Effectiveness of a Stand-alone Telephone-Delivered Intervention for Reducing Problem Alcohol Use: A Randomized Clinical Trial

Medical-surgical patients with untreated hazardous drinking: Randomized controlled trial of the DO-MoST intervention to improve health outcomes over 12-month follow-up

INTRODUCTION

High prevalence and harmful consequences of hazardous drinking among medical-surgical patients underscore the importance of intervening with drinking to improve patients' health. This study evaluated a novel intervention, "Drinking Options - Motivate, Shared Decisions, Telemonitor" (DO-MoST).

METHODS

In a randomized design, 155 medical-surgical patients with untreated hazardous drinking were assigned to enhanced usual care or DO-MoST, and followed 3, 6, and 12 months later. We conducted intent-to-treat and per-protocol analyses.

RESULTS

For the primary outcome, percent days of alcohol abstinence in the past 30 days, intent-to-treat analyses did not find superior effectiveness of DO-MoST. However, per-protocol analyses found abstinence increased between 3 and 12 months among participants assigned to DO-MoST who engaged with the intervention (n=46). Among DO-MoST-assigned participants who did not engage (n=27), abstinence stayed stable during follow-up. Group comparisons showed an advantage on abstinence for Engaged compared to Non-Engaged participants on change over time. Intent-to-treat analyses found that DO-MoST was superior to usual care on the secondary outcome of physical health at 12 months; per-protocol analyses found that Engaged DO-MoST-assignees had better physical health at 12 months than Non-Engaged DO-MoST-assignees. DO-MoST-assignees had lower odds of receiving substance use care during follow-up than usual care-assignees.

DISCUSSION

Patients engaged in DO-MoST showed a greater degree of abstinence and better physical health relative to the non-engaged or usual care group. DO-MoST may be a source of alcohol help in itself rather than only a linkage intervention. Work is needed to increase DO-MoST engagement among medical-surgical patients with untreated hazardous drinking.

Pathways to the persistence of drug use despite its adverse consequences

The persistence of drug taking despite its adverse consequences plays a central role in the presentation, diagnosis, and impacts of addiction. Eventual recognition and appraisal of these adverse consequences is central to decisions to reduce or cease use. However, the most appropriate ways of conceptualizing persistence in the face of adverse consequences remain unclear. Here we review evidence that there are at least three pathways to persistent use despite the negative consequences of that use. A cognitive pathway for recognition of adverse consequences, a motivational pathway for valuation of these consequences, and a behavioral pathway for responding to these adverse consequences. These pathways are dynamic, not linear, with multiple possible trajectories between them, and each is sufficient to produce persistence. We describe these pathways, their characteristics, brain cellular and circuit substrates, and we highlight their relevance to different pathways to self- and treatment-guided behavior change.

A structured, telephone-delivered intervention to reduce methamphetamine use: study protocol for a parallel-group randomised controlled trial

BACKGROUND

Australia has one of the highest rates of methamphetamine (MA) use in the world; however, uptake of in-person psychological treatment remains extremely low due to numerous individual (e.g. stigma, shame) and structural (e.g. service accessibility, geographical location) barriers to accessing care. Telephone-delivered interventions are ideally placed to overcome many of the known barriers to treatment access and delivery. This randomised controlled trial (RCT) will examine the efficacy of a standalone, structured telephone-delivered intervention to reduce MA problem severity and related harms.

METHODS

This study is a double-blind, parallel-group RCT. We will recruit 196 ± 8 individuals with mild to moderate MA use disorder from across Australia. After eligibility and baseline assessments, participants will be randomly allocated to receive either the Ready2Change-Methamphetamine (R2C-M) intervention (n = 98 ± 4; four to six telephone-delivered intervention sessions, R2C-M workbooks and MA information booklet) or control (n = 98 ± 4; four to six ≤5-min telephone check-ins and MA information booklet including information on accessing further support). Telephone follow-up assessments will occur at 6 weeks and 3, 6 and 12 months post-randomisation. The primary outcome is change in MA problem severity (Drug Use Disorders Identification Test, DUDIT) at 3 months post-randomisation. Secondary outcomes are as follows: MA problem severity (DUDIT) at 6 and 12 months post-randomisation, amount of methamphetamine used, methamphetamine use days, methamphetamine use disorder criteria met, cravings, psychological functioning, psychotic-like experiences, quality of life and other drug use days (at some or all timepoints of 6 weeks and 3, 6 and 12 months post-randomisation). Mixed-methods program evaluation will be performed and cost-effectiveness will be examined.

DISCUSSION

This study will be the first RCT internationally to assess the efficacy of a telephone-delivered intervention for MA use disorder and related harms. The proposed intervention is expected to provide an effective, low-cost, scalable treatment for individuals otherwise unlikely to seek care, preventing future harms and reducing health service and community costs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04713124 . Pre-registered on 19 January 2021.

Integrated care – panacea or white elephant? A review of integrated care approaches in Australia over the past two decades

Purpose

Integrated care is widely supported as a means of improving treatment outcomes for people with co-occurring mental health and substance use disorders. Over the past two decades, Australian state and federal governments have identified integrated care as a policy priority and invested in a number of research and capacity building initiatives. This study aims to examine Australian research evaluating the effectiveness of integrated treatment approaches to provide insight into implications for future research and practice in integrated treatment.

Design/methodology/approach

This narrative review examines Australian research evaluating empirical evidence of the effectiveness of integrated treatment approaches within specific populations and evidence from initiatives aimed at integrating care at the service or system level.

Findings

Research conducted within the Australian context provides considerable evidence to support the effectiveness of integrated approaches to treatment, particularly for people with high prevalence co-occurring disorders or symptoms of these (i.e. anxiety and depression). These have been delivered through various modalities (including online and telephone-based services) to improve health outcomes in a range of populations. However, there is less evidence regarding the effectiveness of specific models or systems of integrated care, including for more severe mental disorders. Despite ongoing efforts on behalf of the Australian government, attempts to sustain system-level initiatives have remained hampered by structural barriers.

Originality/value

Effective integrated interventions can be delivered by trained clinicians without requiring integration at an organisational or structural level. While there is still considerable work to be done in terms of building sustainable models at a system level, this evidence provides a potential foundation for the development of integrated care models that can be delivered as part of routine practice.