One-to-Two Session Brief Interventions Don’t Reduce Unhealthy Substance Use in Primary Care Settings

Screening, brief intervention, and referral to treatment (SBIRT) has been widely promoted to address unhealthy substance use. Two recent studies examined its effect on unhealthy drug use in adult primary care.

Saitz and colleagues randomized 528 adults who screened positive for unhealthy drug use to 1 of 3 conditions: a 10–15 minute structured brief negotiated interview with a health educator, a 30–40 minute motivational interview plus a 20–30-minute booster session, or no BI. Follow-up was 98% at 1.5 and 6 months.

• Marijuana was the primary substance for 63% of participants, cocaine for 19%, and opioids for 17%. Of the participants, 82% did not meet the criteria for substance dependence.
• Only 31% of participants in the MI arm received the booster session.
• No differences were found between the groups in the number of days in a month for use of the primary drug, even when stratified by primary drug and risk of drug dependence, or as detected by hair analysis.
• No effects were found on drug use consequences; injection drug use; unsafe sex; health care utilization (hospitalizations and emergency department visits, overall or for substance use or mental health reasons); or mutual help group attendance.
• Drug use remained high (>90%) in all groups and did not decrease over 6 months.

Roy-Byrne and colleagues randomized 868 adults who screened positive for unhealthy drug use in the prior 90 days to 1 of 2 groups. The intervention group received a single motivational interview from a clinic social worker, a 10-minute telephone booster 2 weeks later, an illustrated handout indicating their score on the drug screen, and a list of substance use resources. The comparison group received just the handout and resource list. Follow-up was ≥87% at 3, 6, 9, and 12 months.

• Only 47% of the intervention group could be reached for the booster call.
• No differences were found between the groups in the number of days in a month for use of the primary drug, even when modified for baseline drug use severity, psychiatric comorbidity, or motivation to change.
• No effects were found on drug use severity; medical, psychiatric, employment, social, or legal consequences; acceptance of referral to chemical dependency treatment; or medical care use. Arrests and deaths also did not differ between groups.
• An exploratory analysis detected an increase in chemical dependency treatment entry and a reduction in emergency department use among those with the highest severity of unhealthy drug use.

Comments:

These clinical trials found that 1–2 sessions of brief motivational intervention alone are ineffective in reducing unhealthy drug use or its sequelae among primary care patients over a 6- to 12-month period. Although some have viewed these studies as repudiating SBIRT altogether, this interpretation is overly expansive. These studies cannot speak to the utility of screening, since the benefits of identifying unhealthy substance use extend beyond just cueing the clinician to provide a brief intervention. For example, the expert clinician understands that unhealthy substance use belongs in differential diagnoses for many common conditions, represents an important risk factor for major medical and psychiatric conditions, and is an essential piece of information for safe prescribing of medications with potential for unhealthy use or interactions. These trials also cannot speak to the effectiveness of “referral to treatment” except to affirm that we need better, more accessible treatments that our patients will accept, and more reliable ways to link patients to them.

However, these studies clearly show that 1–2 motivational counseling sessions are insufficient for the effective management of substance use in primary care. Fortunately, primary care providers can see patients with unhealthy substance use over time. In multiple routine and sick visits over years, the provider has the opportunity to express continued concern and challenge the assumption that chronic substance use is benign; develop the trust and therapeutic alliance that are essential for inducing behavior change; monitor and address consequences; mobilize family and other social support for sobriety; refer for addiction consultation or counseling and ensure that the referral was completed; and provide appropriate pharmacotherapy. Primary care clinicians use this longitudinal approach in the management of other chronic diseases like hypertension and diabetes, and it is consistent with the paradigm of unhealthy substance use as a chronic condition. But this extrapolation will require empirical validation.

Peter D. Friedmann, MD, MPH

Reference:

Roy-Byrne P, Bumgardner K, Krupski A, et al. Brief intervention for problem drug use in safety-net primary care settings. JAMA. 2014;312(5):492–501.

Saitz R, Palfai TP, Cheng DM, et al. Screening and brief intervention for drug use in primary care: the ASPIRE randomized clinical trial. JAMA. 2014;312(5):502–513.