Cochrane systematic reviews in the field of addiction: what's there and what should be

Research as due diligence: What can supply-side interventions accomplish and at what cost?

Supply-side interventions, which we define as laws, regulations, enforcement activities, and other measures that extend from drug production to dealing, feature prominently in drug policy and related expenditures internationally, but have undergone relatively little rigorous, empirical evaluation. We argue for filling the knowledge gap and highlight three areas of particular concern: first, the policy community knows less than it should about the efficacy of supply-side interventions; second, it lacks sufficient understanding of the scope, magnitude, and practical implications of adverse consequences that accompany such interventions; third, it lacks tools to gauge the balance of benefits and costs, both monetary and non-monetary. Our interest has been in developing a harm-based approach to address these concerns and we put forward a "harm assessment framework" for that purpose.

Parent participation in alcohol prevention: Evaluation of an alcohol prevention programme

Aim:

The main purpose of this study was to evaluate the effectiveness of the parental part of the Norwegian Unge & Rus (Youth and Alcohol) programme. The intervention was aimed at changing parents’ rules and attitudes towards adolescent alcohol use, and their ability to talk with their adolescents about alcohol, as well as improving parents’ relationships with and knowledge about their adolescents. These topics were addressed during parent meetings at school.

Method:

The effectiveness of the parent programme was tested using a longitudinal quasi-experimental control group design. Parents completed four online questionnaires N = 1166 at T1 in 2011 and N = 591 at T4 in 2013. Mixed models with observations nested in individuals were used to test the difference in rates of change between the groups.

Results:

Parents in both groups reported strict rules and attitudes towards alcohol use. There were no significant differences in the changes between the two parent groups in terms of rules and attitudes at the three follow-up time points. The parents in the intervention did not change significantly compared to the parents in the comparison group on other alcohol-related questions.

Conclusions:

Parents are important facilitators for the transmission of alcohol-related attitudes and rules. However, our study did not show significant differences between changes experienced by the intervention group and those of the comparison group for the main outcome variables, such as rules, attitudes and talking about alcohol with their adolescents.

Large variation in measures used to assess outcomes of opioid dependence treatment: A systematic review of longitudinal observational studies

ISSUES

Treatment outcomes for drug users are critical for informing policy and therapeutic practice. The coherence of outcomes, changes and drug use measures from observational studies on opioid use treatment were reviewed.

APPROACH

Systematic review of the literature for longitudinal observational studies, from 1980 through November 2015, in all languages, with data on treated opioid users, using Pubmed, the Cochrane Library and additional strategies (e.g. Pubmed function 'related citations' and checking reference lists of eligible studies).

KEY FINDINGS

Twenty-seven studies were included (11 countries, 85 publications, recruitment 1962-2009). Baseline n was >65 686 and median follow-up 34.5 months (21 studies) or 51.4 person-months (10 studies). Eight outcome domains were identified: 'drug use' (21/27 studies), 'crime' (13), 'health' (13), 'treatment-related' outcomes (16), 'social functioning' (13), 'harms' (8), 'mortality' (13) and 'economic estimates' (2 studies). All studies using drug use outcomes included a binary (abstinence) category in at least one measure. Studies typically reported outcomes on less than half (on average 3.7 or 46%) of the eight outcome domains, while the average was 5.1 (64%) in seven studies initiated since 2000.

IMPLICATIONS AND CONCLUSION

Wide variation exists in outcome measures found in longitudinal observational studies of treatment of opioid users. This reduces replicability of studies and suggests a lack of common expectations on treatment success. Future studies should consider using all or most of eight outcome domains identified (excluding economic analyses if unfeasible), non-binary measures and amount/value of drugs used and consensus meetings with joint ownership of scientific, treatment and patient communities.

Prevention of alcohol and drug misuse in adolescents: An overview of systematic reviews

Background

– Systematic reviews have evaluated a wide variety of programmes aiming to prevent, reduce or delay substance use in adolescents. This paper presents an overview of recent systematic reviews, summarising the evidence on the effectiveness of prevention strategies which target adolescents misusing alcohol and/or drugs.

Methods

– We performed a comprehensive search in major electronic databases, consulted websites and checked reference lists of relevant articles. Studies that met our inclusion criteria were critically appraised using the AMSTAR instrument. The findings from the included systematic reviews were synthesised using a vote counting procedure.

Results

– Twenty-one systematic reviews were identified. Ten of these were rated as of high quality. There was little overlap between reviews in terms of the target group, intervention, setting and outcome measures. The components or mechanisms of the prevention programmes were poorly described. Ten reviews evaluated school-based prevention. The effects of these prevention programmes are promising, while effects of community-based, family-based and multi-faceted programmes were less convincing.

Conclusion

– Based on the current evidence, there is a small but consistent positive effect of school-based prevention programmes, but it is less clear what the “active ingredient” is. For example, which group should one target, in which setting and in which circumstances? A set of standardised process and outcome measures would allow us to better compare and statistically pool the results of original studies and reviews. This overview of reviews, like similar other overviews, should encourage researchers to increase uniformity and consistency between studies. This would improve the comparability of evidence, which is needed to formulate valid recommendations for practice.

Substance use among persons with homeless experience in primary care

BACKGROUND

Community survey data suggest high prevalence of substance use disorders among currently homeless individuals. There are less data regarding illicit drug and alcohol use problems of homeless-experienced persons engaged in primary care. They may have less severe use and require different care responses from primary care teams.

METHODS

The authors surveyed currently and formerly homeless, i.e., homeless-experienced, persons engaged in primary care at five federally funded programs in the United States, administering the World Health Organization (WHO) Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). The ASSIST definitions of lower, moderate, and high risk were used to assess a spectrum of lifetime and recent substance use, from any use to likely dependence, and to identify sociodemographic and health status characteristics associated with severity of use.

RESULTS

Almost one half of the sample (N = 601) had recently (within the past three months) used alcohol, and one third had recently used an illicit drug. The most commonly used illicit drugs in the past three months were cannabis (19%), cocaine (16%), and opioids (7.5%). Over one half (59%) of respondents had ASSIST-defined moderate- or high-risk substance use. A significant proportion (31%) of those identified as at moderate risk had no recent substance use, but did report past problematic use. Ten percent of the lower-risk group had past problematic use of alcohol. Severity of use was associated with worse health status, but not with housing status or type of homelessness experienced.

CONCLUSIONS

Less severe (moderate-risk) use and past problematic use, potentially indicative of remitted substance use disorders, were more common than high-risk use in this primary care, homeless-experienced sample. These findings highlight the urgency of identifying effective ways to reduce risky substance use and prevent relapse in homeless-experienced persons.

Reviewing and interpreting the effects of brief alcohol interventions: comment on a Cochrane review about motivational interviewing for young adults

BACKGROUND

Cochrane recently published a systematic review on motivational interviewing (MI) for alcohol misuse in young adults. The review authors concluded that 'there are no substantive, meaningful benefits of MI interventions for the prevention of alcohol misuse' (p. 2), as effect sizes were 'small and unlikely to be of any meaningful benefit in practice' (p. 27). As most of these interventions were quite brief, we wish to open a dialogue about interpreting effect sizes in this review and of (brief) alcohol interventions more generally.

ANALYSIS

We analyze four methodological aspects of the review that likely influenced the author's conclusions about intervention effects: (1) risk of bias assessments, (2) search strategies, (3) assessing the quality of the body of evidence and (4) definitions of sustainability and clinical significance.

CONCLUSIONS

We interpret the effect sizes found in this review to indicate modest yet beneficial and potentially meaningful effects of these interventions, given their brevity and low cost. This interpretation is consistent with other reviews on brief, MI-based interventions and brief interventions more generally. We therefore encourage the field to re-open dialogue about the clinical importance of the effects of MI on alcohol misuse by young adults. Rather than dismissing interventions with small effects, we believe a more fruitful way forward for the field would be to catalogue effect sizes for various alcohol interventions. Such a catalogue would help stakeholders themselves to choose which interventions meet their minimum desired impact, and thus may be suitable given their targeted populations, setting and resources.

Remembering the forgotten non-communicable diseases

The forthcoming post-Millennium Development Goals era will bring about new challenges in global health. Low- and middle-income countries will have to contend with a dual burden of infectious and non-communicable diseases (NCDs). Some of these NCDs, such as neoplasms, COPD, cardiovascular diseases and diabetes, cause much health loss worldwide and are already widely recognised as doing so. However, 55% of the global NCD burden arises from other NCDs, which tend to be ignored in terms of premature mortality and quality of life reduction. Here, experts in some of these 'forgotten NCDs' review the clinical impact of these diseases along with the consequences of their ignoring their medical importance, and discuss ways in which they can be given higher global health priority in order to decrease the growing burden of disease and disability.

Development of a self-report format of ASSIST with university students

The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) is a reliable and valid tool to early detection in the harmful and hazardous drug use in primary care settings when administered by interview in the general population. As the risk of substance related problems in university students is high, it is necessary to have screening instruments that can be used beyond the health care settings. Thus, we compared a self-report adaptation of ASSIST with the validated interview format in a convenience sample of university students. A counter-balance design was chosen with students alternating between the interview and the self-report formats. Both formats were completed by all students (n=170) over 30 days. The scores for total involvement, tobacco, alcohol, cannabis and cocaine obtained from the two formats demonstrated good intra-class correlation coefficient (ICC >0.60). The agreement assessed by kappa between questions of the two formats was considered moderate for tobacco (0.76) and cannabis (0.69) and discrete for alcohol (0.47). The consistency of the self-report questionnaire was also good to moderate (Cronbach's alpha of 0.90 for tobacco, 0.71 for alcohol, 0.86 for cannabis and 0.89 for cocaine) and showed acceptable sensitivity (66.7-100%) and specificity (83.5-97.1%) for tobacco, alcohol, cannabis and cocaine when compared to the ASSIST interview format (gold standard). The findings suggest that self-report version is as acceptable as the interview and that the scores on the two formats are comparable. However, the participants reported more motivation for change behavior and more concern about substance use when they were interviewed.

An efficient early phase 2 procedure to screen medications for efficacy in smoking cessation

RATIONALE

Initial screening of new medications for potential efficacy (i.e., Food and Drug Administration (FDA) early phase 2), such as in aiding smoking cessation, should be efficient in identifying which drugs do, or do not, warrant more extensive (and expensive) clinical testing.

OBJECTIVES

This focused review outlines our research on development, evaluation, and validation of an efficient crossover procedure for sensitivity in detecting medication efficacy for smoking cessation. First-line FDA-approved medications of nicotine patch, varenicline, and bupropion were tested as model drugs, in three separate placebo-controlled studies. We also tested specificity of our procedure in identifying a drug that lacks efficacy, using modafinil.

RESULTS

This crossover procedure showed sensitivity (increased days of abstinence) during week-long "practice" quit attempts with each of the active cessation medications (positive controls) versus placebo, but not with modafinil (negative control) versus placebo, as hypothesized. Sensitivity to medication efficacy signal was observed only in smokers high in intrinsic quit motivation (i.e., already preparing to quit soon) and not smokers low in intrinsic quit motivation, even if monetarily reinforced for abstinence (i.e., given extrinsic motivation).

CONCLUSIONS

A crossover procedure requiring less time and fewer subjects than formal trials may provide an efficient strategy for a go/no-go decision whether to advance to subsequent phase 2 randomized clinical trials with a novel drug. Future research is needed to replicate our results and evaluate this procedure with novel compounds, identify factors that may limit its utility, and evaluate its applicability to testing efficacy of compounds for treating other forms of addiction.

Cochrane systematic reviews in the field of addiction: past and future

BACKGROUND AND OBJECTIVE

The Cochrane Drugs and Alcohol Group aims to produce, update, and disseminate systematic reviews on the prevention, treatment, and rehabilitation of problematic drug and alcohol use. This paper describes what the Group has done since the 1990s to produce evidence to guide policy, practice, and research.

METHOD

We analyze the coverage of topics by our reviews, the body of studies they have included, and the evidence produced.

RESULTS

By July 2013, the Group had published 67 reviews, with 376 authors from 25 different countries. These reviews included 906 studies, of 3061 studies considered for inclusion. Most (90%) included studies were randomized trials. Considering the 'Implications for practice' section of each review, 41% interventions were classified as 'do it', 15% as 'do not do', and 44% as 'do only in research'. These proportions varied according to the type of substance of abuse studied. The proportion of 'do it' interventions were 46% for alcohol, 40% for opioids, 20% for psychostimulants, 40% for polydrugs, and 62% for prevention.

CONCLUSION

Cochrane Reviews produced by the Drugs and Alcohol Group provide evidence on the effectiveness of several interventions, and identify areas of uncertainty where new research is needed.

Is there addiction to loud music? Findings in a group of non-professional pop/rock musicians

Listening to loud music may be connected to addictive behavior possibly leading to damaging effects on the cochlea. We hypothesized that members of non-professional pop/rock bands with regular exposure to loud music are more likely to show an addictive-like behavior for loud music than matched control subjects. Fifty non-professional musicians and 50 matched control subjects were asked to complete the Northeastern Music Listening Survey (NEMLS) with two basic components. The first comprises an adaptation of the validated Michigan Alcohol Screening Test (MAST) to study the addictive-like behavior towards loud music. The second comprises the criteria outlined by the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) of the American Psychiatric Society for the diagnosis of substance dependence. The NEMLS was scored using the same point system as used in the MAST.

The DSM-IV criteria for substance dependence were met by nine of the musician group and by one control subject. Seven of these nine musicians also had a positive NEMLS score. Traits of addictive-like behavior to loud music were detected more often in members of nonprofessional pop/rock bands than in control subjects.

Potential role of safer injection facilities in reducing HIV and hepatitis C infections and overdose mortality in the United States

BACKGROUND

Safer injection facilities (SIFs) reduce risks associated with injecting drugs, particularly public injection and overdose mortality. They exist in many countries, but do not exist in the United States. We assessed several ethical, operational, and public health considerations for establishing SIFs in the United States.

METHOD

We used the six-factor Kass framework (goals, effectiveness, concerns, minimization of concerns, fair implementation, and balancing of benefits and concerns), summarized needs of persons who inject drugs in the United States, and reviewed global evidence for SIFs.

RESULTS

SIFs offer a hygienic environment to inject drugs, provide sterile injection equipment at time of injection, and allow for safe disposal of used equipment. Injection of pre-obtained drugs, purchased by persons who inject drugs, happens in a facility where trained personnel provide on-site counseling and referral to addiction treatment and health care and intervene in overdose emergency situations. SIFs provide positive health benefits (reducing transmission of HIV and viral hepatitis, bacterial infections, and overdose mortality) without evidence for negative health or social consequences. SIFs serve most-at-risk persons, including those who inject in public or inject frequently, and those who do not use other public health programs. It is critical to address legal, ethical, and local concerns, develop and implement relevant policies and procedures, and assess individual- and community-level needs and benefits of SIFs given local epidemiologic data.

CONCLUSIONS

SIFs have the potential to reduce viral and bacterial infections and overdose mortality among those who engage in high-risk injection behaviors by offering unique public health services that are complementary to other interventions.

Do Cochrane reviews provide useful information to guide policy and practice? The experience of the Cochrane drugs and alcohol group

This contribution reviewed the experience of the Cochrane Drugs and Alcohol Group (CDAG) in terms of production of evidence to guide policy and practice. By December 2010, the group had published 55 reviews, with 299 authors involved and 744 primary studies included out of 2114 studies considered for inclusion. 90% of the studies included were randomized controlled trials (RCTs). Considering the 'Implication for practice' section of each review, 31% interventions were classified as to do, 11% as do not do it, 52% to do only in research and for 6% a final judgment was impossible because the reviews included no studies or only one study. These proportions varied according to the type of substance of abuse studied; interventions judged as to do were 42% for alcohol, 32% for opioids, 12% for psychostimulants, 33% for poly drugs, and for prevention. The reviews produced by the CDAG provide evidence on effectiveness of several interventions, and identify areas of uncertainty, where more primary research is needed.