EFFECTIVENESS BANK BULLETIN 17 December 2008
EFFECTIVENESS BANK BULLETIN 17 December 2008
The 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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‘Real world’ trial finds emergency patients cut back after brief alcohol intervention ...
Should methadone maintenance be started before prisoners are released? ...
Does residential rehabilitation deliver more heroin abstinence per £ than methadone? ...
The impact of screening, brief intervention, and referral for treatment on emergency department patients' alcohol use.Academic ED SBIRT Research Collaborative.
Annals of Emergency Medicine: 2007, 50(6), p. 699–710.
Just a few minutes with specially hired screening and intervention staff can make a difference to emergency patients' drinking, but in the real world the hospital's own staff will usually do this work. A US study tested this real-world scenario and still found (modest) drinking reductions.
Summary The study set out to determine the impact of a screening, brief intervention, and referral for treatment (SBIRT) programme in reducing alcohol consumption among emergency department patients. Patients drinking above US National Institute of Alcohol Abuse and Alcoholism low-risk guidelines (men, more than 7 UK units in a day and no more than 24.5 in a week; women, no more than 5.25 UK units in a day and no more than 12.25 in a week) were recruited from 14 sites nationwide from April to August 2004. A quasi-experimental comparison group design was used in which control and intervention patients were recruited sequentially at each site. Control patients received a written handout. The intervention group received the handout plus a brief intervention (the Brief Negotiated Interview) to reduce unhealthy alcohol use. Follow-up surveys were conducted three months later by telephone using an interactive voice response system. Of 7751 screened patients, 2051 (26%) exceeded low-risk limits. Of these, 1132 (55%) agreed to join the study and were enrolled (581 control, 551 intervention). Of these, 699 (62%) completed the three-month follow-up survey. At follow-up, patients receiving a Brief Negotiated Interview reported consuming 3.25 fewer US standard drinks (45.5gm alcohol or nearly 6 UK units) per week than controls, and the maximum number of drinks per occasion was almost three quarters of a drink (10gm alcohol or just over one UK unit) less than controls. At-risk drinkers (CAGE score less than 2) appeared to benefit more from a Brief Negotiated Interview than dependent drinkers (CAGE score greater than 2). At three-month follow-up, 37% of patients with CAGE less than 2 in the intervention group no longer exceeded low-risk limits compared to 19% in the control group. The authors concluded that screening, brief intervention, and referral for treatment appears effective in the emergency department setting for reducing unhealthy drinking three months after intervention.
Previous studies have shown that just a few minutes spent addressing the drinking of at-risk drinkers among emergency patients can reduce consumption and alcohol-related injuries, improve welfare, promote treatment uptake, and cut the future workload of emergency services. But in all the studies of non-admitted emergency patients, specialist staff were used 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. This US study went part way to testing a more real-world scenario by training hospitals' own emergency staff to conduct the intervention. In
England and in Scotland, national policy promotes such initiatives as a key way to reduce alcohol-related harm.
The featured study was carefully designed and eliminated major threats to the validity of its findings, except for the third of patients who could not be followed up, a testament to the
transient nature
Half were not working and over a quarter had failed to complete compulsory schooling. On average they typically drank 23.5 US drinks per week (329gm alcohol or 41 UK units).
of US heavy drinking emergency patients. The main question is not over the validity of the findings, but over whether these mean (as the authors believed) that such programmes should be considered for routine implementation. Screening was done by dedicated research staff; experience is that when hospital staff are relied on, unless they are motivated and committed, few people who might benefit from intervention are identified. Despite research-aided screening, on average each interventionist counselled just one patient every 19 days, a figure which might have risen to one every 10–11 without the encumbrance of research procedures. In the absence of dedicated screening personnel, throughput would probably have been much less. Along with the small size of the
extra
Extra that is compared to research procedures, screening, and the handing over of a list of treatment services.
drinking reductions attributable to the interview, and their concentration among the least problematic drinkers, such considerations raise doubts over the cost-effectiveness of training emergency department staff in alcohol interventions. It may also be relevant that the sites in the trial were the 14 US academic departments, whose commitment to implementing evidence-based practice is unlikely to be matched across the board. Elsewhere the extra drinking reductions might have been smaller.
Another way to view the results is to look not at the extra impact of the interview, but at the total impact of the entire intervention package. In UK units, patients' typical drinking per week fell from on average just over 39 units to just under 25, a drop of nearly 15 units or over two units a day. The interview led an extra 9% of patients to dip below US risky drinking limits, but after the entire package nearly 28% did so. Such figures look more worthwhile, but are vulnerable to the possibility that some of these improvements would have occurred anyway in the natural course of events, or as a result of the incident which precipitated the emergency visit.
US guidance is available on the specific intervention used in this study and on emergency department alcohol screening and intervention
in general.
Last revised 15 December 2008
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Injury rate cut in heavy drinking accident and emergency patients STUDY 2003
Brief alcohol interventions: can they deliver population-wide health gains? HOT TOPIC 2010
Alcohol-use disorders: Preventing the development of hazardous and harmful drinking REVIEW 2010
Counselor skill influences outcomes of brief motivational interventions STUDY 2009
The effectiveness of a brief intervention for illicit drugs linked to the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in primary health care settings: a technical report of phase III findings of the WHO ASSIST randomized controlled trial.Humeniuk R, Dennington V, Ali R et al.
Geneva, Switzerland: WHO, 2008.
Rare attempt at screening and brief intervention for actual or potential problems arising from illegal drug use among primary care patients suggests that screening itself reduces use levels and that further intervention might be worthwhile among high-risk populations.
Summary ASSIST phase III was an international randomised controlled trial of the effectiveness of a brief intervention for illicit drugs (cannabis, cocaine, amphetamine-type drugs, and opioids) for moderate risk patients identified using the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). 731 participants recruited from primary care settings in Australia, Brazil, India and the USA were randomly allocated to an intervention or a wait-list control group at baseline and followed up three months later. Intervention participants received a brief intervention for the drug they scored the highest on in the ASSIST, plus written self-help materials relating to that drug. The intervention incorporated FRAMES (Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy) and motivational interviewing techniques. As measured by ASSIST, problem drug use scores overall and for each type of drug were significantly lower at follow-up than at baseline for both control and intervention groups, indicative of a possible effect of being screened and recruited to the study. But reductions were significantly greater among intervention patients on all measures except opioid use. However, the latter too was significantly lower among patients in India where all but a few of the opioid-targeted patients were recruited. For cannabis, only patients at the higher end of the moderate risk spectrum further reduced their ASSIST scores following intervention. The authors concluded that, to the extent that brief interventions for illicit drug use can be formulated in the context of a public health approach directed at high risk populations, strong consideration should be given to translating these kinds of programmes into clinical practice.
Though the study recorded statistically significant reductions in drug use severity after research procedures and screening, and significant extra reductions from the intervention, questions have been raised about the clinical significance of the findings. After the entire package overall drug use severity fell by about 8 points on a scale whose maximum was 336 points. Only an extra 2½ points of this decline could be attributed to the intervention; the rest also occurred in the control group. As in
some alcohol studies, a very minimal intervention, such as
handing over the booklets
Though minimal, this entails the potentially powerful message that the patient has been professionally identified as at risk from their substance use, a realisation which the current study's participants commonly highlighted as instrumental in their improvements.
used in the current study, may have led to as great a reduction in drug use/problems as the motivational-style interview.
As well as generally being minor, there are
questions
Patients usually saw the same person for their baseline and follow-up assessments and for the intervention. The possibility that both parties had an interest in amplifying the impacts of the intervention cannot be ruled out.
over whether the extra gains really were caused by the intervention. Set against this is the fact that more severely problematic patients were excluded from the study and instead referred to specialist treatment services. From a
US study it seems possible that as a result of the processes initiated by screening, their drug use and allied problems might have considerably improved, yet the current study was unable to record such gains.
Some of the biggest effects were seen among opioid users in India, where over 11 points were sliced from opioid use severity scores (maximum 39) by the whole package, of which over half could be attributed to the intervention. Half the patients targeted for their opioid use were daily or near daily users and all but a few were recruited in India. Where, as in parts of that country, regular opioid use is normalised among socially included populations with family and work responsibilities, it seems that in certain cultures it is susceptible to even quite brief intervention.
British readers may be most interested in the results from the two westernised developed nations in the study. US results were negative, possibly due to the intervention being 'swamped' by extended research procedures. In Australia, three quarters of the largely young single population recruited at clinics for sexually transmitted diseases were identified as primarily having problems with amphetamine type drugs. Among this high-risk primary care population, there was a relatively large reduction in overall drug use severity and a significant reduction in problems related to what seems to have been mainly recreational (ie, once a week or less often) stimulant use.
As the authors hint in their conclusions, screening of this kind will probably be reserved for primary care or other populations likely to contain unusually many illegal drug users. How willing they will be to own up to their use is unclear. In the
validation studies for the ASSIST screening questionnaire, patients were interviewed by researchers and assured of confidentiality, even in respect of their doctors – important to at least some of the patients. In routine practice these doctors or their colleagues would be the ones asking the screening questions.
Last revised 13 December 2008
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A meta-analysis of motivational interviewing: twenty-five years of empirical studies REVIEW 2010
Fidelity to motivational interviewing and subsequent cannabis cessation among adolescents STUDY 2011
Student drug users respond well to one-to-one motivational sessions STUDY 2004
Cluster randomised trial of the effectiveness of motivational interviewing for universal prevention STUDY 2011
A study of methadone maintenance for male prisoners: 3-month postrelease outcomes.Kinlock T.W. , Gordon M.S. , Schwartz R.P. et al.
Criminal Justice and Behavior: 2008, 35(1), p. 34–47.
Request reprint using your default e-mail program or write to Dr Kinlock at tkinlock@frisrc.org
US study shows the value of immediate post-release transfer to an awaiting methadone maintenance slot for formerly heroin dependent prisoners willing to try this treatment but is less clear on the value of actually starting the treatment in prison.
Summary The study aimed to examine the benefits of methadone maintenance among pre-release prison inmates. 197 incarcerated males with pre-incarceration heroin dependence were randomly assigned to (a) group educational counselling (counselling only); (b) counselling, with opportunity to begin methadone maintenance on release (counselling + transfer); or (c) counselling and methadone maintenance in prison, with opportunity to continue methadone maintenance on release (counselling + methadone). At 90-day follow-up, counselling + methadone participants were significantly more likely than counselling-only and counselling + transfer participants to attend drug treatment (p = .0001) and less likely to be re-incarcerated (p = .019). Counselling + methadone and counselling + transfer participants were significantly less likely (all ps < .05) to report heroin use, cocaine use, and criminal involvement than counselling-only participants. Follow-up is needed to determine whether these findings hold over a longer period.
Opinion is divided on programmes to (re)introduce formerly heroin dependent prisoners to methadone maintenance while in prison. The aim is to protect newly released prisoners at high risk of relapse, crime and fatal overdose, but perhaps at the cost of reinstating dependence among some who could have used their enforced break to construct a life free of dependence on opiate-type drugs. For Britain this US study
can't decide the issue
Results from such programmes are likely to be highly dependent on the context. In Baltimore (personal communication from Timothy W. Kinlock, 10 December 2008) applicants typically have to wait for treatment and pay fees dependent on their ability to pay. Without these impediments, more of the prisoners without a pre-arranged methadone slot might nevertheless have taken up treatment on release.
but it does gives a rare clue to what might happen. Compared to just referring prisoners to services, in the Baltimore context it convincingly showed the value of immediate post-release transfer to an awaiting methadone slot. Without this few ex-prisoners started treatment, more used illegal opiates and cocaine, and more committed crimes. The extra benefits of also starting methadone in prison were
increased treatment uptake
A possible incentive was that methadone-maintained prisoners left on 60mg methadone a day, an amount which would have led many to experience an uncomfortable withdrawal unless they continued treatment on release or topped up with illegal opiates.
on release and a more than halved
risk of re-imprisonment.
Unless prisoners started their methadone treatment in prison, around 30% were back in prison within three months even if they had a methadone treatment slot awaiting them on release.
However, this did little to further affect the number of prisoners who committed at least some crimes or the amount of
illegal opiate use.
The proportion who admitted using opiates was only slightly less than among the group who could transfer to methadone but did not start it in prison, and as many tested positive for opiates, a proxy for frequent use.
Only half the formerly opiate dependent prisoners approached for the study were keen enough on methadone maintenance to participate. Despite expressing an interest in this treatment, even without an arranged methadone slot over a fifth of prisoners said they had remained opiate free in the first three months after release and
just under a fifth
14 of 62 counselling-only patients said they had not used opiates of whom two had been re-imprisoned and one had entered treatment (personal communication from Timothy W. Kinlock, 10 December 2008).
had done so without treatment or a further spell in prison. Whether the major benefit from starting treatment in prison – reduced re-imprisonment – is considered sufficient to warrant it depends on how much weight is given to the minority of prisoners started on methadone who would have remained
opiate free
At least for the first three months after release.
in any event. Whatever the post-release benefits,
within prison methadone programmes improve the climate and reduce in-prison drug use, injecting and infection risk behaviour.
Thanks for their comments on this entry in draft to Timothy W. Kinlock of the Friends Research Institute Inc. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 10 December 2008
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A randomized clinical trial of methadone maintenance for prisoners: results at 12 months postrelease STUDY 2009
Continuity vital after prison treatment STUDY 2005
Initiating methadone prescribing in prison promotes its continuation on release STUDY 2006
Throughcare fails to build on prison treatment STUDY 2000
The Patel report: Reducing drug-related crime and rehabilitating offenders DOCUMENT 2010
The Drug Treatment Outcomes Research Study (DTORS): final outcomes report STUDY 2009
First randomised trial finds methadone helps prisoners control drug use and infection risk STUDY 2004
Mandatory aftercare (probably) reduces recidivism after prison treatment STUDY 2000
The costs and consequences of three policy options for reducing heroin dependency.Moore T.J., Ritter A., Caulkins J.P.
Drug and Alcohol Review: 2007, 26(4), p. 369–378.
Request reprint using your default e-mail program or write to Dr Ritter at alison.ritter@unsw.edu.au
Australian study addressing an issue greatly exercising the UK: do you get greater returns per £ from residential rehabilitation or from substitute prescribing? In terms of reduction in the frequency of heroin use, prescribing was one-and-a-half to three times more cost-effective.
Summary This study compares the costs and consequences of three interventions for reducing heroin dependence among dependent heroin users who have come to the attention of the authorities in a form which puts them at risk of a one-year prison term: pharmacotherapy maintenance (such as methadone maintenance), residential rehabilitation, and prison. Using Australian data, the interventions' cost-consequence ratio was estimated, taking into consideration: reduction in heroin use during the intervention; the length of intervention; and post-intervention effects (as measured by abstinence rates). Sensitivity analyses were conducted, including varying the magnitude and duration of treatment effects, and ascribing positive outcomes only to treatment completers. A hybrid model which combined pharmacotherapy maintenance with a prison term was also considered. If the post-programme abstinence rates were sustained for two years, then for an average heroin user the cost of averting a year of heroin use is approximately $5000 (Australian dollars) for pharmacotherapy maintenance, $11,000 for residential rehabilitation and $52,000 for prison. Varying the parameters does not alter the ranking of the programmes. If the threat of imprisonment for non-completers raised the completion rate in pharmacotherapy maintenance to over 95%, the combined model of treatment plus prison may become the most cost-effective option.
Though
Australian
The Australian drug problem and responses to it are relatively similar to those in the UK, so the analysis may be applicable to Britain.
this study addresses an issue greatly exercising commentators in the UK: for heroin addiction, do you get greater returns per £ from residential rehabilitation or from substitute prescribing programmes such as methadone maintenance? When the measure was reduction in the frequency of heroin use, the answer was that substitute prescribing was between one-and-a-half and three times more cost-effective than residential rehabilitation. We know from the English NTORS study that heroin use frequency is a reasonable proxy for other outcomes such as crime, convictions, and
infection risk behaviour. Since patients were assumed to be on probation in lieu of imprisonment, costs accounted for in the study included a hefty sum for criminal justice supervision. Without this assumption, the relative advantage of substitute prescribing would have been over 50% greater. One gap is that only the initial treatment episode was costed in. From the
cost analysis on which the study was based, it seems that if follow-on addiction treatment and other medical costs had also been accounted for, the effect would have been to further increase the relative cost-effectiveness of substitute prescribing. The study's other conclusion – that prison is by far the least cost-effective option – is now widely accepted and the reason for the proliferation of schemes to divert drug-driven offenders in to treatment.
As the authors stress, such findings do not justify the abandonment of residential rehabilitation or indeed of imprisonment. Some patients will only profit, or profit most, from these more expensive alternatives. In the case of residential rehabilitation in the UK, that number may be higher than are currently able to access this option.
Last revised 08 December 2008
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Force in the sunshine state OLD GOLD 2000
The Drug Treatment Outcomes Research Study (DTORS): final outcomes report STUDY 2009
Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence DOCUMENT 2009
Drug courts can work in Britain STUDY 2004
Prison treatment in Scotland fails to impress STUDY 2004
Offenders do better in treatment if sanctions credible and clear STUDY 2005
Drug and alcohol services in Scotland STUDY 2009
The Patel report: Reducing drug-related crime and rehabilitating offenders DOCUMENT 2010
Drug Strategy 2010. Reducing Demand, Restricting Supply, Building Recovery: Supporting People to Live a Drug Free Life DOCUMENT 2010
