Madras B.K., Compton W.M., Deepa A. et al.
Drug and Alcohol Dependence: 2008, in press.
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This huge US study set out to test whether widespread screening and brief intervention for illegal drug use (not just heavy drinking) could be implemented in a variety of general medical settings and whether it was effective. Both tests seem to have been passed, but with some important caveats.
Summary Alcohol screening and brief interventions in medical settings can significantly reduce alcohol use. Corresponding data for illicit drug use is sparse. A federally funded screening, brief interventions, referral to treatment (SBIRT) service program, the largest of its kind to date, was initiated by the Substance Abuse and Mental Health Services Administration (SAMHSA) in a wide variety of medical settings. The study compared illicit drug use at intake and 6 months after drug screening and interventions were administered. SBIRT services were implemented in a range of medical settings across six states. A diverse patient population (Alaska Natives, American Indians, African-Americans, Caucasians, Hispanics), was screened and offered score-based progressive levels of intervention (brief intervention, brief treatment, referral to specialised treatment). In this secondary analysis of the SBIRT service programme, drug use data was compared at intake and at a 6-month follow-up, in a sample of a randomly selected population (10%) who screened positive at baseline. Of 459,599 patients screened, 22.7% screened positive for a spectrum of use (risky/problematic, abuse/addiction). The majority were recommended for a brief intervention (15.9%), with a smaller percentage recommended for brief treatment (3.2%) or referral to specialised treatment (3.7%). Among those reporting baseline illicit drug use, rates of drug use at 6-month follow-up (4 of 6 sites), were 67.7% lower (p < 0.001) and heavy alcohol use was 38.6% lower (p < 0.001), with comparable findings across sites, gender, race/ethnic, age subgroups. Among persons recommended for brief treatment or referral to specialised treatment, self-reported improvements in general health (p < 0.001), mental health (p < 0.001), employment (p < 0.001), housing status (p < 0.001), and criminal behaviour (p < 0.001) were found. The authors concluded that SBIRT was feasible to implement and that self-reported patient status at 6 months indicated significant improvements over baseline for illicit drug use and heavy alcohol use, with functional domains improved, across a range of health care settings and a range of patients.
commentary As Findings readers have commented, brief advice is established for risky drinking but not so for the users of illicit drugs. Even rarer is brief advice triggered by screening tests among patients not specifically seeking this kind of help. The US
SBIRT study set about filling this gap by trialing practically universal screening for recent illegal drug use as well as heavy drinking at a variety of hospital, primary care and community health centres. The plan (implemented in nearly two-thirds of cases) was that positive screen patients would be given brief advice or, for the more severely affected minority, a short course of therapy or referral for specialist treatment. Key outcome measure was how many patients who had recently drank heavily or illegally used drugs were still doing so six months later. As the abstract documents, the answer was,
The proportion drinking heavily was cut by more than half and using cannabis by almost two thirds. Usage of less common drugs including heroin, cocaine and methamphetamine had been reduced by similar or greater amounts. Among the more severe cases, there were accompanying gains in quality of life and social functioning.
The two broad aims were to test whether such widespread intervention was feasible and secondly whether it was effective. Both tests seem to have been passed, but with some important qualifications. The study showed that intervention can be made to reliably follow on a positive screen; what we don't know is how many patients were not screened, Screening rates can be very low unless mandated, supervised and systematically encouraged. though it is believed All adult patients within a particular healthcare setting were approached for screening and were asked whether they were willing to respond to a few questions about substance use; according to informal survey, the majority agreed, but this proportion was not quantified. Personal communication from Professor Madras, 4 December, 2008. that most were. It seems likely that the six sites which applied for and were selected for the study were particularly keen on and/or ready to implement these initiatives. Elsewhere things might not go so well, especially if providers are required to fund and staff Screening and brief intervention were conducted by personnel specifically hired for these purposes. the work themselves. The biggest question mark over effectiveness is the absence of a control group either not screened, or screened but not offered further help. Substance use can fall substantially simply as a result of being screened, assessed, identified as having a problem, subject to research procedures, or as over time problems resolve. A multi-national WHO study trialing screening and brief intervention for illegal drug use did feature a control group subject to screening and research procedures only. They reduced substance use significantly; though also statistically significant, extra reductions generated by the intervention were minor and not apparent at the US sites, where consent procedures were most extensive.
Last revised 03 December 2008
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