Problematic drug use is often identified via screening in non-specialised health and care settings, e.g. in primary care.

Brief interventions, primarily focusing on motivation, are recommended by NICE for problematic drug users who are not in contact with more formal drug services. These interventions have shown some success at reducing problematic alcohol use, however little is known about their effectiveness at reducing use of other substances.

JAMA has recently published two randomised clinical trials (RCTs) that assessed whether brief interventions in substance using primary care patients can reduce substance use (both illicit drugs and misused prescription drugs).

Trial 1: Roy-Byrne et al. (2014; Washington State, USA)

This RCT compared a one-time brief intervention (motivational interviewing) plus attempted telephone booster session, to enhanced care as usual.

Participants were:

1. Recruited by screening from waiting rooms of seven “safety-net” public primary care clinics in Washington State, USA
2. 18 years or older
3. Self-reported users of an illegal drug or non-prescribed medication at least once in the 90 days prior to screening
4. Exclusion criteria: past month attendance at formal substance use treatment; high risk of suicide; life-threatening medical illness; severe cognitive impairment; active psychosis

Intervention

After screening, participants were randomised to condition. Social workers from the clinics received training to provide the intervention.

• The intervention condition involved a 30-minute motivational interview brief intervention
  • Core tasks included exploring pros and cons of drug use, increasing confidence in ability to change, and discussing options for change
  • Participants also received a hand-out depicting their Drug Abuse Screening Test score (DAST-10), and a list of substance abuse treatment resources
• The control condition received their DAST-10 hand-out, and the list of substance abuse treatment resources, with only brief explanation.

Assessments

Assessments were conducted at baseline and then repeated at 3, 6, 9, and 12 months, by research assistants blinded to the condition.

Primary outcomes

1. Self-reported past month drug use (of drug participants used most frequently used at baseline);
2. Addiction Severity Index (ASI) drug use subscale score (integrating all drug use frequency and associated problems).

Secondary outcomes

1. Medical, psychiatric, social and legal subscales of the ASI;
2. Administrative record: drug treatment; police arrest; deaths; emergency, outpatient & inpatient hospital visits.

Results

They randomised 868 participants. Drop-out was low, with 87% of assessments at 12-month follow-up completed.

Statistical analyses (generalized estimating equations) demonstrated no treatment differences at 12-months follow-up, on both past month days of drug use (odds ratio, 1.20 [95%CI, 0.96 to 1.50]) and ASI drug use composite (β = 0.005 [95% CI, −0.005 to 0.016]).

There were also no intervention effects on any secondary outcomes.

Conclusion

The authors therefore concluded:

A one-time brief intervention with attempted telephone booster call had no effect on drug use in patients seen in safety-net primary care settings.

Trial 2: Saitz et al. (2014; Boston, Massachusetts, USA)

The second trial was similar to Byrne et al., however notably inclusion criteria required at least weekly drug use, or less frequently with a negative consequence. Recruitment was from an urban hospital-based primary care clinic.

Participants were randomised to either:

• Brief negotiated intervention;
• Motivational interviewing with follow-up booster session; or
• No brief intervention.

This trial also found no treatment differences between any of the conditions on past month drug use, or any of their secondary outcomes, after 6-months follow-up.

Conclusion

Similarly to above, the authors concluded:

…brief intervention for unhealthy drug use in primary care patients identified by screening appears unlikely to be effective for decreasing drug use or consequences.

Strengths of both studies

• Randomisation to intervention;
• Low attrition rates;
• Urine drug screens to corroborate self-reported drug use;
• Samples had high health co-morbidity rates, high poverty and unemployment rates. These samples are therefore representative of populations who are more likely to experience major problems related to their substance use. The failure to find an effect of brief intervention may demonstrate the complexity of substance use in disadvantaged social environments.

Limitations

• Results may not generalise to less disadvantaged drug-user populations;
• In Trial 1, past month drug use declined for both the control and intervention group. Both conditions included five assessment sessions for all participants, which may alone have influenced drug use;
• Inclusion criteria were broad and included occasional users, with no requirement that participants were experiencing any drug-related problems. It may have been inappropriate to call the samples problematic drug-users, since many illicit drug users experience minimal negative consequences.
• The most common drug used was cannabis, which has lower rates of dependence and drug-related problems than opiates and stimulants. Design of interventions may be better directed at individual drug types or specifically at problematic drug use.

Implications for practice

Brief interventions may be seen as quick and simple solutions that can be employed within a primary care setting at minimal cost. Unfortunately these findings suggest they may not be effective for reducing drug use.

However both trials were conducted in the USA. The relationship and engagement patients have with healthcare may differ to the UK, potentially affecting generalisability of findings to the NHS.

Links

Roy-Byrne P, Bumgardner K, Krupski A, Dunn C, Ries R, Donovan D, West II, Maynard C, Atkins DC, Graves MC, Joesch JM, Zarkin GA. Brief intervention for problem drug use in safety-net primary care settings: a randomized clinical trial. JAMA. 2014 Aug 6;312(5):492-501. doi: 10.1001/jama.2014.7860. [PubMed abstract]

Saitz R, Palfai TP, Cheng DM, Alford DP, Bernstein JA, Lloyd-Travaglini CA, Meli SM, Chaisson CE, Samet JH. Screening and brief intervention for drug use in primary care: the ASPIRE randomized clinical trial. JAMA. 2014 Aug 6;312(5):502-13. doi: 10.1001/jama.2014.7862. [PubMed abstract]