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

Jan Klimas; Helen Tobin; Catherine‐Anne Field; Clodagh SM O'Gorman; Liam G Glynn; Eamon Keenan; Jean Saunders; Gerard Bury; Colum Dunne; Walter Cullen

doi:10.1002/14651858.CD009269.pub3

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Figure 1

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

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Figure 2

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

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Figure 3

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

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Figure 4

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

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Analysis 1.1

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

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Analysis 1.2

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

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Analysis 2.1

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

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Analysis 2.2

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

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Analysis 3.1

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

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Analysis 3.2

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

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Analysis 4.1

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

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Analysis 4.2

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

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Analysis 5.1

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

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Analysis 5.2

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

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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)	⊕⊕⊝⊝ low^1,2	‐
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)	⊕⊕⊝⊝ low^1,2	‐
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)	⊕⊕⊝⊝ low^1,2	‐
	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)	⊕⊕⊝⊝ low^1,2	‐
	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

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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)	⊕⊕⊝⊝ low^1,2	‐
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)	⊕⊕⊝⊝ low^1,2	‐
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)	⊕⊕⊝⊝ low^1,2	‐
	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)	⊕⊕⊝⊝ low^1,2	‐
	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

Summary of findings 2. Brief intervention (BI) versus treatment as usual for alcohol use in concurrent problem alcohol and illicit drug users

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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)	⊕⊕⊝⊝ low^1,2	‐
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)	⊕⊕⊝⊝ low^1,2	‐
	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)	⊕⊕⊝⊝ low^1,2	‐
	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

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

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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)	⊕⊕⊝⊝ low^1,2	‐
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)	⊕⊕⊝⊝ low^1,2	‐
	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)	⊕⊕⊝⊝ low^1,2	‐
	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

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

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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

Summary of findings 5. Brief motivational intervention (BMI) versus assessment‐only for alcohol use in concurrent problem alcohol and illicit drug users

Ir a la tabla de la revisión

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]

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

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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]

Comparison 2. Brief intervention (BI) versus treatment as usual

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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]

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

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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]

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

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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]

Comparison 5. Brief motivational intervention (BMI) versus assessment‐only

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