Examining multi-session brief intervention for substance use in primary care: research methods of a randomized controlled trial

Jaclyn E Chambers, Adam C Brooks, Rachel Medvin, David S Metzger, Jennifer Lauby, Carolyn M Carpenedo, Kevin E Favor, Kimberly C Kirby, Jaclyn E Chambers, Adam C Brooks, Rachel Medvin, David S Metzger, Jennifer Lauby, Carolyn M Carpenedo, Kevin E Favor, Kimberly C Kirby

Abstract

Background: Brief interventions such as Screening, a single session of Brief Intervention, and Referral to Treatment (SBIRT) have shown mixed effectiveness in primary care. However, there are indications that multi-session brief interventions may demonstrate more consistently positive outcomes, and perhaps a more intensive approach would be of benefit in addressing substance use in primary care. This study compared the effectiveness of SBIRT with a single BI session (BI/RT) to a multi-session brief-treatment intervention (BI/RT+) in primary care. We also developed easy-to-use, evidence-based materials to assist clinicians in delivering these interventions.

Methods/design: This study was conducted in three Federally Qualified Healthcare Centers (FQHCs). A total of 10,935 patients were screened, and 600 individuals were recruited. The sample was primarily Black/African American (82 %) with a mean age of 40. Patients who attended a healthcare appointment were screened for substance use via the AUDIT and DAST. Patients were eligible for the study if they scored 8 or higher on the AUDIT, were using only marijuana and scored 2 or higher on the DAST, or were using other illicit drugs and scored 1 or higher on the DAST. Participants were randomly assigned to receive one-session BI/RT, or two to six sessions of brief intervention that incorporated elements of motivational enhancement therapy and cognitive-behavioral therapy (BI/RT+). Both interventions were delivered by behavioral health consultants at the FQHCs. Participants completed follow-up assessments every 3 months for 1 year. Primary outcome variables included substance use treatment sessions attended and days of substance use. Secondary outcomes included measures of health, employment, legal, and psychiatric functioning and HIV risk behaviors. Additionally, we will conduct an economic evaluation examining cost-effectiveness and will analyze outcomes from a process evaluation examining patient and provider experiences.

Discussion: The ability of brief interventions to impact substance use has great potential, but research findings have been mixed. By conducting a large-scale randomized controlled trial in real-world health centers, this study will answer important questions about the effectiveness of expanded BIs for patients who screen positive for risky substance use in primary care. Trial registration NCT01751672.

Keywords: Brief intervention; Brief treatment; Primary care; SBIRT; Substance abuse.

References

    1. SAMHSA. Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings NSDUH Series H-46, Publication No. (SMA) 13-4795. Rockville, MD;2013.
    1. Chalk M, Dilonardo J, Rinaldo SG, Oehlmann P. Integrating appropriate services for substance use conditions in health care settings: an issue brief on lessons learned and challenges ahead. Philadelphia: Treatment Research Institute; 2010.
    1. Cherpitel CJ, Ye Y. Drug use and problem drinking associated with primary care and emergency room utilization in the US general population: data from the 2005 national alcohol survey. Drug Alcohol Depend. 2008;97(3):226–230. doi: 10.1016/j.drugalcdep.2008.03.033.
    1. Mertens JR, Lu YW, Parthasarathy S, Moore C, Weisner CM. Medical and psychiatric conditions of alcohol and drug treatment patients in an HMO: comparison with matched controls. Arch Intern Med. 2003;163(20):2511–2517. doi: 10.1001/archinte.163.20.2511.
    1. Mertens JR, Weisner C, Ray GT, Fireman B, Walsh K. Hazardous drinkers and drug users in HMO primary care: prevalence, medical conditions, and costs. Alcohol Clin Exp Res. 2005;29(6):989–998. doi: 10.1097/01.ALC.0000167958.68586.3D.
    1. Babor TF, McRee BG, Kassebaum PA, Grimaldi PL, Ahmed K, Bray J. Screening, brief intervention, and referral to treatment (SBIRT): toward a public health approach to the management of substance abuse. Subst Abuse. 2007;28(3):7–30. doi: 10.1300/J465v28n03_03.
    1. Bien TH, Miller WR, Tonigan JS. Brief interventions for alcohol problems: a review. Addiction. 1993;88(3):315–335. doi: 10.1111/j.1360-0443.1993.tb00820.x.
    1. Moyer A, Finney JW, Swearingen CE, Vergun P. Brief interventions for alcohol problems: a meta-analytic review of controlled investigations in treatment-seeking and non-treatment-seeking populations. Addiction. 2002;97(3):279–292. doi: 10.1046/j.1360-0443.2002.00018.x.
    1. Wilk AI, Jensen NM, Havighurst TC. Meta-analysis of randomized control trials addressing brief interventions in heavy alcohol drinkers. J Gen Intern Med. 1997;12(5):274–283. doi: 10.1007/s11606-006-5063-z.
    1. Whitlock EP, Polen MR, Green CA, Orleans T, Klein J. Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Int Med. 2004;140(7):557–568. doi: 10.7326/0003-4819-140-7-200404060-00017.
    1. Ballesteros J, Duffy JC, Querejeta I, Arino J, Gonzalez-Pinto A. Efficacy of brief interventions for hazardous drinkers in primary care: systematic review and meta-analyses. Alcohol Clin Exp Res. 2004;28(4):608–618. doi: 10.1097/01.ALC.0000122106.84718.67.
    1. Kahan M, Wilson L, Becker L. Effectiveness of physician-based interventions with problem drinkers: a review. Can Med Assoc J. 1995;152(6):851–859.
    1. Jonas DE, Garbutt JC, Amick HR, et al. Behavioral counseling after screening for alcohol misuse in primary care: a systematic review and meta-analysis for the U.S. Preventive Services Task Force. Ann Intern Med. 2012;157(9):645–654. doi: 10.7326/0003-4819-157-9-201211060-00544.
    1. Glass JE, Hamilton AM, Powell BJ, Perron BE, Brown RT, Ilgen MA. Speciality substance use disorder services following brief alcohol intervention: a meta-analysis of randomized controlled trials. Addiction. 2015;110(9):1404–1415. doi: 10.1111/add.12950.
    1. Kaner E, Bland M, Cassidy P, et al. Effectiveness of screening and brief alcohol intervention in primary care (SIPS trial): pragmatic cluster randomised controlled trial. Br Med J. 2013;346:e8501. doi: 10.1136/bmj.e8501.
    1. van Beurden I, Anderson P, Akkermans RP, Grol RP, Wensing M, Laurant MG. Involvement of general practitioners in managing alcohol problems: a randomized controlled trial of a tailored improvement programme. Addiction. 2012;107(9):1601–1611. doi: 10.1111/j.1360-0443.2012.03868.x.
    1. Aalto M, Saksanen R, Laine P, et al. Brief intervention for female heavy drinkers in routine general practice: a 3-year randomized, controlled study. Alcohol Clin Exp Res. 2000;24(11):1680–1686. doi: 10.1111/j.1530-0277.2000.tb01969.x.
    1. Beich A, Gannik D, Malterud K. Screening and brief intervention for excessive alcohol use: qualitative interview study of the experiences of general practitioners. BMJ. 2002;325:870. doi: 10.1136/bmj.325.7369.870.
    1. Bernstein J, Bernstein E, Tassiopoulos K, Heeren T, Levenson S, Hingson R. Brief motivational intervention at a clinic visit reduces cocaine and heroin use. Drug Alcohol Depend. 2005;77(1):49–59. doi: 10.1016/j.drugalcdep.2004.07.006.
    1. Zahradnik A, Otto C, Crackau B, et al. Randomized controlled trial of a brief intervention for problematic prescription drug use in non-treatment-seeking patients. Addiction. 2009;104(1):109–117. doi: 10.1111/j.1360-0443.2008.02421.x.
    1. World Health Organization. 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. Switzerland: World Health Organization; 2008.
    1. Madras BK, Compton WM, Avula D, Stegbauer T, Stein JB, Clark HW. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: comparison at intake and 6 months later. Drug Alcohol Depend. 2009;99(1–3):280–295. doi: 10.1016/j.drugalcdep.2008.08.003.
    1. Saitz R, Palfai TP, Cheng DM, et al. Screening and brief intervention for drug use in primary care: the ASPIRE randomized clinical trial. JAMA. 2014;312(5):502–513. doi: 10.1001/jama.2014.7862.
    1. Roy-Byrne P, Bumgardner K, Krupski A, et al. Brief intervention for problem drug use in safety-net primary care settings: a randomized clinical trial. JAMA. 2014;312(5):492–501. doi: 10.1001/jama.2014.7860.
    1. Saitz R. Screening and brief intervention for unhealthy drug use: little or no efficacy. Front Psychiatry. 2014;5:121. doi: 10.3389/fpsyt.2014.00121.
    1. Miller WR, Zweben A, DiClemente CC, Rychtarik RG. Motivational enhancement therapy manual: a clinical research guide for therapists treating individuals with alcohol abuse and dependence. In: Mattson ME, editor. National Institute on Alcohol Abuse and Alcoholism Project MATCH Monograph Series. Rockville: U.S. Department of Health and Human Services; 1995.
    1. Project MATCH Matching alcoholism treatments to client heterogeneity: project MATCH post-treatment drinking outcomes. J Stud Alcohol. 1997;58(1):7–29. doi: 10.15288/jsa.1997.58.7.
    1. Dunn C, Deroo L, Rivara FP. The use of brief interventions adapted from motivational interviewing across behavioral domains: a systematic review. Addiction. 2001;96(12):1725–1742. doi: 10.1046/j.1360-0443.2001.961217253.x.
    1. Burke BL, Arkowitz H, Menchola M. The efficacy of motivational interviewing: a meta-analysis of controlled clinical trials. J Consult Clin Psychol. 2003;71(5):843–861. doi: 10.1037/0022-006X.71.5.843.
    1. Hettema J, Steele J, Miller WR. Motivational interviewing. Annu Rev Clin Psychol. 2005;1(1):91–111. doi: 10.1146/annurev.clinpsy.1.102803.143833.
    1. Baker A, Lee NK, Claire M, et al. Brief cognitive behavioural interventions for regular amphetamine users: a step in the right direction. Addiction. 2005;100(3):367–378. doi: 10.1111/j.1360-0443.2005.01002.x.
    1. Copeland J, Swift W, Roffman R, Stephens R. A randomized controlled trial of brief cognitive–behavioral interventions for cannabis use disorder. J Subst Abuse Treat. 2001;21(2):55–64. doi: 10.1016/S0740-5472(01)00179-9.
    1. Covi L, Hess JM, Schroeder JR, Preston KL. A dose response study of cognitive behavioral therapy in cocaine abusers. J Subst Abuse Treat. 2002;23(3):191–197. doi: 10.1016/S0740-5472(02)00247-7.
    1. Anton RF, O’Malley SS, Ciraulo DA, et al. Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial. JAMA. 2006;295(17):2003–2017. doi: 10.1001/jama.295.17.2003.
    1. Marijuana Treatment Project Resarch Group Brief treatments for cannabis dependence: findings from a randomized multisite trial. J Consult Clin Psychol. 2004;72(3):455–466. doi: 10.1037/0022-006X.72.3.455.
    1. Weisner C, Mertens J, Parthasarathy S, Moore C, Lu Y. Integrating primary medical care with addiction treatment: a randomized controlled trial. J Am Med Assoc. 2001;286(14):1715–1723. doi: 10.1001/jama.286.14.1715.
    1. Goler NC, Armstrong MA, Taillac CJ, Osejo VM. Substance abuse treatment linked with prenatal visits improves perinatal outcomes: a new standard. [Erratum appears in J Perinatol. 2009 Feb;29(2):181] J Perinatol. 2008;28(9):597–603. doi: 10.1038/jp.2008.70.
    1. Mertens JR, Flisher AJ, Satre DD, Weisner CM. The role of medical conditions and primary care services in 5-year substance use outcomes among chemical dependency treatment patients. Drug Alcohol Depend. 2008;98(1–2):45–53. doi: 10.1016/j.drugalcdep.2008.04.007.
    1. Curry SJ, Ludman EJ, Grothaus LC, Donovan D, Kim E. A randomized trial of a brief primary-care based intervention for reducing at-risk drinking practices. Health Psychol. 2003;22(2):156–165. doi: 10.1037/0278-6133.22.2.156.
    1. Holland CL, Pringle JL, Barbetti V. Identification of physician barriers to the application of screening and brief intervention for problem alcohol and drug use. Alcohol Treat Q. 2009;27(2):174–183. doi: 10.1080/07347320902784890.
    1. Goplerud E, McPherson T. Implementation barriers to and faciltators of screening, brief intervention, referral, and treatment (SBIRT) in Federally Qualified Health Centers (FQHCs): U.S. Department of Health and Human Services; 2015.
    1. Hennessey J. FQHCs and health reform: up to the task? Northwest J Law Soc Policy. 2013;9(1):122–137.
    1. Ku LRP, Dor A, Tan E, Shin P, Rosenbaum S. Strengthening primary care to bend the cost curve: the expansion of community health centers through health reform. Washington, DC: Geiger Gibson/RCHN Community Health Foundation Research Collaborative, George Washington University; 2010.
    1. Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption II. Addiction. 1993;88(6):791–804. doi: 10.1111/j.1360-0443.1993.tb02093.x.
    1. Skinner HA. The drug abuse screening test. Addict Behav. 1982;7(4):363–371. doi: 10.1016/0306-4603(82)90005-3.
    1. Allen JP, Litten RZ, Fertig JB, Babor T. A review of research on the alcohol use disorders identification test (AUDIT) Alcohol Clin Exp Res. 1997;21(4):613–619. doi: 10.1111/j.1530-0277.1997.tb03811.x.
    1. Maisto SA, Carey MP, Carey KB, Gordon CM, Gleason JR. Use of the AUDIT and the DAST-10 to identify alcohol and drug use disorders among adults with a severe and persistent mental illness. Psychol Assess. 2000;12(2):186–192. doi: 10.1037/1040-3590.12.2.186.
    1. Yudko E, Lozhkina O, Fouts A. A comprehensive review of the psychometric properties of the drug abuse screening test. J Subst Abuse Treat. 2007;32(2):189–198. doi: 10.1016/j.jsat.2006.08.002.
    1. Miller WR, Rollnick S. Motivational interviewing: preparing people for change. 2. New York: Guilford Press; 2002.
    1. McLellan AT, Cacciola JC, Alterman AI, Rikoon SH, Carise D. The Addiction Severity Index at 25: origins, contributions and transitions. Am J Addict. 2006;15(2):113–124. doi: 10.1080/10550490500528316.
    1. McLellan AT, Luborsky L, Erdlen F, Laporte D, et al. The Addiction Severity Index: a diagnostic/evaluative instrument for substance abuse clients. In: Gottheil E, et al., editors. Substance abuse and psychiatric illness. New York: Pergamom Press; 1980.
    1. Sheehan DV, Lecrubier Y, Sheehan KH, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry. 1998;59(Suppl 20):22–33.
    1. Laudet AB, Morgen K, White WL. The role of social supports, spirituality, religiousness, life meaning and affiliation with 12-Step fellowships in quality of life satisfaction among individuals in recovery from alcohol and drug problems. Alcohol Treat Q. 2006;24(1–2):33–73. doi: 10.1300/J020v24n01_04.
    1. Cohen S, Williamson G. Perceived stress in a probability sample of the United States. In: Spacapan S, Oskamp S, editors. The social psychology of health. Newbury Park: Sage; 1988.
    1. Carroll KM, Nich C, Sifry RL, et al. A general system for evaluating therapist adherence and competence in psychotherapy research in the addictions. Drug Alcohol Depend. 2000;57(3):225–238. doi: 10.1016/S0376-8716(99)00049-6.
    1. Hauck WW, Anderson S, Marcus SM. Should we adjust for covariates in nonlinear regression analyses of randomized trials? Control Clin Trials. 1998;19(3):249–256. doi: 10.1016/S0197-2456(97)00147-5.
    1. Littell RC, Milliken GA, Stroup WW, Wolfinger RD. SAS system for mixed models. Cary: SAS Institute Inc.; 1996.
    1. Diggle PJ, Heagerty PJ, Laing KY, Zeger SL. Analysis of longitudinal data. 2. Oxford: Oxford University Press; 2002.
    1. Hedeker D, Gibbons RD, Waternaux C. Sample size estimation for longitudinal designs with attrition: comparing time-related contrasts between two groups. J Educ Behav Stat. 1999;24(1):70–92. doi: 10.3102/10769986024001070.
    1. Cohen J. Statistical power analysis for the behavioral sciences. 2. Hillsdale: Lawrence Erlbaum Associates; 1988.
    1. Miller WR, Zweben A, DiClemente CC, Rychartik RG. Motivational enhancement therapy manual: a clinical research guide for therapists treating individuals with alcohol abuse and dependence. Rockville: National Institute on Alcohol Abuse and Alcoholism; 1992.
    1. McLellan AT, O’Brien CP, Lewis DL, Kleber HD. Drug addiction as a chronic medical illness: implications for treatment, incusrance and evaluation. J Am Med Assoc. 2000;284:1689–1695. doi: 10.1001/jama.284.13.1689.
    1. McLellan AT, McKay JR, Forman R, Cacciola J, Kemp J. Reconsidering the evaluation of addiction treatment: from retrospective follow-up to concurrent recovery monitoring. Addiction. 2005;100:447–458. doi: 10.1111/j.1360-0443.2005.01012.x.

Source: PubMed

3
Subscribe