IMPORTANCE Although brief intervention is effective for reducing problem alcohol use, few data exist on its effectiveness for reducing problem drug use, a common issue in disadvantaged populations seeking care in safety-net medical settings (hospitals and community health clinics serving low-income patients with limited or no insurance). OBJECTIVE To determine whether brief intervention improves drug use outcomes compared with enhanced care as usual. DESIGN, SETTING, AND PARTICIPANTS A randomized clinical trial with blinded assessments at baseline and at 3, 6, 9, and 12 months conducted in 7 safety-net primary care clinics in Washington State. Of 1621 eligible patients reporting any problem drug use in the past 90 days, 868 consented and were randomized between April 2009 and September 2012. Follow-up participation was more than 87% at all points. INTERVENTIONS Participants received a single brief intervention using motivational interviewing, a handout and list of substance abuse resources, and an attempted 10-minute telephone booster within 2 weeks (n = 435) or enhanced care as usual, which included a handout and list of substance abuse resources (n = 433). MAIN OUTCOMES AND MEASURES The primary outcomes were self-reported days of problem drug use in the past 30 days and Addiction Severity Index–Lite (ASI) Drug Use composite score. Secondary outcomes were admission to substance abuse treatment; ASI composite scores for medical, psychiatric, social, and legal domains; emergency department and inpatient hospital admissions, arrests, mortality, and human immunodeficiency virus risk behavior. RESULTS Mean days used of the most common problem drug at baseline were 14.40 (SD, 11.29) (brief intervention) and 13.25 (SD, 10.69) (enhanced care as usual); at 3 months postintervention, means were 11.87 (SD, 12.13) (brief intervention) and 9.84 (SD, 10.64) (enhanced care as usual) and not significantly different (difference in differences, β = 0.89 [95% CI, –0.49 to 2.26]). Mean ASI Drug Use composite score at baseline was 0.11 (SD, 0.10) (brief intervention) and 0.11 (SD, 0.10) (enhanced care as usual) and at 3 months was 0.10 (SD, 0.09) (brief intervention) and 0.09 (SD, 0.09) (enhanced care as usual) and not significantly different (difference in differences, β = 0.008 [95% CI, –0.006 to 0.021]). During the 12 months following intervention, no significant treatment differences were found for either variable. No significant differences were found for secondary outcomes. CONCLUSIONS AND RELEVANCE A one-time brief intervention with attempted telephone booster had no effect on drug use in patients seen in safety-net primary care settings. This finding suggests a need for caution in promoting widespread adoption of this intervention for drug use in primary care.

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Objectives To determine if urine drug tests (UDTs) can detect underreporting of drug use (i.e., negative self-report, but positive UDT) and identify patient characteristics associated with underreporting when treating substance use disorders in primary care. Methods Self-reported use (last 30 days) and UDTs were gathered at baseline, 3, 6, 9, and 12 months from 829 primary care patients participating in a drug use intervention study. Rates of underreporting were calculated for all drugs, cannabis, stimulants, opioids, and sedatives. Logistic regressions were used to identify characteristics associated with underreporting. Results 40% (n=331) of participants denied drug use in the prior 30 days despite a corresponding positive UDT during at least one assessment. Levels of underreporting during one or more assessments were 3% (n=22) for cannabis, 20% (n=167) for stimulants, 27% (n=226) opioids, and 13% (n=106) for sedatives. Older (OR=1.04), female (OR=1.66), or disabled (OR=1.42) individuals were more likely to underreport any drug use. Underreporting of stimulant use was also more likely in individuals with lower levels of educational attainment, previous arrests, and family and social problems. Underreporting of opioid use was more likely in those with other drug problems, but less likely in those with better physical health, more severe alcohol and psychiatric comorbidities, and African-Americans. Conclusions With the exception of cannabis, UDTs are important assessment tools when treating drug use disorders in primary care. UDTs might be particularly helpful when treating patients who are older, female, disabled, have legal and social problems, and have more severe drug problems.

Introduction The present study of homeless non-treatment-seeking problem drug users was designed to complement and extend previous studies which focused exclusively on treatment-seeking homeless problem drug users. Method Data were available for 866 primary care patients with drug problems, 30% homeless and 70% housed. Results In the 2 years prior to baseline, homeless participants had less chronic medical co-morbidity than problem drug users who were housed yet were significantly more likely to have used emergency department services, to have used them more frequently, and at higher cost. Compared to their housed counterparts, homeless participants were also more likely to have been admitted to specialized chemical dependency treatment and/or detoxification services, to have been arrested for a felony or gross misdemeanor, and to report having psychiatric problems in the prior 30 days. Conclusions Additional support may be necessary for homeless patients presenting in primary care to benefit from substance abuse treatment given their more severe drug use problems coupled with their co-morbid health, psychiatric, and psychosocial problems.

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Introduction Illicit drug use is a serious public health problem associated with significant co-occurring medical disorders, mental disorders, and social problems. Yet most individuals with drug use disorders have never been treated, though they often seek medical treatment in primary care. The purpose of the present study was to examine baseline characteristics of persons presenting in primary care across a range of problem drug use severity to identify their clinical needs. Methods We examined socio-demographic characteristics, medical and psychiatric comorbidities, drug use severity, social and legal problems, and service utilization for 868 patients with drug problems recruited from primary care clinics in a safety-net medical setting. Based on Drug Abuse Screening Test (DAST-10) results, individuals were categorized as having low, intermediate, or substantial/severe drug use severity. Results Patients with substantial/severe drug use severity had serious drug use (opiates, stimulants, sedatives, intravenous drug use), high levels of homelessness (50%), psychiatric comorbidity (69%), arrests for serious crimes (24%), and frequent use of expensive emergency department and inpatient hospitals. Patients with low drug use severity were primarily users of marijuana with little reported use of other drugs, less psychiatric co-morbidity, and more stable lifestyles. Patients with intermediate drug use severity fell in-between the substantial/severe and low drug use severity subgroups on most variables. Conclusions Patients with highest drug use severity are likely to require specialized psychiatric and substance abuse care in addition to ongoing medical care that is equipped to address the consequences of severe/substantial drug use including intravenous drug use. Because of their milder symptoms, patients with low drug use severity may benefit from a collaborative care model that integrates psychiatric and substance abuse care in the primary care setting. Patients with intermediate drug use severity may benefit from selective application of interventions suggested for patients with highest and lowest drug use severity. Primary care safety-net clinics are in a key position to develop a range of responses to serve patients with problem drug use which are locally effective and which may also inform national efforts to establish Patient-Centered Medical Homes and to implement the Affordable Care Act.

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Whether these premature deaths are preventable is a critical question. With respect to substance use disorders, the risk of premature death varies by many possible factors, including type of drug, severity of use, trajectory of drug use, co-occurring psychiatric illness, and other personal characteristics, including age, gender, race socioeconomic status, health status, or health behaviors, including tobacco and alcohol use (Bargagli et al., 2006; Kertesz et al., 2012; Smyth, Fan, & Hser, 2006). Some of these factors are not modifiable (e.g., age), or are very difficult to modify (e.g., socioeconomic status), whereas others such as drug use severity are potentially modifiable. The purpose of this article is to examine the association between drug use severity and mortality as well as cause of death in primary care patients with substance use disorders. The motivation for conducting this analysis stems from the idea that if there were an association, then intervening to reduce severity could result in lower rates of premature death.