Early Intervention for Unhealthy Alcohol Use: A Review of SBIRT (Screening, Brief Intervention, & Referral to Treatment)

Unhealthy alcohol use can range from risky drinking to alcohol use disorder and is currently the 3rd leading cause of preventable death in the U.S. with an immense economic burden costing over $230 billion each year.

Since a majority of individuals do not seek or receive help for mild to moderate problematic drinking, routine medical visits are an opportune time to identify unhealthy use with universal screening and brief interventions.

WHAT PROBLEM DOES THIS STUDY ADDRESS?

Does adding a referral-to-treatment component to screening and brief intervention (SBIRT) better address more severe alcohol use? While many randomized controlled trials have evaluated the effectiveness of “SBIRT” overall, there is a need to identify, more specifically, how effective these interventions are at linking people to services and improving alcohol-related outcomes.

HOW WAS THIS STUDY CONDUCTED?

This systematic review and meta-analysis by Glass and colleagues included randomized controlled trials (RCTs) evaluating unhealthy alcohol use interventions in medical settings that included linkage to services (e.g., mutual help organizations or professional treatment). All study samples consisted of patients who were not seeking alcohol-related treatment. The primary outcomes evaluated were alcohol treatment utilization and post-intervention drinking outcomes.

This review included 13 RCTs with interventions implemented in medical in-patient units, general health-care settings, and emergency departments. Most interventions included brief advice or motivational interviewing, while some featured additional counseling sessions, and one mailed a letter advising patients to make a specialist appointment.

WHAT DID THIS STUDY FIND?

The authors used data from nine studies to conduct a meta-analysis on the association between receiving a brief intervention and subsequent alcohol treatment initiation. From this pooled dataset with n = 993 in the intervention group and n = 937 in the control group, there was no significant association between brief intervention and treatment initiation.

The brief intervention did not help people get further treatment.

This study did not find evidence for the effectiveness of brief alcohol interventions at increasing alcohol-related treatment utilization. Since the referral to treatment component of SBIRT interventions is aimed at linking patients with more severe alcohol problems with the necessary care, this finding suggests that this model is not producing the intended outcomes.

NOTABLY FROM THE STUDY:

Batel, Pessione, Bouvier, & Rueff, 1995 which mailed letters to patients admitted to the hospital for drunkenness encouraging them to seek outpatient treatment, was the only one to report a significant difference between treatment and control groups in terms of utilization of alcohol treatment.
Highest rates of treatment utilization were found in samples with high-severity of alcohol use and studies conducted in in-patient settings ranging from 19-56% in the intervention groups (see Bischof et al., 2008; Kuchipudi et al., 1990; Saitz et al., 2007)
Treatment utilization was lower for studies conducted in emergency departments and in samples with a mix of severity levels ranging from 2-33% (see Barnett et al., 2007; Batel et al., 1995; Bernstein et al., 2010; Cherpitel et al., 2010; Crawford et al., 2004; Gentilello et al., 1999)
Monti et al., 1999 found that SBI was associated with reductions in drunk driving, moving violations, alcohol-related injuries, and other alcohol-related problems.

WHY IS THIS STUDY IMPORTANT

Referral to treatment is an important part of SBIRT (Screening, Brief Intervention, & Referral to Treatment) programs as it can help link patients with severe alcohol-related issues to treatment. Previous studies have found evidence in support of the effectiveness of brief interventions for reducing alcohol use, showing that SBI can promote drinking reductions. However, the effectiveness surrounding the referral to treatment component of such interventions was still still unknown.

If more studies support this lack of effect, other approaches may be needed to identify and link patients with severe alcohol use to care.

LIMITATIONS

The authors were limited by the low number of studies when conducting subgroup analyses in the meta-analysis.
Additionally, the pooled risk ratio is derived from studies with a variety of differences in important factors such as age of participants and treatment intensity making it difficult to generalize to other settings and populations.
Severity of alcohol use may moderate the effects of these interventions. If patients do not perceive they have a problem with drinking, they may not be motivated to seek further treatment after SBI which may explain the null effect observed in this analysis.

BOTTOM LINE

For individuals & families seeking recovery: SBIRT (Screening, Brief Intervention, & Referral to Treatment) interventions are generally broadly implemented in medical settings and do not directly apply to individuals seeking recovery. These can, however, stimulate help-seeking through providing feedback about one’s harmful/hazardous use patterns.
For scientists: More RCTs designed specifically to evaluate referral to treatment are needed. Additionally, research evaluating interventions aside from SBIRT can help identify other potentially better methods of identifying and connecting patients with severe alcohol use to treatment.
For policy makers: Alcohol Use Disorder (AUD) and related problems confer a major economic cost in lost productivity, criminal justice, and health care. Given the results of this review, funding should be allocated to develop and test other linkage to care interventions for this population.
For treatment professionals and treatment systems: Identifying unhealthy alcohol use, regardless of the intervention used to do so, is important for your patients’ overall wellbeing. See here for more information about screening for alcohol use and related problems.