Universal cannabis outcomes from the Climate and Preventure (CAP) study: a cluster randomised controlled trial

Adolescents' Cannabis Knowledge and Risk Perception: A Systematic Review

To systematically review evidence evaluating cannabis-related knowledge and perception of risk in children and adolescents. We systematically searched Medline, PsycINFO, and EMBASE using Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. 133 studies from around the world (including ages 10-18 yrs) met inclusion criteria, with 70% meeting grade 2C quality. Increased knowledge and perception of risk of cannabis frequently correlated with lower levels of current use and intent to use. Studies examining correlations over time generally demonstrated increased adolescent cannabis use and decreased perception of risk. Included prevention-based interventions often enhanced knowledge and/or perception of risk in adolescents exposed to the intervention. Studies exploring outcomes relating to legislative changes for recreational marijuana use demonstrated considerable heterogeneity regarding knowledge and perception of risk whereas studies that focused on medicinal marijuana legislative changes overwhelmingly demonstrated a decrease in perception of risk post legalization. Increased knowledge and perception of risk of cannabis in adolescents often correlate with lower levels of current use and intention to use in the future. Further study and implementation of public health and clinically-oriented strategies that seek to increase knowledge among youth about the potential health harms of cannabis use should continue and be prioritized.

Trauma-informed prevention programmes for depression, anxiety, and substance use among young people: protocol for a mixed-methods systematic review

BACKGROUND

Mental ill-health and substance use bear a substantial burden and harm on young people and often arise from co-occurring and compounding risk factors, such as traumatic stress. Trauma-informed prevention of mental ill-health and substance use demonstrates significant promise in reducing this burden. A systematic literature review is required to identify and summarise the effectiveness, feasibility, acceptability, and design principles underpinning existing trauma-informed mental ill-health and/or substance use prevention programmes for young people aged 12-24 years.

METHODS

MEDLINE, Embase, CINAHL, PsychINFO, and Cochrane Library will be searched from 2012 through September 2022. Reference lists of included articles will be citation-chained. Title and abstracts will be screened and two reviewers will review articles full-text. One reviewer will extract data from eligible articles using a piloted data extraction form, and 20% of the data will be verified by a second reviewer. Risk of bias will be assessed using the Cochrane risk-of-bias tool for randomised trials (RoB 2), Risk of Bias in Non-randomised Studies of Interventions (ROBINS-I), and The Joanna Briggs Institute Critical Appraisal Checklist for Quasi-Experimental Studies and The Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research (CASP), depending on the study type. Characteristics of existing trauma-informed mental ill-health and/or substance use prevention programmes for young people will be summarised narratively. Effectiveness, feasibility, and acceptability will be qualitatively described and summarised, with proportions and effect sizes quantitatively synthesised, where possible.

DISCUSSION

Trauma-informed approaches to prevention demonstrate significant promise, yet to date, no study has systematically summarised and synthesised the available literature. To fill this gap, the present review will systematically identify and summarise the effectiveness, feasibility, acceptability, and design principles underpinning existing trauma-informed mental health and/or substance use prevention programmes for young people aged 12-24. This review will inform the development, adaptation, evaluation, and implementation of future trauma-informed mental ill-health and substance use prevention programmes for young people. Findings will inform critical efforts to interrupt and prevent already elevated trajectories of mental ill-health, substance use, and related harms among those young people exposed to adversity.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022353883.

Fidelity of implementation of Reptes, an alcohol and cannabis selective prevention program for youngsters

OBJECTIVE

Implementation fidelity is a key dimension in process evaluation but has been scarcely studied. Reptes is a selective alcohol and cannabis use prevention program performed in vulnerable young people (16-21 years) from different educational and leisure settings. The study aimed to describe the components of this program, its implementation fidelity, and satisfaction among participants and facilitators.

METHOD

A descriptive cross-sectional study was conducted. Implementation fidelity was assessed in terms of adherence, dose, participant responsiveness, and quality of the intervention through self-reports completed by 15 facilitators and self-administered questionnaires by 99 youth from the 15 groups completing the program.

RESULTS

70.7% of the groups performed 30 of the 43 planned activities with high use of various teaching methods, except for Information and Communication Technology resources. Fidelity implementation was above 70%. 2/3 groups completed an acceptable intervention and 1/3 completed a qualified intervention. Satisfaction was higher than 7.

CONCLUSIONS

Our results show high implementation fidelity and satisfaction compared with those from similar studies.

Digital interventions for substance use disorders in young people: rapid review

BACKGROUND

Young people are disproportionately more likely than other age groups to use substances. The rise in substance use and related harms, including overdose, during the Covid-19 pandemic has created a critical need for more innovative and accessible substance use interventions. Digital interventions have shown effectiveness and can provide more engaging, less stigmatizing, and accessible interventions that meet the needs of young people. This review provides an overview of recent literature on the nature of recently published digital interventions for young people in terms of technologies used, substances targeted, intended outcomes and theoretical or therapeutic models employed.

METHODS

Rapid review methodology was used to identify and assess the literature on digital interventions for young people. An initial keyword search was conducted using MEDLINE the Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment Database (HTA) and PROSPERO for the years 2015-2020, and later updated to December 2021. Following a title/abstract and full-text screening of articles, and consensus decision on study inclusion, the data extraction process proceeded using an extraction grid developed for the study. Data synthesis relied on an adapted conceptual framework by Stockings, et al. that involved a three-level treatment spectrum for youth substance use (prevention, early intervention, and treatment) for any type of substance.

RESULTS

In total, the review identified 43 articles describing 39 different digital interventions. Most were early interventions (n = 28), followed by prevention interventions (n = 6) and treatment interventions (n = 5). The identified digital technologies included web-based (n = 14), game-based (n = 10), mobile-based (n = 7), and computer-based (n = 5) technologies, and virtual reality (n = 3). Most interventions targeted alcohol use (n = 20) followed by tobacco/nicotine (n = 5), cannabis (n = 2), opioids (n = 2), ketamine (1) and multiple, or any substances (n = 9). Most interventions used a personalized or normative feedback approach and aimed to effect behaviour change as the intended outcome. Interestingly, a harm reduction approach guided only one of the 39 interventions.

CONCLUSIONS

While web-based interventions represented the most common type of technology, more recently developed immersive and interactive technologies such as virtual reality and game-based interventions call for further exploration. Digital interventions focused mainly on alcohol use, reflecting less concern for tobacco, cannabis, co-occurring substance use, and illicit drug use. Specifically, the recent exacerbation in the opioid crisis throughout North American underlines the urgent need for more prevention-oriented digital interventions for opioid use. The uptake of digital interventions among youth also depends on the incorporation of harm reduction approaches.

A Web-Based Alcohol and Other Drug Prevention Program (Strong & Deadly Futures) for Aboriginal and Torres Strait Islander School Students: Protocol for a Cluster Randomized Controlled Trial

Background

There are no available school-based alcohol and drug prevention programs with evidence of effectiveness among Aboriginal and Torres Strait Islander youth. To address this, we codeveloped the Strong & Deadly Futures well-being and alcohol and drug prevention program in partnership with an Indigenous creative design agency and 4 Australian schools.

Objective

This paper presents the protocol to evaluate the effectiveness of Strong & Deadly Futures in reducing alcohol and other drug use and improving well-being among Aboriginal and Torres Strait Islander youth.

Methods

The target sample will be 960 year 7 and 8 students from 24 secondary schools in Australia, of which approximately 40% (384/960) will identify as Aboriginal or Torres Strait Islander. The study design is a 2-group, parallel cluster randomized controlled trial with allocation concealment. Recruited schools will be block randomized (ratio 1:1), stratified by geographical remoteness, by an independent statistician. Schools will be randomized to receive Strong & Deadly Futures, a web-based alcohol and drug prevention and social and emotional well-being program that delivers curriculum-aligned content over 6 lessons via an illustrated story, or health education as usual (control). Control schools will be supported to implement Strong & Deadly Futures following trial completion. Surveys will be administered at baseline, 6 weeks, 12 months, and 24 months (primary end point) post baseline. Primary outcomes are alcohol use (adapted from the National Drug Strategy Household Survey), tobacco use (Standard High School Youth Risk Behavior Survey), and psychological distress (Kessler-5 Psychological Distress Scale). Secondary outcomes are alcohol and drug knowledge and intentions, alcohol-related harms, binge drinking, cannabis use, well-being, empowerment, appreciation of cultural diversity, and truancy.

Results

The trial was funded by the National Health and Medical Research Council in January 2019, approved by the Human Research Ethics Committee of the University of Sydney (2020/039, April 2020), the Aboriginal Health and Medical Research Council of New South Wales (1620/19, February 2020), the Western Australian Aboriginal Health Ethics Committee (998, October 2021), and the ethics committees of each participating school, including the New South Wales Department of Education (2020170, June 2020), Catholic Education Western Australia (RP2020/39, November 2020), and the Queensland Department of Education (550/27/2390, August 2021). Projected dates of data collection are 2022-2024, and we expect to publish the results in 2025. A total of 24 schools have been recruited as of submission of the manuscript.

Conclusions

This will be the first cluster randomized controlled trial of a culturally inclusive, school-based alcohol and drug prevention program for Aboriginal and Torres Strait Islander youth; therefore, it has significant potential to address alcohol and other drug harms among Aboriginal and Torres Strait Islander youth.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12620001038987; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380038&isReview=true

International Registered Report Identifier (IRRID)

PRR1-10.2196/34530

A national effectiveness trial of an eHealth program to prevent alcohol and cannabis misuse: responding to the replication crisis

BACKGROUND

The burden of disease attributable to alcohol and other drug (AOD) use in young people is considerable. Prevention can be effective, yet few programs have demonstrated replicable effects. This study aimed to replicate research behind Climate Schools: Alcohol and Cannabis course among a large cohort of adolescents.

METHODS

Seventy-one secondary schools across three States participated in a cluster-randomised controlled trial. Year 8 students received either the web-based Climate Schools: Alcohol and Cannabis course (Climate, n = 3236), or health education as usual (Control, n = 3150). Outcomes were measured via self-report and reported here for baseline, 6- and 12-months for alcohol and cannabis knowledge, alcohol, cannabis use and alcohol-related harms.

RESULTS

Compared to Controls, students in the Climate group showed greater increases in alcohol- [standardised mean difference (SMD) 0.51, p < 0.001] and cannabis-related knowledge (SMD 0.49, p < 0.001), less increases in the odds of drinking a full standard drink[(odds ratio (OR) 0.62, p = 0.014], and heavy episodic drinking (OR 0.49, p = 0.022). There was no evidence for differences in change over time in the odds of cannabis use (OR 0.57, p = 0.22) or alcohol harms (OR 0.73, p = 0.17).

CONCLUSIONS

The current study provides support for the effectiveness of the web-based Climate Schools: Alcohol and Cannabis course in increasing knowledge and reducing the uptake of alcohol. It represents one of the first trials of a web-based AOD prevention program to replicate alcohol effects in a large and diverse sample of students. Future research and/or adaptation of the program may be warranted with respect to prevention of cannabis use and alcohol harms.

Strong and Deadly Futures: Co-Development of a Web-Based Wellbeing and Substance Use Prevention Program for Aboriginal and Torres Strait Islander and Non-Aboriginal Adolescents

School-based programs can effectively prevent substance use; however, systematic reviews and consultation with stakeholders identified a need for effective, culturally inclusive programs for Aboriginal and/or Torres Strait Islander (hereafter Aboriginal) youth. This paper describes the development of Strong & Deadly Futures, a six-lesson, curriculum-aligned wellbeing and substance use prevention program that was designed for, and with, the Aboriginal youth. Formative reviews and consultation recommended that the program (i) combine effective components of mainstream prevention with cultural elements, highlighting Aboriginal cultural strengths; (ii) avoid stigma and celebrates the cultural diversity by catering to both Aboriginal and non-Aboriginal students; and (iii) use digital technology to enhance engagement, implementation and scalability. Guided by an Appreciative Inquiry approach, the program was developed in partnership with an Indigenous Creative Design Agency, and four schools in New South Wales and Queensland, Australia. Aboriginal (n = 41) and non-Aboriginal students (n = 36) described their role models, positive aspects of their community and reasons to avoid substance use; these formed the basis of an illustrated story which conveyed the key learning outcomes. Feedback from teachers, students and content experts supported the acceptability of the program, which will be evaluated in a subsequent randomised controlled trial.

The effectiveness of an indicated prevention programme for substance use in individuals with mild intellectual disabilities and borderline intellectual functioning: results of a quasi-experimental study

AIMS

To assess the effectiveness of Take it personal!, a prevention programme for individuals with mild intellectual disabilities and borderline intellectual functioning (MID-BIF) and substance use (SU). The prevention programme aims to reduce SU (alcohol, cannabis and illicit drugs) among experimental to problematic substance users.

DESIGN

A quasi-experimental design with two arms and a 3-month follow-up.

SETTING

Adolescents were recruited from 14 treatment centres in the Netherlands specialized in offering intra- and extramural care for people with MID-BIF and behavioural problems.

PARTICIPANTS

Data were collected from 66 individuals with MID-BIF assigned either to the intervention condition (n = 34) or to the control condition (n = 32).

INTERVENTIONS

Take it personal! was designed to target four personality traits: sensation-seeking, impulsive behaviour, anxiety sensitivity and negative thinking. For each of these profiles, interventions were developed that were structurally the same but contained different personality-specific materials, games and exercises. The control group received care as usual.

MEASUREMENTS

Primary outcomes at 3-month follow-up were frequency of SU, severity of SU and binge drinking.

RESULTS

Results showed intervention effects for SU frequency (F_{(1, 50.43)}  = 9.27, P = 0.004) and binge drinking (F_{(1, 48.02)}  = 8.63, P = 0.005), but not for severity of SU (F_{(1, 42.09)}  = 2.20, P = 0.145).

CONCLUSIONS

A prevention programme to reduce substance use among experimental to problematic users with mild intellectual disabilities and borderline intellectual functioning helped participants to decrease substance use frequency and binge drinking.

Primary Substance Use Prevention Programs for Children and Youth: A Systematic Review

CONTEXT

An updated synthesis of research on substance abuse prevention programs can promote enhanced uptake of programs with proven effectiveness, particularly when paired with information relevant to practitioners and policy makers.

OBJECTIVE

To assess the strength of the scientific evidence for psychoactive substance abuse prevention programs for school-aged children and youth.

DATA SOURCES

A systematic review was conducted of studies published up until March 31, 2020.

STUDY SELECTION

Articles on substance abuse prevention programs for school-aged children and youth were independently screened and included if they met eligibility criteria: (1) the program was designed for a general population of children and youth (ie, not designed for particular target groups), (2) the program was delivered to a general population, (3) the program only targeted children and youth, and (4) the study included a control group.

DATA EXTRACTION

Two reviewers independently evaluated study quality and extracted outcome data.

RESULTS

Ninety studies met eligibility criteria, representing 16 programs. Programs evaluated with the largest combined sample sizes were Drug Abuse Resistance Education, Project Adolescent Learning Experiences Resistance Training, Life Skills Training (LST), the Adolescent Alcohol Prevention Trial, and Project Choice.

LIMITATIONS

Given the heterogeneity of outcomes measured in the included studies, it was not possible to conduct a statistical meta-analysis of program effectiveness.

CONCLUSIONS

The most research has been conducted on the LST program. However, as with other programs included in this review, studies of LST effectiveness varied in quality. With this review, we provide an updated summary of evidence for primary prevention program effectiveness.

Evaluating the differential effectiveness of social influence and personality-targeted alcohol prevention on mental health outcomes among high-risk youth: A novel cluster randomised controlled factorial design trial

OBJECTIVE

This study examined the secondary mental health outcomes of two contrasting alcohol prevention approaches, whereby one intervention targets common underlying personality risk for alcohol use and mental health problems (Preventure) and the other targets alcohol- and drug-related behaviours and cognitions (Climate Schools).

METHODS

A 2 × 2 cluster randomised controlled factorial design trial was conducted in 26 Australian schools randomised to the following 4 conditions: Climate Schools (n = 6), Preventure (n = 7), combined Climate Schools and Preventure (CAP; n = 6) or treatment as usual (TAU; n = 7). Participants completed questionnaires at baseline, 6, 12, 24 and 36 months post-baseline including the Brief Symptom Inventory anxiety and depression scales and hyperactivity and conduct scales of the Strengths and Difficulties Questionnaire. Analyses focused on students who were at high-risk based on personality traits (n = 947; M_age = 13.3). The effectiveness of each approach in reducing symptoms of internalising and externalising problems was assessed using multi-level mixed effects analysis.

RESULTS

Main effects for each intervention relative to not receiving that intervention revealed significant main effects of Preventure in reducing anxiety symptoms (d = -0.27, 95% confidence interval [CI] = [-0.53, -0.01], p < 0.05) and a marginal effect in reducing depressive symptoms (d = -0.24, 95% CI = [-0.49, 0.01], p = 0.06) over 3 years. Interaction effects revealed that when delivered alone, Preventure significantly reduced conduct problems (d = -0.45, 95% CI = [-0.78, -0.11], p < 0.05) and hyperactivity symptoms (d = -0.38, 95% CI = [-0.70,-0.07], p < 0.05) compared to TAU.

CONCLUSION

This study is the first to report the effectiveness of personality-targeted alcohol prevention in reducing internalising and externalising symptoms relative to an active control, providing evidence in favour of its specificity in preventing concurrent substance use and mental health problems among high-risk youth.

Combined prevention for substance use, depression, and anxiety in adolescence: a cluster-randomised controlled trial of a digital online intervention

BACKGROUND

Substance use, depression, and anxiety in adolescence are major public health problems requiring new scalable prevention strategies. We aimed to assess the effectiveness of a combined online universal (ie, delivered to all pupils) school-based preventive intervention targeting substance use, depression, and anxiety in adolescence.

METHODS

We did a multicentre, cluster-randomised controlled trial in secondary schools in Australia, with pupils in year 8 or 9 (aged 13-14 years). Participating schools were randomly assigned (1:1:1:1) to one of four intervention conditions: (1) Climate Schools-Substance Use, focusing on substance use only; (2) Climate Schools-Mental Health, focusing on depression and anxiety only; (3) Climate Schools-Combined, focusing on the prevention of substance use, depression, and anxiety; or (4) active control. The interventions were delivered in school classrooms in an online delivery format and used a mixture of peer cartoon storyboards and classroom activities that were focused on alcohol, cannabis, anxiety, and depression. The interventions were delivered for 2 years and primary outcomes were knowledge related to alcohol, cannabis, and mental health; alcohol use, including heavy episodic drinking; and depression and anxiety symptoms at 12, 24, and 30 months after baseline. This trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12613000723785) and an extended follow-up is underway.

FINDINGS

Between Sept 1, 2013, and Feb 28, 2014, we recruited 88 schools (12 391 pupils), of whom 71 schools and 6386 (51·5%) pupils were analysed (17 schools dropped out and 1308 pupils declined to participate). We allocated 18 schools (1739 [27·25%] pupils; 1690 [97·2%] completed at least one follow-up) to the substance use condition, 18 schools (1594 [25·0%] pupils; 1560 [97·9%] completed at least one follow-up) to the mental health condition, 16 schools (1497 [23·4%] pupils; 1443 [96·4%] completed at least one follow-up) to the combined condition, and 19 schools (1556 [23·4%] pupils; 1513 [97·2%] completed at least one follow-up) to the control condition. Compared with controls, the combined intervention group had increased knowledge related to alcohol and cannabis at 12, 24, and 30 months (standardised mean difference [SMD] for alcohol 0·26 [95% CI 0·14 to 0·39] and for cannabis 0·17 [0·06 to 0·28] at 30 months), increased knowledge related to mental health at 24 months (0·17 [0·08 to 0·27]), reduced growth in their odds of drinking and heavy episodic drinking at 12, 24, and 30 months (odds ratio for drinking 0·25 [95% CI 0·12 to 0·51], and for heavy episodic drinking 0·15 [0·04 to 0·58] at 30 months), and reduced increases in anxiety symptoms at 12 and 30 months (SMD -0·12 [95% CI -0·22 to -0·01] at 30 months). We found no difference in symptoms or probable diagnosis of depression. The combined intervention group also showed improvement in alcohol use outcomes compared with the substance use and mental health interventions and improvements in anxiety outcomes when compared with the mental health intervention only.

INTERPRETATION

Combined online prevention of substance use, depression, and anxiety led to increased knowledge of alcohol, cannabis, and mental health, reduced increase in the odds of any drinking and heavy episodic drinking, and reduced symptoms of anxiety over a 30-month period. These findings provide the first evidence of the effectiveness of an online universal school-based preventive intervention targeting substance use, depression, and anxiety in adolescence.

FUNDING

Australian National Health and Medical Research Council.

Technology-Delivered Interventions for Substance Use Among Adolescents

Unhealthy alcohol and drug use are common among adolescents. A range of evidence-based interventions are available, but are rarely accessed by adolescents because of barriers such as cost, limited dissemination, lack of motivation to change, and logistical obstacles such as lack of transportation. Technology-delivered approaches may facilitate receipt of treatment in this vulnerable population. The limited number of controlled trials in this area present a mixed picture in terms of efficacy. Although sufficient to merit close attention and expanded research, the current literature points to a strong need for larger samples and greater use of rigorous and replicable methods.

Excessive substance use screening to encourage behaviour change among young people in primary care: Pilot study in preparation for a randomized trial

INTRODUCTION

Alcohol, cannabis and other substance use affects young people's health. Primary care physicians are encouraged to screen and provide brief interventions for substance use in this population, but implementation is often limited. Pre-consultation self-administered screening may decrease at-risk substance use and could have population-level benefits. A randomized controlled trial is planned to test this hypothesis. The present pilot study's objective was to assess the feasibility of methods for the future trial.

METHODS

The parallel-group randomized controlled pilot trial was undertaken in 6 primary care practices in Geneva, Switzerland, over 2 months. 29 patients aged 15-24 years consulting for any reason were randomly assigned to intervention (substance use screening, n = 14) or control (physical activity questionnaire, n = 15) using computer-generated random number tables. Outcomes were assessed one month later by telephone questionnaire. Physicians, practice staff and outcome assessors were blinded to allocation. The primary outcomes were feasibility of procedures and acceptability to participants, primary care physicians and practice staff.

RESULTS

Of 16 participants reached at follow-up, 3 reported excessive substance use. Methods were acceptable to all participants, especially regarding confidentiality. Three participants were lost due to technical difficulties with the consent form. No major problems with study methods were reported in the practices. 4 practices did not meet recruitment targets.

CONCLUSION

The study procedures proved to be feasible in primary care practices and acceptable to young people who were readily available to participate. The main challenge for the future full-sized trial will be to ensure that recruitment targets can be met.

Short- and long-term effects of digital prevention and treatment interventions for cannabis use reduction: A systematic review and meta-analysis

BACKGROUND

Frequent Cannabis use has been linked to a variety of negative mental, physical, and social consequences. We assessed the effects of digital prevention and treatment interventions on Cannabis use reduction in comparison with control conditions.

METHODS

Systematic review with two separate meta-analyses. Thirty randomized controlled trials met the inclusion criteria for the review, and 21 were included in the meta-analyses. Primary outcome was self-reported Cannabis use at post-treatment and follow-up. Hedges's g was calculated for all comparisons with non-active control. Risk of bias was examined with the Cochrane risk-of-bias tool.

RESULTS

The systematic review included 10 prevention interventions targeting 8138 participants (aged 12 to 20) and 20 treatment interventions targeting 5195 Cannabis users (aged 16 to 40). The meta-analyses showed significantly reduced Cannabis use at post-treatment in the prevention interventions (6 studies, N = 2564, g = 0.33; 95% CI 0.13 to 0.54, p =  0.001) and in the treatment interventions (17 comparisons, N = 3813, g = 0.12; 95% CI 0.02 to 0.22, p =  0.02) as compared with controls. The effects of prevention interventions were maintained at follow-ups of up to 12 months (5 comparisons, N = 2445, g = 0.22; 95% CI 0.12 to 0.33, p <  0.001) but were no longer statistically significant for treatment interventions.

CONCLUSIONS

Digital prevention and treatment interventions showed small, significant reduction effects on Cannabis use in diverse target populations at post-treatment compared to controls. For prevention interventions, the post-treatment effects were maintained at follow-up up to 12 months later.