Do brief programmes for people who take drugs work?

Brief intervention for problem drug use in safety-net primary care settings: a randomized clinical trial.

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. JAMA. 2014 Aug 6;312(5):492-501. doi: 10.1001/jama.2014.7860.

Importance: Although brief intervention is effective for reducing problem alcohol use, few data exist on its effectiveness 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).

Objective: To determine whether brief intervention improves drug use outcomes compared with enhanced care as usual.

Design, setting, and participants: A randomized clinical trial with blinded assessments at baseline and at 3, 6, 9, and 12 months conducted in 7 safety-net primary care clinics in Washington State. Of 1 621 eligible patients reporting any problem drug use in the past 90 days, 868 consented and were randomized between April 2009 and September 2012. Follow-up participation was more than 87% at all points.

Interventions: Participants received a single brief intervention using motivational interviewing, a handout and list of substance abuse resources, and an attempted 10-minute telephone booster within 2 weeks (n = 435) or enhanced care as usual, which included a handout and list of substance abuse resources (n = 433).

Main outcomes and measures: The primary outcomes were self-reported days of problem drug use in the past 30 days and Addiction Severity Index-Lite (ASI) Drug Use composite score. Secondary outcomes were admission to substance abuse treatment; ASI composite scores for medical, psychiatric, social, and legal domains; emergency department and inpatient hospital admissions, arrests, mortality, and human immunodeficiency virus risk behavior.

Results: Mean days used of the most common problem drug at baseline were 14.40 (SD, 11.29) (brief intervention) and 13.25 (SD, 10.69) (enhanced care as usual); at 3 months postintervention, means were 11.87 (SD, 12.13) (brief intervention) and 9.84 (SD, 10.64) (enhanced care as usual) and not significantly different (difference in differences, beta = 0.89 [95% CI, -0.49 to 2.26]). Mean ASI Drug Use composite score at baseline was 0.11 (SD, 0.10) (brief intervention) and 0.11 (SD, 0.10) (enhanced care as usual) and at 3 months was 0.10 (SD, 0.09) (brief intervention) and 0.09 (SD, 0.09) (enhanced care as usual) and not significantly different (difference in differences, beta = 0.008 [95% CI, -0.006 to 0.021]). During the 12 months following intervention, no significant treatment differences were found for either variable. No significant differences were found for secondary outcomes.

Conclusions and relevance: A one-time brief intervention with attempted telephone booster had no effect on drug use in patients seen in safety-net primary care settings. This finding suggests a need for caution in promoting widespread adoption of this intervention for drug use in primary care.

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Editor’s notes: As well as injecting drug use, in some settings, people with problematic use of drugs are at increased risk of HIV. There has been a growing use of brief programmes to reduce drug use and drug-related harm. This is despite a gap in evidence about whether such short activities work or not. This paper presents the findings from a large randomised controlled trial. The trial examined the effectiveness of brief programmes for reducing drug use and increase admission to specialist substance abuse services, compared to an enhanced care package. The study was relatively large (n=868) with high follow-up rate (more than 87%). A range of drugs and severity of use were reported. No differences were found between the brief programme and control in relation to frequency of drug use, or medical, psychiatric, employment, family/social or legal outcomes. This finding is not surprising considering the complex problems that often accompany problematic drug use, including high levels of co-morbid mental illness. What is surprising, is that the increased uptake of specialist care and reduced use of emergency departments was significantly associated with the most severe drug use. This suggests that, for these outcomes, the programme may have had a greater effect on people who were more severe drug users. It would have been helpful if the study reported prevalence of injecting among the sample, since injecting is usually associated with more frequent drug use and drug-related harms than non-injecting. Knowing whether injecting contributed to increased severity of drug use among this sample might have helped interpret the association between the brief programme and reduced use of emergency departments among people who were severe users. This paper rightly urges caution in rolling out brief programmes for a broad spectrum of drug use in primary care settings and suggests the need for more research to examine the effectiveness of brief activities by type, mode and severity of drug use.  

Health care delivery
Northern America
United States of America
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