Effects of brief substance use interventions delivered in general medical settings: a systematic review and meta-analysis

A scoping review of substance use brief interventions in Africa

BACKGROUND

The burden of substance use in Africa is substantial. Brief interventions (BIs) are a recommended public health strategy for the prevention and early intervention for substance use problems. The objective of this scoping review was to map the literature on substance use BIs in Africa, identify gaps, and provide directions for future research.

METHODS

The scoping review was guided by the Arksey O'Malley Framework and the PRISMA-Scoping review (PRISMA-ScR) guidelines. A search of five bibliographic databases (PubMed, PsychINFO, Web of Science, Cumulative Index of Nursing and Allied Professionals (CINAHL) and Cochrane Library) was conducted from inception until 1st November 2023. BIs were defined as those targeting substance use and delivered over 1-4 sessions, or interventions delivered over more than four sessions if the authors referred to them as 'brief'. Results of the review have been summarized descriptively and organized by three broad outcomes: BI effect and feasibility; feasibility and effectiveness of training providers to deliver BIs; Other outcomes i.e. cost-effectiveness, BI adaptation and development, and knowledge attitude and practice of BIs by providers.

RESULTS

Of the 80 studies that were eligible for inclusion, 68 investigated the effect and feasibility of BIs, six studies investigated the feasibility and effectiveness of training providers to deliver BIs, and six explored other outcomes. Most of the available studies had been conducted in Eastern and Southern Africa. BIs were largely based on motivational interviewing and psychoeducational principles. Overall, the BIs were reported as feasible to implement from the perspective of policy makers, providers, and the intervention recipients. Findings on the effect of BIs on substance use were mixed. Key evidence gaps emerged. There was paucity of BI research focusing on substances other than alcohol, and there was limited literature on feasibility and efficacy of BIs among youth and adolescents.

CONCLUSION

The results of this scoping review provide important directions for future substance use BI research in Africa.

Feasibility of alcohol interventions in cardiology: a qualitative study of clinician perspectives in Sweden

AIMS

This study aimed to identify barriers and facilitators to implementing alcohol screening and brief interventions (SBI) in cardiology services.

METHODS AND RESULTS

This was a qualitative study. Individual, semi-structured interviews were conducted with 24 clinical cardiology staff (doctors, nurses, and assistant nurses) of varying experience levels and from various clinical settings (high-dependency unit, ward, and outpatient clinic), in three regions of Sweden. Reflexive thematic analysis was used, with deductive coding applying the Capability, Opportunity, Motivation (COM-B) theoretical framework. A total of 41 barriers and facilitators were identified, including 12 related to capability, 9 to opportunity, and 20 to motivation. Four themes were developed: (i) uncharted territory, where clinicians expressed a need to address alcohol use but lacked knowledge and a roadmap for implementing SBI; (ii) cardiology as a cardiovascular specialty, where tasks were prioritized according to established roles; (iii) alcohol stigma, where alcohol was reported to be a sensitive topic that staff avoid discussing with patients; and (iv) window of opportunity, where staff expressed potential for implementing SBI in routine cardiology care.

CONCLUSION

Findings suggest that opportunities exist for early identification and follow-up of hazardous alcohol use within routine cardiology care. Several barriers, including low knowledge, stigma, a lack of ownership, and a greater focus on other risk factors, must be addressed prior to the implementation of SBI in cardiology. To meet current clinical guidelines, there is a need to increase awareness and to improve pathways to addiction care. In addition, there may be a need for clinicians dedicated to alcohol interventions within cardiology services.

REGISTRATION

OSF (osf.io/hx3ts).

Caring for Hospitalized Adults With Opioid Use Disorder in the Era of Fentanyl: A Review

Importance

The rise of fentanyl and other high-potency synthetic opioids across US and Canada has been associated with increasing hospitalizations and unprecedented overdose deaths. Hospitalization is a critical touchpoint to engage patients and offer life-saving opioid use disorder (OUD) care when admitted for OUD or other medical conditions.

Observations

Clinical best practices include managing acute withdrawal and pain, initiating medication for OUD, integrating harm reduction principles and practices, addressing in-hospital substance use, and supporting hospital-to-community care transitions. Fentanyl complicates hospital OUD care. Fentanyl's high potency intensifies pain, withdrawal, and cravings and increases the risk for overdose and other harms. Fentanyl's unique pharmacology has rendered traditional techniques for managing opioid withdrawal and initiating buprenorphine and methadone inadequate for some patients, necessitating novel strategies. Further, co-use of opioids with stimulants drugs is common, and the opioid supply is unpredictable and can be contaminated with benzodiazepines, xylazine, and other substances. To address these challenges, clinicians are increasingly relying on emerging practices, such as low-dose buprenorphine initiation with opioid continuation, rapid methadone titration, and the use of alternative opioid agonists. Hospitals must also reconsider conventional approaches to in-hospital substance use and expand clinicians' understanding and embrace of harm reduction, which is a philosophy and set of practical strategies that supports people who use drugs to be safer and healthier without judgment, coercion, or discrimination. Hospital-to-community care transitions should ensure uninterrupted access to OUD care after discharge, which requires special consideration and coordination. Finally, improving hospital-based addiction care requires dedicated infrastructure and expertise. Preparing hospitals across the US and Canada to deliver OUD best practices requires investments in clinical champions, staff education, leadership commitment, community partnerships, quality metrics, and financing.

Conclusions and Relevance

The findings of this review indicate that fentanyl creates increased urgency and new challenges for hospital OUD care. Hospital clinicians and systems have a central role in addressing the current drug crisis.

Standard Versus Family-Based Screening, Brief Intervention, and Referral to Treatment for Adolescent Substance Use in Primary Care: Protocol for a Multisite Randomized Effectiveness Trial

BACKGROUND

Screening, brief intervention, and referral to treatment for adolescents (SBIRT-A) is widely recommended to promote detection and early intervention for alcohol and other drug (AOD) use in pediatric primary care. Existing SBIRT-A procedures rely almost exclusively on adolescents alone, despite the recognition of caregivers as critical protective factors in adolescent development and AOD use. Moreover, controlled SBIRT-A studies conducted in primary care have yielded inconsistent findings about implementation feasibility and effects on AOD outcomes and overall developmental functioning. There is urgent need to investigate the value of systematically incorporating caregivers in SBIRT-A procedures.

OBJECTIVE

This randomized effectiveness trial will advance research and scope on SBIRT-A in primary care by conducting a head-to-head test of 2 conceptually grounded, evidence-informed approaches: a standard adolescent-only approach (SBIRT-A-Standard) versus a more expansive family-based approach (SBIRT-A-Family). The SBIRT-A-Family approach enhances the procedures of the SBIRT-A-Standard approach by screening for AOD risk with both adolescents and caregivers; leveraging multidomain, multireporter AOD risk and protection data to inform case identification and risk categorization; and directly involving caregivers in brief intervention and referral to treatment activities.

METHODS

The study will include 2300 adolescents (aged 12-17 y) and their caregivers attending 1 of 3 hospital-affiliated pediatric settings serving diverse patient populations in major urban areas. Study recruitment, screening, randomization, and all SBIRT-A activities will occur during a single pediatric visit. SBIRT-A procedures will be delivered digitally on handheld tablets using patient-facing and provider-facing programming. Primary outcomes (AOD use, co-occurring behavior problems, and parent-adolescent communication about AOD use) and secondary outcomes (adolescent quality of life, adolescent risk factors, and therapy attendance) will be assessed at screening and initial assessment and 3-, 6-, 9-, and 12-month follow-ups. The study is well powered to conduct all planned main and moderator (age, sex, race, ethnicity, and youth AOD risk status) analyses.

RESULTS

This study will be conducted over a 5-year period. Provider training was initiated in year 1 (December 2023). Participant recruitment and follow-up data collection began in year 2 (March 2024). We expect the results from this study to be published in early 2027.

CONCLUSIONS

SBIRT-A is widely endorsed but currently underused in pediatric primary care settings, and questions remain about optimal approaches and overall effectiveness. In particular, referral to treatment procedures in primary care remains virtually untested among youth. In addition, whereas research strongly supports involving families in interventions for adolescent AOD, SBIRT-A effectiveness trial testing approaches that actively engage family members in primary care are absent. This trial is designed to help fill these research gaps to inform the critical health decision of whether and how to include caregivers in SBIRT-A activities conducted in pediatric primary care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05964010; https://www.clinicaltrials.gov/study/NCT05964010.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/54486.

Investigating for Whom Brief Substance Use Interventions Are Most Effective: An Individual Participant Data Meta-analysis

Prior research suggests that brief interventions (BIs) for alcohol and other drug use may vary in effectiveness across patient sociodemographic factors. The objective of this individual participant data (IPD) meta-analysis was to explore for whom BIs delivered in general healthcare settings are more or less effective. We examined variability in BI effects by patient age, sex, employment, education, relationship status, and baseline severity of substance use using a two-stage IPD meta-analysis approach. All trials included in a parent aggregate data meta-analysis (k = 116) were invited to contribute IPD, and 29 trials provided patient-level data (12,074 participants). Among females, BIs led to significant reductions in binge alcohol consumption ([Formula: see text] = 0.09, 95% CI [0.03, 0.14]), frequency of alcohol consumption ([Formula: see text] = 0.10, 95% CI [0.03, 0.17]), and alcohol-related consequences ([Formula: see text] = 0.16, 95% CI [0.08, 0.25]), as well as greater substance use treatment utilization ([Formula: see text] = 0.25, 95% CI [0.21, 0.30]). BIs yielded larger reductions in frequency of alcohol consumption at 3-month follow-up for individuals with less than a high school level education ([Formula: see text] = 0.16, 95% CI [0.09, 0.22]). Given evidence demonstrating modest BI effects on alcohol use and mixed or null findings for BI effects on other drug use, BI research should continue to investigate potential drivers of effect magnitude and variation.  PROTOCOL REGISTRATION DETAILS: The protocol for this review was pre-registered in PROSPERO #CRD42018086832 and the analysis plan was pre-registered in OSF: osf.io/m48g6.

Meta-review on the efficacy of psychological therapies for the treatment of substance use disorders

This meta-review aimed to summarize the current state of knowledge provided by meta-analyzes on the efficacy of psychotherapies for substance use disorders. A systematic search was performed in PubMed, PsycINFO, Web of Science and Google Scholar. Meta-analyzes were included if they quantitatively examined the efficacy of a psychotherapy on substance use. Among the 6866 potential articles that were screened for eligibility, 23 meta-analyzes were eligible (78 effect sizes). Each meta-analysis included 2-156 studies, with samples ranging between approximately 130 to over 33,000 individuals. The quality of evidence was evaluated as being globally of low to moderate quality. Substances were categorized as: alcohol (k = 12), cannabis (k = 7), stimulants (k = 4), opioids (k = 3) and benzodiazepines (k = 1). Interventions comprised brief intervention, cognitive-behavioral therapy, contingency management, voucher-based reinforcement therapy, motivational interview, motivational enhancement therapy, significant other people involved in the treatment, and cue-expose therapy. Concerning solely significant results, small benefits were observed for significant other people involved in treatment, motivational interviewing, and the combination of cognitive-behavioral therapy with motivational interviewing for alcohol use disorder. Likewise, small-to-moderate effects were found for motivational approaches, and cognitive-behavioral therapy as well as the combination of cognitive-behavioral therapy and motivational enhancement therapy in the case of cannabis use disorder. Small effects were observed for contingency management as well as cognitive behavioral-therapy for amphetamine-type use disorder. Small effects were similarly found for contingency management for cocaine use disorder. Concerning opioid use disorder, moderate effects were observed for contingency management and voucher-based reinforcement intervention. For benzodiazepine use disorder, small effects were noted for cognitive-behavioral therapy with taper. Results often displayed small to moderate heterogeneity when reported and were generally compared to inactive controls, such as treatment-as-usual. In all, the psychosocial treatments for substance use disorders included in this meta-review have shown to be at best moderately effective over inactive controls in the short term. Nevertheless, further trials are needed as well as meta-analyzes on interventions not included in this meta-review.

Use of an Automated Bilingual Digital Health Tool to Reduce Unhealthy Alcohol Use Among Latino Emergency Department Patients: A Randomized Clinical Trial

Importance

Alcohol use disorders have a high disease burden among US Latino groups. In this population, health disparities persist, and high-risk drinking has been increasing. Effective bilingual and culturally adapted brief interventions are needed to identify and reduce disease burden.

Objective

To compare the effectiveness of an automated bilingual computerized alcohol screening and intervention (AB-CASI) digital health tool with standard care for the reduction of alcohol consumption among US adult Latino emergency department (ED) patients with unhealthy drinking.

Design, Setting, and Participants

This bilingual unblinded parallel-group randomized clinical trial evaluated the effectiveness of AB-CASI vs standard care among 840 self-identified adult Latino ED patients with unhealthy drinking (representing the full spectrum of unhealthy drinking). The study was conducted from October 29, 2014, to May 1, 2020, at the ED of a large urban community tertiary care center in the northeastern US that was verified as a level II trauma center by the American College of Surgeons. Data were analyzed from May 14, 2020, to November 24, 2020.

Intervention

Patients randomized to the intervention group received AB-CASI, which included alcohol screening and a structured interactive brief negotiated interview in their preferred language (English or Spanish) while in the ED. Patients randomized to the standard care group received standard emergency medical care, including an informational sheet with recommended primary care follow-up.

Main Outcomes and Measures

The primary outcome was the self-reported number of binge drinking episodes within the last 28 days, assessed by the timeline followback method at 12 months after randomization.

Results

Among 840 self-identified adult Latino ED patients (mean [SD] age, 36.2 [11.2] years; 433 [51.5%] male; and 697 [83.0%] of Puerto Rican descent), 418 were randomized to the AB-CASI group and 422 to the standard care group. A total of 443 patients (52.7%) chose Spanish as their preferred language at enrollment. At 12 months, the number of binge drinking episodes within the last 28 days was significantly lower in those receiving AB-CASI (3.2; 95% CI, 2.7-3.8) vs standard care (4.0; 95% CI, 3.4-4.7; relative difference [RD], 0.79; 95% CI, 0.64-0.99). Alcohol-related adverse health behaviors and consequences were similar between groups. The effect of AB-CASI was modified by age; at 12 months, the relative reduction in the number of binge drinking episodes within the last 28 days in the AB-CASI vs standard care group was 30% in participants older than 25 years (RD, 0.70; 95% CI, 0.54-0.89) compared with an increase of 40% in participants 25 years or younger (RD, 1.40; 95% CI, 0.85-2.31; P = .01 for interaction).

Conclusions and Relevance

In this study, US adult Latino ED patients who received AB-CASI had a significant reduction in the number of binge drinking episodes within the last 28 days at 12 months after randomization. These findings suggest that AB-CASI is a viable brief intervention that overcomes known procedural barriers to ED screening, brief intervention, and referral to treatment and directly addresses alcohol-related health disparities.

Trial Registration

ClinicalTrials.gov Identifier: NCT02247388.

Title of the study: Practice and attitude of doctors towards patients with substance use: A study from south India

AIM

To evaluate the practice and attitude of doctors towards substance use disorders (SUD) and their management.

METHODS

Following stratified proportionate random sampling, selected doctors in the south zone of Bengaluru, India, were interviewed face-to-face using a structured questionnaire.

RESULTS

150 doctors were interviewed. In their practice, a quarter of patients (median of 27.5 (IQR: 11.45-45) use one or other form of Alcohol, Tobacco or Other Drugs of abuse (ATOD). Doctors, in general, enquire about substance use but do not actively intervene. They have mixed attitudes (both positive and negative) towards persons with SUD. A significant positive correlation was noted between the number of years of experience (post-MBBS) with practices related to "brief-intervention" (p = 0.014) and "concerned and sympathetic" attitudes (p < 0.001). However, a significant negative correlation was observed between the number of years of experience and "substance-specific management" practices (p < 0.001). Further, there was a positive correlation between "brief-interventions" practices with the attitude of being "concerned and sympathetic" (p < 0.001). A mediation analysis revealed that nearly a third of the overall effect of the number of years of experience on brief-interventions practices was mediated by a concerned and sympathetic attitude.

CONCLUSIONS

Serious efforts must be made to train doctors in the effective management of SUD. Attitudes of the doctors influence practices such as brief interventions. Programs directed towards changing the attitudes of doctors can bring changes in their practices.

Screening and brief intervention for alcohol use disorder risk in three middle-income countries

Background

This study examined the prevalence of screening and brief intervention (SBI) for alcohol use disorder (AUD) risk in samples of adult drinkers in three middle-income countries (Brazil, China, South Africa), and the extent to which meeting criteria for AUD risk was associated with SBI.

Methods

Cross-sectional survey data were collected from adult samples in two cities in each country in 2018. Survey measures included past-year alcohol use, the CAGE assessment for AUD risk, talking to a health care professional in the past year, alcohol use screening by a health care professional, receiving advice about drinking from a health care professional, and sociodemographic characteristics. The prevalence of SBI was determined for past-year drinkers in each country and for drinkers who had talked to a health care professional. Logistic regression analyses were conducted to examine whether meeting criteria for AUD risk was associated with SBI when adjusting for sociodemographic characteristics.

Results

Among drinkers at risk for AUD, alcohol use screening rates ranged from 6.7% in South Africa to 14.3% in Brazil, and brief intervention rates ranged from 4.6% in South Africa to 8.2% in China. SBI rates were higher among drinkers who talked to a health care professional in the past year. In regression analyses, AUD risk was positively associated with SBI in China and South Africa, and with brief intervention in Brazil.

Conclusion

Although the prevalence of SBI among drinkers at risk for AUD in Brazil, China, and South Africa appears to be low, it is encouraging that these drinkers were more likely to receive SBI.

Supplementary information

The online version contains supplementary material available at 10.1186/s12889-022-14358-4.

Prevalence and characteristics of hazardous and harmful drinkers receiving general practitioners' brief advice on and support with alcohol consumption in Germany: results of a population survey

OBJECTIVE

The German treatment guideline on alcohol-related disorders recommends that general practitioners (GPs) offer brief advice on, and support with, reducing alcohol consumption to hazardous (at risk for health events) and harmful (exhibit health events) drinking patients. We aimed to estimate the implementation of this recommendation using general population data.

DESIGN

Cross-sectional analysis of data (2021/2022) of a nationwide, population-based household survey.

SETTING

Germany.

PARTICIPANTS

Population-based sample of 2247 adult respondents who reported hazardous or harmful drinking according to the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C; score women: 4-12 and men: 5-12).

MAIN OUTCOME MEASURE

Ever receipt of 'brief GP advice on, or support with, reducing alcohol consumption'. Differences in the likelihood of ever receiving advice and/or support (yes/no) relative to respondents' sociodemographic, smoking and alcohol consumption characteristics were estimated using logistic regressions.

RESULTS

Ever receipt of GP advice on/support with reducing drinking was reported among 6.3% (95% CI=5.3% to 7.4%), and the offer of support among 1.5% (95% CI=1.1% to 2.1%) of the hazardous and harmful drinking respondents. The likelihood of having ever received advice/support was positively associated with being older (OR=1.03 per year, 95% CI=1.01 to 1.04), a current or former (vs never) smoker (OR=2.36, 95% CI=1.46 to 3.80; OR=2.17, 95% CI=1.23 to 3.81) and with increasing alcohol consumption (OR=1.76 per score, 95% CI=1.59 to 1.95). One in two harmful drinking respondents (AUDIT-C score 10-12) reported appropriate advice/support. The likelihood was negatively associated with being woman (eg, OR=0.32, 95% CI=0.21 to 0.48), having a medium or high (vs low) education and with increasing household income.

CONCLUSIONS

A small proportion of hazardous and harmful drinking people in Germany report having ever received GP advice on, or support with, reducing alcohol consumption. The implementation of advice/support seems to be linked to specific socio-demographic characteristics, tobacco smoking and alcohol consumption level. Health policy measures should aim to increase alcohol screening, brief intervention rates and awareness for at-risk populations in primary care.

TRIAL REGISTRATION NUMBER

DRKS00011322, DRKS00017157.

The Effect of SBIRT on Harmful Alcohol Consumption in the Community Health Centers of Shanghai, China: A Randomized Controlled Study

OBJECTIVE

The present study was a randomized controlled trial with a longitudinal design aimed at examining the effectiveness of Screening, Brief Intervention and Referral to Treatment (SBIRT) on harmful alcohol use in the community health centres in Shanghai, China, and further compared the effects of a multi-session brief intervention (MBI) and a single-session brief intervention (SBI).

METHODS

A total of 362 participants were recruited from four districts of Shanghai and randomly assigned to MBI, SBI and routine care (RC) groups. The MBI group received the brief intervention twice. Follow-up assessments were conducted at 1 and 3 months after the intervention.

RESULTS

Compared with the SBI and the RC groups, the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) scores (F = 6.422, P = 0.002), SDS scores (F = 5.779, P = 0.003) and SAS scores (F = 4.004, P = 0.019) were significant improved in the MBI group at 1and 3-month follow-up assessment. In the SBI group, the SDS scores decreased significantly compared with the RC group, and there were no significant differences in ASSIST scores, drinking knowledge scores and SAS scores 1-month follow-up assessment.

CONCLUSION

The findings suggested that SBIRT with two sessions of BI had considerable effects on individuals with harmful alcohol use. It provided clinical evidence for future use in China and other Asian countries with similar situations.