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The effectiveness of a brief intervention for illicit drugs linked to the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in primary health care settings: a technical report of phase III findings of the WHO ASSIST randomized controlled trial.
Humeniuk R, Dennington V, Ali R et al.
Geneva, Switzerland: WHO, 2008.
Rare attempt at screening and brief intervention for actual or potential problems arising from illegal drug use among primary care patients suggests that screening itself reduces use levels and that further intervention might be worthwhile among high-risk populations.
Summary For a later report on the same study see this Findings analysis.
ASSIST phase III was an international randomised controlled trial of the effectiveness of a brief intervention for illicit drugs (cannabis, cocaine, amphetamine-type drugs, and opioids) for moderate risk patients identified using the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). 731 participants recruited from primary care settings in Australia, Brazil, India and the USA were randomly allocated to an intervention or a wait-list control group at baseline and followed up three months later. Intervention participants received a brief intervention for the drug they scored the highest on in the ASSIST, plus written self-help materials relating to that drug. The intervention incorporated FRAMES (Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy) and motivational interviewing techniques. As measured by ASSIST, problem drug use scores overall and for each type of drug were significantly lower at follow-up than at baseline for both control and intervention groups, indicative of a possible effect of being screened and recruited to the study. But reductions were significantly greater among intervention patients on all measures except opioid use. However, the latter too was significantly lower among patients in India where all but a few of the opioid-targeted patients were recruited. For cannabis, only patients at the higher end of the moderate risk spectrum further reduced their ASSIST scores following intervention. The authors concluded that, to the extent that brief interventions for illicit drug use can be formulated in the context of a public health approach directed at high risk populations, strong consideration should be given to translating these kinds of programmes into clinical practice.
commentary Though the study recorded statistically significant reductions in drug use severity after research procedures and screening, and significant extra reductions from the intervention, questions have been raised about the clinical significance of the findings. After the entire package overall drug use severity fell by about 8 points on a scale whose maximum was 336 points. Only an extra 2½ points of this decline could be attributed to the intervention; the rest also occurred in the control group. As in
some alcohol studies, a very minimal intervention, such as
handing over the booklets
Though minimal, this entails the potentially powerful message that the patient has been professionally identified as at risk from their substance use, a realisation which the current study's participants commonly highlighted as instrumental in their improvements.
used in the current study, may have led to as great a reduction in drug use/problems as the motivational-style interview.
As well as generally being minor, there are questions Patients usually saw the same person for their baseline and follow-up assessments and for the intervention. The possibility that both parties had an interest in amplifying the impacts of the intervention cannot be ruled out. over whether the extra gains really were caused by the intervention. Set against this is the fact that more severely problematic patients were excluded from the study and instead referred to specialist treatment services. From a US study it seems possible that as a result of the processes initiated by screening, their drug use and allied problems might have considerably improved, yet the current study was unable to record such gains.
Some of the biggest effects were seen among opioid users in India, where over 11 points were sliced from opioid use severity scores (maximum 39) by the whole package, of which over half could be attributed to the intervention. Half the patients targeted for their opioid use were daily or near daily users and all but a few were recruited in India. Where, as in parts of that country, regular opioid use is normalised among socially included populations with family and work responsibilities, it seems that in certain cultures it is susceptible to even quite brief intervention.
British readers may be most interested in the results from the two westernised developed nations in the study. US results were negative, possibly due to the intervention being 'swamped' by extended research procedures. In Australia, three quarters of the largely young single population recruited at clinics for sexually transmitted diseases were identified as primarily having problems with amphetamine type drugs. Among this high-risk primary care population, there was a relatively large reduction in overall drug use severity and a significant reduction in problems related to what seems to have been mainly recreational (ie, once a week or less often) stimulant use.
As the authors hint in their conclusions, screening of this kind will probably be reserved for primary care or other populations likely to contain unusually many illegal drug users. How willing they will be to own up to their use is unclear. In the validation studies for the ASSIST screening questionnaire, patients were interviewed by researchers and assured of confidentiality even in respect of their doctors, an important reassurance to at least some of the patients. In routine practice it would be these same doctors or their colleagues who would ask the screening questions.
Last revised 05 September 2013. First uploaded 13 December 2008
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STUDY 2012 A randomized controlled trial of a brief intervention for illicit drugs linked to the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in clients recruited from primary health-care settings in four countries
REVIEW 2015 Prevention of addictive behaviours