‘SBIRT’ is the answer? Probably not

Screening, brief intervention and referral to treatment (SBIRT) addresses the full spectrum of unhealthy substance use 1. It sounds like the answer to the question: ‘how can we reduce substance use and disorders?’ by addressing everything except the delivery of specialized treatment itself. The best evidence suggests that brief intervention among people who drink risky amounts identified by screening (SBI) can reduce self-reported consumption very modestly in primary care patients (among those advised to drink less who are then asked if they have done so). The limitation of efficacy to a narrow band of those who drink too much but not too much is demonstrated by the disparate results of two emergency department SBI studies at the same site that differed largely in drinking eligibility/exclusion criteria 2, 3. The evidence for effects of alcohol SBI on any clinically important outcomes is limited, despite half a century of randomized trials and meta-analyses 4, 5. Studies have largely ignored patients with more severe unhealthy use by excluding such participants 6. Glass et al. 7 assessed the evidence for the main way in which SBIRT addresses more severe unhealthy use—referral to treatment. They find randomized-controlled trial evidence that RT in SBIRT has no efficacy. They suggest that trials could focus more effectively on referral-specific efforts. However, will a focus on referral-specific efforts in SBIRT yield success? It is doubtful. Although more intensive referral (a ‘warm handoff’) can have efficacy (e.g. for Alcoholics Anonymous 8), this evidence is among treatment seekers. A specific plan is not always a good idea, and may explain the null results of a trial of motivational interviewing for drug use that required a change plan 9. Glass et al.’s review 7 focused on patients who are not seeking help for their unhealthy alcohol use, identified six trials that reported specific efforts at referral, and only one (the one with the highest risk of bias) found efficacy; that intervention was a letter—not so warm. Two questions have been considered inadequately by what should have been formative research prior to wide promotion of SBIRT. The situation RT addresses is a patient who has a disorder (e.g. who has continued use despite consequences) who is not seeking help, who is identified during a health-care visit for something else. The first question, then, is how, during this brief encounter, the patient is to recognize their condition, decide to do something about it, decide that the change to be made is to arrange and then attend a specialty treatment visit and to choose the one that fits closest in terms of payment and match to their specific condition (among options that rarely offer the full range of evidence-based services). A tall order. The second question is how to best treat people with a disorder (e.g. dependence) who come to treatment having been identified by screening, who may be even more ambivalent about change than seekers of treatment. Treating them with a referral to treatment assumes that treatment will be received and have efficacy; but efficacy of treatment is only known for treatment seekers (or when mandated), not people identified by screening. Expectations of treatment affect its outcome 10, and motivational interviewing can improve treatment engagement but not substance use outcomes among people entering treatment 11. So, what is next? The warm handoff remains a good idea, but it does not address the barriers to deciding to obtain treatment. The question of efficacy of treatment in people not seeking it could be studied, although it will not be easy, for obvious reasons. We must reconsider the idea that intervention for a complex disorder, one characterized by motivational impairment, must be brief. Patients identified by screening are unlikely to move from not thinking they have a condition that requires help to engaging in specific demanding and stigmatizing specialty treatment in 15 minutes. Although the results have been mixed 12, 13, care management in primary medical care settings, including better counseling to address treatment options, may provide a path. Brief interventions will probably need repeating, perhaps over years; and given that studies have largely been designed to assess surrogate outcomes (drinking), we need trials that assess whether SBI and other approaches in general health settings (e.g. care management) improve clinical outcomes of importance. If the question is how do we identify people with substance use disorders and improve their health, SBIRT is not the answer. There is danger in thinking it is: clinicians can believe that SBIRT addresses a condition for which it has no efficacy; similarly, researchers may not study solutions to a problem thought to have been solved. It is time to address seriously heavier drinking and alcohol disorders in general health settings by going back to the drawing board 14 to design and test models that have promise. I received no financial support for this work other than as a salaried Professor at Boston University. I am and have been principal investigator of grants awarded to Boston Medical Center and Boston University from the National Institutes of Health (including NIAAA and NIDA, and the Substance Abuse and Mental Health Services Administration) to study the management of unhealthy substance use, including to test the efficacy of screening, brief intervention and referral to treatment. I have been paid to speak or had travel reimbursed to speak at numerous professional and scientific organizations, such as the American Society of Addiction Medicine, the Research Society on Alcoholism, the BMJ, the International Conference on Treatment of Addictive Behaviors, and the International Network on Brief Intervention for Alcohol and other drugs. I am an author and editor for Springer, UpToDate, the American Society of Addiction Medicine, the BMJ and the Massachusetts Medical Society. Speaking and writing is often on this topic. I have been paid to serve as an expert witness in malpractice cases related to the management of alcohol and other drug disorders. I am employed by Boston University School of Public Health.