Kelly, 2011), a systemic failure that brings enormous personal costs to families, communities, businesses, and governments (Everett & Benjamin, 2014).
Medical professionals manage the acute and chronic conditions caused by substance use, particularly during hospitalizations and ED visits. People with substance problems overuse these services, which are among the most expensive for health systems (Cornett & Latimer, 2011; Hankin et al., 2013; Hoffman & Cronin, 2015). They are overrepresented among ED patients, needing care for intensive conditions such as trauma, pain, and overdose (Bernardino et al., 2015; Hankin et al., 2013). Prolonged substance use is a major cause of chronic medical illness, which increases the frequency of hospital admissions and length of hospital stays (Friedman, Jiang, & Elixhauser, 2008).
Because about 90% of U.S. residents see a physician at least once per year (CDC, 2020), an innovative alcohol intervention model was developed by the World Health Organization and introduced into medical settings three decades ago: Screening, Brief Intervention, and Referral to Treatment (SBIRT) (Babor et al., 2007; SAMHSA, 2013). Later, SBIRT was adopted for illicit drugs and prescription medication misuse (Babor, Del Boca, & Bray, 2017). A key benefit is its universal nature; SBIRT allows health professionals to detect hidden substance problems and intervene even with patients not actively seeking help (SAMHSA, 2013). Patients of medical practices tend to view substance screening and counseling as part of their providers’ roles, so rarely object to these interventions (Sacks et al., 2016). With a growing evidence base, SBIRT is operational or under implementation in medical practices in over half of U.S. states (Agley et al., 2014) and administered in outpatient, ED, and inpatient settings (Babor et al., 2017).
SBIRT interventions by physicians and nurses are associated with reducing risky alcohol use in outpatient and emergency settings (SAMHSA, 2013). However, research outcomes for SBIRT are inconclusive when applying the intervention to inpatient medical settings, for alcohol use disorders, or for risky or disordered use of illicit drugs or prescription medications (SAMHSA, 2013). For example, a meta-analysis by Mdege and Watson (2013) included 46 studies of SBIRT conducted by medical personnel in inpatient settings (n=17,231), finding that SBIRT by medical providers was not effective with helping hospital inpatients reduce alcohol consumption. An explanation for these disappointing results may be that physicians and nursing staff are willing to screen for substance use but often do not conduct brief interventions or referrals to treatment when use is detected (Agley et al., 2014; Chan et al., 2013; Glass et al., 2015).
Under emerging structures known as integrated care practices, SBIRT interventions are provided primarily by onsite mental health professionals, who collaborate with medical staff to address substance use and other patient biopsychosocial concerns (Collaborative Family Health Association [CFHA], 2020). Vendetti et al. (2017) performed a large-scale evaluation of the U.S. Substance Use and Mental Health Administration’s (SAMHSA) SBIRT grant program with SBIRT provided by mental health professionals such as counselors. The researchers’ foremost conclusion was that these professionals, rather than medical generalists, should be delivering SBIRT. Early research on SBIRT by mental health providers supports benefits for populations and substance use patterns not amenable to SBIRT by medical staff. In a study of the SAMHSA grant program in four states, Barbosa et al. (2017) found reductions in the probability of alcohol use (27%) and illicit drug use (29%) following brief intervention for patients in outpatient and ED settings. Watkins et al. (2017) researched collaborative care, a form of integrated care in primary care clinics, for alcohol and opioid use. A key finding was higher reported abstinence from opioids and/or alcohol at six months when mental health professionals provided SBIRT (33% vs 22%). These findings offer promise for having SBIRT interventions provided by mental health professionals in integrated care settings. Patients with risky or disordered substance use who are not otherwise seeking or accepting their need for treatment may be more likely to make changes when interacting with trained mental health professionals.
SBIRT is well-suited for mental health counselors, who focus on the therapeutic relationship and wellness (Council for Accreditation of Counseling and Related Educational Programs [CACREP], 2020). Recommended SBIRT practice involves facilitative conditions and helping skills that counselors routinely employ, such as empathy, nonjudgmental approach, resistance management, assessments, and patient advocacy (Babor & Higgins-Biddle, 2001). Counselors learn about trauma and psychiatric diagnoses, conditions that often co-occur in risky and disordered substance use (Patel et al., 2016). Preliminary evidence suggests that SBIRT administered by counselors in inpatient settings is associated with reductions in alcohol use. Veach et al. (2018) found average declines in self-reported drinking at six months of 64% to 69% in study subjects, which included inpatients on the spectrum from risky to disordered use.
In most SBIRT studies, the primary outcome is self-reported consumption, which risks overstating results due to potential under-reporting by participants (Agley et al., 2014; Glass et al., 2017). Alternative verifiable health outcomes, such as hospital admissions and ED visits, are of high value to health systems (Cornett & Latimer, 2011; Glass et al., 2017) but not typically found in the SBIRT literature (Bray et al., 2007, 2011). In two of the few studies of SBIRT by mental health professionals that evaluated inpatient utilization, Estee et al. (2010) found a reduction in per-member/per-month inpatient days of 0.12 while Paltzer et al. (2017) found a reduction of .036 days per month.
Researchers from the Wake Forest School of Medicine and The University of North Carolina at Greensboro studied whether SBIRT, when administered by mental health counselors to inpatients with risky or disordered use of alcohol, illicit drugs, and/or prescription medications, was associated with subsequent reduced hospitalization and ED visit costs and frequency counts (McCall et al., 2022). The authors proposed that counselor SBIRT interventions would be associated with decreased substance use, leading to reductions in utilization of inpatient and emergency healthcare and lower costs.
Study subjects, as approved by the Institutional Review Board, were adults aged 18 years and older admitted to a large teaching hospital’s integrated care services (trauma, burns, general medicine) between January 2014 and December 2017. Hospital-based counselors and counselor interns from area graduate programs, hereafter referred to as “counselor(s)”, selected patients for SBIRT via medical records review and/or consultation with medical staff. The intervention group (n=1,577) consisted of patients who received one or more SBIRT counseling interventions during a single hospitalization. The most frequent contact time was 30 minutes, with 79% of patients engaging with counselors for one hour or less over 1-3 sessions. The comparison group (n=618) included patients selected for SBIRT intervention but not receiving one due to timing issues, such as absence from the hospital room, discharge on a weekend when counselors were not available, or discharge earlier than initially predicted due to medical stabilization or response to medical treatment.
Counselors received a minimum of four weeks of training in SBIRT and practiced under supervision and peer review. To select patients with known or potential substance use, counselors reviewed electronic medical records and consulted with physicians and nurses. The counselors conducted as many initial SBIRT sessions as possible then followed up with some patients previously seen. SBIRT sessions used a general format with modification possible based on counselor clinical impressions and judgment. Counselors looked to develop patient trust quickly and create therapeutic alliances using empathy, understanding, and authenticity. Screenings, conducted by counselor interview, employed recommended SBIRT instruments, primarily the Alcohol Use Disorders Identification Test (AUDIT) (Babor & Higgins-Biddle, 2001) or the Cut-down, Annoyed, Guilty, Eye-opener (CAGE) instrument (Ewing, 1984). Brief interventions focused on collaborating and engaging with patients, supplying personalized feedback about screening results, connecting substance use to present health concerns, emphasizing the potential impact of continued use, exploring options for change, and/or developing change goals and plans. If referral to treatment was indicated and patients were willing, counselors connected patients to hospital care coordinators for specialty inpatient treatment options and/or provided patients with names of outpatient counselors in their geographic location.
The researchers estimated the differences in healthcare utilization and costs between intervention and comparison groups using statistical models designed to account for observed dissimilarities in patient demographic and comorbidity profiles between groups (McCall et al., 2022). When mental health counselors conducted SBIRT for inpatients with risky or disordered alcohol use, intervention group patients had a 68% lower likelihood of subsequent hospitalizations or ED visits compared to patients not seen by the counselors. Patients who were hospitalized or visited the ED in the year after their SBIRT intervention had average reductions in hospitalization and ED visit costs of $2,547 per patient compared to patients not receiving SBIRT. The results were not significant for patients using illicit drugs, misusing prescription medications, or using both alcohol and drugs. Thus, SBIRT by counselors for patients with risky or disordered alcohol use was associated with significant reductions in the likelihood of inpatient or emergency care and, if care was needed, with significant reductions in the costs for that care.
This current intensive examination of four years of SBIRT outcomes suggests that counselors embedded in integrated care teams can effectively provide SBIRT for inpatients with risky or disordered alcohol use. The results contradict the preponderance of findings from previous controlled trials that SBIRT is efficacious for risky alcohol use only (Jonas et al., 2012). These findings have implications for the counseling profession, medical professionals and health systems.
According to the study, counselors can effectively administer Screening, Brief Intervention, and Referral to Treatment (SBIRT) for alcohol use at all levels of severity, contradicting previous findings that suggest SBIRT in medical settings is not helpful (Mdege & Watson, 2013) or that SBIRT is efficacious only for risky alcohol use (Jonas et al., 2012). Counselor-provided SBIRT, which includes both assessment and brief interventions, may help reduce subsequent emergency department (ED) visits, hospitalizations, and overall cost per patient for those who use alcohol (Babor et al., 2017).
Therefore, counselors should embrace treatment for patients with all levels of alcohol severity and ensure that alcohol remains a central focus of their SBIRT efforts. Counselors working in medical teams should consider being trained in and implementing SBIRT to be effective in working with patients. Counselors should advocate to be team leaders in SBIRT for their patient populations, working collaboratively and supportively with medical professionals to provide holistic and effective care.
In the critical hospital days following alcohol-related traumatic injuries or medical crises, patients often view the events as near-death experiences and are receptive to help. Counselors attending to patients with empathy, unconditional acceptance, and authenticity while also addressing substance use can change lives. Counselors, with support from the integrated medical team, can help patients connect the dots of alcohol use to their medical condition or injury, leading to new insights that can bring about health changes. Counselors can provide written materials, assist patients with change plans, and offer referrals to more intensive treatment, ensuring patients have resources and support prior to leaving the hospital (Babor et al., 2017). The bedside SBIRT intervention is often the first experience a patient has with a counselor, which has important implications for patient willingness to engage in future counseling experiences (Babor et al., 2017).
The counseling profession has a long history and substantial collective wisdom regarding treating substance use. Currently, nearly 3,400 members of the American Counseling Association (ACA) identify as addictions and substance abuse specialists, placing this specialty area seventh on a list of 43 such areas (Sites, R. A., personal communication, February 19, 2019). In contrast, there are no terms on the ACA specialty list remotely related to integrated care. This oversight is evidence that counselor education and leadership has lagged behind educators and leaders in other professions in embracing the integration of mental health professionals into medical settings and in advocating for substance use interventions to those settings. The foremost organization for integrated care professionals is the Collaborative Family Health Association, which is comprised largely of psychologists, social workers, and marriage and family therapists (CFHA, 2019). Integrated care is the primary emphasis of the American Psychological Association’s Center for Psychology and Health (American Psychological Association, 2019). The marriage and family therapy profession offers graduate training and post-graduate certification in Medical Family Therapy, training clinicians to work in medical settings (CFHA, 2019). Yet there are no comparative organizations or programs for the counseling profession. Many counseling professionals are working in integrated care settings; it is notable that professional counselors and/or substance abuse counselors were listed in all five studies to date involving SBIRT by mental health professionals. An implication of this study and others is that counselor educators and leaders should harness the profession’s substantial expertise in substance use treatment by transferring that expertise to integrated care settings, which is where most people who need help with substance use can be found.
By moving beyond outcomes of self-reported use to verifiable health utilization measures, health systems can clearly measure quantifiable benefits of SBIRT conducted by counselors. Hospitalizations and ED visits are expensive services and therefore of great interest to health system leaders. Cost savings and benefits to health systems can mean increased counselor employment by acute care hospitals and across the healthcare continuum, especially counselors with a clinical understanding of substance-related medical complications.
Moreover, physicians, other medical educators, and providers are witness to the value of counselors intervening at the bedside as an integral part of the medical team. The professional identity of counseling is thereby advanced, leading to increasing opportunities to serve in healthcare settings. Medical learners in academic settings can observe effective SBIRT methods, gain listening skills, and decrease debilitating stigma. With the growing body of confirming research, health system administrators, physicians, and community leaders should become more supportive of integrating counselors into inpatient teams and other medical groups and having them conduct SBIRT, particularly if cost savings are convincingly demonstrated by future research.
As with all research studies, this study may have specific limitations. First, separate analyses for hospitalizations and ED visit outcome variables were not possible, as the data were insufficient. If not for this limitation, the findings may have shown that SBIRT was associated with one or the other type of outcome but not both. Second, in the year following the SBIRT intervention, patients may have been admitted to or sought emergency care at a competitor hospital. Limiting the study perspective to the teaching hospital may have understated the actual occurrence of hospitalizations and ED visits for patients or masked differences in hospitalization choice between the intervention and comparison patient groups. Third, interventions may be subject to measurement variability, as counselors had diverse levels of training and experience and had leeway in how they conducted SBIRT. Fourth, unknown factors might be associated with the outcomes as the study used retrospective data. Fifth, a critical construct may be present but not measured by the model, such as the therapeutic alliance between counselor and patient or patient readiness to change. Finally, our study may be limited by the potential uniqueness of the counseling program and its integration with inpatient care teams of an academic teaching hospital; this treatment milieu may not be generalizable to other locations. The academic health system that attracts physician specialties many hospitals do not offer; integrated care settings in less-specialized hospitals may be quite different.
Until treatment rates and outcomes for people with risky or disordered alcohol, illicit drug and prescription medication use improve, health systems will bear the burdens of conditions caused by substance use, from traumatic injury to life-threatening infections. Many physicians and nurses do not feel comfortable discussing or qualified to intervene with substance use, and their lack of time and motivation may limit effectiveness (Vendetti et al., 2017). In contrast, mental health clinicians, especially counselors, are trained in building therapeutic alliances with empathy, assessing readiness to change, managing resistance, doing assessment, supplying feedback, and advocating for patients and their wellness (CACREP, 2020). Transforming medical teams into integrated care teams by including mental health clinicians can allow medical providers to focus on medical conditions and may increase the likelihood that patients using alcohol will reduce or abstain from harmful use. Importantly, counselors who perform SBIRT interventions in integrated care settings reach people who are not seeking help or have not had access to help. Here, the stage is set for future research and for increased investment in mental health counseling and SBIRT for hospitalized patients struggling with risky or disordered alcohol use.
Marcia H. McCall, Ph.D., M.B.A., is an Assistant Professor of Psychiatry & Behavioral Medicine at the Wake Forest School of Medicine. Dr. McCall studies clinical and economic outcomes of mental health interventions in medical settings, focusing on inpatient interventions for alcohol, drug, and tobacco use. As a licensed mental health counselor, Dr. McCall conducts individual and group counseling with student learners of the medical school as well as adult patients of the Psychiatry practice. Previous experience includes leadership positions in business and operational management of hospitals, academic departments, and research centers.
Kelly L. Wester, Ph.D., is Professor and Chair of the Department of Counseling and Educational Development of The University of North Carolina at Greensboro. Dr. Wester studies non-suicidal self-injury through intrapersonal, contextual, and systematic lenses. She is the Associate Editor of Quantitative Research for the Journal of Counseling & Development and teaches doctoral and master’s level students. She received two national awards for her research developing research competencies for the field of counseling.
Jeremy W. Bray, Ph.D., is a Professor of Economics of The University of North Carolina at Greensboro. Dr. Bray has led or contributed to multiple health services research studies that explored both the economic causes and consequences of substance use and related behaviors. His publications have been referenced thousands of times by other researchers and have had a profound impact on public health.
Amresh D. Hanchate, Ph.D., is a Professor of Social Sciences and Health Policy of the Wake Forest School of Medicine. Dr. Hanchate has long-standing experience in use of econometric causal models, natural experimental study designs, and using large administrative datasets to examine policy impact on disparities in healthcare access and outcomes. He is a PI/co-PI of NIH-funded studies on healthcare policy, health disparities, emergency care, and safety-net and minority-serving hospitals.
Laura J. Veach, Ph.D., is a Professor of Surgery – Trauma of the Wake Forest School of Medicine. Dr. Veach developed specialized services for hospitalized trauma patients, including violently injured youth, while also instituting trauma-informed counselor and addiction specialist training. She is a core faculty member of the School of Medicine’s Addiction Medicine Fellowship Program and the founding director of the Addiction Research & Clinical Health Master’s degree program for the school.
Benjamin D. Smart is a fourth-year medical student at the Wake Forest University School of Medicine. He is dedicated to public health, with educational and volunteer experiences abroad and throughout the United States. His research includes a qualitative study of social determinants of health for transgender women of color and a systematic review of implementation sciences and tobacco cessation in primary care. Mr. Smart also is a working television journalist focusing in public and environmental health. His long-term goal is to work as a researcher, journalist, and policy activist who fights to make sure everyone has access to clean air and a path to well-being.
Carrie Wachter Morris, Ph.D., is a Professor of Counseling and Educational Development at The University of North Carolina at Greensboro. Dr. Wachter Morris studies how counselors can prevent and intervene in a broad variety of crisis situations and how counselor educators can best train future counseling practitioners and counselor educators. She is the President of the Association for Assessment and Research in Counseling, and she serves on the editorial boards of Counselor Education & Supervision and Professional School Counseling. Dr. Wachter Morris teaches doctoral and master’s level students and has received regional recognition for her teaching.