Abstracts

INTRODUCTION

Adherence to treatment for drug addiction is one of the biggest challenges in mental health clinical practice. ⁴²42 . Rutkowski BA, Gallon S, Rawson RA, Freese TE, Bruehl A, Crèvecoeur-Macphail D, et al. Improving client engagement and retention in treatment: The Los Angeles County experience. J Subst Abuse Treat. 2010;39(1):78-86. DOI:10.1016/j.jsat.2010.03.015
https://doi.org/10.1016/j.jsat.2010.03.0... It is measured by the dropout rate, expressed as a percentage, reflecting the losses in monitored individuals, for whatever reason, over a specific time. Poor adherence to treatment is responsible for many setbacks in treating drug addiction as it leads to reductions in the efficacy of treatment, to socioeconomic costs and to high mortality rates. ²2 . Amato L, Minozzi S, Davoli M, Vecchi S, Ferri MM, Mayet S. Psychosocial and pharmacological treatments versus pharmacological treatment for opioid detoxification. Cochrane Database Syst Rev. 2008;(3):CD005031. DOI:10.1002/14651858
https://doi.org/10.1002/14651858... Adherence is related to attitudes and beliefs regarding both the disease and the treatment, to level of knowledge concerning the disease, to personality and family structure characteristics and to the history and severity of the disease, as well as to factors linked to the type of intervention and to the health care professionals, which may or may not facilitate commitment to the therapy, thus increasing motivation to be treated. ⁴¹41 . Rosa AR, Kapczinski F, Oliva R, Stein A, Barros HMT. Monitoramento da adesão ao tratamento com lítio. Rev Psiquiatr Clin. 2006;33(5):249-61. DOI:10.1590/S0101-60832006000500005
https://doi.org/10.1590/S0101-6083200600...

Health care professionals monitor these behaviors which include taking medication, attending appointments, accompaniment by the family and keeping in contact with support services, goals to be developed in order for the patient to improve their health. When the patient is more engaged, this is associated with better outcomes, whereas high levels of abandoning the monitoring and control make it difficult to evaluate the results of the interventions. ³3 . Ball SA, Carroll KM, Canning-Ball M, Rounsaville BJ. Reasons for dropout from drug abuse treatment: Symptoms, personality, and motivation. Addict Behav. 2006;31(2):320-30. DOI:10.1016/j.addbeh.2005.05.013 In studies of efficacy, adherence is essential in order to examine issues such as internal and external validity, which are compromised when there are high losses of patients during treatment and monitoring. ^aa World Health Organization. Adherence to long-term therapies: evidence for action. Geneva; 2003 [cited 2010 Nov 23]. Available from: http://www.who.int/chp/knowledge/publications/adherence_report/en/

Drug addiction interventions using telemedicine, such as counselling via the telephone, ²³23 . Hall JA, Huber DL. Telephone management in substance abuse treatment. Telemed J E Health . 2000;6(4):401-7. DOI:10.1089/15305620050503870
https://doi.org/10.1089/1530562005050387... ^{, 26}26 . Hubbard RL, Leimberger JD, Haynes L, Patkar AA, Holter J, Liepman MR, et al. Telephone enhancement of long-term engagement (TELE) in continuing care for substance abuse treatment: a NIDA clinical trials network (CTN) study. Am J Addict. 2007;16(6):495-502. DOI:10.1080/10550490701641678
https://doi.org/10.1080/1055049070164167... internet ³⁸38 . Postel MG, de Haan HA, ter Huurne ED, van der Palen J, Becker ES, de Jong CAJ. Attrition in web-based treatment for problem drinkers. J Med Internet Res. 2011;13(4):e117. DOI:10.2196/jmir.1811
https://doi.org/10.2196/jmir.1811... and text messages ¹⁴14 . Downer SR, Meara JG, Da Costa AC. Use of SMS text messaging to improve outpatient attendance. Med J Aust. 2005;183(7):366-8. aim to minimize the impact of abandoning treatment when offered together with fate-to-face interventions and often represent significant treatment alternatives when used in isolation. ¹⁸18 . Fernandes S, Ferigolo M, Benchaya MC, Moreira TC, Pierozan PS, Mazoni CG, et al. Brief Motivational Intervention and telemedicine: A new perspective of treatment to marijuana users. Addict Behav. 2010;35(8):750-5. DOI:10.1016/j.addbeh.2010.03.001
https://doi.org/10.1016/j.addbeh.2010.03... ^{, 36}36 . Obermayer JL, Riley WT, Asif O, Jean-Mary J. College smoking-cessation using cell phone text messaging. J Am Coll Health. 2004;53(2):71-8. DOI:10.3200/JACH.53.2.71-78
https://doi.org/10.3200/JACH.53.2.71-78...

Even when it is easy to collect data, there are still few studies on dropout rates for isolated interventions or interventions in combination with face-to-face telemedicine based interventions. ³⁸38 . Postel MG, de Haan HA, ter Huurne ED, van der Palen J, Becker ES, de Jong CAJ. Attrition in web-based treatment for problem drinkers. J Med Internet Res. 2011;13(4):e117. DOI:10.2196/jmir.1811
https://doi.org/10.2196/jmir.1811... In addition, little is known about reasons for non-adherence and the specific components that can improve patient engagement in studies using telemedicine based interventions. ¹⁷17 . Eysenbach G. The law of attrition. J Med Internet Res. 2005;7(1):e11. DOI:10.2196/jmir.7.1.e11
https://doi.org/10.2196/jmir.7.1.e11... Randomized clinical trial with alcohol users showed that 80 of the 136 individuals who participated in an internet intervention completed the six-month monitoring period, representing a dropout rate of approximately 42.0%. ⁵5 . Blankers M, Koeter MW, Schippers GM. Internet therapy versus internet self-help versus no treatment for problematic alcohol use: A randomized controlled trial. J Consult Clin Psychol. 2011;79(3):330-41. DOI:10.1037/a0023498
https://doi.org/10.1037/a0023498... In face-to-face interventions for drug addiction, generally, 50.0% of patients abandon treatment before the end of the period. ¹²12 . de Weert-van Oene GH, Burger H, Grobbee DE, Schrijvers AJ. Identification of patients at high risk of noncompliance in substance dependence treatment. Eur Addict Res. 2007;13(2)74-80. DOI:10.1159/000097936
https://doi.org/10.1159/000097936... The rates have been studied from different perspectives. In Brazil, there are still few studies on telemedicine based interventions. The rate of adherence to treatment for drug addiction and the cultural, technological and disease-related factors that influence its effectiveness and the patients’ engagement with recommendations made through internet, telephone and text message are unknown.

The aim of this study was to estimate non-adherence rates in drug addiction treatment strategies using telemedicine.

METHODS

Randomized clinical trials meeting the following criteria were selected: a) testing different telemedicine treatment methods in drug users and estimating factors associated with non-adherence rates; b) population aged over 18; c) published in English between 2000 and 2012. Telemedicine is a recent field of study and studies were found from 2000 onwards, hence the start date for the search. The authors searched for publications in English as the majority of publications were in this language.

The following search terms were used “randomized controlled trial”, “drug abuse”, “telemedicine” and its “mesh terms” in Google Scholar, and in the PubMed, PsycINFO, SciELO, Wiley (The Cochrane Library), Embase and Clinical trials databases. The search strategy included Boolean operators combining the limits and filters for each term. The studies found were then evaluated to verify the following characteristics: year of publication, demographic region in which the study was carried out, the psychoactive substance included in the studies, a description of the sample allocation (randomization), blinding of outcomes, description of losses and exclusion, analysis by intention to treat, number of drug addicts (sample size), number of groups in the study, division of participants into control or intervention groups, type of intervention used with the groups, type of control used, stratification of groups by sex, age of the individuals being monitored and length of follow-up, the means used to apply the intervention and the frequency with which it was applied, methods of measuring the results, control and intervention group scores before and after the proposed intervention, relationship of adherence for the control and intervention groups.

There were 274 records recovered. Of these, 253 were excluded after analysis of the title and the abstract ( Figure ). The remaining 20 articles were analyzed by 2 investigators (LS and LRF) and compared in case of disagreement. Inclusion or exclusion was decided by a third assessor (TM).

In order to analyze the quality of the randomized clinical trials, the GRADE scale was used. ²²22 . Guyatt GH, Oxman AD, Vist G, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ . 2008;336(7650):924-6. DOI:10.1136/bmj.39489.470347.AD
https://doi.org/10.1136/bmj.39489.470347... To ensure transparency and simplicity, the GRADE system classifies the quality of evidence into one of four levels, high, moderate, low and very low quality. Studies scoring 5/5 were considered high quality, score of 4/5 and 3/5 were of moderate quality and 2/5 and 1/5 were low and very low quality, respectively. Evidence based on randomized clinical trials begins with high quality evidence, but confidence in the evidence can decrease for a variety of reasons including: limitations of the study, inconsistent results, indirect evaluations, inaccuracy and indications of bias. ²²22 . Guyatt GH, Oxman AD, Vist G, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ . 2008;336(7650):924-6. DOI:10.1136/bmj.39489.470347.AD
https://doi.org/10.1136/bmj.39489.470347... Thus, the definitions of quality can be classified as: ²²22 . Guyatt GH, Oxman AD, Vist G, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ . 2008;336(7650):924-6. DOI:10.1136/bmj.39489.470347.AD
https://doi.org/10.1136/bmj.39489.470347...

• High quality research: very unlikely that confidence in the estimate of effect changes;

• Moderate quality research: likely to have a significant impact on confidence in the estimate of effect and may change the estimate;

• Low quality research: very likely to have a significant impact on confidence in the estimate of effect and the estimate is likely to change;

• In very low quality research, the estimate of effect is very uncertain.

• The clinical relevance of the studies included was evaluated using the United States Preventive Services Task Force (USPSTF) criteria ²⁴24 . Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow CD, Teutsch SM, et al. Methods Work Group, Third US Preventive Services Task Force. Current methods of the US Preventive Services Task Force. Am J Prevent Med. 2001;20(3Suppl):21-35. DOI:10.1016/S0749-3797(01)00261-6
  https://doi.org/10.1016/S0749-3797(01)00... in accordance with the five questions recommended by the Cochrane Back Review Group. ⁴³43 . Staal JB, de Bie R, de Vet HC, Hildebrandt J, Nelemans P. Injection therapy for subacute and chronic low-back pain. Cochrane Database Syst Rev. 2008;16(3):CD001824. Each question was classified as positive (+) if the relevant item was met; negative (-) if the item was not found and unclear (u) if the data were not available for analysis. Thus, the relevance of the interventions can be classified as:

• Good (5/5): consistent results, well designed, well conducted study of a representative population that directly evaluates effects on health results;

• Reasonable (4/5 and 3/5): sufficient evidence to determine effects on health results, although the strength of relevancy is limited by the number, quality, size or consistency of the included study, or generalization for routine practice and the results;

• Limited or poor (2/5 and 1/5): there is insufficient evidence to evaluate the effects on health results due to the limited number of studies, inexplicable inconsistency, important faults in the design or conduct of the study, problems in the evaluation of lack of information on important results.

RESULTS

Of the 20 randomized clinical trials analyzed, the most commonly studied substance was alcohol (13 articles) and the majority of the research was on users of single psycho-active substances (13 articles). The number of patients involved in each study varied between 20 and 230 in the studies with smaller samples and between 358 and 873 in those with large samples. The participants’ ages varied between 24 and 58 years of age.

All of the studies used telemedicine combined with different interventions, such as brief motivational intervention, individual therapy, group therapy, cognitive-behavioral therapy – using strategies for coping, for identifying risky situations and identifying problems associated with use, among others – and preventing relapses. The non-adherence rate varied between 7.4% and 68.8%. The majority of studies followed patients for more than six months and described losses and exclusions; randomization and allocation concealment were adequate in half of the studies, 26.0% blinded the results and 63.0% analyzed according to intention to treat ( Table 1 ).

Regarding the quality of the results analyzed, 50.0% were of moderate to high quality ( Table 2 ). As for clinical relevance, 13 studies had a reasonable level of relevance ( Table 3 ).

DISCUSSION

Lower rates of non-adherence are related to high quality studies evaluated using GRADE. Studies with single users, limited intervention time and which used different techniques to stop drug use appeared to increase rates of adherence. The interventions in the randomized clinical trials evaluated in this systematic review were of at least three months duration and, although all of them used telemedicine as primary or secondary support, the treatment methods differed, which may have affected adherence.

Treating drug addiction is a complex process. In addition to the factors related to treatment methods, coping abilities, ⁹9 . Chung T, Langenbucher J, Labouvie E, Pandina RJ, Moos RH. Changes in alcoholic patients’ coping responses predict 12-month treatment outcomes. J Consult Clin Psychol. 2001;69(1):92-100. DOI:10.1037//0022-006X.69.1.92 ^{, 33}33 . Litt MD, Kadden RM, Cooney NL, Kabela E. Coping skills and treatment outcomes in cognitive-behavioral and interactional group therapy for alcoholism. J Consult Clin Psychol. 2003;71(1):118-28. DOI:10.1037/0022-006X.71.1.118
https://doi.org/10.1037/0022-006X.71.1.1... motivation, self-efficacy, ³³33 . Litt MD, Kadden RM, Cooney NL, Kabela E. Coping skills and treatment outcomes in cognitive-behavioral and interactional group therapy for alcoholism. J Consult Clin Psychol. 2003;71(1):118-28. DOI:10.1037/0022-006X.71.1.118
https://doi.org/10.1037/0022-006X.71.1.1... the users’ emotional state ⁴4 . Baker TB, Piper ME, McCarthy DE, Majeskie MR, Fiore MC. Addiction motivation reformulated: an affective processing model of negative reinforcement. Psychol Rev. 2004;111(1):33-51. DOI:10.1037/0033-295X.111.1.33
https://doi.org/10.1037/0033-295X.111.1.... and social support ¹³13 . Dobkin PL, Civita M, Paraherakis A, Gill K. The role of functional social support in treatment retention and outcomes among outpatient adult substance abusers. Addiction. 2002;97(3):347-56. DOI:10.1046/j.1360-0443.2002.00083.x
https://doi.org/10.1046/j.1360-0443.2002... influence the process of changing behavior, affecting adherence to treatment for substance abuse. ⁸8 . Carroll KM, Ball SA, Nich C, Martino S, Frankforter TL, Farentinos C, et al. Motivational interviewing to improve treatment engagement and outcome in individuals seeking treatment for substance abuse: A multisite effectiveness study. Drug Alcohol Depend. 2006;81(3):301-12. DOI:10.1016/j.drugalcdep.2005.08.002
https://doi.org/10.1016/j.drugalcdep.200... For Brazilian alcoholics, rates of non-adherence to drug addiction treatment depend on the type of intervention, on the result related to abstinence, as they had to avoid consuming alcohol for six months after the intervention. ⁴⁵45 . Terra MB, Barros HMT, Stein AT, Figueira I, Palermo LH, Athayde LD, et al. Do Alcoholics Anonymous Groups Really Work? Factors of Adherence in a Brazilian Sample of Hospitalized Alcohol Dependents. Am J Addict. 2008;17(1):48-53. DOI:10.1080/10550490701756393
https://doi.org/10.1080/1055049070175639...

Of the studies evaluated, six ¹1 . Agyapong VIO, Ahern S, McLoughlin DM, Farren CK. Supportive text messaging for depression and comorbid alcohol use disorder: single-blind randomised trial. J Affect Disord . 2012;141(2-3):168-76. DOI:10.1016/j.jad.2012.02.040
https://doi.org/10.1016/j.jad.2012.02.04... ^{, 6}6 . Brendryen H, Drozd F, Kraft P. A digital smoking cessation program delivered through internet and cell phone without nicotine replacement (happy ending): randomized controlled trial. J Med Internet Res. 2008;10(5):e51. DOI:10.2196/jmir.1005
https://doi.org/10.2196/jmir.1005... ^{, 28}28 . Joseph AM, Fu SS, Lindgren B, Rothman AJ, Kodl M, Lando H, et al. Chronic Disease Management for Tobacco Dependence: a randomized, controlled trial. Arch Intern Med. 2011;171(21):1894-900. DOI:10.1001/archinternmed.2011.500
https://doi.org/10.1001/archinternmed.20... ^{, 30}30 . Kavanagh D, Connolly JM. Mailed treatment to augment primary care for alcohol disorders: a randomised controlled trial. Drug Alcohol Rev. 2009;28(1):73-80. DOI:10.1111/j.1465-3362.2008.00011.x
https://doi.org/10.1111/j.1465-3362.2008... ^{, 34}34 . McKay JR, Van Horn D, Oslin DW, Ivey M, Drapkin ML, Coviello DM, et al. Extended telephone-based continuing care for alcohol dependence: 24-month outcomes and subgroup analyses. Addiction. 2011;106(10):1760-9. DOI:10.1111/j.1360-0443.2011.03483.x
https://doi.org/10.1111/j.1360-0443.2011... ^{, 48}48 . Whittaker R, Dorey E, Bramley D, Bullen C, Denny S, Elley CR, et al. A theory-based video messaging mobile phone intervention for smoking cessation: randomized controlled trial. J Med Internet Res. 2011;13(1):e10. DOI:10.2196/jmir.1553
https://doi.org/10.2196/jmir.1553... were of high quality and the clinical relevance of four of these was good. ¹1 . Agyapong VIO, Ahern S, McLoughlin DM, Farren CK. Supportive text messaging for depression and comorbid alcohol use disorder: single-blind randomised trial. J Affect Disord . 2012;141(2-3):168-76. DOI:10.1016/j.jad.2012.02.040
https://doi.org/10.1016/j.jad.2012.02.04... ^{, 6}6 . Brendryen H, Drozd F, Kraft P. A digital smoking cessation program delivered through internet and cell phone without nicotine replacement (happy ending): randomized controlled trial. J Med Internet Res. 2008;10(5):e51. DOI:10.2196/jmir.1005
https://doi.org/10.2196/jmir.1005... ^{, 28}28 . Joseph AM, Fu SS, Lindgren B, Rothman AJ, Kodl M, Lando H, et al. Chronic Disease Management for Tobacco Dependence: a randomized, controlled trial. Arch Intern Med. 2011;171(21):1894-900. DOI:10.1001/archinternmed.2011.500
https://doi.org/10.1001/archinternmed.20... ^{, 34}34 . McKay JR, Van Horn D, Oslin DW, Ivey M, Drapkin ML, Coviello DM, et al. Extended telephone-based continuing care for alcohol dependence: 24-month outcomes and subgroup analyses. Addiction. 2011;106(10):1760-9. DOI:10.1111/j.1360-0443.2011.03483.x
https://doi.org/10.1111/j.1360-0443.2011... Considering the impact of non-adherence rates in each of the six best studies, a difference in non-adherence rates can be identified, even in well-designed studies. Agyapong et al ¹1 . Agyapong VIO, Ahern S, McLoughlin DM, Farren CK. Supportive text messaging for depression and comorbid alcohol use disorder: single-blind randomised trial. J Affect Disord . 2012;141(2-3):168-76. DOI:10.1016/j.jad.2012.02.040
https://doi.org/10.1016/j.jad.2012.02.04... used SMS (an effective technique often used on studies of adherence, ^aa World Health Organization. Adherence to long-term therapies: evidence for action. Geneva; 2003 [cited 2010 Nov 23]. Available from: http://www.who.int/chp/knowledge/publications/adherence_report/en/ as, with the development of new technology, individuals are increasingly more interconnected, due to growing use of this technology), and had the lowest non-adherence rate of the randomized clinical trials. Thus, reminders or messages received during the treatment period contributed to better adherence. ²⁵25 . Hasvold PE, Wootton R. Use of telephone and SMS reminders to improve attendance at hospital appointments: a systematic review. J Telemed Telecare. 2011;17(7):358-64. DOI:10.1258/jtt.2011.110707
https://doi.org/10.1258/jtt.2011.110707... On the other hand, the study by Agyapong et al, ¹1 . Agyapong VIO, Ahern S, McLoughlin DM, Farren CK. Supportive text messaging for depression and comorbid alcohol use disorder: single-blind randomised trial. J Affect Disord . 2012;141(2-3):168-76. DOI:10.1016/j.jad.2012.02.040
https://doi.org/10.1016/j.jad.2012.02.04... when compared to the other good quality ones, had the shortest follow-up time.

Lower rates of non-adherence are also found in shorter treatments, or those with a limited time, irrespective of the use of telemedicine. According to a meta-analysis of data on face-to-face therapy, ⁴⁴44 . Swift JK, Greenberg RP. Premature discontinuation in adult psychotherapy: a meta-analysis. J Consult Clin Psychol. 2012;80(4):547-59. DOI:10.1037/a0028226
https://doi.org/10.1037/a0028226... a short follow-up time is more effective than treatments that have no time limit or even those in which there is a limited, albeit extensive, period. Another important factor in the study by Agyapong et al ¹1 . Agyapong VIO, Ahern S, McLoughlin DM, Farren CK. Supportive text messaging for depression and comorbid alcohol use disorder: single-blind randomised trial. J Affect Disord . 2012;141(2-3):168-76. DOI:10.1016/j.jad.2012.02.040
https://doi.org/10.1016/j.jad.2012.02.04... is that the treatment was only for alcohol users, and the literature describes how it is easier for users of a single substance to follow treatment and stop taking it than for users of more than one drug. ³⁹39 . Ray AL, Hutchison R, Bryan A. Psychosocial predictors of treatment outcome, dropout and change processes in a pharmacological clinical trial for alcohol dependence. Addict Disord Their Treat . 2006;5(4):179-90. DOI:10.1097/01.adt.0000210701.63165.5a
https://doi.org/10.1097/01.adt.000021070... The study using pharmacological treatment ²⁸28 . Joseph AM, Fu SS, Lindgren B, Rothman AJ, Kodl M, Lando H, et al. Chronic Disease Management for Tobacco Dependence: a randomized, controlled trial. Arch Intern Med. 2011;171(21):1894-900. DOI:10.1001/archinternmed.2011.500
https://doi.org/10.1001/archinternmed.20... for tobacco had a low non-adherence rate, which may be explained by the use of medication that, by increasing rates of quitting, ²¹21 . Gourlay SG, Stead LF, Benowitz NL. Clonidine for smoking cessation. Cochrane Database Syst Rev. 2004;(3):CD000058. DOI:10.1002/14651858
https://doi.org/10.1002/14651858... ^{, 27}27 . Hughes JR. Motivating and helping smokers to stop smoking. J Gen Intern Med. 2003;18(12):1053-7. DOI: 10.1111/j.1525-1497.2003.20640.x
https://doi.org/10.1111/j.1525-1497.2003... may motivate the patient to adhere more to treatment. ⁴⁶46 . Velicer WF, Prochaska JO, Fava JL, Norman GJ, Redding CA. Smoking cessation and stress management: Applications of the Transtheoretical Model of behavior change. Homeostasis Hlth Dis . 1998;38(5-6):216-33. Moreover, research conducted with smokers shows that pharmacological treatment is widely studied, ³⁵35 . Mitrouska I, Bouloukaki I, Siafakas NM. Pharmacological approaches to smoking cessation. Pulm Pharmacol Ther. 2007;20(3):220-32. DOI:10.1016/j.pupt.2005.10.012
https://doi.org/10.1016/j.pupt.2005.10.0... with positive results for treating nicotine dependence. ²¹21 . Gourlay SG, Stead LF, Benowitz NL. Clonidine for smoking cessation. Cochrane Database Syst Rev. 2004;(3):CD000058. DOI:10.1002/14651858
https://doi.org/10.1002/14651858... ^{, 27}27 . Hughes JR. Motivating and helping smokers to stop smoking. J Gen Intern Med. 2003;18(12):1053-7. DOI: 10.1111/j.1525-1497.2003.20640.x
https://doi.org/10.1111/j.1525-1497.2003... It is probable that the use of strategies to prevent relapse with longer follow-up than in the other studies (one year) and the patients’ financial incentive ($25 per follow up conducted) may also have positively influenced adherence results.

The study of users of alcohol alone ³⁴34 . McKay JR, Van Horn D, Oslin DW, Ivey M, Drapkin ML, Coviello DM, et al. Extended telephone-based continuing care for alcohol dependence: 24-month outcomes and subgroup analyses. Addiction. 2011;106(10):1760-9. DOI:10.1111/j.1360-0443.2011.03483.x
https://doi.org/10.1111/j.1360-0443.2011... had a higher non-adherence rate compared with other good quality studies. Alcohol dependence is also associated with high rates of non-adherence in face-to-face treatment. ⁴⁵45 . Terra MB, Barros HMT, Stein AT, Figueira I, Palermo LH, Athayde LD, et al. Do Alcoholics Anonymous Groups Really Work? Factors of Adherence in a Brazilian Sample of Hospitalized Alcohol Dependents. Am J Addict. 2008;17(1):48-53. DOI:10.1080/10550490701756393
https://doi.org/10.1080/1055049070175639... Even with more follow-up, the patients in this study ³⁴34 . McKay JR, Van Horn D, Oslin DW, Ivey M, Drapkin ML, Coviello DM, et al. Extended telephone-based continuing care for alcohol dependence: 24-month outcomes and subgroup analyses. Addiction. 2011;106(10):1760-9. DOI:10.1111/j.1360-0443.2011.03483.x
https://doi.org/10.1111/j.1360-0443.2011... were monitored for longer than in other studies, probably due to the use of a combination of different techniques. ³⁴34 . McKay JR, Van Horn D, Oslin DW, Ivey M, Drapkin ML, Coviello DM, et al. Extended telephone-based continuing care for alcohol dependence: 24-month outcomes and subgroup analyses. Addiction. 2011;106(10):1760-9. DOI:10.1111/j.1360-0443.2011.03483.x
https://doi.org/10.1111/j.1360-0443.2011... Making use of more than one technique, including using telemedicine, is a good alternative for treating drug users, ³⁶36 . Obermayer JL, Riley WT, Asif O, Jean-Mary J. College smoking-cessation using cell phone text messaging. J Am Coll Health. 2004;53(2):71-8. DOI:10.3200/JACH.53.2.71-78
https://doi.org/10.3200/JACH.53.2.71-78... as, when the intervention contains different tools and approaches, ⁷7 . Bock BC, Graham AL, Whiteley JA, Stoddard JL. A review of web-assisted tobacco interventions (WATIs). J Med Internet Res. 2008;10(5):e39. DOI:10.2196/jmir.9890
https://doi.org/10.2196/jmir.9890... there is a greater possibility of the individual being engaged, ²2 . Amato L, Minozzi S, Davoli M, Vecchi S, Ferri MM, Mayet S. Psychosocial and pharmacological treatments versus pharmacological treatment for opioid detoxification. Cochrane Database Syst Rev. 2008;(3):CD005031. DOI:10.1002/14651858
https://doi.org/10.1002/14651858... and the results of the treatment may also be better. ²⁹29 . Jungerman FS. Boas Práticas nas abordagens psicossociais da dependência de substâncias. In: Cordeiro DC, Figlie NB, Laranjeira R. Boas práticas no tratamento do uso e dependência de substâncias. São Paulo: Roca; 2007. p. 174-5. The study by Brendryen et al ⁶6 . Brendryen H, Drozd F, Kraft P. A digital smoking cessation program delivered through internet and cell phone without nicotine replacement (happy ending): randomized controlled trial. J Med Internet Res. 2008;10(5):e51. DOI:10.2196/jmir.1005
https://doi.org/10.2196/jmir.1005... highlights using the telemedicine Happy Ending technique, consisting of an intense stop smoking program with the help of contact via e-mail, text messages, a helpline for dealing with cravings and a system to prevent relapse. Moreover, it emphasizes how psychological support can be efficaciously provided through modern communication technology with excellent results. ⁶6 . Brendryen H, Drozd F, Kraft P. A digital smoking cessation program delivered through internet and cell phone without nicotine replacement (happy ending): randomized controlled trial. J Med Internet Res. 2008;10(5):e51. DOI:10.2196/jmir.1005
https://doi.org/10.2196/jmir.1005... The study by Brendryen et al ⁶6 . Brendryen H, Drozd F, Kraft P. A digital smoking cessation program delivered through internet and cell phone without nicotine replacement (happy ending): randomized controlled trial. J Med Internet Res. 2008;10(5):e51. DOI:10.2196/jmir.1005
https://doi.org/10.2196/jmir.1005... was of high quality and had better results for stopping smoking when technological interventions were used, confirming that well-designed studies have more reliable results.

As the quality of the studies included in this systematic review decreased, there was an increase in non-adherence rates. This shows that in research that is more reliable in estimating effect – represents the effect present in the population and not only in the sample studied – there are better adherence rates. ¹⁰10 . Coutinho ESF, Cunha GM. Conceitos básicos de epidemiologia e estatística para a leitura de ensaios clínicos controlados. Rev Bras Psiquiatr. 2005;27(2):146-51. DOI:10.1590/S1516-44462005000200015
https://doi.org/10.1590/S1516-4446200500... In moderate quality studies, ⁵5 . Blankers M, Koeter MW, Schippers GM. Internet therapy versus internet self-help versus no treatment for problematic alcohol use: A randomized controlled trial. J Consult Clin Psychol. 2011;79(3):330-41. DOI:10.1037/a0023498
https://doi.org/10.1037/a0023498... ^{, 26}26 . Hubbard RL, Leimberger JD, Haynes L, Patkar AA, Holter J, Liepman MR, et al. Telephone enhancement of long-term engagement (TELE) in continuing care for substance abuse treatment: a NIDA clinical trials network (CTN) study. Am J Addict. 2007;16(6):495-502. DOI:10.1080/10550490701641678
https://doi.org/10.1080/1055049070164167... ^{, 31}31 . Kay-Lambkin FJ, Baker AL, Lewin TJ, Carr VJ. Computer-based psychological treatment for comorbid depression and problematic alcohol and/or cannabis use: a randomized controlled trial of clinical efficacy. Addiction. 2009;104(3):378-88. DOI:10.1111/j.1360-0443.2008.02444.x
https://doi.org/10.1111/j.1360-0443.2008... ^{, 49}49 . Zanjani F, Bush H, Oslin D. Telephone-based psychiatric referral-care management intervention health outcomes. Telemed J E Health. 2010;16(5):543-50. DOI:10.1089/tmj.2009.0139
https://doi.org/10.1089/tmj.2009.0139... only that of Blankers et al ⁵5 . Blankers M, Koeter MW, Schippers GM. Internet therapy versus internet self-help versus no treatment for problematic alcohol use: A randomized controlled trial. J Consult Clin Psychol. 2011;79(3):330-41. DOI:10.1037/a0023498
https://doi.org/10.1037/a0023498... had high rates of non-adherence (41.0% in six months) and the others showed little variation (between 22.0% and 29.0%). Regarding clinical relevance of the moderate quality studies, only that of Blankers et al ⁵5 . Blankers M, Koeter MW, Schippers GM. Internet therapy versus internet self-help versus no treatment for problematic alcohol use: A randomized controlled trial. J Consult Clin Psychol. 2011;79(3):330-41. DOI:10.1037/a0023498
https://doi.org/10.1037/a0023498... had reasonable relevance, whereas the others met the criteria evaluated with good clinical relevance. Although the study by Blankers et al ⁵5 . Blankers M, Koeter MW, Schippers GM. Internet therapy versus internet self-help versus no treatment for problematic alcohol use: A randomized controlled trial. J Consult Clin Psychol. 2011;79(3):330-41. DOI:10.1037/a0023498
https://doi.org/10.1037/a0023498... was conducted solely with alcohol users, the only intervention technique used was that of online therapy, in which there was no contact with a therapist and the individuals was self-guided by the programs used. The authors themselves highlight the technique as being effective but limited to reduced alcohol consumption. Kay-Lambkin et al ³¹31 . Kay-Lambkin FJ, Baker AL, Lewin TJ, Carr VJ. Computer-based psychological treatment for comorbid depression and problematic alcohol and/or cannabis use: a randomized controlled trial of clinical efficacy. Addiction. 2009;104(3):378-88. DOI:10.1111/j.1360-0443.2008.02444.x
https://doi.org/10.1111/j.1360-0443.2008... and Zanjani et al ⁴⁹49 . Zanjani F, Bush H, Oslin D. Telephone-based psychiatric referral-care management intervention health outcomes. Telemed J E Health. 2010;16(5):543-50. DOI:10.1089/tmj.2009.0139
https://doi.org/10.1089/tmj.2009.0139... used brief intervention techniques associated with other interventions. The former presented an intervention for alcohol and marijuana and had a higher non-adherence rate. ³¹31 . Kay-Lambkin FJ, Baker AL, Lewin TJ, Carr VJ. Computer-based psychological treatment for comorbid depression and problematic alcohol and/or cannabis use: a randomized controlled trial of clinical efficacy. Addiction. 2009;104(3):378-88. DOI:10.1111/j.1360-0443.2008.02444.x
https://doi.org/10.1111/j.1360-0443.2008... This may be related to use of two substances and to the follow-up time, as well as to the characteristics of the profile of those who use marijuana ¹⁹19 . Fernandes S, Ferigolo M, Benchaya MC, Pierozan PS, Moreira TC, Santos V, et al. Abuso e dependência de maconha: comparação entre sexos e preparação para mudanças comportamentais entre usuários que iniciam a busca por tratamento. Rev Psiquiatr Rio Gd Sul. 2010;32(3):80-5. DOI:10.1590/S0101-81082010005000004 who often have difficulty viewing their marijuana consumption as problematic. ⁴⁰40 . Reniscow K, Smith M, Harrison L, Drucker E. Correlates of occasional cigarette and marijuana use: are teens harm reducing? Addict Behav. 1999;24(2):251-66. DOI:10.1016/S0306-4603(98)00059-8
https://doi.org/10.1016/S0306-4603(98)00... The treatment in the study by Zanjani et al ⁴⁹49 . Zanjani F, Bush H, Oslin D. Telephone-based psychiatric referral-care management intervention health outcomes. Telemed J E Health. 2010;16(5):543-50. DOI:10.1089/tmj.2009.0139
https://doi.org/10.1089/tmj.2009.0139... was conducted solely with smokers, with a six-month follow-up to facilitate adherence. ⁴⁴44 . Swift JK, Greenberg RP. Premature discontinuation in adult psychotherapy: a meta-analysis. J Consult Clin Psychol. 2012;80(4):547-59. DOI:10.1037/a0028226
https://doi.org/10.1037/a0028226... Hubbard et al ²⁶26 . Hubbard RL, Leimberger JD, Haynes L, Patkar AA, Holter J, Liepman MR, et al. Telephone enhancement of long-term engagement (TELE) in continuing care for substance abuse treatment: a NIDA clinical trials network (CTN) study. Am J Addict. 2007;16(6):495-502. DOI:10.1080/10550490701641678
https://doi.org/10.1080/1055049070164167... only used groups via telephone with tele-counselors and indicated that in-person clinical monitoring is necessary to keep abstinence.

Studies considered to be of ¹⁶16 . El-Khorazaty MN, Johnson AA, Kiely M, El-Mohandes AAE, Subramanian S, Laryea HA, et al. Recruitment and retention of low-income minority women in a behavioral intervention to reduce smoking, depression, and intimate partner violence during pregnancy. BMC Public Health. 2007;7:233. DOI:10.1186/1471-2458-7-233
https://doi.org/10.1186/1471-2458-7-233... ^{, 18}18 . Fernandes S, Ferigolo M, Benchaya MC, Moreira TC, Pierozan PS, Mazoni CG, et al. Brief Motivational Intervention and telemedicine: A new perspective of treatment to marijuana users. Addict Behav. 2010;35(8):750-5. DOI:10.1016/j.addbeh.2010.03.001
https://doi.org/10.1016/j.addbeh.2010.03... ^{, 20}20 . Girard B, Turcotte V, Bouchard S, Girard B. Crushing virtual cigarettes reduces tobacco addiction and treatment discontinuation. Cyberpsychol Behav. 2009;12(5):477-83. DOI:10.1089/cpb.2009.0118
https://doi.org/10.1089/cpb.2009.0118... ^{, 37}37 . Parker DR, Windsor RA, Roberts MB, Hecht J, Hardy NV, Strolla LO, et al. Feasibility, cost, and cost-effectiveness of a telephone-based motivational intervention for underserved pregnant smokers. Nicotine Tob Res. 2007;9(10):1043-51. DOI:10.1080/14622200701591617
https://doi.org/10.1080/1462220070159161... have high non-adherence rates, which may be explained by difficulty maintaining the effect estimate. ¹⁰1 . Agyapong VIO, Ahern S, McLoughlin DM, Farren CK. Supportive text messaging for depression and comorbid alcohol use disorder: single-blind randomised trial. J Affect Disord . 2012;141(2-3):168-76. DOI:10.1016/j.jad.2012.02.040
https://doi.org/10.1016/j.jad.2012.02.04... The evaluation of the results for the discussion of adherence to telemedicine were based on the relevance of the studies that, in this case, may be considered of poor reliability. Using a greater number of techniques contributed to higher adherence rates ¹⁶16 . El-Khorazaty MN, Johnson AA, Kiely M, El-Mohandes AAE, Subramanian S, Laryea HA, et al. Recruitment and retention of low-income minority women in a behavioral intervention to reduce smoking, depression, and intimate partner violence during pregnancy. BMC Public Health. 2007;7:233. DOI:10.1186/1471-2458-7-233
https://doi.org/10.1186/1471-2458-7-233... ^{, 37}37 . Parker DR, Windsor RA, Roberts MB, Hecht J, Hardy NV, Strolla LO, et al. Feasibility, cost, and cost-effectiveness of a telephone-based motivational intervention for underserved pregnant smokers. Nicotine Tob Res. 2007;9(10):1043-51. DOI:10.1080/14622200701591617
https://doi.org/10.1080/1462220070159161... and adherence to interventions may increase in drug users who have made various attempts to stay clean, ³²32 . Koob GF, Le Moal M. Neurobiological mechanisms for opponent motivational processes in addiction. Philos Trans R Soc Lond B Biol Sci. 2008;363(1507):3113-23. DOI:10.1098/rstb.2008.0094
https://doi.org/10.1098/rstb.2008.0094... irrespective of whether a face-to-face or telemedicine intervention was used.

Among the limitations of this study is the fact that the therapies used in the studies used different telemedicine strategies and had different periods of follow-up, which makes it difficult to compare them. Another limitation is that the studies were on treatments for different types of substances and included users of single substances or poly drug users.

Despite the limitations found, it was possible to observe that certain factors favor non-adherence to treatment for drug addiction using telemedicine. Adherence is better when more than one intervention technique is used and when the treatment time is shorter.

In some countries, the use of telemedicine is of recent date. Treatments that use this tool are still unknown to many patients and professionals, which leads us to believe that this decreases confidence in the possibility of a positive result and leads to non-adherence.

As rates of non-adherence are high, more research is necessary on personal and socioeducational characteristics of patients which affect non-adherence to interventions using telemedicine technology.

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