Psychosocial interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users

BACKGROUND

Problem alcohol use is common among people who use illicit drugs (PWID) and is associated with adverse health outcomes. It is also an important factor contributing to a poor prognosis among drug users with hepatitis C virus (HCV) as it impacts on progression to hepatic cirrhosis or opioid overdose in PWID.

OBJECTIVES

To assess the effectiveness of psychosocial interventions to reduce alcohol consumption in PWID (users of opioids and stimulants).

SEARCH METHODS

We searched the Cochrane Drugs and Alcohol Group trials register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, and PsycINFO, from inception up to August 2017, and the reference lists of eligible articles. We also searched: 1) conference proceedings (online archives only) of the Society for the Study of Addiction, International Harm Reduction Association, International Conference on Alcohol Harm Reduction and American Association for the Treatment of Opioid Dependence; and 2) online registers of clinical trials: Current Controlled Trials, ClinicalTrials.gov, Center Watch and the World Health Organization International Clinical Trials Registry Platform.

SELECTION CRITERIA

We included randomised controlled trials comparing psychosocial interventions with other psychosocial treatment, or treatment as usual, in adult PWIDs (aged at least 18 years) with concurrent problem alcohol use.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included seven trials (825 participants). We judged the majority of the trials to have a high or unclear risk of bias.The psychosocial interventions considered in the studies were: cognitive-behavioural coping skills training (one study), twelve-step programme (one study), brief intervention (three studies), motivational interviewing (two studies), and brief motivational interviewing (one study). Two studies were considered in two comparisons. There were no data for the secondary outcome, alcohol-related harm. The results were as follows.Comparison 1: cognitive-behavioural coping skills training versus twelve-step programme (one study, 41 participants)There was no significant difference between groups for either of the primary outcomes (alcohol abstinence assessed with Substance Abuse Calendar and breathalyser at one year: risk ratio (RR) 2.38 (95% confidence interval [CI] 0.10 to 55.06); and retention in treatment, measured at end of treatment: RR 0.89 (95% CI 0.62 to 1.29), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was very low.Comparison 2: brief intervention versus treatment as usual (three studies, 197 participants)There was no significant difference between groups for either of the primary outcomes (alcohol use, measured as scores on the Alcohol Use Disorders Identification Test (AUDIT) or Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) at three months: standardised mean difference (SMD) 0.07 (95% CI -0.24 to 0.37); and retention in treatment, measured at three months: RR 0.94 (95% CI 0.78 to 1.13), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was low.Comparison 3: motivational interviewing versus treatment as usual or educational intervention only (three studies, 462 participants)There was no significant difference between groups for either of the primary outcomes (alcohol use, measured as scores on the AUDIT or ASSIST at three months: SMD 0.04 (95% CI -0.29 to 0.37); and retention in treatment, measured at three months: RR 0.93 (95% CI 0.60 to 1.43), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was low.Comparison 4: brief motivational intervention (BMI) versus assessment only (one study, 187 participants)More people reduced alcohol use (by seven or more days in the past month, measured at six months) in the BMI group than in the control group (RR 1.67; 95% CI 1.08 to 2.60). There was no difference between groups for the other primary outcome, retention in treatment, measured at end of treatment: RR 0.98 (95% CI 0.94 to 1.02), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was moderate.Comparison 5: motivational interviewing (intensive) versus motivational interviewing (one study, 163 participants)There was no significant difference between groups for either of the primary outcomes (alcohol use, measured using the Addiction Severity Index-alcohol score (ASI) at two months: MD 0.03 (95% CI 0.02 to 0.08); and retention in treatment, measured at end of treatment: RR 17.63 (95% CI 1.03 to 300.48), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was low.

AUTHORS' CONCLUSIONS

We found low to very low-quality evidence to suggest that there is no difference in effectiveness between different types of psychosocial interventions to reduce alcohol consumption among people who use illicit drugs, and that brief interventions are not superior to assessment-only or to treatment as usual. No firm conclusions can be made because of the paucity of the data and the low quality of the retrieved studies.

Core characteristics, treatment process and retention in therapeutic communities for addictions: a summary of four studies

Purpose

– The purpose of this paper is to summarize the main findings and conclusions of four separate studies on treatment in therapeutic communities (TCs) for addictions.

Design/methodology/approach

– The first two studies address the core characteristics of the TC approach: a study on the workable and destructive elements of the Synanon model; and a comparative study on the essential elements of TCs for addictions in Europe and in the USA. The final two studies highlight clients’ perceptions of the TC treatment process in relation to retention: a study on clients’ first month perceptions of the TC treatment process and the influence of fixed and dynamic client factors; and a longitudinal study on changes in clients’ perception of the TC treatment process and the impact of motivation, psychological distress and cluster B personality traits.

Findings

– The first study showed that Synanon’s therapeutic and pedagogical methods are still highly valued despite its negative reputation. The results of the second study suggest that while traditional TCs operate as concept-based TCs in Europe, modified TCs might differ in the extent to which they apply the core principles and elements of the TC approach. The third study provides evidence that suitability for treatment is a very important predictor for clients’ first month perceptions of the community environment. The fourth study shows that with time in treatment clients develop more profound perceptions regarding the essence of TC treatment.

Research limitations/implications

– Finally, implications for clinical practice, general limitations and some concrete recommendations for future research are presented in this paper.

Originality/value

– The PhD summary study contributes to the existing literature on TC treatment.

Psychosocial interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users

BACKGROUND

Problem alcohol use is common among illicit drug users and is associated with adverse health outcomes. It is also an important factor contributing to a poor prognosis among drug users with hepatitis C virus (HCV) as it impacts on progression to hepatic cirrhosis or opiate overdose in opioid users.

OBJECTIVES

To assess the effects of psychosocial interventions for problem alcohol use in illicit drug users (principally problem drug users of opiates and stimulants).

SEARCH METHODS

We searched the Cochrane Drugs and Alcohol Group trials register (June 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 11, June 2014), MEDLINE (1966 to June 2014); EMBASE (1974 to June 2014); CINAHL (1982 to June 2014); PsycINFO (1872 to June 2014) and the reference lists of eligible articles. We also searched: 1) conference proceedings (online archives only) of the Society for the Study of Addiction, International Harm Reduction Association, International Conference on Alcohol Harm Reduction and American Association for the Treatment of Opioid Dependence; 2) online registers of clinical trials: Current Controlled Trials, Clinical Trials.org, Center Watch and the World Health Organization International Clinical Trials Registry Platform.

SELECTION CRITERIA

Randomised controlled trials comparing psychosocial interventions with another therapy (other psychosocial treatment, including non-pharmacological therapies, or placebo) in adult (over the age of 18 years) illicit drug users with concurrent problem alcohol use.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

Four studies, involving 594 participants, were included. Half of the trials were rated as having a high or unclear risk of bias. The studies considered six different psychosocial interventions grouped into four comparisons: (1) cognitive-behavioural coping skills training versus 12-step facilitation (one study; 41 participants), (2) brief intervention versus treatment as usual (one study; 110 participants), (3) group or individual motivational interviewing (MI) versus hepatitis health promotion (one study; 256 participants) and (4) brief motivational intervention (BMI) versus assessment-only (one study; 187 participants). Differences between studies precluded any data pooling. Findings are described for each trial individually.Comparison 1: low-quality evidence; no significant difference for any of the outcomes considered Alcohol abstinence as maximum number of weeks of consecutive alcohol abstinence during treatment: mean difference (MD) 0.40 (95% confidence interval (CI) -1.14 to 1.94); illicit drug abstinence as maximum number of weeks of consecutive abstinence from cocaine during treatment: MD 0.80 (95% CI -0.70 to 2.30); alcohol abstinence as number achieving three or more weeks of consecutive alcohol abstinence during treatment: risk ratio (RR) 1.96 (95% CI 0.43 to 8.94); illicit drug abstinence as number achieving three or more weeks of consecutive abstinence from cocaine during treatment: RR 1.10 (95% CI 0.42 to 2.88); alcohol abstinence during follow-up year: RR 2.38 (95% CI 0.10 to 55.06); illicit drug abstinence as abstinence from cocaine during follow-up year: RR 0.39 (95% CI 0.04 to 3.98), moderate-quality evidence.Comparison 2: low-quality evidence, no significant difference for all the outcomes considered Alcohol use as AUDIT scores at three months: MD 0.80 (95% -1.80 to 3.40); alcohol use as AUDIT scores at nine months: MD 2.30 (95% CI -0.58 to 5.18); alcohol use as number of drinks per week at three months: MD 0.70 (95% CI -3.85 to 5.25); alcohol use as number of drinks per week at nine months: MD -0.30 (95% CI -4.79 to 4.19); alcohol use as decreased alcohol use at three months: RR 1.13 (95% CI 0.67 to 1.93); alcohol use as decreased alcohol use at nine months: RR 1.34 (95% CI 0.69 to 2.58), moderate-quality evidence.Comparison 3 (group and individual MI), low-quality evidence: no significant difference for all outcomes Group MI: number of standard drinks consumed per day over the past month: MD -0.40 (95% CI -2.03 to 1.23); frequency of drug use: MD 0.00 (95% CI -0.03 to 0.03); composite drug score (frequency*severity for all drugs taken): MD 0.00 (95% CI -0.42 to 0.42); greater than 50% reduction in number of standard drinks consumed per day over the last 30 days: RR 1.10 (95% CI 0.82 to 1.48); abstinence from alcohol over the last 30 days: RR 0.88 (95% CI 0.49 to 1.58).Individual MI: number of standard drinks consumed per day over the past month: MD -0.10 (95% CI -1.89 to 1.69); frequency of drug use (as measured using the Addiction Severity Index (ASI drug): MD 0.00 (95% CI -0.03 to 0.03); composite drug score (frequency*severity for all drugs taken): MD -0.10 (95% CI -0.46 to 0.26); greater than 50% reduction in number of standard drinks consumed per day over the last 30 days: RR 0.92 (95% CI 0.68 to 1.26); abstinence from alcohol over the last 30 days: RR 0.97 (95% CI 0.56 to 1.67).Comparison 4: more people reduced alcohol use (by seven or more days in the past month at 6 months) in the BMI group than in the control group (RR 1.67; 95% CI 1.08 to 2.60), moderate-quality evidence. No significant difference was reported for all other outcomes: number of days in the past 30 days with alcohol use at one month: MD -0.30 (95% CI -3.38 to 2.78); number of days in the past month with alcohol use at six months: MD -1.50 (95% CI -4.56 to 1.56); 25% reduction of drinking days in the past month: RR 1.23 (95% CI 0.96 to 1.57); 50% reduction of drinking days in the past month: RR 1.27 (95% CI 0.96 to 1.68); 75% reduction of drinking days in the past month: RR 1.21 (95% CI 0.84 to 1.75); one or more drinking days' reduction in the past month: RR 1.12 (95% CI 0.91 to 1.38).

AUTHORS' CONCLUSIONS

There is low-quality evidence to suggest that there is no difference in effectiveness between different types of interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users and that brief interventions are not superior to assessment-only or to treatment as usual. No firm conclusions can be made because of the paucity of the data and the low quality of the retrieved studies.