best practice

School health services were found in a systematic review with meta-analysis (Montgomery et al., 2021) to be effective (moderate quality evidence) in:

• reducing drinking alcohol (60.1% vs. 70.5%, p < .001),
• reducing using drugs (28.0% vs. 38.3%, p < .001)

School health services were also found to be associated with reductions in suicide planning (male: 7.1% vs. 7.7%, p < .01), hospitalization (relative risks 3.403, 95% confidence interval [CI] 1.536 to 8.473, p < .05), emergency department visits (odds ratio .85, 95% CI .75 to .95, p ¼ .006), school absence (odds ratio .78, 95% CI .69 to .87, p < .0001), carrying weapons (male: 16.1% vs. 25.1%, p < .01), fighting (male: 32.6% vs. 43.1%, p < .01), sexual activity (53.5% vs. 60.5%, p < .05) and physical activity (female: 57.4% vs. 50.4%, p < .01).

In a narrative systematic review (Kerman et al., 2021, studies = 35) harm reduction outcomes and practices in Housing First were examined in four domains: substance-related harms, viral health, sexual health, and harm reduction service use. Overall the review found that harm reduction outcomes in Housing First remain underexamined and any conclusions of the intervention's impacts in this domain would be premature. Effective harm reduction practices in Housing First require strong working relationships between staff and tenants.

Specific results of the analysis found that:

• harm reduction outcome studies focused mostly on nonspecific substance use problems, with Housing First being found to have minimal effects in this domain.
• More severe harms, such as delirium tremens and substance use-related deaths, have been minimally explored, though preliminary evidence is promising.
• Viral health, sexual health, and harm reduction service use outcomes were the focus of few studies. 

A systematic review with meta-analysis (Tanner-Smith et al., 2021, RCTs = 116, N= 64 439) investigated the effectiveness of brief interventions in patients of any age or severity level recruited in general medical settings. Analyses were conducted separately by brief intervention (BI) target substance: alcohol only or drugs. The overall conclusion was that when delivered in general medical settings, alcohol-targeted brief interventions may produce small beneficial reductions in drinking (equivalent to a reduction in 1 drinking day per month), however there is limited evidence regarding the effects of drug-targeted brief interventions on drug use.

Specific results of the analysis found that:

• drug-targeted BIs yielded significant small improvements in multiple drug/mixed substance use (Hedges' g = 0.08; 95% CI = 0.002, 0.15), but after adjusting for multiple comparisons, they did not produce significant effects on cannabis use (g = 0.06; 95% CI = 0.001, 0.12), alcohol use (g= 0.08; 95% CI = -0.0003, 0.17), or consequences (g = 0.05; 95% CI = 0.01, 0.10)
• drug-targeted BIs yielded larger improvements in multiple drug/mixed substance use when delivered by a general practitioner (g = 0.19; 95% CI = 0.187, 0.193)
• alcohol-targeted BIs yielded small beneficial effects on alcohol use (g = 0.12; 95% CI 0.08, 0.16), but no evidence of an effect on consequences (g = 0.05; 95% CI = -0.04, 0.13). However, alcohol-targeted BIs only had beneficial effects on alcohol use when delivered in general medical settings (g = 0.17; 95% CI = 0.10, 0.24); the findings were inconclusive for those delivered in emergency department/trauma centers (g = 0.05; 95% CI = 0.00, 0.10)

Take home naloxone (THN) programs have been rapidly upscaled in response to increasing opioid-related mortality. One often cited concern is that naloxone provision could be associated with increased opioid use, due to the availability of naloxone to reverse opioid overdose.

A narrative systematic review (Tse et al., 2022, studies =7 - two quasi-experimental studies and five cohort studies, N= 2 578) investigated whether THN provision is associated with changes in substance use by participants enrolled in THN programs and found:

• no evidence that THN provision was associated with increased opioid use or overdose. 

Economic evaluations of the pharmacological treatment of opioid use disorder were analysed in a narrative systematic review (Onuoha et al., 2021, studies = 21 - 4 cost-offset studies and 17 cost-effectiveness/cost-benefit studies) that found:

• strengthened evidence on the cost-effectiveness of buprenorphine and methadone, indicating that these treatments are both economically advantageous compared with no pharmacotherapy (no evidence was found supporting superior economic value between the two medications)

Four studies focused on the potential reductions in healthcare costs associated with pharmacological treatment of opioid use disorders and found that OST leads to lower healthcare resource utilization and expenditures than nonpharmacologic therapies. Also results from one population-level study indicate significantly lower criminal justice–related costs among participants who received methadone compared with those who received detoxification only.

Further economic research is needed on Naltrexone, as well as other emerging pharmacotherapies, treatment modalities, and dosage forms.

A narrative systematic review (Özgen et al., 2021) investigated the treatment options of adolescents with attention-deficit/hyperactivity disorder (ADHD) and comorbid substance use disorders (SUD) and overall found that there is very limited evidence of treatments for this comorbidity and does not allow for strong recommendations. Specifically:

• pharmacological treatment - none of the trials in this comorbid adolescent population showed a robust between-group effect of treatment on either ADHD or SUD
• psychosocial treatment - no randomized trials or meta-analyses have been conducted to date in youth with concurrent ADHD and SUD

A narrative systematic review (Razaghizad et al., 2021, studies = 11 RCTs and 17 non-RCTs, N = 33,711 of 37,117 active research participants aged 15-25 yrs) investigated the effectiveness of prevention interventions for drugs-and-driving outcomes. The results found evidence to support the interventions that may improve drugs and driving knowledge, attitudes, and behaviours, specifically: 

• high quality evidence that cannabis packaging with health warnings increases the knowledge about drugged driving effects
• moderate quality evidence that roadside drug testing can reduce drugs-and-driving among cannabis users
• moderate quality evidence that for youth or previous offenders, motivational interviewing can prevent drug-and-driving and driver education programs can increase knowledge

The impact of such interventions on measures of drugs-and-driving morbidity and mortality outcomes is uncertain.

A Cochrane systematic review with meta-analysis (Zankl et al., 2021, studies= 16, N= 1 110) investigated the efficacy and safety of using an opioid as compared to a sedative or non-pharmacological treatment for the treatment of neonatal abstinence syndrome (NAS) due to withdrawal from opioids. The results found:

• moderate quality evidence that treatment failure is reduced by the use of an opioid compared to the use of the sedatives phenobarbital (RR 0.51, 95% CI 0.35 to 0.74; 6 studies, 458 infants) or chlorpromazine (RR 0.08, 95% CI 0.01 to 0.62; 1 study, 90 infants). There was little or no difference in treatment failure according to the type of opioid used (morphine, methadone or buprenorphine)
• moderate quality evidence that the use of sublingual buprenorphine reduces duration of treatment (morphine vs bup MD 12.79, 95% CI 7.57 to 18.00; 3 studies, 112 infants) and hospitalisation (morphine vs bup MD 11.45, 95% CI 5.89 to 17.01; 3 studies, 113 infants) compared to the use of morphine 

There is insufficient evidence to determine the effectiveness and safety of non-pharmacological interventions alone compared to non-pharmacological interventions plus a pharmacological agent (drug such as opioid or sedative).

A Cochrane systematic review with meta-analysis (McGovern et al., 2021 a, studies=22, N= 2 274) assessed complex psychosocial interventions targeting substance use in parents of children under the age of 21 years. Interventions were found to be effective in:

• reducing the frequency at which parents use alcohol and drugs
  • low-quality evidence that psychosocial interventions targeting substance use only may not reduce the frequency of alcohol (6 months: SMD −0.35, 95% CI −0.86 to 0.16; 2 studies, 89 participants and 12 months: SMD −0.09, 95% CI −0.86 to 0.61; 1 study, 34 participants) or drug use (6 months: SMD 0.01, 95% CI −0.42 to 0.44; 2 studies; 87 participants and 12 months: SMD −0.08, 95% CI −0.81 to 0.65; 1 study, 32 participants)
•  Integrated psychosocial interventions which combine parenting skills interventions with a substance use component may show the most promise (low quality evidence)
  • integrated interventions which combined both parenting- and substance use- targeted components may reduce alcohol misuse with a small effect size (6 months: SMD −0.56, 95% CI −0.96 to −0.16 and 12 months: SMD −0.42, 95% CI −0.82 to −0.03; 2 studies, 113 participants) and drug use (6 months: SMD −0.39, 95% CI −0.75 to −0.03 and 12 months: SMD −0.43, 95% CI −0.80 to −0.07; 2 studies, 131 participants)

Authors also found 

• that whilst it appears that mothers may benefit less than fathers from intervention, caution is advised in the interpretation of this evidence, as the interventions provided to mothers alone typically did not address their substance use and other related needs. 
• low-quality evidence from few studies that interventions involving children are not beneficial.

A more comprehensive narrative review (McGovern et al., 2021 b, studies=58) investigating the adverse health and social outcomes derived by the the substance use of a close relative, found behavioural interventions to be effective in:

• improving the social wellbeing of family members (reducing intimate partner violence, enhancing relationship satisfaction and stability and family functioning) when delivered conjointly with the substance user and the affected family members.
• Also  an affected adult family members may derive psychological benefit from an associated individually focused therapeutic intervention component.

However no interventions fully addressed the complex multidimensional adversities experienced by many families affected by substance use and further research is needed to determine the effect of a multi-component psychosocial intervention, which seeks to support both the substance user and the affected family member.

Psychosocial interventions for Amphetamine-type stimulants (ATS - meth/amphetamine and ecstasy) use were found in review of reviews with meta-analysis (Tran et al., 2021) that:

• patients in psychological interventions used injectables substantially less (odds ratio (OR) 0.35, 95% CI: 0.24 to 0.49, low quality evidence)
• the risk of unsafe sex in the psychosocial intervention group was lower than in the control group (RR 0.49, 95% CI: 0.34 to 0.71, moderate quality evidence)

 Psychosocial interventions considered in the analysis were:

1. Cognitive behaviour therapy (CBT)/ Cognitive Behaviour Therapy combined with Text messages/ Computer-based Cognitive Behaviour Therapy intervention; 2. Contingency management (CM); 3. Psychosocial therapies (combined CBT+ MI+ CM+BI + others); Matrix; 4. Motivational interviewing (MI);  5. Brief intervention (BI); 6. Case management;  7. Community-based management, therapeutic community; harm reduction group therapy;  8. Mindfulness;  9. 12 steps facilitation;  10. Family therapy.