EFFECTIVENESS BANK BULLETIN 18 March 2009
EFFECTIVENESS BANK BULLETIN 18 March 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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Most reliable estimate yet that raising the price of drink cuts consumption ...
UK commission calls for less prison, more treatment ...
Brief advice in emergency departments cuts alcohol-related injuries ...
Not just high methadone dose or individualising dose – both help ...
Effects of beverage alcohol price and tax levels on drinking: a meta-analysis of 1003 estimates from 112 studies.Wagenaar A.C., Salois M.J., Komro K.A.
Addiction: 2009, 104, p. 179–190.
Request reprint using your default e-mail program or write to Dr Wagenaar at wagenaar@gmail.com
As the UK considers minimum price policies, from an analysis of 112 studies comes the most reliable indication yet that raising the price of alcohol strongly reduces alcohol consumption, including rates of heavy drinking.
Summary On the basis of a systematic review of studies examining relationships between beverage alcohol tax or price levels and alcohol sales or self-reported drinking, the authors concluded that there was a strong inverse relationship, such that as price/tax levels rose, consumption fell.
112 studies of alcohol tax or price effects were found, containing 1003 estimates of the tax/price–consumption relationship. Studies included analyses of alternative outcome measures, varying subgroups of the population, several statistical models, and used different units of analysis. Multiple estimates were coded from each study, along with numerous study characteristics. After taking in to account the impact of other influences, within each study the analysts calculated the strengths of the correlations Studies might have reported several relationships for example for different populations or different countries or states. If these were independent of each other, each was included in the analysis. If several measures related to the same area or population or were otherwise not independent, the results were combined in to a single estimate. The analysis conservatively assumed that results from the different studies might differ for reasons other than chance sampling variation, and weighted the contribution of each correlation to the combined estimate according to its reliability. between alcohol price or tax on the one hand, and sales or drinking measures on the other.
Some of the correlations were between price/tax and the aggregate level of consumption across a region or population, others estimated the link in terms of how much individuals drank. In each case, different types of beverages might be analysed separately and/or the study might report total alcohol consumption. A negative correlation means that as price/tax rises, consumption falls; the larger the number, the greater the fall for each unit rise in price or tax. For example, a correlation of -0.5 is a stronger relationship than one of -0.1. Conventionally, correlations exceeding plus or minus 0.24 are considered at least of medium size, and those exceeding 0.37 large. However, even large correlations may occur by chance, so the analysts conducted tests of statistical significance indicating how likely it was that chance variation could account for the figures.
Giving a clearer idea of what these correlations might mean in practice, the analysts also calculated an average elasticity estimate across related studies. A negative elasticity means consumption falls as price rises. For example, an elasticity of -1 means a 10% price rise is associated with a 10% fall in consumption. If consumption had fallen by just 5%, elasticity would have been -0.5. If price rises result in an even greater proportionate drop in consumption, then elasticity is greater than -1. For example, a drop of 15% for a 10% price rise means elasticity is -1.5.
Across all the studies elasticity averaged 0.51, indicating that as price levels rise, consumption falls by about half as much. For beer the corresponding figure was -0.46, wine -0.69, and spirits -0.80.
At the aggregate level (typically across a province or state), all but one of 24 studies found that as price/tax rose, total consumption fell, and in 19 this relationship was statistically significant. Combining these findings yielded a large and highly statistically significant correlation for all types of alcoholic beverage of -0.44. For different beverage types estimates were -0.17 for beer, -0.30 for wine, and -0.29 for spirits, all statistically significant figures.
As expected, at the individual level the added variation due to differences between individuals led to smaller estimates of the link between consumption and price/tax levels, but the evidence remained very strong. For all types of alcoholic beverages the correlation was -0.06, for beer -0.12, wine -0.30, and for spirits -0.10, all statistically significant figures.
Ten individual-level studies specifically reported on the relationship between price and tax levels and heavy drinking. All but one found an inverse relationship and in seven this was statistically significant. Combining results from these studies yielded an average elasticity of -0.28 and a correlation of -0.01 – smaller than the relationship with overall drinking, but still statistically significant.
The authors argued that their analysis provided overwhelming evidence of the effects of alcohol prices on drinking across all types of beverages and across the population of drinkers from light drinkers to heavy drinkers, evidence stronger than for any other preventive intervention and effects larger than most. The implication is that adjusting alcohol tax policies to raise prices of alcohol can achieve substantial prevention benefits at very low cost. However, they also cautioned that the strength of the effect varies across groups, situations and times, perhaps due to variations between communities in income levels, alcohol consumption, meanings and uses of alcoholic beverages, and individual, community and societal influences on drinking behaviour.
A commentary published alongside the featured study reminds readers that price or tax rises have been directly linked to falls in drink-related adverse consequences such as deaths from various causes, violence, traffic and other accidents, and poor health. A UK
analysis commissioned by the Department of Health has linked these elements together to estimate the harm reduction impact of various price and tax policies. Scotland is planning to act on such evidence by setting a minimum price for a unit of alcohol and banning the sale of alcohol as a loss-leader. Though the UK government's principal medical adviser has strongly recommended a similar policy, the rest of the UK seems unlikely to follow Scotland's example. The commentary to the featured study argues that the current economic downturn might provide further motivation for governments to raise taxes, but the reverse is also being argued – that a time when the population is having to tighten its belt is not the time to dramatically raise drink prices.
Last revised 16 March 2009
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Independent review of the effects of alcohol pricing and promotion STUDY 2008
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
The likely impacts of increasing alcohol price: a summary review of the evidence base REVIEW 2011
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
Purchasing patterns for low price off sales alcohol: evidence from the Expenditure and Food Survey STUDY 2010
Alcohol misuse: tackling the UK epidemic REVIEW 2008
Reducing drug use, reducing reoffending: are programmes for problem drug-using offenders in the UK supported by the evidence?UK Drug Policy Commission.
London: UK Drug Policy Commission, 2008.
Based on a review of the international literature, this UK report assessed the evidence for the effectiveness of Britain's response to drug using offenders. Recommendations include maximising community treatment options as an alternative to imprisonment.
Summary The headlined report was informed by a review of the international evidence on the treatment and supervision of drug dependent offenders, and by consultations with a range of stakeholders including policymakers, practitioners and service users.
The report addressed the following key questions:
• What is the extent and nature of problem drug use among offenders and to what extent is this associated with crime and disorder?
• What interventions are in place within the UK for problem drug using offenders?
• What is the evidence for the effectiveness of these approaches and what are the key factors that impact on effectiveness?
• What are the implications of this evidence for policy and practice?
It identified reasonable evidence to support: drug courts which specialise in closely supervising and ordering the treatment of drug-related offenders; community sentences which include a treatment requirement such as drug treatment and testing orders (DTTOs) and drug rehabilitation requirements (DRRs); prison-based therapeutic communities; opioid detoxification and methadone maintenance treatment in prisons and the community; and the RAPt 12-step abstinence-based programme implemented in some UK prisons.
There was mixed evidence for: criminal justice integrated teams (CJITs) which assess and case manage drug-related offenders; the restrictions on bail order which allows for drug treatment to be a condition of court bail; and the added value of drug testing as part of a community order.
The review found no evaluations of the effectiveness of: CARAT (Counselling, Assessment, Referral, Advice and Throughcare) teams which assess, support and case manage drug users in prison and on initial release; drug-free wings in prisons; programmes based on cognitive-behavioural therapy, such as short-duration programmes and ASRO (Addressing Substance Related Offending) programmes; conditional cautions which allow for a condition conducive to rehabilitation (such as engaging in drug treatment) to be attached to a police caution; diversion from prosecution schemes to refer suspects to services to address the underlying causes of their offending when formal criminal justice proceedings are considered unnecessary; and intervention orders that can be attached to court-imposed anti-social behaviour orders (ASBOs).
The report's key conclusions were that: A recent report from PricewaterhouseCoopers commissioned by the Department of Health and Ministry of Justice has investigated prison drug treatment in Britain. Its focus was the multi-stranded commissioning and funding systems which the featured report found to hamper the delivery of care packages to address the wide range of needs of problem drug using offenders. Its conclusions overlapped with those of the featured report. Government has initiated a process to consider PricewaterhouseCoopers's recommendations, agree a single set of priorities, and compile national guidance around the streamlining of the commissioning, delivery funding and performance management of drug treatment for offenders.
Last revised 15 March 2009
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Review of the Glasgow & Fife drug courts STUDY 2009
Drug Strategy 2010. Reducing Demand, Restricting Supply, Building Recovery: Supporting People to Live a Drug Free Life DOCUMENT 2010
Drug misuse statistics Scotland 2010 DOCUMENT 2010
Force in the sunshine state OLD GOLD 2000
The family drug and alcohol court (FDAC) evaluation project: final report STUDY 2011
Dedicated drug court pilots: a process report STUDY 2008
Drugs, crime and public health: the political economy of drug policy REVIEW 2010
Flexible DTTOs do most to cut crime STUDY 2005
Managing drug involved probationers with swift and certain sanctions: evaluating Hawaii's HOPE STUDY 2009
The Dedicated Drug Courts Pilot Evaluation Process Study STUDY 2011
Systematic review and meta-analyses of strategies targeting alcohol problems in emergency departments: interventions reduce alcohol-related injuries.Havard A., Shakeshaft A., Sanson-Fisher R.
Addiction: 2008, 103(3), p. 368–376.
Request reprint using your default e-mail program or write to Dr Havard at havard@unsw.edu.au
Combining results from the few available evaluations of emergency department-based alcohol interventions suggests these substantially reduce alcohol-related injuries, but the estimate may not be applicable outside the USA or to all emergency patients.
Summary Brief alcohol interventions in emergency departments substantially reduce the number of alcohol-related injuries later suffered by the patients was the major conclusion of 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. which combined outcomes from evaluations of emergency department-based interventions for alcohol problems in order to assess the extent to which these reduce alcohol consumption and related harm. An electronic search of 11 databases and a manual search of reference lists were conducted to identify studies published in peer-review journals between January 1996 and July 2007 (inclusive). Studies evaluating the outcome of an intervention designed to reduce alcohol problems in patients presenting to emergency departments were eligible for inclusion.
Thirteen such studies were identified for inclusion in the review. All trialled a brief intervention which typically involved one counselling session lasting up to an hour conducted by research project staff rather than the department's own staff. Eight of the counselling interventions incorporated motivational interviewing principles, and the same number provided handouts providing either standard or personalised advice and/or feedback on the patient's drinking or risk profile. Methodological quality of the studies was found to be reasonable, except for poor reporting of the size of the interventions' effects and inconsistent selection of outcome measures.
Combining the findings using meta-analytic techniques revealed that overall the interventions did not significantly reduce subsequent alcohol consumption, and impacts on drink-related problems were variable. However, six to 12 months after the interventions patients were approximately half as likely as comparison patients to have suffered an alcohol-related injury. Though this result derived from just three studies, it was highly statistically significant so very unlikely to have occurred by chance, and tests suggested that the effect was reasonably consistent across the studies.
The analysts concluded that while there are few evaluations of emergency department-based interventions for alcohol problems, such studies as there are suggest these reduce alcohol-related injuries. But they do not appear to do this by reducing alcohol consumption. The implication is that in respect of injury prevention, it may be more profitable to focus on harm minimisation strategies rather than strategies to reduce consumption. However, the authors cautioned that these results derived largely from studies which used research staff, not an option for sustained routine implementation, and that so few studies recorded injuries that the results can only be considered promising.
The three studies from which the featured analysis derived its injury-reduction estimate were all from the USA, and two involved only teenage patients whose drinking would have been illegal in that country. In all three the patients were known to have recently been drinking or had a history of drink problems. This profile underlines the fragility of the estimate as an indication of the general impact of such interventions across the entire emergency department caseload and/or in other countries. The studies concerned were:
• A study of 18–19-year-old teenagers attending an accident and emergency department after an alcohol-related incident. Previously analysed by Drug and Alcohol Findings, this recorded the largest intervention impact of the three studies.
• A study of injured adults not admitted as inpatients who had recently consumed alcohol (but were not still drunk) or who registered a history of hazardous or harmful drinking on the AUDIT screening test. This has also been analysed by Drug and Alcohol Findings.
• A study of 13–17-year-olds treated in an emergency department after an alcohol-related event, whose drinking was revealed by themselves or by a positive blood alcohol concentration.
Last revised 16 March 2009
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Injury rate cut in heavy drinking accident and emergency patients STUDY 2003
A systematic review of emergency care brief alcohol interventions for injury patients REVIEW 2008
Brief intervention leaves teenage drinkers less likely to revisit accident and emergency STUDY 2000
Heavily drinking emergency patients cut down after referral for counselling STUDY 2005
Drink-driving cut by 30-minute talk with hospital patients STUDY 2006
Family doctors' alcohol advice plus follow up cuts long-term medical and social costs STUDY 2003
Investing in alcohol treatment: brief interventions FINDINGS REVIEW 2002
A meta-analysis of retention in methadone maintenance by dose and dosing strategy.Bao Y-P., Liu Z-M., Epstein D.H. et al.
Journal of Drug and Alcohol Abuse: 2009, 35(1), p. 28–33.
Request reprint using your default e-mail program or write to Dr Lu at linlu@bjmu.edu.cn
For the first time an analysis of relevant studies has assessed the relative contributions of higher doses and flexibility in setting doses to improving retention in opiate substitute prescribing programmes. Both it seems help retain patients in treatment.
Summary For the first time an analysis of relevant studies has assessed the relative contributions of higher doses and flexibility in setting doses to improving retention in methadone maintenance treatment for opiate dependence. The conclusion was that both were independently associated with longer retention.
The analysis aimed to use 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. to estimate the influence of different methadone dose ranges and dosing strategies on retention. A systematic literature search identified 18 randomised controlled trials evaluating methadone dose and retention involving 2831 patients, of whom 1797 were prescribed methadone. Retention was defined as the percentage of patients remaining in treatment either in the short term (3–6 months) or in the longer term (6–12 months). Doses were categorised as at least equal to or below the 60mg per day recommended as the minimum effective maintenance dose for most patients in a consensus statement from the US National Institutes of Health. Dose-setting strategies were characterised as either fixed dose for all patients or individualised, flexible dosing. Raw figures showed that either higher doses or flexible dosing raised the percentage of patients retained by 12–13% from below 50% to about 60%. Except for short-term retention at higher doses, flexible dosing significantly raised retention in both dose level categories. Further analysis Multilevel logistic regression. estimated the independent contribution of dose and dose strategy when the other variable (and also length of follow-up) was statistically controlled. Each variable still significantly predicted retention. Doses at or above 60mg daily (compared to lower doses) and flexible dosing (compared to set doses) each raised the proportion of retained patients by just over 70%. The authors concluded that retention will probably be greatest when the dosing strategy is flexible and doses are relatively high.
Effectively the analysis answers two questions. First, if dose levels are taken out of the equation, does flexibility still improve retention, or is it only that flexibly set doses tend to be higher? Secondly, if flexibility is taken out of the equation, do higher doses still improve retention, or is it only that clinics which prescribe higher doses also tend to be flexible? The answers were that each makes its own contribution, implying that a clinic will maximise retention by prescribing adequate doses on average, and further improve retention by also determining dose according to how each individual patient responds. These are of course not the only ways to improve retention, but they are the most basic ones on which other strategies can be built. The featured study offers further support to UK guidelines on the treatment of drug problems, which recommend flexible doses generally in the range 60–120mg. The same message was found in a review of the research conducted for the English National Treatment Agency for Substance Misuse. Yet when in 2004/05 English services were audited, at 60% methadone doses averaged under 60mg a day.
Though the analysis confined itself to retention, the importance of its findings is that retention at least up to one year is associated with better health and crime outcomes for patients and for society.
Last revised 17 March 2009
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International review and UK guidance weigh merits of buprenorphine versus methadone maintenance REVIEW 2008
Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence REVIEW 2009
Methadone programme loosens up, increases capacity, patients do just as well STUDY 2004
The SUMMIT Trial: a field comparison of buprenorphine versus methadone maintenance treatment STUDY 2010
No harm and some benefit in letting methadone patients choose their dose STUDY 2002
Addressing medical and welfare needs improves treatment retention and outcomes STUDY 2005
Barriers cleared in Endell Street IN PRACTICE 2005
Heroin maintenance for chronic heroin-dependent individuals REVIEW 2010
