Category: RCT

Reduce alcohol consumption in illicit drug users: In the news

glass, dollar bill and cocaine

In 2012, we reviewed the evidence for talking therapies to reduce drinking among people who also use other drugs.  This review was published by the Cochrane collaboration and updated in November 2014. Seven months ago, Olivia Maynard, a research associate from the University of Bristol, gives a wonderful summary of the updated review.

Whilst we all know that excessive alcohol consumption is bad for our health, illicit drug users are one group for whom problem alcohol use can be especially harmful, causing serious health consequences.

The prevalence of the hepatitis C virus is high among illicit drug users and problem alcohol use contributes to a poorer prognosis of this disease by increasing its progression to other diseases. In addition, rates of anxiety, mood and personality disorders are higher among illicit drug users, each of which is exacerbated by problem alcohol use.
Despite these health consequences, the prevalence of problem alcohol use is high among illicit drug users, with around 38% of opiate- and 45% of stimulant-using treatment-seeking individuals having co-occurring alcohol use disorders (Hartzler 2010; Hartzler 2011).
Previous Cochrane reviews have investigated the effectiveness of psychosocial interventions (or ‘talking therapies’) for either problem alcohol use, or illicit drug use alone. However, none have investigated the effectiveness of these therapies for individuals with concurrent problem alcohol and illicit drug use. Given the significant health risk and the high prevalence of concurrent problem alcohol and illicit drug use, a Cochrane review of this kind is long over-due.
Luckily, Kilmas and colleagues have done the hard work for us and their comprehensive Cochrane review of the literature evaluates the evidence for talking therapies for alcohol reduction among illicit drug users (Klimas et al, 2014).
This updated Cochrane review looks at psychotherapy for concurrent problem alcohol and illicit drug use.
This updated Cochrane review looks at psychotherapy for concurrent problem alcohol and illicit drug use.
The talking therapies we’re concerned with here are psychologically based interventions, which aim to reduce alcohol consumption without using any pharmacological (i.e. drug-based) treatments. Although there’s a wide range of different talking therapies currently used in practice, the ones which are discussed in this Cochrane review are:
  • Motivational interviewing (MI): this uses a client-centered approach, where the client’s readiness to change and their motivation, is a key component of the therapy.
  • Cognitive-behavioural therapy (CBT): this focuses on changing the way a client thinks and behaves. To address problem alcohol use, CBT approaches identify the triggers associated with drug use and use behavioural techniques to prevent relapse.
  • Brief interventions (BI): often BIs are based on the principles of MI and include giving advice and information. However, as implied by the name, BIs tend to be shorter and so are more suitable for non-specialist facilities.
  • The 12-step model: this is the approach used by Alcoholics Anonymous and operates by emphasising the powerlessness of the individual over their addiction. It then uses well-established therapeutic approaches, such as group cohesiveness and peer pressure to overcome this addiction.

Methods

  • The Cochrane review included all randomised controlled trials which compared psychosocial interventions with another therapy (whether that be other psychosocial therapies (to allow for comparison between therapies), pharmacological therapies, or placebo). Participants were adult illicit drug users with concurrent problem alcohol use
  • Four studies were included, involving 594 participants in total
  • The effectiveness of these interventions were assessed and the authors were most interested in the impact of these therapies on alcohol use, but were also interested in their impact on illicit drug use, participants’ engagement in further treatment and differences in alcohol related harms
  • The quality of the studies was also assessed
The quality of trials included in this review could certainly have been a lot better.
The quality of trials included in this review could certainly have been a lot better.

Results

The four studies were very different, each comparing different therapies:
  • Study 1: cognitive-behavioural therapy versus the 12-step model (Carroll et al, 1998)
  • Study 2: brief intervention versus treatment as usual (Feldman et al 2013)
  • Study 3: group or individual motivational interviewing versus hepatitis health promotion (Nyamathi et al, 2010)
  • Study 4: brief motivational intervention versus assessment only (Stein et al, 2002)
Due to this heterogeneity, the results could not be combined and so each study was considered separately. Of the four studies, only Study 4 found any meaningful differences between the therapies compared. Here, participants in the brief motivational intervention condition had reduced alcohol use (by seven or more days in the past month at 6-month follow up) as compared with the control group (Risk Ratio 1.67; 95% Confidence Interval 1.08 to 2.60; P value = 0.02). However, no other differences were observed for other outcome measures.
Overall, the review found little evidence that there are differences in the effectiveness of talking therapies in reducing alcohol consumption among concurrent alcohol and illicit drug users.
The authors of this review also bemoan the quality of the evidence provided by the four studies and judged them to be of either low or moderate quality, failing to account for all potential sources of bias.
The review found no evidence that any of the four therapies was a winner when it came to reducing alcohol consumption in illicit drug users.
The review found no evidence that any of the four therapies was a winner when it came to reducing alcohol consumption in illicit drug users.

Conclusions

So, what does this all mean for practice?
In a rather non-committal statement, which reflects the paucity of evidence available, the authors report that:
based on the low-quality evidence identified in this review, we cannot recommend using or ceasing psychosocial interventions for problem alcohol use in illicit drug users.
However, the authors suggest that similar to other conditions, early intervention for alcohol problems in primary care should be a priority. They also argue that given the high rates of co-occurrence of alcohol and drug problems, the integration of therapy for these two should be common practice, although as shown here, the evidence base to support this is currently lacking.
And what about the comparison between the different talking therapies?
Again, rather disappointingly, the authors report that:
no reliable conclusions can be drawn from these data regarding the effectiveness of different types of psychosocial interventions for the target condition.
How about the implications for research? What do we still need to find out?
This review really highlights the scarcity of well-reported, methodologically sound research investigating the effectiveness of psychosocial interventions for alcohol and illicit drug use and the authors call for trials using robust methodologies to further investigate this.
Choosing a therapy for this group of patients is difficult with insufficient evidence to support our decision.
Choosing a therapy for this group of patients is difficult with insufficient evidence to support our decision.

Links

Klimas J, Tobin H, Field CA, O’Gorman CSM, Glynn LG, Keenan E, Saunders J, Bury G, Dunne C, Cullen W. Psychosocial interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users. Cochrane Database of Systematic Reviews 2014, Issue 12. Art. No.: CD009269. DOI: 10.1002/14651858.CD009269.pub3.
Hartzler B, Donovan DM, Huang Z. Comparison of opiate-primary treatment seekers with and without alcohol use disorderJournal of Substance Abuse Treatment 2010;39 (2):114–23.
Carroll, K.M., Nich, C. Ball, S.A, McCance, E., Rounsavile, B.J. Treatment of cocaine and alcohol dependence with psychotherapy and dislfram. Addiction 1998; 93(5):713-27. [PubMed abstract]
Feldman N, Chatton A, Khan R, Khazaal Y, Zullino D. Alcohol-related brief intervention in patients treated for opiate or cocaine dependence: a randomized controlled studySubstance Abuse Treatment, Prevention, and Policy 2011;6(22):1–8.
Nyamathi A, Shoptaw S,Cohen A,Greengold B,Nyamathi K, Marfisee M, et al. Effect of motivational interviewing on reduction of alcohol useDrug Alcohol Dependence 2010;107(1):23–30. [1879–0046: (Electronic)]
Stein MD, Charuvastra A, Makstad J, Anderson BJ. A randomized trial of a brief alcohol intervention for needle exchanges (BRAINE). Addiction 2002;97(6):691. [:09652140] [PubMed abstract]

 

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Olivia Maynard

Olivia Maynard
Olivia is a Research Associate in the Tobacco and Alcohol Research Group at the University of Bristol, United Kingdom. Her research interests are primarily in the area of investigating the causes and consequences of unhealthy behaviours, and developing interventions to encourage healthy behaviour change, with a particular focus on tobacco and alcohol use. Her PhD, focussed on assessing the effects of plain packaging of tobacco products on behaviour. You can follow her on Twitter @OliviaMaynard17 and the research group she is part of @BristolTARG.

– See more at: http://www.thementalelf.net/mental-health-conditions/substance-misuse/reducing-alcohol-consumption-in-illicit-drug-users-new-cochrane-review-on-psychotherapies/#sthash.nhqsnqPW.dpuf

Reducing alcohol consumption in illicit drug users

Which talking therapies work for drug users with alcohol problems? A Cochrane update

Have you ever had an unresolved question and you kept asking again, again and again, until you got the answer? We wanted to find out whether talking therapies have an impact on alcohol problems in adult people who use illicit drugs (mainly opiates and stimulants), and which therapy is the best. We queried the scientific literature in 2012 and this year again.

Drinking above the recommended safe drinking limits can lead to serious alcohol problems or dependence. Excessive drinking in people who also have problems with other drugs is common and often makes these problems worse; their health deteriorates. Talking therapies may help people drink less but their impact in people who also have problems with other drugs is unknown. Talking treatments were the focus for an updated Cochrane review (Figure 1) published today (Dec 3).
Figure 1. Cochrane
We found four studies that included 594 people with drug problems. One study focused on the way people think and act, versus an approach based on Alcoholics Anonymous, aiming to motivate the person to develop a desire to stop using drugs or alcohol. One study looked at a practice that aimed to identify an alcohol problem and motivate the person to do something about it, versus usual treatment. One study looked at a counselling style for helping people to explore and resolve doubts about changing their behaviour (group and individual form), versus hepatitis health promotion. The last study looked at the same style versus assessment only.
In sum, the studies were so different that we could not combine their results to answer our question. As of June 2014, we still don’t know whether talking therapies affect drinking in people who have problems with both alcohol and other drugs because of the low quality of the evidence. We still don’t know whether talking therapies for drinking affect illicit drug use in people who have problems with both alcohol and other drugs. There was not enough information to compare different types of talking therapies. Many of the studies did not account for possible sources of bias. New clinical trials would help us to answer our question.
Citation example: Klimas J, Tobin H, Field C-A, O’Gorman CSM, Glynn LG, Keenan E, Saunders J, Bury G, Dunne C, Cullen W. Psychosocial interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users. Cochrane Database of Systematic Reviews 2014 , Issue 11 . Art. No.: CD009269. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009269.pub3/abstract

Cochrane is a global independent network of health practitioners, researchers, patient advocates and others, responding to the challenge of making the vast amounts of evidence generated through research useful for informing decisions about health. Read more at www.cochrane.org

How Cochrane Keeps the Addiction Science in Check

Science isn’t infallible. Humans make mistakes even in this highly sophisticated method of understanding the world around us. Thanks God, addiction researchers get a chance to correct their error. If they publish a big error, the publication may be withdrawn. In smaller cases, the publisher issues a correction. It is interesting to see how such a correction has been issued following publication of our Cochrane systematic review of literature which. Probably this helped to keep the addiction science in check. See it for yourself below.

August 2011: “Alcohol-related brief intervention in patients treated for opiate or cocaine dependence: a randomized controlled study”

Before our review included this study, the authors reported the following figures in tables 3 and 7.

November 2011: “Psychosocial interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users: a Cochrane review”

 Our review was published in November 2011 and re-stated the findings of the above study as: higher rates of decreased alcohol use at three months (risk ratio (RR) 0.32; 95% confidence interval (CI) 0.19 to 0.54) and nine months (RR 0.16; 95% CI 0.08 to 0.33) in the treatment as usual group– See more at: http://summaries.cochrane.org/CD009269/ADDICTN_which-talking-therapies-counselling-work-for-drug-users-with-alcohol-problems#sthash.RcVZGdQA.dpuf

August 2013 “Correction: Alcohol-related brief intervention in patients treated for opiate or cocaine dependence: a randomized controlled study”

After the publication of our review, the authors corrected their figures in tables 1 and 5. The care-as-usual treatment for the control group was no longer stronger than the experimental intervention, the “alcohol-related brief intervention.”

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A note on causality in science

Because causal relationships are hard to prove (i.e. cause -> effect), majority of scientific publications rely on correlations. An example of a correlation is a relationship between shorter living expectancy and male gender. Men die younger than women. Although there are many plausible explanations, we cannot pinpoint a single cause.  Similarly, if an article gets corrected following a review in a major synthesis of scientific evidence – the Cochrane review – it may be a pure coincidence or it may be a consequence of the review. 

Substance Abuse Treatment, Prevention and Policy is an open-access peer-reviewed online journal that encompasses all aspects of research concerning substance abuse, with a focus on policy issues. Text taken from www.substanceabusepolicy.com

Cochrane Collaboration hosts the largest database of systematic reviews to inform healthcare decisions. Cochrane reviews are the jaguars of medical evidence synthesis. Cochrane is a global independent network of health practitioners, researchers, patient advocates and others, responding to the challenge of making the vast amounts of evidence generated through research useful for informing decisions about health. Cochrane is a not-for-profit organisation with collaborators from over 120 countries working together to produce credible, accessible health information that is free from commercial sponsorship and other conflicts of interest. Text taken from www.cochrane.org

76th Annual Conference of College on Problems of Drug Dependence: Decide to be fearless& fabulous

Not one, but two conferences in Puerto Rico made my trip fantastic. As usual, the NIDA International forum happened for the 15th time on the weekend before the Conference of the College on Problems of Drug Dependence. The lines below offer some insights from these meetings.

Integration of addiction treatment into primary care: the portals of entry

Is abstinence related with good health? Is decreased drug use related with good health?
Tae Woo Park and Richard Saitz asked these questions in a secondary analysis of data from a clinical trial of 589 patients using cocaine or cannabis with very low dependence proportion among the sample (ASSIST score >27). To answer their questions, they used clinical measures of good health, such as, SIP-D, PHQ-9, and EUROQoL. Health outcomes were associated with decreases in illicit drug use in primary. However, abstinence and decreased use may represent very different magnitudes. Self-reports related dysphoria could also play a role in the differences. It takes a long time to make improvement in those consequences? 6 months of follow up observations may not be enough. Patient-preferred outcomes are paramount: do they want to have a score lower than XY on PHQ-9? What outcomes are important for them?
The TOPCARE (www.mytopcare.org) project implemented guidelines for potential opioid misuse (Jan Liebschutz). Her slides blew up half-way through the presentation but she delivered the talk excellently. Nurse care management was a component of the guideline implementation trial. Academic detailing (45min, with opioid prescribing expert) included principles of prescribing brochure and difficult case discussion. Is academic detailing effective? The Cochranesystematic review of literature found small-to-medium variable effects. The preliminary results of the project show that the nurse manager programme is a no brainer.
Rich Saitz commented on the sad state of affairs in the addiction treatment, where only 10% of people with addiction are in treatment. Integrated care is the best thing since the sliced bread, but where’s the evidence? His research showed no added benefit of integrated versus care as usual. Why? Maybe, addiction is not a one thing, but we treat it like one thing. Dr Tai provoked the audience with a question: “Do our patients with addiction have the capability to participate in the treatment planning and referral?” If they seek medical care for their broken leg and we refer them to an addiction specialist, will they go? most likely not.
But it is the same with hypertension. Referral is a process and not a once-off thing. Although they may not follow our advice at the first visit, a rapport built by a skilled professional over a series of discussions can help them get the most appropriate care.

Does the efficacy of medications for addiction decrease over time?

An old saying among doctors states “One should prescribe a new medication quickly before it loses its efficacy”. Elias Klemperer pooled the data from several Cochrane systematic reviews on addiction medicines, such as, NIRT gum, Acamprosate, or Buproprion. Their effectiveness decreased over time. The changes in methodologies might have caused the decline; also the sponsorship of trials, target populations or publication bias.

Write, wrote, written

Primary author is in the driver’s seat, others are passengers. Primary author pulls the train. Dr Adam Carrico(UCSF) asked us “What are you really passionate about?” Find it and use your passion for those themes to drive your writing habit. Decide to be fearless& fabulous. Develop a writing routine. Put together a queue of writing projects and don’t churn out 2 products at the same time, one of them will suffer. Schedule writing retreats with colleagues. Set Timelines for writing grant and programme time for reviews by trusted people, give people a warning that this is what you’re planning to do. The JAMA June 2014 issue offers useful tips on how to write an editorial.

Dr Knudsen reported on the editorial internship of the Journal of Substance Abuse Treatment – JSAT, which started in 2006, with Dr McGovern (current editor) and Knudsen as the 1stfellows. Success rate of the fellowship applications is 2/30-45, prior involvement is appreciated (peer reviewer, submission). The new 2014 fellows are: Drs Madson and Rash. In the one year of the fellowship, the fellows typically review 12-15 manuscripts, some years, as a managing editor of a special issue. The Drug and Alcohol Dependence journal has a similar scheme.

Check out the http://www.cpddblog.com/

Dennis McCarty won the 2014 NIDA International Program Award of Excellence

 June 14, 2014 ― Professor Dennis McCarty, Ph.D., professor in the Department of Public Health and Preventive Medicine at Oregon Health & Sciences University (OHSU), and director of the Substance Abuse Policy Center in the Center for Health Systems Effectiveness, has been awarded by the 2014 National Institute on Drug Abuse (NIDA) International Program.

The award is for Excellent Mentoring. Dr. McCarty mentors clinicians and researchers who test emerging drug abuse treatments in community settings through the Western States Node of the NIDA Clinical Trials Network, which he codirects. He extends his mentoring to state and local policymakers through his role as director of the Substance Abuse Policy Center in the Center for Health Systems Effectiveness, which works to link policy, practice, and research on substance abuse treatment.

Dr. McCarty also is scientific director of the University of Amsterdam Summer Institute on Alcohol, Drugs and Addiction. I met Dennis in Amsterdam in 2011. He lectured for several days on different policy models and evidence based treatments. Two years later, on March 1, 2013, I joined Dennis as a NIDA CTN INVEST Fellow. INVEST is International Visiting Scientists & Technical Exchange Program for drug abuse research. Oregon Health & Sciences University hosted my six months fellowship during which I assessed the use of Screening and Brief Intervention (SBIRT) for alcohol use disorders among patients receiving agonist medication for opioid use disorders. Visit this post to read more about how I got here. I did not think that the summer school would lead to a fellowship in Portland, OR and I’m most grateful that it did.

With Dennis, I have learned about things I thought did not exist. For example, about researchers who enjoy writing. Writing up research projects is a task that many new researchers fear the most. Dennis is a master writer and his craft is contagious; I’ve discovered a need in me, a strong urge to write a lot and in many different formats. Dennis received the award today, at the 19th annual NIDA International Forum in San Juan, Puerto Rico. The 2014 Forum focused on “Building International Collaborative Research on Drug Abuse.”

Four other experts were awarded 2014 NIDA International Awards of Excellence. Mr. O’Keeffe, a professor at Virginia Commonwealth University, was honored for Excellence in International Leadership. The award for Excellence in Collaborative Research went to Dr. Chawarski, Ph.D., Yale School of Medicine, and Dr. Kasinather, Ph.D., Universiti Sains Malaysia. A special award was presented to Dr. Dewey, Ph.D., Virginia Commonwealth University, in recognition of his service to the addiction research community as founder of the Friends of NIDA, and his research on how opioids and marijuana change brain and contribute to tolerance and addiction.

NIDA International Awards of Excellence winners are selected based on contributions to areas essential to the mission of the NIDA International Program: mentoring, international leadership, and collaborative research. Anybody can suggest a nomination to NIDA. Read more at www.drugabuse.gov/international/awards-excellence.

The NIDA International Program connects people across continents to find evidence-based solutions for addiction, and drug-related HIV/AIDS. NIDA is part of the National Institutes of Health – the principal research agency of the U.S. Government and a component of the U.S. Department of Health and Human Services.

Story first released by OHSU Newsroom: http://www.ohsu.edu/xd/about/news_events/news/index.cfm