Combined Pharmacotherapy and Cognitive Behavioral Therapy for Adults With Alcohol or Substance Use Disorders: A Systematic Review and Meta-analysis

Therapeutic effects of metformin on cocaine conditioned place preference and locomotion

Lack of Food and Drug Administration-approved treatments for cocaine use disorder contributes to high rates of treatment attrition, relapse, and overdose. Metformin is a Type 2 diabetes drug being investigated for multiple new therapeutic indications. This study set out to determine whether metformin would impact the conditioned rewarding effects of cocaine in an abbreviated or standard two-chamber conditioned place preference (CPP) assay. Adult male (n = 73) and female (n = 82) Sprague Dawley rats were conditioned in a 7-day (abbreviated: 2 × 30 min sessions daily) or a 12-day timeline (standard: 1 × 30 min sessions daily) alternating control and treatment sessions using an unbiased design. Metformin (175 mg/kg) or saline pretreatment occurred 30 min before conditioning with cocaine (20 mg/kg) or vehicle (saline). Data showed sex differences in physiological responses to cocaine and metformin, as well as variant behavioral patterns with different conditioning paradigms. Metformin pretreatment impaired acquisition of cocaine CPP in abbreviated, but not standard conditioning among male rats only. Cocaine-induced locomotor effects are moderated with metformin pretreatment in both female and male rats in different phases of conditioning, suggesting the potential therapeutic value of symptom alleviation when tapering patients off cocaine use with the goal of abstinence. Sex differences observed highlight the importance in better understanding the unique pharmacological profiles of female and male patients. This study provides evidence supporting the potential repurposing of metformin for disrupting rewarding and psychomotor effects of cocaine, paving the way for safe, low-cost, and accessible treatment. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

Efficacy and safety of psilocybin for the treatment of substance use disorders: A systematic review

Psilocybin, a serotonergic psychedelic, may have therapeutic benefits for Substance Use Disorders (SUDs), but its overall efficacy and safety remain uncertain. This systematic review assessed the safety and efficacy of psilocybin for SUDs through a systematic database search conducted via OVID on May 22, 2024, and summarized 26 ongoing clinical trials registered on clinicaltrials.gov. Among 16 published included studies, 7 (43.75 %) focused on Alcohol Use Disorder (AUD), 5 (31.25 %) on Tobacco Use Disorder (TUD), and the remainder on Cocaine Use Disorder (CUD) (1, 6.25 %), Opioid Use Disorder (1, 6.25 %), Nicotine Use Disorder (1, 6.25 %), and multiple SUDs (1, 6.25 %). Study designs included open-label trials (5, 31.25 %), cross-sectional observational studies (6, 37.5 %), qualitative analyses (2, 12.5 %), one double-blind RCT (6.25 %), one pilot fMRI study (6.25 %), and one long-term follow-up (6.25 %). Psilocybin-assisted psychotherapy (PAP) was used in 10 studies (62.5 %), with doses ranging from microdosing to 20-40 mg/70 kg. PAP was associated with significant reductions in alcohol consumption, smoking cessation, and related psychological improvements. AUD studies reported fewer heavy drinking days, increased abstinence rates, and neuroimaging data indicating normalization of brain activity. TUD studies demonstrated high smoking abstinence rates, with mystical experiences predicting long-term outcomes. Findings for other SUDs were mixed, though psilocybin showed potential in reducing opioid dependence and nicotine use. Preliminary evidence supports psilocybin's efficacy and safety for AUD and TUD, particularly with psychotherapy, but larger clinical trials are needed to confirm these findings.

Approved medications for opioid use disorder : current update

INTRODUCTION

Opioid use disorder (OUD) is recognized as a chronic, relapsing disorder with a high mortality and psychiatric and somatic comorbidity.

AREAS COVERED

Existing guidelines and meta-analyses on pharmacotherapy of opioid use disorder were reviewed. Opioid maintenance treatment (OMT) is the generally accepted first line treatment in OUD with oral methadone and buprenorphine being the gold standard. In recent years a number of novel opioids have been introduced into clinical practice including depot formulations of buprenorphine, retarded morphine and heroin (diacetylmorphine). The review refers to the different drugs available and gives an overview on clinical use, side effects, and efficacy in certain subgroups.

EXPERT OPINION

OMT is a success story with emerging new pharmacological options available. While oral methadone or buprenorphine still are the most suitable medications for many patients, depot formulations of buprenorphine may improve adherence and facilitate clinical management of many patients. Diacetylmorphine and retarded morphine are second line medications for treatment refractory patients. Future research may focus on responder characteristics for certain medications and efficacy in special subgroups as well as interaction of psychosocial and pharmacological treatments.

Psychological rehabilitation of individuals with alcohol use disorder, drug addiction, gambling disorder, and codependency

The objective of this study was to assess the impact of a 12-month course of cognitive behavioral therapy (CBT) on individuals diagnosed with alcohol use disorder, drug addiction, gambling disorder, and codependency, with a focus on improving quality of life and reducing symptom severity. A quantitative design was employed, involving both control and experimental groups, each initially comprising 100 participants. By the end of the study, the final sample sizes in the experimental groups were 72 (alcohol use disorder), 70 (drug addiction), 74 (gambling disorder), and 73 (codependent behavior) individuals. An equal number of participants in the corresponding control groups were reassessed. Quality of life was measured using the World Health Organization Quality of Life BREF instrument, which measures physical health, psychological health, social relationships, and environmental conditions. The results indicated a significant improvement in quality-of-life scores in the experimental groups compared to the control groups. The Wilcoxon signed-rank test confirmed statistically significant improvements (p < 0.001) across all addiction categories, while the Mann-Whitney U test demonstrated substantial post-intervention differences between control and experimental groups (p < 0.001). Participants in the experimental group showed marked reductions in addiction severity, as indicated by AUDIT, DAST, G-SAS, and Spann-Fisher Codependency Scale assessments. Effect sizes (Cohen's d) ranged from 2.83 to 3.47, confirming the strong impact of psychotherapy. These findings underscore the effectiveness of CBT in reducing addiction severity and enhancing quality of life, supporting its broader integration into addiction treatment programs. The study provides valuable evidence for addiction rehabilitation efforts in Kazakhstan. From a practical perspective, these findings highlight the importance of structured psychotherapeutic interventions in addressing addiction-related issues. The study underscores the need to expand access to CBT in rehabilitation centers, particularly in regions with high addiction rates. Future policy initiatives should prioritize the development of therapist training programs and the implementation of evidence-based treatment methods. Moreover, the results emphasize the necessity for continuous post-treatment support to maintain long-term recovery and prevent relapse. By incorporating CBT into standardized rehabilitation protocols, policymakers and healthcare providers can enhance the overall effectiveness of addiction treatment services.

Digital Integrated Interventions for Comorbid Depression and Substance Use Disorder: Narrative Review and Content Analysis

BACKGROUND

Integrated digital interventions for the treatment of comorbid depression and substance use disorder have been developed, and evidence of their effectiveness is mixed.

OBJECTIVE

This study aimed to explore potential reasons for mixed findings in the literature on integrated digital treatments. We described the methodologies and core characteristics of these interventions, identified the presence of evidence-based treatment strategies, examined patterns across digital modalities, and highlighted areas of overlap as well as critical gaps in the existing evidence base.

METHODS

In June 2024, a literature search was conducted in Google Scholar to identify digital integrated interventions for comorbid major depressive disorder and substance use disorder. Articles were included if they described interventions targeting both conditions simultaneously; were grounded in cognitive behavioral therapy, motivational interviewing, or motivational enhancement therapy; and were delivered at least in part via digital modalities. In total, 14 studies meeting these criteria were coded using an open-coding approach to identify intervention characteristics and treatment strategies (n=25). Statistical analyses summarized descriptive statistics to capture the frequency and overlap of these strategies.

RESULTS

Studies included a range of digital modalities: internet (n=6, 43%), computer (n=3, 21%), smartphone (n=2, 14%), and supportive text messaging interventions (n=3, 21%). Half (n=7, 50%) of the studies included participants with mild to moderate depression symptom severity and hazardous substance use. Only 36% (n=5) of the studies required participants to meet full diagnostic criteria for major depressive disorder for inclusion and 21% (n=3) required a substance use disorder diagnosis. Most interventions targeted adults (n=11, 79%), with few targeting young or emerging adults (n=4, 29%), and only 36% (n=5) reported detailed demographic data. Treatment duration averaged 10.3 (SD 6.8) weeks. Internet-based interventions offered the widest range of treatment strategies (mean 11.7), while supportive text messaging used the fewest (mean 4.6). Common treatment strategies included self-monitoring (n=11, 79%), psychoeducation (n=10, 71%), and coping skills (n=9, 64%). Interventions often combined therapeutic strategies, with psychoeducation frequently paired with self-monitoring (n=9, 64%), assessment (n=7, 50%), coping skills (n=7, 50%), decisional balance (n=7, 50%), feedback (n=7, 50%), and goal setting (n=7, 50%).

CONCLUSIONS

Among integrated digital interventions for comorbid depression and substance use, there was noteworthy variability in methodology, inclusion criteria, digital modalities, and embedded treatment strategies. Without standardized methods, comparison of the clinical outcomes across studies is challenging. These results emphasize the critical need for future research to adopt standardized approaches to facilitate more accurate comparisons and a clearer understanding of intervention efficacy.

ADHD and Alcohol Use Disorder: Optimizing Screening and Treatment in Co-occurring Conditions

Attention deficit hyperactivity disorder (ADHD) is notably overrepresented in substance use treatment centers, with an estimated prevalence of 21-23% when screening practices are implemented. Many adults in these settings receive an ADHD diagnosis for the first time, highlighting the frequent underdiagnosis of ADHD among individuals seeking treatment for alcohol and substance use issues. Additionally, those entering treatment programs represent only a small fraction of the broader population with problematic alcohol use. This review explores the research on the prevalence and treatment of co-occurring ADHD and substance use disorders (SUD), with a particular emphasis on alcohol use disorders (AUD) as the most common SUD. It also provides clinical guidelines for the screening and diagnosis of ADHD in patients with active alcohol and substance use and offers recommendations to enhance screening practices and improve access to treatment for individuals with co-occurring ADHD and AUD.

Treating Opioid Use Disorder and Opioid Withdrawal in the Context of Fentanyl

The opioid crisis, driven by illicitly manufactured fentanyl, presents significant challenges in treating opioid use disorder (OUD) and opioid withdrawal syndrome. Fentanyl is uniquely lethal due to its rapid onset and respiratory depressant effects, driving the surge in overdose deaths. This review examines the limitations of traditional diagnostic criteria like those of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) and explores the potential of dimensional models such as the Hierarchical Taxonomy of Psychopathology (HiTOP) for a more nuanced understanding of OUD. Current treatments, including medications for OUD, are evaluated for efficacy in managing fentanyl-related OUD. Innovations in drug formulations and alternative induction methods are discussed to address the unique challenges posed by fentanyl. Psychotherapeutic and behavioral interventions, such as cognitive behavioral therapy and contingency management, are highlighted as crucial complements to pharmacotherapy. The review underscores the need for increased precision, comprehensive phenotyping, and advanced diagnostics to develop personalized treatment plans, all with the aim of improving patient outcomes and mitigating the societal impact of the opioid crisis.

A Randomized Clinical Trial of Prolonged Exposure Therapy With and Without Topiramate for Comorbid PTSD and Alcohol Use Disorder

OBJECTIVE

Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) frequently co-occur. Prolonged exposure (PE) is an effective treatment for PTSD but shows smaller effects in patients with co-occurring AUD. Topiramate may help reduce alcohol use and PTSD symptoms. This double-blind, placebo-controlled outpatient clinical trial compared 12 sessions of PE plus either topiramate or placebo.

METHODS

One hundred U.S. veterans (mean age=45 years [SD=12], 84% men) with PTSD+AUD were randomly assigned to 16 weeks of treatment with PE+topiramate (up to 250 mg) or PE+placebo to examine effects on alcohol use and PTSD severity at posttreatment assessment and at 3- and 6-month follow-ups.

RESULTS

Percent heavy drinking days decreased significantly for both conditions but did not differ between groups. PTSD scores were lower in the PE+topiramate group than in the PE+placebo group at posttreatment assessment, but not at follow-ups. The same patterns were observed for loss of PTSD diagnosis and meaningful PTSD symptom change. Change in secondary outcomes (depression, quality of life) did not differ between conditions.

CONCLUSIONS

PE+topiramate was associated with a greater reduction in PTSD symptoms than PE+placebo during active treatment. The addition of topiramate led to more rapid and pronounced PTSD symptom reduction, which may be of benefit to patients. Because effects of topiramate were not maintained at longer-term follow-up, extending time on topiramate or additional strategies to prolong such effects may be useful. Topiramate did not show added benefit to PE for percent heavy drinking days or secondary outcomes.

Polysubstance Use Profiles Among the General Adult Population, United States, 2022

Objectives. To characterize present-day polysubstance use patterns in the general adult population. Methods. From a 2022 nationally representative survey in the United States, we defined polysubstance use as last 12-month use of 2 or more drugs (n = 15 800). Latent class analyses included medical (as indicated) and nonmedical (not as directed) use of prescription opioids, stimulants, benzodiazepines, and antidepressants; recreational use of cannabis, psilocybin or mushrooms, other psychedelics, cocaine, methamphetamine, and illicit opioids; and concomitant use with alcohol, cannabis, prescriptions, or recreational drugs. Results. The national prevalence of polysubstance use was 20.9% (95% confidence interval = 20.5%, 21.3%), broken down into the following 4 latent classes: (1) medically guided polysubstance use (11.5% prevalence, 6.1% substance use disorder [SUD]): prescribed drug use, some cannabis, and no concomitant use; (2) principal cannabis use variety (4.0% prevalence, 31.9% SUD): high probability of cannabis use with various drugs concomitantly used; (3) self-guided polysubstance use (3.4% prevalence, 14.5% SUD): nonmedical use of prescriptions and concomitant use; and (4) indiscriminate coexposures (2.1% prevalence, 58.9% SUD): concomitant drug use with indiscriminate drug preference. Conclusions. Different polysubstance profiles show adults with untreated SUDs, and there are 2 previously unrecognized classes. Prevention and treatment strategies addressing polysubstance use should take a personalized perspective and tailor to individuals' use profile. (Am J Public Health. 2025;115(5):747-757. https://doi.org/10.2105/AJPH.2024.307979).

A preliminary randomized trial of the safety, tolerability, and clinical effects of hemp-derived cannabidiol in alcohol use disorder

Introduction

Cannabidiol (CBD) has recently gained attention for its potential therapeutic effects in substance use disorders, including Alcohol Use Disorder (AUD). This study examined the potential therapeutic effects of commercially available products containing CBD with and without a small amount of tetrahydrocannabinol (THC) on alcohol use and craving among individuals with moderate to severe AUD.

Methods

In this feasibility study, a total of 44 participants were randomized to one of three conditions: full-spectrum CBD (n = 13, fsCBD - <0.3% THC), broad-spectrum CBD (n = 15, bsCBD - without THC), or placebo control (n = 16) for 8 weeks. The study was designed to assess the safety and tolerability of these treatments and to evaluate whether CBD demonstrated any clinical effects (Clinicaltrials.gov Identifier: NCT04873453; https://clinicaltrials.gov/study/NCT04873453). It was hypothesized that both CBD conditions would be well tolerated and would reduce drinking, alcohol dependence, and craving compared to placebo.

Results

Analyses of attrition and side effect data indicated no significant differences across conditions, suggesting that both bsCBD and fsCBD were well tolerated. Individuals receiving fsCBD demonstrated reductions in craving but no reduction in drinks per drinking day.

Discussion

In this pilot study, safety profiles fsCBD and bsCBD were similar, and fsCBD was associated with a greater reduction in craving and AUD symptoms relative to both bsCBD and placebo. Future studies with larger sample sizes will be necessary to replicate and extend these findings by addressing the question of whether a small amount of THC may work synergistically with CBD.

Evaluating the efficacy of valproic acid in alcohol use disorder: a systematic analysis of clinical trials from ClinicalTrials.gov

Background

Alcohol use disorder (AUD) represents a significant global health burden, characterized by high relapse rates and limited treatment options. Valproic acid, primarily used as an anticonvulsant and mood stabilizer, has been suggested as a potential therapeutic agent for AUD, particularly in patients with coexisting psychiatric conditions. This study systematically analyses clinical trials from ClinicalTrials.gov to evaluate the efficacy of valproic acid in treating AUD.

Methods

A systematic search of ClinicalTrials.gov was conducted to identify clinical trials involving valproic acid in the management of substance use disorder (SUD). A total of 3,822 studies related to SUD were initially identified. Screening for anticonvulsant use narrowed this to 96 trials, and four completed studies specifically involving valproic acid and AUD were included in the final analysis. Key outcomes related to relapse rates, substance use reduction, mood stabilization, and withdrawal symptoms were examined.

Results

The included studies focused on various conditions, including alcohol dependence, bipolar disorder with substance abuse, traumatic brain injury with alcohol use, and medication-overuse headache. Valproic acid demonstrated potential benefits in reducing alcohol consumption, stabilizing mood, and managing withdrawal symptoms in specific subpopulations. However, relapse rates remained high in some trials, indicating limited long-term efficacy. Secondary outcomes showed improvements in psychiatric symptoms, though adverse effects such as sedation and gastrointestinal disturbances were noted.

Conclusion

Valproic acid shows potential as a therapeutic option for managing AUD, particularly in individuals with coexisting psychiatric conditions or complex clinical profiles. While the drug showed some efficacy in reducing substance use and stabilizing mood, the overall impact on long-term abstinence remains uncertain. Further research is needed to better define the role of valproic acid in AUD treatment and to identify patient populations that may benefit most from its use.

What apps and websites do those in treatment for substance-related problems use to help them in their recovery? A cross-sectional study of products and use patterns

BACKGROUND

Given the global burden of substance use disorders (SUD), innovations in methods to achieve sustained recovery are critical. Digital health products (e.g., websites, smartphone apps) can complement and enhance existing SUD treatments or provide some assistance to those who cannot access formal treatment. One goal of the present study was to obtain descriptive information regarding the use of digital health products during SUD recovery. We also examined demographic and SUD-related correlates (e.g., severity, duration) of digital health product use and whether patterns of app use were related to perceived utility of the apps.

METHODS

A sample of 255 participants (45 % female, Mage = 41.4 [9.6]) recruited at several outpatient addictions treatment facilities in the northeastern US completed an online survey.

RESULTS

Forty-five percent of participants reported having used some kind of app or website to help them in recovery during their lifetimes. The most common motivations participants reported for using an app alongside treatment were to increase knowledge about addiction, hear advice from others in recovery, and to find motivation to stay sober. Those in most older age groups (35-40, 50+) had significantly lower odds of having used an app relative to 18-35 year-olds, and odds of reporting having used an app were 90 % higher among female participants versus others. Increased frequency of app use and using an app/website over a longer period of time were associated with higher ratings of perceived app helpfulness.

CONCLUSION

Future research is needed to determine whether using these products provides clinically meaningful benefits for patients, both in the presence and absence of traditional treatment.

Treating obesity in patients with depression: a narrative review and treatment recommendation

The high morbidity of obesity and depression pose significant public health concerns, with the prevalence of obesity doubling in the US between 1990 and 2022 and patients frequently presenting with both. Untreated obesity and depression can greatly impact patient health and well-being, as both obesity and depression are associated with a number of comorbidities including sleep apnea, type 2 diabetes mellitus, metabolic syndrome, metabolic dysfunction-associated steatotic liver disease, and cardiovascular disease. This narrative review aims to provide a comprehensive and current overview of the overlapping etiologies between obesity and depression as well as the available treatment options that may be recommended by primary care professionals to treat these patients with concomitant obesity and depression. With the considerable overlap in the population of patients with obesity and depression, as well as the overlap in the neurobiological, hormonal, and inflammatory pathways underlying both diseases, primary care professionals should consider screening patients presenting with obesity for depression. Holistic treatment options, including lifestyle and behavioral modifications, and pharmacotherapy for both depression and obesity and bariatric surgery for obesity are critical to manage both conditions simultaneously. Therefore, due to the overlapping neurobiological pathways and mechanisms responsible for the incidence and progression of both obesity and depression, a holistic treatment plan including strategies with efficacy for both conditions and any additional comorbidities may improve the clinical approach for patients with concomitant obesity and depression.

User Experience of a Just-in-Time Smartphone Resonance Breathing Application for Substance Use Disorder: Acceptability, Appropriateness, and Feasibility

BACKGROUND

Addressing the negative impact of substance use disorders (SUDs) on individuals, families, and communities is a public health priority. Most treatments and interventions require engagement with a healthcare provider or someone who can offer recovery support. The need for interventions that facilitate self-management of relapse triggers at the moment they occur is also critical. Our study aimed to explore the user experience of individuals using a just-in-time smartphone episodic resonance breathing (eRPB) intervention to address stress, anxiety, and drug cravings.

METHODS

We conducted an 8-week pilot study of the eRPB with 30 individuals in recovery from SUD. Data on 3 indicators of user experience-acceptability, appropriateness, and feasibility-were collected using survey questions (n = 30) and semi-structured interviews (n = 11). We performed univariate analysis on the survey data and deductive thematic analysis on the qualitative data.

RESULTS

A majority of the survey respondents agreed that the application (app) was acceptable (> 77%), appropriate (> 82%), and feasible (> 89%). Several interview participants stated that the app helped them relax and manage stress and cravings and expressed appreciation for the simplicity of its design. Participants also reported barriers to feasibility (such as forgetting to use the app) and recommendations for improvement (such as the addition of motivational messages).

CONCLUSIONS

Our findings show that individuals in recovery from SUD had highly positive experiences with the eRPB app. A positive user experience may improve adherence to the intervention and, ultimately, the self-management of stress, anxiety, and craving relapse triggers.

Combined pharmacological and psychosocial interventions for alcohol use disorder

BACKGROUND

Alcohol use disorder (AUD) is a mental disorder characterised by a strong desire to consume alcohol and impaired control of alcohol use, with devastating consequences. Many people with AUD do not respond to psychosocial or pharmacological interventions when these are provided alone. Combining these interventions may improve the response to treatment, though evidence remains limited.

OBJECTIVES

To assess the effects of combined pharmacological and psychosocial interventions for the treatment of AUD in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases, and two trials registers in November 2023, without language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing combined pharmacological and psychosocial interventions versus pharmacological or psychosocial interventions alone, or no intervention/treatment as usual (TAU), in adults with AUD. Our primary outcomes were continuous abstinent participants, frequency of use (measured as heavy drinkers, percentages of abstinent days, heavy-drinking days), amount of use (number of drinks per drinking day), adverse events, serious adverse events, dropouts from treatment, and dropouts due to adverse events.

DATA COLLECTION AND ANALYSIS

We assessed risk of bias using Cochrane's RoB 1 tool, performed random-effects meta-analyses, and evaluated the certainty of evidence according to the GRADE approach.

MAIN RESULTS

We included 21 RCTs (4746 participants). The most studied pharmacological and psychosocial interventions were naltrexone (81.0%) and cognitive behavioural therapy (66.7%), respectively. Most participants were men (74%), aged about 44 years, with AUD, without comorbid mental disorders or other substance use disorders; 15 RCTs detoxified participants before treatment. We judged 28.5% of the studies as at low risk of bias for random sequence generation, allocation concealment, performance bias for objective and subjective outcomes, and detection bias for subjective outcomes; all studies were at low risk of detection bias for objective outcomes; 85.7% of studies were at low risk of attrition bias; 14.2% of studies were at low risk of reporting bias. 1) Compared to psychosocial intervention alone, combined pharmacological and psychosocial interventions probably reduce the number of heavy drinkers (above the clinically meaningful threshold (MID) of 2%; absolute difference (AD) -10%, 95% confidence interval (CI) -18% to -2%; risk ratio (RR) 0.86, 95% CI 0.76 to 0.97; 8 studies, 1609 participants; moderate-certainty evidence). They may increase continuous abstinent participants (MID 5%; AD 5%, 95% CI 1% to 11%; RR 1.17, 95% CI 1.02 to 1.34; 6 studies, 1184 participants; low-certainty evidence). They probably have little to no effect on: • the rate of abstinent days (MID 8%; mean difference (MD) 4.16, 95% CI 1.24 to 7.08; 10 studies, 2227 participants); • serious adverse events (MID 1%; AD -2%, 95% CI -3% to 0%; RR 0.20, 95% CI 0.03 to 1.12; 4 studies; 524 participants); • dropouts from treatment (MID 10%; AD -3%, 95% CI -5% to 0%; RR 0.89, 95% CI 0.79 to 1.01; 15 studies, 3021 participants); and • dropouts due to adverse events (MID 5%; AD 2%, 95% CI 0% to 5%; RR 1.91, 95% CI 1.04 to 3.52; 8 studies, 1572 participants) (all moderate-certainty evidence). They may have little to no effect on: • heavy-drinking days (MID 5%; MD -3.49, 95% CI -8.68 to 1.70; 4 studies, 470 participants); • number of drinks per drinking day (MID 1 drink; MD -0.57, 95% CI -1.16 to 0.01; 7 studies, 805 participants); and • adverse events (MID 30%; AD 17%, 95% CI -5% to 46%; RR 1.25, 95% CI 0.93 to 1.68; 4 studies, 508 participants) (all low-certainty evidence). 2) Compared to pharmacological intervention alone, combined pharmacological and psychosocial interventions may have little to no effect on: • the rate of abstinent days (MID 8%; MD -1.18, 95% CI -4.42 to 2.07; 2 studies, 1158 participants); and • dropouts from treatment (MID 10%; AD 1%, 95% CI -10 to 14%; RR 0.98, 95% CI 0.65 to 1.47; 3 studies, 1246 participants) (all low-certainty evidence). We are uncertain about their effect on: • continuous abstinent participants (MID 5%; AD 3%, 95% CI -5% to 18%; RR 1.22, 95% CI 0.62 to 2.40; 1 study, 241 participants); • the number of heavy drinkers (MID 2%; AD 2%, 95% CI -4% to 8%; RR 1.03, 95% CI 0.94 to 1.12; 1 study, 917 participants); • the number of drinks per drinking day (MID 1 drink; MD -2.40, 95% CI -3.98 to -0.82; 1 study, 241 participants); and • dropouts due to adverse events (MID 5%; AD -1%, 95% CI -3% to 6%; RR 0.61, 95% CI 0.14 to 2.72; 2 studies, 1165 participants) (all very low-certainty evidence). 3) We are uncertain about the effect of combined pharmacological and psychosocial interventions, when compared to TAU, on: • the number of heavy drinkers (MID 2%; AD -5%, 95% CI -13% to 2%; RR 0.93, 95% CI 0.83 to 1.03; 1 study, 616 participants); • the rate of abstinent days (MID 8%; MD 3.43, 95% CI -1.32 to 8.18; 1 study, 616 participants); • dropouts from treatment (MID 10%; AD 0%, 95% CI -10% to 15%; RR 0.98, 95% CI 0.58 to 1.65; 2 studies, 696 participants); and • dropouts due to adverse events (MID 5%; AD 3%, 95% CI 0% to 15%; RR 2.97, 95% CI 0.70 to 12.67; 1 study, 616 participants) (all very low-certainty evidence). The certainty of evidence ranged from moderate to very low, downgraded mainly due to risk of bias and imprecision.

AUTHORS' CONCLUSIONS

As implications for practice, our findings indicate that adding pharmacological to psychosocial interventions is safe and helps people with AUD recover. These conclusions are based on low- to moderate-certainty evidence. Given the few studies and very low-certainty evidence, any benefits of adding psychosocial to pharmacological interventions or comparing the combined intervention to TAU are less clear. As implications for research, further studies should investigate the effects of the combined intervention compared to pharmacotherapy or TAU.

A Brief Cognitive Behavioral Therapy-Based Digital Intervention for Reducing Hazardous Alcohol Use in South Korea: Development and Prospective Pilot Study

Background

Alcohol consumption is a leading cause of death and disability worldwide, associated with numerous acute and chronic medical conditions. Digital health interventions offer a promising solution to overcome barriers associated with traditional treatment methods, providing accessible, scalable, and cost-effective means to support individuals in reducing hazardous drinking.

Objective

This pilot study aims to evaluate the feasibility, acceptability, and preliminary efficacy of the Sober smartphone app in individuals with hazardous alcohol use.

Methods

This single-group, pre- and postpilot study included 20 participants with risky alcohol use, identified using the Alcohol Use Disorder Identification Test. Participants used the Sober app for 4 weeks, incorporating cognitive behavioral therapy-based interventions. Feasibility was assessed by study and session completion rates, acceptability by participant satisfaction and perceived usefulness, and preliminary efficacy by changes in alcohol consumption and psychiatric symptoms. Semistructured interviews with participants and clinicians provided qualitative perspectives on the app's usability, efficacy, and areas for improvement.

Results

Of the 20 enrolled participants, 17 completed the study. The app demonstrated high feasibility with an 85% (17/20) study completion rate, and 59% (10/17) completed all cognitive behavioral therapy sessions. Participants reported positive acceptability, with average satisfaction and usefulness ratings of 3.8 and 3.7 of 5, respectively. Preliminary efficacy outcomes showed significant improvements: abstinence days increased from 67% to 85% (z=-3.17; P=.002), heavy drinking episodes decreased from 3.3 to 1.9 (t16=-2.97; P=.003), and total alcohol consumption reduced from 456.8 to 195.9 mL (t16=3.16; P=.002). Alcohol Use Disorder Identification Test scores dropped from 17.5 to 10.7 (t16=4.51; P<.001). Additionally, depression (Patient Health Questionnaire-9) scores decreased from 5.8 to 4.4 (t16=2.91; P=.01), and anxiety (Generalized Anxiety Disorder-7) scores from 3.4 to 2.1 (z=-2.80; P=.005). No adverse events were reported. Qualitative analysis found participants valued daily logging but noted usability issues, while clinicians called for tailored goals, enhanced communication features, and age-specific content.

Conclusions

The mobile app Sober shows promise as an effective tool for reducing hazardous alcohol consumption and improving related psychiatric symptoms. The study demonstrated high feasibility and positive acceptability, with significant preliminary efficacy in reducing alcohol use. Qualitative findings provided actionable evidence for refining the app's usability and clinical integration. Further research through a randomized controlled trial is warranted to confirm these findings and optimize the app's features and content.

Protocol of an open-label safety and feasibility pilot study of ketamine-assisted psychotherapy for methamphetamine use disorder (the KAPPA trial)

INTRODUCTION

Methamphetamine use disorder is a significant public health concern. No pharmacological treatment options currently exist for methamphetamine use disorder, and psychotherapy is only moderately effective. Preliminary evidence suggests that ketamine-assisted psychotherapy produces sustained improvements in substance use and mental health symptomatology. In addition to direct antidepressant properties, ketamine is hypothesised to increase synaptogenesis and facilitate neuroplasticity, in turn prolonging and enhancing the effects of psychotherapy. Given the withdrawal-associated dysphoria and neurocognitive impairments characterising methamphetamine use disorder, ketamine-assisted psychotherapy may improve the efficacy of psychotherapy alone by addressing these features and facilitating therapeutic engagement. This pilot study aims to investigate the safety and feasibility (time taken to recruit sample, proportion of ineligible participants at pre-screening and screening, number of participants who complete four sessions of psychotherapy, retention rate over full duration of study, acceptability of the intervention) of subanaesthetic ketamine in combination with psychotherapy (cognitive behavioural therapy) for adults with methamphetamine use disorder. Changes in methamphetamine use, cravings and withdrawal, quality of life, and treatment satisfaction will also be explored.

METHODS AND ANALYSIS

This is an open-label, single-arm clinical trial. 20 adults meeting DSM-5-TR criteria for methamphetamine use disorder who are seeking to reduce or cease methamphetamine use will be enrolled in the study through a single-site specialist outpatient stimulant treatment service in inner Sydney (St Vincent's Hospital, Sydney). A 4-week course with three subcutaneous ketamine doses (0.75 mg/kg to 0.9 mg/kg, titrated according to tolerability) at weekly intervals and four sessions of cognitive behavioural therapy (one at treatment initiation and three within 24-48 hours following each ketamine administration session) will be delivered. Safety and feasibility will be assessed over an 8-week period. Secondary outcomes (changes in methamphetamine use, cravings, withdrawal, quality of life and treatment satisfaction) will be assessed over a 24-week period.

ETHICS AND DISSEMINATION

This study has been approved by the St Vincent's Hospital Human Research Ethics Committee, reference 2023/ETH00530. Study findings will be disseminated through articles in scientific, peer-reviewed journals, and at national and international conferences.

TRIAL REGISTRATION NUMBER

ANZCTR: ACTRN12624000895583.

PROTOCOL VERSION

The trial protocol (Version 4.0) was approved on 24 June 2024.

A machine learning model to predict liver-related outcomes after the functional cure of chronic hepatitis B

BACKGROUND & AIMS

The risk of hepatocellular carcinoma (HCC) and hepatic decompensation persists after hepatitis B surface antigen (HBsAg) seroclearance. This study aimed to develop and validate a machine learning model to predict the risk of liver-related outcomes (LROs) following HBsAg seroclearance.

METHODS

A total of 4,787 consecutive patients who achieved HBsAg seroclearance between 2000 and 2022 were enrolled from six centers in South Korea and a territory-wide database in Hong Kong, comprising the training (n = 944), internal validation (n = 1,102), and external validation (n = 2,741) cohorts. Three machine learning-based models were developed and compared in each cohort. The primary outcome was the development of any LRO, including HCC, decompensation, and liver-related death.

RESULTS

During a median follow-up of 55.2 (IQR 30.1-92.3) months, 123 LROs were confirmed (1.1%/person-year) in the Korean cohort. The model with the best predictive performance in the training cohort was selected as the final model (designated as PLAN-B-CURE), which was constructed using a gradient boosting algorithm and seven variables (age, sex, diabetes, alcohol consumption, cirrhosis, albumin, and platelet count). Compared to previous HCC prediction models, PLAN-B-CURE showed significantly superior accuracy in the training cohort (c-index: 0.82 vs. 0.63-0.70, all p <0.001; area under the receiver-operating characteristic curve: 0.86 vs. 0.62-0.72, all p <0.01; area under the precision-recall curve: 0.53 vs. 0.13-0.29, all p <0.01). PLAN-B-CURE showed a reliable calibration function (Hosmer-Lemeshow test p >0.05) and these results were reproduced in the internal and external validation cohorts.

CONCLUSION

This novel machine learning model consisting of seven variables provides reliable risk prediction of LROs after HBsAg seroclearance that can be used for personalized surveillance.

IMPACT AND IMPLICATIONS

Using large-scale multinational data, we developed a machine learning model to predict the risk of liver-related outcomes (i.e., hepatocellular carcinoma, decompensation, and liver-related death) after the functional cure of chronic hepatitis B (CHB). The new model named PLAN-B-CURE was constructed using seven variables (age, sex, alcohol consumption, diabetes, cirrhosis, serum albumin, and platelet count) and a gradient boosting machine algorithm, and it demonstrated significantly better predictive accuracy than previous models in both the training and validation cohorts. The inclusion of diabetes and significant alcohol intake as model inputs suggests the importance of metabolic risk factor management after the functional cure of CHB. Using seven readily available clinical factors, PLAN-B-CURE, the first machine learning-based model for risk prediction after the functional cure of CHB, may serve as a basis for individualized risk stratification.

Associations between employees' alcohol consumption, insomnia and HR management strength

BACKGROUND

Understanding of hazardous alcohol drinking and insomnia among Australian ambulance personnel is limited. Australian ambulance organizations have strengthened their organizational human resource management (HRM) to promote their employees' healthy lifestyles, health and well-being.

AIMS

To describe the prevalence of hazardous alcohol consumption and insomnia among Australian ambulance personnel and to explore their associations with the organizational HRM strength.

METHODS

This cross-sectional study was conducted on 492 ambulance personnel randomly selected from three Australian states. The Alcohol Use Disorders tool, The Insomnia Severity Index and the Perceived HRM System Strength instrument measured alcohol consumption, insomnia and HRM strength. Descriptive analyses, bivariate association analyses and general linear models were used for data analysis.

RESULTS

Twenty per cent of Australian ambulance personnel consumed alcohol at a hazardous level and 68% experienced clinically significant insomnia. There was no significant association between organizational HRM strength and ambulance personnel's hazardous alcohol consumption. There was a significant association between organizational HRM strength (consensus) and ambulance personnel's insomnia experience.

CONCLUSIONS

Hazardous alcohol consumption and insomnia were concerns among Australian ambulance personnel. Even though strengthening the HRM system might reduce their experience of insomnia, simply strengthening the HRM system could not reduce their hazardous alcohol consumption.

Prevalence and correlates of common mental disorders among participants of the Uganda Genome Resource: Opportunities for psychiatric genetics research

Genetics research has potential to alleviate the burden of mental disorders in low- and middle-income-countries through identification of new mechanistic pathways which can lead to efficacious drugs or new drug targets. However, there is currently limited genetics data from Africa. The Uganda Genome Resource provides opportunity for psychiatric genetics research among underrepresented people from Africa. We aimed at determining the prevalence and correlates of major depressive disorder (MDD), suicidality, post-traumatic stress disorder (PTSD), alcohol abuse, generalised anxiety disorder (GAD) and probable attention-deficit hyperactivity disorder (ADHD) among participants of the Uganda Genome Resource. Standardised tools assessed for each mental disorder. Prevalence of each disorder was calculated with 95% confidence intervals. Multivariate logistic regression models evaluated the association between each mental disorder and associated demographic and clinical factors. Among 985 participants, prevalence of the disorders were: current MDD 19.3%, life-time MDD 23.3%, suicidality 10.6%, PTSD 3.1%, alcohol abuse 5.7%, GAD 12.9% and probable ADHD 9.2%. This is the first study to determine the prevalence of probable ADHD among adult Ugandans from a general population. We found significant association between sex and alcohol abuse (adjusted odds ratio [AOR] = 0.26 [0.14,0.45], p < 0.001) and GAD (AOR = 1.78 [1.09,2.49], p = 0.019) respectively. We also found significant association between body mass index and suicidality (AOR = 0.85 [0.73,0.99], p = 0.041), alcohol abuse (AOR = 0.86 [0.78,0.94], p = 0.003) and GAD (AOR = 0.93 [0.87,0.98], p = 0.008) respectively. We also found a significant association between high blood pressure and life-time MDD (AOR = 2.87 [1.08,7.66], p = 0.035) and probable ADHD (AOR = 1.99 [1.00,3.97], p = 0.050) respectively. We also found a statistically significant association between tobacco smoking and alcohol abuse (AOR = 3.2 [1.56,6.67], p = 0.002). We also found ever been married to be a risk factor for probable ADHD (AOR = 2.12 [0.88,5.14], p = 0.049). The Uganda Genome Resource presents opportunity for psychiatric genetics research among underrepresented people from Africa.

Medicaid expansion and medications to treat opioid use disorder in outpatient specialty care from 2010 to 2020

INTRODUCTION

Medications for opioid use disorder (MOUD) are considered the first line treatment for opioid use disorder. As states expanded Medicaid beginning in 2014 under the Affordable Care Act, policymakers and public health officials were interested in the potential for expansion to increase access to MOUD. This study examined whether there were changes in MOUD use within outpatient admissions to specialty treatment facilities in Medicaid expansion states beyond the initial expansion period.

METHODS

Analyses were conducted using 2010-2020 data from the Treatment Episode Data Set - Admissions. For states that expanded Medicaid prior to 2015, a difference-in-differences analysis was conducted to evaluate whether expansion was associated with an increased proportion of MOUD treatment comparing the initial 2014-2017 period and the 2018-2020 period to 2010-2013. We then conducted a difference-in-differences analysis to examine the overall effect of Medicaid expansion on outpatient MOUD using all states that passed expansion at any point during the study period.

RESULTS

Among outpatient treatment episodes for OUD in states that expanded Medicaid in 2014, there was a 9.5 percentage point (95 % CI: 0.7-18.2) increase in the probability of receiving MOUD during the initial expansion period from 2014 to 2017 compared to 2010-2013 period, and a 7.5 percentage point (95 % CI: -8.1 -23.1) increase in 2018-2020 (compared to the 2010-2013 period) after adjusting for individual-level covariates. After incorporating states that expanded Medicaid between 2015 and 2020, there was a 6.4 percentage point (95 % CI: -0.01-13.0) increase in the probability of receiving MOUD among individuals receiving care after expansion (compared to the pre-expansion period). During the study period, there was variability among states in the change in probability of receiving MOUD from prior to after Medicaid expansion from an almost 30 percentage point increase in New York to an almost 20 percentage point decrease in Washington, DC.

CONCLUSIONS

Medicaid expansion increased the probability of receiving MOUD in outpatient settings across states from initial expansion through 2020. However, these results were not statistically significant. Additionally, significant variability between states warrants further study and suggests that improving access to MOUD will require additional state and local strategies.

Evolution of the substance use landscape: Implications for contingency management

Contingency management (CM), which involves the delivery of incentives upon meeting behavioral goals, has the potential to improve substance use treatment outcomes. The intervention allows for flexibility through numerous modifiable components including changes to incentive magnitude and schedule, target behavior, and intervention structure. Unfortunately, numerous changes in the substance use landscape have occurred in the past 10 to 15 years: Substances are more potent, overdose risk has increased, new substances and methods of use have been introduced, and substance classes are increasingly being intentionally and unintentionally mixed. These developments potentially undermine CM outcomes. We explored recent substance use changes due to legislative, regulatory, social, and economic factors for four substance classes: stimulants, opioids, tobacco, and cannabis. We discuss potential adjustments to the modifiable components of CM for future research in response to these changes. By continually adapting to the shifting substance use landscape, CM can maintain optimal efficacy.

Improvement in coping skills from culturally-adapted digital CBT for Spanish-speaking Hispanics with substance use disorder: Secondary analysis of a randomized clinical trial

INTRODUCTION

Developing adaptive coping skills for avoiding substance use is a proposed treatment mechanism of cognitive behavioral therapy (CBT) for substance use disorder (SUD). However, the generalizability of research on treatment mechanisms of CBT for SUD is limited by the underrepresentation of racial/ethnic minorities in clinical trials. In a secondary analysis of clinical trial data, we tested whether a culturally-adapted digital CBT program for Hispanics ("Spanish CBT4CBT") improved the quality of coping skills for avoiding substance use. We also tested whether coping skills' quality was associated with reductions in primary substance use.

METHODS

Participants were Spanish-speaking Hispanic adults seeking outpatient treatment for SUD (n = 85; 68 % male; primary substance type: 36 % cannabis, 33 % alcohol, 26 % cocaine, 5 % other). They were randomized to 8 weeks of outpatient treatment as usual (TAU) or TAU + Spanish CBT4CBT and assessed for 6 months after treatment. The study conducted separate analyses for the full sample (n = 85) and for those who engaged in at least 5 treatment sessions ("treatment exposed"; n = 64). Daily substance use and coping skills' quality were assessed repeatedly during the treatment and follow-up periods. Bayesian mixed models for repeated measures tested hypotheses.

RESULTS

Among treatment-exposed participants, those receiving TAU + Spanish CBT4CBT improved the quality of coping skills more than TAU alone during the treatment period (b = 0.77; 95 % CI[0.08, 1.47]), but this difference was not detected during the follow-up period. In the full sample and treatment exposed subsample, participants with higher quality coping skills during the study reported less primary substance use (b = -0.67; 95 % CI[-1.08, -0.26]). Among treatment-exposed participants only, within-person increases in the quality of coping skills were associated with reductions in future primary substance use (b = -0.18; 95 % CI[-0.36, -0.01]).

CONCLUSIONS

Spanish-speaking Hispanics with SUD may improve the quality of their coping skills more when they are sufficiently exposed to a culturally-adapted digital CBT program during outpatient treatment. Coping skills' quality may be a mechanism of CBT for SUD among Hispanic populations. Spanish-speaking Hispanics' access to treatments that target mechanisms of behavior change may be expanded by digital therapeutics.

Factors affecting problem-solving court team decisions about medications for opioid use disorder

BACKGROUND

Problem-solving courts (PSCs) provide alternatives to prosecution and incarceration for drug-related crimes and offer integrated support for people who have lost custody of children due to drug use. Methadone and buprenorphine are lifesaving medications for opioid use disorder (MOUD) but are underused by PSC clients. Even when PSCs lack a court-level prohibition against MOUD, court staff still make individualized decisions about whether a court client can use MOUD. Therefore, we sought to identify factors involved in such individualized PSC court decisions about clients' use of MOUD.

METHODS

We conducted semi-structured interviews and focus groups between Summer and Fall 2022 with a convenience sample of 54 PSC staff members from 33 courts across four states. Data were analyzed using iterative categorization.

RESULTS

Interviewees indicated that their courts had eliminated blanket prohibitions against MOUD due to federal and state policy funding requirements, widespread dissemination of voluntary best practice standards, fear of lawsuits, and MOUD education targeting courts. Courts allowed MOUD if the court client accessed it through a treatment provider with whom the court collaborates. Some courts only allowed court clients to access MOUD from non-partnering treatment providers after a court-led "vetting" process of the proposed MOUD provider. MOUD provider characteristics considered during the vetting process included the provider's willingness to communicate with the court, frequent drug testing, adjustments of medication or dosage in response to aberrant results, offering of counseling, and acceptance of Medicaid or sliding scale payments. PSC staff were least comfortable with court clients using methadone treatment.

CONCLUSIONS

The presence (or lack of) a PSC-MOUD partnership is a key factor involved in court staff decisions when a court client desires MOUD. Therefore, increasing the number of partnerships between PSCs and MOUD providers could lead to higher rates of MOUD utilization. It is unclear whether court-led vetting processes for non-partnering MOUD treatment providers are necessary or appropriate, and such vetting processes could reduce treatment choice or access in communities with few MOUD providers.

Patient Engagement in Providing Telehealth SUD IOP Treatment: A Retrospective Cohort Study

BACKGROUND

Substance use disorders (SUDs) remain a growing public health issue, with drug- and alcohol-related deaths continuing to increase. A myriad of barriers prevent many with SUDs from seeking care. Telehealth interventions are well-positioned to reduce barriers and increase engagement in SUD treatment. The SUD intensive outpatient program (IOP) is specifically designed for telehealth and offers evidenced-based care delivered by SUD professionals as well as asynchronous assignments to enhance treatment. This study explores the feasibility of providing a telehealth IOP.

METHODS

participant engagement, reasons for disengagement, and days of abstinence were examined using existing records from a cohort of participants between 2021 and 2023 (n = 4724).

RESULTS

Nearly 80% of participants remained engaged in the program for 30 days, and 91% attained at least 30 consecutive days of abstinence over the course of treatment. Nearly 45% demonstrated a successful response to care and no longer required IOP treatment. Those who finished the IOP completed over 70% of the asynchronous assignments.

CONCLUSIONS

Results support the feasibility and effectiveness of delivering a telehealth IOP for SUDs.

EASL Clinical Practice Guidelines on liver transplantation

Liver transplantation (LT) is an established life-saving procedure. The field of LT has changed in the past 10 years from several perspectives, with the expansion of indications, transplantation of patients with acute-on-chronic liver failure, evolution of transplant oncology, the use of donations after cardiac death, new surgical techniques, and prioritisation of recipients on the waiting list. In addition, the advent of organ perfusion machines, the recognition of new forms of rejection, and the attention paid to the transition from paediatric to adult patients, have all improved the management of LT recipients. The purpose of the EASL guidelines presented here is not to cover all aspects of LT but to focus on developments since the previous EASL guidelines published in 2016.

2024 Guideline for the Primary Prevention of Stroke: A Guideline From the American Heart Association/American Stroke Association

AIM

The "2024 Guideline for the Primary Prevention of Stroke" replaces the 2014 "Guidelines for the Primary Prevention of Stroke." This updated guideline is intended to be a resource for clinicians to use to guide various prevention strategies for individuals with no history of stroke.

METHODS

A comprehensive search for literature published since the 2014 guideline; derived from research involving human participants published in English; and indexed in MEDLINE, PubMed, Cochrane Library, and other selected and relevant databases was conducted between May and November 2023. Other documents on related subject matter previously published by the American Heart Association were also reviewed.

STRUCTURE

Ischemic and hemorrhagic strokes lead to significant disability but, most important, are preventable. The 2024 primary prevention of stroke guideline provides recommendations based on current evidence for strategies to prevent stroke throughout the life span. These recommendations align with the American Heart Association's Life's Essential 8 for optimizing cardiovascular and brain health, in addition to preventing incident stroke. We also have added sex-specific recommendations for screening and prevention of stroke, which are new compared with the 2014 guideline. Many recommendations for similar risk factor prevention were updated, new topics were reviewed, and recommendations were created when supported by sufficient-quality published data.

Multidisciplinary Management of Complex Trauma and Burn Injuries: A Case Series of Challenging Clinical Scenarios

Trauma and burn injuries often present with multiple complications, necessitating a coordinated, multidisciplinary approach to management. This case series reviews the outcomes and challenges of treating high-risk trauma and burn patients, with a focus on complex polytrauma, alcohol withdrawal, high-voltage electrical injuries, and lightning strikes. Each case underscores the importance of early intervention, multidisciplinary team involvement, and individualized treatment protocols for improving patient outcomes in critically injured burn victims.

Sociodemographic and Clinical Profiles of Patients With Substance Use Disorders Admitted to a Psychiatric Hospital in Erbil: A Retrospective Study

BACKGROUND

Substance use is a growing concern, impacting the health, social stability, and economic well-being of individuals and communities. In Iraq, particularly in Erbil, limited data exists on the sociodemographic and clinical characteristics of patients with substance use disorders (SUDs). This study aims to identify these characteristics among inpatients at Hawler Psychiatric Hospital to better understand the profiles and associated factors influencing substance use in this region.

METHODS

A retrospective study was conducted at Hawler Psychiatric Hospital from January 2023 to September 2024. A total of 115 patient records with substance use disorder diagnoses were reviewed. Data on sociodemographic details, clinical characteristics, types of substances used, and comorbidities were collected and analyzed using Microsoft Excel 2016 (Microsoft Corp., Redmond, WA) and IBM SPSS Statistics version 26 (IBM Corp., Armonk, NY). Frequency, percentages, and mean values were calculated, while Chi-square and Fisher's exact tests were used to assess associations between categorical variables. A P-value of 0.05 or less was deemed statistically significant.

RESULTS

The majority of the patients were male (112, 97.4%), with an age of 31.95 ± 9.46 years (mean ± standard deviation (SD)). Among them, 67 (58.3%) had only primary school education. Methamphetamine was the most commonly used substance (52, 45.2%), followed by alcohol (28, 24.3%), opioids (13, 11.3%), and heroin (13, 11.3%). High rates of psychiatric comorbidities were observed, with 97 (84.3%) patients diagnosed with additional mental health conditions, such as depression and psychosis. Furthermore, 73 (63.5%) patients exhibited aggressive behaviors, and 33 (28.7%) had a forensic history. Significant associations were identified between aggression and factors such as educational level, occupation, psychiatric comorbidity, and forensic history.

CONCLUSION

The study highlights a pattern of poly-substance use among patients and the pressing need for comprehensive treatment strategies, including both pharmacotherapy and psychotherapy, to address the complex needs of individuals with substance use disorders in Erbil. These findings underscore the importance of targeted interventions and preventive measures to reduce substance misuse and improve patient outcomes.

Exploring and describing alcohol harm reduction interventions: a scoping review of literature from the past decade in the western world

CONTEXT

Regular alcohol use is a predominant risk factor for disease, injury, and social harm. While robust evidence is advocating for implementing interventions to reduce the harms of illegal substance use, less literature is dedicated to identifying and understanding interventions aiming at reducing the various harms associated with alcohol.

OBJECTIVES

This review describes how alcohol harm reduction (AHR) interventions are currently conducted and analyzes the facilitators and barriers identified by the studies on their efficacy.

METHOD

This scoping review with evidence appraisal included articles published between 2011 and 2022, addressing one or more AHR interventions for population of at least 18 years (including alcohol user who have an addiction but also alcohol user with harmful drinking), conducted in North industrialized countries (Europe, Nort America, Australia).

RESULTS

Among the 61 articles selected, we identified several forms of support (face-to-face or remote, support in residential settings, structural interventions, and interventions created upon spontaneous initiatives), and strategies of intervention were also analyzed (the ones based upon learning and skill development, the ones based upon psychological support, the ones focusing upon socio-economic conditions, strategies focusing on the coordination and adaptation of the care system, and those strategies based on peer support). The facilitators linked to fundamental characteristics of the interventions were the promotion of empowerment and autonomy of beneficiaries, setting objectives tailored to individual needs, professionals harmonizing their values, evidence-based interventions taking into account cultural contexts, and comprehensive and holistic support. Practical facilitators from the intervention process consist of increasing the number of sessions, involvement, and formation of members of staff, disposing of the necessary resources, and using technological tools.

DISCUSSION

The sheer variety of AHR interventions demonstrates that this is a fertile field in terms of intervention design and innovation. This work illustrates the importance of designing effective, adapted harm reduction interventions, prioritizing interventions that make support more accessible to more people. This also prompts us to consider the potential benefits of invoking proportionate universalism in the design of AHR interventions in order to operationalize alcohol harm reduction philosophy. accessible to more people.

Barriers and facilitators to medication-assisted treatment for cocaine use disorder among men who have sex with men: a qualitative study

BACKGROUND

Rates of cocaine use disorder (CUD) among men who have sex with men (MSM) are high and rising. Among MSM, cocaine use is associated with negative socioeconomic, medical, and psychological outcomes. There are no FDA-approved pharmacotherapy options to treat CUD, and psychosocial interventions demonstrate limited efficacy. While there have been numerous trials evaluating possible medications for CUD, there is a scarcity of qualitative data on the barriers and facilitators of medication-assisted treatment.

METHODS

Semi-structured interviews were conducted with 16 participants enrolled in a phase II randomized control trial evaluating extended-release lorcaserin among MSM with CUD. Participants were asked about their motivations for enrolling in the study, attitudes towards taking a medication for CUD, barriers and facilitators of study pill adherence, and their general study experience. Interviews were analyzed using an inductive and exploratory approach to thematic analysis.

RESULTS

Participants were highly motivated to reduce cocaine use and viewed pharmacotherapy as a viable and desirable treatment option. Pharmacotherapy was seen as having fewer access and adherence structural barriers compared to existing psychosocial therapies. Medication reminders facilitated pill taking, while side effects, travel, and active substance use presented barriers to study pill adherence. Disclosure of study participation within social networks was variable pointing to anticipated substance use and treatment stigma.

CONCLUSIONS

Our study highlights important factors affecting the acceptability and uptake of medication-assisted treatment for CUD among a diverse sample of MSM. These findings can help guide the development and implementation of future pharmacotherapy options for CUD and other substance use disorders in this key population.

Disparities in Treatment for Alcohol Use Disorder Among All of Us Participants

OBJECTIVE

The authors examined racial/ethnic and socioeconomic disparities in receiving treatment for alcohol use disorder (AUD).

METHODS

A retrospective cohort study was conducted that included adults (≥18 years) with AUD from the All of Us Controlled Tier database v7. Outcomes were lifetime receipt of FDA-approved medications (disulfiram, acamprosate, and naltrexone), psychotherapy (individual, family, and group-based session), and combination treatment (medication and psychotherapy). The study examined treatment receipt by race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, other), insurance (private, Medicare, Medicare and Medicaid, Medicaid, Veteran Affairs [VA], none), income (<$10K, $10-<$50K, $50-$100K, >$100K), and area deprivation index (ADI) quintiles. Multivariable logistic and multinomial logistic regressions were used to assess the association between patient characteristics and treatment receipt.

RESULTS

The cohort consisted of 18,692 patients (mean age=57.1 years; 60.7% were male; 47.1% were non-Hispanic White). Almost 70% received no treatment, 11.4% received medication, 24.0% received psychotherapy, and 4.9% received combination treatment. In adjusted analysis, non-Hispanic Black (aOR=0.78, 95% CI=0.69-0.89) and Hispanic (aOR=0.75, 95% CI=0.64-0.88) individuals were less likely to receive medication than non-Hispanic White counterparts. There was no association between race/ethnicity and receipt of psychotherapy or combination treatment. Compared with private insurance, dual eligibility was associated with less use of medication, Medicare and Medicaid with less use of medication and combination treatment, and VA and no insurance with more use of psychotherapy and combination treatment. Higher income and lower ADI were positively associated with all treatment types.

CONCLUSIONS

There are disparities in AUD treatment by race/ethnicity, socioeconomic status, and insurance. Systematic approaches are required to improve equitable access to effective treatment.

Do treatments for mental disorders affect relationship satisfaction? A systematic review and meta-analysis

Objective: Psychiatric disorders have been linked to poor social functioning, including deficits in relationship satisfaction. Treatments have shown strong effectiveness in reducing clinical symptoms for a range of disorders, though less is known of the effects disorder-focused treatments have on relationship satisfaction.

Methods: The present study describes a systematic review that was conducted to determine the efficacy of treatments for specific psychiatric disorders in improving relationship satisfaction. Surprisingly, only seventeen studies were identified and included in the review.

Results: We found that a majority of these studies reported modest improvement in relationship satisfaction among people who completed treatment. However, studies were severely hampered by methodological limitations, and all therapy-related improvements could be attributable to placebo effects or the passage of time.

Conclusion: Important gaps in the literature were found that future research should seek to address to maximize treatment outcomes and psychosocial functioning.

Treatment of insomnia associated with alcohol and opioid use: a narrative review

Substance use disorders (SUDs) are associated with profound sleep disturbances, including insomnia, sleep fragmentation, and circadian rhythm dysfunction resulting in serious mental and physical consequences. This minireview presents an overview of the neurocircuitry underlying sleep disturbances in SUDs and elaborates on treatment options with emphasis on alcohol use disorder (AUD) and opioid use disorder (OUD). A PubMed, Embase, CINAHL Plus, Cochrane, and Scopus search were conducted using sleep- and AUD/OUD related keywords from January 1st, 2000, to January 31st, 2023, with preferences for recent publications and randomized-controlled trials. A bidirectional relationship exists between insomnia and addiction with the status of each condition impacting the other in dictating clinical outcome. Existing evidence points to a resurgence of insomnia during detoxification, and unless treated satisfactorily, insomnia may lead to relapse. The discussion summarizes the strengths and limitations of cognitive behavioral therapy and pharmacological treatment for insomnia in SUDs covering evidence from both animal and clinical studies. The assumption of reestablishing normal sleep patterns by attaining and maintaining sobriety is misguided. Comorbid insomnia in patients with SUDs should be approached as an independent condition that requires its own treatment. Future clinical trials are needed with the aim of providing a resource for guiding clinical management of the many patients with insomnia and SUD.

Integrated behavioral interventions for adults with alcohol use disorder: A systematic review

BACKGROUND

This systematic review synthesized evidence from randomized controlled trials (RCTs) on the effects of integrated behavioral interventions for adults with alcohol use disorder (AUD).

METHODS

A comprehensive search of three databases was conducted in 2022, utilizing terms related to alcohol/substance use disorders and integrated interventions. The sample included adults aged ≥18 years at low, moderate, or high risk for AUD, and had at least two other mental health conditions. Only RCTs were included and screened using Covidence. The quality of the study was evaluated using Cochrane risk of bias tool.

RESULTS

Across all 11 studies, the total AUD participants were 1543 aged 18 or older. Integrated intervention led to significant reductions in heavy drinking compared to usual care or other interventions. Measures included percent days of alcohol use, grams of alcohol consumed, and increased days of abstinence. Three studies compared integrated treatments with Twelve-Step Facilitation, indicating a better abstinence rate among participants in the integrated group at the end of treatment. Comparisons between delivery modes demonstrated more significant reductions in alcohol consumption with interventionists. Integrated interventions were also compared with various other treatments, including brief intervention, telephone and individual counseling, and psychological education. Participants in the integrated group showed greater improvement in alcohol consumption and depression compared to those in the standalone intervention group.

CONCLUSIONS

Integrated behavioral interventions effectively reduce alcohol consumption, decrease heavy drinking and promote alcohol abstinence. However, there is limited evidence to determine whether these interventions are more effective than usual care for individuals with AUD.

Predictors of alcohol and other drug treatment completion among young people accessing residential and community-based treatment: A retrospective analysis of routinely collected service data

BACKGROUND AND AIMS

Young people accessing alcohol and other drug (AOD) treatment experience high rates of treatment disengagement, contributing to poorer outcomes. To improve outcomes, it is important to identify factors associated with treatment retention. This study measured the relationships between client characteristics, treatment characteristics, clinical severity measures and completion of treatment among young people.

DESIGN, SETTING AND PARTICIPANTS

This study was a retrospective analysis of routinely collected data set in residential- and community-based AOD services in New South Wales, Australia. Routinely collected data from the Network of Alcohol and Other Drug Agencies' (NADA) database were used. Included individuals were aged 10-24 years and accessed treatment between 2012 and 2023 (n = 17 474).

MEASUREMENTS

Variables included client-related characteristics, service characteristics and baseline measures of clinical severity [Kessler-10 (K10), EUROHIS-QoL, severity of dependence scale (SDS)]. Multivariable binary logistic regression models assessed the relationships between these characteristics and treatment completion.

FINDINGS

Rates of treatment completion were highest among adolescents in community-based treatment (57%) and lowest among young adults in residential treatment (35%). Polysubstance use was negatively associated with treatment completion among adolescents [adjusted odds ratio (adjOR) = 0.71, P < 0.001] and adults (adjOR = 0.70, P < 0.001) in community-based treatment, and adolescents in residential treatment (adjOR = 0.62, P = 0.006), as was housing insecurity (adolescents in community treatment, adjOR = 0.61, P = 0.001; adults in community treatment, adjOR = 0.77, P = 0.002; adolescents in residential treatment, adjOR = 0.42, P = 0.005). Attending youth-specific services was associated with higher treatment completion rates among adults in community-based (adjOR = 1.81, P < 0.001) and residential treatment (adjOR = 1.72, P < 0.001). Varying correlates of treatment completion were identified throughout treatment groups, reflecting the differences in population and/or needs across contexts.

CONCLUSIONS

In New South Wales, Australia, fewer than half of young people accessing alcohol and other drug treatment between 2012 and 2023 completed treatment, and completion rates were lower among those facing barriers such as polysubstance use and housing insecurity.

Effective but Undertaught: Training Psychiatrists in Psychotherapy for Substance Use Disorders

Considering the escalating gap between the population-level need for substance use services and the availability of board-certified addiction specialty physicians, all psychiatrists must be equipped to treat substance use disorders. Residency training programs must therefore ensure that graduates are equipped with a sufficient knowledge base and skill set to treat substance use disorders, including an understanding of medications for addiction treatment and appropriate selection and utilization of psychotherapy for substance use disorders. Resources for teaching psychiatric residents about psychotherapeutic approaches to substance use disorders are often limited, and many programs may struggle to include this content in their curricula. The authors highlight the core evidence-based psychotherapeutic approaches relevant to the care of patients with substance use disorders and identify supervised experiential learning opportunities for psychiatric residents to practice psychotherapy for substance use disorders during existing clinical rotations within their general psychiatry residency programs.

Designing clinical trials to address alcohol use and alcohol-associated liver disease: an expert panel Consensus Statement

Most patients with alcohol-associated liver disease (ALD) engage in heavy drinking defined as 4 or more drinks per day (56 g) or 8 (112 g) or more drinks per week for women and 5 or more drinks per day (70 g) or 15 (210 g) or more drinks per week for men. Although abstinence from alcohol after diagnosis of ALD improves life expectancy and reduces the risk of decompensation of liver disease, few studies have evaluated whether treatment of alcohol use disorders will reduce progression of liver disease and improve liver-related outcomes. In November 2021, the National Institute of Alcohol Abuse and Alcoholism commissioned a task force that included hepatologists, addiction medicine specialists, statisticians, clinical trialists and members of regulatory agencies to develop recommendations for the design and conduct of clinical trials to evaluate the effect of alcohol use, particularly treatment to reduce or eliminate alcohol use in patients with ALD. The task force conducted extensive reviews of relevant literature on alcohol use disorders and ALD. Findings were presented at one in-person meeting and discussed over the next 16 months to develop the final recommendations. As few clinical trials directly address this topic, the 28 recommendations approved by all members of the task force represent a consensus of expert opinions.

Advancements in addressing drug dependence: A review of promising therapeutic strategies and interventions

Substance dependence represents a pervasive global concern within the realm of public health. Presently, it is delineated as a persistent and recurrent neurological disorder stemming from drug-triggered neuroadaptations in the brain's reward circuitry. Despite the availability of various therapeutic modalities, there has been a steady escalation in the mortality rate attributed to drug overdoses. Substantial endeavors have been directed towards the exploration of innovative interventions aimed at mitigating cravings and drug-induced repetitive behaviors. Within this review, we encapsulate the most auspicious contemporary treatment methodologies, accentuating meta-analyses of efficacious pharmacological and non-pharmacological approaches: including gabapentin, topiramate, prazosin, physical exercise regimens, and cerebral stimulation techniques.

A mixed method study exploring similarities and differences in general and social services-specific barriers to treatment-seeking among individuals with a problematic use of alcohol, cannabis, or gambling

INTRODUCTION

The treatment gap for addictive disorders is one of the largest in health care. Several studies have investigated barriers to treatment for different addictive disorders, but very few studies conducted have explored whether the barriers differ depending on substance or behavior or if they are common among all addictive disorders. In Sweden, addiction care is provided both by the healthcare and social services, where the latter is common, but also less popular. To our knowledge, there are no studies exploring whether the barriers are different depending on where the treatment is given.

AIM

The aim was to thoroughly explore both which general and social services-specific barriers to treatment that are common, which barriers that differs, and how the barriers are described among individuals with a problematic use of alcohol, cannabis and/or gambling.

METHOD

A mixed method convergent parallel design was conducted. For the quantitative measures, surveys including the validated Barriers to Treatment Inventory as well as questions regarding barriers in the Swedish multi-provider landscape, were collected from individuals with a problematic use of alcohol (n = 207), cannabis (n = 51), and gambling (n = 37). In parallel, 17 semi-structured interviews from the same population were conducted and analyzed with thematic analysis. Thereafter, the quantitative and qualitative data was compared, contrasted, and at last, interpreted.

RESULTS

The quantitative data showed that the largest general barriers in all groups were privacy concern and poor availability, and the largest barriers for seeking help from the social services was stigma, unawareness of what is offered, and fear of consequences for all groups. The qualitative data resulted in five general barriers: stigma, ambivalence, accessibility, fear of consequences, and lack of knowledge about addiction and its' treatments, and three barriers specifically towards social services: social services reputation, fear of meeting acquaintances, and lack of knowledge. The themes were developed from data from all groups, but different aspects of the themes were mentioned by different groups.

CONCLUSION

There are details and aspects that differentiates both the general and social service-specific barriers to treatment between individuals with a problematic use of alcohol, cannabis, and gambling, but in large they perceive similar barriers.

Predictors of urine toxicology and other biologic specimen missingness in randomized trials of substance use disorders

BACKGROUND

High levels of missing outcome data for biologically confirmed substance use (BCSU) threaten the validity of substance use disorder (SUD) clinical trials. Underlying attributes of clinical trials could explain BCSU missingness and identify targets for improved trial design.

METHODS

We reviewed 21 clinical trials funded by the NIDA National Drug Abuse Treatment Clinical Trials Network (CTN) and published from 2005 to 2018 that examined pharmacologic and psychosocial interventions for SUD. We used configurational analysis-a Boolean algebra approach that identifies an attribute or combination of attributes predictive of an outcome-to identify trial design features and participant characteristics associated with high levels of BCSU missingness. Associations were identified by configuration complexity, consistency, coverage, and robustness. We limited results using a consistency threshold of 0.75 and summarized model fit using the product of consistency and coverage.

RESULTS

For trial design features, the final solution consisted of two pathways: psychosocial treatment as a trial intervention OR larger trial arm size (complexity=2, consistency=0.79, coverage=0.93, robustness score=0.71). For participant characteristics, the final solution consisted of two pathways: interventions targeting individuals with poly- or nonspecific substance use OR younger age (complexity=2, consistency=0.75, coverage=0.86, robustness score=1.00).

CONCLUSIONS

Psychosocial treatments, larger trial arm size, interventions targeting individuals with poly- or nonspecific substance use, and younger age among trial participants were predictive of missing BCSU data in SUD clinical trials. Interventions to mitigate missing data that focus on these attributes may reduce threats to validity and improve utility of SUD clinical trials.

Management of alcohol-associated liver disease and alcohol use disorder in liver transplant candidates and recipients: Challenges and opportunities

Alcohol-associated liver disease poses a significant global health burden, with rising alcohol consumption and prevalence of alcohol use disorder (AUD) contributing to increased morbidity and mortality. This review examines the challenges and opportunities in the care of candidates and recipients of liver transplant (LT) with AUD. Despite advancements in posttransplant patient survival, the risk of disease recurrence and alcohol relapse remains substantial. Several challenges have been identified, including (1) rising disease burden of alcohol-associated liver disease, variable transplant practices, and systemic barriers; (2) disparities in mental health therapy access and the impact on transplant; (3) variable definitions, underdiagnosis, and stigma affecting access to care; and (4) post-LT relapse, its risk factors, and consequential harm. The review focuses on the opportunities to improve AUD care for candidates and recipients of LT through effective biochemical monitoring, behavioral and pharmacologic approaches, creating Centers of Excellence for post-LT AUD care, advocating for policy reforms, and ensuring insurance coverage for necessary services as essential steps toward improving patient outcomes. The review also highlights unmet needs, such as the scarcity of addiction specialists, and calls for further research on personalized behavioral treatments, digital health, and value-based care models to optimize AUD care in the LT setting.

Novel therapeutics in development for the treatment of stimulant-use disorder

Misuse and accidental overdoses attributed to stimulants are escalating rapidly. These stimulants include methamphetamine, cocaine, amphetamine, ecstasy-type drugs, and prescription stimulants such as methylphenidate. Unlike opioids and alcohol, there are no therapies approved by the US Food and Drug Administration (FDA) to treat stimulant-use disorder. The high rate of relapse among this population highlights the insufficiency of current treatment options, which are limited to abstinence support programs and behavioral modification therapies. Here, we briefly outline recent regulatory actions taken by FDA to help support the development of new stimulant use disorder treatments and highlight several new therapeutics in the clinical development pipeline.

The Brain Salience Network at the Intersection of Pain and Substance use Disorders: Insights from Functional Neuroimaging Research

Purpose of Review

The brain's salience network (SN), primarily comprising the anterior insula and anterior cingulate cortex, plays a key role in detecting salient stimuli and processing physical and socioemotional pain (e.g., social rejection). Mounting evidence underscores an altered SN in the etiology and maintenance of substance use disorders (SUDs). This paper aims to synthesize recent functional neuroimaging research emphasizing the SN's involvement in SUDs and physical/socioemotional pain and explore the therapeutic prospects of targeting the SN for SUD treatment.

Recent Findings

The SN is repeatedly activated during the experience of both physical and socioemotional pain. Altered activation within the SN is associated with both SUDs and chronic pain conditions, characterized by aberrant activity and connectivity patterns as well as structural changes. Among individuals with SUDs, functional and structural alterations in the SN have been linked to abnormal salience attribution (e.g., heightened responsiveness to drug-related cues), impaired cognitive control (e.g., impulsivity), and compromised decision-making processes. The high prevalence of physical and socioemotional pain in the SUD population may further exacerbate SN alterations, thus contributing to hindered recovery progress and treatment failure. Interventions targeting the restoration of SN functioning, such as real-time functional MRI feedback, neuromodulation, and psychotherapeutic approaches, hold promise as innovative SUD treatments.

Summary

The review highlights the significance of alterations in the structure and function of the SN as potential mechanisms underlying the co-occurrence of SUDs and physical/socioemotional pain. Future work that integrates neuroimaging with other research methodologies will provide novel insights into the mechanistic role of the SN in SUDs and inform the development of next-generation treatment modalities.

A Descriptive Review and Meta-Regression Study of Demographic and Study Context Factors in US Clinical Trials of Cognitive Behavioral Interventions for Alcohol or Other Drug Use

Objectives. Cognitive-Behaviorally Based Interventions (CBIs) are evidence-based treatments for alcohol and other drug (AOD) use with potential variable effectiveness by population sub-groups. This study used evidence synthesis to examine treatment effect by demographic and study context factors in clinical trials of CBI for AOD. Methods. Studies were systematically identified, and their characteristics and outcome data were extracted and summarized. Standardized mean differences were calculated for within- and between-condition effects on substance use outcomes. Demographic and study context moderators were identified during data acquisition and several sensitivity analyses were conducted. Results. The sample included K = 29 trials and a total of 15 study-level moderators were examined. Information on participants' age, biological sex, and race were reported in at least 26 trials, but information on gender identity, sexual orientation, and ethnicity were reported infrequently or in non-inclusive ways. The mean between-condition effect size was small and moderately heterogenous (d = 0.158, 95% CI = 0.079, 0.238, I2 = 46%) and the mean within-condition effect size was large and showed high heterogeneity (dz = 1.147, 95% CI = 0.811, 1.482, - I2 = 96%). The specific drug targeted in the study and whether biological assay-based outcomes were used moderated between-condition CBI efficacy and the inclusion of co-occurring mental health conditions and study publication date moderated within-condition CBI effects. Conclusions. Results provide preliminary data on study context factors associated with effect estimates in United States based clinical trials of CBI for AOD.

The methods and baseline characteristics of a multi-site randomized controlled trial evaluating mindfulness-based relapse prevention in conjunction with peer support to improve adherence to medications for opioid use disorders

Introduction

Medications for opioid use disorders (MOUD) remain the gold standard for treating OUD, but treatment initiation and adherence remain challenging. Exclusive utilization of pharmacotherapy as a treatment modality for OUD is sub-optimal, and a combination of psychotherapies and pharmacotherapies is recommended. General trends indicate the benefits of peer mentoring and MBRP separately. Therefore, we hypothesize that the combined effect of MBRP and Peer mentoring will produce synergistic improvements in MOUD adherence compared to an enhanced twelve-step facilitation (TSF).

Methods

This paper describes the methods and baseline characteristics of a multi-site randomized controlled trial evaluating the effectiveness of a combination of MBRP and peer support (MiMP) compared to an enhanced TSF in improving adherence to MOUD. Both MiMP and TSF are 12-week manualized protocols that utilize licensed therapists. The interventions are delivered in weekly group sessions that last about 75-90 minutes per session. The primary outcome is MOUD adherence. Secondary and exploratory outcomes include relapse, cravings, depression, anxiety, stress, quality of life, and pain catastrophizing.

Results

The participants' ages ranged from 21 years to 77 years, with a mean age of 44.5 (SD ± 11.5 years). There was an almost equal distribution of gender and place of residence. Overall, 51.9% (n=54) of participants identified as female and 48.1% (n=50) were male. Similarly, 51.9% (n=54) of participants resided in urban areas, while 48.1% (n=50) resided in rural areas. Participants identified as either black or white, with over three-quarters identifying as white (77.9%, n= 81) and 22.1% (n= 23) as black. Most participants randomized to the 12-step facilitation group were white (93.1%). Relationships and employment status were well distributed between categories. Over half of the participants reported some college or higher education. Over 90% of the participants made less than $75,000 per year. Some participants indicated that they had both public and private health insurance.

Discussion and conclusion

This study is innovative in several ways including combining MBRP and peer support, addressing comorbid mental health issues among individuals with OUD, utilizing manualized protocols, and evaluating of both physiological and self-reported measures in assessing cortisol reactivity as a predictor of relapse and treatment outcomes.

Novel medications for problematic alcohol use

Alcohol-related harm, a major cause of disease burden globally, affects people along a spectrum of use. When a harmful pattern of drinking is present in the absence of significant behavioral pathology, low-intensity brief interventions that provide information about health consequences of continued use provide large health benefits. At the other end of the spectrum, profound behavioral pathology, including continued use despite knowledge of potentially fatal consequences, warrants a medical diagnosis, and treatment is strongly indicated. Available behavioral and pharmacological treatments are supported by scientific evidence but are vastly underutilized. Discovery of additional medications, with a favorable balance of efficacy versus safety and tolerability can improve clinical uptake of treatment, allow personalized treatment, and improve outcomes. Here, we delineate the clinical conditions when pharmacotherapy should be considered in relation to the main diagnostic systems in use and discuss clinical endpoints that represent meaningful clinical benefits. We then review specific developments in three categories of targets that show promise for expanding the treatment toolkit. GPCRs remain the largest category of successful drug targets across contemporary medicine, and several GPCR targets are currently pursued for alcohol-related indications. Endocrine systems are another established category, and several promising targets have emerged for alcohol indications. Finally, immune modulators have revolutionized treatment of multiple medical conditions, and they may also hold potential to produce benefits in patients with alcohol problems.

Support after return to alcohol use: a mixed-methods study on how abstinence motivation and app use change after return to alcohol use in an app-based aftercare intervention for individuals with alcohol use disorder

BACKGROUND

As the return to alcohol use in individuals with alcohol use disorder (AUD) is common during treatment and recovery, it is important that abstinence motivation is maintained after such critical incidences. Our study aims to explore how individuals with AUD participating in an app-based intervention with telephone coaching after inpatient treatment perceived their abstinence motivation after the return to alcohol use, whether their app use behavior was affected and to identify helpful factors to maintain abstinence motivation.

METHODS

Using a mixed-methods approach, ten participants from the intervention group of the randomized controlled trial SmartAssistEntz who returned to alcohol use and recorded this in the app Appstinence, a smartphone application with telephone coaching designed for individuals with AUD, were interviewed about their experiences. The interviews were recorded, transcribed and coded using qualitative content analysis. App use behavior was additionally examined by using log data.

RESULTS

Of the ten interviewees, seven reported their abstinence motivation increased after the return to alcohol use. Reasons included the reminder of negative consequences of drinking, the desire to regain control of their situation as well as the perceived support provided by the app. App data showed that app use remained stable after the return to alcohol use with an average of 58.70 days of active app use (SD = 25.96, Mdn = 58.50, range = 24-96, IQR = 44.25) after the return to alcohol use which was also indicated by the participants' reported use behavior.

CONCLUSIONS

The findings of the study tentatively suggest that the app can provide support to individuals after the return to alcohol use to maintain and increase motivation after the incidence. Future research should (1) focus on specifically enhancing identification of high risk situations and reach during such critical incidences, (2) actively integrate the experience of the return to alcohol use into app-based interventions to better support individuals in achieving their personal AUD behavior change goals, and (3) investigate what type of support individuals might need who drop out of the study and intervention and discontinue app use altogether.

TRIAL REGISTRATION

The primary evaluation study is registered in the German Clinical Trials Register (DRKS, registration number DRKS00017700) and received approval of the ethical committee of the Friedrich-Alexander University Erlangen-Nuremberg (193_19 B).