Psychosocial Interventions for Alcohol and/or Drug Misuse and Use Disorders in Women: A Systematic Review

Abstract

Background:

Although men and women who misuse substances have different needs, no rigorous systematic literature review has been conducted examining psychosocial substance use interventions for women across a broad range of types of therapeutic approaches and populations.

Materials and Methods:

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were used to guide this review. English language, peer-reviewed research articles indexed in PubMed, PsycINFO, CINAHL Complete, and Web of Science through May 6, 2021, were searched. Peer-reviewed articles were included in the review if they were written in English; described a randomized controlled trial of a psychosocial intervention to reduce substance misuse and related problems in women; and reported quantitative data on alcohol or illicit drug use as an outcome that was linked to the interventions.

Results:

A total of 51 articles met eligibility criteria, reflecting a broad array of interventions with different levels of methodological rigor. Several, but not most, interventions were tailored to meet the needs of specific subgroups of women, but evidence regarding the efficacy of tailoring was inconclusive. Overall, 61% of studies reported one or more positive substance-related intervention effects, with target substance (alcohol only vs. other drugs only or both alcohol and other drugs) and intervention dosage associated with intervention success.

Conclusions:

Fewer studies targeting alcohol only reported one or more positive intervention outcomes. This warrants further study, given that polysubstance use is the norm, not the exception. Future research might also focus on reducing treatment barriers to women, as this has the potential to improve overall treatment outcomes for this population.

Introduction

Globally, alcohol, tobacco, and other drug use disorders are recognized as a major public health problem with increased morbidity and mortality.¹ In the United States, substance misuse and use disorders are prevalent and contribute to development of physical and mental health problems, accidents, and reduced quality of life.²

Worldwide, tobacco use is one of the largest preventable causes of premature death, with attributable death rates three times higher for smoking than for alcohol, and more than 15 times higher than for illicit drug use.³ The World Health Organization (WHO) Report (2019)⁴ estimated that globally, 19% of adults were current smokers, with prevalence five times higher in men (33%) compared to women (6%). Tobacco accounts for more than 8 million deaths annually, of which 1.2 million are caused by second-hand smoke exposure.⁵ The impact is greater on people in low- and middle-income countries, with an annual cost of over $1.4 trillion to the global economy.

Alcohol also contributes to significant morbidity and mortality. The WHO⁶ estimates that worldwide, alcohol alone contributes to more than 200 illnesses and injuries (e.g., violence, accidents, and suicides), and is responsible for 3 million deaths annually, making it the ninth leading global risk factor for morbidity and premature death.⁷ In the United States, while the 12-month prevalence of harmful alcohol use and dependence in persons 15 years of age and older is higher for males (17.6%) than females (10.4%), alcohol use disorder (AUD)-related risks to maternal and child health (e.g., fetal alcohol effects and alcohol-related violence) are of particular concern and were identified as a global priority by the WHO.⁶

Latest data from the World Drug Report 2021 indicate that in 2019, it was estimated that more than 275 million people between the ages of 15 and 64 reported past year psychoactive substance use.⁸ Of these, 36 million met criteria for a drug use disorder, with 11 million endorsing intravenous drug use. Substance use disorders (SUDs) contribute to increased morbidity and mortality, in part, because of concomitant medical (e.g., HIV and Hepatitis B and C) and psychiatric (e.g., depression and post-traumatic stress disorder [PTSD]) disorders and psychosocial problems (e.g., trauma, homelessness, and incarceration).^1,9

As cogently noted in the World Drug Report 2021, treatment for drug use often is not tailored to the specific needs of women, who face significant stigma and marginalization as a result of their use.^8,10,11

While rates of alcohol and other drug use are lower in women than in men, females progress more rapidly than males from substance use to dependence to first treatment episode.^8,12,13 Furthermore, women who use alcohol or other drugs, relative to men, are at greater risk for developing medical and psychological problems.¹⁴ Because women progress more rapidly than men from alcohol and other drug use to dependence, early screening and intervention are critical to prevent the development of SUDs. In addition, early screening and intervention can prevent adverse fetal consequences arising from unintended pregnancies,¹⁵ and victimization that occurs at a higher rate among women, versus men, who use alcohol or other drugs.¹⁶

Despite male-female differences in the initiation and progression of substance use to problems and dependence, decades of research comparing SUD treatment outcomes for programs serving both males and females have yielded mixed results.¹³ A review by Greenfield et al.¹² found that, while SUD treatment retention generally did not differ for men and women, women were less likely than men to seek SUD treatment.^17,18

One of the reasons for disparity between men and women is the differential rate of psychiatric co-morbidities. Women are two to three times more likely to have a co-morbid psychiatric diagnosis (depression, anxiety, and post-traumatic stress), which is recognized as a barrier to both engagement and retention in SUD treatment.^19,20 Practical barriers such as lack of transportation, housing, and childcare,^21

–25 as well as involvement in violent relationships and greater social stigma^14,26 also can hinder a woman's ability to initiate SUD treatment.

Factors that have impeded women's engagement and retention in SUD treatment have led to the development of women-centered drug treatment services. Terplan et al.,²⁷ in a study of the availability of women-centered drug treatment services in the USA, describe programs designed to address practical barriers to care for women and tailored to meet the needs of women. While they indicate such programs have lower rates of treatment dropout and less drug use,²⁸ in the absence of randomized controlled trials (RCTs), interpretation of such data is limited.

Despite the fact that scholars have suggested that substance use interventions should be adapted specifically to the needs of women,^29,30 which could involve tailored content or women-only treatment delivery, the overall body of SUD intervention research continues to report on programs that are not specific to women. This is problematic because the efficacy of intervention content that is not tailored to women or intervention delivery that includes a predominantly male or mixed male and female sample may be very different from the efficacy of intervention approaches that take the unique needs of women into account.

Of course, the efficacy of female-specific interventions may not differ from interventions that are not specific to women.¹⁹ However, unless tailored intervention content is compared with nontailored content, or researchers report the effectiveness of interventions separately for men and women, scholars are unable to access this information.

Although there have been recent reviews of interventions for very specific populations of women (e.g., women who are pregnant³¹ and women who are incarcerated^32,33), no rigorous systematic literature review has been conducted to date examining substance use interventions for women that are psychosocial in nature across a broad range of types of therapeutic approaches and populations. Because the literature tends to be fragmented, the lack of such a comprehensive review and synthesis makes it difficult to identify gaps in research. The purpose of this systematic review, therefore, was to summarize original, quantitative reports of RCTs evaluating the efficacy of psychosocial interventions targeting alcohol and/or drug misuse and use disorders in women.

Materials and Methods

Sources

To ensure transparent reporting, this systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines,³⁴ which include a 27-item checklist and a 4-phase flow diagram illustrating identified, screened, eligible, and included studies. A literature review was conducted using the following electronic databases: PubMed, PsycINFO, CINAHL Complete, and Web of Science. Searches were conducted between February 28, 2017, and March 17, 2017, and then updated on May 6, 2021. In each database, a combination of keywords joined using Boolean operators was used to represent the concepts of substance use, psychosocial interventions, and females/women.

Substance use was described using a combination of broad and specific terminology, including substance use, drug use, alcohol use, illicit drugs, substance abuse, substance use disorders, opiates, hashish, heroin, cocaine, crack cocaine, marijuana, morphine dependence, and amphetamines. Psychosocial intervention terminology included broad terms for interventions as well as for specific psychological, social, and educational interventions, as well as terminology related to recovery and harm reduction strategies. A validated search filter was used to limit results to RCT.³⁵ Please see Supplementary Appendix SA1 for a list of the specific search terms used. To ensure that our search was as comprehensive as possible, databases also were searched for key authors' names and frequently employed interventions (e.g., Seeking Safety).

Eligibility criteria

Articles were included in the review if they met the following inclusion criteria: (1) described an RCT that employed a psychosocial intervention designed to reduce or eliminate substance misuse and/or associated harms, (2) reported quantitative data on alcohol or illicit drug use as a primary or secondary outcome that was linked to the intervention, (3) was published in a peer-reviewed journal with a full-text copy of the article available, (4) was written in English, and (5) included only women in the randomized conditions in the study design. Thus, studies that compared women receiving couple-focused treatment or a combination of couple-focused and individually focused treatment as one or more of the intervention arms were included if men in these studies were not part of the randomization process, and data on women were the focus of the report.

All studies that were not RCTs were excluded, including studies that described an intervention or the study design, but did not report outcome data, or only reported qualitative findings. RCTs were excluded if the randomization was something other than the psychosocial intervention component (e.g., living location³⁶). RCTs that focused solely on tobacco use were excluded. RCTs that focused solely on prevention of substance use among adolescents or young adults, and had no risky substance use criteria for inclusion in the intervention also were excluded.

We did not restrict the types of psychosocial interventions included in the review, and included interventions that targeted physical and mental health outcomes, or aimed to improve or modify behavior if they also reported alcohol or drug use outcomes linked to the intervention. Because there have been several recent reviews with very specialized populations,^31
–33 we excluded studies if they focused on women who were incarcerated or pregnant.

Study selection

To select studies, the article titles and abstracts were screened for eligibility by two independent researchers, at least one of whom was one of the study authors. The vast majority of articles screened out during this process did not meet the sampling criteria (e.g., the randomized sample was not 100% female). Other common reasons for exclusion during this phase included presentation of study protocols only and non-RCT studies. Following this process, the unique articles that remained were full text reviewed for inclusion/exclusion criteria by at least two of the study authors. Additional articles were screened out during this process, leaving a final sample for analysis. Figure 1 describes the study selection process and the results from each stage of review.

FIG. 1.

PRISMA diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Data abstraction, assessment of risk of bias, and analysis

Data were abstracted from the selected articles by two of the study authors using a standardized form that captured information on study design, population, the nature of the intervention, measures utilized to assess alcohol or drug use, and findings. Abstracted data were compiled, reviewed, and summarized in table form by study authors.

Consistent with recommendations by Cochrane,³⁷ risk of bias assessments, but not assessments of study quality, were conducted to examine limitations in design and implementation using the Cochrane Collaboration Risk of Bias Tool.³⁷ Assessments were made in the areas of sequence generation (Was the allocation sequence adequately generated?), allocation concealment (Was allocation adequately concealed?), blinding of participants, personnel, and outcome assessors (Was knowledge of the allocated intervention adequately prevented during the study?), incomplete outcome data (Was incomplete outcome data adequately addressed?), and selective outcome reporting (Are reports of the study free of suggestion of selective outcome reporting?).

Judgments of “Yes (low risk of bias),” “Unclear,” and “No (high risk of bias)” were applied to each question and then summarized across studies. These assessments were independently conducted for each article by at least one of the study authors; 20% of the articles were assessed by two of the study authors to assess inter-rater reliability, which was >90%.

Results

As seen in Figure 1, the search strategies yielded 12,486 articles for review. After eliminating duplicates, 11,015 studies remained. After reviewing the titles and abstracts, 168 articles were full text reviewed for inclusion/exclusion criteria, and 117 additional articles were eliminated, leaving a final sample of 51 articles.

All articles included in the final review are summarized in Table 1. As seen in the table, a range of samples and types of interventions was utilized across the 51 studies. It should be noted that studies were not classified by intervention type or intensity. This was because some of the interventions contained novel elements, making it difficult to categorize them accurately. Other interventions combined features from multiple evidence-based treatments (e.g., motivational interviewing [MI] plus cognitive behavioral therapy [CBT]) adding to the dilemma.

Table 1.

Summary of Articles Included in the Review

Study	Sample and recruitment	Study conditions	Dosage	Substance use outcome(s)	Assessment at baseline and end of treatment	Follow-up period after end of treatment	Sig effect(s)
Low-severity samples (n = 6)
Focus: alcohol only (n = 2)
Delrahim-Howlett et al.⁴⁰	N: 150 Age range: 18–44 M age: 25.75_control; 26.91_intervention years Race/ethnicity: 34% White; 8% AA; 44% Hispanic; 8% multiracial; 6% other Recruitment: low-income, nonpregnant women of child-bearing age who were drinking at a moderate-risk level were recruited from 3 WIC clinics	Intervention: web-based assessment and tailored intervention. Control: general information about alcohol consumption and fetal alcohol syndrome.	1 session	1. No. of RDO (at 1 month; follow-up days in the past month) 2. No. of RDOs at 1 in past month. 3. MDPO in 2-week period 4. MDPO at 1-month follow-up 5. No. of RDOs at 2-month follow-up	Yes	1 and 2 months
Dvorak et al.⁴¹	N: 62Age range: 18–24 M age: 20.5 yearsRace/ethnicity: 95% white; 3% AA; 2% otherRecruitment: College students at a mid-sized University who were current drinkers and who planned to drink on SB	Intervention: participants received one of two messages delivered online: positively framed message delivered online about individuals who do use PBSs during SB or a negatively framed message about individuals who do not use PBSs during SB	1 message	1. Daily alcohol use over a 10-day period during SB2. Alcohol-related problems over a 10-day period during SB	Yes	No	^*

Focus: Drugs other than alcohol-only (N = 2)
De Dios et al.⁴²	N: 34Age range: 18–29 M age: 23.0 yearsRace/ethnicity: 50% white; 32% AA; 6% Hispanic; 12% otherRecruitment: community newspaper and radio advertisements for young adult women who had smoked marijuana three times in the past month and endorsed a desire to quit.	Intervention: MI and MM. Focus on reducing marijuana use through alternative coping skills to manage negative affect states.Control: assessment only	2 sessions 2 weeks apart (45 minutes each)	1. No. of days used marijuana (past 90 days)Verified with urine analysis	Yes	1, 2, and 3 months	^*
Stein et al.⁴³	N: 332Age range: 18–24 M age: 20.5 yearsRace/ethnicity: 68% white; 10% AA; 12% Hispanic; 10% otherRecruitment: community sample of nonpregnant women who used marijuana at least three times in the last 3 months who were recruited through newspaper and radio advertisements	Intervention: in-person MI session about marijuana use through a discussion of values and goals with option of a change plan for any goal.Control: assessment only	2 sessions (45 minutes each)	1. No. of days used marijuana in a month (past 90 days)2. Severity of marijuana use within a month ranked by the Marijuana Problem Scale (past 90 days)	Yes	1, 3, and 6 months postbaseline	^*

Focus: Both alcohol and other drugs (N = 2)
Mason et al.⁴⁴	N: 28Age range: 14–18 M age: 16.0 yearsRace/ethnicity: 82% AA; 18% multiracialRecruitment: adolescents attending an urban, public primary care clinic who screened positive for substance use.	Intervention: in-person session that combined MI with SN counselingControl: assessments only	1 session (20 minutes)	1. No. of days used alcohol in past month2. No. of times used alcohol on days used3. No. of days used marijuana in past month4. No. of times used marijuana on days used5. Negative consequences from substance use	No	1 month	^*
Walsh et al.⁴⁵	N: 154Age range: 15 and older M age: 27.5 yearsRace/ethnicity: 31% AA; 11% Hispanic; 8% native American; 12% multiracial; other races not reportedRecruitment: recent victims of SA who participated SAMFE within 7 days of the assault, were recruited from two medical centers in a metropolitan area	Intervention: watched brief, 9-minute, female-narrated video of PPRS with information useful to prevent future emotional problems and substance misuse.Active control: watched PIRI, a shortened version of PPRSControl: TAU	(1) 9-minute video session of PPRS	1. Alcohol use problems in past 2 weeks2. Days of marijuana use in past 2 weeks3. Drug use in past 2 weeks	No	6 weeks and 3 and 6 months postbaseline

Moderate-severity samples (n = 17)
Focus: Alcohol only (n = 8)
Carey et al.⁴⁶	N: 48Age range: 18–29 M age: 22.67Race/ethnicity: 61% white; 11% AA; 9% Asian; 11% multiracial; 9% otherRecruitment: adolescents and young adults receiving care at an urban reproductive health and family planning clinic, who screened positive for at-risk drinking and risky sexual behavior	Intervention: participants received a face-to-face counseling based on MI principles and personalized normative feedbackControl: two informational brochures	1 session (<60 minutes) plus 12 weeks of daily text messages and website	1. Drinks per week2. Maximum drinks per day3. Heavy episodic drinking days4. Alcohol consequences	Yes	No	^*
Connors and Walitzer⁵²	N: 144Age range: not reported M age: 38.7Race/ethnicity: 90% white; 8% AA; 2% otherRecruitment: newspaper advertisements targeting women with heavy drinking who wanted to reduce their alcohol intake.	Intervention: 13 hours of drinking reduction training+either (a) life skill training, (b) 8 booster sessions, or (c) both life-skills training and booster sessions.Control: 13 hours of drinking reduction training +7 hours of alcohol and general health-related lectures and videotapes.	13 hours of drinking reduction training over a 10-week period +7 hours in life-skills or 8 booster sessions over a 6-month period; telephone contact from therapists between group sessions	1. Abstinent-light drinking days per month2. Alcohol-related problems3. Drug use4. Drinking self-efficacy	Yes	3, 6, 9, 15, and 18 months
Finfgeld-Connett and Madsen⁴⁹	N: 44Age range: 18 or older M age: 50.0 yearsRace/ethnicity: 100% whiteRecruitment: newspaper and radio advertisements targeting women with heavy drinking from rural areas in the Midwest.	Intervention: web-based self-guided treatment program based on the harm reduction paradigm utilizing self-efficacy theory, and the Transtheoretical Model of Change.Control: baseline assessment with hard copy survey.	8 reference modules and 15 decision-making modules, self-guided for 3-month period	1. Mean % of drinking days2. Mean number of drinks per drinking day3. Overall mean number of drinks per day.	Yes	No
Kenney et al.⁴⁷	N: 226Age range: not reported M age:18.1 yearsRace/ethnicity: 62% White; 14% multiracial; 8% Asian; 7% other; 3% AA; 2% Hawaiian/Pacific Islander; and 1%American Indian/Alaskan Native; 16% reported Hispanic ethnicityRecruitment: email invitations to heavy drinking first year college women	Intervention: single-session group cognitive behavioral skill training with a focus on increasing PBSControl: group discussion about importance of good study skills for academic success and reflected on note-taking strategies.	1 group session (45 minutes each)	1. No. of drinks per week in the past month2. No. of occasions in past month that 4+ drinks in a 2-hour period were consumed3. No. of days with alcohol-related problems	No	1 and 6 months	^*
Manwell et al.⁴⁸	N: 205Age range: 18–40 M age: not reportedRace/ethnicity: 85% white; 9% AA; 1% Hispanic; 1% Native American; 3% othersRecruitment: women of child-bearing age with problem drinking attending community primary care clinics	Intervention: two physician-delivered counseling visits; session 1: BI and session 2: reinforcement. Visits with the physician were scheduled 1 month apartControl: booklet on general health issues and instructions to address health concerns in their usual manner.	2 in-office visits 1 month apart (15 minutes)	1. No. of drinks in past 7 days2. Excessive drinking in past 7 days3. Binge drinking in past 30 days4. No. of binge drinking episodes in past 30 days	No	(5) Follow-up at 6, 12, 24, 36, and 48 months	^*
Ondersma et al.⁵¹	N: 123Age range: 18–44 M age: 27.1 yearsRace/ethnicity: 87% AA; 4% white; 4% multiracial; 5% other; 4% identified as Hispanic.Recruitment: In-hospital postchildbirth women with heavy drinking in the year prior pregnancy	Intervention: single BI session, e-intervention using tablet PC using FRAMES model plus MI principles.Control: group assessment questions about music and television preferences with video clips and feedback questions.	1 session (20 minutes)	1. Any alcohol use past 7 days2. No. of days use alcohol (past 30 days)3. No. of binge episodes per week (past 30 days)	No	3 and 6 months
Palm et al.⁵⁰	N: 172 (76 intervention)Age range: 15–22 M age: 18.3 yearsRace/ethnicity: SwedishRecruitment: adolescents and young adults were recruited from youth health centers in Sweden at participants' first visit to a center	Intervention: one session of MI delivered by a midwife or nurse at the time of the health center visit only to intervention participants with high-risk drinking scoresControl: TAU	1 session (time duration was not reported)	1. Frequency of alcohol use2. Binge drinking	No	3 and 12 months
Upshur et al.⁵³	N: 82Age range: Not reported M age: 45.4Race/ethnicity: 33% white; 41% AA; 26% otherRecruitment: homeless women seeking primary health care services from a clinic serving the homeless	The study used a clinician-randomized design.Intervention: guideline-based brief intervention for problem alcohol use delivered by the PCP, 4–6 follow-up visits with the PCP, referral to addiction services, and ongoing support from a care manager (15+ follow-up sessions) for 6 months.Control: TAU	1 brief intervention session, variable follow-up visits with PCP, ongoing support for 6 months from care manager	1. No. of drinks/month last 3 months2. No alcohol consumption last 3 months3. Alcohol use consequences4. No. of days used other drugs last 3 months	Yes	No

Focus: Drugs other than alcohol-only (n = 4)
Jemison et al.⁵⁶	N: 16Age range: 33–60 M age: 47.9 yearsRace/ethnicity: 6% white; 81% AA; 6% Latina; 6% multiracial.Recruitment: HIV+ women from hospital and community HIV clinics, who were having difficulties with their HIV care, reported a psychological trauma and using cocaine for past 60 days, enrolled in a CM study.	Intervention: four-session, trauma-informed Syndemics intervention (TIARAS) where expressive writing was delivered during CM with HIV-positive, cocaine-using womenControl: completed 4 sessions writing about neutral topics during CM with HIV-positive, cocaine-using women.	4 sessions (20 minutes each)	1. ASSIT severity score for cocaineVerified with urine analysis	No	3 and 6 months
Mullins et al.⁵⁷	N: 71Age range: 18–42 M age: 27.1 yearsRace/ethnicity: 50%, white; 32% AA; 13% Native American; 7% HispanicRecruitment: mothers enrolled in a 12-month outpatient program for SUDs, who used drugs during pregnancy and who were referred by CPS.	Intervention: three individual, MI sessions given at intake, 1 week following intake, and 2 months postintake.Control: watched a 30-minute educational video pertaining to substance misuse and its effects on families, and at 1 week postintake, (session 2) they watched a second, similar video. Two months postintake (session 3, participants received a supplementary 60-minute home visit	3 sessions (1 hour each)	1. Urine drug screen for alcohol during initial week of intake until 6 negatives were obtained2. Urine screening outcome for illicit drugs during initial week of intake until 6 negatives were obtained3. Maintenance of negative urine screening for duration of 2 months	Yes	No
Ondersma et al.⁵⁴	N: 143Age range: 18–44 M age: 26.6 yearsRace/ethnicity: 6% white; 91% AA; 3% other; 2% Hispanic.Recruitment: In-hospital postchildbirth women with drug use in the month before pregnancy.	Intervention: 20-minute BI session, e-intervention using tablet PC using FRAMES model plus MI principles.Control: assessment questions about music and television preferences with video clips and feedback questions.	1 session (20 minutes)	1. Abstinence from drug use (past 7 days) verified with urine and hair toxicology reportsSelf-reported use of2. Marijuana3. Cocaine4. Alcohol5. Tobacco6. Amphetamines7. Opiates8. Sedatives	No	3 and 6 months	^*
Wechsberg et al.⁵⁵	N: 620Age range: 18 or older M age: 36.7 yearsRace/ethnicity: 100% AARecruitment: AA women reporting unprotected sex during past 3 months and use crack 13+ days of past 90 days were recruited throughIndigenous community outreach workers.	Intervention: a woman-focused interventionComparison: HIV prevention intervention modeled on the NIDA standard HIV preventionControl: delayed treatment	4 modules: 2 individual sessions (30–40 minutes each)2 group sessions (60–90 minutes each)	1. Number of days used crack (past 30 days)Verified with urine analysis	No	3 and 6 months postbaseline	^*

Focus: Both alcohol and other drugs (n = 5)
Kirtdaze et al.⁶²	N: 128Age range: 20–64 yearsM age: 41.7Race/ethnicity: 89% GeorgianRecruitment: women who reported past 30-day injection drug use were recruited from organizations delivering specialized treatment for substance misuse and harm reduction services in Tbilisi, Georgia, and surrounding communities; from female injection drug users who participated in the formative stages of the research; from a Community Advisory Board; and from a Beneficiary Advisory Board.	Intervention: RBT+WC, a structured intervention designed to reduce HIV/HCV risk and drug and alcohol use.Control: information booklets on the same topics covered in the intervention+case management sessions	12 sessionsADD TIME	Nonprescribed use of1. Buprenorphine2. Methadone3. Opioids other than buprenorphine and methadone4. Cannabis5. Benzodiazepines, and6. Amphetamines/methamphetaminesAll drug outcomes were based on urine analysis7. Any use of alcohol (based on breathalyzer).	Yes	3 months
Nyamathi et al.⁵⁸	N: 130Age range: 19–64 M age: 38.8 yearsRace/ethnicity: 14% white; 41% AA; 40% Latino; 5% OtherRecruitment: homeless women on parole or probation with drug use before their most recent incarceration recruited through community shelters and service centers	Intervention: DBT-CM (6) weekly group and individual sessions for 45–60 minutes for 12 weeksControl: HP program, (6) weekly group and individual sessions for 45–60 minutes for 12 weeks	12 sessions (6 individual and 6 group) 540–720 minutes total	1. Abstinence from any drug use2. Abstinence from alcohol use3. Abstinence from alcohol and drugsVerified with urine analysis	No	6 months postbaseline	^*
Pearson et al.⁵⁹	N: 73Age range: 18–60 M age: not providedRace/ethnicity: 100% native AmericansRecruitment: native American women reporting heavy drinking in past year or illegal drug use during the past 3 months and reported subthreshold or above, PTSD symptoms, and being sexually active were recruited using flyers posted at tribal service centers, local fairs and powwows, and nearby colleges and churches.	Intervention: 13 sessions of culturally adapted CPTControl: 6-week wait list	13 sessions	1. Alcohol-related problem in past 3 months2. Alcohol use frequency in past 3 months3. SUD in past 3 months	Yes	3 months	^*
Scott et al.⁶⁰	N: 480Age range: 18 years or older M age: 36.7 yearsRace/ethnicity: 8% white; 83% AA; 5% Hispanic; 4% multiracial or otherRecruitment: women who were about to be released from jail by department of justice services and who were referred to community-based treatment for substance misuse.	Intervention: probation and RMCs. RMCs delivered by linkage managers using MI-based case management to address substance use, HIV risk, and criminal activity.Control: TAU: could include community-based treatment, self-help, and/or probation	Interview check-ups monthly (months 1–3) and quarterly thereafter for 3 years	1. Any past week alcohol or other drug use at visits 1–14.Verified with urine analysis	Yes, both within (n = 13) and at completion of intervention	No	^*
Zule et al.⁶¹	N: 84Age range: 18–33 M age: 23.9_intervention, 22.8_comparison yearsRace/ethnicity: For Intervention group—84% black African; 16% colored. Comparison group—83% black African; 17% colored.Recruitment: women who were HIV positive, sexually active, lived in a low-income disadvantaged community, and reported using alcohol and one or more other drugs for the past 3 months were recruited using street outreach techniques.	Intervention: WHC+TAU (HIV counseling and testing)Comparison: nutrition intervention+TAUControl: TAU	Four 1-hour intervention modules delivered over two contact sessions (two 2-hour sessions)	1. Abstinence from alcohol2. Negative urine screen for use of opiates, cocaine, methamphetamine, and methaqualone	No	3, 6, 9, and 12 months	^*

High-severity samples (n = 28)
Focus: Alcohol only (n = 5)
Epstein et al.⁶⁵	N: 155Age range: 19–75 M age: 48.7 yearsRace/ethnicity: 87% white; 9% AA; 4% multiracialRecruitment: women with a past-year diagnosis of alcohol dependence (DSM-IV) and used alcohol (past 60 days) recruited through advertisements, referral outreach, flyers, and media.	Intervention: G-FS-CBT; first session was 90 minutes, subsequent sessions were 60 minutes.“Pure comparison”^a: I-FS-CBT first session was 2 hours; remaining sessions were 90 minutes	12 manual-guided weekly outpatient sessions	1. Percent drinking days2. Percent heavy drinking3. Any alcohol use4. Any heavy drinkingAll measures were collected during treatment weeks 1–6, 7–12 and 12 months post-treatment	Yes	12 months
Epstein et al.⁶⁶	N: 99Age range: 19–75 M age: 47.9 yearsRace/ethnicity: 91% whiteRecruitment: women who met criteria for alcohol abuse or dependence (DSM-IV), had used alcohol (past 30 days), and were in a committed heterosexual relationship were recruited through media articles, advertisements, and community outreach.	Intervention: 12 sessions of FS-CBT.Control: 12 session of nonfemale-specific CBT	12 manual guided outpatient sessions (1 session 90 minutes and remaining sessions 60 minutes)	1. Percent drinking2. Percent heavy drinkingAll measures collected treatment weeks 1–8, weeks 9–16 , and 12 months post-treatment	Yes	9 and 15 months postbaseline
McCrady et al.⁶³	N: 102Age range: Not reported M age: 44.78_{ABCT group}, 45.31_{ABIT group} yearsRace/ethnicity: 99% whiteRecruitment: women who met criteria for alcohol abuse or dependence (DSM-IV), who had used alcohol (past 60 days) and were in a committed heterosexual relationship, male partner was willing to participate in the study, were recruited through advertising in the community and referrals from local alcohol treatment programs	Intervention: ABCTControl: ABIT, 60-minute sessions	20 ninety-minute sessions conducted over 6 months	1. Percent days abstinent2. Percent days of heavy drinkingBoth collected during treatment and at 9, 12, 15, and 18 months postbaseline	Yes	9, 12, 15, and 18 months postbaseline	^*
McCrady et al.⁶⁷	N: 59Age range: Not reported M age: 46.0 yearsRace/ethnicity: 95% whiteRecruitment: women who met criteria for alcohol abuse or dependence, used alcohol in the past 30 days, and were in a committed heterosexual relationship were recruited through print and online advertisements, outreach to community groups and health care providers, and various media outlets	Intervention: couples' CBTControl: couples' blend of individual and couple therapy	Both 12 sessions (90 minutes)	1. Percent of heavy drinking days	Yes	12 months
Polcin et al.⁶⁴	N: 215Age range: 18 or older M age: 50.9 yearsRace/ethnicity: 83.3% whiteRecruitment: women with current AUD were recruited through radio and newspaper advertising from an outpatient treatment program in northern California	Intervention: 9 sessions of “intensive MI”Control: 1 session of standard MI +8 sessions of nutritional education.	(9) 1-hour sessions	Past 60 days;1. Percent drinking days2. Percent heavy drinking3. Severity of alcohol problems	Yes	No	^*

Focus: Drugs other than alcohol only (n = 8)
Andersen⁶⁸	N: 155Age range: 18 or older M age: 29_experimental, 28_control yearsRace/ethnicity: 14% white; 85% AA; 1% HispanicRecruitment: nontreatment-seeking women with drug dependence recruited from an urban hospital ER	Intervention: opportunity for personalized nursing intervention post-ER recruitment (maximum of eight 1-hour weekly sessions)Control: TAU with community resources information	Maximum of (8) weekly 1-hour sessions	1. Number of drugs in urine at end of treatmentAt end of end of treatment and 6 months post-ER visit:2. Daily drug cost3. Daily heroin cost4. Number of days with drug abstinence	Yes	6 months post-ER visit	^*
Linehan et al.⁶⁹	N: 23Age range: 18–45 M age: 36.1 yearsRace/ethnicity: 66% white; 26% AA; 4% MultiethnicRecruitment: women with diagnoses of borderline personality disorder and current opiate dependence were recruited from mental health clinics, needle exchange programs, clinics for substance misuse, methadone maintenance clinics, and nonprofit HIV/AIDS prevention organizations treating underserved minority populations	Intervention: DBT+opiate agonist therapyControl: comprehensive validation therapy with participation in 12-step programs+opiate agonist therapy	Treatments extended over a 12-month period, with treatments up to 3 times per week	1. Proportion of positive opioid urinalyses assays2. Proportion of positive urinalysis tests for other drugs	Yes	No	^*
Luthar et al.⁷¹	N: 127Age range: Not reported M age: 35.9_RMPG, 36.3_RT yearsRace/ethnicity:39% white; 43% AA; 16% Hispanic; 2% not reportedRecruitment: heroin-dependent mothers with at least one child younger than 16 years and reported problems with parenting were recruited from three methadone clinics in metropolitan areas through referrals by counselors, research assistants, and mothers who had already participated in the study	Intervention: relational psychotherapy (RPMG), a group-based intervention+TAU (methadone+counseling)Control: RT+TAU	No. of sessions:RPMG:244RT: 153All treatment extended over 6 months	1. Positive urine test for cocaine2. Positive urine test for opioids	Yes	32, 40, and 48 weeks postbaseline	^*
Luthar and Suchman⁷⁰	N: 61Age range: M age: 34.9_{RPMG group}, 34.4_{DC group} yearsRace/ethnicity:74% white; 18% AA; 8% HispanicRecruitment: heroin-dependent mothers with at least one child younger than 16 years and reported problems with parenting were recruited from three methadone clinics in metropolitan area through referrals by counselors, visits made by research assistants to ongoing drug-counseling groups and medication lines, and mothers who had already participated in the study	Intervention: relational psychotherapy (RPMG), a group-based intervention+TAU (methadone+counseling)Control: TAU	Treatment extended over 6 months	1. Positive urine test for cocaine2. Positive urine test for opioids	Yes	No	^*
Stahler et al.⁷²	N: 18Age range: 18 or older M age: 32.4 yearsRace/ethnicity: 94% AA; 6% HispanicRecruitment: women residential in SUD treatment <2 weeks with primary misuse of or dependence on cocaine.	Intervention: bridges—included interaction with mentor or CAP, group activities, workshops, training sessions, and cultural and recreational endeavors. It was implemented as a treatment adjunct with existing residential program. +TAU (residential treatment)Control: speakers and activities+TAU	Treatments extended over a 9-month period, with individual and group counseling sessions	1. Cocaine abstinence measured by urine drug assay	Yes	No	^*
Suchman et al.⁷³	N: 87Age range: 18 or older M age: 29.7 yearsRace/ethnicity: 77%, white; 14% AA; 3% Hispanic; 6% multiethnicRecruitment: mothers in medication-assisted treatment (methadone or Suboxone) and caring for a child between 11 and 60 months of age recruited through clinician referrals, research staff visits to clinic groups and medication lines, and word of mouth	Intervention: MIO+TAU (mediation-assisted therapy)Control: PE, a psychoeducation. Active control+TAU	12 weekly 1-hour sessions	Monthly self-report of drug use, looking separately at;1. Heroin use2. Opioid use3. Cocaine useThrough 6 months postbaseline.	Yes	1, 2, and 3 months	^*
Suchman et al.⁷⁵	N: 47Age range: Not reported M age: 31.4_{MTP group}, 28.9_{PE group} yearsRace/ethnicity: 30% minority (unspecified)Recruitment: mothers in outpatient drug treatment and caring for a child between birth and 36 months were recruited through clinician referrals, research staff visits to clinic groups and medication lines, and self-referral	Intervention: MTPControl: PE Program	12 weekly 1-hour sessions	Monthly presence or absence of drug use by urine drug assay for1. Opiate use2. Cocaine use3. Cannabis use metabolites in urine sample	Yes	6 weeks
Wechsberg et al.⁷⁴	N: 100Age range: 18–30 M age: 25.9 yearsRace/ethnicity: 100% RussianRecruitment: women reporting injection drug use (past year) enrolled in inpatient treatment for substance misuse for more than 4 days were recruited from the inpatient facility using staff or self-referrals from posted advertisements	Intervention: women-focused intervention, interactive, manualized intervention focused on empowerment of women through education activities, skill building demonstrations, guided practice and role playingControl: time+attention matched nutrition program	Two 1-hour sessions, delivered a week apart	1. Mean number of days heroin injected, past 30 days2. Any drug injected, past 30 days3. Any drug smoked, snorted, past 30 daysDrug use verified with urine analysis	Unclear	3 months postbaseline

Focus: Both alcohol and other drugs (n = 15)
Dakof et al.⁷⁶	N: 62Age range: 18 or older M age: 30.2 yearsRace/ethnicity:23% white; 42% AA; 35% HispanicRecruitment: mothers recruited from family drug courts, which required a diagnosis of substance abuse or dependence (DSM-IV), at least one dependent child, and the potential for family reunification.	Intervention: EMP+family drug court with ICMSControl: family drug court with ICMS	Phase 1: 1 month—weekly contact with counselorPhase II: 3 months—weekly contact with counselorPhase III: 3 months—biweekly contact with counselorPhase IV: month 8 to graduation—monthly contact with counselor	1. Alcohol use severity (past 90 days)2. Drug use severity (past 90 days)3. Positive urinalysis assay alcohol, cannabis, amphetamines, barbiturates, benzodiazepines, cocaine, opiates, and phencyclidine [PCP]	Yes	18 months postbaseline at 3–6 months	^*
Feaster et al.⁷⁷	N: 126Age range: 43–71 M age: 44.1_intervention, 42.2_control yearsRace/ethnicity: 79% AA; 12% Hispanic; 9% otherRecruitment: women who were HIV+, on antiretroviral medication, and who met the criteria for a substance use diagnosis (past year) (with cocaine as either the primary or secondary drug being misused), were recruited from residential and outpatient drug treatment, HIV treatment providers, and self-referrals. At least one family was required to participate in a companion program.	Intervention: SET focused on building family support for relapse prevention and HIV medication adherence through individual counseling sessionsControl: psychoeducational HG. SET focused on building family support for relapse prevention and HIV medication adherence through individual counseling sessions with participants	Weekly 50 minutes sessions for up to 4 months	1. Self-reported days of use of alcohol and illicit drugs in the past 30 days (composite measure)Verified with urine analysis	Yes	6-, 8-, 10-, and 12-month assessment with time post-treatment varying by participant up to 4 months.	^*
Greenfield et al.⁷⁸	N: 23Age range: 23–67 M age: 45.0 yearsRace/ethnicity: 96% white; 4% Native AmericanRecruitment: women with current substance dependence diagnosis and reporting past 60-day substance use were recruited from an academic hospital program with advertisements, flyers, and clinician referrals	Intervention: WRG treatment——structured relapse prevention group therapy with women onlyControl: GDC with men and women	WRG: (12) 90-minute sessions GDC: (12) 90-minute sessions	1. No. of days of any substance use (past month);2. No. of drinking days per month (past month)3. No. of drinks/day (past month)4. Severity of addiction symptoms (past month)Verified with urine analysis	Yes	6 months	^*
Greenfield et al.⁸⁷	N: 100Age range: Not reported M age: 47Race/ethnicity: 95% white; 4% AA; 1% AsianRecruitment: women with current substance dependence diagnosis and reporting past 60-day substance use were recruited through treatment programs and private practices, websites, and advertisements	Intervention: WRG—structured relapse prevention group therapy with women onlyControl: GDC with men and women	12 weekly 90-minute sessions	1. Mean days of substance use (past 30 days)2. Problem severity—alcohol3. Problem severity—drugsVerified with urine analysis	Yes	1, 2, 3, and 6 months
Hien et al.⁸⁶	N: 353Age range: 18–65 M age: 39.2 yearsRace/ethnicity: 46% white; 34% AA; 6% Hispanic; 13% multiracial; 1% otherRecruitment: women with alcohol or illicit substance use (past 6 months) and current diagnosis of drug or alcohol abuse or with dependence (DSM-IV) with a diagnosis of at least one traumatic event (lifetime) and full or subthreshold PTSD were recruited from seven community-based treatment programs for substance misuse (CTPs) across the United States using advertising brochures, fliers, newspaper, print media, and referrals from treatment staff	Intervention: seeking safety, a cognitive behavioral treatmentControl: WHE	2 sessions per week over ∼6 weeks for 2.5–3 hours	1. Seven-day abstinence from any illicit drug or alcohol use.2. Percentage of days using drugs or alcohol in the previous week.Verified with urine analysis	Yes	3, 6, and 12 months
Morgenstern et al.⁷⁹	N: 302Age range: 35–37 M age: 37.00_intervention, 35.5_control yearsRace/ethnicity: 96% AA; 3% Hispanic; 1% otherRecruitment: women with a diagnosis of substance dependence were recruited from urban welfare to work program offices by screening for TANF benefit eligibility	Intervention: ICM, a coordinated social and health care services with long-term support and monitoring+usual careTAU: health assessment and referral to treatment services for substance misuse	Ongoing services over a 15-month period	1. Self-reported drug abstinence (past 30 days) supplemented by urine drug assay screening and collateral verification when needed	Yes	24 months postbaseline (∼9 months post-treatment)	^*
Morgenstern et al.⁸⁰	N: 302Age range: 35–37 M age: 37.0_intervention, 35.5_control yearsRace/ethnicity: 96% AA; 3% Hispanic; 1% otherRecruitment: women with a diagnosis of substance dependence were recruited from urban welfare to work program offices by screening for TANF benefits eligibility.	Intervention: ICM, a manual-guided coordinated social and health care service with long term support and monitoring plus usual careTAU: Health assessment and referral to treatment services for substance misuse	Ongoing services over a 15 month period	1. Self-reported drug abstinence (past 30 days) supplemented by urine assay screening and collateral verification when needed	Yes	24 months postbaseline (∼9 months post-treatment)	^*
Najavits et al.⁸⁸	N: 66Age range: 18–65 M age: 47/0_intervention, 48.5_{contrrol group} yearsRace/ethnicity: 26% minority _intervention, 27% minority_{contrrol group} Recruitment: female military veterans with current SUD and with recent substance use (past 90 days) were recruited by research staff and flyers from the greater urban area in which the study took place	Intervention: a WPR, a woman-focused SUD recovery modelControl: TSF, SUD recovery model that was not focused on women	12 weekly sessions, 1-hour each	1. Severity of alcohol problems (past 30 days)2. Severity of drug problems (past 30 days)3. Past 30 day frequency of alcohol or drug useVerified with urine analysis and breathalyther	Yes	3 months
O'Farrell et al.⁸¹	N: 61 (+ male partners)Age range: not reported M age: 39Race/ethnicity: 87% white; 7% AA; 7% HispanicRecruitment: women with SUD (with the primary substance other than nicotine or alcohol) seeking treatment at a large SUD treatment center in the northeastern United States	Intervention: BCT+IBTControl: IBT only	26 sixty-minute sessions over 20 weeks	1. Percentage days abstinent from drug or alcohol use during past 3 months2. Percentage days of any illicit drug use during past 3 months2. Adverse consequences of alcohol and drug useduring past 3 monthsVerified with urine analysis	Yes	3, 6, 9, and 12 months	^*
Price et al.⁸²	N: 46Age range: 19–58 M age: 39 yearsRace/ethnicity: 93% white; 2% Asian; 4% MultiethnicRecruitment: women in a community nonprofit outpatient SUD treatment program recruited through posted flyers and presentations by the research coordinator	Intervention: MABT, including massage and training to address of issues alexithymia and body awareness practices+TAU (SUD treatment)Control: TAU	8 weekly sessions, 1.5 hours each	1. Mean days abstinent from alcohol or other drugs (past 90 days)2. Dichotomous indication of abstinence during assessment windowVerified with urine analysis and breathalyzer	Yes	6 and 9 months postbaseline	^*
Price et al.⁸³	N: 187Age range: 22–61 M age: 35 yearsRace/ethnicity: 79% white; 11% multiethnic; 5% AA; 4% native American; 1% Asian; 8% identified as Hispanic.Recruitment: women from 3 community, nonprofit intensive outpatient clinics for SUD receiving treatment using flyers posted in the clinics or through presentations by the research coordinator	Intervention: MABT, including massage and training to address of issues alexithymia and body awareness practices+TAUTime and Attention Control: women's health education+TAUControl: TAU only	8 weekly sessions, 1.5 hours each	1. Mean days abstinent from alcohol or other drugs (past 90 days)2. Dichotomous indication of abstinence during assessment windowVerified with urine analysis	Yes	6 and 12 months postbaseline	^*
Schäfer et al.⁸⁹	N: 343Age range: Not reported M age: 40.9Race/ethnicity: 90% German born.Recruitment: women with an SUD and either subthreshold or full PTSD were recruited from German hospitals with departments dedicated to treating substance misuse through referrals from mental health clinics, community psychotherapists, and advertisements.	Intervention: seeking safety+TAUTime and Attention Control: RPT+TAUControl: TAU only	14 ninety-minute group sessions +2 individual sessions (both seeking safety and RPT)	1. Drug and alcohol-free days past 30 days2. Alcohol problem severity past 30 days3. Drug problem severity past 30 days	Yes	3 and 6 months
Schumn et al.⁸⁴	N: 105Age range: Not reported M age: 44.42Race/ethnicity: 97% whiteRecruitment: women with AUD seeking treatment at a large SUD treatment center in the northeastern United States	Intervention: BCT+IBTControl: IBT only	26 sixty-minute sessions over 20 weeks	1. Percentage days abstinent2. Adverse consequences of alcohol and drug use during past 90 daysVerified with urine analysis	Yes	3, 6, 9, and 12 months	^*
Slesnick and Erdem⁹⁰	N: 60Age range: Not reported M age: 26.3 yearsRace/ethnicity:12% white; 75% AA; 2% Asian; 10% multiethnic or otherRecruitment: homeless women with substance dependence and a biological child between the ages of 2 to 6 years in their care were recruited from a local family shelter	Intervention: ecologically based treatment with 3 months of rental and utility assistance (up to $600 per month), and case management services+substance misuse counseling.Control: TAU group received housing and services through the family shelter and community housing programs.	Intervention delivered over 6 months	1. Frequency and quantity of drug and alcohol use (past 90 days)2. Consequences of substance misuse (past 90 days)Verified with urine analysis	Yes	9 months postbaseline
Zhang et al.⁸⁵	N: 183Age range: 22–54 M age:33.9 yearsRace/ethnicity: 54% white; 43% AA; 3% otherRecruitment: women with AUD or SUD and seeking outpatient treatment for SUD, and had a child between 8 and 16 years of age, who lived with them, were recruited from a community treatment center for substance use in a large Midwestern city	Interventions: EBFT delivered at homePure comparison: EFBT delivered in the officeControl: WHE	12 sessions completed within 6 months	1. Percent days of drug and alcohol use (past 90 days)Verified with urine analysis	Yes	12 and 18 months postbaseline	^*

All study participants identified as female. All studies included in the review were either 2-arm or 3-arm RCTs. If session length was not noted, it was not reported. The term “alcohol dependence” appears if study authors used DSM-IV criteria to screen or diagnose participants.

In the column, “Significant Effect(s)” indicates that at least one substance use effect hypothesized by the study authors was significant. Generally, this involved improvement in the intervention condition relative to the comparison or control condition.

The term “Pure comparison” was used when the authors of a study specified no difference between treatment conditions. This typically occurred when a standard treatment was compared to a variation (e.g., ABCT vs. ABIT) (Sobell et al., 2009).¹⁰⁰

AA, African American; ABCT, alcohol behavior couples' therapy; ABIT, alcohol behavior individual therapy; AUD, alcohol use disorder; BCT, behavioral couples therapy; CBT, cognitive behavioral therapy; CM, contingency management; CPT, cognitive processing therapy; DBT-CM, dialectical behavioral therapy case management; EBFT, ecologically based family therapy; EMP, Engaging Moms Program; ER, emergency room; FS-CBT, female-specific cognitive behavioral therapy; GDC, group drug counseling; G-FS-CBT, group-based female-specific cognitive behavioral therapy; HG, health group; HP, health promotion; IBT, individually based therapy; ICM, intensive case management; ICMS, Intensive Case Management Services; I-FS-CBT, individual female-specific cognitive behavioral therapy; MABT, mindful awareness in body-oriented therapy; MDPO, mean number of drinks per occasion; MI, motivational interviewing; MIO, mothering from the inside out; MM, mindfulness meditation; MTP, Mothers and Toddlers Program; NIDA, National Institute on Drug Abuse; PBSs, protective behavioral strategies; PCP, primary care provider; PE, parent education; PIRI, pleasant imagery and relaxation instruction; PPRS, prevention of postrape stress; PTSD, post-traumatic stress disorder; RBT+WC, Reinforcement-Based Treatment and the Women's CoOp; RCT, randomized controlled trial; RD, risky drinking session; RMCs, recovery management check-ups; RPMG, relational psychotherapy; RPT, relapse prevention training; SA, sexual assault; SAMFE, Sexual Assault Medical Forensic Examiner; SB, spring break; SET, structural ecosystems therapy; SN, social network; SUD, substance use disorder; TANF, temporary assistance for needy families; TAU, treatment as usual; TIARAS, Trauma Intervention for Affect Regulation, AIDS, and Stimulants; TSF, 12-step facilitation; WHC, Women's Health CoOp; WHE, Women's Health Education; WIC, Women Infant and Children; WPR, Woman's Path to Recovery; WRG, Women's Recovery Group.

Instead, we grouped the studies on the basis of two factors. The first was substance use severity for the target population in each clinical trial. Studies were categorized as having participants with either high- (N = 28), moderate- (N = 17), or low- (N = 6) severity substance use. Studies assigned to the high-severity group only enrolled women who met diagnostic criteria for one or more SUDs. In contrast, the moderate-severity group studies recruited women with heavy or at-risk alcohol use or heavier drug use, as well as comorbid mental health or psychosocial challenges. While some women in the moderate severity group would likely meet the criteria for SUD, no diagnosis was required for study enrollment. Finally, low-severity studies were those with no inclusion criteria for heavy or problem substance use. As a result, these studies enrolled women both with and without heavy or problem substance use.

Second, within each severity group, studies were classified based on the type(s) of substance(s) that were the focus of each RCT. Specifically, studies were labeled as targeting: alcohol use and problems only (alcohol only; N = 15); other drugs, but not alcohol (drugs only; N = 14); and both alcohol and other drugs (alcohol and drugs; N = 22). This nomenclature acknowledged the historical separation in the United States of treatment services for AUD from services for other drug use disorders. It also recognized that alcohol treatment research has been funded by a different National Institutes of Health (NIH) Institute (National Institute on Alcohol Abuse and Alcoholism [NIAAA]) than drug treatment research (National Institute on Drug Abuse [NIDA]), and that each institute has guided research based on its own funding priorities.

In addition, there is research to support use of this classification method, with both epidemiological³⁸ and clinical³⁹ studies finding differences in treatment outcomes for patients with alcohol only, drug only, and both alcohol and drug problems. Taken together, this classification system allowed us to characterize the type and intensity of the interventions both within and across participant substance use and problem severity subgroups.

Risk of bias ratings

Risk of bias ratings varied across the 51 studies reviewed, with most studies revealing no apparent risk of bias in selective reporting, very little risk of bias in incomplete outcome data, and unclear risk of bias in blinding of outcome assessment, allocation concealment, and random sequence generation. The greatest risk of bias observed in these studies was failure to blind outcome assessments: nearly one-fifth of the studies (24%) demonstrated high risk of bias in this category, with another 45% failing to provide enough information to provide a judgment about this risk. Some risks of bias are to be expected, given the psychosocial nature of the interventions. The majority of studies reported low risk of selection bias through random sequence generation (71%), but a sizable percentage (29%) did not report sufficient detail to make a judgment in this category or regarding allocation concealment (65%). Please see Figure 2 for complete risk of bias information.

FIG. 2.

Risk of bias graph.

Studies targeting low-severity samples

Six of the 51 studies targeted low-severity participant samples; 4 of the 6 (67%) studies reported one or more positive substance-related intervention effects (Table 2).

Table 2.

Percentage of Studies with At Least One Positive Intervention Effect by Severity Status of the Sample and Substance Targeted

Severity level	Alcohol only (n = 15; 29%)	Other drugs only (n = 14; 27%)	Both alcohol and other drugs (n = 22; 43%)	Overall %
Low severity (n = 6; 12%)	50% (1/2)	100% (2/2)	50% (1/2)	67% (4/6)
Moderate severity (n = 17; 33%)	38% (3/8)	50% (2/4)	80% (4/5)	53% (9/17)
High severity (n = 28; 55%)	40% (2/5)	75% (6/8)	67% (10/15)	64% (18/28)
Overall %	40% (6/15)	71% (10/14)	68% (15/22)	61% (31/51)

N = 51.

Alcohol-only studies

Two of the six low-severity studies focused on alcohol only,^40,41 but only Dvorak et al.⁴¹ reported intervention effects on at least one outcome. Both studies used a single session, web-based intervention, but they differed substantively in sample size, target population, outcome measures, and follow-up period. Dvorak et al.⁴¹ focused on reducing drinking among women who indicated they intended to party during spring break (SB) and found reductions in alcohol-related problems during the SB period. In contrast, Delrahim-Howlett et al.⁴⁰ recruited women with children from WIC (Women Infant and Children) clinics who reported drinking at moderate levels and followed them for 2 months postintervention. Neither RCT reported changes in alcohol consumed, and Delrahim-Howlett et al.⁴⁰ reported no change in any alcohol-related outcome.

Drugs-only studies

Two low-severity studies targeted drugs other than alcohol. Both focused on marijuana use, and both reported one or more intervention effects.^42,43 While the two studies differed dramatically in sample size (N = 34 and 332), both evaluated two-session interventions and followed participants for at least 3 months postintervention.

Alcohol and drug studies

Two low-severity studies targeted both alcohol and other drugs, with one reporting positive outcomes on at least one measure⁴⁴ and the other finding no substance-related intervention effects.⁴⁵ Both studies evaluated a single-session intervention and both focused on early intervention and prevention of a progression in alcohol or drug use among adolescents. Mason et al.⁴⁴ used MI and social networking and delivered their intervention in a primary care setting. They measured substance use and negative consequences of use and reported a significant intervention effect on trouble due to alcohol use before sex. In contrast, participants in Walsh et al.'s⁴⁵ study were recent victims of sexual assault, who may or may not have had a history of risky drinking or drug use. Participants received a 9-minute intervention (watching a video) and no significant intervention effect was reported.

Studies targeting moderate-severity samples

Seventeen of the 51 studies in this review targeted moderate-severity samples; 9 of these, studies (53%) reported one or more positive substance-related intervention outcomes.

Alcohol-only studies

Eight of the 17 studies in this category targeted heavy/problem drinking. Three reported positive findings,^46
–48 and five indicated no significant intervention result.^49

–53 When studies with positive outcomes were compared to those with no significant alcohol-related intervention effects, one notable difference centered on baseline levels of alcohol use. For the three studies with intervention effects,^46
–48 women were enrolled, who reported recent (past month) heavy drinking, which provided an opportunity to observe group differences in change from baseline to follow-up assessment. For example, 92% of participants in Manwell et al.'s⁴⁸ study reported recent binge drinking, with an average of 5+ episodes in the past month.

In contrast, inclusion criteria for the five studies with no group differences tended to survey participants about more distal (past year) drinking⁵¹ or used screening tools such as the AUDIT that combined quantity and frequency measures with adverse consequences.⁵⁰ Still others⁴⁹ lacked detail such that baseline drinking patterns could not be determined. The importance of this methodological issue was illustrated in the Connors and Walitzer report.⁵² While testing of primary hypotheses yielded no intervention effect, a post hoc analysis focused solely on the heavier drinking women at baseline did in fact find a differential effect by intervention group.

Drugs-only studies

Of the four studies in this category, two^54,55 reported significant differences in drug use-related outcomes, while two^56,57 found no significant intervention effect. All four interventions in this group were relatively brief, ranging from a minimum of one³² to a maximum of four sessions.^33,34 Two of the four studies contained MI elements; intervention components of the other two studies included expressive writing and women-focused HIV prevention. Studies with positive outcomes differed from those with nonsignificant findings in several ways. First, the two studies with positive outcomes had much larger sample sizes than the two studies with nonsignificant findings. Second, both studies with positive outcomes recruited women who were not engaged in other substance-related treatment.^54,55 The two studies with negative outcomes examined brief interventions delivered as adjuncts to ongoing treatment for substance use and targeted women with stimulant⁵⁶ or primarily cocaine⁵⁷ use.

Alcohol and drug studies

Four of five moderate-severity studies targeting both alcohol and other drugs reported one or more positive substance-related outcomes.^58

–61 The four articles with positive findings described interventions that varied by type and amount, ranging from two 2-hour Women's Health Co-op sessions⁶¹ to 12 sessions of dialectical behavior therapy (DBT) and case management⁵⁸ to 13 sessions of a culturally adapted cognitive processing therapy⁵⁹ to 14 check-up interviews over a 3-year time period.⁶⁰ Sample sizes ranged from a low of N = 73⁵⁹ to a high of N = 480.⁶⁰ In addition, sample recruitment and target groups also varied widely from Native American women with heavy drinking or illegal drug use and symptoms of PTSD⁵⁹ to women recently released from jail and referred to community treatment⁶⁰ to homeless women on probation or parole with past history of alcohol or drug use⁵⁸ to women living with HIV and reporting recent alcohol and drug use.⁶¹

In contrast, the one study with negative results⁶² was conducted in the Republic of Georgia and recruited women with a recent (past 30 day) history of injecting illicit drugs and heterosexual activity. While the majority of women in that study reported recent IV opioid use, in the absence of formal SUD diagnoses, the study was classified as moderate severity. Furthermore, substance use outcomes were limited to urine drug assays and breathalyzers for alcohol use, and the study occurred during what appeared to be a significant shift in policy concerning methadone and buprenorphine and the treatment of opioid use disorder (OUD).

Studies targeting high-severity samples

Twenty-eight of the 51 studies in this review targeted high-severity samples; 18 studies (64%) reported significant intervention effects on at least one substance-related outcome.

In these studies, all but one of the alcohol-only studies enrolled women with a diagnosis of AUD (past year) and self-report of recent use, typically defined as the past 60 days. For the drugs-only studies, all but one of the studies recruited from SUD treatment programs. These ranged from inpatient medical detoxification to residential to outpatient counseling or medication-assisted treatment programs. For those studies targeting both alcohol and drugs, half recruited from SUD treatment programs, with other studies focused on homeless women, women in family drug court, and women enrolled in a TANF (temporary assistance for needy families) welfare to work program, among others.

Alcohol-only studies

For the five studies targeting women with AUDs, two reported intervention effects on all alcohol-related outcomes,^63,64 while three reported no intervention effect on any alcohol-related outcome in the study.^65
–67

Polcin et al.⁶⁴ tested the effects of a nine-session intensive MI (IMI) intervention versus a single session of MI plus eight sessions of nutrition education on alcohol problem severity, percentage of drinking days, and percentage of heavy drinking days. At 2 months postintervention, the IMI intervention was superior to the control group on all outcome measures. The second study with positive intervention effects tested a variation of CBT, and compared women randomized to a 20-session alcohol behavioral couple therapy (ABCT) with women assigned to a 20-session alcohol behavioral individual therapy (ABIT).⁶³ McCrady et al.⁶³ found improvements in days abstinent and fewer days of heavy drinking among women randomized to ABCT versus ABIT.

Interestingly, McCrady et al.⁶³ and the three articles with no significant intervention effects were from the same research group.^65
–67 All four tested variations of CBT, comparing modes of delivery (individual or group format) and different target groups (couples, individuals, or a blend) with similar procedures and follow-up periods. McCrady et al.⁶⁷ had a smaller sample size than McCrady et al.⁶³ and found no difference in alcohol-related outcomes for women randomized to 12 sessions of ABCT compared to those receiving a combination of 5 individual CBT sessions and 7 ABCT sessions. Similarly, while women in both treatment conditions significantly reduced their percent drinking days and percent heavy drinking days by equivalent amounts, no difference was found when group-based female-specific CBT was compared to individually based female-specific CBT,⁶⁵ and no difference was found between CBT that was female specific versus neutral.⁶⁶

Drugs-only studies

Six of the eight studies in this category reported significant intervention effects on at least one outcome.^68

–72 All these studies focused on women with one or more drug use disorders, and in some cases, a comorbid diagnosis.

Among the six studies with at least one positive drug-related finding, the types of interventions tested varied widely, ranging from DBT⁶⁹ to faith-based community support⁷² to relational psychotherapy.^70,71 Interestingly, all but one examined an intervention delivered in conjunction with treatment as usual (TAU). Four of the six studies with positive outcomes enrolled women with OUD; three recruited from medication-assisted treatment programs, and those participants received medication for Opioid Use Disorder (MOUD)^70,71,73; the fourth study⁶⁹; provided an opioid medication (no longer available) to all participants. The remaining two studies with positive outcomes either tested an intervention delivered to women in the context of longer term residential care (3–6 months)⁷²; or examined a nurse-delivered intervention for nontreatment-seeking women with SUD seen in a hospital Emergency Room.⁶⁸

The two studies with negative substance-related outcomes also tested interventions delivered as adjuncts to treatment, but one examined a lower intensity (two sessions) intervention and paired it with a shorter duration inpatient program (7 days–4 weeks),⁷⁴ and the other intervention was offered in tandem with a more heterogeneous network of outpatient SUD treatment options that included (but did not require) MOUD.⁷⁵ The Wechsberg et al.'s study⁷⁴ was conducted in Russia and targeted women with injection drug use, with many likely to have an OUD diagnosis in the absence of MOUD treatment.

Alcohol and drug studies

Ten of the 15 studies in this category reported significant intervention effects on at least one outcome.^{76

–85} The interventions tested in this group of studies varied widely. While by definition all women met diagnostic criteria for one or more SUDs, many presented with comorbid conditions that put them at risk for continued alcohol and other drug use and problems. Such comorbidities included the following: a diagnosis of trauma exposure, HIV+ status, and homelessness, among others. As with the studies of high-severity samples that targeted drugs, many of the treatment periods were lengthy, ranging from 6 weeks to 15 months. Interestingly, none of the 15 studies enrolled women receiving MOUD.

Study outcomes were diverse, and included assessment of abstinence only, frequency of drug and alcohol use, and severity of use, or combinations of the above. Fourteen studies verified drug use with urinalysis. The time frames of substance use outcomes varied from the past week⁸⁶ to the past month^{77

–80,87
–89} to the past 90 days.^{76,81

–85,90}

In the 10 studies with positive substance-related intervention effects, 3 described RCT inclusion criteria that may have restricted enrollment to women with some family and social support resources. Feaster et al.⁷⁷ only enrolled women who could identify a family member willing to participate in the required companion program. Similarly, a male partner willing to participate in Behavioral Couples Therapy was a requirement for both the O'Farrell et al.⁸¹ and Schumm et al.⁸⁴ clinical trials. Another three of the 10 studies with positive intervention outcomes focused on women with additional incentives to participate in an intervention, including Dakof et al.⁷⁶ who recruited from family drug court and Morgenstern et al.^79,80 who enrolled women from welfare to work programs. The remaining three studies recruited from community outpatient SUD programs.

Two studies by Price et al.^82,83 tested mindful awareness in body-oriented therapy as an add-on to outpatient SUD treatment (TAU). Zhang et al.⁸⁵ tested ecologically based family therapy delivered either at home or in the office to a health education control group in a sample of women who had a child between the ages of 8 and 16 years living with them.

The last study with positive findings was one of two that compared a woman-only recovery group in combination with structured relapse prevention group therapy to a drug counseling group that included both men and women. While one study found at least one positive outcome (Greenfield et al.⁷⁸), the other reported no significant group difference for any substance-related outcome (Greenfield et al.⁸⁷). The first study⁷⁸ had a smaller sample (N = 23) than the second⁸⁷ (N = 100), and only the latter enrolled some women who were also receiving MOUD. Of the remaining four studies with negative findings, two were clinical trials of Seeking Safety and targeted women with SUD and either subthreshold or full PTSD (Hien et al.⁸⁶ and Schäfer et al.⁸⁹).

Another by Slesnick and Erdem⁹⁰ tested an ecologically based treatment in a sample of homeless women, and Najavits et al.⁸⁸ found no difference in outcomes for a woman-focused versus nonwoman-focused intervention in a sample of female military veterans with SUD.

Discussion

This article describes outcomes of 51 randomized clinical trials of psychosocial interventions targeting alcohol and/or drug misuse and use disorders in women. During our initial review of these studies, we found significant heterogeneity in the types of interventions examined, the substance(s) they centered on, and the baseline levels of use, misuse, and related problems needed to qualify for study enrollment. Because our primary focus was on the psychosocial interventions themselves, we sought to reduce some of this variability by first categorizing the studies into low-, moderate-, and high-severity groups based on participant substance use severity. Within each severity group, we further classified studies by substance(s) targeted in the intervention, namely alcohol only, other drugs (excluding alcohol), or alcohol and other drugs.

Participant severity risk groups

The proportion of studies reporting one or more positive outcomes ranged from 53% for moderate-severity studies to 67% for low-severity studies, with 64% of high-severity studies reporting one or more positive outcomes. As would be expected, brief, single-session interventions were more typical in the low-severity group of studies, while higher intensity and longer duration interventions predominated in the high-severity group. In fact, all the interventions with the low-severity samples used one or two sessions. Interestingly, the success rate in these low-severity studies was comparable to that found for high-severity samples.

In contrast to the stand-along interventions delivered in the low-severity studies, many of the interventions in this high-severity group of studies were delivered in conjunction with other ongoing services ranging from medication for Opioid Use Disorder (MOUD) and contingency management to housing and employment assistance. Notably, all the studies with high-risk samples in which women received MOUD did not target alcohol; all but one of these studies reported a positive intervention effect on one or more drug-related outcomes. In addition to all participants meeting criteria for SUDs, participants presented with comorbid conditions that included physical and/or mental health disorders and psychosocial challenges. Not surprisingly, the interventions in this group of studies were heterogenous, but notably, most reported intervention efficacy on at least one substance-related outcome. Participants in these studies were diverse in terms of race/ethnicity, rural-urban living location, and educational attainment.

The moderate-severity studies were the most variable in a number of ways. In terms of sample characteristics, participants varied on their baseline levels of substance use, their recency of problematic use, their use of illicit substances, and the presence of comorbid conditions. In addition, while a subgroup of participants might have had a diagnosis of SUD, this was not an inclusion criterion for participation, and therefore did not meet our criteria for a high-severity study. Overall, the wide range of participants in this group of studies may have accounted for the lower success rate relative to studies targeting low- and high-severity samples.

Target substance(s)

Classifying studies based on the substance(s) targeted revealed distinct differences in the pattern in outcomes. Fewer than half of the studies in the alcohol-only group reported one or more positive outcomes (40%) compared to three-fourths of the studies in the other drugs-only group (71%) and two-thirds of the studies (68%) in the alcohol and other drug use group. A variety of factors may have contributed to this difference in the alcohol-only group and warrant further study. First, a greater percentage of studies in the alcohol-only group compared intervention modalities (e.g., group vs. individually focused CBT) than either the drugs-only or both alcohol and drugs groups.

In addition, different interventions were tested across the three targeted substance groups, and there was a greater reliance on self-report versus objective biological measures for outcome assessment in the alcohol-only group (although this is changing with real-time ability to collect breathalyzer data through cell phones and PeTH).⁹² From a research perspective, alcohol-related treatment research is funded by a separate agency (NIAAA vs. NIDA) and it is not illegal for adults to consume alcohol in moderation. Across severity groups, studies that focused on drugs other than alcohol or both alcohol and other drugs tended to show that intervention success, defined as at least one positive intervention outcome, increased with dosage. This was true regardless of the nature of the intervention.

However, direct comparisons by intervention dose should be avoided, given the myriad methodological issues likely to impact substance-related outcomes such as sample size, types of control or comparison group(s), outcome variables assessed, and follow-up assessment points. For example, McCaul et al.⁹³ found that patient demographics predicted outpatient SUD treatment better than substance type (alcohol only, drugs only, or both).

Methodological limitations of studies included in the review

Although all the studies included in this review were RCTs, they varied in quality. For example, 20% of the studies had no follow-up after the end of treatment, and an additional 24% of studies followed participants less than 6 months after the end of treatment. Other common concerns included vague descriptions of the intervention content and low intervention dosage. Some low-dosage studies were pilot investigations and were meant to be brief, but other studies reported low dosage for moderate- and high-severity samples, many of whom had comorbid conditions. While many studies analyzed data using an intent-to-treat approach, other studies used listwise deletion in their analyses. This may have skewed results in a positive direction.

Methodological limitations of our review strategy

Although our search strategy yielded over 11,000 unique studies to review, resulting in 51 studies that met all criteria, several limitations of our approach should be noted. First, although we took care to specify appropriate terms in our search, some relevant studies may have been missed due to terminology. For example, our study was not focused on co-occurring disorders per se, so this was not one of our search terms. Second, we did not include RCTs specific to women who were pregnant or who were serving time in jail or prison. We made this decision due to recent reviews targeting these populations and based on our observations that many interventions for women who are pregnant are pharmacological, and many interventions for women who are incarcerated use quasi-experimental designs due to the limitations of the setting.

However, by excluding RCTs for these populations we may have missed unique insights into treatment for women. Interestingly, several studies included in our review focused on women who were at risk for pregnancy or were postpartum; likewise, there were several studies in our review that focused on women after their release from jail or prison. A third limitation of our review strategy was that we did not specifically compare intervention effects for men versus women. A fourth limitation was our decision to classify studies as having at least one substance-related intervention effect that was hypothesized, but not calculating a percentage of positive results for each study. We classified studies as having at least one, versus no, intervention effect, for simplicity, but this decision could have inflated the assessment of intervention effectiveness.

Finally, we included psychosocial intervention studies with substance use as either a primary or secondary outcome. This meant that a study focused on HIV risk behavior, which also assessed substance use, for example, was evaluated using the same criteria as a study whose primary aim was to reduce substance use. While we have no evidence to suggest any difference in substance use outcomes using this differentiation, it may have been useful to systematically differentiate these foci in our results.

Implications for future research

Our review suggested that future RCTs focused on evaluating psychosocial interventions to reduce substance use (SU) and SUDs in women might be improved in several ways. First, additional research is needed to determine whether content tailored to women or delivered to women only is more efficacious than generic content or other delivery modes. These were some of the questions that we wanted to answer in this review, and also were raised by McCrady et al.⁹⁴ in a recent review of treatment for women with AUD. We were unable to conclusively answer these questions, as few studies included in our review compared tailored and generic intervention content, or delivery to women only versus other designs.

However, more impactful research efforts might focus on reducing the structural barriers to treatment, a topic our review did not address, but has been noted as a significant issue for women.^{8,19

–25} Exposure to trauma, psychiatric comorbidities, and family responsibilities, including child care, are examples of barriers that impede women from seeking or remaining in treatment.

Second, RCTs might focus on polysubstance use rather than single substances, as use of multiple substances is more normative than use of one.⁹⁵ None of the studies with high-severity samples that included women receiving MOUD, for example, assessed alcohol use. Although women may respond differently to RCTs based on the substances they predominantly misuse, it is important to characterize the full scope of women's SU at baseline and follow-up. Variability of baseline SU, particularly in low-severity samples, likely contributed to the variability in intervention efficacy.

Third, the dosage delivered in RCTs should match the risk level of samples recruited. Many women present with comorbid mental health conditions or psychosocial impairment, necessitating a coordinated care approach to SU reduction. Several studies with moderate- and high-severity samples in our review, for example, included women with comorbid mental health conditions, but delivered a low intervention dosage.

Fourth, future research should assess interventions implemented with sexual minority women, who have higher trauma and stress exposure than other populations.⁹⁶ Fifth, based on several of the studies with low-severity samples included in this review, additional RCTs that utilize MI to reduce marijuana use may be promising. Cannabis use disorders are on the rise⁸; thus, the potential impact of such RCTs could be quite high. Finally, assets that women have should be evaluated, as these promotive or protective factors may play a critical role in treatment efficacy. Attending to these recommendations will improve our understanding of women's responses to SU treatment.

Implications for clinical practice

Our review suggested that a range of psychosocial interventions across groups of women with different SU and risk levels is effective. This is good news. Thus, having multiple evidence-based approaches on which to draw is important versus relying on a single therapeutic approach. Selection of a specific intervention can be guided by practical issues. Individual-, group-, or web-based approaches can be effective, depending on the individual's circumstances.

Our review of studies targeting low-severity samples in particular revealed the importance of screening for problematic SU patterns to prevent progression to misuse or dependence. Screening for problematic SU patterns is less common for women than men.⁹⁷ For moderate- and high-severity populations of women, initial evaluation with standardized assessment should include items that capture the unique needs of women as well as recent and lifetime patterns of use. Although tailoring interventions may not affect treatment outcomes, a recent review by Milward et al.⁹¹ suggests that tailoring is an effective strategy for promoting engagement in substance use interventions, and thus a tool that clinicians might use.

Conclusion

We began this review intending to evaluate the efficacy of psychosocial interventions targeting alcohol and/or drug misuse and use disorders in women, given that men and women who misuse or who are dependent on substances have different needs. Previous research has tended to summarize interventions targeting specific populations or specific intervention approaches. By choosing to cast a wider net, we discovered substantial diversity in these RCTs targeting women. By looking across a range of types of interventions, sample severity, and substances targeted, we found that regardless of severity level or intervention type, most approaches for women had at least one positive outcome.

While many studies recognized the importance of targeting both alcohol and other drug use in interventions, this was not the case for the majority of studies in our review. Strikingly, none of the studies conducted in a MOUD context assessed alcohol use, despite the high rates of co-morbid alcohol use and problems reported in the literature.^98,99 Conversely, many of the studies focused on alcohol only did not report other drug use. Researchers and clinicians who invested in reducing SU and SUDs in women should recognize and address barriers to treatment engagement that disproportionally affect women, as this has the potential to improve treatment outcomes for this population.

Footnotes

Acknowledgments

The authors thank Dr. Anna W. Wright for her assistance with setting up the database and for reviewing search procedures for this review, while completing her PhD in clinical psychology at Virginia Commonwealth University. The authors also thank Ms. Daniela Ocana-Gordillo, a 2016-17 VCU Hubert H. Humphrey Fellow, and the undergraduate students in Dr. Kliewer's Prevention Research Lab who assisted with article title and abstract screening. We are grateful to the Hubert H. Humphrey Program, a Fulbright exchange activity, who supported Ms. Yousaf during 2016-17 year, during which time this project was initiated and partially completed.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this work.

Supplementary Material

Supplementary Appendix SAP1

References

Connery

, McHugh

, Reilly

, Shin

, Greenfield

. Substance use disorders in global mental health delivery: Epidemiology, treatment gap, and implementation of evidence-based treatments. Harv Rev Psychiatry, 2020; 28:316–327.

U.S. Department of Health and Human Services (HHS). Office of the Surgeon General, Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health. Washington, DC: HHS, 2016.

Peacock

, Leung

, Larney

, et al. Global statistics on alcohol, tobacco and illicit drug use: 2017 status report. Addiction, 2018; 113:1905–1926.

World Health Organization. WHO Report on the Global Tobacco Epidemic, 2019: The MPOWER package. Geneva, Switzerland: World Health Organization, 2019.

World Health Organization. WHO Report on the Global Tobacco Epidemic, 2021: Addressing new and emerging products. Geneva, Switzerland: World Health Organization, 2021.

World Health Organization. Global status report on alcohol and health 2018. Geneva, Switzerland: World Health Organization, 2018.

GBD 2015 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990– 2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet, 2016; 388:1545–1602.

United Nations Office on Drugs and Crime. World Drug Report 2021. Vienna, Austria: United Nations Publication, 2021.

Keyser-Marcus

, Alvanzo

, Rieckmann

, et al. Trauma, gender, and mental health symptoms in individuals with substance use disorders. J Interpers Violence, 2015; 30:3–24.

10.

International Narcotics Control Board. Report of the International Narcotics Control Board for 2016 (E/INCB/2016/1).

11.

International Narcotics Control Board. Report of the International Narcotics Control Board for 2017 (E/INCB/2017/1).

12.

Greenfield

, Back

, Lawson

, Brady

. Substance abuse in women. Psychiatr Clin North Am, 2010; 33:339–355.

13.

Polak

, Haug

, Drachenberg

, Svikis

. Gender considerations in addiction: Implications for treatment. Curr Treat Options Psychiatry, 2015; 2:326–338.

14.

Greenfield

, Brooks

, Gordon

, et al. Substance abuse treatment entry, retention, and outcome in women: A review of the literature. Drug Alcohol Depend, 2007; 86:1–21.

15.

Kelpin

, Rusteikas

, Karjane

, Svikis

. Screening for at-risk alcohol and drug use in the perinatal period: How do young women compare to older adult women?. J Pediatr Adolesc Gynecol, 2019; 32:325–329.

16.

Alvanzo

, Svikis

. History of physical abuse and periconceptional drinking in pregnant women. Subst Use Misuse, 2008; 43:1098–1099.

17.

Tuchman

. Women and addiction: The importance of gender issues in substance abuse research. J Addict Dis, 2010; 29:127–138.

18.

Svikis

, Reid-Quinones

. Screening and prevention of alcohol and drug use disorders in women. Obstet Gynecol Clin North Am, 2003; 30:447–468.

19.

Polak

, Kelpin

, Reisweber

, Svikis

. Evidence-based behavioral therapies for substance use disorders. In Moeller

, Terplan

, eds. Primer on Substance Use Disorders. New York: Oxford University Press, 2020:267–281.

20.

Najavits

, Gastfriend

, Barber

, et al. Cocaine dependence with and without PTSD among subjects in the National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Am J Psychiatry, 1998; 155:214–219.

21.

Jansson

, Svikis

, Lee

, et al. Pregnancy and addiction: A comprehensive care model. J Subst Abuse Treat, 1996; 13:321–329.

22.

The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). Women's voices: Experiences and perceptions of women facing drug-related problems in Europe. Thematic Paper Series (Luxembourg, Office for Official Publications of the European Communities), 2009.

23.

National Institute on Drug Abuse. Substance use in women: Research report. USA: National Institute on Drug Abuse, 2020.

24.

Arpa

. Women who use drugs: Issues, needs, responses, challenges and implications for policy and practice. EMCDDA Commissioned Paper, Lisbon, EMCDDA, 2017.

25.

United Nations Office on Drugs and Crime (UNODC). Guidelines on Drug Prevention and Treatment for Girls and Women. Vienna: UNODC, 2016.

26.

Green

. Gender and use of substance abuse treatment services, 2006. Available at: http://pubs.niaaa.nih.gov/publications/arh291/55-62.htm Accessed February 23, 2017 .

27.

Terplan

, Longinaker

, Appel

. Women-centered drug treatment services and need in the United States, 2002–2009. Am J Public Health, 2015; 105:e50-e54.

28.

Ashley

, Marsden

, Brady

. Effectiveness of substance abuse treatment programming for women: A review. Am J Drug Alcohol Abuse, 2003; 29:19–53.

29.

Armstrong

. Foundations for a gender-based treatment model for women in recovery from chemical dependency. J Addict Nurs, 2008; 19:77–82.

30.

Covington

, Surrey

. The relational model of women's psychological development: Implications for substance abuse. In Wilsnack

, Wilsnack

, eds. Gender and alcohol: Individual and social perspectives. New Brunswick, New Jersey: Rutgers Center of Alcohol Studies, 1997:335–351.

31.

Minozzi

, Amato

, Bellisario

, Marica

, Marina

. Maintenance agonist treatments for opiate-dependent pregnant women. Cochrane Database Syst Rev, 2020; 11:CD006318.

32.

Perry

, Neilson

, Martyn-St James

, Glanville

, Woodhouse

, Hewitt

. Interventions for female drug-using offenders. Cochrane Database Syst Rev, 2015; 2015:CD010910.

33.

Perry

, Neilson

, Martyn-St James

, et al. Pharmacological interventions for drug-using offenders. Cochrane Database Syst Rev, 2015; 2015:CD01082.

34.

Moher

, Liberati

, Tetzlaff

, Altman

. The PRISMA group preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Ann Intern Med, 2009; 151:264–269.

35.

Haynes

, McKibbon

, Wilczynski

, Walter

, Werre

. Optimal search strategies for retrieving scientifically strong studies of treatment from Medline: Analytical survey. Br Med J, 2005; 330:1179.

36.

Smith

, North

, Fox

. Eighteen-month follow-up data on a treatment program for homeless substance abusing mothers. J Addict Dis, 1995; 14:57–72.

37.

Higgins

JPT

, Green

, eds. Cochrane handbook for systematic reviews of interventions (version 5.1.0). London: The Cochrane Collaboration, 2011.

38.

Karno

, Grella

, Niv

, Warda

, Moore

. Do substance type and diagnosis make a difference? A study of remission from alcohol- versus drug-use disorders using the National Epidemiologic Survey on Alcohol and Related Conditions. J Stud Alcohol Drugs, 2008; 69:491–495.

39.

Carroll

, Rounsaville

, Bryant

. Alcoholism in treatment-seeking cocaine abusers: Clinical and prognostic significance. J Stud Alcohol, 1993; 54:199–208.

40.

Delrahim-Howlett

, Chambers

, Clapp

, et al. Web-based assessment and brief intervention for alcohol use in women of childbearing potential: A report of the primary findings. Alcohol Clin Exp Res, 2011; 35:1331–1338.

41.

Dvorak

, Kramer

, Stevenson

, Sargent

, Kilwein

. An application of deviance regulation theory to reduce alcohol-related problems among college women during spring break. Psychol Addict Behav, 2017; 31:295–306.

42.

De Dios

, Herman

, Britton

, Hagerty

, Anderson

, Stein

. Motivational and mindfulness intervention for young adult female marijuana users. J Subst Abuse Treat, 2012; 42:56–64.

43.

Stein

, Hagerty

, Herman

, Phipps

, Anderson

. A brief marijuana intervention for non-treatment-seeking young adult women. J Subst Abuse Treat, 2011; 40:189–198.

44.

Mason

, Pate

, Drapkin

, Soxinho. Motivational interviewing integrated with social network counseling for female adolescents: A randomized pilot study in urban primary care. J Subst Abuse Treat, 2011; 41:148–155.

45.

Walsh

, Gilmore

, Frazier

, et al. A randomized clinical trial examining the effect of video-based prevention of alcohol and marijuana use among recent sexual assault victims. Alcohol Clin Exp Res, 2017; 41:2163–2172.

46.

Carey

, Rich

, Norris

, et al. A brief clinic‑based intervention to reduce alcohol misuse and sexual risk behavior in young women: Results from an exploratory clinical trial. Arc Sex Behav, 2020; 49:1241–1250.

47.

Kenney

, Napper

, LaBrie

, Martens

. Examining the efficacy of a brief group protective behavioral strategies skills training alcohol intervention with college women. Psychol Addict Behav, 2014; 28:1041–1051.

48.

Manwell

, Fleming

, Mundt

, Stauffacher

, Barry

. Treatment of problem alcohol use in women of childbearing age: Results of a brief intervention trial. Alcohol Clin Exp Res, 2000; 24:1517–1524.

49.

Finfgeld-Connett

, Madsen

. Web-based treatment of alcohol problems among rural women. J Psychosoc Nurs Ment Health Serv, 2008; 46:46–53.

50.

Palm

, Olofsson

, Danielsson

, Skalkidou

, Wennberg

, Högberg

. Motivational interviewing does not affect risk drinking among young women: A randomised, controlled intervention study in Swedish youth health centres. Scand J Public Health, 2016; 44:611–618.

51.

Ondersma

, Svikis

, Thacker

, Beatty

, Lockhart

. A randomised trial of a computer-delivered screening and brief intervention for postpartum alcohol use Steven. Physiol Behav, 2016; 176:139–148.

52.

Connors

, Walitzer

. Reducing alcohol consumption among heavily drinking women: Evaluating the contributions of life-skills training and booster sessions. J Consult Clin Psychol, 2001; 69:447–456.

53.

Upshur

, Weinreb

, Bharel

, Reed

, Frisard

. A randomized control trial of a chronic care intervention for homeless women with alcohol use problems. J Subst Abuse Treat, 2015; 51:19–29.

54.

Ondersma

, Svikis

, Thacker

, Beatty

, Lockhart

. Computer-delivered screening and brief intervention (e-SBI) for postpartum drug use: A randomized trial. J Subst Abuse Treat, 2014; 46:52–59.

55.

Wechsberg

, Lam

WKK

, Zule

, Bobashev

. Efficacy of a woman-focused intervention to reduce HIV risk and increase self-sufficiency among African American crack abusers. Am J Public Health, 2004; 94:1165–1173.

56.

Jemison

, Jackson

, Oni

, et al. Pilot randomized controlled trial of a syndemics intervention with HIV-positive, cocaine-using women. AIDS Behav, 2019; 23:2467–2476.

57.

Mullins

, Suarez

, Ondersma

, Page

. The impact of motivational interviewing on substance abuse treatment retention: A randomized control trial of women involved with child welfare. J Subst Abuse Treat, 2004; 27:51–58.

58.

Nyamathi

, Shin

, Smeltzer

, et al. Achieving drug and alcohol abstinence among recently incarcerated homeless women: A randomized controlled trial comparing dialectical behavioral therapy-case management with a health promotion program. Nurs Res, 2017; 66:432–441.

59.

Pearson

, Kaysen

, Huh

, Bedard-Gilligan

. Randomized control trial of culturally adapted cognitive processing therapy for PTSD substance misuse and HIV sexual risk behavior for Native American Women. AIDS Behav, 2019; 23:695–706.

60.

Scott

, Dennis

, Lurigio

. The effects of specialized probation and recovery management checkups (RMCs) on treatment participation, substance use, HIV risk behaviors, and recidivism among female offenders: Main findings of a 3-year experiment using subject by intervention interaction analysis. J Exp Criminol, 2017; 13:53–77.

61.

Zule

, Myers

, Carney

, Novak

, McCormick

, Wechsberg

. Alcohol and drug use outcomes among vulnerable women living with HIV: Results from the Western Cape Women's Health CoOp. AIDS Care, 2014; 26:1494–1499.

62.

Kirtadze

, Otiashvili

, O'Grady

, et al. Comprehensive women-centered treatment for psychoactive substance use in the Republic of Georgia: Outcomes of a randomized clinical trial. Int J Ment Health Addict, 2018; 16:1249–1260.

63.

McCrady

, Epstein

, Cook

, Jensen

, Hildebrandt

. A randomized trial of individual and couple behavioral alcohol treatment for women. J Consult Clin Psychol, 2009; 77:243–256.

64.

Polcin

, Korcha

, Pugh

, et al. Intensive motivational interviewing for heavy drinking among women. Addict Disord Their Treat, 2019; 18:70–80.

65.

Epstein

, McCrady

, Hallgren

, et al. Individual versus group female-specific cognitive behavior therapy for alcohol use disorder. J Subst Abuse Treat, 2018; 88:27–43.

66.

Epstein

, McCrady

, Hallgren

, Cook

, Jensen

, Hildebrandt

. A randomized trial of female-specific cognitive behavior therapy for alcohol dependent women. Psychol Addict Behav, 2018; 32:1–15.

67.

McCrady

, Epstein

, Hallgren

, Cook

, Jensen

. Women with alcohol dependence: A randomized trial of couple versus individual plus couple therapy. Psychol Addict Behav, 2016; 30:287–299.

68.

Andersen

. Personalized nursing: An effective intervention model for use with drug-dependent women in an emergency room. Int J Addict, 1986; 21:105–122.

69.

Linehan

, Dimeff

, Reynolds

, et al. Dialectical behavior therapy versus Comprehensive Validation Therapy plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder. Drug Alcohol Depend, 2002; 67:13–26.

70.

Luthar

, Suchman

. Relational Psychotherapy Mothers' Group: A developmentally informed intervention for at-risk mothers. Dev Psychopathol, 2000; 12:235–253.

71.

Luthar

, Suchman

, Altomare

. Relational Psychotherapy Mothers' Group: A randomized clinical trial for substance abusing mothers. Dev Psychopathol, 2007; 19:243–261.

72.

Stahler

, Kirby

, Kerwin

. A faith-based intervention for cocaine-dependent Black women. J Psychoactive Drugs, 2007; 39:183–190.

73.

Suchman

, Decoste

, McMahon

, Dalton

, Mayes

, Borelli

. Mothering from the inside out: Results of a second randomized clinical trial testing a mentalization-based intervention for mothers in addiction treatment. Dev Psychopathol, 2017; 29:617–636.

74.

Wechsberg

, Krupitsky

, Romanova

, et al. Double jeopardy—Drug and sex risks among Russian women who inject drugs: Initial feasibility and efficacy results of a small randomized controlled trial. Subst Abuse Treat Prev Policy, 2012; 7:1.

75.

Suchman

, Decoste

, Mcmahon

, Rounsaville

, Mayes

. The Mothers and Toddlers program, an attachment-based parenting intervention for substance-using women: Results at 6-week follow-up in a randomized clinical pilot. Infant Ment Health J, 2011; 32:427–449.

76.

Dakof

, Cohen

, Henderson

, et al. A randomized pilot study of the Engaging Moms Program for family drug court. J Subst Abuse Treat, 2010; 38:263–274.

77.

Feaster

, Mitrani

, Burns

, et al. A randomized controlled trial of structural ecosystems therapy for HIV medication adherence and substance abuse relapse prevention. Drug Alcohol Depend, 2010; 111:227–234.

78.

Greenfield

, Trucco

, McHugh

, Lincoln

, Gallop

. The Women's Recovery Group study: A stage I trial of women-focused group therapy for substance use disorders versus mixed-gender group drug counseling. Drug Alcohol Depend, 2007; 90:39–47.

79.

Morgenstern

, Blanchard

, McCrady

, McVeigh

, Morgan

, Pandina

. Effectiveness of intensive case management for substance-dependent women receiving temporary assistance for needy families. Am J Public Health, 2006; 96:2016–2023.

80.

Morgenstern

, Neighbors

, Kuerbis

, et al. Improving 24-month abstinence and employment outcomes for substance-dependent women receiving temporary assistance for needy families with intensive case management. Am J Public Health, 2009; 99:328–333.

81.

O'Farrell

, Schumm

, Murphy

, Muchowski

. A randomized clinical trial of behavioral couples therapy versus individually-based treatment for drug-abusing women. J Consult Clin Psychol, 2017; 85:309–322.

82.

Price

, Wells

, Donovan

, Rue

. Mindful awareness in body-oriented therapy as an adjunct to women's substance use disorder treatment: A pilot feasibility study. J Subst Abuse Treat, 2012; 43:94–107.

83.

Price

, Thompson

, Crowell

, Pike

. Longitudinal effects of interoceptive awareness training through mindful awareness in body-oriented therapy (MABT) as an adjunct to women's substance use disorder treatment: A randomized controlled trial. Drug Alcohol Depend, 2019; 198:140–149.

84.

Schumm

, O'Farrell

, Kahler

, Murphy

, Muchowski

. A randomized clinical trial of behavioral. J Consult Clin Psychol, 2014; 82:993–1004.

85.

Zhang

, Slesnick

, Feng

. Co-occurring trajectory of mothers' substance use and psychological control and children's behavior problems: The effects of a family systems intervention. Fam Process, 2018; 57:211–225.

86.

Hien

, Wells

, Jiang

, et al. Multisite randomized trial of behavioral interventions for women with co-occurring PTSD and substance use disorders. J Consult Clin Psychol, 2009; 77:607–619.

87.

Greenfield

, Sugarman

, Freid

, et al. Group therapy for women with substance use disorders: Results from the Women's Recovery Group Study. Drug Alcohol Depend, 2014; 142:245–253.

88.

Najavits

, Enggasser

, Brief

, Federman

. A randomized controlled trial of a gender-focused addiction model versus 12-step facilitation for women veterans. Am J Addict, 2018; 27:210–216.

89.

Schäfer

, Lotzin

, Hiller

, et al. A multisite randomized controlled trial of seeking safety vs. relapse prevention training for women with co-occurring posttraumatic stress disorder and substance use disorders. Eur J Psychotraumatol, 2019; 10:1577092.

90.

Slesnick

, Erdem

. Efficacy of ecologically-based treatment with substance-abusing homeless mothers: Substance use and housing outcomes. J Subst Abuse Treat, 2013; 45:416–425.

91.

Milward

, Drummond

, Fincham-Campbell

, Deluca

. What makes online substance-use interventions engaging? A systematic review and narrative synthesis. Digit Health, 2018; 4:1–25.

92.

Hämäläinen

, Zetterström

, Winkvist

, et al. Breathalyser-based eHealth data suggest that self-reporting of abstinence is a poor outcome measure for alcohol use disorder clinical trials. Alcohol Alcohol, 2020; 55:237–245.

93.

McCaul

, Svikis

, Moore

. Predictors of outpatient treatment retention: Patient versus substance use characteristics. Drug Alcohol Dep, 2001; 62:9–17.

94.

McCrady

, Epstein

, Fokas

. Treatment interventions for women with alcohol use disorder. Alcohol Res, 2020; 40:08.

95.

Crummy

, O'Neal

, Baskin

, Ferguson

. Once is not enough: Understanding and modeling polysubstance use. Front Neurosci, 2020; 14:569.

96.

Mereish

, O'Cleirigh

, Bradford

. Interrelationships between LGBT-based victimization, suicide, and substance use problems in a diverse sample of sexual and gender minorities. Psychol Health Med, 2014; 19:1–13.

97.

Center for Substance Abuse Treatment. Substance Abuse Treatment. Addressing the Specific Needs of Women. Treatment Improvement Protocol (TIP) Series 51. HHS Publication No. (SMA) 09-4426. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2009.

98.

Srivastava

, Kahan

, Ross

. The effect of methadone maintenance treatment on alcohol consumption: A systematic review. J Subst Abuse Treat, 2008; 34:215–223.

99.

Herdener

, Dürsteler

, Seifritz

, Nordt

. Changes in substance use in patients receiving opioid substitution therapy and resulting clinical challenges: A 17-year treatment case register analysis. Lancet Psychiatry, 2017; 4:302–309.

100.

Sobell

, Sobell

, Agrawal

. Randomized controlled trial of a cognitive-behavioral motivational intervention in a group versus individual format for substance use disorders. Psychol Addict Behav, 2009; 23:672–683.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.02 MB