Comparative trial of the WHO ASSIST-linked brief intervention and simple advice for substance abuse in primary care☆
Introduction
Substance misuse is a worldwide problem, accounting for much morbidity and mortality (Lim et al., 2012, Degenhardt et al., 2013, World Health Organization, 2014). Most substance users do not seek treatment even when it is available. A national household survey in Thailand in 2011 revealed that only 0.57% of participants who reported using alcohol, tobacco or illicit drugs had received previous treatment for their substance use (Administrative Committee on Substance Abuse Academic Network, 2012). Routine screening for alcohol and other substance use in primary healthcare could increase this figure by engaging in treatment non-dependent abusers seeking help for other reasons (Nilsen, 2010).
Most previous studies of screening and brief counselling were of alcohol and tobacco users and the results suggested that the interventions are effective in decreasing the use of these substances (Jonas et al., 2012). However, the evidence for other drugs is scant.
To help decrease the public health burden of substance-related problems, the World Health Organization (WHO) developed the Alcohol, Smoking, Substance Involvement Screening Test (ASSIST), a sensitive screening questionnaire to help identify misuse of alcohol and a wide range of substances, that is linked to Brief Intervention (BI) (WHO ASSIST Working Group, 2002, Humeniuk et al., 2010). Humenick et al. (2012) demonstrated in a multi-country study that primary care patients receiving the BI had significantly reduced ASSIST scores, compared with waiting-list control participants, over the course of three months.
The aims of the study reported in this paper were to assess the effectiveness of the WHO ASSIST-BI procedure compared with ASSIST-screening followed by simple advice (SA) in primary care in low-population areas of southern Thailand, and to determine if any changes shown were maintained for three and six months after treatment.
Section snippets
Ethics
The trial was implemented according to Good Clinical Practice guidelines and the protocol and materials were approved by the Ethics Committee (EC) for Research in Human Subjects, Faculty of Medicine, Prince of Songkla University.
The procedure at all stages was fully explained to patients and written permission to participate was obtained. In the case of participants aged 16–17 years, written consent was obtained from them directly, as they came to the hospitals unaccompanied and were unwilling
Participants
Of 775 eligible patients attending clinics during the study period, 747 agreed to be screened with the ASSIST and 55, 498 and 194 of them were categorised into the ‘high-’, ‘moderate-’ and ‘low-risk’ groups, respectively. Of the 498 ‘moderate-risk’ patients, 262 were excluded because they used tobacco only, leaving 236 to be randomised to receive brief intervention or simple advice (Fig. 1).
Most participants were men, aged 16 to 25 (60.7%), had secondary school education (12 years of study in
Main findings
Our study is one of the few randomised controlled trials that assessed the longer-term effects of ASSIST-linked Brief Intervention in primary care. The results showed that alcohol and other substance use risk scores decreased significantly over time in both the intervention and control groups, with no significant difference between groups. There were also no significant between-group differences in proportions of participants who changed to the ‘low-risk’ category and in frequency of substance
Conclusions
Our findings suggest that screening with the ASSIST followed by its linked brief intervention (taking on average 8 min), or the same screening followed by simple advice (average 4 min), do not have significantly different effects in decreasing alcohol and other substance use over three and six month periods. The finding is important in screening large numbers of patients in specialties where time is limited and where the difference between 8 and 4 min, although small, can be the main factor in
Role of funding source
The study was supported by the Integrated Community Management for Substance Abuse Programme (I-MAP) of the Thai Health Promotion Foundation [54-02-003]. The Epidemiology Unit is partially supported by the National Science and Technology Development Agency (P-10-10307), Ministry of Science and Technology, Thailand. JGE's contributions incurred no fees or expenses.
Contributors
SA and PN conceived and designed the study with advice from JGE; PN collected data; PN and EM analysed the data; each author interpreted the data and contributed to the drafting of the manuscript.
Conflict of interest statement
None declared.
Acknowledgements
We thank the staff in district and sub-district hospitals and study participants for their collaboration. We also express our appreciation to the WHO Collaborating Centre for Research in the Treatment of Drug and Alcohol Problems, Drug and Alcohol Services South Australia, University of Adelaide, for providing training on the ASSIST-BI process and other technical assistance.
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Web address of the trial registration: http://www.ANZCTR.org.au/ACTRN12613000080729.aspx; Trial ID: ACTRN12613000080729; Date submitted: 11/08/2012; Date registered: 22/01/2013. The full protocol of the trial is available on request from the corresponding author.