Effectiveness of a brief-intervention and continuity of care in enhancing attendance for treatment by adolescent substance users

Abstract

Aims: To evaluate the effectiveness of a brief intervention enhanced by a consistent support person in facilitating attendance for substance use treatment following a hospital alcohol or other drug (AOD) presentation. Participants: We recruited 127 adolescents (aged 12–19 years) from hospital emergency departments, 57 were female. Sixty were randomly assigned to receive the intervention and 67 to receive standard hospital care. For the purpose of comparison, normative data were also collected (at baseline) from 122 non-AOD presenting adolescents. Intervention: The brief intervention involved identifying impediments to treatment service attendance and facilitating attendance via a consistent support person. Results: At 4 months, a significantly greater proportion of the intervention group, both daily and “occasional” drug users, had attended treatment than the usual care group. Regardless of attendance at the treatment service the intervention group showed a greater improvement in GHQ-12 scores than the usual care group. Across groups, a greater proportion of those who attended treatment moved to “safer” drug use behaviour (non-hazardous alcohol consumption and/or non-injecting drug use (IDU)), and showed a greater decline on a composite total drug use score. Conclusions: Adolescent attendance for treatment can be improved by brief intervention with harmful substance use behaviours reduced for both “occasional” and daily users. Improvements in psychosocial well-being is observed regardless of attendance at a treatment service.

Introduction

The early onset of alcohol or other drug (AOD) use is associated with a number of negative outcomes. Those who start consuming alcohol before the age of 14 have an increased likelihood of a life-time diagnosis of alcohol abuse or dependence, with the odds of these diagnoses declining by 8 and 14%, respectively, for each year that onset can be delayed (Grant and Dawson, 1997). Similarly, for each year that the onset of other substance use is delayed the odds of future abuse or dependence reduces by 4 and 5%, respectively. Adolescent AOD consumption is also associated with deaths from a range of causes (English et al., 1995) plus other serious outcomes including unintentional injuries (Hingson et al., 2000), accidents (Brismar and Bergman, 1998), unplanned sexual intercourse and pregnancy (Poulin and Graham, 2001, Spingarn and DuRant, 1996. Therefore, early intervention with adolescents, especially prior to the development of abuse or dependence, may prevent serious and long-lasting consequences.

Programs delivered in schools offer a means of intervening with the majority of young adolescents, yet those at the greatest risk are likely to be outside the school system (Bauman and Phongsavan, 1999). An alternative is to deliver programs at a point of contact within the health system such as hospital emergency departments (ED) to those who have incurred an AOD related morbidity or who screen positively for AOD use. Moreover, the use of interventions to reduce AOD consumption has been recommended in hospital ED given that the health message is likely to be highly salient and persuasive following an AOD related presentation (Gentilello et al., 1988).

Whilst the evidence for the effectiveness of brief interventions (BI) with adolescents is limited, there have been successful outcomes in some interventions (Levy et al., 2002) including an ED-based intervention. In the latter, a brief motivational interview with alcohol positive adolescents resulted in significant improvements compared with a usual care group in terms of alcohol related injuries, alcohol related social problems, drinking and driving plus other traffic violations (Monti et al., 1999).

However, it has previously been noted that BI are less effective among those with substance dependence, at least for alcohol disorders, rather than those with less severe substance use problems (Moyer et al., 2002, Bien et al., 1993). This suggests that BI techniques may be an appropriate modality of intervention with many adolescents presenting to ED with less entrenched substance use behaviours. However, given that a significant proportion of adolescents presenting to ED with AOD associated morbidity are daily users and some are likely to have significant abuse or dependence including repeated overdose presentations (Tait et al., 2002), the use of BI is unlikely to be effective for all adolescent presentations.

Another and perhaps more realistic but as yet unproven or established approach is to use a BI at the ED presentation to encourage the patient to engage with a referred treatment programme (Longabaugh et al., 2001). In this context, the BI rather than targeting substance reduction or cessation can be directed at facilitating attendance at an alcohol or drug treatment centre where the most appropriate form of intervention can be identified and delivered.

One of the earliest BI took this approach to encourage people with alcohol dependence who presented to ED to take up referrals to the hospital’s alcohol treatment centre (Chafetz, 1961). Less than 1% of the usual care patients attended for treatment compared with 42% of the intervention group. The author identified meaningful social contact and continuity of care as being critical in achieving this outcome compared with the standard care where interactions were fragmented and often punitive.

The current study intervened with adolescents presenting to hospital ED with presentations related to the use of AOD. The objective of the study was to assess the effectiveness of a brief intervention enhanced by a consistent follow-up support person in facilitating adolescent attendance at a community AOD treatment agency. Outcomes were assessed in terms of: (1) attendance at a treatment agency; (2) changes in AOD consumption patterns by 4 months and; (3) changes in psycho-social indicators at 4 months.