Screening and brief intervention (BI) is recommended to identify patients with unhealthy alcohol use and to treat them, even though there are still many questions about the effectiveness of the procedure, according to the Chair of the upcoming INEBRIA conference in Boston.
“It’s probably not the case that screening everyone in every circumstance and doing a brief intervention will always lead to improvement,” says Richard Saitz, MD, MPH, Director of the Clinical Addiction, Research and Education Unit at Boston University Medical Center.”It’s more likely that there are times and circumstances when BI is more or less effective. The problem is that we don’t yet know what those circumstances are.”
Unlike traditional treatment for alcohol dependence, BI is generally aimed at people who drink in ways that are risky or harmful but who are not alcohol-dependent. While traditional treatment for alcohol dependence can last weeks or months, BI is generally much shorter.
Experts do not agree on many aspects of BI, ranging from the definition of ‘brief,’ to who the treatment works best for, and in which settings it is most effective, according to Dr. Saitz.
“BI can be spending a few minutes with someone and telling them, ‘You’re drinking too much and here’s what I advise,’ but the more effective brief interventions consist of counseling someone for 10 to 15 minutes at least twice,” notes Dr. Saitz. “When you hear ‘BI’ you need to drill down on what is meant by that. No one says something as general as, ‘heart disease treatment is effective,’ so we shouldn’t be dumbing down our language around addiction treatment.”
An important concern surrounding BI is how a person comes to the treatment, he says. People who are screened for alcohol use when they go to their primary care doctor for a sore throat are different from those who are screened when they go to the hospital with pneumonia, or who end up in a trauma center because they have just caused a fatal car crash while under the influence of alcohol. “It’s unlikely that BI has the same effect in all these circumstances—it’s not a monolithic thing,” stated Dr. Saitz. “Like anything in health care, there is nuance and complexity to BI.”
Setting is Important
The setting in which the screening is done is another variable that affects the treatment, notes Dr. Saitz. He points out the American College of Surgeons requires trauma centers to perform alcohol screening and intervention as part of their accreditation, even though data are mixed on whether this practice has any measurable effectiveness in this setting. “Half of serious trauma is related to alcohol, so we should be worried about it and address it, but we don’t know whether BI in those circumstances works,” says Dr. Saitz, who will be speaking on “What We Know and Don’t Know About BI Effectiveness” at the INEBRIA conference in September. “Some high-quality randomized studies show no effect, while other studies suggest promising results.”
Even More Questions Surrounding BI for Drug Use
While there are many unknowns about BI for alcohol, there are even more questions about BI for drug use, Dr. Saitz says. “We have very little evidence that BI for drug use works in any setting or circumstance. Drug use spans a much larger set of behaviors than alcohol use, ranging from someone who uses marijuana once a month, to someone who injects heroin seven times a day.”
Dr. Saitz is conducting a study on BI and drug use in a primary care setting, funded by the Substance Abuse and Mental Health Services Administration and the National Institute on Drug Abuse. “Both agencies have recognized the dearth of evidence of the effectiveness of BI for drug use,” he says.
The Assessing Screening Plus Brief Intervention’s Resulting Efficacy to Stop Drug Use, known as the ASPIRE Study, is randomly assigning patients to one of three groups and following them for six months. In one group, patients will receive standard BI conducted by trained health promotion advocates. A second group will receive more intensive BI conducted by counselors with a master’s degree. A third group will receive written information about resources, and if they are still using drugs at the end of six months, they will also receive standard BI.
“If we are going to do BI universally, we should require the highest level of evidence that it is effective,” commented Dr. Saitz. “Since most people who will be screened won’t be using drugs or risky amounts of alcohol, we want to make sure we have a high level of evidence to justify what we’re doing, just as we do for screening guidelines for other diseases such as colon cancer.”