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Screening and Brief Interventions for Illicit Drug Use in Primary Health Care: ASSIST Study

Screening and Brief Interventions for Illicit Drug Use in Primary Health Care: ASSIST Study. Dr Hem Raj Pal on Behalf of the WHO study Group. Developed by international group of researchers Initially 12 item and now (V3.0) 8 item instrument

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Screening and Brief Interventions for Illicit Drug Use in Primary Health Care: ASSIST Study

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  1. Screening and Brief Interventions for Illicit Drug Use in Primary Health Care: ASSIST Study Dr Hem Raj Pal on Behalf of the WHO study Group

  2. Developed by international group of researchers Initially 12 item and now (V3.0) 8 item instrument Screens for health risks & problems associated with any psychoactive substance use Designed to provide lifetime and current (past 3 months) estimates of substance use and related risk WHO Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)

  3. Stages of the WHO ASSIST Project • Phase I (1997-1999) • ASSIST development • International Feasibility and Reliability Study of the ASSIST • Phase II (2000-2002) • International Validity Study of the ASSIST • Feasibility Study of Brief Interventions Linked to the ASSIST • Phase III (2003-2007) • Development of guiding and training materials • International Study of Efficacy ofBrief Interventions Linked to the ASSIST (randomized clinical trial)

  4. R. Ali 1, 2#, 3# (Australia) E. Awwad 1 (Palestine) T. Babor 1#, 2, 3 (USA) F. Bradley 1(Ireland) T. Butau 1 (Zimbabwe) M. Farrell 1, 2 (UK) M. Formigoni 1, 2, 3 (Brazil) R. Humeniuk 1, 2#, 3# (Australia) R. Isralowitz 1 (Israel) J. Jittiwutikarn 1, 2, 3 (Thailand) R. de Lacerda 1, 2, 3 (Brazil) W. Ling 2, 3 (USA) J. Marsden 1, 2(UK) J. Martinez 3 (Spain) B. McRee 1#, 3 (USA) M. Monteiro 1#, 2#, 3#(WHO) D. Newcombe 3 (Australia) S. Nhiwatiwa 2 (Zimbabwe) H. Pal 1, 2, 3 (India) V. Poznyak 1#, 2#, 3# (WHO) M. Rubio-Stipec 1 (Puerto Rico) S. Simon 2,3 (USA) J. Vendetti 1#, 3 (USA) WHO-ASSIST Study Group 1 - Phase I 2 - Phase II 3 - Phase III # - Coordination

  5. Problematic substance use associated with significant public health burden worldwide Why use the ASSIST screening & BI in primary care? *Disability Adjusted Life Years ** Heroin and cocaine World Health Report, 2002

  6. Phase I outcomes:reliability & feasibility of the ASSIST • 9 countries involved • Feasible instrument across cultures • High item & substance class reliability • (K = 0.58 - 0.90) • Revised 8 item questionnaire (ASSIST V2.0) • tobacco, alcohol, cannabis, cocaine, ATS, inhalants, sedatives, hallucinogens, opioids, ‘other’. • Derived scores • Specific Substance Involvement Score • Global continuum of risk (total substance involvement)

  7. 7 countries involved Australia, Brazil, India, Thailand, UK, USA, Zimbabwe ASSIST has high validity  concurrent validity  construct validity  discriminative validity  predictive validity Valid across diverse cultures Phase II outcomes: Assessment of ASSIST validity

  8. Alcohol, Smoking & Substance Involvement Screening Test 8 item questionnaire (paper & pen) Administration time ~5-10 minutes Developed for health care workers in primary care settings May be used by professionals in other areas (eg. prisons) Useful in a variety of cultures Designed to be linked to a Brief Intervention What is the ASSIST?

  9. Screens for risky substance use Alcohol, tobacco, cannabis, cocaine, amphetamine-type stimulants, sedatives, hallucinogens, inhalants, opioids, ‘other drugs’ Determines risk score for each substance Current use (last 3 months) Lifetime use Score provides an opportunity to start discussion (Brief Intervention) with client about their substance use What does the ASSIST do?

  10. Questions asked for all substance groups Lifetime use Q1 Ever used Current use – frequency in last 3 months Q2 Frequency of use Q3 Desire to use Q4 Health, social, legal, financial problems Q5 Failure to fulfil role obligations Lifetime use – recency of problems Q6 Concern by others Q7 Failed attempts to control use Q8 Injecting behaviour WHO-ASSIST V3.0

  11. ASSIST Manuals for Field Testing

  12. Australia: Drug and Alcohol Services South Australia Brazil: Departamento de Psicobiologia, Universidade Federal de Sao Paulo, Sao Paulo - and - Departamento de Farmacologia, Universidade Federal do Parana Curitiba, Paraná; India: National Drug Dependence Treatment Centre and Department of Psychiatry, All India Institute of Medical Sciences, New Delhi; USA: UCLA Integrated Substance Abuse Programs & Friends Research Institute, Los Angeles – and – Department of Community Medicine and Health Care, University of Connecticut, School of Medicine, Connecticut. Sites of Phase III

  13. Components of Phase III ASSIST score positive Cannabis, Amphetamine, Cocaine, Opioids Score 0-3: Information Score 27+ or frequent IV user: Intensive treatment Score 4-26 Group 1: Brief Intervention Group 2: Control Delayed treatment 3-month follow-up: ASSIST & feedback 3-month follow-up: ASSIST & BI

  14. Levels of risk – target group • Low risk (0-3) • Abstinent or infrequent use, small amounts • Moderate risk (4-26) • Increased regularity of use • May be some problems – relationship, health, finance • Usual role obligations may not be fulfilled • Others may be concerned • Increase in risk taking behaviour • High risk (27+) • Weekly/daily use • Increased desire to use • More serious health & social problems, legal, occupational • Failed attempts to cut down • IV users

  15. 9easy-to-follow steps Purpose designed form to give feedback & information to patients about their risk scores Bolstered with take-home materials Components of ASSIST BI

  16. 1. Feedback – use card 2. Advice 3. Responsibility 4. Concern about ASSIST score 5. Good things about using 6. Less good things about using 7. Summarise 8. Concern about less good things 9. Take home information & booklet 9 Steps of ASSIST BI

  17. Does ASSIST significantly reduce Total Illicit Substance Involvement? Does the ASSIST reduce Specific Substance Involvement (cannabis, stimulants, opioids) Does the ASSIST-linked BI perform better for some substances than others? Do people who score higher within the moderate risk range respond to the BI any differently than people in the lower range? Are there any countries differences? Aims of Phase III

  18. Recruited from a variety of PHC setting 50% randomised to BI group (vs. Control group) Demographic profile n=731 72% male Age 31.4 years (16-62) 55.5% never been married 72% employed 93.7% own home or rented accommodation 9.5 years education Results

  19. Ethnicity

  20. 15% received prior treatment Australia 8.8% Brazil 18.2% India 0% USA 29.8% 3% injected in last 3 months Prior treatment

  21. Substance group by country

  22. mean Total Illicit Substance Involvement Score at baseline was 36.2 (SD = 19.4) (max 336) Australia (45.2, sd=18.9) USA (37.1, sd=23.6) India (34.7, sd=14.3) Brazil (27.2, sd=13.5). 86% never injected 628 (86%) followed up at 3 months Substance Involvement Score

  23. Frequency lifetime substance use, positive SSI scores and ASSIST scores

  24. no significant differences Total Illicit Substance Involvement Scores (p=0.73) Tobacco SSI (p=0.43) Alcohol SSI (p=0.90) Cannabis SSI (p=0.19) Cocaine SSI (p=0.92) ATS SSI (p=0.53) Opioid SSI (p=0.98) no significant difference in injecting behaviour between (Chi squared=0.99, p=0.61). BI and Control at Baseline

  25. Total Illicit Substance Involvement Control vs. Brief Intervention Significant reduction over time regardless of group BI significantly lower at follow-up compared with the Control groupF(1,626) = 7.2, p<0.01 Control n=306 BI n=322 BI n=50

  26. Total Illicit SIS –Baseline and Follow-up

  27. Cannabis Substance Involvement Control vs. Brief Intervention Significant reduction over time regardless of group BI significantly lower at follow-up compared with the Control groupF(1,326) = 4.2, p<0.05 Control n=152 Control n=13 BI n=176 BI n=17

  28. Cannabis Substance Involvement by country

  29. Stimulant Substance Involvement BI vs. Control Significant reduction over time regardless of group BI had significantly lower Stimulant Substance Involvement score at follow-up F(1,227) = 9.4, p<0.005 BI n=110 Control n=119

  30. Stimulant Substance Involvement country

  31. Opioid Substance Involvement BI vs. Control Significant reduction over time regardless of group BI not significantly lower Opioid Substance Involvement scores at follow-up F(1,71) = 3.4, p=0.07 (BUT was significant for India group who had largest number) Control n=36 BI n=37

  32. high scoring group significant reduction over time independent of group Brief Intervention group significantly lower at follow-up : Total Illicit Substance Involvement scores F(1,391) = 4.2, p<0.05 Cannabis Involvement scores F(1,202) = 4.8, p<0.05 Brief Intervention not significantly lower Stimulant Specific Substance Involvement scores at follow-up low scoring group significant reduction over time independent of group Brief Intervention not significantly lower Total Illicit Substance Involvement scores at follow-up F(1,233) = 3.0, p=0.09 F(1,233) = 3.0, p=0.09 Brief Intervention significantly lower Stimulant Specific Substance Involvement scores at follow-up F(1,106) = 8.5, p<0.005 High scorers (17-26)vrs Low scorers (4-16)

  33. Did you attempt to cut down after getting the feedback? n=317

  34. “It made me realise my drug use was probably linked to my depression and that I should reduce (my use)…” “Made me realise that long term use has effected me….I have reduced my use to one bong a day and it has assisted my work output…” “Clarified what I already knew….(and provided) an impetus for changing my behaviour” How did the feedback influence you?

  35. http://www.who.int/substance_abuse/activities/assist_technicalreport_phase3_final.pdf WHO ASSIST Project Phase III

  36. ASSIST developed in response to overwhelming burden of disease related to substance use Valid & reliable Designed for use in PHC settings Cross culturally relevant Risk score provided for each substance – easily links into brief intervention Overview

  37. Broad dissemination by WHO of the ASSIST manuals under the guidance of WHO ASSIST Advisory Committee Establishment of training and reference centers in different parts of the world Planning and monitoring of demonstration projects integrating ASSIST-based procedures in health care delivery systems Further research focusing on ASSIST training, programme implementation and cost-effectiveness at the national and international levels. The Way Forward

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