The use of a brief intervention (BI) has been recommended by the World Health Organization (WHO) as an intervention to address problematic substance use.1 It recommends a two-step approach, whereby the most problematic substance is first identified using the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). Once identified, the clinician can deliver a BI tailored for the identified substance. WHO advises refining and tailoring the BI to meet the needs of the target population, to consider the context and culture of the service setting, thus ensuring it meets local needs and is both culturally and contextually suitable.2

This paper outlines the development and process used to customise a BI for use with opioid-dependent methadone-maintained patients and to ensure its compatibility with the culture of an Irish drug-using population.3 The authors sought to tailor all intervention materials for use in a subsequent cluster randomised controlled trial.

Method

Clinicians and patients took part in the process, which occurred in Dublin between December 2012 and February 2013. 

• Fifteen clinicians participated in two focus group sessions, which were conducted in two large addiction treatment centres in Dublin.
• Patient participants were opioid-dependent methadone-maintained polydrug users not attending any of the study sites. They were recruited through a forum representing service users of addiction services.
• One-to-one qualitative semi-structured interviews were conducted with 10 patients, which were carried out in a neutral setting.
• Clinicians and patients were given a participant information sheet about the research, a draft of the intervention manual, and all relevant draft materials.

– The intervention manual contained a description of the main elements of the ASSIST screening tool and brief interventions.

– Draft material included a step-by-step guide for use by the clinician during the BI. Patient materials included items such as example pros and cons for changing substance use behaviour and take-home materials.

• The main points of the focus groups and interviews were summarised and presented at the end of each session. Participants were asked to confirm whether it accurately reflected what had been discussed.
• Thematic analysis was chosen for data analysis. Themes were not determined in advance but emerged as patterns in the data and were grouped into themes. Themes were reviewed and refined. 

Results

Feedback from clinicians and patients was used to guide the development of the BI and associated materials. Suggested changes were implemented if there was majority agreement, if in line with the key elements of BIs, and if practical.

• WHO uses two manuals to describe the ASSIST and a BI; these were combined into a single BI manual and the style of the manual refined.
• A sample script of a screening and BI session was developed as well as an algorithm to facilitate clinicians during the BI session.
• A Substance Risk Card had been created for each individual substance assessed within the ASSIST screening tool. These cards outlined risks associated with the use of certain substances.
• The cards were modified: changes included weighting the severity of the risks, reordering associated risks with the more problematic risks at the top and the inclusion of how particular substances might interact with methadone and exacerbate problems for users.
• Tickboxes were added to the risk cards. These boxes allow risks that are pertinent to a patient to be ticked by the clinician during a session, therefore tailoring the BI to the patient based on their own individual risk profile.
• To address literacy concerns for illiterate or semi-literate patients, photographs were added to illustrate key risk factors.
• The language on the card was simplified and written in the first person to personalise the feedback.
• Patients recognised the physical risks of taking drugs, such as dental damage and the physical damage that long-term drug use can have on appearance.
• The ‘Pros and Cons of Substance Use’ section of a BI was used by the clinician to help patients explore why they use a substance and to consider reasons to reduce use or quit. Issues such as addiction, financial reasons to quit or cut down, risk of criminal activity and court conviction were important to patients and included as categories. More detail was added to examples.
• The value of proposed patient take-home material from the BI session, comprising the Feedback Report Card with results from the ASSIST screening tool and a personalised Substance Risk Card, was discussed. Patient opinion was divided on its usefulness. Concerns for patient confidentiality led to the adoption of a generic folder with a neutral title and cover. 

Conclusion

The authors adhered to WHO recommendations to tailor BI programmes to be culturally and contextually appropriate to the treatment cohort and clinical environment. Qualitative methods were used to identify and implement modifications to the BI and material for use in a later trial. The BI manual was used to standardise training of clinicians for the later trial. Outcome data published elsewhere demonstrated that the tailored intervention was effective.4 

2   Humeniuk R, Dennington V and Ali R (2008) The effectiveness of a brief intervention for illicit drugs linked to the alcohol, smoking and substance involvement screening test (ASSIST) in primary health care settings: a technical report of phase III findings of the WHO ASSIST randomized controlled trial. Geneva: Department of Mental Health and Substance Dependence, World Health Organization. Available online at https://www.drugsandalcohol.ie/28120/

3 Darker CD, Sweeney B, Keenan E, Whiston L, Anderson R, Barry J (2016) Tailoring a brief intervention for illicit drug use and alcohol use in Irish methadone maintained opiate dependent patients: a qualitative process. BMC Psychiatry, 16(1): 373. https://www.drugsandalcohol.ie/26362/

4 Darker CD, Sweeney B, Keenan E, Whiston L, Anderson R, Barry J (2016) Screening and brief interventions for illicit drug use and alcohol use in methadone maintained opiate-dependent patients: results of a pilot cluster randomized controlled trial feasibility study. Subst Use Misuse, 51(9): 1104—15. https://www.drugsandalcohol.ie/25507/