Clinical Protocol Handbook

SBIRT Protocol Handbook: Universal Screening & Brief Negotiated Interview

Primary care teams identify risky substance use early by pairing a 60-second universal pre-screen with a structured 5-to-15 minute Brief Negotiated Interview and immediate warm handoff.

Evidence basis: USPSTF Grade B Alcohol Screening Guideline and SAMHSA Systems-Level SBIRT Monograph (SMA 13-4741).

1. Rooming Workflow & Universal Pre-Screen

Targeted screening based on clinical suspicion misses most patients with hazardous drinking or early prescription misuse. Standard outpatient workflows embed two single-item questions into medical assistant intake alongside vital signs for every adult aged 18 or older at least once annually.

• NIAAA Single-Item Alcohol Pre-Screen: "How many times in the past year have you had 5 or more drinks in a day (for men under 65) or 4 or more drinks in a day (for women and adults 65 or older)?" Any answer of 1 or more times is positive and triggers the 3-item AUDIT-C.
• NIDA Quick Screen (Single-Item Drug Question): "How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?" Any response greater than zero triggers the DAST-10 or full NIDA-Modified ASSIST.
• Standard Drink Calibration: Remind patients that one standard drink equals 14 grams of pure alcohol: 12 oz of 5% beer, 5 oz of 12% wine, or 1.5 oz of 80-proof spirits. Large craft pours and cocktails frequently contain 2 to 3 standard drinks.

2. The 4-Step Brief Negotiated Interview (BNI / FLO)

Once AUDIT-C or DAST-10 confirms risky use, confrontational lecturing reliably increases patient defensiveness and resistance. The WIPHL clinical model adapts Motivational Interviewing into a rapid four-step outpatient structure known as FLO (Feedback, Listen and Understand, Options Explored).

1. Minute 0-1 · Step 1

   Raise the Subject & Ask Permission

   Build autonomy before sharing scores: "Thank you for completing our clinic health questionnaire. Would it be okay if we take five minutes to look at your drinking or substance screen alongside your blood pressure today?"

2. Minute 1-4 · Step 2

   Provide Objective Medical Feedback

   Connect quantitative screening results directly to the patient's chief complaint without moral judgment: "National health thresholds stay under 7 drinks weekly for women or 14 for men. Your score puts you in a range that can raise systolic blood pressure, disrupt REM sleep, and reduce antidepressant efficacy."

3. Minute 4-8 · Step 3

   Listen, Reflect & Deploy the Readiness Ruler

   Ask the patient what benefits they experience from current use alongside any concerns. Then ask: "On a scale from 1 to 10, how ready are you to make a change right now?" Follow up by asking why they chose their number instead of a lower one (e.g., "Why a 6 instead of a 2?") to elicit natural change talk.

4. Minute 8-12 · Step 4

   Explore Options & Close with Warm Handoff

   Summarize the patient's own motivations, co-create one measurable 2-week target (such as alcohol-free weekdays or carrying intranasal naloxone), and offer an immediate hallway introduction to the clinic behavioral health educator or prescribe FDA-approved pharmacotherapy.

3. Clinical Severity Tiers & Escalation Matrix

4. Interactive BNI Script & Readiness Generator

5. Primary Care Pharmacotherapy Bridge

Behavioral interventions achieve higher durability when primary care clinicians do not defer medication-assisted treatment solely to external specialty centers. For uncomplicated moderate-to-severe alcohol use disorder without acute decompensated cirrhosis, oral naltrexone 50 mg once daily (after verifying opioid-free status) reduces heavy drinking days, while acamprosate 666 mg three times daily supports abstinence in patients with hepatic transaminitis or renal clearance eGFR > 50 mL/min.

For opioid use disorder, primary care clinics can initiate home or office buprenorphine-naloxone induction alongside intranasal naloxone 4 mg rescue kits and connect the patient through a same-day behavioral health warm handoff. Confirm billing time capture using the SBIRT coding and reimbursement guide.

6. Protocol Questions