Structured programs for the self-management of substance addiction consequences in outpatient services: A scoping review

Abstract

Structured intervention programs are an important resource for supporting people with substance addiction. Although evidence suggests that they improve health outcomes, such as specific symptoms, less is known about their impact on patients' ability to self-manage the consequences of substance addiction. The aim of this review is to scope outpatient intervention programs focused on the self-management of substance addiction consequences. Approach. This review followed the Joanna Briggs Institute (JBI) methodology for scoping reviews. MEDLINE and CINAHL (through Ebsco), Psychology & Behav-ioral Sciences Collection (including PsycINFO) and Web of Science were screened to identify articles published in the last 10 years. Only primary research was included. Out of 891 records, 19 were eligible for this review-12 randomized controlled trials (RCT), 6 quasi-experimental study and 1 observational study. Those studies reported group interventions (10), individual interventions (8) and 1 mixed approach. The most common interventions were based on motivational strategies, relapse prevention and definition of active plans for risky situations. 10 studies reported positive effects. The identification of structured programs may support the development of new approaches focused on empowerment and quality of life of people with substance addiction. Programs to empower patients for self-management of substance addiction consequences are often complex and rely on health professionals' commitment. Nevertheless, they are a feasible approach that seems to benefit patients managing chronic conditions associated with substance addiction.

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Current Psychology (2024) 43:165–178
https://doi.org/10.1007/s12144-023-04267-z
Structured programs fortheself‑management ofsubstance addiction
consequences inoutpatient services: Ascoping review
PauloSeabra1,2,3 · GabriellaBoska4 · RuiSequeira5 · AnaSequeira5 · AnaSimões5 · InêsNunes1 ·
CarlosSequeira6
Accepted: 12 January 2023 / Published online: 23 January 2023
© The Author(s) 2023
Abstract
Structured intervention programs are an important resource for supporting people with substance addiction. Although evi-
dence suggests that they improve health outcomes, such as specific symptoms, less is known about their impact on patients’
ability to self-manage the consequences of substance addiction. The aim of this review is to scope outpatient intervention
programs focused on the self-management of substance addiction consequences. Approach. This review followed the Joanna
Briggs Institute (JBI) methodology for scoping reviews. MEDLINE and CINAHL (through Ebsco), Psychology & Behav-
ioral Sciences Collection (including PsycINFO) and Web of Science were screened to identify articles published in the last
10years. Only primary research was included. Out of 891 records, 19 were eligible for this review—12 randomized con-
trolled trials (RCT), 6 quasi-experimental study and 1 observational study. Those studies reported group interventions (10),
individual interventions (8) and 1 mixed approach. The most common interventions were based on motivational strategies,
relapse prevention and definition of active plans for risky situations. 10 studies reported positive effects. The identification
of structured programs may support the development of new approaches focused on empowerment and quality of life of
people with substance addiction. Programs to empower patients for self-management of substance addiction consequences
are often complex and rely on health professionals’ commitment. Nevertheless, they are a feasible approach that seems to
benefit patients managing chronic conditions associated with substance addiction.
Keywords Substance-related disorders· Substance addiction consequences· Addiction severity· Treatment program·
Interventions
Introduction
Psychoactive substance use is common in most societies
(World Health Organization (WHO), 2018). It is estimated
that about 3.5 millions of Europeans used cocaine last year
and 1 million are high-risk opioid users (EMCDDA, 2022).
Europe is the region of the world with the highest alcohol
consumption rate, especially in Eastern Europe (Griswold
etal., 2018; WHO, 2018). Over the next few years about 1.2
million people will undergo treatment for the use of illegal
substances in Europe (EMCDDA, 2018) and a significant
burden on health systems, caused by the high incidence
and frequently chronic consequences of substance use, will
increase.
* Paulo Seabra
pauloseabra@esel.pt
1 Nursing School ofLisbon (ESEL), Nursing Research,
Innovation andDevelopment Centre ofLisbon (CIDNUR),
Lisbon, Portugal
2 Center forHealth Services andTechnology Research
(CINTESIS) From Faculty ofMedicine oftheUniversity
ofPorto (FMUP), Oporto, Portugal
3 Escola Superior de Enfermagem de Lisboa, Av. Prof. Egas
Moniz, 1600-179Lisbon, Portugal
4 Nursing Department ofState University ofMidwest
(UNICENTRO), Study Group ofAlcohol andOther Drugs
(GEAD) atSchool ofNursing, University ofSão Paulo,
SãoPaulo, Brazil
5 Specialized Technical Treatment Unit ofBarreiro, Division
ofIntervention inAdditive Behaviors andDependencies
(DICAD), Barreiro, Portugal
6 Nursing School ofOporto, Center forHealth Services
andTechnology Research (CINTESIS) From Faculty
ofMedicine oftheUniversity ofPorto (FMUP), Oporto,
Portugal
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166 Current Psychology (2024) 43:165–178
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Substance use negatively impacts on physical, mental and
social health of patients, families and communities3. It may
cause comorbidities, such as sexually transmitted diseases,
chronic conditions related to risky behaviours or careless
health surveillance, mood and anxiety disorders, functional
impairment (including the capacity to maintain a job), social
and family disfunction and suffering (Carew & Comiskey,
2018). This set of complex and multidimensional problems
can be defined as the “consequences of substance addiction”,
and they compromise both health status and social function-
ing (Seabra etal., 2018).
Since the second half of the twentieth century, special-
ized care for people with substance addiction have been
developed in many countries. Since then, users are often
supported by health professionals in different specialized
intervention programs, that include medication and/or psy-
chotherapeutic and psychosocial support. Access to this type
of care has increased the average life expectancy of the pop-
ulation of substance users, meaning that today many users
are older and have more comorbidities. These comorbidities
result both from the greater number of years of consump-
tion, and from the ageing process itself. Despite the attempt
that has been done by the health systems to promote a more
functional and positive life for these people, they still suffer
from social exclusion (Carew & Comiskey, 2018; Gowing
etal., 2015).
Most of the available intervention programs focus primar-
ily on maintaining abstinence, preventing relapse, or improv-
ing the relationship with addictive substances by enhancing
the ability to manage their use. Despite the well-recognised
consequences of substance use and its often-chronic nature,
increasing the capacity to self-manage these consequences
still seems to be a less common focus for these programs.
Self-management is defined as the “intrinsically con-
trolled ability of an active, responsible, informed, and
autonomous individual to live with the medical, role and
emotional consequences of his chronic conditions in part-
nership with his social network and the healthcare provid-
ers” (Velde etal., 2019). This concept is particularly use-
ful to promote users’ engagement and responsibility, which
is particularly important given the chronic nature of many
of the consequences of substance use. Also, this concept
appeals to a community context as it is in the proximity to
the environment in which the person lives that the support
can be most effective.
The development of training programmes to improve
self-management of substance addiction consequences is
recommended (Velde etal., 2019). Interventions targeting
specific substance use consequences, such as anxiety (Erim
etal., 2016), depression (Spilsburry, 2012), aggressive
behaviour and consumption impulse (Jones etal., 2016) have
already been reported as effective, allowing for improved
self-management of substance addiction consequences.
The identification of available intervention programmes
is important to understand their scope, structure, results,
and limitations, which may inform the development of new
programmes focused on promoting self-management of the
consequences of substance use. The problem is that many
times research and clinical practices does not entitle a group
of interventions as “programs” with a structure (objectives,
target population, number of sections, type of intervention,
time of execution, outcomes, follow-up) and detail set of
content interventions (Sousa & Sequeira, 2012).
In September 2020, an initial search on PubMed (Med-
line) and PsycINFO (APA) was undertaken, but no literature
reviews focused on self-management of substance addiction
consequences were found. We have also searched Cochrane
Database of Systematic Reviews, the Joanna Briggs Institute
(JBI) Database of Systematic Reviews and Implementation
Reports, the Center for Open Science, and the PROSPERO
platform. No registered protocols or completed reviews were
identified. Only one review protocol with similar objec-
tives was found but it focused exclusively on substance
abstinence.
This review aims to identify outpatient structured pro-
grams that focus on empowerment for the self-management
of substance addiction consequences. The following research
question was formulated, based on the PCC acronym (Popu-
lation, Concept and Context): What are the existing inter-
vention programs focused on self-management of substance
addiction consequences for adults in outpatient services?
Materials andmethods
This scoping review followed the JBI methodology for
scoping reviews (Peters etal., 2020) and used the Preferred
Reporting Items for Systematic Reviews and Meta-Analy-
sis Extension for Scoping Reviews (PRISMA-ScR) (Tricco
etal., 2018).
Protocol andregistration
The protocol was registered prospectively in the Open Sci-
ence Framework on 14th June 2020 (https:// osf. io/ bry9n/).
Eligible criteria
We have searched for English, Spanish, and Portuguese arti-
cles published between December 2010 and December 2020.
The search strategy included keywords based on PCC:
• Participants—Adults (more than 18years), both sex,
undergoing any kind of treatment in a drug addiction
health outpatient facility (medication-assisted or non-
medication assisted treatments), with problematic use of
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167Current Psychology (2024) 43:165–178
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all psychoactive substances (opioids, cocaine, cannabis,
amphetamines, alcohol, nicotine), except caffeine.
• Concept—Structured programs or interventions to
improve self-management and/or self-care of substance
addiction consequences. The structure, objectives, con-
tent, time of execution, outcomes and existence or not of
follow-up must be clearly defined.
• Context—Primary health care or community outpatient
addiction units.
Exclusion criteria
Exclusion criteria were defined based on both population
and intervention characteristics.
Population: all participants with the same psychological
comorbidity; studies using financial incentives during or
after completing the programs.
Intervention: interventions for inpatient units, even if
continued in outpatient contexts; trials of pharmaceutical
drugs; interventions not focused on improving self-manage-
ment and/or self-care on patients with substance addiction
consequences.
Search strategy
An initial limited search of MEDLINE and CINAHL was
undertaken to identify articles on the topic. The words from
titles and abstracts of relevant articles and the indexed terms
were used to develop a complete search strategy. The fol-
lowing databases were screened: MEDLINE and CINAHL
(through Ebsco), Psychology & Behavioral Sciences Col-
lection (including PsycINFO) and Web of Science. We
used Google Scholar and ResearchGate and contacted the
author(s) by e-mail when full text access was not available.
The search was conducted between 1st- 5th January 2021
(see Appendix 1). The search strategy, including all identi-
fied keywords and index terms, was adapted for each source.
Reference lists of the identified articles were screened to
identify additional studies.
Selection ofsources ofevidence
This scoping review considered primary qualitative and
quantitative studies, economic and mixed methods, experi-
mental and quasi-experimental studies, including rand-
omized and non-randomized controlled trials, before and
after studies and interrupted time-series studies. Obser-
vational analytical studies, including prospective and ret-
rospective cohort studies, case–control studies, and cross-
sectional analytical studies were also included. We have
decided to exclude gray literature to ensure the inclusion of
only the most rigorous studies.
Data charting process
All identified records were uploaded into Mendeley and
duplicates were removed. The decision process, including
the selection of titles, abstracts, and full texts, was guided
by the inclusion/exclusion criteria. Articles were screened
by three independent paired reviewers (PS and GB and IN).
In case of disagreement, another reviewer of the team was
consulted for discussion (CS or RS). The review decision
process is presented in a PRISMA-ScR flowchart (Fig.1)
(Tricco etal., 2018). Two independent reviewers extracted
data using a pretested form to register all the necessary
information, according to the objectives and research ques-
tion (Peters etal., 2020). This information is summarized in
Table1. All data can be found on Appendix 2.
Results
Synthesis ofresults
As shown in Fig.1, 891 potentially relevant studies were
identified. Of these, 873 were excluded since they were
duplicated and did not fit the inclusion criteria. 18 studies
were selected for this review, and 1 was included by screen-
ing the references of the articles. Table1 presents the infor-
mation about the 19 articles that have been included.
Different types of studies have been identified: 12 rand-
omized control studies (RCT) (Amiri etal., 2016; Andersson
etal., 2017; Carmody etal., 2012; Feldman etal., 2013;
Ghasemi etal., 2014; Imani etal., 2015; Raes etal., 2011;
Schuman etal., 2015; Tarp etal., 2017; Tiburcio etal.,
2018; Walitzer etal., 2015; Wüsthoff etal., 2014), 6 quasi-
experimental research designs with pre and post evaluation
(Alfonso etal., 2011; Campbell etal., 2015; Khan etal.,
2020; Tam etal., 2016; Wieben etal., 2018; Wodarski &
Green, 2015), and 1 observational study (McKowen etal.,
2018). Six of these studies were conducted in the United
States of America (USA), three in Iran, two in Denmark,
and the others in different countries. The mean age of par-
ticipants was 23–55years old, with greater representative-
ness of the age groups 20–30years (Ghasemi etal., 2014;
Raes etal., 2011; Schuman etal., 2015) and 31–40years
(Campbell etal., 2015; McKowen etal., 2018; Wodarski &
Green, 2015).
Structure oftheprograms
A total of 3410 different substance users participated in the
interventions identified by this review. 5 studies explicitly
focused on alcohol problematic users (Andersson etal.,
2017; Tarp etal., 2017; Walitzer etal., 2015; Wieben
etal., 2018; Wüsthoff etal., 2014), 1 on methamphetamine
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168 Current Psychology (2024) 43:165–178
1 3
users (Amiri etal., 2016), 2 on patients under medica-
tion-assisted treatment with methadone (Feldman etal.,
2013; Imani etal., 2015) and the remaining 13 addressed
polysubstance users. The articles identified 10 group
approaches, 8 individual and 1 based on a mix of indi-
vidual and group approaches.
The most usual time frame for the intervention is 4
or 8weeks (four studies each). In the remaining studies,
the interventions took place between 5–28weeks. The
most frequent number of sessions were 12, followed by
8 sessions. In the remaining studies, the intervention ran
between 5–40 sessions. The duration of each session was
reported in only 12 studies. The most usual duration per
session was 1h (five studies), followed by < 1h (three
studies). The most frequent duration for the total interven-
tion was 12h.
The main objective of the programs was to reduce sub-
stance use (nine studies), improve health outcomes (seven
studies), increase treatment compliance (five studies),
followed by diverse objectives such as improving qual-
ity of life, decision-making and social skills and reducing
relapses and mental suffering.
Therapeutic interventions
We found a wide range of individual and group interven-
tions. They were delivered face-to-face, online (with syn-
chronous and asynchronous sessions), or in hybrid mode.
The most prevalent aim of the interventions was to empower
patients to better cope with addiction and to self-manage its
consequences.
Cognitive-behavioural therapy (CBT) underlies 13 of the
studies and was the most frequent intervention, including
the classical approach (six studies), web-based therapy (one
study) and CBT techniques focused on emotion, anxiety,
and mood (six studies). The second most used intervention
may be designated as "Identification and definition of action
plans for risk situations—triggers and desire situations and
use of rejection skills" (10 studies). In third place, "Motiva-
tional interviewing—exploring motivation for change and
personal responsibility" stands out (nine studies). Other
interventions, in descending order of frequency include:
'Relapse prevention' (seven studies); 'Psychoeducation
(addiction and recovery, comorbidities and drug effects)',
along with 'Goal setting' and 'Social support' (each with six
Fig. 1 Study selection and
inclusion process
+ Selected from the
references of SLR
n=1
Records identified through database searching
(n = 891)
MedLine n=242
CINAHL n=175
Web of Science n=399
Psychology and Behavioral Sciences Collection n=75
Records after 428 duplicates
removed
n=463
Idenficaon
Eli
g
ibilit
y
IncludedScreenin
g
Studies included to final
extraction
(n=19)
Records excluded=380
(Title n=206)
(Abstractn=169)
(No full text after contacting
theauthor=5)
Records screened based on title and
abstract
n=463
Full-text articles excluded, with reasons=65
Financial compensation=31
Population inadequacy=12
Does not evaluate interventions=15
Systematic Literature Review (SLR)=4
out of time period =1
ExclusiveAA=2
Full-text articles assessed for
eligibility
n= 83
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169Current Psychology (2024) 43:165–178
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Table 1 Data extracted from the included studies
Nº of the study Country Study type Sample (If RCT,
intervention/control
group)
Type of substance use Objectives Intervention Weeks/number of ses-
sions/time of each session/
Total time
1
México
(Tiburcio etal., 2018)
RCT (3 arms) 83 (27 + 27 + 29)
Age 18–25
Cannabis; Cocaine;
Inhalants
↓Substance use and
depression
Group – 1st arm—Web-based CBT based
on the transtheoretical model of change.
Structure: Retrospective baseline; Deci-
sional balance; Motivation to change;
Definition of goals; Diary of drug use
behavior; Functional analysis of drug
use behavior; Action plans for risk
situations; Psychoeducation; Emotional
control techniques for anxiety; Positive
self-reinforcement; Social skills; Social
support; Drug use rejection skills;
Relapse prevention; Cognitive restruc-
turing techniques
Group 2nd arm: ASSIST Self-Help
Strategies guide. Daily register of
substance use, establishment of goals,
identification of high-risk situations,
and techniques for resisting pressure
to use drugs
8weeks/8 sessions/1h
each session/Total of 8h
Findings: ↓ average days of substance use; ↓depressive symptoms; → No more effective than Treatment as Usual (TAU)
2
USA
(McKowen etal., 2018)
Observational longi-
tudinal study
30 participants
mean age 36years
[22–64]
Alcohol and drugs ↓substance use
↑ neurocognitive
functioning
Group—Psychoeducation about addic-
tion and recovery; CBT for mood and
emotions; Relapse prevention strate-
gies; Motivational strategies
4weeks/12 sessions/2h
each session/Total of
24h
Findings: ↓average days of use; ↓depressive symptoms; No improvement on global neurocognitive functioning, except material organization
3
Norway
(Wüsthoff etal., 2014)
RCT 56 (39 + 17)
Mean age:
Intervention group 32;
Control Group 42
Alcohol ↓substance use, anxiety
and depression
↑ motivation to treat-
ment
Individual – CBT + motivational
interview + personal and social func-
tionality support (housing, vocational
function, ability to manage psychiatric
illness and family and social relation-
ships) + family approach
No available information
Findings: ↑ Motivation to treatment → No more effective in reducing substance use, anxiety and depression than TAU
4
Belgium
(Raes etal., 2011)
RCT 227 (116 + 111)
Mean age: Interven-
tion Group 27;
Control Group 26
Cannabis, Cocaine, Opi-
ates, Amphetamines
↑ Compliance with
treatment
Individual—Feedback sessions on the
stages of change, personal resources
and focus on the areas of life that peo-
ple identified as wanting to change
4weeks/12 sessions/1h
each/Total of 12h
Findings: ↑ Compliance with treatment at and beyond eight sessions compared to TAU
5
USA
(Wodarski & Green, 2015)
Quasi-experimental Unknown number of
participants
Mean age 31years
[18–56]
Alcohol and/or drugs ↑ motivation to avoid
or reduce levels of
alcohol and or drugs
use
Mixed individual and group approach—
Face-to-face screening, brief assess-
ment, and referral + Texting and/
or e-mailing users for appointment
reminders/ Online facilitated recover
support (E-therapy) + Online individual
and group counseling—Brief interven-
tions/ Virtual community and peer sup-
port + Computer-based interventions/
Supplemental face to face counseling,
treatment, and recovery support
No available information
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170 Current Psychology (2024) 43:165–178
1 3
Table 1 (continued)
Nº of the study Country Study type Sample (If RCT,
intervention/control
group)
Type of substance use Objectives Intervention Weeks/number of ses-
sions/time of each session/
Total time
Findings: ↓ Alcohol and drug use; ↓injection use; ↓Depression; physical complaints; violent behaviors; ↑Overall Health
6
Denmark
(Wieben etal., 2018)
Coorte Quasi- experi-
mental
1398 participants
2 groups: > 60years
and 40–59years
Alcohol ↓alcohol use
↑ compliance with
treatment
Individual—Initial detoxification if
necessary—motivational interview-
ing + CBT + Family Therapy + support-
ive consult ations + optional disulfiram
No available information
about the number of
weeks and sessions/1h
each session
Findings: ↓ Alcohol—elderly patients had better outcomes compared with middle age patients;↑compliance with treatment in elderly compared with middle-aged patients
7
USA
(Schuman etal., 2015)
RCT 263 participants
(137 + 126)
Mean age 27
Alcohol, Cannabis,
cocaine
↑ therapy results and
retention rates
Group approach. CBT + inter personal
process + psychodynamic + solution-
focused approaches + feedback.
Before each session, participants
completed the computerized version
of the Outcome Rating Scale (ORS),
Psychological functioning and
distress. The program automatically
scored which allows clinicians to
identify clients who were making
progress as expected, as well as those
at risk for premature termination or a
negative outcome
5week/5 sessions/1,5h
session/Total of 7,5h
Findings: ↑ Clinical Outcome compared to TAU; ↑ retention scales compared to TAU
8
USA
(Campbell etal., 2015)
Mixed methods.
Coorte Quasi
experimental Pilot
study
40 participants
Mean age 37,5years
Alcohol, metham-
phetamines, Opiates,
Cannabis
↑ treatment outcomes Individual—therapeutic education
system (TES) with 32 interactive,
multimedia modules (basic cognitive
behavioral relapse prevention + skills
to improve psychosocial function-
ing + psychoeducation content of
prevention of HIV, Hepatitis and other
sexually transmitted infections) (see
on Appendix 2)
8weeks/16 ses-
sions/40min/Total of
10,6h
Findings: ↓ number of days of alcohol and drug use
9
USA
(Walitzer etal., 2015)
RCT 76 participants
(36 + 40)
Age [18–65]
Alcohol ↑ Alcohol outcomes Group approch—Anger management
therapy (relaxation, cognitive coping
skills for anger regulation, identification
of external situations that elicit anger)
No available information
about the number of
weeks/ 12 sessions/1h
each session/Total of
12h
Findings: ↓ anger on all measures; ↓ maladaptive angry thoughts. ↑Increased self-confidence in managing alcohol use in the face of anger
→ No results about the efficacy of the program compared to Anonymous Alcoholics (AA)
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171Current Psychology (2024) 43:165–178
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Table 1 (continued)
Nº of the study Country Study type Sample (If RCT,
intervention/control
group)
Type of substance use Objectives Intervention Weeks/number of ses-
sions/time of each session/
Total time
10
Sweden
(Andersson etal., 2017)
RCT (3 arms) 248 participants
(86 + 86 + 76)
Alcohol ↓alchool use Individual approach
# Telephone brief intervention—feed-
back about participant’s hazardous
alcohol use + establishment of an
individual goal for alcohol use
# Telephone extensive intervention—
feedback on participant’s hazardous
alcohol use + definition of an individ-
ual goal either to reduce drinking or
attain abstinence. Intervention: menu
of spoken texts on the advantages
and disadvantages of drinking and
vignettes presenting different strate-
gies; learning to refuse alcohol in
social situations, and relaxation/mind-
fulness exercises. Unlimited access to
the platform for 4weeks, with weekly
automated follow-up calls
4weeks
Findings: ↓ alcohol use. No overall differences between groups
11
Switzerland
(Feldman etal., 2013)
RCT (2 arms) 112 participants
(60 + 52)
Mean age 35 [18–56]
Alcohol, opiates, cocaine ↑ self-observation
related with alcohol
use
↓ reduce alcohol use or
abstinence
Individual approach
- Brief Intervention (patients in metha-
done substitution (56.2%) and diacetyl
morphine (12%)) = Provide feedback
after AUDIT assessment; Identify risks
and discuss consequences; Display an
emphatic and nonjudgmental attitude;
Solicit the patient’s commitment;
Identify alcohol related goal; Choice of
personal strategies; Emphasize personal
responsibility for change; stimulate an
attitude of change; Give advice and
encouragement
4weeks/ no information
about number of ses-
sions/ 16min session
Findings: ↓ number of drinks per week and frequency were observed at T3, but results did not persist at T9; ↓ AUDIT scores: between T0 and T3 but not between T3 and T9; → No statistically significant difference on AUDIT
between treatment groups was observed; Between T0 and T3 AUDIT score reduce for alcohol dependent patients and an increase for excessive drinkers. The difference between excessive drinkers and alcohol dependents for the
number of alcoholic drinks consumed is statistically significant
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172 Current Psychology (2024) 43:165–178
1 3
Table 1 (continued)
Nº of the study Country Study type Sample (If RCT,
intervention/control
group)
Type of substance use Objectives Intervention Weeks/number of ses-
sions/time of each session/
Total time
12
Iran
(Imani etal., 2015)
Pilot RCT 30 participants
(15 + 15)
Age [18–40]
Opiates and alcohol ↑ Treatment outcomes Group approach
- Mindfulness based prevention group
therapy for patients on medication
assisted treatment: Predefined title
and content for each session. Sessions
were kept in sequence. Topics: relapse,
its consequences and emotional
disturbances; awareness of triggers and
craving; mindfulness in daily life situa-
tions; mindfulness in high risk situation
related do drug use; acceptance and
skillful action (learning the role of
acceptance in the change process);
seeing thoughts as thoughts; self-care
and lifestyle balance (warning signs for
relapse and response); social support
and continuing practice
8weeks/ 8 sessions/2h
each session / Total
of 16h
Findings: ↓ opioid and alcohol use in both groups but more significantly on the intervention group; ↑observing, describing, acting with awareness, non-judgemental, nonreacting
13
China
(Tam etal., 2016)
Pre and post Experi-
mental design
with comparative
approach for 2
groups
12 participants (6 + 6)
Age [25–30]
Drug users ↓ Relapse Group approach
1- Cognitive – behavioral relapse
prevention: (1) understand the impor-
tance of thoughts and emotions in
keeping abstinence, (2) anticipate pos-
sible high-risk situations associated
with relapse, (3) modify maladaptive
beliefs about drug-related behavior,
(4) practice skills to cope with and
handle drug urges and craving, and
(5) identify supportive networks and
develop a future recovery plan
2- Art-based relapse prevention. Art
means (drawing, clay making, cartoon
and finger puppets, collage, treasure box
and group mural) to (1) express inner-
most feelings in using drugs, and the
difficulties in facing the road to recovery
ahead; (2) review internal strengths to
manage the problem, the high-risk situ-
ations around, and the external supports
that could help to remain abstinent. (3)
re-think and re-construct life goals and
future ways of living in a metaphori-
cally expressed way
No available information
about the number of
weeks / 6 sessions
Findings: ↑ relapse perception. → the art-based relapse prevention group was found to be as effective as the cognitive-behavioral-based group, particularly for men
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173Current Psychology (2024) 43:165–178
1 3
Table 1 (continued)
Nº of the study Country Study type Sample (If RCT,
intervention/control
group)
Type of substance use Objectives Intervention Weeks/number of ses-
sions/time of each session/
Total time
14
Spain
(Alfonso etal., 2011)
Pre and post experi-
mental pilot study
with 2 groups
34 participants
(18 + 16)
Alcohol and multiple
drugs
↓executive and
decision-making
deficits
↑ improved
performance on
neuropsychological
measures—work-
ing memory and
response inhibition
Group approach
- Goal Management Training (to
improve participants’ organization
and ability to achieve goals, to stop
prepotent responses, inadequate
forethought and poor planning or
decision-making skills) + Mindfulness
(meditation to improve attentional
scanning and “reading” of emotional
signals involved in adaptive decision-
making + strategy to overcome
attentional lapses)
7weeks/14 sessions/1h
each session/ Total of14
hours
Findings: ↑ Performance on neuropsychological measures of working memory, selective attention/response inhibition and executive and decision-making → No significant improvement on planning and flexibility; Individuals
enrolled in standard treatment alone failed to show significant changes
15
Canada
(Khara & Okoli, 2011)
Quasi Experimental
Pilot study with
one group
259 participants Tobacco and other sub-
stance use
↑ Smoking cessation Group approach
No-cost pharmacotherapy and group
counseling. Structured behavioral
counseling: topics such as nicotine
dependence, coping strategies for
quitting, relapse prevention, and
pharmacotherapy for quitting
Optional 18weeks of “after care” group
support
8weeks/ 8 sessions/1,5h
each session/Total of
12h
Optional 18weeks/18 ses-
sions/1h each session/
Total of 18h
Findings: 75% of participants completed the program with an abstinence rate of 43%. Not having a primary substance use history and a lower carbon monoxide (CO) level at intake, predicted abstinence
16
Denmark
(Tarp etal., 2017)
RCT (2 arms) 71 participants
(32 + 39)
Mean age 47
Alcohol ↑ compliance with treat-
ment
↓Use of alcohol
Individual—TAU + I = Motivational
interview + CBT + supportive
consultation or family therapy or
contract treatment (TAU) + offered
optional videoconferencing
7months/ 28–40 ses-
sions/30-60min each
session
Findings: ↑compliance with treatment → No significant difference between the 2 groups concerning successful completion of treatment and treatment outcome
17
Iran
(Amiri etal., 2016)
RCT (2 arms) 24 participants
(12 + 12)
Mean age of 47years
vs 28years
Methamphetamine ↓Lapses
↓ Methamphetamine
use
Group—Regulated 12-Session Matrix
Model: 1- Why I withdraw substance?
(Justice balance); 2- Starters and
their types; 3- Major problems in
remission: Family mistrust/ Energy
reduction/ Drug misuse; 4- Lapse and
ways of coping with it; 5- Thoughts,
feelings, and precedent behaviors; 6-
Impatience and depression; 7/8- Pre-
ventive and susceptible activities to
relapse/ sexual relations; 9- Occupa-
tion and remission/ getting involved;
10—Shame and guilt/ Honesty; 11—
Motive to remission/ full abstinence;
12—Anticipation of relapse
12weeks / 12 sessions
Findings: ↓ methamphetamine use, comparing to control group
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174 Current Psychology (2024) 43:165–178
1 3
Table 1 (continued)
Nº of the study Country Study type Sample (If RCT,
intervention/control
group)
Type of substance use Objectives Intervention Weeks/number of ses-
sions/time of each session/
Total time
18
Iran
(Ghasemi etal., 2014)
RCT (3 arms) 285 participants
(95 + 95 + 95)
Mean age 23
Mean age of family
participants (2nd
arm) 31
Methamphetamines and
other drugs
↑ Social support
↑ Health (physical,
mental and social
perceived support)
↑ Quality of life
Group—Sessions: 1) introduction
of group members, statement of
treatment purpose, definition of
drugs, and methods of prevention; 2)
definition of QoL and its dimensions;
3) emphasis on identification of sup-
portive resources and optimal usage
of these resources in addiction treat-
ment; 4) training on problem solving
methods in order to encounter life in
a sustain manner and identification
of opportunities to express emotions
to identified members of social
support resources; 5) training relief
techniques and positive visualization
to reduce anxiety and enhance internal
tranquility; 6) analysis of the sense of
sin and alleviation of it and seize of
chances to express emotions to group
members; 7) training on methods
of self-confidence and self-esteem
reinforcement based on personal
abilities and applying them to deal
with daily activities; and 8) statement
of summary of last sessions topics and
giving feedback. 9) Free topics
9 sessions
Findings: ↑health-promoting lifestyle, health-related QoL, self-efficacy, perceived affect, perceived social support, and perceived barriers compared to control group
19
USA
(Carmody etal., 2012)
RCT (2 arms) 162 participants
(82 + 80)
Mean age 50
Tobacco; alcohol ↑ compliance with
treatment
↑cessation outcome
and not increase of
alcohol use
Individual
- 16 sessions of CBT, including motiva-
tional enhancement for smoking ces-
sation, including mood management,
nicotine patches. First 5 sessions
focused on the health consequences of
smoking and preparation for the quit
date. The final 11 sessions included
treatment modules addressing skills
training in mood management,
cognitive restructuring, behavioral
activation, social support, and weight
management. After the 16 sessions
more 10weeks with nicotine lozenges
16weeks/16 sessions/ The
first 12 sessions on a
weekly basis—Sessions
13 and 14 conducted on
alternate weeks / 15 and
16 four weeks apart
Findings: ↑ quit rates at 12 and 26weeks on intensive program, but no difference at 38 or 52weeks; ↑ Prevalence abstinence compared with TAU; ↓ number of cigarettes in the 7days prior to each assessment in the intensive pro-
gram compared with TAU except on 52weeks follow up; ↓ CO levels; → 30-day alcohol abstinence rates were not significantly different for the two treatment groups at any of the follow-up assessments
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175Current Psychology (2024) 43:165–178
1 3
studies); 'Providing feedback' (five studies); 'Relaxation',
(four studies); 'Decision balancing techniques' and 'Behav-
ioural counselling' (three studies). Finally, a group of dif-
ferent less frequent interventions can be found in Table1.
Strategies to encourage participation in interventions and
programmes, such as phone calls, text messages and e-mails,
should also be mentioned.
Outcomes
All studies report positive outcomes on users' health and
quality of life.
In 10 studies there was a significant improvement in the
experimental group vs control group with usual treatment
after the final evaluation of the intervention program (high-
lighted in Table1). The most frequent outcomes are: less
substance use (Amiri etal., 2016; Campbell etal., 2015;
Imani etal., 2015; McKowen etal., 2018; Wieben etal.,
2018; Wodarski & Green, 2015); improvement of general
health (Alfonso etal., 2011; Ghasemi etal., 2014; Schu-
man etal., 2015; Wodarski & Green, 2015); more treatment
adhering (Raes etal., 2011; Schuman etal., 2015; Wieben
etal., 2018) and less depression (McKowen etal., 2018;
Wodarski & Green, 2015).
In the remaining nine studies important positive outcomes
were also achieved, including: less substance use (Anders-
son etal., 2017; Carmody etal., 2012; Tiburcio etal., 2018);
more motivation to treatment (Wüsthoff etal., 2014); less
depressive symptoms (Tiburcio etal., 2018); less anger and
maladaptive behavior (Wüsthoff etal., 2014); more self-con-
fidence related to substance use (Wüsthoff etal., 2014); more
relapse perception (Tam etal., 2016) and more compliance
with treatment (Amiri etal., 2016; Khara & Okoli, 2011).
Most interventions were focused on alcohol or one other
substance or the use of multiple substances. Only in three
studies, we find interventions directed exclusively to a single
substance (Amiri etal., 2016; Imani etal., 2015; Wieben
etal., 2018). Some studies do not identity the type of the
substance who they are facing, telling only “drugs” and,
some of them distinguishes between alcohol and drugs.
Discussion
The objective of this review was to map the available evi-
dence about structured outpatient programs and interven-
tions for training self-management of substance addiction
consequences. We looked for structure, objectives, target
population, type of intervention, time of execution, out-
comes in different dimensions (physical, psychological,
and social) and follow-up. We have found programmes,
with a clearly defined structure, including 9 to 32 the-
matic sessions (Amiri etal., 2016; Campbell etal., 2015;
Carmody etal., 2012; Ghasemi etal., 2014). The remain-
ing studies reported different therapeutic strategies or
interventions aiming at specific goals.
Overall, these programs and interventions showed pos-
itive outcomes on self-management, self-care and qual-
ity of life. The studies without comparison with a TAU
group revealed positive effects, such as less substance use
(Andersson etal., 2017; Carmody etal., 2012; Tiburcio
etal., 2018), more motivation for treatment (Wüsthoff
etal., 2014), fewer depressive symptoms (Tiburcio etal.,
2018), less anger and maladaptive behaviour (Wüsthoff
etal., 2014), more self-confidence (Wüsthoff etal., 2014),
more perceived risk of relapse (Tam etal., 2016) and more
treatment adherence (Khara & Okoli, 2011). On the other
hand, interventions that were compared to TAU achieved
important goals including improved health (Ghasemi
etal., 2014; Wodarski & Green, 2015), less substance use
(McKowen etal., 2018; Wieben etal., 2018), more treat-
ment adherence (Raes etal., 2011; Schuman etal., 2015)
and less depression (McKowen etal., 2018; Wodarski &
Green, 2015). These results strongly support evidence-
based practice and suggest the value of e-therapy interven-
tions with synchronous or asynchronous remote support
from a therapist (Kelly etal., 2020; Sousa etal., 2020).
Since some of the articles did not explicitly present
their methodology, we have faced some difficulties
identifying the context in which the intervention took
place. Concerning the concepts of self-management
and self-care, we were able to identify the objectives
that were directedly related to self-determination,
autonomy, self-monitoring, empowerment and deci-
sion support, not only in most of the programs but also
in single interventions (Grady & Gough, 2014; Long
etal., 2018; Velde etal., 2019). We found programmes
with different structures, mostly lasting four or eight
weeks, with 1h or less per session. This structure is in
accordance with the proposal by Sampaio etal. (2018)
for psychotherapeutic programmes but is shorter than
other interventions for different psychiatric conditions
(Liu etal., 2021).
Since the available literature suggests that elderly patients
are a growing problem in treatment units (Han & Moore,
2018), we expected to find a greater expressiveness of this
age group. However, only two studies had participants
whose mean-age was over 40years (Amiri etal., 2016;
Wieben etal., 2018). Labour issues, such as employment
status and financial difficulties, were addressed in some
studies (Campbell etal., 2015; Carmody etal., 2012; Khara
& Okoli, 2011; Raes etal., 2011; Schuman etal., 2015;
Tiburcio etal., 2018), although this information was absent
in many of them. Employment is a key factor for quality of
life and for self-management of substance addiction conse-
quences, so it is surprising that only a few interventions took
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176 Current Psychology (2024) 43:165–178
1 3
this aspect into account (Campbell etal., 2015; Ghasemi
etal., 2014).
These studies identified a reduction in substance use
regardless of type of intervention, type of substance used
and whether it was directed at a single substance (Amiri
etal., 2016; Raes etal., 2011) or multiple substances (Gha-
semi etal., 2014; McKowen etal., 2018). Multiple substance
use is common and is a predictor of worse outcomes (Seabra
etal., 2018), which justifies the need to develop interven-
tions targeting it because their prevalence is quite common
and their neuropsychological action and functioning are sim-
ilar (Volkow etal., 2016). To face this need to help patients
to deal step by step to multiple substances, is the reason why
these studies highlight the applicability of CBT as one of the
preferred theoretical references in substance use disorders
(Mueller etal., 2012; NIDA, 2018). Others include inter-
ventions based on motivational strategies (McKowen etal.,
2018; Wieben etal., 2018), relapse prevention (Campbell
etal., 2015; Imani etal., 2015), psychoeducation (Camp-
bell etal., 2015; McKowen etal., 2018), risk awareness,
personal goals, decision-making skills, acceptance (Alfonso
etal., 2011; Amiri etal., 2016; Imani etal., 2015), behav-
ioural counselling, and feedback sessions (Schuman etal.,
2015; Wodarski & Green, 2015), social support (Ghasemi
etal., 2014; Imani etal., 2015) and relaxation and mindful-
ness (Alfonso etal., 2011; Imani etal., 2015; Walitzer etal.,
2015), which have been highly recommended (NIDA, 2018).
Limitations
Some of the exclusion criteria may have limited the scope of
this review, namely: the inclusion of publications only from
the last 10years, the exclusion of grey literature, and the
exclusion of all studies in which participants received any
direct or indirect monetary compensation.
Conclusions
This review identified 19 studies that answered our research
question and met our inclusion criteria. Four of them were
structured intervention programs; the other reported a vari-
ety of organized therapeutic interventions. All the articles
support positive outcomes for the identified programs and
interventions. This data was reinforced by 94.7% of the stud-
ies with pre and post evaluation. The outcomes were ana-
lysed considering different dimensions, such as the physical,
psychological, and social one.
The main objective of the programs was to reduce sub-
stance use, improve health outcomes and increase com-
pliance with treatment. There is growing evidence of the
effectiveness of E-health interventions that complement, and
sometimes even replace, face-to-face approaches. Computer-
based therapy and hybrid approaches may allow patients to
enroll the intervention at their own individual pace.
The most common interventions and strategies were
cognitive-behavioural therapy, identification and definition
of action plans for risky situations, motivational interview,
relapse prevention, psychoeducation, definition of goals,
social support, feedback sessions, relaxation, decision bal-
ance skills and behavior counseling.
The most frequent outcomes were less substance use,
improved health, more motivation and/or compliance with
treatment, more self-confidence, more relapse awareness,
less depression and less anger and maladaptive behaviours.
This review synthesises a wide range of interventions
with positive outcomes and can be a resource for evidence-
based practice and the future development of systematic
reviews. It presents evidence to support the development of
a clinical intervention targeting the problem of substance use
and self-management of its consequences and may contrib-
ute to stimulate a much needed social and political reflection
about healthcare for people with problematic substance use.
Supplementary Information The online version contains supplemen-
tary material available at https:// doi. org/ 10. 1007/ s12144- 023- 04267-z.
Author contribution All authors have made substantial contributions to
this research process. Paulo Seabra (PS) and Carlos Sequeira (CS) had
the idea for the article. Paulo Seabra, Inês Nunes (IN), Gabriela Boska
(GB), Rui Sequeira (RS), Ana Sequeira (AS) and Ana Simões (AS)
performed the literature search and data analysis, and Paulo Seabra,
Inês Nunes, Gabriela Boska and Carlos Sequeira drafted and critically
revised the work. Finally, all authors were responsible for writing the
article. All authors have approved the submitted version.
Funding Open access funding provided by FCT|FCCN (b-on). The
authors did not receive financial support from any organization for the
submitted work.
Data availability No additional data are available.
Code availability Not applicable.
Declarations
Ethical approval This article does not contain any studies with human
participants performed by any of the authors.
Consent to participate Not applicable.
Consent for publication Not applicable.
Conflicts of interest None.
Open Access This article is licensed under a Creative Commons Attri-
bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes
were made. The images or other third party material in this article are
included in the article's Creative Commons licence, unless indicated
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177Current Psychology (2024) 43:165–178
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otherwise in a credit line to the material. If material is not included in
the article's Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.
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