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Effectiveness of brief interventions as part of the screening, brief intervention and referral to treatment (SBIRT) model for reducing the non-medical use of psychoactive substances: a systematic review protocol

Effectiveness of brief interventions as part of the screening, brief intervention and referral to... Background: There is a significant public health burden associated with substance use in Canada. The early detection and/or treatment of risky substance use has the potential to dramatically improve outcomes for those who experience harms from the non-medical use of psychoactive substances, particularly adolescents whose brains are still undergoing development. The Screening, Brief Intervention, and Referral to Treatment model is a comprehensive, integrated approach for the delivery of early intervention and treatment services for individuals experiencing substance use-related harms, as well as those who are at risk of experiencing such harm. Methods: This article describes the protocol for a systematic review of the effectiveness of brief interventions as part of the Screening, Brief Intervention, and Referral to Treatment model for reducing the non-medical use of psychoactive substances. Studies will be selected in which brief interventions target non-medical psychoactive substance use (excluding alcohol, nicotine, or caffeine) among those 12 years and older who are opportunistically screened and deemed at risk of harms related to psychoactive substance use. We will include one-on-one verbal interventions and exclude non-verbal brief interventions (for example, the provision of information such as a pamphlet or online interventions) and group interventions. Primary, secondary and adverse outcomes of interest are prespecified. Randomized controlled trials will be included; non-randomized controlled trials, controlled before-after studies and interrupted time series designs will be considered in the absence of randomized controlled trials. We will search several bibliographic databases (for example, MEDLINE, EMBASE, CINAHL, PsycINFO, CORK) and search sources for grey literature. We will meta-analyze studies where possible. We will conduct subgroup analyses, if possible, according to drug class and intervention setting. Discussion: This review will provide evidence on the effectiveness of brief interventions as part of the Screening, Brief Intervention, and Referral to Treatment protocol aimed at the non-medical use of psychoactive substances and may provide guidance as to where future research might be most beneficial. Keywords: Brief intervention, Drug use, Psychoactive substance, Referral to treatment, SBIRT, Screening, Substance use, Systematic review * Correspondence: myoung@ccsa.ca Canadian Centre on Substance Abuse (CCSA), 75 Albert Street, Ottawa, ON K1P 5E7, Canada Department of Psychology, Carleton University, 1125 Colonel By Drive, Ottawa, ON K1S 5B6, Canada Full list of author information is available at the end of the article © 2012 Young et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Young et al. Systematic Reviews 2012, 1:22 Page 2 of 11 http://www.systematicreviewsjournal.com/content/1/1/22 Background moderate risk of harms; individuals identified as experi- We used the Preferred Reporting Items for Systematic encing significant harm and/or having more serious signs Reviews and Meta-Analyses for Protocols (PRISMA-P) of substance dependence warranting formal diagnosis checklist to guide the reporting of this protocol [1]. may be referred to treatment services that are outside According to the 2010 Canadian Alcohol and Drug Use the scope of BIs. Monitoring Survey [2], 11.2% of Canadians aged 15 years and older reported past-year use of at least one of the Screening following psychoactive substances: cannabis, cocaine/ To evaluate the likelihood that an individual is experien- crack, methamphetamine/crystal methamphetamine, ec- cing, or is at risk of experiencing, substance use-related stasy, hallucinogens, salvia, inhalants, heroin, pain relie- harms, individuals are screened. Screening may be con- vers, stimulants or sedatives. The rate of past-year use of ducted in a number of different ways. For example, screen- any of these substances was higher among males than ing may be conducted via psychometrically validated females (15.3% versus 7.5%, respectively). Rates were also questionnaires or tests developed to accurately categorize higher among those aged 15- to 24-years-old compared users into low, moderate, and high risk categories. Such with adults 25 years and older (26.3% versus 8.3%, respect- tests have been developed for different types of substances ively). Furthermore, among those reporting past-year use, such as alcohol (Alcohol Use Disorders Identification Test 17% reported experiencing substance use-related harm. [6]), cannabis (the Cannabis Use Disorders Identification There is also a significant public health burden asso- Test [7]) or prescription opioids (for example, the Opioid ciated with substance use in Canada. According to 2002 Risk Tool [8]). General drug screening tests also exist (for estimates, substance abuse costs Canadians close to $40 example, the Drug Abuse Screening Test [9]). However, billion ($1,267 per Canadian), with use of psychoactive screening tests that reliably categorize users into low or substances (excluding alcohol) accounting for approxi- moderate risk groups have not been developed for other mately $8.2 billion (20.7%) of the total costs [3]. The vast substances (for example, heroin and cocaine). For these majority of those costs are associated with Canadians’ substances, screening may simply take the form of self- lost productivity and health. reported use or biological markers indicating use (such as For the purpose of this review, non-medical psychoactive hair, urine, oral fluid or blood) rather than psychometric- substance use includes the use of drugs prohibited by ally validated self-report instruments. In the absence of international law including, but not limited to, amphet- validated tests or biological markers, others may rely on amine-type stimulants, cannabis, cocaine, heroin and 3,4- even less rigorous screening methods, such as the subject- methylenedioxymethamphetamine (MDMA) [4]; the non- ive judgment of the individual conducting the assessment. medical use of pharmaceuticals such benzodiazepines, Regardless of the screening method employed, those opioids or dextromethorphan; and the use of substances deemed at risk of harms are typically provided a BI or such as solvents or inhalants (for example, gasoline, acet- referred to treatment. In cases where self-reported use or one) when they are used for their intoxicating effects. It biological markers indicating use are used for screening, it does not include alcohol, nicotine or caffeine. is unclear how practitioners make the decision whether to The early detection and/or treatment of risky substance administer a BI versus referral to treatment. use has the potential to dramatically improve outcomes for In reviews where the effectiveness of SBIRT models in those who experience harms from the non-medical use of reducing harms associated with alcohol use have been psychoactive substances, particularly adolescents whose evaluated systematically [10-12], few protocols have brains are still undergoing development. Screening, Brief employed a rigid definition of the screening criteria used Intervention, and Referral to Treatment (SBIRT) is a com- to determine whether a BI was administered. This is prehensive, integrated approach to the delivery of early likely a result of two factors: poor descriptions of screen- intervention and treatment services for individuals experi- ing procedures employed in studies reviewed and/or the encing substance use-related harms, as well as those who heterogeneity of screening procedures employed. are at risk of experiencing such harms [5]. The SBIRT model is based on public health principles and procedures, Brief intervention and is designed to reduce the burden of injury, disease and In addition to the variability in screening procedures disability associated with the non-medical use of psycho- employed, there is also much variation in how BIs are active substances. defined and delivered. In general, BIs are in-person, time- The protocol typically begins with a screening proced- limited efforts to provide information or advice, increase ure that involves asking questions to evaluate whether motivation to avoid substance use, or to teach behavior the individual has experienced, or is at risk of experien- change skills with the aim of reducing substance use and cing, substance use-related harms. Brief interventions the likelihood of experiencing negative consequences. This (BIs) are typically delivered to those individuals at low to variation includes the number of conversations or meetings Young et al. Systematic Reviews 2012, 1:22 Page 3 of 11 http://www.systematicreviewsjournal.com/content/1/1/22 that take place during intervention delivery as well as the in adolescents and adults identified as experiencing, or at amount of time spent conducting the BI. Reviews such as risk of experiencing, harms related to the non-medical Kaner et al.[11]havedefined ‘brief ’ to mean four or less use of psychoactive substances (excluding alcohol, and note that BIs for alcohol that are provided in primary caffeine and nicotine). In addition, potential moderating health care settings are typically delivered within the nor- factors that may impact SBIRT effectiveness will be eval- mal consultation period of 5 to 30 minutes. Levy et al.[13] uated, if possible. suggest that successful BIs typically focus on the following elements (collectively referred to using the acronym Methods FRAMES): feedback on behavior and consequences; Selection criteria responsibility to change; advice; menu of options to bring Population about change; empathy; and self-efficacy for change. Studies in which BIs are administered to adolescents (12 There is substantial scientific evidence of the benefits of to 18 years of age or equivalent by level of schooling), the SBIRT model in primary health care settings as a means young adults (19 to 24 years of age), or adults (25 years to address the harms associated with alcohol use [14-16]. and older) at risk of harms related to psychoactive sub- This evidence suggests the SBIRT process can serve as an stance use as determined by the screening component of effective ‘early warning’ system to prevent and/or reduce the SBIRT protocol will be included. We will exclude the serious long-term harms associated with excessive alco- studies evaluating interventions targeting children less hol use. A corresponding analysis for SBIRT targeting the than 12 years of age. non-medical use of other psychoactive substances is needed. Screening There is accumulating evidence suggesting that BIs may Screening must be opportunistic in nature (that is, it must be effective in reducing the non-medical use of psycho- be conducted among a population not seeking treatment active substances, such as cannabis [17-21], ecstasy [22], for substance use) and is defined as any procedure or cocaine [18,23,24], benzodiazepines [25] and opioids method used to identify those experiencing or at risk of [6,13,23] among both youths and adults. Traditionally, the harms associated with the non-medical use of psychoactive SBIRT model has been implemented in primary care set- substances. This may include, but is not limited to, ques- tings, emergency departments, inpatient trauma units and tions regarding the use of substances, the use of psycho- other health care settings. These settings see the broadest metrically validated scales, or biological (for example, number and range of patients and thus provide ideal blood, hair, urine, oral fluid) screening tools. We will opportunities to screen for, and address, substance use be- exclude studies failing to indicate they used a method of fore more severe consequences occur [26]. More recently, screening to determine who receives a BI. however, the protocol is being applied in schools [21,27] and community settings [22] in an attempt to reach young Brief intervention people. It is unclear whether the effectiveness of the SBIRT BIs are time-limited efforts to provide information or ad- approach is dependent on the setting in which it is applied. vice, increase motivation to avoid substance use, or to The diversity of substances used and the high prevalence teach behavioral change skills with the aim of reducing of use and dependence have raised some concerns about substance use and the likelihood of experiencing negative the efficacy of a SBIRT protocol for substances other than consequences. alcohol [26]. Individuals who use more than one substance We will include studies in which BIs target non-medical or use alcohol and other substances make administering psychoactive substance use. This includes the use of drugs and evaluating SBIRT more complicated than when prohibited by international law including, but not limited addressing alcohol alone [28]. Substances have variable to: amphetamine-type stimulants, cannabis, cocaine, her- forms, costs, risks, consequences and ways for clinicians to oin and MDMA [4]; the non-medical use of pharmaceuti- identify use. Moreover, most psychoactive substances that cals such benzodiazepines, opioids or dextromethorphan; are used without medical supervision are illegal or used il- and the use of substances such as solvents or inhalants legally, which can complicate addressing their use in med- (for example, gasoline, acetone) when they are used for ical settings by raising patient and physician concerns their intoxicating effects. We will exclude studies in which about confidentiality. Prescription drug misuse presents the BI only targets alcohol, nicotine or caffeine use. In additional challenges as clinicians struggle to distinguish addition, interventions that do not provide feedback on at between appropriate and inappropriate use. least one of the FRAMES elements or provide five or more sessions [11] will be excluded. Objectives For the current review we will only examine one-on-one This systematic review will determine the effects of BIs, verbal interventions and exclude non-verbal BIs (for ex- as part of the SBIRT protocol, on reducing substance use ample, the provision of information such as a pamphlet or Young et al. Systematic Reviews 2012, 1:22 Page 4 of 11 http://www.systematicreviewsjournal.com/content/1/1/22 online interventions) and group interventions, as these primary health care, emergency room, school and other interventions differ sufficiently from verbal one-on-one. community settings. However, we will collate studies assessing the effectiveness of online and group interventions and report on the search Study designs yield in the review. All randomized controlled trials (RCTs) will be included, including any cluster RCTs. Where RCTs are lacking or, Referral to treatment for issues relating to feasibility, not conducted, non- We will not address the effectiveness of the referral to RCTs, controlled before-after studies and interrupted treatment component of the SBIRT protocol in this time series designs will be considered. These latter review. designs will include some form of control group, whether concurrent or within-patient. Interrupted time series Comparisons studies must have a clearly defined time point at which Studies comparing BI to no BI, provision of pamphlets the intervention is introduced and at least three data or other information only, or delayed intervention will points before and after introducing the intervention; be included. Studies without a comparison or control those ignoring secular changes and performing simple group will be excluded. pre-post analyses will not be included unless re-analysis is possible [29]. We will not evaluate retrospective stud- ies or studies with historical controls. We will exclude Outcomes comments, letters and editorials. We will evaluate the outcomes listed below for any period of follow-up. Primary outcomes: Search methods Electronic bibliographic databases 1. Substance use versus non-use. A comprehensive literature search for studies and sys- 2. Frequency and quantity of use. tematic reviews using high recall subject searches will be 3. Any standard or accepted biological markers of conducted using several electronic databases: MEDLINE, substance use (for example, blood, oral fluid). EMBASE, The Cochrane Library, Cumulative Index to 4. Self- or other reported use-related harms or negative Nursing and Allied Health Literature (CINAHL), Psy- consequences of use. cINFO, Education Resources Information Center (ERIC) 5. Self- or other reported changes in behavior likely to and the CORK Database. All electronic search strategies result in the reduction of negative substance use- will be peer-reviewed using the PRESS tool prior to im- related consequences. plementation [30]. The proposed MEDLINE search strat- 6. Decision to attend treatment. egy is shown in Appendix 1; the search will be adapted to the other databases. Secondary outcomes: Other sources 1. Use of different substances from that for which the ‘Grey literature’ searches will be conducted for other po- client received the BI (including use of alcohol, tentially relevant studies. Websites of health technology caffeine, or nicotine) as assessed by self- or other assessment and evidence-based review organizations as reported or biological markers substance use. listed in Grey Matters: a practical tool for evidence-based 2. Self- or other reported intention to reduce substance searching [31] will be searched as well as PsycEXTRA. use. Websites of relevant organizations, such as the Canadian 3. Self- or other reported health measure. Centre on Substance Abuse, Centre for Addiction and Mental Health, the Substance Abuse and Mental Health Adverse outcomes: Services Administration, National Institute for Drug Abuse and the Centre for Addictions Research British 1. Self- or other reported use or increased use of Columbia, as well as those indicated on the Substance different substances from that for which the client Abuse Librarians & Information Specialists site will be received the BI as assessed by self- or other reported searched. We will also access the websites of specific orga- or biological markers substance use. nizations, such as the College of Physicians and Surgeons 2. Other adverse outcomes. of Ontario. We will consult within our internal team to identify additional studies that may not be in the published Settings literature. We will search the Campbell Collaboration for We will include studies that use opportunistic screening systematic reviews. We will scan bibliographies of included regardless of location, including, but not limited to, articles and relevant systematic reviews. We will consult Young et al. Systematic Reviews 2012, 1:22 Page 5 of 11 http://www.systematicreviewsjournal.com/content/1/1/22 clinicaltrials.gov and the WHO International Clinical 4. study design methodology (for example, methods of Trials Registry Platform for ongoing studies. allocation, blinding) for conducting a risk of bias assessment; Language 5. population details of the target group (for example, We will not restrict our search based on language but will sample size, characteristics such as age, sex and only include articles available in the English and French ethnic background); languages. A list of the possibly relevant titles available in 6. details on the screening method used to determine other languages will be provided as an appendix. who should be provided a BI (for example, nature of method, whether validated, administration method, Study selection length to screen, type of professional conducting the The results of the literature search will be assessed using screening, the extent of training they received in a two-step process. First, one individual will screen cita- conducting screening); tions by title and/or abstract according to the prespeci- 7. details of the intervention and comparison groups, fied screening questions (level 1). Those records deemed including any theoretical frameworks and intensity of to be ‘included’ or ‘unclear’ will automatically pass to the the intervention (for example, length of and time next level of screening (level 2). However, if the record is between sessions); deemed ‘excluded’, then it needs to be reviewed by a sec- 8. fidelity of the intervention; ond reviewer to confirm exclusion. This process is 9. setting; referred to as liberal accelerated screening, a more effi- 10. outcome details including definitions, outcome cient means of initially assessing records for relevancy. measures used and data. Second, full text screening will be performed inde- pendently by two reviewers and discordance will be Disagreements will be resolved first by consensus and resolved first by consensus and then by third member of then by a third member of the research team, as needed. the research team, as needed (level 2 assessment). The Prior to performing data abstraction, the review team selection process and reasons for exclusion will be docu- will refine the development of the extraction forms and mented using the PRISMA flow diagram [32]. will conduct a calibration and training exercise. Literature search results will be uploaded to Distiller Systematic Review Software (DSR), an Internet-based soft- Assessing the risk of bias ware program that facilitates collaboration among Two independent reviewers will assess the risk of bias reviewers during the study selection process. The team will for each included study. Any disagreements will be develop and test screening questions and forms for level 1 resolved first through discussion and then by third mem- and 2 assessments based on the inclusion and exclusion ber of the research team, as needed. Determining risk of criteria. Citation abstracts and full text articles will be bias summary assessments for outcomes will follow that uploaded with screening questions to DSR. Prior to the proposed by The Cochrane Collaboration [33] and incor- formal screening process, a calibration exercise will be porated into grading the quality of evidence. undertaken to pilot and refine the screening questions. All RCTs will be assessed using the Cochrane Risk of Further, we will provide training to new members of the Bias (RoB) tool [33]. The Cochrane RoB tool evaluates review team not familiar with the DSR software and the seven domains (sequence generation, allocation conceal- content area prior to the start of the review. ment, blinding of participants and personnel, blinding of outcome assessors, incomplete outcome data, selective Data abstraction outcome reporting, and other sources of bias). Other Two independent reviewers will extract and document sources of bias will include single versus multicenter stud- the content of each included study using a standardized ies and study sponsorship. We will also assess cluster ran- data abstraction form in DSR to capture information on domized trials for the possibility of recruitment bias [34]. the descriptive and quantitative characteristics of individ- If included, other study designs will be critically appraised ual studies. Useful data to collect will include: with the Cochrane Effective Practice and Organisation of Care group’s modified RoB tool (Appendix 2) [29]. 1. publication details (for example, year of publication, language of publication, country in which the study Unit of analysis issues was conducted, publication status, sources of For studies whose allocation design is a group level (for funding); example, schools) and yet analyzed at the individual level 2. substance targeted by the BI; (for example, students), ‘unit of analysis’ errors can occur, 3. study details (for example, date, number of centers, whereby results can be overly precise and contribute follow-up); greater weight in a meta-analysis. Where possible, we Young et al. Systematic Reviews 2012, 1:22 Page 6 of 11 http://www.systematicreviewsjournal.com/content/1/1/22 will adjust the analysis according to the intracluster cor- on similar scales or with similar measures; standardized relation coefficient to address these errors [35], prefer- mean differences will be used where continuous out- ably with empirically-derived values. comes are reported using different scales or measures. Transformation of data to allow analyses with mean dif- ferences will be made wherever possible. Where change- Missing data from-baseline data are reported in the studies, we will If information or data is missing or incomplete, we will extract in addition to post-intervention data. attempt to contact the study authors twice over four weeks by email. We will analyze data as close to the Ordinal outcomes intention-to-treat principle (all participants analyzed Decisions about handling and analyzing ordinal out- according to assigned treatment group) as possible. If comes will be determined post hoc, subject to the body loss to follow-up occurs, we will incorporate any add- itional data provided in study reports or by the authors; of evidence available. we will not impute data for any outcomes. Time-to-event data For time-to-event data, the generic inverse variance Evidence synthesis method will be used to meta-analyze outcomes using Study characteristics will be summarized narratively in the log hazard ratios and standard errors; the Parmar text, and/or summary tables in the report; such data may method [37] will be used to estimate data, as needed. be presented as frequencies and percentages, medians and interquartile ranges, or means and standard deviations, Other statistical considerations where appropriate. For outcomes, where appropriate and possible (depending on the quantity, quality, and statistical Data conversions Where needed, we will convert data and clinical homogeneity of the available data), pooled esti- mates of intervention efficacy or effectiveness will be com- (for example, standard error to standard deviation) for use in analyses and to facilitate consistent presentation puted using standard meta-analytic methods [36]. Random of results across studies. effects models will be used for all meta-analyses. A narra- tive synthesis of the evidence will be conducted when Interrupted time series designs If interrupted time quantitative pooling of data is not possible. series studies are included we will re-analyze data, where needed and if feasible, for change in level and Main analyses slope according to time series regression analyses For the primary analysis, our intent is to evaluate all BIs for [38]. all drug classes together. We are uncertain what exists in the literature regarding how interventions are targeted (that Statistical heterogeneity is, for general drug use or for specific drugs), and we do Statistical heterogeneity will be evaluated using not know how varied they may be in study characteristics 2 2 I-squared (I ) statistics; for the interpretation of I ,a or methodology. Before proceeding with a pooled analysis, rough guide of low (0% to 25%), moderate (25% to we will determine whether studies are homogeneous with 50%), substantial (50% to 75%), and considerable (75% respect to those characteristics. If too much heterogeneity to 100%) heterogeneity will be used [36,38]. Possible exists, we will not meta-analyze all studies together. In reasons contributing to heterogeneity will be explored. addition, should considerable statistical heterogeneity (≥75%) exist, we will also not present a pooled analysis. Exploring statistical heterogeneity We will also conduct subgroup analyses according to If studies are determined to be statistically heterogeneous, drug class (for example, cannabinoids, opioids and amphe- we will conduct the following subgroup analyses, where tamines, with general use as a separate category) and inter- possible: vention setting (for example, school, hospital, community). Dichotomous outcomes 1. age of participants (12 to 18 years, 19 to 24 years, For dichotomous outcomes, the risk ratio and 95% confi- 25 years or greater); dence intervals will be presented. The unit of analysis is 2. sex; the proportion of study participants with the outcome 3. description of screening method (well-described, for intervention and control groups. poorly described, unclear screening method); 4. type of intervention provided (for example, cognitive behavioral therapy, motivational enhancement Continuous outcomes therapy, motivational interviewing); For continuous outcomes, mean differences and 95% 5. type of practitioner. confidence intervals will be used for outcomes reported Young et al. Systematic Reviews 2012, 1:22 Page 7 of 11 http://www.systematicreviewsjournal.com/content/1/1/22 If appropriate and with sufficient, complete data, we of BIs as part of SBIRT aimed at the non-medical use of will verify results of the subgroup analyses with univari- psychoactive substances, which will be helpful in establish- able meta-regression. The variables outlined above for ing guidelines for implementation in general practice and subgroup analyses will be considered statistically signifi- other relevant settings. Finally, synthesizing the evidence cant at P <0.01. base may provide guidance as to where future research might be most beneficial. Sensitivity analyses If data permit, and where needed, sensitivity analyses Appendices may be undertaken regarding the risk of bias (restricting Appendix 1. Proposed MEDLINE search strategy the analyses to studies with low risk of bias), the fidelity of the intervention, data issues and measurement of out- 1. SBIRT.tw. comes or to explore reasons for heterogeneity. 2. (SBI or SBIs).tw. 3. exp Substance Abuse Detection/ Test for funnel plot asymmetry 4. ((substance* adj2 test*) or (substance* adj2 detect*) If at least 10 studies are included in a given meta-ana- or (substance* adj2 screen*) or (drug* adj2 detect*) lysis, we will evaluate for funnel plot asymmetry, depend- or (drug* adj2 screen*) or (drug* adj2 test*)).tw. ing on the outcome, and postulate reasons for the 5. 3 or 4 asymmetry (for example, publication bias) [39-41]. 6. Substance-Related Disorders/ 7. exp Amphetamine-Related Disorders/ Grading the quality of evidence 8. exp Cocaine-Related Disorders/ The quality of evidence for all outcomes will be judged 9. exp Marijuana Abuse/or exp Marijuana Smoking/ using the Grading of Recommendations Assessment, De- 10. exp Opioid-Related Disorders/ velopment and Evaluation working group methodology 11. exp Phencyclidine Abuse/ [41]. The quality of evidence will be assessed across the 12. Psychoses, Substance-Induced/ domains of risk of bias, consistency, directness, precision 13. exp Substance Abuse, Intravenous/ and publication bias. Additional domains may be consid- 14. ((substance-related or substance-induced) ered where appropriate. Quality will be adjudicated as adj3 (disorder* or psychosis or psychoses)).tw. high (further research is very unlikely to change our con- 15. ((drug or drugs or substance* or opioid* or opiate* or amphetamine* or amfetamine* or methamphetamine* fidence in the estimate of effect), moderate (further re- or methamfetamine or benzodiazepine* or morphine* search is likely to have an important impact on our or methadone* or prescription* or phencyclidine* or confidence in the estimate of effect and may change the solvent* or barbiturate* or depressant* or stimulant* or estimate), low (further research is very likely to have an psychotherap* or psycho-therap* or steroid*) adj3 important impact on our confidence in the estimate of effect and is likely to change the estimate), or very low (addict* or abuse* or abusing or abusive or misuse* or (very uncertain about the estimate of effect). mis-use* or misusing or mis-using or illicit* or illegal* or unlawful* or unsanction* or habit* or dependen* or disorder or disorders or relapse* or consumption)).tw. Quality assurance 16. or/6-15 We will discuss results in light of the strength of findings 17. Dextropropoxyphene/ as well as their research and practice implications. This 18. (Dextropropoxyphene or D-Propoxyphene review will be reported according to the PRISMA state- or Propoxyphene or Darvon or Vicodin).tw. ment [32] and using the assessment of multiple system- 19. Hydromorphone/ atic reviews tool for additional quality control [42]. 20. (Hydromorphon* or Dihydromorphinone or Dilaudid or Laudacon or Palladone).tw. Discussion 21. exp Meperidine/ The accumulating research assessing the effectiveness of 22. (Meperidine or Demerol or Dolantin or Dolargan or SBIRT for the non-medical use of psychoactive substances Dolcontral or Dolin or Dolosal or Dolsin or Isonipecain underscores the need for a systematic review in order to or Lidol or Lydol or Operidine or Pethidine or assist clinicians and others to inform evidence-based prac- Promedol or Dimethylmeperidine or Isopromedol or tice. The results from a recent evidence map of systematic Trimeperidine or Lomotil or Reasec).tw. reviews to inform the prevention, treatment and/or harm 23. Pentobarbital/ reduction for illicit drug use [43] revealed no published 24. (Pentobarbital or Diabutal or Etaminal or Ethaminal or systematic reviews or meta-analyses on the effectiveness of Mebubarbital or Mebumal or Nembutal or the SBIRT model in reducing illicit drug use. A systematic Pentobarbitone or Sagatal).tw. review will yield a better understanding of the effectiveness Young et al. Systematic Reviews 2012, 1:22 Page 8 of 11 http://www.systematicreviewsjournal.com/content/1/1/22 25. exp Diazepam/ pancodine or theocodin or "gamma hydroxybutrate" or 26. (Diazepam or Apaurin or Diazemuls or Faustan or GHB or PCP).tw. 49. ((sniff* or inhal* or snort*) adj3 (solvent* or glue or Relanium or Seduxen or Sibazon or Stesolid or Valium drug or drugs)).tw. or Nordazepam or Calmday or Dealkylprazepam or 50. ("inhalant use" or "inhalant usage").tw. Demethyldiazepam or Deoxydemoxepam or 51. exp Lysergic Acid Diethylamide/ Desmethyldiazepam or Nordaz or Nordiazepam or 52. (LSD or Lysergide or Lysergic Acid Diethylamide).tw. Norprazepam or "Tranxilium N" or Vegesan).tw. 53. ("drug use" or "drug usage" or (drug adj user*)).tw. 27. ("substance use" or "substance usage").tw. 54. or/37-53 28. Alprazolam/ 55. 36 or 54 29. (Alprazolam or Alprazolan or Alprox or "Apo- 56. Mass Screening/ Alpraz" or Cassadan or Esparon or Kalma or "Novo- 57. screen*.tw. Alprazol" or "Nu-Alpraz" or Ralozam or Tafil or 58. Self Disclosure/ Trankimazin or Xanax).tw. 59. (detect* or disclos* or identif* or question* or reveal* 30. Dextroamphetamine/ or survey* or unveil*).tw. 31. (Dextroamphetamine or Curban or 60. Interview, Psychological/ "d-Amphetamine" or Dexamfetamine or 61. ((interview* or encounter* or visit*) adj3 (counsellor* Dexamphetamine or Dexedrine or dextro- or counselor* or nurse* or physician* or doctor* or Amphetamine or DextroStat or Oxydess).tw. clinician* or psychologi* or social worker*)).tw. 32. Methylphenidate/ 33. (Methylphenidate or Centedrin or Daytrana or 62. or/56-61 63. 55 and 62 Dexmethylphenidate or Equasym or Focalin or 64. 5 or 63 Metadate or Methylin or Phenidylate or Ritalin* or 65. Psychotherapy, Brief/or Crisis Intervention/ Tsentedrin or Adderall or Obetrol).tw. 66. (brief intervention* or brief prevention*).tw. 34. or/17-33 67. 65 or 66 35. 34 and (addict* or abuse* or abusing or abusive or 68. exp Motivation/ misuse* or mis-use* or misusing or mis-using or 69. exp Psychotherapy/ illicit* or illegal* or unlawful* or unsanction*).tw. 70. (psycho-therap* or psychotherap*).tw. 36. 16 or 35 71. ((cogniti* or behavior* or behaviour* or conditioning 37. exp designer drugs/or exp street drugs/ 38. (designer drug$1 or street drug$1 or recreational or motivation* or psychosocial* or psycho-social* or drug$1 or narcotic* or non-therapeutic drug$1 or psychological) adj3 (therapy or therapies or non-medical drug$1).tw. therapeutic or interven* or modify or modifies or 39. exp Cannabis/ modified or modification)).tw. 72. (counselling or counseling).tw. 40. (Cannabi* or marijuana or marihuana or hemp or 73. or/68-72 hash or hashish or ganja).tw. 74. (brief* or short* or short-rang* or short-term or 41. exp Heroin/ abbreviate* or concise or limited or time-limited or 42. (Heroin or Diacetylmorphine or Diagesil crisis or crises or immediate*).tw. or Diamorphine or Diamorf or speed).tw. 75. 73 and 74 43. exp Cocaine/ 76. 67 or 75 44. (cocaine or crack).tw. 77. exp "Referral and Consultation"/ 45. exp Hallucinogens/ 78. (refer or refers or referral* or gatekeeper* or 46. (hallucinogen* or psychedelic*).tw. gate-keeper* or specialist* or specialty).tw. 47. exp amphetamine/or exp methamphetamine/or exp 79. 77 or 78 n-methyl-3,4-methylenedioxyamphetamine/or 80. 64 and (76 or 79) mescaline/or ketamine/or oxycodone/ 81. 1 or 2 or 80 48. (methylenedioxymethamphetamine or MDMA or 82. limit 81 to "reviews (specificity)" ecstasy or methamphetamine or crystal meth or 83. meta analysis.pt. mescaline or mezcalin or peyote or 84. exp meta-analysis as topic/ trimethoxyphenethylamine or ketamine or Calipsol or 85. (meta-analy* or metanaly* or metaanaly* or met Calypsol or "CI-581" or Kalipsol or Ketalar or Ketanest analy* or integrative research or integrative or Ketaset or "special k" or mushroom* or prilocybin or review* or integrative overview* or research oxycodone* or oxycontin* or dihydrohydroxycodeinone or dihydrone or dinarkon or integration or research overview* or collaborative eucodal or oxiconum or oxycodeinon or oxycone or review*).ti,ab. Young et al. Systematic Reviews 2012, 1:22 Page 9 of 11 http://www.systematicreviewsjournal.com/content/1/1/22 86. (systematic review* or systematic overview*  Were baseline outcome measurements similar? or technology assessment* or HTA or HTAs).ti,ab.  Were baseline characteristics similar? 87. exp Technology assessment, biomedical/  Were incomplete outcome data adequately 88. health technology assessment winchester england.jn. addressed? 89. (evidence report technology assessment or evidence  Was knowledge of the allocated interventions report technology assessment summary).jn. adequately prevented during the study? 90. or/83-89  Was the study adequately protected against 91. 81 and 90 contamination? 92. 82 or 91  Was the study free from selective outcome 93. (controlled clinical trial or randomized controlled trial).pt. reporting? 94. exp RCTs as topic/or exp controlled clinical trials as  Was the study free from other risks of bias? topic/or exp random allocation/or exp double-blind method/or exp single-blind method/or exp placebos/ Interrupted time series studies 95. "controlled clinical trial".tw. 96. (random* or RCT$1 or placebo*).tw.  Was the intervention independent of other changes? 97. ((singl* or doubl* or trebl* or tripl*) and (mask* or  Was the shape of the intervention effect blind* or dumm*)).tw. prespecified? 98. or/93-97  Was the intervention unlikely to affect data 99. 81 and 98 collection? 100. clinical trial.pt.  Was knowledge of the allocated interventions 101. exp Clinical Trials as Topic/ adequately prevented during the study? 102. "clinical trial".ti,ab.  Were incomplete outcome data adequately 103. (volunteer or volunteers or open label* addressed? Was the study free from selective outcome or nonrandom* or non random* or quasirandom* reporting? or quasi-random*).tw. Was the study free from other risks of bias? 104. exp Cohort Studies/or exp Longitudinal Studies/or exp Prospective Studies/or exp Follow-Up Studies/ 105. (cohort or cohorts or longitudinal or prospective).tw. Abbreviations 106. ((observational or follow-up or followup) adj stud*).tw. BI: Brief intervention; CINAHL: Cumulative Index to Nursing and Allied Health 107. (population-based stud* or population-based Literature; DSR: Distiller Systematic Review Software; ERIC: Education analys* or population stud* or population analys*).tw. Resources Information Center; FRAMES: Feedback on behavior and consequences, Responsibility to change, Advice, Menu options to bring 108. ((descriptive adj stud*) or (multidimensional about change, Empathy, Self-efficacy for change; MDMA: 3:4- adj stud*) or (multi-dimensional adj stud*) or methylenedioxymethamphetamine; PRISMA-P: Preferred Reporting Items for (multicenter adj stud*) or (multi-center adj stud*) or Systematic Reviews and Meta-Analyses for protocols; RCT: Randomized control trial; RoB: Risk of bias; SBIRT: Screening, Brief Intervention, and Referral (multicentr* adj stud*) or (multi-centr* adj stud*)).tw. to Treatment. 109. exp Multicenter Study/or exp Multicenter Studies as Topic/ Competing interests 110. Comparative Study.pt. The authors declare that they have no competing interests. 111. ((comparative adj study) or (comparative adj Acknowledgments studies) or "before and after").tw. The authors would like to thank James Galipeau, Mary Gauthier, Mistrel Pratt 112. or/100-111 and Chad Dubeau for their assistance in the development of this protocol. 113. 81 and 111 JG holds a Canada Research Chair in Health Knowledge Transfer and Update. DM holds a University of Ottawa Research Chair in Systematic Reviews. This 114. 92 or 99 or 113 systematic review is funded by the Institute for Neurosciences, Mental Health and Addition, Canadian Institutes of Health Research (funding reference Appendix 2. Cochrane Effective Practice and Organisa- number KSD-115551; Effectiveness of the Screening, Brief Intervention and Referral to Treatment (SBIRT) Model for Reducing Illicit Drug Use: A Systematic tion of Care Review group’s criteria for assessing risk of Review). The funder had no involvement in the development of the protocol. bias in non-randomized, controlled before-and-after, and interrupted time series studies Author details Canadian Centre on Substance Abuse (CCSA), 75 Albert Street, Ottawa, ON K1P 5E7, Canada. Department of Psychology, Carleton University, 1125 Non-randomized controlled trials and controlled before-after Colonel By Drive, Ottawa, ON K1S 5B6, Canada. Ottawa Hospital Research studies Institute (OHRI), Ottawa Hospital - General Campus, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada. Independent Research and Information Consultant, Ottawa, Canada. Département de Pédiatrie, Hôpital Sainte-Justine, 3175 Ch Was the allocation sequence adequately generated? 6 DE LA Cote-Sainte-Cath, Montréal, QC H3T 1C5, Canada. Direction de Santé Was the allocation adequately concealed? Publique de Montréal, Faculté de Médecine, Université de Montréal, Young et al. 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Canadian Institutes Health Res (CIHR) 2011, www.ohri.ca/ksgroup/publications.asp. doi:10.1186/2046-4053-1-22 Cite this article as: Young et al.: Effectiveness of brief interventions as part of the screening, brief intervention and referral to treatment (SBIRT) model for reducing the non-medical use of psychoactive substances: a systematic review protocol. Systematic Reviews 2012 1:22. Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Systematic Reviews Springer Journals

Effectiveness of brief interventions as part of the screening, brief intervention and referral to treatment (SBIRT) model for reducing the non-medical use of psychoactive substances: a systematic review protocol

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Springer Journals
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Copyright © 2012 by Young et al.; licensee BioMed Central Ltd.
Subject
Medicine & Public Health; Medicine/Public Health, general; Biomedicine general; Statistics for Life Sciences, Medicine, Health Sciences
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2046-4053
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10.1186/2046-4053-1-22
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22587894
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Abstract

Background: There is a significant public health burden associated with substance use in Canada. The early detection and/or treatment of risky substance use has the potential to dramatically improve outcomes for those who experience harms from the non-medical use of psychoactive substances, particularly adolescents whose brains are still undergoing development. The Screening, Brief Intervention, and Referral to Treatment model is a comprehensive, integrated approach for the delivery of early intervention and treatment services for individuals experiencing substance use-related harms, as well as those who are at risk of experiencing such harm. Methods: This article describes the protocol for a systematic review of the effectiveness of brief interventions as part of the Screening, Brief Intervention, and Referral to Treatment model for reducing the non-medical use of psychoactive substances. Studies will be selected in which brief interventions target non-medical psychoactive substance use (excluding alcohol, nicotine, or caffeine) among those 12 years and older who are opportunistically screened and deemed at risk of harms related to psychoactive substance use. We will include one-on-one verbal interventions and exclude non-verbal brief interventions (for example, the provision of information such as a pamphlet or online interventions) and group interventions. Primary, secondary and adverse outcomes of interest are prespecified. Randomized controlled trials will be included; non-randomized controlled trials, controlled before-after studies and interrupted time series designs will be considered in the absence of randomized controlled trials. We will search several bibliographic databases (for example, MEDLINE, EMBASE, CINAHL, PsycINFO, CORK) and search sources for grey literature. We will meta-analyze studies where possible. We will conduct subgroup analyses, if possible, according to drug class and intervention setting. Discussion: This review will provide evidence on the effectiveness of brief interventions as part of the Screening, Brief Intervention, and Referral to Treatment protocol aimed at the non-medical use of psychoactive substances and may provide guidance as to where future research might be most beneficial. Keywords: Brief intervention, Drug use, Psychoactive substance, Referral to treatment, SBIRT, Screening, Substance use, Systematic review * Correspondence: myoung@ccsa.ca Canadian Centre on Substance Abuse (CCSA), 75 Albert Street, Ottawa, ON K1P 5E7, Canada Department of Psychology, Carleton University, 1125 Colonel By Drive, Ottawa, ON K1S 5B6, Canada Full list of author information is available at the end of the article © 2012 Young et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Young et al. Systematic Reviews 2012, 1:22 Page 2 of 11 http://www.systematicreviewsjournal.com/content/1/1/22 Background moderate risk of harms; individuals identified as experi- We used the Preferred Reporting Items for Systematic encing significant harm and/or having more serious signs Reviews and Meta-Analyses for Protocols (PRISMA-P) of substance dependence warranting formal diagnosis checklist to guide the reporting of this protocol [1]. may be referred to treatment services that are outside According to the 2010 Canadian Alcohol and Drug Use the scope of BIs. Monitoring Survey [2], 11.2% of Canadians aged 15 years and older reported past-year use of at least one of the Screening following psychoactive substances: cannabis, cocaine/ To evaluate the likelihood that an individual is experien- crack, methamphetamine/crystal methamphetamine, ec- cing, or is at risk of experiencing, substance use-related stasy, hallucinogens, salvia, inhalants, heroin, pain relie- harms, individuals are screened. Screening may be con- vers, stimulants or sedatives. The rate of past-year use of ducted in a number of different ways. For example, screen- any of these substances was higher among males than ing may be conducted via psychometrically validated females (15.3% versus 7.5%, respectively). Rates were also questionnaires or tests developed to accurately categorize higher among those aged 15- to 24-years-old compared users into low, moderate, and high risk categories. Such with adults 25 years and older (26.3% versus 8.3%, respect- tests have been developed for different types of substances ively). Furthermore, among those reporting past-year use, such as alcohol (Alcohol Use Disorders Identification Test 17% reported experiencing substance use-related harm. [6]), cannabis (the Cannabis Use Disorders Identification There is also a significant public health burden asso- Test [7]) or prescription opioids (for example, the Opioid ciated with substance use in Canada. According to 2002 Risk Tool [8]). General drug screening tests also exist (for estimates, substance abuse costs Canadians close to $40 example, the Drug Abuse Screening Test [9]). However, billion ($1,267 per Canadian), with use of psychoactive screening tests that reliably categorize users into low or substances (excluding alcohol) accounting for approxi- moderate risk groups have not been developed for other mately $8.2 billion (20.7%) of the total costs [3]. The vast substances (for example, heroin and cocaine). For these majority of those costs are associated with Canadians’ substances, screening may simply take the form of self- lost productivity and health. reported use or biological markers indicating use (such as For the purpose of this review, non-medical psychoactive hair, urine, oral fluid or blood) rather than psychometric- substance use includes the use of drugs prohibited by ally validated self-report instruments. In the absence of international law including, but not limited to, amphet- validated tests or biological markers, others may rely on amine-type stimulants, cannabis, cocaine, heroin and 3,4- even less rigorous screening methods, such as the subject- methylenedioxymethamphetamine (MDMA) [4]; the non- ive judgment of the individual conducting the assessment. medical use of pharmaceuticals such benzodiazepines, Regardless of the screening method employed, those opioids or dextromethorphan; and the use of substances deemed at risk of harms are typically provided a BI or such as solvents or inhalants (for example, gasoline, acet- referred to treatment. In cases where self-reported use or one) when they are used for their intoxicating effects. It biological markers indicating use are used for screening, it does not include alcohol, nicotine or caffeine. is unclear how practitioners make the decision whether to The early detection and/or treatment of risky substance administer a BI versus referral to treatment. use has the potential to dramatically improve outcomes for In reviews where the effectiveness of SBIRT models in those who experience harms from the non-medical use of reducing harms associated with alcohol use have been psychoactive substances, particularly adolescents whose evaluated systematically [10-12], few protocols have brains are still undergoing development. Screening, Brief employed a rigid definition of the screening criteria used Intervention, and Referral to Treatment (SBIRT) is a com- to determine whether a BI was administered. This is prehensive, integrated approach to the delivery of early likely a result of two factors: poor descriptions of screen- intervention and treatment services for individuals experi- ing procedures employed in studies reviewed and/or the encing substance use-related harms, as well as those who heterogeneity of screening procedures employed. are at risk of experiencing such harms [5]. The SBIRT model is based on public health principles and procedures, Brief intervention and is designed to reduce the burden of injury, disease and In addition to the variability in screening procedures disability associated with the non-medical use of psycho- employed, there is also much variation in how BIs are active substances. defined and delivered. In general, BIs are in-person, time- The protocol typically begins with a screening proced- limited efforts to provide information or advice, increase ure that involves asking questions to evaluate whether motivation to avoid substance use, or to teach behavior the individual has experienced, or is at risk of experien- change skills with the aim of reducing substance use and cing, substance use-related harms. Brief interventions the likelihood of experiencing negative consequences. This (BIs) are typically delivered to those individuals at low to variation includes the number of conversations or meetings Young et al. Systematic Reviews 2012, 1:22 Page 3 of 11 http://www.systematicreviewsjournal.com/content/1/1/22 that take place during intervention delivery as well as the in adolescents and adults identified as experiencing, or at amount of time spent conducting the BI. Reviews such as risk of experiencing, harms related to the non-medical Kaner et al.[11]havedefined ‘brief ’ to mean four or less use of psychoactive substances (excluding alcohol, and note that BIs for alcohol that are provided in primary caffeine and nicotine). In addition, potential moderating health care settings are typically delivered within the nor- factors that may impact SBIRT effectiveness will be eval- mal consultation period of 5 to 30 minutes. Levy et al.[13] uated, if possible. suggest that successful BIs typically focus on the following elements (collectively referred to using the acronym Methods FRAMES): feedback on behavior and consequences; Selection criteria responsibility to change; advice; menu of options to bring Population about change; empathy; and self-efficacy for change. Studies in which BIs are administered to adolescents (12 There is substantial scientific evidence of the benefits of to 18 years of age or equivalent by level of schooling), the SBIRT model in primary health care settings as a means young adults (19 to 24 years of age), or adults (25 years to address the harms associated with alcohol use [14-16]. and older) at risk of harms related to psychoactive sub- This evidence suggests the SBIRT process can serve as an stance use as determined by the screening component of effective ‘early warning’ system to prevent and/or reduce the SBIRT protocol will be included. We will exclude the serious long-term harms associated with excessive alco- studies evaluating interventions targeting children less hol use. A corresponding analysis for SBIRT targeting the than 12 years of age. non-medical use of other psychoactive substances is needed. Screening There is accumulating evidence suggesting that BIs may Screening must be opportunistic in nature (that is, it must be effective in reducing the non-medical use of psycho- be conducted among a population not seeking treatment active substances, such as cannabis [17-21], ecstasy [22], for substance use) and is defined as any procedure or cocaine [18,23,24], benzodiazepines [25] and opioids method used to identify those experiencing or at risk of [6,13,23] among both youths and adults. Traditionally, the harms associated with the non-medical use of psychoactive SBIRT model has been implemented in primary care set- substances. This may include, but is not limited to, ques- tings, emergency departments, inpatient trauma units and tions regarding the use of substances, the use of psycho- other health care settings. These settings see the broadest metrically validated scales, or biological (for example, number and range of patients and thus provide ideal blood, hair, urine, oral fluid) screening tools. We will opportunities to screen for, and address, substance use be- exclude studies failing to indicate they used a method of fore more severe consequences occur [26]. More recently, screening to determine who receives a BI. however, the protocol is being applied in schools [21,27] and community settings [22] in an attempt to reach young Brief intervention people. It is unclear whether the effectiveness of the SBIRT BIs are time-limited efforts to provide information or ad- approach is dependent on the setting in which it is applied. vice, increase motivation to avoid substance use, or to The diversity of substances used and the high prevalence teach behavioral change skills with the aim of reducing of use and dependence have raised some concerns about substance use and the likelihood of experiencing negative the efficacy of a SBIRT protocol for substances other than consequences. alcohol [26]. Individuals who use more than one substance We will include studies in which BIs target non-medical or use alcohol and other substances make administering psychoactive substance use. This includes the use of drugs and evaluating SBIRT more complicated than when prohibited by international law including, but not limited addressing alcohol alone [28]. Substances have variable to: amphetamine-type stimulants, cannabis, cocaine, her- forms, costs, risks, consequences and ways for clinicians to oin and MDMA [4]; the non-medical use of pharmaceuti- identify use. Moreover, most psychoactive substances that cals such benzodiazepines, opioids or dextromethorphan; are used without medical supervision are illegal or used il- and the use of substances such as solvents or inhalants legally, which can complicate addressing their use in med- (for example, gasoline, acetone) when they are used for ical settings by raising patient and physician concerns their intoxicating effects. We will exclude studies in which about confidentiality. Prescription drug misuse presents the BI only targets alcohol, nicotine or caffeine use. In additional challenges as clinicians struggle to distinguish addition, interventions that do not provide feedback on at between appropriate and inappropriate use. least one of the FRAMES elements or provide five or more sessions [11] will be excluded. Objectives For the current review we will only examine one-on-one This systematic review will determine the effects of BIs, verbal interventions and exclude non-verbal BIs (for ex- as part of the SBIRT protocol, on reducing substance use ample, the provision of information such as a pamphlet or Young et al. Systematic Reviews 2012, 1:22 Page 4 of 11 http://www.systematicreviewsjournal.com/content/1/1/22 online interventions) and group interventions, as these primary health care, emergency room, school and other interventions differ sufficiently from verbal one-on-one. community settings. However, we will collate studies assessing the effectiveness of online and group interventions and report on the search Study designs yield in the review. All randomized controlled trials (RCTs) will be included, including any cluster RCTs. Where RCTs are lacking or, Referral to treatment for issues relating to feasibility, not conducted, non- We will not address the effectiveness of the referral to RCTs, controlled before-after studies and interrupted treatment component of the SBIRT protocol in this time series designs will be considered. These latter review. designs will include some form of control group, whether concurrent or within-patient. Interrupted time series Comparisons studies must have a clearly defined time point at which Studies comparing BI to no BI, provision of pamphlets the intervention is introduced and at least three data or other information only, or delayed intervention will points before and after introducing the intervention; be included. Studies without a comparison or control those ignoring secular changes and performing simple group will be excluded. pre-post analyses will not be included unless re-analysis is possible [29]. We will not evaluate retrospective stud- ies or studies with historical controls. We will exclude Outcomes comments, letters and editorials. We will evaluate the outcomes listed below for any period of follow-up. Primary outcomes: Search methods Electronic bibliographic databases 1. Substance use versus non-use. A comprehensive literature search for studies and sys- 2. Frequency and quantity of use. tematic reviews using high recall subject searches will be 3. Any standard or accepted biological markers of conducted using several electronic databases: MEDLINE, substance use (for example, blood, oral fluid). EMBASE, The Cochrane Library, Cumulative Index to 4. Self- or other reported use-related harms or negative Nursing and Allied Health Literature (CINAHL), Psy- consequences of use. cINFO, Education Resources Information Center (ERIC) 5. Self- or other reported changes in behavior likely to and the CORK Database. All electronic search strategies result in the reduction of negative substance use- will be peer-reviewed using the PRESS tool prior to im- related consequences. plementation [30]. The proposed MEDLINE search strat- 6. Decision to attend treatment. egy is shown in Appendix 1; the search will be adapted to the other databases. Secondary outcomes: Other sources 1. Use of different substances from that for which the ‘Grey literature’ searches will be conducted for other po- client received the BI (including use of alcohol, tentially relevant studies. Websites of health technology caffeine, or nicotine) as assessed by self- or other assessment and evidence-based review organizations as reported or biological markers substance use. listed in Grey Matters: a practical tool for evidence-based 2. Self- or other reported intention to reduce substance searching [31] will be searched as well as PsycEXTRA. use. Websites of relevant organizations, such as the Canadian 3. Self- or other reported health measure. Centre on Substance Abuse, Centre for Addiction and Mental Health, the Substance Abuse and Mental Health Adverse outcomes: Services Administration, National Institute for Drug Abuse and the Centre for Addictions Research British 1. Self- or other reported use or increased use of Columbia, as well as those indicated on the Substance different substances from that for which the client Abuse Librarians & Information Specialists site will be received the BI as assessed by self- or other reported searched. We will also access the websites of specific orga- or biological markers substance use. nizations, such as the College of Physicians and Surgeons 2. Other adverse outcomes. of Ontario. We will consult within our internal team to identify additional studies that may not be in the published Settings literature. We will search the Campbell Collaboration for We will include studies that use opportunistic screening systematic reviews. We will scan bibliographies of included regardless of location, including, but not limited to, articles and relevant systematic reviews. We will consult Young et al. Systematic Reviews 2012, 1:22 Page 5 of 11 http://www.systematicreviewsjournal.com/content/1/1/22 clinicaltrials.gov and the WHO International Clinical 4. study design methodology (for example, methods of Trials Registry Platform for ongoing studies. allocation, blinding) for conducting a risk of bias assessment; Language 5. population details of the target group (for example, We will not restrict our search based on language but will sample size, characteristics such as age, sex and only include articles available in the English and French ethnic background); languages. A list of the possibly relevant titles available in 6. details on the screening method used to determine other languages will be provided as an appendix. who should be provided a BI (for example, nature of method, whether validated, administration method, Study selection length to screen, type of professional conducting the The results of the literature search will be assessed using screening, the extent of training they received in a two-step process. First, one individual will screen cita- conducting screening); tions by title and/or abstract according to the prespeci- 7. details of the intervention and comparison groups, fied screening questions (level 1). Those records deemed including any theoretical frameworks and intensity of to be ‘included’ or ‘unclear’ will automatically pass to the the intervention (for example, length of and time next level of screening (level 2). However, if the record is between sessions); deemed ‘excluded’, then it needs to be reviewed by a sec- 8. fidelity of the intervention; ond reviewer to confirm exclusion. This process is 9. setting; referred to as liberal accelerated screening, a more effi- 10. outcome details including definitions, outcome cient means of initially assessing records for relevancy. measures used and data. Second, full text screening will be performed inde- pendently by two reviewers and discordance will be Disagreements will be resolved first by consensus and resolved first by consensus and then by third member of then by a third member of the research team, as needed. the research team, as needed (level 2 assessment). The Prior to performing data abstraction, the review team selection process and reasons for exclusion will be docu- will refine the development of the extraction forms and mented using the PRISMA flow diagram [32]. will conduct a calibration and training exercise. Literature search results will be uploaded to Distiller Systematic Review Software (DSR), an Internet-based soft- Assessing the risk of bias ware program that facilitates collaboration among Two independent reviewers will assess the risk of bias reviewers during the study selection process. The team will for each included study. Any disagreements will be develop and test screening questions and forms for level 1 resolved first through discussion and then by third mem- and 2 assessments based on the inclusion and exclusion ber of the research team, as needed. Determining risk of criteria. Citation abstracts and full text articles will be bias summary assessments for outcomes will follow that uploaded with screening questions to DSR. Prior to the proposed by The Cochrane Collaboration [33] and incor- formal screening process, a calibration exercise will be porated into grading the quality of evidence. undertaken to pilot and refine the screening questions. All RCTs will be assessed using the Cochrane Risk of Further, we will provide training to new members of the Bias (RoB) tool [33]. The Cochrane RoB tool evaluates review team not familiar with the DSR software and the seven domains (sequence generation, allocation conceal- content area prior to the start of the review. ment, blinding of participants and personnel, blinding of outcome assessors, incomplete outcome data, selective Data abstraction outcome reporting, and other sources of bias). Other Two independent reviewers will extract and document sources of bias will include single versus multicenter stud- the content of each included study using a standardized ies and study sponsorship. We will also assess cluster ran- data abstraction form in DSR to capture information on domized trials for the possibility of recruitment bias [34]. the descriptive and quantitative characteristics of individ- If included, other study designs will be critically appraised ual studies. Useful data to collect will include: with the Cochrane Effective Practice and Organisation of Care group’s modified RoB tool (Appendix 2) [29]. 1. publication details (for example, year of publication, language of publication, country in which the study Unit of analysis issues was conducted, publication status, sources of For studies whose allocation design is a group level (for funding); example, schools) and yet analyzed at the individual level 2. substance targeted by the BI; (for example, students), ‘unit of analysis’ errors can occur, 3. study details (for example, date, number of centers, whereby results can be overly precise and contribute follow-up); greater weight in a meta-analysis. Where possible, we Young et al. Systematic Reviews 2012, 1:22 Page 6 of 11 http://www.systematicreviewsjournal.com/content/1/1/22 will adjust the analysis according to the intracluster cor- on similar scales or with similar measures; standardized relation coefficient to address these errors [35], prefer- mean differences will be used where continuous out- ably with empirically-derived values. comes are reported using different scales or measures. Transformation of data to allow analyses with mean dif- ferences will be made wherever possible. Where change- Missing data from-baseline data are reported in the studies, we will If information or data is missing or incomplete, we will extract in addition to post-intervention data. attempt to contact the study authors twice over four weeks by email. We will analyze data as close to the Ordinal outcomes intention-to-treat principle (all participants analyzed Decisions about handling and analyzing ordinal out- according to assigned treatment group) as possible. If comes will be determined post hoc, subject to the body loss to follow-up occurs, we will incorporate any add- itional data provided in study reports or by the authors; of evidence available. we will not impute data for any outcomes. Time-to-event data For time-to-event data, the generic inverse variance Evidence synthesis method will be used to meta-analyze outcomes using Study characteristics will be summarized narratively in the log hazard ratios and standard errors; the Parmar text, and/or summary tables in the report; such data may method [37] will be used to estimate data, as needed. be presented as frequencies and percentages, medians and interquartile ranges, or means and standard deviations, Other statistical considerations where appropriate. For outcomes, where appropriate and possible (depending on the quantity, quality, and statistical Data conversions Where needed, we will convert data and clinical homogeneity of the available data), pooled esti- mates of intervention efficacy or effectiveness will be com- (for example, standard error to standard deviation) for use in analyses and to facilitate consistent presentation puted using standard meta-analytic methods [36]. Random of results across studies. effects models will be used for all meta-analyses. A narra- tive synthesis of the evidence will be conducted when Interrupted time series designs If interrupted time quantitative pooling of data is not possible. series studies are included we will re-analyze data, where needed and if feasible, for change in level and Main analyses slope according to time series regression analyses For the primary analysis, our intent is to evaluate all BIs for [38]. all drug classes together. We are uncertain what exists in the literature regarding how interventions are targeted (that Statistical heterogeneity is, for general drug use or for specific drugs), and we do Statistical heterogeneity will be evaluated using not know how varied they may be in study characteristics 2 2 I-squared (I ) statistics; for the interpretation of I ,a or methodology. Before proceeding with a pooled analysis, rough guide of low (0% to 25%), moderate (25% to we will determine whether studies are homogeneous with 50%), substantial (50% to 75%), and considerable (75% respect to those characteristics. If too much heterogeneity to 100%) heterogeneity will be used [36,38]. Possible exists, we will not meta-analyze all studies together. In reasons contributing to heterogeneity will be explored. addition, should considerable statistical heterogeneity (≥75%) exist, we will also not present a pooled analysis. Exploring statistical heterogeneity We will also conduct subgroup analyses according to If studies are determined to be statistically heterogeneous, drug class (for example, cannabinoids, opioids and amphe- we will conduct the following subgroup analyses, where tamines, with general use as a separate category) and inter- possible: vention setting (for example, school, hospital, community). Dichotomous outcomes 1. age of participants (12 to 18 years, 19 to 24 years, For dichotomous outcomes, the risk ratio and 95% confi- 25 years or greater); dence intervals will be presented. The unit of analysis is 2. sex; the proportion of study participants with the outcome 3. description of screening method (well-described, for intervention and control groups. poorly described, unclear screening method); 4. type of intervention provided (for example, cognitive behavioral therapy, motivational enhancement Continuous outcomes therapy, motivational interviewing); For continuous outcomes, mean differences and 95% 5. type of practitioner. confidence intervals will be used for outcomes reported Young et al. Systematic Reviews 2012, 1:22 Page 7 of 11 http://www.systematicreviewsjournal.com/content/1/1/22 If appropriate and with sufficient, complete data, we of BIs as part of SBIRT aimed at the non-medical use of will verify results of the subgroup analyses with univari- psychoactive substances, which will be helpful in establish- able meta-regression. The variables outlined above for ing guidelines for implementation in general practice and subgroup analyses will be considered statistically signifi- other relevant settings. Finally, synthesizing the evidence cant at P <0.01. base may provide guidance as to where future research might be most beneficial. Sensitivity analyses If data permit, and where needed, sensitivity analyses Appendices may be undertaken regarding the risk of bias (restricting Appendix 1. Proposed MEDLINE search strategy the analyses to studies with low risk of bias), the fidelity of the intervention, data issues and measurement of out- 1. SBIRT.tw. comes or to explore reasons for heterogeneity. 2. (SBI or SBIs).tw. 3. exp Substance Abuse Detection/ Test for funnel plot asymmetry 4. ((substance* adj2 test*) or (substance* adj2 detect*) If at least 10 studies are included in a given meta-ana- or (substance* adj2 screen*) or (drug* adj2 detect*) lysis, we will evaluate for funnel plot asymmetry, depend- or (drug* adj2 screen*) or (drug* adj2 test*)).tw. ing on the outcome, and postulate reasons for the 5. 3 or 4 asymmetry (for example, publication bias) [39-41]. 6. Substance-Related Disorders/ 7. exp Amphetamine-Related Disorders/ Grading the quality of evidence 8. exp Cocaine-Related Disorders/ The quality of evidence for all outcomes will be judged 9. exp Marijuana Abuse/or exp Marijuana Smoking/ using the Grading of Recommendations Assessment, De- 10. exp Opioid-Related Disorders/ velopment and Evaluation working group methodology 11. exp Phencyclidine Abuse/ [41]. The quality of evidence will be assessed across the 12. Psychoses, Substance-Induced/ domains of risk of bias, consistency, directness, precision 13. exp Substance Abuse, Intravenous/ and publication bias. Additional domains may be consid- 14. ((substance-related or substance-induced) ered where appropriate. Quality will be adjudicated as adj3 (disorder* or psychosis or psychoses)).tw. high (further research is very unlikely to change our con- 15. ((drug or drugs or substance* or opioid* or opiate* or amphetamine* or amfetamine* or methamphetamine* fidence in the estimate of effect), moderate (further re- or methamfetamine or benzodiazepine* or morphine* search is likely to have an important impact on our or methadone* or prescription* or phencyclidine* or confidence in the estimate of effect and may change the solvent* or barbiturate* or depressant* or stimulant* or estimate), low (further research is very likely to have an psychotherap* or psycho-therap* or steroid*) adj3 important impact on our confidence in the estimate of effect and is likely to change the estimate), or very low (addict* or abuse* or abusing or abusive or misuse* or (very uncertain about the estimate of effect). mis-use* or misusing or mis-using or illicit* or illegal* or unlawful* or unsanction* or habit* or dependen* or disorder or disorders or relapse* or consumption)).tw. Quality assurance 16. or/6-15 We will discuss results in light of the strength of findings 17. Dextropropoxyphene/ as well as their research and practice implications. This 18. (Dextropropoxyphene or D-Propoxyphene review will be reported according to the PRISMA state- or Propoxyphene or Darvon or Vicodin).tw. ment [32] and using the assessment of multiple system- 19. Hydromorphone/ atic reviews tool for additional quality control [42]. 20. (Hydromorphon* or Dihydromorphinone or Dilaudid or Laudacon or Palladone).tw. Discussion 21. exp Meperidine/ The accumulating research assessing the effectiveness of 22. (Meperidine or Demerol or Dolantin or Dolargan or SBIRT for the non-medical use of psychoactive substances Dolcontral or Dolin or Dolosal or Dolsin or Isonipecain underscores the need for a systematic review in order to or Lidol or Lydol or Operidine or Pethidine or assist clinicians and others to inform evidence-based prac- Promedol or Dimethylmeperidine or Isopromedol or tice. The results from a recent evidence map of systematic Trimeperidine or Lomotil or Reasec).tw. reviews to inform the prevention, treatment and/or harm 23. Pentobarbital/ reduction for illicit drug use [43] revealed no published 24. (Pentobarbital or Diabutal or Etaminal or Ethaminal or systematic reviews or meta-analyses on the effectiveness of Mebubarbital or Mebumal or Nembutal or the SBIRT model in reducing illicit drug use. A systematic Pentobarbitone or Sagatal).tw. review will yield a better understanding of the effectiveness Young et al. Systematic Reviews 2012, 1:22 Page 8 of 11 http://www.systematicreviewsjournal.com/content/1/1/22 25. exp Diazepam/ pancodine or theocodin or "gamma hydroxybutrate" or 26. (Diazepam or Apaurin or Diazemuls or Faustan or GHB or PCP).tw. 49. ((sniff* or inhal* or snort*) adj3 (solvent* or glue or Relanium or Seduxen or Sibazon or Stesolid or Valium drug or drugs)).tw. or Nordazepam or Calmday or Dealkylprazepam or 50. ("inhalant use" or "inhalant usage").tw. Demethyldiazepam or Deoxydemoxepam or 51. exp Lysergic Acid Diethylamide/ Desmethyldiazepam or Nordaz or Nordiazepam or 52. (LSD or Lysergide or Lysergic Acid Diethylamide).tw. Norprazepam or "Tranxilium N" or Vegesan).tw. 53. ("drug use" or "drug usage" or (drug adj user*)).tw. 27. ("substance use" or "substance usage").tw. 54. or/37-53 28. Alprazolam/ 55. 36 or 54 29. (Alprazolam or Alprazolan or Alprox or "Apo- 56. Mass Screening/ Alpraz" or Cassadan or Esparon or Kalma or "Novo- 57. screen*.tw. Alprazol" or "Nu-Alpraz" or Ralozam or Tafil or 58. Self Disclosure/ Trankimazin or Xanax).tw. 59. (detect* or disclos* or identif* or question* or reveal* 30. Dextroamphetamine/ or survey* or unveil*).tw. 31. (Dextroamphetamine or Curban or 60. Interview, Psychological/ "d-Amphetamine" or Dexamfetamine or 61. ((interview* or encounter* or visit*) adj3 (counsellor* Dexamphetamine or Dexedrine or dextro- or counselor* or nurse* or physician* or doctor* or Amphetamine or DextroStat or Oxydess).tw. clinician* or psychologi* or social worker*)).tw. 32. Methylphenidate/ 33. (Methylphenidate or Centedrin or Daytrana or 62. or/56-61 63. 55 and 62 Dexmethylphenidate or Equasym or Focalin or 64. 5 or 63 Metadate or Methylin or Phenidylate or Ritalin* or 65. Psychotherapy, Brief/or Crisis Intervention/ Tsentedrin or Adderall or Obetrol).tw. 66. (brief intervention* or brief prevention*).tw. 34. or/17-33 67. 65 or 66 35. 34 and (addict* or abuse* or abusing or abusive or 68. exp Motivation/ misuse* or mis-use* or misusing or mis-using or 69. exp Psychotherapy/ illicit* or illegal* or unlawful* or unsanction*).tw. 70. (psycho-therap* or psychotherap*).tw. 36. 16 or 35 71. ((cogniti* or behavior* or behaviour* or conditioning 37. exp designer drugs/or exp street drugs/ 38. (designer drug$1 or street drug$1 or recreational or motivation* or psychosocial* or psycho-social* or drug$1 or narcotic* or non-therapeutic drug$1 or psychological) adj3 (therapy or therapies or non-medical drug$1).tw. therapeutic or interven* or modify or modifies or 39. exp Cannabis/ modified or modification)).tw. 72. (counselling or counseling).tw. 40. (Cannabi* or marijuana or marihuana or hemp or 73. or/68-72 hash or hashish or ganja).tw. 74. (brief* or short* or short-rang* or short-term or 41. exp Heroin/ abbreviate* or concise or limited or time-limited or 42. (Heroin or Diacetylmorphine or Diagesil crisis or crises or immediate*).tw. or Diamorphine or Diamorf or speed).tw. 75. 73 and 74 43. exp Cocaine/ 76. 67 or 75 44. (cocaine or crack).tw. 77. exp "Referral and Consultation"/ 45. exp Hallucinogens/ 78. (refer or refers or referral* or gatekeeper* or 46. (hallucinogen* or psychedelic*).tw. gate-keeper* or specialist* or specialty).tw. 47. exp amphetamine/or exp methamphetamine/or exp 79. 77 or 78 n-methyl-3,4-methylenedioxyamphetamine/or 80. 64 and (76 or 79) mescaline/or ketamine/or oxycodone/ 81. 1 or 2 or 80 48. (methylenedioxymethamphetamine or MDMA or 82. limit 81 to "reviews (specificity)" ecstasy or methamphetamine or crystal meth or 83. meta analysis.pt. mescaline or mezcalin or peyote or 84. exp meta-analysis as topic/ trimethoxyphenethylamine or ketamine or Calipsol or 85. (meta-analy* or metanaly* or metaanaly* or met Calypsol or "CI-581" or Kalipsol or Ketalar or Ketanest analy* or integrative research or integrative or Ketaset or "special k" or mushroom* or prilocybin or review* or integrative overview* or research oxycodone* or oxycontin* or dihydrohydroxycodeinone or dihydrone or dinarkon or integration or research overview* or collaborative eucodal or oxiconum or oxycodeinon or oxycone or review*).ti,ab. Young et al. Systematic Reviews 2012, 1:22 Page 9 of 11 http://www.systematicreviewsjournal.com/content/1/1/22 86. (systematic review* or systematic overview*  Were baseline outcome measurements similar? or technology assessment* or HTA or HTAs).ti,ab.  Were baseline characteristics similar? 87. exp Technology assessment, biomedical/  Were incomplete outcome data adequately 88. health technology assessment winchester england.jn. addressed? 89. (evidence report technology assessment or evidence  Was knowledge of the allocated interventions report technology assessment summary).jn. adequately prevented during the study? 90. or/83-89  Was the study adequately protected against 91. 81 and 90 contamination? 92. 82 or 91  Was the study free from selective outcome 93. (controlled clinical trial or randomized controlled trial).pt. reporting? 94. exp RCTs as topic/or exp controlled clinical trials as  Was the study free from other risks of bias? topic/or exp random allocation/or exp double-blind method/or exp single-blind method/or exp placebos/ Interrupted time series studies 95. "controlled clinical trial".tw. 96. (random* or RCT$1 or placebo*).tw.  Was the intervention independent of other changes? 97. ((singl* or doubl* or trebl* or tripl*) and (mask* or  Was the shape of the intervention effect blind* or dumm*)).tw. prespecified? 98. or/93-97  Was the intervention unlikely to affect data 99. 81 and 98 collection? 100. clinical trial.pt.  Was knowledge of the allocated interventions 101. exp Clinical Trials as Topic/ adequately prevented during the study? 102. "clinical trial".ti,ab.  Were incomplete outcome data adequately 103. (volunteer or volunteers or open label* addressed? Was the study free from selective outcome or nonrandom* or non random* or quasirandom* reporting? or quasi-random*).tw. Was the study free from other risks of bias? 104. exp Cohort Studies/or exp Longitudinal Studies/or exp Prospective Studies/or exp Follow-Up Studies/ 105. (cohort or cohorts or longitudinal or prospective).tw. Abbreviations 106. ((observational or follow-up or followup) adj stud*).tw. BI: Brief intervention; CINAHL: Cumulative Index to Nursing and Allied Health 107. (population-based stud* or population-based Literature; DSR: Distiller Systematic Review Software; ERIC: Education analys* or population stud* or population analys*).tw. Resources Information Center; FRAMES: Feedback on behavior and consequences, Responsibility to change, Advice, Menu options to bring 108. ((descriptive adj stud*) or (multidimensional about change, Empathy, Self-efficacy for change; MDMA: 3:4- adj stud*) or (multi-dimensional adj stud*) or methylenedioxymethamphetamine; PRISMA-P: Preferred Reporting Items for (multicenter adj stud*) or (multi-center adj stud*) or Systematic Reviews and Meta-Analyses for protocols; RCT: Randomized control trial; RoB: Risk of bias; SBIRT: Screening, Brief Intervention, and Referral (multicentr* adj stud*) or (multi-centr* adj stud*)).tw. to Treatment. 109. exp Multicenter Study/or exp Multicenter Studies as Topic/ Competing interests 110. Comparative Study.pt. The authors declare that they have no competing interests. 111. ((comparative adj study) or (comparative adj Acknowledgments studies) or "before and after").tw. The authors would like to thank James Galipeau, Mary Gauthier, Mistrel Pratt 112. or/100-111 and Chad Dubeau for their assistance in the development of this protocol. 113. 81 and 111 JG holds a Canada Research Chair in Health Knowledge Transfer and Update. DM holds a University of Ottawa Research Chair in Systematic Reviews. This 114. 92 or 99 or 113 systematic review is funded by the Institute for Neurosciences, Mental Health and Addition, Canadian Institutes of Health Research (funding reference Appendix 2. Cochrane Effective Practice and Organisa- number KSD-115551; Effectiveness of the Screening, Brief Intervention and Referral to Treatment (SBIRT) Model for Reducing Illicit Drug Use: A Systematic tion of Care Review group’s criteria for assessing risk of Review). The funder had no involvement in the development of the protocol. bias in non-randomized, controlled before-and-after, and interrupted time series studies Author details Canadian Centre on Substance Abuse (CCSA), 75 Albert Street, Ottawa, ON K1P 5E7, Canada. Department of Psychology, Carleton University, 1125 Non-randomized controlled trials and controlled before-after Colonel By Drive, Ottawa, ON K1S 5B6, Canada. Ottawa Hospital Research studies Institute (OHRI), Ottawa Hospital - General Campus, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada. Independent Research and Information Consultant, Ottawa, Canada. Département de Pédiatrie, Hôpital Sainte-Justine, 3175 Ch Was the allocation sequence adequately generated? 6 DE LA Cote-Sainte-Cath, Montréal, QC H3T 1C5, Canada. Direction de Santé Was the allocation adequately concealed? Publique de Montréal, Faculté de Médecine, Université de Montréal, Young et al. Systematic Reviews 2012, 1:22 Page 10 of 11 http://www.systematicreviewsjournal.com/content/1/1/22 Montréal, QC H3C 3J7, Canada. Division of Adolescent Medicine, 16. Wilk AI, Jensen NM, Havighurst TC: Meta-analysis of randomized control Department of Pediatrics, University of Toronto, 555 University Avenue, trials addressing brief interventions in heavy alcohol drinkers. J Gen Int Toronto, ON M5G 1X8, Canada. College of Physicians and Surgeons of Med 1997, 12(5):274–283. Ontario, 80 College Street, Toronto, ON M5G 2E2, Canada. Centre for 17. Copeland J, Swift W, Roffman R, Stephens R: A randomized controlled trial Addiction and Mental Health, Faculty of Pharmacy and Department of of brief cognitive-behavioral interventions for cannabis use disorder. J Psychiatry, University of Toronto, 33 Russell Street, Toronto, ON M5S 2S1, Subst Abus Treat 2001, 21(2):55–64. Canada. Faculty of Medicine, University of Ottawa, 451 Smyth Road, Ottawa, 18. Humeniuk R, Ali R, Babor T, Souza-Formigoni ML, de Lacerda RB, Ling W, ON K1H 8M5, Canada. Department of Epidemiology & Community McRee B, Newcombe D, Pal H, Poznyak V, Simon S, Vendetti J: A Medicine, Faculty of Medicine, University of Ottawa, 451 Smyth Road, Ottawa, randomized controlled trial of a brief intervention for illicit drugs linked ON K1H 8M5, Canada. to the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in clients recruited from primary health care settings in four countries. Addiction 2012, 107(5):957–966. Authors’ contributions 19. Lang E, Engelander M, Brooke T: Report of an integrated brief intervention with MMY is the guarantor. MMY, AS, APW, TP and CG drafted the manuscript. self-defined problem cannabis users. J Subst Abus Treat 2000, 19(2):111–116. MMY, AS and TP developed the selection criteria, specified outcome 20. Martin G, Copeland J, Swift W: The Adolescent Cannabis Check-Up: measures and determined the data to be abstracted. 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Canadian Institutes Health Res (CIHR) 2011, www.ohri.ca/ksgroup/publications.asp. doi:10.1186/2046-4053-1-22 Cite this article as: Young et al.: Effectiveness of brief interventions as part of the screening, brief intervention and referral to treatment (SBIRT) model for reducing the non-medical use of psychoactive substances: a systematic review protocol. Systematic Reviews 2012 1:22. Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit

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