EFFECTIVENESS BANK BULLETIN 26 February 2009
EFFECTIVENESS BANK BULLETIN 26 February 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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Accreditation drives up US treatment outcomes, cost-containment systems drive them down ...
Intensive, continuing, holistic, practical support helps welfare mothers escape dependency ...
Housing and work help homeless and workless; benefits of yoking to abstinence less clear ...
GPs save time by 'as needed' consultations after brief alcohol interventions ...
Organizational- and individual-level correlates of posttreatment substance use: a multilevel analysis.Ghose T.
Journal of Substance Abuse Treatment: 2008, 34(2), p. 249–262.
Request reprint using your default e-mail program or write to Dr Ghose at toorjo.ghose@yale.edu
Using advanced methods, this US study asked what makes for an effective treatment agency. Being constrained by funders in terms of services and ability to individualise treatments was the clearest negative factor, quality accreditation the clearest positive.
Summary The objective in this US study was to identify what it is about a service or about its patients which makes for good treatment outcomes. To do this it used sophisticated 'hierarchical' models to disentangle relationships between post-treatment substance misuse and features of the organisation and the individual patients. Such methods are able to correct for the fact that treatment services operate within a broader environment, and that individual patients are clustered within treatment services. Without these corrections, multiple 'nesting' can give rise to false associations. For example, some apparent links between individual characteristics and treatment success no longer held when nesting was accounted for. The analysis had available to it one of the world's richest and largest datasets It used data from the Alcohol and Drug Services Study (ADSS) 1996–1999, a national treatment study conducted by the US government. The dataset permits an examination of a more comprehensive set of organisational and individual-level variables than previous similar studies. The current analysis relied on a random sample of 155 residential and outpatient non-methadone treatment facilities. Records of 2670 clients eligible to be followed up were abstracted from these facilities to gather information on the clients and their treatments. Three years after leaving treatment, 1184 clients from 128 facilities were interviewed to establish long-term outcomes. documenting features of the treatment services, the patients, and their substance use three years after leaving treatment.
Different services in different areas saw on average different types of patients. But even after this had been taken in to account, the probability of post-treatment substance misuse Including any use of: crack/cocaine; heroin; cannabis; amphetamines; hallucinogens; non-prescribed methadone, opiates, sedatives or tranquillisers; and non-medical use of over-the-counter medications. varied significantly across services. The single most important factor was the degree to which a service was funded through managed care A US system in which non-medical administrators such as insurance companies control and limit the provision of medical procedures and medications and allied services. A primary aim is to controls costs by restricting patient choice and limiting clinical discretion, though 'levelling up' and quality improvement may also be objectives. arrangements intended to contain costs; the more it relied on these funding sources, the greater chance that its patients would use drugs after treatment. On the other hand, patients were much less likely to misuse substances if they had been treated by services with a recognised quality accreditation. Namely that offered by the Joint Commission on the Accreditation of Healthcare Organizations. Now known as The Joint Commission (see www.jointcommission.org), this not-for-profit agency aims "To continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services". In both cases the links were far stronger for residential than non-residential services.
Several characteristics of the individual patients (such as their ages and main drugs of choice) were also related to later substance misuse. After these and organisational factors had been taken in to account, longer treatment episodes and completing treatment remained strongly associated with a reduced risk of later substance misuse. However, the apparent benefits of length of stay were reduced in services more reliant on managed care funding, subject to monitoring by a parent organisation, whose workers had large caseloads, or which had higher proportions of highly qualified (doctorate level) staff.
The observation in Britain and elsewhere that broadly similar services differ greatly in outcomes has driven
attempts
Leading investigators include Dwayne Simpson and his team at the Institute of Behavioral Research (http://www.ibr.tcu.edu) in Texas, who are working with the English National Treatment Agency for Substance Misuse to improve performance by diagnosing and rectifying organisational processes.
to establish what accounts for this variation and to rectify poor performance. Mechanisms like accreditation and managed care are major ways to achieve this objective. Findings from the featured study, probably the most reliable to emerge from the USA, suggest that on-site inspection and accreditation has substantially improved substance use outcomes, while an externally imposed value-for-money mandate motivated by cost-containment has even more substantially eroded them. In each case there are more or less distant parallels in the UK. Because impacts depend on how these mechanisms are implemented and the services involved, and because of the different national contexts, these US findings are best seen as indicative of potential impacts in the UK.
The positive implication is that having a relatively widely used quality accreditation process does improve treatment processes in ways which also improve outcomes. However, an alternative explanation is that the minority of services which sought accreditation were already implementing quality processes and achieving good outcomes, for which they sought recognition. One study which advanced this explanation found that different accreditation and licensing processes differed in the degree to which (if at all) they were associated with various indicators of quality. The featured accreditation agency based its awards largely on on-site inspections (now typically unannounced). Services had strong incentives In the US context, partly competitive and financial. to raise their games to meet the agency's standards, and doing so may have been a condition of funding.
In contrast, England's inspection process dedicated to substance misuse services is largely paper-based, involving on-site visits Other than for data collection. only to the 'worst' 10% of services. Within this process there are no minimum standards services must meet to receive public funding, good services do not receive public recognition, and competitive pressures are muted compared to those in the USA. Much closer to the model tested in the study is the inspection work of the Commission for Social Care Inspection in England and allied bodies elsewhere in the UK. They inspect registered care homes which include most residential rehabilitation houses dealing with substance users. Inspections are usually unannounced and the reports and quality ratings are made public on the commission's web site. Services are assessed against national minimum standards but inspectors also attempt to judge how far they are making a difference to the lives of the residents. However, non-residential drug/alcohol services and unregistered care homes generally fall outside the commission's ambit, and English service providers have agreed that the process "provides little oversight of the quality or appropriateness of the treatment programme itself".
On the debit side in the featured study was the association between poor outcomes and funding through the cost-containment mechanism of managed care. This fetters the discretion of patients and providers to provide expensive Either in time, breadth, intensity or the cost of staff time and facilities. services, but also aims to eliminate unnecessary or less effective practices and to mandate good practice. Here again though, the possibility remains that reliance on managed care was not a causal factor but merely reflected features which, whatever the funding arrangements, would have led to poorer outcomes. If managed care was detrimental, how that came about is unclear. The researcher highlighted the pressure to de-individualise service provision, apparent in another analysis drawing on the same dataset which found that specialised treatment for HIV positive drug users was much less likely in services reliant on managed care. Though de-individualisation may be the typical result, it can be countered. Aware of this risk, in Oregon authorities paired managed care implementation with mandatory guidelines on the intensity of care required to match individual need and discharge criteria which took account of the patient's progress. The combination actually enhanced individualisation of treatment placement and discharge Though the average length of stay did not differ from that in a comparator state, there was significantly greater variability. and increased the use of more intensive (and expensive) outpatient options.
Possible implications of the managed care findings for the UK relate to the 'value for money' exercise being mounted by the National Treatment Agency for Substance Misuse A special health authority within the NHS, established by government in 2001 to improve the availability, capacity and effectiveness of treatment for drug misuse in England. (NTA). This attempts to link model treatment system components with the standard or typical costs of those components. The aim is to offer a benchmark to local drug action teams to help level up quality and identify possible economies. With falling per-patient funding for treatment, it also has the unintended potential to be used as a cost-containment tool to cap and de-individualise service provision. In all these respects, the exercise shares aims and possibilities with managed care, though it also differs in important ways. Notably the UK exercise does not directly force cost-capping or standardisation through funding mechanisms; instead pressure to maintain or increase patient numbers with in real terms less funding may have a similar effect.
The featured study indicates the potential for such initiatives to worsen outcomes, but this is not inevitable. Several other There are several studies which found no or a mixed impact. The study linked to next as an example is particularly useful for its mini-review of the literature. more limited studies did not find such a relationship. Managed care funders vary in which treatment processes they seek to control and how stringently, and in their focus on cost-containment versus quality improvement. Impacts of managed care also differ for different treatment modalities. In the featured study the apparently detrimental impact was much greater on residential than non-residential services, presumably because funders were more concerned to contain expensive residential provision. Similarly, a national US survey of youth substance misuse services found that, as expected, in residential services quality was impaired when funders were prepared to pay less for therapeutic programmes. But this was not the case for non-residential services, perhaps (the authors suspected) because even the highest levels of funding available to them were insufficient Relatedly, in Oregon researchers suspect that the advent of managed care was unrelated to outcomes because outcomes were already so poor that little detriment was possible. See: McFarland B.H. et al. "Outcomes for clients of public substance abuse treatment programs before and after Medicaid managed care." Journal of Substance Abuse Treatment: 2005, 28(2), p. 149–157, http://dx.doi.org/10.1016/j.jsat.2004.12.001 to support quality improvement initiatives.
Methadone services were excluded from the featured study. In another national US study, managed care was associated But not always to a statistically significant degree. with increased provision of psychosocial therapies and more drug/alcohol testing in methadone maintenance services and better discharge planning, but also with a lesser focus on reintegration through employment and housing or testing for infectious diseases. In respect of medical services, similar relationships were found among drug-free counselling agencies. The findings were broadly consistent with managed care resulting in a narrowing in on core services, implementing these more consistently but at the cost of broader medical, social and public health concerns.
One of the clearest illustrations of how managed care can diminish quality and outcomes comes from a US study of a specialist service for drug dependent pregnant women. Counselling time and with it therapeutic content were reduced and limits on methadone treatment durations imposed by health insurance companies forced mothers to drop out or seek alternative providers, fragmenting care. It is unclear whether these mechanisms resulted in the worsening in neonatal and child welfare outcomes.
Thanks for their comments on this entry in draft to independent consultant Richard Phillips. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 18 February 2009
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The grand design: lessons from DATOS STUDY 2002
Crack: making and sustaining the break STUDY 2004
Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence DOCUMENT 2009
Are we right to spend more? IN PRACTICE 1999
Addressing medical and welfare needs improves treatment retention and outcomes STUDY 2005
Matching resources to needs is key to achieving 'wrap-around' care objectives STUDY 2006
Improving public addiction treatment through performance contracting: the Delaware experiment STUDY 2008
Drug and alcohol services in Scotland STUDY 2009
Systematic but simple way to determine who needs residential care STUDY 2003
Improving 24-month abstinence and employment outcomes for substance-dependent women receiving Temporary Assistance For Needy Families with intensive case management.Morgenstern J., Neighbors C.J., Kuerbis A. et al.
American Journal of Public Health: 2009, 99(2), p. 328–333.
Request reprint using your default e-mail program or write to Dr Morgenstern at jm977@columbia.edu
Intensive, long-term case management coordinating treatment and other services helped US 'welfare mothers' overcome their drug problems and gain full time employment.
Summary This abstract incorporates additional information from an earlier journal article and from a report by the responsible research centre.
The US Temporary Assistance for Needy Families (TANF) welfare-to-work programme offers financial support to unemployed parents normally for up to five years as long as they comply with requirements intended quickly to transition the family to self-sufficiency through employment or other means. Non-compliance results in sanctions including loss of benefit. Depending on state rules, substance use treatment may be a required or discretionary component. The programme has dramatically reduced the number of welfare beneficiaries. A substantial minority of those who are left are hampered by problems related to substance use, and this group are also more likely to face other barriers to employment.
At the time of the study the typical response of US states was to refer individuals identified through screening for assessment and if appropriate to treatment, with little follow-up. The featured study compared outcomes from such an approach to intensive case management. This entailed two case managers working with each woman to motivate treatment entry, help overcome barriers, coordinate services such as childcare, housing and transport, prepare for employment, find jobs, and arrange relapse-prevention support once employed. Treatment engagement was rewarded with shopping vouchers. Case management continued throughout the two-year follow-up period of the study.
302 substance-dependent A comparison group of TANF applicants not identified as substance dependent were also recruited to the study. women identified after routine screening procedures In accordance with New Jersey regulations, welfare workers administered the CAGE-AID brief screening survey to everyone (re)applying for TANF benefits. Women who responded positively to two or more questions were referred for assessment to addictions professionals at the welfare offices who screened clients for study eligibility. were randomly allocated to usual TANF procedures or to intensive case management. Typically the women were non-injecting Opiate injectors were usually referred to methadone maintenance which disqualified them from the study. users dependent on heroin or cocaine, black and poor, had three or four children, and had not completed compulsory schooling. On average they had been in receipt of welfare benefits for 12 years. Across the follow-up period, those offered case management were over twice as likely to be abstinent during any particular month, and the advantage conferred by case management grew over the two years. By the final month 47% were abstinent compared to 24% of the usual care women. Across the entire follow-up period, case managed women did not work significantly more days per month, but they were 68% more likely to be in full time employment. They consistently achieved steeper rates of improvement in any employment, full time employment, and days worked, until by the final month they were working an extra week a month and 22% were working full time compared to just 9% after usual care. The authors concluded that intensive case management is a promising intervention for managing substance dependence among women receiving welfare benefits and for improving employment rates among this vulnerable population.
The key findings in this study are the clear differences in trends in abstinence and,
associated with this,
Prior abstinence was associated with later employment both year to following year and month to following month. However, it is unclear whether abstinence facilitated employment, or whether having been employed earlier made it more likely that you would later both remain employed and be abstinent. In the former scenario abstinence is a contributor to employment, in the latter either a consequence of employment or simply a marker of individuals in a position to make both sorts of changes in their lives. Possibly some mixture of all these influences were in play.
in employment, promising increasing post-study gains for the case managed women, but an
uncertain future
Their continuing vulnerability to problem drug use despite work seems apparent in the fact that among women who had worked that month there was no trend to increased abstinence over the two years. In contrast, there was an increasing trend among case managed women who worked. By the end of the follow-up, more than three fifths of the case managed women who were working were also abstinent, compared to just a third among usual care participants.
for those given minimal help to enter and stay in treatment apart from the negative incentives of the TANF system. Further analysis suggested that the degree of contact with their care coordinator (for case managed women, this was their case manager) was what mainly accounted for the abstinence-fostering advantage of case management. In particular, these contacts helped improve outcomes for women who at least initially did not engage with treatment. Without much treatment, and also in the usual care group without much compensatory contact with a care coordinator, at the extreme these women were half as likely to later sustain abstinence.
As the authors explain, the lack of an advantage in days worked across the full two years seems due to the fact that in the first 15 months of the follow-up, case managed women were more likely to start treatment, and far more likely to stay in it and complete it. It seems they were busy overcoming their drug problems and sorting out their lives and support structures with the aid of the case managers. But while employment itself came later in the process, preparation for employment came earlier and was far more intense In the first 15 months case managed women spent four to five times as much time working on employment issues with their care coordinator than usual care women; after addressing substance misuse, it was the single greatest focus for case management. than among the usual care group.
During this initial period, women in the usual care group were less likely to engage with treatment and were instead it seems pressured to rapidly enter some form of employment, at the cost of failing to stabilise their substance use as adequately as the case managed women. The result was that in the early months, on average the usual care group worked more days, but later the case managed women (by this stage far more likely to be completely sober) caught up and overtook. Particularly telling is the fact that the usual care group were less able to convert their early employment experiences in to full time employment. Possibly the kind of employment they sought or were able to sustain (not full time, possibly short-term) was the sort compatible with continued substance use problems.
However, finding work for long-term unemployed, under-qualified women with young children to care for was bound to be an uphill struggle. Employment outcomes were less convincing than the substance use outcomes more under the control of the women and susceptible to the tools available to them via their case managers. Despite the support they received, even among the case managed group, over two-thirds were totally unemployed in each of the final three months of the study.
The featured study was a methodological advance on an earlier study dealing with TANF claimants which found similar improvements associated with holistic case management. Random allocation to a 'usual care' comparison group was the major advance. Also, during the two-year follow-up the women's own accounts of their substance use were validated through urine tests and corroborated by people close to them. Better than 90% follow-up rates give confidence that the findings were applicable to the entire caseload identified as having similar problems at the welfare offices feeding in to the study. However, the study did exclude women referred for methadone maintenance. It seems possible that the attraction and retention power of this treatment would have reduced the advantage gained by adding intensive case management.
Government-backed legislation currently being debated in Britain would introduce a welfare-to-work model closer to the US model, in particular making welfare benefits for problem drug users conditional At this time the plans are going through the parliamentary process. This element of the plans is being resisted by the Scottish government (Macleod A. "SNP rejects plan to cut benefits for drug addicts" The Times: 14 December 2008 http://www.timesonline.co.uk/tol/news/uk/scotland/article5342246.ece). on engaging with and making progress in the rehabilitation plan agreed with (or determined by) their employment adviser. The plans envisage an initial period during which the patient will be in treatment supported by a treatment allowance and will not be required to show they are actively seeking work. In this sense they resemble the intervention tested in the featured study, though there is as yet no commitment to provide intensive case management support. Without this the risk is that problem substance users and their families will be disproportionately subject to sanctions for non-compliance rather than make progress in their recovery.
One possibly relevant UK study concerned benefits sanctions for offenders who did not comply with community orders. Among the offenders were many with drug and alcohol problems whose orders may have incorporated a treatment requirement. Due it was thought to the lack of social/family support and disordered lives dominated by drug use, they were among the groups least likely to comply in response to the threat of benefit cuts, a disadvantage mitigated among those who had successfully completed or were engaging in treatment. When sanctions were imposed, families and partners suffered along with the claimant.
While the US women voluntarily identified themselves, UK plans include identifying drug using claimants through criminal justice records, drawing those unwilling to admit to their substance use, or who consider it non-problematic, in to the ambit of welfare-to-work treatment requirements. Also, the majority of UK claimants subject to these procedures will not be women with children. Nevertheless the study's core message is likely to be relevant in Britain: clients facing multiple barriers to employment do better with intensive support which coordinates treatment, employment and other services in a mutually reinforcing, individually tailored package driven by their needs.
Thanks for their comments on this entry in draft to Jon Morgenstern of the National Center on Addiction and Substance Abuse at Columbia University and Mike Stewart of the Centre for Economic and Social Inclusion in London. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 03 March 2009
Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Does coordinated care management improve employment for substance-using welfare recipients? STUDY 2009
Effective services for substance misuse and homelessness in Scotland: evidence from an international review REVIEW 2008
Take the network into treatment FINDINGS REVIEW 2004
Evaluation of the Jobcentre Plus Intensive Activity trial for substance misusing customers STUDY 2011
Toward cost-effective initial care for substance-abusing homeless STUDY 2008
Self-financing resident-run houses maintain recovery after treatment STUDY 2008
The Drug Treatment Outcomes Research Study (DTORS): final outcomes report STUDY 2009
Matching resources to needs is key to achieving 'wrap-around' care objectives STUDY 2006
Toward cost-effective initial care for substance-abusing homeless.Milby J.B., Schumacher J.E., Vuchinich R.E. et al.
Journal of Substance Abuse Treatment: 2008, 34(2), p. 180–191.
Request reprint using your default e-mail program or write to Dr Milby at jmilby@uab.edu
Offering homeless, unemployed people seeking treatment for cocaine dependence access to housing and paid employment if they stay drug-free is a powerful incentive, but adding intensive counselling helps maintain abstinence once the incentives end.
Summary This US trial was one of a series conducted in Birmingham, Alabama with a consistent methodology, each involving homeless men and women generally dependent on cocaine and suffering severe distress but not psychotic, and prepared to enter treatment for their drug problems. The series aimed to disentangle the active ingredients of aiding this difficult-to-treat population to resolve their drug problems and get back on their feet in terms of housing and employment.
In the current study participants were identified at a medical facility serving homeless patients and invited to participate in the study. It entailed them being given a furnished flat with food from week two of the study up to 24 weeks, as long as frequent urine tests showed they had not used alcohol or other drugs. During the first 24 weeks urine tests were conducted three times a week for cocaine, cannabis and alcohol. Participants who had tested positive for these drugs at entry to the study were also tested for benzodiazepines, opiates, and amphetamine but with no contingencies attached. Earnings (explained next) paid the study housing's modest rents in weeks nine to 24, before which it was free. From weeks one to 24 participants also had access to vocational training and employment with pay rates Starting pay of $1.25 increased daily to a maximum $5.25 per hour if urine tests were neither missed nor positive and the worker complied fully with workplace guidelines (ie, arrived on time, completed shift, and was non-confrontational). Failing on any of these counts meant pay was reduced to the starting rate and the same contingencies were re-applied. dependent on abstinence. Sustained abstinence qualified participants for follow-on public housing.
Additionally, a randomly selected half of the participants were allocated to an intensive day care programme aiming to help them set and achieve objectives In five common problem domains: addiction; homelessness; unemployment; non-drug-related social and recreational activities; and mental/health and emotional problems. to improve their lives in ways which could be expected to buttress their recovery. Attainment of milestones was rewarded with shopping vouchers. Further counselling Consisting of: a daily patient-conducted morning meeting; emotional processing group; drug and alcohol education; relapse prevention; anger management and assertiveness training; role playing; rational evaluation of mood and emotions; relaxation and stress management training; healthy decision making; healthy communication; healthy self-esteem; weekend planning; recreational outings organised within the treatment context; and recreation/art therapy. In addition, clients met with their individual counsellors for about an hour or more each week. helped them resolve personal and emotional problems and develop coping skills.
The main issue was whether adding day care could further improve outcomes when the participants were already subject to powerful employment/housing incentives. During the 24 weeks these incentives were applied, day care participants were only slightly and non-significantly more likely to be abstinent at any point or to sustain abstinence. But after incentives ended, their abstinence rate declined more slowly than that of incentives-only participants. The result was that on both measures, day care resulted in significantly higher abstinence rates in last year of the study. The authors concluded that for this caseload, employment/housing rewards and punishments on their own were a viable initial intervention, and that intensive day care might be reserved for participants who did not respond well to these contingencies or with co-morbidities such as serious mental illness.
The key finding that combining day care with incentives improved
abstinence
However, it is unclear to what degree participants substituted other drugs for the ones being tested. Also, using abstinence as the outcome fails to reflect what may nevertheless be clinically significant changes in the intensity of drug use. Within wide limits, urine tests are insensitive to such changes.
outcomes had previously been confirmed in reverse – by adding incentives to day care, rather than day care to incentives. Adding incentives substantially improved retention and abstinence outcomes and led to smaller but still worthwhile gains in
housing and employment
In both cases, by the end of the incentive programme at six months around 20% more participants in the combined intervention were housed or employed, though only the housing figures met conventional standards of statistical significance.
rates. An important difference is that in the earlier study, once the added incentives had been withdrawn, associated abstinence, housing and employment gains eroded until one year after treatment entry there was little difference between the groups. In contrast, in the featured study abstinence gains from adding day care became more apparent after incentives ended.
Both studies left open the possibility that simply providing housing and employment assistance, but without abstinence requirements attached, might have been just as effective. For the housing component, this was tested by the same research team in a study which supplemented day care and paid employment opportunities with housing which was either dependent on abstinence, or provided regardless of the participant's substance use. Even while this was in place, requiring abstinence to qualify for housing increased abstinence rates consistently but only slightly. Across the 25 weeks, participants in the group whose housing was threatened by substance use were consistently more likely to be abstinent, but on average the difference was just a few per cent and across the study fell just short of being statistically significant. Neither did it further improve housing or employment outcomes compared to day care only, or to this plus no-strings housing.
Another US research team has investigated the impact of making employment dependent on abstinence, but among a different population – unemployed patients living in poverty in Baltimore who despite being maintained on methadone continued to inject and used cocaine/crack. They volunteered for a data-entry and keypad skills training/work programme remunerated by shopping vouchers. Half were randomly allocated to have access to the workplace (and therefore to pay) only if they submitted a cocaine-negative urine test. The other half were also tested, but the results made no difference to their access to work. This regimen lasted six months. During that time patients required to be abstinent were less likely to use cocaine or to inject, but non-users were still in the minority. Most continued to use cocaine and probably as a result, they spent far fewer days at work and earned less money than patients not required to be abstinent, who also tended to make greater progress in their training. Also the abstinence gains were transitory. Six months after the programme ended, if anything it was the patients who had not been required to be abstinent who were more likely to be cocaine-free. They were also less likely to be trading sex, sharing injecting equipment, or patronising shooting galleries, though by his stage nearly all the diffidence between the two groups were minor and all were statistically insignificant.
The combined implication of these studies is that among these poor, unemployed, and largely black In the US context, commonly a marker of severe relative poverty and disadvantage. populations enmeshed in illegal drug use, work and housing incentives can help initiate and extend drug-free periods, but intensive support is needed to maximise and maintain the benefits once incentives are withdrawn. Without this, the gains from making housing and work dependent on abstinence rapidly erode, and it is unclear whether the long-term benefits justify disrupting the housing and employment stability of patients subject to the contingencies. This disruption is consequent on requiring abstinence in a population for whom this is a very high hurdle. In the featured study, even with intensive support and after a programme lasting from 7.30am to 4pm four days week plus a half day, by the end of the follow-up period most participants continued to use alcohol or other drugs. It also seems that offering decent, affordable housing, substantial employment assistance, and paid employment itself, but without requiring abstinence, has in the longer term been just as effective as making these benefits contingent on abstinence, though the evidence is sparse.
The featured study faced several challenges common to contingency management programmes. Most studies have only documented the limited period Typically 12 weeks. during which incentives were in place. Through this window, the approach seems very effective. But extending the view to the post-incentive period reveals that participants often quickly reverse towards to their previous behaviour. This is not inevitable but it is common, a contrast with approaches like cognitive-behavioural therapy which develop skills and lifestyles in patients which in several studies seem to become more securely embedded as time passes. This may be partly because impacts are typically limited to the targeted behaviours and/or the targeted drugs. Effectively, people do what is needed to get the rewards or avoid the punishments, potentially leaving other relapse-precipitating features of their lives ready to exert their influence once the programme ends. Overcoming this by extending the intervention may be impractical, and may in any event not work; unlike other interventions, in general the longer a contingency management programme runs, the weaker its effects. Another limitation is that such programmes are most feasible and work best when they target a single drug, yet many patients use several to excess. Targeting all these risks setting the bar so high that many patients do not experience the incentives. Even with simpler regimens, patients commonly qualify for none of the rewards or are subjected to sanctions because they do not exert the required control over their behaviour. The risk is that the most vulnerable, unstable and severely dependent participants are further disadvantaged, either missing out altogether or being repeatedly 'knocked back' as they fail to sustain the required standards.
Other studies have attempted to mitigate these risks by enabling incentives to be earned through smaller steps, rewarding recovery-promoting activities rather than or as well as abstinence, and by combining contingency management with programmes which address the individual's psychological or social vulnerabilities. The featured study tried several of these tactics. Within the contingency management regimen, recovery-promoting vocational and employment-related activities were financially rewarded, while psychosocial vulnerabilities were addressed by pairing the incentives with intensive day care. Whether the more severely dependent or unstable patients were relatively disadvantaged is not reported. We know from an earlier study in the series that a quarter of the participants offered intensive day care and housing/employment incentives did not control their substance use sufficiently to qualify for any rewards.
Based on a recommendation from the National Institute for Health and Clinical Excellence (NICE), contingency management programmes are now being trialled in British drug treatment services. Government welfare-to-work plans incorporate a 'contingency management' type element At this time the plans are going through the parliamentary process. See http://www.dwp.gov.uk/mediacentre/pressreleases/2009/jan/drc124-140109.asp. This element of the plans is being resisted by the Scottish government (Macleod A. "SNP rejects plan to cut benefits for drug addicts" The Times: 14 December 2008 http://www.timesonline.co.uk/tol/news/uk/scotland/article5342246.ece). in the form of reduced benefit payments for problem drug users who do not engage with and make progress in the rehabilitation plan agreed with (or determined by) their employment adviser. These moves take Britain closer (but still quite distant) to a policy context in which the type of programme tested in the featured study might be feasible and acceptable.
If contingency management does become prevalent in Britain, much will depend on the particular form it takes. The evidence is strongest for rewarding desired behaviour and this is the approach staff and patients may be most comfortable with, but it risks a public and media backlash. Punishing undesired behaviour is less effective and risks counterproductive side effects, but may be more acceptable to the broader public. Another alternative is to reward good behaviour by removing punishments, but this has not been adequately researched.
Thanks for their comments on this entry in draft to Tim Leighton of Action on Addiction's Centre for Addiction Treatment Studies. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 24 February 2009
Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Take the network into treatment FINDINGS REVIEW 2004
The Drug Treatment Outcomes Research Study (DTORS): final outcomes report STUDY 2009
Long-term outcomes of office-based buprenorphine/naloxone maintenance therapy STUDY 2010
Addressing medical and welfare needs improves treatment retention and outcomes STUDY 2005
Self-financing resident-run houses maintain recovery after treatment STUDY 2008
Does coordinated care management improve employment for substance-using welfare recipients? STUDY 2009
Continuing care research: what we have learned and where we are going REVIEW 2009
Evaluation of a telephone-based stepped care intervention for alcohol-related disorders: a randomized controlled trial.Bischof G., Grothues J.M., Reinhardt S. et al.
Drug and Alcohol Dependence: 2008, 93(3), p. 244–251
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This German study saved valuable counselling time by only offering further advice to primary care patients who had not yet responded to brief computerised feedback on their risky drinking.
Summary Brief interventions for problem drinking in medical settings are effective but rarely conducted, mainly due to insufficient time. A stepped care approach (starting with a very brief intervention and intensifying efforts in case of no success) could save resources and improve effectiveness. However, research is lacking. The present study compared a full care brief intervention for patients with at-risk drinking, alcohol abuse or dependence, against a stepped care approach in a randomised controlled trial. Participants were proactively recruited from general practices in two northern German cities. In total, 10,803 screenings were conducted (refusal rate: 5%). Alcohol use disorders according to DSM-IV The Diagnostic and Statistical Manual of Mental Disorders (the 'IV' signifies the fourth edition) is published by the American Psychiatric Association and provides diagnostic criteria for mental disorders. It is used particularly in the USA. were assessed with the Munich-Composite International Diagnostic Interview (M-CIDI). Eligible participants were randomly assigned to one of three conditions: 1 stepped care – a computerised intervention plus up to three 40-minute telephone-based interventions depending on the success of the previous intervention; 2 full-care – a computerised intervention plus a fixed number of four 30-minute telephone-based interventions, equalling the maximum of the stepped care intervention; 3 an untreated control group. Time spent in counselling in the intervention conditions and quantity/frequency of drinking were assessed at 12-month follow-up. These measures showed that stepped care patients received roughly half the amount of intervention in minutes compared to full-care patients yet these groups did not differ in drinking outcomes. Among at-risk drinkers (rather than those already dependent or those who drank relatively rarely but heavily when they did), the intervention groups reduced their drinking relative to the control group, impacts assessed as small to medium in size. The authors concluded that a stepped care approach can be expected to improve the cost effectiveness of brief interventions for patients with at-risk drinking.
Generally the duration of a single-session brief intervention makes
little or no difference to drinking outcomes. However,
several
But not all. See for example:
● WHO Brief Intervention Study Group. "A cross-national trial of brief interventions with heavy drinkers." American Journal of Public Health: 1996, 86(7), p. 948–955. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1380435
● Burge S.K. et al. "An evaluation of two primary care interventions for alcohol abuse among Mexican-American patients." Addiction: 1997, 92(12), p. 1705–1716. http://dx.doi.org/10.1111/j.1360-0443.1997.tb02891.x
previous studies have indicated that follow-on advice sessions do improve outcomes. For the first time in a randomised trial, the issue addressed by the featured study is whether it is best to offer these sessions as a set programme, or whether time and money can be saved by offering them only to patients who have not yet responded to the initial interventions(s).
In the context of the study, the verdict was clear: the 'as needed' strategy cut counselling time in half, saving Assuming the doctor was doing the counselling. 22 Euros per patient, yet with minor exceptions Puzzlingly, these favoured the 'as needed' strategy, the briefer of the two interventions. This difference was seen only among the least heavy drinkers (the episodic 'bingers'), raising the possibility that making these patients go through four advice sessions in addition to the brief intervention was counterproductively disproportionate to their need. the outcomes were not significantly different. It was, however, important to at least monitor progress and offer further help if needed: about 30% of patients seemed to have securely resolved their drinking problems after brief intervention alone, but after another two advice sessions this proportion had doubled.
In line with earlier findings that dependent or long-term very heavy drinkers do not benefit from brief interventions, the other major finding in the study was that neither of the interventions seemed to have benefited dependent drinkers. At the start of the study these averaged about 80gm of alcohol a day, 10 UK units. Neither did they benefit patients who on average drank quite moderately At the start of the study averaging about 14gm of alcohol a day, under two UK units. but sometimes to excess. It was the in-between patients At the start of the study they averaged about 37–49gm of alcohol a day, about five or six UK units. who benefited – patients whose health was at risk from regular excessive drinking and/or who were experiencing adverse consequences, but in both cases short of dependence. Yet even among these patients, classic targets for brief intervention, this on its own At least in the form studied, ie, computerised assessment feedback with tailored written advice rather than face-to-face consultation. was insufficient for many.
The findings have clear implications for primary care alcohol interventions, where the nature of the practice-patient relationship makes it feasible to follow brief advice with periodic check-ups and further intervention if needed. It suggests this potential is worth exploiting. However, as the authors caution, it cannot simply be assumed that such a strategy would be feasible and effective in normal primary care practice. Though patients were identified in GP practices, both the identification and the interventions were conducted by specialist staff. Nearly half the patients who screened positive for possible risky drinking refused to participate in the study, raising doubts about the representativeness of those who did. Also it is unfortunate that by chance the risky drinkers in the study's intervention groups were from the start drinking more A not quite statistically significant extra 10gm a day. than the non-intervention control group, raising the possibility that the clearest benefit from the intervention was partly It did not account for all the extra drop in consumption among the intervention groups. due to catching these patients at an atypical high in their drinking, from which they might in any event have descended.
Last revised 05 February 2009
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