Referral to Treatment (the “RT” in “SBIRT”) Does Not Lead to Treatment

It is widely assumed that although brief intervention may be inadequate, patients with substance use disorders identified by screening can be helped by referring them to treatment. Researchers did a systematic review and meta-analysis of the efficacy of brief alcohol intervention for increasing alcohol-related care (treatment). Most of the 13 randomized controlled trials in 5 countries (general medical outpatient and hospital and emergency care settings) studied brief advice or motivational interviewing that could have led to referral; 8 studies specified a referral intervention.

• Treatment receipt was not associated with drinking outcomes (examined in only 2 trials).
• Only one study found an effect on receipt of treatment—the intervention was a letter mailed to patients advising them to make an appointment.
• Ten studies had sufficient data for meta-analysis and one was excluded due to high risk of bias; there was no effect on receipt of treatment (relative risk, 1.08, 95% confidence interval 0.91–1.29).

Comments:

Clinicians know that advising patients to seek substance use disorder treatment rarely leads to them receiving it. It is a tall order for a brief intervention to take a patient who is not seeking help from screening all the way to entering treatment. Now we have data that RT (the referral to treatment component of screening, brief intervention, and RT [SBIRT]) doesn’t work for unhealthy alcohol use. It is possible, though unlikely, that improved referral strategies will be the solution. In general health settings, we need better ways to manage patients with screen-identified unhealthy alcohol use who could benefit from treatment.

Richard Saitz, MD, MPH

Reference:

Glass JE, Hamilton AM, Powell BJ, et al. Specialty substance use disorder services following brief alcohol intervention: a meta-analysis of randomized controlled trials. Addiction. 2015;110(9):1404–1415.