Brief and e-Health Interventions for the Treatment of Alcohol or Other Drug Addiction

Drug Use and Problems

A broad range of treatment approaches are available and necessary for the management of persons with problem drug and/or alcohol use. Individuals with problem substance use can present anywhere along a continuum, from early stage problems associated with acute, recreational, or binge use to severe dependence with major physical and psychosocial problems. This latter group commonly has multiple health problems with poor or negligible non–drug-using social support and requires intensive intervention, often with the objective of achieving abstinence. Traditionally, most therapeutic resources were directed at the management of this group. These interventions have generally been intensive in nature and costly to deliver and have failed to reach the majority of individuals using these substances.

Although the impact of drug and alcohol dependence on health and society is widely recognized, the effects of nondependent excessive drug use are often underestimated by the community and the health care system. For example, the number of nondependent heavy drinkers far outweighs the number of dependent people. Most alcohol-related problems result from people drinking below levels that cause major physical dependence. Nevertheless, the societal, family, and health impacts of nondependent drinking have a greater influence than dependent drinking on the community’s burden of alcohol problems: the so-called prevention paradox.

A report by the Institute of Medicine recommended that given the number of people with mild or moderate alcohol problems, a range of therapeutic approaches needed to be developed to cover the full gamut of alcohol use problems. Similar conclusions could be drawn concerning clinical and subclinical use of other types of substances. Table 43.1 summarizes key definitions for problematic use of alcohol or other substances.

Drug Treatment in Primary Care and Nonspecialist Settings

People who consume hazardous levels of alcohol (use that will probably lead to harmful consequences for the user if it continues) rarely seek treatment. Indeed, less than 30% of individuals with alcohol use disorders are likely to have sought professional care in the previous year, and only 14% of those with other substance use disorders seek professional help. People with early stage problem drug use commonly present to general practitioners or community health services for reasons that are not drug-related. Health workers in hospital emergency departments typically encounter a greater proportion of cases, such as acute trauma presentations, accident, injury, and overdose that are common consequences of drug use.

The nondependent population, unlike their dependent counterparts, typically have an intact psychosocial fabric and, therefore, do not require the intensive interventions directed at dependent individuals. The identification and effective management of these individuals before the development of more significant use, dependence, and associated major physical and/or psychosocial problems is clearly desirable. Individuals who have early problem substance use but who are not dependent are a major target group for early identification. The importance of this approach has resulted in screening, brief intervention, and referral to treatment (SBIRT) being mandated in the United States for level 1 and 2 trauma centers.

This approach has a sound rationale. Screening clients to identify at-risk users combined with brief interventions provides an efficient way of reaching a larger portion of clients with alcohol or other drug problems than provided by traditional intensive interventions, and may be especially suited to clients with less severe diagnoses. By using opportunistic screening, brief interventions may reach a proportion of individuals who would not normally present at specialist treatment facilities. Moreover, screening in primary care for subclinical alcohol consumption or other drug use to identify at-risk individuals allows preventive measures or treatment to be initiated before clinical-level disorders and the associated health and social problems develop.

A large number of short screening tests are available to aid in the systematic identification of alcohol or other drug use problems in primary care. Two of the most commonly used tests are the Drug Abuse Screening Test and the 10-item Alcohol Use Disorders Identification Test (AUDIT). The latter was developed by the World Health Organization and validated in numerous countries and populations. It is also available in three shortened versions and has been used widely. The Drug Abuse Screening Test is available as a 28-item form or a 10-item short form and screens for general drug abuse rather than a specific class of drug. The brevity of these instruments and their ease of use make them suitable for a range of general medical settings. Biological screening tests (e.g., breath, hair, urine, saliva, laboratory markers) would appear to offer a more robust assessment, but to date, these are of limited use in primary care, where results are needed quickly, must be inexpensive, and must show more than just recent use. Therefore, biological assays may be more appropriate in specialist settings, clinical trials, or where they are required to comply with legal requirements.

What Is Screening and Brief Intervention?

Screening and brief intervention (SBI) is generally used as part of a consultation in a primary care setting—for instance, general practice or a community health service. However, as is explored in more detail below, some brief interventions may be initiated at a teachable moment such as in general hospital emergency, medical, or surgical departments, when individuals may be highly motivated to change their behavior.

Brief interventions are sometimes described as minimal interventions due to the less-intensive nature of the intervention required to effect changes toward more positive substance use patterns in nondependent individuals, or as early interventions because they are directed at individuals who have not progressed to more serious drug use patterns. However, even at the extreme end of the spectrum, SBI has a role in identifying people with dependence and enhancing referral for treatment.

There is no universally accepted definition of what constitutes a brief intervention. Babor provided a convenient heuristic where a single client contact with a professional constitutes a minimal intervention, 1–3 sessions constitute a brief intervention, 5–7 sessions a moderate intervention, and 8 or more an intensive intervention. Miller and Wilbourne suggested that 1 or 2 sessions of treatment constitute a brief intervention, whereas Moyer and colleagues used a threshold of 4 sessions to define brief interventions. In the first section of this chapter, the focus is on interventions that can be delivered in 4 or fewer sessions. In the second section, the focus is on brief interventions to increase compliance with pharmacotherapies used in the treatment of problem alcohol or other drug use, which often extend over 12 or more sessions.

Notably, none of these definitions delineate the length or content of the intervention. Interventions are typically of 30- to 45-minute duration; however, within a community/primary care setting, interventions can be incorporated within a 5- to 10-minute physician consultation. Five key elements have been identified for inclusion in an intervention. First, the clinician assesses the quantity and frequency of alcohol or other drug use and provides direct feedback to the client regarding health or psychosocial morbidity relevant to his or her level of use. Second, goals for alcohol or other drug use are established that are acceptable to both provider and client. These goals may be a reduction in consumption, such as using alcohol in a low-risk fashion, or complete cessation, as is commonly employed with tobacco use. Third, the provider uses behavioral modification techniques—for example, to help the client identify high-risk situations and develop strategies to deal with these. Fourth, the clinician should supply support material on problems associated with substance use plus self-help techniques. Fifth, the provider should offer ongoing support. Others have summarized the content under the acronym FRAMES —that is, F eedback on personal risk, personal R esponsibility for the problem, A dvice that is clear and explicit, a M enu of options on how to change, an E mpathic style of counseling to avoid coercion or authoritarianism, and enhancement of the client’s S elf-efficacy.

Babor and colleagues provided a thorough discussion of the psychological principles and behavioral change strategies thought to underlie early or brief intervention programs; these incorporate principles from social, cognitive, and behavioral psychology to increase motivation and commitment to change. For example, a health care professional can be seen as having social power, and, as a credible source of relevant health information, the provision of normative information allows social comparison and support networks to use social influence to modify behavior.

A concept that often arises in the screening and brief intervention literature is that of the teachable moment when a person is particularly likely to be open to changing his or her behavior—for example, when a major health event or hospitalization related to substance use occurs. McBride and colleagues suggested a model to help determine whether a given event, such as hospitalization for a substance-related morbidity, will cue the client to reduce his or her substance use. First, does the event (e.g., hospitalization or ill health) serve to increase perceived risk from the client’s use of the drug and the potential for positive outcomes to occur if the use is reduced or ceased? Second, does the event provoke a strong emotional response? Third, does it lead to redefining the person’s self-concept? For instance, a child being diagnosed with asthma may be associated with smoking by a parent, leading to the parent reevaluating his or her role as a protective caregiver. Even in the presence of all these factors, preexisting individual factors may override the impact of the event. Nevertheless, delivering interventions at a teachable moment is likely to amplify greatly the impact of the intervention—for example, increasing cessation of smoking by up to 70% compared with a background quit rate of about 5%.

Some have contended that the stress associated with a hospital presentation and the often chaotic environment in hospital emergency departments may mean that this is not a conducive setting in which to deliver an intervention. However, it may still be appropriate to use the opportunity to arrange a follow-up intervention, and there is the possibility of using motivational techniques to encourage people to attend treatment rather than attempting to deliver treatment under these difficult conditions.

Screening and Brief Intervention—Effectiveness and Delivery