EFFECTIVENESS BANK BULLETIN 18 June 2009
EFFECTIVENESS BANK BULLETIN 18 June 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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Intercept and treat relapse by checking how former patients are doing ...
Mentally ill patients particularly benefit from aftercare enhancements ...
Harm reduction case for crack kits from needle exchanges ...
Health service saves by vaccinating needle exchange users for hepatitis B ...
Results from two randomized clinical trials evaluating the impact of quarterly recovery management checkups with adult chronic substance users.Scott C,K., Dennis M.L.
Addiction: 2009, 104, p. 959–971.
Request reprint using your default e-mail program or write to Dr Scott at cscott@chestnut.org
In the USA two studies have shown that quarterly check-ups on former patients help identify the need for and motivate further treatment, but gains in substance use/problem reductions only became evident when improved procedures were introduced, and even then remained modest.
Summary The featured report documents whether a promising post-treatment check-up and (if needed) treatment re-engagement protocol could be improved by taking on board the lessons of an initial evaluation. Check-ups are one attempt to address the fact that rapid relapse is typical after short-term treatment of severe addiction, especially when complicated by social and psychiatric problems. Instead of leaving it to the patient to seek further help, the intervention rests on the assumption that proactive, long-term monitoring through regular check-ups and early re-intervention will improve long-term outcomes by facilitating early detection of relapse and reducing time to treatment re-entry.
During a three-month period, the initial trial recruited 448 people Out of 796 referrals of whom 533 who met the study's profile. The main stipulation was that they were and would remain resident in the city. referred by a central assessment unit in Chicago for treatment at a centre specialising in the care of substance users who are new mothers or mothers-to-be, homeless, or mentally ill. Typically they were dependent on cocaine Though large minorities also or instead were dependent on alcohol or opioids. and three-quarters had serious mental health or behavioural problems. About half were women, most were black and out of work, and a substantial minority homeless. Generally they were referred to short-term residential treatment, the remainder mainly to short-term, intensive outpatient programmes. Three months later they were randomly assigned to 21 months of quarterly recovery management check-up interviews, or to a control group re-assessed according to the same schedule.
Questions put by researchers to both groups were designed to identify clients not already in treatment or custody, but who needed to return to treatment. For the control group, this was where the interviews ended; except rarely in an emergency, no attempt was made to re-connect them with treatment. In contrast, during check-up interviews, the researcher went on to identify ex-patients in need of returning to treatment, indicated by a positive response one of six questions probing for a return to regular, 'binge', or problem substance use, and whether the client themselves felt in need. Patients screened as in need of treatment (usually about 30%) were referred immediately to a 'linkage manager' whose role was to motivate Using motivational interviewing principles and feedback on the client's problems. treatment re-entry and to offer practical assistance. As intended, the check-ups (details below) improved treatment re-entry rates, but the results were far from perfect. For example, just a third of the people encouraged to return to treatment actually did so, the intervention did not improve retention once in treatment, and benefits did not become statistically significant until the end of the two-year follow-up.
Later the study was replicated on 446 patients Somewhat fewer were diagnosed as dependent or had recent psychological problems, but generally they were quite similar to the initial set. recruited in the same way at the same centre. They were subject to the same intervention, except for three modifications suggested by the initial evaluation. To facilitate identification of treatment need, researchers countered the tendency of a small minority to deny drug use by reminding them of previous assessments and urine test results, and probing inconsistencies. To facilitate treatment entry, from the start there was a requirement to provide transport to treatment intake and initial sessions. To facilitate retention, linkage managers now maintained contact with patients in treatment, and treatment staff gave the managers a chance to intervene beforehand with patients about to leave prematurely. Either of their own volition or because staff were going to discharge them.
The first issue was whether and at what stage the modifications enhanced treatment access. Feedback countering denial of drug use helped increase the proportion of former patients identified as in need of treatment from an average 30% to 44% across all the follow-ups, giving the modified procedures a head start. This was extended when practically all the second set of 'in-need' participants agreed to see the linkage manager; previously a quarter had refused. However, it made virtually no difference to the proportion of in-need participants who agreed to attend a treatment intake assessment (44% study 1; 45% study 2), though more did complete it (30% versus 42%). This fed through to a slight but statistically significant advantage in the proportion who actually started treatment (25% versus 30%). Of these patients, many more in study 2 stayed for at least a fortnight (39% versus 58%), the study's engagement criterion. Recalculating these figures as proportions of in-need participants, in study 1, 10% met the study's engagement criterion, in study 2, 17%.
Next was whether across the entire samples, these procedural improvements had translated in to better treatment re-entry and substance use outcomes compared to the respective control groups. A key statistic was the proportion who re-entered treatment at some time during the intervention period; in study 1, check-ups improved on control procedures by 9%, From 51% to 60%. in study 2, by twice as much. From 37% to 55%. However, increases in the average time in treatment remained modest. Up by on average 13 days in study 1 and 17 in study 2. The length of time patients in need of treatment failed to receive it also fell by a greater amount From 2.31 to 1.86 successive quarters in study 1 and from 3.41 to 2.59 in study 2. in study 2. By the end of two years, in both studies the check-ups had led to about 10% fewer people Down from 44% to 34% in study 1 and from 57% to 46% in study 2. still being assessed as in need of treatment. Only in the second study was there an impact on substance use: a slight increase in days abstinent from on average 68% in the control group to 76%, and a further slight reduction in an already quite low index of substance abuse, dependence or related problems.
The standard way to express these differences is as 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. Except for average days in treatment, consistently effect sizes on the reported measures of treatment access and substance use or problems were greater in study 2, suggesting that the modified procedures had the desired effects. Results were altered little by adjustments for caseload differences across the two studies, adding weight to this conclusion.
The authors concluded that post-treatment monitoring leading (if needed) to treatment re-entry is feasible and effective for adults with chronic substance dependence, and that the modifications introduced for study 2 facilitated and improved the consistency with which the protocols were implemented. The result was fewer people in need of treatment and less time without help when it was needed. They argued that for such caseloads, ideally check-ups would be required as a condition of licensing, accrediting and funding treatment programmes, linked to a broader strategy of reorienting addiction treatment from an acute care model to a model which provides services ranging from brief intervention to long-term recovery management.
The studies worked with people with multiple problems and little stake in conventional society, the kind of caseloads most likely to repeatedly relapse and be in need of continuing care. But these same problems also make it difficult to effectively provide that care, especially where access to wrap-around services and practical help is limited for indigent populations. Their primary substance use problem (cocaine) ruled out maintenance prescribing as a major long-term anti-relapse strategy. Check-ups helped, especially when assessment,
transport
Possibly particularly important because the caseload will have included many women with young children, a particular target for the service.
and treatment engagement procedures were improved, but the gains compared to not having the check-ups were
modest
In neither study did effect sizes exceed the level commonly thought of as at best moderate.
and least evident in terms of recovery from substance dependence. Presumably check-ups work best when there are adequate services for patients to re-engage with. In the face of the problems posed by these caseloads, brief episodes of care focused on their substance use were perhaps not adequate enough. Repeated access to these services is in these circumstances more a sign of the intractability of the patient's situation, than a way to lastingly resolve it.
How well the criteria of need for treatment identified people normally placed in that category is questionable. They would have included someone who had spent just one day drunk in the past three months and never used any other drug. They may justifiably see themselves as not really in need, possibly why many did not return to treatment. It is unclear whether the reduction in treatment need at two years was due to remission of substance use problems, or because more recovery check-up patients were already in treatment, so could not be assessed as needing to return.
Also questionable is whether in routine, real-world use, the check-ups would work as well as they did. As the authors acknowledged, such gains as there were resulted from specially trained staff using a standardised and supervised protocol; a substantial investment was required to reach required standards. Also the interventions took place during visits when research data was collected, for which these poor participants were financially reimbursed; presumably Because they were offered (presumably) in order to increase attendance. fewer would have attended without these incentives. While the patient was still in the initial treatment, the studies paved for the way for later follow-ups by verifying potential contact points and carefully preparing the patient, their nominated associates, and the agencies they were likely to be in touch with, so they would respond to later re-contact attempts. On the other hand, it could be that routinised check-ups would be more successful if familiar faces from the initial treatment agency were involved, and there was no burden of completing research assessments. Also, regular re-assessment of the control group participants may have raised their awareness of need for treatment, narrowing the gap with the check-up patients. Modifications made for study 2 might have raised outcomes even further had study 1 not already made some of the changes (notably transport assistance) in the face of disappointing early results.
Other studies have shown that proactively re-contacting former patients can transform aftercare attendance, and that re-contacts can in themselves be therapeutic, even without leading to a return to treatment. In some studies the work was done by a service's routine staff. Approaches which evidence individualised concern for the patient work best, probably because they convey active caring rather than a bureaucratic reminder-mill. The more socially excluded and damaged the caseload, the more active and personal the follow-ups need to be, and the greater the help needed to re-establish aftercare contact.
Case management is a more common form of continuing care than featured study's check-ups, one which typically also tries to orchestrate multiple sources of help for multiply problematic caseloads. Despite recent successes with US welfare applicants, like the check-ups, in general these interventions improve service access, but rarely does this in turn improve substance use outcomes. Another approach is to encourage all former patients to return for aftercare whether they need it or not, and to make it easier for them to do so by adopting a welcoming, personal approach and implementing systematic reminders. Especially among the more psychologically vulnerable patients, this has proved effective in another US study.
Guidance for England stresses the need for aftercare following residential rehabilitation, and for continued post-detoxification treatment. Arrangements are often complicated by the fact that residents return to their home areas, beyond the reach of the initial service. However, the principles behind the featured intervention could be applied in the home area. Most services do make some arrangements, but in a survey in England, 4 in 10 residents were at best unclear who was to coordinate their aftercare, and care plans relied on mutual aid groups for ongoing support. A US study has shown that attendance at these groups and substance use outcomes can be modestly improved by systematic and intensive referral and checks on attendance. Mutual aid groups do not however relieve services of the obligation to attempt to check on vulnerable former patients. The featured study's check-ups offer one way for short-term programmes to meet this obligation, but at considerable cost. Routinising them in to the work of the service would cut costs, but may also reduce the already modest effectiveness. Using volunteer former patients for the check-ups might be a partial solution to both problems.
Thanks for their comments on this entry in draft to David McCartney of the Lothians and Edinburgh Abstinence Programme (LEAP) and John Witton of the National Addiction Centre in London.
Last revised 12 June 2009
Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Check how your former patients are doing STUDY 2004
Continuing care research: what we have learned and where we are going REVIEW 2009
Improving continuity of care in a public addiction treatment system with clinical case management STUDY 2006
Does coordinated care management improve employment for substance-using welfare recipients? STUDY 2009
The Drug Treatment Outcomes Research Study (DTORS): final outcomes report STUDY 2009
The power of the welcoming reminder FINDINGS REVIEW 2004
Promoting continuing care adherence among substance abusers with co-occurring psychiatric disorders following residential treatment.DeMarce J.M., Lash S.J., Stephens R.S. et al.
Addictive Behaviors: 2008, 33, p. 1104–1112.
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Further analysis of findings from a US inpatient centre shows that systematically applying simple prompts and motivators especially and substantially improved aftercare attendance among patients with mental health problems, helping sustain progress made during initial treatment.
Summary This entry provides new information from a study previously analysed by Findings. For more details see the earlier report.
The Salem Veterans Affairs medical centre offers a 28-day residential rehabilitation programme to its alcohol and/or drug dependent ex-military patients. To sustain sobriety, staff stressed the importance of aftercare, but attendance was poor. A series of studies had previously shown that attendance radically improved as step by step researchers added enhancements. A further study tested the impact of the entire package Plus further enhancements, termed in the study Contracting, Prompting and Reinforcing (CPR) continuing substance abuse treatment. on aftercare attendance and assessed changes in substance use. 150 eligible patients agreed to join the study and were randomly allocated to the centre's standard procedure or to the enhanced package. During the final days of their stay, standard procedure patients were encouraged to attend the centre's aftercare groups and individual sessions, as well as mutual aid groups such as NA and AA. Initial appointments and/or attendance schedules were agreed and listed in an aftercare 'contract' handed to the patient, who was also shown a motivational video.
Intervention manual and materials and related publications are available from Steven Lash.
For the enhanced version, the contract was strengthened by asking patients to commit in writing (witnessed by the therapist) to over the next eight weeks The aim was to retain patients for at least three months of treatment overall, the minimum associated with improved outcomes in this population. attend weekly groups and AA/NA meetings and monthly individual sessions. Veterans Affairs' data showing that aftercare attendance was associated with abstinence was used to motivate agreement. Therapists also explained the reminder system and showed patients the awards (see next paragraph) for attendance specified in the contract. After eight weeks patients were invited to re-contract to continue in aftercare for eleven months in total.
Letters from the therapist, Saying they were pleased the patient had chosen to join their group and that they looked forward to seeing them. appointment cards Which also tallied the patient's attendance to date. and automated telephone reminders prompted patients to attend the next session in a few days time. Non-attendance was followed by a letter and phone call from the therapist. Awards consisted of medallions and certificates handed out during individual aftercare sessions. Further reinforcement took the form of a handwritten letter congratulating the patient on initiating aftercare followed by another after three sessions.
Researchers Unaware of to which procedure patients had been allocated. were able to re-assess around 80% of patients two, five and 11 months after they left treatment, reassuring them that their responses Urinalysis results confirmed the accuracy of their answers regarding substance use. were confidential. As documented in the earlier Findings analysis, compared to the standard procedure, the enhancements led more patients to initiate and continue in aftercare, and 11 months after leaving treatment, nearly 20% more (57% v. 37%) had been abstinent In contrast, the average intensity of substance use did not differ between the two sets of patients and nor generally did the severity of related problems. from alcohol and drugs for the past three months.
The featured report assessed whether these differences were related to the mental health status of the patients. Of these, 51% had been diagnosed by the unit's psychiatrist as suffering from a mental disorder, spread evenly across the standard and enhanced intervention groups. Personality disorders, depression, and schizophrenia were the most common diagnoses. Among patients without a psychiatric diagnosis, the enhanced protocol led slightly more to start (97% v. 91%) and to
engage
Defined, as per the earlier report in this study, as attending at least two aftercare sessions each month.
with aftercare for at least the first two months after leaving the centre (84% v. 62%). Following that until the study ended a year after treatment entry, participation was unaffected by the engagement enhancements. Impacts among patients with a psychiatric diagnosis were substantially greater and more persistent chart. Compared to the standard procedure, 20% more (93% v. 73%) started aftercare and at each time point until the study ended more remained engaged, the difference being greatest during the two months after leaving treatment (68% v. 24%). Because they particularly increased engagement among patients with mental health disorders, the enhancements evened out the differences between these and the other patients. Without the enhancements the mentally ill patients engaged relatively poorly at each stage; with them, they did as well or almost as well. In terms both of statistical significance and size, these impacts were greatest during the first two months after patients left the residential centre.
In contrast, impacts in terms of abstinence from alcohol and drugs became apparent only in the last three months of the follow-up; without the enhancements, just 21% of patients with mental health disorders had sustained abstinence, with them, 50%, the sole statistically significant difference. Effects on abstinence were confined to patients with mental disorders. At no stage did the enhancements substantially affect abstinence rates among the other patients.
For the authors, the findings suggested that given the enhanced engagement interventions, participants with co-occurring psychiatric disorders were more likely than those receiving standard care to begin and remain in an aftercare programme for at least three months, and to be abstinent one year later. In general, the enhancements were more effective for individuals with co-occurring disorders than among those with substance use problems only.
As acknowledged by the authors, post-hoc subsample analyses of this kind are
best seen
The main problems are that they rob the results of the reassurance of the level playing field created by randomising patients to different treatments, and they risk (there is no implication that this was a real problem in this case) capitalising on the fact that samples can be sub-sampled in any number of ways until one (perhaps purely by chance) results in a significant finding.
as generating hypotheses for testing in a study specially designed for this purpose. For this reason, the analysis presented here focuses more on the size of the differences between the interventions' impacts than on their statistical significance.
While the difference in aftercare attendance was consistently substantial, the difference in abstinence rates in the last three months of the follow up must be treated more cautiously, since no such differences were seen at the previous two time points. An earlier report on the study found that across the full samples, the improved abstinence rate was largely due to more patients becoming abstinent in the previous six months, possibly because the enhancements made more willing to return for help after relapse. Though as defined by the study, aftercare engagement during the final three months was unaffected by the enhancements, following these nearly twice as many patients attended aftercare at some point during this period (40% v. 22%). This greater willingness to stay in touch to at least some degree partly accounted for why abstinence rates during this period showed a similar difference in favour of the enhancements. From the featured report it now seems that these processes were at work mainly if not exclusively among the patients with diagnosed psychiatric or personality disorders.
Because the centre served ex-military personnel there were very few women. All the studies excluded participants who would have had significant difficulty Due to distance, lack of transport or work commitments. Eliminating these practical barriers probably allowed the influence of the interventions to show through so clearly. attending an aftercare centre. The greatest attendance gains were observed while contracting and rewarding procedures were also at their height (the first two months after leaving the centre) and for the type of aftercare provision (the centre's own sessions) most explicitly targeted. From the prior studies, we know that each of the elements in the enhanced package added to its impact. Gains from this package might have been greater still if awards had been made in front of peers This was trialled in one of the earlier studies but in the featured study the opportunity had to be foregone because some of the patients in each group would have been from the standard care set. at group therapy sessions and if it had replaced more typical procedures; even the standard comparator was an advance on the most basic procedure tested in an earlier study, and probably also on what typically happens to encourage aftercare attendance.
If, as is being strongly argued in some quarters, Britain is to re-balance its treatment system to offer more residential treatment slots, aftercare provision and encouragement of the kind trialled in the study will be crucial to help patients avoid or overcome lapses or relapses, and to sustain support for services which might otherwise be seen as costly revolving doors. These settings radically alter the patient's social and physical environment, enabling residents who would otherwise be unable to do so to attain abstinence. By the same token, unless steps have been taken to alter this or sustainably alter how the patient reacts to it, they are likely to relapse when they return to the environments in which they were previously unable to stop using.
The enhancements in the featured study tried to meet this need by encouraging all former patients to return for aftercare, and seem to have made it easier for the more psychologically vulnerable to do so by adopting a welcoming, personal approach and implementing systematic reminders. Another approach is to check on former patients to see who needs to return to care, and then to focus efforts on them, a strategy tried with some success in Chicago. See the Findings analysis of that study for UK guidance on aftercare and information on the extent of implementation in Britain.
Earlier studies from Salem and related work were reviewed by Findings in parts one and two of the Manners Matter series. These concluded that treating the patient as an individual, being welcoming, and showing respect and caring persistence, are among the hallmarks of services which retain clients. The reviews argued that there is no conflict between these qualities and efficient administrative procedures of the kind used to deliver reminders in the featured study. Such procedures are needed to give practical expression to the qualities and values which motivate them. In turn, these procedures will not have the desired impact unless they express these qualities; a cold or standardised reminder letter signifies that the sender cares little about the individual and whether they turn up or not. Personal approaches are more effective.
Thanks for their comments on this entry in draft to Josephine M. DeMarce of the Veterans Affairs Medical Center in Salem, USA. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 19 June 2009
Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Benefits of residential care preserved by systematic, persistent and welcoming aftercare prompts STUDY 2008
Continuing care research: what we have learned and where we are going REVIEW 2009
How to transform a poor aftercare attendance record into an excellent one STUDY 2004
Self-financing resident-run houses maintain recovery after treatment STUDY 2008
The power of the welcoming reminder FINDINGS REVIEW 2004
The grand design: lessons from DATOS STUDY 2002
Shared decision-making: increases autonomy in substance-dependent patients STUDY 2011
"I inject less as I have easier access to pipes": injecting, and sharing of crack-smoking materials, decline as safer crack-smoking resources are distributed.Leonard L., DeRubeis E., Pelude L. et al.
International Journal of Drug Policy: 2008, 19(3), p. 255–264.
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After needle exchanges started distributing crack smoking equipment, drug injectors in Ottawa shifted from injecting to smoking the drug and less often shared their smoking equipment. The result was safer drug use and greater service contact by crack smokers.
Summary Among drug injectors in Ottawa, the prevalence of HIV (21%) and of hepatitis C (76%)infection are among the highest in Canada. Recent research suggests the potential for both viruses to be transmitted through the multi-person use of crack-smoking implements. On the basis of this evidence, in April 2005 Ottawa's needle exchange programme started distributing these implements and associated items to reduce the harms associated with smoking crack. Items distributed included: glass stems; rubber mouthpieces; brass screens; chopsticks; lip balm; chewing gum; and written material emphasising non-sharing behaviour and safe disposal. There was no restriction on the amount of equipment which could be collected; implements were distributed in the quantities requested by the users. Items in the crack kits were also available individually in the quantities requested.
This study aimed to evaluate the impact of this initiative on a variety of practices which risk viral transmission. Via street-based outreach, it recruited people who had injected drugs in the past six months who consented to personal interviews and provided saliva for hepatitis C and HIV testing. Injectors were sampled at four time points: six months before distribution started; and one, six and 12 months after it had started. From among the sampled injectors, the study focused on those (500 out of 634) who also reported having smoked crack in the past six months. Sample sizes ranged from 114 to 167 people; the same injectors might be sampled at several time points. Most had recently lived in unstable housing. Saliva tests indicated that over half were infected with hepatitis C. Apart from cannabis and alcohol, cocaine was the most widely used drug and it was also the most widely injected.
At all the time points about 90% of the participants were using needle exchanges in Ottawa. Within a month, 80% had taken up the offer of crack-smoking implements from the exchanges, rising to 87% after 12 months, at first generally in the form of complete kits, later individual items. Accounting for people who received exchange equipment via other users, access to crack-smoking equipment became virtually universal.
By definition, all the participants had injected in the past six months, but more recent injecting significantly declined after distribution started. 96% of the pre-implementation sample reported injecting in the past month compared to 84% one month after distribution started and 78% after six and 12 months. Six and 12 months post-implementation, people who had directly or indirectly received fresh crack-smoking equipment from the exchanges (the great majority of the samples) were asked about changes in their drug use practices since the equipment became available. At both time points, about 4 in 10 said they injected less often (very few said more often), and the third most commonly cited reason was the new service. At the same time points, about a quarter (25% and 29% respectively) of participants said they now smoked crack more frequently, and about 1 in 10 less frequently. At six months advent of the new service was the most common explanation offered. Together these statistics represent a shift to a less harmful way of consuming the drug (ie, from injecting to smoking).
Infection-related risks associated with crack smoking were also reduced. Following the start of the new service, the proportion (80% or more) who in the past six months had shared non-injecting drug consumption equipment remained stable, but among these respondents there was a statistically significant decline in the frequency of sharing: the proportion sharing 'every time' fell from 37% in the six months before implementation, to 31% one month after, and 12% and 13% respectively six and 12-months post-implementation.
The authors observed that uptake of the initiative by Ottawa's injectors/crack smokers was immediate, high and sustained, demonstrating a high level of unmet need for such resources, and that this uptake was accompanied by transitions to safer drug use methods and practices less likely to spread disease. Given this finding, they argued that other needle exchanges should adopt this practice.
Impact of the initiative in terms of transitioning from injecting to smoking might have been greater had cocaine powder (not suitable for smoking) been less dominant and crack (suitable for smoking) more common. On the other hand, the very high proportion of sampled injectors who used the exchanges must have created an extensive platform for the distribution of crack-smoking equipment to affect drug use practices in the city. Where exchange use is less widespread, the impact across an area would probably be less apparent, even if exchange users themselves reacted as intended. However, as it did in both Ottawa and Toronto, providing such equipment can itself extend exchange usage, exposing new drug users to harm reduction assistance and a route to treatment interventions. It may also attract users to exchanges earlier in their drug using careers when they have yet to fully (or at all) embrace injecting; hepatitis C is commonly contracted rapidly after injecting commences, so early contact is vital.
The main queries over the study arise from the absence of a control site without access to crack smoking equipment from the exchanges. Without this benchmark, it is impossible to be sure that the initiative was responsible for the changes in drug use practices. For example, 12 months after implementation, increased availability of crack was the most common reason given for smoking the drug more often, and reduced injecting was most often attributed to a desire to stop injecting and a preference for smoking. However, even in these cases it seems likely that advent of the new service enabled more people to realise these desires and plans, and to use the newly available crack supplies more safely. Whether these changes were extensive enough to seriously dent transmission of the highly transmissible hepatitis C virus seems questionable, though the chance that that they might, and the potential for other benefits, may be seen as justifying the effort.
England has about 200,000 crack users who potentially might benefit from services of the kind researched by the study. Such services are partly justified by concern over possible spread of infection due to sharing equipment used to smoke the drug, though the reality of the risk is not yet securely confirmed. Just as or perhaps more important is the role provision of equipment might play in converting injectors to (or at least, towards) non-injecting drug use.
Trying to convert crack/cocaine injectors to smokers or sniffers is important not just in terms of preventing the immediate complications of injecting, but also because crack/cocaine injecting heightens the risk of disease transmission. One reason is the frequency of injecting due to the short-lived nature of the drug's effects, making it hard for exchanges in Britain and elsewhere to match supply to need. The spread of crack injecting has probably contributed to the rapid transmission of the hepatitis C virus in Britain and the continuing spread of HIV. In 2006 in England, nearly three-quarters of the customers of pharmacy-based needle exchanges used crack, an indication of the potential scope for crack-focused harm reduction initiatives. Another is the fact that a third of injectors sampled at British drug services in 2007 said they injected crack, and crack or cocaine injectors were more likely to have recently shared injecting equipment, to have suffered injecting site damage, and to have been infected with hepatitis C.
Indications that distributing non-injecting drug use equipment in Britain might result in some of the benefits suggested by the study come from a pilot project at four needle exchange programmes in south west England in 2006 and 2007. During the study the exchanges offered foil packs to service users. Just over half the opiate users among them took up the offer, which also provided an opportunity to discuss the risks of injecting and transition to non-injecting. While foil was available, service visits increased by a third and new visitors attended the services who chased heroin but did not inject. At one of the exchanges surveys revealed that all but two people who took foil reported using it, and that as a result, 85% reported smoking their drugs when they would otherwise have injected.
Despite these indicators of need and potential benefit, UK law makes it an offence to supply equipment to be used for smoking crack or foil for smoking heroin, leaving needle exchanges in the perverse situation of being able to supply equipment to make the most dangerous method of drug use (injecting) somewhat less risky, but unable to supply equipment which might support transition to a far less dangerous method (smoking). The result is to limit their capacity to fulfil their harm reduction role. It was perhaps this legal barrier which led the UK's National Institute for Health and Clinical Excellence (NICE) to recommend that needle exchanges "encourage [their users] to ... switch to non-injecting methods", but not to advocate the distribution of equipment to facilitate this transition. Consulted on the guidance, people working with needle exchange programmes were disappointed with this omission. Their comments were in line with the results of a survey conducted in 2008 of UK needle exchange workers. Due mainly to the law, just 15% of the 445 respondents said their services distributed foil, but most supported its provision as a useful harm reduction intervention for both heroin and crack cocaine users. Attempts are currently being made to remove or amend the legal restrictions in the UK. In North America, where in recent years crack use has been the major illicit drug problem, a response including distribution of crack kits has been common if sometimes controversial.
As foreshadowed in the featured report, despite public health support, in July 2007 the city council headed by a newly elected major, who wished to restrict needle exchange in general, cancelled Ottowa's safer crack use initiative. However, provincial funding has enabled the programme to continue at another site.
Thanks for their comments on this entry in draft to Jamie Bridge of the International Harm Reduction Association and Pauline Rigby of Cyngor Sir Powys County Council in Wales. Both are also officers of the UK National Needle Exchange Forum. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 15 June 2009
Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Needle and syringe programmes: providing people who inject drugs with injecting equipment REVIEW 2009
Hepatitis C is spreading more rapidly than was thought OFFCUT 2005
Optimal provision of needle and syringe programmes for injecting drug users: a systematic review REVIEW 2010
Female crack smokers respond well to standard HIV risk-reduction sessions STUDY 2004
Addressing heavy drinking by needle exchange users could reduce infection risk STUDY 2003
Hepatitis C and needle exchange SERIES OF ARTICLES 2004
The primary prevention of hepatitis C among injecting drug users REVIEW 2009
Adequate needle exchange helps prevent bacterial as well as viral infections STUDY 2008
Needle and syringe programs and bleach in prisons: reviewing the evidence REVIEW 2008
Economic evaluation of delivering hepatitis B vaccine to injection drug users.Hu Y., Grau L.E., Scott G. et al.
American Journal of Preventive Medicine: 2008, 35(1), p. 25–32.
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US figures show that testing needle exchange users for hepatitis B and at the same time starting a short course of vaccinations (the UK model) saves lives and thousands of health service dollars, but UK exchanges have lagged behind in offering these services.
Summary People who inject drugs are at high risk of hepatitis B infection, yet among this group, hepatitis B vaccination coverage is low. Recent studies have shown that that needle exchange programmes are effective venues to reach and immunise injectors. The purpose of this paper was to determine if targeting injectors for hepatitis B vaccination through syringe exchange programmes is economically desirable for the healthcare system, and to assess the relative effectiveness of four vaccination strategies.
Through syringe exchange programmes in the US cities of Chicago, Hartford and Bridgeport, the study recruited 1964 currently injecting drug users and conducted blood tests to screen for those at risk of hepatitis B infection. Of the 860 susceptible That is, not already infected or with immunity against the disease. to the disease, 595 returned to receive their first doses of vaccine. They were randomly allocated either to a condensed vaccination schedule (initial dose plus doses one and two months later) or to the longer standard version (initial dose plus doses one and six months later), and followed up for about seven months in the period from May 2003 to March 2006. Blood tests before the last dose, and at the final assessment seven months after the first dose, were used to establish whether immunisation had been successful. These respectively indicated the success rate after two of the intended doses and after all three.
In reality, all the injectors had to return after screening for the results and to get their first doses. The impact of instead administering the first dose to everyone at the screening visit – without waiting for test results to confirm whether they actually needed vaccination – was simulated by the mathematical model which estimated the consequences of the different vaccination strategies. The potential benefit is to ensure that everyone gets at least one dose, feeding through to more people (if the test proves they need these) also getting two and three doses.
This gave the study four combinations of initial dosing (at screening or after results known) and length of dosing schedule (standard or condensed). Of the four, waiting for the screening result and then dosing according to the longer schedule was normal practice. The study aimed to test whether this could be bettered by starting dosing actually at the screening visit and/or by condensing the vaccination schedule.
On the longer standard schedule, 76% of the injectors who took their first dose also took a second, and 52% took all three. On the condensed schedule, the corresponding proportions were 78% and 64%, indicating that this improved completion of the course of vaccinations. Nevertheless, the longer schedule achieved a slightly better rate of successful immunisation (86% versus 78%). After just two doses, across both groups 60% were successfully immunised.
These results were fed in to the mathematical simulation which embraced all 1964 injectors recruited to the study. Compared to not vaccinating at all, the estimates were that vaccination would prevent from 225 to 382 infections among the 1964 injectors (of whom 860 were vulnerable to infection), and per person preserve from on average just under a month to nearly one and a half months of life adjusted for quality chart. Condensing the schedule and dosing at screening both made their own contributions to raising the figures; maximum gains were achieved when they were combined. This combination averted 70% more infections than the usual programme and gained around 70% more quality adjusted years of life.
The order of preference was the same when each programme's costs were balanced against future medical costs associated with hepatitis B infection. Without vaccination, over the injectors' lifetimes the health service would spend $1,414,526 treating complaints associated with hepatitis B infection. After accounting for their own costs, each of the four vaccination programmes would cut this bill If vaccine costs were increased to retail levels savings were diminished but remained substantial. by from $157,967 to $473,999; again, maximum savings amounting to about $241 per injector accrued from starting vaccination at screening and condensing the schedule.
Next the researchers tried varying the assumptions built in to the mathematical simulation. Enabling more injectors to complete their vaccination programmes would make a substantial contribution to increasing benefits and savings. Savings were also dependent on how many of the screened injectors were susceptible to the disease and therefore in a position to benefit from vaccination. When 75% were already infected, none of the vaccination programmes any longer paid for themselves by averting future medical costs. The same would be true if under 1 in 40 became infected each year, or if each year at least 29% permanently stopped injecting, reducing their infection risk even in the absence of vaccination. The simulation initially assumed that all infected injectors would be appropriately treated for their hepatitis B disease. If in contrast it was assumed that at least 54% did not have access to medical care, then again none of the vaccination programmes would any longer pay for themselves.
For the authors, their results indicated that over the long term, hepatitis B vaccination campaigns targeting injectors through needle exchanges save money for the health service, largely because many exchange users are not yet infected or immune, but many would become infected due to risky injecting. This logic can be extended to any programme or service in repeated contact with such populations. The most cost-saving and cost-effective vaccination strategy included giving the first dose to all screened participants before knowing their test results, and then (if needed) administering further doses according to the condensed schedule. The implications of the findings are that US needle exchange programmes and other services repeatedly seeing high risk injectors should screen and offer vaccination for hepatitis B infection.
Substantial as the estimated savings in money and lives were, the authors pointed out that these figures are likely to underestimate the benefits of a hepatitis B vaccination programme for injectors.
For example,
Other considerations are that:
• immunity is achieved in some people after just one dose;
• 'occult' infection was not taken into account in the study's simulation model. Because there is no detectable hepatitis B surface antigen, diagnosis is complicated, but vaccination can prevent acquisition of this form of the disease with consequent benefits and savings;
• the study's injectors averaged 40 years of age; greater savings would be realised by enrolling younger injectors;
• the cohort effect of universal vaccination was not considered;
• neither was the impact on other diseases of preventing the complications that can arise if there is co-infection with hepatitis B.
the calculations were confined to the screened injectors, excluding benefits accruing because successfully immunised patients would not infect other people. On the other hand, patients were paid
on average $15
These fees were included in the simulation model estimating the costs and savings from the programme.
for each immunisation visit. To what degree these incentives raised completion rates is unclear but important, because these rates are critical to the benefits and savings.
For most people including injectors, UK health departments now recommend the condensed schedule used in the featured study, with if possible a booster a year after the first dose for those at continued risk. An even more condensed version over three weeks is licensed for injectors and others at imminent risk of infection. The guidance also recommends starting vaccination immediately and before test results are available. Together this means UK guidance replicates the programme found most cost-effective in the featured study.
Parameters of infection and testing in Britain are similar to those assumed in the featured study, suggesting that on these grounds there is no reason to discount the relevance of its findings to the UK. In Britain in 2007, 15% of injectors tested for hepatitis B at drug services tested positive, including 5% injecting for up to three years. These figures had dipped from 21% and 10% the previous year. At the time these figures were published, introduction of a new test in 2007 could not be ruled out as a cause of the dip. Relying on the previous year's test of known accuracy, the figures are well within the range which, in the US context, the featured study found resulted in health care cost savings from the programmes. So too is the vaccination completion rate; in 2004, 63% of injectors sampled in England who had started the course completed it, nearly the same as in the condensed schedule in the featured study.
As the authors point out, the logic of the study can be extended to any programme or service which comes into repeated (or extended) contact with such populations. As well as needle exchanges, prime amongst these in Britain must be drug services (especially substitute prescribing programmes), general practitioners and prisons. In Britain, injectors tested for infection at drug services increasingly report having been vaccinated against hepatitis B, rising to nearly two thirds in 2006, probably reflecting improved provision through drug services and prisons. Despite this general progress, needle exchanges have been lagging behind. In 2003–2004, injectors in or out of treatment in England were twice as likely to have been vaccinated at a treatment service as at a needle exchange (where just 14% received their doses); prisons had vaccinated nearly three times as many injectors as exchanges. In 2006, a survey of drug service and needle exchange clients in England painted a similar picture; the great majority had been vaccinated, but for just over 10% had this been done at needle exchanges.
Britain's Health Protection Agency has expressed concern that at most only half of English non-pharmacy exchanges provide on-site vaccination. Even fewer (42%) of the non-pharmacy services who responded to this survey in 2005 tested on-site for hepatitis B infection, and very few pharmacy-based schemes asked about virus infection or directed clients to screening and vaccination services. When England's local drug action teams were audited in 2006/2007, testing and vaccination for hepatitis B was among the least well provided harm reduction service. In Scotland in 2005 the situation was even worse, with under 30% of non-pharmacy exchanges providing on-site vaccination and just over 30% testing.
The UK's National Institute for Health and Clinical Excellence (NICE) recommends that all specialist needle exchanges should offer (or help people access) hepatitis B testing and vaccination, and the National Treatment Agency for Substance Misuse now monitors the offer of vaccination by drug services and actively promotes improved provision through the annual treatment planning process.
In summary, for Britain the overall picture is one of substantially but patchily improved access to hepatitis B testing and vaccination, with a wide service gap at needle exchanges in particular, despite their being among the most important venues for this work. Conceivably progress at exchanges has been held back by the emphasis in recent national policies (feeding through to associated targets and funding) on treatment in the service of crime reduction and reintegration rather than harm reduction. What the featured study shows for the USA, and suggests for the UK, is that in respect of hepatitis B testing and vaccination, this may a short-sighted policy which will cost lives and health service resources in years to come.
Thanks for their comments on this entry in draft to Lauretta E Grau of Yale University School of Medicine. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 17 June 2009
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