USPSTF: Insufficient evidence to recommend primary care-based behavioral counseling to prevent illicit drug use

There’s still not enough evidence to back up primary care-based behavioral counseling interventions to keep kids and young people off illicit drugs, according to the U.S. Preventive Services Task Force (USPSTF).

“Because of limited and inadequate evidence, the USPSTF concludes that the benefits and harms of primary care-based interventions to prevent illicit drug use in children, adolescents, and young adults are uncertain and that the evidence is insufficient to assess the balance of benefits and harms. More research is needed,” according to Alex H. Krist, MD, MPH, of Virginia Commonwealth University in Richmond, and task force members.

The current “I” statement is in line with the task force’s 2014 recommendation, they wrote in JAMA, and applies to children (ages ≤11 years), adolescents (ages 12 to 17 years), and young adults (ages 18 to 25 years), including pregnant people. It does not apply to young people with a history of regular or harmful illicit drug use or who have been diagnosed with a substance use disorder, Krist’s group emphasized.

Also, the term “illicit drug use” in the recommendation covers “using illegal drugs or misusing prescription medications or household products,” including cocaine, heroin, and hallucinogens, sedatives, opioids, solvents, and gasoline, explained Jill Jin, MD, MPH, of Northwestern Medicine in Chicago, in a JAMA Patient Page. However, alcohol and tobacco are not considered “illicit” drugs within the scope of the USPSTF recommendation, although use of those products by those under age 21 years is illegal.

Despite some new studies done in young adults, the current data on primary care-based interventions — such as face-to-face or group counseling, print materials, and technology-based tools — have not kept pace with trends in illicit drug use among young people (ages 12 to 17 years). The authors noted that in 2017, an estimated 7.9% of people that age reported illicit drug use in the past month, and an estimated 50% of U.S. adolescents had used an illicit drug by the time they graduated from high school.

While “The theoretical benefit of providing…counseling interventions is preventing young persons from starting to use illicit drugs or reducing the amount that they currently use,” Jin pointed out, “studies on these interventions provide inconsistent evidence on the net benefit to behavioral outcomes (drug abstinence or reduced frequency or quantity of illicit drug use) or health outcomes (morbidity, mortality, educational, or legal outcomes),” according to Krist’s group.

The recommendation is based on an evidence report by Elizabeth O’Connor, PhD, of the Kaiser Permanente Evidence-based Practice Center in Portland, Ore., and co-authors. They looked at 29 (n=18,353) trials of interventions and, among those, “health, social, or legal outcomes such as mental health symptoms, family functioning, consequences of drug use, and arrests were reported in 19 trials and most showed no group differences.”

The majority of trial participants were ages 10 to 18 years, while two trials focused on young adults. Also, the planned intervention dose was variable, with a median of three sessions, and a median duration of 6 weeks. Interventions for a dozen trials were computer-based, such as the Dutch E-health4Uth trial, while seven trials took place in primary care settings, such as the “Screening and Brief Advice to Reduce Teen Substance Use” study from Boston.

O’Connor’s group also reported that only four trials seemed to “focus on illicit drugs without explicit discussion of other substances or behaviors,” while nine trials had broader focus, including alcohol or alcohol and/or tobacco.

The researchers highlighted the trio of Family Spirit trials, which were conducted among Native American (American Indian) adolescent mothers. In terms of outcomes, mental health ones (depression, anxiety, externalizing symptoms, family functioning) were reported in all three trials, and the results were mixed. For instance, one trial reported a reduction in illicit drug use at 38 months, but not at earlier follow-up assessments.

Overall, “there was no group differences on mental health symptom scales after 3 to 24 months” of the intervention, O’Connor’s group stated.

As for harms of interventions, Krist and co-authors noted that “Potential harms include a paradoxical increase in illicit drug use.” O’Connor and co-authors pointed out that only one of the Family Spirit trials directly reported on harms, specifically that “the proportion of adverse events and serious adverse events was similar between groups after accounting for increased contact time within the intervention group, but the [Family Spirit trialists] did not provide detailed data.”

Krist’s group stated that other groups, such as the American Academy of Pediatrics, the Canadian Pædiatric Society, and the Substance Abuse and Mental Health Services Administration, encourage “universal screening for substance use, brief intervention, and/or referral to treatment…be part of routine health care.”

They called for more research on interventions to prevent cannabis use, more data on “health, social, or legal outcomes,” and more information on up-and-running interventions, such as the Familias Unidas program in Latino youth.

  1. Current evidence is insufficient to assess the balance of benefits and harms of primary care–based behavioral counseling interventions to prevent illicit drug use in children, adolescents, and young adults, according to the U.S Preventive Services Task Force (USPSTF).

  2. The USPSTF recommendations applies to children (ages ≤11 years), adolescents (ages 12 to 17 years), and young adults (ages 18 to 25 years), including pregnant people.

Shalmali Pal, Contributing Writer, BreakingMED™

The USPSTF is supported by the Agency for Healthcare Research and Quality.

Krist and co-authors reported travel reimbursement and an honorarium for participating in USPSTF meetings. A co-author reported a relationship with, and support from, Healthwise.

O’Connor and co-authors, as well as Jin, reported no relationships relevant to the contents of this paper to disclose.

Cat ID: 138

Topic ID: 85,138,730,138,139,192,144,151