Two studies in the August 6 issue of JAMA examine the effectiveness of using brief interventions in primary care settings to reduce drug use.
In one study, Peter Roy-Byrne, M.D., formerly of the University of Washington, Seattle, and colleagues write that few data exist on the effectiveness of brief (1-2 sessions) interventions for reducing problem drug use, a common issue in disadvantaged populations seeking care in safety-net medical settings (hospitals and community health clinics serving low-income patients with limited or no insurance). Based on the established efficacy of brief interventions for hazardous alcohol use among patients seen in medical settings, national dissemination programs of screening, brief intervention, and referral to treatment for "alcohol and drugs" have been implemented on a widespread scale, according to background information in the article.
The researchers randomly assigned 868 patients from 7 safety-net primary care clinics in Washington State who had reported problem drug use in the past 90 days to a single brief intervention (n = 435) or enhanced care as usual, which included a handout and list of substance abuse resources (n = 433). The single brief intervention included a handout and list of substance abuse resources along with giving participants feedback about their drug use screening results, exploring the pros and cons of drug use, increasing participant confidence in being able to change, and discussing options for change. In addition, attempts were made for a 10-minute follow-up session by telephone within 2 weeks of the initial intervention. The patients were assessed for drug use at the beginning of the study, and at 3, 6, 9, and 12 months.
Average days used of the most common problem drug at baseline were 14.40 (brief intervention) and 13.25 (enhanced care as usual); at 3 months postintervention, averages were 11.87 (brief intervention) and 9.84 (enhanced care as usual) and not significantly different. During the 12 months following intervention, no significant treatment differences were found between the two groups for drug use or for secondary outcomes, which included admission to substance abuse treatment, emergency department and inpatient hospital admissions, arrests, death and behavior that increases risk of human immunodeficiency virus transmission.
The authors write that these "finding suggests a need for caution in promoting widespread adoption of this intervention for drug use in primary care."
"... further research to identify subgroups responsive to this intervention, as well as the role of more intensive interventions, appears to be warranted. For example, targeting intervention efforts toward individuals with severe drug abuse, many of whom use stimulants and opiates and may be at higher risk of overdose and other harmful consequences, might increase the uptake of specialty treatment and reduce emergency department utilization."
This study was funded by a grant from the National Institute on Drug Abuse. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, etc.
In another study, Richard Saitz, M.D., of the Boston University School of Public Health, and colleagues tested the effectiveness of two brief counseling interventions for unhealthy drug use (any illicit drug use or prescription drug misuse) among primary care patients identified by screening.
The United States has invested substantially in screening and brief intervention for illicit drug use and prescription drug misuse, based in part on evidence of efficacy for unhealthy alcohol use. However, it is not a recommended universal preventive service in primary care because of lack of evidence of efficacy, according to background information in the article.
The researchers randomly assigned 528 adult primary care patients with unhealthy drug use to one of three groups: to receive a brief negotiated interview (BNI), which was a 10- to 15-minute structured interview conducted by health educators; an adaptation of motivational interviewing (MOTIV), which was a 30- to 45-minute intervention based on motivational interviewing with a 20- to 30-minute booster conducted by masters-level counselors; or no brief intervention. All study participants received a written list of substance use disorder treatment and mutual help resources. At the beginning of the study, 63 percent of participants reported their main drug was marijuana, 19 percent cocaine, and 17 percent opioids.
For the primary outcome (number of days of use in the past 30 days of the self-identified main drug), there were no significant differences between the BNI, MOTIV or control groups (adjusted average days using the main drug at 6 months, 11, 12 and 12 days, respectively). In addition, there were no significant between-group differences overall or in stratified analyses at 6 weeks or 6 months in drug use consequences, injection drug use, unsafe sex, health care utilization (hospitalizations and emergency department visits, overall or for addiction or mental health reasons), or mutual help group attendance.
The authors write that despite the potential for benefit with a brief intervention, drug use differs from unhealthy alcohol use in that it is often illegal and socially unacceptable, and is diverse - from occasional marijuana use, which was illegal during this study, to numerous daily heroin injections. "Prescription drug misuse is particularly complex, with diagnostic confusion between misuse for symptoms (e.g., pain, anxiety), euphoria-seeking, and drug diversion. Brief counseling may simply be inadequate to address these complexities, even as an initial strategy."
"These results do not support widespread implementation of illicit drug use and prescription drug misuse screening and brief intervention."
Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
Editorial: Screening and Brief Intervention and Referral to Treatment for Drug Use in Primary Care - Back to the Drawing Board
In an accompanying editorial, Ralph Hingson, Sc.D., M.P.H., of the National Institute on Alcohol Abuse and Alcoholism, Bethesda, Md., and Wilson M. Compton, M.D., M.P.E., of the National Institute on Drug Abuse, Rockville, Md., comment on the findings of these studies.
"Although these studies offer no direct evidence of effectiveness for universal drug screening, brief intervention, and referral to treatment in primary care settings, exploring drug use with patients should remain a priority in primary care. The goal for clinical research is to develop and test new interventions with potential for benefiting patients. Drug screening and brief intervention research that focuses on adolescents and young adults is especially needed because rates of marijuana use among young people and the potency of marijuana have increased at the same time that recognition among youth of the health risks of marijuana use have declined."
"If brief interventions are insufficient, then easily accessible treatment services with long-term follow-up may be needed, as will development of efficient primary care referral approaches to address risky substance use and related physical and mental comorbidities."
Both authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.