Drug Abuse

7 Brief interventions and therapies for illicit drug abuse

Guidelines for treatment improvement

Moretreat-project
TUD, Dresden Germany
October 2008
EUROPEAN COMMISSION
HEALTH & CONSUMER PROTECTION DIRECTORATE-GENERAL

Directorate C - Public Health and Risk Assessment

The content of this report does not necessarily reflect the opinion of the European Commission. Neither the Commission nor anyone acting on its behalf shall be liable for any use made of the information in this publication.

Content

1 Introduction
1.1 Problem definition  
1.2 Brief interventions   
1.3 Brief therapies    
1.4 Requirements   
1.5 Settings   
1.6 Limitations   
1.7 Techniques   
2 Evidence Base    
2.1 Efficacy of Brief Interventions and Therapies   
2.2 Brief Interventions and Therapies vs. Extended Therapy  
2.3 Motivational Enhancement Therapy and Motivational Interviewing 
2.4 Cognitive-behavioural therapy   
2.5 Combination of MET and CBT   
2.6 Family and social therapy   
3 Recommendations  
3.1 Evidence strength rankings   
3.2 Motivational Enhancement Therapy    
3.3 Cognitive-behavioural Therapy
3.4 Social and family therapy  
3.5 Pharmacological interventions   
3.6 Techniques to be chosen   
3.7 Settings   
3.8 Number of sessions and duration of treatment  
References   

1    Introduction

1.1    Problem definition

Illicit drug abuse became a significant social and medical problem in the last decades. In spite of numerous attempts to cut the consumption of drugs in Europe – multiple legislative incentives, acts prohibiting the production, import and distribution of various substances, including the number of medications, - the number of drug abusers remains high as well as the number of urgent, chronic and disabling medical conditions, related to drugs use.

According to the 2007 Annual Report of European Monitoring Center for Drugs and Drug Addiction the most prevalent is cannabis abuse with the lifetime prevalence of 70 million or one in five European adults. 23 million European adults used marijuana during the last year and over 13 — during the last month, that is close to real prevalence. Cannabis was the primary reason for entering treatment in about 20% (approximately 70 million treatment demands) of all treatment demand cases that made cannabis the second most commonly reported drug after heroin.

Heavier drugs are less prevalent but at the same time quite widespread. Cocaine is used by 12 million in their lifetime, 4.5 million during the last year and around 2 million – during the last month. In 2005, approximately 48000 demands for treatment for cocaine as a primary drug were reported in EU, accounting for 13% of all treatment demands across EU.

Club drugs, such as ecstasy and amphetamines are have similar numbers with the lifetime prevalence of 9.5 and 11 million correspondingly and last year use of 3 and 2 million and last month use of around 1 million European adults. The number of demands for treatment relating to the use of ecstasy and amphetamines is relatively small.

Problem opioids use is counted between 1 to 8 cases per 1000 adult population, with 70% of opioids found among 7500 acute drug deaths in 2004 and 585000 substitution treatment cases in 2005. Treatment demand for opioids is the highest with approximately 61% of illicit drug use demands across EU (EMCDDA 2007).
High prevalence of illicit drug use and drug use disorders translates into high treatment demands (326000 in EU in 2005) which cannot be completely satisfied neither by specialized addictions services nor by primary care institutions that requires implementation of brief and cost-effective techniques in various settings, both inside and outside health care system.

1.2    Brief interventions

Brief interventions are clinical practices aimed to investigate the problem and motivate an individual to change something about his substance abuse either directly during the intervention itself or indirectly Ð by seeking additional substance abuse treatment. Taking into consideration short-term character of brief-interventions their principal goal is rather harm reduction than complete abstinence. Specific goal for each individual client is determined by various factors including type of the drug and its consumption, medical and social consequences of drug use and settings in which the brief intervention is delivered.

According to the goal of brief interventions their obvious components are FRAMES:

•    To give a Feedback to the individual about personal risk or impairment.
•    To place Responsibility for change on the participant.
•    To give an Advice to change.
•    To offer a Menu of alternative self-help or treatment options to the participant.
•    Empathic style is to be used by the counsellor.
•    To engender Self-efficacy or optimistic empowerment is engendered in the participant.

1.3    Brief therapies

Brief therapies are systematic, focused processes that rely on assessment, client engagement, and rapid implementation of change strategies. Brief therapies usually feature more (as well as longer) sessions than brief interventions. Brief therapies are to provide clients with tools to change basic attitudes and handle a variety of underlying problems.

As brief therapies are much longer and comprehensive than brief interventions, their principal goal in the most of the cases is to achieve complete abstinence.

Major components of brief therapies are similar to those of brief interventions and are the following:

•    Clear definition of the goals related to a specific change or behaviour.
•    Setting measurable and understandable outcomes.
•    Putting responsibility for change on the client.
•    Helping the client to enhance his self-efficacy and understand that change is possible.
•    Rapid establishment of a strong working relationship between client and therapist.
•    Achievement and maintenance of immediate results.
•    Active and empathic counselling style of the therapist. Directive style is appropriate in some cases.

1.4    Requirements

Delivery of effective brief interventions and therapies requires the provider to possess certain knowledge, skills and personal abilities. The most important ones are the following:

•    Comprehensive knowledge of addictions: their clinical features and dynamics, potential complications and emergencies.
•    Ability to make proper primary assessment and to determine certain competency in each individual case and to redi rect the patient to specialized addiction service if necessary.
•    Counselling skills such as active listening and helping clients explore and resolve ambivalence.
•    Ability to set the understandable goals and objectives of individual treatment and to redefine them according to the client’s progress.
•    Working knowledge of psychology of the patient and the stages of change through which a client moves during the treatment.
•    An overall empathic and non-judgemental attitude, understanding and acceptance.

1.5    Settings

Settings in which brief interventions and therapies are delivered form the attitude of the patient to the treatment and determine the psychotherapeutic techniques which may be used in different circumstances. While specialized addiction services institutions are the most preferable site for delivery of any kind of specialized treatment, including short-term treatments, high level of treatment demand stipulates delivery of brief therapeutic techniques in various settings including other primary care institutions and various social services which may be involved in treatment.

It must be noted also, that specificity of drug addictions make a number of drug addicts to attend medical institutions with the reasons other than addiction itself, such as drug-related medical conditions, emergencies and chronic diseases. Some addicts will contact the health care system through certain psychological, social and legal reasons. Moreover, taking into consideration the fact that heavier drug addictions are not the larger pa rt of all treatment demand, not all users demand need full set of long-term treatment in specialized institutions.

While treatment of substance use disorders can occur in almost any type of setting, the most commonly used are:

•    Inpatient settings, in psychi atric or general hospitals.
•    Outpatient settings, in clinics or private practice.
•    Intensive day treatment settings.
•    Half-way houses.
•    Therapeutic communities.
•    Penal institutions (Galanter and Kleber 2004).

Beside the settings listed above brief interventions and therapies may be delivered in a variety of other settings, where the patient contacts the health care system for the first time i.e. by social workers, college or army psychological services settings etc. and each of them, though fitting minimal requirements, has specific features that obviously set certain limitations of care provision in comparison with specialized addictions service institutions.

1.6    Limitations

While requirements for delivery of brief interventions and therapies are minimal and allow it in the large variety of settings, there are number of limitations that may compromise the treatment process or make it undeliverable in certain conditions. Primarily, these limitations are determined by the capacities and major purpose of service providing the brief interventions and therapies.
While specialized in-patient departments have full spectrum of means for maintaining the patients, 24 hour monitoring their medical condition and handling all types of medical complications, they are expensive and cannot cover large number of patients. Non-addiction-specialized in-patient departments are able to handle most of the complications and cover larger number of patients and provide them with proper clinical management, at the same time the competence of specialists is lower, they are still expensive and their major field of expertise is rather treatment of somatic complications than brief interventions and therapies.
General practitioners as the major providers of out-patient care are able to cover the largest network of patients, but their capacities in emergencies handling is substantially lower than for in-patient clinics. However, they are the most probable point of the first contact of the patient with the health care system and specificity of their practice favours delivery of brief interventions and therapies.
Social and psychological services settings are the least competent in emergencies handling and dealing with medical complications. At the same time these services are specialized in psychological support and psychotherapeutic interventions and cover the larger number of clients that in total stipulates them to be the major providers of brief interventions and therapies in non-complicated cases of mild and moderate addictions.
Taking into consideration the capacities of different providers of brief interventions and therapies, basic understanding of the patient and medical requirements related to his state is necessary for successful treatment. In the most of the cases drug addicts have more medical problems than addiction itself; therefore the primary assessment may be complex and competence decision must be based on the following aspects:

• Emergency states: emergency states are quite common for drug abusers and may be the main reason for applyin g for medical help. In case of emergency state the patient should be redirected to emergency room to cope with it.
• Acute intoxication: In a large number of cases drug addicts might be intoxicated to certain extent, which would make impossible further therapeutic interventions other than detoxification.
•    Acute complications: Besides the first two conditions there may be a number of acute medical complications such as for example increased blood pressure, that would require certain pharmacological correction.
•    Potential acute complications: Drug addictions may produce certain complications such as delirium, changes of mood and behaviour, onset of seizures etc. This must be taken into consideration when starting any treatment.
•    Chronic medical complications: most of the drug addicts have chronic medical complications such as cardiovascular and liver diseases, cognitive dysfunctions etc. They may require specific treatment in respect for them.
•    Psychotic symptoms: Some of the patients may either produce psychotic symptoms or have a great potential of their onset.
•    Severity of anxiety and depression: Anxiety and depression are common complications of drug addictions and may cause suicidal behaviour and impede the treatment process.
•    Severity of dependence: severity of dependence must be estimated as the patients with severe dependence may require specific treatment and therefore should not be treated in primary care institutions.

1.7    Techniques

While there is a large variety of psychotherapeutic techniques suitable for treatment of illicit drug addictions, according to the goals and objectives of brief interventions an therapies, their short-term nature and description of settings for their delivery given above, techniques suitable for them must meet the following criteria:

•    Simplicity and understandability for the patient.
•    Ability to be used both by medical and non-medical specialists.
•    Minimal special training is required.
•    Minimal time is required for their delivery.
•    Cost-effectiveness.
•    Compatibility to the settings and to each other.

According to these criteria we propose the following set of psychotherapeutic techniques which clinical effectiveness has been proved, which are simple in their nature, complementary to each other and are appropriate for implementation as part of brief interventions and therapies in all variety settings:

•    Motivational Enhancement Therapy
•    Cognitive-Behavioural Therapy
•    Family Therapy
•    Social Therapy

Though, pharmacological correction is not an obvious part of brief interventions and therapies, its use becomes appropriate in some cases in medical settings and will be briefly discussed in these guidelines.

2    Evidence Base

2.1    Efficacy of Brief Interventions and Therapies

Multiple studies have shown efficacy of different types of brief interventions used separately or in various combinations.
Recent meta-analytical study of Dutra and coauthors covering 34 controlled treatment projects in several countries and 2340 patients has proven efficacy of brief interventions in various settings in respect for decreasing dropout rate, reducing quantity and frequency of drug consumption (Dutra 2008).
In the study of Martin and coauthors, they have assessed the feasibility and effectiveness of the brief interventions for young cannabis users in Australia in clinical settings. Participants were cannabis users aged between 14 and 19 years (n = 73) and concerned parents (n = 69). The intervention comprised an individual assessment session followed 1 week later by a session of personalized feedback delivered in a motivational interviewing style. An optional third session that focused on skills and strategies for making behavioural change was offered. Of the entire sample of cannabis users, 78% reported voluntarily reducing or stopping their cannabis use during the 90 days to follow-up and 16.7% reported total abstinence during this time. In addition, significant reductions were found on measures of both quantity and frequency of use and dependence. These reductions were maintained at 6-month follow-up. The approach was acceptable to young people and associated with reductions in cannabis use. Thus the study has shown the effectiveness of short motivational enhancement treatment for cannabis users as well as its combination with cognitive-behavioural therapy (Martin et al 2005).
Srisurapanont and co-authors did a research on comparison of short-term (eight-week) brief intervention with psychoeducation for students using methamphetamine. The study was carried out in Thailand at Chiang Mai University Hospital. According to their results students assigned BI demonstrated higher decrease in the consumption of methamphetamine as well as in the number of days of use (Srisurapanont et al. 2007). Another clinical trial of single brief interventions performed in Brazil on 99 young adults in out-patient settings has shown effectiveness of even single brief intervention in comparison with control group. In the 6-month follow-up, the BI group showed a significant reduction in the number of users during the last month with respect to most substances, as well as in relation to substance-related problems (De Micheli et al. 2004).

2.2    Brief Interventions and Therapies vs. Extended Therapy

Stephens and coauthors performed corresponding clinical trial with statistically authentic number of cases in United States in out-patient settings. Adult marijuana users (N = 291) seeking treatment were randomly assigned to an extended 14-session cognitive-behavioural group treatment (relapse prevention support group; RPSG), a brief 2-session individual treatment using motivational interviewing (individualized assessment and intervention; IAI), or a 4-month delayed treatment control (DTC) condition. Results indicated that marijuana use, dependence symptoms, and negative consequences were reduced significantly in relation to pre-treatment levels at 1-, 4-, 7-, 13-, and 16-month follow-ups. Participants in the RPSG and IAI treatments showed significantly and substantially greater improvement than DTC participants at the 4- month follow-up. There were no significant differences between RPSG and IAI outcomes at any follow-up. This study has shown effectiveness of both types of psychotherapeutic interventions, emphasizing the cost-effectiveness of brief interventions as well. Also there are strong evidences of high cost -effectiveness of brief interventions and relatively close treatment outcomes to extended ones (Stephens et al. 2000).

2.3    Motivational Enhancement Therapy and Motivational Interviewing

Effectiveness of Motivational Enhancement therapy has been shown is research of McCambridge and Strang, who compared 105 patients receiving MET with 95 controls in a cluster randomized trial. Research was carried out in United Kingdom in college settings. They’ve shown better follow-up rate and higher drug use reduction in MET group (McCambridge and Strang 2004).
At the same time, consecutive study by the same research team showed poor results of single session motivational interviewing delivered by youth workers in respect for cannabis abuse. They have performed a naturalistic quasi-experimental study of 162 young people (mean age 17 years) who were daily cigarette smokers, weekly drinkers or weekly cannabis smokers, comparing 59 receiving MI with 103 non-intervention assessment-only controls. MI was delivered in a single session by youth workers or by the first author. Assessment was made of changes in self-reported cigarette, alcohol, cannabis use and related indicators of risk and problems between recruitment and after 3 months by self-completion questionnaire. 87% of subjects (141 of 162) were followed up. The most substantial evidence of benefit was achieved in relation to alcohol consumption, with those receiving MI drinking on average two days per month less than controls after 3 months. Weaker evidences of impact on ciga rette smoking, and no evidence of impact on cannabis use, were obtained (Gray et al. 2005).

Another trial performed by Marsden and coauthors in United Kingdom has also shown poor efficacy of MET. Brief motivational interventions were carried out on peripatetic basis by National Addiction Centre. In a randomized trial of Motivational Interviewing
vs. Controls, receiving written health risk information materials only included 342 adolescents and young adult stimulant (ecstasy, cocaine powder and crack cocaine) users aged 16-22 years. This study has shown no difference between motivational intervention and provision of information alone (Marsden et al. 2006).

Similar results were observed by Walker and coauthors, who studied 97 adolescent cannabis users, randomly assigned to either a 2-session MET or to a 3 month delay condition. Study was school-based and was carried out in United States. Marijuana use and associated negative consequences were assessed at baseline and at a 3-month follow-up. Analyses revealed that both groups have reduced marijuana use, however no between-group differences were observed (Walker et al. 2006).
Saunders and coauthors studied brief motivational interventions in opiate users attending a methadone programme in Australia in methadone clinic settings. They have enrolled 122 participants dividing them into two groups: assigned motivational intervention (n=122) and controls (n=65), who have received only educational procedure. Over the 6-month follow-up period the motivational subjects demonstrated a greater, immediate commitment to abstention, reported more positive expected outcomes for abstention, fewer opiate-related problems, complied with methadone programme longer and relapsed less quickly than the control group (Saunders et al. 1995).
Peterson and others have performed a randomized trial testing a brief feedback and motivational intervention for substance use among homeless adolescents in Washington in social service network settings. Homeless adolescents ages 14-19 (N = 285) recruited from drop-in centers at agencies and from street intercept were randomly assigned to either a brief motivational enhancement (ME) group or 1 of 2 control groups. The 1- session motivational intervention presented personal feedback about patterns of risks related to alcohol or substance use in a style consistent with motivational interviewing. Follow-up interviews were conducted at 1 and 3 months postintervention. Youths who received the motivational intervention reported reduced illicit drug use other than marijuana at 1-month follow-up compared with youths in the control groups. Treatment effects were not found with respect to alcohol or marijuana. Post hoc analyses within the ME group suggested that those who were rated as more engaged and more likely to benefit showed greater drug use reduction than did those rated as less engaged (Peterson et al. 2006).

Baer and coauthors have modified this protocol and performed a brief motivational intervention with 117 homeless adolescents in a randomized design with 3-month follow-up in the same settings. Participants also reported overall reductions in substance use (Baer et al. 2007).

Another randomized study of effectiveness of MET was performed by Babor and coauthors at several sites across United States both in in- and out-patient settings. A multisite randomized controlled trial compared cannabis use outcomes included 450 participants across 3 study conditions:

•    a) 2 sessions of MET.
•    b) 9 sessions of multicomponent therapy including MET, CBT and case management.
•    c) delayed treatment control (DTC).

Assessments were conducted at baseline and at 4, 9 and 15 months postrandomization. The 9-session treatment reduced marijuana smoking and associated consequences significantly more than the 2-session treatment, which also reduced marijuana use relative to the controls (Babor et al. 2004). This study shows effectiveness of MET, superior effectiveness of combined and prolonged treatment.
A large-scale randomized controlled trial for Brief Motivational Interventions effectiveness in primary care setting was performed by Bernstein and coauthors in United States in clinical settings. Having randomized 1175 heroin and cocaine abusers into two groups: a) Intervention Group (n=590) and b) Control Group (n=585), authors have shown than brief motivational intervention can reduce cocaine and heroin use as it was demonstrated by higher abstinence rates and reduction of drug levels in hair (Bernstein et al. 2005).

2.4    Cognitive-behavioural therapy

Several research projects directed on estimation of efficacy of cognitive-behavioural therapy were performed. In Australia, Copeland and coauthors undertook a randomized controlled trial of brief cognitivebehavioural interventions (CBT) for cannabis dependence in out-patient treatment settings. A total of 229 participants were assessed and randomly assigned to either a six -session CBT programme (6CBT), a single-session CBT intervention (1CBT), or a delayed-treatment control (DTC) group. Participants were assisted in acquiring skills to promote cannabis cessation and maintenance of abstinence. Participants were followed-up a median of 237 days after last attendance. Participants in the treatment groups reported better treatment outcomes than the DTC group. They were more likely to report abstinence, were significantly less concerned about their control over cannabis use, and reported significantly fewer cannabis-related problems than those in the DTC group. Those in the 6CBT group also reported more significantly reduced levels of cannabis consump tion than the DTC group. While the therapist variable had no effect on any outcome, a secondary analysis of the 6CBT and 1 CBT groups showed that treatment compliance was significantly associated with decreased dependence and cannabis -related problems. This study supports the attractiveness and effectiveness of individual CBT interventions for cannabis use disorders as well as the higher effectiveness of multiple-session cognitive behavioural therapy in comparison to single sessions (Copeland et al. 2001).
A randomized controlled trial on effectiveness of brief CBT interventions was performed by Baker and coauthors in Australia in out-patient treatment settings on 214 amphetamine users randomized into 2-session CBT (n=74), 4-session CBT (n=66) and control (n=74) groups. This study showed both efficacy of CBT for amphetamine abuse and dose-response relationship represented by higher efficacy of 4-session CBT in comparison to 2-session CBT (Baker et al. 2005).
Azrin and coauthors in United States performed a comparative evaluation of behavioural vs. supportive treatment for illegal drug use in counselling center settings. Having studied 82 subjects with follow-ups at 2, 6 and 12 months, they showed superior efficacy of behavioural treatment with 65% drug-free subjects after 12 months against 20% for the alternative treatment. The behavioural treatment was more effective across sex, age, educational level, marital status and type of drug (Azrin et al. 1994).
This study has also shown dose-response relation for behavioural therapy in substance abuse treatment with 37% drug-free subjects after 2 months of therapy, 54% and 65% after 6 and 12 month correspondingly.
Another comparative study, performed by Maude-Griffin in United States and coauthors compared cognitive-behavioural therapy with 12-step facilitation in treating cocaine abuse in Veteran Affairs Medical Center settings. Having studied 128 participants with assessment at baseline and weeks 4, 8, 12 and 26 with treatment duration of 12 weeks, researchers have shown that CBT patients were significantly more likely to achieve abstinence than participants in 12SF (Maude-Griffin et al. 1998).
Dose-response study for frequency of CBT in cocaine abusers was done by Covi and coauthors in United States in out-patient clinical settings, who studied 68 cocaine-dependent outpatients during the 12-week treatment programme with randomly assigned twice weekly, weekly and bi-weekly CBT sessions. Though final results were better in patients who were assigned bi-weekly therapy, the difference between groups was not statistically significant (Covi et al. 2002).
Rohsenow and coauthors studied 108 cocaine abusers who undergone cognitive-behavioural interventions (Coping Skills Training) at Rhode Island, US. Brief treatment was added to a standard inpatient or partial-hospital treatment programme. Their study showed reduction of cocaine use in 3-month follow-up and fewer cocaine use days than controls, who received meditation-relaxation treatment (Rohsenow et al. 2000).
In another study on CBT for cocaine abusers undergoing methadone treatment done by Rowan-Szal and colleagues, using contingency management and relapse prevention techniques both interventions were associated with positive treatment response but the effects were reflected in different behavioural outcomes (Rowan-Szal et al. 2005).
Appropriateness of CBT implementation into the heroin-dependent persons was shown by Hollonds and coauthors in Australia in ambulatory treatment settings. They have randomized twenty-three volunteers into four groups:

•    Receiving only methadone withdrawal programme.
•    Receiving only Behavioural Therapy.
•    Combination of two treatments.
•    Control group receiving no treatment.

According to their results, behavioural therapy showed efficacy both in combination with methadone treatment and separately. Relapse was prevented in persons, receiving behavioural therapy, decreased in group with combined treatment, but was prevented neither in persons receiving methadone only nor in ones in control group (Hollonds et al. 1980).
Another study on CBT for heroin and methamphetamine users was done by Yen and coauthors in Taiwan in an abstinence center settings. A total of 70 (40 heroin and 30 methamphetamine users) subjects in intervention group and 75 (38 heroin and 37 methamphetamine users) subjects in control group were completed pre- and post-test assessments. The study revealed that among both heroin and methamphetamine users, the intervention group had greater improvement in confidence to manage interpersonal situations related to drug use, methamphetamine users also showed better results in respect for management of intrapersonal situations in comparison to controls (Yen et al. 2004).
Dzialdowski and London in United Kingdom have described two cases demonstrating CBT in combination with elements of motivational interviewing and relapse prevention techniques as effective complementary treatment for methadone maintenance in opiate addiction treatment (Dzialdowski and London, 1999).
Budney et coauthors reported that CBT enhances posttreatment maintenance for cannabis dependence treatment. Study was carried out in United States in out -patient treatment settings (Budney et al. 2006). Another study of CBT implementation as an additive treatment performed by Epstein and coauthors in methadone maintanence treatment clinic settings in Unites States showed appropriateness of its use for cocaine abusers (Epstein et al. 2003).

2.5    Combination of MET and CBT

Comprehensive research of effectiveness of both motivational enhancement therapy and cognitive-behavioural therapy for cannabis abuse was performed by Dennis and coauthors in United States in medical and community-based settings. By its design it was two inter-related randomized trials conducted at four sites to evaluate the effectiveness and cost-effectiveness of five short-term outpatient interventions for adolescents with cannabis use disorders. Trial 1 compared five sessions of Motivational Enhancement Therapy plus Cognitive Behavioural Therapy (MET/CBT) with a 12- session regimen of MET and CBT (MET/CBT12) and another that included family education and therapy components (Family Support Network [FSN]). Trial II compared the five-session MET/CBT with the Adolescent Community Reinforcement Approach (ACRA) and Multidimensional Family Therapy (MDFT). The 600 cannabis users were predominately white males, aged 15-16. All five interventions demonstrated significant pre-post treatment during the 12 months after random assignment to a treatment intervention in the two main outcomes: days of abstinence and the percent of adolescents in recovery (no use or abuse/dependence problems and living in the community). Overall, the clinical outcomes were very similar across sites and conditions; however, after controlling for initial severity, the most cost-effective interventions were MET/CBT5 and MET/CBT12 in Trial 1 and ACRA and MET/CBT5 in Trial 2. It is possible that the similar results occurred because outcomes were driven more by general factors beyond the treatment approaches tested in this study; or because of shared, general helping factors across therapies that help these teens attend to and decrease their connection to cannabis and alcohol (Dennis et al. 2004).
There are also evidences of positive effects of combination of motivational enhancement therapy and cognitive-behavioural therapy provided by McKee and coauthors, who randomized 74 participants into two groups for comparison:

•    a) participants who were assigned 3-session CBT and
•    b) participants who received 3-session combined CBT and MET. Though their conclusions are mixed, their results showed that participants, receiving combined therapy attended more drug treatment sessions and reported significantly great desire for abstinence and expectation of success. Research was carried out in United States in outpatient substance abuse clinic settings (McKee et al. 2007).

This is also supported by the survey of trials focussing on cannabis treatment done by Zumdick and coauthors, showing that the optimal treatment of cannabis-dependent adults would be a short intervention which consists of a combination of motivational-enhancement and cognitive-behavioural elements as well as individual case-counselling (Zumdick et al. 2006).

Jungerman and others have performed a randomized controlled trial that have shown higher efficacy of motivational interviewing in comparison with delayed treatment control as well as the dose-response effect of motivational interviewing Ð longer course showed better results. Research was done in Brazil in out-patient settings. A randomized controlled trial compared 3 conditions: 4 weekly individual sessions of motivational interviewing and relapse prevention over 1 month (1 MIRP); the same 4 sessions over 3 months (3MIRP), and delayed treatment control (DTC). The short term impact of each intervention was followed up 4 months after randomization. Participants were 160 highly educated adults with a long history of frequent cannabis use. Both treatments showed better results than the DTC, and for primary outcomes (i.e., cannabis consumption) there was no difference between treatments, while the 3MIRP scheme showed greater efficacy in reducing dependence symptoms and other drug use according to the ASI drug subscale. There was a tendency for the longer treatment to have better outcomes, regardless of intensity, although the waiting list did have some positive effect. The cohort needs to be followed up for a longer period in order to ascertain whether changes are maintained over time (Jungerman et al. 2007).

2.6    Family and social therapy

Implementation of brief family-based interventions has a great potential in drug abuse treatment both used separately or in combination with other techniques, especially in adolescents. Systematic review of Family Therapy done by Szapocznik and Williams included seven major completed randomized trials in various settings. By their conclusions, brief strategic family therapy is effective in improving family functioning, decreasing resistance in treatment and reducing drug abuse problems in adolescents (Szapocznik and Williams, 2000).
Liddle and colleagues in United States compared effectiveness of multidimensional family therapy and individual CBT techniques in respect for drug abuse treatment in community-based drug abuse clinic settings. They randomized 224 adolescents with drug use disorders (mostly cannabis-related) into two equal-sized groups:

•    Multidimensional Family Therapy Group.
•    Cognitive Behaviour Therapy Group.

Findings of their research showed that both interventions produced significant reduction of cannabis consumption. There was no significant differences in treatment outcomes between these two intervention. MDFT was found to reduce substance use (Liddle et al. 2008).
Another embodiment of family-based interventions is behavioural couples therapy. As follows from the review made by Fals-Stewart and colleagues, in multiple studies with diverse populations, patients who engage in BCT have reported greater reductions in substance use than patients, who receive only individual counseling. Couples received BCT also have reported higher level of relationship satisfaction and more improvements in other areas of relationship and family functioning (Fals-Stewart et al. 2004).
Waldron and coauthors in United States studied effectiveness of family therapy alone and in combination with CBT in social network settings. They have randomized 120 adolescents into four groups:

•    Functional Family Therapy (n=30).
•    Individual CBT (31).
•    Combined Functional Family Therapy and CBT (n=29).
•    Group intervention (n=30).

According to the research outcome, family therapy showed better treatment results at seven moths after treatment. Treatment outcome was better when family therapy was combined with CBT (Waldron et al. 2002).
Socialisation of patients with drug use disorders plays important role in their effective treatment and rehabilitation. Okruhlica and colleagues in their three-year follow-up study of heroin users in specialized treatment facility in Bratislava have emphasized that a significantly better outcome after 3 years was observed among those subjects who were well socialized i.e. were working or studying at the time of admission (Okruhlica et al. 2002).

3 Recommendations

3.1    Evidence strength rankings

According to the quality of evidence presented in different res earch reports, all evidences are classified as follows:

**** Strong evidence: High quality meta-analyses, systematic reviews including one or more RCT with a very low risk of bias, more than one RCT a very low risk of bias.
*** Moderate evidence: Limited systematic reviews, one RCT with a low risk of bias or more RCT with a high risk of bias.
** Some evidence: one RCT limited by research factors or more case-control or cohort studies with a high risk of confounding.
* Expert opinion.
? Insufficien t evidence/unclear/unable to assess.

3.2    Motivational Enhancement Therapy

Motivational Enhancement Therapy is aimed at motivating the patient to quit using the substance, or harm reduction, if the patient is not ready or able to quit for any reason. The evidence of effectiveness of motivational enhancement therapy is multiple and diversified, mostly presented for cannabis and stimulants abuse and less Ð for opiates. While certain studies report poor efficacy of MET, most of them show its high effectiveness (****Bernstein et al. 2005; ***McCambridge and Strang 2004; ***Baer et al. 2007; Babor et al. 2004).
Motivational enhancement should include informational component and be based on the following key points:

Harm reduction is one of the major points of brief interventions. Specialist is to discuss the potential and existing medical complications as well as the probabilities of their onset. Medical complications are quite similar for major substances starting with the cognitive deterioration, higher probability of exacerbation of genetically predisposed disorders like schizophrenia, schizoaffective and schizophrenia-like disorders, onset of transient psychoses at the peak of intoxication and at withdrawal states, high risk of development of mood and anxiety disorders, deterioration of general medical condition, investable changes of personality and higher suicidal risk.

Even assuming that each of the disorders mentioned above has a very small probability of onset, in total and in long-term prospective they represent a serious risk for the health of drug user.

Second point of motivational enhancement should be emphasis on the social and economic aspects of drug use. Thus hundreds or thousands (for severe dependence) of dollars are spent imperceptibly every year and hundreds of hours are wasted for nothing. Performer of intervention may discuss with the patient what could be bought for this money, how else could he or she spend this money and time — for family, other less harmful or even healthy amusements, professional growth, doing sports, travelling etc.

Social aspects of drug use are not limited to using it in a “friendly environment”. Drug abuse may provoke a number of social problems in the family and at the job. This should be considered when performing a brief intervention. In most of the cases, the patient will come to his physician due to social reasons even if not legally coerced to do so. Another reason for quitting might be the children of the patient and the vicious example that he or she shows to them by using the drug.

One of the most prominent features of addictions is denial. Patient may deny the fact that his use of drug is abusive and/or that he is dependent. Specialist should discuss the real reasons for the visit, previous attempts to quit this addiction and in this way show the patient the very necessity to quit.

Legal status of drug is another good reason for motivating the patient. In most of the countries the use of drugs itself is not punished, but there are no legal ways to obtain it Ð in order to get them patient has to contact a drug dealer. This fact, as well as potential emergency situations, may destroy his or her reputation.

3.3    Cognitive-behavioural Therapy

Cognitive-behavioural Therapy is aimed at teaching a patient how to handle various situations and psychological conditions that may lead to substance use. It is grounded in the cognitive theory and relatively easy to implement. There are multiple evidences of high efficacy of cognitive-behavioural therapy for substance abuse treatment (***Copeland et al. 2001; ***Baker et al. 2005; ***Azrin et al. 1994; **Maude-Griffin et al. 1998; **Rohsenow et al. 2000; ***Yen et al. 2004).

This therapy has been shown to be efficient, cost-effective and compatible with Motivational Enhancement Therapy (***Dennis et al. 2004; ***McKee et al. 2007; ***Zumdick et al. 2006; Jungerman et al. 2007).

Most of the patients with substance abuse have certain patterns of using the drugs. These may be certain situations, friends or companies or certain life events. Consequently, there are some associative psychological “triggers” that will obviously lead the patient into temptation to continue using the substance.

These conditions/situations may be various but the task of physician is to teach the patient either how to avoid them or how to cope with them. Actually, the main idea of behavioural psychotherapy in the case of addiction is to replace a bad habit with a neutral one.

A very important task is to find a psychological substitute for the substance Ð something that would distract the patient from craving it. The substitute must be emotionally significant for the patient. One of the best choices would be some kind of sportive activity, especially one involving team sports.

3.4    Social and family therapy

Studies of implementation of family- and/or social-based techniques have shown their efficacy in coping of social deprivation and facilitating the treatment process. Thus, itÕs desirable that his or her family and friends were involved into the treatment process (***Szapocznik and Williams, 2000; ***Liddle et al. 2008; ***Fals-Stewart et al. 2004; **Okruhlica et al. 2002).
The main goals and potential achievements of engaging the family and friends in the treatment are:
•    creating the psychologically comfortable circumstances for treatment.
•    encouraging and inspiring the patient.
•    preventing “occasional” relapses and
•    increasing socialisation of the patient.

3.5    Pharmacological interventions

While pharmacological treatment is not a part of brief interventions there are certain medical complications to be predicted to arise during withdrawal such as anxiety and mood disorders, psychotic symptoms etc.
There is no specific treatment neither for most of the drugs nor for related disorders. However, related disorders are supposed to be predicted on the basis of severity of drug abuse and dependence and treated accordingly with respect to the patient’s status and appropriate pharmacological therapy has to be chosen (e.g. benzodiazepines, antidepressants, anticonvulsants etc.)
There are evidences of positive effects of combination of psychosocial interventions and maintenance treatment for opiate dependence (***Saunders et al. 1995; *** Rowan - Szal et al. 2005; ***Hollonds et al. 1980; *Dzialdowski and London, 1999). Pharmacological therapy may and must be used to improve general medical condition of the patient as well.

3.6    Techniques to be chosen

All techniques described are suitable for brief interventions and may be performed by any brief intervention/therapy provider. They are also compatible and complementary to each other to the extent they may and should be used in complex. Evidence given above shows higher effectiveness of complex treatment in comparison to using single technique (***Greg et al. 2005; ***Dennis et al. 2004 ; ***McKee et al. 2007; * * *Zumdick et al. 2006; * * *Jungerman et al. 2007).

3.7    Settings

Gathered evidences show that different forms of substance abuse are more likely to be treated in specific settings. Opioids abuse is characterized by the number of complications, severe withdrawal and in the most of the studies brief psychotherapeutic techniques are used as the complementary to the maintenance programme in specialized clinical settings, in- or out-patient, depending on severity of dependence (***Saunders et al. 1995; ***Hollonds et al. 1980; **Dzialdowski and London, 1999).

Cocaine abuse, while having a number of complications most probably may require medical attention and thus might be treated equipotentially in in-patient and out-patient clinical settings (***Bernstein et al. 2005; **Covi et al. 2002; *** Rohsenow et al. 2000). Evidences of brief interventions and therapies in non-medical settings are scarce and related mostly to mild forms of abuse (***Maude-Griffin et al. 1998).

Club drugs and cannabis are the most prevalent forms of illicit drug abuse and at the same time requirements for specialized medical attention are much weaker. Current evidence shows high effectiveness of brief interventions and therapies for these forms of abuse in all settings with the most preferable out-patient or social network settings (***Liddle et al. 2008; ***Jungerman et al. 2007; ***Martin et al. 2005; * * * Srisurapanont et al. 2007; ***Stephens et al. 2000; * * *Babor et al. 2004; ***Copeland et al. 2001; ***Baker et al. 2005; ***Dennis et al. 2004).

3.8    Number of sessions and duration of treatment

In spite of the fact, that current evidence base shows that single session brief interventions are effective method of treatment and harm reduction of drug abuse, this evidence is scarce and poorly supported. Stronger evidences are gathered in respect for multiple sessions brief interventions, showing them being more effective than single session ones (***Covi et al. 2002; ***Baker et al. 2005; ***Azrin et al. 1994; ***Jungerman et al. 2007).

The number of sessions and duration of treatment depend on severity of dependence and the goals of treatment. Successful treatment comprises 6-20 sessions and lasts until achievement of its goals.

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