CLINICAL QUESTION

Is SBIRT (i.e., screening, brief intervention, and referral to treatment) effective for reducing alcohol use in adolescents?

EVIDENCE-BASED ANSWER

It is unclear how effective SBIRT is for reducing alcohol use in adolescents. Elements of SBIRT, including a brief intervention alone with no screening or referral to treatment, may reduce alcohol consumption and alcohol-related consequences in adolescents. (Strength of Recommendation [SOR]: A, systematic review of randomized controlled trials [RCTs].) The use of elements of SBIRT (i.e., brief intervention only or screening plus brief intervention) may reduce alcohol consumption in adolescents with heavy alcohol use at baseline. (SOR: B, RCT.) The use of SBIRT does not reduce alcohol use over 6 to 24 months but may decrease the diagnosis of alcohol use disorder in adolescents over a 7-year follow-up. (SOR: B, RCTs.)

EVIDENCE SUMMARY

A 2022 systematic review examined the effects of brief interventions on substance use and internalizing symptoms (e.g., depression/anxiety) in adolescents.¹ Participants were between 13 and 21 years of age and had a brief psychosocial intervention, a comparison condition, and at least one treatment outcome evaluating mental health and one treatment outcome evaluating substance use. Six studies met inclusion criteria (n = 2,380 in treatment conditions; n = 1,422 in control groups).

Modalities varied and included brief interventions and motivational interviewing, relaxation training, cognitive behavior therapy, and telephone- and computer-delivered feedback. Interventions ranged from 15 to 240 minutes, comprising one to four sessions over periods ranging from a minimum of 1 day to a maximum of 12 weeks. Five studies used treatment-as-usual control groups; one study used an attention control group. Follow-up periods ranged from 12 weeks to 3 years across the six studies and used self-report measures, including the Daily Drinking Questionnaire, the Young Adult Alcohol Consequences Questionnaire, and reported drinks per week or onset/frequency of binge drinking. In five of the six studies, authors reported significant reductions in self-reported daily drinking or alcohol-related consequences. The findings of two studies (n = 1,210; n = 151) could not be independently confirmed; therefore, the effect size was not reported. One RCT (n = 393) showed one brief intervention condition reduced substance use and substance use–related consequences at the first follow-up only (effect sizes = 3.6 and 0.52, respectively; CIs not reported), and one brief intervention condition reduced substance use and substance use–related consequences at the first follow-up (effect sizes = 0.62 and 0.29, respectively) and the last follow-up (effect sizes = 0.60 and 0.34, respectively).

One RCT (n = 104) showed a significant reduction in drinks per week and drinking days per week at the first follow-up (effect sizes = 0.99 and 0.76, respectively) but not at the last follow-up. Another RCT (n = 1,871) showed a reduction in substance use diagnoses following brief intervention at the 3-year follow-up (effect size = 0.29) but not at the first follow-up. The final RCT (n = 73) did not show a significant independently confirmed treatment effect for telephone-delivered feedback intervention. The authors noted that high variability in the type of intervention limited the generalizability of the findings, and that the treatment effect was inconsistent across follow-up intervals. This systematic review examined only the brief intervention element of SBIRT and lacked the screening and referral-to-treatment components. The brief interventions reviewed were not delivered in a health care setting (e.g., primary care, emergency department), which is generally considered a point of emphasis for SBIRT.

A 2019 RCT studied the effect of a brief primary care intervention, 15- to 20-minute motivational interviews with in-office visits, in 294 adolescents 12 to 18 years of age.2 At baseline, the sample was stratified into low, moderate, and high risk based on the National Institute on Alcohol Abuse and Alcoholism screening guide. Outcomes measured at the 12-month follow-up included drinking frequency, heavy drinking, negative alcohol consequences, perceived peer use, time spent around peers who use, and resistance self-efficacy. Patients in the intervention group who were considered high risk at baseline reported less use at follow-up (regression coefficient = −0.12; 95% CI, −0.22 to −0.02), less heavy use (regression coefficient = −0.14; 95% CI, −0.22 to −0.06), and fewer alcohol-related consequences (regression coefficient = −0.16; 95% CI, −0.31 to −0.01) at the 12-month follow-up compared with the usual care group. This study evaluated only screening and brief interventions and did not include the referral-to-treatment element of SBIRT.

A 2018 unblinded, individually randomized trial that assigned pediatric offices to three study arms examined the effects of SBIRT on substance use in adolescents.³ Patients in the study were 12 to 18 years of age. Those who screened positive for substance use completed follow-up screening between 6 months and 2 years. A total of 5,183 patients were screened, and 1,871 were eligible for further assessment. Patients completed the CRAFFT (car, relax, alone, forget, friends, trouble), a brief self-report screening tool for high-risk alcohol and substance use disorders. Patients were randomized to one of three conditions: two intervention arms (pediatricians trained to deliver SBIRT; pediatricians trained to refer to in-house behavioral health clinicians to engage in SBIRT) and one control arm (care as usual, including standard screening for substance use). For long-term analysis, intervention arms were combined into a single treatment arm. The odds of substance use did not differ over time (adjusted odds ratio = 1.19; 95% CI, 0.97 to 1.46) and did not differ across treatment arms.

A 2022 follow-up RCT of the same sample of 1,871 adolescents evaluated the effect of the previously described SBIRT interventions on adolescent substance use diagnoses over the following 7-year period.4 Participants in the intervention arm had fewer diagnoses of alcohol use (designated by the International Classification of Diseases [ICD], 9th and 10th revisions) than the usual care arm (0.4% vs. 1.8%; P < .01; number needed to screen = 72). A total of 45% of the adolescents were lost to follow-up over the 7 years (loss of health system membership was similar between groups).

RECOMMENDATIONS FROM OTHERS

In a policy statement revised and updated in 2016, the American Academy of Pediatrics recommended that pediatricians increase their capacity in substance use detection, assessment, and intervention.⁵ They specifically recommended pediatricians be familiar with and implement the SBIRT model. In a 2020 recommendation statement, the U.S. Preventive Services Task Force concluded that there is insufficient evidence to recommend screening for unhealthy alcohol or drug use in adolescents 18 years and younger.⁶