Richard Saitz discussed several potential reasons for the spectacular failures seen with motivational interviewing (MI) in some studies and clinical settings. In 3 sentences: MI may fail due to unclear outcomes being measured, effects of assessment on self-reported outcomes, poor fidelity of MI implementation in real-world settings, treating patients of varying severity levels where MI may not be enough, and implementing MI in contexts like emergency departments or trauma centers where expectations differ from primary care settings aimed at prevention. Saitz reviewed evidence on these potential factors from multiple studies to explain when and why MI has not shown effects in some trials and clinical situations.

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.

2. OUTCOMES
ASSESSMENTS
SEVERITY
FIDELITY
CONTEXT/SETTING

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

8. CONTEXT/SETTING
• Expectations and goals differ
– Comprehensive preventive longitudinal care?
– Long-term therapeutic alliance?
– Teachable vs. learnable moments?

9. Addiction Science & Clinical Practice
(formerly published by NIDA, now Biomed Central)
www.ascpjournal.org

10. THANKS, BILL