Motivational enhancement treatment in outpatient addiction centers: A multisite randomized trial

Motivational interviewing for substance use reduction

BACKGROUND

Substance use is a global issue, with around 30 to 35 million individuals estimated to have a substance-use disorder. Motivational interviewing (MI) is a client-centred method that aims to strengthen a person's motivation and commitment to a specific goal by exploring their reasons for change and resolving ambivalence, in an atmosphere of acceptance and compassion. This review updates the 2011 version by Smedslund and colleagues.

OBJECTIVES

To assess the effectiveness of motivational interviewing for substance use on the extent of substance use, readiness to change, and retention in treatment.

SEARCH METHODS

We searched 18 electronic databases, six websites, four mailing lists, and the reference lists of included studies and reviews. The last search dates were in February 2021 and November 2022.

SELECTION CRITERIA

We included randomised controlled trials with individuals using drugs, alcohol, or both. Interventions were MI or motivational enhancement therapy (MET), delivered individually and face to face. Eligible control interventions were no intervention, treatment as usual, assessment and feedback, or other active intervention.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane, and assessed the certainty of evidence with GRADE. We conducted meta-analyses for the three outcomes (extent of substance use, readiness to change, retention in treatment) at four time points (post-intervention, short-, medium-, and long-term follow-up).

MAIN RESULTS

We included 93 studies with 22,776 participants. MI was delivered in one to nine sessions. Session durations varied, from as little as 10 minutes to as long as 148 minutes per session, across included studies. Study settings included inpatient and outpatient clinics, universities, army recruitment centres, veterans' health centres, and prisons. We judged 69 studies to be at high risk of bias in at least one domain and 24 studies to be at low or unclear risk. Comparing MI to no intervention revealed a small to moderate effect of MI in substance use post-intervention (standardised mean difference (SMD) 0.48, 95% confidence interval (CI) 0.07 to 0.89; I2 = 75%; 6 studies, 471 participants; low-certainty evidence). The effect was weaker at short-term follow-up (SMD 0.20, 95% CI 0.12 to 0.28; 19 studies, 3351 participants; very low-certainty evidence). This comparison revealed a difference in favour of MI at medium-term follow-up (SMD 0.12, 95% CI 0.05 to 0.20; 16 studies, 3137 participants; low-certainty evidence) and no difference at long-term follow-up (SMD 0.12, 95% CI -0.00 to 0.25; 9 studies, 1525 participants; very low-certainty evidence). There was no difference in readiness to change (SMD 0.05, 95% CI -0.11 to 0.22; 5 studies, 1495 participants; very low-certainty evidence). Retention in treatment was slightly higher with MI (SMD 0.26, 95% CI -0.00 to 0.52; 2 studies, 427 participants; very low-certainty evidence). Comparing MI to treatment as usual revealed a very small negative effect in substance use post-intervention (SMD -0.14, 95% CI -0.27 to -0.02; 5 studies, 976 participants; very low-certainty evidence). There was no difference at short-term follow-up (SMD 0.07, 95% CI -0.03 to 0.17; 14 studies, 3066 participants), a very small benefit of MI at medium-term follow-up (SMD 0.12, 95% CI 0.02 to 0.22; 9 studies, 1624 participants), and no difference at long-term follow-up (SMD 0.06, 95% CI -0.05 to 0.17; 8 studies, 1449 participants), all with low-certainty evidence. There was no difference in readiness to change (SMD 0.06, 95% CI -0.27 to 0.39; 2 studies, 150 participants) and retention in treatment (SMD -0.09, 95% CI -0.34 to 0.16; 5 studies, 1295 participants), both with very low-certainty evidence. Comparing MI to assessment and feedback revealed no difference in substance use at short-term follow-up (SMD 0.09, 95% CI -0.05 to 0.23; 7 studies, 854 participants; low-certainty evidence). A small benefit for MI was shown at medium-term (SMD 0.24, 95% CI 0.08 to 0.40; 6 studies, 688 participants) and long-term follow-up (SMD 0.24, 95% CI 0.07 to 0.41; 3 studies, 448 participants), both with moderate-certainty evidence. None of the studies in this comparison measured substance use at the post-intervention time point, readiness to change, and retention in treatment. Comparing MI to another active intervention revealed no difference in substance use at any follow-up time point, all with low-certainty evidence: post-intervention (SMD 0.07, 95% CI -0.15 to 0.29; 3 studies, 338 participants); short-term (SMD 0.05, 95% CI -0.03 to 0.13; 18 studies, 2795 participants); medium-term (SMD 0.08, 95% CI -0.01 to 0.17; 15 studies, 2352 participants); and long-term follow-up (SMD 0.03, 95% CI -0.07 to 0.13; 10 studies, 1908 participants). There was no difference in readiness to change (SMD 0.15, 95% CI -0.00 to 0.30; 5 studies, 988 participants; low-certainty evidence) and retention in treatment (SMD -0.04, 95% CI -0.23 to 0.14; 12 studies, 1945 participants; moderate-certainty evidence). We downgraded the certainty of evidence due to inconsistency, study limitations, publication bias, and imprecision.

AUTHORS' CONCLUSIONS

Motivational interviewing may reduce substance use compared with no intervention up to a short follow-up period. MI probably reduces substance use slightly compared with assessment and feedback over medium- and long-term periods. MI may make little to no difference to substance use compared to treatment as usual and another active intervention. It is unclear if MI has an effect on readiness to change and retention in treatment. The studies included in this review were heterogeneous in many respects, including the characteristics of participants, substance(s) used, and interventions. Given the widespread use of MI and the many studies examining MI, it is very important that counsellors adhere to and report quality conditions so that only studies in which the intervention implemented was actually MI are included in evidence syntheses and systematic reviews. Overall, we have moderate to no confidence in the evidence, which forces us to be careful about our conclusions. Consequently, future studies are likely to change the findings and conclusions of this review.

The process and challenges of language translation and cultural adaptation of study instruments: a case study from the NIDA CTN CHOICES-2 trial

BACKGROUND

As the U.S. grows more diverse, researchers decide how to include non-English speakers. Budget limitations may not allow for translation of all instruments. Study teams must determine which instruments must receive certified translations. This paper describes the procedures utilized in one U.S.-based, multi-site clinical trial to decide which study instruments should undergo certified translation and discusses dialect review procedures.

METHODS

The team determined which instruments (n = 31) would be translated using a qualitative evaluation to determine the need to obtain a Spanish-language certified translation: 1) "Could the meaning of these questions change (and potentially elicit a different response) if the translations were not consistent?" and 2) "Is it acceptable to have potential inconsistencies in these data?" Instruments for which question 1 was "yes" and question 2 was "no" (e.g., eligibility, outcomes, safety) were marked for certified translation. A dialect committee reviewed all translated patient-reported outcome measures to ensure that the translations had accounted for different meanings of words based on respondents' countries or regions of origin and recommended changes where necessary.

RESULTS

Fourteen interview-based instruments underwent certified forward-only translation into U.S. Spanish. The remaining 2 interview-based instruments were translated via real-time conversation with participants by bilingual staff. Six forms were administrative and not translated. Five out of 9 professionally translated patient-reported outcome measures were amended to better reflect relevant dialects.

CONCLUSIONS

In the absence of specific guidance, it is feasible for study team members to 1) determine which instruments should undergo certified translation and 2) incorporate dialect into translations.

Motivational interviewing quality assurance: A systematic review of assessment tools across research contexts

The need for sustained skill development and quality assurance when executing behavioral interventions is best demonstrated in the empirical evolution of Motivational Interviewing (MI). As a brief behavioral intervention that identifies the therapeutic process as an active treatment ingredient, it is critical for researchers, trainers, and administrators to use psychometrically sound and theoretically congruent tools to evaluate provider skills and fidelity when executing MI. Yet, no prior work has evaluated the breadth of MI tools employed across research contexts. Therefore, this review identified MI fidelity and skill development tools across measurement, training and efficacy/effectiveness studies and evaluated their psychometric strength and fit with current MI theory. We identified 199 empirical studies that employed an MI fidelity/skill tool and we found 21 tools with varying degrees of empirical support and theoretical congruence. Specifically, we identified five observer-, two trainee- and one client-rated tool with strong empirical support, and nine observer- and two client-rated tools with preliminary empirical support. We detailed the empirical strength, including the extent to which tools were linked to trainee/client outcomes across research contexts and offer recommendations on which MI tools to use in training, efficacy, and effectiveness trials.

Strategies to improve treatment utilization for substance use disorders: A systematic review of intervention studies

BACKGROUND

Many people who need specialty treatment for substance use disorders (SUDs) do not receive it. Clinical interventions could increase treatment utilization but are not routinely used. This systematic review aimed to describe clinical interventions that may increase SUD specialty treatment utilization (i.e., treatment initiation, attendance, meaningful engagement) and to determine which intervention(s) most consistently increase treatment utilization.

METHODS

We conducted a systematic review of clinical intervention studies (published in English between 2000 and 2017) reporting outcomes relevant to specialty SUD treatment utilization. Outcomes were treatment initiation, attendance, and meaningful engagement. Risk of bias was assessed using Cochrane guidelines and randomized controlled trials (RCTs) with bias scores < 3 were included in a synthesis of results. Proportions of positive to negative utilization outcomes were calculated for each low-bias RCT; studies with 50% positive outcomes or more were considered "majority-positive". Studies were categorized by theory-based approach.

RESULTS

Twenty-three RCTs had low risk of bias and were synthesized. Among intervention types with two or more studies, cognitive-behavioral (100% majority-positive) and coordinated care (67% majority-positive) interventions were most likely to increase treatment initiation, while 12-step promotion interventions were most likely to increase treatment attendance (50% majority-positive). One study (12-step promotion) measured meaningful engagement, with majority-positive outcomes.

CONCLUSIONS

A systematic review and narrative synthesis of clinical interventions promoting specialty SUD treatment utilization provided preliminary evidence that cognitive-behavioral and coordinated care interventions may increase treatment initiation, while 12-step promotion interventions may promote treatment attendance. More quality studies and greater consistency in treatment utilization measurement are needed.

Profiles of Violence and Alcohol and Tobacco Use in Relation to Impulsivity: Sustainable Consumption in Adolescents

The purpose of this study was to identify different adolescent profiles identified by their tobacco and alcohol use and patterns of violent behavior, as well as to analyze the extent to which such adolescents show impulsivity traits. The participants were selected by cluster random sampling. There were a total of 822 high school students in the sample, aged 13 to 18 years with a mean age of 14.84 (SD = 0.87). A cluster analysis with the following variables was conducted to form the groups: use of tobacco, use of alcohol, physical aggression, verbal aggression, anger, and hostility. A total of three groups of adolescents resulted from these six variables. A multivariate comparison demonstrated the existence of significant between-group differences, and an individual analysis of each of the dependent variables (impulsivity dimensions) showed that the relationship was statistically significant in all cases. In conclusion, the analysis of factors possibly associated with risk behavior in adolescents creates the possibility for and guides intervention in different stages of development in order to encourage sustainable consumption in adolescents.

Development and evaluation of addiction treatment programs in Latin America

PURPOSE OF REVIEW

The aim of this article is to present a state-of-the-art review of the scientific studies that have evaluated healthcare systems, services and programs for addiction treatment in Latin America. As a secondary aim, this article presents a brief description and analysis of the addiction prevention and treatment resources and programs available in Latin America, based on information from the ATLAS on Substance Use (ATLAS-SU) project led by the WHO.

RECENT FINDINGS

Substance use disorders (SUDs) are among the main causes associated with global burden of disease. Around the world, many initiatives have been proposed to promote policies to reduce substance use and reduce the impact of SUD, including integrating treatments into healthcare systems, increasing access to treatment programs and impacting outcome measures. In Latin America, multiple efforts have been implemented to improve addiction services and programs, although little is known about the impact they have generated.

SUMMARY

International studies report the availability of strategies and public inicitatives on prevention and treatment of addiction in Latin America. These studies also report established networks of public and private services that include prevention and detoxification programs, outpatient and residential treatment, and also social reintegration initiatives. However, despite these advances, information on the evaluation of the progress, results and impact of these programs is limited.

Predictive validity of the Sidorkiewicz instrument in Spanish: Assessing individual drug adherence in psychiatric patients

Background/Objective: Concomitant prescription of two or more psychiatric medications has become the rule and patients could adhere differently to their various drugs prescribed. Sidorkiewicz et al. published a questionnaire for assessing adherence to each specific drug. Method: This study explored the predictive validity of the Spanish version of the Sidorkiewicz questionnaire in a sample of 470 consecutive psychiatric outpatients using 897 psychiatric drugs. Results: The questionnaire showed adequate predictive validity in both univariate and multivariate analyses (logistic regression and CHAID segmentation) since they demonstrated a significant association with the 10-item Drug Attitude Inventory and with the Necessity and Concern Scales of the Beliefs about Medications Questionnaire. Some demographic and clinical variables were significant in the univariate analyses but lost significance in the multivariate analyses. Conclusions: The adherence of the psychiatric patient to his/her prescribed treatment may not be significantly influenced by socio-demographic or clinical characteristics, but rather by attitudes toward medication, perceptions of personal necessity for medication, and concerns about its potential adverse effects. This study's findings suggest that the Spanish version of the Sidorkiewicz questionnaire may be a useful and valid instrument for assessing adherence to each individual drug taken by psychiatric outpatients undergoing polypsychopharmacy.