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.

Effectiveness of a Theory-Based mHealth Intervention for High-Risk Drinking in College Students

Background: College students are among the most vulnerable groups to problems associated with high-risk drinking consequences such as illness, injury, sexual abuse, and death. Promising mobile health (mHealth) approaches, such as smartphone (SP) apps, can be used in interventions to address or prevent excessive drinking. Method: The aim of the investigation was to examine the efficacy of a theoretically based mHealth SP app for alcohol intervention in two independent samples (N = 379): Mandated participants (Study 1) and voluntary participants (Study 2). Study 1 included a controlled trial with Mandated participants randomized into either an in-person Brief Motivational Interviewing BMI (n = 70) or BMI + SP app intervention (n = 71). Study 2 included Voluntary participants who participated in either a Control group (n = 157) or the BMI + SP app intervention (n = 81). Participants in both studies completed baseline and 6-week assessments. Results: In Study 1, peak Blood Alcohol Concentration (BAC) of participants in the in-person BMI group had increased slightly at six weeks, while it had decreased for the app-based BMI + SP group. Study 2 participants using the BMI + SP app reported significant reductions in drinking and consequences; there were no changes in the (AO) Control group. Conclusions: The BMI + SP app was effective with both Mandated and Voluntary participants. Future testing with the BMI + SP app is needed to assess whether reach, adoptability, portability, and sustainability are greater with the mHealth smartphone app for alcohol intervention than in-person approaches.

Retention and Treatment Outcome of Youth with Cannabis Use Disorder Referred By the Legal System

Background

Youth with Substance Use Disorders (SUDs) referred to treatment from the Juvenile Justice System (JJS) account for approximately half of the treatment admissions nationwide. The objective of this paper is to report a comparison of retention and outcomes for JJS referrals to those from the general community.

Methods

A total of 172 adolescents, 13-18 years of age, 83% males, 70% JJS referrals, diagnosed with DSM-IV Cannabis Use Disorder (CUD), enrolled in this outpatient, randomized, continued care study. Following a 7-session weekly motivational enhancement and cognitive behavioral therapy intervention (MET/CBT-7), only poor responders were randomized into a 10-week second phase of either an individualized enhanced CBT or an Adolescent Community Reinforcement Approach (ACRA) intervention.

Results

JJS referrals' retention rates were significantly higher than those of non-JJS referrals (X ² (1) = 11.21, p < .01) at the end of Phase I (i.e. week 7). However, there was no difference in abstinence rates between the groups at the end of phase I or II and any of the quarterly additional follow-up assessments up to one year from treatment onset.

Conclusions

Additional research examining how to capitalize on improved retention rates among youth JJS referrals is necessary in order to advance abstinence.

"Here's to a Night of Drunken Mistakes": Exploring Experiences, Regrets, and Optimism in Young Adult Drinkers

BACKGROUND

Studies exploring "anticipated regret" concerning alcohol rarely consider the broader consequences of excessive drinking that might be regretted. Even if specific regrettable experiences are identified, interventions targeting them may not succeed because individuals are often optimistic about their risk susceptibility.

OBJECTIVES

This study examined the consequences young adult drinkers reported, and the extent to which these were regretted. It then explored whether consequences and regrets differentiated between high risk, low risk and light drinkers, and whether regret was related to optimism.

METHODS

A cross-sectional on-line questionnaire measured drinking behavior, consequences (frequency) and regrets (extent of likely regret) and risk perceptions (in general, and compared to others).

RESULTS

273 participants were recruited (light (30%), low-risk (40%), and high-risk drinkers (30%). PCA detected three types of experience (common-e.g., vomiting; after-effects-e.g., being depressed; and "serious"-e.g., drunk-driving), and three types of regret ("serious"-e.g., being aggressive; "common"-e.g., wasting time; and "risky behavior regrets"-e.g., drugs). Multinomial regression found the high-risk drink group more likely to be male, had more experiences but regretted these experiences less than other groups. Regrets and optimism interacted, so that higher scores on common regrets were associated with greater optimism. The high-risk group was particularly characterized by optimism.

CONCLUSIONS

High-risk drinkers may be unresponsive to anticipated regret manipulations as they do not regret post-alcohol "bad" experiences, and some regrets were associated with comparative optimism. Interventions may need to focus less on regret and aim to change risk perceptions.

I Am Quite Mellow But I Wouldn't Say Everyone Else Is": How UK Students Compare Their Drinking Behavior to Their Peers'

BACKGROUND

Excessive drinking is commonplace at UK Universities. Individuals may misperceive how much they drink compared to others and are less likely to think that they will suffer adverse consequences. Young people often distance themselves and their friends from 'problem drinkers'.

OBJECTIVES

The aim of the study was to explore how student drinkers compared their own drinking behaviors to the drinking behaviors of others.

METHODS

An online survey was completed by 416 students aged 18-30 (68.5% female). They were asked 'how do you think your drinking compares with other people like you?' and 'how do you think your behavior when you drink compares with other people like you?' Answers were subjected to thematic analysis.

RESULTS

The first main theme was about 'identification as a 'good' drinker'. Participants suggested their own behavior when drinking was similar to their sober behavior. Further, they viewed themselves as more able to maintain a balance between staying in control and having fun while drinking. The second main theme was about 'distancing from being a 'bad' drinker. Participants distanced themselves from negative prototypical drinkers, such compulsive or anti-social drinkers. They also attributed their own drinking behaviors to situational factors, but described other people as intentionally violent or aggressive. Conclusions/Importance: These findings may explain the failure of some health messages to change drinking behaviors. If drinkers perceive that their behavior when they drink is better than other people's then they may discount intervention messages. Targeting these biases could be incorporated into future interventions.

You have to be prepared to drink

Purpose

Many existing interventions to reduce excessive drinking in university students attempt to target individual cognitions, which ignore the wider contextual features that drive excessive drinking and mark this as an important aspect of university life. The purpose of this paper is to explore students’ views about preventing excessive drinking at university, specifically by using frameworks that take into both account individual and social influences.

Design/methodology/approach

In all, 23 young adults aged 20-30 (12 females; M age=22.91; SD=2.57; 18 students, five recent graduates) took part in semi-structured interviews to explore their views about drinking and measures to reduce excessive consumption. Transcripts were analysed using thematic analysis.

Findings

There were three themes identified in the analysis. These themes were named “the role of alcohol in student life”, drinking transitions’, and “prevention challenges” and each had related sub-themes.

Practical implications

Targeting students before they commence their course and highlighting aspects of university life that do not involve alcohol may help to reduce the pressure often felt to drink in social situations. Providing novel, credible alternative socialising options that do not involve alcohol should be explored to determine their acceptability, and their potential to reduce excessive drinking.

Originality/value

Few studies explore what students themselves think about reducing alcohol consumption and most interventions focus on changing individual cognitions rather than features of the social environment. This study highlights that changing social practices related to drinking in combination with targeting individuals may be more fruitful avenue to reduce excessive alcohol consumption.

Acceptability of targeting social embarrassment in a digital intervention to reduce student alcohol consumption: A qualitative think aloud study

Objective

Increasing knowledge about alcohol-related harms, changing social norms, or encouraging drinking within safe unit levels often fails to change behaviour in young people. A novel intervention called ‘OneTooMany’ was developed, which targets the short-term social, and potentially, embarrassing consequences of drinking alcohol. The aim of this paper was to explore its acceptability, and to determine any features that might influence its effectiveness as a means of reducing alcohol consumption.

Methods

Participants were 23 young adults (aged 18–30) currently studying at university (n = 18) or in the first six months following graduation (n = 5). A think aloud interview approach was employed. Three main themes were identified in a deductive thematic analysis.

Results

Embarrassing experiences were a normalised part of drinking occasions, while some were actively avoided, others were celebrated. Humour served as a device to engage and interest participants, but could also diminish intervention messages. OneTooMany prompted reflections on many regrettable drinking experiences, but the participants did not see themselves as the target audience for this intervention.

Conclusions

Interventions may benefit from focusing on some of the short term, embarrassing consequences of excessive alcohol consumption. Further research is needed to ensure that reflections on past behaviour are helpful in addressing future behaviour.

Addictive Behavior Interventions Among College Students

PURPOSE OF REVIEW

Addictive behaviors among college students are a significant public health concern. This manuscript reviews the past two years of literature on prevention and treatment approaches for college students who engage in addictive behaviors.

RECENT FINDINGS

In-person skills-based interventions and motivational interventions that incorporate personalized feedback are effective in the short-term but little support was found for long-term effects. Although web-based interventions reduced certain addictive behaviors (e.g., alcohol, problematic gambling), in-person interventions that include motivational interviewing components and personalized feedback appear to be more efficacious.

SUMMARY

Research has largely focused on alcohol and little is known about the utility of interventions for students who use tobacco or illicit substances or who engage in problematic gambling. Research on interventions for these high-risk behaviors is recommended.

Do As I Say, Not As I Do

Little is known about the drinking behaviors and perceptions of the peers facilitating campus alcohol interventions. The current study examined these trajectories in peer counselors ( N = 12) providing personalized normative feedback interventions to undergraduates mandated to clinical services. Peer counselors completed four monthly self-assessments. In spite of facilitating interventions to reduce drinking and associated harms, peer drinking behaviors and expectancies did not change, although significant between subjects effects suggest various trajectories. Peer counselors did correct overestimates of binge drinking but progressively underestimated abstinence norms. Despite the lack of change in the peer counselor behaviors, the mandated clients significantly reduced their drinking, suggesting it may be more important to "Do as I Say" rather than as the facilitator does.

The impact of defensiveness and incident reactions on post-sanction drinking behaviors among mandated students

INTRODUCTION

Prior studies with mandated students (students referred for an intervention following violation of a campus alcohol policy) have suggested that decreases in drinking behaviors may occur before clinical intervention. Others studies have suggested that greater reductions were associated with lower defensiveness and stronger incident reactions, such as responsibility and aversiveness. The current study sought to integrate these findings and examine the influence of pre-sanction drinking and perceptions on mandated students' post-sanction drinking levels prior to attending a brief intervention.

METHODS

Data were collected as part of a longitudinal study of brief interventions in a mandated student sample (N=61, 43% female, 97% White). Participants completed demographic measures, scales measuring incident reactions and defensiveness, and a Time Line Follow Back assessing drinking quantity and frequency both pre- and post-sanction.

RESULTS

Analyses revealed significant post-sanction decreases in quantity (average total drinks per month) and frequency (number of monthly drinking days). Pre-sanction drinking quantity and frequency significantly predicted post-sanction quantity and frequency, respectively. Interaction effects suggest higher post-sanction quantities among moderate and heavier drinkers with higher defensiveness and lower aversiveness perceptions, while perceptions did not influence outcomes among light drinkers. None of the interactions involving blame or responsibility, or predicting post-sanction frequency, were significant.

CONCLUSIONS

These findings suggest a complex relationship between pre-sanction drinking and student reactions. Implications for mandated student interactions and future research directions are discussed.