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Brief alcohol interventions in medical settings aren't leading to specialty care

May 22, 2015
by Gary A. Enos, Editor
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Evidence remains scant that brief interventions in medical settings to address alcohol use problems lead to utilization of specialty addiction treatment. The lead author of a meta-analysis of research published through mid-2013 suggests that screening and brief intervention initiatives to this point have shown results only for lower-severity alcohol users, and that other measures might be needed in order to target the most severe untreated cases.

“Is this an intervention only for people with mild to moderate problems?” says Joseph E. Glass, PhD, assistant professor of social work at the University of Wisconsin.

The new report, published in the journal Addiction, encompassed 13 randomized controlled trials of brief alcohol interventions in medical settings ranging from inpatient hospital units to primary care clinics, and meta-analyzed nine of those studies. The analysis found no evidence that individuals receiving a brief intervention were more likely to utilize alcohol treatment than those not receiving an intervention.

This led study authors to write in a draft of their research paper, “Despite the widespread support for [Screening, Brief Intervention and Referral to Treatment] implementation as a public health program to address all forms of unhealthy alcohol use, there is a lack of evidence from existing studies of brief alcohol interventions to support the assumption that SBIRT, as currently implemented, is efficacious in linking individuals to higher levels of alcohol-related care.”

Some surprising observations

This analysis sought to identify randomized trials examining medical setting-based interventions on unhealthy alcohol use (studies involving participants with drug use problems were excluded). Researchers looked only at studies that involved referral of patients to specialty addiction treatment services, as opposed to follow-up services delivered by medical professionals in the general health settings. Most of the interventions that took place in the examined settings involved brief advice or a motivational interview.

In 11 of the 13 selected trials, receiving at least one session of specialty addiction treatment met the study's definition for treatment utilization. It is therefore noteworthy that only one of the examined studies found a significant difference between intervention and control groups in specialty treatment utilization. Post-intervention treatment occurred more often for patients who had higher severity and/or were originally seen in inpatient medical settings.

Only two studies went on to examine the relationship between specialty treatment utilization and alcohol-related outcomes, with one stating that a small sample size hindered interpretation of the results and the other concluding that the effects of brief intervention on outcomes did not result from receiving specialty treatment.

Researchers stated that much of the past SBIRT research surprisingly failed to evaluate the referral component of the continuum. Based on their latest findings, they wrote in their draft, “This lack of evidence calls into question the assumption that referral to treatment as part of SBI or SBIRT effectively links patients to higher levels of care for their alcohol problems.”

Glass adds, however, that screening and brief intervention does have a body of supporting evidence for its use with less severe alcohol problems, assisting these individuals in reducing their drinking.

An examination of patient subgroups in the meta-analysis, grouped by age, setting, severity and treatment intensity, also did not find statistically significant differences in intervention and non-intervention populations.

Glass believes that the results point to the need for alternative strategies for engaging individuals (particularly the highest-risk patients) into treatment. Some have suggested that brief intervention in and of itself is too low-intensity a service to act as a successful referral source, and say hat more aggressive case management and telephone monitoring may be needed as well.

“Do we need to involve other kinds of professionals?” Glass says.





Although a brief interaction accompanied by Motivational Interviewing may be enough for less severe cases, I have found that we often forget the "warm hand-off" into treatment is best practice. Once the SBIRT is completed, our team will assist the client in entering treatment by providing transportation and follow up. This "extra" piece is critical to ensure the client not only receives information on treatment, but assistance in breaking the barriers that interfere in making it to scheduled appointments. Of course, the client is the one to make this decision, but once the decision is made, our team will take the client home to get a change of clothing, pick up children and deliver them to the treatment facility. This eliminates barriers that interfere with the client's best intentions of going to treatment. The warm hand-off allows for the substance use professional, whom the client trusts, can introduce them to the facility intake counselor, and other staff, reducing client anxiety and increasing chances of successful program completion. Follow up is critical to completion of this interaction and to let the client know that you are available should they find themselves needing assistance again.