Brief drug-abuse interventions typically used in primary care and emergency departments simply don’t work, two randomized trials have concluded.
Neither of the approaches in the trials decreased illicit drug use over a 6-12 month follow-up period. The findings don’t support the use of the programs, Dr. Richard Saitz and Dr. Peter P. Roy-Byrne reported in the Aug. 5 issue of JAMA.
While such interventions might be helpful for smoking and alcohol use, they are probably too simplistic for the multifactorial problem of drug use, which involves not only personal choice, but medical, psychological, social, and, possibly, legal issues, wrote Dr. Saitz of the department of community health sciences at Boston University, and his colleagues (JAMA 2014;312:502-13).
"Despite the potential for benefit with this approach, 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," the investigators noted. "Prescription drug misuse is particularly complex, with diagnostic confusion between misuse for symptoms (pain, anxiety), euphoria-seeking, and drug diversion. Brief counseling may simply be inadequate to address these complexities, even as an initial strategy."
Dr. Saitz’s study took place in a hospital-based urban primary care practice. After identifying patients with high scores on the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST), the researchers randomized 528 patients to one of three arms: a brief negotiated interview (BNI), an adaptation of motivational interviewing (MOTIV), or a control group of no intervention.
The BNI was a 10- to 15-minute structured interview conducted by health educators. The MOTIV was a 30- to 45-minute intervention based on motivational interviewing, with a 20- to 30-minute booster conducted by master’s degree–level counselors. The booster session was conducted by telephone 6 weeks after the initial interaction. All study participants received a written list of substance use disorder treatment and mutual help resources. The final assessment was conducted at 6 months
Most of the patients (70%) were men; the mean age was 41 years. Marijuana was the most commonly used substance (63%), followed by cocaine (19%) and opioids (17%) and prescription opioids (6%). The mean baseline ASSIST score was at least 27 in 18% of the cohort. During the prior month, patients had used drugs a mean of 14 days.
Follow-up was very good, with 98% of patients available for assessment. Compared with the control group, however, neither intervention group showed any benefit from intervention.
At 6 months, the mean ASSIST score was at least 27 in 20% of the MOTIV and 19% of the control group but had risen to 25% in the BNI group. The mean number of drug use days per month was 14 for all three groups. When the analysis was stratified by particular drug, the results were unchanged.
Motivational interviewing fell flat
The second study was conducted in seven primary care safety-net settings in King County, Washington (JAMA 2014;312:492-501). The investigators randomized 868 patients to enhanced care as usual, which included a list of drug abuse resources; or motivational interviewing, plus the resource handout and a 10-minute telephone booster at 2 weeks. All patients were assessed at 3, 6, 9, and 12 months.
Most of the patients were men (70%), with a mean age of 48 years. Most were unemployed (91%). A total of 30% reported being homeless at least 1 night in the prior 3 months. Medical comorbidities were common, with 26% reporting recent hospitalizations and half a recent emergency department visit. A total of 11% had received prior treatment for substance abuse. The mean number of drug use days in the past month was 14. The mean composite Addiction Severity Index (ASI) was 0.11.
"The treatment [outcomes were] virtually identical," with minimal change in either intervention over the 12-month follow-up period, wrote Dr. Roy-Byrne of the department of psychiatry and behavioral sciences at the University of Washington, Seattle, and his coauthors. "There is no evidence of an intervention effect."
Mean days used of the most commonly used drug at 3 months were 12 for the brief intervention and 10 for enhanced care – not significantly different from each other or from baseline. The mean ASI composite score at 3 months was 0.10 in the brief intervention group and 0.09 in the enhanced care group, neither of which was significantly different from baseline.
There were also no differences in the secondary outcomes of medical and psychiatric comorbidity; employment, social, and legal domains; or the number of patients who accepted a referral to chemical dependency treatment.