A nine session manual of motivational enhancement therapy for methamphetamine dependence: adherence and efficacy

An adaptive design to screen, treat, and retain people with opioid use disorders who use methamphetamine in methadone clinics (STAR-OM): study protocol of a clinical trial

BACKGROUND

Methamphetamine use could jeopardize the current efforts to address opioid use disorder and HIV infection. Evidence-based behavioral interventions (EBI) are effective in reducing methamphetamine use. However, evidence on optimal combinations of EBI is limited. This protocol presents a type-1 effectiveness-implementation hybrid design to evaluate the effectiveness, cost-effectiveness of adaptive methamphetamine use interventions, and their implementation barriers in Vietnam.

METHOD

Design: Participants will be first randomized into two frontline interventions for 12 weeks. They will then be placed or randomized to three adaptive strategies for another 12 weeks. An economic evaluation and an ethnographic evaluation will be conducted alongside the interventions.

PARTICIPANTS

We will recruit 600 participants in 20 methadone clinics.

ELIGIBILITY CRITERIA

(1) age 16+; (2) Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) scores ≥ 10 for methamphetamine use or confirmed methamphetamine use with urine drug screening; (3) willing to provide three pieces of contact information; and (4) having a cell phone.

OUTCOMES

Outcomes are measured at 13, 26, and 49 weeks and throughout the interventions. Primary outcomes include the (1) increase in HIV viral suppression, (2) reduction in HIV risk behaviors, and (3) reduction in methamphetamine use. COVID-19 response: We developed a response plan for interruptions caused by COVID-19 lockdowns to ensure data quality and intervention fidelity.

DISCUSSION

This study will provide important evidence for scale-up of EBIs for methamphetamine use among methadone patients in limited-resource settings. As the EBIs will be delivered by methadone providers, they can be readily implemented if the trial demonstrates effectiveness and cost-effectiveness.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04706624. Registered on 13 January 2021. https://clinicaltrials.gov/ct2/show/NCT04706624.

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.

Characteristics of women with alcohol use disorders who benefit from intensive motivational interviewing

BACKGROUND

Women with alcohol disorders have more severe problems related to their drinking than men. They have higher mortality from alcohol-related accidents and enter treatment with more serious medical, psychiatric, and social consequences.

Objective: This study assessed the effects of Intensive Motivational Interviewing (IMI), a new, 9-session counseling intervention for women with drinking problems.

Methods: A randomized clinical trial was conducted with 215 women. Most were white (83%), college educated (61%), and older (mean age 51). Half received IMI and half a standard single session of MI (SMI) along with an attention control (nutritional education).

Results: Generalized estimating equations models showed women who were heavy drinkers at baseline in the IMI condition reduced heavy drinking more than those in the SMI condition at 2-, 6-, and 12-month follow-up. Analyses of disaggregated subgroups showed IMI was most effective for women with low psychiatric severity, more severe physical and impulse control consequences associated with drinking, and higher motivation. However, formal 3-way interaction models (condition by moderator by time) showed significant effects primarily at 2 months.

Conclusions: Improvements associated with IMI were limited to heavy drinking and varied among subgroups of women. Studies of women with more diverse characteristics are needed.

Non-pharmacological interventions for methamphetamine use disorder: a systematic review

BACKGROUND

Methamphetamine (METH) use is on the rise globally, with the number of treatment seekers increasing exponentially across the globe. Evidence-based therapies are needed to meet rising treatment needs. This systematic review intends to appraise the existing evidence to identify effective non-pharmaceutical approaches for the treatment of METH use disorder.

METHODS

Five electronic bibliographic databases-Ovid (Medline), Embase, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Web of Science and PsycINFO- were searched to identify relevant studies that were published between January 1995 to February 2020. Studies were selected and assessed by two independent reviewers. A systematic review of data from both randomised control trials (RCT) and non-RCTs was conducted to appraise the evidence.

RESULTS

A total of 44 studies were included in the review. Behavioural interventions, i.e. cognitive behavioural therapy (CBT), contingency management (CM), exercise, residential rehabilitation based therapies, repetitive transcranial magnetic stimulation (rTMS), and matrix model demonstrated treatment efficacy in promoting abstinence, reducing methamphetamine use or craving in the participants. While CM interventions showed the strongest evidence favouring the outcomes assessed, tailored CBT alone or with CM was also effective in the target population.

CONCLUSIONS

Behavioural interventions should be considered as the first line of treatment for methamphetamine use disorder. Future studies should address the longevity of the effects, and limitations due to smaller sample sizes and high dropout rates to enable better assessment of evidence.

Heavy Drinking among Women Receiving Intensive Motivational Interviewing: 6-Month Outcomes

Compared to men, women with alcohol use disorders experience more severe consequences related to drinking. Intensive Motivational Interviewing (IMI) is a new 9-session version of Motivational Interviewing (MI) designed for women with alcohol use disorders. The current study reports outcomes from a randomized clinical trial of IMI compared to a single session of MI. Data were collected at baseline, 2-month, and 6-month follow-up. In addition to a standard "intent-to-treat" (ITT) analysis, we conducted disaggregated subgroup analyses of women who were heavy drinkers and a "per protocol" (PP) analysis of women in the IMI condition who attended 7-9 sessions (80% of the IMI sample). Women in both study conditions made large reductions in drinking between baseline and 2 months that were maintained at 6 months. Generalized estimating equation (GEE) models using the full sample (N = 215) did not show time by condition differences, but heavy drinkers(n = 153) receiving IMI showed significantly larger reductions in drinking at 2- and 6-month follow-up than the comparison condition. Assessment of heavy drinkers using the PP sample showed larger between condition differences favoring IMI at both follow-up time points. Results support the efficacy of IMI in terms of reducing drinking, particularly among women who are heavy drinkers.

Psychosocial interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users

BACKGROUND

Problem alcohol use is common among people who use illicit drugs (PWID) and is associated with adverse health outcomes. It is also an important factor contributing to a poor prognosis among drug users with hepatitis C virus (HCV) as it impacts on progression to hepatic cirrhosis or opioid overdose in PWID.

OBJECTIVES

To assess the effectiveness of psychosocial interventions to reduce alcohol consumption in PWID (users of opioids and stimulants).

SEARCH METHODS

We searched the Cochrane Drugs and Alcohol Group trials register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, and PsycINFO, from inception up to August 2017, and the reference lists of eligible articles. We also searched: 1) conference proceedings (online archives only) of the Society for the Study of Addiction, International Harm Reduction Association, International Conference on Alcohol Harm Reduction and American Association for the Treatment of Opioid Dependence; and 2) online registers of clinical trials: Current Controlled Trials, ClinicalTrials.gov, Center Watch and the World Health Organization International Clinical Trials Registry Platform.

SELECTION CRITERIA

We included randomised controlled trials comparing psychosocial interventions with other psychosocial treatment, or treatment as usual, in adult PWIDs (aged at least 18 years) with concurrent problem alcohol use.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included seven trials (825 participants). We judged the majority of the trials to have a high or unclear risk of bias.The psychosocial interventions considered in the studies were: cognitive-behavioural coping skills training (one study), twelve-step programme (one study), brief intervention (three studies), motivational interviewing (two studies), and brief motivational interviewing (one study). Two studies were considered in two comparisons. There were no data for the secondary outcome, alcohol-related harm. The results were as follows.Comparison 1: cognitive-behavioural coping skills training versus twelve-step programme (one study, 41 participants)There was no significant difference between groups for either of the primary outcomes (alcohol abstinence assessed with Substance Abuse Calendar and breathalyser at one year: risk ratio (RR) 2.38 (95% confidence interval [CI] 0.10 to 55.06); and retention in treatment, measured at end of treatment: RR 0.89 (95% CI 0.62 to 1.29), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was very low.Comparison 2: brief intervention versus treatment as usual (three studies, 197 participants)There was no significant difference between groups for either of the primary outcomes (alcohol use, measured as scores on the Alcohol Use Disorders Identification Test (AUDIT) or Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) at three months: standardised mean difference (SMD) 0.07 (95% CI -0.24 to 0.37); and retention in treatment, measured at three months: RR 0.94 (95% CI 0.78 to 1.13), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was low.Comparison 3: motivational interviewing versus treatment as usual or educational intervention only (three studies, 462 participants)There was no significant difference between groups for either of the primary outcomes (alcohol use, measured as scores on the AUDIT or ASSIST at three months: SMD 0.04 (95% CI -0.29 to 0.37); and retention in treatment, measured at three months: RR 0.93 (95% CI 0.60 to 1.43), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was low.Comparison 4: brief motivational intervention (BMI) versus assessment only (one study, 187 participants)More people reduced alcohol use (by seven or more days in the past month, measured at six months) in the BMI group than in the control group (RR 1.67; 95% CI 1.08 to 2.60). There was no difference between groups for the other primary outcome, retention in treatment, measured at end of treatment: RR 0.98 (95% CI 0.94 to 1.02), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was moderate.Comparison 5: motivational interviewing (intensive) versus motivational interviewing (one study, 163 participants)There was no significant difference between groups for either of the primary outcomes (alcohol use, measured using the Addiction Severity Index-alcohol score (ASI) at two months: MD 0.03 (95% CI 0.02 to 0.08); and retention in treatment, measured at end of treatment: RR 17.63 (95% CI 1.03 to 300.48), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was low.

AUTHORS' CONCLUSIONS

We found low to very low-quality evidence to suggest that there is no difference in effectiveness between different types of psychosocial interventions to reduce alcohol consumption among people who use illicit drugs, and that brief interventions are not superior to assessment-only or to treatment as usual. No firm conclusions can be made because of the paucity of the data and the low quality of the retrieved studies.

Development of Intensive Motivational Interviewing (IMI) and Modifications for Treating Women with Alcohol Use Disorders

Women have greater vulnerability to alcohol problems than men. They become intoxicated after drinking half as much as men, develop cirrhosis of the liver more rapidly, and have a greater risk of dying from alcohol-related accidents. Despite more serious consequences related to their drinking, treatment for women with alcohol use disorders has been understudied relative to treatment for men. Intensive motivational interviewing (IMI) is a recent psychotherapeutic intervention for substance abuse problems that draws on the principles of brief motivational interviewing (1-2 session). However, the intervention includes 9 sessions designed to enable therapists to have maximum flexibility to facilitate factors known to be important for women with substance use disorders, such as active facilitation of client-therapist collaboration, empowerment, and affirmation of strengths. This paper reviews the development of IMI, initial favorable findings for women with co-occurring methamphetamine and alcohol problems, and the design of an ongoing longitudinal study assessing the effects of MI for women with alcohol problems over a 12-month time period. Relational Theory is used as a conceptual framework for understanding IMI for women. The theory emphasizes understanding, building, and modifying interpersonal relationships as a central goal. From this perspective, self-efficacy, self-esteem, and reduction in drinking are enhanced through interpersonal connections with others. Plans for additional study of IMI are described along with suggestions for therapists.

Changes in psychiatric symptoms among persons with methamphetamine dependence predicts changes in severity of drug problems but not frequency of use

BACKGROUND

Few studies have examined how changes in psychiatric symptoms over time are associated with changes in drug use and severity of drug problems. No studies have examined these relationships among methamphetamine (MA)-dependent persons receiving motivational interviewing within the context of standard outpatient treatment.

METHODS

Two hundred seventeen individuals with MA dependence were randomly assigned to a standard single session of motivational interviewing (MI) or an intensive 9-session model of MI. Both groups received standard outpatient group treatment. The Addiction Severity Index (ASI) and timeline follow-back (TLFB) for MA use were administered at treatment entry and 2-, 4-, and 6-month follow-ups.

RESULTS

Changes in ASI psychiatric severity between baseline and 2 months predicted changes in ASI drug severity during the same time period, but not changes on measures of MA use. Item analysis of the ASI drug scale showed that psychiatric severity predicted how troubled or bothered participants were by their drug us, how important they felt it was for them to get treatment, and the number of days they experienced drug problems. However, it did not predict the number days they used drugs in the past 30 days. These associations did not differ between study conditions, and they persisted when psychiatric severity and outcomes were compared across 4- and 6-month time periods.

CONCLUSIONS

Results are among the first to track how changes in psychiatric severity over time are associated with changes in MA use and severity of drug problems. Treatment efforts targeting reduction of psychiatric symptoms among MA-dependent persons might be helpful in reducing the level of distress and problems associated with MA use but not how often it is used. There is a need for additional research describing the circumstances under which the experiences and perceptions of drug-related problems diverge from frequency of consumption.

Client and Therapist Views about Intensive and Standard Motivational Interviewing

Although motivational interviewing (MI) is a widely used intervention for alcohol and drug problems, little is known about client and therapist experiences. Client and therapist views could help better understand how MI works and what factors are important. This paper investigates experiences of clients and therapists who participated in a study that examined a standard single session of MI (MI 1) and a more intensive 9-session model (MI 9) for methamphetamine dependence. Qualitative methods included open ended questions presented to 184 clients at 2-month follow-up and 189 clients at 6-month follow-up. In addition, a focus group consisting of two therapists who delivered the interventions and two adherence monitors who listened to audiotape recordings of sessions was conducted. Clients in both conditions felt supportive, nonjudgmental therapist attitudes were helpful. Most clients in the MI 9 condition but few receiving MI 1 volunteered that feedback and advice were helpful. A strong majority in both conditions desired more sessions. Expert panel members emphasized: 1) multiple benefits of a nonjudgmental stance, 2) finding the right balance among different MI interventions, and 3) understanding the interaction of supportive and directive interventions. Panel members also emphasized that one advantages of MI 9 over MI 1 was that it enabled client change plans to be implemented over time.

Randomized trial of intensive motivational interviewing for methamphetamine dependence

An intensive, 9-session motivational interviewing (IMI) intervention was assessed using a randomized clinical trial of 217 methamphetamine (MA) dependent individuals. Intensive motivational interviewing (IMI) was compared with a single standard session of MI (SMI) combined with eight nutrition education sessions. Interventions were delivered weekly over 2 months. All study participants also received standard outpatient group treatment three times per week. Both study groups showed significant decreases in MA use and Addiction Severity Index drug scores, but there were no significant differences between the two groups. However, reductions in Addiction Severity Index psychiatric severity scores and days of psychiatric problems during the past 30 days were found for clients in the IMI group but not the SMI group. SMI may be equally beneficial to IMI in reducing MA use and problem severity, but IMI may help alleviate co-occurring psychiatric problems that are unaffected by shorter MI interventions. Additional studies are needed to assess the problems, populations, and contexts for which IMI is effective.

Attitudes toward methamphetamine use and HIV risk behavior in men who have sex with men

BACKGROUND AND OBJECTIVES

Methamphetamine use has been strongly associated with high-risk sexual behaviors, and its use has been increasing among men who have sex with men (MSM). Although the behavioral implications of methamphetamine use and sexual risk have been broadly examined, fewer studies have examined attitudes about methamphetamine use.

METHODS

This study investigates the relationship between personal beliefs regarding methamphetamine use, patterns of use, and sexual risk behaviors within a sample of MSM attending a gay pride event (N= 342).

RESULTS

A minority of MSM reported lifetime (27%) or recent (7%) methamphetamine use. Only a minority of MSM who had used methamphetamine believed that it enhanced sexual pleasure (32%) or incorporated methamphetamine use into their sexual activity (31%). Individuals who used methamphetamine during sexual activity were more likely to be recent users of the drug and more likely to engage in high-risk behaviors. A significant minority of participants endorsed items assessing the disinhibiting effects of methamphetamine including being less likely to use a condom (35%) and less selective in their choice of partners (26%).

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Results suggest that prevention efforts may benefit from targeting the minority of methamphetamine users who perceive methamphetamine as enhancing sexual activity and use it for this purpose.

Intensive motivational interviewing for women with concurrent alcohol problems and methamphetamine dependence

Motivational interviewing (MI) for the treatment of alcohol and drug problems is typically conducted over 1 to 3 sessions. The current work evaluates an intensive 9-session version of MI (Intensive MI) compared to a standard single MI session (Standard MI) using 163 methamphetamine (MA) dependent individuals. The primary purpose of this paper is to report the unexpected finding that women with co-occurring alcohol problems in the Intensive MI condition reduced the severity of their alcohol problems significantly more than women in the Standard MI condition at the 6-month follow-up. Stronger perceived alliance with the therapist was inversely associated with alcohol problem severity scores. Findings indicate that Intensive MI is a beneficial treatment for alcohol problems among women with MA dependence.

A randomized, placebo-controlled trial of sustained-release dextroamphetamine for treatment of methamphetamine addiction

Sixty treatment-seeking individuals with methamphetamine (MA) dependence entered a randomized, placebo-controlled, double-blind clinical trial of oral dextroamphetamine (d-AMP) as a replacement therapy for MA dependence. The subjects took 60 mg sustained-release d-AMP for 8 weeks, during which time they received eight 50-min sessions of individual psychotherapy. Adverse events and urine toxicology for MA were assessed two times a week. There were no serious adverse events. Urine samples containing <1,000 ng/ml of MA were classified as negative for MA. The MA-negative scores in the d-AMP group (3.1 ± SD 4.6) were no higher than those in the placebo group (3.3 ± SD 5.3; P > 0.05). However, withdrawal and craving scores were significantly lower in the d-AMP group (P < 0.05 for both). Although subjects taking d-AMP did not reduce their use of MA, the significant reductions observed in withdrawal and craving scores in this group support the need for further exploration of d-AMP as a pharmacologic intervention for MA dependence, possibly at higher doses.