supplementary online content - jama€¦ · it incorporated elements of mi,3 motivational...

©2014AmericanMedicalAssociation.Allrightsreserved.

Supplementary Online Content Saitz R, Palfai TPA, Cheng DM, et al. Screening and brief intervention for drug use in primary

care: the ASPIRE randomized clinical trial. JAMA. doi:10.1001/jama.2012.9630.

eMethods. Intervention details

eTable 1. Effects of brief intervention on drug use, drug use consequences, sex and drug risk

behaviors, healthcare utilization, mutual help group attendance and hair drug test results at 6-

month follow-up

eTable 2. Secondary outcomes, stratified by main drug and severity, at 6-month follow-up: effects

of brief intervention in primary care patients with drug use identified by screening

eTable 3. Secondary outcomes stratified by main drug and severity at 6-week follow-up: effects of

brief intervention in primary care patients with drug use identified by screening

eTable 4. Hair drug testing: effects of brief intervention at 6-month follow-up among primary care

patients with drug use identified by screening

eTable 5. Inter-rater reliability

eTable 6. Intervention fidelity

This supplementary material has been provided by the authors to give readers additional

information about their work.

Downloaded From: https://jamanetwork.com/ by a Non-Human Traffic (NHT) User on 11/26/2020


eMethods. Intervention details Both the Adaptation of motivational interviewing (MOTIV) manual and the brief negotiated interview (BNI) manual are available from the authors on request. Brief negotiated interview (BNI)

Training. Training (120 hours initially then 1-2 booster sessions a year) was didactic and experiential (with direct observation) with competency demonstrated by video recordings scored for content using a standardized form.1 Interventionists had two 90-minute group and one or two 1-hour individual meetings a month with a Master’s trained, licensed independent clinical social worker supervisor to discuss job performance and cases, and for direct observation.

Description. The BNI began with becoming acquainted (e.g. tell me a bit about yourself). To enhance motivation for change the counselor next reviewed “pros and cons” of drug use and used reflective listening to develop discrepancy between participant values and actions. Feedback of screening results was followed by discussion of any perceived risks and discussion of readiness and confidence for change (“readiness ruler”). Finally, goals (e.g. cut down, quit, seek further help) and next steps were negotiated, and a change plan generated and discussed, which could include a recommendation to discuss with their physician. Adaptation of motivational interviewing (MOTIV)

Training. Didactic and experiential training (40 hours) was followed by practice towards, and confirmation of proficiency using audio recordings coded for motivational interviewing content. Counselors, who were clinical psychology doctoral students, had weekly 1-hour meetings to discuss issues surrounding the implementation of the intervention and to review with their supervisor (licensed doctoral level faculty clinical psychologist) audio recordings facilitated by a Motivational Interviewing(MI) assessment instrument.2 Description. The MOTIV was less structured than the BNI, with the interchange guided by patient responses. It incorporated elements of MI,3 motivational enhancement therapy,4 and brief intervention for drug use.5 The main goals of the intervention were to enhance motivation and self-efficacy to change drug use and, if relevant, help the participant choose drug-related behavior change goals and increase commitment to them. Although elements varied by patient, objectives generally included developing rapport, increasing an understanding of the link between drug use and participant health concerns, helping the patient become aware of how drug use related to values and life goals, identifying strengths that could support change, supporting and affirming participants’ beliefs and abilities related to behavior change, and providing treatment choices and options to facilitate change.

The MOTIV was designed to incorporate relevant patient health information and structured assessment information into motivational interviewing. The MOTIV utilized the key principles of MI such as expressing empathy, rolling with resistance, developing discrepancy, and supporting self-efficacy.3 MOTIV was collaborative—the patients’ views are respected, valued and integrated into efforts to promote change. The counselor focused on providing the patient a sense of autonomy by emphasizing their control, choice and decision-making options. The interview began with an open-ended question to elicit the patient’s perspective on his/her drug use. Strategies in the interview included reflective listening, open-ended questions, and decisional balance to develop the discrepancy between important goals/values and drug use. Through these and other strategies, the interventionist sought to elicit and elaborate on change talk from patients (i.e., patient statements reflecting personal reasons and advantages of changing drug use). The counselor was also able to use assessment information provided by the patient to facilitate these objectives including items from the ASSIST (The Alcohol, Smoking and Substance Involvement Screening Test), readiness and confidence for change, and drug use consequences experienced by the participant (SIP-D - The Short Inventory of Problems—Modified for Drug Use). Where relevant, the counselor also provided personalized information and feedback about medical conditions that may be influenced by drug use based on electronic medical record review of emergency visits, hospitalizations, problem lists, medications and visit notes. If appropriate, change plans were developed, including the change goal (cut down, quit, treatment referral), reasons for change, the specific plan, potential barriers and identification of those who could help with change plan efforts. In order to facilitate referral, those who identified outpatient counseling as a preferred option were provided with a specific contact person (e.g., outpatient counselor) who was called at the end of the interview. Electronic medical record documentation was supplemented with a “flag” to the primary care physician that also included patient reasons for change, barriers, the



change plan and any scheduled follow-up. All patients were offered a follow-up 20-30 minute counseling session (that could be conducted by phone if the participant preferred) that was to be completed over the subsequent 2 weeks. Intervention fidelity

There were 14 BNI and 4 MOTIV interventionists who performed 175 BNI and 177 MOTIV interventions. MOTIV counselors performed 8, 42, 42 and 85 interventions each. BNI counselors performed between 2 and 65 interventions each (7 interventionists performed between 2 and 4 interventions; the remaining counselors performed 8-65 sessions). All audible intervention recordings from both conditions were coded by at least one of three trained coders (master’s and doctoral level psychology students) using both an established measure of motivational interviewing fidelity and a study specific measure--the Motivational Interviewing Treatment Integrity (MITI 3.1.1) code system and a 9-item coding system developed for this study (ASPIRE codes, available from author TP on request), respectively. For each intervention, the complete recording was coded rather than specific segments. Twenty percent of the recordings were coded by at least 2 coders. To prevent drift, coders met weekly with a psychologist to review key issues in coding and review reliability recordings.

The MITI contains a set of 5 global codes rated on a 1 (low) to 5 (high) scale and a number of therapist behavior categories that are represented by counts (e.g., number of open questions, reflections). Summary scores are also calculated to determine MI-consistent behavior (e.g., open-ended questions/total questions).6 Motivational interviewing proficiency is typically determined by thresholds associated with global coder ratings and summary scores from behavioral counts. The ASPIRE codes included a list of common and unique intervention elements that were rated on a scale of 1 (not implemented/implemented incorrectly) to 5 (implemented in an ideal/exceptional manner). The rating scale designated a score of 3 as performance to standard, 2 as successful implementation of an element but performance below standard, and 4 as performance above standard.

Inter-rater reliability for the key MITI codes were in the good to excellent range according to Cicchetti’s (1994) criteria of intraclass correlation coefficients (ICCs)(i.e., below 0.40 as poor, 0.40-0.59 as fair, 0.60-0.74 as good and above 0.75 as excellent).7 For the ASPIRE codes, all ICCs were > 0.60 (see eTable 4 for complete set of ratings).

To evaluate treatment fidelity, we used relevant codes from the MITI and ASPIRE coding systems. The interventions were adaptations of motivational interviewing in that they were structured, single session brief interventions delivered in a primary care context; the content of the protocol differed between BNI and MOTIV, as described above. However, both were constructed to be delivered using an MI style. Thus, we expected that the MI Spirit variable (i.e., mean of evocation, autonomy, collaboration) and the percent MI adherent variable (pMIA) would be appropriate indices of treatment adherence along with the intervention specific ASPIRE code items developed for this study. (See eTable 5 for the complete list of ratings).

Examination of global codes from the MITI suggested that MOTIV interventions were delivered consistent with an MI style as indicated by MI Spirit composite, mean (M) standard deviation (SD)=4.56 (0.46) and percent MI adherent scores (pMIA) of 0.96 (0.13). Using commonly used MITI thresholds for proficiency, 98% of the MOTIV interventions showed adequate MI Spirit and 90% were proficient on pMIA. As anticipated, the BNI condition showed lower MI Spirit scores M (SD) = 3.58 (0.71) and had a lower rate of MI adherence in the interviews as indicated by pMIA scores, M (SD) = 0.70 (0.26). Indeed only, 64% attained proficiency for MI Spirit and 28% for pMIA.

Other elements of treatment fidelity were calculated based on the study specific ASPIRE codes. eTable 5 shows mean (SD) ratings for each code by intervention condition and percent of interventions that met thresholds for implementation (score of 2 or greater) and implementation to standard (score of 3 or greater) by intervention condition. For the MOTIV group, mean ratings for the relevant ASPIRE codes ranged from 2.88 (1.39) to 3.97 (1.08) [median = 3.56]. As anticipated, the BNI showed lower rates of treatment fidelity as mean scores ranged from 2.21 (1.19) to 3.01 (1.08) [median = 2.51]. Intervention Discriminability

There were a number of structural features (e.g., time, provider training, supervision) that discriminated between the two interventions delivered. Although the interventions shared an emphasis on motivational interviewing style, the MOTIV had a stronger emphasis on motivational interviewing and had fewer structured elements. As shown in eTable 5, motivational interviewing style (as indicated by



MI-Spirit and pMIA) was significantly higher for MOTIV interventions compared with BNI. On the study specific coding instrument, items discriminated between the interventions as anticipated. The BNI interventions showed higher scores on the use of the readiness ruler while the MOTIV scored higher on use of medical record assessment, affirmation, and developing discrepancy. Although the change plan was specifically part of the BNI intervention, it was an optional component of the MOTIV and consequently did not differ between groups.

All Participants

The websites provided to participants were www.alcoholscreening.org and www.drugscreening.org.

References

1. Boston University Brief Negotiated Interview-Active Referral to Treatment Institute. Tools for the brief negotiated interview (BNI). http://www.bu.edu/bniart/sbirt-in-health-care/sbirt-educational-materials/sbirt-brief-intervention/. Accessed February 18, 2014.

2. Martino S, Ball S, Gallon S, et al. Motivational interviewing supervisory tool for enhancing proficiency. Salem, OR: Northwest Frontier Addiction Technology Transfer Center, Oregon Health and Science University; 2006.

3. Miller WR, Rollnick S. Motivational interviewing: Preparing people for change. New York, NY: Guilford press; 2002.

4. Miller WR. Motivational enhancement therapy with drug abusers. Albuquerque, NM: Department of Psychology and Center on Alcoholism, Substance Abuse, and Addictions, The University of New Mexico; 1995.

5. Henry-Edwards S, Humeniuk R, Ali R, Poznyak V. The alcohol, smoking and substance involvement screening test (ASSIST): guidelines for use in primary care (draft version 1.1 for field testing). Updated 2003. http://www.who.int/substance_abuse/activities/en/Draft_The_ASSIST_Guidelines.pdf. Accessed February 18, 2014.

6. Moyers TB, Martin T, Manuel JK, Hendrickson SM, Miller WR. Assessing competence in the use of motivational interviewing. J Subst Abuse Treat. 2005;28(1):19-26.

7. Ciccetti DV. Guidelines, criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology. Psychological Assessment. 1994;6(4):284-290.



eTable 1. Effects of brief intervention on drug use, drug use consequences, sex and drug risk behaviors, healthcare utilization, mutual help group attendance and hair drug test results at 6-month follow-up

BNIa MOTIVb

Control

BNI vs. Control MOTIV vs. Control

Predicted Valuesc

Negative Binomial Regression Analyses

n

Means

IRR (95% CI)

p-valued

IRR (95% CI)

p-valued

Days >1 time use main druge in last 30 days

516 8.6 8.5 7.2 1.20

(0.86,1.66) 0.31

1.19 (0.86,1.65)

0.31

Days use main drug in last 90 days

516 33.5 38.4 36.0 0.93

(0.72, 1.20) 0.61

1.07 (0.83, 1.37)

0.61

Days > 1 time use of main drug in last 90 days

516 26.5 26.9 23.0 1.15

(0.80, 1.65) 0.45

1.17 (0.81, 1.68)

0.45

Drug use consequences (SIP-Df)

513 5.8 6.8 6.1 0.95

(0.71,1.26) 0.71

1.11 (0.83,1.47)

0.71

Number of unsafe sexual encounters in past 3 months

434 10.4 10.3 10.2 1.02

(0.63,1.65) 0.97

1.01 (0.62,1.63)

0.97

Median Regression Analyses

n

Median

β (95% CI)

p-value

β (95% CI)

p-value

Main drug ASSISTg score

516 16.4 17.5 16.0 0.41

(-1.73,2.54) 0.71

1.50 (-

0.81,3.81) 0.41

Global ASSIST score

516 21.7 23.4 22.7 -1.00

(-3.62,1.62) 0.50

0.73 (-

1.41,2.87) 0.50

90th Quantile Regression Analysesh,i

n

90th percentile

β (95% CI)

p-value

β (95% CI)

p-value

Marijuana ASSIST score

516 21.4 23.5 22.2 -0.79

(-4.18, 2.61)0.65

1.29 (-2.59, 5.16)

0.65

Cocaine ASSIST score

516 11.8 11.8 14.7 -2.89

(-6.47, 0.70)0.12

-2.89 (-6.51, 0.74)

0.12

Opioid ASSIST score

516 10.2 10.2 10.2 0 (0, 0) 1.00 0 (0, 0) 1.00



Logistic Regression Analyses

n Proportionsj (n (%)) OR (95% CI)

p-value

OR (95% CI)

p-value

Any drug use in past 3 months

516 153

(90.5) 158

(91.3) 165

(94.3) 0.56

(0.24, 1.29) 0.26

0.61 (0.26, 1.44)

0.26

Any heavy alcohol or drug use in past 3 months

516 158

(93.5) 160

(92.5) 166

(94.9) 0.76

(0.30, 1.93) 0.56

0.66 (0.27, 1.63)

0.56

Any marijuana use in past 3 months

516 130

(76.9) 139

(80.4) 141

(80.6) 0.60

(0.30,1.18) 0.28

0.85 (0.43,1.69)

0.64

Any opioid use in past 3 months

516 40

(23.7) 40

(23.1) 53

(30.3) 0.64

(0.36,1.13) 0.12

0.59 (0.33,1.05)

0.12

Any cocaine use in past 3 months

516 51

(30.2) 51

(29.5) 57

(32.6) 0.84

(0.46,1.51) 0.56

0.78 (0.43,1.42)

0.56

Any sedative use in past 3 months

516 9 (5.3) 15

(8.7) 13

(7.4) 0.64

(0.24,1.70) 0.74

1.09 (0.45,2.61)

0.85

Any amphetamine use in past 3 months (unadjusted)k

517 4 (2.4) 3 (1.7) 4 (2.3)1.04

(0.26,4.21) 0.96

0.76 (0.17,3.42)

0.96

Any hallucinogen use in past 3 months (unadjusted)k

517 3 (1.8) 3 (1.7) 7 (4.0)0.43

(0.11,1.71) 0.23

0.42 (0.11,1.67)

0.23

Any inhalant use in past 3 months (unadjusted)k

517 2 (1.2) 0 (0.0) 2 (1.1) 1.04

(0.07,14.44) 1.00

0.42 (0.00,5.38)

1.00

Any injection drug use in past 3 months

505 18

(10.8) 13

(7.6) 15

(8.7) 0.84

(0.26,2.75) 0.78

0.47 (0.13,1.67)

0.49

Any unsafe sex in past 3 months

443 88

(55.4) 82

(51.9) 93

(60.4) 0.62

(0.35,1.09) 0.10

0.57 (0.32,1.00)

0.10

Any unsafe sex in past 3 months with non-primary or transactional partners

454 21

(13.1) 19

(11.7) 25

(15.6) 0.76

(0.36,1.59) 0.46

0.73 (0.35,1.53)

0.46



Any unsafe sex in past 3 months with transactional partners (unadjusted)k

489 7 (4.3) 8 (4.9) 12

(7.4) 0.57

(0.18,1.61) 0.46

0.64 (0.22,1.75)

0.46

Hospitalization in past 6 monthsl

515 23

(13.6) 34

(19.8) 24

(13.7) 1.01

(0.52,1.96) 0.97

1.90 (1.02,3.54)

0.09

Hospitalization for addiction or mental health in past 6 months

515 10

(5.9) 12

(7.0) 8 (4.6)

0.95 (0.29,3.09)

1.00 1.44

(0.49,4.42) 1.00

Emergency department visit in past 6 months

516 49

(29.0) 51

(29.5) 52

(29.7) 0.95

(0.58,1.53) 0.95

1.02 (0.63,1.65)

0.95

Emergency department visit for addiction or mental health in past 6 months

516 13

(7.7) 11

(6.4) 17

(9.7) 0.79

(0.36,1.76) 0.57

0.63 (0.27,1.44)

0.54

Any other outpatient visits in past 6 months

516 89

(52.7) 104

(60.1) 95

(54.3) 0.94

(0.60,1.45) 0.76

1.12 (0.72,1.75)

0.76

Specialty inpatient or any outpatient (not emergency) treatment for addiction or mental health in past 6 months

516 53

(31.4) 51

(29.5) 44

(25.1) 1.41

(0.83,2.39) 0.41

0.98 (0.57,1.68)

0.93

Mutual help group in past 6 months

516 34

(20.1) 31

(17.9) 28

(16.0) 1.53

(0.78,2.98) 0.43

1.07 (0.54,2.13)

0.85



a BNI-Brief negotiated interview. b MOTIV-Adaptation of motivational interviewing. c Model-based expected values, unless otherwise indicated, calculated for population with observed means and proportions of the overall sample. d All p-values were adjusted for multiple comparisons using the Hochberg procedure. e Main drug - Drug of most concern, as determined by the participant. f SIP-D - Short Inventory of Problems—Alcohol and Drugs modified for Drug Use (Ranges from 0-45, higher score means worse consequences). gASSIST - The Alcohol, Smoking and Substance Involvement Screening Test (substance-specific scores range from 0-39, global scores range from 0-273; higher scores means riskier use/greater severity). h 90th quantile was modeled due to a highly skewed distribution with excess zero’s. i Quantile regression was not possible for the other substance specific ASSIST scores (sedative, amphetamines, hallucinogens, and inhalants) due to large number of excess zero’s, all p-values were >0.3 in unadjusted analyses. j These are observed proportions not adjusted for covariates. k We were not able to do adjusted analyses in these models due to low numbers of events. l All of the utilization questions (including mutual help group) asked about visits since study entry, which was assessed at the 6-month interview.



eTable 2 – Secondary outcomes, stratified by main drug and severity, at 6-month follow-up: effects of brief intervention in primary care patients with drug use identified by screening

BNIa MOTIVb Control BNI vs. Control MOTIV vs. Control

Predicted values Negative Binomial Regression Analyses

n Means IRR

(95% CI) p-

valuecIRR

(95% CI) p-

valuec

Days use of main drugd >1 time in last 30 days

Unadjusted 517 10.79 11.08 9.07 1.19

(0.83,1.70) 0.35

1.22 (0.85,1.74)

0.35

Adjustede 516 8.57 8.50 7.16 1.20

(0.86,1.66) 0.31

1.19 (0.86,1.65)

0.31

Stratified by main drug

Opioids

Unadjusted 88 5.17 4.21 5.45 0.95

(0.30,3.02) 0.93

0.77 (0.24,2.50)

0.93

Adjustede 88 5.10 3.29 4.45 1.15

(0.35,3.74) 0.82

0.74 (0.24,2.32)

0.82

Cocaine

Unadjusted 97 4.81 5.19 3.79 1.27

(0.55,2.95) 0.58

1.37 (0.59,3.17)

0.58

Adjustede 97 3.52 4.60 3.72 0.95

(0.41,2.20) 0.90

1.24 (0.54,2.82)

0.90

Marijuana

Unadjusted 323 14.33 15.06 11.85 1.21

(0.83,1.77) 0.33

1.27 (0.87,1.86)

0.33

Adjustede 322 13.37 12.88 10.20 1.31

(0.91,1.88) 0.20

1.26 (0.88,1.81)

0.20

Stratified by severity (ASSISTf)

ASSIST < 27

Unadjusted 424 10.70 11.03 9.02 1.19

(0.79,1.77) 0.41

1.22 (0.82,1.82)

0.41

Adjustede 423 6.21 5.76 5.10 1.22

(0.85,1.75) 0.51

1.13 (0.78,1.63)

0.51

ASSIST >= 27

Unadjusted 93 11.27 11.32 9.26 1.22

(0.53,2.78) 0.64

1.22 (0.55,2.74)

0.64

Adjustede 93 7.62 11.09 7.29 1.05

(0.47,2.34) 0.91

1.52 (0.72,3.21)

0.54



Days use main drug in last 90 days

Unadjusted 517 40.93 42.76 41.00 1.00

(0.76, 1.31) 0.99

1.04 (0.79, 1.37)

0.99

Adjustede 516 33.52 38.44 35.99 0.93

(0.72, 1.20) 0.61

1.07(0.83, 1.37)

0.61


Opioids

Unadjusted 88 16.93 23.18 25.97 0.65

(0.26, 1.63) 0.72

0.89 (0.35, 2.25)

0.81

Adjustede 88 15.30 20.49 20.80 0.74

(0.29, 1.84) 0.97

0.99 (0.40, 2.44)

0.97

Cocaine

Unadjusted 97 23.31 22.50 12.58 1.85

(0.92, 3.74) 0.10

1.79 (0.89, 3.61)

0.10

Adjustede 97 16.73 21.46 12.02 1.39

(0.71, 2.74) 0.34

1.79 (0.92, 3.46)

0.17

Marijuana

Unadjusted 323 53.58 55.55 54.61 0.98

(0.76, 1.27) 0.90

1.02 (0.79, 1.31)

0.90

Adjustede 322 47.88 52.29 50.49 0.95

(0.75, 1.20) 0.77

1.04 (0.82, 1.31)

0.77

Stratified by severity (ASSIST)

ASSIST < 27

Unadjusted 424 41.66 43.30 42.67 0.98

(0.73, 1.31) 0.92

1.01 (0.76, 1.36)

0.92

Adjustede 423 31.56 35.49 33.68 0.94

(0.73, 1.21) 0.69

1.05 (0.81, 1.37)

0.69

ASSIST >= 27

Unadjusted 93 36.88 39.96 35.18 1.05

(0.51, 2.15) 0.90

1.14 (0.56, 2.29)

0.90

Adjustede 93 28.15 39.98 29.06 0.97

(0.48, 1.97) 0.93

1.38 (0.70, 2.70)

0.71

Days use main drug>1 time in last 90 days

Unadjusted 517 31.34 33.07 26.98 1.16

(0.79, 1.70) 0.44

1.23 (0.84, 1.79)

0.44

Adjustede 516 26.47 26.91 23.04 1.15

(0.80, 1.65) 0.45

1.17 (0.81, 1.68)

0.45


Opioids

Unadjusted 88 12.79 12.61 15.29 0.84

(0.23, 2.98) 0.78

0.82 (0.23, 2.98)

0.78

Adjustede 88 11.28 9.53 12.45 0.91

(0.25, 3.31) 0.88

0.77(0.21, 2.74)

0.88

Cocaine

Unadjusted 97 15.53 15.91 9.45 1.64

(0.67, 4.00) 0.27

1.68 (0.69, 4.10)

0.27



Adjustede 97 10.55 13.68 10.14 1.04

(0.41, 2.65) 0.93

1.35 (0.54, 3.35)

0.93

Marijuana

Unadjusted 323 41.77 44.78 36.08 1.16

(0.77, 1.73) 0.48

1.24 (0.83, 1.86)

0.48

Adjustede 322 38.21 37.86 31.47 1.21

(0.83, 1.79) 0.35

1.20 (0.82, 1.77)

0.35


ASSIST < 27

Unadjusted 424 31.08 32.95 27.63 1.13

(0.73, 1.73) 0.59

1.19 (0.78, 1.83)

0.59

Adjustede 423 23.29 22.61 20.89 1.11

(0.75, 1.65) 0.70

1.08 (0.73, 1.61)

0.70

ASSIST >= 27

Unadjusted 93 32.73 33.68 24.72 1.32 (0.56,

3.11) 0.52

1.36 (0.59, 3.15)

0.52

Adjustede 93 20.28 34.17 17.10 1.19 (0.51,

2.75) 0.69

2.00 (0.92, 4.33)

0.16

Unadjusted 424 31.08 32.95 27.63 1.13

(0.73, 1.73) 0.59

1.19 (0.78, 1.83)

0.59

Adjustede 423 23.29 22.61 20.89 1.11

(0.75, 1.65) 0.70

1.08 (0.73, 1.61)

0.70

Drug use consequences (SIP-Dg)

Unadjusted 517 9.26 9.21 9.37 0.99

(0.70,1.40) 0.95

0.98 (0.70,1.39)

0.95

Adjustede 513 5.80 6.77 6.12 0.95

(0.71,1.26) 0.71

1.11 (0.83,1.47)

0.71


Opioids

Unadjusted 88 13.52 12.21 17.16 0.79

(0.37,1.67) 0.53

0.71 (0.33,1.52)

0.53

Adjustede 87 13.00 9.74 13.49 0.96

(0.46,2.03) 0.92

0.72 (0.35,1.48)

0.75

Cocaine

Unadjusted 97 18.06 16.38 16.39 1.10

(0.65,1.88) 1.00

1.00 (0.59,1.70)

1.00

Adjustede 96 14.79 14.27 14.73 1.00

(0.63,1.61) 0.99

0.97 (0.60,1.56)

0.99

Marijuana

Unadjusted 323 5.52 6.32 4.95 1.11

(0.70,1.77) 0.65

1.28 (0.81,2.02)

0.59

Adjustede 321 3.28 4.66 3.14 1.04

(0.72,1.52) 0.82

1.48 (1.02,2.15)

0.08


ASSIST < 27

Unadjusted 424 6.76 7.41 6.96 0.97

(0.65,1.45) 0.89

1.06 (0.71,1.59)

0.89



Adjustede 422 4.34 5.43 4.87

0.89 (0.63,1.25)

0.53 1.11

(0.79,1.56) 0.53

ASSIST >= 27

Unadjusted 93 23.04 18.54 17.77 1.30

(0.78,2.16) 0.64

1.04 (0.63,1.72)

0.87

Adjustede 91 19.56 17.42 16.64 1.18

(0.72,1.93) 0.85

1.05 (0.64,1.71)

0.85

Number of unsafe sexual encounters In past 3 months

Unadjusted 466 12.66 13.97 12.87 0.98

(0.60,1.62) 0.95

1.09 (0.66,1.79)

0.95

Adjustede 434 10.42 10.27 10.19 1.02

(0.63,1.65) 0.97

1.01 (0.62,1.63)

0.97


Opioids

Unadjusted 82 22.14 7.37 12.48 1.77

(0.54,5.82) 0.39

0.59 (0.18,1.97)

0.39

Adjustede 73 14.79 7.75 11.21 1.32

(0.38,4.55) 0.66

0.69 (0.17,2.80)

0.66

Cocaine

Unadjusted 87 5.63 12.59 12.32 0.46

(0.16,1.30) 0.28

1.02 (0.36,2.90)

0.97

Adjustede 77 5.56 12.01 8.87 0.63

(0.21,1.84) 0.59

1.35 (0.45,4.07)

0.59

Marijuana

Unadjusted 289 11.87 16.77 13.11 0.90

(0.48,1.70) 0.76

1.28 (0.68,2.41)

0.76

Adjustede 276 10.50 9.14 10.41 1.01

(0.55,1.84) 0.98

0.88 (0.49,1.57)

0.98


ASSIST < 27

Unadjusted 380 11.67 12.92 13.09 0.89

(0.50,1.59) 0.96

0.99 (0.55,1.76)

0.96

Adjustede 357 9.96 8.80 10.62 0.94

(0.53,1.65) 0.82

0.83 (0.47,1.46)

0.82

ASSIST >= 27

Unadjusted 86 17.88 19.04 12.09 1.48

(0.57,3.84) 0.42

1.57 (0.62,4.00)

0.42

Adjustede 77 11.08 17.29 8.50 1.30

(0.54,3.14) 0.55

2.03 (0.84,4.90)

0.23

Median Regression Analyses

n Median β

(95% CI) p-

valuec β

(95% CI) p-

valuec

ASSIST score for main drug

Unadjusted 517 15.00 15.00 16.00-1.00

(-5.63,3.63) 0.67

-1.00(-5.24,3.24)

0.67



Adjustede 516 16.38 17.47 15.97

0.41 (-1.73,2.54)

0.71 1.50(-

0.81,3.81) 0.41


Opioids

Unadjusted 88 11.00 13.00 19.00-8.00

(-24.41,8.41)

0.46 -5.66(-

20.83,9.50) 0.46

Adjustede 88 14.10 17.40 18.15-4.05

(-15.05,6.96)

0.91 -0.76(-

13.49,11.97) 0.91

Cocaine

Unadjusted 97 24.50 19.50 21.003.44

(-5.13,12.01)

0.70 -1.48(-

9.14,6.17) 0.70

Adjustede 97 22.92 19.85 20.922.00

(-3.07,7.07) 0.76

-1.07(-8.11,5.97)

0.76

Marijuana

Unadjusted 323 13.00 15.00 12.001.00

(-2.83,4.83) 0.61

3.00(-1.20,7.20)

0.32

Adjustede 322 15.08 16.08 14.580.50

(-1.78,2.78) 0.67

1.50(-0.84,3.84)

0.41


ASSIST < 27

Unadjusted 424 12.00 14.00 12.000.00

(-2.97,2.97) 1.00

2.00(-1.44,5.44)

0.51

Adjustede 423 14.23 14.93 14.350.13

(-2.16,1.91) 0.90

0.58(-1.78,2.94)

0.90

ASSIST >= 27

Unadjusted 93 29.00 24.50 21.00 8.00

(2.60,13.40) 0.01

3.51(-4.54,11.56)

0.39

Adjustede 93 27.57 24.04 22.24 5.33

(-1.05,11.72)

0.20 1.80(-

7.07,10.67) 0.69

Global (total) ASSIST score

Unadjusted 517 19.00 19.00 20.00 -1.00

(-7.22,5.22) 0.75

-1.00(-4.74,2.74)

0.75

Adjustede 516 21.65 23.38 22.65 -1.00

(-3.62,1.62) 0.50

0.73(-1.41,2.87)

0.50


Opioids

Unadjusted 88 29.00 28.50 31.00 -2.00

(-23.10,19.10)

0.85 -2.85

(-20.97,15.26)

0.85

Adjustede 88 32.08 34.32 31.52 0.56

(-16.07,17.20)

0.95 2.80(-

10.38,15.97) 0.95



Cocaine

Unadjusted 97 30.50 27.50 29.00 1.47

(-11.05,13.98)

0.85 -1.24

(-14.03,11.56)

0.85

Adjustede 97 29.80 30.92 31.94 -2.14

(-9.97,5.69) 0.81

-1.02(-9.36,7.32)

0.81

Marijuana

Unadjusted 323 15.00 18.00 17.00 -2.00

(-6.69,2.69) 0.61

1.00(-2.86,4.86)

0.61

Adjustede 322 17.68 18.01 16.77 0.91

(-1.88,3.70) 0.52

1.24(-1.00,3.48)

0.52


ASSIST < 27

Unadjusted 424 15.00 18.00 18.00 -3.00

(-7.59,1.59) 0.40

0.00(-3.42,3.42)

1.00

Adjustede 423 18.73 19.33 20.06 -1.33

(-3.91,1.26) 0.51

-0.73(-2.92,1.46)

0.51

ASSIST >= 27

Unadjusted 93 32.50 36.50 29.00 4.44

(-8.17,17.04)

0.49 7.54(-

6.33,21.42) 0.49

Adjustede 93 39.36 41.36 30.69 8.67

(-3.27,20.61)

0.15 10.67(-

2.16,23.49) 0.15

90th Quantile Regression Analysesh

N 90th percentile β

(95% CI) p-

valuecβ

(95% CI) p-

valuec

Marijuana ASSIST score

Unadjusted 517 27.00 27.00 25.00 2.00

(-1.93, 5.93) 0.33

2.00(-2.06, 6.06)

0.33

Adjustede 516 21.42 23.49 22.20 -0.79

(-4.18, 2.61) 0.65

1.29(-2.59, 5.16)

0.65

Cocaine ASSIST score

Unadjusted 517 27.00 24.00 26.00 1.00

(-5.09, 7.09) 0.75

-2.00(-8.42, 4.42)

0.75

Adjustede 516 11.84 11.84 14.73 -2.89

(-6.47, 0.70) 0.12

-2.89(-6.51, 0.74)

0.12

Logistic Regression Analyses

N Proportioni (n (%)) OR

(95% CI) p-

valuecOR

(95% CI) p-

valuec

Any Drug use in past 3 months

Unadjusted 517 153

(90.5) 158

(91.3) 165

(94.3) 0.58

(0.26, 1.32) 0.29

0.64 (0.28, 1.46)

0.29

Adjustede 516 0.56

(0.24, 1.29) 0.26

0.61 (0.26, 1.44)

0.26




Opioids

Unadjusted 88 23

(79.3) 21

(75.0) 29

(93.6) 0.26

(0.05, 1.44) 0.12

0.21 (0.04, 1.10)

0.12

Adjustede 88 0.26

(0.05, 1.43) 0.12

0.20 (0.04, 1.08)

0.12

Cocaine

Unadjusted 97 28

(87.5) 27

(84.4) 30

(90.9) 0.70

(0.14, 3.41) 0.66

0.54 (0.12, 2.48)

0.66

Adjustede 97 0.70

(0.14, 3.42) 0.66

0.55 (0.12, 2.61)

0.66

Marijuana

Unadjusted 323 101

(95.3) 106

(98.2) 104

(95.4) 0.97

(0.27, 3.46) 0.96

2.55 (0.48, 13.4)

0.54

Adjustede 322 0.94

(0.26, 3.35) 0.92

2.42 (0.46, 12.8)

0.60


ASSIST < 27

Unadjusted 424 129

(90.2) 135

(93.1) 130

(95.6) 0.43

(0.16, 1.14) 0.18

0.62 (0.22, 1.76)

0.37

Adjustede 423 0.44

(0.16, 1.22) 0.23

0.64 (0.22, 1.90)

0.42

ASSIST >= 27

Unadjusted 93 24

(92.3) 23

(82.1) 35

(89.7) 1.37

(0.23, 8.09) 0.73

0.53 (0.13, 2.17)

0.73

Adjustede 93 1.62

(0.20, 20.1) 0.94

0.58 (0.10, 3.20)

0.94

Any risky alcohol* or drug use in past 3 months

Unadjusted 517 158

(93.5) 160

(92.5) 166

(94.9) 0.78

(0.31, 1.93) 0.59

0.67 (0.28, 1.60)

0.59

Adjustede 516 0.76

(0.30, 1.93) 0.56

0.66 (0.27, 1.63)

0.56


Opioids

Unadjusted 88 24

(82.8) 22

(78.6) 29

(93.6) 0.33

(0.06, 1.86) 0.21

0.25 (0.05, 1.38)

0.21

Adjustede 88 0.33

(0.03, 2.33) 0.37

0.25 (0.02, 1.64)

0.37

Cocaine

Unadjusted 97 30

(93.8) 28

(87.5) 31

(93.9) 0.97

(0.13, 7.32) 0.97

0.45 (0.08, 2.66)

0.76

Adjustede 97 0.98

(0.13, 7.57) 0.98

0.54 (0.09, 3.37)

0.98

Marijuana

Unadjusted 323 103

(97.2) 106

(98.2) 104

(95.4) 1.65

(0.38, 7.09) 0.50

2.55 (0.48, 13.4)

0.50



Adjustede 322

1.61 (0.37, 6.96)

0.53 2.46 (0.46,

13.1) 0.53


ASSIST < 27

Unadjusted 424 134

(93.7) 136

(93.8) 131

(96.3) 0.57

(0.19, 1.74) 0.34

0.58 (0.19, 1.77)

0.34

Adjustede 423 0.63

(0.20, 1.97) 0.47

0.65 (0.20, 2.08)

0.47

ASSIST >= 27

Unadjusted 93 24

(92.3) 24

(85.7) 35

(89.7) 1.37

(0.23, 8.09) 0.73

0.69 (0.16, 3.01)

0.73

Adjustede 93 1.63

(0.21, 20.2) 1.00

0.75 (0.12, 4.72)

1.00

Any marijuana use in past 3 monthsj

Unadjusted 517 130

(76.9) 139

(80.4) 141

(80.6) 0.80

(0.48,1.35) 0.82

0.99 (0.58,1.68)

0.96

Adjustede 516 0.60

(0.30,1.18) 0.28

0.85 (0.43,1.69)

0.64

Any opioid use in past 3 monthsj

Unadjusted 517 40

(23.7) 40

(23.1) 53

(30.3) 0.71

(0.44,1.15) 0.17

0.69 (0.43,1.12)

0.17

Adjustede 516 0.64

(0.36,1.13) 0.12

0.59 (0.33,1.05)

0.12

Any cocaine use in past 3 monthsj

Unadjusted 517 51

(30.2) 51

(29.5) 57

(32.6) 0.90

(0.57,1.41) 0.63

0.87 (0.55,1.36)

0.63

Adjustede 516 0.84

(0.46,1.51) 0.56

0.78 (0.43,1.42)

0.56

Any sedative use in past 3 monthsj

Unadjusted 517 9

(5.3) 15

(8.7) 13

(7.4) 0.70

(0.29,1.69) 0.67

1.18 (0.55,2.57)

0.67

Adjustede 516 0.64

(0.24,1.70) 0.74

1.09 (0.45,2.61)

0.85

Any amphetamine use in past 3 monthsj

Unadjustedk 517 4 (2.4) 3

(1.7) 4 (2.3)

1.04 (0.26,4.21)

0.96 0.76

(0.17,3.42) 0.96



Any hallucinogen use in past 3 monthsj


(1.7) 7 (4.0)

0.43 (0.11,1.71)

0.23 0.42

(0.11,1.67) 0.23

Any inhalant use in past 3 monthsj


(0.0) 2 (1.1)

1.04 (0.07,14.44)

1.00 0.42

(0.00,5.38) 1.00

Any injection drug use in past 3 months

Unadjusted 510 18

(10.8) 13

(7.6) 15

(8.7) 1.27

(0.62, 2.60) 0.71

0.86 (0.40, 1.87)

0.71

Adjustede 505 0.84

(0.26, 2.75) 0.78

0.47 (0.13, 1.67)

0.49


Opioids

Unadjusted 87 12

(41.4) 8

(28.6) 14

(46.7) 0.81

(0.29, 2.26) 0.68

0.46 (0.15, 1.36)

0.32

Adjusted e 86 0.44

(0.11, 1.82) 0.26

0.23 (0.05, 0.99)

0.10

Cocaine

Unadjustedk 95 4(12.5) 3

(9.7) 1(3.1)

4.43 (0.47, 42.02)

0.31 3.32 (0.33,

33.80) 0.31

Marijuana


(0.9) 0(0.0)

2.52 (0.20, ∞)

0.96 1.01 (0.03,

∞) 1.00


ASSIST < 27

Unadjusted 417 9 (6.4) 8

(5.6) 6 (4.5)

1.44 (0.50, 4.17)

0.68 1.25 (0.42,

3.72) 0.68

Adjustede 413 0.64

(0.09, 4.43) 0.89

0.57 (0.08, 3.85)

0.89

ASSIST >= 27

Unadjusted 93 9

(34.6) 5

(17.9) 9

(23.1) 1.77

(0.59, 5.30) 0.61

0.73 (0.21, 2.46)

0.61

Adjustede 92 0.79

(0.09, 6.40) 1.00

0.29 (0.02, 2.95)

0.83

Any unsafe sex in past 3 months

Unadjusted 471 88

(55.4) 82

(51.9) 93

(60.4) 0.81

(0.52,1.27) 0.37

0.71 (0.45,1.11)

0.26

Adjustede 443 0.62

(0.35,1.09) 0.10

0.57 (0.32,1.00)

0.10




Opioids

Unadjusted 84 19

(65.5) 13

(48.2) 15

(53.6) 1.65

(0.57,4.79) 0.69

0.81 (0.28,2.32)

0.69

Adjustede 75 1.18

(0.34,4.08) 0.80

0.59 (0.17,2.03)

0.80

Cocaine

Unadjusted 90 19

(61.3) 15

(50.0) 19

(65.5) 0.83

(0.29,2.39) 0.73

0.53 (0.19,1.50)

0.46

Adjustede 82 0.21

(0.04,1.12) 0.07

0.19 (0.04,1.03)

0.07

Marijuana

Unadjusted 289 49

(50.5) 53

(55.2) 58

(60.4) 0.67

(0.38,1.18) 0.33

0.81 (0.46,1.43)

0.47

Adjustede 278 0.63

(0.30,1.30) 0.36

0.71 (0.34,1.48)

0.36


ASSIST < 27

Unadjusted 384 67

(50.4) 65

(49.6) 71

(59.2) 0.70

(0.43,1.15) 0.16

0.68 (0.41,1.12)

0.16

Adjustede 365 0.54

(0.29,1.02) 0.11

0.60 (0.31,1.13)

0.11

ASSIST >= 27

Unadjustedk 87 21

(80.8) 17

(63.0) 22

(64.7) 2.29

(0.69,7.63) 0.35

0.93 (0.32,2.65)

0.89

Any unsafe sex in past 3 months with secondary or transactional partnersj

Unadjusted 482 21

(13.1) 19

(11.7) 25

(15.6) 0.82

(0.44,1.53) 0.52

0.72 (0.38,1.36)

0.52

Adjustede 454 0.76

(0.36,1.59) 0.46

0.73 (0.35,1.53)

0.46

Any unsafe sex in past 3 months with transactional partnersj


(4.9) 12

(7.4) 0.57

(0.18,1.61) 0.46

0.64 (0.22,1.75)

0.46

Hospitalization in past 6 monthsj

Unadjusted 516 23

(13.6) 34

(19.8) 24

(13.7) 0.99

(0.54, 1.83) 0.98

1.55 (0.88, 2.75)

0.26

Adjustede 515 1.01

(0.52, 1.96) 0.97

1.90 (1.02, 3.54)

0.09



Hospitalization for addiction or mental health in past 6 monthsj

Unadjusted 516 10

(5.9) 12

(7.0) 8 (4.6)

1.31 (0.51, 3.41)

0.58 1.57 (0.62,

3.93) 0.58

Adjustede 515 0.95

(0.29, 3.09) 1.00

1.44 (0.49, 4.42)

1.00

Emergency department visit in past 6 monthsj

Unadjusted 517 49

(29.0) 51

(29.5) 52

(29.7) 0.97

(0.61, 1.54) 0.96

0.99 (0.62, 1.57)

0.96

Adjustede 516 0.95

(0.58, 1.53) 0.95

1.02 (0.63, 1.65)

0.95

Emergency department visit for addiction or mental health in past 6 monthsj

Unadjusted 517 13

(7.7) 11

(6.4) 17

(9.7) 0.77

(0.36, 1.65) 0.51

0.63 (0.29, 1.39)

0.51

Adjustede 516 0.79

(0.36, 1.76) 0.57

0.63 (0.27, 1.44)

0.54

Any other outpatient visits in past 6 monthsj

Unadjusted 517 89

(52.7) 104

(60.1) 95

(54.3) 0.94

(0.61, 1.43) 0.76

1.27 (0.83, 1.94)

0.54

Adjustede 516 0.94

(0.60, 1.45) 0.76

1.12 (0.72, 1.75)

0.76

Specialty inpatient or any outpatient (not emergency) treatment for addiction or mental health in past 6 months

Unadjusted 517 53

(31.4) 51

(29.5) 44

(25.1) 1.36

(0.85, 2.18) 0.36

1.25 (0.78, 2.00)

0.36

Adjustede 516 1.41

(0.83, 2.39) 0.41

0.98 (0.57, 1.68)

0.93




Opioids

Unadjusted 88 16

(55.2) 16

(57.1) 15

(48.4) 1.31

(0.48, 3.63) 0.60

1.42 (0.51, 3.98)

0.60

Adjustede 88 1.54

(0.51, 4.69) 0.64

1.31 (0.43, 3.96)

0.64

Cocaine

Unadjusted 97 12

(37.5) 10

(31.3) 11

(33.3) 1.20

(0.43, 3.32) 0.86

0.91 (0.32, 2.57)

0.86

Adjustede 97 0.96

(0.32, 2.87) 0.94

0.60 (0.19, 1.87)

0.75

Marijuana

Unadjusted 323 23

(21.7) 21

(19.4) 17

(15.6) 1.50

(0.75, 3.00) 0.46

1.31 (0.65, 2.64)

0.46

Adjustede 322 1.49

(0.71, 3.10) 0.58

1.02 (0.48, 2.18)

0.95


ASSIST < 27

Unadjusted 424 39

(27.3) 38

(26.2) 24

(17.7) 1.75

(0.99, 3.11) 0.09

1.66 (0.93, 2.95)

0.09

Adjustede 423 1.67

(0.87, 3.24) 0.26

1.23 (0.63, 2.42)

0.62

ASSIST >= 27

Unadjusted 93 14

(53.9) 13

(46.4) 20

(51.3) 1.11

(0.41, 3.00) 0.84

0.82 (0.31, 2.18)

0.84

Adjustede 93 0.93

(0.24, 3.64) 1.00

0.53 (0.13, 1.95)

0.85

Mutual help group in past 6 months

Unadjusted 517 34

(20.1) 31

(17.9) 28

(16.0) 1.32

(0.76, 2.30) 0.63

1.15 (0.65, 2.01)

0.63

Adjustede 516 1.53

(0.78, 2.98) 0.43

1.07 (0.54, 2.13)

0.85


Opioids

Unadjusted 88 17

(58.6) 13

(46.4) 13

(41.9) 1.96

(0.70, 5.48) 0.40

1.20 (0.43, 3.36)

0.73

Adjustede 88 2.32

(0.73, 7.40) 0.31

0.95 (0.30,3.00)

0.93

Cocaine

Unadjusted 97 7

(21.9) 8

(25.0) 6

(18.2) 1.26

(0.37, 4.26) 0.71

1.50 (0.46, 4.94)

0.71

Adjustede 97 0.79

(0.17, 3.76) 0.77

1.79 (0.40, 8.06)

0.77

Marijuana

Unadjusted 323 10

(9.4) 10

(9.3) 9 (8.3)

1.16 (0.45, 2.97)

0.79 1.13 (0.44,

2.91) 0.79

Adjustede 322 1.43

(0.50, 4.11) 0.98

1.02 (0.35, 2.99)

0.98



a BNI-Brief negotiated interview. b MOTIV-Adaptation of motivational interviewing. c p-values adjusted for multiple comparisons using the Hochberg procedure. d Main drug - Drug of most concern, as evaluated by subject. e All models adjusted for main drug (unless stratified by main drug), CIDI-SF drug dependence, and outpatient addiction or mental health treatment during the past 3 months, and the baseline value of the outcome.f ASSIST - The Alcohol, Smoking and Substance Involvement Screening Test. g SIP-D - Short Inventory of Problems—Alcohol and Drugs modified for Drug Use. h Quantile regression was not possible for the substance specific ASSIST scores for opioid, sedative, amphetamines, hallucinogens, and inhalants for which all median values were 0 and all p-values were >0.3 in unadjusted analyses. i These are observed proportions not adjusted for covariates. j Stratification for logistic regression analyses by main drug and by ASSIST were not done. k Unadjusted – We were not able to do adjusted analyses in these models due to low numbers. *Risky alcohol=>3 (>4 for men) standard drinks in any one day


ASSIST < 27

Unadjusted 424 20

(14.0) 21

(14.5) 14

(10.3) 1.42

(0.68, 2.93) 0.35

1.48 (0.72, 3.03)

0.35

Adjustede 423 1.48

(0.59, 3.83) 0.64

1.34 (0.53, 3.50)

0.64

ASSIST >= 27

Unadjusted 93 14

(53.9) 10

(35.7) 14

(35.9) 2.08

(0.76, 5.73) 0.31

0.99 (0.36, 2.73)

0.99

Adjustede 93 2.02

(0.52, 8.51) 0.79

0.74 (0.18, 2.96)

0.87



eTable 3 – Secondary outcomes stratified by main drug and severity at 6-week follow-up: effects of brief intervention in primary care patients with drug use identified by screening

BNIa MOTIVb Control BNI vs. Control MOTIV vs. Control

Negative Binomial Regression Analyses

N Means IRR

(95% CI) p-

valc IRR

(95% CI) p-

valc Days use main drugd in last 30 days

Unadjusted 525 12.17 12.48 12.15 1.00

(0.76,1.32) 0.99 1.03(0.78,1.35) 0.99

Adjustede 524 7.81 9.42 8.92 0.88

(0.71,1.08) 0.44 1.06(0.85,1.31) 0.62

Stratified by main drug Opioids

Unadjusted 90 7.00 7.89 6.61 1.06

(0.42,2.64) 0.90 1.19(0.47,3.05) 0.90

Adjustede 90 3.67 6.68 6.05 0.61

(0.26,1.43) 0.51 1.11(0.48,2.55) 0.81

Cocaine

Unadjusted 97 5.71 4.73 5.33 1.07

(0.54,2.12) 0.85 0.89(0.45,1.74) 0.85

Adjustede 97 3.62 3.79 4.47 0.81

(0.46,1.44) 0.57 0.85(0.48,1.49) 0.57

Marijuana

Unadjusted 329 15.73 16.53 15.80 1.00

(0.76,1.31) 0.97 1.05(0.80,1.37) 0.97

Adjustede 328 12.13 14.12 12.57 0.97

(0.78,1.19) 0.74 1.12(0.91,1.39) 0.57

Stratified by severity (ASSIST)f

ASSIST < 27

Unadjusted 428 12.22 12.69 12.73 0.96

(0.71,1.29) 0.98 1.00(0.74,1.34) 0.98

Adjustede 427 8.14 9.36 9.55 0.85

(0.68,1.07) 0.34 0.98(0.78,1.23) 0.86

ASSIST >= 27

Unadjusted 97 11.97 11.39 10.15 1.18

(0.58,2.42) 0.75 1.12(0.54,2.32) 0.75

Adjustede 97 5.47 9.37 5.58 0.98

(0.57,1.68) 0.94 1.68(0.96,2.94) 0.14

Days use of main drug >1 time in last 30 days

Unadjusted 525 8.35 8.34 8.80 0.95

(0.63,1.42) 0.80 0.95(0.64,1.42) 0.80

Adjustede 524 5.01 5.15 5.42 0.92

(0.66,1.29) 0.77 0.95(0.68,1.34) 0.77


Unadjusted 90 3.71 3.39 2.35 1.58

(0.41,6.11) 0.61 1.44(0.36,5.80) 0.61



Adjustede 90 0.67 4.26 2.38 0.28

(0.06,1.22) 0.18 1.78(0.45,7.06) 0.41

Cocaine

Unadjusted 97 3.74 2.58 3.97 0.94

(0.39,2.30) 0.90 0.65(0.27,1.57) 0.68

Adjustede 97 2.41 2.40 2.75 0.88

(0.39,1.96) 0.75 0.87(0.40,1.89) 0.75

Marijuana

Unadjusted 329 11.16 11.70 12.19 0.92

(0.59,1.41) 0.85 0.96(0.62,1.48) 0.85

Adjustede 328 9.02 7.84 8.86 1.02

(0.70,1.48) 0.92 0.89(0.61,1.29) 0.92


ASSIST < 27

Unadjusted 428 8.08 8.69 9.25 0.87

(0.56,1.37) 0.78 0.94(0.60,1.47) 0.78

Adjustede 427 5.20 5.16 5.82 0.89

(0.61,1.30) 0.55 0.89(0.60,1.31) 0.55

ASSIST >= 27

Unadjusted 97 9.72 6.50 7.25 1.34

(0.55,3.28) 0.81 0.90(0.36,2.22) 0.81

Adjustede 97 3.66 4.58 3.18 1.15

(0.58,2.29) 0.68 1.44(0.74,2.83) 0.57

Drug use consequences (SIP-Dg)

Unadjusted 523 8.67 7.98 7.79 1.11

(0.77,1.62) 0.90 1.02(0.71,1.49) 0.90

Adjustede 519 5.14 5.09 5.07 1.01

(0.75,1.37) 0.98 1.00(0.74,1.37) 0.98


Unadjusted 89 13.77 12.36 11.26 1.22

(0.59,2.52) 0.80 1.10(0.53,2.29) 0.80

Adjustede 88 12.30 8.73 10.33 1.19

(0.57,2.50) 0.64 0.84(0.42,1.72) 0.64

Cocaine

Unadjusted 97 16.94 14.18 14.73 1.15

(0.62,2.14) 0.90 0.96(0.52,1.77) 0.90

Adjustede 96 12.15 10.94 13.45 0.90

(0.53,1.55) 0.71 0.81(0.47,1.40) 0.71

Marijuana

Unadjusted 328 5.05 4.84 4.67 1.08

(0.64,1.82) 0.89 1.04(0.62,1.74) 0.89

Adjustede 326 2.85 3.50 2.62 1.09

(0.71,1.65) 0.70 1.33(0.87,2.05) 0.38


ASSIST < 27

Unadjusted 427 5.87 5.68 5.83 1.01

(0.65,1.56) 0.98 0.97(0.63,1.51) 0.98

Adjustede 425 3.65 3.80 3.73 0.98

(0.68,1.41) 0.92 1.02(0.70,1.48) 0.92



ASSIST >= 27

Unadjusted 96 23.00 20.07 14.50 1.59

(0.95,2.64) 0.15 1.38(0.83,2.30) 0.21

Adjustede 94 20.84 18.28 14.24 1.46

(0.88,2.45) 0.29 1.28(0.77,2.15) 0.34

Logistic Regression Analysesh N Proportions (n (%))

OR (95% CI)

p-valu

e

OR (95% CI)

p-valu

e Hospitalization in past 6 weeks

Unadjusted 523 12

(7.0) 17

(9.7) 13 (7.3)

0.95 (0.42,2.15)

0.91 1.36(0.64,2.89) 0.85

Adjustede 522 1.04

(0.39,2.78) 1.00 2.20(0.88,5.71) 0.19

Hospitalization for addiction or mental health in past 6 weeks

Unadjusted 523 7 (4.1) 9 (5.1) 5 (2.8) 1.47

(0.46,4.72) 0.52 1.87(0.61,5.68) 0.52

Adjustede 522 0.98

(0.22,4.56) 1.00 2.02(0.53,8.74) 0.77

Emergency department visit in past 6 weeks

Unadjusted 523 19

(11.1) 23

(13.1) 32 (18.1)

0.57 (0.31,1.04)

0.14 0.69(0.38,1.23) 0.20

Adjustede 522 0.55

(0.29,1.03) 0.12 0.71(0.39,1.30) 0.27

Emergency department visit for addiction or mental health in past 6 weeks

Unadjusted 523 5 (2.9) 7 (4.0) 6 (3.4) 0.86

(0.26,2.87) 0.80 1.19(0.39,3.61) 0.80

Adjustede 522 0.95

(0.22,3.90) 1.00 1.25(0.33,4.82) 1.00

Any other outpatient visits in past 6 weeks

Unadjusted 523 55

(32.2) 63

(36.0) 62 (35.0)

0.88 (0.56,1.37)

0.85 1.04(0.67,1.62) 0.85

Adjustede 522 0.88

(0.55,1.39) 0.57 0.87(0.55,1.39) 0.57

Specialty inpatient or any outpatient (not emergency) treatment for addiction or mental health in past 6 weeks

Unadjusted 523 34

(19.9) 39

(22.3) 32 (18.1)

1.13 (0.66,1.92)

0.67 1.30(0.77,2.19) 0.65

Adjustede 522 1.09

(0.59,2.00) 0.98 1.01(0.55,1.85) 0.98


Unadjusted 89 11

(36.7) 12

(42.9) 12 (38.7)

0.92 (0.33,2.58)

0.87 1.19(0.42,3.36) 0.87



Adjustede 89 0.97

(0.31,3.03) 0.95 1.08(0.35,3.36) 0.95

Cocaine

Unadjusted 97 11

(35.5) 11

(33.3) 8 (24.2)

1.72 (0.58,5.08)

0.42 1.56(0.53,4.58) 0.42

Adjustede 97 1.46

(0.43,4.98) 0.88 0.91(0.26,3.17) 0.88

Marijuana

Unadjusted 327 12

(11.1) 15

(13.8) 10 (9.0)

1.26 (0.52,3.06)

0.61 1.61(0.69,3.76) 0.54

Adjustede 328 1.20

(0.47,3.09) 0.71 1.25(0.50,3.12) 0.71


ASSIST < 27

Unadjusted 426 23

(16.1) 29

(19.7) 15 (11.0)

1.56 (0.78,3.13)

0.21 2.00(1.02,3.92) 0.09

Adjustede 427 1.42

(0.67,3.03) 0.37 1.40(0.67,2.95) 0.37

ASSIST >= 27

Unadjusted 96 11

(39.3) 10

(35.7) 17 (42.5)

0.88 (0.33,2.34)

0.79 0.75(0.28,2.03) 0.79

Adjustede 96 0.67

(0.17,2.45) 0.70 0.53(0.14,1.89) 0.70

Mutual help group in past 6 weeks

Unadjusted 523 28

(16.4) 30

(17.1) 26 (14.7)

1.14 (0.64,2.03)

0.66 1.20(0.68,2.13) 0.66

Adjustede 522 1.21

(0.56,2.62) 0.92 1.04(0.48,2.25) 0.92


Unadjusted 89 15

(50.0) 12

(42.9) 13 (41.9)

1.39 (0.50,3.80)

0.94 1.04(0.37,2.92) 0.94

Adjustede 89 1.29

(0.37,4.48) 0.69 0.62(0.17,2.28) 0.69

Cocaine

Unadjusted 97 7

(22.6) 9

(27.3) 4 (12.1)

2.12 (0.55,8.09)

0.27 2.72(0.74,9.94) 0.26

Adjustede 97 1.72

(0.34,8.60) 0.51

2.59 (0.53,12.69)

0.48

Marijuana

Unadjusted 328 6 (5.6) 8 (7.3) 7 (6.3) 0.87

(0.28,2.69) 0.81 1.18(0.41,3.37) 0.81

Adjustede 327 1.19

(0.29,4.91) 0.81 0.78(0.19,3.20) 0.81


ASSIST < 27

Unadjusted 427 16

(11.2) 20

(13.6) 14 (10.2)

1.11 (0.52,2.36)

0.79 1.38(0.67,2.86) 0.76

Adjustede 426 1.15

(0.42,3.12) 0.79 1.16(0.44,3.12) 0.79



ASSIST >= 27

Unadjusted 96 12

(42.9) 10

(35.7) 12 (30.0)

1.75 (0.64,4.80)

0.55 1.30(0.46,3.62) 0.62

Adjustede 96 2.29(0.50,11.

57) 0.74 0.94(0.20,4.21) 1.00

a BNI-Brief negotiated interview. b MOTIV-Adaptation of motivational interviewing. c all p-values adjusted for multiple comparisons using the Hochberg procedure. d Main drug - Drug of most concern, as determined by the subject e All models adjusted for drug of most concern (DOMC)(unless stratified by DOMC), CIDI-SF drug dependence, and outpatient addiction or mental health treatment during the past 3 months, and the baseline value of the outcome.f ASSIST - The Alcohol, Smoking and Substance Involvement Screening Test. g SIP-D - Short Inventory of Problems—modified for Drug Use. h Stratification for logistic regression analyses by DOMC and by ASSIST were only done for Inpatient or outpatient treatment for addiction or mental health in past 6 weeks and mutual help group in the past 6 weeks.



eTable 4 – Hair drug testing: effects of brief intervention at 6-month follow-up among primary care patients with drug use identified by screening

BNIa MOTIVb

Control BNI vs. Control MOTIV vs. Control

Any Drug N Proportions (n (%)) OR

(95% CI)

p-valuec

OR (95% CI)

p-valuec

Present Unadjusted 454 142

(94.7) 142

(92.8) 138

(90.8) 1.79(0.73,4.40) 0.41 1.31(0.57,2.98) 0.52

Adjustedd 454 1.65(0.64, 4.23) 0.59 1.25(0.52,3.00) 0.61Present: sensitivity analysise

Unadjusted 484 150 (94.9)

152 (93.2)

150 (91.5)

1.74 (0.71, 4.27) 0.45 1.29(0.57,2.93) 0.54Adjustedd 484 1.65 (0.65, 4.21) 0.57 1.29(0.54,3.06) 0.57Cocaine or benzylecognine


(45.9) 70

(52.2) 67

(49.3) 0.86(0.53, 1.39) 0.63 1.13(0.70,1.82) 0.63



99 (60.7)

95 (57.9)

0.84 (0.54, 1.30) 0.61 1.12(0.72,1.75) 0.61Adjustedd 484 0.80 (0.49, 1.30) 0.41 1.23(0.75,1.99) 0.41Decreased use of drug*


33 (26.2)

27 (21.3)

1.00 (0.54, 1.83) 0.99 1.31(0.73,2.35) 0.71Adjustedd 375 0.95 (0.51, 1.77) 0.87 1.39(0.76,2.54) 0.57Opioids Present Unadjusted 411 28

(20.9) 21

(15.6) 18

(12.6) 1.85(0.97, 3.53) 0.12 1.28(0.65,2.52) 0.48



49 (30.1)

39 (23.8)

1.59 (0.97, 2.59) 0.13 1.38(0.84,2.25) 0.20Adjustedd 484 1.70 (1.02, 2.83) 0.09 1.53(0.91,2.56) 0.11Decreased Use of Drug*


9 (7.3)17

(12.7) 0.76 (0.35, 1.67) 0.50 0.54(0.23,1.26) 0.31

Adjustedd 378 0.67 (0.29, 1.55) 0.35 0.59(0.24,1.43) 0.40Carboxy-tetrahydrocannabinol (Marijuana)

N OR

(95% CI)

p-valuec

OR (95% CI)

p-valuec


(73.1) 117

(79.6) 105

(71.4) 1.08(0.64, 1.80) 0.78 1.56(0.91,2.67) 0.21



133 (81.6).

122 (74.4)

1.04 (0.63, 1.72) 0.87 1.53(0.90,2.59) 0.23Adjustedd 484 0.99 (0.56, 1.75) 0.97 1.66(0.91,3.02) 0.20



Decreased Use of Drug*


55 (39.6)

53 (37.6)

1.12 (0.69, 1.83) 0.67 1.11(0.69,1.80) 0.67Adjustedd 415 1.06 (0.64, 1.76) 0.81 1.09(0.66,1.78) 0.81

Median Regression N Medians (ng/Ml) β (95% C.I.) p-

valuec

β (95% C.I.) p-valuec

Cocaine Unadjusted median 158 93.4 70.8 106.5 -7.74 (-120, 105) 0.89 -39.3 (-109,30.7) 0.54Adjusted mediand 158 120.5 118.7 120.0 0.49 (-35.4, 36.4) 0.98 -1.39 (-31.8,29.0) 0.98Benzoylecognine Unadjusted median 125 10.8 7.20 10.0 2.27 (-6.03, 10.6) 0.59 -2.66 (-7.44,2.13) 0.55Adjusted mediand 125 18.7 14.8 13.0 5.71 (-0.28, 11.7) 0.12 1.79 (-3.21, 6.80) 0.48Carboxy-tetrahydrocannabinol (Marijuana)

Unadjusted median 287 19.2 16.3 12.7 6.50 (-1.42, 14.4) 0.21 3.60(-3.82, 11.0) 0.34Adjusted mediand 287 19.3 17.8 19.3 0.05 (-3.00, 3.10) 0.98 -1.46 (-4.35,1.42) 0.64Codeine Unadjusted medianf 39 2.60 3.65 4.50 0.77 0.77Morphine Unadjusted medianf 45 4.15 2.10 6.50 0.37 0.176-Monoacetylmorphine

Unadjusted medianf 39 7.10 2.40 4.85 0.88 0.56Oxycodone Unadjusted medianf 35 3.20 2.40 2.70 0.78 0.78Hydrocodone Unadjusted medianf 22 2.40 6.55 2.30 0.88 0.40Hydromorphine Unadjusted medianf 23 0.30 1.20 0.40 0.75 0.75

a BNI-Brief negotiated interview. b MOTIV-Adaptation of motivational interviewing c p-values adjusted for multiple comparisons using the Hochberg procedure. d Adjusted on baseline covariates: Drug of most concern (DOMC), Number days heavy use of DOMC in past 30 days, CIDI-SF drug dependence, and outpatient treatment during past 3 months for addiction or mental health. e Unable to complete and insufficient samples assumed to be positive. f Adjusted regression analysis was not done as there were too few samples. *% with positive value of difference between baseline and follow-up quantitative drug test



eTable 5 – Inter-rater reliability CODE MITIa

ICCb

MI Spirit 0.80 pMIA 0.64

ASPIRE

ICC

Opening 0.64

Assessments/Record 0.81

Health information 0.76

Pros/Cons 0.60

Developing discrepancy 0.63

Enhancing self-efficacy 0.73

Affirmation 0.71

Readiness ruler 0.75

Change plan 0.61

a MITI=motivational interviewing treatment integrity code system b ICC=intraclass correlation coefficients



eTable 6 – Intervention fidelity CODE BNI MOTIV MITI

M (SD)

Profa Compb M (SD) prof comp Z-score /

t-test valuec

p-

value

MI Spirit (3.5, 4.0) 3.58

(0.71) 64% 40%

4.56 (0.46)

98% 93% -12.99 <0.001

pMIA (90%, 100%) 0.70

(0.26) 28% 24%

0.96 (0.13)

90% 81% -12.06 <0.001

ASPIRE M

(SD) %2+d %3+e M (SD) %2+ %3+ Z-score

p-value

Opening 3.01f

(1.08) 92% 63%

3.97f (1.08)

97% 89% -7.90 <0.001

Assessments/Record 1.25

(0.64) 15% 7%

2.88f (1.39)

74% 62% -11.85 <0.001

Health information 2.52f (1.30)

70% 44% 2.89f (1.54)

65% 57% -2.25 <0.05

Pros/Cons 2.50f (0.83)

90% 43% 3.62f (1.08)

94% 85% -10.01 <0.001

Developing discrepancy 2.31

(1.03) 67% 49%

3.77f (1.01)

98% 87% -11.23 <0.001

Enhancing self-efficacy 2.66f (1.05)

79% 60% 3.56f (1.20)

90% 83% -7.62 <0.001

Affirmation 2.26

(0.76) 84% 31%

3.50f (1.15)

95% 77% -10.24 <0.001

Readiness ruler 2.34f (1.36)

59% 40% 1.30

(0.83) 13% 9% 8.93 <0.001

Change plan 2.21f (1.19)

56% 43% 2.35g (1.27)

61% 45% -0.93 0.35

aIndicates the percent of interventions by group that were conducted at level of beginning proficiency or better (MI Spirit variable > 3.5; pMIA variable > 90%) bIndicates the percent of intervention by group that were conducted at level competency (MI Spirit variable > 4.0; pMIA variable =100%) cDifference between groups on the variable pMIA was assessed using a t-test. All other group comparisons were conducted using Wilcoxon non-parametric tests. dASPIRE intervention component implemented eASPIRE intervention component implemented to standard fDenotes intervention component for specific intervention gDenotes optional intervention component for specific intervention


supplementary online content - jama€¦ · it incorporated elements of mi,3 motivational...

Documents