Brief intervention in substance use disorders.

Unhealthy substance use lies on a wide range that extends from occasional mild risky/harmful/hazardous use to severe substance use disorder. Brief intervention (BI) is a technique, used to initiate change for an unhealthy or risky substance use. It can be delivered by a vast array of trained professionals, in opportunistic settings (i.e. in people seeking help not for their substance use, but either its consequences or for completely unrelated physical or psychiatric disorders), and across substances, age and ethno-cultural groups. The six common elements of BIs are summarized by the acronym FRAMES, consisting of Feedback, Responsibility, Advise, Menu for change, Empathy, and enhancing Self-efficacy. BI has also been strategically combined with referral to appropriate treatment services. BI has shown efficacy for reducing substance use and its harmful consequences. The evidence for post-BI improved functionality and quality of life are also emerging.

INTRODUCTION

Brief intervention (BI) is a structured, client-centred, non-judgemental therapy by a trained interventionist using 1-4 counselling sessions of shorter duration (typically 5-30 minutes). Based on a harm reduction paradigm BI aims to reduce a person's substance consumption to safe level or complete abstinence.1 It promotes a continuum of care by integrating prevention, intervention and treatment services. BI typically consists of face-to-face counselling sessions which can be delivered by a wide array of professionals, like physicians, psychiatrists, psychologists, nurses, or social workers.123 Recent research supports its effectiveness via phone or website as well.456 BI can also be delivered at opportunistic settings (treatment settings where clients are seeking medical treatment for physical or psychiatric disorders unrelated to substance use).7 Screening for risky substance use and its consequences has largely become an integral part of BI. This model is popularly known as Screening with Brief Intervention (SBI) and Referral to an appropriate Treatment setting (SBIRT). A growing body of evidence supports the use of this approach with diverse ethnic and cultural groups. It is an integrated public health approach for the identification and, if necessary, facilitation of substance abuse treatment.89 One of the most influential models of BI goes by the acronym FRAMES which was first invoked by Miller and Rollnick in their book on MI.10 FRAMES succinctly presents the content of BI. Prior to that, the content of BI was not being articulated explicitly. BI needs to be differentiated from brief therapy that is a systematic focused process that relies on client engagement, assessment and rapid implementation of change strategies. Brief therapies include more sessions of longer duration11 and address various area of concern such as personality issues, psychosocial disturbances, and psychiatric illness.12

Theoretical background

BI emphasises on behaviour change based on Prochaska and DiClemente's transtheoretical model of change.131415 It provides a framework to understand and assess “the readiness to change substance use or other lifestyle behaviours”. Clients go through the discrete stages of change as proposed by the model described below.

Pre-contemplation (not ready for change)

In this stage, the individuals are unaware that their behaviour is problematic. They neither have any worry about their substance use nor want to change it. However, they are “receptive to information about the risks associated with their level and pattern of substance use”. Providing information can encourage them to recognize the risks of substance use and think about reducing or stopping their use of substances.

Contemplation (getting ready for change)

People at this stage are beginning to recognize that their behavior is problematic and are in an ambiguous situation regarding their substances use. They may be willing to make a change but may not be sure of doing that or may not know how to make a change. The intervention aims to inspire them to discuss, explore, and resolve their ambivalence for change. A useful approach to deal with the ambivalence is to think it in terms of ‘balance’ (as depicted in the figure below). On one side of the scale are the benefits to the patient of their current substance use behavior and the costs associated with their change (reasons to stay the same), while on the other side are the costs of current substance use and benefits of change (reasons for change).

The motivational grid

Change is not likely to happen until the reasons for change override the reasons for no-change. The intervention aims to encourage them to have a discussion and find their individual reasons for dropping or stopping their substance use. A useful approach at this phase is to see the ambivalence about substance use as a balance.

Preparation (ready for change)

In this stage, the individual intends to take action in the immediate future, and may begin by taking small steps toward behaviour change.

Action (taking steps for change)

Individuals in this stage have made the choice that their substance intake needs to be changed by refraining or reducing substance use. They need encouragement and support to implement their decision. Interventions for this stage include a series of strategies to identify situations in which they may be at risk for substance use and discuss solutions to handle such situations and reduce or stop their substance use.

Maintenance (sustain their planned action)

In this stage, people make changes in their behaviour to sustain their planned action and work to prevent a relapse. They need the confirmation that they are doing a god job and strengthening of resolve to persist with the desired behaviour. They can be assisted to avoid circumstances where they are at possibility of relapse or to help them progress forward after a lapse of substance use.

Relapse

It is the return from action or maintenance to an earlier stage. Most people who try to make changes in their substance use behaviours will use the substance again, at least for a while. These lapses may act as teaching moments for maintaining abstinence from substances in future.

Stages of change

Components of brief intervention

The major elements of BI are based on the acronym FRAMES i.e. Feedback, Responsibility, Advice, Menu of options, Empathy and Self efficacy.15161718 FRAMES can be explained in the following way:

Feedback

The provision of personally relevant feedback (as opposed to general feedback) is an important constituent of BI, and usually follows a comprehensive evaluation of substance use and its associated complications. It includes knowledge concerning the personal risks or harm and the associated consequences with it. Feedback may also include a comparison between the person's substance use patterns and its problems with the standard pattern of use.

Many people are unaware that they are using substance at hazardous or harmful levels. Hence, highlighting the risks associated with this pattern of substance use can be a powerful motivator for change.

Example: “You’ve scored 16 on the AUDIT which indicates that you are at high risk of harm from your current pattern of drinking…”

For instance, ‘feedback’ highlights that the person's substance use may be placing their health at risk, and is above recommended consumption guidelines.

As per definition given by NIAAA's (National Institute on Alcohol Abuse and Alcoholism) for Developing Alcohol Use Disorder (AUD”): low-risk drinking is no more than 3 drinks for female and 4 drink for male on any single day and no more than 7 drinks for women and 14 drinks for men per week.19

In India, while driving a motor vehicle, if a person has a Blood Alcohol Concentration (BAC) exceeding 30 mg/100 ml of blood detected by a breath-analyzer, he or she can be booked as an offence.20

Thus, the model of SBI and SBIRT plays a major role in which screening instruments AUDIT, ASSIST quickly assess the severity of substance use and identify the appropriate level of treatment. BI focuses on increasing understanding and knowledge about substance use and motivation for behaviour change. Referral to treatment provides those identified as needing more extensive treatment with access to specialized care.

Responsibility

An important principle of intervention with substance users is to acknowledge that they are responsible for their own behaviour and that they can make choices about their substance use. Communicating with client in terms such as, “Are you interested in seeing how you scored on this questionnaire?”, “What you do with this information I’m giving you is up to you” and “How concerned are you about your score?”, enables him to retain personal control and also facilitate a direction for the intervention.16

Assessing their importance and confidence of taking steps towards changes

The clients who actually want to change their substance use pattern need to be ready, have will power and confidence to change.

21 The willingness to reduce or stop substance use is related to how important they believe this change is and at the same time how confident they are to be able to do so. Thus, “importance and confidence” need to be addressed as a part of the intervention to encourage the change in behaviour.

Importance Ruler

The importance ruler can be used at the commencement of BI to assist direct intervention at the suitable phase of change or can be used during the ‘intervention’ as a means to encourage the patient to speak regarding reasons for change. This ruler is comprised of gradations from zero to ten, where zero is not at all significant and ten denotes extremely significant. Substance users can be asked to rate the importance of changing their substance use. Example: “On a scale of one to ten how important is it to make a change in your behaviour (smoking)?” Query: “What makes it an 8 and not a 2?”

Confidence Ruler

This ruler can be used with people who have agreed that it is important for them to make a change or it can be used as an imaginary question to promote them to talk about how they would make a change.

Example: “On a scale of one to ten how confident do you feel that you can make a change in your behaviour?”

Query: “What would it take to move it up to an 8?”

Advice

The important element of effective BI is to provide clear advice on how to reduce the harm associated with continued use of the substance. Providing insight into the benefits of reducing or stopping substance use not only increases awareness of their substance use problems but also provides reasons for changing their unwanted behaviour.

The advice can be summarized by providing a simple statement like, “The best way you can reduce your risk is to cut down or stop completely”.

Examples: ‘The risky or hazardous drinking is associated more likely with a fatal motor vehicle crash’.22 ‘Injection overdose of opioid leads to unresponsiveness, progressive decrease in blood pressure and the heart rate, ultimately leading to cardiac arrest’.23 ‘Researchers are now able to described that cannabis may affect the typical brain development, earlier the age of initiation of cannabis more adversely it alter brain structures that underlie higher order thinking’.24

Menu of options

BI provides choices to reinforce the sense of personal control and responsibility for making change, and may help to strengthen the attitude for change. The various options for the persons include:

Keeping a diary for substance use (mentioning details such as where, when, why, how much, with whom…).

Identifying high risk situations and strategies to avoid them”.

Identifying substitute activities instead of substance use such as hobbies, exercises, sports, spending time with family”.

Encourage the client to identify people who could provide support and help for the changes they want to make”.

Set aside the money they would normally spend on substances for a specific purpose”.

Empathy

A reliable part of efficient BI is compassionate and understanding approach by the therapist delivering the intervention. It includes an accepting, non-judgmental approach and tries to understand the client's point of view. The use of labels such as ‘alcoholic’ or ‘drug addict’ is avoided. As opposed to the confrontational approach, the approach here is of reflective listening and empathetic understanding.

Example: “I know this process can be confusing.” “I’m sorry to see that you’re in this situation.” “I’d like to help you if I can.” “Let's see if we can solve this together.”

Self efficacy

The final element of BI is to foster the persons' confidence to make changes in their use of substances. It is particularly useful for obtaining self-efficacy statements from clients, as they are likely to create what they are heard to say. It is an important way to gather what has already been said and prepare the client to move forward. Summarizing is an effective way of communicating interest with the prospect of the client, recalling the highlights of the discussion and preparing for further elaboration.

The client is the main resource for finding answers and solutions. Resistance is a signal to respond differently. Reluctance and ambivalence must be recognized (and even respected) and not directly confronted. Questions and problems can be returned to the patient for their solution. The resistor provides energy that can be used therapeutically. “Solutions are usually evoked from the client rather than provided by the therapist.”

A case vignette describing the components of FRAMES

Mr JS was a 45 year old 12th pass married business man from a middle socio-economic status living with his wife and two children. He was referred from the department of Medicine for his chronic use of smoking tobacco and alcohol. His liver function tests were deranged and chest X-ray showed features suggestive of chronic obstructive pulmonary disease. He visited de-addiction out-patient reluctantly after the third referral, as he denied any problem related to substance use. However, for his tobacco and alcohol use, he scored 16 and 25 respectively on ASSIST questionnaire, reflecting use in the moderate and high-risk categories respectively.

The application of FRAMES techniques and Motivational strategies in his case was as follow:

Thank you very much Mr. JS that you have come to the de-addiction centre and have completed the questionnaire with me. I appreciate your willingness to discuss about your tobacco and alcohol use (affirmation).

Well, thank you! So, do you think, I need to be treated for my condition? Frankly, I don't see any problem.

Taking treatment is entirely your choice and I respect whatever decision you deem suitable for you (Responsibility; also showing empathy and respect for autonomy). You had already undergone some tests and questionnaire based assessment. Would you mind me discussing the implications of the results for your health? (once again putting the responsibility on the client)

No, I wouldn't.

Thank you.

I have your liver function test and Chest X ray results. Your liver enzymes are elevated by 3 times than normal and bilirubin level is high as well. [Showing the client, the results with normal values] But the good thing is, albumin and prothrombin time are normal. These tests indicate that although you have an acute liver problem, perhaps there might not be any permanent or irreversible damage and your liver function could recover completely. The ASSIST score also suggests you are in the high-risk category for alcohol use. In my opinion, the deranged liver function is majorly contributed to by alcohol. [Personalized feedback]

Likewise, your chest X ray shows increased bronchovascular markings and a tubular heart [showing the client, the x ray film] which suggest chronic obstructive lung disease. The changes are at an early stage and not very severe. To the best of my knowledge, these changes could be due to smoking tobacco. [Personalized feedback]

[Give some time to the client to ponder over the findings]

But I don't drink much. My uncle used to drink a bottle of Whiskey everyday and he lived happily for ninety years!

People react differently to different drugs. Some, like your uncle, can tolerate higher amounts used over longer periods; other show signs of harm with smaller amounts and over shorter periods.

: Ok.....I don't know......I never thought in this way.....it may be worrisome.... if it causes all such problems (dissonance).

Would you like to have information about how you can help yourself with your risky substance use?

Okay!

Remember, the best way to avoid the substance related problems is to not use them at all; if you cannot do that, then at least to cut down the frequency and quantity of their use (Advice). It is not easy and needs a lot of effort, but many people do it successfully and I think, you would be able to do it (enhancing Selfefficacy).

Well, I don't know!

Do you want me to suggest some steps?

I don't see, why not?

Well, these are the options which you might like to try:

Keep a diary for your substance use

Record time, place and circumstances of each substance use

Other people present while using substance

Money spent in using substance

Identifying high risk situation and strategies to handle them effectively

Identifying other options instead of substance use

Taking help of people to maintain change

It sounds nice......I shall think over it

By now you may be aware of the consequences of your substance use. Should you have any more question, I would love to answer those? (Address all the queries in empathetic and non-judgemental manner). Many people find it reassuring to learn that they could take action on their own to improve their health. I'm confident that you can follow the advice and cut down or abstain completely from tobacco and alcohol use (enhancing Self Efficacy). If you face any difficulty while trying these, please call me/visit again so that we can discuss the issues.

DEALING WITH RESISTANT CLIENTS

Client's resistance is a genuine concern. Failure to follow a therapist's instructions and resistant behaviors within treatment sessions, e.g., arguing, interrupting, denying a problem, and straying are the signs of resistance and these might predict a poor response to intervention.

Various types of reflections25

Listen to clients, demonstrate a desire for mutual understanding, begin with the simpler levels of reflection and advance as the relationship builds.

Simple reflection - One strategy is simply to reflect what the client is saying. This sometimes has the effect of extracting the patient's response and stabilizing the situation. Example: “Focused on feelings e.g. You’re angry about being sent here”

Reflection with amplification – The therapist exaggerates or amplifies what the client is saying to the point where the client is likely to contradict it. There is a precise balance here, because overdoing an exaggeration can elicit conflict with the therapist. Example- client: “No. I just don't think I have a drug problem”.

Therapist: “So as far as you can see, there really haven't been any problems or harm because of your drug use”.

Double-Sided Reflection: Sometime if the client offers a resistant statement then it becomes important to reflect it back with other side. Example, “You are not quite sure you are ready to make a change, but you are quite aware that your drug use has caused concerns in your relationships, effected your work and that your doctor is worried about your health”.

Shifting Focus- Another strategy is to defuse the resistance offered by the client by shifting their attention away from the problematic issue. Example- Client: “But I can't just quit drugs. I mean all of my friends use them”!

Therapist: “You’re getting way ahead of things. I’m not talking about your quitting here, and I don't think you should get stuck on that concern right now. Let's just stay with what we’re doing right now - going through your feedback - and later on we can worry about what, if anything, you want to do about it”.

Roll with resistance (avoid argument)

When the person expresses resistance, the health worker must reformulate or reflect it instead of opposing it. It is particularly important to avoid the argument of change, since this puts the person in a position to argue against it.

Open-Ended Questions

The client should do most of the conversation (“yes/no” questions should be avoided); building the relationships and providing direction for change, calling for “both sides of the coin.” The open-ended question allows the client to create momentum for forward movement such as, “What makes you feel that it might be time for a change?”

Affirming

It includes praise or statements of admiration and understanding that help to generate a more encouraging environment. Affirming one's strengths and efforts to build trust, while affirming one's self-motivating statements (or the exchange conversation) foster willingness to change.

Examples: “Thanks for coming today.” “I appreciate that you are willing to talk to me about your substance use.” “You are obviously a resourceful person to have coped with those difficulties.”

A special Brief Intervention for tobacco use:

The Five A's (Ask, Advise, Assess, Assist, Arrange)26 approach for the SBI services include:

Ask

It refers to screening and assessment of the risk level: “Screen, then intervene.” Intervention may then include all remaining “A's” and is dependent on the screening results and determined risk level.

It includes direct personal advice on the use of substances and their harmful effects on health.

Assess

It is about evaluating the person's readiness (“preparation”) to change unhealthy behaviour (reduction in use or quitting), after listening to the clinician's advice.

Assist

It is about helping the agreeable person to develop a treatment plan following the personal goals.

Arrange

It refers to the consideration of a follow-up visit and specialty referrals. The aim is ongoing care and alteration in the plan, if needed.

Effectiveness of brief intervention

Meta analysis of studies, conducted by Wilk et al. and Bertholet et al. at primary health care settings and by McQueen et al. at general hospital wards in which BI was done with heavy drinkers, found that heavy drinkers under interventional groups significantly reduced their drinking.272829 A meta-analysis on the effect of BIs on mortality of heavy alcohol users concluded that BIs might have reduced mortality rates by an estimated 23 to 26 percent.30 An international RCT in primary health care settings in Australia, Brazil, India and the USA compared wait-list controls vs. ASSIST linked BI groups for illicit drugs (cannabis, cocaine, amphetamine type stimulants and opioids). The results showed that the intervention group reduced the substance use and, improvements were maintained at the 3-month follow-up.31 Bertha et al. conducted a study in which SBIRT model was used at wide variety of medical health settings and screening was done with AUDIT and Drug Abuse Screening Test (DAST). The study showed that the intervention was feasible and there were significant improvements in illicit drug as well as heavy alcohol use including functional domains when compared at six months over baseline.32 Mitchell et al. evaluated the effectiveness SBIRT protocol at 6 months follow up in a school program, and reported significant reductions in the frequency of drinking at intoxication and in the consumption of drugs.33 Another study with frequent cannabis users found that a single session of 20-30 minutes verbal or written BI produced significant reductions in cannabis-related risk behaviours that persisted for one year.34 A systematic review of 42 trials by Stead et al. found that the therapist delivered BI to quit substance use increased the likelihood of cessation attempts as well as abstinence at 12-month follow-up35; the efficacy was greater in women whose alcohol consumption was higher at baseline and the effect of peer participation in the intervention was greater when both the couple participated.36 O’ Connor et al. compared BI with simple advice in the pregnant women and found significant reduction in alcohol intake, more abstinence rate and less associated fetal complications, in the BI group.37 Geriatric patients have also been shown to respond well to BI related to their substance use pattern in the primary care setting.38 Loretta et al. provided preliminary evidence of the effectiveness of ASSIST-linked BI in a college mental health clinic (ages 18–24) and it was concluded that routine screening and BI procedures reduced problematic substance use (binge drinking and marijuana use).39 However, the effect sizes varied across various metaanalyses.4041

Two workplace based ASSIST-linked BI studies were conducted at a tertiary care hospital in North India. The first one, an uncontrolled study where the intervention group of unskilled workers was assessed at the baseline and 4 months after the intervention, showed significant reduction in harmful drinking.42 The second study, a randomized controlled trial done among the same class of workers, also concluded that BI was more effective in: reducing substance use, improving motivation for change, seeking of specialized treatment and, improving the quality of life.43

CONCLUSION

BI is based on solid scientific principles of harm reduction, stages of change, motivational interviews, community delivery and cost-effectiveness. It can be used in opportunistic settings even by non-specialist professionals, and for extending services for individuals who need help but may not seek it through substance abuse services. Thus, BI can be viewed as a part of the clinician's responsibilities, in addition to ordering tests, performing surgical procedures, prescribing medications, and filling out medical records. Evidence for BI is favorable for alcohol use disorders but its role for illicit drug use is emerging.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.