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Screening, brief intervention, and referral to treatment (SBIRT) for cannabis: A scoping review

Published:January 23, 2023DOI:https://doi.org/10.1016/j.josat.2023.208957

      Highlights

      • Scoping review found inconsistent support for SBIRT for cannabis.
      • Use of cannabis-specific screening could increase engagement.
      • Modifications to brief interventions yielded inconsistent outcomes.
      • Limited research has evaluated referral to treatment.

      Abstract

      Introduction

      Screening, brief intervention, and referral to treatment (SBIRT) has been used to change substance use behavior. Despite cannabis being the most prevalent federally illicit substance, we have limited understanding of use of SBIRT for managing cannabis use. This review aimed to summarize the literature on SBIRT for cannabis use across age groups and contexts over the last two decades.

      Methods

      This scoping review followed the a priori guide outlined by the PRISMA (Preferred Reporting Items for Scoping Reviews and Meta-Analyses) statement. We gathered articles from PsycINFO, PubMed, Sage Journals Online, ScienceDirect, and SpringerLink.

      Results

      The final analysis includes forty-four articles. Results indicate inconsistent implementation of universal screens and suggest screens assessing cannabis-specific consequences and utilizing normative data may increase patient engagement. Broadly, SBIRT for cannabis demonstrates high acceptability. However, the impact of SBIRT on behavior change across various modifications to intervention content and modality has been inconsistent. In adults, patients with primary cannabis use are not engaging in recommended treatment at similar rates to other substances. Results also suggest a lack of research addressing referral to treatment in adolescents and emerging adults.

      Discussion

      Based on this review, we offer several to improve each component of SBRIT that may increase implementation of screens, effectiveness of brief interventions, and engagement in follow-up treatment.

      Keywords

      1. Introduction

      Screening, brief intervention, and referral to treatment (SBIRT) is a therapeutic strategy that first emerged to address alcohol use (
      • Saitz R.
      Screening and brief intervention enter their 5th decade.
      ). SBIRT has since been applied to a broad range of substance use patterns and health behaviors including depression, anxiety, and oral health (
      • Cuevas J.
      • Chi D.L.
      SBIRT-based interventions to improve pediatric oral health behaviors and outcomes: Considerations for future behavioral SBIRT interventions in dentistry.
      ;
      Substance Abuse and Mental Health Services Administration
      White paper on screening, brief intervention and referral to treatment (SBIRT) in behavioral healthcare.
      ), in a variety of settings (e.g., primary care, schools), across the lifespan, and using different modalities (e.g., in-person, computerized). SBIRT comprises three components: an initial screen of the target behavior; a brief review of screening results and an intervention targeting the behavior; and referral to additional treatment when appropriate. Benefits of SBIRT include increased detection of risky substance use, reduced health care costs, and decreased provider bias regarding substance use (e.g.,
      • Barbosa C.
      • Cowell A.
      • Bray J.
      • Aldridge A.
      The cost-effectiveness of alcohol screening, brief intervention, and referral to treatment (SBIRT) in emergency and outpatient medical settings.
      ;
      • Lukowitsky M.R.
      • Balkoski V.I.
      • Bromley N.
      • Gallagher P.A.
      The effects of screening brief intervention referral to treatment (SBIRT) training on health professional trainees’ regard, attitudes, and beliefs toward patients who use substances.
      ;
      • Moberg D.P.
      • Paltzer J.
      Clinical recognition of substance use disorders in medicaid primary care associated with universal screening, brief intervention and referral to treatment (SBIRT).
      ). Potential barriers to SBIRT include inconsistent screening and application of brief interventions (BIs), inconsistent provider training, and difficulty managing patient ambivalence (
      • Hammond C.J.
      • Parhami I.
      • Young A.S.
      • Matson P.A.
      • Alinsky R.H.
      • Adger Jr., H.
      • Horner M.
      Provider and practice characteristics and perceived barriers associated with different levels of adolescent SBIRT implementation among a national sample of US pediatricians.
      ;
      • McAfee N.W.
      • Schumacher J.A.
      • Madson M.B.
      • Hurlocker-Villarosa M.C.
      • Williams D.C.
      The status of SBIRT training in health professions education: A cross-discipline review and evaluation of SBIRT curricula and educational research.
      ).
      Broadly, best practices for substance use indicate that the screening component should be universally applied to all patients using a validated assessment instrument. Items on screeners may capture quantity, frequency, and/or consequences associated with substance use. Generally, individuals meeting pre-defined thresholds are presented with an opportunity to engage in a BI and/or referral to future treatment. The intervention component can take many forms. Commonly for substance use, a brief negotiated interview (BNI) using a motivational interviewing approach is used to solicit patient utterances that support behavior change (
      Substance Abuse and Mental Health Services Administration
      White paper on screening, brief intervention and referral to treatment (SBIRT) in behavioral healthcare.
      ). Other approaches include brief (1 to 2 sessions) CBT for substance use, motivational enhancement therapy, mindfulness, and coping skills building (e.g.,
      • Aldridge A.
      • Dowd W.
      • Bray J.
      The relative impact of brief treatment versus brief intervention in primary health-care screening programs for substance use disorders.
      ;
      • Fuster D.
      • Cheng D.M.
      • Wang N.
      • Bernstein J.A.
      • Palfai T.P.
      • Alford D.P.
      • Saitz R.
      Brief intervention for daily marijuana users identified by screening in primary care: A subgroup analysis of the ASPIRE randomized clinical trial.
      ;
      • McCarty C.A.
      • Gersh E.
      • Katzman K.
      • Lee C.M.
      • Sucato G.S.
      • Richardson L.P.
      Screening and brief intervention with adolescents with risky alcohol use in school-based health centers: A randomized clinical trial of the check yourself tool.
      ).

      1.1 SBIRT for cannabis use

      Meta-analyses and systematic reviews of SBIRT have produced inconsistent findings with regard to substance use behaviors (e.g.,
      • Barata I.A.
      • Shandro J.R.
      • Montgomery M.
      • Polansky R.
      • Sachs C.J.
      • Duber H.C.
      • Macias-Konstantopoulos W.
      Effectiveness of SBIRT for alcohol use disorders in the emergency department: A systematic review.
      ;
      • Mitchell S.G.
      • Gryczynski J.
      • O'Grady K.E.
      • Schwartz R.P.
      SBIRT for adolescent drug and alcohol use: Current status and future directions.
      ;
      • Steele D.W.
      • Becker S.J.
      • Danko K.J.
      • Balk E.M.
      • Adam G.P.
      • Saldanha I.J.
      • Trikalinos T.A.
      Brief behavioral interventions for substance use in adolescents: A meta-analysis.
      ). However, much of the literature in these reviews and meta-analyses has primarily focused on alcohol-related outcomes and we know less about the utility of SBIRT for other substances. Cannabis has several unique considerations that differentiate it from other substances (e.g., alcohol, cocaine), and may influence the impact of SBIRT on use. Perhaps most importantly, many individuals and medical providers view cannabis as an effective tool for managing physical (e.g.,
      • Piper B.J.
      • Beals M.L.
      • Abess A.T.
      • Nichols S.D.
      • Martin M.
      • Cobb C.M.
      • DeKeuster R.M.
      Chronic pain patients' perspectives of medical cannabis.
      ;
      • Gali K.
      • Winter S.J.
      • Ahuja N.J.
      • Frank E.
      • Prochaska J.J.
      Changes in cannabis use, exposure, and health perceptions following legalization of adult recreational cannabis use in California: a prospective observational study..
      ) and mental health concerns (e.g.,
      • Kilwein T.M.
      • Wedell E.
      • Herchenroeder L.
      • Bravo A.J.
      • Looby A.
      A qualitative examination of college students’ perceptions of cannabis: Insights into the normalization of cannabis use on a college campus.
      ;
      • Rup J.
      • Freeman T.P.
      • Perlman C.
      • Hammond D.
      Cannabis and mental health: Adverse outcomes and self-reported impact of cannabis use by mental health status.
      ). Although extant literature suggests that at moderate-to-high levels of use, cannabis is associated with deleterious outcomes such as decreased respiratory fitness, cognitive impairment, and prolonged mental health symptoms (e.g.,
      • Campeny E.
      • López-Pelayo H.
      • Nutt D.
      • Blithikioti C.
      • Oliveras C.
      • Nuño L.
      • Gual A.
      The blind men and the elephant: Systematic review of systematic reviews of cannabis use related health harms.
      ;
      • Figueiredo P.R.
      • Tolomeo S.
      • Steele J.D.
      • Baldacchino A.
      Neurocognitive consequences of chronic cannabis use: A systematic review and meta-analysis.
      ;
      • Mammen G.
      • Rueda S.
      • Roerecke M.
      • Bonato S.
      • Lev-Ran S.
      • Rehm J.
      Association of cannabis with long-term clinical symptoms in anxiety and mood disorders: A systematic review of prospective studies.
      ), relative to nicotine and alcohol (e.g.,
      • Quintana D.S.
      • McGregor I.S.
      • Guastella A.J.
      • Malhi G.S.
      • Kemp A.H.
      A meta-analysis on the impact of alcohol dependence on short-term resting-state heart rate variability: Implications for cardiovascular risk.
      ;
      • Roerecke M.
      • Vafaei A.
      • Hasan O.S.
      • Chrystoja B.R.
      • Cruz M.
      • Lee R.
      • Rehm J.
      Alcohol consumption and risk of liver cirrhosis: A systematic review and meta-analysis.
      ;
      • To N.
      • Ford A.C.
      • Gracie D.J.
      Systematic review with meta-analysis: The effect of tobacco smoking on the natural history of ulcerative colitis.
      ), literature assessing long-term effects of cannabis use is lacking. Further, given its variable legal status, assessing the utility of SBIRT for cannabis use is difficult as some individuals may be legally prescribed cannabis while others may be in an environment without any legalized form of cannabis.
      As research continues to evaluate the potential risks and benefits of cannabis and SBIRT continues to spread as a tool to identify and modify health risk behaviors, research should assess the effectiveness of SBIRT as a tool for detection of risky cannabis use and initial intervention. Given the unique challenges that cannabis presents, a scoping literature review examining SBIRT for cannabis use is crucial in elucidating whether this approach is effective in its current form or if modifications are needed to maximize its utility. A scoping review of the literature on SBIRT serves to provide an overview of the available research, review modifications to components of SBIRT, and provide recommendations for future work using an SBIRT approach (
      • Munn Z.
      • Peters M.D.
      • Stern C.
      • Tufanaru C.
      • McArthur A.
      • Aromataris E.
      Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach.
      ). The primary purpose of the current review is to evaluate the extant literature applying SBIRT to cannabis use. Specifically, each component of SBIRT (screening, brief intervention, and referral to treatment) is synthesized separately for adult samples and adolescent and emerging adult samples. Additionally, a second goal of this review is to discuss studies evaluating mechanisms implicated in the adoption and implementation of SBIRT such as feasibility, acceptability, and fidelity.

      2. Method

      2.1 Selection criteria

      The authors agreed on a set of a priori inclusion and exclusion criteria. The inclusion criteria required the articles: (1) were published in peer-reviewed journals between 2000 and 2022, (2) were published in English or translated into English, (3) included SBIRT, (4) included analyses specific to cannabis use (e.g., cannabis using sample, cannabis-specific indicator or outcome), and (5) articles used quantitative, qualitative, or mixed methods. The exclusion criteria were: (1) review papers (e.g., systematic reviews, meta-analyses), (2) results not specific to or not including SBIRT, and (3) articles lack analyses specific to cannabis use.

      2.2 Search strategy

      Fig. 1 depicts the article selection process following the recommendation by the Preferred Reporting Items for Scoping Reviews and Meta-Analyses (PRISMA) Statement. The team used keywords (SBIRT* OR screening, brief intervention, and referral to treatment* OR motivational interviewing) AND (cannabis* OR marijuana*). We searched for these keywords in PsycINFO, PubMed, Sage Journals Online, ScienceDirect, and SpringerLink. Two co-authors independently screened titles, abstracts, and the full articles within the above databases and evaluated articles based on the inclusion and exclusion criteria detailed above. The lead author conducted a second review of the included articles for accuracy and appropriateness for the scope of this review and consulted with the co-authors as necessary.
      Fig. 1
      Fig. 1Flow diagram summary of the article selection process as recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines.

      3. Results

      The team identified an initial total of 705 articles. After adjusting for duplicates (n = 15), 690 remained. The initial screen by reviewers resulted in the removal of 617 articles as a result of failing to meet the inclusion and exclusion criteria. The full text of the remaining 73 articles were examined in more detail. Upon further examination, we excluded 28 articles for not fully meeting inclusion or exclusion criteria, 12 for not using an SBIRT framework, 9 for not having a cannabis-specific indicator or outcome variables, 6 for not being a research article (e.g., commentary, review), and we removed 2 duplicates. In total, the scoping review includes 44 articles. The reviewed literature used the terms “marijuana” and “cannabis”; the term “cannabis” is used throughout this review for consistency. Given the included studies had a wide range of substances included in their analyses, this review only reports on cannabis-related outcomes related to SBIRT components, considerations for different age groups, contexts, or specialty populations, and modifications to SBIRT that may be particularly efficacious when considering cannabis. See Table 1 for review of the included literature.
      Table 1Summary of articles included in final review.
      ArticlePopulationSample SizeSBIRT ComponentsModalityProviderCannabis VariablesRelevant AssessmentsFidelity Procedure
      • Aldridge A.
      • Dowd W.
      • Bray J.
      The relative impact of brief treatment versus brief intervention in primary health-care screening programs for substance use disorders.
      Multisite adults; outpatient, inpatient, and emergency medical settingsFull sample: 7632

      Cannabis sample: 2554
      BIIn-personVaried by citeCannabis use days pre- and post-interventionTLFB
      TLFB = timeline follow-back.
      , GRPA
      GRPA = government Performance and Results Act assessment tool.
      Not described
      • Alinsky R.H.
      • Percy K.
      • Adger Jr., H.
      • Fertsch D.
      • Trent M.
      Substance use screening, brief intervention, and referral to treatment in pediatric practice: A quality improvement project in the Maryland adolescent and young adult health collaborative improvement and innovation network.
      Adolescents and providers, outpatient medical settingProviders: 9

      Patients: 120
      SElectronic or paper/pencilPhysicians, NPs, PAsPositive cannabis screensCRAFFTNot described, no intervention
      • Appel L.
      • Ramanadhan S.
      • Hladky K.
      • Welsh C.
      • Terplan M.
      Integrating screening, brief intervention and referral to treatment (SBIRT) into an abortion clinic: An exploratory study of acceptability.
      Adults, abortion clinic settingN = 100S, BI, RTIn-personResearch teamAcceptability and attitudes about cannabis screeningLikert-like acceptability itemsNot described, no intervention
      • Baumeister S.E.
      • Gelberg L.
      • Leake B.D.
      • Yacenda-Murphy J.
      • Vahidi M.
      • Andersen R.M.
      Effect of a primary care based brief intervention trial among risky drug users on health-related quality of life.
      Adults, primary careN = 259 analyzed at follow-up; cannabis sample = 137BIHybridPrimary care providersPre- and post-scores stratified by substanceASSIST
      ASSIST = The Alcohol, Smoking and Substance Involvement Screening Test.
      ; Short-Form Health Survey
      Not described, scripted
      • Bertholet N.
      • Meli S.
      • Palfai T.P.
      • Cheng D.M.
      • Alford D.P.
      • Bernstein J.
      • Saitz R.
      Screening and brief intervention for lower-risk drug use in primary care: A pilot randomized trial.
      Adults, primary careN = 61

      Cannabis sample = 43
      S, BIIn-personHealth educators; Masters level cliniciansPre- and post-use days, consequencesTLFB
      TLFB = timeline follow-back.
      , SIP-D
      SIP-D = The Short Inventory of Problems – Modified for Drug Use.
      , ASSIST
      ASSIST = The Alcohol, Smoking and Substance Involvement Screening Test.
      Not described
      • Blow F.C.
      • Walton M.A.
      • Bohnert A.S.
      • Ignacio R.V.
      • Chermack S.
      • Cunningham R.M.
      • Barry K.L.
      A randomized controlled trial of brief interventions to reduce drug use among adults in a low-income urban emergency department: The HealthiER you study.
      Adults, emergency careN = 780

      Cannabis sample = 687
      BIIn-person or computerizedMaster's level cliniciansPre- and post-use daysTLFB
      TLFB = timeline follow-back.
      , ASSIST
      ASSIST = The Alcohol, Smoking and Substance Involvement Screening Test.
      Audio recording with MITI
      MITI = Motivational Interviewing Treatment Integrity.
      and the Clinical Skill/Competence Scale coding
      • Bonar E.E.
      • Cunningham R.M.
      • Sweezea E.C.
      • Blow F.C.
      • Drislane L.E.
      • Walton M.A.
      Piloting a brief intervention plus mobile boosters for drug use among emerging adults receiving emergency department care.
      Emerging adults, emergency careN = 63BIHybridCounselorsPre- and post-joints per monthTLFB
      TLFB = timeline follow-back.
      , Likert-like acceptability items
      Audio recording, supervision by MINT
      MINT = Motivational Interviewing Network of Trainers.
      member
      • Bucci S.
      • Baker A.
      • Halpin S.A.
      • Hides L.
      • Lewin T.J.
      • Carr V.J.
      • Startup M.
      Intervention for cannabis use in young people at ultra high risk for psychosis and in early psychosis.
      Adolescents and emerging adults, early psychosisN = 58S, BIIn-personStaff therapistsPre- and post-intervention daily frequencyOpiate Treatment Index, Global Assessment of FunctioningPeer supervision
      • Chan Y.F.
      • Huang H.
      • Bradley K.
      • Unützer J.
      Referral for substance abuse treatment and depression improvement among patients with co-occurring disorders seeking behavioral health services in primary care.
      Adults, behavioral health clinicN = 2373

      Cannabis sample = 582
      RTEMR reviewVariedPost-intervention treatment referral and utilizationGlobal Assessment of Individual Needs – Short ScreenerNot described, no intervention
      • D'Amico E.J.
      • Parast L.
      • Shadel W.G.
      • Meredith L.S.
      • Seelam R.
      • Stein B.D.
      Brief motivational interviewing intervention to reduce alcohol and marijuana use for at-risk adolescents in primary care.
      Adolescents, primary careN = 153

      Cannabis sample = 242
      BIIn-personBachelor's and Master's levelPre- and post-use days, consequences, peer normsNIAAA scree; quantity, frequency, and consequences itemsAudio recording with MITI coding and fidelity checklist
      • Dawson-Rose C.
      • Draughon J.E.
      • Cuca Y.
      • Zepf R.
      • Huang E.
      • Cooper B.A.
      • Lum P.J.
      Changes in specific substance involvement scores among SBIRT recipients in an HIV primary care setting.
      Adults, HIV primary careN = 208S, BIIn-person or computerizedTrained staff memberPre- and post-ASSIST scores stratified by substanceASSIST
      ASSIST = The Alcohol, Smoking and Substance Involvement Screening Test.
      Written documentation, supervision
      De Oliveira Christoff & Boerngen-Lacerda, 2015College students, volunteersN = 815

      Intervention sample = 333
      S, BIIn-person or computerizedResearch teamPre- and post-ASSIST scores stratified by substanceASSIST
      ASSIST = The Alcohol, Smoking and Substance Involvement Screening Test.
      Not described
      • de Gee E.A.
      • Verdurmen J.E.
      • Bransen E.
      • de Jonge J.M.
      • Schippers G.M.
      A randomized controlled trial of a brief motivational enhancement for non-treatment-seeking adolescent cannabis users.
      Adolescents, outpatientN = 119BIHybridPrevention workerPre- and post-severity scoresCUPIT; Severity of Dependence ScaleAudio recording, supervision with MINT member
      • Field C.A.
      • Von Sternberg K.
      • Velasquez M.M.
      Randomized trial of screening and brief intervention to reduce injury and substance abuse in an urban level I trauma center.
      Adults, trauma centerN = 395

      Cannabis sample = 348
      S, BIIn-person, telephone boostersResearch teamPre- and post-use daysToxicology screen, TLFB
      TLFB = timeline follow-back.
      Audio recording with MITI coding, supervision with MINT member
      • Fischer B.
      • Dawe M.
      • McGuire F.
      • Shuper P.A.
      • Capler R.
      • Bilsker D.
      • Rehm J.
      Feasibility and impact of brief interventions for frequent cannabis users in Canada.
      College studentsN = 134BIIn-personResearch teamPre- and post-use daysCannabis Use Disorders Identification Test, researcher-developed questionsNot described
      • Fuster D.
      • Cheng D.M.
      • Wang N.
      • Bernstein J.A.
      • Palfai T.P.
      • Alford D.P.
      • Saitz R.
      Brief intervention for daily marijuana users identified by screening in primary care: A subgroup analysis of the ASPIRE randomized clinical trial.
      Adults, primary careN = 167BIIn-personBachelor's or Master's-level providerPre- and post-use days, problemsSIP-D
      SIP-D = The Short Inventory of Problems – Modified for Drug Use.
      , TLFB
      TLFB = timeline follow-back.
      , ASSIST
      ASSIST = The Alcohol, Smoking and Substance Involvement Screening Test.
      Audio recording, supervision

      Gette et al., n.d.Gette, J. A., McKenna, K. R., McAfee, N. W., Schumacher, J. A., Parker, J. D., & Konkle-Parker, D (n.d.). Users of cannabis-only are less likely to accept brief interventions than other substance use profiles in a sample of people living with HIV/AIDS. The American Journal on Addictions.

      Adults, HIV clinicN = 331

      Cannabis sample = 101
      S, BIHybridSocial WorkerEngagement in BNIDASTNot described, no intervention
      • Graham L.J.
      • Davis A.L.
      • Cook P.F.
      • Weber M.
      Screening, brief intervention, and referral to treatment in a rural Ryan white part C HIV clinic.
      Adults, HIV clinicN = 1616S, BI, and RTIn-personBilingual educatorPositive cannabis screens, ASSIST scoresASSIST
      ASSIST = The Alcohol, Smoking and Substance Involvement Screening Test.
      , binary items
      Not described
      • Gryczynski J.
      • Mitchell S.G.
      • Gonzales A.
      • Moseley A.
      • Peterson T.R.
      • Ondersma S.J.
      • Schwartz R.P.
      A randomized trial of computerized vs. In-person brief intervention for illicit drug use in primary care: Outcomes through 12 months.
      Adults, community health centersN = 359BIIn-person or computerizedMaster's level clinicianASSIST
      ASSIST = The Alcohol, Smoking and Substance Involvement Screening Test.
      None
      • Gryczynski J.
      • Mitchell S.G.
      • Schwartz R.P.
      • Dusek K.
      • O’Grady K.E.
      • Cowell A.J.
      • DiClemente C.C.
      Computer-vs. Nurse practitioner-delivered brief intervention for adolescent marijuana, alcohol, and sex risk behaviors in school-based health centers.
      School-based health centersN = 300

      Cannabis sample = 233
      BIIn-person or computerizedNurse practitionerPre- and post-use days and cannabis-problemsTLFB
      TLFB = timeline follow-back.
      , CRAFFT, ASSIST
      ASSIST = The Alcohol, Smoking and Substance Involvement Screening Test.
      Not described
      • Gunderson L.M.
      • Sebastian R.R.
      • Willging C.E.
      • Ramos M.M.
      Ambivalence in how to address adolescent marijuana use: Implications for counseling.
      Providers, high school-based health centersN = 12S, BI, and RTIn-personResearch teamSemi-structured interviews on SBIRT for cannabis implementationQualitative outcomesNot described, no intervention
      • Hides L.
      • Carroll S.
      • Scott R.
      • Cotton S.
      • Baker A.
      • Lubman D.
      Quik fix: A randomized controlled trial of an enhanced brief motivational interviewing intervention for alcohol/cannabis and psychological distress in young people.
      Adolescents and emerging adults, primary careN = 61BIHybridDoctoral-level psychologistsPre- and post-use days, distressTLFB
      TLFB = timeline follow-back.
      , Kessler Distress Scale
      Not described
      • Karno M.P.
      • Rawson R.
      • Rogers B.
      • Spear S.
      • Grella C.
      • Mooney L.J.
      • Glasner S.
      Effect of screening, brief intervention and referral to treatment for unhealthy alcohol and other drug use in mental health treatment settings: A randomized controlled trial.
      Adults, medical centersN = 718S, BI, and RTIn-personResearch team, Master's-level clinicianPre- and post-use days, DAST, distress scoresASSIST
      ASSIST = The Alcohol, Smoking and Substance Involvement Screening Test.
      , DAST, Kessler Distress Scale, TLFB
      TLFB = timeline follow-back.
      Audio recording, supervision, session content checklist
      • Kim T.W.
      • Bernstein J.
      • Cheng D.M.
      • Lloyd-Travaglini C.
      • Samet J.H.
      • Palfai T.P.
      • Saitz R.
      Receipt of addiction treatment as a consequence of a brief intervention for drug use in primary care: A randomized trial.
      Adults, primary careN = 528

      Cannabis sample = 333
      RTIn-personHealth educators, Master's-level clinicianPost-intervention referral ratesASSIST
      ASSIST = The Alcohol, Smoking and Substance Involvement Screening Test.
      Audio recording with MITI coding, fidelity checklist
      • Lee C.M.
      • Kilmer J.R.
      • Neighbors C.
      • Cadigan J.M.
      • Fairlie A.M.
      • Patrick M.E.
      • White H.R.
      A marijuana consequences checklist for young adults with implications for brief motivational intervention research.
      College students and emerging adultsStudy 1 N = 207

      Study 2 N = 410

      Study 3 N = 336
      SOnlineN/AUse days, consequences, CUD symptomsCUDIT-R, Marijuana Consequences Checklist, quantity/frequency itemsNot described, no intervention
      • Lerch J.
      • Walters S.T.
      • Tang L.
      • Taxman F.S.
      Effectiveness of a computerized motivational intervention on treatment initiation and substance use: Results from a randomized trial.
      Adults on probation or paroleN = 316BI, RTIn-person or computerizedCounselorsUse days, treatment attendanceTLFBNot described
      • Madras B.K.
      • Compton W.M.
      • Avula D.
      • Stegbauer T.
      • Stein J.B.
      • Clark H.W.
      Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: Comparison at intake and 6 months later.
      Adults, medical centersN = 459,599

      Follow-up analyses = 12,284
      S, BI, and RTVaried by siteSAMHSA-trained personnelPositive screens, BNI use, referrals, and frequency at follow-upChart review, GRPA
      GRPA = government Performance and Results Act assessment tool.
      Not described, no intervention
      • Martin G.
      • Copeland J.
      The adolescent cannabis check-up: Randomized trial of a brief intervention for young cannabis users.
      Adolescents, general communityN = 40BIIn-persontherapistPre- and post-use days, quantity, DSM-IV symptomsTLFB
      TLFB = timeline follow-back.
      , Global Assessment of Individual Needs, Severity of Dependence Scale
      Audio recording, fidelity ratings
      • Martino S.
      • Ondersma S.J.
      • Forray A.
      • Olmstead T.A.
      • Gilstad-Hayden K.
      • Howell H.B.
      • Yonkers K.A.
      A randomized controlled trial of screening and brief interventions for substance misuse in reproductive health.
      Adults, reproductive health clinicN = 439

      Cannabis sample = 90
      S, BIComputerized or in-personNurses, social workers, OBGYNPre- and post-use daysASSIST
      ASSIST = The Alcohol, Smoking and Substance Involvement Screening Test.
      , TLFB
      TLFB = timeline follow-back.
      Audio recording, fidelity ratings, supervision
      • Maslowsky J.
      • Whelan Capell J.
      • Moberg D.P.
      • Brown R.L.
      Universal school-based implementation of screening brief intervention and referral to treatment to reduce and prevent alcohol, marijuana, tobacco, and other drug use: Process and feasibility.
      Adolescents, school-basedN = 2513

      Cannabis sample = 242
      S, BIHybridBachelor's-level health educatorsPost-intervention use intentions and SBIRT acceptabilityCRAFFT, Likert-like intention to use and acceptability itemsAudio recording, live observation, supervision
      • Matheson C.
      • Pflanz-Sinclair C.
      • Almarzouqi A.
      • Bond C.M.
      • Lee A.J.
      • Batieha A.
      • El Kashef A.
      A controlled trial of screening, brief intervention and referral for treatment (SBIRT) implementation in primary care in the United Arab Emirates.
      Adults, primary careN = 906S, BIIn-personPrimary care physiciansPositive screensASSIST
      ASSIST = The Alcohol, Smoking and Substance Involvement Screening Test.
      Not described
      • McCarty C.A.
      • Gersh E.
      • Katzman K.
      • Lee C.M.
      • Sucato G.S.
      • Richardson L.P.
      Screening and brief intervention with adolescents with risky alcohol use in school-based health centers: A randomized clinical trial of the check yourself tool.
      Adolescents, school-based health centersN = 148S, BIHybridSchool-based Health cliniciansPositive screens, post-intention to reduce use, hours high“Check Yourself” toolNot described
      • Moore J.R.
      • DiNitto D.M.
      • Choi N.G.
      Associations of cannabis use frequency and cannabis use disorder with receiving a substance use screen and healthcare professional discussion of substance use.
      Adults, medical centersN = 214,505

      Cannabis sample = 36,374
      S, BIVaried by siteVaried by siteScreening rates, discussion of use ratesChart reviewNot described, no intervention
      • Morris S.L.
      • Hospital M.M.
      • Wagner E.F.
      • Lowe J.
      • Thompson M.G.
      • Clarke R.
      • Riggs C.
      SACRED connections: A university-tribal clinical research partnership for school-based screening and brief intervention for substance use problems among native american youth.
      Adolescents, school-basedN = 98BIIn-person, computerizedHealth educatorsPre- and post-use daysTLFB
      TLFB = timeline follow-back.
      , Composite International Diagnostic Interview, Personal Experiences Screening Questionnaire, Drug Use Screening Inventory – Revised, readiness to change
      Supervision, team meetings
      • Ondersma S.J.
      • Beatty J.R.
      • Puder K.S.
      • Janisse J.
      • Svikis D.S.
      Feasibility and acceptability of e-screening and brief intervention and tailored text messaging for marijuana use in pregnancy.
      Adults, pregnant personsN = 45BIElectronic and/or text messagesComputerized intervention authoring systemAcceptability ratingsPatient satisfaction scale, ASSIST
      ASSIST = The Alcohol, Smoking and Substance Involvement Screening Test.
      Computerized
      • Ondersma S.J.
      • Svikis D.S.
      • Schuster C.R.
      Computer-based brief intervention: A randomized trial with postpartum women.
      Adults, postpartumN = 107

      Cannabis sample = 90
      BIElectronicComputerized programPre- and post-use daysASSIST
      ASSIST = The Alcohol, Smoking and Substance Involvement Screening Test.
      , readiness to change scale
      Computerized
      • Papinczak Z.E.
      • Connor J.P.
      • Feeney G.F.
      • Gullo M.J.
      Additive effectiveness and feasibility of a theory-driven instant assessment and feedback system in brief cannabis intervention: A randomised controlled trial.
      Adults, outpatient clinicN = 87S, BIHybridPsychologists, social workers, nursesFeasibility and intention to changeMotivation to change, Likert-like satisfaction itemsNone
      • Prendergast M.L.
      • McCollister K.
      • Warda U.
      A randomized study of the use of screening, brief intervention, and referral to treatment (SBIRT) for drug and alcohol use with jail inmates.
      Adults, jailN = 732

      Cannabis sample = 686
      S, BI, RTHybridHealth educatorsPre- and post-use, treatment utilization, risk level via ASSISTASSIST
      ASSIST = The Alcohol, Smoking and Substance Involvement Screening Test.
      , readiness to change scale
      Not described
      • Richards J.E.
      • Bobb J.F.
      • Lee A.K.
      • Lapham G.T.
      • Williams E.C.
      • Glass J.E.
      • Bradley K.A.
      Integration of screening, assessment, and treatment for cannabis and other drug use disorders in primary care: An evaluation in three pilot sites.
      Adults, primary careN = 53,133S, BI, RTIn-personLicensed independent clinical social workersScreening rates, CUD diagnoses, treatment utilizationSUD symptom checklist, chart reviewNot described, no intervention
      • Richmond M.K.
      • Page K.
      • Rivera L.S.
      • Reimann B.
      • Fischer L.
      Trends in detection rates of risky marijuana use in Colorado health care settings.
      Adults, multisite medical centersN = 108,907SVaried by siteVaried by sitePositive screens, symptom severityASSIST
      ASSIST = The Alcohol, Smoking and Substance Involvement Screening Test.
      Not described, no intervention
      • Saitz R.
      • Palfai T.P.
      • Cheng D.M.
      • Alford D.P.
      • Bernstein J.A.
      • Lloyd-Travaglini C.A.
      • Samet J.H.
      Screening and brief intervention for drug use in primary care: The ASPIRE randomized clinical trial.
      Adults, primary careN = 528

      Cannabis sample = 333
      S, BIIn-personHealth educators; Master's-level cliniciansPre- and post-use days, symptom severityASSIST
      ASSIST = The Alcohol, Smoking and Substance Involvement Screening Test.
      , TLFB
      TLFB = timeline follow-back.
      , SIP-D
      SIP-D = The Short Inventory of Problems – Modified for Drug Use.
      Audio recording with MITI coding
      • Stephens R.S.
      • Walker R.
      • Fearer S.A.
      • Roffman R.A.
      Reaching nontreatment-seeking cannabis users: Testing an extended marijuana check-up intervention.
      Adults, community recruitmentN = 186S, BIHybridtherapistsPre and post-use days, hours intoxicated, cannabis problemsReadiness to change, TLFB
      TLFB = timeline follow-back.
      , SCID, Marijuana Problems Scale
      Audio recording with MITI and YAC coding, supervision
      • Woodruff S.I.
      • Eisenberg K.
      • McCabe C.T.
      • Clapp J.D.
      • Hohman M.
      Evaluation of California's alcohol and drug screening and brief intervention project for emergency department patients.
      Adults, emergency departmentsN = 2436S, BIIn-personHealth educatorsPre- and post-use daysGRPA
      GRPA = government Performance and Results Act assessment tool.
      , ASSIST
      ASSIST = The Alcohol, Smoking and Substance Involvement Screening Test.
      Not described
      • Woolard R.
      • Baird J.
      • Longabaugh R.
      • Nirenberg T.
      • Lee C.S.
      • Mello M.J.
      • Becker B.
      Project reduce: Reducing alcohol and marijuana misuse: Effects of a brief intervention in the emergency department.
      Adults, emergency departmentsN = 515BIIn-personMaster's and doctoral level cliniciansPre and post-use days, consequences, and related injuriesAlcohol, marijuana, and drug use index; noteworthy index of problems; injury behavior checklistAudio recording, supervision
      Note. If “Cannabis sample” is specified, outcome analyses specific to cannabis use were conducted for the subsample.
      a TLFB = timeline follow-back.
      b GRPA = government Performance and Results Act assessment tool.
      c SIP-D = The Short Inventory of Problems – Modified for Drug Use.
      d ASSIST = The Alcohol, Smoking and Substance Involvement Screening Test.
      e MITI = Motivational Interviewing Treatment Integrity.
      f MINT = Motivational Interviewing Network of Trainers.

      3.1 Screening

      3.1.1 Screening in adult samples

      Among the reviewed literature, 20 articles discussed the screening component of SBIRT in adults with six studies providing cannabis-specific outcome data. The included studies used 18 different assessments with adult samples. Commonly used screening instruments include the Alcohol, Smoking and Substance Involvement Screening Text (ASSIST;
      • Humeniuk R.
      • Ali R.
      World Health OrganizationASSIST Phase II Study Group
      Validation of the alcohol, smoking and substance involvement screening test (ASSIST) and pilot brief intervention [electronic resource]: A technical report of phase II findings of the WHO ASSIST Project.
      ), timeline follow-back (
      • Sobell L.C.
      • Sobell M.B.
      Timeline follow-back.
      ), and the Short Inventory of Problems – Modified for Drug Use (SIP-D;
      • Alterman A.I.
      • Cacciola J.S.
      • Ivey M.A.
      • Habing B.
      • Lynch K.G.
      Reliability and validity of the alcohol short index of problems and a newly constructed drug short index of problems.
      ; see Table 1 for review of screening measures). Looking at screening and discussion procedures,
      • Moore J.R.
      • DiNitto D.M.
      • Choi N.G.
      Associations of cannabis use frequency and cannabis use disorder with receiving a substance use screen and healthcare professional discussion of substance use.
      examined a nationally representative primary care sample of individuals who used cannabis in the past year (N = 36,374) via electronic health records. Those who used cannabis had higher odds of being screened than those without past-year cannabis use. Among those using any cannabis, compared to those reporting recreational use only or recreational and medicinal use, those reporting medicinal-only use had higher odds of being screened and of having a discussion about their use regardless of whether or not they were screened. Further, residing in a state with legal cannabis was associated with higher odds of being screened. Several demographic patterns emerged with regard to screening procedures. Specifically, being age 26–34 compared to 18–25; being in poverty compared to >2× poverty income; having private v. no insurance; and having increased chronic health conditions were all associated with greater odds of being screened for cannabis use. Among those screened, being age 26–34 compared to 18–25; being age 35–49 or 50+ compared to 18–25; White race compared to Hispanic; having public compared to private insurance; and having increased chronic health conditions were associated with higher odds of having a discussion about cannabis use. Importantly, the studies did not screen 27 % of individuals meeting criteria for a cannabis use disorder.
      Given the changing legal status of cannabis use,
      • Richmond M.K.
      • Page K.
      • Rivera L.S.
      • Reimann B.
      • Fischer L.
      Trends in detection rates of risky marijuana use in Colorado health care settings.
      assessed if rates of positive cannabis screens in primary care settings in Colorado have increased post-medicinal cannabis legalization. Per electronic health records, the studies screened a total of 108,907 patients with 13,340 screening positive for cannabis use. The number of positive cannabis screens significantly increased post-legalization. Additionally, the study found a significant increase in ASSIST scores post-legalization and this increase was most pronounced among younger men. To improve the efficiency and accuracy of screening feedback,
      • Papinczak Z.E.
      • Connor J.P.
      • Feeney G.F.
      • Gullo M.J.
      Additive effectiveness and feasibility of a theory-driven instant assessment and feedback system in brief cannabis intervention: A randomised controlled trial.
      developed the iAx tool. This tool utilizes a computer-based screening that provides feedback on normative behaviors with graphic representations of the patient's responses that can be included in computerized or clinician delivered feedback. The iAx tool resulted in greater understanding of the screening results (p = .03).
      In addition to general adult samples, SBIRT has been applied to specialty population. Observing rates of positive cannabis screens in HIV clinics over time,
      • Graham L.J.
      • Davis A.L.
      • Cook P.F.
      • Weber M.
      Screening, brief intervention, and referral to treatment in a rural Ryan white part C HIV clinic.
      found that positive screens have ranged from 6 % to 16 % between 2008 and 2013 compared to the NIDA benchmark 7 % of the general population. Further, mean ASSIST scores for cannabis rose overtime reaching a mean of 5.5 in 2013. Importantly,

      Gette et al., n.d.Gette, J. A., McKenna, K. R., McAfee, N. W., Schumacher, J. A., Parker, J. D., & Konkle-Parker, D (n.d.). Users of cannabis-only are less likely to accept brief interventions than other substance use profiles in a sample of people living with HIV/AIDS. The American Journal on Addictions.

      found that individuals with HIV/AIDS who report using only cannabis had significantly lower odds of accepting a BNI following screening compared to other patterns of illicit substance use. Comparison of clinician and computer delivered SBIRT for cannabis use in an HIV clinic found no significant impact of intervention. However, those initially at low-risk group for cannabis had significantly higher ASSIST scores at follow-up with a mean change of 3.13 points (
      • Dawson-Rose C.
      • Draughon J.E.
      • Cuca Y.
      • Zepf R.
      • Huang E.
      • Cooper B.A.
      • Lum P.J.
      Changes in specific substance involvement scores among SBIRT recipients in an HIV primary care setting.
      ). A nonsignificant reduction in ASSIST scores occurred at follow-up for individuals in the moderate-risk category at baseline.

      3.1.2 Screening in adolescent and emerging adult samples

      Studies in adolescent and emerging adult samples used 17 different screening and assessment tools, most commonly timeline follow-back (
      • Sobell L.C.
      • Sobell M.B.
      Timeline follow-back.
      ) and in-house measures (see Table 1 for review of all assessments). Of the reviewed literature, eight studies have examined the screening component of SBIRT in adolescent and emerging adult populations with two studies providing outcome data. Work by
      • Lee C.M.
      • Kilmer J.R.
      • Neighbors C.
      • Cadigan J.M.
      • Fairlie A.M.
      • Patrick M.E.
      • White H.R.
      A marijuana consequences checklist for young adults with implications for brief motivational intervention research.
      aimed to address gaps in screening by developing a cannabis-specific screening tool, the Marijuana Consequences Checklist (MCC). Through a series of three independent studies, these authors developed the MCC and evaluated its utility and validity. Commonly endorsed consequences of use included getting the munchies, concentration and memory impairment, acting “goofy,” and dry mouth. The MCC demonstrated convergent and discriminant validity and evinced incremental validity in predicting cannabis consequences over and above frequency of use and demographics. To increase implementation of screening among adolescents in outpatient care,
      • Alinsky R.H.
      • Percy K.
      • Adger Jr., H.
      • Fertsch D.
      • Trent M.
      Substance use screening, brief intervention, and referral to treatment in pediatric practice: A quality improvement project in the Maryland adolescent and young adult health collaborative improvement and innovation network.
      engaged 9 primary care providers in an SBIRT screening training. Following training, the study found a significant increase in provider confidence and knowledge about SBIRT, total screens, and positive screens. Importantly, a significant increase occurred in the use of validated assessment instruments and a significant increase of patients receiving a BNI post-training.

      3.2 Brief intervention

      3.2.1 Brief intervention in adult samples

      The BI component of SBIRT garnered the most attention in the reviewed literature with 14 articles providing outcome data on BIs in general adult samples and five providing outcomes in adult specialty populations. Of these articles, two did not include a control or comparison group and 12 had a control group only, multiple interventions, or both. BIs were predominately clinician delivered with 22 clinician delivered conditions and seven computerized conditions across these studies. BIs ranged from one to two sessions with sessions lasting between 5 and 90 min. Examining a subset of 120,000 adults (n = 2176, cannabis use sample = 1044) in an emergency department that received a screen and BNI,
      • Woodruff S.I.
      • Eisenberg K.
      • McCabe C.T.
      • Clapp J.D.
      • Hohman M.
      Evaluation of California's alcohol and drug screening and brief intervention project for emergency department patients.
      assessed changes in cannabis use abstinence rates and use days via electronic health records. Prevalence of any cannabis use and cannabis use days per month significantly decreased using the full sample and when examining just those completing the follow-up (n = 672). Similarly,
      • Madras B.K.
      • Compton W.M.
      • Avula D.
      • Stegbauer T.
      • Stein J.B.
      • Clark H.W.
      Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: Comparison at intake and 6 months later.
      examined the utility of SBIRT across 6 large health care settings using electronic health records. They selected a subsample of 12,284 for follow-up analyses at 6-months. Of the subsample, 32.9 % endorsed any cannabis use at baseline compared to 12.1 % at follow-up (p < .001) and the study found significant reductions across all gender, age, and racial groups. Among the 32.9 % endorsing cannabis use at baseline, 29.1 % continued to endorse use at follow-up (p < .001).
      The remaining reviewed BI literature assessed the utility of BIs compared to a control group and/or alternative intervention. Comparison of in-person v. computerized-BI on a sample of 359 adults (cannabis sample = 316) in primary care found no significant differences in positive hair analyses at 6- or 12-months (
      • Gryczynski J.
      • Mitchell S.G.
      • Gonzales A.
      • Moseley A.
      • Peterson T.R.
      • Ondersma S.J.
      • Schwartz R.P.
      A randomized trial of computerized vs. In-person brief intervention for illicit drug use in primary care: Outcomes through 12 months.
      ). The study found a significant reduction in ASSIST scores at 12-month follow-up for the full sample, with the computerized sample demonstrating larger treatment gains at 6-months, but equivalent gains at 12-months. Among concurrent users of alcohol and cannabis in an emergency setting (N = 515), 2-session BI resulted in significant reduction of concurrent use at 3- and 12-month follow-up, but did not result in significant decreases in cannabis use compared to a control group (
      • Woolard R.
      • Baird J.
      • Longabaugh R.
      • Nirenberg T.
      • Lee C.S.
      • Mello M.J.
      • Becker B.
      Project reduce: Reducing alcohol and marijuana misuse: Effects of a brief intervention in the emergency department.
      ). Comparison of clinician delivered BNIs following use of pencil-and-paper v. electronic screening and feedback using the iAx tool (
      • Papinczak Z.E.
      • Connor J.P.
      • Feeney G.F.
      • Gullo M.J.
      Additive effectiveness and feasibility of a theory-driven instant assessment and feedback system in brief cannabis intervention: A randomised controlled trial.
      ) among 87 individuals reporting cannabis use found a significant interaction of time and condition such that the iAx group demonstrated higher motivation to change compared to the pencil and paper group over time (p = .03). No significant differences occurred in intervention satisfaction; over a 10-month period, use of the iAx tool was estimated to have saved the clinic $13,160.
      When brief MI was compared to a BI comprising CBT and motivational enhancement therapy (MET) in primary care (N = 3218), no significant difference occurred in cannabis frequency for the CBT-MET group compared to the brief MI group (β = −0.13, p > .10;
      • Aldridge A.
      • Dowd W.
      • Bray J.
      The relative impact of brief treatment versus brief intervention in primary health-care screening programs for substance use disorders.
      ). Comparison of a brief MI (BI, 2 sessions) to extended MI (brief treatment, 6 sessions) for individuals using cannabis at least 15 times per week found that readiness to change was crucial in reducing use days and problems (
      • Stephens R.S.
      • Walker R.
      • Fearer S.A.
      • Roffman R.A.
      Reaching nontreatment-seeking cannabis users: Testing an extended marijuana check-up intervention.
      ). Specifically, those in the preparation stage demonstrated the greatest decreases in cannabis use days at 6-week and 3-month follow-up. Those in the pre-contemplation stage did not demonstrate significant reductions in use but had significantly fewer cannabis problems at baseline and follow-up, suggesting that the lack of problems results in minimal incentive to change use patterns. Over time, the 6-session condition had significantly greater reductions in use sessions per day but not in use days than the 2-session condition. No main effect of intervention occurred on use days, sessions per day, or consequences.
      Several studies examined the MOTIV protocol in several settings as a modification to BNI (
      • Bertholet N.
      • Meli S.
      • Palfai T.P.
      • Cheng D.M.
      • Alford D.P.
      • Bernstein J.
      • Saitz R.
      Screening and brief intervention for lower-risk drug use in primary care: A pilot randomized trial.
      ;
      • Fuster D.
      • Cheng D.M.
      • Wang N.
      • Bernstein J.A.
      • Palfai T.P.
      • Alford D.P.
      • Saitz R.
      Brief intervention for daily marijuana users identified by screening in primary care: A subgroup analysis of the ASPIRE randomized clinical trial.
      ;
      • Saitz R.
      • Palfai T.P.
      • Cheng D.M.
      • Alford D.P.
      • Bernstein J.A.
      • Lloyd-Travaglini C.A.
      • Samet J.H.
      Screening and brief intervention for drug use in primary care: The ASPIRE randomized clinical trial.
      ). MOTIV is a BI combining traditional BNI with values and self-efficacy building. Comparison of MOTIV, BNI, and control groups in primary care (N = 528; cannabis sample n = 331) found no significant differences in cannabis use days, consequences, emergency room visits, or self-help group utilization as a function of intervention group at 6-month follow-up (
      • Saitz R.
      • Palfai T.P.
      • Cheng D.M.
      • Alford D.P.
      • Bernstein J.A.
      • Lloyd-Travaglini C.A.
      • Samet J.H.
      Screening and brief intervention for drug use in primary care: The ASPIRE randomized clinical trial.
      ). Additionally, no significant interaction occurred of intervention group and readiness to change on outcomes. Looking at low-risk cannabis users, as defined by an ASSIST score of 2–3,
      • Bertholet N.
      • Meli S.
      • Palfai T.P.
      • Cheng D.M.
      • Alford D.P.
      • Bernstein J.
      • Saitz R.
      Screening and brief intervention for lower-risk drug use in primary care: A pilot randomized trial.
      compared three groups (N = 57; 40 primary users of cannabis): a control group, BNI group, and the MOTIV group. At 6-month follow-up, no main effect of condition existed on use days or consequences.
      • Fuster D.
      • Cheng D.M.
      • Wang N.
      • Bernstein J.A.
      • Palfai T.P.
      • Alford D.P.
      • Saitz R.
      Brief intervention for daily marijuana users identified by screening in primary care: A subgroup analysis of the ASPIRE randomized clinical trial.
      examined the utility of MOTIV in a sample of adults in primary care with high-risk cannabis use (i.e., 21+ use days in the past month and an ASSIST score of 4+). These authors compared BNI, MOTIV, and a control group. At 6-week and 6-month follow-up, no significant effects of intervention condition existed on use days or problems. The lack of significant findings remained when patients were stratified by readiness-to-change level. Together, the MOTIV protocol did not outperform BNI or controls, regardless of risk severity. Though most research has focused on use outcomes,
      • Baumeister S.E.
      • Gelberg L.
      • Leake B.D.
      • Yacenda-Murphy J.
      • Vahidi M.
      • Andersen R.M.
      Effect of a primary care based brief intervention trial among risky drug users on health-related quality of life.
      examined a sample of 261 individuals in primary care with a positive substance use screen at 3-month follow-up to assess for changes in mental and physical quality of life. Of these individuals, 136 patients' highest ASSIST score was for cannabis. For this subset, no significant differences in mental or physical quality of life occurred at follow-up after receiving a BI compared to controls. Recent literature has examined the inclusion of phone-based follow-ups. In a sample of 395 adults at a trauma center (cannabis use sample = 348),
      • Field C.A.
      • Von Sternberg K.
      • Velasquez M.M.
      Randomized trial of screening and brief intervention to reduce injury and substance abuse in an urban level I trauma center.
      compared a control group to BNI and BNI with a phone booster. The study found an overall significant increase in abstinence rates at 12-month follow-up; however, no significant effect of intervention type occurred. Comparison of computer- v. provider-delivered BI with or without boosters in an emergency room sample found that the control group and the provider-delivered BI without boosters yielded significant decreases in cannabis use days at 12-month follow-up (
      • Blow F.C.
      • Walton M.A.
      • Bohnert A.S.
      • Ignacio R.V.
      • Chermack S.
      • Cunningham R.M.
      • Barry K.L.
      A randomized controlled trial of brief interventions to reduce drug use among adults in a low-income urban emergency department: The HealthiER you study.
      ). No significant reductions occurred for any condition using booster sessions or employing computerized BI; however, the therapist-delivered BI without boosters (d = −0.24) and computer-delivered without boosters (d = −0.17) evinced small, significant effect sizes. Comparison of general health education to BNI in 718 adults in primary care found that the BNI was ineffective for reducing cannabis use (
      • Karno M.P.
      • Rawson R.
      • Rogers B.
      • Spear S.
      • Grella C.
      • Mooney L.J.
      • Glasner S.
      Effect of screening, brief intervention and referral to treatment for unhealthy alcohol and other drug use in mental health treatment settings: A randomized controlled trial.
      ). In fact, at 6- and 12-month follow-up, patients in the BNI group were significantly more likely to use cannabis compared to the control group.
      Examination of SBIRT in reproductive clinics found that among pregnant persons reporting pre-pregnancy cannabis use (N = 45), no significant differences existed in self-reported satisfaction, likeability, or helpfulness when comparing electronically administered SBIRT with or without daily booster texts (
      • Ondersma S.J.
      • Beatty J.R.
      • Puder K.S.
      • Janisse J.
      • Svikis D.S.
      Feasibility and acceptability of e-screening and brief intervention and tailored text messaging for marijuana use in pregnancy.
      ). Further, those with higher perceived risk of cannabis use during pregnancy reported significantly higher satisfaction with SBIRT regardless of condition. In an abortion clinic with pregnant persons seeking abortion consultations (N = 100), patients reported high acceptability and low embarrassment of engaging in SBIRT for cannabis use (
      • Appel L.
      • Ramanadhan S.
      • Hladky K.
      • Welsh C.
      • Terplan M.
      Integrating screening, brief intervention and referral to treatment (SBIRT) into an abortion clinic: An exploratory study of acceptability.
      ). Notably, Black women reported significantly lower acceptability of SBIRT in this setting (p = .002). Looking at changes in cannabis use behavior in a sample of persons at a reproductive health clinic,
      • Martino S.
      • Ondersma S.J.
      • Forray A.
      • Olmstead T.A.
      • Gilstad-Hayden K.
      • Howell H.B.
      • Yonkers K.A.
      A randomized controlled trial of screening and brief interventions for substance misuse in reproductive health.
      compared electronic SBIRT, in-person SBIRT, and a control group. The study found a significant reduction in cannabis use across all conditions but no main effect of treatment condition. Similarly, in a sample of 107 post-partum persons that used substances prior to pregnancy (N = 107), no significant change occurred in cannabis use following electronic SBIRT compared to a control group and no significant moderation effects of motivation to change, self-efficacy, or IQ (
      • Ondersma S.J.
      • Svikis D.S.
      • Schuster C.R.
      Computer-based brief intervention: A randomized trial with postpartum women.
      ).
      Two studies examined use of SBIRT in justice-involved adults.
      • Prendergast M.L.
      • McCollister K.
      • Warda U.
      A randomized study of the use of screening, brief intervention, and referral to treatment (SBIRT) for drug and alcohol use with jail inmates.
      assessed the utility of SBIRT for 732 individuals currently in jail. At follow-up (12 months post- release), no significant differences occurred in cannabis use risk category, use days, days to first use, or treatment utilization in the SBIRT group compared to the control group. In a sample of adults completing parole or probation intakes (N = 316),
      • Lerch J.
      • Walters S.T.
      • Tang L.
      • Taxman F.S.
      Effectiveness of a computerized motivational intervention on treatment initiation and substance use: Results from a randomized trial.
      compared in-person brief-MI and computerized-MI (MAPIT) to standard intake procedures. At six-month follow-up, those in the MAPIT condition were more likely to report cannabis use compared to the control group (d = 0.25). Intent-to-treat analyses found no significant differences in cannabis use by treatment condition at 2- or 6-month follow-up.

      3.2.2 Brief intervention in adolescent and emerging adult samples

      Brief interventions have been the primary focus on studies of SBIRT in adolescent and emerging adult samples with 19 of the reviewed works examining this component with 15 providing outcome data. Of these studies, 12 have reported outcomes using clinician delivered BIs and three with computerized BIs. Broadly, BIs among adolescents and emerging adults have shown inconsistent utility in reducing cannabis use. Comparison of 119 Dutch adolescents randomly assigned to an MI-based BI or control found that at 3-month follow-up, no significant differences occurred in cannabis quantity, frequency, or CUDIT scores between conditions. When the intervention group was stratified to compare high frequency use (i.e., 14 or more joints per week) to low frequency use, those in the high frequency group showed greater reductions in use than those in the low frequency use group. Examination of adolescents in primary care deemed as “at-risk” for alcohol use (N = 294) randomly assigned to either a 15-min BI focused on normative data and MI or control group found that at 3- at 6-month follow-up, no significant differences existed in cannabis frequency or consequences by group (
      • D'Amico E.J.
      • Parast L.
      • Shadel W.G.
      • Meredith L.S.
      • Seelam R.
      • Stein B.D.
      Brief motivational interviewing intervention to reduce alcohol and marijuana use for at-risk adolescents in primary care.
      ). However, at 12-month follow-up, the intervention group demonstrated significantly greater reductions in consequences, but not use, compared to the control group. At all three time points, the intervention group had significantly lower perceived peer use of cannabis.
      Emerging adults (N = 61) at a mental health clinic with high distress at baseline were assigned to either MI or “Quick Fix,” a single-session intervention incorporating MI, personalized feedback, and coping skills training (
      • Hides L.
      • Carroll S.
      • Scott R.
      • Cotton S.
      • Baker A.
      • Lubman D.
      Quik fix: A randomized controlled trial of an enhanced brief motivational interviewing intervention for alcohol/cannabis and psychological distress in young people.
      ). The “Quick Fix” sample demonstrated significantly greater reductions in cannabis use frequency at 3-month (p = .01) and 6-month (p = .03) than the MI-only group. Additionally, the “Quick Fix” group had greater reductions in psychological distress than the MI-only group (p = .04). In an emergency room sample of emerging adults endorsing both past-month cannabis use and condomless sex,
      • Bonar E.E.
      • Cunningham R.M.
      • Sweezea E.C.
      • Blow F.C.
      • Drislane L.E.
      • Walton M.A.
      Piloting a brief intervention plus mobile boosters for drug use among emerging adults receiving emergency department care.
      examined absolute reductions in cannabis use following BI. Their BI was comprised of identification of primary motives for use with specific tools for addressing those motives with text message boosters. Participants in the intervention group rated the text boosters as helpful and likeable. The intervention group had absolute reductions of 31.91 use days (36.96 % reduction) at 1- and 2-month follow-up compared to a reduction of 26.10 use days (54.75 % reduction) in the control group. Among teens at-risk of psychosis or in first-episode psychosis (N = 58), 19 screened positive for cannabis use and received a BI (
      • Bucci S.
      • Baker A.
      • Halpin S.A.
      • Hides L.
      • Lewin T.J.
      • Carr V.J.
      • Startup M.
      Intervention for cannabis use in young people at ultra high risk for psychosis and in early psychosis.
      ). Among those screening positive for cannabis, a significant decrease in cannabis use days (p < .01) and polysubstance use days (p < .01) occurred at 12-month follow-up. Of the 10 patients returning for follow-up, 7 were abstinent.
      School-based SBIRT has garnered attention as a means for early prevention and intervention. In a large sample of high school students screened for substance use, 9.6 % (n = 242) screened positive for cannabis use (
      • Maslowsky J.
      • Whelan Capell J.
      • Moberg D.P.
      • Brown R.L.
      Universal school-based implementation of screening brief intervention and referral to treatment to reduce and prevent alcohol, marijuana, tobacco, and other drug use: Process and feasibility.
      ). All students engaged in SBIRT regardless of use status with the BI modified to address intention to use among students with no prior cannabis use. On a 0 to 7 scale, with higher values representing intention to continue abstinence following SBIRT, the mean rating among those with no use history was 6.67. Intention to reduce use among those who have used cannabis was 5.57. However, no data regarding levels of use or use intentions prior to intervention was available. Alternatively,
      • McCarty C.A.
      • Gersh E.
      • Katzman K.
      • Lee C.M.
      • Sucato G.S.
      • Richardson L.P.
      Screening and brief intervention with adolescents with risky alcohol use in school-based health centers: A randomized clinical trial of the check yourself tool.
      compared the “Check Yourself” tool to a control group of 428 high school students that screened as at-risk for alcohol and cannabis. This tool integrates screening with normative feedback by age and gender, strategies targeting individuals' specific motives, and creates discrepancy between use and goals. Students in the “Check Yourself” condition were significantly more likely to receive school-based counseling and to discuss their cannabis use with their provider and reported higher intention to change their cannabis use. At follow-up, no significant differences existed in cannabis use days or hours of cannabis intoxication by group. Comparison of computer-delivered v. nurse practitioner-delivered BI v. archival assessment only data in high school-based health centers found no significant impact of condition or time by condition interaction on cannabis use frequency or ASSIST scores at 3- or 6-month follow-up. The study found a significant impact of treatment v. assessment at 3-months when the treatment conditions were combined; significance was not retained at 6-months. In a version of SBIRT for Native American youth that accounts for Native American identity and resilience, a comparison of brief advice, feedback with MI, and feedback with MI and booster sessions found that the feedback with MI and booster group showed significantly greater reductions in cannabis use at 3-month follow-up than the brief advice condition (β = −0.11, p < .01).
      Comparison of screening only, online screening with BNI, and in-person screening with BNI among Brazilian college students found no significant differences in ASSIST scores for cannabis use at 90 day follow-up by condition (
      • de Oliveira Christoff A.
      • Boerngen-Lacerda R.
      Reducing substance involvement in college students: A three-arm parallel-group randomized controlled trial of a computer-based intervention.
      ). Males in the in-person screen with BNI showed significant reductions in cannabis use days. Assessing individual items of the ASSIST found significant reductions in past month use days for the in-person condition and negative problems of use for both treatment groups. In a sample of Canadian college students, no significant reductions occurred in cannabis use days as a function of completing oral BI, written BI, oral control, or written control (
      • Fischer B.
      • Dawe M.
      • McGuire F.
      • Shuper P.A.
      • Capler R.
      • Bilsker D.
      • Rehm J.
      Feasibility and impact of brief interventions for frequent cannabis users in Canada.
      ). However, those in the combined intervention sample demonstrated reductions in deep inhalation practices and driving while intoxicated. Within the intervention conditions, the oral BI group had significant reductions in deep inhalation practices and the written BI group had reductions in driving while intoxicated.

      3.3 Referral to treatment

      Of the articles reviewed, nine discussed referral to treatment, with one study supplying outcome data in a general adult population.
      • Kim T.W.
      • Bernstein J.
      • Cheng D.M.
      • Lloyd-Travaglini C.
      • Samet J.H.
      • Palfai T.P.
      • Saitz R.
      Receipt of addiction treatment as a consequence of a brief intervention for drug use in primary care: A randomized trial.
      examined treatment engagement among 528 (331 with primary cannabis use) adults in primary care referred to treatment following screening and BI. Those with primary cannabis use were significantly less likely to seek services compared to primary cocaine, opioids, or other substance use (ps < 0.01) and these results were maintained when stratified by ASSIST scores.

      3.4 Feasibility and acceptability

      Two studies examined of the acceptability and feasibility of SBIRT for cannabis use in adult settings. A study of a sample of adults in the United Arab Emirates (N = 906, cannabis use sample n = 10) found that though providers reported increased positive attitudes about SBIRT and willingness to screen patients following an SBIRT training, no significant increase occurred in the number of screens conducted (
      • Matheson C.
      • Pflanz-Sinclair C.
      • Almarzouqi A.
      • Bond C.M.
      • Lee A.J.
      • Batieha A.
      • El Kashef A.
      A controlled trial of screening, brief intervention and referral for treatment (SBIRT) implementation in primary care in the United Arab Emirates.
      ). Of those screening positive for cannabis use at follow-up, none received a BI. Limited knowledge about cannabis and discomfort with screening for substances emerged as barriers to cannabis screening (
      • Richards J.E.
      • Bobb J.F.
      • Lee A.K.
      • Lapham G.T.
      • Williams E.C.
      • Glass J.E.
      • Bradley K.A.
      Integration of screening, assessment, and treatment for cannabis and other drug use disorders in primary care: An evaluation in three pilot sites.
      ). The study reviewed electronic records of 53,133 patients in a large hospital to assess changes in substance use screens and treatment to evaluate utility of a provider training and inclusion of prompts when charting. The study screened approximately half of patients (57 %) for cannabis use, 15.7 % of which endorsed use. Following training, cannabis use disorder diagnoses rose from 5 per 10,000 to 17 per 10,000 (p < .0001); however, the study found no significant increases in treatment for CUD.
      In an adolescent sample, several qualitative themes emerged when assessing barriers for provision of SBIRT interventions for cannabis use in high schools (
      • Gunderson L.M.
      • Sebastian R.R.
      • Willging C.E.
      • Ramos M.M.
      Ambivalence in how to address adolescent marijuana use: Implications for counseling.
      ). Specifically, these authors identified six general themes: 1) cannabis use is a sign of mental health concerns; 2) BIs are not effective; 3) cannabis use is less risky than alcohol use; 4) difficulty balancing trust versus authority; 5) providers lack skills and/or knowledge about cannabis use and intervention; 6) cannabis use is a low risk behavior.

      4. Discussion

      Broadly, the reviewed literature suggests that more work is needed to advance screening tools for high-risk cannabis use, ensure brief interventions are delivered with fidelity, and improve the referral to treatment process (e.g., use of warm handoffs) to increase the utility of SBIRT for cannabis. Though some work did find significant reductions of use, the effect appears small as studies with significant findings utilized the largest samples and did not include comparison groups (e.g.,
      • Madras B.K.
      • Compton W.M.
      • Avula D.
      • Stegbauer T.
      • Stein J.B.
      • Clark H.W.
      Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: Comparison at intake and 6 months later.
      ;
      • Woodruff S.I.
      • Eisenberg K.
      • McCabe C.T.
      • Clapp J.D.
      • Hohman M.
      Evaluation of California's alcohol and drug screening and brief intervention project for emergency department patients.
      ). Further, many studies demonstrating reductions in use did not document significant differences between the intervention and control groups, suggesting that changes in behavior may not be attributable to the intervention(s). Despite limited impact on behavior, the reviewed literature offers important considerations for all SBIRT components and future research.
      Reviewed literature found that although studies did not universally apply validated assessment instruments, implementation of provider trainings served to increase the frequency of screens, use of validated instruments, and detection of cannabis use disorders (
      • Alinsky R.H.
      • Percy K.
      • Adger Jr., H.
      • Fertsch D.
      • Trent M.
      Substance use screening, brief intervention, and referral to treatment in pediatric practice: A quality improvement project in the Maryland adolescent and young adult health collaborative improvement and innovation network.
      ;
      • Richards J.E.
      • Bobb J.F.
      • Lee A.K.
      • Lapham G.T.
      • Williams E.C.
      • Glass J.E.
      • Bradley K.A.
      Integration of screening, assessment, and treatment for cannabis and other drug use disorders in primary care: An evaluation in three pilot sites.
      ). Importantly, many commonly used screening tools (e.g., DAST, timeline follow-back), do not capture nuanced information important to understanding cannabis use patterns. Cannabis screens should aim to include items capturing form (e.g., loose leaf, concentrations), method of use (e.g., inhalation, ingestion), and potency of cannabis use to better understand unique patterns of use and subsequent risk.
      In addition to increasing implementation and specificity of screens, modifications have been made to screening strategies (e.g., iAx, [
      • Papinczak Z.E.
      • Connor J.P.
      • Feeney G.F.
      • Gullo M.J.
      Additive effectiveness and feasibility of a theory-driven instant assessment and feedback system in brief cannabis intervention: A randomised controlled trial.
      ],“Check Yourself” [
      • McCarty C.A.
      • Gersh E.
      • Katzman K.
      • Lee C.M.
      • Sucato G.S.
      • Richardson L.P.
      Screening and brief intervention with adolescents with risky alcohol use in school-based health centers: A randomized clinical trial of the check yourself tool.
      ]) that incorporate real-time normative feedback or integrate motives for use with future personal goals to foster cognitive dissonance. The Marijuana Consequences Checklist (
      • Lee C.M.
      • Kilmer J.R.
      • Neighbors C.
      • Cadigan J.M.
      • Fairlie A.M.
      • Patrick M.E.
      • White H.R.
      A marijuana consequences checklist for young adults with implications for brief motivational intervention research.
      ) highlighted cannabis-related consequences often not captured in commonly used screening tools (e.g., the “munchies”, concentration problems) that could help patients and providers to better understand consequences of use. Shifts to incorporate cannabis-specific screening may help patients to contextualize their use and serve as motivation to change when use exceeds norms (
      • Blevins C.E.
      • Walker D.D.
      • Stephens R.S.
      • Banes K.E.
      • Roffman R.A.
      Changing social norms: The impact of normative feedback included in motivational enhancement therapy on cannabis outcomes among heavy-using adolescents.
      ) and could increase patient engagement in the BI. For example,

      Gette et al., n.d.Gette, J. A., McKenna, K. R., McAfee, N. W., Schumacher, J. A., Parker, J. D., & Konkle-Parker, D (n.d.). Users of cannabis-only are less likely to accept brief interventions than other substance use profiles in a sample of people living with HIV/AIDS. The American Journal on Addictions.

      found that individuals using cannabis but no other illicit substances had lower odds of engaging in the BNI regardless of symptom severity. This finding may be due to provider and/or patient bias or lack of understanding about the potential risks of cannabis. Increased understanding of results and subsequent motivation may help to bridge the gap from screening to BI and referral to treatment for at-risk individuals.
      Studies examined a number of modifications to the BI component, to mixed success. Generally, modifications to BIs did not yield significantly greater change in outcomes compared to an MI-based BNI or control group. Further, no differences occurred in outcomes whether SBIRT was conducted virtually, in-person, or hybrid (
      • Blow F.C.
      • Walton M.A.
      • Bohnert A.S.
      • Ignacio R.V.
      • Chermack S.
      • Cunningham R.M.
      • Barry K.L.
      A randomized controlled trial of brief interventions to reduce drug use among adults in a low-income urban emergency department: The HealthiER you study.
      ;
      • Field C.A.
      • Von Sternberg K.
      • Velasquez M.M.
      Randomized trial of screening and brief intervention to reduce injury and substance abuse in an urban level I trauma center.
      ;
      • Gryczynski J.
      • Mitchell S.G.
      • Gonzales A.
      • Moseley A.
      • Peterson T.R.
      • Ondersma S.J.
      • Schwartz R.P.
      A randomized trial of computerized vs. In-person brief intervention for illicit drug use in primary care: Outcomes through 12 months.
      ,
      • Gryczynski J.
      • Mitchell S.G.
      • Schwartz R.P.
      • Dusek K.
      • O’Grady K.E.
      • Cowell A.J.
      • DiClemente C.C.
      Computer-vs. Nurse practitioner-delivered brief intervention for adolescent marijuana, alcohol, and sex risk behaviors in school-based health centers.
      ). This finding suggests that modality is not responsible for lack of significant findings. Rather, the implementation and content of BIs for cannabis warrant further examination. Implementation may be a critical starting point as extant literature has found inconsistent implementation of SBIRT. In fact, many studies lack fidelity assessments to the SBIRT protocol that may be crucial in determining its success, given it can take several training and coaching sessions to reach SBIRT mastery (see
      • McAfee N.W.
      • Schumacher J.A.
      • Madson M.B.
      • Hurlocker-Villarosa M.C.
      • Williams D.C.
      The status of SBIRT training in health professions education: A cross-discipline review and evaluation of SBIRT curricula and educational research.
      and
      • Madson M.B.
      • Villarosa-Hurlocker M.C.
      • Schumacher J.A.
      • Williams D.C.
      • Gauthier J.M.
      Motivational interviewing training of substance use treatment professionals: A systematic review.
      for review). Further, lack of fidelity assessments, particularly for motivational approaches, may be responsible for lack of significant behavior change as it is unclear if the brief interventions are being presented to patients as intended with adherence to the principles of motivational interviewing. Of the reviewed literature, 17 of 32 studies utilizing provider administered BIs included a description of fidelity procedures. Of the 17 describing fidelity procedures, 10 used a standardized coding protocol (e.g., the Motivational Interviewing Treatment Integrity protocol). Future studies applying SBIRT should include a description of these efforts to ensure treatments are being conducted to fidelity.
      Generally, participants self-report finding SBIRT helpful, likeable, and acceptable across contexts and age groups. One exception occurred in a study of acceptability at an abortion clinic (
      • Appel L.
      • Ramanadhan S.
      • Hladky K.
      • Welsh C.
      • Terplan M.
      Integrating screening, brief intervention and referral to treatment (SBIRT) into an abortion clinic: An exploratory study of acceptability.
      ) in which Black women were significantly less likely to view discussion of their substance use as acceptable. This finding may be due to historical bias toward women of color in reproductive health settings (e.g.,
      • Prather C.
      • Fuller T.R.
      • Jeffries IV, W.L.
      • Marshall K.J.
      • Howell A.V.
      • Belyue-Umole A.
      • King W.
      Racism, African American women, and their sexual and reproductive health: A review of historical and contemporary evidence and implications for health equity.
      ) and/or racial disparities in substance use treatment (e.g.,
      • Farahmand P.
      • Arshed A.
      • Bradley M.V.
      Systemic racism and substance use disorders.
      ). This finding warrants further examination in future studies of brief interventions. Despite being broadly acceptable, these ratings do not translate into significant behavior change. Reviewed studies examining intention to change following SBIRT found significantly higher motivation or intention in the intervention groups but no significant changes in behavior at follow-up (
      • Maslowsky J.
      • Whelan Capell J.
      • Moberg D.P.
      • Brown R.L.
      Universal school-based implementation of screening brief intervention and referral to treatment to reduce and prevent alcohol, marijuana, tobacco, and other drug use: Process and feasibility.
      ;
      • McCarty C.A.
      • Gersh E.
      • Katzman K.
      • Lee C.M.
      • Sucato G.S.
      • Richardson L.P.
      Screening and brief intervention with adolescents with risky alcohol use in school-based health centers: A randomized clinical trial of the check yourself tool.
      ). Overall, SBIRT may be a good tool for introducing discussion of cannabis use, but additional work is needed to maximize its potential for behavior change. In their current form, BIs for cannabis use may best serve to get individuals thinking about goals or motives, but follow-up is likely needed to sustain change. Future SBIRT interventions may benefit from expanding the BIs to include multiple sessions or broadening the criteria for referral to treatment.
      The referral to treatment component has garnered the least amount of examination. Of the reviewed literature, two studies of adults (
      • Kim T.W.
      • Bernstein J.
      • Cheng D.M.
      • Lloyd-Travaglini C.
      • Samet J.H.
      • Palfai T.P.
      • Saitz R.
      Receipt of addiction treatment as a consequence of a brief intervention for drug use in primary care: A randomized trial.
      ;
      • Prendergast M.L.
      • McCollister K.
      • Warda U.
      A randomized study of the use of screening, brief intervention, and referral to treatment (SBIRT) for drug and alcohol use with jail inmates.
      ) examined engagement in treatment following BI. These studies found that individuals in an intervention group were not significantly more likely to attend treatment than the control group (
      • Prendergast M.L.
      • McCollister K.
      • Warda U.
      A randomized study of the use of screening, brief intervention, and referral to treatment (SBIRT) for drug and alcohol use with jail inmates.
      ) and that compared to other substances, individuals with primary cannabis use are less likely to attend follow-up treatment than individuals with other primary substances regardless of symptom severity (
      • Kim T.W.
      • Bernstein J.
      • Cheng D.M.
      • Lloyd-Travaglini C.
      • Samet J.H.
      • Palfai T.P.
      • Saitz R.
      Receipt of addiction treatment as a consequence of a brief intervention for drug use in primary care: A randomized trial.
      ). Several potential reasons may exist for these gaps. First, cannabis may be perceived as less harmful than other substances by both provider and patient, which could lead to decreased discussion about future treatment (e.g.
      • Gunderson L.M.
      • Sebastian R.R.
      • Willging C.E.
      • Ramos M.M.
      Ambivalence in how to address adolescent marijuana use: Implications for counseling.
      ;
      • Philpot L.M.
      • Ebbert J.O.
      • Hurt R.T.
      A survey of the attitudes, beliefs and knowledge about medical cannabis among primary care providers.
      ). Second, a large time gap may exist between the BI session and subsequent referral appointments that could attribute to no-shows or lack of interest in treatment. This time lag due to availability along with contextual barriers (e.g., transportation, insurance) could result in lack of follow-up care for cannabis use (
      • Blevins C.E.
      • Rawat N.
      • Stein M.D.
      Gaps in the substance use disorder treatment referral process: Provider perceptions.
      ). Importantly, no adolescent or emerging adult literature had outcome data for the referral to treatment component, highlighting a large gap in the literature. Notably, in an SBIRT model, the referral to treatment component is meant to connect individuals to additional treatment in instances of moderate- to severe-risk and/or in response to patient desire to change their behavior. Among those at moderate- to high-risk, it is not expected that the brief intervention component alone will result in significant, lasting change without follow-up care. As such, it is crucial to our understanding of SBIRT to understand aspects of the referral to treatment process including who is referred and under what circumstances; the length of time from referral to first session; access to care; and mechanisms implicated in follow-up such as patient and provider attitudes. Importantly, absence of effective, widely utilized referral to treatment could attenuate the effects of the brief intervention component of SBIRT.

      4.1 Limitations and future directions

      One limitation of the reviewed literature is the inconsistency in screening and outcome measurement. The majority of studies used frequency as the primary outcome. However, other studies used outcomes such as abstinence, quantity, and consequences. Though each outcome adds nuance to our understanding of cannabis use behavior change following SBIRT, use of many instruments and outcomes makes it difficult to compare SBIRT across studies. Future studies on SBIRT for cannabis use should include multiple measures of cannabis behavior to facilitate comparison across several outcomes. Importantly, though the majority of the reviewed literature did not find changes in frequency of use, several studies found decreases in cannabis-related consequences following intervention, particularly among adolescents and emerging adults (e.g.,
      • D'Amico E.J.
      • Parast L.
      • Shadel W.G.
      • Meredith L.S.
      • Seelam R.
      • Stein B.D.
      Brief motivational interviewing intervention to reduce alcohol and marijuana use for at-risk adolescents in primary care.
      ;
      • Fischer B.
      • Dawe M.
      • McGuire F.
      • Shuper P.A.
      • Capler R.
      • Bilsker D.
      • Rehm J.
      Feasibility and impact of brief interventions for frequent cannabis users in Canada.
      ). Assessing consequences as a metric of intervention success is an important consideration for future work on SBIRT for cannabis use. Further, studies varied widely in the duration of BIs with BIs lasting from 5 to 90 min and occurring over one or two sessions, making it difficult to directly compare the effectiveness of BIs.
      Additionally, cannabis has varying medicinal and recreational laws across states and countries. In some instances, individuals may possess medical cannabis cards or prescriptions from a medical provider. However, only one study assessed rates of recreational v. medicinal use of cannabis (
      • Moore J.R.
      • DiNitto D.M.
      • Choi N.G.
      Associations of cannabis use frequency and cannabis use disorder with receiving a substance use screen and healthcare professional discussion of substance use.
      ). To effectively apply SBIRT, it is critical understand reasons for use. Evaluation of use for recreational v. medicinal purposes, including mental health management, and the presence of medical cannabis cards and prescriptions should be included in screening tools and as a variable of interest in SBIRT outcome studies.
      Regarding the BIs, development of cannabis-specific interventions is arguably the most critical direction for future research. Use of normative data and assessing motives for use have shown promise as screening tools (
      • Bonar E.E.
      • Cunningham R.M.
      • Sweezea E.C.
      • Blow F.C.
      • Drislane L.E.
      • Walton M.A.
      Piloting a brief intervention plus mobile boosters for drug use among emerging adults receiving emergency department care.
      ;
      • McCarty C.A.
      • Gersh E.
      • Katzman K.
      • Lee C.M.
      • Sucato G.S.
      • Richardson L.P.
      Screening and brief intervention with adolescents with risky alcohol use in school-based health centers: A randomized clinical trial of the check yourself tool.
      ;
      • Papinczak Z.E.
      • Connor J.P.
      • Feeney G.F.
      • Gullo M.J.
      Additive effectiveness and feasibility of a theory-driven instant assessment and feedback system in brief cannabis intervention: A randomised controlled trial.
      ). Future work should assess if applying norms and motives into BIs results in behavior change. Additional future research avenues include assessing the effectiveness of multi-session BI and incorporation of BI into routine care. Notably, though the current review sought to evaluate the literature on SBIRT for cannabis use, the review found several brief interventions outside of the SBIRT framework that have demonstrated promise in reducing cannabis use and associated consequences in adults and emerging adults compared to control groups (see
      • DiClemente C.C.
      • Corno C.M.
      • Graydon M.M.
      • Wiprovnick A.E.
      • Knoblach D.J.
      Motivational interviewing, enhancement, and brief interventions over the last decade: A review of reviews of efficacy and effectiveness.
      ;
      • Halladay J.
      • Scherer J.
      • MacKillop J.
      • Woock R.
      • Petker T.
      • Linton V.
      • Munn C.
      Brief interventions for cannabis use in emerging adults: A systematic review, meta-analysis, and evidence map.
      ; and
      • Parmar A.
      • Sarkar S.
      Brief interventions for cannabis use disorders: A review.
      for reviews). Applying findings from these works could serve to improve outcomes from the brief intervention component of SBIRT.
      Further, improvements to the referral component are necessary. As noted, none of the included research assessed referral to treatment in adolescent or emerging adult populations. It is important to understand how SBIRT relates to treatment engagement for these age groups in particular, as adolescents are more vulnerable to adverse effects of cannabis (e.g.,
      • Levine A.
      • Clemenza K.
      • Rynn M.
      • Lieberman J.
      Evidence for the risks and consequences of adolescent cannabis exposure.
      ;
      • Lorenzetti V.
      • Hoch E.
      • Hall W.
      Adolescent cannabis use, cognition, brain health and educational outcomes: A review of the evidence.
      ) and emerging adults have the highest prevalence rates of cannabis use and cannabis use disorder (
      • Hasin D.S.
      • Saha T.D.
      • Kerridge B.T.
      • Goldstein R.B.
      • Chou S.P.
      • Zhang H.
      • Huang B.
      Prevalence of marijuana use disorders in the United States between 2001–2002 and 2012–2013.
      ;
      • Johnston L.D.
      • O’Malley P.M.
      • Bachman J.G.
      • Schulenberg J.E.
      • Miech R.A.
      Monitoring the Future national survey results on drug use, 1975–2015: Volume 2, college students and adults ages 19–55.
      ). In response to qualitative work highlighting gaps in provider knowledge about cannabis use and comfort discussing use with patients, it would be beneficial for providers with expertise in SBIRT and cannabis to provide training and coaching sessions with providers less familiar with SBIRT in order to increase their confidence. Notably, few studies examined all components of SBIRT simultaneously, limiting the ability to evaluate the SBIRT framework as a whole for cannabis use.

      4.2 Conclusion

      In its current form, research provides inconsistent support for SBIRT as a framework for modifying cannabis use behaviors. This held true across a myriad of contexts and ages. Despite limited behavior change, feasibility research demonstrates that participants find SBIRT likeable and helpful. However, a disconnect between feasibility and subsequent behavior change is apparent. This disconnect may be due in part to inconsistent provision of SBIRT. Further, traditional BNIs may not be appropriate for addressing cannabis use. Given the unique considerations relevant to cannabis (e.g., medicinal use, varying legality), we recommend developing a cannabis-specific screening and brief intervention rather than attempting to fit traditional SBIRT approaches to cannabis. Additionally, the field needs to pay greater attention to fidelity, use of validated screening tools, and the referral to treatment process.

      CRediT authorship contribution statement

      Jordan A. Gette: Conceptualization, Methodology, Data Curation, Writing – original draft and revisions.
      Timothy Regan: Methodology, Data Curation, Writing – Reviewing and Editing.
      Julie A. Schumacher: Conceptualization, Methodology, Supervision, Writing – Reviewing and Editing.

      Declaration of competing interest

      The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

      Appendix A. Supplementary data

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