Questioning Effectiveness of Referring Patients to Addiction Specialists from Primary Care.
In recent years, federal policymakers have promoted drug screening, brief intervention, and referrals to specialists as key tactics for primary care clinicians to motivate patients with unhealthy drug use to seek help.
While intervention has been the focus, the goal has been to get patients into treatment.
But a new study led by Boston University and Boston Medical Center researchers finds that such interventions did not significantly increase the likelihood of patients getting any addiction treatment—and that a “motivational” intervention approach actually lowered the odds that patients would enter treatment.
The study, published online in the journal Addiction, assigned more than 500 primary-care patients with recent unhealthy drug use to one of three groups: a 10- to 15-minute intervention by health educators, a 30- to 45-minute intervention that involved motivational interviewing by trained counselors, or no intervention. Patients in the intervention groups received treatment referrals that included “active efforts” by case managers to link them to programs.
Neither of the two interventions resulted in a higher likelihood of patients receiving treatment within six months, the study found. And the more extensive counseling resulted in lower odds of patients receiving addiction treatment.
Regardless of intervention assignment, only 15 percent received any addiction treatment within six months of study entry.
“Our study’s results may reflect the fact that accessing treatment is a challenging process in primary care,” the research team said. “It is possible that (brief intervention) helped patients to realize why they might seek treatment, but not how to access treatment or help them feel empowered to seek treatment.”
Especially in question is whether the referral component has any impact, said senior author Richard Saitz, professor and chair of community health sciences at the School of Public Health.
“Our findings add to growing evidence that the referral-to-treatment component of the screening and intervention process does not increase actual receipt of addiction treatment,” Saitz said. “This means that unless treatment is provided in primary care, the SBIRT (Screening, Brief Intervention, and Referral to Treatment) approach won’t benefit patients who need it.
“We need research on better ways to increase treatment receipt, regardless of referral,” he added.
Lead author Theresa Kim, assistant professor at MED, said that while brief counseling may be useful in some cases where patients’ drug use is relatively mild, the study suggests that referrals do not help patients with more serious problems.
“Primary care should be able to facilitate access to addiction specialists for its patients,” Kim said. “This is especially important because most people do not get treatment, as evidenced by our finding that only 15 percent obtained addiction treatment within six months. We need to do better than that.”
The study—part of a larger study known as ASPIRE—was based in a primary care practice in a Boston hospital. Participants were identified as having recent unhealthy drug use. The most common drug used was marijuana (63 percent), followed by cocaine (19 percent) and opioids (17 percent).
The analysis found that the odds of treatment receipt were lower for those using marijuana and higher for those with substance dependence. Older patients were less likely than younger ones to enter treatment. Overall health status, depression symptoms, and homelessness did not impact the likelihood of treatment receipt.
Co-authors were: Judith Bernstein, professor of community health sciences at SPH; Jeffrey Samet, chief of general internal medicine at Boston Medical Center and professor of medicine and community health sciences at MED and SPH; Debbie Cheng, professor of biostatistics at SPH; Christine Lloyd-Travaglini, statistical manager of the SPH Data Coordinating Center; and Tibor Palfai, professor of psychological and brain sciences at BU.
The study was funded by the National Institute on Drug Abuse and the Substance Abuse and Mental Health Services Administration.