Predictors of alcohol and other drug treatment completion among young people accessing residential and community-based treatment: A retrospective analysis of routinely collected service data

BACKGROUND AND AIMS

Young people accessing alcohol and other drug (AOD) treatment experience high rates of treatment disengagement, contributing to poorer outcomes. To improve outcomes, it is important to identify factors associated with treatment retention. This study measured the relationships between client characteristics, treatment characteristics, clinical severity measures and completion of treatment among young people.

DESIGN, SETTING AND PARTICIPANTS

This study was a retrospective analysis of routinely collected data set in residential- and community-based AOD services in New South Wales, Australia. Routinely collected data from the Network of Alcohol and Other Drug Agencies' (NADA) database were used. Included individuals were aged 10-24 years and accessed treatment between 2012 and 2023 (n = 17 474).

MEASUREMENTS

Variables included client-related characteristics, service characteristics and baseline measures of clinical severity [Kessler-10 (K10), EUROHIS-QoL, severity of dependence scale (SDS)]. Multivariable binary logistic regression models assessed the relationships between these characteristics and treatment completion.

FINDINGS

Rates of treatment completion were highest among adolescents in community-based treatment (57%) and lowest among young adults in residential treatment (35%). Polysubstance use was negatively associated with treatment completion among adolescents [adjusted odds ratio (adjOR) = 0.71, P < 0.001] and adults (adjOR = 0.70, P < 0.001) in community-based treatment, and adolescents in residential treatment (adjOR = 0.62, P = 0.006), as was housing insecurity (adolescents in community treatment, adjOR = 0.61, P = 0.001; adults in community treatment, adjOR = 0.77, P = 0.002; adolescents in residential treatment, adjOR = 0.42, P = 0.005). Attending youth-specific services was associated with higher treatment completion rates among adults in community-based (adjOR = 1.81, P < 0.001) and residential treatment (adjOR = 1.72, P < 0.001). Varying correlates of treatment completion were identified throughout treatment groups, reflecting the differences in population and/or needs across contexts.

CONCLUSIONS

In New South Wales, Australia, fewer than half of young people accessing alcohol and other drug treatment between 2012 and 2023 completed treatment, and completion rates were lower among those facing barriers such as polysubstance use and housing insecurity.

Psychotherapeutic interventions for cannabis use disorder. What do we know and what should we do?

BACKGROUND

Cannabis use disorder is the most commonly reported illegal substance use disorder and demand for treatment is growing worldwide.

OBJECTIVES

Our aim was to compare the two last Cochrane systematic reviews of the literature concerning psychotherapeutic and psychosocial interventions for cannabis use disorder to determine what new evidence emerged and how craving was considered as a treatment mediator.

METHOD

We extracted raw data from both reviews regarding their titles, objectives, methods and results. This information was analyzed by face validity to distinguish apparent differences from real differences. It enabled us to describe similarities and differences between reviews. We also screened both reviews looking for craving or related words.

RESULTS

The objective and methods of both reviews were mostly similar. Although the second review covered a wider range of psychotherapies, including drug counseling and mindfulness-based meditation as an intervention group and minimal treatment as a control group. Five of the six studies included in the first review were also included in the second review. One study excluded from the first review was included in the last review that included an additional 17 studies published after the first review. The 2016 review performed a meta-analysis whereas the first review was descriptive. Both reviews supported the efficacy of motivational enhancement therapy and cognitive and behavioral therapy interventions with adjunction of contingency management for abstinence when possible. There was no relevant mention of craving in the 2006 review and very few in the 2016 review.

CONCLUSION

The methods and results of the last two Cochrane reviews on psychosocial interventions for cannabis use disorder were mostly similar. Consistent with other reviews on the same subject and reviews of psychotherapies for other substance use disorders, the 2016 review confirmed evidence already available in the 2006 review. Instead of confirming already confirmed evidence, future research is needed to determine if craving focused treatment would increase efficiency and how to maintain initial treatment outcomes long-term.

Vouchers versus reminders to prevent dropout: Findings from the randomized youth drug abuse treatment project (youthDAT project)

BACKGROUND

Over the last few decades, evidence-based treatments for emerging adults with drug use disorder (DUD) have been developed, but dropout and inconsistent session attendance persist. This study assessed the efficacy of voucher reinforcement and/or text reminders for treatment attendance and completion in emerging adults with DUD in Denmark.

METHODS

The study compared four levels of treatment intensity, with participants randomly assigned to standard outpatient counseling only (STD), outpatient counseling plus vouchers for attendance (VOU), outpatient counseling plus text reminders (REM), or outpatient counseling plus vouchers and text reminders (REM + VOU). A total of 460 individuals aged 15-25 years seeking treatment for DUD were randomly assigned to the four treatment conditions across nine sites.

RESULTS

STD counseling had the lowest completion rate (25%), followed by REM (39%), VOU (46%), and REM + VOU (49%). Additionally, post hoc comparisons indicated that clients randomized to the REM + VOU condition differed in terms of zero no-shows from clients who were randomized to the VOU condition (χ2(1) = 6.90, p = 0.009) and the REM condition (χ2(1) = 5.87, p = 0.015).

CONCLUSIONS

Vouchers and text reminders contribute to reduced dropout and increased treatment attendance in emerging adults with DUD. The combination of vouchers and reminders in particular has the potential to reduce the number of no-shows.

Interventions for female drug-using offenders

BACKGROUND

This review represents one in a family of three reviews focusing on the effectiveness of interventions in reducing drug use and criminal activity for offenders.

OBJECTIVES

To assess the effectiveness of interventions for female drug-using offenders in reducing criminal activity, or drug use, or both.

SEARCH METHODS

We searched 12 electronic bibliographic databases up to February 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 13 trials with 2560 participants. Interventions were delivered in prison (7/13 studies, 53%) and community (6/13 studies, 47%) settings. The rating of bias was affected by the lack of clear reporting by authors, and we rated many items as 'unclear'. In two studies (190 participants) collaborative case management in comparison to treatment as usual did not reduce drug use (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.20 to 2.12; 1 study, 77 participants; low-certainty evidence), reincarceration at nine months (RR 0.71, 95% CI 0.32 to 1.57; 1 study, 77 participants; low-certainty evidence), and number of subsequent arrests at 12 months (RR 1.11, 95% CI 0.83 to 1.49; 1 study, 113 participants; low-certainty evidence). One study (36 participants) comparing buprenorphine to placebo showed no significant reduction in self-reported drug use at end of treatment (RR 0.57, 95% CI 0.27 to 1.20) and three months (RR 0.58, 95% CI 0.25 to 1.35); very low-certainty evidence. No adverse events were reported. One study (38 participants) comparing interpersonal psychotherapy to a psychoeducational intervention did not find reduction in drug use at three months (RR 0.67, 95% CI 0.30 to 1.50; low-certainty evidence). One study (31 participants) comparing acceptance and commitment therapy (ACT) to a waiting list showed no significant reduction in self-reported drug use using the Addiction Severity Index (mean difference (MD) -0.04, 95% CI -0.37 to 0.29) and abstinence from drug use at six months (RR 2.89, 95% CI 0.73 to 11.43); low-certainty evidence. One study (314 participants) comparing cognitive behavioural skills to a therapeutic community programme and aftercare showed no significant reduction in self-reported drug use (RR 0.86, 95% CI 0.58 to 1.27), re-arrest for any type of crime (RR 0.73, 95% CI 0.52 to 1.03); criminal activity (RR 0.80, 95% CI 0.63 to 1.03), or drug-related crime (RR 0.95, 95% CI 0.68 to 1.32). A significant reduction for arrested (not for parole) violations at six months follow-up was significantly in favour of cognitive behavioural skills (RR 0.43, 95% CI 0.25 to 0.77; very low-certainty evidence). A second study with 115 participants comparing cognitive behavioural skills to an alternative substance abuse treatment showed no significant reduction in reincarceration at 12 months (RR 0.70, 95% CI 0.43 to 1.12; low certainty-evidence. One study (44 participants) comparing cognitive behavioural skills and standard therapy versus treatment as usual showed no significant reduction in Addiction Severity Index (ASI) drug score at three months (MD 0.02, 95% CI -0.05 to 0.09) and six months (MD -0.02, 95% CI -0.09 to 0.05), and incarceration at three months (RR 0.46, 95% CI 0.04 to 4.68) and six months (RR 0.51, 95% CI 0.20 to 1.27); very low-certainty evidence. One study (171 participants) comparing a single computerised intervention versus case management showed no significant reduction in the number of days not using drugs at three months (MD -0.89, 95% CI -4.83 to 3.05; low certainty-evidence). One study (116 participants) comparing dialectic behavioural therapy and case management (DBT-CM) versus a health promotion intervention showed no significant reduction at six months follow-up in positive drug testing (RR 0.67, 95% CI 0.43 to 1.03), number of people not using marijuana (RR 1.23, 95% CI 0.95 to 1.59), crack (RR 1.00, 95% CI 0.87 to 1.14), cocaine (RR 1.02, 95% CI 0.93 to 1.12), heroin (RR 1.05, 95% CI 0.98 to 1.13), methamphetamine (RR 1.02, 95% CI 0.87 to 1.20), and self-reported drug use for any drug (RR 1.20, 95% CI 0.92 to 1.56); very low-certainty evidence. One study (211 participants) comparing a therapeutic community programme versus work release showed no significant reduction in marijuana use at six months (RR 1.03, 95% CI 0.19 to 5.65), nor 18 months (RR 1.00, 95% CI 0.07 to 14.45), heroin use at six months (RR 1.59, 95% CI 0.49 to 5.14), nor 18 months (RR 1.92, 95% CI 0.24 to 15.37), crack use at six months (RR 2.07, 95% CI 0.41 to 10.41), nor 18 months (RR 1.64, 95% CI 0.19 to 14.06), cocaine use at six months (RR 1.09, 95% CI 0.79 to 1.50), nor 18 months (RR 0.93, 95% CI 0.64 to 1.35). It also showed no significant reduction in incarceration for drug offences at 18 months (RR 1.45, 95% CI 0.87 to 2.42); with overall very low- to low-certainty evidence. One study (511 participants) comparing intensive discharge planning and case management versus prison only showed no significant reduction in use of marijuana (RR 0.79, 95% CI 0.53 to 1.16), hard drugs (RR 1.12, 95% CI 0.88 to 1.43), crack cocaine (RR 1.08, 95% CI 0.75 to 1.54), nor positive hair testing for marijuana (RR 0.75, 95% CI 0.55 to 1.03); it found a significant reduction in arrests (RR 0.19, 95% CI 0.04 to 0.87), but no significant reduction in drug charges (RR 1.07, 95% CI 0.75 to 1.53) nor incarceration (RR 1.09, 95% CI 0.86 to 1.39); moderate-certainty evidence. One narrative study summary (211 participants) comparing buprenorphine pre- and post-release from prison showed no significant reduction in drug use at 12 months post-release; low certainty-evidence. No adverse effects were reported.

AUTHORS' CONCLUSIONS

The studies showed a high degree of heterogeneity for types of comparisons, outcome measures and small samples. Descriptions of treatment modalities are required. On one outcome of arrest (no parole violations), we identified a significant reduction when cognitive behavioural therapy (CBT) was compared to a therapeutic community programme. But for all other outcomes, none of the interventions were effective. Larger trials are required to increase the precision of confidence about the certainty of evidence.

Interventions for drug-using offenders with co-occurring mental health problems

BACKGROUND

This review represents one from a family of three reviews focusing on interventions for drug-using offenders. Many people under the care of the criminal justice system have co-occurring mental health problems and drug misuse problems; it is important to identify the most effective treatments for this vulnerable population.

OBJECTIVES

To assess the effectiveness of interventions for drug-using offenders with co-occurring mental health problems in reducing criminal activity or drug use, or both.This review addresses the following questions.• Does any treatment for drug-using offenders with co-occurring mental health problems reduce drug use?• Does any treatment for drug-using offenders with co-occurring mental health problems reduce criminal activity?• Does the treatment setting (court, community, prison/secure establishment) affect intervention outcome(s)?• Does the type of treatment affect treatment outcome(s)?

SEARCH METHODS

We searched 12 databases up to February 2019 and checked the reference lists of included studies. We contacted experts in the field for further information.

SELECTION CRITERIA

We included randomised controlled trials designed to prevent relapse of drug use and/or criminal activity among drug-using offenders with co-occurring mental health problems.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by Cochrane .

MAIN RESULTS

We included 13 studies with a total of 2606 participants. Interventions were delivered in prison (eight studies; 61%), in court (two studies; 15%), in the community (two studies; 15%), or at a medium secure hospital (one study; 8%). Main sources of bias were unclear risk of selection bias and high risk of detection bias.Four studies compared a therapeutic community intervention versus (1) treatment as usual (two studies; 266 participants), providing moderate-certainty evidence that participants who received the intervention were less likely to be involved in subsequent criminal activity (risk ratio (RR) 0.67, 95% confidence interval (CI) 0.53 to 0.84) or returned to prison (RR 0.40, 95% CI 0.24 to 0.67); (2) a cognitive-behavioural therapy (one study; 314 participants), reporting no significant reduction in self-reported drug use (RR 0.78, 95% CI 0.46 to 1.32), re-arrest for any type of crime (RR 0.69, 95% CI 0.44 to 1.09), criminal activity (RR 0.74, 95% CI 0.52 to 1.05), or drug-related crime (RR 0.87, 95% CI 0.56 to 1.36), yielding low-certainty evidence; and (3) a waiting list control (one study; 478 participants), showing a significant reduction in return to prison for those people engaging in the therapeutic community (RR 0.60, 95% CI 0.46 to 0.79), providing moderate-certainty evidence.One study (235 participants) compared a mental health treatment court with an assertive case management model versus treatment as usual, showing no significant reduction at 12 months' follow-up on an Addictive Severity Index (ASI) self-report of drug use (mean difference (MD) 0.00, 95% CI -0.03 to 0.03), conviction for a new crime (RR 1.05, 95% CI 0.90 to 1.22), or re-incarceration to jail (RR 0.79, 95% CI 0.62 to 1.01), providing low-certainty evidence.Four studies compared motivational interviewing/mindfulness and cognitive skills with relaxation therapy (one study), a waiting list control (one study), or treatment as usual (two studies). In comparison to relaxation training, one study reported narrative information on marijuana use at three-month follow-up assessment. Researchers reported a main effect < .007 with participants in the motivational interviewing group, showing fewer problems than participants in the relaxation training group, with moderate-certainty evidence. In comparison to a waiting list control, one study reported no significant reduction in self-reported drug use based on the ASI (MD -0.04, 95% CI -0.37 to 0.29) and on abstinence from drug use (RR 2.89, 95% CI 0.73 to 11.43), presenting low-certainty evidence at six months (31 participants). In comparison to treatment as usual, two studies (with 40 participants) found no significant reduction in frequency of marijuana use at three months post release (MD -1.05, 95% CI -2.39 to 0.29) nor time to first arrest (MD 0.87, 95% CI -0.12 to 1.86), along with a small reduction in frequency of re-arrest (MD -0.66, 95% CI -1.31 to -0.01) up to 36 months, yielding low-certainty evidence; the other study with 80 participants found no significant reduction in positive drug screens at 12 months (MD -0.7, 95% CI -3.5 to 2.1), providing very low-certainty evidence.Two studies reported on the use of multi-systemic therapy involving juveniles and families versus treatment as usual and adolescent substance abuse therapy. In comparing treatment as usual, researchers found no significant reduction up to seven months in drug dependence on the Drug Use Disorders Identification Test (DUDIT) score (MD -0.22, 95% CI -2.51 to 2.07) nor in arrests (RR 0.97, 95% CI 0.70 to 1.36), providing low-certainty evidence (156 participants). In comparison to an adolescent substance abuse therapy, one study (112 participants) found significant reduction in re-arrests up to 24 months (MD 0.24, 95% CI 0.76 to 0.28), based on low-certainty evidence.One study (38 participants) reported on the use of interpersonal psychotherapy in comparison to a psychoeducational intervention. Investigators found no significant reduction in self-reported drug use at three months (RR 0.67, 95% CI 0.30 to 1.50), providing very low-certainty evidence. The final study (29 participants) compared legal defence service and wrap-around social work services versus legal defence service only and found no significant reductions in the number of new offences committed at 12 months (RR 0.64, 95% CI 0.07 to 6.01), yielding very low-certainty evidence.

AUTHORS' CONCLUSIONS

Therapeutic community interventions and mental health treatment courts may help people to reduce subsequent drug use and/or criminal activity. For other interventions such as interpersonal psychotherapy, multi-systemic therapy, legal defence wrap-around services, and motivational interviewing, the evidence is more uncertain. Studies showed a high degree of variation, warranting a degree of caution in interpreting the magnitude of effect and the direction of benefit for treatment outcomes.

Systematic review of outcome domains and measures used in psychosocial and pharmacological treatment trials for cannabis use disorder

Cannabis use disorder (CUD) is prevalent and demand for treatment is increasing, yet few individuals engage in formal treatment and the efficacy of established interventions for CUD is modest. Existing clinical trials evaluating psychosocial and pharmacological treatments for CUD have incorporated a wide variety of measures for assessing cannabis use outcomes, including abstinence, self-reported frequency and quantity used, withdrawal, use/dependence severity, and other psychosocial outcomes. The heterogeneity of measures and outcomes has limited quantitative analyses of the comparative effectiveness of existing interventions. The purpose of this systematic review is to: 1) identify and characterize approaches for measuring cannabis use in existing CUD intervention trials, including abstinence, frequency and quantity of use, and 2) summarize measures used to assess treatment efficacy in other outcome domains (e.g., cannabis use severity, psychosocial functioning, cannabis withdrawal), and provide a platform for future research to evaluate which outcome measures are most likely to reflect treatment efficacy and clinically significant improvement in other outcome domains.

Psychosocial interventions for cannabis use disorder

BACKGROUND

Cannabis use disorder is the most commonly reported illegal substance use disorder in the general population; although demand for assistance from health services is increasing internationally, only a minority of those with the disorder seek professional assistance. Treatment studies have been published, but pressure to establish public policy requires an updated systematic review of cannabis-specific treatments for adults.

OBJECTIVES

To evaluate the efficacy of psychosocial interventions for cannabis use disorder (compared with inactive control and/or alternative treatment) delivered to adults in an out-patient or community setting.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 6), MEDLINE, EMBASE, PsycINFO, the Cumulaive Index to Nursing and Allied Health Literature (CINAHL) and reference lists of articles. Searched literature included all articles published before July 2015.

SELECTION CRITERIA

All randomised controlled studies examining a psychosocial intervention for cannabis use disorder (without pharmacological intervention) in comparison with a minimal or inactive treatment control or alternative combinations of psychosocial interventions.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by The Cochrane Collaboration.

MAIN RESULTS

We included 23 randomised controlled trials involving 4045 participants. A total of 15 studies took place in the United States, two in Australia, two in Germany and one each in Switzerland, Canada, Brazil and Ireland. Investigators delivered treatments over approximately seven sessions (range, one to 14) for approximately 12 weeks (range, one to 56).Overall, risk of bias across studies was moderate, that is, no trial was at high risk of selection bias, attrition bias or reporting bias. Further, trials included a large total number of participants, and each trial ensured the fidelity of treatments provided. In contrast, because of the nature of the interventions provided, participant blinding was not possible, and reports of researcher blinding often were unclear or were not provided. Half of the reviewed studies included collateral verification or urinalysis to confirm self report data, leading to concern about performance and detection bias. Finally, concerns of other bias were based on relatively consistent lack of assessment of non-cannabis substance use or use of additional treatments before or during the trial period.A subset of studies provided sufficient detail for comparison of effects of any intervention versus inactive control on primary outcomes of interest at early follow-up (median, four months). Results showed moderate-quality evidence that approximately seven out of 10 intervention participants completed treatment as intended (effect size (ES) 0.71, 95% confidence interval (CI) 0.63 to 0.78, 11 studies, 1424 participants), and that those receiving psychosocial intervention used cannabis on fewer days compared with those given inactive control (mean difference (MD) 5.67, 95% CI 3.08 to 8.26, six studies, 1144 participants). In addition, low-quality evidence revealed that those receiving intervention were more likely to report point-prevalence abstinence (risk ratio (RR) 2.55, 95% CI 1.34 to 4.83, six studies, 1166 participants) and reported fewer symptoms of dependence (standardised mean difference (SMD) 4.15, 95% CI 1.67 to 6.63, four studies, 889 participants) and cannabis-related problems compared with those given inactive control (SMD 3.34, 95% CI 1.26 to 5.42, six studies, 2202 participants). Finally, very low-quality evidence indicated that those receiving intervention reported using fewer joints per day compared with those given inactive control (SMD 3.55, 95% CI 2.51 to 4.59, eight studies, 1600 participants). Notably, subgroup analyses found that interventions of more than four sessions delivered over longer than one month (high intensity) produced consistently improved outcomes (particularly in terms of cannabis use frequency and severity of dependence) in the short term as compared with low-intensity interventions.The most consistent evidence supports the use of cognitive-behavioural therapy (CBT), motivational enhancement therapy (MET) and particularly their combination for assisting with reduction of cannabis use frequency at early follow-up (MET: MD 4.45, 95% CI 1.90 to 7.00, four studies, 612 participants; CBT: MD 10.94, 95% CI 7.44 to 14.44, one study, 134 participants; MET + CBT: MD 7.38, 95% CI 3.18 to 11.57, three studies, 398 participants) and severity of dependence (MET: SMD 4.07, 95% CI 1.97 to 6.17, two studies, 316 participants; MET + CBT: SMD 7.89, 95% CI 0.93 to 14.85, three studies, 573 participants), although no particular intervention was consistently effective at nine-month follow-up or later. In addition, data from five out of six studies supported the utility of adding voucher-based incentives for cannabis-negative urines to enhance treatment effect on cannabis use frequency. A single study found contrasting results throughout a 12-month follow-up period, as post-treatment outcomes related to overall reduction in cannabis use frequency favoured CBT alone without the addition of abstinence-based or treatment adherence-based contingency management. In contrast, evidence of drug counselling, social support, relapse prevention and mindfulness meditation was weak because identified studies were few, information on treatment outcomes insufficient and rates of treatment adherence low. In line with treatments for other substance use, abstinence rates were relatively low overall, with approximately one-quarter of participants abstinent at final follow-up. Finally, three studies found that intervention was comparable with treatment as usual among participants in psychiatric clinics and reported no between-group differences in any of the included outcomes.

AUTHORS' CONCLUSIONS

Included studies were heterogeneous in many aspects, and important questions regarding the most effective duration, intensity and type of intervention were raised and partially resolved. Generalisability of findings was unclear, most notably because of the limited number of localities and homogeneous samples of treatment seekers. The rate of abstinence was low and unstable although comparable with treatments for other substance use. Psychosocial intervention was shown, in comparison with minimal treatment controls, to reduce frequency of use and severity of dependence in a fairly durable manner, at least in the short term. Among the included intervention types, an intensive intervention provided over more than four sessions based on the combination of MET and CBT with abstinence-based incentives was most consistently supported for treatment of cannabis use disorder.

Brief school-based interventions and behavioural outcomes for substance-using adolescents

BACKGROUND

Adolescent substance use is a major problem in and of itself, and because it acts as a risk factor for other problem behaviours. As substance use during adolescence can lead to adverse and often long-term health and social consequences, it is important to intervene early in order to prevent progression to more severe problems. Brief interventions have been shown to reduce problematic substance use among adolescents and are especially useful for individuals who have moderately risky patterns of substance use. Such interventions can be conducted in school settings. This review set out to evaluate the effectiveness of brief school-based interventions for adolescent substance use.

OBJECTIVES

To evaluate the effectiveness of brief school-based interventions in reducing substance use and other behavioural outcomes among adolescents compared to another intervention or assessment-only conditions.

SEARCH METHODS

We conducted the original literature search in March 2013 and performed the search update to February 2015. For both review stages (original and update), we searched 10 electronic databases and six websites on evidence-based interventions, and the reference lists of included studies and reviews, from 1966 to February 2015. We also contacted authors and organisations to identify any additional studies.

SELECTION CRITERIA

We included randomised controlled trials that evaluated the effects of brief school-based interventions for substance-using adolescents.The primary outcomes were reduction or cessation of substance use. The secondary outcomes were engagement in criminal activity and engagement in delinquent or problem behaviours related to substance use.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures outlined by The Cochrane Collaboration, including the GRADE approach for evaluating the quality of evidence.

MAIN RESULTS

We included six trials with 1176 adolescents that measured outcomes at different follow-up periods in this review. Three studies with 732 adolescents compared brief interventions (Bls) with information provision only, and three studies with 444 adolescents compared Bls with assessment only. Reasons for downgrading the quality of evidence included risk of bias of the included studies, imprecision, and inconsistency. For outcomes that concern substance abuse, the retrieved studies only assessed alcohol and cannabis. We generally found moderate-quality evidence that, compared to information provision only, BIs did not have a significant effect on any of the substance use outcomes at short-, medium-, or long-term follow-up. They also did not have a significant effect on delinquent-type behaviour outcomes among adolescents. When compared to assessment-only controls, we found low- or very low-quality evidence that BIs reduced cannabis frequency at short-term follow-up in one study (standardised mean difference (SMD) -0.83; 95% confidence interval (CI) -1.14 to -0.53, n = 269). BIs also significantly reduced frequency of alcohol use (SMD -0.91; 95% CI -1.21 to -0.61, n = 242), alcohol abuse (SMD -0.38; 95% CI -0.7 to -0.07, n = 190) and dependence (SMD -0.58; 95% CI -0.9 to -0.26, n = 190), and cannabis abuse (SMD -0.34; 95% CI -0.65 to -0.02, n = 190) at medium-term follow-up in one study. At long-term follow-up, BIs also reduced alcohol abuse (SMD -0.72; 95% CI -1.05 to -0.40, n = 181), cannabis frequency (SMD -0.56; 95% CI -0.75 to -0.36, n = 181), abuse (SMD -0.62; 95% CI -0.95 to -0.29, n = 181), and dependence (SMD -0.96; 95% CI -1.30 to -0.63, n = 181) in one study. However, the evidence from studies that compared brief interventions to assessment-only conditions was generally of low quality. Brief interventions also had mixed effects on adolescents' delinquent or problem behaviours, although the effect at long-term follow-up on these outcomes in the assessment-only comparison was significant (SMD -0.78; 95% CI -1.11 to -0.45).

AUTHORS' CONCLUSIONS

We found low- or very low-quality evidence that brief school-based interventions may be more effective in reducing alcohol and cannabis use than the assessment-only condition and that these reductions were sustained at long-term follow-up. We found moderate-quality evidence that, when compared to information provision, brief interventions probably did not have a significant effect on substance use outcomes. It is premature to make definitive statements about the effectiveness of brief school-based interventions for reducing adolescent substance use. Further high-quality studies examining the relative effectiveness of BIs for substance use and other problem behaviours need to be conducted, particularly in low- and middle-income countries.

Effectiveness of Using Incentives to Improve Parolee Admission and Attendance in Community Addiction Treatment

This study is a randomized effectiveness trial of the use of incentives to improve treatment utilization among parolees in community treatment. In prison, Admission phase parolees were randomized to Admission Incentive (N=31) or Education (N=29). Attendance phase parolees entering community treatment were randomized to Attendance Incentive (N=104) or Education (N=98). There was no main effect for incentives in either study phase. Neither admission to community treatment (Incentive 60%, Education 64%; p =.74), nor intervention completion (Incentive 22%; Education 27%; p =.46) appeared to be impacted. Time-in-treatment was predicted by age, first arrest age, and type of parole status (Cox regression p<.05), but not by treatment group. Providing incentives did not increase the likelihood that parolees enrolled in or stayed in community treatment. In light of this finding, criminal justice practitioners who are considering incentives to increase admission or retention should be aware that they may not produce the desired outcomes.

Clinician-delivered contingency management increases engagement and attendance in drug and alcohol treatment

OBJECTIVE

This study examined the impact of a low-cost contingency management (CM) delivered by program clinicians on treatment attendance and utilization for patients enrolled in outpatient psychosocial substance abuse treatment.

METHODS

The study used a pre-posttest design to compare substance abuse patients who received Reinforcement-Based Treatment (RBT) plus low cost CM (n=130; RBT+CM) to patients who received RBT only (n=132, RBT). RBT+CM participants received a $10 incentive for returning to treatment the day following intake assessment (day one), and a $15 incentive for attending treatment on day five following admission. RBT clients received standard care intervention without the addition of the CM procedures. Groups were compared on proportion of participants who returned to treatment on day one, mean days of treatment attendance, individual sessions attended, and treatment utilization during the first week and the first month following treatment admission.

RESULTS

Both the RBT+CM and RBT group participants returned to the clinic on day one at high rates (95% versus 89%, respectively). However, the RBT group participants were more likely to attend the intake assessment only (i.e., never return to treatment) compared to the RBT+CM participants. Additionally, the RBT+CM participants attended significantly more treatment days, attended more individual counseling sessions, and had higher rates of overall treatment utilization compared to the RBT participants during the one week and one month following treatment admission.

CONCLUSIONS

Findings support the feasibility and effectiveness of a CM intervention delivered by clinicians for increasing treatment attendance and utilization in a community substance abuse program.

Pharmacological interventions for drug-using offenders

BACKGROUND

The review represents one in a family of four reviews focusing on a range of different interventions for drug-using offenders. This specific review considers pharmacological interventions aimed at reducing drug use or criminal activity, or both, for illicit drug-using offenders.

OBJECTIVES

To assess the effectiveness of pharmacological interventions for drug-using offenders in reducing criminal activity or drug use, or both.

SEARCH METHODS

We searched Fourteen electronic bibliographic databases up to May 2014 and five additional Web resources (between 2004 and November 2011). We contacted experts in the field for further information.

SELECTION CRITERIA

We included randomised controlled trials assessing the efficacy of any pharmacological intervention a component of which is designed to reduce, eliminate or prevent relapse of drug use or criminal activity, or both, in drug-using offenders. We also report data on the cost and cost-effectiveness of interventions.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by Cochrane.

MAIN RESULTS

Fourteen trials with 2647 participants met the inclusion criteria. The interventions included in this review report on agonistic pharmacological interventions (buprenorphine, methadone and naltrexone) compared to no intervention, other non-pharmacological treatments (e.g. counselling) and other pharmacological drugs. The methodological trial quality was poorly described, and most studies were rated as 'unclear' by the reviewers. The biggest threats to risk of bias were generated through blinding (performance and detection bias) and incomplete outcome data (attrition bias). Studies could not be combined all together because the comparisons were too different. Only subgroup analysis for type of pharmacological treatment were done. When compared to non-pharmacological, we found low quality evidence that agonist treatments are not effective in reducing drug use or criminal activity, objective results (biological) (two studies, 237 participants (RR 0.72 (95% CI 0.51 to 1.00); subjective (self-report), (three studies, 317 participants (RR 0.61 95% CI 0.31 to 1.18); self-report drug use (three studies, 510 participants (SMD: -0.62 (95% CI -0.85 to -0.39). We found low quality of evidence that antagonist treatment was not effective in reducing drug use (one study, 63 participants (RR 0.69, 95% CI 0.28 to 1.70) but we found moderate quality of evidence that they significantly reduced criminal activity (two studies, 114 participants, (RR 0.40, 95% CI 0.21 to 0.74).Findings on the effects of individual pharmacological interventions on drug use and criminal activity showed mixed results. In the comparison of methadone to buprenorphine, diamorphine and naltrexone, no significant differences were displayed for either treatment for self report dichotomous drug use (two studies, 370 participants (RR 1.04, 95% CI 0.69 to 1.55), continuous measures of drug use (one study, 81 participants, (mean difference (MD) 0.70, 95% CI -5.33 to 6.73); or criminal activity (one study, 116 participants, (RR 1.25, 95% CI 0.83 to 1.88) between methadone and buprenorphine. Similar results were found for comparisons with diamorphine with no significant differences between the drugs for self report dichotomous drug use for arrest (one study, 825 participants, (RR 1.25, 95% CI 1.03 to 1.51) or naltrexone for dichotomous measures of reincarceration (one study, 44 participants, (RR 1.10, 95% CI 0.37 to 3.26), and continuous outcome measure of crime, (MD -0.50, 95% CI -8.04 to 7.04) or self report drug use (MD 4.60, 95% CI -3.54 to 12.74).

AUTHORS' CONCLUSIONS

When compared to non-pharmacological treatment, agonist treatments did not seem effective in reducing drug use or criminal activity. Antagonist treatments were not effective in reducing drug use but significantly reduced criminal activity. When comparing the drugs to one another we found no significant differences between the drug comparisons (methadone versus buprenorphine, diamorphine and naltrexone) on any of the outcome measures. Caution should be taken when interpreting these findings, as the conclusions are based on a small number of trials, and generalisation of these study findings should be limited mainly to male adult offenders. Additionally, many studies were rated at high risk of bias.

Interventions for drug-using offenders with co-occurring mental illness

BACKGROUND

This is an updated version of an original Cochrane review published in Issue 3 2006 (Perry 2006). The review represents one from a family of four reviews focusing on interventions for drug-using offenders. This specific review considers interventions aimed at reducing drug use or criminal activity, or both for drug-using offenders with co-occurring mental illness.

OBJECTIVES

To assess the effectiveness of interventions for drug-using offenders with co-occurring mental illness in reducing criminal activity or drug use, or both.

SEARCH METHODS

We searched 14 electronic bibliographic databases up to May 2014 and 5 Internet resources (searched between 2004 and 11 November 2009). We contacted experts in the field for further information.

SELECTION CRITERIA

We included randomised controlled trials designed to reduce, eliminate, or prevent relapse of drug use and criminal activity, or both in drug-using offenders with co-occurring mental illness. We also reported data on the cost and cost-effectiveness of interventions.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

Eight trials with 2058 participants met the inclusion criteria. The methodological quality of the trials was generally difficult to rate due to a lack of clear reporting. On most 'Risk of bias' items, we rated the majority of studies as unclear. Overall, we could not statistically combine the results due to the heterogenous nature of the different study interventions and comparison groups. A narrative summary of the findings identified that the interventions reported limited success with reducing self report drug use, but did have some impact on re-incarceration rates, but not re-arrest. In the single comparisons, we found moderate-quality evidence that therapeutic communities determine a reduction in re-incarceration but reported less success for outcomes of re-arrest, moderate quality of evidence and self report drug use. Three single studies evaluating case management via a mental health drug court (very low quality of evidence), motivational interviewing and cognitive skills (low and very low quality of evidence) and interpersonal psychotherapy (very low quality of evidence) did not report significant reductions in criminal activity and self report drug use respectively. Quality of evidence for these three types of interventions was low to very low. The trials reported some cost information, but it was not sufficient to be able to evaluate the cost-effectiveness of the interventions.

AUTHORS' CONCLUSIONS

Two of the five trials showed some promising results for the use of therapeutic communities and aftercare, but only in relation to reducing subsequent re-incarceration. Overall, the studies showed a high degree of variation, warranting a degree of caution in the interpretation of the magnitude of effect and direction of benefit for treatment outcomes. More evaluations are required to assess the effectiveness of interventions for drug-using offenders with co-occurring mental health problems.

Interventions for female drug-using offenders

BACKGROUND

This is an updated version of a Cochrane review first published in Issue 3, 2006 (Perry 2006). The review represents one in a family of four reviews focusing on the effectiveness of interventions in reducing drug use and criminal activity for offenders. This specific review considers interventions for female drug-using offenders.

OBJECTIVES

To assess the effectiveness of interventions for female drug-using offenders in reducing criminal activity, or drug use, or both.

SEARCH METHODS

We searched 14 electronic bibliographic databases up to May 2014 and five additional Website resources (between 2004 and November 2011). We contacted experts in the field for further information.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) designed to reduce, eliminate or prevent relapse of drug use or criminal activity in female drug-using offenders. We also reported data on the cost and cost-effectiveness of interventions.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

Nine trials with 1792 participants met the inclusion criteria. Trial quality and risks of bias varied across each study. We rated the majority of studies as being at 'unclear' risk of bias due to a lack of descriptive information. We divided the studies into different categories for the purpose of meta-analyses: for any psychosocial treatments in comparison to treatment as usual we found low quality evidence that there were no significant differences in arrest rates, (two studies; 489 participants; risk ratio (RR) 0.82, 95% confidence interval (CI) 0.45 to 1.52) or drug use (one study; 77 participants; RR 0.65, 95% CI 0.20 to 2.12), but we found moderate quality evidence that there was a significant reduction in reincarceration, (three studies; 630 participants; RR 0.46, 95% CI 0.34 to 0.64). Pharmacological intervention using buprenorphine in comparison to a placebo did not significantly reduce self reported drug use (one study; 36 participants; RR 0.58, 95% CI 0.25 to 1.35). No cost or cost-effectiveness evidence was reported in the studies.

AUTHORS' CONCLUSIONS

Three of the nine trials show a positive trend towards the use of any psychosocial treatment in comparison to treatment as usual showing an overall significant reduction in subsequent reincarceration, but not arrest rates or drug use. Pharmacological interventions in comparison to a placebo did not significantly reduce drug use and did not measure criminal activity. Four different treatment comparisons showed varying results and were not combined due to differences in the intervention and comparison groups. The studies overall showed a high degree of heterogeneity for types of comparisons and outcome measures assessed, which limited the possibility to pool the data. Descriptions of treatment modalities are required to identify the important elements for treatment success in drug-using female offenders. More trials are required to increase the precision of confidence with which we can draw conclusions about the effectiveness of treatments for female drug-using offenders.

Association of race and age with treatment attendance and completion among adult marijuana users in community-based substance abuse treatment

OBJECTIVES

African American youth who use marijuana are less likely to attend and complete treatment than white youth. Limited information is available on racial and age variation in treatment attendance and completion among adults who use marijuana.

METHODS

The current research examined differences in community-based substance abuse treatment attendance and completion between adult African American and white marijuana users in 2 independent samples from the US southeastern (N = 160; 70.6% African American) and mid-Atlantic (N = 450; 34.7% African American) regions.

OUTCOMES

Attended at least 3 treatment sessions, successful treatment completion, number of days in treatment, and percentage of positive urine drug screens. Adjusted regression models examined the association of race, age, and the interaction of race and age with treatment attendance and completion.

RESULTS

In the southeastern sample, successful treatment completion was significantly associated with the interaction of race and age (adjusted odds ratio = 1.35, 95% confidence interval = 1.08-1.69); whereas younger African Americans were less likely to complete treatment than older African Americans, age was unrelated to treatment completion among whites. In the mid-Atlantic sample, African Americans were significantly less likely to attend at least 3 treatment sessions (adjusted odds ratio = 0.37, 95% confidence interval = 0.23-0.58), and younger adult marijuana users were retained for fewer days in treatment (adjusted β = 0.13, 95% confidence interval = 0.27-2.48). Among African Americans, 37.9% (SD = 38.0) of urine drug screens tested positive for at least 1 illicit drug, and among whites, 34.2% (SD = 37.8%) tested positive; the percentage of positive urine drug screens was not associated with race or age.

CONCLUSIONS

Among marijuana-using adults, treatment attendance and completion differ by race and age, and improvements in treatment completion may occur as some African Americans mature out of young adulthood.

Nationwide dissemination of contingency management: the Veterans Administration initiative

BACKGROUND

Contingency management (CM) is an empirically validated intervention but one not often applied in practice settings in the US.

OBJECTIVES

The aim of this article is to describe the Veterans Administration (VA) nationwide implementation of CM treatment.

METHODS

In 2011, the VA called for integration of CM in its intensive outpatient substance abuse treatment clinics. As part of this initiative, the VA funded training and ongoing implementation support, and it provided direct funds for reinforcers and other intervention costs.

RESULTS

Over 100 clinics received this funding in 2011, and CM has been implemented in over 70 substance abuse treatment clinics since August 2011.

CONCLUSIONS

This training and implementation experience has been highly successful and represents the largest scale training in evidence-based treatments for substance use disorders in the VA health care system to date.

SCIENTIFIC SIGNIFICANCE

This program may serve as a model for training in evidence-based treatments.

Solving the problem of non-attendance in substance abuse services

ISSUES

Rates of non-attendance are among the highest in substance misuse services. Non-attendance is costly and results in the inefficient use of limited resources. Patients who frequently miss their appointments have worse outcomes including treatment dropout and decreased likelihood of achieving long-term abstinence.

APPROACH

This narrative review evaluates interventions targeting non-attendance in addiction services and draws upon the wider health-care literature to identify interventions that could be adapted for substance-abusing populations.

KEY FINDINGS

Both fixed value and intermittent reinforcement contingency management demonstrate potential for improving attendance. However, small sample sizes and heterogeneous populations make it difficult to draw firm conclusions. Appointment reminders by letter or telephone have demonstrated moderate evidence for improving attendance in substance-abusing populations. Text message appointment reminders are extensively utilised in general health-care settings and consistently improve attendance; however, there is a paucity of research examining the feasibility and effectiveness of text message reminders in addiction services.

IMPLICATIONS

A lack of evidence for methods to improve attendance is reflected in the continuing challenge faced by addiction services attempting to manage high rates of non-attendance.

CONCLUSIONS

Non-attendance remains a persistent issue for addiction services. While there is limited evidence that contingency management improves attendance, more rigorous research is needed to determine the optimal intervention components and effectiveness in different populations, particularly those receiving maintenance treatments. Multicomponent text message interventions incorporating different delivery and content strategies demonstrate a promise for improving non-attendance and poor engagement.

Brief school-based interventions and behavioural outcomes for substance-using adolescents

BACKGROUND

Adolescent substance use is a major problem, in and of itself and because it acts as a risk factor for other problem behaviours. As substance use during adolescence can lead to adverse and often long-term health and social consequences, it is important to intervene early on in order to prevent progression to more severe problems. Brief interventions have been shown to reduce problematic substance use among adolescents and are especially useful for individuals who have moderately risky patterns of substance use. Such interventions can be conducted in school settings. This review set out to evaluate the effectiveness of brief school-based interventions for adolescent substance use.

OBJECTIVES

To evaluate the effectiveness of brief school-based interventions on reducing substance use and other behavioural outcomes among adolescents compared to another intervention or assessment-only conditions.

SEARCH METHODS

We searched 10 electronic databases and six websites on evidence-based interventions, and the reference lists of included studies and reviews, from 1966 to March 2013. We also contacted authors and organisations to identify any additional studies.

SELECTION CRITERIA

We included randomised controlled trials that evaluated the effects of brief school-based interventions for substance-using adolescents.The primary outcomes were reduction or cessation of substance use. The secondary outcomes were engagement in criminal activity and engagement in delinquent or problem behaviours related to substance use.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures outlined by The Cochrane Collaboration, including the GRADE approach for evaluating the quality of evidence.

MAIN RESULTS

Six studies involving 1139 participants were included in this review. Overall the quality of evidence was moderate in the information provision comparison, and low or very low in the assessment only comparison. Reasons for downgrading the quality included risk of bias of the included studies, imprecision and inconsistency. Our findings suggested that compared to information provision only, brief interventions (BIs) did not have a significant effect on any substance use (three studies, 732 participants, standardised mean difference (SMD) -0.06; 95% confidence interval (CI) -0.20 to 0.09) or delinquent-type behaviour outcomes among adolescents (two studies, 531 participants, SMD -0.26; 95% CI -0.54 to 0.02). When compared to assessment-only controls, BIs had some significant effects on substance use and delinquent-type or problem behaviours, but high levels of heterogeneity existed between studies and it was not always possible to pool the results. When the comparison was with assessment-only conditions, studies of individual interventions that measured BI effectiveness reported significantly reduced substance use in general and in two studies reduced frequency of alcohol use specifically. When the data were pooled, BIs reduced cannabis frequency (SMD -0.22; 95% CI -0.45 to -0.02) across three studies (n = 407). Cannabis quantity was also reduced by BIs in comparison to assessment only (SMD -60.27; 95% CI -66.59 to -53.95) in one study (n = 179). However, the evidence for studies that compared brief interventions to assessment-only conditions was generally of low quality. Brief interventions also had mixed effects on participants' delinquent or problem behaviours.

AUTHORS' CONCLUSIONS

There was limited quality evidence that brief school-based interventions were more effective in reducing substance use than the assessment-only condition, but were similar to information provision. There is some evidence for the effectiveness of BI in reducing adolescent substance use, particularly cannabis, when compared to assessment only. However, it is premature to make definitive statements about the effectiveness of brief school-based interventions for reducing adolescent substance use. Further high quality studies examining the relative effectiveness of BIs for substance use and other problem behaviours need to be conducted, particularly in low- and middle-income countries.

CANDIS treatment program for cannabis use disorders: findings from a randomized multi-site translational trial

BACKGROUND

In a recent paper, we reported the efficacy of a modular cognitive-behavioral intervention for treating adolescents and adults with cannabis use disorders (CUD). In this study, we examine the outcome of this intervention after translating it into clinical practice.

METHODS

A multi-site, randomized controlled trial of 279 treatment seekers with ICD-10 cannabis use disorders aged 16- 63 years was conducted in 11 outpatient addiction treatment centers in Germany. Patients were randomly assigned to an Active Treatment (AT, n=149) or Delayed Treatment Control (DTC, n=130). Treatment consisted of 10 sessions of fully manualized individual psychotherapy that combined Cognitive-Behavioral Therapy, Motivational EnhancementTherapy and problem-solving training. Assessments were conducted at baseline, during each therapy session, at post-treatment and at three and six month follow-ups.

RESULTS

At post assessment 53.3% of AT patients reported abstinence (46.3% negative urine screenings) compared to 22% of DTC patients (17.7% negative drug screenings) (p<0.001, Intention-to-treat analysis). AT patients improved in the frequency of cannabis use, number of cannabis dependence criteria, severity of dependence, as well as number and severity of cannabis-related problems. Effect sizes were moderate to high. While abstinence rates in the AT group decreased over the 3-month (negative urine screenings: 32.4%) and 6-month (negative urine screenings: 35.7%) follow-up periods, the effects in secondary outcomes were maintained.

CONCLUSIONS

The intervention can successfully be translated to and applied in clinical practice. It has the potential to improve access to evidence-based care for chronic CUD patients.

Effectiveness of a self-guided web-based cannabis treatment program: randomized controlled trial

Background

Self-help strategies offer a promising way to address problems with access to and stigma associated with face-to-face drug and alcohol treatment, and the Internet provides an excellent delivery mode for such strategies. To date, no study has tested the effectiveness of a fully self-guided web-based treatment for cannabis use and related problems.

Objectives

The current study was a two-armed randomized controlled trial aimed at testing the effectiveness of Reduce Your Use, a fully self-guided web-based treatment program for cannabis use disorder consisting of 6 modules based on cognitive, motivational, and behavioral principles.

Methods

225 individuals who wanted to cease or reduce their cannabis use were recruited using both online and offline advertising methods and were randomly assigned to receive: (1) the web-based intervention, or (2) a control condition consisting of 6 modules of web-based educational information on cannabis. Assessments of cannabis use, dependence symptoms, and abuse symptoms were conducted through online questionnaires at baseline, and at 6-week and 3-month follow-ups. Two sets of data analyses were undertaken—complier average causal effect (CACE) modeling and intention to treat (ITT).

Results

Two thirds (149) of the participants completed the 6-week postintervention assessment, while 122 (54%) completed the 3-month follow-up assessment. Participants in the intervention group completed an average of 3.5 of the 6 modules. The CACE analysis revealed that at 6 weeks, the experimental group reported significantly fewer days of cannabis use during the past month (P=.02), significantly lower past-month quantity of cannabis use (P=.01), and significantly fewer symptoms of cannabis abuse (P=.047) relative to controls. Cannabis dependence symptoms (number and severity) and past-month abstinence did not differ significantly between groups (Ps>.05). Findings at 3 months were similar, except that the experimental group reported significantly fewer and less severe cannabis dependence symptoms (Ps<.05), and past-month quantity of cannabis consumed no longer differed significantly between groups (P=.16). ITT analyses yielded similar outcomes.

Conclusion

Findings suggest that web-based interventions may be an effective means of treating uncomplicated cannabis use and related problems and reducing the public health burden of cannabis use disorders.

Trial registration

ACTRN12609000856213, Australian New Zealand Clinical Trials Registry.

Bupropion reduces some of the symptoms of marihuana withdrawal in chronic marihuana users: a pilot study

Bupropion’s (Zyban^® SR) effectiveness to treat symptoms experienced in marihuana withdrawal was tested in a double-blind, placebo-controlled study with chronic, heavy marihuana users. Participants maintained their usual marihuana intake until Quit Day after which they were required to cease intake of THC products for 14 days. A Withdrawal Discomfort Score revealed that for 7 days immediately following cessation, placebo-treated subjects reported more symptoms than bupropion-treated subjects. Self-reported craving for marihuana increased for the placebo-treated group but not for those treated with bupropion. Measures of sleep and cognitive performance were not different between the two groups. Participants in the bupropion treatment arm were more likely to complete the study than those randomized to the placebo arm (50% completion for bupropion vs. 33% completion for placebo). These results suggest that bupropion may be useful for alleviating marihuana withdrawal symptoms and be useful in subject retention during long-term cessation programs.

A pilot study of low-cost contingency management to increase attendance in an adolescent substance abuse program

Numerous studies demonstrate the efficacy of contingency management (CM) for improving patient outcomes, yet it is rarely used in treatment settings due to the high cost of implementation. This quasi-experimental study (N = 52) examined the effect of a low-cost "Fishbowl" CM intervention on attendance/retention in an early intervention adolescent substance abuse program. The CM group attended significantly more sessions compared to the control group. Furthermore, the CM intervention costs $3.27 per patient per session. Our findings support the use of low-cost CM to improve adolescent attendance in clinical settings.

State of the art treatments for cannabis dependence

The treatment of cannabis dependence can be viewed as a cup half empty or half full. On the one hand, few people who might benefit from treatment actually receive it. Among those who undergo treatment in randomized trials, long-term abstinence is achieved by fewer than 20%. Moderate use goals have been associated with decreases in consequences, but the differential impact of such goals on the long-term course of cannabis dependence is unknown. Optimal duration of treatment is unclear, and certain populations, particularly patients with co-occurring disorders, have not been studied adequately. Twelve-step programs are low cost, effective for other substance use disorders, and readily available in most regions of the world. However, their role and efficacy in cannabis dependence has not been examined. Finally, effective pharmacologic treatments are under development, but none have yet been firmly established. On the other hand, psychotherapeutic strategies used to treat other substance use disorders can be effective for cannabis dependence. A recent meta-analysis of psychosocial interventions for illicit substance use disorders found that treatments for cannabis dependence had comparatively larger effect sizes than treatments for other substance use disorders. Combination therapies have proven most effective, particularly those that begin with a motivational intervention, utilize incentives to enhance the commitment to change, and teach behavioral and cognitive copings skills to prevent relapse. Among adolescents, family engagement and collaboration with community stakeholders adds substantial value. Although only 9% of cannabis users develop cannabis dependence, the volume of people who smoke cannabis ensures that the total number of people in need of help is larger than the capacity of substance abuse specialty services. Thus, although efforts to refine and improve the efficacy of treatment interventions continue, innovations that increase the availability and accessibility of treatment are also needed. Computer- and phone-based interventions, social media, and brief interventions that can be implemented in primary care settings are areas that may hold promise for reaching at-risk populations. Adolescents and persons with co-occurring mental illness are at particularly high risk of cannabis dependence, and may suffer disproportionately from cannabis’s adverse effects. As in the treatment of other substance use disorders, there is a need for a continuing care model with long-term follow-up that extends past the periods typically evaluated in treatment studies. Additionally, there is a need for further investigation of genetic underpinnings and endophenotypes underlying cannabis dependence to identify neurobiological mechanisms for targeted intervention. One benefit of the societal focus on cannabis has been a prominent increase in research covering everything from the basic science to public health impact of cannabis. Over the next decade, physicians who provide treatment for individuals with cannabis dependence are likely to see their armamentarium of effective interventions expand, to the ultimate betterment of patients, their families, and society at large.

Linking basic and advanced motivational interviewing training outcomes for juvenile correctional staff in California

Motivational interviewing (MI) is an evidence-based communication method that can be effective in engaging incarcerated juveniles in substance abuse programming and other treatment services. However, MI can be difficult to learn and often requires several training exposures for skill change. Few studies have examined MI training outcomes over time. This study reports outcomes for 222 juvenile corrections workers trained in MI in a three-day introductory and two-day advanced training. MI skills were measured via video-administered pre- and post-tests and with a written questionnaire. Combined results from a linear mixed model found that overall MI skills were positively associated with staff education level, and negatively associated with age and time between trainings. Those who attended their second training within nine months of the first training were more likely to score in the proficiency range. Motivation to use MI, belief in its efficacy with youth, job classification, and sex were not related to skill attainment.

Adding positive reinforcement in justice settings: acceptability and feasibility

Although contingency management (CM) approaches are among the most promising methods for initiating drug abstinence (S. T. Higgins, S. M. Alessi, & R. L. Dantona, 2002; S. T. Higgins, S. H. Heil, & J. P. Lussier, 2004), adoption and implementation of CM protocols into treatment programs are both challenging and infrequent. In criminal justice agencies, where roughly 70% of clients report substance abuse issues (F. S. Taxman, K. L. Cropsey, D. W. Young, & H. Wexler, 2007), CM interventions are virtually nonexistent. The Justice Steps (JSTEPS) study uses a longitudinal, mixed-method design to examine the implementation of a CM-based protocol in five justice settings. This article presents qualitative data collected during Phase 1 of the JSTEPS project regarding the acceptability and feasibility of CM in these justice settings. The study finds a level of acceptability (find CM tolerable) and feasibility (find CM suitable) within justice agencies, but with some challenges. These challenges are reflected in the following: (a) incorporating too many desired target behaviors into CM models; (b) facing intraorganizational challenges when designing CM systems; and (c) emphasizing sanctions over rewards despite the evidence-base for positive reinforcers. These findings have implications for advancing the dissemination, adoption, and implementation of evidence-based treatments (and CM in particular) in criminal justice settings.

ENROLLING AND ENGAGING HIGH-RISK YOUTH AND FAMILIES IN COMMUNITY-BASED, BRIEF INTERVENTION SERVICES

Increasing interest has been shown in Brief Interventions for troubled persons, including those with substance abuse problems. Most of the published literature on this topic has focused on adults, and on the efficacy of these interventions. Few of these studies have examined the critical issues of enrollment and engagement in Brief Intervention services. The present paper seeks to address the shortcomings in the current literature by reporting on our experiences implementing NIDA funded, Brief Intervention projects involving truant and diversion program youth.

Varenicline versus bupropion XL for smoking cessation in older adolescents: a randomized, double-blind pilot trial

INTRODUCTION

Despite tremendous potential public health impact, little work has focused on development of evidence-based smoking cessation treatments for adolescents, including pharmacotherapies. No prior studies have explored the feasibility and safety of varenicline and bupropion XL, 2 potentially promising pharmacotherapies, as smoking cessation treatments in adolescents.

METHODS

Treatment-seeking older adolescent smokers (ages 15-20) were randomized (double-blind) to varenicline (n = 15) or bupropion XL (n = 14), with 1-week titration and active treatment for 7 weeks. Structured safety, tolerability, and efficacy assessments (cotinine-confirmed 7-day point prevalence abstinence) were conducted weekly.

RESULTS

There were no serious adverse events. Two participants discontinued bupropion XL due to adverse effects, and none discontinued varenicline. Over the course of treatment, participants receiving varenicline reduced from 14.1 ± 6.3 (mean ± SD) to 0.9 ± 2.1 cigarettes/day (CPD, 4 achieved abstinence), while those receiving bupropion XL reduced from 15.8 ± 4.4 to 3.1 ± 4.0 CPD (2 achieved abstinence).

CONCLUSIONS

These preliminary results support the feasibility and safety of conducting adequately powered, placebo-controlled efficacy studies of varenicline and bupropion XL for adolescent smoking cessation.

Untersuchungskonzept für die CANDIS 1CANnabis DISorders -Studie zur Behandlung von cannabisbezogenen Störungen: Ein Beispiel translationaler Forschung

Zielsetzung: Es wird ein zweistufiges Untersuchungskonzept vorgestellt, das zunächst die Entwicklung und Überprüfung der Wirksamkeit eines Behandlungsprogramms für Cannabisstörungen unter Forschungsbedingungen umfasst. Anschließend erfolgt die Prüfung der Wirksamkeit des Programms unter Praxisbedingungen in Einrichtungen der ambulanten Suchtkrankenhilfe in Deutschland. Methodik: In der ersten Phase wurde ein manualisiertes Behandlungsprogramm für Jugendliche (> = 16 Jahre) und Erwachsene mit Cannabisstörungen entwickelt und im Rahmen einer randomisiert-kontrollierten Effektivitätsstudie mit n = 97 Teilnehmern überprüft. Die Behandlung umfasste 10 Sitzungen und kombinierte Motivationsförderung, kognitiv-behaviorale Therapie und ein psychosoziales Problemlösetraining. Neben einer standardisierten Therapie (ST) wurde auch eine individualisiertere, standardisierte Form (TST) in ihrer Wirksamkeit gegenüber einer Wartekontrollgruppe getestet. In der zweiten Phase wurde eine mehrstufige, multizentrische randomisiert-kontrollierte Transferstudie in n = 11 Einrichtungen der ambulanten Suchtkrankenhilfe durchgeführt. Wirksamkeit, Machbarkeit und Akzeptanz der standardisierten Therapieversion wurden in einer Stichprobe von n = 279 Patienten geprüft. Schlussfolgerungen: Das zweistufige Konzept, als Beispiel einer gezielten translationalen Forschung zur Anwendung grundlagenbasierter Interventionsprinzipien in einem praxisrelevanten Therapieprogramm, konnte von 2004 bis 2009 umgesetzt werden. Die Erfahrungen belegen, dass ein anspruchsvoller Untersuchungsplan zur Wirksamkeitsprüfung therapeutischer Interventionen auch in Einrichtungen der Versorgung umgesetzt werden kann. Weiterhin konnte gezeigt werden, dass auch Transferfragestellungen zur Adäquatheit, Machbarkeit und Akzeptanz eines Therapieprogrammes in ein wissenschaftliches Untersuchungskonzept einbezogen werden können.

Motivational interviewing for substance abuse

BACKGROUND

There are 76.3 million people with alcohol use disorders worldwide and 15.3 million with drug use disorders. Motivational interviewing (MI) is a client-centred, semi-directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. The intervention is used widely, and therefore it is important to find out whether it helps, harms or is ineffective.

OBJECTIVES

To assess the effectiveness of motivational interviewing for substance abuse on drug use, retention in treatment, readiness to change, and number of repeat convictions.

SEARCH STRATEGY

We searched 18 electronic databases, 5 web sites, 4 mailing lists, and reference lists from included studies and reviews. Search dates were November 30, 2010 for Cochrane Library, Medline, Embase and PsychINFO.

SELECTION CRITERIA

Randomized controlled trials with persons dependent or abusing substance. Interventions were MI or motivational enhancement therapy. The outcomes were extent of substance abuse, retention in treatment, motivation for change, repeat conviction.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed studies for inclusion, and two authors extracted data. Results were categorized into (1) MI versus no-treatment control, (2) MI versus treatment as usual, (3) MI versus assessment and feedback, and (4) MI versus other active treatment. Within each category, we computed meta-analyses separately for post-intervention, short, medium and long follow-ups.

MAIN RESULTS

We included 59 studies with a total of 13,342 participants. Compared to no treatment control MI showed a significant effect on substance use which was strongest at post-intervention SMD 0.79, (95% CI 0.48 to 1.09) and weaker at short SMD 0.17 (95% CI 0.09 to 0.26], and medium follow-up SMD 0.15 (95% CI 0.04 to 0.25]). For long follow-up, the effect was not significant SMD 0.06 (95% CI-0.16 to 0.28). There were no significant differences between MI and treatment as usual for either follow-up post-intervention, short and medium follow up. MI did better than assessment and feedback for medium follow-up SMD 0.38 (95% CI 0.10 to 0.66). For short follow-up, there was no significant effect . For other active intervention there were no significant effects for either follow-up.There was not enough data to conclude about effects of MI on the secondary outcomes.

AUTHORS' CONCLUSIONS

MI can reduce the extent of substance abuse compared to no intervention. The evidence is mostly of low quality, so further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

The epidemiology of cannabis use and cannabis-related harm in Australia 1993-2007

AIMS

To examine trends in patterns of cannabis use and related harm in the Australian population between 1993 and 2007.

DESIGN

Analysis of prospectively collected data from: (1) the National Drug Strategy Household Survey (NDSHS) and Australian Secondary Student Alcohol and Drug Survey (ASSADS); (2) the National Hospital Morbidity Database (NHMD); and (3) the Alcohol and Other Drug Treatment Services National Minimum Dataset (AODTS-NMDS).

PARTICIPANTS

Australians aged 14 years and over from the general population; students aged 12-17 years; public and private hospital in-patients; public and private in-patients and out-patients attending for drug treatment.

MEASUREMENT

Prevalence of 12-month cannabis use among the general population and secondary students. Proportions in the general population by age group reporting: daily cannabis use; difficulties in controlling cannabis use; and heavy cannabis use on each occasion. Number of hospital and treatment presentations for cannabis-related problems.

FINDINGS

Prevalence of past-year cannabis use has declined in the Australian population since the late 1990s. Among those reporting past-year use, daily use is prevalent among 40-49-year-olds, while heavy patterns of use are prevalent among 14-19-year-olds. Hospital presentations for cannabis-related problems reflect similar trends. Past-year cannabis use has decreased among the 10-19-year age group, but those who are daily users in this age group report using large quantities of cannabis.

CONCLUSIONS

Despite declines in the prevalence of cannabis use, continued public health campaigns warning of the harms associated with cannabis use are essential, aimed particularly at users who are already experiencing problems. The increasing demand for treatment for cannabis problems in Australia suggests the need for more accessible and more effective interventions for cannabis use disorders.

Intervenções farmacológica e psicossocial para os distúrbios por uso da cannabis

OBJETIVO: A cannabis continua sendo a substância ilegal mais amplamente utilizada na maioria dos países desenvolvidos. Seu potencial aditivo foi estabelecido e a necessidade de intervenções em problemas relacionados à cannabis se tornou clara. Este artigo faz uma revisão sobre as pesquisas que avaliam os tratamentos potenciais para transtornos por uso de cannabis. MÉTODO: Uma busca nos bancos de dados de publicações identificou os estudos e revisões na literatura científica sobre as intervenções psicossociais e farmacológicas nos transtornos por uso de cannabis. RESULTADOS: Para adultos, as intervenções com base comportamental geram efeitos positivos significativos na abstinência e nas reduções no uso de cannabis. Em adolescentes, tratamentos similares e intervenções com base na família demonstraram eficácia. Entre os estudos, os índices de resposta parecem ser modestos mesmo com os mais potentes tratamentos psicossociais. As avaliações das abordagens farmacológicas para os transtornos por uso de cannabis têm ainda que fornecer dados sobre a eficácia clínica de qualquer medicação específica. Enfoques baseados em agonistas e antagonistas parecem ser os mais promissores. Os avanços na compreensão da neurobiologia do sistema canabinoide são fonte de otimismo no sentido de que a síntese de compostos que alteram o funcionamento do sítio receptor CB1 possa produzir medicações promissoras. CONCLUSÃO: As pesquisas clínicas identificaram tratamentos psicossociais eficazes, mas ainda não produziram farmacoterapias eficazes. Muitos estudos ainda têm que ser feitos para aumentar a potência e o acesso às intervenções para aqueles que buscam o tratamento para transtornos por uso de cannabis.

Contingency management for attendance to group substance abuse treatment administered by clinicians in community clinics

Contingency management (CM) is effective in enhancing retention in therapy. After an 8-week baseline, four community-based substance abuse treatment clinics were exposed in random order to 16 weeks of standard care with CM followed by 16 weeks of standard care without CM or vice versa. In total, 75 outpatients participated. Patients who were enrolled in the clinics when the CM treatment phase was in effect attended a significantly greater percentage of therapy sessions than patients who were enrolled in treatment when CM was not in effect. This study is one of the first to investigate CM in community settings implemented entirely by community clinicians, and results suggest that CM is effective in improving therapy attendance.

A randomized controlled pilot study of motivational interviewing for patients with psychotic and drug use disorders

AIMS

This pilot study examined the efficacy of a two-session motivational interview adapted for dually diagnosed psychotic and drug-related disordered patients (DDMI) in comparison to a two-session standard psychiatric interview (SI).

DESIGN

The study used a randomized controlled trial design. Participants received either DDMI or SI and were assessed at baseline, 4-, 8- and 12-week follow-up points. The principal analysis for examination of treatment effects across time was a random effects regression model.

SETTING

Both DDMI and SI interviews served as pre-admission intake interventions to an ambulatory specialty dual diagnosis intensive out-patient and partial hospital program.

PARTICIPANTS

Forty-four treatment-seeking participants (DDMI = 24; SI = 20) who had co-occurring psychotic and drug-related disorders were assigned randomly to the treatment conditions. Measurements Primary outcomes were days of primary drug use, secondary drug use, alcohol use and psychotropic medication adherence, proportion of participants admitted into the program and days of attendance.

FINDINGS AND CONCLUSIONS

DDMI and SI resulted in improved treatment outcomes, but there were no main effects for the sample as a whole. Separate examination of primary cocaine and primary marijuana using subsamples, however, suggested that DDMI resulted in significantly better primary drug treatment outcomes for the cocaine-using group, whereas SI resulted in significantly better primary drug treatment outcomes for the marijuana-using group. These findings indicate that MI may not work equally well for all types of psychotic disordered dually diagnosed patients and that alternative approaches may be as effective in fostering improved substance use treatment outcomes for subgroups of these individuals.

Psychotherapeutic interventions for cannabis abuse and/or dependence in outpatient settings

BACKGROUND

Cannabis use disorder is the most common illicit substance use disorder in general population. Despite that, only a minority seek assistance from a health professional, but the demand for treatment is now increasing internationally. Trials of treatment have been published but to our knowledge, there is no published systematic review .

OBJECTIVES

To evaluate the efficacy of psychosocial interventions for cannabis abuse or dependence.

SEARCH STRATEGY

We searched the Cochrane Central Register of Trials (CENTRAL) The Cochrane Library Issue 3, 2004; MEDLINE (January 1966 to August 2004), PsycInfo (1985 to October 2004), CINAHL (1982 to October 2004), Toxibase (until September 2004) and reference lists of articles. We also contacted researchers in the field.

SELECTION CRITERIA

All randomized controlled studies examining a psychotherapeutic intervention for cannabis dependence or abuse in comparison with a delayed-treatment control group or combinations of psychotherapeutic interventions.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data

MAIN RESULTS

Six trials involving 1297 people were included. Five studies took place in the United States, one in Australia. Studies were not pooled in meta-analysis because of heterogeneity. The six included studies suggested that counseling approaches might have beneficial effects for the treatment of cannabis dependence. Group and individual sessions of cognitive behavioral therapy (CBT) had both efficacy for the treatment of cannabis dependence and associated problems, CBT produced better outcomes than a brief intervention when CBT was delivered in individual sessions. Two studies suggested that adding voucher-based incentives may enhance treatment when used in combination with other effective psychotherapeutic interventions. Abstinence rates were relatively small overall but favored the individual CBT 9-session (or more) condition. All included trials reported a statistically significant reductions in frequency of cannabis use and dependence symptoms. But other measures of problems related to cannabis use were not consistently different.

AUTHORS' CONCLUSIONS

The included studies were too heterogenous and could not allow to draw up a clear conclusion. The studies comparing different therapeutic modalities raise important questions about the duration, intensity and type of treatment. The generalizability of findings is also unknown because the studies have been conducted in a limited number of localities with fairly homogenous samples of treatment seekers. However, the low abstinence rate indicated that cannabis dependence is not easily treated by psychotherapies in outpatient settings.

A meta-analysis of voucher-based reinforcement therapy for substance use disorders

AIMS

To systematically investigate the effectiveness of voucher-based reinforcement therapy for the treatment of substance use disorders.

METHODS

Effect sizes and 95% confidence intervals were calculated for studies published between January 1991 and March 2004 that utilized voucher-based reinforcement therapy (VBRT) or related monetary-based incentives to treat substance use disorders (SUDs).

FINDINGS

Thirty studies involved interventions targeting abstinence from drug use using experimental designs where effects on treatment outcome could be attributed to the VBRT intervention. The estimated average effect size (r) for those studies was 0.32 (95% CI 0.26-0.38). Analyses of variables thought to moderate VBRT effect sizes revealed that more immediate voucher delivery and greater monetary value of the voucher were associated with larger effect sizes. Additional studies were identified wherein VBRT was used to target clinic attendance (n = 6) or medication compliance (n = 4). VBRT studies targeting attendance produced average effect sizes of 0.15 (95% CI 0.02-0.28), while those that targeted medication compliance produced an average effect of 0.32 (95% CI 0.15-0.47). No significant moderators were identified for these 10 studies.

CONCLUSIONS

Overall, VBRT generated significantly better outcomes than did control treatments. These results further support the efficacy of VBRT, quantify the magnitude of its effects, identify significant moderators and suggest potential directions for future research.