How Best to Intervene for Problem Drug Use?
The the epidemic of prescription drug misuse and abuse has raised awareness among primary care physicians and pain specialists about the need to screen patients before prescribing addictive medications. This is especially important when dealing with patients in chronic pain. It is estimated that between 1.9 million people in the U.S. meet abuse or dependence criteria for prescription opioids, according statistics from the National Institute of Drug Abuse.1
Just how to address this risk has been a subject of much debate, study, and investment. "The United States has invested substantially in recent years 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," noted the researchers of a new study published in JAMA that sheds new light on just how difficult a job this is.2
Richard Saitz, MD, of the Boston University School of Public Health, and colleagues tested the effectiveness of two brief counseling interventions for unhealthy drug use (any illicit drug use or prescription drug misuse) among primary care patients identified by screening. “Prescription drug misuse is particularly complex, with diagnostic confusion between misuse for symptoms (eg, pain, anxiety), euphoria-seeking, and drug diversion. Brief counseling may simply be inadequate to address these complexities, even as an initial strategy,” he noted.
Study Examines Interventions
The researchers randomly assigned 528 adult primary care patients who were identified as having unhealthy drug use to 1 of 3 groups: 1) to receive a brief negotiated interview (BNI), which was a 10- to 15-minute structured interview conducted by health educators; 2) an adaptation of motivational interviewing (MOTIV), which was a 30- to 45-minute intervention based on motivational interviewing with a 20- to 30-minute booster conducted by masters-level counselors; 3) or no brief intervention.
All study participants received a written list of substance use disorder treatment and mutual help resources. At the beginning of the study, 63% of participants reported their main drug was marijuana, 19% cocaine, and 17% opioids.
For the primary outcome (number of days of use in the past 30 days of the self-identified main drug), there were no significant differences between the BNI, MOTIV or control groups (adjusted average days using the main drug at 6 months, 11, 12 and 12 days, respectively). In addition, there were no significant differences overall or in stratified analyses at 6 weeks or 6 months in drug use consequences, injection drug use, unsafe sex, health care utilization (hospitalizations and emergency department visits, overall or for addiction or mental health reasons), or mutual help group attendance.
The authors write that despite the potential for benefit with a brief intervention, drug use differs from unhealthy alcohol use in that it is often illegal and socially unacceptable, and is diverse—from occasional marijuana use, which was illegal during this study, to numerous daily heroin injections.
In the final analysis, “these results do not support widespread implementation of illicit drug use and prescription drug misuse screening and brief intervention,” concluded the authors.
Exploring Drug Use Should Remain Priority
Despite these findings, screening and interventions should remain a priority for primary care physicians treating chronic pain patients with history of substance abuse disorders. "Although the study offered no direct evidence of effectiveness for universal drug screening, brief intervention, and referral to treatment in primary care settings, exploring drug use with patients should remain a priority in primary care," wrote Ralph Hingson, ScD, MPH, of the National Institute on Alcohol Abuse and Alcoholism, Bethesda, and Wilson M. Compton, MD, MPE, of the National Institute on Drug Abuse, Rockville, Maryland, in an accompanying editorial.3
"The goal for clinical research is to develop and test new interventions with potential for benefiting patients. Drug screening and brief intervention research that focuses on adolescents and young adults is especially needed because rates of marijuana use among young people and the potency of marijuana have increased at the same time that recognition among youth of the health risks of marijuana use have declined,” they noted.
“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,” concluded the authors.