Psychosocial interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users.

ABSTRACT

BACKGROUND: Problem alcohol use is common among illicit drug users 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 opiate overdose in opioid users. OBJECTIVES: To assess the effects of psychosocial interventions for problem alcohol use in illicit drug users (principally problem drug users of opiates and stimulants). SEARCH METHODS: We searched the Cochrane Drugs and Alcohol Group trials register (June 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 11, June 2014), MEDLINE (1966 to June 2014); EMBASE (1974 to June 2014); CINAHL (1982 to June 2014); PsycINFO (1872 to June 2014) 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; 2) online registers of clinical trials Current Controlled Trials, Clinical Trials.org, Center Watch and the World Health Organization International Clinical Trials Registry Platform. SELECTION CRITERIA Randomised controlled trials comparing psychosocial interventions with another therapy (other psychosocial treatment, including non-pharmacological therapies, or placebo) in adult (over the age of 18 years) illicit drug users with concurrent problem alcohol use. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS: Four studies, involving 594 participants, were included. Half of the trials were rated as having a high or unclear risk of bias. The studies considered six different psychosocial interventions grouped into four comparisons (1) cognitive-behavioural coping skills training versus 12-step facilitation (one study; 41 participants), (2) brief intervention versus treatment as usual (one study; 110 participants), (3) group or individual motivational interviewing (MI) versus hepatitis health promotion (one study; 256 participants) and (4) brief motivational intervention (BMI) versus assessment-only (one study; 187 participants). Differences between studies precluded any data pooling. Findings are described for each trial individually.Comparison 1 low-quality evidence; no significant difference for any of the outcomes considered Alcohol abstinence as maximum number of weeks of consecutive alcohol abstinence during treatment mean difference (MD) 0.40 (95% confidence interval (CI) -1.14 to 1.94); illicit drug abstinence as maximum number of weeks of consecutive abstinence from cocaine during treatment MD 0.80 (95% CI -0.70 to 2.30); alcohol abstinence as number achieving three or more weeks of consecutive alcohol abstinence during treatment risk ratio (RR) 1.96 (95% CI 0.43 to 8.94); illicit drug abstinence as number achieving three or more weeks of consecutive abstinence from cocaine during treatment RR 1.10 (95% CI 0.42 to 2.88); alcohol abstinence during follow-up year RR 2.38 (95% CI 0.10 to 55.06); illicit drug abstinence as abstinence from cocaine during follow-up year RR 0.39 (95% CI 0.04 to 3.98), moderate-quality evidence.Comparison 2 low-quality evidence, no significant difference for all the outcomes considered Alcohol use as AUDIT scores at three months MD 0.80 (95% -1.80 to 3.40); alcohol use as AUDIT scores at nine months MD 2.30 (95% CI -0.58 to 5.18); alcohol use as number of drinks per week at three months MD 0.70 (95% CI -3.85 to 5.25); alcohol use as number of drinks per week at nine months MD -0.30 (95% CI -4.79 to 4.19); alcohol use as decreased alcohol use at three months RR 1.13 (95% CI 0.67 to 1.93); alcohol use as decreased alcohol use at nine months RR 1.34 (95% CI 0.69 to 2.58), moderate-quality evidence.Comparison 3 (group and individual MI), low-quality evidence no significant difference for all outcomes Group MI number of standard drinks consumed per day over the past month MD -0.40 (95% CI -2.03 to 1.23); frequency of drug use MD 0.00 (95% CI -0.03 to 0.03); composite drug score (frequency*severity for all drugs taken) MD 0.00 (95% CI -0.42 to 0.42); greater than 50% reduction in number of standard drinks consumed per day over the last 30 days RR 1.10 (95% CI 0.82 to 1.48); abstinence from alcohol over the last 30 days RR 0.88 (95% CI 0.49 to 1.58).Individual MI number of standard drinks consumed per day over the past month MD -0.10 (95% CI -1.89 to 1.69); frequency of drug use (as measured using the Addiction Severity Index (ASI drug) MD 0.00 (95% CI -0.03 to 0.03); composite drug score (frequency*severity for all drugs taken) MD -0.10 (95% CI -0.46 to 0.26); greater than 50% reduction in number of standard drinks consumed per day over the last 30 days RR 0.92 (95% CI 0.68 to 1.26); abstinence from alcohol over the last 30 days RR 0.97 (95% CI 0.56 to 1.67).Comparison 4 more people reduced alcohol use (by seven or more days in the past month at 6 months) in the BMI group than in the control group (RR 1.67; 95% CI 1.08 to 2.60), moderate-quality evidence. No significant difference was reported for all other outcomes: number of days in the past 30 days with alcohol use at one month MD -0.30 (95% CI -3.38 to 2.78); number of days in the past month with alcohol use at six months MD -1.50 (95% CI -4.56 to 1.56); 25% reduction of drinking days in the past month RR 1.23 (95% CI 0.96 to 1.57); 50% reduction of drinking days in the past month RR 1.27 (95% CI 0.96 to 1.68); 75% reduction of drinking days in the past month RR 1.21 (95% CI 0.84 to 1.75); one or more drinking days' reduction in the past month RR 1.12 (95% CI 0.91 to 1.38). AUTHORS' CONCLUSIONS: There is low-quality evidence to suggest that there is no difference in effectiveness between different types of interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users 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.