An evaluation of a brief motivational intervention among young ecstasy and cocaine users: no effect on substance and alcohol use outcomes

Psychosocial interventions for stimulant use disorder

BACKGROUND

Stimulant use disorder is a continuously growing medical and social burden without approved medications available for its treatment. Psychosocial interventions could be a valid approach to help people reduce or cease stimulant consumption. This is an update of a Cochrane review first published in 2016.

OBJECTIVES

To assess the efficacy and safety of psychosocial interventions for stimulant use disorder in adults.

SEARCH METHODS

We searched the Cochrane Drugs and Alcohol Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, three other databases, and two trials registers in September 2023. All searches included non-English language literature. We handsearched the references of topic-related systematic reviews and the included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing any psychosocial intervention with no intervention, treatment as usual (TAU), or a different intervention in adults with stimulant use disorder.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included a total of 64 RCTs (8241 participants). Seventy-three percent of studies included participants with cocaine or crack cocaine use disorder; 3.1% included participants with amphetamine use disorder; 10.9% included participants with methamphetamine use disorder; and 12.5% included participants with any stimulant use disorder. In 18 studies, all participants were in methadone maintenance treatment. In our primary comparison of any psychosocial treatment to no intervention, we included studies which compared a psychosocial intervention plus TAU to TAU alone. In this comparison, 12 studies evaluated cognitive behavioural therapy (CBT), 27 contingency management, three motivational interviewing, one study looked at psychodynamic therapy, and one study evaluated CBT plus contingency management. We also compared any psychosocial intervention to TAU. In this comparison, seven studies evaluated CBT, two contingency management, two motivational interviewing, and one evaluated a combination of CBT plus motivational interviewing. Seven studies compared contingency management reinforcement related to abstinence versus contingency management not related to abstinence. Finally, seven studies compared two different psychosocial approaches. We judged 65.6% of the studies to be at low risk of bias for random sequence generation and 19% at low risk for allocation concealment. Blinding of personnel and participants was not possible for the type of intervention, so we judged all the studies to be at high risk of performance bias for subjective outcomes but at low risk for objective outcomes. We judged 22% of the studies to be at low risk of detection bias for subjective outcomes. We judged most of the studies (69%) to be at low risk of attrition bias. When compared to no intervention, we found that psychosocial treatments: reduce the dropout rate (risk ratio (RR) 0.82, 95% confidence interval (CI) 0.74 to 0.91; 30 studies, 4078 participants; high-certainty evidence); make little to no difference to point abstinence at the end of treatment (RR 1.15, 95% CI 0.94 to 1.41; 12 studies, 1293 participants; high-certainty evidence); make little to no difference to point abstinence at the longest follow-up (RR 1.22, 95% CI 0.91 to 1.62; 9 studies, 1187 participants; high-certainty evidence); probably increase continuous abstinence at the end of treatment (RR 1.89, 95% CI 1.20 to 2.97; 12 studies, 1770 participants; moderate-certainty evidence); may make little to no difference in continuous abstinence at the longest follow-up (RR 1.14, 95% CI 0.89 to 1.46; 4 studies, 295 participants; low-certainty evidence); reduce the frequency of drug intake at the end of treatment (standardised mean difference (SMD) -0.35, 95% CI -0.50 to -0.19; 10 studies, 1215 participants; high-certainty evidence); and increase the longest period of abstinence (SMD 0.54, 95% CI 0.41 to 0.68; 17 studies, 2118 participants; high-certainty evidence). When compared to TAU, we found that psychosocial treatments reduce the dropout rate (RR 0.79, 95% CI 0.65 to 0.97; 9 studies, 735 participants; high-certainty evidence) and may make little to no difference in point abstinence at the end of treatment (RR 1.67, 95% CI 0.64 to 4.31; 1 study, 128 participants; low-certainty evidence). We are uncertain whether they make any difference in point abstinence at the longest follow-up (RR 1.31, 95% CI 0.86 to 1.99; 2 studies, 124 participants; very low-certainty evidence). Compared to TAU, psychosocial treatments may make little to no difference in continuous abstinence at the end of treatment (RR 1.18, 95% CI 0.92 to 1.53; 1 study, 128 participants; low-certainty evidence); probably make little to no difference in the frequency of drug intake at the end of treatment (SMD -1.17, 95% CI -2.81 to 0.47, 4 studies, 479 participants, moderate-certainty evidence); and may make little to no difference in the longest period of abstinence (SMD -0.16, 95% CI -0.54 to 0.21; 1 study, 110 participants; low-certainty evidence). None of the studies for this comparison assessed continuous abstinence at the longest follow-up. Only five studies reported harms related to psychosocial interventions; four of them stated that no adverse events occurred.

AUTHORS' CONCLUSIONS

This review's findings indicate that psychosocial treatments can help people with stimulant use disorder by reducing dropout rates. This conclusion is based on high-certainty evidence from comparisons of psychosocial interventions with both no treatment and TAU. This is an important finding because many people with stimulant use disorders leave treatment prematurely. Stimulant use disorders are chronic, lifelong, relapsing mental disorders, which require substantial therapeutic efforts to achieve abstinence. For those who are not yet able to achieve complete abstinence, retention in treatment may help to reduce the risks associated with stimulant use. In addition, psychosocial interventions reduce stimulant use compared to no treatment, but they may make little to no difference to stimulant use when compared to TAU. The most studied and promising psychosocial approach is contingency management. Relatively few studies explored the other approaches, so we cannot rule out the possibility that the results were imprecise due to small sample sizes.

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.

Educational Attainment and Differences in Patterns of Alcohol, Cannabis, and Tobacco Use Among Young Adults

Multigroup latent profile analysis examined whether patterns of alcohol, cannabis, and tobacco use varied between college student and nonstudent young adults ( N = 745), and profiles were characterized by alcohol- and drug-related problems, psychological distress, and perceived stress. Findings supported three profiles (high use across substances, primarily high tobacco use, and low use across substances) among students. Students in the high use group, relative to other groups, experienced the highest number of problems and psychological distress. Among nonstudents, two profiles emerged (high use across substances and primarily high tobacco use), and noncollege participants in the high use group experienced the highest problems, psychological distress, and perceived stress. Students, compared to nonstudents, reported more variability in their substance use profiles, as a low substance use group was not observed among nonstudents. Prevention and intervention efforts should target nonstudents, which could aid in reducing negative health outcomes based on disparities in education.

When Stimulant Use Becomes Problematic: Examining the Role of Coping Styles

Objective: Stimulant use among college students is a significant public health concern due to its consequential effects. Given that many students reportedly use prescription stimulants for academic purposes, empirical investigations are needed to identify those students at risk for prescription stimulant misuse (PSM). The purpose of the current study was to examine the role of coping styles on the association between prescription stimulant use and related consequences. We hypothesized that more maladaptive (vs. adaptive) coping strategies would mediate this association, particularly for underclassmen (freshmen/sophomores) and men.Method: Participants were n = 787 college students across seven universities in the United States who completed an online survey assessing substance use and coping behaviors. Prior to hypothesis testing, we conducted factor analysis on the COPE measure and found support for a three-factor solution, which we named maladaptive coping, adaptive coping, and supportive coping.Results: Prescription stimulant use was positively related to stimulant-related negative consequences. Multiple mediation analyses indicated that the maladaptive coping factor partially mediated this direct association. Multi-group analyses revealed that maladaptive coping style was a significant mediator for college women in the sample, but not men. Conclusions: These results scratch the surface of the relationship between coping and risky stimulant use among college students and imply that the building of coping strategies is a useful target in identifying at-risk students.

Efficacy of brief intervention for drug misuse in primary care facilities: systematic review and meta-analysis protocol

INTRODUCTION

Drug misuse is associated with significant global morbidity, mortality, economic costs and social costs. Many primary care facilities have integrated drug misuse screening and brief intervention (BI) into their usual care delivery. However, the efficacy of BI for drug misuse in primary care has not been substantiated through meta-analysis. The aim of this systematic review and meta-analysis is to determine the efficacy of BI for drug misuse in primary care settings.

METHODS AND ANALYSIS

We will include all randomised controlled trials comparing primary care-delivered BI for drug misuse with no intervention or minimal screening/assessment and usual care. Primary outcomes are (1) drug use frequency scores and (2) severity scores at intermediate follow-up (4-8 months). We will retrieve all studies through searches in CENTRAL, Embase, MEDLINE and PsycINFO until 31 May 2020. The reference list will be supplemented with searches in trial registries (eg, www.clinicaltrials.gov) and through relevant existing study reference lists identified in the literature. We will conduct a random-effect pairwise meta-analysis for primary and secondary outcomes. We will assess statistical heterogeneity though visual inspection of a forest plot and calculate I2 statistics. We will assess risk of bias using the Cochrane Risk of Bias Tool V.2 and evaluate the certainty of evidence through the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Sensitivity analyses will account for studies with control group variations and studies with a high risk of bias. If heterogeneity is present, subgroup analyses will consider patient variables of age, sex/gender, race/ethnicity, per cent insured, baseline severity and primary drug misused.

ETHICS AND DISSEMINATION

This study will use published aggregate data and will not require ethical approval. Findings will be disseminated in a peer-reviewed journal.

Brief interventions for young adults who use drugs: The moderating effects of resilience and trauma

Among participants in an intervention clinical trial (N = 602), we examined resilience as a moderator of substance use outcomes by intervention condition and between participants with and without severe traumatic stress (STS). Eligibility included men and women ages 18-39 with recent multidrug use; drug treatment enrollees were excluded. Outcome measures were past 90-day frequencies of substance use and abstinence. Putative moderators were measured using the Resilience Research Centre's Adult Resilience Measure (RRC-ARM) and the Traumatic Stress Scale from the Global Appraisal of Individual Needs (GAIN). Analyses employed hierarchical linear models. High resilience predicted better substance use outcomes, and the ordering of intervention effects for high resilience participants was stepwise by intervention condition intensity. Participants with low resilience scores had poorer outcomes, and those outcomes were largely unaffected by intervention condition. Participants without STS experienced the interventions similarly to the overall sample. Regardless of the level of resilience, however, participants with STS did not benefit from the interventions. The findings point to the importance of screening for both resilience and traumatic stress prior to intervention to maximize the impact of brief interventions for substance users, and also to link those needing more intensive approaches to additional services and professional care.

Examining subgroup effects by socioeconomic status of public health interventions targeting multiple risk behaviour in adolescence

BACKGROUND

Multiple risk behaviour (MRB) refers to two or more risk behaviours such as smoking, drinking alcohol, poor diet and unsafe sex. Such behaviours are known to co-occur in adolescence. It is unknown whether MRB interventions are equally effective for young people of low and high socioeconomic status (SES). There is a need to examine these effects to determine whether MRB interventions have the potential to narrow or widen inequalities.

METHODS

Two Cochrane systematic reviews that examined interventions to reduce adolescent MRB were screened to identify universal interventions that reported SES. Study authors were contacted, and outcome data stratified by SES and intervention status were requested. Risk behaviour outcomes alcohol use, smoking, drug use, unsafe sex, overweight/obesity, sedentarism, peer violence and dating violence were examined in random effects meta-analyses and subgroup analyses conducted to explore differences between high SES and low SES adolescents.

RESULTS

Of 49 studies reporting universal interventions, only 16 also reported having measured SES. Of these 16 studies, four study authors provided data sufficient for subgroup analysis. There was no evidence of subgroup differences for any of the outcomes. For alcohol use, the direction of effect was the same for both the high SES group (RR 1.26, 95% CI: 0.96, 1.65, p = 0.09) and low SES group (RR 1.14, 95% CI: 0.98, 1.32, p = 0.08). The direction of effect was different for smoking behaviour in favour of the low SES group (RR 0.83, 95% CI: 0.66, 1.03, p = 0.09) versus the high SES group (RR 1.16, 95% CI: 0.82, 1.63, p = 0.39). For drug use, the direction of effect was the same for both the high SES group (RR 1.29, 95% CI: 0.97, 1.73, p = 0.08) and the low SES group (RR 1.28, 95% CI: 0.84, 1.96, p = 0.25).

CONCLUSIONS

The majority of studies identified did not report having measured SES. There was no evidence of subgroup difference for all outcomes analysed among the four included studies. There is a need for routine reporting of demographic information within studies so that stronger evidence of effect by SES can be demonstrated and that interventions can be evaluated for their impact on health inequalities.

The search for relevant outcome measures for cost-utility analysis of systemic family interventions in adolescents with substance use disorder and delinquent behavior: a systematic literature review

PURPOSE

Systemic family interventions have shown to be effective in adolescents with substance use disorder and delinquent behavior. The interventions target interactions between the adolescent and involved systems (i.e. youth, family, peers, neighbors, school, work, and society). Next to effectiveness considerations, economic aspects have gained attention. However, conventional generic quality of life measures used in health economic evaluations may not be able to capture the broad effects of systemic interventions. This study aims to identify existing outcome measures, which capture the broad effects of systemic family interventions, and allow use in a health economic framework.

METHODS

We based our systematic review on clinical studies in the field. Our goal was to identify effectiveness studies of psychosocial interventions for adolescents with substance use disorder and delinquent behavior and to distill the instruments used in these studies to measure effects. Searched databases were PubMed, Education Resource Information Center (ERIC), Cochrane and Psychnet (PsycBOOKSc, PsycCRITIQUES, print). Identified instruments were ranked according to the number of systems covered (comprehensiveness). In addition, their use for health economic analyses was evaluated according to suitability characteristics such as brevity, accessibility, psychometric properties, etc.

RESULTS

One thousand three hundred seventy-eight articles were found and screened for eligibility. Eighty articles were selected, 8 instruments were identified covering 5 or more systems.

CONCLUSIONS

The systematic review identified instruments from the clinical field suitable to evaluate systemic family interventions in a health economic framework. None of them had preference-weights available. Hence, a next step could be to attach preference-weights to one of the identified instruments to allow health economic evaluations of systemic family interventions.

A randomized trial of brief assessment interventions for young adults who use drugs in the club scene

BACKGROUND

Efficacious interventions to reduce drug use and its consequences for club drug using populations are not apparent in the literature. We tested interviewer- (CAPI) and self-administered (ACASI) comprehensive health and social risk assessments as distinct interventions compared to waitlist control.

METHODS

750 men and women ages 18-39 with multidrug use and heterosexual behavior were randomized in equal proportions to the three conditions. Instrumentation included well-tested measures of drug use, risky sex, mental distress and substance dependence.

RESULTS

The sample was 56% male; mean age=25. Reported risk behaviors and health consequences did not differ by assessment modality. Adjusted HLM analyses showed a significant main effect of assigned condition on all outcomes. CAPI participants had greater reductions in drug use, risky sex, mental distress and substance dependence symptoms, and greater increases in abstinence, compared to ACASI intervention or control participants at 12months, except that the CAPI and ACASI conditions had similar efficacy for reductions in drug use. Effect sizes for CAPI versus ACASI participants were d=0.2-0.3, and between CAPI and controls d=0.2-0.4. Effect sizes for improved outcomes between ACASI compared to controls were small to non-significant.

CONCLUSIONS

The study established the therapeutic benefit of interviewer interaction in reducing risky behavior among this young drug using population. The study demonstrated the efficacy and acceptability of a low threshold intervention in reducing drug use, sexual risk and related co-morbidities among a not-in-treatment young adult population that exhibits severe and complex levels of drug use, but that is also highly resistant to intervention.

A randomized study of the use of screening, brief intervention, and referral to treatment (SBIRT) for drug and alcohol use with jail inmates

BACKGROUND

Screening, brief intervention, and referral to treatment (SBIRT) is an evidence-based practice that has been shown to reduce alcohol and drug use in healthcare, educational, and other settings, but research on the effectiveness of SBIRT with populations involved in the criminal justice system is limited. These populations have high rates of substance use but have limited access to interventions.

METHODS

The study randomized 732 jail inmates from a large urban jail to the SBIRT intervention or to the control group. Using the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST), the intervention assessed the risk level for drug and alcohol misuse by inmates and provided those who were at low or medium risk with a brief intervention in jail and referred those at high risk to community treatment following release, including the opportunity to participate in a brief treatment (eight sessions) protocol. Using interview and records data from a 12-month follow-up, analyses compared the two groups with respect to the primary study outcomes of reductions in drug and alcohol use and the secondary outcomes of participation in treatment, rearrest, reduction in HIV risk behaviors, and quality of life. In addition, the costs of delivering the SBIRT intervention were calculated.

RESULTS

When baseline differences were controlled, the groups did not differ at follow-up on any of the primary or secondary outcomes.

CONCLUSIONS

Future research should develop and evaluate SBIRT models that are specifically adapted to the characteristics and needs of the jail population. Until more favorable results emerge, attempts to use SBIRT with jail inmates should be implemented with caution, if at all.

TRIAL REGISTRATION NUMBER

NCT01683643.

Benzodiazepine Dependence among Young Adult Participants in the Club Scene Who Use Drugs

Young adults ages 18-29 report the highest rates of benzodiazepine (BZD) misuse in the United States. The majority of club drug users are also in this age group, and BZD misuse is prevalent among participants in club scenes. This article examines BZD dependence and its correlates among young adult participants in the electronic dance music (EDM) culture in Miami, Florida, who use drugs. Structured interviews were with men and women (N = 356) ages 18 to 29 who reported regular attendance at EDM venues and recent use of both club drugs and BZDs. Prevalences of BZD-related problems were 12.6% for BZD dependence, 21.1% BZD abuse, and 24.2% BZD abuse and/or dependence. In a multivariate logistic regression model, younger age (OR 0.85; 95% CI 0.76, 0.96), severe mental distress (OR 8.30; 95% CI 3.07, 22.49), daily marijuana use (OR 2.10; 95% CI 1.03, 4.27), and heavy opioid use (OR 2.33; 95% CI 1.12, 4.83) were associated with BZD dependence. BZD dependence was higher in this sample than in other populations described in the literature. The links between BZD dependence, overdose history, and heavy opioid misuse are especially worrisome among this young sample. Recommendations for intervention and research are discussed.

Psychosocial interventions for psychostimulant misuse

BACKGROUND

Psychostimulant misuse is a continuously growing medical and social burden. There is no evidence proving the efficacy of pharmacotherapy. Psychosocial interventions could be a valid approach to help patients in reducing or ceasing drug consumption.

OBJECTIVES

To assess the effects of psychosocial interventions for psychostimulant misuse in adults.

SEARCH METHODS

We searched the Cochrane Drugs and Alcohol Group Specialised Register (via CRSLive); Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; CINAHL; Web of Science and PsycINFO, from inception to November 2015. We also searched for ongoing and unpublished studies via ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (apps.who.int/trialsearch/).All searches included non-English language literature. We handsearched references of topic-related systematic reviews and the included studies.

SELECTION CRITERIA

We included randomised controlled trials comparing any psychosocial intervention with no intervention, treatment as usual (TAU) or a different intervention in adults with psychostimulant misuse or dependence.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included a total of 52 trials (6923 participants).The psychosocial interventions considered in the studies were: cognitive behavioural therapy (19 studies), contingency management (25 studies), motivational interviewing (5 studies), interpersonal therapy (3 studies), psychodynamic therapy (1 study), 12-step facilitation (4 studies).We judged most of the studies to be at unclear risk of selection bias; blinding of personnel and participants was not possible for the type of intervention, so all the studies were at high risk of performance bias with regard to subjective outcomes; the majority of studies did not specify whether the outcome assessors were blind. We did not consider it likely that the objective outcomes were influenced by lack of blinding.The comparisons made were: any psychosocial intervention versus no intervention (32 studies), any psychosocial intervention versus TAU (6 studies), and one psychosocial intervention versus an alternative psychosocial intervention (13 studies). Five of included studies did not provide any useful data for inclusion in statistical synthesis.We found that, when compared to no intervention, any psychosocial treatment: reduced the dropout rate (risk ratio (RR): 0.83, 95% confidence interval (CI) 0.76 to -0.91, 24 studies, 3393 participants, moderate quality evidence); increased continuous abstinence at the end of treatment (RR: 2.14, 95% CI 1.27 to -3.59, 8 studies, 1241 participants, low quality evidence); did not significantly increase continuous abstinence at the longest follow-up (RR: 2.12, 95% CI 0.77 to -5.86, 4 studies, 324 participants, low quality evidence); significantly increased the longest period of abstinence: (standardised mean difference (SMD): 0.48, 95% CI 0.34 to 0.63, 10 studies, 1354 participants, high quality evidence). However, it should be noted that the in the vast majority of the studies in this comparison the specific psychosocial treatment assessed in the experimental arm was given in add on to treatment as usual or to another specific psychosocial or pharmacological treatment which was received by both groups. So, many of the control groups in this comparison were not really untreated. Receiving some amount of treatment is not the same as not receiving any intervention, so we could argue that the overall effect of the experimental psychosocial treatment could be smaller if given in add on to TAU or to another intervention than if given to participants not receiving any intervention; this could translate to a smaller magnitude of the effect of the psychosocial intervention when it is given in add on.When compared to TAU, any psychosocial treatment reduced dropout rate (RR: 0.72, 95% CI 0.59 to 0.89, 6 studies, 516 participants, moderate quality evidence), did not increase continuous abstinence at the end of treatment (RR: 1.27, 95% CI 0.94 to 1.72, 2 studies, 224 participants, low quality evidence), did not increase longest period of abstinence (MD -3.15 days, 95% CI -10.35 to 4.05, 1 study, 110 participants, low quality evidence). No studies in this comparison assessed the outcome of continuous abstinence at longest follow-up.There were few studies comparing two or more psychosocial interventions, with small sample sizes and considerable heterogeneity in terms of the types of interventions assessed. None reported significant results.None of the studies reported harms related to psychosocial interventions.

AUTHORS' CONCLUSIONS

The addition of any psychosocial treatment to treatment as usual (usually characterised by group counselling or case management) probably reduces the dropout rate and increases the longest period of abstinence. It may increase the number of people achieving continuous abstinence at the end of treatment, although this might not be maintained at longest follow-up. The most studied and the most promising psychosocial approach to be added to treatment as usual is probably contingency management. However, the other approaches were only analysed in a few small studies, so we cannot rule out the possibility that the results were not significant because of imprecision. When compared to TAU, any psychosocial treatment may improve adherence, but it may not improve abstinence at the end of treatment or the longest period of abstinence.The majority of the studies took place in the United States, and this could limit the generalisability of the findings, because the effects of psychosocial treatments could be strongly influenced by the social context and ethnicity. The results of our review do not answer the most relevant clinical question, demonstrating which is the most effective type of psychosocial approach.Further studies should directly compare contingency management with the other psychosocial approaches.

Motivational interviewing for the prevention of alcohol misuse in young adults

BACKGROUND

Alcohol use and misuse in young people is a major risk behaviour for mortality and morbidity. Motivational interviewing (MI) is a popular technique for addressing excessive drinking in young adults.

OBJECTIVES

To assess the effects of motivational interviewing (MI) interventions for preventing alcohol misuse and alcohol-related problems in young adults.

SEARCH METHODS

We identified relevant evidence from the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 12), MEDLINE (January 1966 to July 2015), EMBASE (January 1988 to July 2015), and PsycINFO (1985 to July 2015). We also searched clinical trial registers and handsearched references of topic-related systematic reviews and the included studies.

SELECTION CRITERIA

We included randomised controlled trials in young adults up to the age of 25 years comparing MIs for prevention of alcohol misuse and alcohol-related problems with no intervention, assessment only or alternative interventions for preventing alcohol misuse and alcohol-related problems.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included a total of 84 trials (22,872 participants), with 70/84 studies reporting interventions in higher risk individuals or settings. Studies with follow-up periods of at least four months were of more interest in assessing the sustainability of intervention effects and were also less susceptible to short-term reporting or publication bias. Overall, the risk of bias assessment showed that these studies provided moderate or low quality evidence.At four or more months follow-up, we found effects in favour of MI for the quantity of alcohol consumed (standardised mean difference (SMD) -0.11, 95% confidence interval (CI) -0.15 to -0.06 or a reduction from 13.7 drinks/week to 12.5 drinks/week; moderate quality evidence); frequency of alcohol consumption (SMD -0.14, 95% CI -0.21 to -0.07 or a reduction in the number of days/week alcohol was consumed from 2.74 days to 2.52 days; moderate quality evidence); and peak blood alcohol concentration, or BAC (SMD -0.12, 95% CI -0.20 to 0.05, or a reduction from 0.144% to 0.131%; moderate quality evidence).We found a marginal effect in favour of MI for alcohol problems (SMD -0.08, 95% CI -0.17 to 0.00 or a reduction in an alcohol problems scale score from 8.91 to 8.18; low quality evidence) and no effects for binge drinking (SMD -0.04, 95% CI -0.09 to 0.02, moderate quality evidence) or for average BAC (SMD -0.05, 95% CI -0.18 to 0.08; moderate quality evidence). We also considered other alcohol-related behavioural outcomes, and at four or more months follow-up, we found no effects on drink-driving (SMD -0.13, 95% CI -0.36 to 0.10; moderate quality of evidence) or other alcohol-related risky behaviour (SMD -0.15, 95% CI -0.31 to 0.01; moderate quality evidence).Further analyses showed that there was no clear relationship between the duration of the MI intervention (in minutes) and effect size. Subgroup analyses revealed no clear subgroup effects for longer-term outcomes (four or more months) for assessment only versus alternative intervention controls; for university/college vs other settings; or for higher risk vs all/low risk participants.None of the studies reported harms related to MI.

AUTHORS' CONCLUSIONS

The results of this review indicate that there are no substantive, meaningful benefits of MI interventions for preventing alcohol use, misuse or alcohol-related problems. Although we found some statistically significant effects, the effect sizes were too small, given the measurement scales used in the included studies, to be of relevance to policy or practice. Moreover, the statistically significant effects are not consistent for all misuse measures, and the quality of evidence is not strong, implying that any effects could be inflated by risk of bias.

Prevention, early intervention, harm reduction, and treatment of substance use in young people

We did a systematic review of reviews with evidence on the effectiveness of prevention, early intervention, harm reduction, and treatment of problem use in young people for tobacco, alcohol, and illicit drugs (eg, cannabis, opioids, amphetamines, or cocaine). Taxation, public consumption bans, advertising restrictions, and minimum legal age are effective measures to reduce alcohol and tobacco use, but are not available to target illicit drugs. Interpretation of the available evidence for school-based prevention is affected by methodological issues; interventions that incorporate skills training are more likely to be effective than information provision-which is ineffective. Social norms and brief interventions to reduce substance use in young people do not have strong evidence of effectiveness. Roadside drug testing and interventions to reduce injection-related harms have a moderate-to-large effect, but additional research with young people is needed. Scarce availability of research on interventions for problematic substance use in young people indicates the need to test interventions that are effective with adults in young people. Existing evidence is from high-income countries, with uncertain applicability in other countries and cultures and in subpopulations differing in sex, age, and risk status. Concerted efforts are needed to increase the evidence base on interventions that aim to reduce the high burden of substance use in young people.

Brief school-based interventions and behavioural outcomes for substance-using adolescents

BACKGROUND

Adolescent substance use is a major problem in and of itself, and because it acts as a risk factor for other problem behaviours. As substance use during adolescence can lead to adverse and often long-term health and social consequences, it is important to intervene early in order to prevent progression to more severe problems. Brief interventions have been shown to reduce problematic substance use among adolescents and are especially useful for individuals who have moderately risky patterns of substance use. Such interventions can be conducted in school settings. This review set out to evaluate the effectiveness of brief school-based interventions for adolescent substance use.

OBJECTIVES

To evaluate the effectiveness of brief school-based interventions in reducing substance use and other behavioural outcomes among adolescents compared to another intervention or assessment-only conditions.

SEARCH METHODS

We conducted the original literature search in March 2013 and performed the search update to February 2015. For both review stages (original and update), we searched 10 electronic databases and six websites on evidence-based interventions, and the reference lists of included studies and reviews, from 1966 to February 2015. We also contacted authors and organisations to identify any additional studies.

SELECTION CRITERIA

We included randomised controlled trials that evaluated the effects of brief school-based interventions for substance-using adolescents.The primary outcomes were reduction or cessation of substance use. The secondary outcomes were engagement in criminal activity and engagement in delinquent or problem behaviours related to substance use.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures outlined by The Cochrane Collaboration, including the GRADE approach for evaluating the quality of evidence.

MAIN RESULTS

We included six trials with 1176 adolescents that measured outcomes at different follow-up periods in this review. Three studies with 732 adolescents compared brief interventions (Bls) with information provision only, and three studies with 444 adolescents compared Bls with assessment only. Reasons for downgrading the quality of evidence included risk of bias of the included studies, imprecision, and inconsistency. For outcomes that concern substance abuse, the retrieved studies only assessed alcohol and cannabis. We generally found moderate-quality evidence that, compared to information provision only, BIs did not have a significant effect on any of the substance use outcomes at short-, medium-, or long-term follow-up. They also did not have a significant effect on delinquent-type behaviour outcomes among adolescents. When compared to assessment-only controls, we found low- or very low-quality evidence that BIs reduced cannabis frequency at short-term follow-up in one study (standardised mean difference (SMD) -0.83; 95% confidence interval (CI) -1.14 to -0.53, n = 269). BIs also significantly reduced frequency of alcohol use (SMD -0.91; 95% CI -1.21 to -0.61, n = 242), alcohol abuse (SMD -0.38; 95% CI -0.7 to -0.07, n = 190) and dependence (SMD -0.58; 95% CI -0.9 to -0.26, n = 190), and cannabis abuse (SMD -0.34; 95% CI -0.65 to -0.02, n = 190) at medium-term follow-up in one study. At long-term follow-up, BIs also reduced alcohol abuse (SMD -0.72; 95% CI -1.05 to -0.40, n = 181), cannabis frequency (SMD -0.56; 95% CI -0.75 to -0.36, n = 181), abuse (SMD -0.62; 95% CI -0.95 to -0.29, n = 181), and dependence (SMD -0.96; 95% CI -1.30 to -0.63, n = 181) in one study. However, the evidence from studies that compared brief interventions to assessment-only conditions was generally of low quality. Brief interventions also had mixed effects on adolescents' delinquent or problem behaviours, although the effect at long-term follow-up on these outcomes in the assessment-only comparison was significant (SMD -0.78; 95% CI -1.11 to -0.45).

AUTHORS' CONCLUSIONS

We found low- or very low-quality evidence that brief school-based interventions may be more effective in reducing alcohol and cannabis use than the assessment-only condition and that these reductions were sustained at long-term follow-up. We found moderate-quality evidence that, when compared to information provision, brief interventions probably did not have a significant effect on substance use outcomes. It is premature to make definitive statements about the effectiveness of brief school-based interventions for reducing adolescent substance use. Further high-quality studies examining the relative effectiveness of BIs for substance use and other problem behaviours need to be conducted, particularly in low- and middle-income countries.

Implementation of a Brief Treatment Counseling Toolkit in Federally Qualified Healthcare Centers: Patient and Clinician Utilization and Satisfaction

INTRODUCTION

The need to integrate behavioral health care within medical settings is widely recognized, and integrative care approaches are associated with improved outcomes for a range of disorders. As substance use treatment integration efforts expand within primary care settings, training behavioral health providers in evidence-based brief treatment models that are cost-effective and easily fit within the medical flow is essential.

METHODS

Guided by principles drawn from Diffusion of Innovations theory (Rogers, 2003) and the Consolidated Framework of Implementation Research (Damschroder et al., 2009), we adapted elements of Motivational Enhancement Therapy, cognitive-behavioral therapy, and 12-step facilitation into a brief counseling toolkit. The toolkit is a menu driven assortment of 35 separate structured clinical interventions that each include client takeaway resources to reinforce brief clinical contacts. We then implemented this toolkit in the context of a randomized clinical trial in three Federally Qualified Healthcare Centers. Behavioral Health Consultants (BHCs) used a pre-screening model wherein 10,935 patients received a brief initial screener, and 2011 received more in-depth substance use screening. Six hundred patients were assigned to either a single session brief intervention or an expanded brief treatment encompassing up to five additional sessions. We conducted structured interviews with patients, medical providers, and BHCs to obtain feedback on toolkit implementation.

RESULTS

On average, patients assigned to brief treatment attended 3.29 sessions. Fifty eight percent of patients reported using most or all of the educational materials provided to them. Patients assigned to brief treatment reported that the BHC sessions were somewhat more helpful than did patients assigned to a single session brief intervention (p=.072). BHCs generally reported that the addition of the toolkit was helpful to their work in delivering screening and brief treatment.

DISCUSSION

This work is significant because it provides support to clinicians in delivering evidence-based brief interventions and has been formatted into presentation styles that can be presented flexibly depending on patient need.

Is motivational interviewing effective at reducing alcohol misuse in young adults? A critical review of Foxcroft et al. (2014)

Foxcroft, Coombes, Wood, Allen, and Almeida Santimano (2014) recently conducted a meta-analysis evaluating the effectiveness of motivational interviewing (MI) in reducing alcohol misuse for youth up to Age 25. They concluded that the overall effect sizes of MI in this population were too small to be clinically meaningful. The present article critically reviews the Foxcroft et al. meta-analysis, highlighting weaknesses such as problems with search strategies, flawed screening and reviews of full-text articles, incorrect data abstraction and coding, and, accordingly, improper effect size estimation. In addition, between-study heterogeneity and complex data structures were not thoughtfully considered or handled using best practices for meta-analysis. These limitations undermine the reported estimates and broad conclusion made by Foxcroft et al. about the lack of MI effectiveness for youth. We call for new evidence on this question from better-executed studies by independent researchers. Meta-analysis has many important utilities for translational research. When implemented well, the overall effectiveness, as well as different effectiveness for different populations, can be examined via meta-analysis. Emerging methods utilizing individual participant-level data, such as integrative data analysis, may be particularly helpful for identifying the sources of clinical and methodological heterogeneity that matter. The need to better understand the mechanisms of alcohol interventions has never been louder in the addiction field. Through more concerted efforts throughout all phases of generating evidence, we may achieve large-scale evidence that is efficient and robust and provides critical answers for the field.

A Qualitative Study of African American/Black MSM's Experiences of Participating in a Substance Use and Sexual Risk Reduction Intervention

The majority of new HIV infections in the United States are among men who have sex with men (MSM), and African American/Black MSM are especially affected. Employing a grounded theory approach, this study presents qualitative data from 21 African American/Black MSM who participated in a substance use and sexual risk reduction intervention trial (Project ROOM [men Reaching Out to Other Men]) in South Florida. African American/Black MSM from Project ROOM reduced their substance use and sexual risk behaviors at a faster rate than other men in the study. The present study examines how the experiences of participation in Project ROOM influenced the behavior change among African American/Black MSM. In-depth interviews indicate that study assessments enhanced African American/Black men's mindfulness and self-realization of behaviors leading to behavior modification and changes in social relationships. Furthermore, these findings suggest that interventions tailored to the social environment of HIV transmission and substance use behaviors are key to reducing risk behaviors among this population.

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.

A group-based brief intervention for surgery patients with high-risk substance use

OBJECTIVE

This study examined the feasibility and efficacy of a psychosocial intervention to address high-risk substance use in patients scheduled for elective surgery.

METHOD

A group-format intervention, based on motivational interviewing principles, was provided prior to elective surgery to 107 participants with at-risk substance use, identified using the Alcohol Use Disorders Identification Test - Condensed (AUDIT-C) and self-report of illicit drug use. Patient satisfaction was assessed with an anonymous survey. Within-subject comparisons of substance use at baseline and at a postoperative follow-up evaluation were conducted. A control group of 67 surgery patients reporting high-risk substance use completed baseline assessments and received usual care. Medical outcomes and measures of utilization were compared between groups.

RESULTS

Patient satisfaction with the brief intervention was high. A paired t test comparing average pre- and post-AUDIT-C scores showed significant reduction in substance use postsurgery (t = 9.94, P = .000), and participants reported intention to maintain reduced substance use levels. Between-group analyses revealed no significant differences in medical complications or utilization.

CONCLUSION

Findings suggest that a group-based intervention for substance use disorder can be implemented as part of preoperative care and may contribute to decreased substance use prior to and following surgery. Further work is needed to identify methods to reduce adverse medical outcomes in surgical patients.

Brief interventions to reduce Ecstasy use: a multi-site randomized controlled trial

Studies examining the ability of motivational enhancement therapy (MET) to augment education provision among ecstasy users have produced mixed results and none have examined whether treatment fidelity was related to ecstasy use outcomes. The primary objectives of this multi-site, parallel, two-group randomized controlled trial were to determine if a single-session of MET could instill greater commitment to change and reduce ecstasy use and related problems more so than an education-only intervention and whether MET sessions delivered with higher treatment fidelity are associated with better outcomes. The secondary objective was to assess participants' satisfaction with their assigned interventions. Participants (N=174; Mage=23.62) at two Australian universities were allocated randomly to receive a 15-minute educational session on ecstasy use (n=85) or a 50-minute session of MET that included an educational component (n=89). Primary outcomes were assessed at baseline, and then at 4-, 16-, and 24-weeks postbaseline, while the secondary outcome measure was assessed 4-weeks postbaseline by researchers blind to treatment allocation. Overall, the treatment fidelity was acceptable to good in the MET condition. There were no statistical differences at follow-up between the groups on the primary outcomes of ecstasy use, ecstasy-related problems, and commitment to change. Both intervention groups reported a 50% reduction in their ecstasy use and a 20% reduction in the severity of their ecstasy-related problems at the 24-week follow up. Commitment to change slightly improved for both groups (9%-17%). Despite the lack of between-group statistical differences on primary outcomes, participants who received a single session of MET were slightly more satisfied with their intervention than those who received education only. MI fidelity was not associated with ecstasy use outcomes. Given these findings, future research should focus on examining mechanisms of change. Such work may suggest new methods for enhancing outcomes. Australia and New Zealand Clinical Trial Registry: ACTRN12611000136909.

A pilot feasibility cluster randomised controlled trial of screening and brief alcohol intervention to prevent hazardous drinking in young people aged 14–15 years in a high school setting (SIPS JR-HIGH)

Background

Approximately 33% of 15- to 16-year-olds in England report alcohol intoxication in the past month. This present work builds on the evidence base by focusing on Alcohol Screening and Brief Intervention (ASBI) to reduce hazardous drinking in younger adolescents.

Objectives

To explore the feasibility and acceptability of a future definitive cluster randomised controlled trial (cRCT) of ASBI in a school setting to staff, young people and parents; to explore the fidelity of the interventions as delivered by school learning mentors; to estimate the parameters for the design of a definitive cRCT of brief alcohol intervention, including rates of eligibility, consent, participation and retention at 12 months; and to pilot the collection of cost and resource-use data to inform the cost-effectiveness/utility analysis in a definitive trial.

Setting

Seven schools across one geographical area in North East England.

Methods

Feasibility of trial processes, recruitment and retention and a qualitative evaluation examined facilitators and barriers to the use of ASBI approaches in the school setting in this age group. A three-arm pilot cRCT (with randomisation at the school level) with qualitative evaluation to assess the feasibility of a future definitive cRCT of the effectiveness and cost-effectiveness of ASBI in a school setting, with an integrated qualitative component. The trial ran in parallel with a repeated cross-sectional survey, which facilitated screening for the trial.

Participants

Year 10 school pupils (aged 14–15 years).

Interventions

Young people who screened positive on a single alcohol screening question, and consented to take part, were randomised to one of three groups: (1) feedback that their drinking habits may be risky and provision of an advice leaflet (control condition,n = two schools); (2) feedback as for the control condition plus a 30-minute brief interactive session, which combined structured advice and motivational interviewing techniques, delivered by the school learning mentor (intervention 1,n = two schools); or (3) feedback as for the control condition plus a 30-minute brief interactive session as for intervention 1 plus a 60-minute session involving family members delivered by the school learning mentor (intervention 2,n = three schools). Young people were followed up at 12 months.

Main outcome measures

Feasibility and acceptability.

Randomisation

Randomisation was carried out at the school level. Randomisation achieved balance on two school-level variables (numbers of pupils in school year and proportion receiving free school meals).

Blinding

School staff, young people and researchers were not blind to the intervention allocated.

Results

A total of 229 young people were eligible for the trial; 182 (79.5%) were randomised (control,n = 53; intervention 1,n = 54; intervention 2,n = 75). Of the 75 randomised to intervention 2, 67 received intervention 1 (89%). Eight received both intervention 1 and intervention 2 (11%). In total, 160 out of 182 were successfully followed up at 12 months (88%). Interviews were carried out with six school lead liaisons, 13 learning mentors, 27 young people and seven parents (n = 53). Analysis shows that the school setting is a feasible and acceptable place to carry out ASBI, with learning mentors seen as suitable people to do this. Intervention 2 was not seen as feasible or acceptable by school staff, parents or young people.

Outcomes/conclusions

It is feasible and acceptable to carry out a trial of the effectiveness and cost-effectiveness of single-session ASBI with young people in the school setting, with learning mentors delivering the intervention. Future work should include a definitive study that does not include a parental arm.

Trial registration

Current Controlled Trials ISRCTN07073105.

Funding

The National Institute for Health Research Public Health Research programme.

Motivational interviewing for alcohol misuse in young adults

BACKGROUND

Globally, harmful use of alcohol results in approximately 2.5 million deaths each year. About 9% of these deaths are young people between the ages of 15 and 29 years (WHO 2011), mainly resulting from motor vehicle accidents, homicides, suicides and drownings. Hazardous drinking levels for men (consuming over 40 g/day alcohol on average, that is 5 units) double the risk of liver disease, raised blood pressure, some cancers and violent death (because some people who have this average alcohol consumption drink heavily on some days). For women, over 24 g/day average alcohol consumption (3 units) increases the risk for developing liver disease and breast cancer. Motivational interviewing (MI) is a popular technique for addressing excessive drinking in young adults but its effectiveness has not previously been examined in a Cochrane review.

OBJECTIVES

The specific objectives were:(1) to summarise current evidence about the effects of MI intended to address alcohol and alcohol-related problems in young adults, compared with no intervention or a different intervention, on alcohol consumption and other substantive outcome measures;(2) to investigate whether the effects of MI are modified by the length of the intervention.

SEARCH METHODS

Relevant evidence was identified from (1) Cochrane Central Register of Controlled Trials (CENTRAL) (October 2013), (2) MEDLINE (January 1966 to October 2013), (3) EMBASE (January 1988 to October 2013), and (4) PsycINFO (1985 to October 2013). References of topic-related systematic reviews and the included studies were handsearched.

SELECTION CRITERIA

Randomised controlled trials and cluster randomised controlled trials of young people up to the age of 25 years in college and non-college settings comparing MIs with no intervention or a different intervention for prevention of alcohol misuse and alcohol-related problems were included.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

A total of 66 randomised trials (17,901 participants) were included four of which were cluster randomised. Studies with longer-term follow-up (four plus months) were of more interest when considering the sustainability of intervention effects.At four or more months follow-up, effects were found for the quantity of alcohol consumed (standardised mean difference (SMD) -0.14; 95% confidence interval (CI) -0.20 to -0.08 or a reduction from 13.7 drinks/week to 12.2 drinks/week), moderate quality of evidence; frequency of alcohol consumption (SMD -0.11; 95% CI -0.19 to -0.03 or a reduction in the number of days/week alcohol was consumed from 2.74 days to 2.57 days), moderate quality of evidence; and peak blood alcohol concentration (BAC) (SMD -0.14; 95% CI -0.23 to -0.05 or a decrease in peak BAC from 0.144% to 0.129%), moderate quality of evidence. A marginal effect was found for alcohol problems (SMD -0.08; 95% CI -0.15 to 0.00 or a reduction in an alcohol problems scale score from 8.91 to 8.18), low quality of evidence. No effects were found for binge drinking (SMD -0.05; 95% CI -0.12 to 0.01), moderate quality of evidence; or average BAC (SMD -0.08; 95% CI -0.22 to 0.06), moderate quality of evidence. We also considered other outcomes and at four or more months follow-up we found no effects on drink-driving (SMD -0.11; 95% CI -0.31 to 0.09), moderate quality of evidence; or other alcohol-related risky behaviour (SMD -0.14; 95% CI -0.30 to 0.02), moderate quality of evidence.Further analyses showed that the type of control comparison (assessment only versus alternative intervention) did not predict the outcome in a clear or straightforward way; and there was no consistent relationship between the duration of the MI intervention (in minutes) and effect size.

AUTHORS' CONCLUSIONS

The results of this review indicate that there are no substantive, meaningful benefits of MI interventions for the prevention of alcohol misuse. Although some significant effects were found, we interpret the effect sizes as being too small, given the measurement scales used in the studies included in the review, to be of relevance to policy or practice. Moreover, the statistically significant effects are not consistent for all misuse measures, heterogeneity was a problem in some analyses and bias cannot be discounted as a potential cause of these findings.

Efficacy of the telephone-based Brief Motivational Intervention for alcohol problems in Brazil

BACKGROUND

The Brief Motivational Intervention (BMI) is an effective treatment for alcohol misuse but has not been adequately tested for use in helplines for alcoholics. The main objective of this study was to evaluate the efficacy of a telephone-based BMI for Brazilians seeking help with alcohol use cessation.

METHODS

A randomized, controlled trial was performed with Brazilian subjects. Participants were randomly assigned to either the minimal intervention group (i.e., given reference materials) or the BMI group. Alcohol abstinence was evaluated in a 6-month follow-up telephone counseling session. The analysis was based on the intention to treat (ITT).

RESULTS

Of the 5,896 drug users who called the helpline, 700 (12%) used alcohol, 637 of whom enrolled in this study. At 6-month follow-up, 70% of the BMI group had stopped consuming alcohol compared to 41% in the control group (odds ratio = 1.5; 95% confidence interval = 1.2-1.9; p = 0.001).

CONCLUSIONS

A helpline-based BMI helps alcohol users achieve abstinence.

Brief school-based interventions and behavioural outcomes for substance-using adolescents

BACKGROUND

Adolescent substance use is a major problem, in and of itself and because it acts as a risk factor for other problem behaviours. As substance use during adolescence can lead to adverse and often long-term health and social consequences, it is important to intervene early on in order to prevent progression to more severe problems. Brief interventions have been shown to reduce problematic substance use among adolescents and are especially useful for individuals who have moderately risky patterns of substance use. Such interventions can be conducted in school settings. This review set out to evaluate the effectiveness of brief school-based interventions for adolescent substance use.

OBJECTIVES

To evaluate the effectiveness of brief school-based interventions on reducing substance use and other behavioural outcomes among adolescents compared to another intervention or assessment-only conditions.

SEARCH METHODS

We searched 10 electronic databases and six websites on evidence-based interventions, and the reference lists of included studies and reviews, from 1966 to March 2013. We also contacted authors and organisations to identify any additional studies.

SELECTION CRITERIA

We included randomised controlled trials that evaluated the effects of brief school-based interventions for substance-using adolescents.The primary outcomes were reduction or cessation of substance use. The secondary outcomes were engagement in criminal activity and engagement in delinquent or problem behaviours related to substance use.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures outlined by The Cochrane Collaboration, including the GRADE approach for evaluating the quality of evidence.

MAIN RESULTS

Six studies involving 1139 participants were included in this review. Overall the quality of evidence was moderate in the information provision comparison, and low or very low in the assessment only comparison. Reasons for downgrading the quality included risk of bias of the included studies, imprecision and inconsistency. Our findings suggested that compared to information provision only, brief interventions (BIs) did not have a significant effect on any substance use (three studies, 732 participants, standardised mean difference (SMD) -0.06; 95% confidence interval (CI) -0.20 to 0.09) or delinquent-type behaviour outcomes among adolescents (two studies, 531 participants, SMD -0.26; 95% CI -0.54 to 0.02). When compared to assessment-only controls, BIs had some significant effects on substance use and delinquent-type or problem behaviours, but high levels of heterogeneity existed between studies and it was not always possible to pool the results. When the comparison was with assessment-only conditions, studies of individual interventions that measured BI effectiveness reported significantly reduced substance use in general and in two studies reduced frequency of alcohol use specifically. When the data were pooled, BIs reduced cannabis frequency (SMD -0.22; 95% CI -0.45 to -0.02) across three studies (n = 407). Cannabis quantity was also reduced by BIs in comparison to assessment only (SMD -60.27; 95% CI -66.59 to -53.95) in one study (n = 179). However, the evidence for studies that compared brief interventions to assessment-only conditions was generally of low quality. Brief interventions also had mixed effects on participants' delinquent or problem behaviours.

AUTHORS' CONCLUSIONS

There was limited quality evidence that brief school-based interventions were more effective in reducing substance use than the assessment-only condition, but were similar to information provision. There is some evidence for the effectiveness of BI in reducing adolescent substance use, particularly cannabis, when compared to assessment only. However, it is premature to make definitive statements about the effectiveness of brief school-based interventions for reducing adolescent substance use. Further high quality studies examining the relative effectiveness of BIs for substance use and other problem behaviours need to be conducted, particularly in low- and middle-income countries.

Screening and brief intervention for unhealthy drug use: little or no efficacy

Unhealthy drug use ranges from use that risks health harms through severe drug use disorders. This narrative review addresses whether screening and brief intervention (SBI), efficacious for risky alcohol use, has efficacy for reducing other drug use and consequences. Brief intervention among those seeking help shows some promise. Screening tools have been validated though most are neither brief nor simple enough for use in general health settings. Several randomized trials have tested the efficacy of brief intervention for unhealthy drug use identified by screening in general health settings (i.e., in people not seeking help for their drug use). Substantial evidence now suggests that efficacy is limited or non-existent. Reasons likely include a range of actual and perceived severity (or lack of severity), concomitant unhealthy alcohol use and comorbid mental health conditions, and the wide range of types of unhealthy drug use (e.g., from marijuana, to prescription drugs, to heroin). Although brief intervention may have some efficacy for unhealthy drug users seeking help, the model of SBI that has effects in primary care settings on risky alcohol use may not be efficacious for other drug use.

A randomized trial of a behavioral intervention for high risk substance-using MSM

Substance-using men who have sex with men (MSM) are among the groups at highest risk for HIV infection in the United States. We report the results of a randomized trial testing the efficacy of a small group sexual and substance use risk reduction intervention based on empowerment theory compared to an enhanced efficacious control condition among 515 high risk not-in-treatment MSM substance users. Effect sizes for sexual risk and substance use outcomes were moderate to large: HIV transmission risk frequency, d = 0.71 in the control versus 0.66 in the experimental group; number of anal sex partners, d = 1.04 versus 0.98; substance dependence symptoms, d = 0.49 versus 0.53; significant differences were not observed between conditions. Black MSM reduced their risks at a greater rate than White or Latino men. The findings point to a critically important research agenda to reduce HIV transmission among MSM substance users.

Screening, brief intervention, and referral to treatment (SBIRT) for offenders: protocol for a pragmatic randomized trial

BACKGROUND

Although screening, brief intervention, and referral to treatment (SBIRT) is an evidence-based technique that, in some health-care settings, has been shown to cost-effectively reduce alcohol and drug use, research on the efficacy of SBIRT among criminal offender populations is limited. Such populations have a high prevalence of drug and alcohol use but limited access to intervention, and many are at risk for post-release relapse and recidivism. Thus, there exists a need for treatment options for drug-involved offenders of varying risk levels to reduce risky behaviors or enter treatment.

METHODS/DESIGN

This protocol describes an assessment of SBIRT feasibility and effectiveness in a criminal justice environment. Eight-hundred persons will be recruited from a large metropolitan jail, with the experimental group receiving an intervention depending on risk level and the control group receiving minimal intervention. The intervention will assess the risk level for drug and alcohol misuse by inmates, providing those at low or medium risk a brief intervention in the jail and referring those at high risk to community treatment following release. In addition, a brief treatment (eight-session) option will be available. Using data from a 12-month follow-up interview, the primary study outcomes are a reduction in drug and alcohol use, while secondary outcomes include participation in treatment, rearrest, quality of life, reduction in HIV risk behaviors, and costs of SBIRT.

EXPECTED VALUE

Individual reductions in alcohol and drug use can have significant effects on public health and safety when observed over a large population at risk for substance-use problems. With wider dissemination statewide or nationwide, a relatively low-cost intervention such as SBIRT could offer demonstrated benefits in this population.

TRIAL REGISTRATION

Clinical Trials Government Identifier, NCT01683643.

Revisão sistemática sobre tratamentos psicológicos para problemas relacionados ao crack

OBJETIVO: O objetivo deste artigo é apresentar uma revisão sistemática da literatura sobre tratamentos psicológicos oferecidos para usuários de crack. MÉTODOS: Foi realizada uma revisão sistemática por meio de uma busca na literatura internacional e nacional, indexada nas bases de dados Medline, SciELO, Lilacs e Web of Science. Os descritores utilizados foram: crack or crack cocaine or cocaine smokers (crack) and psychosocial treatment or psycotherapy or psychosocial treatment (tratamento psicológico) e a busca incluiu artigos publicados no período de 2001 a 2011. RESULTADOS: No total foram encontrados 155 artigos por meio dos descritores utilizados. Os artigos foram agrupados em três dimensões: tratamentos psicossociais na internação e cuidados continuados, relaxamento respiratório e outras técnicas comportamentais e abordagens fundamentadas na Entrevista Motivacional, Cognitivo-Comportamental e Modelo Transteórico de Mudança. CONCLUSÃO: Com base nos estudos examinados, pode ser formulado um elenco de algumas intervenções que estão sendo estudadas para o tratamento de usuários de crack e algumas apresentam resultados satisfatórios. Os poucos esforços de comparação entre técnicas resultaram em evidências de pouca ou nenhuma diferença, ainda que se registre o benefício para os usuários na aplicação de qualquer delas. Não existe consenso acerca da efetividade no tratamento de usuários de crack. Parece oportuno e necessário o aprofundamento dos estudos nesse campo.

SBIRT for adolescent drug and alcohol use: current status and future directions

Adolescence is a period of rapid biological, psychological, and social development in the human life cycle. Drug and alcohol misuse during this critical period poses substantial problems for individual and public health, yet is highly prevalent in the United States and elsewhere. The screening, brief interventions, and referral to treatment (SBIRT) model may be well-suited for identifying and intervening with adolescents who are at-risk of developing substance use disorders and those adolescents whose substance use puts them at risk for injury or illness. This article reviews the literature on SBIRT for adolescent populations, focusing on findings from randomized controlled trials. The limited evidence suggests that brief interventions may be effective with adolescents, but a number of gaps in the literature were identified. Considerations for implementing SBIRT with adolescent populations are discussed. Randomized trials are needed that have adequate statistical power, employ longer-term follow-ups, and test the effectiveness of SBIRT for adolescents in various service delivery settings.

Assessing covariates of drug use trajectories among adolescents admitted to a drug addiction center: mental health problems, therapeutic alliance, and treatment persistence

This study aimed to assess covariates of drug use trajectories among 102 adolescents admitted to a drug user treatment program between November 2005 and November 2006 in Québec, Canada. The influences of mental health, therapeutic alliance, and treatment persistence were examined. The Addiction Severity Index was used to measure drug use severity and mental health problems; the California Psychotherapy Alliance Scales was used for therapeutic alliance. latent growth curve analysis showed associations between (1) mental health and initial drug use severity; (2) therapeutic alliance and initial drug use severity; and (3) number of post-treatment sessions attended and drug use severity over time.

Preventing alcohol use with a voluntary after-school program for middle school students: results from a cluster randomized controlled trial of CHOICE

There are many mandated school-based programs to prevent adolescent alcohol and drug (AOD) use, but few are voluntary and take place outside of class time. This cluster randomized controlled trial evaluates CHOICE, a voluntary after-school program for younger adolescents, which reduced both individual- and school-level alcohol use in a previous pilot study. We evaluated CHOICE with 9,528 students from 16 middle schools. The sample was 51% female; 54% Hispanic, 17% Asian, 15% white, 9% multiethnic and 3% African American. Fifteen percent of students attended CHOICE. All students completed surveys on alcohol beliefs and use at baseline and 6-7 months later. We conducted intention-to-treat (ITT) school-level analyses and propensity-matched attender analyses. Lifetime alcohol use in the ITT analysis (i.e., school level) achieved statistical significance, with an odds ratio (OR) of 0.70 and a NNT of 14.8. The NNT suggests that in a school where CHOICE was offered, 1 adolescent out of 15 was prevented from initiating alcohol use during this time period. Although not statistically significant (p = .20), results indicate that past month alcohol use was also lower in CHOICE schools (OR = 0.81; NNT = 45). Comparisons of attenders versus matched controls yielded results for lifetime use similar to school-wide effects (OR = 0.74 and NNT = 17.6). Initial results are promising and suggest that a voluntary after-school program that focuses specifically on AOD may be effective in deterring alcohol use among early adolescents; however, further research is needed as program effects were modest.

Motivational Interviewing for adolescent substance use: a review of the literature

Motivational Interviewing (MI) is a widely-used approach for addressing adolescent substance use. Recent meta-analytic findings show small but consistent effect sizes. However, differences in intervention format and intervention design, as well as possible mediators of change, have never been reviewed. This review of the literature summarizes the most up-to-date MI interventions with adolescents, looks at differences between intervention format and design, and discusses possible theory-based mechanisms of change. Of the 39 studies included in this review, 67% reported statistically significant improved substance use outcomes. Chi square results show no significant difference between interventions using feedback or not, or interventions combined with other treatment versus MI alone. The need for systematic investigation in theory-based mechanisms of change is presented.

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 in 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 (November 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 11, November 2011), PUBMED (1966 to 2011); EMBASE (1974 to 2011); CINAHL (1982 to 2011); PsycINFO (1872 to 2011) and reference list of articles. We also searched: 1) conference proceedings (online archives only) of the Society for the Study of Addiction (SSA), International Harm Reduction Association (IHRA), International Conference on Alcohol Harm Reduction (ICAHR), and American Association for the Treatment of Opioid Dependence (AATOD); 2) online registers of clinical trials, Current Controlled Trials (CCT), Clinical Trials.org, Center Watch and International Clinical Trials Registry Platform (ICTRP).

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

Two review authors independently assessed risk of bias and extracted data from included trials.

MAIN RESULTS

Four studies, 594 participants, were included. Half of the trials were rated as having high or unclear risk of bias. They considered six different psychosocial interventions grouped into four comparisons: (1) cognitive-behavioural coping skills training versus 12-step facilitation (N = 41), (2) brief intervention versus treatment as usual (N = 110), (3) hepatitis health promotion versus motivational interviewing (N = 256), and (4) brief motivational intervention versus assessment-only group (N = 187). Differences between studies precluded any pooling of data. Findings are described for each trial individually:comparison 1: no significant difference; comparison 2: higher rates of decreased alcohol use at three months (risk ratio (RR) 0.32; 95% confidence interval (CI) 0.19 to 0.54) and nine months (RR 0.16; 95% CI 0.08 to 0.33) in the treatment as usual group; comparison 3 (group and individual format): no significant difference; comparison 4: more people reduced alcohol use (by seven or more days in the past 30 days at 6 months) in the brief motivational intervention compared to controls (RR 1.67; 95% CI 1.08 to 2.60).

AUTHORS' CONCLUSIONS

Very little evidence exists that there is no difference in the effectiveness between different types of interventions and that brief interventions are not superior to assessment only or treatment as usual. No conclusion can be made because of the paucity of the data and the low quality of the retrieved studies.

Screening, brief intervention, and referral to treatment (SBIRT) for substance use in a school-based program: services and outcomes

BACKGROUND

Despite the advantages of using high schools for conducting school-based Screening, Brief Intervention, and Referral to Treatment (SBIRT) programs for adolescent substance misuse, there have been very few studies of Brief Interventions (BIs) in these settings.

OBJECTIVES

This multi-site, repeated measures study examined outcomes of adolescents who received SBIRT services and compared the extent of change in substance use based on the intensity of intervention received.

METHODS

Participants consisted of 629 adolescents, ages 14-17, who received SBIRT services across 13 participating high schools in New Mexico. The level of service received and number of sessions were collected through administrative records, while the number of self-reported days in the past month of drinking; drinking to intoxication; and drug use were gathered at baseline and 6-month follow-up.

RESULTS

BI was provided to 85.1% of adolescents, while 14.9% received brief treatment or referral to treatment (BT/RT). Participants receiving any intervention reported significant reductions in frequency of drinking to intoxication (p < .05) and drug use (p < .001), but not alcohol use, from baseline to 6-month follow-up. The magnitude of these reductions did not differ based on service variables. Controlling for baseline frequency of use, a BT/RT service level was associated with more days of drinking at 6-month follow-up (p < .05), but was no longer significant when controlling for number of service sessions received.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

These findings support school-based SBIRT for adolescents, but more research is needed on this promising approach.

Interview as intervention: the case of young adult multidrug users in the club scene

This paper reports on changes in substance use and substance dependence symptoms-without intervention-among young adult multidrug users in the club scene, ages 18-29, (N = 444) who participated in a natural history study. Computer-assisted personal interviews at baseline and 6-, 12-, and 18-month follow-ups included well-tested measures of substance use and dependence. Changes in substance dependence symptoms and drug use frequencies were calculated using Cohen's d statistic. Mean age was 22; 40% were female; 58% were Hispanic, 17% White, and 21% Black. At 18-month follow-up assessment, participants reported significantly fewer days of cocaine (d = -.85 at 18 months), ecstasy (d = -.93), benzodiazepine (d = -.82), and prescription opioid (d = -.81) use, as well as reduced substance dependence symptoms (d = -.42). These results, together with data from focus groups with completers, suggest that comprehensive health and social risk assessments may have quite strong intervention effects among young adult multidrug users.

Drug policy and the public good: evidence for effective interventions

Debates about which policy initiatives can prevent or reduce the damage that illicit drugs cause to the public good are rarely informed by scientific evidence. Fortunately, evidence-based interventions are increasingly being identified that are capable of making drugs less available, reducing violence in drug markets, lessening misuse of legal pharmaceuticals, preventing drug use initiation in young people, and reducing drug use and its consequences in established drug users. We review relevant evidence and outline the likely effects of fuller implementation of existing interventions. The reasoning behind the final decisions for action might be of a non-scientific nature, focused more on what the public and policy-makers deem of value. Nevertheless, important opportunities exist for science to inform these deliberations and guide the selection of policies that maximise the public good.

Design of NIDA CTN Protocol 0047: screening, motivational assessment, referral, and treatment in emergency departments (SMART-ED)

BACKGROUND

Medical settings such as emergency departments (EDs) present an opportunity to identify and provide services for individuals with substance use problems who might otherwise never receive any form of assessment, referral, or intervention. Although screening, brief intervention, and referral to treatment models have been extensively studied and are considered effective for individuals with alcohol problems presenting in EDs and other medical settings, the efficacy of such interventions has not been established for drug users presenting in EDs.

OBJECTIVES

This article describes the design of a NIDA Clinical Trials Network protocol testing the efficacy of an screening, brief intervention, and referral to treatment model in medical EDs, highlighting considerations that are pertinent to the design of other studies targeting substance use behaviors in medical treatment settings.

METHODS

The protocol is described, and critical design decisions are discussed.

RESULTS

Design challenges included defining treatment conditions, study population, and site characteristics; developing the screening process; choosing the primary outcome; balancing brevity and comprehensiveness of assessment; and selecting the strategy for statistical analysis.

CONCLUSION

Many of the issues arising in the design of this study will be relevant to future studies of interventions for addictions in medical settings.

SCIENTIFIC SIGNIFICANCE

Optimal trial design is critical to determining how best to integrate substance abuse interventions into medical care.

Benzodiazepine dependence among multidrug users in the club scene

BACKGROUND

Benzodiazepines (BZs) are among the most frequently prescribed drugs with the potential for abuse. Young adults ages 18-29 report the highest rates of BZ misuse in the United States. The majority of club drug users are also in this age group, and BZ misuse is prevalent in the nightclub scene. BZ dependence, however, is not well documented. This paper examines BZ dependence and its correlates among multidrug users in South Florida's nightclub scene.

METHODS

Data were drawn from structured interviews with men and women (N=521) who reported regular attendance at large dance clubs and recent use of both club drugs and BZs.

RESULTS

Prevalences of BZ-related problems were 7.9% for BZ dependence, 22.6% BZ abuse, and 25% BZ abuse and/or dependence. In bivariate logistic regression models, heavy cocaine use (OR 2.27; 95% CI 1.18, 4.38), severe mental distress (OR 2.63; 95% CI 1.33, 5.21), and childhood victimization history (OR 2.43; 95% CI 1.10, 5.38) were associated with BZ dependence. Heavy cocaine use (OR 2.14; 95% CI 1.10, 4.18) and severe mental distress (OR 2.16; 95% CI 1.07, 4.37) survived as predictors in the multivariate model.

DISCUSSION

BZ misuse is widespread among multidrug users in the club scene, who also exhibit high levels of other health and social problems. BZ dependence appears to be more prevalent in this sample than in other populations described in the literature. Recommendations for intervention and additional research are described.

ENROLLING AND ENGAGING HIGH-RISK YOUTH AND FAMILIES IN COMMUNITY-BASED, BRIEF INTERVENTION SERVICES

Increasing interest has been shown in Brief Interventions for troubled persons, including those with substance abuse problems. Most of the published literature on this topic has focused on adults, and on the efficacy of these interventions. Few of these studies have examined the critical issues of enrollment and engagement in Brief Intervention services. The present paper seeks to address the shortcomings in the current literature by reporting on our experiences implementing NIDA funded, Brief Intervention projects involving truant and diversion program youth.

Motivational interviewing for substance abuse

BACKGROUND

There are 76.3 million people with alcohol use disorders worldwide and 15.3 million with drug use disorders. Motivational interviewing (MI) is a client-centred, semi-directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. The intervention is used widely, and therefore it is important to find out whether it helps, harms or is ineffective.

OBJECTIVES

To assess the effectiveness of motivational interviewing for substance abuse on drug use, retention in treatment, readiness to change, and number of repeat convictions.

SEARCH STRATEGY

We searched 18 electronic databases, 5 web sites, 4 mailing lists, and reference lists from included studies and reviews. Search dates were November 30, 2010 for Cochrane Library, Medline, Embase and PsychINFO.

SELECTION CRITERIA

Randomized controlled trials with persons dependent or abusing substance. Interventions were MI or motivational enhancement therapy. The outcomes were extent of substance abuse, retention in treatment, motivation for change, repeat conviction.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed studies for inclusion, and two authors extracted data. Results were categorized into (1) MI versus no-treatment control, (2) MI versus treatment as usual, (3) MI versus assessment and feedback, and (4) MI versus other active treatment. Within each category, we computed meta-analyses separately for post-intervention, short, medium and long follow-ups.

MAIN RESULTS

We included 59 studies with a total of 13,342 participants. Compared to no treatment control MI showed a significant effect on substance use which was strongest at post-intervention SMD 0.79, (95% CI 0.48 to 1.09) and weaker at short SMD 0.17 (95% CI 0.09 to 0.26], and medium follow-up SMD 0.15 (95% CI 0.04 to 0.25]). For long follow-up, the effect was not significant SMD 0.06 (95% CI-0.16 to 0.28). There were no significant differences between MI and treatment as usual for either follow-up post-intervention, short and medium follow up. MI did better than assessment and feedback for medium follow-up SMD 0.38 (95% CI 0.10 to 0.66). For short follow-up, there was no significant effect . For other active intervention there were no significant effects for either follow-up.There was not enough data to conclude about effects of MI on the secondary outcomes.

AUTHORS' CONCLUSIONS

MI can reduce the extent of substance abuse compared to no intervention. The evidence is mostly of low quality, so further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

Randomized controlled trial of personalized motivational interventions in substance using patients with facial injuries

PURPOSE

The proximate use of illicit drugs or alcohol (substance use) is the most common precipitator of facial injuries among socioeconomically disadvantaged populations. Reducing these risky behaviors could minimize adverse health sequelae and potential reinjury. The objective of our study was to test whether a culturally competent, personalized motivational intervention incorporated into surgical care could significantly reduce existing substance use behaviors in facial injury patients.

PATIENTS AND METHODS

Substance-using subjects (n = 218) presenting with facial injuries to a level 1 trauma center were randomly assigned to either a personalized motivational intervention (PMI) condition or a health-information (HI) control condition. After a brief assessment of the individual's substance use severity and willingness to change these behaviors, both groups attended 2 counseling sessions with a trained interventionist. The PMI subjects (n = 118) received individualized, motivational interventions, whereas the HI subjects (n = 100) received only general health information. Both groups were reassessed at 6 and 12 months postinjury, and changes in substance-use patterns were measured to assess the effects of intervention.

RESULTS

The PMI and HI groups were closely matched on their sociodemographic and substance use characteristics. Subjects in the PMI group showed statistically significant declines in drug use at both the 6- and 12-month assessments. The intervention's effect on lowering illicit drug use was greatest at the 6-month assessment but had weakened by the 1-year follow-up. The efficacy of the PMI was moderated by an individual's initial drug use severity; individuals with greater drug use dependency at baseline were seen to have larger intervention effects, as did individuals who were most aware of their drug problem and willing to change their substance use behaviors. Unlike illicit drug use, changes in alcohol use did not differ significantly between the intervention and control groups, irrespective of an individuals' recognition of the alcohol problem or willingness to take steps to address it.

CONCLUSION

A culturally competent, motivational intervention integrated into the care of vulnerable patients with facial injury can reduce illicit drug use behaviors. Subgroups of injured patients appear to benefit most from such personalized motivational interventions. A better articulation of target populations, intervention content, and delivery would allow for directed interventions and an appropriate focusing of limited time and health care resources.

Harmful alcohol consumption and patterns of substance use in HIV-infected patients receiving antiretrovirals (ANRS-EN12-VESPA Study): relevance for clinical management and intervention

Alcohol abuse affects secondary prevention and disease progression in HIV-infected patients, and adherence and response to treatment in those chronically treated. The objective of this study was to estimate the prevalence of harmful alcohol consumption (HAC) using various indicators and identify which groups of patients may require specific targeted interventions for HAC risk reduction. A cross-sectional survey, based on a random sample representative of people living with HIV/AIDS (PLWHA) was carried out in 102 French hospital departments delivering HIV care. As alcohol abuse is particularly detrimental to patients receiving highly active antiretroviral therapy (HAART), we focused only on those individuals receiving HAART with complete alcohol assessment (CAGE, AUDIT-C, regular binge drinking, N=2340). Collected information included medical and socio-demographic data, HIV risk behaviors, adherence to treatment and substance and alcohol use, together with depression, anxiety, and experience of attempted suicide or sex work. HAC prevalence was evaluated as follows: 12% (CAGE score > or =2), 27% (AUDIT-C), and 9% (regular binge drinking). Three groups were at higher risk of HAC: men who have sex with men using stimulants, polydrug users, and to a lesser degree, ex-drug users. Innovative intervention strategies to reduce HAC and improve HIV prevention and HAART adherence in various PLWHA populations need urgent testing and implementation. Such interventions for alcohol risk reduction remain central to promoting improved HIV prevention and assuring HAART effectiveness in these populations.