IMPORTANCE The United States has invested substantially in screening and brief intervention for illicit drug use and prescription drug misuse, based in part on evidence of efficacy for unhealthy alcohol use. However, it is not a recommended universal preventive service in primary care because of lack of evidence of efficacy. OBJECTIVE To test the efficacy of 2 brief counseling interventions for unhealthy drug use (any illicit drug use or prescription drug misuse)—a brief negotiated interview (BNI) and an adaptation of motivational interviewing (MOTIV)—compared with no brief intervention. DESIGN, SETTING, AND PARTICIPANTS This 3-group randomized trial took place at an urban hospital-based primary care internal medicine practice; 528 adult primary care patients with drug use (Alcohol, Smoking, and Substance Involvement Screening Test [ASSIST] substance-specific scores of $4) were identified by screening between June 2009 and January 2012 in Boston, Massachusetts. INTERVENTIONS Two interventions were tested: the BNI is a 10- to 15-minute structured interview conducted by health educators; the MOTIV is a 30- to 45-minute intervention based on motivational interviewing with a 20- to 30-minute booster conducted by master’s-level counselors. All study participants received a written list of substance use disorder treatment and mutual help resources. MAIN OUTCOMES AND MEASURES Primary outcome was number of days of use in the past 30 days of the self-identified main drug as determined by a validated calendar method at 6 months. Secondary outcomes included other self-reported measures of drug use, drug use according to hair testing, ASSIST scores (severity), drug use consequences, unsafe sex, mutual help meeting attendance, and health care utilization. RESULTS At baseline, 63% of participants reported their main drug was marijuana, 19% cocaine, and 17% opioids. At 6 months, 98% completed follow-up. Mean adjusted number of days using the main drug at 6 months was 12 for no brief intervention vs 11 for the BNI group (incidence rate ratio [IRR], 0.97; 95% CI, 0.77-1.22) and 12 for the MOTIV group (IRR, 1.05; 95% CI, 0.84-1.32; P = .81 for both comparisons vs no brief intervention). There were also no significant effects of BNI or MOTIV on any other outcome or in analyses stratified by main drug or drug use severity. CONCLUSIONS AND RELEVANCE Brief intervention did not have efficacy for decreasing unhealthy drug use in primary care patients identified by screening. These results do not support widespread implementation of illicit drug use and prescription drug misuse screening and brief intervention. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00876941

The prevalence of PTSD in the urban primary care setting, and particularly among certain high-risk conditions, compels a critical examination of optimal approaches for screening, intervention, and referral to PTSD treatment.

Among individuals leaving residential detoxification, chronic pain is a common problem and is associated independently with long-term substance use after detoxification. Addressing pain as a treatable chronic condition among adults receiving detoxification presents a potential opportunity to improve long-term clinical outcomes and warrants further intervention research.

IMPORTANCE People with substance dependence have health consequences, high health care utilization, and frequent comorbidity but often receive poor-quality care. Chronic care management (CCM) has been proposed as an approach to improve care and outcomes.OBJECTIVE To determine whether CCM for alcohol and other drug dependence improves substance use outcomes compared with usual primary care. DESIGN, SETTING, AND PARTICIPANTSThe AHEAD study, a randomized trial conducted among 563 people with alcohol and other drug dependence at a Boston, Massachusetts, hospital-based primary care practice. Participants were recruited from September 2006 to September 2008 from a freestanding residential detoxification unit and referrals from an urban teaching hospital and advertisements; 95% completed 12-month follow-up.INTERVENTIONS Participants were randomized to receive CCM (n=282) or no CCM (n=281). Chronic care management included longitudinal care coordinated with a primary care clinician; motivational enhancement therapy; relapse prevention counseling; and on-site medical, addiction, and psychiatric treatment, social work assistance, and referrals (including mutual help). The no CCM (control) group received a primary care appointment and a list of treatment resources including a telephone number to arrange counseling. MAIN OUTCOMES AND MEASURESThe primary outcome was self-reported abstinence from opioids, stimulants, or heavy drinking. Biomarkers were secondary outcomes. RESULTSThere was no significant difference in abstinence from opioids, stimulants, or heavy drinking between the CCM (44%) and control (42%) groups (adjusted odds ratio, 0.84; 95% CI, 0.65-1.10; P=.21). No significant differences were found for secondary outcomes of addiction severity, health-related quality of life, or drug problems. No subgroup effects were found except among those with alcohol dependence, in whom CCM was associated with fewer alcohol problems (mean score, 10 vs 13; incidence rate ratio, 0.85; 95% CI, 0.72-1.00; P=.048).CONCLUSIONS AND RELEVANCE Among persons with alcohol and other drug dependence, CCM compared with a primary care appointment but no CCM did not increase self-reported abstinence over 12 months. Whether more intensive or longer-duration CCM is effective requires further investigation.

BACKGROUND: Health literacy has been linked to health status in a variety of chronic diseases. However, evidence for a relationship between health literacy and mental health outcomes is sparse. OBJECTIVE: We hypothesized that low literacy would be associated with higher addiction severity, higher levels of depressive symptoms, and worse mental health functioning compared with those with higher literacy in adults with alcohol and drug dependence. METHODS: The association of literacy with multiple mental health outcomes was assessed using multivariable analyses. Measurement instruments included the Rapid Estimate of Adult Literacy in Medicine (REALM), the Center for Epidemiologic Studies‐Depression (CES‐D) scale, the Mental Component Summary scale of the Short Form Health Survey, and the Addiction Severity Index for drug and alcohol addiction. Subjects included 380 adults recruited during detoxification treatment and followed prospectively at 6‐month intervals for 2 years. Based on the REALM, subjects were classified as having either low (≤8th grade) or higher (≥9th grade) literacy levels. RESULTS: In longitudinal analyses, low literacy was associated with more depressive symptoms. The adjusted mean difference in CES‐D scores between low and high literacy levels was 4 (P<.01). Literacy was not significantly associated with mental health‐related quality of life or addiction severity. CONCLUSIONS: In people with alcohol and drug dependence, low literacy is associated with worse depressive symptoms. The mechanisms underlying the relationship between literacy and mental health outcomes should be explored to inform future intervention efforts.