The effectiveness of helplines for the treatment of alcohol and illicit substance use

Abstract

While tobacco helplines (quitlines) are thought to be effective, helplines which treat other substance use do not have an established evidence base. A review was conducted of the literature on illicit drug or alcohol (IDA) helplines. The literature search was conducted in five databases. Studies prior to 2014 were included if published in English, and involved the use of a telephone counselling helpline for the treatment of illicit drug or alcohol use. Review papers, opinion pieces, letters or editorials, case studies, published abstracts and posters were excluded. Initial searching identified 2178 articles and after removing duplicates and those meeting the exclusion criteria, there were 36 publications for review. A total of 29 articles provided descriptive information about 19 different IDA helplines which operated in the US (42%), Europe (21%), Australia (21%), Asia (11%) and Canada (5%). These services reported monthly call rates from 3.7 to over 23,000 calls per month. A total of nine articles provided evaluative information on eight different IDA helplines: four articles included a comparison of treatment outcomes against a control group and five articles included information on treatment satisfaction or service utilisation. Together they provide some evidence that these services are effective. Although there was little consistency in the measures used between articles which assessed helpline satisfaction, all but one reported high satisfaction. Although the evidence is mainly supportive of IDA helplines, further work is required to compare treatment outcomes in randomized groups.

Introduction

Telephone counselling services (helplines) are a significant part of global care for mental health concerns. These services were originally conceived to provide immediate and inexpensive crisis intervention via telephone. This description defined helpline operation for the last 40 years.^1–4 More recently, advances in communications technology have resulted in a rapid expansion in the number and breadth of telephone counselling services available, and the development of new services, including videoconferencing, interactive voice response telephones and smartphone applications. In fact, in the medical health care and psychiatry field there are now phone-based services referred to as telemedicine⁵ and telepsychiatry.⁶ Telephone counselling, telemedicine and telepsychiatry services have received different levels of academic interest, ranging from a wealth of research in telehealth⁵ to relatively little on telephone counselling helplines.

The bulk of research on helpline services has focussed on those designed to assist individuals with tobacco cessation (quitlines),^4,7–10 and to a lesser extent, has identified efficacious services which can alleviate mental health disorders (typically depression)^11,12 or diet and fitness concerns.¹³ Although quitlines are considered to be a well-established treatment for tobacco smoking^7,8 and thought to be cost-effective,¹⁴ relatively little is known about the utility of helplines for treating substance use other than tobacco. As such, many illicit drug and/or alcohol (IDA) helpline services operate following the prima facie assumption that they are valuable.

There have been no previous systematic reviews of helplines whose primary focus is the use of IDA (IDA helplines). The present paper summarises the findings from a review of IDA helplines.

Methods

Literature published prior to January 2014 was located through online search of five electronic databases (Embase, CINAHL, Cochrane Library/EBM Reviews, Medline and PsycINFO). Search terms were grouped into two blocks: (1) helpline (including helpline, telephone counselling, telepsychiatry, telephone intervention and telecounselling); and (2) substance use (including drug use, substance use, alcohol, cannabis, cocaine, amphetamine, hallucinogen, opioid and inhalant). Article reference lists were also checked for additional articles. Non-English language papers, review papers, posters, opinion pieces, letters, editorials and published abstracts were excluded.

Initial searching resulted in the identification of 2178 articles which were reviewed to remove duplicates and any meeting the exclusion criteria. After removing 155 duplicates and 1987 which met the exclusion criteria, there were 36 relevant articles remaining. These were either: (1) purely descriptive (27 articles);^15–41 (2) evaluations of helpline services including treatment outcomes (7 articles);^42–48 or (3) included both descriptive and evaluative components (2 articles).^49,50

Risk of bias

The risk of bias was evaluated for the nine controlled trials evaluating IDA helplines using a 23-item custom assessment following procedures from the Cochrane Collaboration’s Risk of Bias Assessment Tool,⁵¹ the Effective Practice and Organisation of Care Review Group Data Collection Checklist⁵² and Viswanathan and colleagues.⁵³ A ratio (reported as a percentage) was calculated to represent which of any appropriate risks of bias the article had adequately addressed compared to the number inadequately addressed. A score of 100% was awarded when the article addressed all appropriate risks of bias adequately. Judgements were made by the author and should not be interpreted as representing overall article quality, but as a guide to the validity of outcomes specific to telephone counselling services for the treatment of IDA use.

Illicit drug and alcohol helplines

A total of 29 articles provided descriptive information about 19 different IDA helplines which operated in the US (42%), Europe (21%), Australia (21%), Asia (11%) and Canada (5%).^{15–41,49,50} This is summarised in Table 1.

Table 1.

Information from descriptive articles regarding helpline services for the treatment of illicit drug and/or alcohol use.

Study	Substance(s)	Helpline	Callers	Findings
Bartlett, 2011	Opiates (in particular overdose crises)	An emergency overdose response hotline in Gejiu, China run by 6 staff with emergency naloxone kits	From October 2008 to December 2010 the service received 112 calls. Caller details were not provided.	A 100% resuscitation rate was achieved in 76 instances where naloxone was administered. It demonstrated the immediacy of response afforded via the telephone.
Bilard, 2011	Footballers used cannabinoids (52%), stimulants (13%), and narcotics (10%). Other athletes mostly used steroids	Free anonymous national call-in anti-doping service for athletes (France) “Ecoute Dopage”	Most callers were male (93%) and adult (88%) one third used an illicit substance (33%). Calls were for information (89%) personal expression (2%) requests for help in decision making (7%) and for therapeutic support (3%)	Counsellors offered active listening and expression of empathy. The service was important as it was free, spontaneous, fostered the expression of feelings, and was anonymous
Boehm, 1995	“Drugs and alcohol”	Teen Line; peer listening phone service run by high school volunteers in Ohio, US	11,152 calls from May 1987 to December 1992. Callers were 57% female. Calls were most commonly just to talk (40%). Drug and alcohol calls were 7%	Of the calls not involving suicide, 6% involved drugs and alcohol. Of calls involving suicide, a significantly greater proportion involved drugs and alcohol (21%)
Boehm, 1998	“Drugs and alcohol”	Teen Line; peer listening phone service run by high school volunteers in Ohio, US	372 calls from September 1993 to May 1994. Callers were 55% female, 69% were aged 14–18 years. Drug and alcohol was the most common reason for calling (10%)	A sample of adolescents completed the Chemical Abuse Reduced through Education and Services survey. One-fifth of a sample said they would call a hotline about drug and alcohol (20%) and 26% had drug and alcohol concerns while 70% said drugs and alcohol were the biggest concern of adolescents.
Bjosen-Moller, 2010	Anabolic androgenic steroid abuse	Danish Anti-Doping Agency helpline offering anonymous counselling on performance-enhancing drugs	213 calls over 18 months. Callers were mostly male in their mid-20 s calling from gym membership	15% of callers were users and another 15% were considering using. Most callers were not affiliated with sports but interested in drugs altering physical appearance
Bryant, 1998	“Substance abuse”	Vietnam Veterans national telephone counselling service in Australia	854 calls were received over 9 weeks, of which 31% or 263 were genuine. 77% were veterans, 29% were receiving outpatient counselling	Calls were made evenly throughout the day but more than one-third were made at the weekend. One-quarter were intoxicated when calling, 11% of calls were on substance use. Domestic conflict was the most common reason for calling (21% of calls)
Burgess, 2008	Drug and alcohol use problems	Generalist counselling service, Lifeline in Brisbane, Australia	1404 calls over four weeks in August 2006. Two-thirds (67%) were female, mostly aged 25–64 years. 270 callers answered a survey on demographics and mental health	6% of less frequent, 4% of frequent and 11% of very frequent callers mentioned drug taking problems, and corresponding figures for alcohol taking were 8%, 7% and 5%. The most common concern was loneliness (76% of frequent callers). Most callers had social phobias
Catanzaro, 1970	Alcohol	Wide Area Telephone Service (WATS), the first published aftercare service in the US	A case-study of a 42-year old female client who benefited from the service	Aftercare as delivered by telephone is described as a promising use of technology
Clemens, 2006*	Victorians with a drug or alcohol concern	DirectLine, a 24/7 counselling, information and referral service for Victorians (Australia) (identified 6 other helplines for Victorians)	A survey of 310 callers who were willing to complete a questionnaire at the time of their call (61% of callers agreed to participate). Callers were expecting ‘support/advice’ (34%) ‘referral’ (28%) or both (14%).	40% were contacting DirectLine for the first time and 20% were in drug treatment. Over half were calling about alcohol concerns (56%), then cannabis (24%)
Devaney, 2003	Mostly alcohol (38%) but also opiates (23%) cannabis (21%) tranquilisers (10%) stimulants (8%) and other drugs (7%)	DirectLine, a 24/7 counselling, information and referral service for Victorians (Australia) (identified 6 other helplines for Victorians)	In 2001 to 2002 55,454 calls were received. From a sample of 10,389 callers, 51% were male, over half were less than 36 years of age. The 6 other helplines received an average of 106 calls per month	The authors reviewed a number of drug and alcohol helplines available in Victoria, Australia, but gave caller details only for DirectLine. A large research gap concerning helpline treatments was identified
Eklof, 2003	Anabolic androgenic steroid abuse	Anti-Doping Hot-Line, trained nurses from the Drug Information Centre in Sweden answering calls during business hours	25,385 calls were made during October 1993 to December 2000; over 7800 could not be answered. Mostly male (95%) and mostly non-abusers	Calls were typically regarding information only and were about a friend/family member suspected of using. From abusers the most commonly mentioned concerns were aggressiveness and depression.
Evenpoel, 2010	n/a (various substance use services)	The article reviewed data collected from 16 drug helplines throughout Europe	10 of 16 helplines received 10 or less calls per day while one received over 70 calls per day (“Linha Vida SOS Droga” in Portugal). Across the 16 helplines the average number of calls per month was 323	The article reported changes in call rates and call content from 2002 to 2009. An increase in calls on alcohol, cannabis and benzodiazepines was noted while ecstasy and heroin decreased. An increase in the number of partners and parents of drug users was also noted
Kim, 2010	Mostly alcohol and nicotine, but also commonly cannabis and cocaine	Motherisk Alcohol and Substance Use Helpline at the Hospital for Sick Children in Toronto, Canada offering national assistance relating to substance use during pregnancy during business hours	17,318 genuine calls were received from November 1998 to November 2008. 60% of callers were pregnant and/or breastfeeding women calling about their own use. Over half were less than 30 years old. 80% were Caucasian	Notably, calls came from areas where resources relating to substance use during pregnancy were well established
Klaw, 2003	Alcohol	Moderation Management (MM) national information and referral line for people with alcohol problems based on abstinence assistance via social support and CBT in the US	445 problem drinkers (55% were drinking more than four times a week) called in the first year, 53% were female	Most callers came to the information line via referral from an Internet search (31%). 40% of callers were interested in MM, 28% expressed a desire for support (more females than males; 33% compared to 23%)
Koren, 1993	Mostly alcohol and nicotine, but also commonly cannabis and cocaine	Motherisk Alcohol and Substance Use Helpline	The authors noted that the service received 60 inquiries per day and “most calls are answered through the telephone”	Approximately 10–15% of calls are referred to see a physician. All callers are proactively contacted one year from giving birth
Lavi, 2005	Mostly alcohol and nicotine, but also commonly cannabis and cocaine	Motherisk Alcohol and Substance Use Helpline	This article provided results from a survey of 1521 callers. 85% were Caucasian, nearly two-thirds were users calling on their own behalf, 54% were pregnant	The authors identified that many callers were poly drug users
Lee, 2010	Mostly alcohol and nicotine, but also commonly cannabis and cocaine	Motherisk Alcohol and Substance Use Helpline	188,188 calls were received between January 2002 and December 2007	0.2% of calls pertained to paternal exposure to substances. Calls were usually received after referral from healthcare workers.
Lim, 2009	Mostly “street drugs” and alcohol	MotherSafe, a statewide teratogen counselling service in New South Wales (NSW), Australia, staffed by pharmacists at a hospital pharmacy drug information service	47,138 calls were received between January 2005 and December 2007. 83% of callers were pregnant women, mean age 31 years, mostly in their first trimester. 72% of calls were from the Sydney metropolitan area, 24% were rural/regional and 4% were from outside NSW	Most calls were regarding exposure to substances during pregnancy 55%. 16% of calls were for “street drugs”
Myers, 2005	Unclear “substance use disorder”	Telepsychiatry service (videoconferencing) in a juvenile correction facility in rural Washington, US, to assist with rehabilitation	115 youths were treated with an average of 2.4 sessions. 74% were male, all were under 19 years of age	Substance use disorder was the most commonly treated mental health concern in 64% of clients, followed by ADHD (53%)
Roehrich, 1988	Cocaine	1-800-COCAINE is a national cocaine hotline established in 1983 providing treatment referral and drug education and resources in the US	During the first three months of operation (May to July 1983) over 70,000 calls were received.	Article summarised previous surveys of callers (see Washton et al., 1984)
Staton-Tindall, 2012	Alcohol	A telemedicine service (videoconferencing) offering assistance in reducing alcohol use for individuals in the criminal justice system in the US	75 rural alcohol users on probation or parole, 91% male, an average age of 32 years (97% Caucasian)	Trained staff were able to begin administering 4 counselling sessions based on MET for 73% of participants demonstrating proof of concept that videoconferencing is a viable option for this group
Takahashi, 2007	Anabolic androgenic steroids	Counselling service for athletes,operated by the Faculty of Physical Education in the International Budo University, Chiba, Japan	438 genuine calls were received between 1993 and 2002 (the service operated on Mondays only). In 2002, 52% of callers were “drug abusers”	Number of calls increased from 1993 to 1997 and then decreased to 30–40 cases each year. The article established that abusers of AAS exist in Japan
Toll, 2012	Tobacco and alcohol	A tobacco quitline service in New York, US which described callers with alcohol use problems	88,479 calls were received between May 2008 and October 2009, 53% were female, (65% Caucasian) with a mean age of 43 years. 23% reported hazardous drinking	As hazardous drinking reduced treatment outcomes for tobacco cessation, this service identified that it could provide a venue for brief alcohol interventions
Washton, 1984a also published as Washton and Gold, 1984	Cocaine	1-800-COCAINE	Survey of 500 randomly selected callers. 37% of calls were from New York. 67% were male, with a mean age of 30 years, 85% Caucasian	This article focussed on the debilitating aspects of cocaine use and used the helpline as an epidemiological study
Washton, 1984b	Cocaine	1-800-COCAINE	Survey of 70 callers reporting an annual income over $50,000. 82% were male (85% Caucasian) with a mean age of 31 years	This article focussed on the debilitating aspects of cocaine use and used the helpline as an epidemiological study
Washton and Tatarsky, 1984	Cocaine	1-800-COCAINE	Over 2000 calls were received during the first eight weeks. An unclear survey showed 78% of callers were male (56% Caucasian) with a mean age of 33 years. 70% of calls were from Cocaine abusers	This article focussed on the debilitating aspects of cocaine use and used the helpline as an epidemiological study
White, 2012	Prescription drug abuse (opioids)	West Virginia Prescription Drug Abuse Quitline offering education about drug abuse and treatment referral 24/7 to the US. Proactive calls made at 1-week, 4-weeks and 3-months from initial call	In the first year of operation in 2008, 532 initial calls were received. No detail on callers was provided.	This service was operated by mobile phone and computer technology remotely, thus permitting staff to work from home. Shift work was made easy because staff did not need to travel. Challenges included budget problems, phone company problems and administration problems
Zullig, 2010**	Prescription drug abuse (opioids)	West Virginia Prescription Drug Abuse Quitline	Began in September 2008; service receives a call and offers up to three follow-up calls. Between 2008 and 2010 1056 calls were recorded (670 initial calls, and 177 first follow-up, 89 2^nd follow-up, 36 3^rd follow-up calls, as well as 84 “satisfaction survey” calls; callers 48% male, 95% white, 84% under 39 years	n/a

Clemens et al. (2006) included two studies in the manuscript. The first study is described here and the second study in described as part of the service outcome evaluation.

Zullig et al. (2010) was primarily a service outcome evaluation. However; as this article included descriptive information not reported elsewhere it is also included here.

These services reported monthly call rates from 3.7 to over 23,000 calls per month (mean 2134). The helpline callers were most commonly male (68% on average; range: 43–95%) and white Caucasian (81% on average; range: 56–97%). Most helplines did not limit their services to a particular substance use concern (44% of individual services), although it was also common to focus on alcohol use only (22%) or anabolic androgenic steroid use (17%). Alternatively, opiate- and cocaine-based services were less common (11% and 6%, respectively).

While these articles did not provide formal evaluation of the respective helplines, each supported their utility in assisting with IDA concerns. In particular, they provided information, support and treatment referrals to individuals who were typically calling in an early attempt to find assistance. In addition, the services were described as beginning with modest call rates, but showed an increase in call rates over time. No article described any negative aspects of these services, other than a need for advertising to increase service utilisation.

Effectiveness of helplines

A total of nine articles provided evaluative information on eight different IDA helplines which operated in Australia (50%), the US (25%) and Brazil (25%). These trials were divided into two groups: those which included a comparison of treatment outcomes against a control group (4 articles) and those which included information on treatment satisfaction or service utilisation (5 articles).

Controlled trials

The four controlled trials included two cannabis-specific helplines,^42,45 an alcohol-specific helpline,⁴⁴ and a mental-health helpline with web support which included hazardous alcohol use among the primary treatment outcomes.⁴³ Treatment outcomes from the cannabis helplines (involving one and four calls) were compared to wait-list treatment controls at three and six months from baseline. Cannabis use frequency was significantly reduced at six months following a single call in one trial,⁴⁵ while the other reported significantly reduced dependence severity and cannabis-related problems at three months following four calls.⁴² In addition, cannabis-related treatment outcomes following this four-call treatment were compared to a similar web-based intervention in a descriptive review article and found to be superior.⁵⁴ Similarly, participants receiving a single call from the alcohol-specific helpline were significantly more likely to achieve abstinence at six month follow-up compared to those receiving a self-help booklet.⁴⁴ In contrast, the final trial which assessed the utility of a helpline call to support a web-based intervention found no significant difference in alcohol consumption at 12 months between those receiving up to six helpline calls and those who did not receive any calls.⁴³ Further details of the trial participants, methodology and outcomes are provided in Tables 2 and 3.

Table 2.

Article descriptions of participant demographics and trial methods.

	Participants				Treatment
Study	Mean age (years)	Male (%)	Substance	Main inclusion criteria	Type	Length	Work book	Contingency management ($)	Fidelity check	Proportion of participants completing treatment
Zulig, 2010	?	?	Illicit use of prescription drugs	Callers interested in treatment for prescription drug use	Up to three sessions of TCS based on empathic listening and treatment referral	3 months	N	N	N	?
Gates, 2012	36	62	Cannabis	Callers who reported an interest in treatment	Four sessions of MI + CBT-based TCS	4 weeks	Y	≤60	Supervision only	57%; mean of 3.3 sessions were completed
Gates, 2011	43	41	Cannabis	Callers who reported an interest in evaluating the helpline	One call to a cannabis information and treatment helpline	one call, duration unknown	N	N	N	n/a
Fernandes, 2010	25	74	Cannabis	Cannabis dependent callers who reported an interest in treatment	Eight sessions of MI-based TCS	180 days	Y	N	N	30%; 45% completed day one follow-up
Clemens, 2006	?	?	Alcohol and other drugs	Aged at least 18 years, callers who received a treatment referral	Single call to substance use helpline	one call, duration unknown	N	N	N	n/a
Crocker, 1996	?	?	Alcohol and other drugs	Health professionals	Single call for assistance in managing substance using patients	one call, duration unknown	N	N	N	n/a
Signor, 2013	27	71	Alcohol	Alcohol dependence, interest in treatment	One session of MI-based TCS	20 min session	Y	N	Supervision only	52%
Farrer, 2012	38	18	Alcohol	Diagnosed depression without psychosis	Six weekly TCS sessions based on lifestyle factors	6 weeks	N	N	N	?

TCS = Telephone Counselling Service; MI = Motivational Interviewing; CBT = Cognitive Behavioural Therapy.

Table 3.

Brief study description and main treatment outcomes for helplines.

Study	Country	Number at baseline / Follow-up	Drop out (%)	Final follow-up	Treatment outcome comparison group(s) (B, C … )	Main outcomes at final follow-up	Risk of bias (%)
Clemens, 2006	Australia	258/?	?	1 month	n/a	At follow-up, two-thirds (64%) had contacted their referral and 30% had attended treatment. Likelihood of treatment attendance was significantly greater for females, those who were married, employed, educated beyond year 10, and those who injected drugs. Likelihood of attendance was reduced for those who used non-injecting drugs	n/a
Crocker, 1996	Australia	120/?	?	12 months	n/a	Details on the helpline and selected sample were unclear, however; it took an average of 3–4 min for the helpline to accept a call which was considered excellent by 98% of health-worker participants. Most (96%) found the information sufficient, 92% put it into practice. Two thirds (65%) nominated the helpline as a preferred source of advice and 97% would use it again.	n/a
Gates, 2011	Australia	353/200	43	8 days	n/a	Following a call to the helpline, participants rated ‘ease of access’ as 9.2 out of 10, treatment satisfaction was 28.2 out of 32. Total satisfaction was predicted by ease of getting through and having no unmet needs. Call duration, receiving a treatment referral, making a plan of action, and participant demographics did not predict treatment satisfaction	n/a
Zullig, 2010	US	670/177	74	7 days	n/a	Most (83%) participants were very satisfied with the service. Abstinence rates increased by 26% from baseline to follow-up and intention to quit increased by 4%. One in five of participants were motivated to attend outpatient substance use treatment	n/a
Signor, 2013	Brazil	637/147	77	6 months	(B) Self-help booklet	Controlling for gender, stage of change and dependence severity at baseline, significantly more participants receiving (A) obtained abstinence at follow-up compared to (B). Number-needed-to-treat for a 180 day period of abstinence was 3	57
Farrer, 2012	Australia	155/92	41	12 months	(B) Web intervention without tracking; (C) Web with tracking; (D) No treatment	Hazardous consumption was reduced in all groups with no significant between group differences at 6 or 12 months (reported by 32% at baseline and reduced to 19% at 6 months)	48
Gates, 2012; Rooke, 2014	Australia	160/110	31	3 months	(B) No treatment	Those receiving (A) reported fewer cannabis-related problems and less severe dependence compared to (B). These treatment gains were greater than for a similar but separate web-based intervention although participants in (A) were older than those participating in this intervention and were also more likely to seek concurrent treatment. Treatment adherence did not predict outcomes. No significant between group differences on reductions to days abstinent, quantity of cannabis used, or past 90 day tobacco, alcohol or other substance use	87
Fernandes, 2010	Brazil	1744/524	70	6 months	(B) Feedback and minimal assistance	Odds ratio of attaining abstinence from cannabis use for an unspecified period following receiving (A) compared to (B) was 1.6 (1.2–2.0). The number-needed-to-treat was 7. Males and those in pre-contemplation of quitting at baseline were more likely to relapse to cannabis use	44

Treatment satisfaction and service utilisation

Although there was little consistency in the measures used between articles which assessed helpline satisfaction, each reported high satisfaction, with one exception. Specifically, Hughes and colleagues reported the results from a study on the perceived helpfulness of 30 US drug and alcohol helplines.⁴⁷ In this study, two trained psychologists were recruited to make a series of 346 scripted calls to IDA helplines (two to four calls to each helpline) and take note of whether the service was helpful, neutral or unhelpful. The subjective helpfulness ratings were not uniform across the different drugs of concern, although no particular substance use helpline was commonly thought to provide helpful advice. Calls made regarding an alcohol, cocaine or heroin concern were more commonly recorded to be helpful (43, 40 and 40% were helpful) than were calls about tobacco and cannabis concerns (28 and 25% were helpful). One study found that participant demographics and call content were not significant predictors of helpline satisfaction. However, the ease with which the participant’s call was made successfully and whether or not the participant’s needs were met during the call significantly predicted call satisfaction.⁴⁸ While not assessed statistically, the variables of ease of access and meeting information needs were also important in a final trial which reported high satisfaction with an Australian helpline for health workers.⁴⁶

In addition, two articles reported on the rate at which participants who had called an IDA helpline made use of external treatment referrals obtained during their call.^48,50 The articles provided conflicting results, with rates of treatment access being low for callers to the cannabis-specific helpline (43%)⁴⁸ and high for the general substance use helpline (64%). This may be explained by the difference in the follow-up period between the trials (one week and one month). However, the cannabis helpline callers also stated that they would not be likely to follow-through with their treatment referral in future, but were more likely to call the helpline service instead. In addition, rates of treatment access following a call to the substance use helpline were reportedly significantly greater for females, those who were married, employed, educated beyond year 10, and those who had injected drugs.⁵⁰

Discussion

Results from the present literature review suggest that IDA helplines operate around the world and there is some initial evidence that these services are effective. The majority of articles reviewed were purely descriptive. However, they reported impressive call rates and the authors were uniformly eager to promote their respective helplines. There was an obvious scarceness of randomised controlled trials to support IDA helplines, particularly with trials including comparisons with alternative face-to-face treatments. Nonetheless, the preliminary evidence was positive.

The literature was uniformly supportive of IDA helplines with one exception from an initial investigation into US services which found the helplines to be mostly unhelpful.⁴⁷ In contrast, in the controlled trials, the IDA helplines were found to be more successful in assisting with cannabis and alcohol use concerns with favourable comparisons to no treatment or minimal treatment. In addition, helpline callers were consistently satisfied with the services provided. The importance of advertising and promoting services which did not otherwise attract high call rates was emphasised.

When considering these findings, it is important to note some limitations of the review. First, the assessment and evaluation of studies was not conducted by two independent raters. Moreover, no additional data was obtained from authors.

The available evidence, while chiefly supportive of IDA helplines, is limited in its generalizability. Unlike tobacco helplines, few IDA helplines have been compared to any form of alternative treatment, other than minimal self-help interventions. No controlled trials have been conducted for the treatment of any substances other than cannabis and alcohol. In addition, trials have been limited by a number of methodological problems such as a lack of control for substance use or external treatment access during the trial period, low rates of treatment completion and high rates of trial drop-out. Moreover, the follow-up period of controlled trials was no longer than 6 months with the exception of a single trial including 12 months follow-up of the use of a helpline in supporting an Internet-based intervention.⁴³

In conclusion, although the evidence is mainly supportive of IDA helplines, further work is required to compare treatment outcomes in randomized groups.

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