Project START: Screening to Augment Referral to Treatment

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DESCRIPTION (provided by applicant): Substance abuse is associated with high costs to individuals and to society but less than one- third of individuals who are drug dependent and 6% of those who abuse drugs ever receives treatment. Screening, a brief intervention and referral for treatment (SBIRT) for substance abuse and deployed in a primary care setting has therapeutic potential but clinicians typically have less than 10 minutes with a patient and must address a range of medical problems. SBIRT, delivered by computer or nurse, would be a strong addition to a primary care clinician's therapeutic armamentarium for substance abusers but these interventions need to be tested against usual care. Women, who have lower rates of substance abuse treatment, typically receive primary medical care in a reproductive health setting. The American College of Obstetricians and Gynecologists recommends universal screening to determine if women abuse substances but, other than for alcohol and tobacco, there are no empirical data to support the effectiveness of this approach. In fact, the astonishing lack of data on SBIRT in primary care setting is noted by the US Preventative Services Task Force, in a 2008 report. We propose a controlled, pragmatic, randomized clinical trial that would compare two SBIRTs, offered either by computer or a trained nurse, to usual care (a control condition). We will recruit 660 women with a range of psychoactive substance use (e.g. tobacco, marijuana, cocaine, methamphetamines, alcohol, opiates, prescription drugs) and randomize them to a nurse- administered referral based upon motivation principles, a computer referral based upon motivation principles or brief advice. All subjects will receive a pamphlet with information and resources. Random effects and logistic regression models will be used to estimate group differences in primary drug used, treatment initiation, and treatment attendance among the 3 groups at 1, 3, and 6 months. Random effects models will also be used to test the incremental costs of the computer and nurse administered referrals. PUBLIC HEALTH RELEVANCE: Screening, brief interventions and referral to treatment for substance abuse have therapeutic potential but are understudied in primary care settings, in women and drug users. We propose a pragmatic trial that would randomize 660 women in a reproductive health setting who have a range of psychoactive substance use (e.g. tobacco, marijuana, cocaine, etc.) problems to a nurse-administered referral based upon motivation principles, or a computer referral based upon motivation principles or brief advice (control condition). Costs of the conditions would be estimated to provide models of cost effectiveness.