الفهرس 
substance use disorder and related disorders; clinical features, diagnosis, and statisticsOnly 14 pages are availabe for public view
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Abstract
Introduction
Treating Addiction is of vital Concern for all professional working in health care, behavioral health, and other social services. The worldwide prevalence of addiction problems and the suffering that caused by them would be enough reason. Substance use disorders (SUDS) are by far the leading preventable cause of death worldwide. Due to their pharmacological effects, opioids can cause breathing difficulties, and opioid overdose can lead to death. Worldwide, about 0.5 million deaths are attributable to drug use. More than 70% of these deaths are related to opioids, with over 30% of them caused by an overdose. Yet these very common, disabling, and high-mortality conditions often go unnoticed and untreated.
There are several evidence-based psychological intervention models for treating addiction, one important modality being Motivational Interviewing. Over 1,000 controlled clinical trials on MI have been published, many reporting significant positive effects across a broad range of problem behaviors, with some of the strongest evidence in the area of addictive behaviors. MI has also been successfully applied to reduce drug-related risk through perceived peer norms, injection practices , and overdose . However, it is also clear that the effectiveness of MI varies greatly depending on the program and clinician who offers it). This suggests that MI is sensitive to the manner and context in which it is delivered. In this context, it is important to understand the “active ingredients” of MI and which aspects of it are most important in delivery. Closer adherence and dexterity of the counselor to the prescribed MI style predict greater change in client’s addictive behaviors.
Although MI alone can produce changes, it has become common to combine the clinical style of MI with other treatment modalities. In this sense MI is a way of doing whatever else would be done. The result can be synergistic. Virtually every other treatment described for addiction, including pharmacotherapies, can be delivered in an MI style. Many studies suggest that combining MI with CBT in many domains of addictive behavior such as substance use, alcohol use, and smoking is more effective than usual care; often, but not always, more effective than MI alone; and more effective than CBT alone.
For effective combining with CBT, MI may be delivered as a brief pre-treatment to build motivation for multisession intervention, can be used at specific moments during CBT when client discord or ambivalence arises, or can serve as an integrative framework in which CBT strategies, could be delivered.
This study focused on MI delivery in a group format, MI groups may have several advantages over individual MI. One benefit of group MI is that groups bring people together to share concerns and support one another, in-creasing their hope and confidence. Another advantage is their flexibility and cost‐effectiveness. On the other hand, there are several challenges in using MI in group. Providing high‐quality and productive group leadership is more difficult than individual therapy. group sessions are more complex than individual ones. There are many Implementation challenges related to the many possible interactions and group processes.
group leaders and facilitators need to develop a high level of sensitivity to build upon subtle patterns of interaction or minimize impacts on the group as a whole. Groups also require the presence of at least two experienced therapists to facilitate productive interactions between members with different histories, beliefs, values, and communication styles, while simultaneously processing their own inner tendency to focus on some members more than others. Another challenge is that the group format offers less direct attention and floor time compared to an individual format. In addition, there are group processes that can inhibit or even impede progress and can lead to a negative influence on the group, for example by providing new “drinking buddies,” for its members in the event of a relapse.
The results concerning the efficacy of MI groups are promising regarding substance use, consequences, craving, and adherence to treatment; propensity to quit smoking, and dropout rates ; and alcohol consumption when compared with other group types. In addition, one study suggested a promise for group MI when compared with individual MI in the field of addictions. An important challenge that limits significance of MI group studies is that there are varied procedures used to administer MI groups, and not all the authors detailed the specific format and procedure used when applying MI in groups.
A significant challenge when applying MI in groups is ensuring that the spirit, processes, and fundamental skills and techniques of MI are delivered and incorporated effectively in group. Even when conducted in its group form, the aim of motivational interviewing is to increase intrinsic motivation, particularly by exploring and resolving ambivalence. It maintains a balance between empathy and goal orientation and between focus and openness.
The idea of motivational interviewing in groups is to increase the group’s energy for change, by encouraging the link between the different objectives of the members. It is therefore about broadening the focus, building on the processes of change, in addition to the specific content of each speech. Therapist’s main goal is to develop the change talk within the group, by highlighting the existing links. Therapists encourage group members to express how they relate to each other’s change talk and to elaborate on their motivations for change.
Wagner and Ingersoll described four phases of MI in groups: engaging the group (setting the environment/climate), exploring perspectives (exploring members’ perspectives on their lives and issues), broadening perspectives (expanding awareness of possibilities and developing resources and momentum for change), and moving into action (defining, planning and implementing changes). Velazquez et al published another guide that integrates MI with CBT and based on transtheoretical model. This guide defined how to facilitate moving through stages of change using change processes and change strategies, connecting this approach to traditional CBT strategies, using motivation approaches through all stages, and finally, putting it all together in group psychotherapy.
The objective of this study is to evaluate the effectiveness of MICBT groups in an adult clinical population with SUD in Egyptians. This study integrated the four-phase MI group approach described by Wagner & Ingersoll and transtheoretical model described by Velazquez et. al. into a novel MICBT model.
Method
This study is interventional longitudinal comparative study. The study setting is Addiction Treatment Unit of Shebin Elkom Mental health Hospital, a hospital affiliated to General Secretariat of Mental Health and Addiction treatment, Ministry of Health, Egypt. The setting includes inpatient and outpatient services. The study started in inpatient sitting and continued in outpatient follow up and day care service. The Study Period was12 months
Participants
A total of 60 patients with SUD were recruited from inpatient Addiction Treatment Unit of Shebin Elkom Mental health Hospital, a hospital affiliated to General Secretariat of Mental Health and Addiction treatment, Ministry of Health, Egypt. we enrolled 60 new SUD patients mainly using opiates between patients accepted for admission. The sample size was calculated by reviewing the existing literature of similar studies using STATA program-sample size calculation program. Determining the sample size to be 30 patients for MICBT and 30 patients for NA, using the 2-sided Mann-Whitney test achieved 80% power and settled alpha error at 5%.
The diagnosis of current substance dependance was verified by quantitative urine toxicology) and made by fulfilling DSM-IV criteria of substance dependence (verified by SCID-1). The Severity of Addiction Severity index (ASI). Comorbid personality disorders were verified by SCID-II. Patients with current Substance dependence with age ranging from 18 to 50 were enrolled in the current study after giving informed consent and being detoxified from all illicit drugs.
Detoxification is achieved by abstinence from drugs in a protective environment for one weak. Meanwhile, patients with coexisting major psychiatric disorders were excluded. We also excluded patients with concurrent organic brain disorder or severe medical conditions interfering with cognitive abilities. The rationale of that exclusion is that an MI group may not benefit such population, or that their style or issues may reduce the group’s effectiveness for other members33. Patients who did not complete the addiction treatment program or who could not be reached after 6 months of completion of treatment program was considered as dropped out.
Procedure
Clinical assessment
Patients were interviewed and demographic characteristics were collected. Details of substance dependence were obtained including, duration of intake, daily dose, and periods of abstinence, and stage of change.
Diagnostic measures
Structured clinical interview for DSM-IV for Axis I diagnosis (SCID-I)
It is a semi-structured diagnostic interview that includes 7 diagnostic modules including substance abuse. This study applied the Arabic version of (SCID-I) for DSM-IV axis I diagnosis (Elmesiry et al., 2004) to all participants to diagnose drug Dependence and exclude other psychiatric comorbidities.
Structured Clinical Interview for DSM-IV Axis II diagnosis (SCID-II)
The SCID-II is the counterpart of the SCID for making DSM-IV Axis II diagnoses of personality disorders. The translated Arabic version of SCID-II validated for use is done by Dr Asaad. It was validated through its use in many studies that were conducted in the Institute of Psychiatry-Ain Shams University
The ASI, arabic version
The ASI is widely used as an intake evaluation form to aid in identifying areas in need of treatment and as a multidimensional measure of treatment outcome. Results have been used as a profile that provides descriptive data about the patients contributing in this study, concerning collecting information regarding the nature and se-verity of problems that most commonly affect our client’s lives, identifying types of patients presenting for treatment, understanding the needs and expectations of our clients, and used as covariates in statistical analyses.
Outcome measures
Days of attendance to one year treatment program
The percentage of days of attendance to treatment sessions through the year were obtained and calculated for each patient by attendance record for every session. The target days to be attended are 20 days (one session weekly) basic program through 6 months, 12 days daycare through first three months after the program, and an-other 12 daycare days the second follow up 3 months.
FORM 90
It is a semi-structured interview procedure that yields quantitative indices of alcohol consumption/ illicit drug use and provides detailed day-by-day information regarding alcohol and illicit drug use. It measures the frequency and quantity of drug and alcohol use in the past 90 days and was used for pretreatment evaluation and for follow-up assessment. Separate forms are used at intake (90–DI) and follow-up (90–DF). Form 90 has shown high validity among adults and excellent test-retest reliability for indices of drug use in major categories with Kappas for different drug classes ranging from .74 to 1.0. The current study utilized the calendar data information to provide scores for the number days of substance use in the last 90 days. Form 90 was applied to all participants at baseline before intervention, at 3 and 6 months follow up after basic 20 sessions intervention to estimate number of days of substance use, and number of days of abstinence as outcome measure.
Urge Specific Strategies Questionnaire for Drugs
The USS-D was adapted from the USS for alcoholics. In this study, the USS-D has been applied to evaluate the use of specific coping strategies to high-risk situations and craving in the last 90 days before follow up evaluation. Patients were first asked to describe every strategy they had used in the past 3 months to keep themselves from using substance when they had an urge to use (urge was defined to them as “wish for, temptation, desire, want, craving, close call, etc.”). The time frame was the 6-month follow-up, to match the using periods in the analyses. Open-ended responses are not used in the present study but had the purpose of eliciting free recall be-fore providing the closed-ended questions. Closed-ended questions listed 19 situation-specific coping strategies in plain language that were taught in the study’s coping skills treatments (see Table for types of strategies), plus two commonly ineffective methods (willpower and self- punishment). For each, patients were asked “When you had an urge to use substance in the last 3 months, and were trying to keep yourself from drinking, how often did you....” Patients rated their responses on 7-point Likert scales from 1 (never) to 7 (all the time). The single-factor structure, high reliability and validity of the total score was demonstrated by Monti et al.
General Strategies for Drugs (GSD)
General Strategies for Drugs (GSD) was adapted from General Strategies for Alcoholics (GSA)46,47 and has the same format as the USS. In this study, the GSD has been applied to evaluate the use modification of problematic behaviors and use of General life strategies to prevent relapse in the last 90 days before follow up evaluation. Participants were first asked to describe what they did in general to maintain their sobriety in the past 3 months (ratings of open-ended questions not used in this study). Next, closed-ended questions listed 21 strategies in plain language and patients were asked “In general, as a way to maintain sobriety in the last 3 months, how often did you…”, using the same response ratings as for the USS. The single-factor structure, high reliability and validity of the total score was demonstrated by Monti et al.
Randomization
The patients were randomly allocated to one of 2 groups; MICBT group that participated in integrated CBT and MI group therapy 20 sessions, and NA group (control group) that participated in twelve steps facility already present in the unit care. Randomization of patients in the 2 groups has been double blinded. Computer generated random by the main supervisor and who assigned case by case to one of the two groups according to this table. To have blind assessment, the outcome assessment had been done by the supervisors.
Intervention
The group therapy model
In the study “MICBT” group, MI with CBT elements were integrated and adapted to group. The MI spirits, four MI processes (engaging, focusing, evoking, planning), and different MI skills especially OARS (Open-ended questions, Affirmation, Reflective listening, Summary, and Eliciting change talk) were applied in initial motivational sessions, and integrated with CBT elements (such as; functional analysis, cognitive skills, relapse prevention and other behavioral skills training, and maintenance of change strategies) in all sessions. To apply this MICBT combination in group format, our research Model for MICBT group has integrated four stages model described by Wagner and Ingersoll and model of group therapy for treatment of addiction based on trans-theoretical model described by Velazquez et al. We adapted and translated sessions in these manuals into Arabic language.
group format and structure
In this study, we mixed the three motivational group formats described by Wagner and Ingersoll: psychoeducational, supportive, and psychotherapeutic formats. We have imported elements of the three formats as needed according to pre-determined three goals: Engagement, Behavioral Change, and Behavioral Activation. Some sessions were more structured, and others were less structured, beginning by less structured format; openly exploring values, interests, exploring strengths and previous successes, then shift to a more specific task focus, structured sessions.
The study MICBT group was divided into three groups with size of each was tailored to be from 8 to 12 members with average of 10 members and 2 leaders to achieve the most benefit. Therapeutic groups were of closed type, with long term duration (20 sessions), and session length of about 90 minutes.
The MICBT therapeutic groups were homogenous concerning sharing same diagnosis, similar struggles and goals. All members were using opiates, but many were polysubstance users. The abstinence was the clear goal of our group. Groups were composited with individuals that have near different stages of change; a pre-decision group that include precontemplation/contemplation/ preparation stages, and a planning/action groups that include preparation/action/maintenance stages.
group facilitation style
For study group, therapists used MI group facilitation style described by Wagner & Ingersoll33, which lies in the middle between two approaches at both ends of a continuum of group styles: sequential individual mini-sessions that focus on treating the individual in the group rather than through the group, and interpersonal process approach that uses group interactions to draw out early developed interpersonal patterns and perceptions to be corrected in the here and now through group dynamics. MICBT groups Interweaved a focus on exploring in-dividual issues with a focus on generalizing issues by linking them with others’ concerns, then exploring those together.
Therapists used therapeutic interactions among members and working together as a main source of group power to provide support for change rather than focusing explicitly on group dynamics and aimed at linking members together by similarities in experiences, challenges, or attitudes about change, and so on. As members internalize the linkages, they begin to interact as a working group rather than coexisting as separate individuals in a room with a leader. The MICBT facilitation was relying on engagement in group process, group cohesive-ness, and mutual task involvement as key contributors to group success. The therapists used strategies to bring different members and topics into group discussions suggested by Sobell and Sobell. We had to deal with some inter-personal problems using strategies described by the same authors.
The therapists used some strategies and guidelines for shaping conversation described by American group Psychotherapy Association Science to Service Task Force to get the conversation have a productive focus and flow, leading members toward ever greater clarity of their values and goals, and investment in their plans for change.
Therapists
The MICBT groups were facilitated by two therapists; one therapist- a member of Motivational Interviewing Network of Trainers (MINT)- played the role of the group leader, and the other therapist-qualified in CBT-played the role of co-leader. Both therapists are psychiatrists and has experience of more than 5 years in addiction treatment and groups leadership and facilitation through their service in Addiction Treatment Department of Shebin Elkom mental hospital affiliated to GSMAT, Ministry of Health, Egypt. The leader played the role of content facilitator- focusing on eliciting change talk and commitment talk during a change planning discussion, while the co-leader played the role of process facilitator- focusing on summarizing and creating links between members’ feelings about change, ambivalence, or where they are along the pathway toward change, as well as interpersonal aspects, such as how they support one another. NA groups were facilitated by a certified and experienced ex-addict.
Treatment fidelity monitoring
In the present study, Assessment of Motivational Interviewing Groups – Observer Scales (AMIGOS) was implemented for accomplishing fidelity monitoring to group MI. The AMIGOS includes three scales composed of 18 items documenting group processes, client- centered style, and motivational interviewing (MI) change focus. The AMIGOS showed high inter-rater intraclass correlation coefficient (ICC) and Cronbach’s alpha, strong con-vergent and discriminant validity with the MI Treatment Integrity scales (MITI), the Therapist Empathy Scale (TES), and the group Climate Questionnaire (GCQ). The AMIGOS shows promise as a reliable and valid measure of MI group leadership and group processes and could be useful measuring other group therapies as well . Supervisors applied AMIGOS on audiotaped records of sessions.
Statistical Analysis
All analysis were intend to treatment. Multivariate imputations by chained equations “mice”, a powerful package for imputation in R was used.
Both MICBT and NA groups were compared on the demographic characteristics of the participants, levels of severity of addiction obtained by ASI, age of onset of drug use, and lifetime number of weeks of drug use. t-tests were used for continuous variables with normal distributions, while independent-Samples Mann-Whitney U Test was used for continuous variables without normal distributions.
Chi square tests were used for categorical variables. Fisher exact test helps in determining the relationship among 2 qualitative variables when the expected count is <5% in >20% of the cells. Generalized linear models, specifically hurdle negative binomial regression model were used to examine associations between treatment group and drug use days in the 90-day period before the 3- and 6-month follow-up dates. The negative binomial hurdle model is useful when the outcome is a count (i.e., days of use) with over dispersion and there is an inflation of zero values. It has two components, a truncated count component for positive counts (e.g., days of use) and a hurdle component that models the zero counts and estimates the count outcome as a logistic (e.g., drug use vs no drug use, with the logistic portion predicting no drug use).
Cox proportional hazards regression model was used to estimated group differences in lapse to sub-stance use during the 6-month follow-up. Repeated measures mixed models were used for estimating group effect on percentage days of treatment attendance. The target days to be attended are 20 days (one session weekly) basic program through 6 months, 12 days daycare through first three months after the program, and another 12 daycare days the second follow up 3 months. where the predictors were time (1 = basic 6 months, 2 = 1st day care 3 months, 3 = 2nd day care 3 months, modeled linearly), group (1 = MICBT, 0 = NA) and the time × group interaction term. The baseline level of outcome modeled was included as a covariate.
We used an AR1 structure to account for temporal correlations. We interpreted significant group main effects as overall differences due to randomized group assignment, and significant interaction effects as differences in trends over time. As outcome variables (urge-specific coping strategies and general life coping strategies) are ordinal, generalized linear models, specifically ordinal regression was applied. Baseline demographic and clinical data were included as co-variates with group factor in the linear and survival analyses. Software programs used for processing were SPSS version 26 and R packages V4.2.2.
Results
Sociodemographic variables of the participants
There was no statistically significant difference between patients of both groups regarding age, educational status, employment, and marital state. All participants were male (female admission is not yet available), aged be-tween 18 and 45 years. 43.3% of participants within MICBT group were married, whereas 40% of participants within NA group were divorced. 76.7% of MICBT group participants were educated compared to 80.3% of NA group participants. Forty percent of MICBT group participants and fifty percent of NA group participant were employed.
Clinical characteristics of participants
No statistically significant difference between both groups regarding clinical characteristics. The age of onset was in range of 15 – 30 years old for MICBT participants and 14-33 years old for NA participants. Regarding duration of drug use, the mean number of weeks of use was 305.93±194.780 for MICBT participants and 263.80±141.617 for NA participants. 70% of MICBT group participants diagnosed with various personality dis-orders compared to 64% of NA group participants.
Associations between type of intervention (MICBT Vs NA) and number of drug use days & abstinent days
Using logistic portion of GLMs zero inflated models, there was a significant main effect of treatment modality on probability of abstinence from drug use. MICBT participants, as compared with NA participants, had a significantly higher probability of abstinence from drug use through the 6 months follow up (B is positive, OR>1, p < .05). Using zero truncated count portion of, there was no significant deference between MICB group and NA group in main effect on number of days of substance use among those who still using drugs.
group differences in lapse to substance use during the 6-month follow-up (Survival analysis)
As evidenced by hazard ratios (i.e., risk of lapse given the treatment condition and other covariates). After controlling for other covariates, the mode of treatment and marital status variables. Compared with NA group, the MICBT group showed more than 90 % decreased risk of relapse to drug use.
Attendance to treatment program
There was significant main effect of; treatment group (F (1,76.56) = 87.15, P< .001), Time level (F (2,126.67) = 116.77, P< .001), and group x time interaction (F (2,126.67)= 37.98, P < .005). Attendance days % is more in MICBT than NA group (b = 12.96, SE = 1.39, t = 9.26, P < .005).
group difference in Urge Specific Coping strategies and General behavioral changes
MICBT intervention was a significant positive predictor of several urge specific coping strategies (B is positive, OR>1, and p value<0.05), such as thinking about negative consequences of drug use, alternate behavior, thinking about positive consequences of keeping abstinent, mastery of stress, distracting thoughts, using problem solving skills on facing a problem, using refusal skills when being offered, challenge the negative thoughts, thinking through a behavior chain, delaying waiting it out, using relaxation techniques and meditation, resolving the prob-lem with person, substitution by food or drink.
MICBT was significant -ve predictor for some other urge specific strategies such as cigarette substitution and thinking what therapist would say (B estimate is negative, OR<1, and p value <0.05). This indicates that the subjects in MICBT group in comparison with NA group were more likely to indicate lesser using of cigarette smoking and thinking what therapist would say as coping strategies. General Strategies for Drugs (GSD) was used as indicator for modification of problematic behavioral in order to maintain recovery.
MICBT intervention was a significant positive predictor of several general strategies for drugs (B is positive, OR >1, p value<0.05), such as keeping in contact with other social support people, sober ways for a good time, practicing relaxation or meditation regularly, keeping self-busy, healthy food, sleep, etc., avoiding tempting situations, working toward future goals, regularly reminding self “you’re sober person”, talking over feelings with others, working on problems regularly, recognizing and challenging negative thoughts, exercise regularly, living with clean/sober people, and never keep much money.
Conclusion
• The findings of this study are promising in support of the effectiveness of MICBT groups for treatment of in term of decreased days of substance use, increased abstinence days, more attachment to treatment, improved coping to craving and positive behavioral changes.
• The study applied a will described model with detailed strategies.
• The utilization of MICBT in group settings presents several benefits in clinical contexts.
• Strengths and limitations of the study, as well as recommendations for further research were discussed.
Recommendations
• Further studies are needed for determining the factors in MICBT groups (MI factors, CBT factors, and group factors) and their effect on outcome.
• It is recommended to include these factors in statistics of future studies to determine the relation between these factors and outcome.
• Replicate the study with mentioning detailed specific format and procedure used when applying MI in groups.
• More extensive work on cross-culture adaptation
• Building up a sustained supervision- coding system
• Broadening of MI concepts and spirit among therapists, clients, and families.
Strengths
The research addresses an important gap in efficacy studies by using a robust model of group MI, standardized measures, and implementation within a realistic care setting. This model combined procedures validated by Wagner & Ingersoll and Velazquez et al for MICBT in groups allows standardizing practice and reproducibility of the studies.
The strength of this technique is to elicit group energy for change, bridging across different change targets by broadening focus and change processes in addition to specific content. It allows promoting internal change talk through linking. In addition, the structure and format (closed groups) seem to facilitate group cohesion. The primary findings showed good feasibility, evidence of implementation success, better retention in the group MI condition, and some impact on Substance use. Further research should confirm these preliminary results. Regarding feasibility, there was extensive training for staff regarding MI, CBT, group facilitation skills, and all sessions were translated to Arabic. The positive verbal feedback is reflected in the participants’ adhesion to the MI groups, as the attrition rates are low. Most members were surprised and impressed by the spirit of motivational interviewing.