Early Risky Drug Use Detection in Primary Healthcare: How Does It Work in the Real World?

Abstract

Despite effectiveness in research, the efficacy of screening and brief intervention (SBI) for risky substance users is not adequately understood in routine clinical practice. Primary healthcare professionals (n = 103) from three cities in a metropolitan area in Brazil were trained and supervised in SBI and then screened 40 patients. One year later, meetings were held in each city to obtain feedback. Twenty professionals who fulfilled the task (Yes [Y]) and 24 who did not (No [N]) were individually interviewed about their SBI experience. Reports were independently interpreted and codified by two researchers. The Y and N groups reported the same barriers and positive beliefs, but only the Y group reported no negative issues. The present study lasted from 2007 to 2009.

RÉSUMÉ

La détection précoce risqué l'usage de drogues dans les soins de santé primaires: comment ça marche dans le monde réel?

Malgré l'efficacité dans la recherche, l'efficacité de la détection et l'intervention brève (DIB) pour les utilisateurs des risques des substances n est pas compris dans la pratique clinique courant. Les professionnels de soins de santé primaires (n = 103) de trois villes d'une agglomération au Brésil ont été formés et supervisés dans DIB et ensuite ils devaient pister 40 patients. Une année plus tard, les réunions ont été réalisées dans chaque ville pour recevoir une réaction. Vingt professionnels qui ont accompli la tâche (Oui [O]) et 24 qui n'ont pas été accomplis la tâche (Non [N]) ont été individuellement interviewés de leurs expériences avec DIB. Les rapports ont été interprétés et encodés par deux chercheurs, de façon indépendante. Les groupes O et N ont signalé les mêmes barrières et les convictions positives, mais seulement le groupe O n'a pas signalé de points négatifs. La présente étude est survenue de 2007 à 2009.

Mots clés: mise en oeuvre; prévention d'usage de drogues; intervention brève; l'Alcool, le tabagisme et le Test de déspitage de participation de substance (ASSIST); motivation; le système de soins de santé primaires.

RESUMEN

La detección temprana de riesgo del consumo de drogas en la atención primaria de salud: ¿cómo funciona en el mundo real?

A pesar de la eficacia en la investigación, la eficacia de la detección y la intervención breve (DIB) para los usuarios de riesgo de sustancias no és entendida en la práctica clínica habitual. Profesionales de atención médica primaria (n = 103) de tres ciudades en un área metropolitana en Brasil fueron entrenados y supervisados en DIB y luego tuvieran que detectar 40 pacientes. Un año más tarde, se realizaron reuniones en cada ciudad para obtener reacción. Veinte profesionales que han completado la tarea (Sí [S]) y 24 que no (No [N]) fueron entrevistados individualmente sobre sus experiencias con DIB. Los informes se interpretaron y se codificaron de forma independiente por dos investigadores. Los grupos S y N informaron a los mismos obstáculos y creencias positivos, pero sólo el grupo S no informó problemas negativos. El presente estudio se extendió desde 2007 a 2009.

Palabras clave: aplicación; prevención del consumo de drogas; intervención breve; la prueba de detección de consumo de alcohol, tabaco y sustancias (ASSIST); la motivación; sistema de atención primaria de salud.

Keywords: :

• implementation
• drug use prevention
• brief intervention
• Alcohol
• Smoking
• and Substance Involvement Screening Test (ASSIST)
• motivation
• primary healthcare system
• integrated care
• action research

THE AUTHORS

Roseli Boerngen-Lacerda graduated in Biomedical Science in the Universidade Federal de São Paulo (1977), Master in Pharmacology (1979), and Ph.D. in Psychobiology in the Universidade Federal de São Paulo (1997). She is currently Professor in the Department of Pharmacology and in the program MSc and Ph.D. in Pharmacology in the Universidade Federal do Paraná. She has experience in the area of pharmacology with an emphasis on Neuropsychopharmacology, and in the area of drugs of abuse. She has been working in clinical and basic research in the area of drug abuse. She is a researcher in the ASSIST multicenter collaborative project for early detection and brief intervention on drug abuse and in the e-health Project, which are coordinated by the World Health Organization. She is the regional coordinator of distance course SUPERA coordinated by the National Bureau of Policies on Drugs in Brazil (SENAD). She is an International member of the Research Society on Alcoholism (RSA) and of the International Society on Biomedical Research on Alcohol (ISBRA).

Cassia Regina Zottis graduated in Pharmacy in the Universidade Estadual do Oeste do Paraná (2003), specialization in Pharmacology in the Universidade Paranaense (2006), and Master in Pharmacology in the Universidade Federal do Paraná (2009). She has experience in pharmacy, teaching, lectures, and training, with emphasis on Clinical Pharmacology and Toxicology, working mainly on drugs of abuse.

Viviane Paola Zibe-Piegel graduated in Pharmacy and Biochemistry in the Universidade Federal do Paraná (2003), specialization (2008) and Master in Pharmacology in the Universidade Federal do Paraná (2010). She has experience in Pharmacy, Clinical Analyses, Biosecurity, and Toxicology and also in training activities with emphasis on early detection of drug use.

Cleuse Maria Brandão Barleta graduated in Psychology in the Pontifícia Universidade Católica do Paraná (1986), specialization in Public Health in ENSP/FIOCRUZ (1991), Master in Psychology of Childhood and Adolescence in the Universidade Federal do Paraná (2003), developing her Ph.D. in the Psychoanalysis Program in the Universidade Estadual do Rio de Janeiro (2009). She coordinated the Mental Health Department of Health of Paraná from 2003 to 2009. She was a collaborator Professor in the: PUC/PR, FAFIJA -Jacarézinho/PR, FACINTER/PR, ISEPE/PR. Psychoanalyst in continuing education in the School of Psychoanalysis Laço Analitico, Rio de Janeiro. She has experience in Psychology, Psychoanalysis, Public Health, Public Policy, Mental Health, Clinical Supervision, and Management of Institutional-care Networks.

GLOSSARY

Brief intervention: A time-limited, patient-centered approach based on motivational interview that focuses on changing drug use behavior not necessarily promoting the abstinence from drug.

Harmful use: Defined by WHO as a pattern of substance use that is already causing physical, social, and mental health consequences.

Hazardous or risky use: Defined by WHO as a pattern of substance use that increases the risk of harmful consequences for the user. In contrast to harmful use, hazardous use refers to patterns of use that are of public health significance despite the absence of any current disorder in the individual user. The term is used currently by WHO but is not a diagnostic term in ICD-10.

Primary healthcare: Defined by WHO (1978) as “Essential health care based on practical methods and technology, scientifically proven and socially acceptable, made universally accessible to individuals and families in the community by means acceptable to them and at a cost that both the community and the country can afford at every stage of their development, a spirit of self-reliance and self-determination. It is an integral part of the health system of the country, which is the central feature being the main focus of social and economic development of the global community. It is the first level of contact of individuals, the family and community with the national health system, bringing health care as close as possible to where people live and work and is the first element of a process of continued attention to health.”

Screening: Refers to the application of a test to members of a population to estimate their probability of having a specific disorder.

Notes

1 Treatment can be usefully defined as a unique, planned, goal directed, temporally structured, multidimensional change process, which may be phase-structured, of necessary quality, appropriateness, and conditions (endogenous and exogenous), implemented under conditions of uncertainty, which is bounded (culture, place, time, etc.), which can be (un)successful (partially and/or totally), as well as being associated with iatrogenic harm and can be categorized into professional-based, tradition-based, mutual-help based (AA,NA, etc.), and self-help (“natural recovery”) models. Whether or not a treatment technique is indicated or contra-indicated, and its selection underpinnings (theory-based, empirically based, principle of faith-based, tradition-based, budget-based, etc.) continues to be a generic and key treatment issue. In the West, with the relatively new ideology of “harm reduction” and the even newer Quality of Life (QOL) and “wellness” treatment-driven models there are now new sets of goals in addition to those derived from/associated with the older tradition of abstinence-driven models. Conflict-resolution models may stimulate an additional option for intervention. Treatment is implemented in a range of environments; ambulatory as well as within institutions which can also include controlled environments such as jails, prisons, and military camps. Treatment includes a spectrum of clinician–caregiver–patient relationships representing various forms of decision-making traditions/models: (1) the hierarchical model in which the clinician-treatment agent makes the decision(s) and the recipient is compliant and relatively passive, (2) shared decision-making which facilitates the collaboration between clinician and client(s)/patient(s) in which both are active, and (3) the “informed model” in which the patient makes the decision(s). Within this planned change process, relatively recently in various parts of the world, active substance users who are not in “treatment,” as well as those users who are in treatment, have become social change agents, active advocates, and peer health counselors … which represent just a sampling of their new labels. There are no unique models or techniques used with substance users—of whatever types and heterogeneities—which are not also used with non-substance users. Editor's note.

2 The reader is reminded that the concepts of “risk factors,” “being at-risk,” as well as “protective factors,” are often noted in the literature, without adequately noting their dimensions (linear, non-linear; rates of development; anchoring or integration, cessation, etc.), their “demands,” the critical necessary conditions (endogenously as well as exogenously; from a micro to a meso to a macro level) which are necessary for either of them to operate (begin, continue, become anchored and integrate, change as de facto realities change, cease, etc.) or not to and whether their underpinnings are theory-driven, empirically based, individual and/or systemic stake holder-bound, based upon “principles of faith,” historical observation, precedents and traditions that accumulate over time, perceptual and judgmental constraints, “transient public opinion” or what. This is necessary to consider and to clarify if these terms are not to remain as yet additional shibboleth in a field of many stereotypes, tradition-driven activities, “principles of faith,” and stakeholder objectives. Editor's note.

3 ASSIST is a pencil and paper questionnaire with eight questions (http://www.who.int/substance_abuse/activities/assist_portuguese.pdf; accessed August 29, 2012): Q1, lifetime use; Q2, last 3-month use; Q3, urge to use drug; Q4, intensity of drug-related problems; Q5, negligence caused by drug use; Q6, concern of others with one's drug use; Q7, intensity of “loss of control” over drug use; Q8, drug use by injection. When the value of the sum total of the indices obtained from Q2 to Q7 for each drug is between 4 and 26 for all other drugs except alcohol or between 11 and 26 for alcohol, “risky use” is concluded. When the score is >27, “suggestive of dependent use” is concluded.