What defines a clinically meaningful outcome in the treatment of substance use disorders: reductions in direct consequences of drug use or improvement in overall functioning?

Kiluk, Brian D.; Fitzmaurice, Garrett M.; Strain, Eric C.; Weiss, Roger D.

doi:10.1111/add.14289

Cited by 63 publications

(39 citation statements)

References 47 publications

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“…As such, this body of literature may be well served by a patient‐level meta‐analysis (e.g., Lambert et al., ) if consistent outcome and patient characteristic measures were available. Also, this meta‐analysis selected consumption/abstinence measures a priori, but equally important may be consequences of alcohol use and improvements in overall functioning, particularly when examining primarily harm‐reduction studies (Kiluk et al., ).…”

Section: Limitations and Conclusionmentioning

confidence: 99%

Technology‐Delivered Cognitive‐Behavioral Interventions for Alcohol Use: A Meta‐Analysis

Kiluk

Ray

Walthers

et al. 2019

Alcoholism Clin & Exp Res

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Background: Cognitive-behavioral therapy (CBT) has long-standing evidence for efficacy in the treatment of alcohol use, yet implementation in clinical practice has been challenging. Delivery of CBT through technology-based platforms, such as web-based programs and mobile applications, has the potential to provide widespread access to this evidence-based intervention. While there have been reviews indicating the efficacy of technology-based delivery of CBT for various psychiatric conditions, none have focused on efficacy for alcohol use. The current meta-analysis was conducted to fill this research gap.Methods: Descriptive data were used to characterize the nature of the literature on technology-delivered, CBT-based interventions for alcohol use ("CBT Tech"). Inverse-variance-weighted effect sizes were calculated, and random effects, effect sizes were pooled in 4 subgroups.Results: Fifteen published trials conducted primarily with at-risk or heavy drinkers were identified. Of these studies, 60% explicitly targeted alcohol use moderation. The content of CBT Tech programs varied, ranging from 4 to 62 sessions/exercises, with many programs combining elements of motivational interviewing (47%). With respect to efficacy, CBT Tech as a stand-alone treatment in contrast to a minimal treatment control showed a positive and statistically significant, albeit small effect (g = 0.20: 95% CI = 0.22, 0.38, k es = 5). When CBT Tech was compared to treatment as usual (TAU), effects were nonsignificant. However, when CBT Tech was tested as an addition to TAU, in contrast to TAU only, the effect size was positive, significant (g = 0.30: 95% CI = 0.10, 0.50, k es = 7), and stable over 12-month follow-up. Only 2 studies compared CBT Tech to in-person CBT, and this pooled effect size did not suggest superior efficacy.Conclusions: These results show a benefit for technology-delivered, CBT-based interventions as a stand-alone therapy for heavy drinking or as an addition to usual care in specialty substance use settings.

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Section: Limitations and Conclusionmentioning

confidence: 99%

Technology‐Delivered Cognitive‐Behavioral Interventions for Alcohol Use: A Meta‐Analysis

Kiluk

Ray

Walthers

et al. 2019

Alcoholism Clin & Exp Res

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“…Third, as mentioned above, the use of a bounded outcome variable (NDA per week) imposes ceiling and floor effects. To address the constraints of ceiling and floor effects, future research might consider measuring a spectrum of outcome variables, such as psychosocial functioning and quality of life (Kiluk et al, ). Finally, the classification approach used was empirically driven.…”

Section: Discussionmentioning

confidence: 99%

The Identification of Pretreatment Trajectories of Alcohol Use and Their Relationship to Treatment Outcome in Men and Women With Alcohol Use Disorder

Stasiewicz

Bradizza

Ruszczyk

et al. 2019

Alcoholism Clin & Exp Res

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Background: Few studies have focused on behavioral changes that occur prior to entering treatment for an alcohol use disorder (AUD). In 2 studies (Psychol Addict Behav, 27, 2013, 1159 J Stud Alcohol, 66, 2005, 369), pretreatment reductions in alcohol use were associated with better treatment outcomes. Identifying patterns of pretreatment change has the potential to inform clinical decision making.Methods: This study sought to identify pretreatment change trajectories in individuals seeking outpatient treatment for AUD (N = 205) using finite mixture modeling based on changes in number of days abstinent per week (NDA).Results: The analysis identified 3 pretreatment trajectory classes. Class 1 (High Abstinence-Minimal Increase; HA-MI) (n = 64; 31.2%) reported a high level of pretreatment NDA with minimal change during an 8-week pretreatment interval. Class 2 (Low Abstinence-Steady Increase; LA-SI) (n = 73; 35.6%) reported a low level of pretreatment NDA followed by a steady increase beginning 2 weeks prior to the phone screen. Class 3 (Nonabstinent-Accelerated Increase; NA-AI) (n = 68; 33.2%) reported no or very low levels of pretreatment NDA but demonstrated an increase following the phone screen. With regard to within-treatment change, Class 1 demonstrated the least and Class 3 demonstrated the most change in NDA. From baseline to 6-month follow-up, Class 3 added 2.31 abstinent days per week, Class 2 added 0.69 days, and Class 1 added 0.63 days. The increase in NDA for Class 3 was significantly different from the other 2 classes; however, Class 3 reported fewer overall days abstinent at 6-month follow-up.Conclusions: Study results have clinical and research implications including recommended changes to treatment protocols and research designs. Understanding the impact of pretreatment trajectories of alcohol use on within-treatment and posttreatment outcomes may provide important information about adapting treatment to increase efficiency and effectiveness.

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“…It was shown that such out- comes do not predict functional, symptomatic or substance use-related improvement at 1 year follow-up. So additional outcomes, possibly related to change on the negative consequences of substance use [75], should be considered in future studies to better capture possible improvements and change processes.…”

Section: Discussionmentioning

confidence: 99%

Effect of Assertive Community Treatment for Patients with Substance Use Disorder: A Systematic Review

et al. 2019

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Purpose: Substance use disorders (SUD) are an important health issue internationally. Traditional outpatient programmes often do not adequately address the substantial medical and social needs and in addition many patients have difficulties accessing the care needed. The assertive community treatment (ACT) model was originally developed for patients with a severe mental illness but has been adapted for patients with SUD by integrating specific SUD treatments into the traditional ACT model. This paper aims to assess the effectiveness of ACT for patients with SUD on a number of measures. Methods: We performed a systematic review of ACT interventions for patients with SUD by analyzing randomized controlled studies published before June 2017 found on the electronic databases PsychINFO, MEDLINE, PsychARTICLES. Eleven publications using 5 datasets were included in the analysis. Quality of studies was analyzed using the JADAD scale or Oxford quality scoring system. Outcome measures used were substance use, treatment engagement, hospitalization rates, quality of life, housing status, medication compliance and legal problems. Patients included in the studies had a diagnosis of SUD. Two datasets included homeless patients and 2 datasets included patients with high service use. Results and Conclusions: The results of the very few existing randomized control studies are mixed. Treatment engagement was higher for ACT in 4 datasets. One dataset reported higher service contact rates for the ACT group than for controls. In 2 datasets a positive effect on hospitalization rates was found. Higher fidelity to the ACT model appears to improve outcomes. Substance use reduced only in half of the datasets, of which only one showed a significant reduction in the ACT group. Overall, ACT is a promising approach that may be useful for promoting treatment engagement for patients with SUD. According to earlier studies on patients with severe mental illness, patients with high inpatient service use benefit most from this assertive approach. We hypothesize that a similar high need user group among patients with SUD might benefit most from ACT. Further research is needed to examine which types of clinical interventions might help difficult-to-engage patients with addictions.

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What defines a clinically meaningful outcome in the treatment of substance use disorders: reductions in direct consequences of drug use or improvement in overall functioning?

Abstract: The field of substance use disorders should include measures of negative psychosocial and health consequences of drug use, as opposed to overall functioning, in the effort to establish meaningful non-abstinence-based end-points.

Cited by 63 publications

References 47 publications

Technology‐Delivered Cognitive‐Behavioral Interventions for Alcohol Use: A Meta‐Analysis

Technology‐Delivered Cognitive‐Behavioral Interventions for Alcohol Use: A Meta‐Analysis

The Identification of Pretreatment Trajectories of Alcohol Use and Their Relationship to Treatment Outcome in Men and Women With Alcohol Use Disorder

Effect of Assertive Community Treatment for Patients with Substance Use Disorder: A Systematic Review

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