best practice

Culturally sensitive substance use treatment interventions for racial/ethnic minority youth were found in a systematic review with meta-analysis (Steinka-Fry et al., 2017) to have no significant effect in:

• reducing use when compared to ‘treatment as usual’ and bona fide comparisons (i.e. intervetions that differed only on the culturally sensitive elements)

Internet-based interventions (including unguided stand-alone internet interventions and internet interventions as an add-on to treatment as usual) were found in a systematic review with meta-analysis (Boumparis et al., 2017, 17 RCTs, N = 2 836) to have a small but significant effect in:

• reducing drug use at post-treatment (pooled analysis of the 17 studies, g = 0.31; 95 % CI = 0.23-0.39, P < 0.001, N = 2 836) and at follow-up assessments (g = 0.22; 95 % CI = 0.07-0.37; P = .003, RCTs = 9, N = 1 906)
• decreasing any illicit drug use at post-treatment (g = 0.35; 95 % CI = 0.24-0.45, P < 0.001, RCTs = 9, N= 1 749)
• decreasing opioid use at post-treatment (g = 0.36; 95 % CI = 0.20-0.53, P < .001, RCTs = 4, N=606)

Behavioural therapies targeting specifically adolescents were analysed in a systematic review without meta-analysis (Hogue et al., 2014, 8 RCTs) and found that:

• cognitive behavioural therapies (CBT) are well established but were outperformed  by family-based treatments in several trials
• cognitive behavioural therapies (CBT)  at group level or at individual level are equally effective
• integrated models uniformly performed well

Psychosocial treatments (delivered alone or in combination with pharmacotherapy) were analysed in a systematic review (Hides et al., 2020) that found no significant effect compared with no treatment or treatment as usual in:

• the treatment of comorbid depression and substance use disorders.

 Although some significant effects were found between different phychotherapies, these were inconsistent and small and the evidence of poor quality.

A comprehensive review (EMCDDA 2015) found that:

• there is no evidence that any pharmacotherapy is particularly beneficial in the comorbidity of personality disorders with substance use disorders

The current literature on pharmacological interventions of SUD in ADHD patients involves norepinephrine, dopamine, and nicotinic acetylcholine receptors as prime neurotransmitters. The same neurotransmitters are addressed purposefully at stabilizing ADHD symptoms. The mindset is that medications that manage ADHD symptoms should also help to decrease the risk of developing SUD.

Pharmacological treatment of attention deficit hyperactivity disorder (ADHD) was found in a systematic review with meta-analysis (Fluyau et al., 2020, 17 studies, N = 2155) to have small but positive pooled effect compared to placebo in:

• reducing in substance use (SMD = 0.405, 95% confidence interval [CI]: [0.252, 0.557], P < .001),
• progression toward abstinence (SMD = 0.328, 95% CI: [0.149, 0.507], P < .001),
• reducing craving (SMD = 0.274, 95% CI: [0.103, 0.446], P = .002),
• decrease in the severity of ADHD symptoms (SMD = 0.533, 95% CI: [0.393, 0.672], P < .001),
• reduction in the frequency of ADHD symptoms (SMD = 0.420, 95% CI: [0.259, 0.582], P < .001).

The pooled effect was moderate for the management of withdrawal symptoms (SMD = 0.577, 95% CI: [0.389, 0.764], P = .001]) and the decrease in the severity of ADHD symptoms (SMD = 0.533, 95% CI: [0.393, 0.672], P < .001).

There were differences among different substances (tobacco, cocaine, amphetamine or cannabis) in the different outcomes when considered individually and not pooled together.

Opioid substitution provided in prison settings was found in a systematic review (ECDC/EMCDDA, 2018) to be effective in:

• reducing injecting risk behaviour.

Opioid substitution treatment was found in a systematic review (ECDC/EMCDDA, 2018) to be effective in:

• reducing post-release mortality.

One cohort study (Degenhardt et al., 2014) enrolling N=16453 people released from prison 60161 times (all opioid dependent people who entered OST between 1985 and 2010 and were released from prison at least once between 2000 and 2012 in Australia) showed that those continuously retained in OST after being released from prison (continuity of care):

• had a reduced risk of mortality by 75% (adjusted hazard ration=0.25, 95 % CI 0.12 to 0.53).

One RCT (Dolan et al., 2005, cited in EMCDDA, 2010) suggests that retention in MMT in prison settings is associated with:

• reduced mortality from all causes (OR 0.54, 95 % CI 0.20 to 1.43);
• reduced mortality for overdose.

In an updated version of a systematic review (Minozzi et al., 2011, 13 RCTs, N=1158), pharmacologycal treatment with Naltrexone versus placebo or no pharmacological treatment in opioid dependent patients was found to be not significantly different in:

• retaining patients in treatment (RR 1.18, 95 % CI 0.72 to 1.91, 2 studies, N=88 participants);
• achieving retention and abstinence (combined outcome) (RR 1.43, 95 % CI 0.72 to 2.82, 6 RCTs, N= 393 participants);
• achieving abstinence (RR 1.39, 95 % CI 0.61 to 3.17,4 RCTs, N=143 participants);
• achieving abstinence at follow up (RR 1.28, 95 % CI 0.80 to 2.08, 3 RCTs, N= 116 participants);
• reducing side effects (RR 1.29, 95 % CI 0.54 to 3.11, 4 RCTs, N=159 participants).

The only statistically significant effect was found when considering only the studies with patients forced to adhere to treatment which favoured naltrexone for retention and abstinence.

A systematic review withouth meta-analysis (Jarvis B.J. et al, 2018) confirmed the results above, with inconclusive results of extendend-release injectable Naltrexone (either before or after detoxification) in:

• improving adherence to treatment;
• reducing opiod use;
• reducing overdose.

Needle and syringe programmes implemented in prison were found in a systematic review (ECDC/EMCDDA, 2018) to be effective in:

• reducing HIV transmission among IDUs;
• reducing HCV transmission among IDUs.