p u b l i c h e a l t h 1 2 7 ( 2 0 1 3 ) 1 1 4 0 e1 1 4 2
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Short Communication
Screening and brief intervention for substance misuse in Thailand S. Assanangkornchai a,*, Q. Balthip b, J. Guy Edwards a,c a
Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand Faculty of Nursing, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand c Department of Psychiatry, Royal South Hants Hospital, Southampton SO14 0YG, United Kingdom b
article info Article history: Received 21 January 2013 Received in revised form 19 February 2013 Accepted 20 August 2013 Available online 23 November 2013
Introduction Globally, the use of alcohol and illicit substances accounts for 13 disability-adjusted life years (DALY’s) lost per 1000 population or 5.4% of the total burden of disease, with 11 due to alcohol and two to illegal substances.1 In Thailand alcohol, tobacco and illicit substance use ranked first, second and twelfth among the top risk factors for DALY’s lost in both sexes in 2009.2 Several attempts have been made to combat this escalating problem in Thailand, including the development of prevention and treatment packages and employment and training of healthcare workers to encourage early intervention and engagement in treatment. The implementation of the World Health Organisation recommended Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) and its linked brief intervention3 (ASSIST-BI) in primary care settings is one such effort. The aim of this paper is to report the results of our work on a model for developing and implementing an ASSIST-BI service in primary care units of four districts in the north-eastern
and southern regions and assessing its acceptability and uptake. As a result of our findings, the ASSIST-BI procedure has been incorporated into a national intervention package for substance misuse and the training of healthcare workers across the country. A related study of its effectiveness will be reported elsewhere. The screening component of the ASSIST allows for scoring of the quantity and frequency of use of all legal and illegal substances and related variables. It has cut-off points that suggest low-, moderate- and high-risk levels of substance use. High-risk users were referred to an appropriate treatment unit, while those at moderate-risk were offered ASSIST-linked brief intervention, a structured 10-step brief counselling programme. The aim of this procedure was to identify and provide intervention for substance misuse before it caused excessive harm. There is an increasing body of evidence for its effectiveness.4,5
Implementation of the ASSIST-BI service The English version of the ASSIST6 was translated into Thai. As krathom (mitragynine speciosa, a plant-based narcotic, mostly chewed by the middle aged and elderly) and ‘krathom cocktail’ made by boiling krathom leaves with a benzodiazepine (mostly alprazolam), codeine cough syrup, chlorpheniramine and/or phenylephrine in a cola drink (mostly used by youngsters) are widely used in Thailand, they were added to the substances included in the ASSIST. The Thai translation was back-translated into English and the accuracy of the backtranslation verified. The ASSIST manual, feedback report card,
* Corresponding author. Tel.: þ66 74 451 165-166; fax: þ66 74 429754. E-mail address: [email protected] (S. Assanangkornchai). 0033-3506/$ e see front matter ª 2013 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.puhe.2013.08.011
p u b l i c h e a l t h 1 2 7 ( 2 0 1 3 ) 1 1 4 0 e1 1 4 2
intervention manual and self-help book7,8 were similarly translated. Districts in which the study would best be undertaken were selected on the basis that they had a known drug problem; had adequate transport; were safe for researchers; and had the potential for expansion if the study were to yield costeffective, beneficial results. Choompae and Prayeun in the North East and Chana and Kuan Niang in the South met these criteria and were chosen. In each district, the study was undertaken in district hospitals (called community hospitals in Thailand) and their two to three networking sub-district primary care units (PCU’s). Prior to launching the study the aims, evidence for effectiveness and potential benefits were explained to staff at all levels (from major decision takers to the nurses and health workers who would be administering the procedure) in these districts and their agreement to participate obtained. Workshops with demonstrations, group discussions and role play were arranged to train staff, including future trainers and supervisors, and to provide education on psychoactive drugs and their misuse, the role of primary care staff in early recognition and intervention, and the principles and practice of the ASSIST-BI procedure.
Uptake and acceptability of the ASSIST-BI procedure Within 10 months of the launch, 5931 patients aged 18 to 65 attending the centres agreed to be screened. Of these, 1757 (30%) were rated as being at ‘moderate-risk’ of substancerelated problems and 1627 were given ASSIST-linked brief intervention, while 203 (3.4%) were rated at ‘high-risk’. The main substances abused were tobacco (49% of all those screened), alcohol (32%), cannabis (2%), amphetamine-type stimulants and krathom (less than 1%). The number of patients screened per unit was dependant on the degree of support from management, clear job descriptions, good staff selection, a small financial contribution to the hospital and PCUs for academic activities, and the enthusiasm of staff and their other workload. On completion of the study, its acceptability and uptake were assessed by interviewing seven executive officers, six health workers who provided the screening and intervention, and 23 patients; holding focus-group discussions with 38 health workers; and asking 43 staff members and 75 patients to complete a self-administered questionnaire. The health workers’ knowledge and skills improved during the project, although some remained unconfident and asked senior colleagues to undertake the brief intervention. Every patient regarded the procedure as helpful and more than 85% of them were ‘satisfied’ with it. The procedure was quick to administer and easy to incorporate into busy practices at low cost, which are particularly important in developing countries. It does not produce dramatic results but the benefits achieved, multiplied nationwide, can have an appreciable effect. A difficulty in getting it accepted is that these benefits may not be apparent to those asked to divert scarce resources into implementing it.
1141
Discussion When faced with a large psycho-social problem, with few effective means of alleviating it, people clutch at straws and are at risk of accepting with insufficient analysis an approach that may have a limited effect and/or for which there is weak evidence. Being mindful of this, the authors embarked on the research with an open-minded, long-term view, and provisionally accepted that existing evidence for the effectiveness of brief intervention for alcohol and other substance misuse - coming from countries as diverse as Australia, Brazil, India, the US and UK4,9 e is robust, but did not lose sight of the fact that any beneficial effect could be small. The authors realised that research of this kind is fraught with methodological hazards. Subjects who agree to intervention probably include some people who are already sufficiently motivated that they might modify their substance misuse without intervention, thereby introducing a selection bias. Also, non-disclosure of substance misuse in small communities in which people know each other’s business and are unconfident about assurances of confidentiality can lead to an under-estimation of the problem, while the possibility that people who find it hard to show lack of gratitude or hurt others because of their culture might give overobliging, favourable responses to questions concerning outcome.10 Thus, although existing evidence points towards the value of the screening-intervention procedure, it is crucial that more research is carried out into its effect size and the maintenance of beneficial effects over longer time periods in different cultures and different settings; overviews of costs and benefits are continually reviewed; and judgements and priorities are modified in the light of any new evidence that might be forthcoming.
Author statements Acknowledgements Most importantly the authors thank the participants for agreeing to take part in the study. The authors also express their appreciation to the Integrated Community Management for Substance Abuse Programme (I-MAP) of the Thai Health Promotion Foundation for providing the research grant; WHO Collaborating Centre for Research in the Treatment of Drug and Alcohol Problems, Drug and Alcohol Services South Australia, University of Adelaide for providing training on the ASSIST-BI process and other technical assistance; and all of their colleagues who contributed so much to the success of the project.
Ethical approval Ethical approval for the study was obtained from the Institutional Ethics Review Board of the Faculty of Medicine of Prince of Songkla University and patients and health workers gave their consent to participate.
1142
p u b l i c h e a l t h 1 2 7 ( 2 0 1 3 ) 1 1 4 0 e1 1 4 2
Funding The Integrated Community Management for Substance Abuse Programme (I-MAP) of the Thai Health Promotion Foundation provided the research grant. The I-MAP had no involvement in the study design; collection, analysis or interpretation of data; writing of the manuscript; or decision to submit the paper for publication. The Epidemiology Unit is partially supported by the National Science and Technology Development Agency, Ministry of Science and Technology, Thailand.
3.
4.
5.
Authors’ contribution SA conceived and designed the study with advice from JGE; SA and QB collected and analysed the data; each author interpreted the data and contributed to the drafting of the manuscript.
Competing interests
6.
7.
None. 8.
references 9. 1. World Health Organization. Atlas on substance use (2010): resources for the prevention and treatment of substance use disorders. Geneva: World Health Organization; 2010. p. 137. 2. Thai Burden of Disease Working Group. Burden of diseases, Thailand 2009. Bangkok: International Health Policy Program. Available at: http://www.thaibod.net/index.php? option¼com_phocadownload&view¼category&id¼5%
10.
3A2012-08-22-01-36-53&Itemid¼34&lang¼th; 2012 (accessed 1 October 2012). World Health Organization. The ASSIST project e Alcohol, Smoking and Substance Involvement Screening Test. Available at: http://www.who.int/substance_abuse/activities/assist/en/ index.html; 2009 (accessed 8 January 2010). Humeniuk R, Ali R, Babor T, Souza-Formigoni ML, de Lacerda RB, Ling W, McRee B, Newcombe D, Pal H, Poznyak V, Simon S, Vendetti J. A randomized controlled trial of a brief intervention for illicit drugs linked to the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in clients recruited from primary health-care settings in four countries. Addiction 2012;107:957e66. Jonas DE, Garbutt JC, Amick HR, Brown JM, Brownley KA, Council CL, Viera AJ, Wilkins TM, Schwartz CJ, Richmond EM, Yeatts J, Evans TS, Wood SD, Harris RP. Behavioral counseling after screening for alcohol misuse in primary care: a systematic review and meta-analysis for the U.S. Preventive Services Task Force. Ann Intern Med 2012;157:645e54. Humeniuk R, Henry-Edwards S, Ali R, Poznyak V, Monteiro M. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): manual for use in primary care. Geneva: World Health Organization; 2010. p. 68. Humeniuk R, Henry-Edwards S, Ali R, Meena S. Self-help strategies for cutting down or stopping substance use: a guide. Geneva: World Health Organization; 2010. p. 41. Humeniuk R, Henry-Edwards S, Ali R, Poznyak V, Monteiro M. The ASSIST-linked brief intervention for hazardous and harmful substance use: manual for use in primary care. Geneva: World Health Organization; 2010. p. 40. Kaner E, Bland M, Cassidy P, Coulton S, Dale V, Deluca P, Gilvarry E, Godfrey C, Heather N, Myles J, Newbury-Birch D, Oyefeso A, Parrott S, Perryman K, Phillips T, Shepherd J, Drummond C. Effectiveness of screening and brief alcohol intervention in primary care (SIPS trial): pragmatic cluster randomised controlled trial. BMJ 2013;346:e8501. Assanangkornchai S, Nima P, Edwards JG. Alcohol screening and brief intervention: is screening without intervention sufficient? BMJ 2013;346:e8501.
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Short Communication
Screening and brief intervention for substance misuse in Thailand S. Assanangkornchai a,*, Q. Balthip b, J. Guy Edwards a,c a
Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand Faculty of Nursing, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand c Department of Psychiatry, Royal South Hants Hospital, Southampton SO14 0YG, United Kingdom b
article info Article history: Received 21 January 2013 Received in revised form 19 February 2013 Accepted 20 August 2013 Available online 23 November 2013
Introduction Globally, the use of alcohol and illicit substances accounts for 13 disability-adjusted life years (DALY’s) lost per 1000 population or 5.4% of the total burden of disease, with 11 due to alcohol and two to illegal substances.1 In Thailand alcohol, tobacco and illicit substance use ranked first, second and twelfth among the top risk factors for DALY’s lost in both sexes in 2009.2 Several attempts have been made to combat this escalating problem in Thailand, including the development of prevention and treatment packages and employment and training of healthcare workers to encourage early intervention and engagement in treatment. The implementation of the World Health Organisation recommended Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) and its linked brief intervention3 (ASSIST-BI) in primary care settings is one such effort. The aim of this paper is to report the results of our work on a model for developing and implementing an ASSIST-BI service in primary care units of four districts in the north-eastern
and southern regions and assessing its acceptability and uptake. As a result of our findings, the ASSIST-BI procedure has been incorporated into a national intervention package for substance misuse and the training of healthcare workers across the country. A related study of its effectiveness will be reported elsewhere. The screening component of the ASSIST allows for scoring of the quantity and frequency of use of all legal and illegal substances and related variables. It has cut-off points that suggest low-, moderate- and high-risk levels of substance use. High-risk users were referred to an appropriate treatment unit, while those at moderate-risk were offered ASSIST-linked brief intervention, a structured 10-step brief counselling programme. The aim of this procedure was to identify and provide intervention for substance misuse before it caused excessive harm. There is an increasing body of evidence for its effectiveness.4,5
Implementation of the ASSIST-BI service The English version of the ASSIST6 was translated into Thai. As krathom (mitragynine speciosa, a plant-based narcotic, mostly chewed by the middle aged and elderly) and ‘krathom cocktail’ made by boiling krathom leaves with a benzodiazepine (mostly alprazolam), codeine cough syrup, chlorpheniramine and/or phenylephrine in a cola drink (mostly used by youngsters) are widely used in Thailand, they were added to the substances included in the ASSIST. The Thai translation was back-translated into English and the accuracy of the backtranslation verified. The ASSIST manual, feedback report card,
* Corresponding author. Tel.: þ66 74 451 165-166; fax: þ66 74 429754. E-mail address: [email protected] (S. Assanangkornchai). 0033-3506/$ e see front matter ª 2013 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.puhe.2013.08.011
p u b l i c h e a l t h 1 2 7 ( 2 0 1 3 ) 1 1 4 0 e1 1 4 2
intervention manual and self-help book7,8 were similarly translated. Districts in which the study would best be undertaken were selected on the basis that they had a known drug problem; had adequate transport; were safe for researchers; and had the potential for expansion if the study were to yield costeffective, beneficial results. Choompae and Prayeun in the North East and Chana and Kuan Niang in the South met these criteria and were chosen. In each district, the study was undertaken in district hospitals (called community hospitals in Thailand) and their two to three networking sub-district primary care units (PCU’s). Prior to launching the study the aims, evidence for effectiveness and potential benefits were explained to staff at all levels (from major decision takers to the nurses and health workers who would be administering the procedure) in these districts and their agreement to participate obtained. Workshops with demonstrations, group discussions and role play were arranged to train staff, including future trainers and supervisors, and to provide education on psychoactive drugs and their misuse, the role of primary care staff in early recognition and intervention, and the principles and practice of the ASSIST-BI procedure.
Uptake and acceptability of the ASSIST-BI procedure Within 10 months of the launch, 5931 patients aged 18 to 65 attending the centres agreed to be screened. Of these, 1757 (30%) were rated as being at ‘moderate-risk’ of substancerelated problems and 1627 were given ASSIST-linked brief intervention, while 203 (3.4%) were rated at ‘high-risk’. The main substances abused were tobacco (49% of all those screened), alcohol (32%), cannabis (2%), amphetamine-type stimulants and krathom (less than 1%). The number of patients screened per unit was dependant on the degree of support from management, clear job descriptions, good staff selection, a small financial contribution to the hospital and PCUs for academic activities, and the enthusiasm of staff and their other workload. On completion of the study, its acceptability and uptake were assessed by interviewing seven executive officers, six health workers who provided the screening and intervention, and 23 patients; holding focus-group discussions with 38 health workers; and asking 43 staff members and 75 patients to complete a self-administered questionnaire. The health workers’ knowledge and skills improved during the project, although some remained unconfident and asked senior colleagues to undertake the brief intervention. Every patient regarded the procedure as helpful and more than 85% of them were ‘satisfied’ with it. The procedure was quick to administer and easy to incorporate into busy practices at low cost, which are particularly important in developing countries. It does not produce dramatic results but the benefits achieved, multiplied nationwide, can have an appreciable effect. A difficulty in getting it accepted is that these benefits may not be apparent to those asked to divert scarce resources into implementing it.
1141
Discussion When faced with a large psycho-social problem, with few effective means of alleviating it, people clutch at straws and are at risk of accepting with insufficient analysis an approach that may have a limited effect and/or for which there is weak evidence. Being mindful of this, the authors embarked on the research with an open-minded, long-term view, and provisionally accepted that existing evidence for the effectiveness of brief intervention for alcohol and other substance misuse - coming from countries as diverse as Australia, Brazil, India, the US and UK4,9 e is robust, but did not lose sight of the fact that any beneficial effect could be small. The authors realised that research of this kind is fraught with methodological hazards. Subjects who agree to intervention probably include some people who are already sufficiently motivated that they might modify their substance misuse without intervention, thereby introducing a selection bias. Also, non-disclosure of substance misuse in small communities in which people know each other’s business and are unconfident about assurances of confidentiality can lead to an under-estimation of the problem, while the possibility that people who find it hard to show lack of gratitude or hurt others because of their culture might give overobliging, favourable responses to questions concerning outcome.10 Thus, although existing evidence points towards the value of the screening-intervention procedure, it is crucial that more research is carried out into its effect size and the maintenance of beneficial effects over longer time periods in different cultures and different settings; overviews of costs and benefits are continually reviewed; and judgements and priorities are modified in the light of any new evidence that might be forthcoming.
Author statements Acknowledgements Most importantly the authors thank the participants for agreeing to take part in the study. The authors also express their appreciation to the Integrated Community Management for Substance Abuse Programme (I-MAP) of the Thai Health Promotion Foundation for providing the research grant; WHO Collaborating Centre for Research in the Treatment of Drug and Alcohol Problems, Drug and Alcohol Services South Australia, University of Adelaide for providing training on the ASSIST-BI process and other technical assistance; and all of their colleagues who contributed so much to the success of the project.
Ethical approval Ethical approval for the study was obtained from the Institutional Ethics Review Board of the Faculty of Medicine of Prince of Songkla University and patients and health workers gave their consent to participate.
1142
p u b l i c h e a l t h 1 2 7 ( 2 0 1 3 ) 1 1 4 0 e1 1 4 2
Funding The Integrated Community Management for Substance Abuse Programme (I-MAP) of the Thai Health Promotion Foundation provided the research grant. The I-MAP had no involvement in the study design; collection, analysis or interpretation of data; writing of the manuscript; or decision to submit the paper for publication. The Epidemiology Unit is partially supported by the National Science and Technology Development Agency, Ministry of Science and Technology, Thailand.
3.
4.
5.
Authors’ contribution SA conceived and designed the study with advice from JGE; SA and QB collected and analysed the data; each author interpreted the data and contributed to the drafting of the manuscript.
Competing interests
6.
7.
None. 8.
references 9. 1. World Health Organization. Atlas on substance use (2010): resources for the prevention and treatment of substance use disorders. Geneva: World Health Organization; 2010. p. 137. 2. Thai Burden of Disease Working Group. Burden of diseases, Thailand 2009. Bangkok: International Health Policy Program. Available at: http://www.thaibod.net/index.php? option¼com_phocadownload&view¼category&id¼5%
10.
3A2012-08-22-01-36-53&Itemid¼34&lang¼th; 2012 (accessed 1 October 2012). World Health Organization. The ASSIST project e Alcohol, Smoking and Substance Involvement Screening Test. Available at: http://www.who.int/substance_abuse/activities/assist/en/ index.html; 2009 (accessed 8 January 2010). Humeniuk R, Ali R, Babor T, Souza-Formigoni ML, de Lacerda RB, Ling W, McRee B, Newcombe D, Pal H, Poznyak V, Simon S, Vendetti J. A randomized controlled trial of a brief intervention for illicit drugs linked to the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in clients recruited from primary health-care settings in four countries. Addiction 2012;107:957e66. Jonas DE, Garbutt JC, Amick HR, Brown JM, Brownley KA, Council CL, Viera AJ, Wilkins TM, Schwartz CJ, Richmond EM, Yeatts J, Evans TS, Wood SD, Harris RP. Behavioral counseling after screening for alcohol misuse in primary care: a systematic review and meta-analysis for the U.S. Preventive Services Task Force. Ann Intern Med 2012;157:645e54. Humeniuk R, Henry-Edwards S, Ali R, Poznyak V, Monteiro M. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): manual for use in primary care. Geneva: World Health Organization; 2010. p. 68. Humeniuk R, Henry-Edwards S, Ali R, Meena S. Self-help strategies for cutting down or stopping substance use: a guide. Geneva: World Health Organization; 2010. p. 41. Humeniuk R, Henry-Edwards S, Ali R, Poznyak V, Monteiro M. The ASSIST-linked brief intervention for hazardous and harmful substance use: manual for use in primary care. Geneva: World Health Organization; 2010. p. 40. Kaner E, Bland M, Cassidy P, Coulton S, Dale V, Deluca P, Gilvarry E, Godfrey C, Heather N, Myles J, Newbury-Birch D, Oyefeso A, Parrott S, Perryman K, Phillips T, Shepherd J, Drummond C. Effectiveness of screening and brief alcohol intervention in primary care (SIPS trial): pragmatic cluster randomised controlled trial. BMJ 2013;346:e8501. Assanangkornchai S, Nima P, Edwards JG. Alcohol screening and brief intervention: is screening without intervention sufficient? BMJ 2013;346:e8501.
