Utilizing Screening, Brief Intervention, and Referral to Treatment: Teaching Assessment of Substance Abuse

Abstract

Although social workers regularly encounter clients with substance use problems, social work education rarely addresses addictions with any depth. This pilot study explored the use of screening, brief intervention, and referral to treatment (SBIRT) with 74 social work students. Students completed SBIRT training with pre- and post-questionnaires that assessed attitudes, knowledge, and skills concerning substance misuse. Statistically significant differences were demonstrated with students reporting more confidence in their ability to successfully assess for alcohol misuse and subsequently intervene.

Substance misuse in the United States is high; 30% of adults engage in at-risk drinking.¹ At-risk drinking (typically categorized as “misuse”) does not meet diagnostic criteria for abuse or dependence and is inconsistently identified. Because approximately 70% of the US adult population sees a primary care physician at least once every 2 years,² a screening and brief intervention model for substance misuse was developed for primary care settings.

Screening, brief intervention, and referral to treatment (SBIRT)³ is based on the transtheoretical model of change,⁴ incorporating motivational interviewing to “briefly intervene” with patients who are at-risk drinkers. The transtheoretical model presents 5 stages of client readiness to change: precontemplation (change is not considered); contemplation (some awareness of consequences but ambivalence to change); preparation (change is planned); action (change begins); and maintenance (change is managed).⁴ The idea is to “meet the patient where they are.” SBIRT is efficacious with assessing and intervening with at-risk drinkers in primary care settings⁵–⁷ and emergency departments⁸,⁹; however, SBIRT has not been integrated into social work education or practice.

Social workers are employed in a variety of venues. Like other health care professionals, they are not necessarily trained to identify or treat misuse. Less than 10% of accredited social work programs offer a graduate certificate specific to substance abuse.¹⁰ Research shows similar barriers to screening among health care providers: lack of training to assess alcohol misuse, how to or when to screen for it, and what to do if the client indicates a need for treatment.¹¹ Training practitioners can be effective in increasing confidence in screening and intervention as well as improving attitudes toward people with alcohol problems.¹²–¹⁵

This pilot study assessed social work students’ attitudes, perceived skills, and knowledge of alcohol misuse before and after receiving training on SBIRT. We hypothesized that students would improve skills and knowledge of substance misuse as well as improve attitudes toward people who misuse alcohol.

METHODS

The pilot study sample consisted of 41 graduate and 33 undergraduate social work students who voluntarily completed the Attitudes, Self-Perception of Skills, and Knowledge (AKS) survey. The AKS survey is a 13-question instrument designed specifically for use in SBIRT.¹⁶ The instrument is undergoing validity analyses for continued use as a research tool. Students rated their attitudes, skills, and knowledge on a 5-point Likert scale with responses ranging from “strongly agree” to “strongly disagree.” Internal consistency was measured with Cronbach α (α = 0.730) (Appendix A, available as a supplement to the online version of this article at http://www.ajph.org).

Following the SBIRT protocol used with medical and nursing students, social work students were given the AKS survey as a pretest, then were asked to review a series of 4 PowerPoint training modules before taking the posttest. To ensure confidentiality, no demographic information other than class standing (graduate vs undergraduate) was obtained. The modules covered orientation to SBIRT, types of screening instruments, and motivational interviewing. Students completed the AKS surveys and training modules independently within approximately 30 days.

RESULTS

The paired sample t-test revealed statistically significant differences for 8 of the 13 items. Additionally, analysis of variance examined differences in the AKS between undergraduate and graduate students; however, no statistically significant differences were found.

After completing the SBIRT training, students more strongly agreed they had a good understanding of substance use and abuse and felt more confident in their ability to screen for alcohol or drug problems; to assess clients’ readiness to change behaviors; to discuss clients’ substance use and advise them to change behavior; and to refer clients to specialized treatment. Students also more strongly agreed that their interaction with a client could make a difference regarding substance use and that incorporating screening into routine practice is critical. They more strongly disagreed that clients would be angry if asked about substance use (Table 1).

TABLE 1—

The t-Test Results for Attitudes, Self-Perception of Skills, and Knowledge Survey Items, Teaching Assessment of Substance Abuse, 2011

Question No.	Pretest Score	Posttest Score	t Test (df)	P
1	2.33	2.04	2.438 (70)	.017
2	1.37	1.45	−1.180 (70)	.242
3	1.72	1.59	1.136 (70)	.26
4	4.18	4.34	−1.227 (70)	.224
5	2.70	2.56	1.344 (70)	.183
6	3.55	2.23	10.738 (70)	.001
7	3.04	2.14	7.473 (70)	.001
8	3.08	2.23	7.209 (70)	.001
9	2.75	2.13	5.123 (70)	.001
10	4.34	4.45	−1.210 (70)	.23
11	3.10	3.55	−4.217 (69)	.001
12	2.11	1.54	6.333 (70)	.001
13	1.66	1.34	4.201 (70)	.001

DISCUSSION

Our results showed that social work students positively changed their attitudes toward working with clients with substance use problems and improved their perceived ability to screen and intervene with clients. Results were similar to other findings regarding training medical students¹⁵ and nurses¹² on screening and brief intervention techniques.

An encouraging finding was the statistically significant scores in agreement that incorporating screening for substance misuse into routine care is crucial for health care. The passage of US health care reform¹⁷ makes primary medical homes a critical aspect of preventive care. Screenings for lifestyle behaviors that impact health will be required. SBIRT can be integrated into the medical home, and delivered by health professionals, including social workers.

Study limitations included social desirability bias as well as small sample size, particularly given the number of social work students in the United States. Future research will increase the sample, as well as incorporate use of standardized patients for practicing skills learned in the modules. Training social work students on SBIRT appears to be effective in incorporating a minimum level of substance misuse screening and treatment into social work education.