A single meeting with a peer addiction educator during a routine medical visit has helped out-of-treatment cocaine and opiate abusers attain abstinence, report NIDA-funded researchers who conducted a study at three Boston clinics. The peer educators were bilingual individuals in long-term recovery recruited from the same ethnically mixed community as the out-of-treatment drug abusers. The meeting consisted of a structured motivational interview that culminated in a plan for recovery and referrals.

"Talking with a person like yourself—someone who knows your language and culture and views you as an equal, who has successfully recovered from addiction—shows that change is possible and seems to motivate people to get off drugs. It's not a substitute for treatment, but it is a good first step," says Dr. Edward Bernstein of Boston University School of Medicine, one of the lead investigators of the study.

Dr. Bernstein and his coinvestigator Dr. Judith Bernstein hired and trained individuals who had been in recovery for at least 3 years to serve as peer educators and research assistants. This staff then screened 23,669 outpatients who were seeking routine medical care at Boston Medical Center walk-in clinics between May 1998 and November 2000. Altogether 1,175 patients (about 5 percent of those screened) met the criteria for study participation—they reported abusing cocaine, opiates, or both drugs during the past 30 days; scored 3 or higher on the Drug Abuse Severity Test; and were not in addiction treatment or protective custody—and agreed to participate. A research assistant met with each participant to administer further assessments, including an abbreviated Addiction Severity Index (ASI), and an educator then randomly assigned each patient to either an intervention or a control group. Similar proportions of patients in the two groups had abused cocaine (about half), opiates (about 10 percent), or both drugs (33 to 40 percent) during the month before the study (see "Demographic Characteristics of 1,175 Study Participants").

Motivational Interview During Routine Medical Visit Reduces Drug Abuse Six months after meeting with a peer addiction educator during a routine medical care visit, patients who participated in a motivational interview had higher rates of abstinence than patients who received a treatment sources list only.

An educator conducted a motivational interview with each patient in the intervention group. This lasted from 10 to 45 minutes, engaging the patient in a discussion of drug abuse, its consequences, the gap between his or her actual and desired quality of life, and readiness to seek help. The educator concentrated on a few of the patient's problems as identified by the ASI, negotiated a plan for behavioral change, and provided a handout listing treatment resources in the community. The educator was able to convey personal knowledge about the community programs and mention particular people for patients to contact, having visited the organizations as part of his or her training. Ten days after the motivational interview, the educators telephoned patients to review the action plan, ask what happened, and provide additional referrals, if necessary. These calls reached less than a third of patients (31 percent).

Participants assigned to the control group received written advice—"based on your screening responses, you would benefit from help with drug abuse"—along with the handout listing treatment resources. They were not given a motivational interview, and those who expressed interest in the treatment programs were merely encouraged to call a number from the handout. No followup call was attempted with these patients.

Results at Six Months

All participants, both the intervention group and controls, were given appointments to return to the clinic for followup 6 months after their original assessments. The team's research assistants tracked down no-shows by using the clinic's appointment system and visiting shelters and sites frequented by drug abusers. Altogether, they reached 962 (82 percent) of the 1,175 participants. Ultimately, 184 of these patients were excluded from the data analysis, either because hair samples taken at study entry did not confirm their initial reports of drug abuse, or because they did not give samples at followup.

Among the remaining 778 (66 percent of the original sample), 22.3 percent of those who had participated in the motivational interview had been abstinent from cocaine for at least 30 days at the time of the followup interview, compared with 16.9 percent of those who had received just the referral list. The motivational intervention was associated with superior abstinence rates among the subgroups of participants who abused opiates (40.2 percent versus 30.6 percent) and both cocaine and opiates (17.4 percent versus 12.8 percent). These differences occurred even though patients in the motivational interview group had more severe medical and drug-related problems and reported more psychiatric conditions at the beginning of the study.

About 40 percent of patients in each group reported that they had participated in formal treatment with a health care professional during the 6 months between the initial assessment and followup. This similarity in rates of treatment suggests that the brief motivational encounter with the peer educator was beneficial in itself, and not because it prompted participants to seek therapy. Ninety percent of the patients who said they received professional help underwent detoxification but did not enter ongoing addiction therapy to prevent relapse, a finding the researchers attribute in part to lack of access. "During the study, our patients had very limited access to public methadone treatment, which many had requested," says Dr. Edward Bernstein.

About half the patients in each group who achieved abstinence cited the peer educator as a source of help. The investigators believe patients viewed these individuals as role models for abstinence, which may prompt some to reduce drug abuse even without a motivational interview. "Doctors and patients are not equal, especially when there are language, class, and culture differences. Add drug abuse to the mix, and you usually get 'shaming and shoulding,' which makes patients feel inferior and close down," says Dr. Judith Bernstein. Because of their combination of training and life experiences, peers seemed to inspire optimism about the prospect for recovery, even in patients who felt that others had given up on them. Other sources of support included family, mentioned by 50 percent of patients who achieved abstinence, and self-help groups (68 percent).

Peer Educators Welcomed

Clinic staff at the Boston Medical Center welcomed the study's structured effort to deal with drug abuse, which is a serious problem in the community. They appreciated the fact that the program fit unobtrusively into routine care. "Most doctors don't feel they have the time or training to deal with substance abuse and are happy to suggest that patients see the peer counselor," says Dr. Edward Bernstein. An emergency room physician, Dr. Bernstein plans next to implement and evaluate a peer counseling intervention at five emergency centers.

"It's promising to see reduced drug abuse among these vulnerable patients, many of whom were homeless and unemployed," says Dr. Dorynne Czechowicz of NIDA's Division of Clinical Neurosciences, Development and Behavioral Treatments. Previous studies have demonstrated that alcohol-addicted patients benefit from screening and brief motivational interviews in primary-care settings, but few investigations have involved drug abusers. "More research is needed, but these findings suggest that peer educators can play an important role in busy clinical environments and enhance outreach to abusers of cocaine, opiates, and perhaps other drugs," she says.

Source

• Bernstein, J., et al. Brief motivational intervention at a clinic visit reduces cocaine and heroin use. Drug and Alcohol Dependence 77(1):49-59, 2005. [Abstract]

Volume 20, Number 3 (October 2005)