Substance & Alcohol Use

In 2020, Public Health Scotland​ (9)​ released a publication which reflects drug use prevalence rates from 2015/2016 which applies three definitions. Definition 1: Opioids (including illicit and prescribed methadone use) and/or the illicit use of benzodiazepines; Definition 2: As Definition 1, plus illicit use of cocaine and amphetamines/amphetamine type substances and Definition 3: As Definition 2, plus illicit use of cannabis / synthetic cannabinoids. It has been estimated the prevalence of problem drug users in 2015/16 increased from 1.6% under definition 1, to 1.9% under definition 2, and 2.5% under definition 3. Data shows that the percentage of problem drug users that are male varied from 71% -77% in the definitions. Over 50% of problem drug users were in the age category of 35-64. Prevalence data for substance use in people with intellectual disabilities is limited but suggest that substance use are higher and that people with mild or borderline intellectual disabilities are over-represented in addiction care​(10)​. 

Scotland has a high level of drug-related deaths (DRD) as annual figures for 2018 increased from the previous year by 27% to 1,187, and this is the highest number recorded for the fifth year in a row. The Scottish Drug Deaths Taskforce has prioritised the introduction of Medication Assisted Treatment (MAT) standards to help reduce deaths. It is also important to highlight the use of psychostimulants, including cocaine and crack cocaine, both within traditional substance use services and amongst the broader population in Scotland and the UK, with a growing concern about the impact on mental health, primary care and hospital-based services ​(11,12)​. 

The Scottish Health Survey (2020) ​(13)​, indicates that hazardous or harmful drinking occurs in 24% of Scottish adults. The peak prevalence of hazardous or harmful drinking for men occurs among those aged 55-64 (36%) and the highest prevalence for women is between 45-54 (22%). A growing proportion and number of older people are at risk for hazardous drinking, prescription drug misuse, and illicit substance use and abuse and identification can be difficult because of overlapping symptoms with medical disorders common in older age. Alcohol mortality has tripled since the 1980s in Scotland with 1,136 alcohol-specific deaths in 2018 and rates of alcohol related hospital admissions has quadrupled ​(14)​. The 2019 Health Scotland report indicates that alcohol consumption among young people has been declining since the early 2000s, with later onset of drinking behaviours and fewer children reporting drinking in the last week (for 13 year olds this reduced from 23% in 2002 to 4% in 2015). 

This information is for commissioners, managers, trainers and health care practitioners to consider the evidence base for the delivery of psychological interventions for people using substances. This in turn should help to increase access to appropriate, safe and evidence based support for people working to recover from alcohol and drug use.  This information is also for people using substances, their families, and carers. 

This topic page covers evidence based psychological interventions for the treatment of substance and alcohol use in children, young people, and adults, and the psychological practice/settings in which these interventions can be delivered. Disorders related to fourteen classes of psychoactive substances are included, as are disorders due to harmful non-medical use of non-psychoactive substances. These include alcohol, sedative hypnotics and anxiolytics, opioids, volatile inhalants, nicotine, cocaine, stimulants (including amphetamine and methamphetamine), synthetic cathinone, caffeine, cannabis, synthetic cannabinoids, MDMA and related drugs, hallucinogens, and dissociative drugs (including ketamine and phencyclidine) ​(1)​. 

Exclusions for topic: this topic does not cover pharmacological interventions or interventions which are not informed by psychological theory. There are a wider range of non-psychological interventions and supports that are beyond the scope of this topic and full guidance on best practice in identifying, assessing, and managing substance and alcohol use can be found in the NICE guidance and pathways – for substance use​(15)​ and alcohol ​(16)​. 

According to NICE (2007) ​(15)​, (2011) ​(16)​, there are various psychological treatments with evidence that should be available to those who are experiencing substance use and alcohol issues. The interventions displayed in the evidence tables below illustrate evidence-based practices with A or B level of evidence (classified as high or moderate). The psychological interventions have different strengths of effect on clinical outcomes and, where effect sizes have been established, these have been noted as low, medium, or high level of efficacy.  Within the tables below, there are several psychological treatments for adults for treating substance use and alcohol and these have been grouped by type of intervention to synthesise the information. While the tables below, and the evidence they contain, can be helpful in deciding which psychological interventions to offer, it is important to recognise that much of this evidence comes from research and treatment settings and countries where the context is different to Scotland. This should be reflected in decision making and the Hexagon tool for each intervention can assist with decisions.

Overview of Evidence for Children and Young People

For alcohol use within CYP age 11-18, NICE guidance (2019) ​(17)​ highlights the benefits of universal education on alcohol in schools (see guidance for further information) and recommends referral for further support through targeted interventions based on the young persons’ individual needs. This can include a range of supports going beyond formal psychological interventions, such as school nursing, but also includes referrals to specialist services for psychological interventions, including those based on cognitive behavioural or motivational theories of change. The NICE evidence review of targeted interventions in CYP indicates some benefit for brief one-to-one interventions or group interventions (usually delivered over multiple-sessions). Some interventions indicate reduced alcohol use and frequency, with a trend towards the longer interventions having more effect, but, overall, the impact of these interventions on alcohol use and harms was limited. For CYP with alcohol use along with significant comorbidities and/or poor social support there is evidence for multicomponent interventions including Multidimensional Family Therapy, Brief Strategic Family Therapy, Functional Family Therapy and Multisystemic Therapy.  

For substance use within CYP, an updated review of the literature​(18)​ concluded that family-based therapy, cognitive behavioural therapy, and multicomponent approaches remain the most effective methods of treatment. The effects of brief behavioural interventions on cannabis use are inconclusive ​(19)​ and insufficient to make a recommendation, but there is some evidence for Contingency Management approaches for cannabis use. The current evidence indicates that Multicomponent Family Therapies are recommended for problematic substance use problem behaviours, and Integrated CBT and MI have medium efficacy on outcomes for co-occurring substance use and depression within CYP. 

There is an absence of evidence upon which to draw recommendations for the management of alcohol and substance use in CYP with special educational needs and NICE recommend a focus on research in the area. In the absence of specific guidelines, clinicians should draw upon the recommendations in the tables, making adjustments based on individual formulation. 

Overview of Evidence for Adults

When considering the guidance for adults, the evidence base needs to be considered in relation to the different substances being used and co-occurring mental health and social issues and this is reflected in the way the recommendations are outlined in the evidence table.  In general, guidance for the treatment of adults covers those 16 years and older.   

Psychological interventions can help people presenting with substance use with a range of outcomes depending on presenting needs. This includes promoting engagement with services, reducing use or supporting abstinence from substance use, and treatment of co-occurring problems. Co-occurring alcohol, drug, psychological, medical, and social problem, creating highly complex clinical pictures are the norm in substance misuse services, and therefore psychological interventions are typically offered as part of a wider multidisciplinary package of care. In cases of high complexity, it is important that a clear psychological formulation underpins treatment decision making, and recommended interventions may need to be adapted, delivered flexibly, and tailored to fit individual needs in line with this formulation. Given the high likelihood of co-occurring psychological, medical and social problems, it is also essential to consider the evidence-based treatment recommendations relating to these. 

Contingency management programmes have been recommended to reduce illicit drug use, can be effective in promoting abstinence and in helping people engage people with services when using stimulants, cannabis or receiving methadone maintenance treatment. NICE guidance (2007) ​(15)​ suggests utilising Cognitive Behavioural Therapy (CBT) and psychodynamic therapy for comorbid depression and anxiety with the treatment of drug use such as cannabis or stimulants. These interventions can also help stabilise those on opioid maintenance treatment and achieve abstinence when that is the goal of treatment. NICE guidance (2007) ​(15)​ suggests, based on a number of high-quality studies, that Behavioural Couples Therapy is useful for people who are in close contact with a non-drug misusing partner and who present for treatment of stimulant or opioid use. This intervention includes those who continue to use illicit drugs while receiving opioid maintenance treatment and after completing opioid detoxification. 

NICE guidance for interventions related to alcohol misuse, includes a recommendation that a motivational intervention is included as part of the assessment and that interventions are tailored to the persons situation – varying from community based settings to residential rehabilitation. Recommended psychological interventions can focus on cognitive, behavioural, motivational, social and environmental factors and include CBT, Contingency Management, motivational interviewing and combination treatments. social network and environment-based therapies and Behavioural Couples Therapy.  

In people with mild symptoms of alcohol and substance use and access to digital technologies, there is growing evidence that internet based/computer packages have some effect in reducing alcohol consumption, with evidence that guided packages are associated with higher effect sizes than non-guided digital interventions ​(17)​.  In people with co-occurring substance use and depression, there is also evidence that guided packages have higher effect sizes than non-guided digital interventions, potentially due to the added therapeutic relationship support ​(20,21)​. Digital interventions guided by a practitioner have better outcomes than those that are unguided, and this is the preferred mode of delivery where possible ​(22)​.

Mindfulness-based interventions (MBIs) have been explored as a method for reducing cravings, frequency and severity of substance use, stress and depression in people using alcohol and substances.  There are a range of MBIs with the most studied being based upon Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT) and tailored to addiction populations, e.g. Mindfulness-Based Relapse Prevention (MBRP) and Mindfulness-Oriented Recovery Enhancement (MORE). There is emerging evidence that MBIs reduce substance use, cravings and stress and these are as included as an alternative recommendation as the evidence is less well established as other psychological interventions. 

Overview of Evidence for People with Learning Disabilities

There is an absence of evidence upon which to draw recommendations for the management of alcohol and substance use in people with learning disabilities. In the absence of specific guidelines, clinicians should draw upon the recommendations in the tables, making adjustments based on individual formulation.  An RCT carried out with 30 people with intellectual disability in England indicated that extended Brief Interventions that were based on motivational interviewing and CBT (5 30 min sessions plus follow up) had low drop out and had some benefit ​(10)​. Any intervention should be adapted to the individual. 

As previously mentioned, co-occurring alcohol, drug, psychological, medical, and social problems are common, creating highly complex clinical pictures. Recommended interventions for co-occurring mood, anxiety and trauma-related problems are also included in the evidence tables, as well as more detail available in the relevant Matrix topic. Complex needs may impact treatment and it may be required to offer specialist substance use treatment in partnership with other specialist health care programmes. 

Overview of Evidence for Older People 

Several brief interventions focused on education about the harms of substance use have been shown to be effective with older people ​(23,24)​. For older people with more severe substance use problems, more intensive treatments geared toward a general population have been shown to be effective for older adults; however, treatments tailored for older adults have shown particular promise ​(25,26)​. Clinicians are advised that there are differences in presentation of psychological problems in later life and to consult Delivering Effective Psychological Therapies and Interventions to Older People for further information on factors relevant to practice. 

Overview of Evidence for Harms and Adverse Effects

Psychological therapies have the potential to have adverse effects. Until recently, information on potential harms and rates of adverse effects have not been gathered systematically. Although reports of adverse effects are increasingly included in research trials and gathered as part of service provision we do not know if psychological interventions cause more, fewer or similar numbers of adverse effects than no treatment or another treatment, because the evidence in this area is of very low quality at present.

Recommendation	Who for?	List of interventions	Type of psychological practice	Level of evidence	Level of efficacy
First line intervention	Targeted interventions for alcohol use for CYP 11-18 in school and university settings	Brief interventions including:  Single session individual or group ​(17)​ (school-based interventions)  Online interventions ​(23)​ (mainly university students)  Individual or group programmes based on CBT or MI principles (up to 9 sessions) ​(17,19,24,25)​	Skilled/Enhanced	A	Low
First line intervention	Substance use or alcohol use with significant comorbidities	Family-based therapy, CBT and Multicomponent interventions ​(18)​ including:    Functional Family Therapy (FFT) ​(26-28)​  Multisystemic Therapy (MST) ​(26,27,29)​  Multidimensional family therapy ​(26)​	Enhanced/Specialist	A	Low-medium
First line intervention	Substance use or alcohol use with major depressive disorder	Integrated therapies including CBT+ MI or CM ​(18,30-32)​	Specialist	A	Medium
Alternative (evidence less well established)	Cannabis use	Contingency Management ​(33)​	Skilled/Enhanced	B	N/A

 

Recommendation	Who for?	Intervention	Type of psychological practice	Level of Evidence	Level of Efficacy
Digital Interventions
First line intervention for the presentations listed	Adults with unhealthy alcohol use (mild to moderate presentations)       Co-occurring Depression and/or Anxiety and Alcohol Use	Self-guided digital interventions  Guided Digital interventions ​(19,34-38)​	Informed/  Skilled/Enhanced	A	Low-  Medium
		Guided digital interventions ​(20-22,38)​	Skilled/Enhanced	B	Low
Motivational Interviewing Interventions
First line intervention for the presentations listed	Opportunistic contact with adults using substances (including harmful alcohol use) and adults not in formal treatment (such as primary care, A&E, tertiary education, harm reduction services). Can also be used in initial assessments and in conjunction with other treatments as an engagement strategy.	Brief motivational interviewing (15,16,39-41)​	All types of practice	A	Low-  Medium
	As above and including use in supporting adults to remain in other forms of treatment and those who would benefit from increased motivation to change their behaviour but who do not require other formal psychological interventions.	Motivational Interviewing ​(42-46)​	Skilled/Enhanced/Specialist	A	Low-Medium
	Adults with alcohol addiction and cannabis use. Less evidence for other substances and for adults with co-occurring and complex needs.	Motivational enhancement-based interventions (MET) ​(44,47)​	Enhanced/Specialist		Low-medium
	As above but including co-occurring mood or anxiety disorders and alcohol   use and adults with harmful alcohol or non-dependant substance use.	MI and CBT combination ​(44)​	Enhanced/Specialist		Low-Medium
Cognitive Behavioural Therapy Interventions
First line intervention for the presentations listed	Harmful drinkers (high-risk drinkers) and people with mild alcohol dependence    Benzodiazepine use     Co-occurring mood or anxiety disorders and alcohol use      For people using cannabis and opioids where response to brief interventions, contingency management or self help is insufficient	CBT ​(16,48,49)​ (including group format) ​(50)​	Enhanced/Specialist	A	Low-High
		MI and CBT combination ​(22,30,51)​	Enhanced/Specialist	A	Low-High
	Adults in recovery and working to maintain recovery goals	SMART Recovery ​(16)​	Skilled/Enhanced	B	N/A
	For PTSD and alcohol and/or substance use	Individually delivered trauma focused CBT alongside substance use intervention (include COPE) ​(52-54)​	Enhanced/Specialist	A	Low
Alternative (evidence less well established)	For PTSD and alcohol and/or substance use	Individual or group delivered integrated non-trauma focused CBT (e.g. Seeking Safety) ​(50,54)​	Enhanced/Specialist	A	Low
Behavioural and Social Network Interventions
First line recommendation for the presentations listed	Alcohol use in adults in primary care or community settings	Behaviour therapies and couples therapy including:  Brief Behavioural counselling interventions following screening ​(55,56)​  Behavioural therapies ​(16)​    Social network and environment-based therapies (e.g. SMART recovery and interventions based on 12 steps and coping skills training) ​(16)​	Skilled/Enhanced        Enhanced/Specialist	B      A	N/A      N/A
	Harmful drinkers (high-risk drinkers) and people with mild alcohol dependence with a regular non-using partner consenting to participate in treatment     Stimulant or opioid use, including those receiving   opioid maintenance treatment or who have completed opioid detoxification	Behavioural couples therapy ​(15,16,57)​	Skilled/Enhanced	A
	For promoting abstinence during treatment and up to 3mths following in psychostimulant disorders, e.g. cocaine and amphetamine-type stimulants, cannabis, harmful alcohol use and opiate replacement therapy	Contingency Management (​(15,50,56-58)​ (including delivered in group format) ​(50)​	Skilled, Enhanced	A	N/A
Alternative (evidence less well established)	Reducing cravings, frequency and severity of alcohol and substance use and/or associated stress and depression	Mindfulness based Interventions  (e.g. MBSR) ​(59-61)​	Enhanced, Specialist	A	Low-High
	Complex co-occurring and/or enduring problems	This is very common. Please see other topics as appropriate.

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Technical group: Dr Michelle Cook, Dr Mhairi Fleming, Laura Freeman, Dr Kirsty Macdonald, Marion McPike, Dr Leeanne Nicklas, Dr Lee Hogan, Elaine Wakefield 

Advisory group: Dr Sandra Ferguson, Dr Pete Littlewood, Suzanne Roos, Deborah Wilson, Ann Whittaker