Screening,Brief Intervention,and Referral to Treatment Plus (SBIRT–Plus): A Novel Interprofessional Training for Rehabilitation Science Professional Students

Abstract

Importance: With the increasing amount of substance use–related health conditions in the United States, it is important for rehabilitation science professionals to receive screening and prevention training.

Objective: To describe and examine the preliminary effectiveness of a novel educational program, Screening, Brief Intervention, and Referral to Treatment Plus (SBIRT–Plus), that combines traditional SBIRT training with new modules for cannabis, stimulant, and opioid use.

Design: Prospective, cohort design.

Setting: Academic institution.

Participants: One hundred eighty-one rehabilitation science graduate students.

Intervention: SBIRT–Plus curriculum.

Outcomes and Measures: Outcomes included satisfaction with training, perception of interprofessional training, attitudes, knowledge, and stigma, as assessed with the Readiness for Interprofessional Learning Scale, Alcohol and Alcohol Problems Perception Questionnaire, Drug and Drug Problems Perception Questionnaire, Knowledge Screening Scale, and two stigma instruments.

Results: Most students (>80%) expressed satisfaction with their training, would recommend the training to a colleague, and believed that the training would influence and change the way they practiced with patients at risk for substance use disorders. Students’ attitudes and knowledge increased from pre- to post-training, and stigma perceptions were significantly reduced.

Conclusions and Relevance: SBIRT–Plus is an evidence-based interprofessional training that is feasible to implement in graduate-level education programs. Integrating SBIRT–Plus into professional graduate programs may be an optimal and low-cost model for training rehabilitation health care professionals.

Plain-Language Summary: Screening, Brief Intervention, and Referral to Treatment Plus (SBIRT–Plus) is an evidence-based interprofessional training that can be easily adopted in curricula to train professional students about the importance of screening for substance use disorders.

Integrating Screening, Brief Intervention, and Referral to Treatment Plus (SBIRT–Plus) into professional graduate programs may be an optimal and low-cost model for training rehabilitation health care professionals.

The magnitude of illicit drug use and substance use disorders (SUDs) in the United States is concerning, with approximately 2 in 9 Americans reporting current drug use (National Institute on Drug Abuse [NIDA], 2022; Substance Abuse and Mental Health Services Administration [SAMHSA], 2021). Recent reports also indicate that drug overdose deaths and alcohol-induced deaths are on the rise (Kramarow & Tejada-Vera, 2022a, 2022b). These trends are especially concerning, given that risk factors for SUDs are known and effective prevention interventions exist (Miller & Hendrie, 2008). Despite the evidence-based treatment options available for SUDs at all levels of severity, including for people at risk for developing a SUD, only the most severe cases of SUD receive treatment (Connery et al., 2020). One explanation for the gap between people experiencing SUDs and those receiving treatment is the lack of screening and prevention training among health care practitioners and organizations. The U.S. Preventive Services Task Force (2020) recommends SUD risk screening for individuals age 18 yr or older, as well as pregnant individuals, when services for proper care, precise diagnosis, and effectual treatment can be provided.

Recent acknowledgment by local, state, and national governments prioritizes the need to train health care students to address SUD screening, prevention, and treatment (Accreditation Council for Occupational Therapy Education [ACOTE®], 2018; Council for Accreditation of Counseling and Related Educational Programs [CACREP], 2016; Mattila & Provident, 2017). The Comprehensive Addiction and Recovery Act of 2016 (Pub. L. 114-198) placed substantial emphasis on expanding prevention of, education on, and promotion of treatment and recovery from the use of methamphetamines, opioids, and heroin. Additionally, the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (2018; Pub. L. 115-271) addresses the opioid epidemic and accentuates the vital role that nonpharmacological, interdisciplinary, and multimodal intervention plans for pain management contribute to the prevention of opioid addiction. These legislative examples in combination with new legislation, such as the Mainstreaming Addiction Treatment Act of 2021 (passed as part of the Consolidated Appropriations Act [2023], Pub. L. 117-328), emphasize the need for training frontline health care professionals, such as occupational therapists and rehabilitation and mental health counselors, in identifying people who are at risk for developing a SUD.

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a well-established and widely used method to target early detection and harm reduction by identifying and increasing individuals’ cognizance of their substance use patterns and resultant adverse events. Through SAMHSA’s grant program, SBIRT has been widely disseminated in the United States as an evidence-based program to reduce alcohol misuse among adults. SBIRT training primarily focuses on alcohol use and includes some general training in identification of illicit drug use. Implementation of SBIRT training for health care professional students is relatively cost-effective, because “train the trainer” materials are publicly available from SAMHSA and other agencies, such as the Institute for Research, Education and Training in Addictions. Therefore, the cost of SBIRT implementation in academia is associated with salary support for those trained to administer SBIRT (SBIRT champions) and potential costs associated with engaging standardized patients.

There is evidence that SBIRT training improves health care students’ attitudes, perceived competency, and knowledge with respect to working with individuals at risk for developing a SUD (Lukowitsky et al., 2022; Martin et al., 2021; Puskar et al., 2012; Scudder et al., 2021; Sherwood et al., 2019). A study of baccalaureate nursing students (Puskar et al., 2012) showed significant improvements in perceived attitudes related to working with individuals who were at risk for alcohol use disorder, but the results for perceived attitudes related to working with individuals at risk for illicit drug use were less robust, with no significant changes in attitudes related to motivation, work satisfaction, or task-specific self-esteem. Similarly, in a study of students from multiple disciplines (e.g., nursing, pharmacy, medicine), students showed significant improvements in perceived attitudes toward working with individuals at risk for alcohol use disorder; however, they showed no improvement in attitudes regarding role legitimacy (i.e., having the right to address client issues) when working with individuals at risk for illicit drug use (Lukowitsky et al., 2022).

In late 2019, the Pennsylvania Department of Health released Prescribing Guidelines for Pennsylvania: Treating Pain in Patients With OUD (Ashburn et al., 2019), which recommended that pain treatment be a multimodal approach, with occupational therapy and counseling listed as psychological and psychosocial interventions for pain and its related comorbidities for patients with opioid use disorder. Given this recommendation for a multimodal approach to treatment, interprofessional training for screening and referral to treatment has become more relevant. Recent studies have focused on the development of interprofessional training for SBIRT (Sherwood et al., 2019) and provide preliminary evidence that students receiving interprofessional SBIRT training show improvements in outcomes such as attitudes, knowledge, perceived competency, and satisfaction with training (Lukowitsky et al., 2022; Martin et al., 2021; Scudder et al., 2021). Challenges associated with implementing an interprofessional training program include logistical issues, such as programs housed in various buildings, which limit student access to training (Sherwood et al., 2019).

Accreditation agencies have recognized the importance of training health care professionals in substance use screening. Specifically, ACOTE Standard B.4.0 requires that occupational therapy doctoral students be instructed in screening, evaluation, intervention planning, and referral for the effects of conditions such as mental illness, trauma, and injury on occupational performance. CACREP includes six counseling specialization domain standards related to substance use screening, identification, and treatment. More specific training in illicit drug use is warranted, given the rise in national overdose deaths involving opioids and psychostimulants (NIDA, 2022). Therefore, we created an expanded curriculum, SBIRT–Plus, with additional modules that specifically address cannabis, stimulant, and opioid use. The SBIRT–Plus program has the potential to expand, transform, and strengthen the capacity of health care professional educational programs to address the critical need for well-trained rehabilitation professionals to screen, refer, and provide preventive treatment to patients at risk for SUDs.

In this study, we examined graduate health care professional students’ satisfaction with SBIRT–Plus interprofessional training with two cohorts of occupational therapy and mental health counseling graduate students and explored preliminary evidence for SBIRT–Plus as a method to change students’ attitudes toward, knowledge of, and stigma regarding working with individuals at risk for SUDs. Specifically, we examined the feasibility of implementing SBIRT–Plus with an interprofessional group of rehabilitation science professional graduate students and measured their satisfaction with training and readiness for the interprofessional training format. We did not expect that readiness for interprofessional training would change on the basis of SBIRT–Plus training. Next, we sought to provide preliminary evidence that SBIRT–Plus could improve student training outcomes. Outcomes included knowledge of curriculum content, which focused on terminology, assessment, identification, and therapeutic communication for individuals at risk for SUDs. Additionally, we explored students’ attitudes, measured as role adequacy, role legitimacy, role support, motivation, task-specific self-esteem, and satisfaction with working with individuals at risk for SUDs. We also explored students’ perceptions of stigma, with a focus on familiarity, perceived dangerousness, social distancing, personal responsibility, and psychosocial aspects. We hypothesized that knowledge would increase from pre- to posttraining. We also hypothesized that we would see improvements in each of the six attitude components, as well as reductions in all five aspects of stigma.

Method

Design and Participants

In a prospective, cohort design, OTD students (n = 135) and clinical rehabilitation and mental health counseling (CRMHC) graduate students (n = 46) participated in SBIRT–Plus training with hybrid remote synchronous didactic sessions and remote simulated clinical experiences as part of a SAMHSA training grant (H79FG000044) completed between September 2020 and September 2022. All activities were approved by the University of Pittsburgh’s Institutional Review Board. There were two cohorts of students over the 2-yr training grant period. The SBIRT–Plus curriculum was embedded into coursework for each program (OTD, CRMHC). All students were in the first year of their respective program.

SBIRT – Plus Curriculum and Instructional Design

The authors, an interdisciplinary team of clinical educators and scientists with expertise in SUDs, created an expanded version of SBIRT training, SBIRT–Plus, which focused on building students’ knowledge, improving attitudes, and reducing stigma when working with people with or at risk for developing SUDs.

SBIRT–Plus training follows the same structure and modality as traditional SBIRT, which includes a didactic portion followed by structured simulated patient activities. The traditional SBIRT program consists of three modules that focus on alcohol and general SUDs. SBIRT–Plus includes the traditional SBIRT curriculum plus three additional modules with specific curricula and measurable outcomes for cannabis, stimulant, and opioid use. The additional “Plus” modules were created by a certified addictions registered nurse (Brayden Kameg), a certified rehabilitation counselor (Kelly B. Beck), and a licensed occupational therapist with specialty certifications in therapeutic listening and mental health first aid (Alyson D. Stover). The Plus modules address (1) knowledge of neurobiology as the basis for addiction; (2) terminology, diagnostic criteria, and co-occurring health outcomes associated with cannabis use disorder, opioid use disorder, and stimulant use disorder; (3) management of substance use among children and adolescents; (4) assessment using validated tools for cannabis, opioid, and stimulant use; and (5) intervention and community referral options for these SUDs. Students completed the didactic online modules over the time period of the course and before participation in the simulation scenarios, which were held during the last week of the course. Students spent approximately 6 hr completing the six online modules. Our interprofessional trainers, SBIRT champions who have implemented SBIRT with health care professional students for more than 15 yr, provided didactic workshops during classes within the required curriculum courses (approximately 2 hr). Additionally, health care professionals with expertise in delivering treatment to individuals with SUDs provided guest lectures (approximately 2 hr).

Simulated clinical scenarios, which were linked to measurable objectives from the SBIRT–Plus curriculum, were designed by clinical and simulationist experts from occupational therapy, clinical rehabilitation and mental health counseling, and nursing. Objectives for each clinical case were health care professional goals focused on (1) qualifying the patient’s risk for SUD, (2) quantifying the patient’s readiness for change, and (3) using SBIRT–Plus tools for brief interventions to move the patient to a greater state of readiness. The scenarios represented four different clinical cases (risk for developing alcohol use disorder, opioid use disorder, stimulant use disorder, and cannabis use disorder). Students were provided with prebriefing materials to inform them about the planned scenario. All simulations were guided by facilitators. Facilitators were licensed health care professionals with experience in SUDs and used standardized facilitation guides. Facilitators debriefed each student immediately after each simulation experience, including asking them how they felt about the experience, what they thought went well during the experience, and what they felt was most challenging about the experience.

Standardized patients were recruited from the university’s accredited Technology and Simulation in Medical Education Department. Our patients were paid actors with experience in simulation and SUDs. Standardized patients were prebriefed by our interprofessional training team before simulation training. All standardized patients received a situation and backstory for a real-life clinical case with responses that were designed to provide cues to students. Standardized patients received materials 1 wk before the simulation, and they attended a meeting with all facilitators before the simulation activity to practice their scenarios. Additionally, standardized patients received feedback from facilitators after each simulation rotation.

All simulation experiences were conducted via Zoom. Over the study time period, groups of approximately six interprofessional students rotated through the four simulation scenarios with their facilitator. The facilitator introduced the standardized patient and the scenario. Simulation activities took approximately 2 to 3 hr. At the end of the simulation experience, a 30-min facilitator-led debriefing period was provided so that all students had the opportunity to share feedback about their learning experience within their small group.

We used a hybrid-remote approach for implementation of the SBIRT–Plus curriculum for a variety of reasons. First, the interprofessional programs were housed in different buildings and were not easily accessible to students from different programs. Next, SBIRT champions were also housed in various buildings across campus, and a remote option provided an opportunity for the entire team to easily join training activities. Finally, the coronavirus disease 2019 pandemic made it challenging for all students, SBIRT champions, facilitators, and standardized patients to gather in one space at the same time.

Data Collection

Data were collected using Qualtrics, a web-based software program that allows for generation, distribution, and data capture from surveys. A link to the survey battery was emailed to each student participating in the training. Students were asked to complete the surveys before training and again when all training was completed. Data were anonymous; email information was stripped from the database when creating a dataset for analyses.

Measures

We collected data using several measures to assess the feasibility of implementing SBIRT–Plus with interprofessional training. Satisfaction was measured using an item that asked students to rate satisfaction with the overall training on a scale ranging from 1 (very dissatisfied) to 5 (very satisfied). Additional questions assessed students’ perception of the educational program’s value for their practice and whether they would recommend the program to a colleague. We measured students’ readiness for interprofessional training using the Readiness for Interprofessional Learning Scale (RIPLS; Roopnarine & Boeren, 2020). The RIPLS contains three subscales, Teamwork and Collaboration, Professional Identity, and Roles and Responsibilities, consisting of 19 items rated on a Likert-type response scale (Sullivan & Artino, 2013) ranging from 1 (strongly disagree) to 5 (strongly agree) that measure health care students’ willingness to learn in an interprofessional environment. Higher average subscale scores indicate more readiness or willingness to learn in an interprofessional setting.

Next, we collected data to test hypotheses associated with student outcomes. We assessed attitudes using the Alcohol and Alcohol Problems Perception Questionnaire (AAPPQ; Anderson & Clement, 1987) and the Drug and Drug Problems Perception Questionnaire (DDPPQ; Watson et al., 2003). The AAPPQ consists of 30 items and the DDPPQ consists of 22 items, each with six subscales (Role Adequacy, Role Legitimacy, Role Support, Motivation, Task-Specific Self-Esteem, and Satisfaction) to evaluate perceptions of working with individuals at risk for a SUD. Both scales use a Likert-type response scale, ranging from 1 (strongly disagree) to 5 (strongly agree). We used the average score on each subscale in the analysis. Higher scores on each subscale indicate more positive perceptions of working with individuals at risk for SUDs. The psychometric properties of the AAPPQ and DDPPQ are well documented and have been established with samples of health care professional students (Mahmoud, 2017; Terhorst et al., 2013).

We used the SBIRT–Plus Knowledge Screening Scale, which contains 20 multiple-choice questions designed by the authors to specifically target objectives of SBIRT–Plus training and to assess change in students’ knowledge from pre- to posttraining. The SBIRT–Plus screening scale questions were created and reviewed by each member of the research team. All members of the team rated all items as relevant and representative of the SBIRT–Plus curriculum, establishing content validity for the instrument. Higher knowledge scores are indicative of more knowledge of concepts covered in the SBIRT–Plus curriculum.

We measured students’ stigma perceptions of working with individuals experiencing mild to moderate SUDs using two versions (Alcohol and Opioid) of a composite instrument. The stigma instruments consisted of 35 items and six subscales:

▪ Familiarity (7 items; scoring range = 7–14), with higher scores indicating more familiarity with individuals experiencing alcohol or opioid SUDs

▪ Perceived Dangerousness (8 items; scoring range = 0–40), with higher scores representing perceived dangerousness of individuals experiencing alcohol or opioid SUDs

▪ Fear (5 items; scoring range = 3–27), with higher scores indicating greater fear

▪ Social Distancing (7 items; scoring range = 0–21), with higher scores indicating greater desire to maintain social distance from persons experiencing alcohol or opioid SUDs

▪ Personal Responsibility (3 items; scoring range = 3–27), with higher scores indicating the belief that the person experiencing alcohol or opioid SUD is personally responsible for their SUD and recovery

▪ Psychosocial (5 items; scoring range = 1–25), with higher scores indicating more agreement with psychosocial misconceptions of alcohol or opioid SUDs.

The stigma measure was created using a combination of several instruments and has been previously used in studies of nursing students’ perceptions of working with individuals at risk for SUDs (Mahmoud et al., 2019).

Statistical Analysis

Data were analyzed using OTD and CRMHC students as an interprofessional cohort. We examined frequencies and percentages of students’ satisfaction and general impressions of SBIRT–Plus training. Changes in readiness for interprofessional training were examined using Wilcoxon signed-rank tests. We also tested our hypotheses about students’ changes in attitudes and knowledge using Wilcoxon signed-rank tests. We assessed changes in stigma using either Wilcoxon signed-rank tests or parametric paired-samples t tests. The choice of test was based on whether the assumption of normality was met. Given the exploratory nature of the analyses, we used complete case data for each statistical test. A complete case analysis uses only cases for which data are available for each item of a subscale. We computed effect sizes to examine the magnitude of change from pre- to post-training, using Cohen’s guidelines for interpreting small (d_z = 0.2), moderate (d_z = 0.5), and large (d_z = 0.8) effects. We considered each statistical test as a separate, stand-alone test of our hypotheses; therefore, α was set to .05 for each test (Rubin, 2021). All analyses were performed using IBM SPSS Statistics (Version 28).

Results

One hundred eighty-one students participated in the SBIRT–Plus training (135 OTD students and 46 CRMHC students). Overall, most students were female (77.9%) and White (67.4%). Table 1 reports demographics for each cohort.

Table 1.

Student Demographics by Cohort

Variable	n (%)
Variable	Cohort 1 (n = 90)	Cohort 2 (n = 91)
Student type
Occupational therapy	64 (71)	70 (77)
Counseling	26 (29)	20 (22)
Not reported	0 (0)	1 (1)
Gender
Female	70 (78)	71 (78)
Male	18 (20)	4 (5)
Transgender or self-identified	2 (2)	4 (5)
Not reported	0 (0)	12 (13)
Race/ethnicity
Asian	6 (7)	9 (10)
Black/African American	2 (2)	3 (3)
White	61 (68)	61 (67)
Hispanic/Latino	2 (2)	2 (2)
More than one race	7 (8)	1 (1)
Not reported	12 (13)	15 (17)

Note. Percentages may total more than 100 because of rounding.

Satisfaction and Interprofessional Readiness

Overall, students expressed satisfaction with their SBIRT–Plus training. Specifically, 86% of participants reported that they were satisfied or very satisfied with SBIRT–Plus training. Most students (97%) reported that the information they learned would benefit their future practice, and 92% reported that they would likely use the information to change their future practice. Most students (90%) said that they would recommend the training to a colleague. Students’ readiness for interprofessional training, reported in Table 2, was very high at training onset and remained steady throughout training. Students reported high averages for teamwork and collaboration at both pre- and posttraining, similar high averages for professional identity at pre- and posttraining, and moderate averages for roles and responsibilities, which slightly decreased from pre- to posttraining. There were no statistically significant changes from pre- to posttraining on the Teamwork and Collaboration (Z = −0.298, p = .795, |d_z| = 0.026), Professional Identity (Z = −0.557, p = .578, |d_z| = 0.022), or Roles and Responsibilities (Z = −0.983, p = .325, |d_z| = 0.101) subscales.

Table 2.

Student Readiness for Interprofessional Training

RIPLS Subscale	Pretraining	Posttraining
Teamwork and Collaboration
M (SD)	4.63 (0.49)	4.65 (0.51)
Mdn (IQR)	5.00 (0.78)	5.00 (0.86)
Professional Identity
M (SD)	4.37 (0.56)	4.36 (0.55)
Range (IQR)	4.42 (0.86)	4.42 (0.86)
Roles and Responsibilities
M (SD)	3.20 (0.53)	3.14 (0.35)
Range (IQR)	3.16 (0.67)	3.00 (0.33)

Note. IQR = interquartile range; Mdn = median; RIPLS = Readiness for Interprofessional Learning Scale.

Attitudes

Students’ responses on five of the six AAPPQ and DDPPQ subscales moved in the positive direction, with statistically significant changes in Role Adequacy, Role Legitimacy, Role Support, Task-Specific Self-Esteem, and Work Satisfaction scores (Table 3). Students’ AAPPQ motivation for working with individuals at risk for alcohol SUDs did not improve from pre- to posttraining (p = .083); however, DDPPQ motivation for working with individuals at risk for illicit drug use was significantly more positive after training (p = .002). There was a large magnitude of change for Role Adequacy, Role Legitimacy, and Role Support scores on both the AAPPQ and DDPPQ. The magnitude of change for the AAPPQ Task-Specific Self-Esteem subscale was large (|d_z | = 0.74), but it was considered small for DDPPQ (|d_z | = 0.15). The magnitude of change for the Motivation and Work Satisfaction subscales was small for both the AAPPQ and DDPPQ (see Table 2).

Table 3.

Changes in Scores on the AAPPQ and DDPPQ From Pretraining to Posttraining

Subscale	M (SD)		Mdn (IQR)		Z	p	d_z
Subscale	Pretraining	Posttraining	Pretraining	Posttraining)	Z	p	d_z
AAPPQ a (n = 123)
Role Adequacy	2.72 (0.75)	3.80 (0.71)	2.85 (1.00)	4.00 (0.43)	−8.749	<.001	1.47
Role Legitimacy	3.07 (0.58)	3.89 (0.57)	3.00 (0.75)	4.00 (0.75)	−8.648	<.001	1.42
Role Support	3.39 (0.75)	4.00 (0.63)	3.33 (1.00)	4.00 (0.33)	−6.218	<.001	0.87
Motivation	3.58 (0.61)	3.68 (0.58)	3.60 (1.00)	3.80 (0.60)	−1.710	.087	0.16
Task-Specific Self-Esteem	3.45 (0.52)	3.85 (0.56)	3.50 (0.67)	3.83 (0.83)	−6.258	<.001	0.74
Work Satisfaction	3.57 (0.46)	3.79 (0.52)	3.60 (0.80)	3.80 (0.80)	−4.184	<.001	0.44
DDPPQ a (n = 129)
Role Adequacy	2.63 (0.64)	3.65 (0.63)	2.62 (0.88)	3.75 (0.75)	−9.588	<.001	1.61
Role Legitimacy	3.12 (0.41)	3.75 (0.64)	3.00 (1.00)	4.00 (0.67)	−7.281	<.001	1.12
Role Support	3.31 (0.70)	3.95 (0.58)	3.33 (1.00)	4.00 (0.33)	−7.652	<.001	0.98
Motivation	3.75 (0.75)	4.01 (0.81)	4.00 (1.00)	4.00 (1.00)	−3.092	.002	0.33
Task-Specific Self-Esteem	3.89 (0.59)	3.99 (0.75)	4.00 (1.00)	4.00 (1.00)	−2.149	.032	0.15
Work Satisfaction	3.50 (0.57)	3.67 (0.54)	3.50 (1.00)	3.75 (0.75)	−3.334	<.001	0.31

Note. AAPPQ = Alcohol and Alcohol Problems Perception Questionnaire; DDPPQ = Drug and Drug Problems Perception Questionnaire; IQR = interquartile range; Mdn = median.

Analyses performed with complete case data.

Knowledge

The average score on the SBIRT–Plus Knowledge Screening Scale increased from 58.13 (SD = 12.72; median [Mdn] = 60.00, interquartile range [IQR] = 15.00) at pretraining to 64.78 (SD = 12.53; Mdn = 65.00, IQR = 20.00) at posttraining. This change was statistically significant (Z = −4.551, p < .001), and the magnitude of change was small to moderate (|d_z| = 0.458).

Stigma

Students’ scores remained stable from pre- to posttraining with respect to familiarity with individuals experiencing mild to moderate SUDs (alcohol or opioid); however, there were significant improvements in Perceived Dangerousness, Fear, Social Distancing, Personal Responsibility, and Psychosocial aspects for the Alcohol and Opioid scales (Table 4). Students’ scores on Perceived Dangerousness and Fear significantly decreased, indicating that their perceptions of dangerousness and fear lessened after training. Students’ scores on Social Distancing significantly increased, meaning that posttraining they were more willing to interact with individuals experiencing mild to moderate SUDs. Students’ scores on Personal Responsibility and Psychosocial aspects significantly decreased, indicating that after training they had more understanding of society’s role in the recovery process. The greatest magnitude of change occurred on the Fear and Psychosocial subscales of the Opioid version of the tool (|d_z | > 0.50; see Table 4).

Table 4.

Changes in Scores on the Stigma Subscales From Pretraining to Posttraining

Subscale	M (SD)		Mdn (IQR)		Test Statistic	p	\| d_z \|
Subscale	Pretraining	Posttraining	Pretraining	Posttraining	Test Statistic	p	\| d_z \|
Alcohol
Familiarity (n = 124)	10.45 (1.74)	10.42 (1.91)	10.00 (3.00)	10.00 (3.00)	Z = −0.430	.667	0.020
Perceived Dangerousness a (n = 104)	15.73 (5.53)	14.32 (5.29)	16.00 (8.00)	14.00 (7.75)	t(103) = 3.288	.001	0.322
Fear (n = 122)	12.58 (6.85)	10.37 (5.52)	10.50 (9.25)	10.00 (9.00)	Z = −4.340	<.001	0.424
Social Distancing a (n = 120)	10.19 (3.72)	11.42 (3.74)	10.00 (4.75)	11.00 (5.00)	t(119) = −4.657	<.001	0.425
Personal Responsibility (n = 122)	8.12 (3.38)	9.35 (3.84)	9.00 (6.00)	7.00 (4.00)	Z = −3.505	<.001	0.328
Psychosocial (n = 123)	13.31 (2.89)	11.97 (2.94)	14.00 (3.00)	12.00 (4.00)	Z = −4.968	<.001	0.483
Opioid
Familiarity (n = 121)	11.80 (1.71)	11.63 (1.92)	12.00 (2.00)	12.00 (3.00)	Z = −0.766	.444	0.111
Perceived Dangerousness a (n = 111)	16.64 (5.29)	14.91 (5.11)	17.00 (7.00)	14.50 (5.75)	t(110) = 3.802	<.001	0.361
Fear n = 126	14.23 (6.78)	11.08 (5.76)	13.00 (8.00)	10.00 (10.00)	Z = −5.610	<.001	0.560
Social Distancing a (n = 125)	9.12 (3.83)	10.36 (3.62)	9.00 (5.75)	11.00 (4.75)	t(124) = −3.985	<.001	0.356
Personal Responsibility (n = 126)	8.79 (3.72)	7.95 (3.43)	8.00 (6.25)	7.00 (4.00)	Z = −3.086	.002	0.292
Psychosocial (n = 126)	13.67 (3.22)	12.16 (2.97)	14.00 (3.00)	12.00 (4.00)	Z = −5.239	<.001	0.524

Note. Complete case data used for analyses of each subscale. IQR = interquartile ratio; Mdn = median.

Analysis completed using paired-samples t test; all other analyses completed using Wilcoxon signed-ranks tests.

Discussion

Our study suggests that SBIRT–Plus, an expanded version of the SBIRT curriculum that includes didactic content and simulated educational experiences with cannabis, stimulant, and opioid use, was feasible to implement using interprofessional training in two graduate professional programs. OTD and CRMHC graduate students reported high satisfaction with the program and that they would likely use the information they learned in practice. Integrating SBIRT–Plus into professional graduate programs may be an optimal and low-cost model for training health care professionals in recognizing people who have or are at risk for developing a SUD.

Our findings support our hypothesis that SBIRT–Plus would effectively increase students’ attitudes toward working with individuals at risk of SUDs with respect to their role adequacy, role legitimacy, role support, task-specific self-esteem, and work satisfaction. After SBIRT–Plus training, students had more positive attitudes about their feelings of knowledge of work, or role adequacy. They also had more positive attitudes about having the right to address client issues, which corresponds to role legitimacy. Posttraining, student had more positive attitudes about role support, or the belief that colleagues will provide support when working with individuals at risk for SUDs. They also showed positive improvements in task-specific self-esteem when working with individuals at risk for SUDs and an increased perception that working with individuals at risk for a SUD is rewarding or fulfilling (Work Satisfaction). This provides encouraging evidence that students will continue to believe that working with individuals at risk for a SUD is an important part of their clinical role.

With respect to attitudes from the Motivation subscale of the AAPPQ, our results of no statistically significant change are similar to those of previous studies of traditional SBIRT training for health care students (Martin et al., 2021; Puskar et al., 2012; Scudder et al., 2021). Students did, however, experience statistically significant change on the DDPPQ Motivation subscale. This contrasts with the results of several prior studies that reported no change on this scale (Martin et al., 2021; Puskar et al., 2012). This provides preliminary evidence that SBIRT–Plus training may increase health care students’ motivation to be involved with decision-making and client care for individuals at risk for SUDs, including cannabis, stimulants, and opioids.

It is well documented that stigma for people with SUDs exists among health care professionals (Zwick et al., 2020). We found that SBIRT–Plus reduced stigma perceptions of individuals experiencing mild to moderate SUDs. Our findings were similar to those of a prior study using traditional SBIRT training that examined changes in stigma among undergraduate nursing students (Mahmoud et al., 2019). It was not surprising that there was no change on the Familiarity scale, because these items are reflective of the students’ current environment, which was unlikely to change over the training period. However, students’ perceptions of perceived dangerousness, fear, and social distancing significantly decreased, indicating they had more understanding of society’s role in actively addressing prevention and recovery with those experiencing mild to moderate SUDs. The greatest magnitude of change was seen in the fear and psychosocial aspects of opioid stigma, which could be due to the additional modules in the SBIRT–Plus curriculum, which provided students with information about the neurobiology and management of opioid addiction.

Implications for Occupational Therapy and Rehabilitation Education

Our study provides initial evidence that the SBIRT–Plus curriculum is a valuable tool to enhance knowledge, improve attitudes, decrease stigma, and increase students’ comfort level with actively engaging with individuals at risk for a SUD. Training large cohorts of health care professional students in the SBIRT–Plus curriculum may be one relatively low-cost way to begin addressing the calls to the entire health care community to take responsibility for the prevention of, intervention with, and recovery from SUDs. Despite changes in policy and educational standards, most health care programs have not yet properly implemented concrete and meaningful training in screening, preventive treatment, and referral for individuals using and misusing substances. ACOTE and CACREP include specific requirements for programs to teach students screening, evaluation, intervention planning, and referral of individuals at risk for SUDs. SBIRT–Plus offers a standardized curriculum that can be embedded within clinical programs to teach these skills early on before any clinical placements. Additionally, the SBIRT–Plus curriculum increases opportunities for interdisciplinary education and clinical training. Ultimately, the program’s flexible design allows for in-person, remote, hybrid, or any combination of learning platforms, which is conducive to scalable and sustainable implementation across health care professional training programs.

Limitations and Future Directions

Our study is the first to examine the value of SBIRT–Plus for rehabilitation science graduate students. Although we found initial positive findings, several considerations should be acknowledged before drawing conclusions. For example, our study was limited to occupational therapy and clinical mental health counseling graduate professional students. Future studies should consider a combination of several more professional student programs for interprofessional training and could include an evaluation of the effect of SBIRT–Plus after students complete clinical rotations. Additionally, our outcome measures for attitudes have been well validated in samples of health care and professional students, but more work to establish the reliability and validity of the stigma measure is warranted.

Conclusion

The SBIRT–Plus curriculum demonstrates a feasible evidence-based, interdisciplinary method for preparing health care practitioners to address the increase in SUDs plaguing our communities. SBIRT–Plus training provides a conduit to meet the legislative goals of interdisciplinary and multimodal approaches to prevention, education, and promotion of treatment and recovery while achieving the educational standards for various health care provider degree programs. Large-scale implementation of the SBIRT–Plus curriculum in health care provider training programs is a necessary step in improving access to SUD intervention for all populations, thereby reducing morbidity and mortality associated with SUDs.

References

Accreditation Council for Occupational Therapy Education. (2018). 2018 Accreditation Council for Occupational Therapy Education (ACOTE^®) Standards and interpretive guide (effective July 31, 2020). American Journal of Occupational Therapy , 72(Suppl. 2), 7212410005. https://doi.org/10.5014/ajot.2018.72S217

Anderson

, & Clement

(1987). The AAPPQ revisited: The measurement of general practitioners’ attitudes to alcohol problems. British Journal of Addictions, 82, 753–759. https://doi.org/10.1111/j.1360-0443.1987.tb01542.x

Ashburn

Boateng

Cheatle

Christopher

Cleaver

Cohen

, . . . Gordin

(2019). Prescribing guidelines for Pennsylvania: Treating pain in patients with OUD . Commonwealth of Pennsylvania. https://www.health.pa.gov/topics/Documents/Opioids/Prescribing%20Guidelines%20for%20Individuals%20with%20OUD.pdf

Comprehensive Addiction and Recovery Act of 2016, Pub. L. 114-198, 130 Stat. 36.

Connery

H. S.

McHugh

R. K.

Reilly

Shin

, & Greenfield

S. F.

(2020). Substance use disorders in global mental health delivery: Epidemiology, treatment gap, and implementation of evidence-based treatments. Harvard Review of Psychiatry, 28, 316–327. https://doi.org/10.1097/HRP.0000000000000271

Consolidated Appropriations Act, Pub. L. 117-328, 136 Stat. 4459 (2023).

Council for Accreditation of Counseling and Related Educational Programs. ( 2016 ). 2016 CACREP standards . https://www.cacrep.org/for-programs/2016-cacrep-standards/

Kramarow

E. A.

, & Tejada-Vera

(2022a). Alcohol-induced deaths in adults aged 65 and over: United States, 2019 and 2020. NCHS Health E-Stats. https://doi.org/10.15620/cdc:122045

Kramarow

E. A.

, & Tejada-Vera

(2022b). Drug overdose deaths in adults aged 65 and over: United States, 2000–2020 (NCHS Data Brief No. 455). National Center for Health Statistics. https://doi.org/10.15620/cdc:121828

10.

Lukowitsky

M. R.

Balkoski

V. I.

Bromley

, & Gallagher

P. A.

(2022). The effects of Screening Brief Intervention Referral to Treatment (SBIRT) training on health professional trainees’ regard, attitudes, and beliefs toward patients who use substances. Substance Abuse, 43, 397–407. https://doi.org/10.1080/08897077.2021.1944955

11.

Mahmoud

K. F.

Terhorst

Lindsay

Puskar

K. R.

, & Mitchell

A. M.

(2017). Undergraduate nursing students’ perceptions of individuals with drug use problems: Confirming the factor structure of the Drug and Drug Problems Perception Questionnaire. Journal of Addictions Nursing, 28, 196–202. https://doi.org/10.1097/JAN.0000000000000194

12.

Mahmoud

K. F.

Finnell

Lindsay

MacFarland

Marze

H. D.

Scolieri

B. B.

, & Mitchell

A. M.

(2019). Can Screening, Brief Intervention, and Referral to Treatment education and clinical exposure affect nursing students’ stigma perception toward alcohol and opioid use. Journal of the American Nurses Association, 25, 467–475. https://doi.org/10.1177/1078390318811570

13.

Martin

M. P.

Woodside

S. G.

Lee

Henry

, & Patkar

(2021). SBIRT training: How do social work students compare to medical learners? Social Work in Health Care, 60, 631–641. https://doi.org/10.1080/00981389.2021.2001711

14.

Mattila

, & Provident

(2017). Education for occupational therapists to develop the role of healthcare leaders in Screening, Brief Intervention, and Referral to Treatment (SBIRT). Journal of Occupational Therapy Education, 1(3). https://doi.org/10.26681/jote.2017.010304

15.

Miller

, & Hendrie

(2008). Substance abuse prevention dollars and cents: A cost-benefit analysis (DHHS Pub. No. (SMA) 07-4298) . Center for Substance Abuse Prevention, Substance Abuse and Mental Health Services Administration.

16.

National Institute on Drug Abuse. (2022). Part 1: The connection between substance use disorders and mental illness . https://nida.nih.gov/publications/research-reports/common-comorbidities-substance-use-disorders/part-1-connection-between-substance-use-disorders-mental-illness

17.

Puskar

Gotham

H. J.

Terhorst

Hagle

Mitchell

A. M.

Braxter

et al. Burns, H. K. (2012). Effects of SBIRT training on nursing students’ attitudes toward working with patients who use alcohol and drugs. Substance Abuse, 34, 122–128. https://doi.org/10.1080/08897077.2012.715621

18.

Roopnarine

, & Boeren

(2020). Applying the Readiness for Interprofessional Learning Scale (RIPLS) to medical, veterinary and dual degree Master of Public Health (MPH) students at a private medical institution. PLOS ONE, 15, e0234462. https://doi.org/10.1371/journal.pone.0234462

19.

Rubin

(2021). When to adjust alpha during multiple testing: A consideration of disjunction, conjunction, and individual testing. Synthese, 199, 10969–11000. https://doi.org/10.1007/s11229-021-03276-4

20.

Scudder

A. T.

Bucey

J. C.

Loughran

M. J.

Korach

Strong

Anderson

et al. O’Keefe, L. (2021). Screening, Brief Intervention, and Referral to Treatment (SBIRT) expansion of training to non-physician healthcare graduate students: Counseling psychology, nursing, occupational therapy, physical therapy, and physician assistant studies. Substance Abuse, 42, 76–86. https://doi.org/10.1080/08897077.2019.1695705

21.

Sherwood

D. A.

Kramlich

Rodriguez

, & Graybeal

(2019). Developing a Screening, Brief Intervention, and Referral to Treatment (SBIRT) program with multiple health professions programs. Journal of Interprofessional Care, 33, 828–831. https://doi.org/10.1080/13561820.2019.1569601

22.

Substance Abuse and Mental Health Services Administration. (2021). Key substance use and mental health indicators in the United States: Results from the 2020 National Survey on Drug Use and Health (HHS Publication No. PEP21-07-01-003, NSDUH Series H-56). Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/data/sites/default/files/reports/rpt39443/2021NSDUHNNR122322/2021NSDUHNNR122322.htm

23.

Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act, Pub. L. 115-271, 132 Stat. 3894. (2018).

24.

Sullivan

G. M.

, & Artino

A. R.

Jr . (2013). Analyzing and interpreting data from Likert-type scales. Journal of Graduate Medical Education, 5, 541–542. https://doi.org/10.4300/JGME-5-4-18

25.

Terhorst

Gotham

H. J.

Puskar

K. R.

Mitchell

A. M.

Talcott

K. S.

Braxter

et al. Woomer, G. R. (2013). Confirming the factor structure of the Alcohol and Alcohol Problems Questionnaire (AAPPQ) in a sample of baccalaureate nursing students. Research in Nursing and Health, 36, 412–422. https://doi.org/10.1002/nur.21537

26.

U.S. Preventive Services Task Force;

Krist

A. H.

Davidson

K. W.

Mangione

C. M.

Barry

M. J.

Cabana

Caughey

A. B.

, . . .

Wong

J. B.

(2020). Screening for unhealthy drug use: US Preventive Services Task Force recommendation statement. JAMA, 323, 2301–2309. https://doi.org/10.1001/jama.2020.8020

27.

Watson

Maclaren

Kerr

2007; Staff attitudes towards working with drug users: development of the Drug Problems Perceptions Questionnaire. Addiction, 102,206–215. https://doi.org/10.1111/j.1360-0443.2006.01686.x

28.

Zwick

Appleseth

, & Arndt

(2020). Stigma: How it affects the substance use disorder patient. Substance Abuse Treatment, Prevention, and Policy, 15, 50. https://doi.org/10.1186/s13011-020-00288-0