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Original Investigation |

Screening and Brief Intervention for Drug Use in Primary Care:  The ASPIRE Randomized Clinical Trial

Richard Saitz, MD, MPH1,2; Tibor P. A. Palfai, PhD3; Debbie M. Cheng, ScD2,4; Daniel P. Alford, MD, MPH2; Judith A. Bernstein, PhD, RN, MSN1; Christine A. Lloyd-Travaglini, MPH5; Seville M. Meli, MPH1; Christine E. Chaisson, MPH5; Jeffrey H. Samet, MD, MPH, MA1,2
[+] Author Affiliations
1Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts
2Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts
3Department of Psychology, Boston University, Boston, Massachusetts
4Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
5Data Coordinating Center, Boston University School of Public Health, Boston, Massachusetts
JAMA. 2014;312(5):502-513. doi:10.1001/jama.2014.7862.
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Importance  The United States has invested substantially in screening and brief intervention for illicit drug use and prescription drug misuse, based in part on evidence of efficacy for unhealthy alcohol use. However, it is not a recommended universal preventive service in primary care because of lack of evidence of efficacy.

Objective  To test the efficacy of 2 brief counseling interventions for unhealthy drug use (any illicit drug use or prescription drug misuse)—a brief negotiated interview (BNI) and an adaptation of motivational interviewing (MOTIV)—compared with no brief intervention.

Design, Setting, and Participants  This 3-group randomized trial took place at an urban hospital-based primary care internal medicine practice; 528 adult primary care patients with drug use (Alcohol, Smoking, and Substance Involvement Screening Test [ASSIST] substance-specific scores of ≥4) were identified by screening between June 2009 and January 2012 in Boston, Massachusetts.

Interventions  Two interventions were tested: the BNI is a 10- to 15-minute structured interview conducted by health educators; the MOTIV is a 30- to 45-minute intervention based on motivational interviewing with a 20- to 30-minute booster conducted by master’s-level counselors. All study participants received a written list of substance use disorder treatment and mutual help resources.

Main Outcomes and Measures  Primary outcome was number of days of use in the past 30 days of the self-identified main drug as determined by a validated calendar method at 6 months. Secondary outcomes included other self-reported measures of drug use, drug use according to hair testing, ASSIST scores (severity), drug use consequences, unsafe sex, mutual help meeting attendance, and health care utilization.

Results  At baseline, 63% of participants reported their main drug was marijuana, 19% cocaine, and 17% opioids. At 6 months, 98% completed follow-up. Mean adjusted number of days using the main drug at 6 months was 12 for no brief intervention vs 11 for the BNI group (incidence rate ratio [IRR], 0.97; 95% CI, 0.77-1.22) and 12 for the MOTIV group (IRR, 1.05; 95% CI, 0.84-1.32; P = .81 for both comparisons vs no brief intervention). There were also no significant effects of BNI or MOTIV on any other outcome or in analyses stratified by main drug or drug use severity.

Conclusions and Relevance  Brief intervention did not have efficacy for decreasing unhealthy drug use in primary care patients identified by screening. These results do not support widespread implementation of illicit drug use and prescription drug misuse screening and brief intervention.

Trial Registration  clinicaltrials.gov Identifier: NCT00876941

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Figure.
Enrollment and Follow-up Flow Diagram for ASPIRE Study of Brief Interventions for Unhealthy Drug Use

ASSIST indicates Alcohol, Smoking, and Substance Involvement Screening Test, BNI, brief negotiated interview; MOTIV, an adaptation of motivational interviewing.

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