Cognitive-behavioral treatment with adult alcohol and illicit drug users: a meta-analysis of randomized controlled trials

Expectancies and Motives as Predictors of Risky Alcohol Consumption in College Women

Despite the consequences of alcohol use, it continues showing a high incidence among college students. Besides, the increasing presence of women in risk alcohol patterns calls for a gender-sensitive approach to design specific actions. Some variables have been analyzed as underlying alcohol consumption (expectations and motives). This paper assesses the type and influence of both variables on female university alcohol consumers at different levels of risk. Five hundred four college women were assessed using the Spanish adaptations of the Expectancy Questionnaire, the Drinking Motives Questionnaire-Revised, and the AUDIT. We determine the unique contributions of expectancies, motives, and the presence of binge drinking (BD) to the pattern of risky drinking. The percentage of variance explained by risky drinking is 37.7%. Negative expectancies (20.4%) are the most explanatory variables, followed by enhancement motives (10.4%). Interventions with university women should focus on their negative expectancies, in addition to addressing for improvement, coping with depression, and conformity motives.

A 12-session relapse prevention program vs psychoeducation in the treatment of Japanese alcoholic patients: A randomized controlled trial

Aim

Alcoholism is the most prevalent substance use disorder in Japan; the estimated number of patients and high‐risk drinkers is in the millions. Although studies in the West have shown that cognitive behavioral therapy (CBT) is one of the most effective treatment strategies for alcoholic patients, there is a dearth of efficacy studies of CBT‐based intervention for those patients in the non‐Western setting. The aim of this study is to investigate the efficacy of a 12‐session CBT‐based relapse prevention program for Japanese alcoholic patients.

Methods

Forty‐eight alcoholic patients (M = 36, F = 12) who were admitted to an addiction treatment unit were randomly allocated either to a 12‐session relapse prevention (RP) program (n = 24) or a 12‐session psychoeducation (PE) program (n = 24). Both treatment programs were conducted in a group format once a week for 12 weeks. Other aspects of inpatient treatment (group meetings, etc) were the same in both groups. Self‐rating scales, which measure behavioral and cognitive coping, coping response, self‐efficacy, and cognition of drinking, were administered at pretreatment, mid‐treatment, and posttreatment periods. The proportion of participants who relapsed at 3 and 6 months after discharge was evaluated.

Results

Both RP and PE groups showed significant improvement in self‐efficacy and cognition of drinking at posttreatment. However, there were no significant differences in the self‐rating scales between both groups. In addition, there were no significant differences in relapse rate at 3 and 6 months after discharge between both groups.

Conclusions

The 12‐session CBT‐based relapse prevention program and the psychoeducation program may be equally efficacious for alcoholic patients. Several factors that influenced the results are discussed.

Can psychedelic-assisted psychotherapy play a role in enhancing motivation to change in addiction treatment settings?

Despite growing availability of several evidence-based approaches in the treatment of substance use disorders, existing pharmacotherapy and psychosocial interventions continue to have significant limitations, such as low treatment retention rates and high rates of relapse. There is a need to develop new strategies and models to address these limitations and target underlying psychosocial drivers of addiction, such as motivation to change – a crucial factor in achieving positive addiction treatment outcomes. Re-emerging clinical evidence and literature signal the promise of psychedelic-assisted psychotherapies as being novel, adjunctive treatments for a range of mental health and substance use disorders, encouraging further research. However, there remains a lack of formally validated metrics to evaluate recovery capital and motivation, limiting interpretation of the growing psychedelic literature. This commentary describes the current state of this line of investigation and potential impact of psychedelic-assisted psychotherapy on enhancing motivation to change in addiction treatment, and the need for validated metrics to evaluate recovery motivation and capital to assess the potential for psychedelic-assisted psychotherapies to elicit positive, lasting changes in substance use behaviors among those seeking treatment.

Alcohol-Involved Family and Domestic Violence Reported to Police in Australia

Family and domestic violence (FDV) is a significant social issue that causes major harm across Australia. Alcohol has been identified as a contributing factor to FDV, and as such increased understanding of the role of alcohol in police-reported FDV incidents may provide the basis for developing specific clinical and forensic approaches. This study aims to identify the key correlates of alcohol-related FDV within police-reported FDV incidence. Data sourced from several states and territories across Australia were used to profile demographic and personal factors involved in police-reported FDV incidents, and to identify the types of incidents involving alcohol. For each state, three separate binary regressions were conducted for family violence, intimate partner violence, and FDV incidents in which alcohol was involved. Between 24% and 54% of FDV incidents reported to police were classified as alcohol-related. Although there appeared to be an association between relative socioeconomic disadvantage and an incident being alcohol-related, this association varied across states. Where victim and offender data were available, offenders were significantly more likely to be alcohol-affected than victims. Alcohol-related FDV incidents were also twice as likely to involve severe physical violence including injuries that were life threatening, as well as an increased likelihood of recidivism. This study demonstrates that alcohol plays a substantial role in police-reported FDV across Australia. It also demonstrates that other factors such as drug use, breach of orders, and repeat offending are associated with alcohol involvement across family violence and intimate partner violence.

A randomized controlled trial of the web-based drinking diary program for problem drinking in multi workplace settings

Objectives

To assess the effectiveness of a web‐based brief intervention (BI) program to record daily drinking among people with problem drinking in workplace settings.

Methods

A two‐armed, parallel‐group, randomized controlled trial were conducted at six workplaces in Japan. After obtaining written consent to participate in the study, workers with an Alcohol Use Disorders Identification Test (AUDIT) score of 8 or higher were randomly assigned into two groups. The participants allocated to the intervention group recorded their daily alcohol consumption for 4 weeks using the program, while those allocated to the control group received no intervention. Outcome measures included the amount of alcohol consumption in past 7 days using the Timeline Follow‐Back method in the program at baseline, 8th week, and 12th week and written AUDIT score at baseline and 12th week.

Results

Hundred participants were assigned to either the intervention group (n = 50) or control group (n = 50). The results of two‐way repeated measures ANOVA showed a statistically significant interaction between the group and the week factors in the two primary outcomes (number of alcohol‐free days, total drinks) and secondary outcomes (AUDIT score) (p = .04, .02, and .03, respectively). The between‐group effect sizes (Hedges' g; 95% CI) of the outcomes at 12th week were 0.53; 0.13–0.93 (total drinks), 0.44; 0.04–0.84 (AUDIT score), 0.43; 0.03–0.83 (number of alcohol‐free days).

Conclusions

The web‐based BI program for problem drinking was considered to be effective in reducing alcohol consumption and the AUDIT score in workplace settings.

Treatment of alcohol use disorder in patients with liver disease

Alcohol contributes to more than 5% of global mortality, and causes more than half of all liver-related deaths. The Alcohol Use Disorders Identification Test (AUDIT) can be used to detect those patients with hazardous drinking and alcohol dependence who will benefit from psychosocial and pharmacological alcohol treatment. Psychosocial treatments range from brief interventions and cognitive behavioral therapy, to experimental neuropsychological treatments. Psychosocial intervention can be combined with acamprosate or naltrexone as first line pharmacological treatments. For patients with liver disease, abstinence increases survival and is therefore an important treatment goal. Acamprosate is a good choice, as it prevents relapse to drinking with a number needed to treat of 12. There are no reports indicating high risks of liver toxicity for acamprosate or naltrexone, but evidence is scarce. We recommend vigorous screening for alcohol use disorder in liver disease patients, followed by psychosocial intervention and complemented by pharmaceutical therapy.

Inserção das Estratégias Cognitivo-Comportamentais no CAPS Álcool e Drogas

Resumo Este estudo teve como objetivo conhecer a percepção de psicólogos que trabalham em Centros de Atenção Psicossocial para Álcool e Drogas sobre a inserção de estratégias das terapias cognitivo-comportamentais para o tratamento de dependência de álcool e outras drogas em sua prática. Foi realizado um estudo qualitativo de caráter exploratório, por meio de entrevistas com 16 psicólogos que atuam no Rio de Janeiro e em Minas Gerais. Os dados coletados foram analisados por meio da análise de conteúdo temática de Bardin. Os resultados apontam que, na percepção dos psicólogos, essas estratégias são passíveis de serem adotadas por esses centros e conferem bons resultados ao tratamento, embora haja limitações na formação especializada em terapia cognitivo-comportamental para lidar com a dependência de drogas entre os participantes. São discutidas a contribuição dessas terapias para a prática baseada em evidências no serviço público no que se refere ao monitoramento e avaliação de resultados, bem como sua relação compatível com a estratégia de redução de danos e com a lógica do tratamento psicossocial. Apesar das terapias cognitivo-comportamentais serem reconhecidas em outros países como intervenções bem embasadas cientificamente e apresentarem características importantes para a saúde pública, persistem obstáculos para a adoção destas ferramentas no tratamento da dependência de álcool e outras drogas nos serviços de saúde mental no Brasil.

Getting High or Getting By? An Examination of Cannabis Motives, Cannabis Misuse, and Concurrent Psychopathology in a Sample of General Community Adults

OBJECTIVE:

Few studies have examined cannabis motives in adults and, although associations between cannabis use and psychiatric conditions are well documented, there has been limited investigation of the intersection of cannabis use, cannabis motives, and psychopathology. In a sample of community adults, the present study examined cannabis motives in relation to cannabis misuse, and investigated whether motives linked cannabis misuse with concurrent psychiatric symptoms.

METHOD:

Participants (N = 395; M_age = 34.8; %F = 47.6; % White = 81.3%) completed assessments related to cannabis misuse, cannabis use motives, and symptoms of depression, anxiety, PTSD, and somatic experiences. Bivariate correlations, hierarchical regressions, and indirect effect analyses were performed to examine associations between motives and cannabis misuse and to investigate mechanistic relationships between psychiatric symptoms and cannabis misuse.

RESULTS:

Regressions revealed significant associations between cannabis misuse and social (β = .13, P < .02), enhancement (β = .12, P < .02), and coping motives (β = .48, P < .001). Indirect effects were present such that coping motives consistently linked psychiatric and somatic symptoms with cannabis misuse (anxiety: unstandardized effect = 0.26,and 95% CI = 0.17-0.37; depression: unstandardized effect = 0.12, CI = 0.11-0.25; PTSD: unstandardized effect = 0.07, CI = 0.04-0.10; somatic symptoms: unstandardized effect = 0.20, CI = 0.11-0.30). In addition, enhancement motives exhibited an indirect effect (unstandardized effect = 0.02, CI = 0.002-0.04) between depressive symptoms and cannabis misuse.

CONCLUSION:

These results support a negative reinforcement motivational profile as the predominant pattern in adult cannabis users, albeit with links to enhancement and social motives. This motivational profile is especially pronounced with regard to comorbid psychopathology and cannabis misuse. These results support the importance of treatment strategies targeting maladaptive coping to address cannabis misuse and co-occurring psychopathology.

Cognitive behavioural group therapy with mindfulness for kleptomania: an open trial

Kleptomania is an addiction to stealing without an economic motive; therefore, an examination of effective interventions as a preventive measure is needed. The effectiveness of cognitive behavioural therapy (CBT) combined with mindfulness for the treatment of addiction has been previously indicated, and it is presumed to be effective for kleptomania; however, this relationship remains unstudied. Therefore, this study aimed to examine the effectiveness of cognitive behavioural group therapy (CBGT) combined with mindfulness for treating kleptomania. The results of a 12-session programme of CBGT combined with mindfulness for 22 patients with kleptomania showed that kleptomania symptoms and quality of life (QOL) improved. Furthermore, the recovery process revealed that the improvement of distress tolerance affected the improvement of kleptomania symptoms and that the improvement of reward perception and distress tolerance affected the improvement of stress response and QOL. These results suggest that CBGT combined with mindfulness may be effective in improving symptoms and QOL in kleptomania.

Key learning aims

(1)

Volunteer Recovery Support for Adolescents: Using propensity score based methods to understand dosage effects within a randomized controlled trial

BACKGROUND

In a recently published randomized controlled trial (RCT) of Volunteer Recovery Support for Adolescents (VRSA), a secondary finding indicated that better adherence to planned VRSA telephone session frequency resulted in significantly higher remission rates relative to lower session adherence. However, interpretation of this dose-response relationship may have been confounded by participant characteristics such as baseline levels of substance use and mental health problems.

METHODS

The present study used statistical methods designed to approximate RCTs when comparing more than two nonequivalent groups that include an assessment of the potential impact of omitted variables. Classification and Regression Tree (CRT) analysis was used to establish the cut-point between high (H) and low (L) VRSA dosage groups. Because we were interested in generalizing to youth with poor attendance, the L-VRSA group served as the reference group. Balancing weights for H-VRSA and a services as usual (SAU) control group were calculated to ensure similarity of baseline pretreatment characteristics to the reference group, and sensitivity of findings to unobserved confounding variables was assessed.

RESULTS

Findings suggested that superior remission rates at the end of the intervention phase were the result of high adherence to planned VRSA session frequency. Recommendations to achieve high VRSA participation among a larger segment of youth and to test whether longer VRSA duration improves the stability of recovery outcomes are provided.

CONCLUSION

Few published dose-response studies have adequately controlled for selection confounds from both observed and unobserved confounding. As such, the present study aims to both assess the impact of different dosage levels of VRSA and provide a template for how to apply state-of-the-art statistical methods designed to approximate randomized controlled trials to such studies.

Psychological Interventions on Abstinence in Patients with Alcohol Use Disorder: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

PURPOSE

Accumulating research suggests that psychotherapy helps improve abstinence but the difference in the efficacy of multiple psychotherapies in alcohol use disorder (AUD) remains to be explored.

PATIENTS AND METHODS

A systematic search of databases (Pubmed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and EBSCO) for studies (published from inception to April 10th.) of adults diagnosed with AUD accepting psychotherapies was conducted. Studies covering 9 countries and regions. The qualitative analysis pooled 2646 individuals from 34 randomized controlled trials (RCTs) and the networks included 1928 participants (23 RCTs). The outcomes included percentage of days abstinent (PDA), change in drinks per drinking day (change in DDD), and change in craving compared among individuals accepting various psychotherapies. The protocol followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), and was registered on the International Prospective Register of Systematic Reviews (PROSPERO).

RESULTS

For the network of PDA, motivational enhancement treatment (MET) (35.44, 11.78 to 59.09, high-certainty) and couple therapy (CT) (28.89, 13.42 to 44.36, moderate-certainty) were significantly different from treatment as usual (TAU) with the surface under the cumulative ranking curve (SUCRA) mean rank 1.9 and 1.9 respectively. TAU+supportive psychotherapy (SP) was better than TAU for the change in DDD in the high-quality direct comparison.

CONCLUSION

The motivational enhancement and the couple therapy show potential amelioration for alcohol abstinence. Additionally, the preferred interventions are different for improving PDA and change in DDD. The evidence network remains to be strengthened.

Visualizing a Calculus of Recovery: Calibrating Relations in an Opioid Epicenter

This article uses participatory photography to explore the relationships animating efforts towards recovery from opioid use disorder (OUD) in the Dayton, Ohio area, an epicenter of illicit opioid use and overdose death. A photo-elicitation project was conducted with thirteen people who met the DSM-5 criteria for OUD. Photographs were used as prompts during qualitative interviews, which were thematically analyzed. Analysis of both visual and textual data demonstrated the ways in which recovery became an unfolding process of calculation as participants made strategic choices to navigate relations and encounters with things, people, and places. Relationships across each of these domains could, under some circumstances, serve as supports or motivators in the recovery process, but, in alternate settings, be experienced as "triggers" prompting a resumption of problematic drug use or, at the very least, a reckoning with the feelings and emotions associated with painful or problematic aspects of personal histories and drug use experiences. Findings highlight the importance of understanding recovery as a calibration of the ambiguous relations animating experiences of everyday life. We argue for continued emphasis on recovery as an active performance and ongoing practice of calculation-of risks and benefits, of supports and triggers, of gratification and heartbreak-rather than a goal or static state.

Integration of Twelve Step with Evidence-Based Practices in a Residential Treatment Center

Background: Residential treatment for substance use disorders (SUDs) typically involves both medical and psychological treatments to best meet the needs of service users. Common treatments include Twelve Step Facilitation (TSF) as well as evidence-based practices (EBPs) such as cognitive behavioral therapies and medications. Researchers have discussed the difficulties with implementation and sustainability of EBPs within treatment centers that predominantly use TSF. Objectives: Understanding the process of implementation is an important area of study to inform future implementation efforts. The present study involved a qualitative investigation of a residential treatment center that integrated EBPs alongside TSF. Treatment stakeholders (N=22) were interviewed about their experience with integration. Results: The results indicated that the organization's evolution to integrate evidence-based practices (e.g., medication, evidenced-based psychotherapy) occurred through a process of themes including staff members' personal allegiance to Twelve Step; tension among staff members; staff collaboration; and integration of theoretical orientations. The results parallel those found in the Normalization Process Theory of implementation. Conclusions: The present study provides an understanding as to how Twelve Step and EBPs can be integrated into a residential treatment center, allowing for service users to have choice in their care. The program's ability to navigate the treatment evolution can be used as an example for integrating evidence-based practice with Twelve Step to meet the many needs of individuals seeking substance use treatment.

Factors Having an Impact on Relapse and Survival in Transplant Recipients With Alcohol-Induced Liver Disease

Objective

To assess the impact of standardized pretransplant alcohol abstinence and treatment guidelines on liver transplant outcomes.

Methods

This study assessed the posttransplant relapse and survival associated with a pretransplant guideline mandating alcohol abstinence, addiction treatment, and Alcoholics Anonymous (AA) attendance. This retrospective cohort study included liver recipients with alcohol-induced liver disease transplanted between January 1, 2000, and December 31, 2012, at a Midwest transplant center. Cox regression models tested for associations between pretransplant treatment, demographic and clinical characteristics, and outcome measures.

Results

Of 236 liver recipients (188 [79.7%] male; 210 [89%] white; mean follow-up, 88.6±55.0 months), 212 (90.2%) completed pretransplant treatment and 135 (57.2%) attended AA weekly. At 5 years, 16.3% and 8.2% had relapsed to any alcohol use and to high-dose drinking, respectively. Smoking during the 6 months before transplant was associated with any relapse (P=.0002) and high-dose relapse (P<.0001), and smoking at transplant was associated with death (P=.001). High-dose relapse was associated with death (hazard ratio, 3.5; P<.0001).

Conclusion

A transplant center with a guideline requiring abstinence, treatment, and AA participation experienced lower posttransplant relapse rates from those previously reported in comparable large US transplant programs. Smoking cessation may further improve posttransplant outcomes.

Mean corrected generalized estimating equations for longitudinal binary outcomes with report bias

Cocaine addiction is an important public health problem worldwide. Cognitive-behavioral therapy is a counseling intervention for supporting cocaine-dependent individuals through recovery and relapse prevention. It may reduce patients' cocaine uses by improving their motivations and enabling them to recognize risky situations. To study the effect of cognitive behavioral therapy on cocaine dependence, the self-reported cocaine use with urine test data were collected at the Primary Care Center of Yale-New Haven Hospital. Its outcomes are binary, including both the daily self-reported drug uses and weekly urine test results. To date, the generalized estimating equations are widely used to analyze binary data with repeated measures. However, due to the existence of significant self-report bias in the self-reported cocaine use with urine test data, a direct application of the generalized estimating equations approach may not be valid. In this paper, we proposed a novel mean corrected generalized estimating equations approach for analyzing longitudinal binary outcomes subject to reporting bias. The mean corrected generalized estimating equations can provide consistently and asymptotically normally distributed estimators under true contamination probabilities. In the self-reported cocaine use with urine test study, accurate weekly urine test results are used to detect contamination. The superior performances of the proposed method are illustrated by both simulation studies and real data analysis.

Targeting white matter neuroprotection as a relapse prevention strategy for treatment of cocaine use disorder: Design of a mechanism-focused randomized clinical trial

Cocaine use continues to be a significant public health problem with limited treatment options and no approved pharmacotherapies. Cognitive-behavioral therapy (CBT) remains the mainstay treatment for preventing relapse, however, people with chronic cocaine use display cognitive impairments that are associated with poor response to CBT. Emerging evidence in animal and human studies suggests that the peroxisome proliferator-activated receptor-gamma (PPAR- γ) agonist, pioglitazone, improves white matter integrity that is essential for cognitive function. This project will determine whether adjunctive use of pioglitazone enhances the effect of CBT in preventing relapse during the early phase of recovery from cocaine use disorder. This paper describes the design of a mechanism-focused phase 2 randomized clinical trial that aims first to evaluate the effects of pioglitazone on targeted mechanisms related to white matter integrity, cognitive function, and cocaine craving; and second, to evaluate the extent to which improvements on target mechanisms predict CBT response. Positive results will support pioglitazone as a potential cognitive enhancing agent to advance to later stage medication development research.

New Australian guidelines for the treatment of alcohol problems: an overview of recommendations

OF RECOMMENDATIONS AND LEVELS OF EVIDENCE

Chapter 2: Screening and assessment for unhealthy alcohol use Screening Screening for unhealthy alcohol use and appropriate interventions should be implemented in general practice (Level A), hospitals (Level B), emergency departments and community health and welfare settings (Level C). Quantity-frequency measures can detect consumption that exceeds levels in the current Australian guidelines (Level B). The Alcohol Use Disorders Identification Test (AUDIT) is the most effective screening tool and is recommended for use in primary care and hospital settings. For screening in the general community, the AUDIT-C is a suitable alternative (Level A). Indirect biological markers should be used as an adjunct to screening (Level A), and direct measures of alcohol in breath and/or blood can be useful markers of recent use (Level B). Assessment Assessment should include evaluation of alcohol use and its effects, physical examination, clinical investigations and collateral history taking (Level C). Assessment for alcohol-related physical problems, mental health problems and social support should be undertaken routinely (GPP). Where there are concerns regarding the safety of the patient or others, specialist consultation is recommended (Level C). Assessment should lead to a clear, mutually acceptable treatment plan which specifies interventions to meet the patient's needs (Level D). Sustained abstinence is the optimal outcome for most patients with alcohol dependence (Level C). Chapter 3: Caring for and managing patients with alcohol problems: interventions, treatments, relapse prevention, aftercare, and long term follow-up Brief interventions Brief motivational interviewing interventions are more effective than no treatment for people who consume alcohol at risky levels (Level A). Their effectiveness compared with standard care or alternative psychosocial interventions varies by treatment setting. They are most effective in primary care settings (Level A). Psychosocial interventions Cognitive behaviour therapy should be a first-line psychosocial intervention for alcohol dependence. Its clinical benefit is enhanced when it is combined with pharmacotherapy for alcohol dependence or an additional psychosocial intervention (eg, motivational interviewing) (Level A). Motivational interviewing is effective in the short term and in patients with less severe alcohol dependence (Level A). Residential rehabilitation may be of benefit to patients who have moderate-to-severe alcohol dependence and require a structured residential treatment setting (Level D). Alcohol withdrawal management Most cases of withdrawal can be managed in an ambulatory setting with appropriate support (Level B). Tapering diazepam regimens (Level A) with daily staged supply from a pharmacy or clinic are recommended (GPP). Pharmacotherapies for alcohol dependence Acamprosate is recommended to help maintain abstinence from alcohol (Level A). Naltrexone is recommended for prevention of relapse to heavy drinking (Level A). Disulfiram is only recommended in close supervision settings where patients are motivated for abstinence (Level A). Some evidence for off-label therapies baclofen and topiramate exists, but their side effect profiles are complex and neither should be a first-line medication (Level B). Peer support programs Peer-led support programs such as Alcoholics Anonymous and SMART Recovery are effective at maintaining abstinence or reductions in drinking (Level A). Relapse prevention, aftercare and long-term follow-up Return to problematic drinking is common and aftercare should focus on addressing factors that contribute to relapse (GPP). A harm-minimisation approach should be considered for patients who are unable to reduce their drinking (GPP). Chapter 4: Providing appropriate treatment and care to people with alcohol problems: a summary for key specific populations Gender-specific issues Screen women and men for domestic abuse (Level C). Consider child protection assessments for caregivers with alcohol use disorder (GPP). Explore contraceptive options with women of reproductive age who regularly consume alcohol (Level B). Pregnant and breastfeeding women Advise pregnant and breastfeeding women that there is no safe level of alcohol consumption (Level B). Pregnant women who are alcohol dependent should be admitted to hospital for treatment in an appropriate maternity unit that has an addiction specialist (GPP). Young people Perform a comprehensive HEEADSSS assessment for young people with alcohol problems (Level B). Treatment should focus on tangible benefits of reducing drinking through psychotherapy and engagement of family and peer networks (Level B). Aboriginal and Torres Strait Islander peoples Collaborate with Aboriginal or Torres Strait Islander health workers, organisations and communities, and seek guidance on patient engagement approaches (GPP). Use validated screening tools and consider integrated mainstream and Aboriginal or Torres Strait Islander-specific approaches to care (Level B). Culturally and linguistically diverse groups Use an appropriate method, such as the "teach-back" technique, to assess the need for language and health literacy support (Level C). Engage with culture-specific agencies as this can improve treatment access and success (Level C). Sexually diverse and gender diverse populations Be mindful that sexually diverse and gender diverse populations experience lower levels of satisfaction, connection and treatment completion (Level C). Seek to incorporate LGBTQ-specific treatment and agencies (Level C). Older people All new patients aged over 50 years should be screened for harmful alcohol use (Level D). Consider alcohol as a possible cause for older patients presenting with unexplained physical or psychological symptoms (Level D). Consider shorter acting benzodiazepines for withdrawal management (Level D). Cognitive impairment Cognitive impairment may impair engagement with treatment (Level A). Perform cognitive screening for patients who have alcohol problems and refer them for neuropsychological assessment if significant impairment is suspected (Level A).

SUMMARY OF KEY RECOMMENDATIONS AND LEVELS OF EVIDENCE

Chapter 5: Understanding and managing comorbidities for people with alcohol problems: polydrug use and dependence, co-occurring mental disorders, and physical comorbidities Polydrug use and dependence Active alcohol use disorder, including dependence, significantly increases the risk of overdose associated with the administration of opioid drugs. Specialist advice is recommended before treatment of people dependent on both alcohol and opioid drugs (GPP). Older patients requiring management of alcohol withdrawal should have their use of pharmaceutical medications reviewed, given the prevalence of polypharmacy in this age group (GPP). Smoking cessation can be undertaken in patients with alcohol dependence and/or polydrug use problems; some evidence suggests varenicline may help support reduction of both tobacco and alcohol consumption (Level C). Co-occurring mental disorders More intensive interventions are needed for people with comorbid conditions, as this population tends to have more severe problems and carries a worse prognosis than those with single pathology (GPP). The Kessler Psychological Distress Scale (K10 or K6) is recommended for screening for comorbid mental disorders in people presenting for alcohol use disorders (Level A). People with alcohol use disorder and comorbid mental disorders should be offered treatment for both disorders; care should be taken to coordinate intervention (Level C). Physical comorbidities Patients should be advised that alcohol use has no beneficial health effects. There is no clear risk-free threshold for alcohol intake. The safe dose for alcohol intake is dependent on many factors such as underlying liver disease, comorbidities, age and sex (Level A). In patients with alcohol use disorder, early recognition of the risk for liver cirrhosis is critical. Patients with cirrhosis should abstain from alcohol and should be offered referral to a hepatologist for liver disease management and to an addiction physician for management of alcohol use disorder (Level A). Alcohol abstinence reduces the risk of cancer and improves outcomes after a diagnosis of cancer (Level A).

Evaluating the effects of two alcohol reduction counseling interventions on intimate partner violence perpetration: secondary analysis of a three-arm randomized controlled trial among Vietnamese men with HIV

BACKGROUND AND AIMS

Evidence suggests that alcohol reduction interventions decrease intimate partner violence (IPV) perpetration, although this remains untested in low- and middle-income countries and among men with human immunodeficiency virus (HIV). This study evaluates the effectiveness of alcohol reduction counseling interventions on IPV perpetration among men on anti-retroviral therapy (ART) and tests whether alcohol use explains the intervention effects.

DESIGN

Secondary analysis of data from a three-arm randomized controlled trial among ART patients with hazardous alcohol use. Participants were recruited from March 2016 to May 2017.

SETTING

Thai Nguyen, Vietnam.

PARTICIPANTS, INTERVENTIONS AND COMPARATORS

Male participants (n = 426). Participants received a two-session brief intervention (BI), a six-session combined intervention (CoI) or the standard of care (SOC), comprising alcohol treatment referrals. Alcohol reduction counseling interventions were guided by cognitive-behavioral therapy and motivational enhancement therapy delivered by psychosocial counselors over 3 months.

MEASUREMENTS

IPV perpetration was measured using the shortened Conflict Tactics Scale 2 and alcohol use was measured using timeline followback.

FINDINGS

BI and CoI participants reported reduced IPV perpetration at 3 months compared with SOC participants [BI: adjusted odds ratio (aOR) = 0.27, 95% confidence interval (CI) = 0.11, 0.65; CoI: aOR = 0.50, 95% CI = 0.22, 1.13]; the association was only significant for the BI group. Intervention effects were not sustained at 6 and 12 months. There was little evidence that alcohol use acted as a mediator (indirect effect, BI: aOR = 0.84, 95% CI = 0.63, 1.04; indirect effect, CoI: aOR = 0.86, 95% CI = 0.66, 1.03).

CONCLUSIONS

Among Vietnamese men receiving anti-retroviral therapy, alcohol reduction counseling interventions appeared to reduce intimate partner violence perpetration immediately post-intervention, but reductions were not sustained at 6 and 12 months and were not explained by alcohol reduction.

Pilot Cohorts for Development of Concurrent Mobile Treatment for Alcohol and Tobacco Use Disorders

Alcohol and tobacco are the 2 most frequently used drugs in the United States and represent the highest co-occurrence of polysubstance use. The objective of this study was to refine an intervention combining mobile contingency management with cognitive-behavioral telephone counseling for concurrent treatment of alcohol and tobacco use disorders. Two cohorts (n = 13 total, n = 5 women) of participants were enrolled, with 10/13 completing treatment and 7/13 completing the 6-month follow-up. At enrollment, participants were drinking a mean of 28.9 drinks per week (SD = 14.1), with a mean of 14.7 heavy drinking days in the past month (SD = 9.9), and a mean of 18.1 cigarettes per day (SD = 11.7). Treatment included a mobile application that participants used to record carbon monoxide and breath alcohol content readings to bioverify abstinence. Participants received up to 4 sessions of phone cognitive-behavioral therapy and monetary reinforcement contingent on abstinence. In cohort 1, 4/6 participants reported abstinent or low-risk drinking post-monitoring. Six weeks post quit-date, 2/6 participants were CO-bioverified abstinent from tobacco use, with 2/6 in dual remission. These results were maintained at 6-months. In cohort 2, 6/7 reported abstinent or low-risk drinking post-monitoring, 5 weeks post quit-date. At the post-monitoring visit, 5/7 were CO-bioverified abstinent from smoking, with 5/7 in dual remission. At 6-months, 3/7 reporting abstinent or low-risk drinking, 1/7 had bioverified abstinence from smoking, with 1/7 in dual remission. Observations suggest that it is possible to develop a concurrent mobile treatment for alcohol and tobacco use disorders.

eHealth Interventions to Treat Substance Use in Pregnancy: A Systematic Review and Meta-Analysis

Substance use during pregnancy is associated with adverse pregnancy and neonatal outcomes; eHealth interventions offer a potential accessible treatment option. The objective of this systematic review and meta-analysis was to evaluate the effectiveness of eHealth interventions for the treatment of substance use during pregnancy. A comprehensive search of PsycINFO, Medline, CINAHL, Cochrane and Embase databases was conducted from May 2020 to April 2021. The protocol for this study was registered with Prospero (CRD42020205186) through the University of York Centre for Reviews and Dissemination. Two independent reviewers completed screening, data extraction, and quality assessment. RCTs were included if they reported: (a) administration of an eHealth intervention for (b) substance use outcomes, among (c) pregnant individuals. Comprehensive Meta-Analysis Software (CMA) was used to calculate pooled effect sizes (Odds Ratio) to determine the effect of eHealth interventions on substance use outcomes. Six studies were identified with substance use outcomes that included: smoking (n = 3), alcohol (n = 2), and other (n = 1). eHealth interventions were delivered through the internet (n = 1), computer (n = 3), telephone (n = 1), and text (n = 1). Results suggested that eHealth interventions significantly reduced substance use in pregnant individuals compared to controls (OR = 1.33, 95% CI = 1.06 to 1.65, p = 0.013). eHealth interventions offer a promising and accessible treatment option to reduce substance use during pregnancy. This work was supported by the generous donors of the Alberta Children's Hospital Foundation, the Canadian Child Health Clinician Scientist Program (CCHCSP), the Canadian Institute of Health Research and the Fonds de Recherche du Québec-Santé.

Heavy episodic drinking and HIV disclosure by HIV treatment status among People with HIV in IeDEA Cameroon

BACKGROUND

Heavy alcohol use is common among people with HIV (PWH), leading to sub-optimal HIV care outcomes. Yet, heavy episodic drinking (HED) is not routinely addressed within most HIV clinics in sub-Saharan Africa. HIV disclosure may provide social support, potentially reducing HED to cope with HIV. We examined the prevalence of HED and HIV disclosure by antiretroviral treatment (ART) status among PWH receiving HIV care in Cameroon.

METHODS

We analyzed routine HIV clinical data augmented with systematic alcohol use data among adult PWH receiving HIV care in three regional hospitals from January 2016 to March 2020. Recent HED prevalence was examined across PWH by ART status: those not on ART, recent ART initiators (ART initiation ≤30 days prior), and ART users (ART initiation >30 days prior); and by gender. We used log-binomial regression to estimate prevalence differences (PD) between HIV disclosure and recent HED by ART status.

RESULTS

Among 12,517 PWH in care, 16.4% (95%CI: 15.7, 17.0) reported recent HED. HED was reported among 21.2% (95%CI: 16.0, 26.3) of those not on ART, 24.5% (95%CI: 23.1, 26.0) of recent ART initiators, and 12.9% (95%CI: 12.2, 13.6) of ART users. Regardless of ART status, men were more likely than women to report HED. Those who disclosed HIV status had a lower HED prevalence than those who had not disclosed (aPD: -0.07; 95%CI: -0.10, -0.05) and not modified by gender.

CONCLUSION

The prevalence of recent HED was high among PWH in care. HED prevalence was highest among men and recent ART initiators. Longitudinal analyses should explore how HIV disclosure may support PWH in reducing or abstaining from HED through social support. Systematic HED screening and referral to care should be included in routine HIV clinical care, particularly for men, to improve engagement in the HIV care continuum in Cameroon.

A pilot randomized trial of CBT4CBT for women in residential treatment for substance use disorders

INTRODUCTION

Despite the effectiveness of cognitive behavioral therapy (CBT) for treatment of substance use disorder, dissemination to clinical practice is limited due to a range of barriers (e.g., time, cost). Computer-based training for cognitive behavioral therapy (CBT4CBT) offers a feasible and cost-effective opportunity to improve the quality and reach of SUD treatment. Research to date has supported the effectiveness of CBT4CBT in outpatient settings; however, research has not yet tested it in residential treatment.

METHODS

The current study evaluated the feasibility of CBT4CBT as an adjunct to residential treatment in a sample of women with SUDs using a two-arm pilot RCT comparing women randomized to either standard residential treatment plus access to the CBT4CBT program (N = 34) or residential treatment alone (TAU; N = 29). Assessments occurred at baseline, discharge from residential care, and at 4- and 12-weeks post-discharge. The study compared the two groups over the 12-week follow-up period on relapse to any substance (Y/N), relapse to primary substance (Y/N), and days of use using chi-square for categorical and t-tests for continuous measures. The study team also performed a Kaplan-Meier analysis to compare the two groups on time to relapse.

RESULTS

Demographically, the sample was predominantly African American (79.4%), with a mean age of 41.2 years (SD = 12.1). Although the current study was not powered for statistical significance, findings were in the predicted direction, with women in the CBT4CBT group reporting lower likelihood of relapse, longer time to relapse, and fewer days of substance use in the follow-up period compared to women in TAU.

CONCLUSIONS

This study expands the current literature supporting the use of CBT4CBT in outpatient settings. While a fully powered trial should confirm our findings, the current study provides benchmark data on the use of CBT4CBT in residential treatment for women with SUDs.

Relapse prevention group therapy via video-conferencing for substance use disorder: protocol for a multicentre randomised controlled trial in Indonesia

BACKGROUND

Substance use disorder (SUD) is a leading contributor to the global burden of disease. In Indonesia, the availability of formal treatment for SUD falls short of the targeted coverage. A standardised therapeutic option for SUD with potential for widespread implementation is required, yet evidence-based data in the country are scarce. In this study, we developed a cognitive behavioural therapy (CBT)-based group telemedicine model and will investigate effectiveness and implementability in a multicentre randomised controlled trial.

METHODS

A total of 220 participants will be recruited from the social networks of eight sites in Indonesia: three hospitals, two primary healthcare centres and three rehabilitation centres. The intervention arm will participate in a relapse prevention programme called the Indonesia Drug Addiction Relapse Prevention Programme (Indo-DARPP), a newly developed 12-week module based on CBT and motivational interviewing constructed in the Indonesian context. The programme will be delivered by a healthcare provider and a peer counsellor in a group therapy setting via video-conferencing, as a supplement to participants' usual treatments. The control arm will continue treatment as usual. The primary outcome will be the percentage increase in days of abstinence from the primarily used substance in the past 28 days. Secondary outcomes will include addiction severity, quality of life, motivation to change, psychiatric symptoms, cognitive function, coping, and internalised stigma. Assessments will be performed at baseline (week 0), post-treatment (week 13), and 3 and 12 months post-treatment completion (weeks 24 and 60). Retention, participant satisfaction, and cost-effectiveness will be assessed as the implementation outcomes.

ETHICS AND DISSEMINATION

The study protocol was reviewed and approved by the Ethics Committees of Universitas Indonesia and Kyoto University. The results will be disseminated via academic journals and international conferences. Depending on trial outcomes, the treatment programme will be advocated for adoption as a formal healthcare-based approach for SUD.

TRIAL REGISTRATION NUMBER

UMIN000042186.

Acute impact of self-guided mental imagery on craving in cocaine use disorder: a mixed-methods analysis of a randomized controlled trial

Mental imagery manipulations are used to treat several psychological disorders, but their utility in treating cocaine use disorder (CUD) is unknown. Using prompted re-experiences and simulations with contrasting valence, we assessed the acute impact of a deliberate mental imagery task on cocaine craving.

DESIGN

A quantitative-qualitative 'mixed-methods' analysis of data collected for a randomized controlled trial that was stopped prematurely.

SETTING

UK National Health Service addictions treatment clinic and outpatient clinical research facility (laboratory).

PARTICIPANTS

Adults with CUD. The original target sample was 120. All participants enrolled at the point the original trial was stopped were included (38 enrolled, 31 completed study).

INTERVENTIONS

Personalized (3-minute) cue-exposure (handling cocaine paraphernalia and watching video of drug preparation), immediately followed by a single 5-minute, audio-recorded, self-guided and verbally described imagery task with random assignment to one of four conditions: two mental imagery memory re-experiences (positive image before initiation to cocaine use or a negative image of a 'worst time' adverse cocaine use episode) or two future simulations (positive theme of recovery from CUD or negative theme of worsened CUD).

MEASUREMENTS

Task transcripts were rated for imagery detail using five dimensions using a six-point scale of imagery detail (ID) (total score = 0-25) and thematically coded. The outcome measure was cocaine craving using the Craving Experiences Questionnaire-strengths version (CEQ-S11; score = 0-110) reported at baseline, arrival at the laboratory, and immediately after the cue-exposure and mental imagery tasks.

FINDINGS

A mixed-effects, longitudinal, restricted linear regression, with the past-positive imagery condition as referent, showed main effects of reduced craving after the imagery task (b = -29.2, 95% confidence interval (CI) = -45.3 to -13.1, P-value < 0.001) and increased craving for the future-negative task (b = 14.2, 95% CI = 0.1-28.4, P-value 0.049). There was a future-negative task by post-imagery craving interaction (b = 28.1, 95% CI = 0.1-56.1, P-value 0.049). A theory-driven, deductive/inductive qualitative analysis of the transcripts revealed six major themes: sensory characteristics, CUD vicious cycle, self-care, emotions and appraisals, social role and CUD recovery. Positively themed simulations included interpersonal connections and rewarding activity; negative images included personal adversity, with appraisals of self-criticism and hopelessness. Transcripts with more imagery detail were not associated with significantly greater reductions in craving in the positive or negative imagery task (r = -0.32, 95% CI = -0.69 to 0.13 and r = 0.06, 95% CI = -0.58 to 0.53, respectively).

CONCLUSION

In people with cocaine use disorder, after cue-exposure, a self-guided imagery task with positive themes reduced craving, whereas mental imagery simulating worsened cocaine use disorder did not appear to.

Causal inference under interference with prognostic scores for dynamic group therapy studies

Group therapy is a common treatment modality for behavioral health conditions. Patients often enter and exit groups on an ongoing basis, leading to dynamic therapy groups. Examining the effect of high versus low session attendance on patient outcomes is a research question of interest. However, there are several challenges to identifying causal effects in this setting, including the lack of randomization, interference among patients, and the interrelatedness of patient participation. Dynamic therapy groups motivate a unique causal inference scenario, as the treatment statuses are completely defined by the patient attendance record for the therapy session, which is also the structure inducing interference. We adopt the Rubin causal model framework to define the causal effect of high versus low session attendance of group therapy at both the individual patient and peer levels. We propose a strategy to identify individual, peer, and total effects of high attendance versus low attendance on patient outcomes by the prognostic score stratification. We examine performance of our approach via simulation and apply it to data from a group cognitive behavioral therapy trial for treating depression among patients in a substance use disorders treatment setting.

Alcohol interventions for LGBTQ+ adults: A systematic review

INTRODUCTION

Gender and sexual minority populations are more likely to drink excessively compared to heterosexual and cisgender people. Existing reviews of alcohol interventions focus on specific subgroups within the lesbian, gay, bisexual, trans*, queer, questioning or otherwise gender or sexuality diverse (LGBTQ+) population and neither identify their theoretical basis nor examine how interventions are tailored to meet the needs of specific subgroups.

METHODS

This systematic review includes published studies reporting the effectiveness of interventions to reduce alcohol use in LGBTQ+ people. The review followed PRISMA guidelines. Quality was assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool.

RESULTS

The review includes 25 studies, with the earliest published in 2005. The majority (n = 20) focused on men who have sex with men; only two included sexual minority women and three included trans* people. Most studies were conducted in the USA (n = 21) and used a randomised design (n = 15). Five studies were assessed to be of strong quality, seven moderate and 13 weak. Interventions were mainly delivered face-to-face (n = 21). The most common approaches used to inform interventions were Motivational Interviewing (n = 8) and Cognitive Behavioural Therapy (n = 8). Nineteen studies reported a significant reduction in alcohol consumption.

DISCUSSION AND CONCLUSIONS

This review suggests that for interventions to be effective in reducing alcohol consumption in LGBTQ+ people, they need to be informed by theory and adapted for the target population. Alcohol interventions that focus on sexual minority women, trans* people and people with other gender identities are needed. The findings have implications for professionals who need to identify when gender and/or sexuality are peripheral or central to alcohol use.

Approaching Alcohol Use Disorder After Liver Transplantation for Acute Alcoholic Hepatitis

Severe alcoholic hepatitis portends a high risk of mortality without liver transplantation. Transplant outcomes in patients with severe alcoholic hepatitis exhibit a strong inverse association with post-transplant alcohol relapse. The ingredients most central to ameliorating alcohol relapse risk may include destigmatized post-transplant alcohol monitoring, a nonpunitive clinician-patient partnership, and multimodal therapies to maintain abstinence and mitigate high-risk drinking. We here review the core principles of post-liver transplant management specific to alcohol use disorder.

Mind-body approaches targeting the psychological aspects of opioid use problems in patients with chronic pain: evidence and opportunities

Opioids are commonly prescribed for the management of patients with chronic noncancer pain. Despite the potential analgesic benefits of opioids, long-term opioid therapy (LTOT) may be accompanied by problems such as opioid misuse and opioid use disorder (OUD). In this review, we begin with a description of opioid misuse and OUD and the patient-specific factors associated with these problems among patients with chronic pain. We will focus primarily on highlighting the predominant role played by psychological factors in the occurrence of opioid misuse and OUD in these patients. Several psychological factors have been found to be associated with opioid use problems in patients with chronic pain, and evidence indicates that patients presenting with psychological disturbances are particularly at risk of transitioning to long-term opioid use, engaging in opioid misuse behaviors, and developing OUD. The biological factors that might underlie the association between psychological disturbances and opioid use problems in patients with chronic pain have yet to be fully elucidated, but a growing number of studies suggest that dysfunctions in reward, appetitive, autonomic, and neurocognitive systems might be involved. We end with an overview of specific types of psychological interventions that have been put forward to prevent or reduce the occurrence of opioid misuse and OUD in patients with chronic pain who are prescribed LTOT.

Workaholism Prevention in Occupational Medicine: A Systematic Review

INTRODUCTION

Given the extent of workaholism identified in the literature, it seems essential to consider effective preventive measures. The purpose of this article is to summarize literature data on possible collective and individual preventive measures against workaholism, especially in occupational medicine.

METHOD

We conducted a systematic literature review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

155 articles were retrieved in March 2019, but only 15 well-designed studies providing concrete measures to prevent workaholism were included. The various measures were classified using the traditional distinction between three levels of prevention. At the first level of prevention, workaholism can be avoided by implementing a protective organizational culture. The second level of prevention rather focuses on individual training and counselling to address the negative consequences of workaholism. Finally, the third level of prevention combines cognitive and behavioral interventions that enable professional and social reintegration of workaholics.

DISCUSSION

This literature review confirms the multifactorial origin of workaholism and the involvement of organizational factors, supporting the necessary contribution of companies in its prevention. This review also reinforces the growing perception of workaholism as a behavioral addiction. Occupational physicians play a key role in this preventive approach as they can influence both working conditions and individual care. The highlighted preventive measures seem to be not only favorable to workaholics, but also to companies.

CONCLUSION

This review provides field tools that can be used at the various levels of workaholism prevention. Nevertheless, intervention studies are required to confirm the effectiveness of the measures presented.

Characterizing the Variation of Alcohol Cessation Pharmacotherapy in Primary Care

BACKGROUND

Alcohol use disorder (AUD) imposes a high mortality and economic burden. Effective treatment is available, though underutilized.

OBJECTIVE

Describe trends in AUD pharmacotherapy, variation in prescribing, and associated patient factors.

DESIGN

Retrospective cohort using electronic health records from 2010 to 2019.

PARTICIPANTS

Primary care patients from 39 clinics in Ohio and Florida with diagnostic codes for alcohol dependence or abuse plus social history indicating alcohol use. PCPs in family or internal medicine with at least 20 AUD patients.

MAIN MEASURES

Pharmacotherapy for AUD (naltrexone, acamprosate, and disulfiram), abstinence from alcohol, patient demographics, and comorbidities. Generalized linear mixed models were used to identify patient factors associated with prescriptions and the association of pharmacotherapy with abstinence.

KEY RESULTS

We identified 13,250 patients; average age was 54 years, 66.9% were male, 75.0% were White, and median household income was $51,776 per year. Over 10 years, the prescription rate rose from 4.4 to 5.6%. Patients who were Black (aOR 0.74; 95% CI 0.58, 0.94) and insured by Medicare versus commercial insurance (aOR 0.61; 95% CI 0.48, 0.78) were less likely to be treated. Higher median household income ($10,000 increment, aOR 1.06; 95% CI 1.03, 1.10) and Medicaid versus commercial insurance (aOR 1.52; 95% CI 1.24, 1.87) were associated with treatment. Receiving pharmacotherapy was associated with subsequent documented abstinence from alcohol (aOR 1.60; 95% CI 1.33, 1.92). We identified 236 PCPs. The average prescription rate was 3.6% (range 0 to 24%). The top decile prescribed to 14.6% of their patients. The bottom 4 deciles had no prescriptions. Family physicians had higher rates of pharmacotherapy than internists (OR 1.50; 95% CI 1.21, 1.85).

CONCLUSIONS

Medications for AUD are infrequently prescribed, but there is considerable variation among PCPs. Increasing the use of pharmacotherapy by non-prescribers may increase abstinence from alcohol.

Precision Mental Health Care for Cannabis Use Disorder: Utility of a bioSocial Cognitive Theory to Inform Treatment

Globally, cannabis is the most frequently used controlled substance after alcohol and tobacco. Rates of cannabis use are steadily increasing in many countries and there is emerging evidence that there is likely to be greater risk due to increased concentrations of delta-9-tetrahydrocannabinol (THC). Cannabis use and Cannabis Use Disorder (CUD) has been linked to a wide range of adverse health outcomes. Several biological, psychological, and social risk factors are potential targets for effective evidence-based treatments for CUD. There are no effective medications for CUD and psychological interventions are the main form of treatment. Psychological treatments based on Social Cognitive Theory (SCT) emphasize the importance of targeting 2 keys psychological mechanisms: drug outcome expectancies and low drug refusal self-efficacy. This mini-review summarizes the evidence on the role of these mechanisms in the initiation, maintenance, and cessation of cannabis use. It also reviews recent evidence showing how these psychological mechanisms are affected by social and biologically-based risk factors. A new bioSocial Cognitive Theory (bSCT) is outlined that integrates these findings and implications for psychological cannabis interventions are discussed. Preliminary evidence supports the application of bSCT to improve intervention outcomes through better targeted treatment.

Long-term efficacy of contingency management treatment based on objective indicators of abstinence from illicit substance use up to 1 year following treatment: A meta-analysis

OBJECTIVE

Contingency management (CM) is often criticized for limited long-term impact. This meta-analysis focused on objective indices of drug use (i.e., urine toxicology) to examine the effects of CM on illicit substance use up to 1 year following treatment.

METHOD

Analyses included randomized trials (k = 23) of CM for stimulant, opioid, or polysubstance use disorders that reported outcomes up to 1 year after the incentive delivery had ended. Using random effects models, odds ratios (OR) were calculated for the likelihood of abstinence. Metaregressions and subgroup analyses explored how parameters of CM treatment, namely escalation, frequency, immediacy, and magnitude of reinforcers, moderated outcomes.

RESULTS

The overall likelihood of abstinence at the long-term follow-up among participants who received CM versus a comparison treatment (nearly half of which were community-based comprehensive therapies or protocol-based specific therapies) was OR = 1.22, 95% confidence interval [1.01, 1.44], with low to moderate heterogeneity (I² = 36.68). Among 18 moderators, longer length of active treatment was found to significantly improve long-term abstinence.

CONCLUSIONS

CM showed long-term benefit in reducing objective indices of drug use, above and beyond other active, evidence-based treatments (e.g., cognitive-behavioral therapy, 12-step facilitation) and community-based intensive outpatient treatment. These data suggest that policymakers and insurers should support and cover costs for CM, which is the focus of hundreds of studies demonstrating its short-term efficacy and, now, additional data supporting its long-term efficacy. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Is behavioral activation an effective and acceptable treatment for co-occurring depression and substance use disorders? A meta-analysis of randomized controlled trials

BACKGROUND

Depression often co-occurs with substance use problems and is associated with poor treatment outcomes. While the efficacy of behavioral activation (BA) has been tested in clinical trials with substance users, outcomes have not yet been quantitatively synthesized.

METHODS

The study team performed a random effects meta-analysis of the randomized clinical trial evidence base. We compared outcomes for individual or group BA against passive or active controls. We also compared attendance and dropout rates. The meta-analysis used a grading of recommendations assessment, development, and evaluation (GRADE) approach to assess the quality of each meta-analytic comparison.

RESULTS

We included five trials in the meta-analysis (N = 195). The analysis found no significant differences between BA and controls with regard to depression (Post-treatment: k = 5; N = 195; SMD: 0.19, CI -0.10 to 0.49; p = 0.20; GRADE = Low; Follow-up: k = 5; N = 195; SMD: -0.10, CI -0.51 to -0.30; p = 0.62; GRADE = Low) or substance use (post-treatment: k = 4; N = 151; SMD: 0.14, CI -0.33 to -0.6; p = 0.57, GRADE = Low; Follow-up: k = 4; N = 151; SMD: 0.17, CI -0.34 to 0.69; p = 0.51, GRADE = Low) and there was little evidence of publication bias. The average session attendance rate for BA was 72%. An average dropout rate of 35% was reported for both BA and comparator conditions.

CONCLUSION

BA does not emerge as a differentially efficacious treatment for comorbid depression and substance use disorders, although it does appear to be an acceptable treatment option. Our confidence in the results are limited by the number and quality of the original studies and the possibility of the effect of small study bias. We make suggestions for improving the methodological quality and direction of future BA trials.

Internet-based therapy versus face-to-face therapy for alcohol use disorder, a randomized controlled non-inferiority trial

BACKGROUND AND AIMS

Most people with alcohol use disorder (AUD) are never treated. Internet-based interventions are effective in reducing alcohol consumption and could help to overcome some of the barriers to people not seeking or receiving treatment. The aim of the current study was to compare internet-delivered and face-to-face treatment among adult users with AUD.

DESIGN

Randomized controlled non-inferiority trial with a parallel design, comparing internet-delivered cognitive-behavioural therapy (ICBT) (n = 150) with face-to-face CBT (n = 151), at 3- and 6-month follow-ups.

SETTING

A specialized clinic for people with AUD in Stockholm, Sweden. Participants were recruited between 8 December 2015 and 5 January 2018.

PARTICIPANTS

A total of 301 patients [mean age 50 years, standard deviation (SD) = 12.3] with AUD, of whom 115 (38%) were female and 186 (62%) were male.

INTERVENTION AND COMPARATOR

Participants were randomized in blocks of 20 at a ratio of 1 : 1 to five modules of therapist-guided ICBT or to five modules of face-to-face CBT, delivered over a 3-month period. The same treatment material and the same therapists were used in both groups.

MEASUREMENTS

The primary outcome was standard drinks of alcohol consumed during the previous week at 6-month follow-up, analysed according to intention-to-treat. The pre-specified non-inferiority limit was five standard drinks of alcohol and d = 0.32 for secondary outcomes.

RESULTS

The difference in alcohol consumption between the internet and the face-to-face group was non-inferior in the intention-to-treat analysis of data from the 6-month follow-up [internet = 12.33 and face-to-face = 11.43, difference = 0.89, 95% confidence interval (CI) = -1.10 to 2.88]. The secondary outcome, Alcohol Use Disorder Identification Test score, failed to show non-inferiority of internet compared with face-to-face in the intention-to-treat analysis at 6-month follow-up (internet = 12.26 and face-to-face = 11.57, d = 0.11, 95% CI = -0.11 to 0.34).

CONCLUSIONS

Internet-delivered treatment was non-inferior to face-to-face treatment in reducing alcohol consumption among help-seeking patients with alcohol use disorder but failed to show non-inferiority on some secondary outcomes.

The efficacy of Personalized Normative Feedback interventions across addictions: A systematic review and meta-analysis

Personalized Normative Feedback (PNF) may help address addictive disorders. PNF highlights discrepancies between perceived and actual peer norms, juxtaposed against self-reported behavior. PNF can be self-directed and cost-efficient. Our study estimates the efficacy of PNF alone, and in combination with other self-directed interventions, to address frequency and symptom severity of hazardous alcohol use, problem gambling, illicit drug and tobacco use. We searched electronic databases, grey literature, and reference lists of included articles, for randomized controlled trials published in English (January 2000-August 2019). We assessed study quality using the Cochrane Risk of Bias tool. Thirty-four studies met inclusion criteria (k = 28 alcohol, k = 3 gambling, k = 3 cannabis, k = 0 tobacco). Thirty studies provided suitable data for meta-analyses. PNF alone, and with additional interventions, reduced short-term alcohol frequency and symptom severity. PNF with additional interventions reduced short-term gambling symptom severity. Effect sizes were small. PNF did not alter illicit drug use. Findings highlight the efficacy of PNF to address alcohol frequency and symptom severity. The limited number of studies suggest further research is needed to ascertain the efficacy of PNF for gambling and illicit drug use. Cost-effectiveness analyses are required to determine the scale of PNF needed to justify its use in various settings.

Applying methods for personalized medicine to the treatment of alcohol use disorder

OBJECTIVE

Numerous behavioral treatments for alcohol use disorder (AUD) are effective, but there are substantial individual differences in treatment response. This study examines the potential use of new methods for personalized medicine to test for individual differences in the effects of cognitive behavioral therapy (CBT) versus motivational enhancement therapy (MET) and to provide predictions of which will work best for individuals with AUD. We highlight both the potential contribution and the limitations of these methods.

METHOD

We performed secondary analyses of abstinence among 1,144 participants with AUD participating in either outpatient or aftercare treatment who were randomized to receive either CBT or MET in Project MATCH. We first obtained predicted individual treatment effects (PITEs), as a function of 19 baseline client characteristics identified a priori by MATCH investigators. Then, we tested for the significance of individual differences and examined the predicted individual differences in abstinence 1 year following treatment. Predictive intervals were estimated for each individual to determine if they were 80% more likely to achieve abstinence in one treatment versus the other.

RESULTS

Results indicated that individual differences in the likelihood of abstinence at 1 year following treatment were significant for those in the outpatient sample, but not for those in the aftercare sample. Individual predictive intervals showed that 37% had a better chance of abstinence with CBT than MET, and 16% had a better chance of abstinence with MET. Obtaining predictions for a new individual is demonstrated.

CONCLUSIONS

Personalized medicine methods, and PITE in particular, have the potential to identify individuals most likely to benefit from one versus another intervention. New personalized medicine methods play an important role in putting together differential effects due to previously identified variables into one prediction designed to be useful to clinicians and clients choosing between treatment options. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The future of translational research on alcohol use disorder

In March 2019, a scientific meeting was held at the University of California, Los Angeles (UCLA) Luskin Center to discuss approaches to expedite the translation of neurobiological insights to advances in the treatment of alcohol use disorder (AUD). A guiding theme that emerged was that while translational research in AUD is clearly a challenge, it is also a field ripe with opportunities. Herein, we seek to summarize and disseminate the recommendations for the future of translational AUD research using four sections. First, we briefly review the current landscape of AUD treatment including the available evidence-based treatments and their uptake in clinical settings. Second, we discuss AUD treatment development efforts from a translational science viewpoint. We review current hurdles to treatment development as well as opportunities for mechanism-informed treatment. Third, we consider models of translational science and public health impact. Together, these critical insights serve as the bases for a series of recommendations and future directions. Towards the goal of improving clinical care and population health for AUD, scientists are tasked with bolstering the clinical applicability of their research findings so as to expedite the translation of knowledge into patient care.

Cannabis use and cannabis use disorder

Cannabis use disorder (CUD) is an underappreciated risk of using cannabis that affects ~10% of the 193 million cannabis users worldwide. The individual and public health burdens are less than those of other forms of drug use, but CUD accounts for a substantial proportion of persons seeking treatment for drug use disorders owing to the high global prevalence of cannabis use. Cognitive behavioural therapy, motivational enhancement therapy and contingency management can substantially reduce cannabis use and cannabis-related problems, but enduring abstinence is not a common outcome. No pharmacotherapies have been approved for cannabis use or CUD, although a number of drug classes (such as cannabinoid agonists) have shown promise and require more rigorous evaluation. Treatment of cannabis use and CUD is often complicated by comorbid mental health and other substance use disorders. The legalization of non-medical cannabis use in some high-income countries may increase the prevalence of CUD by making more potent cannabis products more readily available at a lower price. States that legalize medical and non-medical cannabis use should inform users about the risks of CUD and provide information on how to obtain assistance if they develop cannabis-related mental and/or physical health problems.

Mapping data-driven individualized neurobehavioral phenotypes in heavy alcohol drinkers

OBJECTIVE

Recent studies have examined the factor structure and associated correlates of three neurofunctional domains, executive function, incentive salience, and negative emotionality in the development and maintenance of alcohol use disorders in clinical samples. The current study sought to replicate and extend prior work by testing this 3-factor model, utilizing both exact and similar phenotypic measures, as well as novel measures, in a non-treatment-seeking sample.

METHODS

Self-report measures of alcohol addiction, impulsivity, behavior, and exposure to early-life stress were collected as part of baseline assessments for alcohol imaging and pharmacotherapy studies in 335 individuals. Confirmatory factor analysis (CFA) was used to examine model structure and fit. A multiple indicators, multiple causes (MIMIC) model identified predictors of latent factors identified by CFA.

RESULTS

Results supported an intercorrelated model with three factors: executive function, incentive salience, and emotionality. All factors were associated with current AUD, and incentive salience was uniquely associated with past 30-day drinking frequency. MIMIC results identified multiple significant predictors of these latent factors, including history of alcohol use disorder, positive family history of alcohol dependence, earlier age of first drink, and a history of childhood emotional abuse and physical neglect.

CONCLUSIONS

Our results support an intercorrelated 3-factor model of neurofunctional domains in alcohol use models, consistent with published findings. Because childhood physical neglect was a significant predictor of all latent factors, these results also highlight the significant negative impact of childhood neglect on later addiction development.

Comparison of physical effect between two training methods for individuals with substance use disorder

Background

HIIT has recently been widely used for health promotion in healthy people and patients with chronic diseases. Exercise can help SUD reduce drug cravings, enhance mental health and return to normal life. However, whether HIIT can bring better physical rehabilitation benefits to individuals with SUD than MICT is unclear. The study aimed to compare the effects of HIIT versus MICT on the physical fitness of individuals with SUD.

Methods

One hundred twenty individuals with amphetamine-type stimulant dependence voluntarily participated in this study. They were randomly assigned to the HIIT group and MICT group. Both groups received training three times a week. The intervention lasted from January 2019 to December 2019. Physical fitness was assessed at the baseline, 3 months, 6 months, 9 months and 12 months, including blood pressure (BP), vital capacity(VC), hand grip, push-up, sit-and-reach, one-leg standing with eyes closed and choice reaction time. The craving level was assessed using the Visual Analog Scale at baseline, 6 months and 12 months to see any change along with the improvement in physical fitness. Two-way repeated measures ANOVA was applied to analyse the differences in change by group (HIIT and MICT) and time (baseline, 3 months, 6 months, 9 months and 12 months).

Results

The within-group factor displayed significant changes in the HIIT and MICT groups in terms of systolic BP (F _(4,336) = 12.799, P < 0.001,η2 = 0.204), diastolic BP (F_(4,336) = 9.495, P < 0.001, η2 = 0.16), VC (F_(4,336) = 18.121, P < 0.001, η2 = 0.177), hand grip (F_(4,336) = 34.815, P < 0.001, η2 = 0.293), sit-and-reach (F_(4,336) = 13.871, P < 0.001, η2 = 0.142), push-up (F_(4,336) = 28.805, P < 0.001, η2 = 0.255), one-leg standing with eyes closed (F_(4,336) = 14.495, P < 0.001, η2 = 0.156) and choice reaction time (F_(4,336) = 20.603, P < 0.001, η2 = 0.197). The craving level decreased after 12 months of intervention in both groups (F_(2,168) = 11.25, P < 0.001, η2 = 0.118), but no significant differences in physical fitness and craving level were found in between groups and the interactions of group × time.

Conclusions

After 12 months of intervention, physical fitness improved while craving level decreased in the two groups. These findings suggest that both HIIT and MICT have positive effects on individuals with SUD in terms of physical fitness.

Trial registration

ChiCTR1900022158 Chinese Clinical Trial Registry: Registered 27th March, 2019.

Understanding eHealth Cognitive Behavioral Therapy Targeting Substance Use: Realist Review

BACKGROUND

There is a growing body of evidence regarding eHealth interventions that target substance use disorders. Development and funding decisions in this area have been challenging, due to a lack of understanding of what parts of an intervention work in which context.

OBJECTIVE

We conducted a realist review of the literature on electronic cognitive behavioral therapy (eCBT) programs for substance use with the goal of answering the following realist question: "How do different eCBT interventions for substance use interact with different contexts to produce certain outcomes?"

METHODS

A literature search of published and gray literature on eHealth programs targeting substance use was conducted. After data extraction, in order to conduct a feasible realist review in a timely manner, the scope had to be refined further and, ultimately, only included literature focusing on eCBT programs targeting substance use. We synthesized the available evidence from the literature into Context-Mechanism-Outcome configurations (CMOcs) in order to better understand when and how programs work.

RESULTS

A total of 54 papers reporting on 24 programs were reviewed. Our final results identified eight CMOcs from five unique programs that met criteria for relevance and rigor.

CONCLUSIONS

Five strategies that may be applied to future eCBT programs for substance use are discussed; these strategies may contribute to a better understanding of mechanisms and, ultimately, may help design more effective solutions in the future. Future research on eCBT programs should try to understand the mechanisms of program strategies and how they lead to outcomes in different contexts.

Cultural adaptations of cognitive behavioural therapy for Latin American patients: unexpected findings from a systematic review

The current literature extensively recommends making cultural adaptations to psychological therapies, in order to address the differences in values, beliefs and attitudes that patients from different ethnic groups might hold. Although this approach has shown positive outcomes in some settings, it is not well established yet whether such adaptations are needed for all therapies and in all cultures. Therefore, the main aim of this study was to systematically review the literature regarding culturally adapted and ‘conventional’ cognitive behavioural therapy (CBT) for Latin American patients, within Latin American and non-Latin American countries. Sixty empirical studies regarding the effectiveness of culturally adapted and conventional CBT were included in this review. The included studies were carried out in Latin American and non-Latin American countries. The information from all studies was synthesized and assessed, including intervention effect sizes, patient retention rates, methodological quality of the papers, and the type of cultural adaptation made to the therapy. There were no differences between the sets of studies in terms of effectiveness, retention rates, methodological quality, or proportion of statistically significant interventions. Most of the cultural adaptations were peripheral or unspecified. The evidence to date indicates that both conventional and culturally adapted CBT offer the same benefits for Latin American patients in terms of effectiveness and retention rates. Rather than focusing on cultural adaptations, clinicians are encouraged to improve the way they deliver CBT through training and supervision.

Key learning aims

(1)