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

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References

References to studies included in this review

Carroll 1998 {published data only (unpublished sought but not used)}

Carroll KM, Nich C, Ball SA, McCance E, Frankforter TL, Rounsaville BJ. One‐year follow‐up of disulfiram and psychotherapy for cocaine‐alcohol users: sustained effects of treatment. Addiction 2000;95(9):1335‐49.
Carroll KM, Nich C, Ball SA, McCance E, Rounsavile BJ. Treatment of cocaine and alcohol dependence with psychotherapy and disulfiram. Addiction 1998;93(5):713‐27.

Feldman 2013 {published and unpublished data}

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 study. Substance Abuse Treatment, Prevention, and Policy 2011;6(22):1‐8.
Feldman N, Chatton A, Khan R, Khazaal Y, Zullino D. Correction: Alcohol‐related brief intervention in patients treated for opiate or cocaine dependence: a randomized controlled study. Substance Abuse Treatment, Prevention, and Policy 2013;8(1):28.

Nyamathi 2010 {published and unpublished data}

Nyamathi A M, Nandy K, Greengold B, Marfisee M, Khalilifard F, Cohen A, et al. Effectiveness of intervention on improvement of drug use among methadone maintained adults. Journal of Addictive Disorders 2011;30(1):6‐16.
Nyamathi A, Shoptaw S, Cohen A, Greengold B, Nyamathi K, Marfisee M, et al. Effect of motivational interviewing on reduction of alcohol use. Drug Alcohol Dependence 2010;107(1):23‐30. [1879‐0046: (Electronic)]

Stein 2002a {published data only (unpublished sought but not used)}

Stein MD, Anderson B, Charuvastra A, Maksad J, Friedmann PD. A brief intervention for hazardous drinkers in a needle exchange program. Journal of Substance Abuse Treatment 2002;22(1):23‐31.
Stein MD, Charuvastra A, Anderson BJ. Social support and zero sharing risk among hazardously drinking injection drug users. Journal of Substance Abuse Treatment 2002;23(3):225‐30.
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]

References to studies excluded from this review

Abou‐Saleh 2008 {published data only}

Abou‐Saleh M, Davis P, Rice P, Checinski K, Drummond C, Maxwell D, et al. The effectiveness of behavioural interventions in the primary prevention of hepatitis C amongst injecting drug users: a randomised controlled trial and lessons learned. Harm Reduction Journal 2008;5:25.

Alessi 2007 {published data only}

Alessi SM, Hanson T, Wieners M, Petry NM. Low‐cost contingency management in community clinics: delivering incentives partially in group therapy. Experimental and Clinical Psychopharmacology 2007;15(3):293‐300.

Andreasson 2002 {published data only}

Andreasson S, Hansagi H, Osterlund B. Short‐term treatment for alcohol‐related problems: four‐session guided self‐change versus one session of advice ‐ a randomized, controlled trial. Alcohol 2002;28:57‐62.

Azrin 1994 {published data only}

Azrin NH, McMahon PT, Donohue B, Besalel VA, Lapinski KJ, Kogan ES, et al. Behavior therapy for drug abuse: a controlled treatment outcome study. Behaviour Research and Therapy 1994;32:857‐66.

Azrin 1996 {published data only}

Azrin NH, Acierno R, Kogan ES, Donohue B, Besalel VA, McMahon PT. Follow‐up results of supportive versus behavioral therapy for illicit drug use. Behaviour Research and Therapy 1996;34:41‐6.

Baker 2005 {published data only}

Baker A, Lee NK, Claire M, Lewin TJ, Grant T, Pohlman S, et al. Brief cognitive behavioural interventions for regular amphetamine users: a step in the right direction. Addiction 2005;100:367‐78.

Baker 2006 {published data only}

Baker A, Bucci S, Lewin TJ, Kay‐Lambkin F, Constable PM, Carr VJ. Cognitive‐behavioural therapy for substance use disorders in people with psychotic disorders: randomised controlled trial. British Journal of Psychiatry 2006;188:439‐48.

Ball 2007 {published data only}

Ball SA, Martino S, Nich C, Frankforter TL, Van Horn D, Crits‐Christoph P, et al. Site matters: multisite randomized trial of motivational enhancement therapy in community drug abuse clinics. Journal of Consulting and Clinical Psychology 2007;75(4):556‐67.

Bennett 2002 {published data only}

Bennett GA, Edwards S, Bailey J. Helping methadone patients who drink excessively to drink less: short‐term outcomes of a pilot motivational intervention. Journal of Substance Use2002; Vol. 7, issue 4:191‐7. [1465‐9891]

Bernstein 2005 {published data only}

Bernstein J, Bernstein E, Tassiopoulos K, Heeren T, Levenson S, Hingson R. Brief motivational intervention at a clinic visit reduces cocaine and heroin use. Drug Alcohol Dependence 2005;77(1):49‐59.

Black 2011 {published data only}

Black AC, Rosen MI. A money management‐based substance use treatment increases valuation of future rewards. Addictive Behaviors2011; Vol. 36, issue 1‐2:125‐8.

Bowen 2006 {published data only}

Bowen S, Witkiewitz K, Dillworth TM, Chawla N, Simpson TL, Ostafin BD, et al. Mindfulness meditation and substance use in an incarcerated population. Psychology of Addictive Behaviors 2006;20:343‐7.

Brown 2007 {published data only}

Brown TG, Dongier M, Latimer E, Legault L, Seraganian P, Kokin M, et al. Group‐delivered brief intervention versus standard care for mixed alcohol/other drug problems ‐ a preliminary study. Alcoholism Treatment Quarterly 2007;24(4):23‐40.

Burling 2001 {published data only}

Burling TA, Burling AS, Latini D. A controlled smoking cessation trial for substance‐dependent inpatients. Journal of Consulting and Clinical Psychology 2001;69:295‐304.

Chermack 2002 {published data only}

Chermack ST, Blow FC. Violence among individuals in substance abuse treatment: the role of alcohol and cocaine consumption. Drug and Alcohol Dependence 2002;66(1):29‐37.

Cohen 1982 {published data only}

Cohen M, Korts D, Hanbury R, Sturiano V, Jackson G, Stimmel B. The effect of alcoholism in methadone‐maintained persons on productive activity: a randomized control trial. Alcoholism, Clinical and Experimental Research 1982;6:358‐61.
Stimmel B, Cohen M, Sturiano V, Hanbury R, Korts D, Jackson G. Is treatment for alcoholism effective in persons on methadone maintenance?. American Journal of Psychiatry 1983;140(7):862‐6.

Daeppen 2010 {published data only}

Daeppen JB, Bertholet N, Gaume J, Fortini C, Faouzi M, Gmel G. Efficacy of brief motivational intervention in reducing binge drinking in young men: a randomized controlled trial. Drug Alcohol Dependence 2011;113(1):69‐75. [DOI: 10.1016/j.drugalcdep.2010.07.009]

Darker 2011 {published data only}

Darker CD, Sweeney BP, El Hassan HO, Smyth BP, Ivers JH, Barry JM. Brief interventions are effective in reducing alcohol consumption in opiate‐dependent methadone‐maintained patients: results from an implementation study. Drug and Alcohol Review 2012;31(3):348‐56. [DOI: 10.1111/j.1465‐3362.2011.00349.x]

Darker 2012 {published data only}

Darker CD, Sweeney BP, El Hassan HO, Smyth BP, Ivers J‐HH, Barry JM. Brief interventions are effective in reducing alcohol consumption in opiate‐dependent methadone‐maintained patients: Results from an implementation study. Drug and Alcohol Review 2012;31(3):348‐56.

Drapkin 2008 {published data only}

Drapkin ML, Tate SR, McQuaid JR, Brown SA. Does initial treatment focus influence outcomes for depressed substance abusers?. Journal of Substance Abuse Treatment 2008;35(3):343‐50.

Drumright 2011 {published data only}

Drumright LN, Hagan H, Thomas DL, Latka MH, Golub ET, Garfein RS, et al. Predictors and effects of alcohol use on liver function among young HCV‐infected injection drug users in a behavioral intervention. Journal of Hepatology 2011;55(1):45‐52.

Forsberg 2011 {published data only}

Forsberg LG, Ernst D, Sundqvist K, Farbring CA. Motivational Interviewing delivered by existing prison staff: a randomized controlled study of effectiveness on substance use after release. Substance Use and Misuse 2011;46(12):1477‐85.

Gruber 2008 {published data only}

Gruber VA, Delucchi KL, Kielstein A, Batki SL. A randomized trial of 6‐month methadone maintenance with standard or minimal counseling versus 21‐day methadone detoxification. Drug Alcohol Dependence 2008;94(1‐3):199‐206.

Klimas 2013 {published data only}

Klimas J, Anderson R, Bourke M, Bury G, Dunne C, Field CA, et al. Psychosocial interventions for problem alcohol use among problem drug users (PINTA): protocol for a feasibility study in primary care. Research Protocols 2013;2(2):e26.

Marsden 2006 {published data only}

Marsden J, Stillwell G, Barlow H, Boys A, Taylor C, Hunt N, et al. An evaluation of a brief motivational intervention among young ecstasy and cocaine users: no effect on substance and alcohol use outcomes. Addiction2006; Vol. 101:1014‐26.

O'Farrell 2008 {published data only}

O'Farrell TJ, Murphy M, Alter J, Fals‐Stewart W. Brief family treatment intervention to promote continuing care among alcohol‐dependent patients in inpatient detoxification: a randomized pilot study. Journal of Substance Abuse Treatment 2008;34(3):363‐9. [PUBMED: 17614242]

Ruger 2012 {published data only}

Ruger JP, Abdallah AB, Luekens C, Cottler L. Cost‐effectiveness of peer‐delivered interventions for cocaine and alcohol abuse among women: a randomized controlled trial. PLoS One 2012;7(3):e33594.

Sanson‐Fisher 2010 {published data only}

Sanson‐Fisher R, Brand M, Shakeshaft A, Haber P, Day C, Conigrave K, et al. Forming a national multicentre collaboration to conduct clinical trials: increasing high‐quality research in the drug and alcohol field. Drug and Alcohol Review 2010;29(5):469‐74.

Staiger 2009 {published data only}

Staiger PK, Gruenert S, Manning M, Lake A, Long C. A brief alcohol intervention program for adults in residential drug treatment: results from a randomised controlled trial. Drug and Alcohol Review 2009;28:A60.

Van Der Hyde 1995 {published data only}

Van Der Hyde VA. Adatsa Follow‐up Study of Extended Outpatient Care: A Comparison of 90 Days Versus 180 Days of Outpatient Treatment for Clients of Washington State's Alcoholism and Drug Addiction Treatment and Support Act. Washington State Dept. of Social and Health Services, Olympia, 1995:124.

Worden 2010 {published data only}

Worden BL. Effectiveness of a Feedback‐Based Brief Intervention for Alcohol Use Disorders in Community Care [thesis]. Newark, NJ: Graduate School‐New Brunswick Rutgers, The State University of New Jersey, 2010.

Zule 2007 {published data only}

Zule WA, Costenbader EC, Coomes C. Effects of a motivational intervention to reduce alcohol use among injecting drug at risk of HCV. Proceedings of the 69th Annual Scientific Meeting of the College on Problems of Drug Dependence; 2007 June 16‐21; Quebec City, Canada. 2007.

Zule 2009 {published data only}

Zule WA, Costenbader EC, Coomes CM, Wechsberg WM. Effects of a hepatitis C virus educational intervention or a motivational intervention on alcohol use, injection drug use, and sexual risk behaviors among injection drug users. American Journal of Public Health 2009;99(Suppl 1):S180‐6.

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Alcoholics Anonymous. The Story of How More Than One Hundred Men Have Recovered From Alcoholism. New York: Alcoholics Anonymous World Services, Inc., 1939.

Amato 2011a

Amato L, Minozzi S, Davoli M, Vecchi S, Ferri M, Mayet S. Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of opioid dependence. Cochrane Database of Systematic Reviews 2011, Issue 10. [DOI: 10.1002/14651858.CD004147.pub4]

Amato 2011b

Amato L, Minozzi S, Davoli M, Vecchi S, Ferri M, Mayet S. Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of opioid dependence. Cochrane Database of Systematic Reviews 2011, Issue 10. [DOI: 10.1002/14651858.CD004147]

Anderson 2004

Anderson P, Laurant M, Kaner E, Wensing M, Grol R. Engaging general practitioners in the management of hazardous and harmful alcohol consumption: results of a meta‐analysis. Journal of Studies on Alcohol 2004;65(2):191‐9.

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Arias AJ, Kranzler HR. Treatment of co‐occurring alcohol and other drug use disorders. Alcohol Research & Health 2008;31(2):155‐67.

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Babor T, Higgins‐Biddle J. Brief Intervention For Hazardous and Harmful Drinking. A Manual for Use in Primary Care. Geneva: WHO, 2001.

Bickel 1987

Bickel WK, Marion I, Lowinson JH. The treatment of alcoholic methadone patients: a review. Journal of Substance Abuse Treatment 1987;4(1):15‐9.

Blankertz 2004

Blankertz L, Magura S, Staines GL, Madison EM, Spinelli M, Horowitz E, et al. A new work placement model for unemployed methadone maintenance patients. Substance Use and Misuse 2004;39(13‐14):2239‐60.

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Budney 2001

Budney AJ, Sigmon SC, Higgins ST. Contingency management: using science to motivate change. In: Coombs RH editor(s). Addiction Recovery Tools: A Practical Handbook. London: Sage, 2001:147‐72.

Byrne 2011

Byrne SA, Petry NM. Concurrent alcohol dependence among methadone‐maintained cocaine abusers is associated with greater abstinence. Experimetal and Clinical Psychopharmacology 2011;19(2):116‐22.

Chen 2011

Chen IC, Chie WC, Hwu HG, Chou SY, Yeh YC, Yu CY, et al. Alcohol use problem among patients in methadone maintenance treatment in Taiwan. Journal of Substance Abuse Treatment 2011;40(2):142‐9.

Crits‐Christoph 1999

Crits‐Christoph P, Siqueland L, Blaine J, Frank A, Luborsky L, Onken LS, et al. Psychosocial treatments for cocaine dependence: National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Archives of General Psychiatry 1999;56(6):493‐502.

CSAT 2004

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Du J, Wang Z, Xie B, Zhao M. Hepatitis C knowledge and alcohol consumption among patients receiving methadone maintenance treatment in Shanghai, China. The American Journal of Drug and Alcohol Abuse 2012;38(3):228‐32.

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Scalia Tomba GP, Rossi C, Taylor C, Klempova D, Wiessing L. Guidelines for Estimating the Incidence of Problem Drug Use. EMCDDA, Lisbon2008.

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Gossop M, Marsden J, Stewart D, Rolfe A. Patterns of drinking and drinking outcomes among drug misusers: 1‐year follow‐up results. Journal of Substance Abuse Treatment 2000;19(1):45‐50.

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Gossop M, Stewart D, Marsden J. Effectiveness of drug and alcohol counselling during methadone treatment: content, frequency, and duration of counselling and association with substance use outcomes. Addiction 2006;101(3):404‐12.

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Islam MM, Day CA, Conigrave KM, Topp L. Self‐perceived problem with alcohol use among opioid substitution treatment clients. Addictive Behaviors 2013;38(4):2018‐21.

Kaner 2007

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References to other published versions of this review

Klimas 2012a

Klimas J, Field CA, Cullen W, O'Gorman CS, Glynn LG, Keenan E, et al. Psychosocial interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users.. Cochrane Database of Systematic Reviews 2012, Issue 11. [DOI: 10.1002/14651858.CD009269.pub2]

Characteristics of studies

Characteristics of included studies [ordered by study ID]

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Carroll 1998

Methods

Study design: RCT, single blind.

Recruitment modality of participants: individuals seeking treatment at the outpatient treatment unit of the APT Foundation, or respondents to newspaper advertisements or public service announcements.

Participants

Number of participants: 122 (41 in 2 arms selected for this review).

Gender: 27% female.

Age: mean age 30.8 years (SD 5.5 years).

Condition: "All subjects met current DSM‐III‐R criteria for cocaine dependence, and for concurrent alcohol dependence (85%) or alcohol abuse (15%)".

Other relevant information:

TSF arm:

Baseline substance use:

  • mean weekly cocaine use 5.4 ± 8.6;

  • days cocaine use/past 30 12.7 ± 8.0;

  • cocaine use g/week/past 30 days 4.6 ± 6.6;

  • mean drinks per drinking day/past 30 days 10.2 ± 5.7;

  • days of alcohol use/past 30 days 12.3 ± 8.0;

  • years of cocaine use ‐ lifetime 7.5 ± 3.9;

  • years of alcohol misuse ‐ lifetime 7.1 ± 6.3;

  • life‐time psychiatric disorders: any affective disorder 24%, any anxiety disorder 24%, ASP 42%, any non‐ASP 35%;

  • ASI composite scores: medical 0.15 ± 0.26, employment 0.71 ± 0.28, legal 0.09 ± 0.18, family/social 0.21 ± 0.15, psychological 0.26 ± 0.17, alcohol 0.30 ± 0.19, cocaine 0.58 ± 0.24, other drugs 0.06 ± 0.06;

  • race: white 40%, African‐American 56%, Hispanic 0%, other 4%;

  • married/cohabiting 42%;

  • unemployed 76%;

  • education: less than high school 40%;

  • primary route of administration: nasal 20%, smoking 72%, intravenous 8%;

  • previous treatment: alcohol 36%, drugs 72%.

CBT arm:

Baseline substance use:

  • mean weekly cocaine use (mean ± SD) 5.6 ± 6.2;

  • days cocaine use/past 30 days; 15.6 ± 6.5;

  • cocaine use g/week/past 30 days 5.0 ± 5.1;

  • mean drinks per drinking day/past 30 days 10.6 ± 8.0;

  • days of alcohol use/past 30 days 18.5 ± 7.6;

  • years of cocaine use ‐ lifetime 5.8 ± 3.1;

  • years of alcohol misuse ‐ lifetime 7.3 ± 6.4;

  • life‐time psychiatric disorders: any affective disorder 33%, any anxiety disorder 6%, ASP 46%, any non‐ASP 50%;

  • ASI composite scores: medical 0.19 ± 0.29, employment 0.67 ± 0.32, legal 0.09 ± 0.17, family/social 0.12 ± 0.15, psychological 0.16 ± 0.19, alcohol 0.40 ± 0.20, cocaine 0.58 ± 0.18, other drugs 0.07 ± 0.05;

  • race: white 32%, African‐American 63%, Hispanic 1%, other 0%;

  • married/cohabiting 32%;

  • unemployed 53%;

  • education: less than high school 32%;

  • primary route of administration: nasal 11%, smoking 84%, intravenous 5%;

  • previous treatment: alcohol 32%, drugs 58%.

Interventions

Description of the experimental and control interventions

The trial included 5 treatment arms: CBT plus disulphiram; TSF plus disulphiram; CM plus disulphiram; CBT plus no medication; TSF plus no medication. We considered only the latter 2 psychosocial therapy arms. CBT was based on Marlatt's relapse prevention model and TSF was adapted from that used in Project MATCH and was grounded in the concept of substance dependence as a spiritual and medical disease.

Route of delivery: treatments were manual‐guided; 4 doctoral‐level psychologists conducted CBT; 2 masters‐level clinicians conducted TSF.

Number of participants allocated to each group: 25 in CBT plus no medication; 19 in TSF plus no medication.

Duration of the intervention: 12 weeks, 16 individual sessions.

Duration of follow up: 12 weekly assessments within‐treatment, and at 1, 3, 6, 12 months.

Country of origin, setting: a non‐profit substance abuse treatment centre (APT Foundation) affiliated with Yale University in New Haven, Connecticut, USA.

Outcomes

1.1.1 Alcohol abstinence as maximum number of weeks of consecutive alcohol abstinence during treatment

1.1.2 Illicit drug abstinence as maximum number of weeks of consecutive abstinence from cocaine during treatment

1.2.1 Alcohol abstinence as number achieving 3 or more weeks of consecutive alcohol abstinence during treatment

1.2.2 Illicit drug abstinence as number achieving 3 or more weeks of consecutive abstinence from cocaine during treatment

1.2.3 Alcohol abstinence during follow‐up year

1.2.4 Illicit drug abstinence as abstinence from cocaine during follow‐up year

Notes

All sessions were recorded and checked and rated for accuracy and fidelity of the intervention.

"Subjects also met weekly with an independent clinical evaluator who collected urine specimens, assessed cocaine and alcohol use and monitored other clinical symptoms".

"Patients were paid $25 for each follow‐up interview, with a $10 increase for each consecutive interview they attended, to encourage more complete data collection. In addition, patients were paid a $5 bonus for attending an interview within 28 days of the target interview date".

  • Only 39 subjects completed the full 12‐week treatment (compliant treatment completers)

  • Participants in the pharmacological arms stayed longer in treatment (participants were not blind to their intervention)

  • The specific type of self‐report questionnaires was not reported in the primary paper (1998), only in the follow‐up paper

  • Results are reported as number of weeks of continuous abstinence

  • The follow‐up report (2000) does not provide any endpoint scores (only results of the random‐effects regression model)

  • Use of cocaine and alcohol were strongly associated with each other during treatment, particularly for the subjects assigned to disulphiram

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Not enough information provided; e.g. "Of the 122 randomised subjects, 117 initiated the treatment".

Allocation concealment (selection bias)

Unclear risk

Not stated.

Blinding of outcome assessment (detection bias)
Objective outcomes

Unclear risk

Not available.

Objective measures used rather as an accuracy check than an outcome (urine specimens and breathalyser tests conducted by a blinded evaluator).

Blinding of outcome assessment (detection bias)
Subjective outcomes

Low risk

Within‐study assessments:
"independent clinical evaluator who collected urine specimens, assessed cocaine and alcohol use; the evaluator saw patients in an office physically separated from the therapy offices and instructed patients not to disclose detail of their therapist or treatment".
Follow‐up assessments (2000 paper):
"Patients were assessed at face‐to‐face follow‐up interviews conducted 1, 3, 6 and 12 months after the 12‐week termination point by an independent clinical evaluator who was blind to both psychotherapy and pharmacotherapy condition".

Incomplete outcome data (attrition bias)
End of Study outcomes

High risk

Within‐treatment assessments (1998):

"Assignment to disulphiram was associated with significantly better retention in treatment".

The psychotherapy groups had significantly lower retention rates than the medication groups:
"subjects assigned to disulphiram treatment were retained significantly longer than those assigned to no medication (8.4 versus 5.8 weeks. F= 8.7, p< 0.05)".

Retention rates:

  • CBT/disulphiram group (mean 8.8 weeks);

  • CM/disulphiram (8.4 weeks);

  • TSF/disulphiram (8.0);

  • CBT/no medication (6.3);

  • TSF/no medication (5.3).

"However, such analyses, ..., are confounded by differences among the treatments in retention".

Only 30% completed treatment, however:
"Subjects who remained in treatment the full 12 weeks/16 sessions (n=39) did not differ from those who did not start treatment or dropped out (n=83) in terms of gender, race, employment status, route of administration, presence of lifetime affective, anxiety or antisocial personality disorder, but those who met criteria for a nonASP Axis II disorder, were significantly more likely to complete treatment than these who did not (48.1% versus 23.1%)".

Comments:
1) baseline characteristics provided for the ITT sample (n = 122); but
2) rates of consecutive abstinence provided for the exposed sample (n = 117);
3) it is not known whether missing outcome data were balanced in numbers across intervention groups, because group breakdowns for drop‐outs are not provided;
4) psychotherapy groups (CBT, TSF) differed significantly at baseline: for frequency of alcohol use; and medication groups had lower baseline cocaine use.

Incomplete outcome data (attrition bias)
Follow up

High risk

All groups had a comparable number of follow‐up data points. However, number of drop‐outs was not reported for each group separately.

"It is possible that poorer‐functioning subjects who dropped out of treatment early were under‐represented in the follow‐up data, inflating outcomes in all groups".

"Participants who completed more sessions had better outcomes during follow‐up".

  • Subjects with higher age of onset of drug use had more follow‐up data

  • Subjects with non‐ASP Axis II disorders had more follow‐up data

  • No significant differences between those followed up and those not followed up

Percentage of treatment days abstinent from cocaine, percentage of treatment days abstinent from alcohol, percentage of cocaine‐negative urine screens, medication compliance during treatment.

Number of drop‐outs and reasons:

Number randomised: 122 (25 TSF, 19 CBT);

Number initiated: 117 (23 TSF, 18 CBT) ‐ no other reason provided;

Number removed from the trial: 8 (1 did not comply with medication, 1 medication side effects. 4 clinical deterioration, 2 administrative discharge);

Number drop‐outs: 70 (no group breakdowns ‐ no other reasons);

Number completed treatment: 39;

Number followed up at least once: 96, i.e.:

  • 1 month: 68;

  • 3 months: 67;

  • 6 months: 63;

  • 12 months: 72.

Feldman 2013

Methods

Study design: RCT.

Recruitment modality of participants: for 1 year, participation in the study was proposed systematically to each adult outpatient who was treated for opioid or cocaine dependence.

Participants

Number of participants: 110.

Gender: 72.3% male.

Age (mean ± SD): 35 ± 7.8 years.

Condition: problem alcohol use based on questions from the AUDIT questionnaire, i.e. excessive drinking (7 ≤ AUDIT score < 13 for men and 6 ≤ AUDIT score < 13 for women); and alcohol dependence (score > 13); 43.8% were classified as excessive drinkers and 56.2% as alcohol dependents.

Other relevant information: opiate dependence treatment with methadone substitution (56.2%) or diacetyl morphine (heroin treatment; 12%); no opioid substitution and treatment for opiate or cocaine dependence (31.7%).
Most participants with cocaine dependence or with opiate dependence also had tobacco or cannabis dependence. Most participants had 1 or more concomitant psychiatric disorders (mood disorder, 35.6%; personality disorder, 34%; anxiety disorders, 14.7%; psychotic disorders, 9.4%). "Diagnoses were established according to the criteria of the ICD‐10) by a resident and a senior psychiatrist".

Interventions

Description of the experimental and control interventions: the intervention group was BI and the control group was TAU.

(1) BI: BI was delivered in 1 session, based on WHO guidelines, delivered by a trained staff (4 hours' training). The intervention group received the same TAU as controls. The outpatient staff consisted of a psychiatrist, general practitioner, psychologist, nurse, and social worker.

(2) TAU: "The control group received TAU in addition to AUDIT and score feedback. TAU refers to outpatient pharmacological and psychosocial treatment. Maintenance treatment with methadone or heroin included medical and psychiatric follow‐up, primary health care, psychosocial interventions, and administration of opiate treatments in a clinical setting. Psychosocial treatment included medical and psychiatric follow‐up, primary health care, psychosocial interventions, and, if necessary, administration of pharmacotherapy in a clinical setting".

Number of participants allocated to each group: 60 in BI, 52 in TAU.

Duration of the intervention (mean ± SD): 16 ± 4.7 minutes.

Duration of follow up: 3 and 9 months.

Country of origin, setting: specialised outpatient clinic in the Division of Substance Abuse of the University Hospitals of Geneva, Switzerland.

Outcomes

2.1.1 Alcohol use as AUDIT scores at 3 months

2.1.2 Alcohol use as AUDIT scores at 9 months

2.1.3 Alcohol use as number of drinks per week at 3 months (number of glasses of alcohol per week, 1 glass: 10 g of alcohol; wine = 100 mL; beer = 250 mL; spirits = 25 mL)

2.1.4 Alcohol use as number of drinks per week at 9 months

2.2.1 Alcohol use as decreased alcohol use at 3 months

2.2.2 Alcohol use as decreased alcohol use at 9 months

2.2.3 and 2.2.4 Increased or unchanged alcohol use at 3 and 9 months (i.e. reverse of the above)

Notes

The participants in both groups were already in treatment for opioid or cocaine dependence before study inclusion. Participants allocated to BI received this intervention 2 or 3 weeks after AUDIT screening.

The WHO Manual recommends the referral of individuals with alcohol dependence to specialist treatment without providing BI.

All screened participants received feedback that explained the meaning of their AUDIT score.

Almost 40% of the sample was lost to follow up.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: "The randomisation scheme was drawn by a statistician, who used the Web site [http://www.randomizer.org/]. A random permuted block method was used, with blocks of 4 patients".

Allocation concealment (selection bias)

Low risk

Quote: "The sequence was concealed from all investigators with numbered opaque sealed envelopes prepared by the statistician and handed over to the physician in charge of the study".

Blinding of outcome assessment (detection bias)
Objective outcomes

Unclear risk

Not available, objective measures not used.

Blinding of outcome assessment (detection bias)
Subjective outcomes

High risk

Not stated.

Unpublished information: "There is no blinding assessment".

Incomplete outcome data (attrition bias)
End of Study outcomes

Unclear risk

Not available. The study did not assess outcomes at the time of the study end.

Incomplete outcome data (attrition bias)
Follow up

Low risk

Modified ITT analysis (multiple imputation, random assumption).
At T0 ‐ 1 person not included in analysis because of data‐entry errors, both in both control and intervention group.

Number of drop‐outs and reasons:

"Of the BI group, 59.3% completed the last observation and of the control group, 58.8% completed it"

  • Intervention (T0 = 51, T3 = 29, T9 = 30);

  • Control (T0 = 59, T3 = 30, T9 = 35).

No reasons provided for drop‐outs, but regression showed no differences:
"Logistic regressions showed that the ‐ Type of drinker ‐ and ‐ Treatment group ‐ did not explain the missingness of data".
"Hence, these variables displayed no particular pattern, meaning that the data for excessive drinkers and for alcohol‐dependent patients, as well as for the control group and the intervention group, were equally likely to be missing".

Comment: dichotomous outcomes: 40% of participants dropped out, but the observed event risk was 10% to 20% (control), and 60% to 80% (intervention).

Nyamathi 2010

Methods

Study design: RCT open label, 3 arms.

Recruitment modality of participants: flyers displayed in 5 methadone treatment sites.

Participants

Number of participants: 256.

Gender: 59.2% male.

Age (mean ± SD): 51.2 ± 8.4 years.

Condition: reported moderate‐to‐heavy alcohol use based on questions from the ASI. Methadone maintenance treatment was an inclusion criterion (minimum 3 months).

Other relevant information: fair/poor health: 60.4%.
Depressive symptoms: 80.8%.
Poor emotional well‐being: 67.5%.

Ethnicity: African‐American: 45.1%; white: 18.8, Latino: 26.7, Other: 9.4. Education: high school graduate 58%.
Partnered: 54.3%.
Employed: 17.3%.
Recent alcohol use at baseline (Mean number standard drinks last 30 days): 0‐40: 25.1; 41‐89: 24.7; 90‐180: 26.7; 180+: 23.5.
Marijuana use in past 30 days: 16%.
IDU in past 30 days: 40%.
Smoke > 1 pack/day: 56.1%.
Self‐help programme in past 30 days: 21.2%.

Social support: primarily from drug users 12.6%; primarily non‐drug users 48.6%, both: 34.9%.

Interventions

Description of the experimental and control interventions: (1) nurse‐led HHP group sessions; (2) MI delivered in group sessions (MI‐group), and (3) MI delivered in 1‐on‐1 sessions (MI‐single).

(1) HHP: didactic style, also interactive as the group raised questions. Delivered by a nurse and hepatitis‐trained research assistant. Sessions based on "The comprehensive health seeking and coping paradigm (CHSCP; Nyamathi 1989), originally adapted from Lazarus and Folkman's (1984) stress and coping paradigm and Schlotfeldt's (1981) health seeking paradigm". Staff trained on the integration of the CHSCP into their education delivery.

Focus: progression of HCV infection and the culturally sensitive strategies that infected individuals can adopt to prevent or reduce accumulated damage to liver functioning. Strategies included: discussing the dangers of alcohol use on hepatitis (cognitive factors), discussing ways to avoid alcohol and other drugs, eating a balanced diet, dangers of reinfection of HCV by IDU, receiving unsafe tattoos and piercing, having unprotected sexual behaviour, and being consistent in engaging in other health‐related behaviours. Additional health promoting activities: enhancing coping, such as seeking positive social support, getting
support from religion and building self‐esteem in individuals with a history of drug and alcohol addiction. The HHP was directed by a detailed protocol.

(2) MI‐group: focus: alcohol, risky behaviours, MI spirit; by trained MI specialists, i.e. a PhD‐prepared psychologist conducted primarily the MI‐group sessions. Content of the individual and group sessions was identical, guided by a detailed protocol and biweekly meetings with the investigator and therapists. The average number of participants was 6 (range 5 to 7).

(3) MI‐single: focus: alcohol, risky behaviours, MI spirit; a MSW‐prepared researcher conducted primarily the individual MI sessions.

Number of participants allocated to each group: HHP: N = 87; MI group: N = 79; MI single: N = 90.

Duration of the intervention: 3 x 60‐minute sessions, spaced 2 weeks apart.

Duration of follow‐up: 6 months.

Country of origin, setting: 5 methadone treatment sites in Los Angeles and Santa Monica, USA.

Outcomes

3.1.1 Alcohol use (unpublished) as number of standard drinks consumed per day over the last 30 days

3.1.2 Illicit drug use (unpublished) as frequency of drug use (as measured by ASI drug)

3.1.3 Illicit drug use (unpublished) as a composite drug score (frequency*severity for all drugs taken)

3.2.1 Alcohol use as > 50% reduction in number of standard drinks consumed per day over the last 30 days

3.2.2 Alcohol abstinence as abstinence from alcohol over the last 30 days

Outcomes 4.1.1 to 4.2.2 refer to the individual (single) format of MI.

Notes

6 participants reported no alcohol use at baseline.

A total of 86.7% of participants completed all 3 sessions and 91.3% completed the 6‐month follow up.

The sessions were open; i.e. participants who had not completed their 3 sessions with their original cohort could complete with a later cohort.

The original protocol describes HHP as a control intervention (UCG).

Means (SD) of outcomes measures (ASI, TLFB) are not provided for any of the outcomes; baseline scores are also not provided.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: "This study was a randomised controlled trial"

Unpublished information: "As participants were enrolled, they were systematically assigned to each of the three arms. In terms of randomisation, we used random assignment using a random number table".

Allocation concealment (selection bias)

High risk

Masking: open label.
Source of information: published protocol of the trial.

Blinding of outcome assessment (detection bias)
Objective outcomes

Unclear risk

Not available, objective measures not used.

Blinding of outcome assessment (detection bias)
Subjective outcomes

High risk

Masking: open label.
Source of information: published protocol of the trial.

Incomplete outcome data (attrition bias)
End of Study outcomes

Unclear risk

Not available. The study did not assess outcomes at the time of the study end.

Incomplete outcome data (attrition bias)
Follow up

Low risk

Comment:
All analyses were ITT; however, it is not stated which method of data imputation was used for ITT analysis.
Missing data balanced across groups.
Comparability of all 3 arms assessed at baseline.

Number of drop‐outs and reasons:

  • MI‐S (90), 86% completed all sessions, 9% lost to follow up;

  • MI‐G (79), 85% completed all sessions, 10% lost to follow up;

  • HHP (87), 89% completed all sessions, 7% lost to follow up.

Unpublished information: "The 6 reported abstainers were distributed as follows: 2 in MI‐Single, 3 in MI‐Group and 1 in HHP.
No one was excluded from the final regression model based on ethnicity. The statement was erroneously carried over from preliminary modelling. However, since ethnicity was not important in that modelling, it was not included in the final model and there was no need to exclude anyone based on ethnicity.
The 6 abstainers were excluded from the logistic regression analysis. "A missing value for drug‐using partners caused an additional case to be omitted (actually there were 248 cases in the regression model rather than 249. Two subjects had missing values for drug‐using partners)".

Stein 2002a

Methods

Study design: RCT.

Recruitment modality of participants: study was advertised at 3 NEP sites using posters and NEP volunteers offered all clients referral cards. NEP clients called a study telephone to be screened by a research assistant at a separate research site in hospital. During the initial study visit, all NEP clients presented their study cards (received at NEP). Between February 1998 and October 1999.

Participants

Number of participants: 187.

Gender: 119 male (63.6%).

Age: mean 36.2 years.

Condition: problem alcohol use, i.e. AUDIT‐positive (> 8) active IDUs. "Current alcohol abuse or dependence diagnosis was ascertained using the SCID interview. 159 (85.0%) met DSM‐IV criteria for current alcohol abuse or dependence (80% for abuse, 70% for dependence)".

Other relevant information:

  • mean education: 11.5 years;

  • ethnicity: 162 (86.6%) Caucasian;

  • most frequently injected drug: heroin for 141 (75.4%) subjects, cocaine for 15 (8.0%), heroin and cocaine for 31 (16.6%);

  • 120 (64.1%) participants visited the NEP at least once a month;

  • mean AUDIT score at screening was 22.2;

  • 159 (85.0%) met DSM‐IV criteria for current alcohol abuse or dependence (80% for abuse, 70% for dependence);

  • mean ± SD number of drinking days in the past 30 days prior to baseline assessment: 12.0 ± 10.3;

  • 71.4% of quantities on all drinking days exceeded conventional criteria defining heavy alcohol consumption (5+ drinks for men and 3+ drinks for women);

  • mean ± SD drinks per drinking days 7.3 ± 5.8.

Interventions

Description of the experimental and control interventions: (1) brief MI and (2) control group.

(1) MI: focus on alcohol use and HIV risk‐taking

Goals: to assess the degree to which the participant engages in hazardous drinking; to identify relationships between alcohol consumption and alcohol‐related negative consequences including HIV risk behaviour; to identify goals for behaviour change and any barriers to change.

  • Included a written change plan, designed to reduce the link between alcohol consumption and hazardous behaviours that may lead to negative consequences of drinking, including HIV risk behaviour

  • Interventionist trained by studying the manual and watching MI tapes from Project MATCH

  • Standard delivery of the MI protocol

  • Adherence monitoring by: an MI checklist completed by the therapist after each session and audiotapes of sessions were randomly reviewed by a supervisor trained in MI

(2) Control: assessment‐only, approximately 3 hours

Number of participants allocated to each group: 95 in MI, 92 in control group.

Duration of the intervention: 2 therapist sessions, 1 month apart; 1st session: 60 minutes, 2nd session: 30 to 45 minutes.

Duration of follow‐up: 1 and 6 months.

Country of origin, setting: NEP clients, study site: Rhode Island Hospital in Providence, USA.

Outcomes

5.1.1 Alcohol use as number of days in the past 30 days with alcohol use at 1 month

5.1.2 Alcohol use as number of days in the past 30 days with alcohol use at 6 months

5.2.1 Alcohol use as 25% reduction of drinking days in the past 30 days

5.2.2 Alcohol use as 50% reduction of drinking days in the past 30 days

5.2.3 Alcohol use as 75% reduction of drinking days in the past 30 days

5.2.4 Alcohol use as 1 or more drinking days' reduction in the past 30 days

5.2.5 Alcohol use as 7 or more drinking days' reduction in the past 30 days

Secondary outcome: number of days in the past 30 days with IRRB ‐ defined as answer to 1 question: have you used needles etc. after someone else? (reported only for a subset of 109 participants in the 2002b paper).

Notes

Study retention: 96.8% at 6 months.

Control and MI subjects received identical research assessments at baseline, 1 and 6 months:

  • at baseline and 1 month later, both MI and control group received a list of referrals for substance abuse and medical treatment;

  • participants in the control group spent approximately 3 total hours (assessment time) with research staff, "the assessment included sections on demographics, drug and alcohol use, drug and alcohol treatment, health‐related quality of life, attitudes and experiences with alcohol and HIV risk behavior";

  • the assessment control group also experienced meaningful reduction in alcohol use;

  • 6‐month follow up: 11 subjects were interviewed in prison and 6 were interviewed by telephone;

  • total reimbursement: $90 with $20 given at baseline, $30 at the 1‐month interview and $40 at the final interview;

  • 65 (34.8%) participants reported 4 or fewer drinking days at baseline: their maximum possible decrease in drinking days at follow‐up is 4 or less (i.e. floor and ceiling effects);

  • change in heroin use was not associated with change in alcohol use;

  • the association between change in IRRB days and change in alcohol use days was not statistically significant.

The paper reporting IRRB outcomes (Stein 2002b) was included in another Cochrane review (Meader 2010), therefore it was not considered for this review.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Not enough information provided: "Following the baseline interview subjects were assigned to treatment conditions using a randomisation schedule created with permuted blocks of eight assignments." "After randomisation, the research interventionist saw participants assigned to MI...".

Allocation concealment (selection bias)

Unclear risk

Not stated how the randomisation schedule was prepared: "This method ensured that the treatment groups were balanced in number to within four patients throughout the trial. The data manager prepared the randomisation schedule before the first patient enrolled".

Blinding of outcome assessment (detection bias)
Objective outcomes

Unclear risk

Not available. Objective measures used rather as an accuracy check than an outcome:

"During the initial study visit, all NEP subjects presented their study cards (received at NEP), underwent blood alcohol level testing (to ensure subjects were not inebriated, BAL < 0.04)".

Blinding of outcome assessment (detection bias)
Subjective outcomes

Low risk

"At each follow‐up assessment, research assistants were blinded to the treatment condition of the subject; the interventionist did not perform research assessments".

Incomplete outcome data (attrition bias)
End of Study outcomes

Unclear risk

Not available. The study did not assess outcomes at the time of the study end.

Incomplete outcome data (attrition bias)
Follow up

Low risk

"We conducted an intent‐to‐treat analysis using a conservative 'worst case scenario' strategy in which observations with missing follow‐up data were assigned the maximum value of 30 drinking days, a data imputation approach which tends to minimize observed reductions in mean drinking days across time.

To ensure that our substantive results were not sensitive to missing observations (there were no condition differences in missing data) we replicated our analyses using observations with complete data (n = 181), and using other imputation strategies (e.g. mean substitution, regression estimation and 'best case scenario'). All imputation strategies resulted in substantively consistent findings.

To evaluate the adequacy of random assignment, we used t‐ and x2‐tests to compare treatment groups with respect to background characteristics and baseline measures of drinking behaviours and alcohol problems".

Number of drop‐outs and reasons:
There were no study withdrawals: 93 of 95 in the MI group received both MI sessions: 2 people missed their second session. 6‐month follow‐up data were available for 96.8% (n = 181) of the 187 randomly assigned subjects. 3 subjects in each treatment arm were lost to follow‐up at 6 months.

ASI: Addiction Severity Index; ASP: antisocial personality disorder; BAL: blood alcohol level; BI: brief intervention; CBT: cognitive‐behavioural coping skills training; CM: clinical management; DSM‐III‐R: Diagnostic and Statistical Manual of Mental Disorders, Third Edition ‐ Revised; DSM‐IV: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; HCV: hepatitis C virus; HIV: human immunodeficiency virus; HHP: hepatitis health promotion; ICD‐10: International Classification of Diseases ‐ Tenth Revision; IDU: injection drug use; ITT: intention to treat; IRRB: injection‐related HIV risk behaviour; MI: motivational intervention; MSW: master in social work; NEP: needle exchange programme; PhD: doctor of philosophy; RCT: randomised controlled trial; SD: standard deviation; TAU: treatment as usual; TLFB: timeline follow‐back; TSF: 12‐step facilitation; UCG: usual care group; WHO: World Health Organization.

Characteristics of excluded studies [ordered by study ID]

Jump to:

Study

Reason for exclusion

Abou‐Saleh 2008

Participants not in the inclusion criteria: concurrent problem alcohol and drug use not an inclusion criterion

Alessi 2007

Participants not in the inclusion criteria: concurrent problem alcohol and drug use not an inclusion criterion

Andreasson 2002

Participants not in the inclusion criteria: participants had alcohol dependence only

Azrin 1994

Participants not in the inclusion criteria: participants were not problem drug users and concurrent problem alcohol use not an inclusion criterion

Azrin 1996

Participants not in the inclusion criteria: participants were not problem drug users and concurrent problem alcohol use not an inclusion criterion

Baker 2005

Participants not in the inclusion criteria: concurrent problem alcohol use not an inclusion criterion

Baker 2006

Participants not in the inclusion criteria: concurrent problem alcohol use not an inclusion criterion

Ball 2007

Participants not in the inclusion criteria: concurrent problem alcohol use not an inclusion criterion

Bennett 2002

Study design not in the inclusion criteria: not an RCT

Bernstein 2005

Outcome not in the inclusion criteria: alcohol use was not measured, because the intervention focused on drug use and the participants were not reported to have problem alcohol use at randomisation

Black 2011

Participants not in the inclusion criteria: concurrent problem alcohol and drug use not an inclusion criterion

Bowen 2006

Study design not in the inclusion criteria: not an RCT

Brown 2007

Participants not in the inclusion criteria: concurrent problem alcohol use not an inclusion criterion

Burling 2001

Participants not in the inclusion criteria: the MST (multi‐component smoking treatment) condition had a continuous drug and alcohol abstinence rate

Chermack 2002

Study design not in the inclusion criteria: not an RCT

Cohen 1982

Participants not in the inclusion criteria: concurrent problem alcohol use not an inclusion criterion for all subjects randomised into trial. Quote: "Approximately one‐third of all the active alcoholics [n=105] were assigned to each of the three study groups (1983, p864; 1982, p360)." Comment: it is highly probable that non‐alcoholics were randomised into trial. Operative alcoholics (N = 105) versus all subjects randomised into trial (N = 127)

Daeppen 2010

Participants not in the inclusion criteria: concurrent problem drug use not an inclusion criterion. Only 10% to 11% participants smoked cannabis once per week

Darker 2011

Study design not in the inclusion criteria: not an RCT

Darker 2012

Study design not in the inclusion criteria: not an RCT

Drapkin 2008

Participants not in the inclusion criteria: concurrent problem alcohol use not an inclusion criterion

Drumright 2011

Study design not in the inclusion criteria: not an RCT. A secondary analysis of 2 RCTs that did not have concurrent problem alcohol use not an inclusion criterion

Forsberg 2011

Participants not in the inclusion criteria: concurrent problem alcohol use not an inclusion criterion

Gruber 2008

Participants not in the inclusion criteria: concurrent problem alcohol use not an inclusion criterion

Klimas 2013

Study design not in the inclusion criteria: not an RCT

Marsden 2006

Participants not in the inclusion criteria: concurrent problem alcohol use not an inclusion criterion

O'Farrell 2008

Participants not in the inclusion criteria: participants were eligible if they had alcohol dependence diagnosis with or without comorbid
drug diagnosis

Ruger 2012

Participants not in the inclusion criteria: concurrent problem alcohol use not an inclusion criterion

Sanson‐Fisher 2010

Study design not in the inclusion criteria: not an RCT

Staiger 2009

Participants not in the inclusion criteria: concurrent problem alcohol use not an inclusion criterion. Alcohol was used only by 149 of the 166 participants in the 90 days prior to initial presentation

Van Der Hyde 1995

Participants not in the inclusion criteria: concurrent problem alcohol and drug use not an inclusion criterion

Worden 2010

Participants not in the inclusion criteria: concurrent problem alcohol use not an inclusion criterion. Additionally, 46.6% reported alcohol as their primary drug (review exclusion criterion)

Zule 2007

Participants not in the inclusion criteria: concurrent problem alcohol use not an inclusion criterion

Zule 2009

Participants not in the inclusion criteria: concurrent problem alcohol use not an inclusion criterion

RCT: randomised controlled trial.

Data and analyses

Open in table viewer
Comparison 1. Cognitive‐behavioural coping skills training (CBT) versus 12‐step facilitation (TSF)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Continuous outcomes Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

Analysis 1.1

Comparison 1 Cognitive‐behavioural coping skills training (CBT) versus 12‐step facilitation (TSF), Outcome 1 Continuous outcomes.

Comparison 1 Cognitive‐behavioural coping skills training (CBT) versus 12‐step facilitation (TSF), Outcome 1 Continuous outcomes.

1.1 Alcohol abstinence as maximum number of weeks of consecutive alcohol abstinence during treatment

1

41

Mean Difference (IV, Fixed, 95% CI)

0.40 [‐1.14, 1.94]

1.2 Illicit drug abstinence as maximum number of weeks of consecutive abstinence from cocaine during treatment

1

41

Mean Difference (IV, Fixed, 95% CI)

0.8 [‐0.70, 2.30]

2 Dichotomous outcomes Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

Analysis 1.2

Comparison 1 Cognitive‐behavioural coping skills training (CBT) versus 12‐step facilitation (TSF), Outcome 2 Dichotomous outcomes.

Comparison 1 Cognitive‐behavioural coping skills training (CBT) versus 12‐step facilitation (TSF), Outcome 2 Dichotomous outcomes.

2.1 Alcohol abstinence as number achieving 3 or more weeks of consecutive alcohol abstinence during treatment

1

41

Risk Ratio (M‐H, Fixed, 95% CI)

1.96 [0.43, 8.94]

2.2 Illicit drug abstinence as number achieving 3 or more weeks of consecutive abstinence from cocaine during treatment

1

41

Risk Ratio (M‐H, Fixed, 95% CI)

1.10 [0.42, 2.88]

2.3 Alcohol abstinence during follow‐up year

1

41

Risk Ratio (M‐H, Fixed, 95% CI)

2.38 [0.10, 55.06]

2.4 Illicit drug abstinence as abstinence from cocaine during follow‐up year

1

41

Risk Ratio (M‐H, Fixed, 95% CI)

0.39 [0.04, 3.98]

Open in table viewer
Comparison 2. Brief intervention (BI) versus treatment as usual

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Continuous outcomes Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

Analysis 2.1

Comparison 2 Brief intervention (BI) versus treatment as usual, Outcome 1 Continuous outcomes.

Comparison 2 Brief intervention (BI) versus treatment as usual, Outcome 1 Continuous outcomes.

1.1 Alcohol use as AUDIT scores at 3 months

1

110

Mean Difference (IV, Fixed, 95% CI)

0.80 [‐1.80, 3.40]

1.2 Alcohol use as AUDIT Scores at 9 months

1

110

Mean Difference (IV, Fixed, 95% CI)

2.30 [‐0.58, 5.18]

1.3 Alcohol use as number of drinks per week at 3 months

1

110

Mean Difference (IV, Fixed, 95% CI)

0.70 [‐3.85, 5.25]

1.4 Alcohol use as number of drinks per week at 9 months

1

110

Mean Difference (IV, Fixed, 95% CI)

‐0.30 [‐4.79, 4.19]

2 Dichotomous outcomes Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

Analysis 2.2

Comparison 2 Brief intervention (BI) versus treatment as usual, Outcome 2 Dichotomous outcomes.

Comparison 2 Brief intervention (BI) versus treatment as usual, Outcome 2 Dichotomous outcomes.

2.1 Alcohol use as decreased alcohol use at 3 months

1

110

Risk Ratio (M‐H, Fixed, 95% CI)

1.13 [0.67, 1.93]

2.2 Alcohol use as decreased alcohol use at 9 months

1

110

Risk Ratio (M‐H, Fixed, 95% CI)

1.34 [0.69, 2.58]

Open in table viewer
Comparison 3. Motivational interviewing (group) (MI‐G) versus hepatitis health promotion (HHP)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Continuous outcomes Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

Analysis 3.1

Comparison 3 Motivational interviewing (group) (MI‐G) versus hepatitis health promotion (HHP), Outcome 1 Continuous outcomes.

Comparison 3 Motivational interviewing (group) (MI‐G) versus hepatitis health promotion (HHP), Outcome 1 Continuous outcomes.

1.1 Alcohol use as number of standard drinks consumed per day over the last 30 days 

1

147

Mean Difference (IV, Fixed, 95% CI)

‐0.40 [‐2.03, 1.23]

1.2 Illicit drug use as frequency of drug use (as measured by Addiction Severity Index ‐ ASI drug)

1

147

Mean Difference (IV, Fixed, 95% CI)

0.0 [‐0.03, 0.03]

1.3 Illicit drug use as a composite drug score (frequency*severity for all drugs taken)

1

151

Mean Difference (IV, Fixed, 95% CI)

0.0 [‐0.42, 0.42]

2 Dichotomous outcomes Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

Analysis 3.2

Comparison 3 Motivational interviewing (group) (MI‐G) versus hepatitis health promotion (HHP), Outcome 2 Dichotomous outcomes.

Comparison 3 Motivational interviewing (group) (MI‐G) versus hepatitis health promotion (HHP), Outcome 2 Dichotomous outcomes.

2.1 Alcohol use as greater than 50% reduction in number of standard drinks consumed per day over the last 30 days

1

166

Risk Ratio (M‐H, Fixed, 95% CI)

1.10 [0.82, 1.48]

2.2 Alcohol abstinence as abstinence from alcohol over the last 30 days

1

166

Risk Ratio (M‐H, Fixed, 95% CI)

0.88 [0.49, 1.58]

Open in table viewer
Comparison 4. Motivational interviewing (single) (MI‐S) versus hepatitis health promotion (HHP)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Continuous outcomes Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

Analysis 4.1

Comparison 4 Motivational interviewing (single) (MI‐S) versus hepatitis health promotion (HHP), Outcome 1 Continuous outcomes.

Comparison 4 Motivational interviewing (single) (MI‐S) versus hepatitis health promotion (HHP), Outcome 1 Continuous outcomes.

1.1 Alcohol use as number of standard drinks consumed per day over the last 30 days 

1

155

Mean Difference (IV, Fixed, 95% CI)

‐0.10 [‐1.89, 1.69]

1.2 Illicit drug use as frequency of drug use (as measured by Addiction Severity Index ‐ ASI drug)

1

155

Mean Difference (IV, Fixed, 95% CI)

0.0 [‐0.03, 0.03]

1.3 Illicit drug use as a composite drug score (frequency*severity for all drugs taken)

1

157

Mean Difference (IV, Fixed, 95% CI)

‐0.10 [‐0.46, 0.26]

2 Dichotomous outcomes Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

Analysis 4.2

Comparison 4 Motivational interviewing (single) (MI‐S) versus hepatitis health promotion (HHP), Outcome 2 Dichotomous outcomes.

Comparison 4 Motivational interviewing (single) (MI‐S) versus hepatitis health promotion (HHP), Outcome 2 Dichotomous outcomes.

2.1 Alcohol use as greater than 50% reduction in number of standard drinks consumed per day over the last 30 days

1

177

Risk Ratio (M‐H, Fixed, 95% CI)

0.92 [0.68, 1.26]

2.2 Alcohol abstinence as abstinence from alcohol over the last 30 days

1

177

Risk Ratio (M‐H, Fixed, 95% CI)

0.97 [0.56, 1.67]

Open in table viewer
Comparison 5. Brief motivational intervention (BMI) versus assessment‐only

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Continuous outcomes Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

Analysis 5.1

Comparison 5 Brief motivational intervention (BMI) versus assessment‐only, Outcome 1 Continuous outcomes.

Comparison 5 Brief motivational intervention (BMI) versus assessment‐only, Outcome 1 Continuous outcomes.

1.1 Alcohol use as number of days in the past 30 days with alcohol use at 1 month

1

187

Mean Difference (IV, Fixed, 95% CI)

‐0.30 [‐3.38, 2.78]

1.2 Alcohol use as number of days in the past 30 days with alcohol use at 6 months

1

187

Mean Difference (IV, Fixed, 95% CI)

‐1.5 [‐4.56, 1.56]

2 Dichotomous outcomes Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

Analysis 5.2

Comparison 5 Brief motivational intervention (BMI) versus assessment‐only, Outcome 2 Dichotomous outcomes.

Comparison 5 Brief motivational intervention (BMI) versus assessment‐only, Outcome 2 Dichotomous outcomes.

2.1 Alcohol use as 25% reduction of drinking days in the past 30 days

1

187

Risk Ratio (M‐H, Fixed, 95% CI)

1.23 [0.96, 1.57]

2.2 Alcohol use as 50% reduction of drinking days in the past 30 days

1

187

Risk Ratio (M‐H, Fixed, 95% CI)

1.27 [0.96, 1.68]

2.3 Alcohol use as 75% reduction of drinking days in the past 30 days

1

187

Risk Ratio (M‐H, Fixed, 95% CI)

1.21 [0.84, 1.75]

2.4 Alcohol use as 1 or more drinking days' reduction in the past 30 days

1

187

Risk Ratio (M‐H, Fixed, 95% CI)

1.12 [0.91, 1.38]

2.5 Alcohol use as 7 or more drinking days' reduction in the past 30 days

1

187

Risk Ratio (M‐H, Fixed, 95% CI)

1.67 [1.08, 2.60]

Study flow diagram from first publication of this review in 2012.
Figures and Tables -
Figure 1

Study flow diagram from first publication of this review in 2012.

Study flow diagram for a review update: previous studies incorporated into results of new literature search
Figures and Tables -
Figure 2

Study flow diagram for a review update: previous studies incorporated into results of new literature search

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figures and Tables -
Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figures and Tables -
Figure 4

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Comparison 1 Cognitive‐behavioural coping skills training (CBT) versus 12‐step facilitation (TSF), Outcome 1 Continuous outcomes.
Figures and Tables -
Analysis 1.1

Comparison 1 Cognitive‐behavioural coping skills training (CBT) versus 12‐step facilitation (TSF), Outcome 1 Continuous outcomes.

Comparison 1 Cognitive‐behavioural coping skills training (CBT) versus 12‐step facilitation (TSF), Outcome 2 Dichotomous outcomes.
Figures and Tables -
Analysis 1.2

Comparison 1 Cognitive‐behavioural coping skills training (CBT) versus 12‐step facilitation (TSF), Outcome 2 Dichotomous outcomes.

Comparison 2 Brief intervention (BI) versus treatment as usual, Outcome 1 Continuous outcomes.
Figures and Tables -
Analysis 2.1

Comparison 2 Brief intervention (BI) versus treatment as usual, Outcome 1 Continuous outcomes.

Comparison 2 Brief intervention (BI) versus treatment as usual, Outcome 2 Dichotomous outcomes.
Figures and Tables -
Analysis 2.2

Comparison 2 Brief intervention (BI) versus treatment as usual, Outcome 2 Dichotomous outcomes.

Comparison 3 Motivational interviewing (group) (MI‐G) versus hepatitis health promotion (HHP), Outcome 1 Continuous outcomes.
Figures and Tables -
Analysis 3.1

Comparison 3 Motivational interviewing (group) (MI‐G) versus hepatitis health promotion (HHP), Outcome 1 Continuous outcomes.

Comparison 3 Motivational interviewing (group) (MI‐G) versus hepatitis health promotion (HHP), Outcome 2 Dichotomous outcomes.
Figures and Tables -
Analysis 3.2

Comparison 3 Motivational interviewing (group) (MI‐G) versus hepatitis health promotion (HHP), Outcome 2 Dichotomous outcomes.

Comparison 4 Motivational interviewing (single) (MI‐S) versus hepatitis health promotion (HHP), Outcome 1 Continuous outcomes.
Figures and Tables -
Analysis 4.1

Comparison 4 Motivational interviewing (single) (MI‐S) versus hepatitis health promotion (HHP), Outcome 1 Continuous outcomes.

Comparison 4 Motivational interviewing (single) (MI‐S) versus hepatitis health promotion (HHP), Outcome 2 Dichotomous outcomes.
Figures and Tables -
Analysis 4.2

Comparison 4 Motivational interviewing (single) (MI‐S) versus hepatitis health promotion (HHP), Outcome 2 Dichotomous outcomes.

Comparison 5 Brief motivational intervention (BMI) versus assessment‐only, Outcome 1 Continuous outcomes.
Figures and Tables -
Analysis 5.1

Comparison 5 Brief motivational intervention (BMI) versus assessment‐only, Outcome 1 Continuous outcomes.

Comparison 5 Brief motivational intervention (BMI) versus assessment‐only, Outcome 2 Dichotomous outcomes.
Figures and Tables -
Analysis 5.2

Comparison 5 Brief motivational intervention (BMI) versus assessment‐only, Outcome 2 Dichotomous outcomes.

Summary of findings for the main comparison. Cognitive‐behavioural coping skills training (CBT) versus 12‐step facilitation (TSF) for alcohol use in concurrent problem alcohol and illicit drug users

Population: participants with alcohol use in concurrent problem alcohol and illicit drug users
Settings: substance abuse treatment centre
Intervention: CBT versus TSF

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

CBT versus TSF

Maximum number of weeks of consecutive alcohol abstinence during treatment
Substance abuse calendar and breathalyser. Scale from: 0 to 12.
Follow up: 12 weeks

The mean maximum number of weeks of consecutive alcohol abstinence during treatment in the control groups was
1.8 weeks

The mean maximum number of weeks of consecutive alcohol abstinence during treatment in the intervention group was
0.4 higher
(1.14 lower to 1.94 higher)

41
(1 study)

⊕⊕⊝⊝
low1,2

Maximum number of weeks of consecutive abstinence from cocaine during treatment
Substance abuse calendar and urinalysis. Scale from: 0 to 12.
Follow up: 12 weeks

The mean maximum number of weeks of consecutive abstinence from cocaine during treatment in the control groups was
1.3 weeks

The mean maximum number of weeks of consecutive abstinence from cocaine during treatment in the intervention group was
0.8 higher
(0.7 lower to 2.3 higher)

41
(1 study)

⊕⊕⊝⊝
low1,2

Number of people achieving 3 or more weeks of consecutive alcohol abstinence during treatment
Substance abuse calendar and breathalyser
Follow up: 12 weeks

Study population

RR 1.96
(0.43 to 8.94)

41
(1 study)

⊕⊕⊝⊝
low1,2

111 per 1000

218 per 1000
(48 to 993)

Moderate

111 per 1000

218 per 1000
(48 to 992)

Alcohol abstinence
Substance abuse calendar and breathalyser
Follow up: 1 year

Study population

RR 2.38
(0.1 to 55.06)

41
(1 study)

⊕⊕⊝⊝
low1,2

0 per 1000

0 per 1000
(0 to 0)

Moderate

0 per 1000

0 per 1000
(0 to 0)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Incomplete outcome data
2 Sparse data: only 1 study with relatively few participants included in comparison

Figures and Tables -
Summary of findings for the main comparison. Cognitive‐behavioural coping skills training (CBT) versus 12‐step facilitation (TSF) for alcohol use in concurrent problem alcohol and illicit drug users
Summary of findings 2. Brief intervention (BI) versus treatment as usual for alcohol use in concurrent problem alcohol and illicit drug users

Population: participants with alcohol use in concurrent problem alcohol and illicit drug users
Settings:
Intervention: BI versus treatment as usual

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

BI versus treatment as usual

Number of standard drinks per week
unreported
Follow up: 3 months

The mean number of standard drinks per week in the control groups was
16.3 standard drinks

The mean number of standard drinks per week in the intervention groups was
0.7 higher
(3.85 lower to 5.25 higher)

110
(1 study)

⊕⊕⊝⊝
low1,2

Number of standard drinks per week
unreported
Follow up: 9 months

The mean number of standard drinks per week in the control groups was
18.7 standard drinks

The mean number of standard drinks per week in the intervention groups was
0.3 lower
(4.79 lower to 4.19 higher)

110
(1 study)

⊕⊕⊝⊝
low1,2

Decreased alcohol use
1st question from the Alcohol Use Disorders Identification Test: How often do you have a drink containing alcohol?
Follow up: 3 months

Study population

RR 1.13
(0.67 to 1.93)

110
(1 study)

⊕⊕⊝⊝
low1,2

314 per 1000

355 per 1000
(210 to 605)

Moderate

314 per 1000

355 per 1000
(210 to 606)

Decreased alcohol use
1st question from the Alcohol Use Disorders Identification Test: How often do you have a drink containing alcohol?
Follow up: 9 months

Study population

RR 1.34
(0.69 to 2.58)

110
(1 study)

⊕⊕⊝⊝
low1,2

216 per 1000

289 per 1000
(149 to 556)

Moderate

216 per 1000

289 per 1000
(149 to 557)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Allocation and assessment of outcomes weren't blinded
2 Sparse data: only 1 study with relatively few participants included in comparison

Figures and Tables -
Summary of findings 2. Brief intervention (BI) versus treatment as usual for alcohol use in concurrent problem alcohol and illicit drug users
Summary of findings 3. Motivational interviewing (group) (MI‐G) versus hepatitis health promotion (HHP) for alcohol use in concurrent problem alcohol and illicit drug users

Population: participants with alcohol use in concurrent problem alcohol and illicit drug users
Settings: methadone outpatient clinics
Intervention: MI‐G versus HHP

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

MI‐G versus HHP

Number of standard drinks per day
counts
Follow up: 6 months

The mean number of standard drinks per day in the control groups was
3.9 standard drinks

The mean number of standard drinks per day in the intervention groups was
0.4 lower
(2.03 lower to 1.23 higher)

147
(1 study)

⊕⊕⊝⊝
low1,2

Over 50% less standard drinks per day
Timeline follow back
Follow up: 6 months

Study population

RR 1.1
(0.82 to 1.48)

166
(1 study)

⊕⊕⊝⊝
low1,2

494 per 1000

544 per 1000
(405 to 731)

Moderate

494 per 1000

543 per 1000
(405 to 731)

Alcohol abstinence
Timeline follow back
Follow up: 6 months

Study population

RR 0.88
(0.49 to 1.58)

166
(1 study)

⊕⊕⊝⊝
low1,2

230 per 1000

202 per 1000
(113 to 363)

Moderate

230 per 1000

202 per 1000
(113 to 363)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Masking: open label. Allocation and assessment of outcomes weren't blinded
2 Sparse data: only 1 study with relatively few participants included in comparison

Figures and Tables -
Summary of findings 3. Motivational interviewing (group) (MI‐G) versus hepatitis health promotion (HHP) for alcohol use in concurrent problem alcohol and illicit drug users
Summary of findings 4. Motivational interviewing (single) (MI‐S) versus hepatitis health promotion (HHP) for alcohol use in concurrent problem alcohol and illicit drug users

Population: participants with alcohol use in concurrent problem alcohol and illicit drug users
Settings:
Intervention: MI‐S versus HHP

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

MI‐S versus hepatitis HHP

Number of standard drinks consumed per day
counts
Follow up: 6 months

The mean number of standard drinks consumed per day in the control groups was
3.9 standard drinks

The mean number of standard drinks consumed per day in the intervention groups was
0.1 lower
(1.89 lower to 1.69 higher)

155
(1 study)

⊕⊕⊝⊝
low1,2

Over 50% less standard drinks per day
Timeline follow back
Follow up: 6 months

Study population

RR 0.92
(0.68 to 1.26)

177
(1 study)

⊕⊕⊝⊝
low1,2

494 per 1000

455 per 1000
(336 to 623)

Moderate

494 per 1000

454 per 1000
(336 to 622)

Alcohol abstinence
Timeline follow back
Follow‐up: 6 months

Study population

RR 0.97
(0.56 to 1.67)

177
(1 study)

⊕⊕⊝⊝
low1,2

230 per 1000

223 per 1000
(129 to 384)

Moderate

230 per 1000

223 per 1000
(129 to 384)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Masking: open label. Allocation and assessment of outcomes weren't blinded
2 Sparse data: only 1 study with relatively few participants included in comparison

Figures and Tables -
Summary of findings 4. Motivational interviewing (single) (MI‐S) versus hepatitis health promotion (HHP) for alcohol use in concurrent problem alcohol and illicit drug users
Summary of findings 5. Brief motivational intervention (BMI) versus assessment‐only for alcohol use in concurrent problem alcohol and illicit drug users

Population: participants with alcohol use in concurrent problem alcohol and illicit drug users
Settings: addiction clinic
Intervention: BMI versus assessment‐only

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

BMI) versus assessment‐only

Number of days with alcohol use at 6 months
Timeline follow back. Scale from: 0 to 31.
Follow up: 6 months

The mean number of days with alcohol use at 6 months in the control groups was
9.1 days

The mean number of days with alcohol use at 6 months in the intervention groups was
1.5 lower
(4.56 lower to 1.56 higher)

187
(1 study)

⊕⊕⊕⊝
moderate1

25% reduction of drinking days in the past 30 days
Timeline follow back
Follow up: 6 months

Study population

RR 1.23
(0.96 to 1.57)

187
(1 study)

⊕⊕⊕⊝
moderate1

522 per 1000

642 per 1000
(501 to 819)

Moderate

522 per 1000

642 per 1000
(501 to 820)

50% reduction of drinking days in the past 30 days
Timeline follow back
Follow up: 6 months

Study population

RR 1.27
(0.96 to 1.68)

187
(1 study)

⊕⊕⊕⊝
moderate1

457 per 1000

580 per 1000
(438 to 767)

Moderate

457 per 1000

580 per 1000
(439 to 768)

Seven or more drinking days' reduction in the past 30 days
Timeline follow back
Follow up: 6 months

Study population

RR 1.67
(1.08 to 2.6)

187
(1 study)

⊕⊕⊕⊝
moderate1

239 per 1000

399 per 1000
(258 to 622)

Moderate

239 per 1000

399 per 1000
(258 to 621)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Sparse data: only 1 study with relatively few participants included in comparison

Figures and Tables -
Summary of findings 5. Brief motivational intervention (BMI) versus assessment‐only for alcohol use in concurrent problem alcohol and illicit drug users
Comparison 1. Cognitive‐behavioural coping skills training (CBT) versus 12‐step facilitation (TSF)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Continuous outcomes Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

1.1 Alcohol abstinence as maximum number of weeks of consecutive alcohol abstinence during treatment

1

41

Mean Difference (IV, Fixed, 95% CI)

0.40 [‐1.14, 1.94]

1.2 Illicit drug abstinence as maximum number of weeks of consecutive abstinence from cocaine during treatment

1

41

Mean Difference (IV, Fixed, 95% CI)

0.8 [‐0.70, 2.30]

2 Dichotomous outcomes Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.1 Alcohol abstinence as number achieving 3 or more weeks of consecutive alcohol abstinence during treatment

1

41

Risk Ratio (M‐H, Fixed, 95% CI)

1.96 [0.43, 8.94]

2.2 Illicit drug abstinence as number achieving 3 or more weeks of consecutive abstinence from cocaine during treatment

1

41

Risk Ratio (M‐H, Fixed, 95% CI)

1.10 [0.42, 2.88]

2.3 Alcohol abstinence during follow‐up year

1

41

Risk Ratio (M‐H, Fixed, 95% CI)

2.38 [0.10, 55.06]

2.4 Illicit drug abstinence as abstinence from cocaine during follow‐up year

1

41

Risk Ratio (M‐H, Fixed, 95% CI)

0.39 [0.04, 3.98]

Figures and Tables -
Comparison 1. Cognitive‐behavioural coping skills training (CBT) versus 12‐step facilitation (TSF)
Comparison 2. Brief intervention (BI) versus treatment as usual

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Continuous outcomes Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

1.1 Alcohol use as AUDIT scores at 3 months

1

110

Mean Difference (IV, Fixed, 95% CI)

0.80 [‐1.80, 3.40]

1.2 Alcohol use as AUDIT Scores at 9 months

1

110

Mean Difference (IV, Fixed, 95% CI)

2.30 [‐0.58, 5.18]

1.3 Alcohol use as number of drinks per week at 3 months

1

110

Mean Difference (IV, Fixed, 95% CI)

0.70 [‐3.85, 5.25]

1.4 Alcohol use as number of drinks per week at 9 months

1

110

Mean Difference (IV, Fixed, 95% CI)

‐0.30 [‐4.79, 4.19]

2 Dichotomous outcomes Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.1 Alcohol use as decreased alcohol use at 3 months

1

110

Risk Ratio (M‐H, Fixed, 95% CI)

1.13 [0.67, 1.93]

2.2 Alcohol use as decreased alcohol use at 9 months

1

110

Risk Ratio (M‐H, Fixed, 95% CI)

1.34 [0.69, 2.58]

Figures and Tables -
Comparison 2. Brief intervention (BI) versus treatment as usual
Comparison 3. Motivational interviewing (group) (MI‐G) versus hepatitis health promotion (HHP)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Continuous outcomes Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

1.1 Alcohol use as number of standard drinks consumed per day over the last 30 days 

1

147

Mean Difference (IV, Fixed, 95% CI)

‐0.40 [‐2.03, 1.23]

1.2 Illicit drug use as frequency of drug use (as measured by Addiction Severity Index ‐ ASI drug)

1

147

Mean Difference (IV, Fixed, 95% CI)

0.0 [‐0.03, 0.03]

1.3 Illicit drug use as a composite drug score (frequency*severity for all drugs taken)

1

151

Mean Difference (IV, Fixed, 95% CI)

0.0 [‐0.42, 0.42]

2 Dichotomous outcomes Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.1 Alcohol use as greater than 50% reduction in number of standard drinks consumed per day over the last 30 days

1

166

Risk Ratio (M‐H, Fixed, 95% CI)

1.10 [0.82, 1.48]

2.2 Alcohol abstinence as abstinence from alcohol over the last 30 days

1

166

Risk Ratio (M‐H, Fixed, 95% CI)

0.88 [0.49, 1.58]

Figures and Tables -
Comparison 3. Motivational interviewing (group) (MI‐G) versus hepatitis health promotion (HHP)
Comparison 4. Motivational interviewing (single) (MI‐S) versus hepatitis health promotion (HHP)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Continuous outcomes Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

1.1 Alcohol use as number of standard drinks consumed per day over the last 30 days 

1

155

Mean Difference (IV, Fixed, 95% CI)

‐0.10 [‐1.89, 1.69]

1.2 Illicit drug use as frequency of drug use (as measured by Addiction Severity Index ‐ ASI drug)

1

155

Mean Difference (IV, Fixed, 95% CI)

0.0 [‐0.03, 0.03]

1.3 Illicit drug use as a composite drug score (frequency*severity for all drugs taken)

1

157

Mean Difference (IV, Fixed, 95% CI)

‐0.10 [‐0.46, 0.26]

2 Dichotomous outcomes Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.1 Alcohol use as greater than 50% reduction in number of standard drinks consumed per day over the last 30 days

1

177

Risk Ratio (M‐H, Fixed, 95% CI)

0.92 [0.68, 1.26]

2.2 Alcohol abstinence as abstinence from alcohol over the last 30 days

1

177

Risk Ratio (M‐H, Fixed, 95% CI)

0.97 [0.56, 1.67]

Figures and Tables -
Comparison 4. Motivational interviewing (single) (MI‐S) versus hepatitis health promotion (HHP)
Comparison 5. Brief motivational intervention (BMI) versus assessment‐only

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Continuous outcomes Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

1.1 Alcohol use as number of days in the past 30 days with alcohol use at 1 month

1

187

Mean Difference (IV, Fixed, 95% CI)

‐0.30 [‐3.38, 2.78]

1.2 Alcohol use as number of days in the past 30 days with alcohol use at 6 months

1

187

Mean Difference (IV, Fixed, 95% CI)

‐1.5 [‐4.56, 1.56]

2 Dichotomous outcomes Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.1 Alcohol use as 25% reduction of drinking days in the past 30 days

1

187

Risk Ratio (M‐H, Fixed, 95% CI)

1.23 [0.96, 1.57]

2.2 Alcohol use as 50% reduction of drinking days in the past 30 days

1

187

Risk Ratio (M‐H, Fixed, 95% CI)

1.27 [0.96, 1.68]

2.3 Alcohol use as 75% reduction of drinking days in the past 30 days

1

187

Risk Ratio (M‐H, Fixed, 95% CI)

1.21 [0.84, 1.75]

2.4 Alcohol use as 1 or more drinking days' reduction in the past 30 days

1

187

Risk Ratio (M‐H, Fixed, 95% CI)

1.12 [0.91, 1.38]

2.5 Alcohol use as 7 or more drinking days' reduction in the past 30 days

1

187

Risk Ratio (M‐H, Fixed, 95% CI)

1.67 [1.08, 2.60]

Figures and Tables -
Comparison 5. Brief motivational intervention (BMI) versus assessment‐only