Problema de Salud AUGE N°53
Consumo perjudicial y Dependencia de Alcohol y otras Drogas en personas menores de 20 años
r1-2018
En personas menores de 20 años con consumo perjudicial o dependencia de alcohol o drogas, el Ministerio de Salud SUGIERE realizar intervención motivacional de “enganche” previo al inicio de tratamiento.
Comentarios del panel:
►La intervención motivacional esta descrita en la Guía de intervención motivacional (ver documento)
El Panel de Expertos analizó y debatió cada uno de las preguntas de la “Tabla de la evidencia a la decisión”, considerando tanto la evidencia de investigación, experiencia clínica, conocimiento de gestión o experiencia de los pacientes. Una vez consensuada la postura del panel respecto a las preguntas, emitieron un juicio seleccionando la opción de respuesta que mejor representaba la opinión del conjunto (destacada con color). Finalmente cuando el panel emitió su juicio sobre todas las preguntas, se emitió la recomendación.
A continuación se presenta la “Tabla de la evidencia a la decisión” con el resumen de los juicios, la evidencia de investigación evaluada, consideraciones adicionales y comentarios planteados por el panel.
1.- ¿El problema es una prioridad?
| No | Probablemente no | Probablemente sí | Sí | Varía | No lo sé |
|---|
El problema ha sido definido como prioritario en el marco de las Garantías Explícitas en Salud (GES), régimen integral de salud que prioriza un grupo de patologías o problemas de salud, garantizando el acceso a tratamiento oportuno y de calidad.
2.- ¿Qué tan significativos son los efectos deseables anticipados?
| Trivial | Pequeño | Moderado | Grande | Varía | No lo sé |
|---|
Moderados: El panel de expertos consideró que los efectos deseables de realizar intervención motivacional son moderados, en función de la evidencia de investigación, experiencia clínica, conocimiento de gestión o experiencia de los pacientes.
Consideraciones adicionales
El panel considera que la entrevista motivacional genera vínculos para adherir al tratamiento, siendo este el outcome que consideran más importante.
Evidencia de investigación
Tabla de Resumen de Resultados (Summary of Findings)
|
Intervención motivacional en personas menores de 20 años con trastornos por uso de alcohol y drogas |
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|
Pacientes |
En personas menores de 20 años con trastornos por uso de alcohol y otras drogas. |
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|
Intervención |
Realizar intervención motivacional. |
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|
Comparación |
No realizar intervención motivacional. |
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|
Desenlaces |
Efecto relativo (IC 95%) — Estudios/ pacientes |
Efecto |
Certeza de la evidencia (GRADE) |
Mensajes clave en términos sencillos |
|
|
Adherencia al tratamiento** |
— 4 ensayos en una revisión sistemática/ 1354 pacientes [140] |
DME*: 0,11 menos (0,41 a 0,19 más) |
⊕◯◯◯1,2,3 Muy baja |
Realizar intervención motivacional podría tener poca diferencia en la adherencia al tratamiento en comparación a no realizar. Sin embargo, existe considerable incertidumbre dado que la certeza de la evidencia es muy baja. |
|
|
Libre de uso de sustancias*** (Seguimiento de 6 a 12 meses) |
— 5 ensayos en una revisión sistemática/ 890 pacientes [140]
|
DME*: 0,08 más (0,05 a 0,21 más) |
⊕⊕◯◯1,2 Baja |
Realizar intervención motivacional podría tener poca diferencia en el uso de sustancias a mediano plazo en comparación a no realizar, pero la certeza de la evidencia es baja. |
|
DME: Diferencia de medias estandarizada.
GRADE: Grados de evidencia Grading of Recommendations Assessment, Development and Evaluation.
* La diferencia de medias estandarizada se utiliza cuando el desenlace ha sido medido en diferentes escalas y es difícil de interpretar clínicamente. Una regla general es que valores menores a 0,2 son de poca relevancia clínica, valores de 0,5 de relevancia moderada y 0,8 relevancia clínica importante.
** La adherencia o retención del tratamiento fue medido en días de asistencia a las sesiones en relación al número total de sesiones de tratamiento.
*** La proporción de abuso de sustancias fue medido en días de abstinencia de alcohol y drogas en relación al tiempo total de seguimiento.
1 Se disminuyó un nivel de certeza de evidencia por riesgo de sesgo ya que varios ensayos no fueron ciegos y no está claro o no es adecuada la generación de secuencia de aleatorización y ocultamiento de ésta.
2 Se disminuyó un nivel de certeza de evidencia por ser indirecta, ya que la estimación proviene de pacientes adultos.
3 Se disminuyó un nivel de certeza por inconsistencia, ya que existen diferencias entre los resultados de los distintos estudios incluidos y presenta un i2 alto.
Fecha de elaboración de la tabla: Diciembre, 2018.
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110. Spirito A, Sindelar-Manning H, Colby SM, Barnett NP, Lewander W, Rohsenow DJ, Monti PM. Individual and family motivational interventions for alcohol-positive adolescents treated in an emergency department: results of a randomized clinical trial. Archives of pediatrics & adolescent medicine. 2011;165(3):269-74. www.epistemonikos.org/en/documents/ea8a25d3e622b1d7c57f23b8743e95637fae5045
111. Stein LA, Colby SM, Barnett NP, Monti PM, Golembeske C, Lebeau-Craven R. Effects of motivational interviewing for incarcerated adolescents on driving under the influence after release. The American journal on addictions / American Academy of Psychiatrists in Alcoholism and Addictions. 2006;15 Suppl 1:50-7. www.epistemonikos.org/en/documents/6054e90102759d335fc7ca8342252cae4c967f21
112. Stein LA, Clair M, Lebeau R, Colby SM, Barnett NP, Golembeske C, Monti PM. Motivational interviewing to reduce substance-related consequences: effects for incarcerated adolescents with depressed mood. Drug and alcohol dependence. 2011;118(2-3):475-8. www.epistemonikos.org/en/documents/ed8a31b1f667055dfb415d29c510396193faae39
113. Stein LA, Monti PM, Colby SM, Barnett NP, Golembeske C, Lebeau-Craven R, Miranda R. Enhancing Substance Abuse Treatment Engagement in Incarcerated Adolescents. Psychological services. 2006;3(1):25-34. www.epistemonikos.org/en/documents/004044ca45560ef8708038ae9849856c1f4906f8
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115. Suffoletto B, Kristan J, Chung T, Jeong K, Fabio A, Monti P, Clark DB. An Interactive Text Message Intervention to Reduce Binge Drinking in Young Adults: A Randomized Controlled Trial with 9-Month Outcomes. PloS one. 2015;10(11):e0142877. www.epistemonikos.org/en/documents/60625f4d956b4f75f36bb0d6b7caf530e0acab57
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120. Thrush C, Wiers RW, Moerbeek M, Ames SL, Grenard JL, Sussman S, Stacy AW.. Influence of motivational interviewing on explicit and implicit alcohol‐related cognition and alcohol use in at‐risk adolescents. Psychology of Addictive Behaviors. 2009;23(1):146-51. www.epistemonikos.org/en/documents/c1bde28059a05433eafdb45c2a471f28ab866101
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Búsqueda y Síntesis de Evidencia
Búsqueda y síntesis de evidencia de efectos deseables e indeseables
3.- ¿Qué tan significativos son los efectos indeseables anticipados?
| Grande | Moderado | Pequeño | Trivial | Varía | No lo sé |
|---|
Pequeños: El panel de expertos consideró que los efectos indeseables de realizar intervención motivacional son pequeños, en función de la evidencia de investigación, experiencia clínica, conocimiento de gestión o experiencia de los pacientes.
Consideraciones Adicionales
No se reportaron eventos adversos asociado al uso de bastón con un punto de apoyo en la evidencia seleccionada.
Evidencia de investigación
Tabla de Resumen de Resultados (Summary of Findings)
|
Intervención motivacional en personas menores de 20 años con trastornos por uso de alcohol y drogas |
|||||
|
Pacientes |
En personas menores de 20 años con trastornos por uso de alcohol y otras drogas. |
||||
|
Intervención |
Realizar intervención motivacional. |
||||
|
Comparación |
No realizar intervención motivacional. |
||||
|
Desenlaces |
Efecto relativo (IC 95%) — Estudios/ pacientes |
Efecto |
Certeza de la evidencia (GRADE) |
Mensajes clave en términos sencillos |
|
|
Adherencia al tratamiento** |
— 4 ensayos en una revisión sistemática/ 1354 pacientes [140] |
DME*: 0,11 menos (0,41 a 0,19 más) |
⊕◯◯◯1,2,3 Muy baja |
Realizar intervención motivacional podría tener poca diferencia en la adherencia al tratamiento en comparación a no realizar. Sin embargo, existe considerable incertidumbre dado que la certeza de la evidencia es muy baja. |
|
|
Libre de uso de sustancias*** (Seguimiento de 6 a 12 meses) |
— 5 ensayos en una revisión sistemática/ 890 pacientes [140]
|
DME*: 0,08 más (0,05 a 0,21 más) |
⊕⊕◯◯1,2 Baja |
Realizar intervención motivacional podría tener poca diferencia en el uso de sustancias a mediano plazo en comparación a no realizar, pero la certeza de la evidencia es baja. |
|
DME: Diferencia de medias estandarizada.
GRADE: Grados de evidencia Grading of Recommendations Assessment, Development and Evaluation.
* La diferencia de medias estandarizada se utiliza cuando el desenlace ha sido medido en diferentes escalas y es difícil de interpretar clínicamente. Una regla general es que valores menores a 0,2 son de poca relevancia clínica, valores de 0,5 de relevancia moderada y 0,8 relevancia clínica importante.
** La adherencia o retención del tratamiento fue medido en días de asistencia a las sesiones en relación al número total de sesiones de tratamiento.
*** La proporción de abuso de sustancias fue medido en días de abstinencia de alcohol y drogas en relación al tiempo total de seguimiento.
1 Se disminuyó un nivel de certeza de evidencia por riesgo de sesgo ya que varios ensayos no fueron ciegos y no está claro o no es adecuada la generación de secuencia de aleatorización y ocultamiento de ésta.
2 Se disminuyó un nivel de certeza de evidencia por ser indirecta, ya que la estimación proviene de pacientes adultos.
3 Se disminuyó un nivel de certeza por inconsistencia, ya que existen diferencias entre los resultados de los distintos estudios incluidos y presenta un i2 alto.
Fecha de elaboración de la tabla: Diciembre, 2018.
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Búsqueda y Síntesis de Evidencia
Búsqueda y síntesis de evidencia de efectos deseables e indeseables
4.- ¿Cuál es la certeza general de la evidencia sobre efectos?
| Muy baja | Baja | Moderada | Alta | Ningún estudio incluido |
|---|
Muy Baja: Existe considerable incertidumbre respecto del efecto de realizar intervención motivacional.
Evidencia de investigación
|
Desenlaces |
Importancia |
Certeza de la evidencia |
|
Adherencia al tratamiento |
CRÍTICO |
⨁ ◯ ◯ ◯ |
|
Libre de uso de sustancias |
IMPORTANTE |
⨁ ⨁ ◯ ◯ |
a. Se redujo el nivel de certeza de evidencia de riesgo de sesgo y de que varios ensayos no fueron ciegos y no está claro o no es adecuado para la generación de la secuencia de aleatorización y ocultamiento de esta.
b. Se ha reducido el nivel de certeza por la inconsistencia, y se tiene que ver con los resultados de los distintos estudios incluidos.
c. Se ha reducido el nivel de certeza de la evidencia por ser indirecta, y se ha llegado a la conclusión.
5.- ¿Hay incertidumbre importante o variabilidad sobre qué tanto valora la gente los desenlaces principales?
| Incertidumbre o variabilidad importantes | Posiblemente hay incertidumbre o variabilidad importantes | Probablemente no hay incertidumbre ni variabilidad importantes | No hay variabilidad o incertidumbre importante |
|---|
Probablemente no hay incertidumbre ni variabilidad importantes: El panel de expertos consideró que probablemente no hay incertidumbre ni variabilidad importantes respecto a lo que la mayoría de los pacientes podrían llegar a elegir, en función de la evidencia de investigación, experiencia clínica, conocimiento de gestión o experiencia de los pacientes.
Consideraciones Adicionales
EI panel concuerda en que una intervención corta puede ser beneficiosa, y que los pacientes aceptarían una intervención breve.
Evidencia de investigación
Se identificó un estudio (1 ) que describe una intervención breve de entrevistas motivacionales en atención primaria para reducir el consumo de alcohol y marihuana en adolescentes de 12 a 18 años de edad en situación de riesgo.
Se llevó a cabo un ensayo controlado aleatorio en 4 clínicas de atención primaria desde abril de 2013 hasta noviembre de 2015 para determinar el efecto de una intervención (entrevista motivacional de 15 minutos) relacionada con alcohol y marihuana.
Aquellos identificados como en riesgo fueron asignados al azar a la intervención o a atención habitual. Los adolescentes completaron 4 encuestas: de línea de base y a los 3, 6 y 12 meses.
La muestra (n=294) fue 58% femenina, con edad promedio de 16 años.
En comparación con los adolescentes de la atención usual, los adolescentes de la intervención motivacional informaron un consumo significativamente menor de alcohol y marihuana entre los tres meses siguientes (alcohol: p <.0001; marihuana p = .01) y 6 meses (alcohol: p = .04; marihuana p = .04). Estos adolescentes también informaron menos consecuencias negativas asociadas a alcohol experimentadas a los 6 meses (p = .08). A los 12 meses, en comparación con la atención habitual, los adolescentes de la intervención motivacional informaron menor consumo de alcohol (p = .04) y marihuana (p <.01) entre pares y que el consumo de alcohol (p = .03) y marihuana (p = .04) tuvieron menos consecuencias negativas.
Una breve intervención motivacional entregada en atención primaria redujo las consecuencias negativas del consumo de alcohol y marihuana un año después. Los hallazgos enfatizan que los adolescentes pueden beneficiarse de las intervenciones en atención primaria que abordan de manera breve y efectiva el consumo de alcohol y marihuana.
Referencia
1. D’Amico EJ, Parast L, Shadel WG, Meredith LS, Seelam R, Stein BD. Brief motivational interviewing intervention to reduce alcohol and marijuana use for at-risk adolescents in primary care. J Consult Clin Psychol. 2018 Sep;86(9):775-786.
Búsqueda y Síntesis de Evidencia
Búsqueda y síntesis de evidencia de valores y preferencias de los pacientes
6.- El balance entre efectos deseables e indeseables favorece la intervención o la comparación?
| Favorece la comparación | Probablemente favorece la comparación | No favorece la intervención ni la comparación | Probablemente favorece la intervención | Favorece la intervención | Varía | No lo sé |
|---|
Favorece la intervención: Considerando que la intervención es «realizar intervención motivacional» y la comparación es «no realizar», el panel de experto opinó que el balance entre efectos deseables e indeseables claramente favorece realizar intervención motivacional.
7.- ¿Qué tan grandes son los recursos necesarios (costos)?
| Costos extensos | Costos moderados | Costos y ahorros despreciables | Ahorros moderados | Ahorros extensos | Varía | No lo sé |
|---|
Costos y ahorros despreciables: El panel de expertos consideró que para implementar la intervención realizar intervención motivacional no implica ni recursos ni ahorros significativos, en función de los antecedentes recolectados, experiencia clínica, conocimiento de gestión o experiencia de los pacientes.
Evidencia de investigación
Tabla. Precios referenciales*
|
Ítem |
Realizar intervención motivacional |
No realizar intervención motivacional |
|
Consulta de psiquiatría
|
$ 7.8001 |
—– |
|
Consulta o control por psicólogo clínico
|
$3.0601 |
—– |
|
Consulta o control por enfermera, matrona o nutricionista |
1.2501 |
—–
|
|
Consulta de salud mental por otros profesionales |
$3.0601 |
—–
|
|
|
Rango: $ 1.250-$7.800 |
—– |
*El porcentaje de cobertura del seguro de salud sobre el precio de la(s) prestación (es) sanitaria(s), dependerá del tipo de seguro de cada paciente.
Referencias:
1. Arancel MAI, 2018
Búsqueda y Síntesis de Evidencia
Búsqueda de costos
8.- ¿La costo-efectividad de la intervención beneficia la intervención o la comparación?
| Favorece la comparación | Probablemente favorece la comparación | No favorece la intervención ni la comparación | Probablemente favorece la intervención | Favorece la intervención | Varía | Ningún estudio incluido |
|---|
Ningún estudio incluido: No se realizó búsqueda de estudios que abordaran costo-efectividad, debido a que esta búsqueda se realiza sólo cuando la intervención es considerada un tratamiento o diagnóstico de alto costo (1).
Ministerio de Salud. Decreto 80: Determinar umbral nacional de costo anual al que se refiere el artículo 6° de la Ley 20.850 [Internet]. Santiago; 2015 Nov.
9.- ¿Cuál sería el impacto en equidad en salud?
| Reducido | Probablemente reducido | Probablemente ningún impacto | Probablemente aumentado | Aumentado | Varía | No lo sé |
|---|
Probablemente ningún impacto: El panel de expertos consideró que probablemente no tendría ningún impacto en la equidad en salud si se recomendase realizar intervención motivacional.
Consideraciones Adicionales
Existen grupos que no acuden a servicios de salud.
En algunos lugares no está disponible.
No siempre está disponible una persona entrenada que realice esta intervención.
10.- ¿La intervención es aceptable para las partes interesadas?
| No | Probablemente no | Probablemente sí | Sí | Varía | No lo sé |
|---|
Sí: El panel de expertos consideró que realizar intervención motivacional SÍ es aceptable para las partes interesadas (profesionales de la salud, gestores de centros de salud, directivos servicios de salud, pacientes, cuidadores, seguros de salud, otros).
11.- ¿Es factible implementar la intervención?
| No | Probablemente no | Probablemente sí | Sí | Varía | No lo sé |
|---|
Sí: El panel de expertos consideró que realizar intervención motivacional SÍ es factible implementar, contemplando la capacidad de la red asistencial, los recursos humanos disponibles a nivel país, recursos financieros, preferencias de los pacientes, etc.