Nicole Lee

A systematic review of cognitive and behavioural therapies for methamphetamine dependence.

INTRODUCTION AND AIMS The use of methamphetamine is widespread and poses significant challenges for treatment providers. Much of the treatment knowledge about this group has been extrapolated from studies of treatment for cocaine dependence. Medications have been shown to be of limited effectiveness for methamphetamine users, making psychological interventions the treatment of choice. APPROACH This paper describes a systematic review of cognitive-behavioural and behavioural interventions for methamphetamine users. A systematic search of published literature was undertaken focusing only on randomised trials. KEY FINDINGS There were a relatively small number of intervention studies that compared cognitive-behavioural or behavioural interventions using randomised trial methodology. Most commonly, studies examined cognitive-behaviour therapy (CBT) and/or contingency management (CM). Treatment with CBT appears to be associated with reductions in methamphetamine use and other positive changes, even over very short periods of treatment (two and four sessions). CM studies found a significant reduction of methamphetamine during application of the procedure, but it is not clear if these gains are sustained at post-treatment follow-up. IMPLICATIONS The review highlights that there are effective treatments for methamphetamine dependence. Alcohol and other drug (AOD) clinicians are familiar with these types of interventions and should use them and convey to clients that they are effective. Services and policy makers should ensure that best practice interventions are implemented within AOD services. CONCLUSION Psychological intervention is effective in addressing methamphetamine use and dependence. CBT and contingency management are two accessible interventions that are implemented easily within current AOD services. There is still more work to conduct in improving methamphetamine treatment, however, and further research into cognitive-behavioural and behavioural treatments for methamphetamine users is required, with a focus on improving longevity of the effect of intervention and improving effectiveness among more complex presentations.

Evaluating the impact of community-based treatment options on methamphetamine use: findings from the Methamphetamine Treatment Evaluation Study (MATES)

AIMS To evaluate the impact of community-based drug treatment on methamphetamine use using inverse probability of treatment-weighted (IPTW) estimators to derive treatment effects. DESIGN A longitudinal prospective cohort study with follow-ups at 3 months, 1 year and 3 years. Treatment effects were derived by comparing groups at follow-up. IPTW estimators were used to adjust for pre-treatment differences between groups. SETTING Sydney and Brisbane, Australia. PARTICIPANTS Participants were methamphetamine users entering community-based detoxification (n = 112) or residential rehabilitation (n = 248) services and a quasi-control group of methamphetamine users (n = 101) recruited from the community. MEASUREMENTS Frequency of methamphetamine use between interviews (no use, less than weekly, 1-2 days per week, 3+ days per week), continuous abstinence from methamphetamine use, past month methamphetamine use and methamphetamine dependence. FINDINGS Detoxification did not reduce methamphetamine use at any follow-up relative to the quasi-control group. Relative to quasi-control and detoxification groups combined, residential rehabilitation produced large reductions in the frequency of methamphetamine use at 3 months [odds ratio (OR) = 0.23, 95% confidence interval (CI) 0.15-0.36, P < 0.001), with a marked attenuation of this effect at 1 year (OR 0.62, 95% CI 0.40-0.97, P = 0.038) and 3 years (OR = 0.71, 95% CI 0.42-1.19, P = 0.189). The greatest impact was for abstinence: for every 100 residential rehabilitation clients there was a gain of 33 being continuously abstinent at 3 months, with this falling to 14 at 1 year and 6 at 3 years. CONCLUSIONS Community-based residential rehabilitation may produce a time-limited decrease in methamphetamine use, while detoxification alone does not appear to do so.

Characteristics and harms associated with injecting versus smoking methamphetamine among methamphetamine treatment entrants

INTRODUCTION AND AIMS To compare the characteristics and harms associated with injecting and smoking methamphetamine among methamphetamine treatment entrants. METHOD AND DESIGN A structured face-to-face interview was used to assess demographics, drug use patterns and harms [physical and mental health, psychological distress, psychotic symptoms, crime and human immunodeficiency virus (HIV) risk behaviour] among 400 methamphetamine treatment entrants in Sydney and Brisbane, Australia. Participants who had injected but not smoked methamphetamine in the month before treatment (n = 195, injectors) were compared to participants who had either: (a) injected and smoked (n = 90, injectors who smoke), or (b) smoked but not injected (n = 73, smokers), during this time. RESULTS In comparison with injectors, smokers were primarily non-injecting drug users, who were younger, more likely to be female and use ecstasy rather than heroin. After adjusting for these differences smokers were less dependent on methamphetamine than injectors, but they took the drug as often and had similarly high levels of psychological distress, poor physical and mental health, psychotic symptoms, sexual risk behaviour and criminal involvement. Injectors who smoked had a similar demographic and clinical profile to injectors, including comparable levels of needle sharing, but they used methamphetamine more often and had greater criminal involvement. CONCLUSION Within this treatment sample, smoking methamphetamine occurred among both long-standing injecting drug users and a comparatively younger group of non-injecting drug users. It was associated with less severe methamphetamine dependence than injecting, but more intense use patterns and similar levels of other harms.

General Practitioners, Prevention and Alcohol - A powerful cocktail? Facilitators and inhibitors of practising preventive medicine in general and early intervention for alcohol in particular: A 12-nation key informant and general practitioner study

This study reports a qualitative investigation of the views of key informants (KIs) and general practitioners (GPs) on the nature and extent of preventive medicine and early alcohol intervention in general practice and the current barriers and potential facilitating factors that influence practice. Sixty-seven KIs and 126 GPs were interviewed in 12 countries. There was strong personal and professional support for GP-delivered preventive medicine in general and early intervention for alcohol problems in particular. Opinions differed on whether national health policies encouraged or discouraged GPs to do more preventive medicine. The two key areas identified for prevention were smoking and alcohol, although all but two countries thought that alcohol was the most difficult area for GPs to discuss with patients. KIs and GPs identified similar barriers and facilitating factors. The main barriers were time constraints, lack of financial reimbursement or incentives and insufficient training and education. The ma...This study reports a qualitative investigation of the views of key informants (KIs) and general practitioners (GPs) on the nature and extent of preventive medicine and early alcohol intervention in general practice and the current barriers and potential facilitating factors that influence practice. Sixty-seven KIs and 126 GPs were interviewed in 12 countries. There was strong personal and professional support for GP-delivered preventive medicine in general and early intervention for alcohol problems in particular. Opinions differed on whether national health policies encouraged or discouraged GPs to do more preventive medicine. The two key areas identified for prevention were smoking and alcohol, although all but two countries thought that alcohol was the most difficult area for GPs to discuss with patients. KIs and GPs identified similar barriers and facilitating factors. The main barriers were time constraints, lack of financial reimbursement or incentives and insufficient training and education. The main facilitating factors were more societal concern about alcohol, proactive patients, more time, financial reimbursement and supportive government policy.

Opportunistic screening and clinician-delivered brief intervention for high-risk alcohol use among emergency department attendees: A randomized controlled trial

Objective:  To evaluate the feasibility and efficacy of routine opportunistic screening and brief intervention (BI) by ED staff to reduce high‐risk alcohol consumption.

A review of psychosocial interventions for amphetamine use

There are clear signs that amphetamine use is increasing in Australia and internationally, yet there are few services that offer amphetamine-specific interventions. This review examines the evidence for the use of psychosocial interventions for amphetamine users. The literature is very limited in the number of well-conducted, controlled studies, but the evidence available suggests that cognitive-behavioural therapy appears to be current best practice. Motivational interviewing has been recommended as a strategy to assist those ambivalent for treatment. There is also some evidence that contingency management is effective while clients are in treatment. The effectiveness of other types of intervention is not well supported. The literature is particularly hindered by a paucity of well-conducted studies among primary amphetamine users. Recommendations about appropriate interventions for use in clinical settings are offered and directions for future research are considered.

The Effects of Modafinil Treatment on Neuropsychological and Attentional Bias Performance During 7-Day Inpatient Withdrawal From Methamphetamine Dependence

The cognitive benefits of modafinil to patients undergoing 7-day inpatient withdrawal from methamphetamine (MA) dependence were examined as part of a double-blind, randomized, placebo-controlled pilot trial. Recent evidence has identified modafinil-related improvements in treatment outcomes for MA-dependent patients; however, the benefits to cognition function, which is critical to treatment success but known to be impaired, has yet to be examined. The first 20 participants recruited to the study were administered either 200 mg of modafinil (once daily) or placebo, and a neuropsychological test battery (including an MA version of the emotional Stroop task) at admission (n = 17) and discharge (n = 14). Follow-up interviews were conducted at 1-month postdischarge (n = 13). After participant withdrawals (3 in each group), treatment was associated with a significant improvement in immediate verbal memory recall and nonsignificant trend toward improvement on executive function and delayed memory tasks. No benefit was seen for measures of verbal learning, visual memory, processing speed, or verbal fluency. All participants showed a significant attentional bias for MA-related stimuli on the emotional Stroop task. The magnitude of bias predicted both retention in treatment and relapse potential at follow-up but was not significantly ameliorated by modafinil treatment. While nonsignificant, the effect sizes of modafinil-related improvements in executive function and memory were consistent with those found in more robustly powered studies of cognitive benefits in attention-deficit/hyperactivity disorder and schizophrenia, supporting the need for further research.

Efficacy of motivational interviewing and cognitive behavioral therapy for anxiety and depression symptoms following traumatic brain injury.

BACKGROUND Anxiety and depression are common following traumatic brain injury (TBI), often co-occurring. This study evaluated the efficacy of a 9-week cognitive behavioral therapy (CBT) program in reducing anxiety and depression and whether a three-session motivational interviewing (MI) preparatory intervention increased treatment response. METHOD A randomized parallel three-group design was employed. Following diagnosis of anxiety and/or depression using the Structured Clinical Interview for DSM-IV, 75 participants with mild-severe TBI (mean age 42.2 years, mean post-traumatic amnesia 22 days) were randomly assigned to an Adapted CBT group: (1) MI + CBT (n = 26), or (2) non-directive counseling (NDC) + CBT (n = 26); or a (3) waitlist control (WC, n = 23) group. Groups did not differ in baseline demographics, injury severity, anxiety or depression. MI and CBT interventions were guided by manuals adapted for individuals with TBI. Three CBT booster sessions were provided at week 21 to intervention groups. RESULTS Using intention-to-treat analyses, random-effects regressions controlling for baseline scores revealed that Adapted CBT groups (MI + CBT and NDC + CBT) showed significantly greater reduction in anxiety on the Hospital Anxiety and Depression Scale [95% confidence interval (CI) -2.07 to -0.06] and depression on the Depression Anxiety and Stress Scale (95% CI -5.61 to -0.12) (primary outcomes), and greater gains in psychosocial functioning on Sydney Psychosocial Reintegration Scale (95% CI 0.04-3.69) (secondary outcome) over 30 weeks post-baseline relative to WC. The group receiving MI + CBT did not show greater gains than the group receiving NDC + CBT. CONCLUSIONS Findings suggest that modified CBT with booster sessions over extended periods may alleviate anxiety and depression following TBI.

Differences in self and independent ratings on an organisational dual diagnosis capacity measure.

INTRODUCTION AND AIMS There are a number of tools to assist services to measure their capacity to respond to co-occurring substance use and mental health disorders. This study aimed to examine whether services could accurately self-rate their dual diagnosis capacity. DESIGN AND METHODS Data were collected from 13 alcohol and drug services across Australia that participated in a comorbidity capacity building initiative. The organisations provided a range of services, including pharmacotherapy and counselling services, residential and outpatient services, youth and adult services and withdrawal. There was a mix of government and non-government services. RESULTS Services rated themselves substantially higher than the independent raters at both baseline and follow up. DISCUSSION AND CONCLUSIONS The results suggest that services may not accurately assess their own capacity. For organisations trying to make improvements in their services, independent assessment may be more helpful than self-assessment in accurately determining service gaps. Overestimation of capacity may lead to failure to address important service needs.

A systematic review of interventions for co-occurring substance use and borderline personality disorders

ISSUES The aim of this study was to undertake a systematic review on effective treatment options for co-occurring substance use and borderline personality disorders to examine effective treatments for this group. APPROACH A systematic review using a narrative analysis approach was undertaken as there were too few studies within each intervention type to undertake a meta-analysis. The inclusion criteria comprised of English language studies (between 1999 and 2014) and a sample of >70% borderline personality disorder, with measurable outcomes for substance use and borderline personality disorder. All abstracts were screened (n = 376) resulting in 49 studies assessed for eligibility, with 10 studies, examining three different treatment types, included in the final review. KEY FINDINGS There were four studies that examined dialectical behaviour therapy (DBT), three studies that examined dynamic deconstructive psychotherapy (DDP) and three studies that examined dual-focused schema therapy (DFST). Both DBT and DDP demonstrated reductions in substance use, suicidal/self-harm behaviours and improved treatment retention. DBT also improved global and social functioning. DFST reduced substance use and both DFST and DPP improved treatment utilisation, but no other significant positive changes were noted. IMPLICATIONS Overall, there were a small number of studies with small sample sizes, so further research is required. However, in the absence of a strong evidence base, there is a critical need to respond to this group with co-occurring borderline personality disorder and substance use. CONCLUSION Both DBT and DPP showed some benefit in reducing symptoms, with DBT the preferred option given its superior evidence base with women in particular.