EFFECTIVENESS BANK BULLETIN 26 May 2009
EFFECTIVENESS BANK BULLETIN 26 May 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. Abstracts are intended to summarise 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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Compulsory drug testing and assessment nets few treatment entrants at high cost ...
Computerised cognitive-behavioural therapy cuts substance use by a third ...
Limits on methadone treatment in Norway reveal its lifesaving potential ...
Intensive support helps drug problem welfare applicants quit using ...
Evaluation of the mandatory drug testing of arrestees pilot.Skellington Orr K., McCoard S., McCartney P.
Scottish Government Social Research, 2009.
Scotland withdrew funding when it saw this evaluation of testing for heroin/cocaine use on arrest. It looked like a very expensive way to get a few users in to treatment; at two of the three sites, six to eight times more costly per treatment entry than voluntary referral.
Abstract Mandatory drug testing aims to encourage problem drug users who come into contact with the criminal justice system to engage with treatment services as a means of addressing the individual's drug problems and associated offending. Under the scheme, anyone arrested for defined 'trigger' offences (acquisitive crime and drug offences) are required Failure to accept testing is an offence as is failure to attend for any subsequent assessment. to undergo oral fluid testing for heroin and/or cocaine. Those testing positive must attend for an assessment by a drugs assessor to determine any dependence on drugs. Individuals who would benefit from treatment are introduced to drug treatment providers; any subsequent uptake of treatment services is voluntary.
For two years from June 2007 this procedure was piloted at three police stations in Scotland (in Edinburgh, Aberdeen, and Glasgow) known to have high levels of drug use among arrestees. An evaluation sought to establish how well the schemes had worked, drawing on interviews with service providers Police, drugs assessors and treatment providers and Crown Office and Procurator Fiscal Service representatives. involved in the schemes and with a few arrestees, plus records kept by the schemes on their first 18 months in operation. Voluntary arrest referral schemes perform a similar function to the pilots but do not involve mandatory testing or sanctions for failing to attend for assessment. Data from local arrest referral schemes provided a rough benchmark against which to compare the pilots.
In Aberdeen and Edinburgh The Glasgow station was unable to provide this figure due it was said to the high throughput of (over 7000 a year) of arrestees. police saw 4204 people whose offences and other characteristics made them eligible to be tested under the schemes. Of these, just over a third were not tested, largely due to having already been detained for six hours, Legislation currently dictates that arrestees cannot be drug tested if they were held in custody for more than 6 hours without being arrested. intoxication, violence, or staff unavailability. Of those tested, about a third were positive for heroin or cocaine and the great majority were referred for assessment. Of those assessed, the assessors reported For Aberdeen and Glasgow these records were cross-checked with the national addiction treatment database. There were substantial discrepancies in both directions due to differing time periods and possibly also because this source of referral in to treatment was inadequately documented. that just over a fifth had attended treatment services. Refusal to be tested was rare but a third referred for assessment did not attend, sometimes Only the Glasgow site kept these figures and then only for a minority of cases. because they were already in prison. Once an assessment had started no one was recorded as having left early.
It had been expected that the three schemes would in total test 420 people a month, half of whom would test positive and a quarter of whom would start treatment. In the event ( chart upper right) numbers were far fewer than anticipated and the proportions moving from one stage of the process to the next were smaller. The net result was that over 18 months, 3211 arrestees were tested instead of the expected 7560, and 223 attended for treatment instead of the expected 1890. Of the 223 treatment entrants,
up to
This breakdown was not available for Edinburgh. The assumption is made that all the treatment starters from that scheme were not already in treatment.
156 were not already in some form of treatment. People assessed but not entering treatment may nevertheless have received valuable information, help and support.
These throughput figures were combined with estimates of how much of the grant for each of the schemes had been spent over the same 18 months: £658,000 in Aberdeen, £809,000 in Edinburgh and £732,000 in Glasgow. The key calculation was the cost per person who started treatment. For the same areas this was £9821, £17,586 and £6655 respectively. Similar calculations were made for voluntary arrest referral schemes in areas as closely aligned as possible with the three mandatory schemes. For these the cost per person who started treatment was (in the same order) £9169, £2797 and £865. The implication is that as a treatment recruitment mechanism, the mandatory scheme was about as cost-effective as arrest referral in Aberdeen, but less cost-effective by a factor of from six to eight in Edinburgh and Glasgow chart lower right.
The main concern of staff involved in delivering the schemes was the far lower than anticipated numbers of referrals. Police and assessor organisations said the expectations had been unrealistic and their genesis unclear. Resources allocated to assessor organisations reflected these expectations, resulting in too many staff for the numbers actually referred by the police. As the pilots progressed, schemes modified their working practices so that assessors became more involved in delivering care rather than just initial assessment. In contrast, police seemed under-resourced in terms of staff availability to identify eligible arrestees and do drugs tests. Time required to complete associated paper-work was also seen as creating bottlenecks and the legislation was universally seen as too restrictive, especially the rule preventing testing after more than six hours in detention. The restricted range of trigger offences, exclusion of people on warrant, and restriction to people living in pilot areas, also limited throughput. Assessors were sited in police stations, the right location it was felt, but accommodation was sometimes unsuitable and on two sites for safety reasons they were shielded from arrestees by physical barriers, impeding rapport. Due to the low numbers of people being processed, partners had reservations about the true success of the schemes. Nevertheless, there was a shared view that a small number of vulnerable drug users had been helped to enter treatment, aided by funding enabling rapid access, particularly to methadone programmes. The few arrestees who contributed to the evaluation felt their interaction with service staff had been positive and enabled ready access to a wide variety of care and treatment programmes, resulting in reduced drug use and offending.
The researchers argued that despite their relatively smooth day-to-day operation, any continuation of the scheme needs to be resourced more accurately in terms of police and assessor staff allocation. More police may increase the referrals but the numbers are still unlikely to require the level of assessor and treatment staff capacity allowed for in the pilots. In each of the areas, partnership working between police and assessor organisations had at times been slightly problematic. Police felt they lacked feedback from assessors and treatment providers in terms of eventual outcomes for people referred, while assessors and treatment staff felt police were insufficiently motivated to maximise referrals. There was, perhaps, a lack of understanding of respective roles and cultures which could have been broken down with more up-front awareness raising. Also, more rigorous data collection and management systems are needed to permit accurate monitoring and evaluation.
The conclusion was that mandatory testing does appear to be targeting some of the most vulnerable and at-risk drug users, but the numbers helped are not large. Based on these numbers, it seems the schemes have had limited impacts, especially considering the resources allocated to them and in comparison with anticipated numbers and voluntary arrest referral schemes. The true impacts on arrestees' future drug use and offending is not likely to be known for some time.
On average, at each of the schemes two to three people a month entered treatment who might not otherwise have done so. Some of the throughput shortfall may have been due to a slow build up, but month-by-month trends suggest this was not a major cause chart. Given that the host police stations were selected for high levels of drug use among arrestees, this seems a very disappointing payoff. The study was unable to explore why two thirds of assessed arrestees did not attend for treatment. In Glasgow, the netting of employed cocaine users who did not see themselves as having a problem may have been a factor. Others may not have required or wanted treatment or been prevented from following through on the referral due to being taken in to custody. Some may have been negative about the testing process or about their previous treatment experiences, possibly with the same services they were being referred to.
The possibly 156 people not already in treatment who started it during the first 18 months of the mandatory schemes must be set against an estimated 197 people were known to have been referred to the authorities and 151 prosecuted, but the time period was June 2007 to mid-March 2009 rather than to November 2008 as for the treatment entry figures. Adjusting for this longer time period reduces the figures to the estimates given. 165 referred to the prosecuting authorities for failing to comply with laws requiring testing and assessment, of whom an estimated 126 were prosecuted. Though these crimes and prosecutions were entirely a by-product of the schemes, the associated criminal justice costs were not included among their costs, which covered assessment and treatment only. Other unaccounted costs included developing the legislation and procedures needed to bring the schemes to the piloting stage. Had these costs been included, the cost-effectiveness of the schemes would have been considerably worse.
About 5% of all arrestees tested and 14% of those who tested positive entered treatment who were not already in treatment. This compares to an estimated 5–6% and 11% The research concerned arrestees who already had a criminal record, about 70% of those testing positive, and the 11% figure refers to those not already on the drug interventions programme's caseload. respectively in England in similar mandatory schemes. In England the number of offences for which people tested on charge (rather than arrest as in Scotland and also later in England) were convicted fell by 26% from the six months before the test to the six months after. It is impossible to say to what degree testing and/or treatment versus arrest and charge contributed to the changes. Such gains as there were in crime reductions were secured at the cost of considerable 'net-widening', drawing in people not previously convicted and low-level offenders who might never otherwise have come to notice, and exposing them to the risk of conviction for failing to comply with testing and assessment requirements. In Scotland there are signs that this too may have happened in the observation that the Glasgow scheme netted many employed people using cocaine but not heroin who did not see themselves as having a drug problem.
In contrast to England, the Scottish treatment entry figures were based on the assessors' reports. Glasgow's assessment staff worked for the treatment provider so are likely to have been well informed; similarly in Aberdeen where assessors usually accompanied arrestees to their first appointments. In Edinburgh it is unclear how assessors would normally have known whether people turned up for their treatment appointments.
Partnership working difficulties due partly to the competing priorities and requirements of criminal justice and care/treatment systems seem endemic to this kind of enterprise, having been remarked on in the early days of arrest referral in England.
The English and Scottish experiences raise doubts over whether making testing and assessment mandatory is a cost-effective alternative to voluntary arrest referral. Costs, and the potential for offences and convictions to be generated simply by the schemes themselves, are a concern, as are the ethics of forcing people in to assessment and re-assessment. If effective assessment is considered not a preparation for treatment but the start, it may be argued that this amounts to compulsory treatment. Set against this is the possibility of drawing people in to treatment who will benefit from it with consequential benefits for society, but who would not have otherwise have owned up to heroin or cocaine use or accepted the offer an in-depth assessment. Whatever the balance of these benefits and risks, it would seem financially and ethically prudent to maximise the reach of voluntary schemes before resorting to compulsion.
In the light of the featured research, on 12 May the Scottish Executive announced that it was terminating funding of the mandatory testing schemes but continuing with the voluntary schemes.
Thanks for their comments on this entry in draft to Tim McSweeney of the Institute for Criminal Policy Research at King's College London. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 23 May 2009 Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Testing on arrest scatter gun nets some extra treatment entrants NUGGET 2008
Testing children pointless but arrest referral offers early intervention opportunities NUGGET 2008
Treatment on bail makes little discernable difference NUGGET 2008
Coerced arrest referral as early intervention NUGGET 1999
Arrest referral tackles drug-driven crime NUGGET 2003
The Drug Treatment Outcomes Research Study (DTORS): final outcomes report STUDY 2009
Arrest referral cost-effective way to cut drug-related offending NUGGET 1999
Botched DTTO response to crack using offenders NUGGET 2008
Throughcare fails to build on prison treatment NUGGET 2000
Computer-assisted delivery of cognitive-behavioral therapy for addiction: a randomized trial of CBT4CBT.Carroll K.M., Ball S.A., Martino S. Request reprint
American Journal of Psychiatry: 2008, 165, p. 881–888.
An interactive computer program may offer a way to overcome the shortage of trained cognitive-behavioural therapists; supplementing routine counselling by program access twice a week reduced substance use by a third.
Abstract This randomised clinical trial evaluated the efficacy of a computer-based version of cognitive-behavioural therapy for substance dependence. Excluding only those with untreated psychoses or about to move or be imprisoned, the study recruited individuals seeking treatment at an outpatient community setting who met criteria for
dependence
A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
• Tolerance, as defined by either of the following:
a need for markedly increased amounts of the substance to achieve Intoxication or desired effect;
markedly diminished effect with continued use of the same amount of the substance.
• Withdrawal, as manifested by either of the following:
the characteristic withdrawal syndrome for the substance;
the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms.
• The substance is often taken in larger amounts or over a longer period than was intended.
• There is a persistent desire or unsuccessful efforts to cut down or control substance use.
• A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.
• Important social, occupational, or recreational activities are given up or reduced because of substance use.
• The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
and had recently used alcohol or drugs. The 77 who joined the study were mainly dependent on cocaine and/or alcohol. At the time they joined the study were on average using substances every two or three days. They were randomly assigned to the clinic's standard weekly individual and group drug counselling sessions, or to this plus access twice a week for eight weeks to computer-based training in cognitive-behavioural skills. The program known as CBT4CBT was built on a widely researched manual developed by the study's first author. Its six interactive modules, each intended to take roughly 45 minutes, explained and presented in simple language and images video scenarios in which the outcome was changed through the application of skills such as assertive refusal. A research associate guided participants through their initial use of the program and was available to answer questions and assist participants each time they used it.
On average the program was well received by the patients, just over four of its six modules were completed, and retention and attendance at counselling sessions were equivalent across the groups. Urine tests taken twice a week revealed that patients assigned to the CBT4CBT program were significantly less likely to have used
illegal drugs.
Breath tests for alcohol were universally negative.
Without access to the program, 53% of tests were positive compared to 34% with it. This difference was most marked (44% versus 28%) for cocaine, the most common drug of dependence used by the patients
chart. Urine test results largely confirmed the patients' own accounts of their substance use, but the gap on the self-report measure was smaller (just over 6%) and not statistically significant. The difference in the longest time patients reported sustained abstinence (21 versus 15 days) was greater and neared significance. Without access to the program, pre-treatment substance use severity (notably days used in the past month) was strongly related to more substance use during treatment. Access to the program weakened this relationship. The authors concluded that while further study was needed, the program showed promise as an effective adjunct to standard outpatient treatment which could be made widely available in services otherwise unable to offer expert cognitive-behavioural therapy.
A later report reassessed at some time 60 of the 73 patients who had initiated treatment Four had not done so, three due to being arrested. at the clinic one, three and six months after the end of the eight weeks of the study. Urine tests for any illegal drug use continued to favour those offered the program, but significantly so only at the first follow-up. Nevertheless, the difference of 62% versus 46% drug-free at the final follow-up remained substantial. The patients' own accounts of their substance use revealed a month by month increase in drug-free days among those offered access to the program, but a falling off among the usual care patients, resulting in a statistically significant difference Which was not accounted for by retention or progress made in the earlier eight-week treatment period, nor by further treatment received during the follow-up period. in trends between the two groups. Moreover, as during the study, on average program patients sustained a significantly longer period drug-free. However, over the entire follow-up there was no difference in the proportion of drug-free days.
An interview with the lead author of the study affords insights in to the motivation for undertaking it – to overcome the difficulty and expense of training therapists to a high degree of competence.
Access to the program seems to have been effective in its own right, not because it enhanced engagement with the clinic's core service. Not only did it improve outcomes overall, but people who would otherwise have been destined to have poor outcomes associated with their immediate pre-treatment cocaine use were rescued from this trajectory. Commonly the main influence on cocaine use outcomes is whether patients had been willing and able to cut down before treatment, suggesting that treatment itself is a relatively inactive ingredient. In the featured study, this was the case without access to the program, but not with it, in turn carrying the opposite implication; that working through the program was a more active therapy which disrupted the typical pattern.
From this perspective it may have been the inadequacies of the standard treatment to which CBT4CBT was added which allowed it to shine. Given the usual counselling schedule at the clinic, encounters with the research team for computer access might have seemed to the patients a considerable addition to the clinic's therapeutic programme. Set against or added to (as other studies have done; see below) a more active treatment, the program may have made less difference. In the event, neither group of patients made a radical advance on their pre-treatment drug use. In the four weeks before starting treatment, patients were abstinent on about 65% of days; during treatment this rose to 81% with the program and 75% without. Despite its undemanding and short-term nature, a third of patients who started treatment did not complete it. These statistics perhaps reflect a challenging caseload of single, unemployed men and women commonly under criminal justice supervision and with a history of mental illness.
Inevitably there are questions over whether the gains associated with the CBT4CBT program would be replicated in normal practice. Access to the program seems to have coincided with the twice-weekly research assessments. This bundling together of the two activities may have raised usage of the program beyond that to be expected in normal conditions. As the authors cautioned, the study is unable to disentangle whether extra attention from research assistants overseeing program access was the active ingredient, the program itself, or some combination of the two. Finally, the study was led by the creator of the manual behind the program, raising the possibility of 'allegiance' effects.
A different issue is raised by the follow-up study. This indicated a growing advantage for program patients even after they had stopped using the program (reminiscent of other studies of cognitive-behavioural therapies; see below), but only in terms of the patients' own accounts of their substance use, not urine test results. It was the reverse during the eight-week treatment period. By choosing to focus on different outcome indicators, the program can be portrayed as demonstrating its efficacy during both phases, during one but not the other, or as showing questionable efficacy in both phases. However, insisting on statistical significance with such a small sample may be overly fastidious. On both measures there was an advantage in both phases of the study, which with a larger sample might have been consistently significant.
Cognitive-behavioural approaches are perhaps the world's most commonly used and widely researched formal psychological therapies, applied often with good results to a range of psychological problems. For substance use too, these therapies have an impressive research record (for example for problem drinking), but this is partly because more good quality studies have been done than in respect of competing approaches. It is by no means clear that cognitive-behavioural therapies are more effective than other similarly extensive and coherent approaches. Studies which have directly tested this proposition often found little or no difference, even when the competing therapy amounted simply to well structured medical care (1 2). Reviewers too have broadly reached this conclusion in respect of the use of substances in general, cannabis in particular (1 2), methamphetamine, and these and other stimulants, including cocaine. In respect of alcohol problems, a recent analysis has concluded that any differences between outcomes from psychosocial therapies are likely to have been due to chance or the allegiance of the researchers.
These findings fit with the discovery that, despite in theory working through very different psychological processes, in practice cognitive-behavioural and other therapies create change through similar mechanisms. Studies have rarely confirmed that the theoretical mechanisms behind cognitive-behavioural therapies actually were responsible for substance use outcomes.
Where cognitive-behavioural approaches sometimes do score better than alternatives is in the persistence of their effects. Gains relative to other therapies have been found to emerge only after the end of therapy and to grow over the follow-up period. This has been observed for some psychological problems, for cocaine use problems (1 2), and recently in respect of cannabis dependence. There is also some evidence that more severely dependent cocaine users particularly benefit from cognitive-behavioural as opposed to other approaches.
Recent guidance from Britain's National Institute for Health and Clinical Excellence (NICE) recommended against cognitive-behavioural therapy as a routine treatment for drug problems, suggesting its main role was in tackling accompanying depression and anxiety. However, the analyses on which this was based did not show that cognitive-behavioural therapy is ineffective, just that (as other reviewers have concluded) it is not convincingly more effective than other well structured therapies. If this is the case, then the decision between such therapies can safely be taken on the grounds of what makes most sense to patient and therapist, the therapist's training, availability, and cost. In respect of cost and availability, cognitive-behavioural therapy may (more evidence is needed) prove to have two important advantages. The first is that effects persist and even amplify without having to continue in therapy. The second is that it lends itself to manualisation to the point where, as demonstrated in the featured study, it can be packaged as an interactive computer program and made available in services lacking trained therapists – potentially a crucial advantage for widespread implementation. In the UK implementation has been held back by the shortage of therapists, an obstacle currently being addressed by a government-funded training initiative. The program offers an another way to overcome this shortage, as long as further studies find no dramatic loss in effectiveness compared to in-person delivery.
Thanks for their comments on this entry in draft to Kathleen Carroll of the Yale University School of Medicine and Aidan Gray of Rugby House-ARP. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 11 May 2009 Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Cognitive-behavioral treatment with adult alcohol and illicit drug users: a meta-analysis of randomized controlled trials REVIEW ABSTRACT 2009
The grand design: lessons from DATOS KEY STUDY 2002
Continuing care research: what we have learned and where we are going REVIEW 2009
Aftercare calls suit less relapse-prone patients NUGGET 2005
Relating counselor attributes to client engagement in England STUDY 2009
Anti-alcohol drug also reduces cocaine use NUGGET 2005
Behavioral couples therapy (BCT) for alcohol and drug use disorders: a meta-analysis REVIEW 2008
The Drug Treatment Outcomes Research Study (DTORS): final outcomes report STUDY 2009
Mortality prior to, during, and after opioid maintenance treatment (OMT): a national prospective cross-registry study.Clausen T., Anchersen K., Waal H. Request reprint
Drug and Alcohol Dependence: 2008, 94(1–3), p. 151–157.
Limited access to opiate substitute prescribing in Norway opened a window on its powerful lifesaving potential, a view obscured in countries where barriers create a confounding selection effect or where everyone who needs and wants this treatment can quickly get it.
Abstract At the time of the study Since 1998 intake criteria have been modified (no strict age limits) and by the end of 2009 new national guidelines will be implemented. These will be less restrictive and include no age limits. Intake criteria will only be verified opioid dependence and exclusion criteria will be limited to cases where continuation of treatment is judged medically irresponsible. Personal communication from Thomas Clausen, May 2009. Norway's substitute prescribing programme for opiate addiction was designed to recruit severely addicted heroin users aged 25 and over who have not benefited from other types of treatment. Priority was given to applicants also suffering from other severe physical or psychiatric illnesses. The featured study investigated mortality reductions associated with entering this programme, drawing on national registry data on the treatment careers of all 3789 opioid-dependent patients accepted for this treatment at any time in the seven years from 1997 to 2003 inclusive. This was cross-linked with data from the national deaths registry on deaths up to the end of 2003. On average each patient was tracked for nearly three years.
Death rates were calculated during: • Waiting time The typically five or six months patients had to wait between being assessed as qualifying for treatment and starting their programmes. • In-treatment time Total number of days in the programme whether during one or several episodes, typically about two years. Sometimes referred to below as 'during' treatment. • Post-treatment time Number of days out of treatment within the study period, whether between successive treatment episodes, or following a single or the last episode. Combining the last two periods afforded an estimate of the change in death rate after entering treatment, regardless of whether the patient remained in the treatment or had left.
While waiting,
per year
These figures should be understood as the death rate grossed up to an equivalent rate over a year. For example, one death among 100 people over six months is equivalent to two deaths over a year, yielding a death rate of 2% per year. Another way of expressing the figure (used in the chart) is as two deaths per 100 person years.
2.4% of the would-be patients died. This fell to 1.4% during treatment and rose to 3.4% after leaving. Combining the last two periods, the death rate fell from 2.4% before treatment to 1.8% after starting it chart. A more sophisticated analysis indicated that the risk of death after entering treatment (whether still in it or after leaving) was 60% of the risk while waiting, and that while still in treatment, patients were half as likely to die as while they were waiting.
Given the priority afforded to ill applicants, many deaths might have been due to preceding illnesses which could not be prevented by the treatment. Overdose deaths Defined as acute intoxications/deaths from all substances, comprising ICD 10 codes F11.0 (acute intoxication due to use of opioids), F19.0 (acute intoxication due to multiple drug use and use of psychoactive substances other than those with their own codes), X42.0 (accidental poisoning by opiates and related narcotics) and X44.0 (accidental poisoning by other and unspecified drugs, medicaments and biological substances). offered a more direct indicator of the impact of starting treatment. The overdose death rate fell from 1.9% a year while waiting to 0.4% during treatment, and rose to 2.1% after leaving. Combining the last two periods, the overdose death rate fell from 1.9% before treatment to 0.7% after starting it. Again a more sophisticated analysis quantified the relative risks run by patients in the different phases of their treatment careers. Waiting for treatment, patients were three times more likely to suffer a fatal overdose than after starting treatment. While still in treatment, overdose deaths were cut to a fifth of their pre-treatment level.
Though studies which sample only patients still in treatment may overestimate mortality reductions, the authors concluded that their study shows reductions remains significant and substantial, even when patients who have left are included in the calculations.
This study takes us closer to an answer to the question, 'How many more people dependent on heroin would die if there were no substitute prescribing programmes?' Its most important feature was a by-product of the time patients had to wait for treatment as the programme came to terms with the workload revealed when the new service became available. At the time participants started contributing data to the study, all had already been assessed as needing and qualifying for treatment and had applied to enter the programme. The fact that many had to wait enables us to assess what happens when such people are forced to wait, and by extension, to estimate what the impact might have been had there been no maintenance programmes for them to wait for. Unlike other studies, the study's design strips away confounding variables like severity of dependence and motivation which influence whether someone seeks treatment, exposing the impact of the treatment itself.
What it implies is that if 100 people are made to wait for treatment, an extra one or two will die per year compared to a situation where treatment was made immediately available. In line with many other studies, the bounce back to pre-treatment overdose death rates after leaving treatment supports a view of methadone and other substitute prescribing programmes as an on-off switch. People in need of this treatment generally quickly improve when it is 'switched on' but rapidly relapse once it is off, and especially so if it is switched off against the patient's wishes. Over the span of the study, in-treatment gains overshadowed post-treatment reverses, leaving a substantial overall benefit.
The Norwegian context at the time does however limit the findings to patients failed by non-prescribing approaches, turning the spotlight on the adequacy those approaches. Had these been better developed, these patients may never had got as far as the doors of a prescribing service and as many lives may have been saved. For Norway this seems unlikely, as drug-free treatment aimed at achieving a drug-free life is the mainstay of the treatment response; maintenance prescribing is a late and relatively peripheral addition. Nevertheless, in 2003 about 30% of the established and severe cases of opiate addiction in the country were in substitute prescribing programmes. Nine out of ten injected, exposing them to the highest risk of overdose. This caseload gives the programmes great scope to demonstrate their power to reduce this risk, but also concentrates the most difficult to treat addicts in the clinics. The study also reflects the results of a tightly controlled programme with an avowed rehabilitation objective (highlighting housing and – generally unsuccessfully – employment), entailing supervised consumption, frequent urine tests for unauthorised drug use, and discharge of patients who do not progress sufficiently, divert medication, or do not comply with the requirement for frequent attendance. Despite this stringency, the programme has very high retention, possibly aided by most provision being in the hands of local GPs, and by methadone doses averaging well over 100mg and buprenorphine doses averaging 16mg daily, very high average levels. While the 'all deaths' figures are unambiguous, deciding what is or is not an overdose death Also, the overdose codes appeared to exclude, for example, death due to sedative overdose, potentially an important cause of deaths in opiate-dependent patients. If deaths due to this and other excluded categories like cocaine varied across the treatment careers of the patients, this could have biased the impression of relative risks across different phases. is less straightforward.
Neighbouring Sweden also has a programme with restricted access. As in Norway, this has provided insights in to the lifesaving potential of substitute prescribing obscured in other countries. Based on expected death rates for Swedes of a similar age, one seminal study showed that patients eligible for maintenance treatment, but denied it and offered detoxification and drug-free services instead, were eight times as likely to die as those admitted to the maintenance programme. These and other studies have been reviewed for Drug and Alcohol Findings.
Because of their restricted access, studies of such programmes are not well suited to demonstrating a protective effect across a population of heroin users. In Spain this seems to have been clearly demonstrated by a low-threshold programme which in the '90s contributed to a 21-year increase in the life expectancy of heroin users in Barcelona.
It is not however inevitable that any substitute prescribing programme will save lives overall, including among non-patients; it all depends on reaching the right balance between access and control, flexibility and regulation. Get this right and methadone – perhaps even more so buprenorphine programmes – make the greatest known contribution to reducing opiate-related deaths. Get this wrong, and deaths due to diverted medication, among patients unable to access the programme, who continue to use illegal drugs due to inadequate doses, whose induction on to methadone has not been sufficiently well monitored, or who have been forced out or deterred by expense, onerous requirements, or unrealistic expectations of compliance and progress, can all become a concern.
Partly as a result of such research, access to Norway's substitute prescribing programme is no longer as restricted both in terms of intake criteria and waiting times.
Thanks for their comments on this entry in draft to Thomas Clausen of Norway's National Centre for Addiction Research and Neil McKeganey of the Centre for Drug Misuse Research at the University of Glasgow. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 17 May 2009 Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Opiate antagonist treatment risks overdose NUGGET 2004
Methadone maintenance as low-cost lifesaver NUGGET 2004
High risk of overdose death for opiate detoxification completers NUGGET 2008
Naltrexone implants prevent opiate overdose NUGGET 2006
Under-dosing and poor initial assessment undermine success of British methadone services NUGGET 2001
The Drug Treatment Outcomes Research Study (DTORS): final outcomes report STUDY 2009
International review and UK guidance weigh merits of buprenorphine versus methadone maintenance NUGGET 2008
Low threshold methadone extends life expectancy in Barcelona NUGGETTE 2006
A practical clinical trial of coordinated care management to treat substance use disorders among public assistance beneficiaries.Morgenstern J., Hogue A., Dauber S. et al. Request reprint
Journal of Consulting and Clinical Psychology: 2009, 77(2), p. 257–269.
Further demonstration from a US research team that relatively intensive case management support does help welfare applicants overcome substance use problems, but in this case only those not already managed through substitute prescribing.
Abstract This US study was designed as a practical clinical trial maximising real-world applicability The case management functions at issue were delivered by an existing clinical programme supported by welfare funding, treatment fidelity was assessed with quality assurance methods, research assessments minimally intruded on routine care, and outcomes were used which were measurable in routine clinical care via self-report and biological confirmation. while maintaining research integrity. It was implemented in partnership with a large city welfare agency. Participants were 421 substance using single adults and adults with dependent children applying for welfare benefits. They were selected from 1519 such applicants on the basis of their reporting a substance use problem and being motivated to receive treatment. Initially they had been identified by welfare workers using a standard screening A modified version of the CAGE screening questionnaire. questionnaire. Depending solely on where the next assessment slot was available, the workers transferred substance users for further assessment at one of the two offices in the study.
One of the offices offered usual assessment and care services: assessment by an addiction counsellor focused on substance use problems in relation to employability, followed by allocation to a generic welfare worker whose role was to assess eligibility for welfare payments and deal with non-compliance with the welfare system's requirements. They also referred the beneficiary to services, but only during infrequent meetings limited by a large caseload.
At the other office, more rounded and detailed assessments were conducted by a multidisciplinary team. Of psychiatrists, psychologists, social workers, nurses, vocational rehabilitation specialists, and addiction counsellors. After referring applicants to a range of services to meet identified needs, they transferred them to case managers. Their role was to maintain intensive contact Aided by relatively small caseloads, they contacted each client at least twice a week and visited them at their treatment programme every fortnight. They also familiarised themselves with local services, withdrawing clients from those not serving their needs, and cutting referrals to underperforming programmes. with the beneficiary and with the agencies providing them with services, and to ensure that these agencies matched the individual's needs and performed acceptably. In the usual care option, quarterly reassessments focused on welfare system requirements, but in the case management option the focus was on client progress and adjusting the service mix accordingly.
All 108 applicants who were in methadone maintenance treatment during the study were already in this treatment The study says that all clients in methadone maintenance were already enrolled in a programme when they entered the intervention, and transfer to another service was difficult and hence unlikely to occur. at the time they applied for benefits, and generally simply continued. Beyond these existing methadone patients, there were few if any heroin dependent applicants who might benefit from initiating treatment. Welfare case workers had more latitude to initiate or change other sorts of substance use treatments.
Diagnostic interviews found that about 6 in 10 of the sample met criteria for substance
dependence,
A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
• Tolerance, as defined by either of the following:
a need for markedly increased amounts of the substance to achieve Intoxication or desired effect;
markedly diminished effect with continued use of the same amount of the substance.
• Withdrawal, as manifested by either of the following:
the characteristic withdrawal syndrome for the substance;
the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms.
• The substance is often taken in larger amounts or over a longer period than was intended.
• There is a persistent desire or unsuccessful efforts to cut down or control substance use.
• A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.
• Important social, occupational, or recreational activities are given up or reduced because of substance use.
• The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
mainly in respect of cocaine, alcohol or heroin, and another fifth for substance
abuse.
A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:
• Recurrent substance use resulting in a failure to fulfil major role obligations at work, school, or home (eg, repeated absences or poor work performance related to substance use; substance-related absences, suspensions or expulsions from school; neglect of children or household).
• Recurrent substance use in situations in which it is physically hazardous (eg, driving an automobile or operating a machine when impaired by substance use).
• Recurrent substance-related legal problems (eg, arrests for substance-related disorderly conduct).
• Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (eg, arguments with spouse about consequences of intoxication, physical fights).
Psychological problems and criminal justice involvement were common. About 1 in 6 had some degree of responsibility for dependent children.
As intended, over the year of the follow-up period, case managed clients saw their case workers more often than their counterparts in usual care. Especially during the first three months, they also received a broader range of services. However, this was entirely due to greater service access among clients not already in methadone maintenance. When usual care was replaced with relatively intensive and proactive case management, these non-methadone clients were significantly more likely to be in (drug-free) substance use treatment and to get help with medical, employment, mental health and basic needs. They also achieved significantly higher rates of
abstinence
Based on the clients' own accounts, which were overwhelmingly in agreement with the results of urine and hair sample tests. Similar differences between the groups were found when urine tests were relied on as indicators of abstinence.
from alcohol and illegal drugs chart. Once other influences had been taken in to account, for every four people who were abstinent during any given month in the follow-up period, another three achieved this with the help of more intensive case management. This advantage
emerged early
In fact, seemed to be emerging even before the intervention started. However, the researchers conducted analyses which indicated that pre-baseline differences in abstinence rates were probably due to random fluctuations, and that even taking these differences in to account, the case management option resulted in greater abstinence rates.
in treatment and was sustained throughout the follow-up period. In contrast, and just as with services received, abstinence rates among clients already in methadone treatment were not increased by case management.
Four in ten of the non-methadone clients were already in treatment, and largely were applying for benefits to help pay for it. Given this, the researchers argued that not only did their study demonstrate the value of case management for welfare applicants, but also for poor clients in publicly funded treatment in general.
The study deliberately selected the
most promising candidates
The 421 clients in the study were whittled down from 8986 applicants screened positive by welfare workers for substance use and sent for more comprehensive assessment. Over 1800 did not turn up for assessment. The remainder were sampled on a quasi-random basis by the research project's interviewers. Fewer than a third of this sample were selected for the study. Selected applicants were assessed as problem substance users motivated to attend treatment, who did not face major barriers such as serious mental illness or impending/actual homelessness. As intended, these selection processes would have resulted in a sample willing to accept both assessment and treatment, and potentially in a position benefit from that treatment. Indeed, just over half were already in treatment.
for substance use treatment. Its results cannot be assumed to generalise to the bulk of welfare applicants identified by front-line welfare workers as potentially hindered by their substance use, but who do not have a serious problem, have one but are unwilling to acknowledge it, or are not motivated to tackle it. More information on the sample can be found in an earlier report.
Findings were line with a sparse evidence base suggesting that increased provision/receipt of welfare and medical services improves outcomes from addiction treatment. Lack of impact among methadone-maintained patients was expected because at the start of the study they were already in a treatment which entailed regular clinical and counselling contacts, leaving in this respect little for case managers to improve on. Had case managers been able to initiate methadone treatment, the picture might have been reversed, with greater impacts among those introduced to methadone programmes. It does however remain puzzling why the methadone patients in the study did not access the social, medical and welfare services made available through the case managers, services generally underprovided by US methadone programmes. Despite intensive case management contact, for these patients the status quo applied. The assumption may have been that simply turning up for methadone was sufficient engagement with treatment, and/or that patients on methadone could not take advantage of reintegration opportunities. Certainly the US requirement for long-term supervised consumption would constrict vocational and employment opportunities.
The same research team had recently conducted a similar study among substance-dependent mothers applying for benefits for families in need. Those offered case management were over twice as likely to be abstinent during any particular month in the two-year follow-up period, and across this period were 68% more likely to be in full time employment.
These two studies from in and around New York are at odds with the general picture reported recently in a review of studies of case management for drug users. Across 11 studies which randomly allocated clients to case management versus 'usual care', case management did improve access to services, but there was no statistically significant impact on illegal drug use. Results varied substantially from study to study, suggesting that effectiveness depends on the circumstances. One of the few reviewed studies which did report significant impacts on drug use was the study described Based on an earlier report than the one cited above: Morgenstern J. et al. "Effectiveness of intensive case management for substance-dependent women receiving Temporary Assistance for Needy Families." American Journal of Public Health: 2006, 96(11), p. 2016–2023; http://dx.doi.org/10.2105/AJPH.2005.076380. in the previous paragraph. The authors argued that their studies may have bucked the generally negative trend because the interventions they tested were robust, well resourced by the providing authority, and there was a clear divide between these services and those provided to comparison groups. Other factors include whether services are so easily accessible that case management is unnecessary, or so hard to access that case management cannot help (or not until new systems/resources have been developed), and the type and intensity of the case management model. Evidence is strongest for the strengths-based model which focuses on the client's strengths, abilities and assets, and puts them in control of setting goals and obtaining resources to achieve those goals.
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. There is though 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. Even if Britain did adopt a case management model, the UK caseload may react differently to the applicants in the featured study. The US sample was dominated by cocaine users and it was among these and other non-opiate users (mostly drinkers) that positive effects were noted. All or nearly all the heroin dependent applicants in the sample were among the group on methadone who did not profit from case management. In contrast, at least initially The draft legislation includes a provision to extend the act's requirements to drinkers. in Britain, heroin users are likely to form the bulk of welfare applicants considered appropriate for treatment. If they are already in treatment, the featured study suggests that it will take a highly intensive, resource-rich and ambitious case management programme to take them further along the road to reintegration and employment. If they are not already in treatment, it may be because they are unable or unwilling to take up the treatment opportunities currently available. Again intensive work may be needed to overcome these obstacles. Such UK evidence as there is suggests that drug users not already in treatment will be among the welfare applicants least likely to comply with requirements in response to threats of benefit cuts.
Thanks for their comments on this entry in draft to Nicola Singleton of the UK Drug Policy Commission. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
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