EFFECTIVENESS BANK BULLETIN 3 June 2009: reviews and meta-analyses
EFFECTIVENESS BANK BULLETIN 3 June 2009: reviews and meta-analysesThe entries below are our accounts of documents selected by Drug and Alcohol Findings as particularly relevant to improving outcomes from drug or alcohol interventions in the UK. Entries were drafted after consulting related research, study authors and other experts and are © Drug and Alcohol Findings. Permission is given to distribute these entries or incorporate passages in other documents as long as the source is acknowledged including the web address http://findings.org.uk. However, the original documents were not published by Findings; click on the Titles to obtain copies. Free reprints may also be available from the authors; if displayed, click Request reprint to send or adapt the pre-prepared e-mail message. Abstracts are intended to summarise the findings and views expressed in the study. Below are comments from Drug and Alcohol Findings. Links to source documents are in blue. Hover mouse over orange text for explanatory notes.
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Brief alcohol advice in A&E can reduce drinking and injuries ...
No reason to deny hepatitis C treatment to methadone patients ...
Is public health best served by targeted or universal prevention? ...
Respected review process finds no case for special dual diagnosis care ...
A systematic review of emergency care brief alcohol interventions for injury patients.Nilsen P., Baird J., Mello M.J. et al. Request reprint
Journal of Substance Abuse Treatment: 2008, 35, p. 184–201.
Confirmation that brief advice to risky drinkers identified in accident and emergency departments can cut drinking and reduce the chance of further injuries and readmissions; the issue now is why this happens sometimes but not always.
Abstract The authors searched for English-language reports of studies which randomly allocated injured emergency department patients to normal care plus a brief alcohol intervention or to normal care without the intervention or with an alternative. Usually the intervention consisted of a single session of advice lasting up to an hour in the department itself or during later care, but some studies used computerised interventions or arranged 'booster' contacts. Studies aimed to test whether these reduced drinking, alcohol-related consequences, or injuries measured up to a year later. 14 reports were found based on 13 studies from the USA and Europe. Generally they targeted patients identified by screening procedures as risky or hazardous drinkers. Of the 12 which reported before and after measures, 11 found significant effects of the intervention on at least some of the outcomes: alcohol intake; risky drinking; alcohol-related negative consequences; and injury frequency. Five studies found no significant differences between outcomes for patients allocated to different interventions or to a control group. More intensive interventions tended to yield more favourable results. Intervention patients achieved greater reductions than control group patients, although there was a tendency for control groups also to show improvements. Variations in study protocols, alcohol-related recruitment criteria, screening and assessment methods, and injury severities limit the conclusions that can be drawn.
The authors felt differences between the studies were so great as to preclude an attempt to
meta-analytically
A study which uses recognised procedures to summarise quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually.
combine the outcomes, leaving the less satisfactory method of counting which studies did and did not find an effect. Of greatest current interest are the studies which compared an intervention against a no-intervention control group rather than against another intervention. Of such studies which looked for this outcome, four found the intervention further reduced drinking and four did not. Of the similar studies which measured negative consequences of drinking, four found intervention further reduced these, and two did not. Concerning injuries in particular, these were further reduced by intervention in two studies, but not in another. Combining these categories, six studies found that intervention further reduced drinking and/or drink related consequences, but four did not.
Unlike the featured analysis, another recent review of brief emergency department alcohol interventions did not confine itself to injured patients, but excluded studies where the intervention was conducted during follow-on inpatient care. The result was an overlapping but different set of 13 studies. Combining findings from some of the studies revealed that overall the interventions did not significantly reduce subsequent alcohol consumption and that impacts on alcohol-related problems were variable. However, six to 12 months later, interventions patients were approximately half as likely as comparison patients to have suffered an alcohol-related injury. The three studies on which this estimate was based were all from the USA; two involved only teenage patients whose drinking would have been illegal in that country.
An earlier analysis investigated injury reductions after interventions targeting problem drinking, regardless of where these took place. As in the featured analysis, the studies were considered too diverse to combine their findings. Reviewers concluded that such interventions reduce injuries and incidents actually or potentially leading to injury, such as falls, motor vehicle crashes, and suicide attempts. When the analysis narrowed in on brief interventions, five of the seven relevant trials found fewer injuries after intervention than in a control group, and in two the differences were statistically significant. Interestingly, these two trials did not find reductions in drinking; across all the studies, injury reductions often did not parallel drinking reductions and vice versa.
This accumulation of evidence is enough to show that brief intervention during or after emergency department admission can work, and work against the most stringent and (for the departments themselves) relevant criterion – reducing injuries. It also shows that positive impacts are by no means inevitable. What accounts for why sometimes intervention works, and sometimes does not, remains unclear. Possibly what the researcher sees as the 'intervention' may be overwhelmed by patients' reactions to injury, admission, screening and research assessments, potentially powerful interventions in their own right. Beyond such methodological issues, it could be that interventions work (or work best) only with the heaviest drinkers, or when some kind of follow-up is factored in, even if a minority of patients actually attend.
A major limitation of the evidence base is that nearly all emergency department studies used specialist staff to intervene with patients and generally also to screen them, yet in the real world usually the hospital's own staff will do this work. A recent US study went part way to testing a more real-world scenario by training hospital emergency staff to conduct the intervention. It did lead to drinking reductions over and above those resulting from screening, assessment, an alcohol advice handout, and research follow-up. However, the study leaves a question mark over the feasibility of routine screening. Without dedicated staff, screening rates are often very low unless staff are highly motivated or robustly required to comply with screening requirements.
With varying degrees of specificity and enthusiasm, national strategies across the UK recognise the potential value of brief alcohol interventions in accident and emergency departments, but only in Scotland is there a specific requirement in the form of a brief intervention target for the health service, with emergency departments seen as a priority. Research is best developed in England, where a London hospital has shown such interventions can reduce later drinking and re-admissions, possibly an attractive finding for commissioners seeking to meet national targets to reduce alcohol-related hospital admissions. Further pilot studies are planned at nine departments. Details in background notes.
Given this context, commissioners and emergency department managements may not feel alcohol screening and intervention initiatives are mandated either by the evidence or by national policy. However, neither should they ignore the possibility that patients' health can be improved, and department workloads relieved, by brief advice to risky drinkers identified through a rapid screening procedure and/or through indications Such as blood alcohol levels, reports on the precipitating incident, or the nature of the patient's complaint. that the attendance was alcohol-related. If procedures permit, screening questions should be built in to routine assessment/triage procedures. Unless actively and continuously monitored and encouraged, screening may be applied haphazardly and to only a small proportion of the patients who could benefit. If possible the intervention should be conducted while the patient is waiting in the department or on the ward if admitted as an inpatient. If a follow-up reminder and progress check (in person or by telephone or letter) can be factored in, outcomes can be monitored and are likely also to be improved. More severely dependent patients require referral to treatment, preferably actively pursued then and there by hospital staff. A letter to the GPs of positive-screen patients would alert them to the need to pay attention to the patient's drinking, and offer a second chance of intervention if counselling in the hospital proved impractical or was refused.
Last revised 25 May 2009 Background notes Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Injury rate cut in heavy drinking accident and emergency patients NUGGET 2003
Heavily drinking emergency patients cut down after referral for counselling NUGGET 2005
Brief intervention leaves teenage drinkers less likely to revisit accident and emergency NUGGET 2000
Family doctors' alcohol advice plus follow up cuts long-term medical and social costs NUGGET 2003
A&E units save health service resources by addressing drinking NUGGET 2006
Counselor skill influences outcomes of brief motivational interventions STUDY 2009
Investing in alcohol treatment: brief interventions THEMATIC REVIEW 2002
Brief alcohol interventions: can they deliver population-wide health gains? HOT TOPIC 2010
How brief can you get? OLD GOLD 1999
Critical issues in the treatment of hepatitis C virus infection in methadone maintenance patients.Novick D.M., Kreek M.J. Request reprint
Addiction: 2008, 103(6), p. 905–918.
European and US studies show that methadone patients stick with therapy for hepatitis C disease and do as well as other patients, bolstering the case for drug services to encourage clients to consider diagnostic testing and therapy.
Abstract This review focuses on the medical care of patients in methadone or buprenorphine maintenance programmes who are infected with the hepatitis C virus, with or without co-infection with HIV. Literature searches identified papers since 1990 on antiviral therapy for hepatitis C infection and on liver transplantation in opioid maintenance patients. Their findings and the review's conclusions are most applicable to developed countries.
Misuse of drugs by injection is the most significant infection risk factor in most developed countries. Sexual transmission is possible but inefficient. From 53–96% of injectors test positive for the hepatitis C antibody (indicative of infection). Infection rates climb rapidly to reach in some studies 65% a year after people start injecting. From 67–96% of patients starting methadone maintenance treatment are already infected and may require treatment.
Currently recommended treatment consists of weekly For 48 or 24 weeks depending on the variant of the virus. injections of pegylated interferon supplemented by daily oral ribavirin. This clears the virus ('sustained virological response') in around half of patients, with large variability depending on the variant of the virus and other factors. The recognised criterion for clearance is negative HCV-RNA 24 weeks after the end of treatment. Even if this is not achieved, patients often still benefit from the therapy.
Six studies All from continental Europe or the United States. were found which followed up methadone maintenance patients in treatment for hepatitis C infection. Rates of sustained virological response ranged from 28% to 94%. Studies which contrasted methadone patients with other people also being treated for hepatitis C infection found no significant differences in success rates or in the frequency of psychiatric side-effects. In five In the sixth excess early termination meant that only half completed compared to three quarters of the comparison group. Despite this there was no significant difference in the rates of sustained virological response. of the six studies from 72% to 100% of methadone patients completed the treatment, excellent completion rates. None of the studies investigated the risk of hepatitis C re-infection (for example, due to relapse to unsafe injecting) in the period after sustained virological response has been established, but other studies of drug users who continue to inject have found this is rare. Co-infection with HIV complicates treatment of both diseases, but in suitable patients antiviral therapy for hepatitis C infection can still be effective.
Liver transplantation may be the only treatment option for patients who have progressed to end-stage cirrhosis. This has been successful in methadone maintenance patients but has not been used widely. In four relevant US studies, post-operative substance use was rarely documented (six out of 52 patients) but, as with non-drug using patients, survival was compromised by recurrent infection and post-operative complications.
Methadone maintenance does not cause or aggravate liver problems, liver disease does not normally affect the required dose of methadone, and the reviewed studies show that high quality hepatitis C infection therapy can successfully be provided to methadone patients. Nevertheless, the current reality for most falls far short of this standard. Barriers to drug injectors receiving antiviral therapy include practical issues such as cost and transport, and lifestyles complicated by substance use, psychiatric problems, and housing and legal difficulties. They may also be unaware of their infection, the nature of the disease, or the treatments available, and distrust health services. Treatment providers may have negative attitudes to substance users and believe they will not comply with treatment. Provision of hepatitis C services through drug treatment programmes is underdeveloped. Research on overcoming these barriers suggests that entry in to methadone maintenance can act as a gateway to hepatitis C treatment. Among methadone patients, compliance with treatment is aided by effective therapy for psychiatric disorders, a multi-disciplinary team, and a treatment site acceptable to the patients (often, but not necessarily, the same site providing methadone treatment).
The authors concluded that the literature strongly supports the feasibility of antiviral therapy in methadone patients. High quality medical care for all aspects of hepatitis C infection can be provided with acceptable rates of compliance with the therapy and of successful outcomes in the form of a sustained virological response. There is no scientific or clinical reason to withhold antiviral therapy from methadone or buprenorphine maintenance patients.
National strategies on hepatitis C published or being prepared across the UK (Northern Ireland; Wales; Scotland; England) aim to raise awareness and improve diagnosis and treatment entry rates. In recent years progress has been made but arrangements remain deeply unsatisfactory.
The Health Protection Agency has summarised the state of play across the UK, where an estimated 184,000 people are chronically infected. Around 90% of new infections occur among drug injectors. All those chronically infected are now considered candidates for treatment, but for most an essential first step is missing because they remain undiagnosed, leaving an estimated 130,000 people in England and Scotland unaware that they may need treatment.
Even among drug service clients, in 2007 nearly half the (in England) 40% or so infected with the virus were unaware of their infection. By that year the proportion of drug service clients who had been tested (not necessarily at the drug service itself) had risen to 75%, but only about 40% recalled being tested within the past two years. Drug services, trusted and regularly visited by their clients, are probably the sites most likely to facilitate testing. Yet in 2004, 22 drug services in England Wales were found on average to have tested just 5% of their caseloads over a six-month period. Introduction of the simpler dried blood spot test more than doubled the testing rate. Oral swab testing has also permitted an expansion of testing at drug services. However, the infrastructure remained poor in 2006/07, when drug action teams Local partnerships of health, social, enforcement and other services which coordinate service provision in their areas. had recorded hepatitis C tests for only just over a fifth of injectors attending drug services in their areas. Nearly two thirds of areas had not integrated hepatitis C testing in to their open access services. Responding to hepatitis C was the service strand on which teams scored worst in the review.
Despite England's head start in national planning, lack of funding and of specific targets has undermined implementation; even among those whose chronic infection has been diagnosed, just 3% receive antiviral treatment each year. Local arrangements to identify and transition patients from testing through to treatment have improved, but when last audited by a parliamentary committee, two thirds of responding health commissioning authorities fell short of effectively implementing the national plan. Bottlenecks in treatment capacity reduce the incentive to extend testing and diagnosis. Without treatment slots to go on to, diagnosing more patients would simply extend waiting lists, risking a failure to meet general diagnosis–to-treatment waiting time targets.
In Scotland, the combination of under-testing and poor treatment access has meant that just an estimated 4% of chronically infected individuals have been treated. Among those who have been diagnosed, the proportion is estimated at 14%. A particularly well informed and well funded national plan aims to make significant progress in the near future. At the time of writing Wales had yet to finalise its plan. Northern Ireland's plan was published in 2007.
Guidance from Britain's National Institute for Health and Clinical Excellence (NICE) on antiviral therapy for moderate or severe chronic hepatitis C disease recognises that injectors may not start therapy, or start but quickly leave, but also that beyond this point compliance and disease outcomes match those of other patient groups. Compliance problems were not considered so great as to render treatment no longer cost-effective. Neither was the risk of relapse to injecting considered a bar to treatment, since reinfection was rare. Later NICE extended this verdict to mild forms of the disease.
Around half of drug users in treatment in Britain are in methadone programmes. Regular medical and pharmacy contact offers a ready-made platform for enhancing compliance with the demanding interferon-based therapy for hepatitis C. The featured review shows this has been used to good effect in the USA and Europe. There is also evidence that it cost-effectively contributes to saving lives. A New Zealand study has profiled a hypothetical set of patients being maintained on methadone of whom over 80% are infected with hepatitis C. Its conclusions for non-Maori patients are likely to be broadly applicable to the UK. Because it reduced overdose deaths and suicide, the starting point was that methadone itself was an effective life-saver. Treating hepatitis C infection once patients had stabilised on methadone further prolonged life but (partly because of the averted costs of later having to treat more advanced disease) at no greater cost per life-year saved. More lives would be saved at lower per-year cost if patients were stabilised and anti-viral therapy started earlier. These calculations did not take in to account the improved quality of life of the patients nor the potential for reduced spread to other people.
Starting anti-viral therapy soon after infection and among younger patients are important factors in its success and should also help reduce transmission of the disease, highlighting the importance of screening high risk groups even if there are no symptoms of disease. The high chance of finding infections means screening programmes among drug injectors meet common European standards of cost-effectiveness in terms of the cost per year of life gained, adjusted for quality of life.
Implications of these and other findings have been encapsulated in recommendations from Westminster's All-Party Parliamentary Hepatology Group. For drug services, integrating the new simpler testing procedures in to their service provision so patients do not have to go elsewhere for testing will be an important first step, enabling advice to be given (such as not drinking) even if treatment is not immediately available. Assuming treatment slots are available, proactively linking patients to these services (such as going with them to their first appointments) and offering continuing support during the therapy will help patients start and complete the therapy. Medically based services such as methadone prescribing units, which in any event require regular attendance, offer an opportunity for hosting hepatitis C clinics to oversee the therapy on the same site.
The medical considerations outlined above are not the only ones to influence the decision on testing and treatment. Issues such as the implications for life insurance or mortgage agreements and psychological and relationship impacts also need to be addressed in pre-test counselling.
Last revised 23 May 2009 Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Hepatitis C therapy cost-effective for injectors NUGGET 2005
Outcomes from GP methadone maintenance in Britain match those from specialist clinics NUGGET 2001
The Drug Treatment Outcomes Research Study (DTORS): final outcomes report STUDY 2009
The primary prevention of hepatitis C among injecting drug users REVIEW 2009
Addressing medical and welfare needs improves treatment retention and outcomes NUGGET 2005
Needle and syringe programmes: providing people who inject drugs with injecting equipment REVIEW 2009
Prescription of heroin for the management of heroin dependence: current status REVIEW 2009
A preliminary study of the population-adjusted effectiveness of substance abuse prevention programming: towards making IOM program types comparable.Shamblen S.R., Derzon J.H. Request reprint
Journal of Primary Prevention: 2009, 30, p. 89–107.
One of the biggest strategic decisions facing prevention planners is whether to target high-risk groups or to prioritise universal programmes. This analysis won't decide the issue, but it does create an important new tool for comparing these strategies.
Abstract The US Institute of Medicine distinguishes between prevention programmes based on who is targeted: the entire population (universal); those at risk (selective); or people exhibiting the early stages of use or related problem behaviour (indicated). Evaluations suggest that while universal programmes can reduce and prevent substance use, selective and indicated programmes are both more effective and have better cost-benefit ratios. Nevertheless, universal programmes may have a greater impact across the population because they affect more people. This paper attempts to 'level the playing field' by comparing the impact of these three different types of programmes in reducing and preventing tobacco, alcohol or cannabis There were too few studies reporting on other substances to include these substances in the analysis. use not only among individuals exposed to the intervention, but also across the same-age population as a whole (ie, those exposed and not exposed to the intervention), often termed a 'public health' perspective. Effectively the analysis statistically 'transformed' selective/indicated programmes in to their universal-impact equivalents.
To do this the 102 programmes listed as effective or model by the US National Registry of Effective Prevention were examined to identify those specified in a manual and evaluated in such a way that the results could be included in a meta-analysis A study which uses recognised procedures to summarise quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually. combining their outcomes. The analysis was able to include the results of 43 studies of 25 programmes classified as either universal, selective or targeted depending on the way the samples were selected for the studies. Impacts were assessed in terms of effect sizes, A standard way of expressing the magnitude of a difference (eg, between outcomes in control and experimental groups) applicable to most quantitative data. Enables different measures taken in different studies to be compared or (in meta-analyses) combined. Based on expressing the difference in the average outcomes between control and experimental groups as a proportion of the variability in the outcome across both groups. a metric which enables different outcomes to be compared and combined. To estimate the population-level impact of non-universal programmes, these calculations were adjusted for the proportions of the population targeted For selective programmes, this was the at-risk population, operationalised as the proportion exhibiting risk factors (or lacking protective factors) which would mean that half would go on to use each of the three substances in the study. These calculations were based on a national US survey. On this basis, 31% of 12–17-year-olds were at risk for using tobacco or alcohol and 12% for cannabis. For indicated programmes the proportions were based on (in the same survey) the proportions of the population in different age ranges who reported using each of the substances in the past month. For tobacco the proportions for 12–17-year-olds, 18–25-year-olds, and people aged 26 and over were 17%, 45%, and 30%; for alcohol the corresponding proportions were 17%, 57%, and 49%; and for cannabis, 7%, 14%, and 3%. by the programme.
Because there were relatively few selective or indicated programmes, and because many fell in both camps, estimates for these were combined. As expected, for the populations they targeted selective/indicated programmes for alcohol and cannabis use had greater effects than universal programmes. Unexpectedly, this was not the case for tobacco, where universal programmes had greater impacts chart. But as discussed above, selective/indicated programmes affect fewer people. When their impacts were statistically 'spread' across the population as a whole, they remained slightly more successful in reducing drinking and less successful in curbing smoking. In respect of cannabis use, the verdict changed; though relatively successful with the populations they targeted, across the population as a whole selective/indicated programmes fell short of the impact of universal programmes.
The upshot was a consistent advantage for universal programmes in preventing smoking, the same for selective/indicated programmes in curbing drinking, but for cannabis a mixed picture; greater impacts for selective/indicated than universal programmes on the their target populations, but a lesser impact across the population as whole. On the basis of these figures, from a public health perspective universal programmes achieve the greatest tobacco and cannabis use reductions, selective/indicated programmes the greatest drinking reductions.
These findings correct the false impression that because programmes focused on at-risk groups or individuals have greater and more statistically significant effects, this means they are preferable to universal programmes if the aim is to affect the population as a whole. Only in respect of
drinking
Presumably because (even in the US context where drinking is relatively uncommon compared to Europe, including the UK) drinking is so common that selective/indicated programmes come close to targeting the population as a whole, and it is easier to identify who to target with selective or indicated programmes.
was this impression correct. Conclusions are very tentative because differences were sometimes small and because programmes within the same broad universal/selective/indicated categories significantly differed in their effectiveness, meaning the results of the analysis are likely to change if other programmes are included in the mix. However, the methodology pioneered in the study offers a way for public health authorities to level the playing field between universal and more selective programmes, whatever the mix of programmes for which data is available at the time, aiding the decision over which to prioritise.
Several issues remain to complicate this decision. Counting against selective programmes is the difficulty (previously addressed by one of the featured study's authors) of discerning who really is at risk of later use or problem use, meaning such programmes will exclude many who later prove to have been in need of their services. Because youngsters usually have strong incentives to hide signs of a developing problem, a similar issue hinders the targeting of indicated programmes. Partly because of this, delaying intervention until problems indicators have surfaced might be to leave it too late. Indicated programmes also face the issues of avoiding stigmatisation, counterproductive labelling of youngsters as on track to become problem adults, and the possibility that grouping these youngsters together for intervention will give a peer reinforcement boost to anti-social development.
Universal programmes also face complicating issues. They may lead the population as a whole to reduce use of the targeted substances, but within this population may at the same time exacerbate inequalities in use and health. This happens because well resourced individuals and groups are best able to take on board and act on health promotion messages, while the most vulnerable are less able to do so. The net result is to widen the gap between the two. Selective and indicated programmes should help mitigate this effect by delivering more intensive services to the more vulnerable sections of the population – assuming, as noted above, that these can be identified and that the programmes are able to counter sometimes deep-seated problems. Aggravation of health inequalities is not however an inevitable side-effect of universal programming. Sometimes (example 1; example 2) it can work the other way, partly because universal programmes cannot reduce use/problems in children who are in any event never going to engage in these behaviours.
Finally, though selective and indicated programmes sometimes make things worse, so too can universal programmes, especially those based on fear-arousal. Portraying drug-related damage may inadvertently attract youngsters Cragg Ross & Dawson Ltd. 1988/89 misuse of drugs anti-injecting campaign. Qualitative research report. July 1989. This report on the UK anti-injecting/anti-sharing campaigns running through the winter of 1988/9 found that emphasising revulsion and danger could attract non-injecting drug users into injecting. "For many respondents", commented the researchers, injection "represented the ultimate drug experience and initiation into an elite." Heroin itself – one of the drugs most likely to be injected – "had a formidable reputation... as... the ultimate drug." What made heroin 'ultimate' for the young drug users interviewed for the study was their belief that it led "most remorselessly" to injection, addiction and ruin – the theme of many of the pre-1988 anti-heroin ads in England and Wales. "For those fascinated by drugs as a challenge, heroin was the most challenging. Using heroin had clear potential to be an act of defiance," said the report's authors. bent on self-destruction or who see extreme forms of drug use as the ultimate drug experience and initiation into an elite. Those already using in the ways portrayed in the messages can feel under attack Andrew Irving Associates Limited. Anti-misuse campaign: qualitative evaluation research report. January 1986. This report concerned Britain's 1985/86 Heroin Screws You Up campaign. and further alienated from society. Fear-arousing messages also make communication between children and parents so fraught with emotion Cragg A. "The two sides of fear". Druglink: 1994, 9(5), p 10–12. that both steer clear, making it more difficult for parents to intervene. Even non-fear based campaigns risk counterproductively making use the targeted substance seem ('Otherwise why would they bother?') widespread, 'normal' and difficult to avoid.
The most fundamental issue facing both sorts of programmes relates to where the bulk of preventable problems lie in the society for each substance – an amalgam of the distribution of the problems plus their susceptibility to intervention. If these arise only among highly atypical (for example, very heavy) users, universal programmes which curb substance use among normal users make little contribution to reducing related problems, while they may fail to tackle the few problem-generating users. In this scenario, compared to more targeted programmes, universal programmes may make a greater dent in use levels across the population, but a lesser dent in related problems. Because it focused solely on use levels, the featured study was unable to exclude this possibility.
Where even typical use levels are associated with significant problems, the reverse can be the case. Because there are (by definition) far more typical than atypical users, the bulk of related problems across society may be found among normal users – the so-called 'prevention paradox' much discussed in respect of drinking. By reaching typical as well as atypical users, universal programmes can reduce these problems to a greater degree than programmes targeting just the atypical end of the spectrum. Of course, this argument only applies if universal programmes actually work. Raising the price of alcohol seems one effective example.
In the end these decisions must be taken on the basis of how things stand in a particular population for a particular problem related to a particular substance, and the adequacy of the interventions which can be brought to bear on those problems. It can vary for example by age; in some societies, acute problems like accidents and fights are spread across the younger population, but among the over-30s, largely confined to the heaviest drinkers. It can also vary depending on the problem being targeted: long-term health damage such as liver disease is concentrated among very heavy drinkers, but one-off incidents such as accidents and violence are more widely spread. When the targeting issue was looked at in respect of secondary school children in one Australian state, the verdict was that most problem drinking and smoking was found among children with moderate or low levels of risk factors. Because these children would be missed by selective programmes, the implication was that universal programmes were a priority. The reverse was the case for illegal drug use. But as this review argued, the evidence does not support mounting either type of programme exclusively.
Last revised 10 May 2009 Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Using correlational evidence to select youth for prevention programming REVIEW 2007
Confident kids ... like to party NASTY SURPRISES 2004
Education's uncertain saviour KEY STUDY 2000
Harnessing peer interaction in school-based prevention can backfire NUGGET 2008
Family programme improves on school lessons NUGGET 2003
Growth in youth drinking curbed by correcting 'normative' beliefs NUGGET 2002
Community mobilisation cuts drinking and drug use, but implementation complex and costly NUGGET 1999
Psychosocial interventions for people with both severe mental illness and substance misuse.Cleary M., Hunt G., Matheson S. et al.
Cochrane Database of Systematic Reviews: 2008, 1, Art.No.: CD001088
Latest update from the respected Cochrane review process still finds no reason to advocate replacing conventional care with specialised therapeutic approaches/teams when severe mental illness is complicated by substance use.
Abstract Over 50% of people with a severe mental illness also use illicit drugs and/or alcohol at hazardous levels. Even low levels of substance misuse among these groups is associated with detrimental effects including higher rates of treatment non-compliance, relapse, suicide, incarceration, hepatitis, HIV, homelessness and aggression. It is therefore extremely important to determine the most effective psychosocial (non-pharmaceutical) interventions for reducing substance use in this population. To date, trials assessing the effectiveness of interventions such as cognitive-behavioural therapy, motivational interviewing, 12-step recovery, skills training and psychoeducation have had mixed results.
This review analysed all relevant trials which randomly allocated severely mentally ill patients to different treatments in order to assess whether a psychosocial intervention intended to reduce substance use improved on standard care or treatment as usual. 25 such trials were found with a total of 2478 participants, testing either one-off treatments or integrated or non-integrated programmes. Therapeutic approaches included case management, cognitive-behavioural therapy, motivational interviewing and combinations of these. Meta-analytic techniques A study which uses recognised procedures to summarise quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually. were used to combine outcomes from similar interventions in order to test whether the composite outcome differed from that achieved with standard/usual care. Among the outcomes considered were substance use, psychological health, social and other dimensions of functioning, quality of life, and retention in the treatment or in the study.
No compelling evidence was found to support any one psychosocial treatment over treatment as usual. Pooling results was hindered by differences between trials with regards to outcome measures (particularly substance use), sample characteristics, Level of baseline motivation to change, type of mental illness, substances used. settings (community or hospital), levels of adherence to treatment guidelines, and the nature of standard care. More quality trials are required which adhere to proper randomisation methods, use clinically valuable, reliable and validated measurement scales, and accurately report data, including retention in treatment, relapse, hospitalisation and abstinence rates. It is also crucial that future trials offer programmes which adhere to treatment guidelines.
Most disappointing was the lack of evidence for interventions custom-made for patients whose severe mental illness is complicated by substance use. At the pinnacle are the integrated models, whose multi-disciplinary teams are intended to overcome service coordination gaps by unifying addiction, mental health and other services at the point of delivery, rather than expecting patients to negotiate separate mental health and substance use programmes. Featuring small caseloads and assertive outreach to maintain contact with patients, they should also have helped overcome their reluctance or inability to stay in touch, a key obstacle to service delivery. In theory, this combination should have been a major advance on the typical 'falling between the gaps' scenario. In practice it was not according to this analysis.
If even intensive and integrated approaches fail, commissioners and service providers could be forgiven for thinking they might just as well carry on as usual. However, just four studies fell in this category and, as for other studies, often it was impossible to exploit the power of meta-analysis by pooling their results. In this situation, meta-analysis was perhaps an inappropriate review methodology. By confining itself to fully randomised trials, the analysis also missed out on the results of about 20 otherwise relevant studies. Many allocated patients sequentially to the different treatments, sometimes a reasonable alternative to random allocation. More on this issue below.
Aware of this issue, later four of the five authors of the featured study conducted a broader review which included non-randomised trials, as long as there was a comparison group against which to benchmark the treatment being trialled. Though findings were somewhat mixed, among this wider selection of studies, motivational interviewing in psychiatric settings had the strongest evidence for at least short-term reductions in substance use; combined with cognitive behavioural therapy, there were also improvements in mental state. Cognitive behavioural therapy alone was not well supported. Long-term residential programmes tackling substance use and mental health together also evidenced improvements in substance use and mental health, but studies were generally methodologically poor.
A study previously analysed by Drug and Alcohol Findings offers an example of the data loss resulting from restricting oneself to randomised trials. One of the rare tests of a fully integrated approach, it was excluded from the featured study because two of the three centres in the trial did not allocate patients randomly. Nevertheless patients allocated or not to integrated treatment were very similar on the dimensions recorded by the study. Several indicators did not support integrated care, but some important ones did. All three service access indicators of mental health crises fell under integrated care but increased under conventional care, creating statistically significant differences between the regimens. Relative to virtually no improvement under conventional care, the proportion arrested also fell significantly.
Variability in outcomes may itself be related to variations in relationships between substance use and mental health problems across the caseloads of the studies. Some evidence suggests that a degree of integrated care may have more of a role when mental health symptoms are not a transient consequence of substance use, but the primary problem, and more specifically when drugs or alcohol are used to ameliorate these symptoms. Another source of variability may be the degree to which specialised models of care are actually implemented as intended; that is, truly are integrated, assertive and/or sensitive to the vulnerabilities and capabilities of mentally ill patients.
In line with the featured study, UK guidance avoids recommending any particular therapeutic approach. Guidance for England stresses the 'mainstreaming' of treatment for severely mentally ill substance users within mental health services. These patients are among those considered candidates for a specially designated care coordinator to orchestrate provision from a range of services, an alternative to integration which also avoids the patient having to negotiate multiple care systems. Rather than advocating a particular treatment programme, the guidance offers principles such as taking care not to prematurely advance in treatment or treatment goals when clients are not yet ready or willing. In cases of severe mental illness, drug and alcohol services are seen as supporting mental health services rather than taking the therapeutic lead, though (with reciprocal support from mental health services) they are seen as handling less severe cases themselves. Indeed, this seems inescapable due to the prevalence of psychiatric problems among their clients, as high as three quarters in inner city areas of England. Since less severe cases will not be severe enough to be taken on by psychiatric services, drug and alcohol services must develop relevant competencies and programmes and/or work with GPs if they are not to leave a high proportion of their clients under-served.
Corresponding guidance in Scotland also avoids advocating any particular therapeutic approach in favour of general principles. Though less prescriptive than the English guidance, it too sees the response to severe mental illness complicated by substance use as being led by mental health services. When substance problems are severe but mental health problems milder, substance misuse services are seen as taking the lead. When both are severe, it calls for a pragmatic, individualised approach, possibly delivered through specialist regional units. In other cases coordination across mental health and substance misuse services is seen as the core delivery vehicle. Repeatedly however, coordination has been found to be inadequate; details below. Given this disjunction, the argument for a degree of integration remains strong as a way of closing the gaps in service provision. Specialist joint services may have a role, but general provision is likely to rely on less ambitious initiatives, such as training some staff in both settings to deal with co-occurring substance use and mental illness.
In London severe psychotic illness was common among patients of mental health services but relatively rare among drug and alcohol service clients, in line with what would be expected from national guidelines. However, the degree to which mental health units are themselves capable of dealing with substance misuse problems, or plug this gap by linking with substance misuse services, has been questioned. Over a third of mentally disordered offenders in secure psychiatric units had serious problems due to alcohol or drugs, yet in this area of their work staff expertise and treatment programmes were underdeveloped, and few units systematically drew on the resources of substance misuse services. One problem is that the substance use profile of psychiatric patients (often dominated by alcohol and cannabis) does not match the availability of substance use services, which focus on opiate use. In Scotland, typically substance use services did not work with the substance use problems of mental health patients, and mental health services did not address the less severe forms of mental illness common among substance use service caseloads. In England, alcohol and mental health services commonly failed to work together, and some mental health services refused to care for alcohol patients until their drinking was resolved.
Last revised 20 October 2009 Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Dual diagnosis add-on to mental health services improves outcomes NUGGET 2004
Continuing care research: what we have learned and where we are going REVIEW 2009
Antidepressants curb depression but add little to strong 'talking therapies' NUGGET 2006
Soup kitchen turned into therapeutic setting NUGGET 2006
Improving public addiction treatment through performance contracting: the Delaware experiment STUDY 2008
Toward cost-effective initial care for substance-abusing homeless STUDY 2008
