EFFECTIVENESS BANK BULLETIN 8 January 2009
EFFECTIVENESS BANK BULLETIN 8 January 2009The 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. The Summary is intended to convey 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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UK study concludes that minimum alcohol pricing and promotion controls will bring major benefits ...
Methadone-maintained do just as well as opioid-free therapeutic community residents ...
Universal provision versus targeting prevention at high risk youth ...
Too few syringe disposal sites? Cafe, church and shopping centre toilets can plug the gap ...
Independent review of the effects of alcohol pricing and promotion.Meier P. et al.
University of Sheffield, 2008.
Commissioned by the English health department, the first study to model the impacts of alcohol policies by integrating data on pricing, promotion, purchasing, consumption and harm found that raising price or banning promotions can bring major benefits. Findings informed a Home Office assessment of the impacts of raising the price of alcohol.
Summary For the English Department of Health, independent researchers examined the potential effects of different pricing and promotion policies on patterns of alcohol consumption and the resulting impact on the UK's health, crime, absenteeism in the workplace and unemployment. Over 40 policy scenarios were tested, including setting minimum prices per unit A UK unit is 8gm by weight or 1cl (10ml) by volume of pure alcohol. of alcohol at different levels and bans on price-based promotions in off-licences and supermarkets, and impacts were assessed on different groups including moderate, hazardous, harmful and underage drinkers both in the on-trade (such as pubs, clubs and restaurants) and the off-trade (supermarkets, off licenses) sectors. Overall the results suggest that policies which increase the price of alcohol can bring significant health and social benefits and lead to considerable financial savings in the health service, criminal justice system and in the workplace. Generally, the more restrictive the policy, the greater the harm reduction. Most of the options tested would reduce harm by over £500m and some were valued higher than £5 billion over a ten-year period.
The researchers felt their most important findings were that • pricing policies can be effective in reducing health, crime and employment-related harm • pricing policies can be targeted so people who drink within recommended limits are hardly affected and very heavy drinkers – who cause by far the most alcohol-related harm – pay the most • minimum unit pricing and discount bans could save hundreds of millions of £s every year in NHS, crime and employment costs • policies which raise the prices of cheaper drinks available in pubs, clubs and supermarkets promise the greatest impact in terms of crime and accident prevention by reducing the consumption of 18–24-year-old binge drinkers.
Targeting price increases at cheaper types of alcohol would affect harmful and hazardous drinkers far more than moderate drinkers, because the former tend to buy more of the cheaper beers, wines and spirits. Minor restrictions on promotions would have little impact but major changes such as a ban of discounts of greater than 10% or a total ban on off-trade discounting might rival the effectiveness of some minimum price options.
In three reviews feeding in to a modelling report, the study comprehensively draws on available research to assess • the effect of pricing and taxation on alcohol consumption • the effect of promotion on alcohol consumption • and the effect of alcohol consumption on alcohol-related harm. Though each element in this chain has previously been examined, uniquely the report joins up the dots to assess what impact national policies on pricing and promoting drink might have on the nation's health, safety, and productivity, using as far as possible UK data. The same simulation model has been used to estimate the impacts of plans in Scotland to prohibit discounting of alcohol and to introduce a minimum retail price per unit of alcohol. The reviews focused on the impacts of policy changes on illness and other adverse consequences of drinking. The other side of the equation is that in British society people value drinking, and social activities and forums such as pubs based on drinking. To the extent that, for example, price rises impede these activities, some things people value are lost, even as another thing they value, health, improves. If the impact is greatest on low income groups – and the relevant review was unable to determine this – then greater social inequality may be the result even as health inequality diminishes. As the report acknowledges, in the face of price rises drinkers do not generally cut back sufficiently to avoid spending more. Again, the impact of a greater proportion of the family budget being diverted to drinking is likely to be felt most sharply among the poorest in society. Economic impacts of this kind can of course be mitigated depending on how governments choose to disperse revenues from higher taxes and/or public sector cost savings.
The major questions are not over the validity of the findings, which broadly accord with those of other analyses (1 2), but over whether governments mindful of the opinions of the drinking public, the social role of alcohol alluded to above, and the importance of drink-related industries, will do what research suggests is needed to significantly reduce alcohol-related harm. This is especially the case in Britain, which compared to other European nations already has among the highest alcohol taxes, and where drink prices are relatively high compared to other commodities.
The featured report was commissioned by the English Department of Health under the Labour government in power before May 2010. There have also been strong recommendations on minimum pricing from the UK government's principal medical adviser, and Britain's National Institute for Health and Clinical Excellence has lent its weight to setting a minimum price on the basis of the health and social costs of alcohol-related harm and the expected impact on alcohol consumption.
Despite the official origins of the research and this high-level backing, under the previous Labour government there were no immediate plans in England and Wales to respond by setting minimum prices. In this respect, not much has changed since the advent of the Conservative-Liberal Democrat coalition government in May 2011. In 2011 the UK government's Home Office hedged its bets on the key tactic recommended in the featured report – an across-the-board and appreciable price rise – judging that "on balance" the evidence "suggests" that increasing the price of alcohol "may" reduce alcohol-related harms. It also pointed out that there were other influences on consumption and harm which operate at the level of the individual or of drinking cultures and environments rather than national taxation and availability restrictions.
It is now apparent that it is these levers which the UK government prefers to rely on most, applying them to what is perceived as particularly troublesome drinkers/drinking patterns (especially young 'binge' drinkers) while deliberately avoiding population-wide measures of the kind investigated by the featured report and advocated by NICE and other public health and alcohol experts. The price changes announced so far target 'binge' drinkers in particular and will have little across-the-board impact, loose agreements have been made with the alcohol industry to tighten adherence to responsible marketing and sales guidelines, and the licensing act and guidelines are to be reformed, mainly to give greater powers to curtail disorder related to licensed premises. Moves are also being made which might end in health impact becoming a relevant issue in licensing decisions, seen as key change by campaigners for more health-oriented alcohol policies. For the great majority of drinkers, little will change as a result of these initiatives and nor will their drinking change, unless they choose to make these changes in response to other influences. Some further details below.
Some limited moves are being made to adjust price which fall far short of an across the board minimum per unit price set at a level which might substantially affect public health. Instead the UK coalition government announced in its March 2011 budget that in October 2011 it would cut the duty on low strength beers, and levy an extra tax on strong beers containing over 7.5% alcohol preferred by teenagers and very heavy drinkers. The aim is not the population-wide health gains – including for non-problem drinkers – sought by minimum-price advocates, but to "reduce the health and social harms resulting from problem drinking" while not "unfairly penalising responsible drinkers". Though unlikely to alienate many adult voters, this option is similar to one estimated to have very minor effects on overall consumption. Early on the government also committed itself to "ban the sale of alcohol below cost price". In January 2011 it was announced that the below-cost ban would be based But it was also signalled that this might just be a "first step". on the rate of duty plus value added tax, ie, the total tax drinkers pay on their drinks. No research has yet directly assessed such a policy, but at this low level a ban would it is predicted (1 2) have little impact.
Among the nations of the UK, Scotland came closest to breaching the political barriers to introducing more effective alcohol harm-reduction policies. Its 2009 alcohol strategy committed the government to a minimum price per unit of alcohol and included plans to ban the sale of alcohol as a loss-leader. These plans were fortified by a study which focused on the probable impact of such changes in the Scottish context, but faced challenges from within the Scottish parliament, which in November 2010 rejected the minimum pricing element of the Scottish National Party's Alcohol Bill. Following the May 2011 elections which left the Scottish National Party with an overall majority in the parliament, it seems likely that another attempt will be made and that this time the party will have the votes it needs. However, it remains possible that UK devolution and European Union free trade laws may obstruct the plan.
The featured report has also been summarised in a journal article included in the Effectiveness Bank database.
Thanks for their comments on this entry in draft to Petra Meier of the University of Sheffield. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 13 May 2011
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The likely impacts of increasing alcohol price: a summary review of the evidence base REVIEW 2011
Model-based appraisal of alcohol minimum pricing and off-licensed trade discount bans in Scotland ABSTRACT 2009
The effectiveness of tax policy interventions for reducing excessive alcohol consumption and related harms REVIEW 2010
Economic impacts of alcohol pricing policy options in the UK STUDY 2011
Alcohol-use disorders: Preventing the development of hazardous and harmful drinking REVIEW 2010
Effects of alcohol tax and price policies on morbidity and mortality: a systematic review REVIEW 2010
Methadone patients in the therapeutic community: a test of equivalency.Sorensen J.L., Andrews S, Delucchi K.L. et al.
Drug and Alcohol Dependence: 2009, 100, p. 100–106.
Request reprint using your default e-mail program or write to Dr Sorensen at James.Sorensen@ucsf.edu
Are therapeutic communities incompatible with methadone maintenance? Not when staff have been prepared to accept and work with methadone patients and programmes adapted to accommodate them. Then patients stay as long and sustain abstinence from illegal drug use just as well as other residents.
Summary Residential therapeutic communities have demonstrated effectiveness, yet for the most part they adhere to a drug-free ideology incompatible with the use of methadone. This study used equivalency testing As explained in the source paper, equivalence testing is a statistical technique often used to show that a new medication is indistinguishable from an approved standard medication. Outcomes from the two treatments (in this case therapeutic community residence with versus without methadone maintenance) are declared equivalent if the confidence interval for the difference between them is completely within 20% plus and minus the value of outcomes from the standard treatment. An equivalence test can find that two treatments are not equivalent yet a traditional test can also find that they fail to differ to a statistically significant degree (for an illustration see http://www.mors.org/meetings/test_eval/presentations/C_Warner.pdf). In other words, a finding of equivalence is not the same as simply finding a failure to differ. to explore the consequences of admitting opioid-dependent clients currently on methadone maintenance treatment into a therapeutic community. The study compared 24-month outcomes between 125 methadone patients and 106 opioid-dependent drug-free clients with similar psychiatric histories, criminal justice pressures and expected lengths of stay, who were all newly enrolled in a therapeutic community. Statistical equivalence was expected between groups on retention in the therapeutic community and illicit opioid use. Secondary hypotheses posited statistical equivalence in the use of stimulants, benzodiazepines, and alcohol, as well as in HIV risk behaviours. As hypothesised, the average number of days in treatment was statistically equivalent for the two groups (166.5 for the methadone group and 180.2 for the comparison group). At each assessment, the proportion of the methadone group testing positive for illicit opioids was indistinguishable from the proportion in the comparison group. The equivalence found for illicit opioid use was also found for stimulant and alcohol use. The groups were statistically equivalent for benzodiazepine use at all assessments except at 24 months where 7% of the methadone group and none in the comparison group tested positive. Injection- and sex-risk behaviours were equivalent at all observation points. The authors concluded that in these therapeutic community settings, methadone patients fared as well as other opioid users, providing additional evidence that therapeutic communities can successfully be modified to accommodate methadone patients.
Generally considered incompatible treatment modalities, this is one of the few studies to show that a therapeutic community environment can be combined with methadone maintenance, and the first to do so in respect of a residential community. As the authors stress, it is important to remember that these were not the usual run of communities. For decades they had embraced methadone patients and made
modifications
Among those mentioned in the source article are the designation of a methadone counsellor who plays a vital role in the process of helping the programme modify its services to accept and treat methadone patients. Counsellors periodically offer methadone sensitivity training sessions to staff and patients, providing education and confronting stigma about methadone maintenance. They also conduct weekly methadone therapy groups for residents on methadone. Residents who opt to attempt withdrawal from methadone have greater access to alternative therapies and medical services.
to meet their particular needs and increase their acceptance by staff and residents. It's also possible that these modifications and the presence of methadone patients changed the environment for non-methadone residents too. Residents were not randomly allocated to the two regimens but entered the facilities in the normal way. All had the kind of experience of opiate use which would have made them eligible for methadone maintenance, they were
matched
However, the three key variables identified in the abstract were very simply matched in an either/or way rather than in terms of degrees.
on some key variables and differed little on most others, yet before, during and after leaving the communities, far more of the methadone group were in methadone treatment. The implication is that the major remaining difference between the two groups of residents lay in their preferences for alternative routes to recovery – complete abstinence, or abstinence from illegal drugs supported by substitute prescribing. The outcomes seem to suggest that in welcoming and suitably modified communities, residents who favour these different routes end up abstinent from illegal drugs in roughly the same numbers and
converge somewhat
Two years after joining the communities 70% of the methadone group were still being prescribed methadone compared to 30% of the non-methadone group, a narrowing of the gap of 95% versus 12% recorded at entry to the programmes.
in their preferences for how to attempt to maintain this. They also show that
many from both camps
At six months after treatment entry, when most of the residents had left the therapeutic community treatment system, about a third tested positive for opiates rising to about a half at 18 months. Stimulant use showed the same upward trajectory but at a lower level, reaching about 40% positive by 18 months.
do not totally succeed. What we don't know, however, is how the residents fared in other ways such as reintegration and mental and physical well being.
Though this study seems unique, previous reports have documented the integration of non-residential day care therapeutic communities with methadone programmes, demonstrating that patients who opt for this additional support evidence Perhaps because of their greater motivation and in this study, degree of psychological distress, as well as any impact of the community. greater remission in opiate and cocaine use. Other studies have established that with staff facilitation, 12-step mutual aid groups can (but not always See for example an account of the initially low take-up and stuttering progress of such groups in a Norwegian clinic in: Espegren O. Twelve step programme and methadone maintenance treatment. In: Waal H., Haga E., eds. Maintenance treatment of heroin addiction: evidence at the crossroads. Oslo: Cappelens, 2003, p. 321–333. smoothly) be integrated with methadone treatment and that patients who choose this option seem to benefit. Such initiatives are line with the cooperation between the founders of Alcoholics Anonymous and Vincent Dole, founder of methadone maintenance, who served on AA's board.
Simultaneous integration of residential rehabilitation and methadone is by no means unknown in Britain, In particular in the form of the ROMA rehabilitation houses in London which specialised in methadone patients. Their work was documented in: Glanz A. ROMA; Talgarth road. Report of an information-gathering exercise. London: DHSS, 1983. but far more common is the serial integration of these modalities within a client's treatment journey. In Scotland's DORIS study of drug treatment services, within 33 months most clients starting residential rehabilitation had left and spent a period on methadone. In England's similar NTORS study, perhaps a third had done so within a year. In neither case do we know how many rehabilitation clients had traversed the opposite route, though its seems likely In NTORS three-quarters of the total sample (ie, not just those entering residential rehabilitation) had been prescribed methadone in the past two years. that many had.
Thanks for their comments on this entry in draft to James L. Sorensen of the UCSF at San Francisco General Hospital. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 25 December 2008
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The Drug Treatment Outcomes Research Study (DTORS): final outcomes report STUDY 2009
The SUMMIT Trial: a field comparison of buprenorphine versus methadone maintenance treatment STUDY 2010
Continuity vital after prison treatment STUDY 2005
Methadone programme loosens up, increases capacity, patients do just as well STUDY 2004
Outpatient versus inpatient opioid detoxification: a randomized controlled trial STUDY 2011
The grand design: lessons from DATOS STUDY 2002
What is the role of harm reduction when drug users say they want abstinence? STUDY 2011
Force in the sunshine state OLD GOLD 2000
Using correlational evidence to select youth for prevention programming.Derzon H.
Journal of Primary Prevention: 2007, 28, p. 421–447.
Request reprint using your default e-mail program or write to Dr Derzon at derzonj@battelle.org
Is it best to focus prevention efforts on youngsters most likely to use substances - or will that miss out many future users who could have benefited from these efforts? This well informed and clear analysis concludes that we just can't predict well enough to risk leaving some youngsters out.
Summary In a period of increased accountability and reduced prevention resources, the effective targeting of those limited resources is critical. One way limited resources are focused is to identify and provide services to those most at risk for later substance use. Risk status, or propensity, is typically estimated from correlational evidence. Using meta-analytic techniques, this paper examines the evidence that 29 of the 35 constructs specified by the risk and protective factor model developed by the Communities that Care project are related to alcohol, tobacco, or cannabis use. It finds that while these factors are generally predictive of substance use, the strength of the relations are modest. Ten factors show a significantly different strength of relation with tobacco than with alcohol or cannabis. Selection of 'high risk' youngsters for targeting does raise the proportion receiving services who are likely to benefit from them. But given the correlations observed and the rate of substance use in the population, providing only selective intervention services is likely to miss the majority who will later use substances. Given typical base and selection rates, though the average effect of an intervention may be reduced by universal as opposed to selective application, these smaller effects applied across the board may keep a greater number of youth from becoming involved with alcohol, tobacco, or cannabis. The journal editor commented that "The data make a strong and provocative argument for primary prevention of youth substance abuse that should be heard by policymakers and service providers involved in strategic planning and appropriate deployment of resources".
This unusually well constructed paper will not settle the issue of whether the balance of the prevention effort is best focused on high-risk youngsters or spread across the board, but it certainly makes an important contribution to that debate. Its strength is that it drew on an archive of reports from 940 studies which tracked the development of cohorts of young people, and related other factors in their lives to their
current or later
60% of the relationships were between substance use and concurrently measured factors, but the study observes that "No systematic differences in effect size strength were noted between cross-sectional and prospective estimates" – that is, it made little difference whether substance use was assessed at the same time as, or some time after, the factors to which it was related.
involvement in substance use. This data was then used to test whether the risk and protective factors identified by the Communities that Care (CTC) project really are related to alcohol, tobacco, or cannabis use. CTC's model is a well developed and influential way to assess the propensity for substance use problems in a community as means of prioritising prevention activities. 29 of CTC's 35 factors could be tested. Most were indeed related to substance use, some
fairly strongly.
For example for drinking, the top four were having few opportunities for conventional involvement, sensation seeking tendencies, positive attitudes towards substance use, and early initiation of problem behaviour.
But on average relationships were weak, some factors were not related to use, and a few were related in the 'wrong' direction. This predictive weakness is the fundamental reason why the paper advocates persisting with universal prevention efforts.
However, its outcome measures were to do with substance use, not necessarily substance use problems. Some forms of early experimentation with substances are normative and not indicative of psychological or social risk or lack of resilience. In turn this could be why in some studies early substance use is poorly related to adult substance use or problems, while early regular use is a more reliable predictor. Given this background, it is no surprise that the featured study found substance use itself poorly predicted by many of the CTC factors.
The interesting observation that smoking is often differently related to risk and protective factors than drinking or cannabis use chimes with the common finding that preventive interventions also affect smoking differently from other forms of substance use. Several studies have found significant preventive impacts on smoking not found (or not to a statistically significant degree) for other substances.
Thanks for their comments on this entry in draft to Jim Derzon of the Battelle Centers for Public Health Research and Evaluation. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 28 December 2008
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Confident kids ... like to party NASTY SURPRISES 2004
Substances, adolescence (meta-analysis) STUDY 2003
Harnessing peer interaction in school-based prevention can backfire STUDY 2008
Project SUCCESS' effects on the substance use of alternative high school students STUDY 2010
Early intervention: the next steps. An independent report to Her Majesty's Government REVIEW 2011
UK-style school drug prevention programme helps prevent regular drinking STUDY 2003
Syringe disposal bins: the outcomes of a free trial for city traders in an inner-city municipality Australia.Devaney M., Berends L.
Substance Use and Misuse: 2008, 43(1), p. 139–153.
Request reprint using your default e-mail program or write to Dr Devaney at madonna.devaney@turningpoint.org.au
What happens when city authorities ask retail and service premises to host syringe disposal bins in their toilets? There were misgivings, but when the bins meant customers and staff could avoid discarded syringes, they were welcomed and retained, safely disposing of over 2000 syringes a month.
Summary Community responses toward discarded syringes have the potential to threaten the sustainability of harm reduction interventions. Many retailers in the central business district of Melbourne, Australia, have expressed concern about drug use and the associated discarded syringes. Melbourne City Council has responded to these concerns through a variety of strategies. One such strategy was a six-month free trial of syringe bins for businesses during 2003–2004. The council commissioned an external evaluation of the trial. Eighteen business representatives and six key informants undertook semi-structured interviews to monitor issues arising throughout the trial. Syringe disposal bins are a useful option for facilitating appropriate syringe disposal; 11 of the 13 businesses which participated in the trial continued with the maintenance of the syringe disposal bins beyond the free trial period.
Syringe disposal units sited in public toilets and other publicly controlled facilities are not uncommon in Britain, but units sited on private premises are. When Melbourne sought to broaden access to disposal facilities, it took the unusual step of canvassing toilet-equipped city centre
business and leisure premises
Including restaurants, cafés, cinemas, department stores, theatres, gyms and fitness centres.
as well as hospitals, colleges, churches and welfare groups, offering free installation and servicing of bins. Over the six months of the trial, 62 bins were installed and some existing bins began to be properly serviced, accounting for an estimated 12,590 syringes. After the trial period, nine of the 11 businesses involved took on the costs of continuing to service 58 bins. Motivating their involvement was typically concern that customers were coming across discarded syringes and the risks for staff who had to clear them up. Melbourne now routinely offers a disposal bin service to businesses.
Though theoretically possible, Especially in the case of hepatitis B, least so in respect of HIV. in practice acquisition of a blood-borne virus infection due to a needlestick injury from a discarded syringe is virtually unheard of. In Australia, no such incidents have been recorded. Yet the fear that this might happen is real enough and so is the environmental degradation caused by discards and the negative impression they give of injecting drug users. Despite there being no evidence that discards increase when a needle exchange opens, such concerns mean that discards jeopardise public support for facilities serving injectors, especially needle exchanges. Indirectly, this makes discards an important public health issue because opposition may threaten viral control via exchanges.
Current UK government guidance acknowledges these points and potential public hostility to bins, before calling on local partnerships to "fully explore the potential for sharps bins", and in particular to ensure their effective promotion and siting. Though there is no specific call to consider non-public premises, this general recommendation would legitimise a move beyond the usual siting in public toilets. Such initiatives could build on the trend in the UK to persuade private premises managers such as pub landlords to make their toilets accessible to the public. As with that initiative, it has the potential to greatly increase access to facilities (in this case, syringe disposal bins) at relatively little cost.
Last revised 29 December 2008
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'Most compelling evidence yet' that injecting rooms reduce overdose deaths STUDY 2003
Needle and syringe programmes: providing people who inject drugs with injecting equipment REVIEW 2009
Environmental gains from injecting room STUDY 2005
Hepatitis C and needle exchange SERIES OF ARTICLES 2004
European report says drug consumption rooms can work OFFCUT 2004
Hepatitis C and needle exchange part 4: the active ingredients FINDINGS REVIEW 2004
Hepatitis C and needle exchange part 3: the British record FINDINGS REVIEW 2004
Syringe sharing cut by two-thirds after injecting room opens STUDY 2005
Adequate needle exchange helps prevent bacterial as well as viral infections STUDY 2008
Hepatitis C and needle exchange part 2: case studies FINDINGS REVIEW 2003
