Transcript Days Use of Main Drug (in past 30)

Screening and brief
intervention for low risk
drug use in primary care:
A pilot randomized trial
SM Meli, TP Palfai, DM Cheng, DP Alford, JA Bernstein,
JH Samet, CA Lloyd -Travaglini, CE Chaisson, R Saitz
AMERSA Conference 2015
Schools of Public Health and Medicine
INTRODUCTION
 The US Preventive Ser vices Task Force (USPSTF) recommends brief
inter vention (BI) for primar y care patients with unhealthy alcohol
use identified by screening. 1
 Federal ef for ts suppor t “SBIRT” dissemination. SBIRT includes
Screening and BI, and Referral and Treatment , for alcohol and other
drugs.
 “The USPSTF concludes that the current evidence is insuf ficient to
assess the balance of benefits and harms of screening adolescents,
adults, and pregnant women for illicit drug use. ” 2
 U niversal screening and brief inter vention (SBI) for moderate/high
risk drug use among primar y care (PC) patients lacks ef ficacy but
the ef ficacy of SBI for low risk drug use is unknown.
1U.S.
Preventive Services Task Force, Agency for Healthcare Research and Quality (2013). Screening and Behavioral Counseling Interventions in Primary Care
To Reduce Alcohol Misuse: Recommendation Statement . Ann Intern Med 140(7):554-556. doi:10.7326/0003-4819-140-7-200404060-00016.
2U.S. Preventive Services Task Force (2008). Screening for Illicit Drug Use: U.S. Preventive Services Task Force Recommendation Statement. Retrieved from:
http://www.uspreventiveservicestaskforce.org/uspstf08/druguse/drugrs.htm
AIM
 We tested the ef ficacy of brief intervention (BI) for low risk
drug use among primary care (PC) patients identified by
screening.
 An exploratory aim was to assess whether ef fects dif fered by
main drug.
METHODS
 Design:
Pilot randomized controlled trial with 3 arms.
 Subjects:
 Adults in primary care at an urban medical center screened by
trained personnel; Alcohol, Smoking, and Substance
Involvement Screening Test (ASSIST) drug-specific involvement
score of 2 or 3 (i.e. low risk drug use).
 A score of 2=use of main drug once or twice, in the past 3 months.
 A score of 3=use of main drug monthly, in the past 3 months.
INTERVENTION
 Groups:
1. No Brief Intervention (No BI).
2. Brief Negotiated Interview (BNI): 10-15 minute structured
interview conducted by trained health educators.
3. Adaptation of Motivational Interviewing (MOTIV): ≤45 minutes
of motivational interviewing and an optional booster conducted
by trained masters-level counselors.
INCLUSION CRITERIA
18 years or older.
Arrived for a primary care visit.
ASSIST drug-specific involvement score of 2 or 3.
Drug use in the past 3 months.
No previous MASBIRT intervention in the past 3 months.
Fluent in English or Spanish.
2 contacts who can assist in locating the subject for follow up.
 Able to return to Boston Medical Center in the next 6 months.
 Not pregnant (for female subjects).
 Able to be interviewed by trained research staf f (excluding
those in acute discomfort or with significantly impaired
cognition).
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METHODS
 Primary Outcome:
# days use of main drug* in past 30 days at 6-months.
 Secondary Outcome:
Drug use consequences at 6-months.
 Measured by the Short Inventory of Problems–Drugs (SIP-D).
 Analyses:
Negative binomial regression models, adjusted for baseline
use and main drug*.
*Main drug is the drug of most concern.
ENROLLMENT & FOLLOW-UP
Persons potentially available for screening
1504
Screened
1287
Of those with drug use identified by screening,
total eligible for pilot study
142
Randomized
61/142 (43%)
No BI group 19
BNI group 23
Followed up at 6 months
57/61 (93%)
MOTIV group 19
RESULTS
BASELINE CHARACTERISTICS
Characteristic
% (n)
Race/ethnicity
Black or African American
Hispanic or Latino
White
Other
77 (47)
5 (3)
16 (10)
2 (1)
Mean age (SD)
41 (13)
Male
54 (33)
1+ nights in shelter OR on street in past 3 months
11 (7)
High school graduate or higher
77 (47)
PHQ-9** score >10 (mod to severe depressive symptoms)
21 (13)
OASIS# score > 8 (clinically significant anxiety)
28 (17)
Any outpatient counseling (doctor, nurse, or other health professional) or mutual
help during past 3 months for alcohol, drugs or mental health*
20 (12)
*There were no significant differences between groups at baseline except for outpatient or self-help treatment
**PHQ-9 = Patient Health Questionnaire depression module
#OASIS = Overall Anxiety Severity and Impairment Scale (OASIS)
RESULTS
BASELINE CHARACTERISTICS
DRUG USE:
Main Drug##
% (n)
Prescription Opioids
10 (6)
Cocaine
15 (9)
Marijuana
70 (43)
Other Drug
5 (3)
Days Use of Main Drug (in past 30)
Injected Drugs (past 3 Months)
Mean (SD) = 3.4 (5)
7 (4)
Use of more than 1 drug in past three months
25 (15)
Misuse of any RX drug in past three months
15 (9)
ASSIST Score of 2
74 (45)
ASSIST Score of 3
26 (16)
ALCOHOL USE:
Any heavy drinking days in past month (Women 4+ drinks/day, Men 5+
drinks/day)
##Drug
of most concern, as determined by the participant
49 (30)
PRIMARY OUTCOME RESULTS
( # DAY S U S ED M AIN D RUG I N PAST 3 0 DAY S AT 6 M ONTHS)
No BI
N
Days used
main drug++
57
BNI
MOTIV
Adjusted Means
6.4
2.1
2.3
BNI vs. no BI
IRR
p-value
(95% CI)
MOTIV vs. no BI
IRR
p-value
(95% CI)
0.33
(0.15,0.74)
0.01
0.36
(0.15,0.85)
0.02
Exploratory analyses stratified by main drug
Days used
main drug‡
(Cocaine,
Opioids§,
and Other)
Days used
main drug‡
(Marijuana)
++Model
17
2.3
0.3
1.9
0.12
(0.03,0.43)
0.003
0.81
(0.17,3.91)
0.79
40
7.4
3.6
3.1
0.49
(0.19,1.25)
0.13
0.42
(0.15,1.14)
0.13
adjusted for the following baseline covariates: # days main drug use in past 30 and main drug
adjusted for the following baseline covariates: # days main drug use in past 30
§Opioid use does not include heroin
‡Model
SECONDARY OUTCOME RESULTS
(S IP -D AT 6 M O NTHS )
No BI
N
SIP-D++
57
BNI
MOTIV
Adjusted Means
1.7
1.8
0.5
BNI vs. no BI
IRR
p(95% CI)
value
MOTIV vs. no BI
IRR
p-value
(95% CI)
1.05
(0.20,5.60)
0.96
0.31
(0.05,1.92)
0.41
Exploratory analyses stratified by main drug
SIP-D‡
(Cocaine,
Opioids§,
and Other)
17
6.9
2.9
2.1
0.41
(0.04,4.13)
0.45
0.30
(0.02,3.63)
0.45
SIP-D‡
(Marijuana)
40 0.45
0.48
0.39
1.07
0.96
(0.10,11.33)
0.80
(0.05,12.46)
0.96
++Model
adjusted for the following baseline covariates: SIP-D and main drug
adjusted for the following baseline covariates: SIP-D
§Opioid use does not include heroin in this sample
SIP-D=Short Inventory of Problems, Drug
‡Model
FIDELITY OF THE INTERVENTION
 All audible intervention recordings were coded using both the
MITI and an ASPIRE-study -developed instrument.
 Both had scores consistent with proficiency.
*MITI=motivational
interviewing treatment integrity
LIMITATIONS
 Ef fectiveness design choices: No exclusions for heavy
drinking, multiple drug use, or comorbidity.
 May have limited applicability beyond urban hospital -based
primary care.
 Likely underpowered especially to detect ef fects within
subgroups and for drug use consequences.
 Hair testing results not reported herein; however, results for
tetrahydrocannabinol were consistent with self report
findings.
 Fewer than half of those eligible enrolled (and small sample),
potentially limiting conclusions regarding ef fectiveness and
generalizability.
CONCLUSION
 BNI and MOTIV appear to have ef ficacy for preventing an
increase in drug use in primary care patients with low risk use
identified by screening.
 We did not detect an ef fect of BI on drug use-related
problems, though problem scores were already low at study
entry.
IMPLICATIONS
 Less severe patterns of drug use in primary care may be
uniquely amenable to brief intervention.
 Findings warrant replication in a larger trial.
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