Self-reported alcohol and drug use six months after brief intervention: do changes in reported use vary by mental-health status?

Clinical Recognition of Substance Use Disorders in Medicaid Primary Care Associated With Universal Screening, Brief Intervention and Referral to Treatment (SBIRT)

OBJECTIVE

Screening, Brief Intervention and Referral to Treatment (SBIRT) programs have been effective for moderate reductions of alcohol use among participants in universal settings. However, there has been limited evidence of effectiveness in referring individuals to specialty care, and the literature now often refers to screening and brief intervention (SBI). This study examines documentation of substance use disorder (SUD) diagnoses in a low-income Medicaid population to evaluate the effect of universal SBIRT on healthcare system recognition of SUDs, a first step to obtaining a referral to treatment (RT) for individuals with SUDs.

METHOD

SBI patient data from Wisconsin's Initiative to Promote Healthy Lifestyles (WIPHL) were linked to Wisconsin Medicaid claims data. A comparison group of Medicaid beneficiaries was identified from a matched sample of non-SBIRT clinics (total study N = 14,856). Hierarchical generalized linear modeling was used to assess rates of SUD diagnosis in the 12 months following receipt of SBIRT in WIPHL clinics compared with rates in non-SBIRT clinics. Analysis controlled for clinic, individual patient's health status, demographics, and baseline substance use diagnoses.

RESULTS

SBIRT was associated with greater odds of being diagnosed with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), alcohol abuse or dependence as well as drug abuse or dependence over the 12 months subsequent to receipt of the screen. The overall diagnostic rate for any DSM-IV substance abuse or dependence was 9.9% at baseline and 12.2% during the follow-up year. SBIRT patients had 42% (p = .003) greater odds of being diagnosed with a substance use disorder within 12 months relative to comparison clinic patients. However, there were very few claims for specialty SUD services.

CONCLUSIONS

The presence of SBIRT in a primary care clinic appears to increase the awareness and recognition of patients with SUDs and a greater willingness of healthcare providers to diagnose patients with an alcohol or drug use disorder on Medicaid claims. Further research is needed to determine if this increase in diagnosis reflects integrated care for SUDs or if it leads to improved access to specialty care, in which case abandonment of the RT component of SBIRT may be premature.

Clinical Recognition of Substance Use Disorders in Medicaid Primary Care Associated With Universal Screening, Brief Intervention and Referral to Treatment (SBIRT)

OBJECTIVE

Screening, Brief Intervention and Referral to Treatment (SBIRT) programs have been effective for moderate reductions of alcohol use among participants in universal settings. However, there has been limited evidence of effectiveness in referring individuals to specialty care, and the literature now often refers to screening and brief intervention (SBI). This study examines documentation of substance use disorder (SUD) diagnoses in a low-income Medicaid population to evaluate the effect of universal SBIRT on healthcare system recognition of SUDs, a first step to obtaining a referral to treatment (RT) for individuals with SUDs.

METHOD

SBI patient data from Wisconsin's Initiative to Promote Healthy Lifestyles (WIPHL) were linked to Wisconsin Medicaid claims data. A comparison group of Medicaid beneficiaries was identified from a matched sample of non-SBIRT clinics (total study N = 14,856). Hierarchical generalized linear modeling was used to assess rates of SUD diagnosis in the 12 months following receipt of SBIRT in WIPHL clinics compared with rates in non-SBIRT clinics. Analysis controlled for clinic, individual patient's health status, demographics, and baseline substance use diagnoses.

RESULTS

SBIRT was associated with greater odds of being diagnosed with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), alcohol abuse or dependence as well as drug abuse or dependence over the 12 months subsequent to receipt of the screen. The overall diagnostic rate for any DSM-IV substance abuse or dependence was 9.9% at baseline and 12.2% during the follow-up year. SBIRT patients had 42% (p = .003) greater odds of being diagnosed with a substance use disorder within 12 months relative to comparison clinic patients. However, there were very few claims for specialty SUD services.

CONCLUSIONS

The presence of SBIRT in a primary care clinic appears to increase the awareness and recognition of patients with SUDs and a greater willingness of healthcare providers to diagnose patients with an alcohol or drug use disorder on Medicaid claims. Further research is needed to determine if this increase in diagnosis reflects integrated care for SUDs or if it leads to improved access to specialty care, in which case abandonment of the RT component of SBIRT may be premature.

Brief intervention for problem drug use in safety-net primary care settings: a randomized clinical trial

IMPORTANCE

Although brief intervention is effective for reducing problem alcohol use, few data exist on its effectiveness for reducing problem drug use, a common issue in disadvantaged populations seeking care in safety-net medical settings (hospitals and community health clinics serving low-income patients with limited or no insurance).

OBJECTIVE

To determine whether brief intervention improves drug use outcomes compared with enhanced care as usual.

DESIGN, SETTING, AND PARTICIPANTS

A randomized clinical trial with blinded assessments at baseline and at 3, 6, 9, and 12 months conducted in 7 safety-net primary care clinics in Washington State. Of 1621 eligible patients reporting any problem drug use in the past 90 days, 868 consented and were randomized between April 2009 and September 2012. Follow-up participation was more than 87% at all points.

INTERVENTIONS

Participants received a single brief intervention using motivational interviewing, a handout and list of substance abuse resources, and an attempted 10-minute telephone booster within 2 weeks (n = 435) or enhanced care as usual, which included a handout and list of substance abuse resources (n = 433).

MAIN OUTCOMES AND MEASURES

The primary outcomes were self-reported days of problem drug use in the past 30 days and Addiction Severity Index-Lite (ASI) Drug Use composite score. Secondary outcomes were admission to substance abuse treatment; ASI composite scores for medical, psychiatric, social, and legal domains; emergency department and inpatient hospital admissions, arrests, mortality, and human immunodeficiency virus risk behavior.

RESULTS

Mean days used of the most common problem drug at baseline were 14.40 (SD, 11.29) (brief intervention) and 13.25 (SD, 10.69) (enhanced care as usual); at 3 months postintervention, means were 11.87 (SD, 12.13) (brief intervention) and 9.84 (SD, 10.64) (enhanced care as usual) and not significantly different (difference in differences, β = 0.89 [95% CI, -0.49 to 2.26]). Mean ASI Drug Use composite score at baseline was 0.11 (SD, 0.10) (brief intervention) and 0.11 (SD, 0.10) (enhanced care as usual) and at 3 months was 0.10 (SD, 0.09) (brief intervention) and 0.09 (SD, 0.09) (enhanced care as usual) and not significantly different (difference in differences, β = 0.008 [95% CI, -0.006 to 0.021]). During the 12 months following intervention, no significant treatment differences were found for either variable. No significant differences were found for secondary outcomes.

CONCLUSIONS AND RELEVANCE

A one-time brief intervention with attempted telephone booster had no effect on drug use in patients seen in safety-net primary care settings. This finding suggests a need for caution in promoting widespread adoption of this intervention for drug use in primary care.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00877331.