Mani Vahidi

Project QUIT (Quit Using Drugs Intervention Trial): a randomized controlled trial of a primary care‐based multi‐component brief intervention to reduce risky drug use

AIMS To assess the effect of a multi-component primary care delivered brief intervention for reducing risky psychoactive drug use (RDU) among patients identified by screening. DESIGN Multicenter single-blind two-arm randomized controlled trial of patients enrolled from February 2011 to November 2012 with 3-month follow-up. Randomization and allocation to trial group were computer-generated. SETTING Primary care waiting rooms of five federally qualified health centers in Los Angeles County (LAC), USA. PARTICIPANTS A total of 334 adult primary care patients (171 intervention; 163 control) with RDU scores (4-26) on the World Health Organization (WHO) Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) self-administered on tablet computers. 261 (78%) completed follow-up. Mean age was 41.7 years; 62.9% were male; 37.7% were Caucasian. INTERVENTION(S) AND MEASUREMENT Intervention patients received brief (typically 3-4 minutes) clinician advice to quit/reduce their drug use reinforced by a video doctor message, health education booklet and up to two 20-30-minute follow-up telephone drug use coaching sessions. Controls received usual care and cancer screening information. Primary outcome was patient self-reported use of highest scoring drug (HSD) at follow-up. FINDINGS Intervention and control patients reported equivalent baseline HSD use at 3-month follow-up. After adjustment for covariates, in the complete sample linear regression model, intervention patients used their HSD on 3.5 fewer days in the previous month relative to controls (P<0.001), and in the completed sample model, intervention patients used their HSD 2.2 fewer days than controls (P < 0.005). No compensatory increases in use of other measured substances were found. CONCLUSIONS A primary-care based, clinician-delivered brief intervention with follow-up coaching calls may decrease risky psychoactive drug use.

Effect of a Primary Care based Brief Intervention Trial among Risky Drug Users on Health-related Quality of Life

BACKGROUND Improvement in quality of life (QOL) is a long term goal of drug treatment. Although some brief interventions have been found to reduce illicit drug use, no trial among adult risky (moderate non-dependent) drug users has tested effects on health-related quality of life. METHODS A single-blind randomized controlled trial of patients enrolled from February 2011 to November 2012 was conducted in waiting rooms of five federally qualified health centers. 413 adult primary care patients were identified as risky drug users using the WHO-ASSIST and 334 (81% response; 171 intervention, 163 control) consented to participate in the trial. Three-month follow-ups were completed by 261 patients (78%). Intervention patients received the QUIT intervention of brief clinician advice and up to two drug-use health telephone sessions. The control group received usual care and information on cancer screening. Outcomes were three-month changes in the Short Form Health Survey (SF-12) mental health component summary score (MCS) and physical health component summary score (PCS). RESULTS The average treatment effect (ATE) was non-significant for MCS (0.2 points, p-value=0.87) and marginally significant for PCS (1.7 points, p-value=0.08). The average treatment effect on the treated (ATT) was 0.1 (p-value=0.93) for MCS and 1.9 (p-value=0.056) for PCS. The effect on PCS was stronger at higher (above median) baseline number of drug use days: ATE=2.7, p-value=0.04; ATT=3.21, p-value=0.02. CONCLUSIONS The trial found a marginally significant effect on improvement in PCS, and significant and stronger effect on the SF-12 physical component among patients with greater frequency of initial drug use.

Prevalence of Substance Use Among Patients of Community Health Centers in East Los Angeles and Tijuana

ABSTRACT Background: Given the increased use of psychoactive substances on the United States–Mexico border, a binational study (Tijuana, Mexico–Los Angeles, USA) was conducted to identify the prevalence of substance use in primary care settings. Objectives: To compare the prevalence and characteristics of patients at risk for substance use disorders in Tijuana and East Los Angeles (LA) community clinics with special attention paid to drug use. Methods: This was an observational, cross-sectional, analytical study, comparing substance use screening results from patients in Tijuana and LA. The settings were 2 community clinics in LA and 6 in Tijuana. Participants were 2,507 adult patients in LA and 2,890 in Tijuana eligible for WHO Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) screening during March–October 2013. Patients anonymously self-administered the WHO ASSIST on a tablet PC in the clinic waiting rooms. Results: Of eligible patients, 96.4% completed the ASSIST in Tijuana and 88.7% in LA (mean 1.34 minutes and 4.20 minutes, respectively). The prevalence of patients with moderate-to-high substance use was higher in LA than Tijuana for each substance: drugs 19.4% vs. 5.7%, alcohol 15.2% vs. 6.5%, tobacco 20.4% vs. 16.2%. LA patients born in Mexico had 2x the odds and LA patients born in the United States had 6x the odds of being a moderate-to-high drug user compared to Tijuana patients born in Mexico. Conclusions: Moderate-to-high drug use is higher in LA than in Tijuana but rates are sufficiently high in both to suggest that screening for drug use (along with alcohol and tobacco use) should be integrated into routine primary care of community clinics in both cities.

A pilot replication of QUIT, a randomized controlled trial of a brief intervention for reducing risky drug use, among Latino primary care patients

BACKGROUND QUIT is the only primary care-based brief intervention that has previously shown efficacy for reducing risky drug use in the United States (Gelberg et al., 2015). This pilot study replicated the QUIT protocol in one of the five original QUIT clinics primarily serving Latinos. DESIGN Single-blind, two-arm, randomized controlled trial of patients enrolled from March-October 2013 with 3-month follow-up. SETTING Primary care waiting room of a federally qualified health center (FQHC) in East Los Angeles. PARTICIPANTS Adult patients with risky drug use (4-26 on the computerized WHO ASSIST): 65 patients (32 intervention, 33 control); 51 (78%) completed follow-up; mean age 30.8 years; 59% male; 94% Latino. INTERVENTIONS AND MEASURES Intervention patients received: 1) brief (typically 3-4 minutes) clinician advice to quit/reduce their risky drug use, 2) video doctor message reinforcing the clinicians advice, 3) health education booklet, and 4) up to two 20-30 minute follow-up telephone drug use reduction coaching sessions. Control patients received usual care and cancer screening information. Primary outcome was reduction in number of days of drug use in past 30days of the highest scoring drug (HSD) on the baseline ASSIST, from baseline to 3-month follow-up. RESULTS Controls reported unchanged HSD use between baseline and 3-month follow-up whereas Intervention patients reported reducing their use by 40% (p<0.001). In an intent-to-treat linear regression analysis, intervention patients reduced past month HSD use by 4.5 more days than controls (p<0.042, 95% CI: 0.2, 8.7). Similar significant results were found using a complete sample regression analysis: 5.2 days (p<0.03, 95% CI: 0.5, 9.9). Additionally, on logistic regression analysis of test results from 47 urine samples at follow-up, intervention patients were less likely than controls to test HSD positive (p<0.05; OR: 0.10, 95% CI: 0.01, 0.99). CONCLUSIONS Findings support the efficacy of the QUIT brief intervention for reducing risky drug use.

Screening, brief intervention, and referral to treatment among homeless and marginally housed primary-care patients in Skid Row

The University of California at Los Angeles Quit Using Drugs Intervention Trial (UCLA QUIT) tested a very brief primary-care–based screening and brief intervention (SBI) approach to reduce risky substance use and substance-related harm in safety-net clinics. The QUIT involves screening, very brief clinician advice (two to three minutes), and two telephone drug-use health education sessions versus usual care (control group) (n = 240 per condition). We present findings on unique recruitment issues in Skid Row, an east-central area of Los Angeles with a high population of homeless individuals. Between February 18 and April 28, 2011, previsit screening of adults in the clinic waiting room was conducted using a touch screen tablet PC. At-risk substance use was defined as casual, frequent, or heavy episodic use without the physiological or psychological manifestations of dependence (i.e., a score of 4 to 26 on the World Health Organization’s Alcohol, Smoking, and Substance Use Involvement Screening Test [ASSIST]). The focus of the study was on risky stimulant use, however, patients were screened for co-occurring alcohol, tobacco, and other drug use. A total of 920 patients were approached: 89% were ≥40 years old; 68% were male; and 62% were black. Of these, 706 were excluded prior to taking the ASSIST (reasons included being pregnant, presenting for a non-primary-care visit, being in substance use treatment, or refusal to participate). Of the 214 patients who completed the ASSIST, substance use rates based on scores were as follows: no/low risk, 11%; moderate risk, 42%; and dependence, 47%. Totals for each risk group, respectively, were as follows: tobacco (55, 101, 58), alcohol (62, 98, 54), cannabis (94, 77, 43), cocaine (89, 74, 51), amphetamines (145, 45, 23), inhalants (185, 20, 9), sedatives (143, 45, 26), hallucinogens (174, 30, 10), and opioids (130, 54, 30). Few patients qualified for the study because of substance use treatment or co-occurring alcohol or cannabis dependence. Key informants revealed that many of those approached received intermittent substance use treatment required by shelters. Enrollment criteria were relaxed to allow intermittent past-month substance use treatment or co-occurring alcohol or cannabis dependence. Enrollment rates increased several-fold. Our findings indicate SBIRT conducted in clinics with homeless and marginally housed populations must be tailored to their unique substance use and housing characteristics.

Under-reporting of risky drug use among primary care patients in federally qualified health centers

Objective:The Affordable Care Act encourages integration of behavioral health into primary care. We aim to estimate the level of under-reporting of drug use in federally qualified health centers (FQHCs) among self-reported risky drug users. Methods:Adult patients in the waiting rooms of 4 FQHCs who self-reported risky drug use on the screening instrument World Health Organizations Alcohol, Smoking and Substance Involvement Screening Test (score 4–26), who participated in the “Quit Using Drugs Intervention Trial,” submitted urine samples for drug testing. Under-reporters were defined as patients who denied use of a specific drug via questionnaire, but whose urine drug test was positive for that drug. Descriptive statistics, Pearson chi-square test, and logistic regression were used for analysis. Results:Of the 192 eligible participants, 189 (96%) provided urine samples. Fifty-four samples were negative or indeterminate, yielding 135 participants with positive urine drug tests for this analysis: 6 tested positive for amphetamines, 18 opiates, 21 cocaine, 97 marijuana. Thirty patients (22%) under-reported drug use and 105 (78%) reported drug use accurately. Under-reporting by specific substances was: amphetamines 66%, opiates 45%, cocaine 14%, and marijuana 7%. Logistic regression revealed that under-reporting of any drug was associated with history of incarceration and older age (odds ratios 2.6 and 3.3, respectively; P < 0.05). Conclusions:Under-reporting of drug use is prevalent even among self-reported drug users in primary care patients of FQHCs (22%), but varied considerably based on the substance used. Further research is indicated to assess the extent of under-reporting among all primary care patients, regardless of their self-reported drug use status.