Screening, brief intervention in primary care appear ineffective for reducing drug use

Screening and brief intervention targeting drug use do not appear to be effective in primary care, according to the findings of 2 recent studies.

In the first study, researchers performed a randomized clinical trial in 7 safety-net primary clinics to examine whether a brief intervention compared with enhanced usual care would reduce drug use. Patients who reported any problem drug use in the past 90 days were randomly assigned to receive brief motivational interviewing, a handout and list of resources for substance abuse, and an attempted 10-minute telephone booster within 2 weeks, or to enhanced usual care, which included the handout and resources list.

The study's primary outcomes were self-reported days of problem drug use in the past 30 days and composite score on the Addiction Severity Index-Lite (ASI) Drug Use scale. Admission to substance abuse treatment; ASI medical, psychiatric, social, and legal composite scores; ED and inpatient hospital admissions; arrests; death; and HIV risk behavior were secondary outcomes. The study appeared in the Aug. 6 Journal of the American Medical Association (JAMA).

A total of 868 patients were randomly assigned to a study group between April 2009 and September 2012. Four hundred thirty-five were assigned to the brief intervention group, and 433 were assigned to the enhanced usual care group. Mean days of use of the most common problem drug (11.87 days vs. 9.84 days) and mean composite ASI Drug Use score (0.10 vs. 0.09) did not differ significantly 3 months after the intervention in the brief intervention versus enhanced usual care groups. This finding persisted in the 12 months postintervention for the 2 main outcome measures and for the secondary outcomes.

The second study, which appeared in the same issue of JAMA, examined the efficacy of screening and 2 brief counseling interventions for decreasing unhealthy drug use, which was defined as any illicit drug use or prescription drug misuse. A brief negotiated interview (a 10- to 15-minute structured interview by health educators) and an adapted motivational interview (a 30- to 45-minute intervention based on motivational interviewing and including a 20- to 30-minute booster conducted by counselors) were compared with no intervention in a 3-group randomized, clinical trial performed at a primary care practice based at an urban hospital. All participants received a resources list regardless of study group assignment. The study's primary outcome was days of use of the self-identified main drug in the past 30 days at 6 months. Other self-reported drug use measures, hair testing of drug use, and health care utilization were among the secondary outcomes.

A total of 529 patients enrolled in the study, but 1 withdrew before randomization. Of the 528 randomized, 177 were assigned to motivational interviewing, 174 were assigned to the brief negotiated interview, and 177 were assigned to no intervention. Sixty-three participants reported a main drug of marijuana at baseline, 19% reported cocaine, and 17% reported opioids. Ninety-eight percent of participants completed follow-up at 6 months.

At 6 months, the mean adjusted days using the main reported drug were 12 in the no intervention group, 11 in the brief negotiated interview group, and 12 in the motivational interviewing group. The incidence rate ratios in the 2 intervention groups were 0.97 (95% CI, 0.77 to 1.22) and 1.05 (95% CI, 0.84 to 1.32), respectively (P=0.81 for both comparisons with no intervention). Neither intervention appeared to have significant effects on any other outcomes, and no effects were seen in analyses stratified by main drug or by severity of drug use.

The authors of both studies concluded that the methods they examined did not appear to reduce drug use in their study populations. Both groups of study authors called for caution in promoting widespread use of such interventions to attempt to curb unhealthy drug use in primary care settings.

The authors of an accompanying editorial pointed out the studies' strengths (including random assignment, high rates of follow-up, and low attrition) and limitations (including no analysis of alcohol or tobacco as the primary drug and no measurement of same-day alcohol/drug or drug/drug use). The editorialists said that although the 2 studies don't directly support drug screening, brief intervention, and treatment referral in primary care, researchers should continue to develop and test new interventions that may be effective. This is especially important for adolescents and young adults, the editorialists said, who may be more likely to begin combined use of drugs, tobacco, and alcohol rather than a single substance. “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,” the editorialists concluded.