The effectiveness of telephone counselling in the treatment of illicit drug and alcohol use concerns.

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J Telemed Telecare OnlineFirst, published on May 29, 2015 as doi:10.1177/1357633X15587406

RESEARCH/Original article

The effectiveness of telephone counselling in the treatment of illicit drug and alcohol use concerns

Journal of Telemedicine and Telecare 0(0) 1–19 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1357633X15587406 jtt.sagepub.com

Peter Gates and Lucy Albertella

Abstract Introduction: Technology-assisted substance use interventions such as ‘high-tech’ internet-based treatments are thought to be effective; however, the relatively ‘low-tech’ use of telephone counselling does not yet have an established evidence base. This paper reviews the literature including articles with information on the use of telephone counselling for the treatment of illicit drug or alcohol use. Methods: A systematic literature search using a set of telephone counselling and substance-related terms was conducted across four electronic databases. English studies prior to June 2014 that involved the use of telephone counselling with the treatment of illicit drug or alcohol use as a primary or secondary outcome were included. Review papers, opinion pieces, letters or editorials, case studies, published abstracts, and posters were excluded. In all, 94 publications were included in the review. Results and discussion: The literature was supportive of telephone counselling for the treatment of alcohol use in the short term; however, literature regarding illicit drug use was particularly scarce. The generalisability of findings was limited by evident methodological issues in the included studies. Keywords substance use, treatment, telehealth, telephone counselling, helplines Date received: 1 February 2015; accepted: 20 March 2015

Introduction The impact of alcohol and illicit drug use on public health is of global concern. Recent estimates of the global burden of disease attributable to illicit drug use and dependence were at 20 million disability-adjusted life years (DALYs) in 2010 and the burden of alcohol use disorders at almost 18 million DALYs.1 In 2011, between 3.6 and 6.9% of the world population aged 15–64 years had used an illicit substance, most commonly cannabis (approximately 3.9%).2 In combination with the substantial prevalence of use, the significant harm from substance use highlights the financial and health benefits of intervention and prevention efforts. Such interventions come in different modalities, such as self-help booklets and face-to-face inpatient or outpatient treatments, as well as technology-assisted interventions including computer-based and telephone/mobilebased interventions. Moreover, treatment clients bring additional complexity to each session with differing patterns of substance use, levels of social support, individual demographic characteristics and reactance to treatment. Although substance use interventions are typically thought of as face-to-face treatments based on motivational interviewing3 or cognitive behavioural therapies,4 there is growing evidence that similar technology-assisted interventions can be at least as effective. In particular,

computer-based interventions may be effective for illicit5,6 and licit drug use.7 In addition, mobile-based interventions,8,9 interactive voice response interventions10 and videoconferencing (often collectively referred to as telehealth or telemedicine) also show promise for licit drug treatment.11,12 Unlike these ‘high-tech’ interventions which are rapidly increasing,13 comparatively ‘low-tech’ interventions such as telephone counselling (TC) for substance use remain largely overlooked. Interestingly, TC is a well-established treatment for tobacco smoking14,15 and thought to be cost-effective.16 In addition, the utility of the telephone is also beginning to be recognised as a modality for delivering continuing care (treatment that follows an initial episode of more intensive care).17,18 However, TC to treat substance use other than tobacco smoking has gone relatively unnoticed since the first publication on the topic became available over 40 years ago.19

National Cannabis Prevention and Information Centre, Randwick NSW, Australia Corresponding author: Peter Gates, National Cannabis Prevention and Information Centre, UNSW, PO Box 684, Randwick NSW 2031, Australia. Email: [email protected]

Downloaded from jtt.sagepub.com at University of Otago Library on November 14, 2015


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Journal of Telemedicine and Telecare 0(0)

As with any treatment modality, there are benefits and drawbacks that may contribute to the effectiveness of TC substance use treatment. The client may feel that their personal space is less threatened and that the session is less intensive compared with approaching face-to-face treatment (with the associated waiting rooms, receptionists and dress codes).20,21 Anonymity is more easily preserved, which may reduce experiences of any associated stigma, removing a potential barrier to treatment.22 The client is also empowered to end treatment sessions at will by hanging up the phone, which may result in greater forthrightness and honesty.23 Location is no longer as significant, opening up accessibility for those in remote locations or the physically disabled and allowing more freedom for treatment providers.24 Telephone services can have wide operation hours and take advantage of fleeting motivation to enter substance use treatment,21 or provide assistance during times of a craving or relapse to use.25 Service providers are encouraged to improve their active listening and speaking communication skills, as visual cues are absent.24 Alternatively, demands of infrastructure can be overwhelming, with a majority of calls likely to be unanswered due to a lack of resources.26 The deaf and speech impaired are disadvantaged (although relay technology is available to prevent their exclusion) and even among the hearing abled there may be problems with getting a clear line. In addition, despite wide operation, telephone services may not reach more than approximately 1–5% of their target audience without advertising.27–29 To date there has been no systematic review of the literature specific to TC for the use of alcohol or illicit drugs (AOD; that is, substances other than tobacco or licit prescription drugs). Without such a summary, the effectiveness of TC for the treatment of AOD use is unclear. This article addresses this research gap by providing a summary of the findings from a systematic literature review and discussion for future research.

Methods Search strategy The literature search, evaluation and data extraction processes were conducted according to protocol outlined by the Cochrane Collaboration.30 Two researchers independently conducted a literature search for articles published prior to June 2014, located through online search of four electronic databases (Embase, CINAHL, Medline, and PsycINFO). Search terms were grouped into two blocks: (1) intervention (including telephone counselling, telepsychiatry, telephone intervention, helpline, telecounselling and phone); and (2) substance use (including drug use, substance use, abuse, dependence, alcohol, cannabis, cocaine, amphetamine, hallucinogen, opioid, and inhalant).

Study inclusion For purposes of this review, only articles describing a TC treatment (including those where TC was only a component of treatment such as ‘booster’ calls or continuing care) with a measure of AOD use as a primary or secondary outcome were included. As such, articles regarding TC in a capacity other than AOD treatment, such as for disorder diagnosis or treatment reminder calls, were excluded. In addition, review papers, posters, opinion pieces, letters or editorials and published abstracts were excluded. Finally, articles not specifically involving counselling via two-way audio telephones – such as the use of interactive voice response, smart-phone texting or applications, or telehealth software – were excluded. Articles were not excluded by location, however; non-English language papers were excluded. All articles prior to June 2014 were included. Initial searching resulted in the identification of 5806 manuscripts which were reviewed to remove duplicates and articles meeting exclusion criteria. A total of 2191 duplicates and 3521 articles meeting exclusion criteria were removed, leaving 94 relevant articles on TC which included treatment outcomes relevant to AOD use.19,21,31–142 Further details are provided in the PRISMA diagram, Figure 1.

Risk of bias Risk of bias was evaluated for the 64 articles which included a randomised controlled trial evaluating TC through a purpose-built, 31-item custom assessment following procedures from the Cochrane Collaboration’s Risk of Bias Assessment Tool,143 the Effective Practice and Organisation of Care Review Group Data Collection Checklist144 and Viswanathan and colleagues.145 A ratio (reported as a percentage) was calculated to represent which of any appropriate risks of bias the article had adequately addressed compared with the number inadequately addressed. As such, a score of 100% was awarded when the article addressed all appropriate risks of bias adequately. Judgements on article selection, data extraction and risk of bias were made by two researchers independently, with third party arbitration in cases where consensus could not be reached.

Results Included articles The 94 included articles were observed to be regarding TC in an continuing care setting following formal face-to-face AOD treatment (21 articles42–45,54,55,60,65,73,79,90,95,102,106, 112,115,116,118,125,132,133 ); TC used as a booster session(s) following a face-to-face AOD treatment (14 articles35,46, 51,59,64,67,68,78 80,82,87,98,99,119 ); TC as the primary form of AOD treatment (41 articles32,34,36–41,47–50,52,53,57,58,61,62,



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Figure 1. PRISMA diagram showing study inclusion/exclusion process.

66,69,71,72,81,86,91,94,96,101,103,105,108,110,113,114,117,120,121,126,128, 130,146

); and finally, articles that included a secondary analysis of one of these TC treatments (18 articles31,33,56, 63,74–77,84,92,93,100,104,107,111,122–124 ). As such, this review included information on 72 separate studies of TC for the treatment of AOD use. Details from these trials are provided in Tables 1 to 5.

Substances of interest in telephone counselling trial studies The majority of the treatment trials were regarding alcohol use (63.8% [46 trials]). The second largest group of trials did not specify a particular substance but referred to any AOD use (29.2% [21 trials]). As such, only five trials focussed on a particular illicit substance; four trials were regarding cannabis use and one trial on opioid use.

Characteristics of included participants The number of participants recruited into these trials ranged from 12 to 4094, with an average sample size of 412.5 (SD¼68.9). The included participants represented an average of 68.8% (SD¼22.7, range: 21.4–100.0%) of those found eligible from initial screening, demonstrating a lack of interest in treatment only by a minority of potential participants. These participants had an average age of 38.3 (SD¼15.6, range: 13.0–71.0) years and were typically male (58.7% on average, SD¼25.9, range: 0–100%) and white Caucasian (50.0% on average, SD¼30.2, range: 0–97.3%) (see Table 1). Participants were recruited from a variety of settings, most commonly from substance use treatment centres (22.2% [16 trials]) or other health clinics (15.3% [11 trials]). Only a handful of trials recruited from existing helplines (9.7% [seven trials]) (Table 2). Over twothirds of trials recruited participants from the US (72.2%



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Table 1. Trials of telephone counselling in the treatment of substance use concerns: study and participant descriptions.

Primary author, year

Country

Study attrition FU ‘N’ at duration (% complete data) Study type baseline (mos.)

Bernstein, 2010 Bernstein, 2009 Bischof, 2008 Bonevski, 2012 Borsari, 2014 Brown, 2007 Burleson, 2007 Burleson, 2012 Cacciola, 2008 Chong, 2003 Connors, 1992 Cooper, 1988 Currie, 2004 Curry, 2003 Dembo, 1998 Dembo, 2002 D’Onforio, 2012 Drinkard, 2001 Eberhard, 2009 Emmons, 2005 Ettner, 2014 Farabee, 2013 Farrell-Carnahan, 2013 Farrer, 2012 Fernandes, 2010 Field, 2014 Fleming, 2002 Gates, 2011 Gates, 2012 Gillham, 2010 Godley, 2010 Gwaltney, 2011 Haggerty, 2007 Ham, 2011 Han, 2010 Hanson, 2011 Hawkes, 2009 Hawkes, 2013a Hawkes, 2013b Holtrop, 2008 Horng, 2007 Kalapatapu, 2014 Kim, 1998 Linakis, 2013 Marasinghe, 2012 Mbilinyi, 2011 McKay, 2005

US US Germany Australia US US US US US US US US Canada US US US US US Sweden US US US US Australia Brazil US US Australia Australia UK US US US South Korea US US Australia Australia Australia US Taiwan US US US Sri-Lanka US US

853 210 408 12 57 897 50 144 4094 30 80 60 40 307 119 315 888 684 344 1247 1186 302 46 155 1744 596 774 200 160 52 104 198 331 64 397 231 20 430 410 446 77 103 307 99 68 124 359

12 12 12 1.5 9 3 12 12 6 6 12 6 6 12 12 36 12 2 6 8 12 12 6 12 6 12 48 0.25 3 3 6 6 24 8 15 12 1.5 6 12 6 3 4.5 3 6 12 1 24

72.0 71.0 91.7 50.0 84.2 84.1 80.0 85.4 27.7 63.3 93.8 100.0 57.5 72.0 79.8 86.3 61.5 unclear 84.6 87.4 88.4 75.2 76.1 50.3 30.0 74.7 83.1 100.0 69.0 96.2 84.6 82.9 71.3 62.5 90.7 22.1 100.0 78.1 78.5 57.4 88.3 87.4 Unclear 80.8 Unclear 85.5 86.1

RCT RCT RCT Pre-post trial RCT RCT Pilot trial RCT Pre-post trial Pre-post trial RCT RCT RCT RCT RCT RCT RCT Pilot trial RCT RCT RCT RCT Pre-post trial RCT RCT RCT RCT Pilot trial RCT RCT RCT RCT RCT RCT RCT Pre-post trial Pre-post trial RCT RCT Pilot trial RCT RCT RCT RCT RCT RCT RCT

Participant Average age (SD)*

Male (%)

Caucasian Quality (%) rating

18–21* 18–21* 35–37* 18–49 19.07 (0.9) 20–49* 13–18 16.0 (1.2) 43.0 (13.0) 31.1 (6.8) 36.9 (7.8) 22–66 43.3 (10.9) 46.9 14.0 14.5 32.5 >24 37–39 >60 71.0 (7.3) 37.0 (9.8) 27.1 (5.5) 37.5 (12.0) 25.0 >18 18–65 43.0 (13.0) 36.0 (10.1) 68.3 31.6 20.6 (1.9) 13.7 52.7 51.9 (5.7) 18–44 66.0 60.6 66.4 48.4 40.4 43.8 48.3 (13.5) 13.0 29–34 39.4 41.9

45.5 34.5 68.1 58.3 61.4 44.6 65.0 66.1 48.0 30.0 67.5 100.0 100.0 64.5 62.0 56.0 72.3 0.0 28.0 58.1 65.7 73.0 0.0 18.1 74.0 76.5 62.3 41.0 61.9 Unclear 60.0 67.7 unclear 0.0 47.2 0.0 50.0 74.7 53.9 30.0 92.6 12.6 64.2 49.0 50.0 100.0 82.6

25.6 5.8 Unclear Unclear Unclear 86.2 Unclear 81.8 Unclear 0.0 Unclear Unclear Unclear 80.0 64.0 unclear 62.5 Unclear Unclear 82.9 97.3 66.0 26.1 Unclear Unclear 39.8 Unclear Unclear Unclear Unclear 76.0 74.0 50.8 Unclear 0.0 0.0 Unclear Unclear Unclear 78.0 Unclear 64.1 79.7 63.9 0.0 65.0 22.9

74.1 64.0 80.8 n/a 51.9 76.9 n/a 74.1 n/a n/a 54.2 28.6 65.5 71.4 60.7 64.3 85.2 n/a 50.0 72.0 71.4 65.4 n/a 60.0 59.3 73.1 67.9 n/a 78.6 44.0 75.9 64.0 69.2 52.2 58.3 n/a n/a 62.5 60.0 n/a 42.3 66.7 65.4 61.5 64.3 59.3 77.4 (continued)



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Table 1. Continued


Country

Study attrition FU duration (% complete ‘N’ at data) Study type baseline (mos.)

McKay, 2011 McKay, 2013a McKay, 2013b McKay, 2003 McKellar, 2012 Mello, 2008 Monti, 2007 Moore, 2011 Oslin, 2003 Rosen, 2013 Rotheram-Borus, 2004 Ruetsch, 2012 Rus-Makovec, 2008 Sanchez-Craig, 1996 Seal, 2012 Sedlack, 2005 Signor, 2013 Soderstrom, 2007 Stanford, 2010 Sussman, 2012 Wilton, 2013 Wongpakarang, 2011 Woollard, 1995 Zanjani, 2010 Zulig, 2010

US US US US US US US US US US US US Slovenia Canada US US Brazil US US US US Thailand Australia US US

252 321 152 187 667 285 198 631 97 837 175 1426 622 155 73 124 637 497 32 1676 434 60 146 113 84

24 24 12 12 12 12 12 12 4 12 15 12 24 12 4 6 6 12 13 12 12 4.5 4.5 6 0.25

77.0 74.8 74.3 Unclear 79.0 87.4 81.3 82.6 76.3 64.3 82.3 65.8 32.2 88.4 78.0 100.0 23.1 71.2 100.0 70.8 20.5 90.0 Unclear 77.9 Unclear

RCT RCT RCT RCT RCT RCT RCT RCT RCT RCT RCT Unclear RCT Controlled trial RCT RCT Controlled trial RCT RCT Pilot trial RCT RCT RCT RCT RCT Pilot trial

Participant

43.0 (7.4) 64.3 43.2 (7.4) 76.0 42.3 (9.0) 77.0 Unclear 68.0 51.0 95.0 29.5 61.0 20.5 67.7 68.4 (6.9) 71.0 61.6 (10.5) 95.9 50.1 87.0 23.0 78.0 31.8 (11.3) 59.0 45.0 74.9 42.5 64.1 21–39* 64.0 56.2 0.0 27.0 71.0 33.3 (12.4) 85.1 Unclear 66.0 16.8 (0.9) 56.6 25.5 0.0 36.1 86.4 58.5 55.0 52.8 (11.5) 95.5 Unclear Unclear

Average age (SD)*

Male (%)

Caucasian Quality (%) rating 11.1 7.5 9.9 27.0 50.0 72.3 65.7 87.0 49.5 62.0 23.0 87.9 Unclear Unclear 45.0 90.3 Unclear 63.0 Unclear 11.7 63.4 Unclear Unclear 30.0 Unclear

87.1 71.0 90.3 38.7 75.0 65.4 73.1 69.2 61.5 86.7 51.9 73.3 25.0 50.0 83.3 34.8 65.4 69.2 n/a 70.4 61.5 77.8 44.0 77.8 n/a

*Participant age is presented as the sample mean (standard deviation) in years where possible, or as an age range using the detail available. FU: Follow-up

[52 trials]), with Australia being the next most common (11.1% [eight trials]).

Treatment descriptions The evaluated treatments included an average of 6.8 sessions (SD¼7.9, range: 1–39) on the telephone, with a median of four sessions (Table 2). These sessions were typically described to last an average of 29.4 minutes (SD¼22.1, range: 5–120 minutes), with an average overall treatment duration of 4.9 months (SD¼5.0, range: 0.25–24 months) and a median of 3 months. Over half of treatments included a supplementary workbook (57.5%). From those trials which reported treatment completion rates, most participants completed the full number of offered sessions (a mean of 59.4%, SD¼26.7, range: 7–100%) (Table 2).

median of 12 months from baseline assessment (Table 1). The risk of bias among controlled trials was moderate, with an average score of 64.5% (SD¼13.9, range: 25.0–90.3%). Notably, under half of trials reported that treatment sessions were checked for fidelity – either by weekly supervision (9.6%) or review of recorded sessions (32.9%). Other commonly cited risks of biases included: a lack of controlling for the participant’s substance use history prior to participation (73.4% of trials); or controlling for the use of external treatment during the trial period (67.2% of trials); or controlling for substance use other than the targeted drug during the trial period (65.6% of trials); high rates of missing data due to study attrition (56.3% of trials); and including an underpowered sample or the absence of performing a power analysis when determining sample size (31.3%).

Trial outcomes Trial methods Participant follow-up extended for an average of 10.3 months (SD¼7.9, range: 0.25–48 months), with a

The outcomes assessed across trials included measures of overall consumption (including frequency and quantity of use – observed in 67 treatment comparisons) and


Health clinics

Homeless shelters

Treatment completers

Health clinics Treatment completers




Media ad.

Treatment completers Referral þ media ad.

Health clinics

Juvenile justice

Juvenile justice

Emergency Department Alcohol consumption MI þ CBT

Pregnancy program

Psychiatric outpatient attendance

Colonoscopy patients

Health clinics


Bischof, 2008

Bonevski, 2012

Borsari, 2014

Brown, 2007 Burleson, 2007

Burleson, 2012

Cacciola, 2008

Chong, 2003

Connors, 1992

Cooper, 1988 Currie, 2004

Curry, 2003

Dembo, 1998

Dembo, 2002

D’Onforio, 2012

Drinkard, 2001

Eberhard, 2009

Emmons, 2005

Ettner, 2014

Farabee, 2013

MI (Aftercare)

MI

MET

1

6

4

2

2

# TC sessions

Unclear (Aftercare)


Helpline callers

Fernandes, 2010

Cannabis consumption MI

Alcohol consumption Unclear ‘‘tracking’’

Helpline callers

Farrer, 2012

MI

Risky drinking

Unclear

MET (Booster)

Farrell-Carnahan, 2013 Media ad.

AOD consumption

Risky drinking

Alcohol consumption SCT þ MI

Educational feedback

Unclear

unclear

unclear

3

1

6

1

7

3

5

1

9

(Booster) 1



MI (Booster)

6 5

8

6

One session

1.5

6

Unclear 2.5

2.5

Booster call at 1 mos. post F2F Tx.

4

One session

20

10

60

5

One session

1.5

One session

3

Unclear 6

75

15

Unclear 9

10

Unclear 2.5

Unclear 2.5

14

Unclear 6 20 1.8

Unclear 6

Unclear 6

Unclear 11

Trained peer educators

Y

Y (web)

Y

N

Y

Y

Y (PFR)

87.0

Trained college students

$0

$0

$180

$0

$0

$0

$0

$0

$60

$70

$30

$0

$0 $0

$0

$30

$0

$0

$125 $0

$175

$0

$0

$80

$80

PR $*

(continued)

Average of 5.4 (1.7) calls received

88% attended at least one session

60% attended at least 4 sessions

94.0

82.0% attended at least one session

81.0

Unclear

Unclear

18.0

Unclear Unclear

Average of 6.2 calls received

63.3

28.0

86.0

Unclear Unclear

72.2

33.3

Unclear

Unclear

Unclear

Treatment attrition (% completion)

‘‘lay telephone counsellor’’ Unclear

Trained psychology graduates

Trained university staff

Trained professionals

Trained health advisors

Trained nurses

Obstetric nurse (training unclear)

Trained primary care nurse

N

Y

‘‘Paraprofessional’’

‘‘Paraprofessional’’


Unclear Trained professionals

Unclear

Unclear

Unclear

Unclear

Trained professionals Unclear




Trained peer educators

N

N

Y

Y N

N

N

N

N

Y N

Y (PFR)

N

N

Y

Y

Work-book? Treatment providers

6

Risky drinking

AOD consumption

AOD consumption

AOD consumption

Risky drinking

Alcohol consumption Unclear (Aftercare) Alcohol consumption CBT

Alcohol consumption Unclear (Aftercare)

14

0.4 0.4

Unclear 3 15 3

35–45

18

20–30

20–30

20–30

Overall Call time duration (min) (mos.)

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Alcohol consumption Unclear (Aftercare)

Alcohol dependence

Alcohol consumption MI þ CBT (Aftercare) 5

Alcohol dependence MI 6 Alcohol consumption MI þ CBT (Aftercare) 4

Risky drinking

AOD consumption

Risky drinking

Emergency Department Cannabis consumption MI (Booster)

Bernstein, 2009

MI (Booster)

Emergency Department Risky drinking

Bernstein, 2010

Type^

Recruitment source

Substance-related focus


Treatment

Table 2. Trials of telephone counselling in the treatment of substance use concerns: treatment description.

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Helpline callers

Helpline callers

Hospital patients



School approach

Media ad.

Unclear

Helpline callers

Hospital patients Hospital patients

Registered cancer patients

Health clinics

Hospital patients

Unclear

Health clinics

Emergency Department Alcohol consumption MI (Booster)

Gates, 2011

Gates, 2012

Gillham, 2010

Godley, 2010

Gwaltney, 2011

Haggerty, 2007

Ham, 2011

Han, 2010

Hanson, 2011

Hawkes, 2009 Hawkes, 2013a

Hawkes, 2013b

Holtrop, 2008

Horng, 2007

Kalapatapu, 2014

Kim, 1998

Linakis, 2013

MI (Booster)

MIþCBT

MI (Booster) 10

2

8

2

4

24


Risky drinking

Risky drinking

Alcohol dependence

18

unclear

4

11

2

MI þ CBT (Aftercare) 3

CBT

Unclear (Aftercare)

Alcohol consumption MI

Alcohol consumption ACT

Alcohol consumption Behavioural education 6 Alcohol consumption Behavioural education 10

Alcohol consumption MET (Booster)

Alcohol consumption Educational feedback (Booster)

Alcohol consumption Goal setting (Booster) 1

AOD Prevention

Alcohol consumption 12-step program (Aftercare)

4

1

2

1

# TC sessions

1.5

Booster call at 1 mos. post F2F Tx.

1

2

2.5

12

6

1.5 6

2.5

4.5

3.25

Unclear 3

14–22

45

30-60

Unclear 1.2

32

45 26

Unclear 9

18

Unclear Booster call at 1.5 mos. post Tx.

11

Unclear 6

20

Unclear 1.5

60

Unclear One session

5

28

Overall Call time duration (mos.) (min)

Y

Y

Y

N

N

Y

Y Y

Y

N

Y

Y

N

N

Unclear

Y

N

Y

Y

Trained ‘‘physicians’’


Unclear

Trained health care workers


Trained ‘‘health coaches’’ Trained ‘‘health coaches’’

Unclear

Unclear


Trained ‘‘experienced staff’’

Unclear


Unclear



Trained nurses



$0

$110

$150

PR $*

18.9

75.0

Unclear

71% at least 3 of the 4 calls

72.2

$55

$0

$0

$0

$0

$0

$0 $0

$0

$0

$0

$165

$0

$90

$0

(continued)

100.0 83% received at least half of the calls; average of 8 calls received

Unclear

74.2

Unclear

81.0

74.0

Average of 3 calls received

Unclear

57% completed full $60 treatment; average of 3.3 (1.2) calls received

n/a

Unclear

Unclear

Unclear; 45% attended FU at one day post TC


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Alcohol consumption MI (Booster)

Cannabis consumption MIþCBT

Cannabis consumption MI

Risky drinking

Health clinics

Fleming, 2002

MI (Booster)


Field, 2014

Type^

Recruitment source


Treatment


Table 2. Continued


Gates and Albertella 7







Health clinics

Veteran care clinic

Veteran care clinic

Health clinics

Pharma-health clinics

McKay, 2013a

McKay, 2013b

McKay, 2003

McKellar, 2012

Mello, 2008

Monti, 2007

Moore, 2011


Oslin, 2003

Rosen, 2013

Rotheram-Borus, 2004

Ruetsch, 2012

Opioid consumption

AOD consumption

AOD consumption

Risky drinking

Goal orientation

CBT

Educational feedback (Aftercare) MET (Aftercare)

MI (Booster)

MI (Booster)

MI (Aftercare)

8

18

6

7

3

2

2

24

12

Goal orientation (Aftercare) Goal orientation (Aftercare)

30

CBT (Aftercare)

39

36

12

1

10

# TC sessions

3

3

6

3

12

24 (Delivered as needed)

15

3

6

Unclear 3

120

16

45

Y

Y (PFR)

N

Y (web)

Y

N

Y

N

Y (PFR)

N

Y

Y

Y

N

Trained social workers

Psychology graduates (unclear training)

Trained nurses

$0

$400

73.5

69.0

$0

$0

(continued)

$225

35.0; an average of 7.5 $280 calls were received

An average of 4.5 (1.6) calls were received

Unclear

$0

$180

$70

Average of 10.5 calls $40 received

Unclear

33.0%; an average of 18.0 (11.7) calls were received

$350

$330

Around g of the sample began TC, completing approx.. 10 calls Average of 16 calls without monetary incentive and 26 with incentive

$0

$0

$0

PR $*

56.9% received 75% or more of the planned calls

84.5

unclear

53% completed the first call and 38% the second


Trained ‘‘health educator’’ 80.3% completed at least one call



Unclear

Unclear



Unclear



Unclear



As needed (typically Y within one year)

As needed

One session

6

Unclear 2

20–30

31

15

15–20

24

21

8–17

15

60–90

10–15


8

Risky drinking

AOD consumption

Alcohol þ cocaine consumption


CBT (Aftercare)

Goal orientation (Aftercare)

Goal orientation (Aftercare)

MET

Educational feedback (Aftercare)

Type^

Treatment

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AOD consumption

McKay, 2011

Media ad.

Mbilinyi, 2011

AOD consumption


Hospital patients

Marasinghe, 2012


McKay, 2005

Recruitment source


Table 2. Continued




Media ad.

Veteran care clinic

Unclear Helpline callers

Hospital patients


School approach

Health clinics

Media ad.

Health clinics

Veteran care clinic

Helpline callers

Rus-Makovec, 2008

Sanchez-Craig, 1996

Seal, 2012

Sedlack, 2005 Signor, 2013

Soderstrom, 2007

Stanford, 2010

Sussman, 2012

Wilton, 2013

Wongpakarang, 2011

Woollard, 1995

Zanjani, 2010

Zulig, 2010

MI

MI

Educational feedback (Aftercare)

Type^

MI þ CBT

MI þ CBT

MI (Booster)

Brief check-up (Aftercare)

MI (Booster)


MI Empathic listening þ referral

2

2

5

6

2

2

2

One session

24

9

Unclear

4.5

1.5

Unclear 0.25

15

15

20–30

Unclear Unclear

20

Up to 13 (as needed)

Unclear 1

Unclear One session 20 One session

25

30

45


Up to 10 13 (as needed)

2

1 1

4

1

4

# TC sessions

N

Y

Y

N

Y

N

N

Y

Y (PFR) Y

N

Y

N


Nurses (unclear training) Trained professionals



Unclear

Unclear


Unclear Trained professionals


Unclear

Nurses (unclear training)

Trained nurses and professionals


$0

$0

PR $*

Unclear

Unclear

Unclear

Unclear

73.0

24.0

Unclear

Unclear

$0

$0

$0

$0

$150

$0

$0

$0

Unclear $5 Unclear; 52% $0 attended FU at one day post TC

79.0%; an average of $0 3.7 (0.6) calls were received

Unclear

33.4

7%; an average of 3.2 (2.7) calls were received


Treatment type is provided, cases where the telephone counselling treatment was a booster component to a previous face-to-face intervention or aftercare following extensive outpatient face-to-face treatment are shown AOD: Alcohol or other drug; PR $*: Participant Reimbursement – the total possible amount that participants were reimbursed by adhering to all trial protocol. $0 is used in the case where PR was not described or stated to have not been used; F2F: Face to face; Tx: Treatment; TC: Telephone counselling; MI: Motivational Interviewing; MET: Motivational Enhancement Therapy; PFR: Participant feedback report; CBT: Cognitive behavioural therapy; SCT: social cognitive theory; ACT: Acceptance Commitment Therapy.

AOD consumption

AOD consumption

Alcohol consumption MI

Alcohol dependence

Risky drinking

AOD consumption

AOD consumption

Alcohol dependence

Alcohol consumption Educational feedback Alcohol dependence MI

AOD consumption

Risky drinking

Alcohol dependence


Treatment

(JTT)

^

Recruitment source


Table 2. Continued




(JTT)


10


frequency of risky consumption (including descriptions of ‘heavy’ use and dependence severity – observed in 38 treatment comparisons). In addition, less frequently assessed outcomes included indications of clinical improvement, motivation to change, treatment satisfaction, substance-related problems, and help-seeking behaviours. A total of 53 trials included a comparison of TC for AOD treatment outcomes to a minimal treatment control group (including wait-list and assessment-only controls, minimal advice, self-help and brief check-ups; see Table 3), while 23 trials included a comparison with an alternative active treatment (intensive care-as-usual, other behavioural treatments; as well as face-to-face versions of the TC treatments; see Table 4). Finally, a minority of trials did not include a comparison group, and information from these articles is provided in Table 5.

Intervention effectiveness The available evidence base supporting TC in the treatment of AOD use was mixed, but was somewhat positive overall. While one trial found outcomes following continuing care TC in addition to outpatient treatment to be inferior to that of outpatient treatment alone among adults,45 and one trial found outcomes of extended TC treatment to be inferior to that of treatment without such extension among adolescents,126 the majority of treatment comparisons found TC to be at least as effective as either minimal or active treatments. Notably, as the median follow-up period across trials was at 12 months, the available evidence base was not short term. Moreover, there was no obvious trend of outcomes decreasing as follow-up period increased. Compared with minimal treatment in particular, the evidence supporting TC as an effective means to assist with reductions to AOD use was mixed. That is, when assessing frequency of use, 16 trials supported TC, while 36 trials failed to support TC (see Table 3). Similarly, when assessing the frequency of risky substance use, eight trials supported TC, while 21 trials failed to support TC. This pattern was observed for trials investigating quantity per day of use, help-seeking behaviours, and substance-related problems. The strongest exception to this pattern was regarding the secondary outcome of changes to the participants’ motivation to quit, where four trials supported TC over minimal treatment, while three trials failed to support TC (not assessed in 45 trials). In contrast, TC did tend to be at least similar to alternative active treatments in regards to assisting with illicit substance use reductions. That is, only one trial reported an inferior effect.126 When assessing frequency of use, 19 trials found TC to be comparable with alternative treatments, one trial favoured TC, and one trial favoured alternative treatments (see Table 4). Similarly, all nine trials that assessed the frequency of risky substance use found TC to be comparable with alternative treatment. The same was true for secondary outcomes, including the four trials assessing help-seeking behaviours, one trial assessing

motivation to change, and the one trial assessing clinically relevant changes. Notably, there was no obvious trend between those trials including TC treatments of greater session numbers and those reporting more positive outcomes. In contrast, 10 trials included a statistical analysis investigating the impact of treatment adherence on outcomes. The majority of these articles reported that as the number of calls increased, treatment outcomes significantly improved.45,52–54,79,95,103 The minority of remaining articles found a trend toward improvement, although these did not reach statistical significance.57,96,125

Cost analysis Several articles referred to TC as ‘low cost’;31,50,58,61,73,106,119 however, a handful of articles included further information on the cost of TC.36,74,96,108,110,123 In summary, these articles describe per-participant costs ranging between approximately 100–200 dollars. The detailed cost information from these studies is reported here. First, one article reported that physicians were remunerated $400 for intervention training and reviewing study materials, and then $100 for successfully enrolled participants to a buprenorphine medication-assisted treatment including continuing care of eight educational coaching calls and web-based support.74 A second article stated that, based on a comparison of average annual salaries for primary care nurses, counsellors and physicians, approximately two motivational interviewing-based telephone sessions (accompanying a computerised feedback intervention) were estimated to cost E22.23 if conducted by a physician, E18.0 by a counsellor and E13.5 by a primary care nurse.96 A third article investigated the cost of materials, preparatory time, time on the phone and labour in delivering the five-session motivational and goal-setting intervention. This treatment cost $45.53 per contact, and based on health-related treatment outcomes, this translated to be $228 per unit change in a multiple health risk factor score.108 A fourth article reported on the cost of supplies, data coordination, and the physician and health coordinator’s time in delivering a three-session intervention that was founded on goal setting and the use of a personalised educational booklet. The estimated cost per-participant was $79. In addition, the cost of training the intervention therapists was estimated to be $3600 for the 17 physicians.36 A fifth article investigated clinic and patient expenses relating to a four-session intervention with health booklet delivered in a hospital setting. The per-participant cost was estimated to be $205. This translated to be a net societal benefit of $7780 per patient when considering the intervention outcomes relating to reductions in emergency department visits, legal events, and motor vehicle accidents.119



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11

Table 3. Controlled trials of telephone counselling in the treatment of substance use concerns: treatment outcomes compared to minimal treatment at final follow-up’.


Substance- HelpFinal follow-up Consumption Consumption Risky Clinical Motivation related seeking period (mos.) frequency quantity consumption improvement to change problems behaviour

Bernstein, 2010 ^ Bernstein, 2009 Bischof, 2008 Brown, 2007 Burleson, 2012 Connors, 1992 Cooper, 1988 Currie, 2004 Curry, 2003 D’Onforio, 2012 Eberhard, 2009 Emmons, 2005 Ettner, 2014 $ Farabee 2013 Farrer, 2012 ^ Fernandes, 2010 Field, 2014 Fleming, 2002 ^ Gates, 2012 Gillham, 2010 Gwaltney, 2011 $ Haggerty, 2007 Ham, 2011 Hawkes, 2013a Hawkes, 2013b Horng, 2007 Kim, 1998 Linakis, 2013 $ Marasinghe, 2012 $ Mbilinyi, 2011 ^ McKay, 2005 ^ McKay, 2011 ^ McKay, 2013a ^ McKay, 2013b ^ McKay, 2003 $ McKellar, 2012 Mello, 2008 Monti, 2007 Moore, 2011 Oslin, 2003 $ Rosen, 2013 Rotheram-Borus, 2004 ^ Ruetsch, 2012 Rus-Makovec, 2008 Sanchez-Craig, 1996 $ Seal, 2012 Sedlack, 2005

12 12 12 3 12 12 6 1.75 12 12 6 8 12 12 6 6 12 48 3 3 6 24 8 12 12 3 3 6 12 1 24 24 12 12 12 12 12 12 12 4 12 15 12 24 12 4 6

& & & 3 & 33 & & & 33

3 33 & 3

& 33 &

& &

&

& 33 & 3 & & &^ &

& &

3 33 3

3 &

& & & 33 & &

& 3 33

33 &

33

33

33

33 &

& & & 33 & 33

&

unclear

unclear

&

&

33 &

33 &

& & 3 & 3 5 & & & 33 33 & & 33 & & 3 &

& 3 & &

& &

33

& & &

5

& 33 & & & & & & & &

& & 33

3 & 33 (continued)



(JTT)


12


Table 3. Continued


Substance- Helpseeking Final follow-up Consumption Consumption Risky Clinical Motivation related period (mos.) frequency quantity consumption improvement to change problems behaviour

Signor, 2013 Soderstrom, 2007 Sussman, 2012 Wongpakarang, 2011 Woollard, 1995 $ Zanjani, 2010

6 12 12 4.5 4.5 6

33 & 3 & 33 &

&

&

&

& &

33: Telephone-based treatment showed significantly greater improvement compared with no treatment control without qualification; 3: Telephone-based treatment showed significantly greater improvement compared with no treatment control with some qualifications such as improvement that was specific to certain participants; &: Telephone-based treatment outcomes were comparable with that of no treatment control; 5: Telephone-based treatment outcomes were significantly less positive compared with no treatment control; Articles are regarding alcohol consumption unless indicated with a ^ which is referring to a particular illicit substance or $ which indicates that the trial was regarding any substance use.

Notably, a final article reported that – based on intervention delivery costs, including personnel transportation, materials, overheads and training costs – an 18-session intervention on health (including six 2-hour sessions on substance use) was estimated to cost $2692 per participant. This was found to be $808 less per-participant compared with the same intervention when delivered face to face, mostly due to reductions in travelling time and personnel costs.110

face-to-face alcohol treatment, which is thought to range between $138 for cognitive behavioural therapy and $812 for motivational enhancement therapy per contact hour.147 This combination of positive treatment outcomes at a probable low cost (compared with alternative treatment) highlights the importance of exploring the potential of telecounselling further.

Discussion

Although the focus of this review was on TC as a treatment for AOD use, there was huge variability in the content of the included trials and it was not consistently the case that the primary aim was to reduce substance use. As such, this review should be considered as an initial summary of literature warranting future systematic, meta-analytic study. In addition, during literature search and data extraction, no additional information was obtained from authors or article reference lists.

TC appears to be a promising treatment for AOD use with some notable limitations. Most importantly, only a handful of trials have investigated the utility of TC for the treatment of illicit substance use. This was consistent with a number of trials which reportedly excluded the recruitment of individuals with high scores of dependence severity due to an assumption that this should be treated by other means. In comparison, TC for the treatment of alcohol use has been explored in several trials (both as primary treatment and as continuing care). Compared with alternative treatments, TC for alcohol use showed significantly greater improvements on at least one measure of treatment outcomes relating to frequency of use in one of 12 trials,35 with the remaining trials showing comparable outcomes to alternative. Compared with minimal treatment, TC for alcohol use showed improved outcomes in 14 of 34 trials (41.2%). Importantly, several articles referred to the low cost of TC compared with face-to-face treatment, although this was largely anecdotal and without a substantial evidence base. That is, only one trial provided a formal evaluation of the cost effectiveness of TC for the treatment of AOD use compared with face-to-face treatment.110 Although this evaluation supported TC over face-to-face treatment, it was underpowered to observe significant between-group differences in substance use treatment outcomes. Regardless, those articles reporting cost evaluations per session (all below $210) were each below that of typical

Limitations of this systematic review

Implications for future telephone counselling research The available literature highlights important lessons for future research. First, the available research leaves several significant gaps in the evidence base before the utility of TC for AOD use can be confirmed. Importantly, the weight of research has assessed TC for the treatment of licit substance use – alcohol and tobacco. This is surprising, as illicit drug users may be an even more relevant target group as these individuals may face increased stigma in approaching traditional treatment services due to the illicit nature of their substance use.148 In addition, TC treatments were often singly focussed on substance use reductions and failed to address broader or concurrent issues. This kind of holistic treatment is known to improve outcomes among face-to-face substance use treatments.149 Second, treatment adherence is likely to be a significant predictor of outcomes and was supported in seven from 10 studies including such assessment. Importantly, these


12 9 12 12 6 1.2 12 36 12 12 6 12 6 24 15 4.5 24 24

12

12 15 12 12


Bischof, 2008 Borsari, 2014 Burleson, 2012 Connors, 1992 Cooper, 1988 Currie, 2004 $ Dembo, 1998 $ Dembo, 2002 D’Onforio, 2012 $ Farabee 2013 Farrer, 2012 Field, 2014 Godley, 2010 $ Haggerty, 2007 Han, 2010 Kalapatapu, 2014 McKay, 2005 McKay, 2011

McKay, 2013a

McKay, 2003 $ Rotheram-Borus, 2004 $ Sussman, 2012 Wilton, 2013

Web-based Brief advice F2F version Group-based Brief advice F2F version F2F, with family F2F version, with family F2F version Alternative TC* Web-based F2F, no booster call Alternative aftercare Group-based Less intensive TC F2F version F2F relapse prevention Alternative TC. and F2F group care TC without monetary incentives F2F relapse prevention F2F version F2F without TC booster F2F version

Treatment comparator

& & & &

3

& &

& & & &

& & & & & & & &

Consumption frequency

&

33

& &

&

& & & &

& &

& &

Risky consumption

Consumption quantity

&

Clinical improvement

&

Motivation to change

33

Treatment Satisfaction

&

&

&

&

33

Substancerelated problems

& &

&

&

Help-seeking behaviour

(JTT)


33: Telephone-based treatment showed significantly greater improvement compared with alternative treatment without qualification; 3: Telephone-based treatment showed significantly greater improvement compared with alternative treatment with some qualifications such as improvement that was specific to certain participants; &: Telephone-based treatment showed comparable improvement; *: In this article the treatment groups included directive and non-directive and structured and non-structured sessions. All conditions showed comparable improvements to stimulant use at final follow-up (FU), however; among patients in the directive conditions, increased levels of patient reactance were associated with less improvement at 3 months. FU: articles are regarding alcohol consumption unless indicated with a ^ which is referring to a particular illicit substance or $ which indicates that the trial was regarding any substance use.

Final follow-up period (mos.)

Table 4. Controlled trials of telephone counselling in the treatment of substance use concerns: treatment outcomes compared with alternative treatment at final follow-up.




(JTT)


14


Table 5. Descriptive information from non-controlled trials of telephone counselling treatments. Primary author, year

Final follow-up period (mos.)

Bonevski, 2012

1.5

Burelson, 2007

3

Cacciola, 2008

6

Chong, 2003

6

Drinkard, 2001

2

Farrell-Carnahan, 2013

6

Gates, 2011

0.25

Hanson, 2011

12

Hawkes, 2009

1.2

Holtrop, 2008

6

Stanford, 2010

13

Zulig, 2010

0.25

Main outcomes TC completion rates were low and only 2 out of 6 participants felt that the intervention helped them reduce substance use. Participants and therapists rated the TC in terms of accessibility, helpfulness and therapist empathy on 5-point Likert scales. These ratings were typically low (less than 3 on average) and often rated more highly by the therapist compared with the participants. TC completion rates were low, with only 71% beginning aftercare treatment and attending a median of 5 out of 14 sessions. Participants were motivated to attend external self-help groups and the majority reported sustained abstinence during the trial follow-up period (73% sober). The TC was described to assist American Indians return to their reservations upon completing outpatient treatment for alcohol use. This trial was conducted to determine if pregnant women would call a TC treatment for assistance with substance use concerns. The majority called at least once (82%) and 20% used the service at least 4 times. 96% reported satisfaction with the service; 72% mentioned that the service helped them reduce alcohol use. The therapist empathy and treatment integrity to motivational interviewing (MI) were assessed post treatment and alcohol consumption was assessed at 6 months. The treatment adhered to MI protocol successfully. Alcohol consumption (drinks per drinking day and risky drinking occasions) all reduced significantly. Callers to the Cannabis Helpline rated their satisfaction with the service in a follow-up interview. Ease of access was rated highly as was satisfaction and therapist empathy. Predictors of satisfaction included the ease of getting through and having all needs met. Non-significant predictors included call duration, receiving a referral, making a plan of action, age, sex, socio-economic status and cannabis use frequency. The intervention group showed significant improvements from baseline to follow-up regarding alcohol consumption per drinking day, and past 90-day drinking frequency. Previous marriage and less than a high school diploma were predictors of more frequent alcohol consumption at follow-up. Participants rated their satisfaction with the programme highly (76% satisfied). From baseline to follow-up the proportion of non-drinkers increased; however, so did the proportion of high-risk drinkers, and the proportion of low-risk drinkers decreased. Trial to determine the acceptability of a community health educator referral liaison in 15 different practices among adults needing help with unhealthy behaviours including alcohol consumption. Improvements in alcohol use were noted and the sessions were well attended with 71% attending 3 or more sessions; however, the intended number of calls for complete treatment protocol was unclear. This was a pilot trial to determine the feasibility of an aftercare intervention provided by substance use treatment workers. The results showed that "counsellors could take on several continuing care clients with a relatively small increase to their workload". Interestingly, those participants reporting no urge to use substances at the beginning of aftercare tended to have longer calls. Pilot trial of a proactive TC call to illicit substance users who called a prescription drug abuse helpline. Satisfaction with the helpline was rated highly (83% very satisfied) and it was easily accessed (98% ‘got through’ on the first call). As a result of the call selfreported substance use decreased and motivation to abstain increased.

TC: Telephone counselling.

trials could not determine whether treatment completers were also those who were more motivated to make change. Regardless, given that treatment adherence was found to be important, it is likely that the reported treatment outcomes underestimate the efficacy of TC as rates of treatment completion were low across trials, with only just over half of participants completing all intended

sessions (60.4%). As such, future research should assess the relative importance of treatment initiation as compared with treatment completion. Should a single session of treatment be effective, this would benefit TC services which can theoretically reach a wider audience of treatment seekers than traditional services which are limited by their location.



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15

Third, there is a paucity of research on existing helplines, with a total of only four randomised controlled trials,41,57,58,81 only two of which included comparisons with alternative treatments.41,58 The first was an evaluation of an internet-based intervention primarily focussed on depression which compared the addition of telephone tracking to the intervention alone and found no effect of tracking on hazardous alcohol consumption.58 The single evaluation of a dedicated alcohol use helpline in Brazil showed significantly improved consumption reductions compared with self-help reference materials at 6-month follow-up.41 Obviously, given the prevalence of existing substance use helplines, there is a need for further evidence to support their effectiveness. The validity of the study findings reviewed was limited by a number of methodological issues. Most frequently, the available trials did not account for the participants’ substance use history or the use for additional treatments or pharmaceuticals during the period of the evaluation. Moreover, less than half of trials included ongoing monitoring of the intervention fidelity to ensure the treatments were delivered as intended. As a result, the findings summarised here cannot be taken as consistently reliable. In addition, across trials the participants were typically white Caucasian males in their late thirties. Although this profile reflects those seeking face-to-face treatment (mostly white, male, in their mid-thirties),150 this leaves the effectiveness of TC for the treatment of AOD use particularly unclear among non-whites, females, adolescents, and older adults. Importantly, in eight trials which reported gender differences in treatment outcomes, five showed improved illicit substance treatment outcomes for females55,74,81,93,146 and two showed improved alcohol treatment outcomes for males.95,103 No trial reported age or ethnicity to be a significant predictor of outcomes. Finally, information regarding any difficulties in establishing and maintaining a TC service or in delivering AOD use treatment in this manner was largely absent. A single exception came from the evaluation of a TC service in Thailand which referred to frequent connection problems and background noise.62 In addition, as described, a consistent finding across trials was that treatment adherence is likely to be a concern and should be monitored, as all trials reported significant rates of treatment drop out. Although not peer reviewed, the European Foundation of Drug Helplines offers guidance on establishing a substance use helpline available through their website (http:// fesat.org). Most importantly, this organisation highlights the need to assure the availability of resources to operate the telephones and collect call information, to adequately recruit, train and supervise staff, and to advertise the service.

Conclusions Limitations to the available evidence prevent conclusive statements as to the utility of TC for the treatment of AOD. Although the findings summarised here are

generally positive, particularly concerning alcohol use, substantial gaps in the research are evident. Additional research is required which includes adequate controls for confounding variables and a sample size adequate to power the investigation of treatment mediators and to establish an ideal number and length of sessions. This is particularly relevant to research on the use of TC for the treatment of illicit drug use. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

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The effectiveness of helplines for the treatment of alcohol and illicit substance use.

Illicit drug and alcohol use during pregnancy.

Alcohol, tobacco, and illicit drug use among adolescents.

Licit and illicit drug initiations and alcohol-related problems amongst illicit drug users in Edinburgh.

Illicit drug use.

Perceived neighborhood illicit drug selling, peer illicit drug disapproval and illicit drug use among U.S. high school seniors.

ethnic differences in patterns of adolescent alcohol use and associations with adolescent and adult illicit drug use.

The prevalence of illicit-drug or alcohol use during pregnancy and discrepancies in mandatory reporting in Pinellas County, Florida.

Urological complications of illicit drug use.

Illicit drug use and HIV risk in the Dominican Republic: tourism areas create drug use opportunities.

Illicit drug use and problem gambling.

Mucocutaneous manifestations of illicit drug use.

Illicit drug use in acute care settings.

Alcohol and Illicit Drug Use Are Important Factors for School-Related Problems among Adolescents.

alcohol use disorders.

HIV co-infection.

Stress, alcohol, tobacco and illicit drug use amongst nurses: a Scottish study.

alcohol use, concerns, needs, and resources in four Washington State Tribal communities.

Alcohol, tobacco and illicit drug use amongst nurses: a Scottish study.

The illicit drug scene.

A note on the use of statistical models in epidemiologic research on illicit drug use.

Classification of alcohol use disorders among nightclub patrons: associations between high-risk groups, sociodemographic factors and illicit drug use.

Effect of a brief intervention for alcohol and illicit drug use on trauma recidivism in a cohort of trauma patients.

Sport participation and alcohol and illicit drug use in adolescents and young adults: a systematic review of longitudinal studies.