Effectiveness of psychosocial interventions for alcohol use disorder: a systematic review and meta-analysis update.

Background: Given the accumulating research, evolving psychosocial treatment, and equivocal findings, updating WHO's Mental Health Gap Action Programme-2015 was necessary to ensure guidelines reflect effective strategies for alcohol use disorder (AUD).Objective: To estimate the effects of psychosocial interventions on drinking and related outcomes.Methods: We included randomized controlled trials published between January 2015 and June 2022 on adults with alcohol dependence (ICD 10/DSM-IV) and moderate to severe AUD (DSM-5), and those examined psychosocial interventions against treatment-as-usual (TAU) and active controls. Eight databases and registries were searched. Relative Risk (RR) and standardized mean difference (SMD) were used for dichotomous and continuous outcomes. We used Cochrane's risk of bias assessment (RoB2).Results: Of 873 screened records, 14 and 13 studies in the narrative synthesis and meta-analysis. Of the 2,575 participants, 71.5% were men. Thirteen studies used ICD 10/DSM IV diagnosis. Compared to TAU, any psychosocial intervention increased the relative risk of abstinence by 28% [N = 7, RR = 1.28, 95% CI: 1.07 to 1.53, p = .01, NNT = 9]. There were minimal heterogeneity and no evidence of publication bias. Psychosocial interventions were not effective in reducing the drinking frequency (n = 2, Hedge's g = -0.10, 95% CI: -0.46 to 0.26, p = .57) and drinks/drinking days (N = 5, g = -0.10, 95% CI: -0.37 to 0.16, p = .43). Treatment discontinuation did not differ between intervention and control groups [RR = 1.09, 95% CI: 0.66 to 1.80].Conclusion: Psychosocial interventions are effective in improving abstinence but not in reducing drinking frequency or amount. Policymakers must consider this evidence to generate AUD treatment guidelines.Registration: PROSPERO 2022 CRD42022342608.

The test-retest reliability of the Opiate Treatment Index in nyaope users in Johannesburg.

Background: Epidemiological studies suggest that nyaope, a heroin-based drug, is widely used in South Africa. Yet few reliable research tools are available to assess treatment outcomes of users. The Opiate Treatment Index (OTI), a tool developed in Australia, could potentially facilitate research on context-specific South African treatment outcomes. However, we know little of its test-retest reliability. Aim: This study aimed to assess the test-retest reliability of the OTI among a sample of nyaope users in Johannesburg. Setting: This study was conducted across three substance use treatment facilities in Johannesburg. Methods: The OTI was administered to 53 nyaope users at baseline and one week later. To determine the test-retest reliability of the OTI, the intra-class correlation coefficients (ICC) and the Brennan-Prediger coefficients of the two interviews were calculated. Results: The ICC of the Q-scores from the data sets along with the Brennan-Prediger coefficient for the substance use domain were calculated. The ICC for nyaope was 0.38. Brennan-Prediger coefficients were as follows: alcohol - 0.96, crack-cocaine - 0.89, cannabis - 0.92, methaqualone - 0.85 and crystal methamphetamine - 0.89. Conclusion: A significant positive finding was the excellent test-retest reliability of the injecting and sexual behaviour domains and moderate reliability of the criminality, general health and social functioning domains. Contribution: The results of this study provide insight into the reliability of this tool and for its use in future studies in the South African context.

A prospective observational study of heroin users in Johannesburg, South Africa: Assessing psychiatric comorbidities and treatment outcomes.

BACKGROUND: Despite the rise in heroin use in sub Saharan-Africa opioid agonist maintenance treatment (OAMT) is still not state-funded in South Africa and many other African countries. In South Africa there has been little data published on the profile of heroin users and the outcomes of treatment for those who attend public treatment services. METHODS: 300 heroin users from two state-funded rehabilitation centres in Johannesburg were studied at entry into rehabilitation and 3-months after treatment. Treatment consisted of inpatient detoxification and inpatient psychosocial rehabilitation. Structured interviews measured changes in drug use, psychopathology and criminality post rehabilitation. RESULTS: Most (65.7%) smoked heroin in combination with cannabis while 29.7% were injecting users. Almost half the sample (49.3%) had at least one mental illness. Of the 252 (84%) participants seen at 3-month follow-up, 6.3% were abstinent of all substances (excluding tobacco), 65.5% had continued heroin use (CHU) and the balance used other substances. At follow-up there were significant decreases in heroin use (p<0.0001) and criminality (p<0.0001). There were however significant increases in alcohol use (p<0.0001), crystalmetamphetamine use (p=0.032) and the prevalence of current episode of major depression (p<0.0001). Just 11.9% received formal psychosocial treatment after leaving rehabilitation. None were on OAMT and only three participants were on psychotropic medication. None were tested for Hepatitis C during the study period and the majority (53%) did not know their HIV status. CONCLUSION: There are significant gaps in current treatment services for heroin users in South Africa. Retention in treatment and assessment and management of psychiatric and non-psychiatric comorbidities is low. Services need to be more integrated and should also include the provision of OAMT.

Smoking heroin with cannabis versus injecting heroin: unexpected impact on treatment outcomes.

BACKGROUND: In several countries, especially in Africa, the dominant method of heroin intake is smoking a joint of cannabis laced with heroin. There is no data exploring the impact of smoking heroin with cannabis on treatment outcomes. AIM: To compare treatment outcomes between people who inject heroin and people who smoke heroin with cannabis. METHODOLOGY: Three hundred heroin users were assessed on admission to inpatient rehabilitation and after treatment. We compared drug use, psychopathology, criminality, social functioning and general health between heroin injectors and heroin-cannabis smokers at treatment entry, and at 3 and 9 months after rehabilitation. RESULTS: The sample comprised 211 (70.3%) heroin-cannabis smokers and 89 (29.7%) heroin injectors. Eighty-four percent were followed up at 3 months and 75% at 9 months. At 9 months, heroin-cannabis smokers had a higher proportion of those who relapsed to heroin use compared with intravenous (IV) users (p = 0.036). The median number of heroin use episodes per day was lower for IV users than heroin-cannabis smokers at both follow-up points (p = 0.013 and 0.0019). A higher proportion of IV users was HIV positive (p = 0.002). There were no significant differences in psychopathology, general health, criminality and social functioning between IV users and heroin-cannabis smokers at all three time points. CONCLUSIONS: Heroin users who do not inject drugs but use other routes of administration may have increased risk for relapse to heroin use after inpatient rehabilitation and should therefore have equal access to harm reduction treatment services. Advocating a transition from injecting to smoking heroin in an African context may pose unique challenges.

The Cytotoxic Effects of Nyaope, a Heroin-based Street Drug, in SH-SY5Y Neuroblastoma Cells.

Nyaope is a local adulterated drug that contributes significantly to the psychosocial challenge of substance use in South Africa. Despite being a huge burden on society and the health care system, research into the deleterious effects of nyaope is limited. The aim of the present study was therefore to perform a chemical analysis of the drug and to assess its toxic effects on neuroblastoma cells. Gas chromatography-mass spectrometry (GC/MS) analysis showed that nyaope mainly consists of heroin and heroin-related products. SH-SY5Y cells were subsequently exposed to increasing concentrations of nyaope (0.625, 1.25, 2.5, 5 and 10 µg/µL) for 1, 6 or 24 h. The toxic effects of nyaope were determined by measuring lactate dehydrogenase (LDH) released into the cell culture medium as an indicator of necrosis, the mRNA expression levels of Bax and Bcl-2 as markers of apoptosis, and the mRNA expression levels of p62 and microtubule-associated protein 1 A/1B light-chain 3 (LC3) as indicators of autophagy. Exposing SH-SY5Y cells to concentrations of nyaope 5 µg/µL and greater for 24 h, resulted in a significant increase in LDH levels in the cell culture medium, unchanged mRNA expression of Bax and Bcl-2 mRNA, and significantly reduced p62 and elevated LC3 mRNA expression levels. The chemical analysis suggests that nyaope should be considered synonymous with heroin and the toxic effects of the drug may recruit pathways involved in necrosis and autophagy.

Optimizing Digital Tools for the Field of Substance Use and Substance Use Disorders: Backcasting Exercise.

BACKGROUND: Substance use trends are complex; they often rapidly evolve and necessitate an intersectional approach in research, service, and policy making. Current and emerging digital tools related to substance use are promising but also create a range of challenges and opportunities. OBJECTIVE: This paper reports on a backcasting exercise aimed at the development of a roadmap that identifies values, challenges, facilitators, and milestones to achieve optimal use of digital tools in the substance use field by 2030. METHODS: A backcasting exercise method was adopted, wherein the core elements are identifying key values, challenges, facilitators, milestones, cornerstones and a current, desired, and future scenario. A structured approach was used by means of (1) an Open Science Framework page as a web-based collaborative working space and (2) key stakeholders' collaborative engagement during the 2022 Lisbon Addiction Conference. RESULTS: The identified key values were digital rights, evidence-based tools, user-friendliness, accessibility and availability, and person-centeredness. The key challenges identified were ethical funding, regulations, commercialization, best practice models, digital literacy, and access or reach. The key facilitators identified were scientific research, interoperable infrastructure and a culture of innovation, expertise, ethical funding, user-friendly designs, and digital rights and regulations. A range of milestones were identified. The overarching identified cornerstones consisted of creating ethical frameworks, increasing access to digital tools, and continuous trend analysis. CONCLUSIONS: The use of digital tools in the field of substance use is linked to a range of risks and opportunities that need to be managed. The current trajectories of the use of such tools are heavily influenced by large multinational for-profit companies with relatively little involvement of key stakeholders such as people who use drugs, service providers, and researchers. The current funding models are problematic and lack the necessary flexibility associated with best practice business approaches such as lean and agile principles to design and execute customer discovery methods. Accessibility and availability, digital rights, user-friendly design, and person-focused approaches should be at the forefront in the further development of digital tools. Global legislative and technical infrastructures by means of a global action plan and strategy are necessary and should include ethical frameworks, accessibility of digital tools for substance use, and continuous trend analysis as cornerstones.

Longitudinal Patterns of Suicidality Among Heroin Users in Johannesburg, South Africa: A Need for Suicide Screening and Intervention.

Objectives: The objective of the study was to longitudinally assess the outcomes and correlates of suicidal ideation and behavior (SIB) among heroin users who attended inpatient detoxification and psychosocial rehabilitation. SIB was assessed in 300 heroin users upon entry into inpatient detoxification (baseline) as well as 3-months (t1) (n = 252; 84%) and 9-months (t2) (n = 225; 75%) post treatment. Multivariable logistic regression was used to determine the demographic, clinical and treatment related factors that increased the risk for a high SIB score. Results: From baseline to t1 there was a significant decrease in the proportion of those who endorsed SIB (68.7 vs. 38.9%, p < 0.0001). There was an increase in the proportion of those who endorsed SIB from t1 to t2 (38,9 vs. 47.1%, p = 0.047). There was a significant increase in the proportion of those reporting suicide likely in the near future from baseline to t1 (8.7 vs. 16.3%: p < 0.0049) and this was repeated from t1 to t2 (22.7%) (t1 vs. t2: p = 0.031). After controlling for all other variables, a comorbid mental illness (MI) at baseline was a significant independent risk factor for a high SIB score at t1(RR 1.63; 95% CL 1.30-2.03) (p < 0.0001) and a comorbid MI at t1 increased the risk for a high SIB score at t2 (RR 2.73; 95% CL 1.78-4.19) (p < 0.0001). A poorer general health score and poorer social functioning score at baseline were associated with a high SIB score at baseline (RR 1.02; 95% CL 1.01-1.04) (p = 0.001) and t2, respectively (RR 1.07; 95% CL 1.04-1.11) (p < 0.0001). Conclusions: Among heroin users, a comorbid mental illness, poorer physical health and poorer social functioning are important factors to consider in suicide risk assessment. Although there were decreases in overall SIB 3 months after detoxification, this trend was not sustained at 9-month follow-up. After detoxification there were significant increases in the proportion of those reporting a likelihood of suicide in the following 3 months. The results suggests that the treatment exposure did not adequately mitigate suicide risk. There is a need for review of the treatment as well as targeted screening and management of SIB in heroin users attending treatment services.

Fronto-temporal cortical atrophy in 'nyaope' combination heroin and cannabis use disorder.

Sub-Saharan Africa is one of the top three regions with the highest rates of opioid-related premature mortality. Nyaope is the street name for what is believed to be a drug cocktail in South Africa although recent research suggests that it is predominantly heroin. Nyaope powder is most commonly smoked together with cannabis, a drug-use pattern unique to the region. Due to the increasing burden of this drug in low-income communities and the absence of human structural neuroimaging data of combination heroin and cannabis use disorder, we initiated an important cohort study in order to identify neuroanatomical sequelae. Twenty-eight male nyaope users and thirty healthy, matched controls were recruited from drug rehabilitation centers and the community, respectively. T1-weighted MRI images were obtained using a 3 T General Electric Discovery and cortical thickness was examined and compared. Nyaope users displayed extensive grey matter atrophy in the right hemispheric medial orbitofrontal, rostral middle frontal, superior temporal, superior frontal, and supramarginal gyri (two-sided t-test, p < 0.05, corrected for multiple comparisons). Our findings indicate cortical abnormality in nyaope users in regions involved in impulse control, decision making, social- and self-perception, and working memory. Importantly, affected brain regions show large overlap with the pattern of cortical abnormalities shown in heroin use disorder.

An Inverse Relationship Between Alcohol and Heroin Use in Heroin Users Post Detoxification.

BACKGROUND: Given that fewer than 50% of countries provide Opioid Agonist Maintenance Therapies (OAMT), it is important to assess whether other substances act as a substitute for heroin in recovering heroin users who receive detoxification models of treatment. There is a dearth of prospective studies from low-and-middle-income countries evaluating these patterns of substance use. METHODS: 300 heroin users from the Gauteng province of South Africa were assessed on entry into inpatient detoxification and then followed-up 3 and 9 months after leaving treatment. Treatment consisted of 1 week of detoxification followed by 6-8 weeks of psychosocial therapy. We measured the overall changes in the prevalence of heroin, alcohol and other drug use at baseline and postrehabilitation. Comparison of these outcomes at enrolment, 3 months and 9 months was performed by a Generalised Estimating Equation (GEE) with the outcome as the dependent variable, observation point as the independent variable, and participant as the repeated measure. Injecting status and treatment completion were included as covariates. We also measured the individual pathways between heroin and alcohol use in the 210 participants that were seen at all three timepoints. RESULTS: Of the original cohort, 252 (84.0%) were re-interviewed at 3 months and 225 (75.0%) at 9 months. From baseline to 3 months, the proportion of past month heroin users decreased significantly to 65.5%; however, during this time, the proportion of past month alcohol users increased from 16.3% to 55.2% (p<0.0001). When assessing the pathways between heroin and alcohol use at an individual level, 55.4% (n-97) of those who were past month alcohol abstinent prior to rehabilitation were using alcohol at 3 months. From 3 to 9 months the proportion of heroin users increased to 72.4% (p<0.0001), and during this time, the proportion of alcohol users decreased. CONCLUSION: After detoxification, a significant reduction in heroin use was observed with a concomitant increase in alcohol consumption. Under these circumstances, alcohol may have acted as a substitute for heroin in the short term. The initial reduction in heroin use 3 months postrehabilitation was followed by increased consumption 6 months later. This observation supports the need for interventions to prevent, monitor and treat high levels of alcohol use in heroin users post detoxification. The provision of OAMT is a necessary consideration to address both the risk of increased alcohol intake as well as the decline in heroin abstinence rates.

The Changing Landscape of Alcohol Use and Alcohol Use Disorder During the COVID-19 Pandemic - Perspectives of Early Career Professionals in 16 Countries.

: Alcohol use is a major risk factor for infectious disease and reduction of harms associated with alcohol consumption are essential during times of humanitarian crises, such as the COVID-19 pandemic. As a network of early career professionals working in the area of addiction medicine, we provide our views with regards to national actions related to reducing alcohol-related harm and providing care for people with alcohol use disorder during COVID-19. We believe that COVID-19 related measures have affected alcohol consumption in the majority of countries represented in this commentary. Examples of these changes include changes in alcohol consumption patterns, increases in cases of alcohol withdrawal syndrome, disruptions in access to medical care for alcohol use disorder and increases in illegal production of alcohol. Our members urge that treatment for acute and severe conditions due to substance use should be considered as essential services in times of humanitarian crises like COVID-19.

Access to Healthcare and Harm Reduction Services During the COVID-19 Pandemic for People Who Use Drugs.

: Globally, there are concerns about access to healthcare and harm reduction services for people who use drugs (PWUD) during the coronavirus disease 2019 (COVID-19) pandemic. Members from the Network of Early Career Professionals working in Addiction Medicine shared their experiences of providing treatment to PWUD during the COVID-19 pandemic. Drawing on these qualitative reports, we highlight the similarities and discrepancies in access to services for PWUD in 16 countries under COVID-10 restrictions. In most countries reported here, efforts have been made to ensure continued access to services, such as mobilising opioid agonist maintenance treatment and other essential medicines to patients. However, due to travel restrictions and limited telemedicine services, several Network of Early Career Professionals working in Addiction Medicine members from lower-resourced countries experienced challenges with providing care to their patients during periods of COVID-19 lock-down. The insights provided in this commentary illustrate how the COVID-19 lock-down restrictions have impacted access to services for PWUD.

Pathways between urbanization and harmful substance use.

PURPOSE OF REVIEW: Epidemiological literature suggests that urbanization is potentially linked to a number of stressors that could be associated with harmful substance use and mental disorders. This may vary by country. This review gives attention to emergent literature examining the pathways between urbanization and harmful substance use. RECENT FINDINGS: Studies examining the links between urbanization, mental health and substance use suggest complex pathways between urbanization and substance use as well as a range of modifying variables that could contribute to these associations. Such variables include increased supply of illicit and licit substances brought about by economic development, globalization and technology as well as an increased demand for particular substances. Rural areas may also have unique factors associated with harmful substance use but these are beyond the scope of this review. SUMMARY: We have presented evidence to suggest potential associations between urbanization and harmful substance use. We acknowledge that data are limited because of a paucity of longitudinal studies elucidating these relationships.

Factors associated with recidivism at a South African forensic psychiatric hospital.

AIMS: This study examines common factors associated with recidivism among state patients at a South African forensic psychiatric hospital. More specifically, demographic, clinical and criminological factors of a recidivist group are compared to a non-recidivist group with the intention of understanding to what extent these factors might determine the likelihood of re-offending. METHOD: A retrospective case file review of 293 inpatients and a random selection of 120 outpatients was conducted. For the purpose of the study, a patient was classified as a recidivist if an additional charge or act of violence was added to the file while the patient was on leave of absence in the community. Of the inpatients, only those who met the criteria for recidivism were included in the study. All 120 randomly selected outpatients were included. Demographic, clinical and criminological data were captured for all patients. RESULTS: Eighty recidivists were compared with 100 non-recidivists. Using the × 2 and Fischer's exact test, substance-use disorder, antisocial personality disorder, an index offence of assault and in-ward adverse events were found to be associated with recidivism (p < 0.05). Using logistic regression analysis, the odds of recidivism in a patient with an index offence of assault was 8.4 times of those who did not commit assault as an index offence (95.0% CI 1.6-43.1). The odds of recidivism for patients with cannabis use was 2.8 (95.0% CI 1.3-6.0) and for patients with in-ward adverse sexual behaviour was 17.2 (95.0% CI 2.0-150). CONCLUSION: Substance-use disorder and antisocial personality disorder are associated with higher risk for recidivism. This study also highlights that a less serious offence such as assault had a higher association with recidivism. Patients noted to display adverse sexual behaviour in the ward pose a potentially high risk for re-offence. Important criminal history factors and certain clinical factors could not be interpreted because of large amounts of missing data in patients' files.