Which talking therapies work for people who use drugs and also have alcohol problems?

Review question

We wanted to see whether talking therapies reduce drinking in adult users of illicit drugs (mainly opioids and stimulants). We also wanted to find out whether one type of therapy is more effective than another.

Background

Drinking alcohol above the low-risk drinking limits can lead to serious alcohol use problems or disorders. Drinking above those limits is common in people who also have problems with other drugs. It worsens their physical and mental health. Talking therapies aim to identify an alcohol problem and motivate an individual to do something about it. Talking therapies can be given by trained doctors, nurses, counsellors, psychologists, etc. Talking therapies may help reduce alcohol use but we wanted to find out if they can help people who also have problems with other drugs.

Search date: the evidence is current to August 2017.

Study characteristics

We found seven studies that examined five talking therapies among 825 people with drug problems.

Cognitive-behavioural coping skills training (CBCST) is a talking therapy that focuses on changing the way people think and act.

The twelve-step programme is based on theories from Alcoholics Anonymous and aims to motivate the person to develop a desire to stop using drugs or alcohol.

Motivational interviewing (MI) helps people to explore and resolve doubts about changing their behaviour. It can be delivered in group, individual and intensive formats.

Brief motivational interviewing (BMI) is a shorter MI that takes 45 minutes to three hours.

Brief interventions are based on MI but they take only five to 30 minutes and are often delivered by a non-specialist.

Six of the studies were funded by the National Institutes for Health or by the Health Research Board; one study did not report its funding source.

Key results

We found that the talking therapies led to no differences, or only small differences, for the outcomes assessed. These included abstinence, reduced drinking, and substance use.

One study found that there may be no difference between CBCST and the twelve-step programme.

Three studies found that there may be no difference between brief intervention and usual treatment.

Three studies found that there may be no difference between MI and usual treatment or education only.

One study found that BMI is probably better at reducing alcohol use than usual treatment (needle exchange), but found no differences in other outcomes.

One study found that intensive MI may be somewhat better than standard MI at reducing severity of alcohol use disorder among women, but not among men and found no differences in other outcomes.

It remains uncertain whether talking therapies reduce alcohol and drug use in people who also have problems with other drugs. High-quality studies are missing and are needed.

Quality of evidence

The quality of the evidence was moderate for brief and intensive motivational interviewing, but low for brief interventions and standard motivational interviewing, and very low for CBCST versus twelve-step programme.

Authors' conclusions: 

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

Read the full abstract...
Background: 

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

Objectives: 

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

Search strategy: 

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

Selection criteria: 

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

Data collection and analysis: 

We used the standard methodological procedures expected by Cochrane.

Main results: 

We included seven trials (825 participants). We judged the majority of the trials to have a high or unclear risk of bias.

The psychosocial interventions considered in the studies were: cognitive-behavioural coping skills training (one study), twelve-step programme (one study), brief intervention (three studies), motivational interviewing (two studies), and brief motivational interviewing (one study). Two studies were considered in two comparisons. There were no data for the secondary outcome, alcohol-related harm. The results were as follows.

Comparison 1: cognitive-behavioural coping skills training versus twelve-step programme (one study, 41 participants)

There was no significant difference between groups for either of the primary outcomes (alcohol abstinence assessed with Substance Abuse Calendar and breathalyser at one year: risk ratio (RR) 2.38 (95% confidence interval [CI] 0.10 to 55.06); and retention in treatment, measured at end of treatment: RR 0.89 (95% CI 0.62 to 1.29), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was very low.

Comparison 2: brief intervention versus treatment as usual (three studies, 197 participants)

There was no significant difference between groups for either of the primary outcomes (alcohol use, measured as scores on the Alcohol Use Disorders Identification Test (AUDIT) or Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) at three months: standardised mean difference (SMD) 0.07 (95% CI -0.24 to 0.37); and retention in treatment, measured at three months: RR 0.94 (95% CI 0.78 to 1.13), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was low.

Comparison 3: motivational interviewing versus treatment as usual or educational intervention only (three studies, 462 participants)

There was no significant difference between groups for either of the primary outcomes (alcohol use, measured as scores on the AUDIT or ASSIST at three months: SMD 0.04 (95% CI -0.29 to 0.37); and retention in treatment, measured at three months: RR 0.93 (95% CI 0.60 to 1.43), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was low.

Comparison 4: brief motivational intervention (BMI) versus assessment only (one study, 187 participants)

More people reduced alcohol use (by seven or more days in the past month, measured at six months) in the BMI group than in the control group (RR 1.67; 95% CI 1.08 to 2.60). There was no difference between groups for the other primary outcome, retention in treatment, measured at end of treatment: RR 0.98 (95% CI 0.94 to 1.02), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was moderate.

Comparison 5: motivational interviewing (intensive) versus motivational interviewing (one study, 163 participants)

There was no significant difference between groups for either of the primary outcomes (alcohol use, measured using the Addiction Severity Index-alcohol score (ASI) at two months: MD 0.03 (95% CI 0.02 to 0.08); and retention in treatment, measured at end of treatment: RR 17.63 (95% CI 1.03 to 300.48), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was low.

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