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Saitz icmi discussion of spectacular failures2
1. Discussion
Spectacular Failures with MI
ICMI 2012, Venice
Richard Saitz MD, MPH, FACP, FASAM
Professor of Medicine & Epidemiology
Boston University Schools of Medicine & Public Health
Director, Clinical Addiction, Research and Education (CARE) Unit
Boston Medical Center
Boston Medical Center is the primary teaching affiliate
of the Boston University School of Medicine.
3. OUTCOMES
• Many outcomes
– Need to specify at start of trial, choose primary
• Monti et al 1999, 5 outcome categories; no effect on consumption
• Some MI successes may not be
• Long-term outcomes?
– Does one session of MI affect a lifetime of behavior?
• Maybe, but should we expect that to be the rule?
• Sweet spot (medium term outcomes?)
• “Objective” outcomes?
– Alcohol self-report , vs. urine drug, blood pressure, hemoglobin A1C
• Differential report of better outcome may be more likely in MI groups
4. PROBABLY NOT ASSESSMENT
Though if assessment works, we wouldn’t need to bother with MI, brief or not …
• McCambridge et al. PLoS ONE 2011
– Evidence for research assessment bias: inconsistent and insufficient
• McCambridge & Kypri systematic review (PLoS ONE 2011)
– Small effect (about 1/3rd size of BI effect) of assessment on drinking—in primary
care alcohol BI after screening mainly among university students on 2 of 3
outcomes…
• Or, maybe they are more likely to report socially desirable responses after assessment
• Large emergency department brief intervention studies: no
effects
– Daeppen et al 2008 Addiction
– Bernstein et al 2009 Acad Emerg Med
– D’Onofrio et al 2012 Acad Emerg Med
• Clifford P et al. JSAD 2007: outpatient addiction treatment
– Assessment effects on drinking, consequences, treatment engagement
• BUT: effects varied by outcome measure, and early or late
5. FIDELITY
• Problematic if this is the answer
– Limits dissemination and widespread utility
• Two recent large pragmatic studies of brief motivational
intervention implementation in real clinical practice find…
– Clinicians don’t implement it
– When they do, it doesn’t work
Screening and Intervention Programme for Sensible Drinking (SIPS).
McGovern R et al. 2012. http://www.sips.iop.kcl.ac.uk
Beurden, Anderson et al. Addiction 2012 epub ahead of print
DOI: 10.1111/j.1360-0443.2012.03868.x
6. SEVERITY
• In most healthcare treatment situations, treatments are
developed for specific condition or level of severity
– Even when the mechanism of disease is thought to be the same
or similar (e.g heart attack, stroke) treatment effect sizes and
even efficacy differ
• We shouldn’t be surprised when this happens for MI
– It isn’t always all about behavior
– Sometimes MI isn’t enough
Sometimes fat and fur isn’t enough
Sometimes therapy just isn’t enough
7. CONTEXT/SETTING (and severity)
• Alcohol screening and brief motivational intervention
– Consistent, modest effects on drinking in primary care
– No effect in the general hospital
• Unless trial with highest risk of bias included
– Few detectable effects in trauma centers
• 4 negative studies (including one usually cited as positive)
– Decidedly mixed results in emergency departments
Saitz et al. Ann Intern Med 2007;146:167-76
McQueen J et al. Cochrane Database Syst Rev 2011;8:CD005191.
Gentilello LM et al. Ann Surg 1999;230:473
Schermer CR et al. J Trauma. 2006;60:29-34
Sommers MS et al. J Trauma. 2006;61:523-31
Soderstrom CA et al. J Trauma. 2007;62:1102-11
Nilsen P et al. J Subst Abuse Treat. 2008; 35:184-201
Havard A et al. Addiction 2008; 103:368-76
D'Onofrio G et al. Ann Emerg Med. 2008; 51(6):742-750
D’Onofrio G et al. Ann Emerg Med 2012
http://dx.doi.org/10.1016/j.annemergmed.2012.02.006
