Acceptability of nonabstinent treatment outcome goals among addiction treatment providers in Ukraine

Facilitators of and obstacles to practitioners' adoption of harm reduction in cannabis use: a scoping review

BACKGROUND

Cannabis use can generate potential avoidable harms, hence the need for effective preventive measures and treatment. Studies show the efficacy of harm reduction (HR) in minimizing undesirable consequences associated with this use. Despite its proven efficacy, HR in cannabis use remains poorly applied by many health and social services (HSS) practitioners, especially with young people. However, knowledge regarding the underlying reasons for this is limited. To fill this gap, we aimed to identify facilitators of and obstacles to HSS practitioners' adoption of HR in cannabis use across OECD countries.

METHODS

We conducted a scoping review, guided by Arksey and O'Malley's model. The search strategy, executed on health databases and in the grey literature, captured 1804 studies, of which 35 were retained. Data from these studies were extracted in summary sheets for qualitative and numerical analysis.

RESULTS

Facilitators and obstacles were grouped into four themes: stakeholders' characteristics (e.g., education, practice experience); clients' characteristics (e.g., personal, medical); factors related to HR (e.g., perceived efficacy, misconceptions); factors related to the workplace (e.g., type of workplace). Data were also extracted to describe the populations recruited in the selected studies: type of population, clientele, workplace.

CONCLUSION

Several factors might facilitate or hinder HSS practitioners' adoption of HR in cannabis use. Taking these into consideration when translating knowledge about HR can improve its acceptability and applicability. Future research and action should focus on this when addressing practitioners' adoption of HR.

Re-examining provider perceptions of best pre-war practices: what elements can help opiate agonist therapy programs in Ukraine successfully survive the crisis?

Purpose

This paper seeks to explore and understand what constitutes successful opioid agonist therapy (OAT) programs from the views of Ukrainian OAT providers in their context-specific accounts. Prior to the ongoing war the Ukrainian addiction treatment system made great strides to expand its OAT program and increase the number of patients. Since the beginning of the war there has been much alarm that those hard-earned successes will be destroyed. However, emerging evidence suggests that the Ukrainian OAT programs have shown signs of resilience in the face of adversity albeit at great cost. What aspects of the OAT programs developed prior to the crisis have been helpful to allow them to weather the storm? Using the data from 24 addiction treatment providers, this paper describes the essential elements of the OAT programs that preceded the current crisis which made them robust over time. By examining the narratives of the participants interviewed pre-war and pre-COVID-19 the paper reveals structural and cultural elements of the OAT programs before the perfect storm that are likely to endure. To the best of our knowledge, no one else has investigated OAT providers perspectives in Ukraine prior to the crisis which makes this paper extremely salient to understand both the robustness and the vulnerability of MAT programs in Ukraine during the war and going forward.

Methodology

The data come from qualitative semi-structured interviews with 24 OAT providers throughout 5 regions of Ukraine. Participants included front-line clinicians, head narcologists, and chief doctors from TB clinics, district hospitals and drug addiction centers. Using a coding scheme of 103 inductively developed categories we explored participants' perceptions of their OAT program.

Findings

In the stories shared by clinicians pre crisis, three major interconnected themes focused on economic uncertainty at the institutional level (leading to under-staffing), structural capacity of the program, and clinicians' professional identity, shaping differing views on application of rules for administrative discharge, take-home dosing, and the potential for scale-up. Knowing the data collection was completely unbiased to the current crisis, interpreting the findings helps us understand that OAT clinicians have had "years" of training under conditions of duress in Ukraine to overcome barriers, find creative solutions and form a support network that became indispensable in surviving the current humanitarian catastrophe.

Conclusion

In the discussion we point out that the current crisis magnified the pre-existing challenges as the providers approach toward overcoming them was already largely present before the crisis (just on a different scale). The underlying fragility of resources was a constant since OAT inception in Ukraine. Historically, providers in Ukraine operated in a system that was under-funded in the absence of solid governmental funding for OAT programs, yet they came up with solutions which required ingenuity that they took pride in. This gives hope that addiction treatment in Ukraine and OAT programs will not be casualties of this humanitarian crisis and providers and their patients will persevere.

Behavioural self-control training versus motivational enhancement therapy for individuals with alcohol use disorder with a goal of controlled drinking: A randomized controlled trial

BACKGROUND AND AIMS

Controlled drinking (CD) is an attractive treatment goal for a large proportion of individuals with alcohol use disorder (AUD), but the availability of treatment methods supporting a goal of CD is scarce. We tested if behavioural self-control training (BSCT) was superior to motivational enhancement therapy (MET) for individuals with AUD with a treatment goal of CD.

DESIGN

Randomized controlled two-group trial. Follow-ups were conducted at 12 and 26 weeks (primary end-point) after inclusion.

SETTING

Three specialized dependency care clinics in Stockholm, Sweden.

PARTICIPANTS

Two hundred and fifty self-referred adults (52% men) fulfilling criteria of AUD (DSM-5) and a stated treatment goal of CD.

INTERVENTION AND COMPARATOR

BSCT (n = 125), a five-session treatment based on cognitive behavioural therapy versus the active comparator, MET (n = 125), containing four sessions based on Motivational Interviewing.

MEASUREMENTS

Primary outcome measure was mean weekly alcohol consumption at the 26-week follow-up, adjusted for baseline consumption.

CONCLUSIONS

A randomized controlled trial found no evidence of a difference between behavioural self-control training and motivational enhancement therapy in reducing weekly alcohol consumption. Both groups substantially reduced consumption and behavioural self-control training was superior in reducing hazardous drinking.

The impact of integrated care in community-based substance use treatment in Brazil: A longitudinal study

Integrated care (outpatient-inpatient) plays a vital function in community care for people with drug use problems. Its recent and innovative treatment model is representing a challenge for the deinstitutionalisation process. The purpose of this study was to assess the impact of integrated care using biopsychosocial indicators. We conducted a prospective longitudinal study with 122 clients from the baseline undergoing integrated care of two Psychosocial Care Centers for Alcohol and Other Drugs in São Paulo, Brazil, with three months follow-up (February 2019-January 2020). To assess the biopsychosocial indicators of the impact, we used the Substance Addiction Consequences (SAC), WHOQOL-BREF quality of life scales and the psychosocial rehabilitation axes (housing, work/income, and support network). We conducted a longitudinal analysis with linear mixed-effects models. The integrated care impacted the reduction in the days of substance use and increase of abstinence with a significant difference for cannabis (p < 0.001) and crack (p = 0.021). It reduced the substance use harms in all SAC scale dimensions (p < 0.001). Quality of life increased and remained mainly associated with the psychological size (p < 0.001). All psychosocial rehabilitation axes improved with a difference for income (p = 0.025). The increase in people's participation in treatment was relevant. The integrated care of Brazilian services has a positive impact on reducing substance use days and harms associated, improves the quality of life and contributes to the psychosocial rehabilitation of clients. Should be taken efforts to maintain long-term results.

Controlled drinking-non-abstinent versus abstinent treatment goals in alcohol use disorder: a systematic review, meta-analysis and meta-regression

BACKGROUND AND AIMS

The proportion of untreated patients with alcohol use disorder (AUD) exceeds that of any other mental health disorder, and treatment alternatives are needed. A widely discussed strategy is to depart from the abstinence paradigm as part of controlled drinking approaches. This first systematic review with meta-analysis aims to assess the efficacy of non-abstinent treatment strategies compared with abstinence-based strategies.

METHODS

CENTRAL, PubMed, PsycINFO and Embase databases were searched until February 2019 for controlled (randomized and non-randomized) clinical trials (RCTs and non-RCTs) among adult AUD populations, including an intervention group aiming at controlled drinking and a control group aiming for abstinence. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Cochrane Collaboration guidelines, literature search, data collection and risk of bias assessment were carried out independently by two reviewers [International Prospective Register of Systematic Reviews (PROSPERO), registration no. CRD42019128716]. The primary outcome was the proportion of participants consuming alcohol at or below the recommended threshold. Secondary outcomes were social functioning, drinking reductions, abstinence rates and dropouts. Using random-effects models, RCTs and non-RCTs were analyzed separately. Sensitivity and subgroup analyses accounted for methodological rigor, inclusion of goal-specific treatment, length of follow-up and AUD severity.

RESULTS

Twenty-two studies (including five RCTs) with 4204 patients were selected. There was no statistically significant difference between both treatment paradigms in RCTs [odds ratio (OR) = 1.32, 95% confidence interval (CI) = 0.51-3.39]. Non-randomized studies of free goal choice favored abstinence-orientation (OR = 0.60, 95% CI = 0.40-0.90), unless goal-specific treatment was provided (OR = 0.79, 95% CI = 0.40-1.56), or in studies of low risk of bias (OR = 0.73, 95% CI = 0.49-1.09) or with long follow-up (OR = 1.49, 95% CI = 0.78-2.85). Effect sizes were not clearly dependent upon AUD severity. Abstinence- and controlled drinking interventions did not clearly differ in their effect on social functioning and drinking reductions.

CONCLUSIONS

Available evidence does not support abstinence as the only approach in the treatment of alcohol use disorder. Controlled drinking, particularly if supported by specific psychotherapy, appears to be a viable option where an abstinence-oriented approach is not applicable.