Multiplatform web app (My Way Up) plus motivational interviewing for improving treatment retention in patients with onset of alcohol-related liver disease and alcohol use disorder - an example of participatory research.

Background: With the aim of improving treatment retention in patients with the onset of alcohol-related liver disease (ArLD), we designed a blended intervention (brief motivational intervention + 'serious game' (SG)). We present the participatory design methodology and outcomes and the usability assessment of the intervention. Methods: (1) The design of the SG was based on the outcomes of two 3-h co-creation sessions with 37 participants (healthcare and technology professionals, patients, and patients' relatives). The brief face-to-face motivational intervention was based on the 5 As Model and adapted to the ArLD population. (2) Usability pilot study: 20 participants (10 ArLD patients + 10 healthcare professionals) received the intervention. System Usability Scale (SUS) and Post-Study System Usability Questionnaire (PSSUQ) were applied to assess the SG usability and patients' satisfaction with it. Weekly semi-structured interviews on the phone were conducted to identify the preferred elements in the SG and those aspects that should be improved. Results: (1) Design: an SG in the form of a gamified web app, consisting of a daily activity for six weeks and adapted brief motivational interviewing. (2) Usability pilot study: usability results were excellent for both patients and healthcare professionals (SUS median score = 85). The general usability, the quality of the information provided by the SG and the quality of the interface were very positively rated in the PSSUQ (overall median score = 2, IQR = 1-2). The best-rated aspects were the provision of feedback, the use of metaphors and the application of audiovisual material. Changes in the design, response mechanics and content were applied after the study. Conclusions: The usability and acceptability of an intervention for increasing retention to treatment in patients with recent onset of ArLD and AUD were excellent for patients and healthcare professionals. A randomized-controlled trial is required to test the efficacy of this approach.

Medications for alcohol use disorder promote abstinence in alcohol-associated cirrhosis: Results from a systematic review and meta-analysis.

BACKGROUND AND AIMS: The role of medications for alcohol use disorder (MAUD) in patients with cirrhosis is not well established. Evidence on the efficacy and safety of these drugs in these patients is scarce. APPROACH AND RESULTS: We performed a systematic review and meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocol guidelines on the efficacy of MAUD in patients with cirrhosis. A search was conducted in PubMed, Embase, and Scopus, including all studies until May 2022. The population was defined as patients with AUD and cirrhosis. The primary outcome was alcohol abstinence. Safety was a secondary outcome. We performed a random-effect analysis and expressed the results as relative risk of alcohol consumption. Heterogeneity was measured by I2 . Out of 4095 unique references, 8 studies on 4 different AUD treatments [baclofen (n = 6), metadoxine (n = 1), acamprosate (n = 1), and fecal microbiota transplant (n = 1)] in a total of 794 patients were included. Four were cohort studies, and 4 were RCTs. Only RCTs were included in the meta-analysis. MAUD was associated with a reduced rate of alcohol consumption [relative risk = 0.68 (CI: 0.48-0.97), P = 0.03], increasing alcohol abstinence by 32% compared to placebo or standard treatment, despite high heterogeneity ( I2 = 67%). Regarding safety, out of 165 serious adverse events in patients treated with MAUD, only 5 (3%) were possibly or probably related to study medications. CONCLUSION: MAUD in patients with cirrhosis is effective in promoting alcohol abstinence and has a good safety profile. Larger studies on the effects of MAUD are needed, especially in patients with advanced liver disease.

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.

Social disparities in alcohol's harm to others: evidence from 32 European countries.

BACKGROUND: Alcohol use can cause harm not only to the person who consumes it but also to others. Prior research has found that these alcohol-attributable harms to others differ across socioeconomic groups, though several findings have been contradictory. The aim of this contribution was to study the role of individual-level and population-level income inequalities in alcohol's harm to others among women and men. METHODS: Logistic regression analysis of cross-sectional survey data from 2021, covering 39,629 respondents from 32 European countries. Harms from others' drinking were defined as experiences of physical harm, involvement in a serious argument, or involvement in a traffic accident, due to another person's drinking, within the past year. We examined the association of individual-level income and country-specific income inequality (Gini index) with harms from a known person's or a stranger's drinking, adjusting for the respondent's age, daily drinking levels, and at least monthly risky single-occasion drinking. RESULTS: At the individual level, people with lower incomes had 21% to 47% increased odds of reporting harms from a known person's drinking (women and men) or stranger's drinking (men only) than their same-gender counterparts in the highest income quintile. At the national level, countries with higher income inequality showed increased risks of harms from a known person's drinking among women (OR = 1.09, 95% confidence interval [CI]: 1.05 - 1.14), while among men the risk of harm from strangers' drinking decreased with higher income inequality (OR = 0.86, 95% CI: 0.81 - 0.92). These associations with income inequality were observed among respondents from all but the lowest income groups. CONCLUSION: Alcohol can cause harm to others, with women and people with low incomes being disproportionally exposed to these harms. Alcohol control policies targeting high consumption levels, especially among men, as well as upstream policies to reduce inequalities, are needed to lower the health burden of alcohol beyond those who consume it.

The impact of legal cannabis availability on cannabis use and health outcomes: A systematic review.

BACKGROUND: For alcohol, regulating availability is an effective way to reduce consumption and harm. Similarly, the higher availability of medical cannabis dispensaries has been linked to increased cannabis consumption and harm. For recreational cannabis markets, such a link is suspected but still poorly understood. METHODS: A systematic literature review (PROSPERO registration number 342357) was conducted on 1 July 2022 in common libraries (Medline, Web of Science, PsycInfo, Psyndex, CINAHL, Embase, SCOPUS, Cochrane) for publications since 2012. Studies linking variations in the availability of legal cannabis products to behavioral outcomes (cannabis use or related health indicators) were included, while studies focusing solely on the legalization of medical cannabis were excluded. The risk of bias was assessed using an adapted version of the Newcastle-Ottawa-Scale. RESULTS: After screening n = 6,253 studies, n = 136 were selected for full-text review, out of which n = 13 met the inclusion criteria, reporting on n = 333,550 study participants and n = 855,630 presentations to emergency departments. All studies were conducted in North America, with the majority from Western US states. Using longitudinal (n = 1), cross-sectional (n = 4), or repeated cross-sectional (n = 8) study designs, an increased availability of legal cannabis was linked to increased current cannabis use and health-related outcomes (vomiting, psychosis, or cannabis-involved pregnancies), regardless of the indicator employed to measure availability (proximity or density) among both adults and adolescents. The positive correlation between cannabis availability and consumption is most pronounced among those groups who have been less exposed to cannabis before legalization. The association between the availability of legal cannabis and risky use indicators was less consistent. CONCLUSIONS: Groups who have been least exposed to cannabis before legalization may be most susceptible to increased availability. In jurisdictions with legal cannabis markets, restrictions on the number of legal cannabis retailers, especially in densely populated areas, appear warranted.

Measuring cannabis quantities in online surveys: A rapid review and proposals for ways forward.

OBJECTIVES: Cannabis use quantities are relevant for determining cannabis-related harms. This research aims to provide an overview of the available methods to assess quantities through self-report. METHODS: A rapid review of various strategies to collect information on cannabis use quantities through self-report. Two independent literature searches resulted in n = 38 studies included for review. RESULTS: A total of n = 14 studies employed methods for collecting cannabis use quantities that are not suitable for online surveys (e.g., rolling a fake joint). Of the remaining n = 24 studies with items that are suitable for online surveys, the quantity assessment was performed in three different ways. The data collection was either carried out by asking (a) for the total number of joints (i.e., crude joint method), (b) for the total weight (i.e., crude weight method), or (c) for specific products separately, for example, for the amount of flower and resin (i.e., product-specific method). In only n = 8 studies, cannabis use quantities were ascertained by providing visual aids (e.g., illustration of various amounts of flower). CONCLUSIONS: The crude joint method and the product-specific method are the two most promising methods to collect information on cannabis use quantities. Using visual aids may potentially improve the accuracy of those methods.

Unrecorded alcohol use in 33 European countries: Analyses of a comparative survey with 49,000 people who use alcohol.

BACKGROUND: Using data from 33 European countries (including all EU member states), this study aimed to 1) estimate the prevalence of unrecorded alcohol use among past-week alcohol users, 2) describe how unrecorded alcohol use is associated with drinking patterns, and 3) estimate the contribution of unrecorded alcohol to the total amount of alcohol consumed annually in these countries. METHODS: Data from 25,728 adults who drank alcohol in the past week and self-reported their use of unrecorded alcohol in 2021 were analysed. Prevalence of unrecorded alcohol use in the last week was estimated for those with low, medium, and high risk drinking categorised using the WHO-recommended risk thresholds and definition of risky single occasion drinking. Prevalence estimates were weighted for the country-specific gender, age, and geographical population distribution. An adjusted weighted proportion of unrecorded drinking occasions in total drinking occasions was calculated and compared to 2020 recorded annual per capita consumption estimates. RESULTS: Among past-week alcohol users, the average prevalence of past-week unrecorded alcohol use was 12.1% (95% CI: 11.7-12.5%), with considerable difference between countries (min: 2.0% in Malta; max: 27.0% in Greece). Unrecorded alcohol use was much more prevalent among people with high-risk alcohol use in the past week (24.2%, 95% confidence interval [CI]: 22.9-25.5%) compared to people with low- (6.5, 95% CI: 6.0-6.9%) or medium-risk alcohol intake in the past week (13.6%, 95% CI: 12.9-14.3%). Unrecorded alcohol accounted for 7% of per capita consumption in 2020. CONCLUSIONS: This is the first comparable assessment of unrecorded alcohol use across EU and affiliated countries. The findings add support to the observation that availability of unrecorded alcohol may contribute to risky drinking in Europe. The observed country variations may be related to differences in country-specific pricing policies and measures to reduce the production and consumption of unrecorded alcoholic beverages.

The relevance of patterns of use: A survey to assess cannabis use related harm. / La importancia de los patrones de consumo: Diseño de una encuesta que permita evaluar daño relacionado al consumo de cannabis.

Lifetime prevalence of cannabis use is estimated 192 million adults worldwide (2017) and has increased by 16% in the last decade. However, data on quantity and frequency of use that can lead to harm is lacking. We have developed a survey to assess patterns of cannabis use and related harms in a sample of cannabis users. This paper focuses on evaluating the feasibility of the survey and the users' satisfaction in a pilot sample. Forty cannabis users were recruited (>18 years old, living in Spain, cannabis use at least once during the last 12 months) between December 2018 and January 2019. Participants answered an online survey (mental health, organic harm and injury) and an ad hoc questionnaire to assess accessibility, feasibility, satisfaction, design and content appropriateness. Of the participants, 93.23% (n = 37.3) were satisfied with the design, 94.92% (n = 38.2) were satisfied with the content, and 94.73% (n = 37.0) were satisfied with the accessibility of the survey; only minor changes were required to improve feasibility and accessibility. Participants used a median of 1.0 Standard Joint Unit per day (Interquartile Range [IQR] 1.0-2.0). Of the sample, 92.5% reported at least one related harm and suffers a median of 4.0 disorders (IQR, 1.25-5.0). The present study allows for designing a feasible online survey to conduct a cross-sectional study with a larger sample.

Globalmente, 192 millones de adultos han consumido cannabis alguna vez en su vida (2017), un consumo que se ha incrementado en un 16% en la última década. Sin embargo, seguimos sin tener información clara sobre qué cantidad y qué frecuencia de consumo va a causar daño. Por tanto, este proyecto desarrolla una encuesta para evaluar los patrones de consumo de cannabis y los daños relacionados en una muestra de consumidores. Este artículo se centra en mostrar la factibilidad de la encuesta y la satisfacción de los usuarios en una muestra piloto. Cuarenta usuarios de cannabis fueron reclutados (>18 años, viviendo en España, consumo de cannabis mínimo una vez en los últimos 12 meses) entre diciembre de 2018 y enero de 2019. Los participantes respondieron una encuesta en línea (consumo cannábico, salud mental, organicidad y lesiones) y un cuestionario ad hoc para evaluar la accesibilidad, factibilidad, satisfacción, diseño y contenido. El 93,23% de participantes estaba satisfecho con el diseño; el 94,92% estaba satisfecho con el contenido y el 94,73% estaba satisfecho con la accesibilidad de la encuesta, y fueron necesarios solo cambios menores para mejorar la factibilidad y la accesibilidad de algunos ítems. Los participantes consumieron una mediana de 1,0 Unidades de Porro Estándar por día (Rango Intercuartílico [RIQ] 1,0-2,0). El 92,5% de la muestra puntuó como mínimo en un daño relacionado y con una mediana de 4,0 patologías (RIQ 1,25-5,0). El presente estudio nos permite diseñar una encuesta en línea con determinada factibilidad que pueda ser usada en un estudio transversal a gran escala.

Vickybot, a Chatbot for Anxiety-Depressive Symptoms and Work-Related Burnout in Primary Care and Health Care Professionals: Development, Feasibility, and Potential Effectiveness Studies.

BACKGROUND: Many people attending primary care (PC) have anxiety-depressive symptoms and work-related burnout compounded by a lack of resources to meet their needs. The COVID-19 pandemic has exacerbated this problem, and digital tools have been proposed as a solution. OBJECTIVE: We aimed to present the development, feasibility, and potential effectiveness of Vickybot, a chatbot aimed at screening, monitoring, and reducing anxiety-depressive symptoms and work-related burnout, and detecting suicide risk in patients from PC and health care workers. METHODS: Healthy controls (HCs) tested Vickybot for reliability. For the simulation study, HCs used Vickybot for 2 weeks to simulate different clinical situations. For feasibility and effectiveness study, people consulting PC or health care workers with mental health problems used Vickybot for 1 month. Self-assessments for anxiety (Generalized Anxiety Disorder 7-item) and depression (Patient Health Questionnaire-9) symptoms and work-related burnout (based on the Maslach Burnout Inventory) were administered at baseline and every 2 weeks. Feasibility was determined from both subjective and objective user-engagement indicators (UEIs). Potential effectiveness was measured using paired 2-tailed t tests or Wilcoxon signed-rank test for changes in self-assessment scores. RESULTS: Overall, 40 HCs tested Vickybot simultaneously, and the data were reliably transmitted and registered. For simulation, 17 HCs (n=13, 76% female; mean age 36.5, SD 9.7 years) received 98.8% of the expected modules. Suicidal alerts were received correctly. For the feasibility and potential effectiveness study, 34 patients (15 from PC and 19 health care workers; 76% [26/34] female; mean age 35.3, SD 10.1 years) completed the first self-assessments, with 100% (34/34) presenting anxiety symptoms, 94% (32/34) depressive symptoms, and 65% (22/34) work-related burnout. In addition, 27% (9/34) of patients completed the second self-assessment after 2 weeks of use. No significant differences were found between the first and second self-assessments for anxiety (t8=1.000; P=.34) or depressive (t8=0.40; P=.70) symptoms. However, work-related burnout scores were moderately reduced (z=-2.07, P=.04, r=0.32). There was a nonsignificant trend toward a greater reduction in anxiety-depressive symptoms and work-related burnout with greater use of the chatbot. Furthermore, 9% (3/34) of patients activated the suicide alert, and the research team promptly intervened with successful outcomes. Vickybot showed high subjective UEI (acceptability, usability, and satisfaction), but low objective UEI (completion, adherence, compliance, and engagement). Vickybot was moderately feasible. CONCLUSIONS: The chatbot was useful in screening for the presence and severity of anxiety and depressive symptoms, and for detecting suicidal risk. Potential effectiveness was shown to reduce work-related burnout but not anxiety or depressive symptoms. Subjective perceptions of use contrasted with low objective-use metrics. Our results are promising but suggest the need to adapt and enhance the smartphone-based solution to improve engagement. A consensus on how to report UEIs and validate digital solutions, particularly for chatbots, is required.

Systematic review on the clinical management of chronic pain and comorbid opioid use disorder. / Revisión sistemática sobre el manejo clínico del dolor crónico y el trastorno por uso de opioides simultáneo.

The crisis caused by prescribed opioids and their related side effects are a public health problem worldwide. Most of these are prescribed for coping with chronic pain. The coexistence of opioid use disorder (OUD) in patients with chronic pain represents a complex challenge due to the need for managing both pain and OUD. The aim of this systematic review is to evaluate the efficacy of feasible treatments for this population with OUD and comorbid chronic pain for both conditions. A systematic database search has been performed using Cochrane Library, MEDLINE, PsycINFO and ClinicalTrials.gov in compliance with PRISMA guidelines. Eligible articles addressed the outcomes in chronic pain patients with comorbid opioid use disorder after treatment interventions were applied. Of 593 identified articles, nine were eligible for qualitative review (n = 7 pharmacological interventions; n = 2 psychological interventions). Methadone, buprenorphine, cognitive-behavioral and mindfulness showed promising results, but data were inconclusive (<2 RCT with low risk of bias). It is unclear whether the opioid agonist treatment should be maintained or tapered and which drug should be prescribed for the opioid substitution therapy (methadone or buprenorphine/naloxone). Mindfulness and cognitive behavioral therapy have a discrete effect on improving negative affect but not pain. The therapeutic approach might be individualized under a shared decision-making basis.

La crisis causada por los opioides recetados y sus efectos secundarios relacionados son un problema de salud pública en todo el mundo. La mayoría de estos medicamentos se recetan para el afrontamiento del dolor crónico. La coexistencia del trastorno por uso de opioides (TUO) en pacientes con dolor crónico representa un desafío complejo debido a la necesidad de controlar tanto el dolor como el TUO. El objetivo de esta revisión sistemática es evaluar la eficacia de los tratamientos posibles para dicha población con TUO y dolor crónico. Se ha realizado una revisión sistemática usando las bases de datos Cochrane Library, MEDLINE, PsycINFO y ClinicalTrials.gov, conforme a las pautas PRISMA. Los artículos elegibles abordaron los resultados en pacientes con dolor crónico y diagnóstico comórbido de TUO, después de aplicar una intervención. De 593 artículos identificados, nueve eran elegibles para la revisión cualitativa (n = 7 intervenciones farmacológicas; n = 2 intervenciones psicológicas). La metadona, la buprenorfina, la terapia cognitivo-conductual y el mindfulness mostraron resultados prometedores, pero los datos no eran concluyentes (<2 ECA con bajo riesgo de sesgo). No está claro si el tratamiento con agonistas opioides debe mantenerse o disminuirse y qué fármaco debe prescribirse para la terapia de sustitución de opioides (metadona o buprenorfina/naloxona). El mindfulness y la terapia cognitivo-conductual tienen un efecto discreto en la mejora del afecto negativo, pero no del dolor. El enfoque terapéutico podría individualizarse sobre la base de una toma de decisiones conjunta.

La importancia de los patrones de consumo: Diseño de una encuesta que permita evaluar daño relacionado al consumo de cannabis / The relevance of patterns of use: A survey to assess cannabis use-related harm

Globalmente, 192 millones de adultos han consumido cannabis alguna vezen su vida (2017), un consumo que se ha incrementado en un 16% en laúltima década. Sin embargo, seguimos sin tener información clara sobrequé cantidad y qué frecuencia de consumo va a causar daño. Por tanto, esteproyecto desarrolla una encuesta para evaluar los patrones de consumo decannabis y los daños relacionados en una muestra de consumidores. Esteartículo se centra en mostrar la factibilidad de la encuesta y la satisfacciónde los usuarios en una muestra piloto. Cuarenta usuarios de cannabis fueronreclutados (> 18 años, viviendo en España, consumo de cannabis mínimouna vez en los últimos 12 meses) entre diciembre de 2018 y enero de 2019.Los participantes respondieron una encuesta en línea (consumo cannábico,salud mental, organicidad y lesiones) y un cuestionario ad hoc para evaluarla accesibilidad, factibilidad, satisfacción, diseño y contenido. El 93,23% departicipantes estaba satisfecho con el diseño; el 94,92% estaba satisfecho conel contenido y el 94,73% estaba satisfecho con la accesibilidad de la encuesta,y fueron necesarios solo cambios menores para mejorar la factibilidad y laaccesibilidad de algunos ítems. Los participantes consumieron una medianade 1,0 Unidades de Porro Estándar por día (Rango Intercuartílico [RIQ] 1,0-2,0). El 92,5% de la muestra puntuó como mínimo en un daño relacionadoy con una mediana de 4,0 patologías (RIQ 1,25-5,0). El presente estudionos permite diseñar una encuesta en línea con determinada factibilidad quepueda ser usada en un estudio transversal a gran escala. (AU)

Lifetime prevalence of cannabis use is estimated 192 million adultsworldwide (2017) and has increased by 16% in the last decade. However,data on quantity and frequency of use that can lead to harm is lacking.We have developed a survey to assess patterns of cannabis use and relatedharms in a sample of cannabis users. This paper focuses on evaluating thefeasibility of the survey and the users’ satisfaction in a pilot sample. Fortycannabis users were recruited (>18 years old, living in Spain, cannabis use atleast once during the last 12 months) between December 2018 and January2019. Participants answered an online survey (mental health, organic harmand injury) and an ad hoc questionnaire to assess accessibility, feasibility,satisfaction, design and content appropriateness. Of the participants,93.23% (n = 37.3) were satisfied with the design, 94.92% (n = 38.2) weresatisfied with the content, and 94.73% (n = 37.0) were satisfied with theaccessibility of the survey; only minor changes were required to improvefeasibility and accessibility. Participants used a median of 1.0 Standard JointUnit per day (Interquartile Range [IQR] 1.0-2.0). Of the sample, 92.5%reported at least one related harm and suffers a median of 4.0 disorders(IQR, 1.25-5.0). The present study allows for designing a feasible onlinesurvey to conduct a cross-sectional study with a larger sample. (AU)

Revisión sistemática sobre el manejo clínico del dolor crónico y el trastorno por uso de opioides simultáneo / Systematic review on the clinical management of chronic pain and comorbid opioid use disorder

La crisis causada por los opioides recetados y sus efectos secundarios relacionados son un problema de salud pública en todo el mundo. La mayoría de estos medicamentos se recetan para el afrontamiento del dolor crónico. La coexistencia del trastorno por uso de opioides (TUO)en pacientes con dolor crónico representa un desafío complejo debido ala necesidad de controlar tanto el dolor como el TUO. El objetivo de esta revisión sistemática es evaluar la eficacia de los tratamientos posibles para dicha población con TUO y dolor crónico. Se ha realizado una revisión sistemática usando las bases de datos Cochrane Library, MEDLINE, PsycINFO y ClinicalTrials.gov, conforme a las pautas PRISMA. Los artículos elegibles abordaron los resultados en pacientes con dolor crónico y diagnóstico comórbido de TUO, después de aplicar una intervención. De593 artículos identificados, nueve eran elegibles para la revisión cualitativa(n = 7 intervenciones farmacológicas; n = 2 intervenciones psicológicas). Lametadona, la buprenorfina, la terapia cognitivo-conductual y el mindfulness mostraron resultados prometedores, pero los datos no eran concluyentes (<2ECA con bajo riesgo de sesgo). No está claro si el tratamiento con agonistas opioides debe mantenerse o disminuirse y qué fármaco debe prescribirse para la terapia de sustitución de opioides (metadona o buprenorfina/naloxona). El mindfulness y la terapia cognitivo-conductual tienen un efecto discreto en la mejora del afecto negativo, pero no del dolor. El enfoque terapéutico podría individualizarse sobre la base de una toma de decisiones conjunta. (AU)

The crisis caused by prescribed opioids and their related side effects area public health problem worldwide. Most of these are prescribed forcoping with chronic pain. The coexistence of opioid use disorder (OUD)in patients with chronic pain represents a complex challenge due tothe need for managing both pain and OUD. The aim of this systematic review is to evaluate the efficacy of feasible treatments for this population with OUD and comorbid chronic pain for both conditions. A systematic database search has been performed using Cochrane Library, MEDLINE, PsycINFO and ClinicalTrials.gov in compliance with PRISMA guidelines. Eligible articles addressed the outcomes in chronic pain patients with comorbid opioid use disorder after treatment interventions were applied. Of 593 identified articles, nine were eligible for qualitative review (n = 7pharmacological interventions; n = 2 psychological interventions). Methadone, buprenorphine, cognitive-behavioral and mindfulness showed promising results, but data were inconclusive (<2 RCT with low risk of bias). It is unclear whether the opioid agonist treatment should be maintained ortapered and which drug should be prescribed for the opioid substitution therapy (methadone or buprenorphine/naloxone). Mindfulness andcognitive behavioral therapy have a discrete effect on improving negativeaffect but not pain. The therapeutic approach might be individualized under a shared decision-making basis. (AU)

"Doctor, Can I Drink an Alcohol-Free Beer?" Low-Alcohol and Alcohol-Free Drinks in People with Heavy Drinking or Alcohol Use Disorders: Systematic Review of the Literature.

No- and low-alcohol drinks (NoLo) have been proposed as a potential way forward for the reduction in the alcohol burden of disease. So far, there is scarce synthesized evidence on the effects of these products on people with alcohol use disorder (AUD), or with a heavy or high-risk drinking pattern. The aim of the present study is to systematically review the evidence of the use of NoLo drinks in these populations. A total of 4045 records were screened and 10 studies were included in the review. Craving and desire to drink have been found to increase after the consumption of NoLo drinks in patients with AUD. The increase in craving correlates with the severity of alcohol dependence. In addition, in this population, alcohol-related cues might trigger physiological responses similar to those experienced when using alcohol. Furthermore, as mentioned, in some of the studies, consumption was shown to increase as the %ABV or verbal descriptors indicate lower alcohol. Last, according to the epidemiological data, heavy drinkers tend to use NoLo drinks on top of their usual alcohol consumption rather than as part of regular drinking patterns. Further studies should be conducted in people with AUD or people with a high-risk drinking pattern to provide new insight to guide clinicians, patients, and other stakeholders to make evidence-based informed decisions.

Tailoring an evidence-based clinical intervention and training package for the treatment and prevention of comorbid heavy drinking and depression in middle-income country settings: the development of the SCALA toolkit in Latin America.

BACKGROUND: Effective interventions exist for heavy drinking and depression but to date there has been limited translation into routine practice in global health systems. This evidence-to-practice gap is particularly evident in low- and middle-income countries. The international SCALA project (Scale-up of Prevention and Management of Alcohol Use Disorders and Comorbid Depression in Latin America) sought to test the impact of multilevel implementation strategies on rates of primary health care-based measurement of alcohol consumption and identification of depression in Colombia, Mexico, and Peru. OBJECTIVE: To describe the process of development and cultural adaptation of the clinical intervention and training package. METHODS: We drew on Barrero and Castro's four-stage cultural adaption model: 1) information gathering, 2) preliminary adaption, 3) preliminary adaption tests, and 4) adaption refinement. The Tailored Implementation in Chronic Diseases checklist helped us identify potential factors that could affect implementation, with local stakeholder groups established to support the tailoring process, as per the Institute for Healthcare Improvement's Going to Scale Framework. RESULTS: In Stage 1, international best practice guidelines for preventing heavy drinking and depression, and intelligence on the local implementation context, were synthesised to provide an outline clinical intervention and training package. In Stage 2, feedback was gathered from local stakeholders and materials refined accordingly. These materials were piloted with local trainers in Stage 3, leading to further refinements including developing additional tools to support delivery in busy primary care settings. Stage 4 comprised further adaptions in response to real-world implementation, a period that coincided with the onset of the COVID-19 pandemic, including translating the intervention and training package for online delivery, and higher priority for depression screening in the clinical pathway. CONCLUSION: Our experience highlights the importance of meaningful engagement with local communities, alongside the need for continuous tailoring and adaptation, and collaborative decision-making.

Telemedicine in the treatment of addictions.

PURPOSE OF REVIEW: The purpose of this update is to provide an overview of recent research publications (January 2020-January 2022) on real-time telemedicine solutions for the management of addictions (alcohol, tobacco, opioids, and other drugs). RECENT FINDINGS: Motivational interviewing by real-time telemedicine showed effectiveness in youth and adults for risky alcohol use and alcohol use disorders, even when a concurrent mental health disorder exists. Live telemedicine is well accepted for managing tobacco use disorders. The range of interventions for treating opioid use disorder by real-time telemedicine is large and has been increased due to the coronavirus disease 2019 (COVID-19) pandemic (prescription of opioid agonists, peer-to-peer support, counseling, and group therapy). SUMMARY: The COVID-19 pandemic has accelerated the implementation of real-time telemedicine and, in parallel, research has been conducted to test its effectiveness. Videoconferencing and telephone interventions are supported by solid evidence for risky alcohol use and alcohol use disorder, tobacco use disorder and opioid use disorder. The Integration of other types of telemedicine (asynchronous telemedicine and remote monitoring) and with the entire health system is lacking. Many areas and vulnerable populations (e.g., homeless, elderly, and cannabis use disorders) need more attention.

Reduced alcohol consumption during the COVID-19 pandemic: Analyses of 17 000 patients seeking primary health care in Colombia and Mexico.

Background: During the COVID-19 pandemic, an increase of heavy alcohol use has been reported in several high-income countries. We examined changes in alcohol use during the pandemic among primary health care (PHC) patients in two middle income countries, Colombia and Mexico. Methods: Data were collected during routine consultations in 34 PHC centres as part of a large-scale implementation study. Providers measured patients' alcohol consumption with the three item 'Alcohol Use Disorders Identification Test' (AUDIT-C). Generalized linear mixed models were performed to examine changes in two dependent variables over time (pre-pandemic and during pandemic): 1) the AUDIT-C score and 2) the proportion of heavy drinking patients (8+ on AUDIT-C). Results: Over a period of more than 600 days, data from N = 17 273 patients were collected. During the pandemic, the number of patients with their alcohol consumption measured decreased in Colombia and Mexico. Each month into the pandemic was associated with a 1.5% and 1.9% reduction in the mean AUDIT-C score in Colombia and Mexico, respectively. The proportion of heavy drinking patients declined during the pandemic in Colombia (pre-pandemic: 5.4%, 95% confidence interval (CI) = 4.8% to 6.0%; during the pandemic: 0.8%, 95% CI = 0.6% to 1.1%) but did not change in Mexico. Conclusions: Average consumption levels declined and the prevalence of heavy drinking patterns did not increase. In addition to reduced opportunities for social drinking during the pandemic, changes in the population seeking PHC and restrictions in alcohol availability and affordability are likely drivers for lower levels of alcohol use by patients in this study.