EFFECTIVENESS BANK BULLETIN 28 September 2009
EFFECTIVENESS BANK BULLETIN 28 September 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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Remarkable impact from alcohol parenting advice at parent-school meetings ...
Counsellor skill influences outcomes of brief motivational interventions ...
The power of walking in the client's shoes ...
UK study supports naloxone-based opiate overdose reversal training ...
Reducing youth alcohol drinking through a parent-targeted intervention: the Örebro Prevention Program.Koutakis N., Stattin H., Kerr M.
Addiction: 2008, 103, p. 1629–1637.
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In Sweden routine parent-school meetings incorporating parenting advice and encouraging commitment to take a strong stand against underage drinking had a remarkable impact on adolescent drunkenness – but would this simple, low-cost tactic work as well in the UK?
Summary The Örebro Prevention Programme built on the fact that Swedish schools start each term with a parent information meeting. A survey of pupils in the final grade of compulsory schooling (roughly age 16) in the county of Örebro in central Sweden was used to select schools for the project in communities typified as inner cities, public housing areas, or small towns. Within each type of community, And in small towns, within each town. pairs of matched Matched on the size of the school and pupil alcohol use and delinquency. schools were selected, one of which carried on as normal, the other of which was assigned to test the prevention programme. None of the schools refused to participate in the study.
The programme was implemented across the final three years (grades seven to nine) of compulsory schooling when pupils were aged 13 to 16. Before the programme started, a survey of pupils in grade seven formed the baseline against which to assess impacts in this and the following two years. In each succeeding year the next higher grade was surveyed, meaning that largely the same pupils were followed up each year. In each year roughly 900 pupils Of whom about 90% agreed, were given permission by their parents, and completed the classroom surveys. In different sets of schools and years, from 68% to 84% of parents also agreed to be surveyed by post at home. evenly split between both sets of schools were asked to participate in the study.
Rather than through classroom lessons, the programme worked via the parents. At a seventh-grade parent information meeting, project staff gave a presentation describing the programme and advising parents to maintain a zero-tolerance stance towards youth drinking and to communicate clear rules to their children. This was reinforced by inviting attending parents to sign agreements about their positions on (among other issues) youth drinking; most did so. The agreement was mailed to all parents including those who had not been at the meeting. In each of the next two years project staff attended two further parent meetings to emphasise the key message of strict rules. Reports on the meetings were one of at least three mailings each term to parents. Mailings included letters (most co-signed by project workers and teachers) which stressed the importance of communicating family rules against alcohol and drug use and of promoting organised leisure activities. Based on information from local clubs and organisations, also mailed were catalogues describing leisure activities in the community which parents were asked to read through with their children.
The key question in the pupil surveys asked how often pupils had been drunk in the past four weeks. From virtually no times at age 13, in the control schools not participating in the programme the average rose to nearly once in four weeks at age 16 chart. From a similar starting point, it rose just half as much in programme schools, a medium to large programme impact as represented by the
effect size
A standard way of expressing the magnitude of a difference (eg, between outcomes in control and experimental groups) applicable to most quantitative data. Enables different measures taken in different studies to be compared or (in meta-analyses) combined. Based on expressing the difference in the average outcomes between control and experimental groups as a proportion of the variability in the outcome across both groups. the most common statistic used to quantify this difference is called Cohen's d. Conventionally this is considered to indicate a small effect when no greater than 0.2, a medium effect when around 0.5, and a large effect when at least 0.8.
metric. Also the proportion of pupils who had been drunk more than once during this period was twice as high (27% versus 13%) in non-programme schools.
At age 13 just under a fifth of the pupils said they had already been drunk. Among these high risk pupils the programme was just as, if not more, effective, halving the increase in the frequency of drunkenness; by age 16, without the programme these children were getting drunk on average twice a month compared to less than once a month in programme schools chart. On all these measures for both full and high risk samples, there were statistically significant differences between programme and non-programme schools, and no indication that the programme was any less effective with boys than with girls or vice versa.
Pupils were also asked how often they had committed criminal or antisocial acts Such as breaking into stores or cars, hurting someone with a weapon, painting graffiti, shoplifting, stealing a bike, or vandalism. over the past year. Though the intervention had focused on drinking, here too there were statistically significant and medium to large programme benefits In the form of smaller increases and lower levels of delinquency. across the entire samples and among pupils in the top fifth of delinquency before the programme started. In respect both of drunkenness and delinquency, the there were no major differences between the three types of communities in the effectiveness of the programme.
One mechanism underlying these benefits was expected to be an extension of the parents' strict anti-drinking norms in respect of their 13-year-old children to older ages. Based on the parents' own accounts, the programme did significantly maintain these norms. However, there was no evidence from the children that involvement in adult-led organised group activities – another supposed means by which the programme would affect drinking – had in fact been enhanced by the intervention.
For the authors their study demonstrated that the parent programme had successfully influenced parental attitudes against underage drinking, resulting in (compared to most other prevention programmes) relatively large reductions three years later in drunkenness and delinquency across both boys and girls, among high risk pupils as well as the entire school year, and in different types of communities. It achieved these impacts despite being easily administered through existing parent–teacher meetings, costing very little to implement, and requiring just a two-day course for the people delivering the programme, who need not be specialist professionals. In the Swedish context they believed these attributes meant the programme could be implemented widely and largely within existing resources.
In the Swedish context this was a convincing demonstration of the power of harnessing the parent involvement mechanisms and influence of the school to reinforce parental responsibility in respect of their children's drinking. It is also a testimony to the potential power of unambiguous and simple messages congruent with the culture and to the strong influence exerted by parental attitudes and behaviours on when and then how young people drink.
Though not clear in the featured report, it seems that parents at the initial meeting jointly develop an agreement concerning their stance on youth drinking, possibly adding group solidarity and continuing parent-to-parent reinforcement to the mix of influences leading to impacts As a measure of its impact, in programme schools, children who had already been drunk by age 13 ended up getting drunk on average no more often than the general run of pupils in schools without the parent programme; stiffening the stance of their parents averted a developmental trajectory which would have seen these high risk youngsters drinking regularly to intoxication at age 16. several times greater and more consistent than typical of alcohol prevention programmes applied universally to the entire youth population. This is the case even in respect of programmes recognised as effective and usually far more costly and difficult to implement. Confidence in the validity of these findings is weakened slightly by methodological issues; in particular, the failure to account for the grouping of children and parents within schools could have falsely magnified the apparent impacts. More in background notes.
However, a later Swedish trial failed to replicate these findings. It tested the programme's effectiveness in a study conducted by independent researchers not involved in its development, and using the current (in Sweden) widely disseminated version of the programme presented by experienced Örebro presenters. Though the programme was fairly fully implemented, it had no reliable effects on regular drinking or on drunkenness, and the apparent impacts on parental attitudes and behaviour may have been due to parents and children exposed to the Örebro programme being more likely to give the responses 'approved' by the programme. Even in Sweden it seems that routinising the programme diluted its impact compared to the featured trial, when the schools and the presenters were participating in a trailblazing project led by the programme's
developers,
Editor's note: A reference is being made here to the 'researcher allegiance' effect. In several social research areas,1 programme developers and other researchers with an interest in the programme's success have been found to record more positive findings than fully independent researchers. Such overlaps between developers and researchers are endemic2 in drug prevention research.
1. See articles at the following web addresses:
http://dx.doi.org/10.1007/s11292-009-9071-y
http://dx.doi.org/10.1177/0193841X06287188
http://dx.doi.org/10.1093/clipsy.6.1.95
2. See article at the following web address:
http://dx.doi.org/10.1016/j.evalprogplan.2007.06.004
who can be expected to be both expert on its implementation and enthusiastic about its potential.
Accepting these initial results as an indication of the programme's potential, the question remains whether it would have the same potential in drinking cultures like that of the UK. A trial in the Netherlands of a Dutch version of the Örebro programme may be a better pointer to how it would perform in Britain. If so, it suggests that it would be an effective addition to alcohol use prevention lessons, but not the standalone success it was at first in Sweden. Ease of implementation, low cost, the fact that no classroom time is involved, and the potential for extra impacts, may be seen as making it worth a try alongside whole school programmes, the promotion of activities which give young people a sense of achievement and belonging, and perhaps above all, cultural change which makes parents more willing and able to control drinking among underage children.
Efforts to involve parents have generally been more elaborate but less successful than the one trialled in the featured study. A meta-analysis A study which uses recognised procedures to summarise quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually. combining findings from randomised studies of parent-focused substance use prevention programmes found modest effects in the form of fewer adolescent children starting to drink and a lower frequency of drinking. This was particularly the case when whole schools were engaged in the intervention, offering an opportunity for pupils and parents who participated in the programme to influence those who did not. However, the findings were undermined by a general failure to account for families which were unable to be followed up.
A common practical problem is getting parents to participate in face-to-face substance use prevention programmes. Typically in Britain (see for example 1 2 3) and elsewhere in Europe, attendance is very low, especially among parents most in need of parenting support and with lenient attitudes to substance use. Generally in these studies the attempt was to encourage attendance at special add-on events. On this count the featured study's strategy of incorporating prevention in to the school's core parent involvement programme has a distinct advantage. The downside is that at these events schools have a limited time in which communicate with parents; educational and other social issues (such as knife-carrying, guns, bullying, illegal drugs, teenage pregnancy) are likely to be seen as higher priorities both by the school and by the parents. Other solutions tried in Australia and the USA involve mailings to parents from the school or parent-child homework assignments; more in background notes.
An obvious risk of encouraging parents to make their strictness about underage drinking known to their children, is that the children will respond by hiding their drinking, depriving parents of awareness and the opportunity to intervene. In Sweden but perhaps less so in Britain, voluntary self-disclosure is an important way parents learn about their children's leisure-time activities. More in background notes.
As the authors acknowledged, the main question mark for readers outside Sweden will be the programme's applicability to their cultures. Rather than having to create this, it merely had to extend the strict On a scale of 1 (lenient) to 4 (strict), from the start these attitudes averaged 3.8. anti-underage drinking norms held by parents and communicated to their children when they were 13 years of age to later ages, when legal purchase was still many years away for their children. Such attitudes reflect national policy. For a European nation, Sweden has unusually restrictive alcohol laws, allowing legal purchase only at age 20 and confining the sale of anything other than low-content beverages to state-run stores, restrictions which make it clear that drinking is not mainstream and accepted.
As in Sweden, in Britain too parents seem influential in their children's drinking, but as much in the direction of condoning as outright opposition. It would be a far bigger task to persuade the majority of British parents to harden their attitudes and keep them hardened as their child approaches the lower legal alcohol purchase age in the UK, where full-strength drinks are available in virtually every supermarket. In drinking cultures like Britain, advice originating from the school about the parent's responsibility to communicate an unambiguous stance on drinking risks being seen as unwelcome meddling, especially by the heavy drinking parents whose children could most benefit from stronger parenting. See background notes for some relevant studies. A trial in the Netherlands of a Dutch version of the Örebro programme may be a better pointer to how it would perform in a drinking culture more like that of the UK. If so, it suggests that it would be a worthwhile addition to alcohol use prevention lessons, but not the standalone success it was at first in Sweden.
Attempts are being made in Britain to harden parental attitudes to youth drinking. Aided perhaps by media coverage highlighting the risks of youth drinking, the relevant English national policy aims to develop a national consensus on young people and drinking. At the sharp end of the policy are court orders requiring parents whose children persistently drink in public to exercise greater control. Further down the scale are support for parents whose children are at risk of problems such as drinking, and the attempt to establish a partnership with parents based on a clear understanding of acceptable and unacceptable levels and patterns of youth drinking. So far however the message received by parents from other aspects of alcohol policy – alcohol's mainstream position in society, and particularly the recent extension of opening hours – is that the government is not taking a stand to manage the issue of alcohol in society, undermining the credibility of calls for parents themselves to shoulder that responsibility.
For more on the Örebro programme see this Findings analysis of the later Swedish trial, and this analysis of the trial in the Netherlands.
Thanks for their comments on this entry in draft to Richard Velleman of the Mental Health Research & Development Unit of the Avon & Wiltshire Mental Health Partnership NHS Trust and the University of Bath. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 13 August 2011
Background notes Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Universal school-based prevention programs for alcohol misuse in young people REVIEW 2011
Blueprint drugs education: the response of pupils and parents to the programme STUDY 2009
Doing it together strengthens families and helps prevent substance use STUDY 2004
Effects of a school-based prevention program on European adolescents' patterns of alcohol use STUDY 2011
Counselor skill influences outcomes of brief motivational interventions.Gaume J., Gmel G., Faouzi M. et al.
Journal of Substance Abuse Treatment: 2009, 37, p. 151–159.
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Few studies can manage the painstaking analyses needed to identify what makes for successful counselling. This Swiss study broke new ground in dissecting why some brief interventionists had far better results than others with risky drinking A&E patients.
Summary The featured report is one of several from a study of brief advice to heavy drinkers among injured adult patients attending a Swiss emergency department. They attended Switzerland's Lausanne University Hospital over the 18 months from January 2003 to June 2004. Among 8439 patients, 1472 heavy drinkers were identified by a health screening survey, of whom 987 joined the study. They were randomly allocated to carry on as usual, to also be assessed by a researcher for about half an hour, or in addition to receive about 15 minutes of advice on drinking immediately after assessment. Adopting the style of motivational interviewing, this compared the patient's drinking with national norms and led the patient to consider the pros and cons of their drinking and their readiness to change, culminating if appropriate in a setting a goal for change. Over the following year, this typical brief intervention format did not lead to greater reductions in drinking. About two-thirds of the patients continued to drink heavily Neither this measures of change in drinking nor any of the others revealed any advantage for the intervention across the entire sample, or among certain types of patients. regardless of advice and/or assessment.
During a period of the study and when patients allowed, intervention sessions were audio-taped. 97 sessions could be rated for the degree to which the counsellor adhered to a motivational style, and for comments from the patient indicative of their ability and willingness to change their drinking. Of these ratings, an initial analysis found that only the patient's expressed degree of ability to change was related to later drinking; none of the counsellor's behaviours was significantly linked. However, this analysis tried to separately link each behaviour Such as advising with/without permission, affirming or confronting, asking closed or open questions, and so on. (in)consistent with motivational interviewing's principles with drinking. The possibility remained that combining these behaviours to characterise the counsellor's overall style would yield significant results.
This was the approach taken in two further reports, one of which was the featured report. An earlier analysis established that counsellor comments consistent with the style of motivational interviewing were most likely to elicit positive statements about changing their drinking from the patient. The featured report related the same (and other) measures of counselling style to later drinking, limiting itself Of the seven counsellors one was a nurse who contributed only one session which could be coded, as did one of the psychologists. Neither was included in the analysis, leaving 95 of the 97 tapes to be analysed. to interventions conducted by five counsellors They were all masters level psychologists pursuing a career in clinical psychology who had been trained in motivational interviewing and brief alcohol interventions as part of the study. with similar qualifications and experience and uniform preparatory training. Despite this they differed significantly in the their patients' weekly drinking at the 12-month follow-up, and in the degree to which this represented an improvement on the amount they were drinking on entry to the study. At the extremes were one counsellor whose patients ended up drinking on average 18 UK units more per week, while another registered an average nine unit reduction.
These differences were at least partly accounted for by how far the counsellor was able to actually deliver the intervention in a motivational style. Drinking reductions were greater the more the counsellor demonstrated acceptance Essentially unconditional positive regard as opposed to non-acceptance, disregard, or disapproval. of the patient, conducted the intervention in the intended spirit, The overall competence of the counsellor in using motivational interviewing consisting of the three inter-related characteristics of collaboration, evocation (drawing out the client's perspectives), and supporting the client's autonomy. made more comments consistent Advising with permission, affirming, emphasising the client's control over their own behaviour, asking open questions, reflecting back the client's statements, reframing issues, and offering support. versus inconsistent Advising without permission, confrontation, being directive, raising concerns without permission, and issuing warnings. with a motivational approach, avoided inconsistent comments, elaborated on the patient's comments rather than simply reflecting them back, and reflected back the patient's comments with or without elaboration rather than asking questions. Empathy levels narrowly missed featuring among these strong and statistically significant links. These same attributes tended to even out the relationship between the patient's expressed feelings of (in)ability to change and how much they did change their drinking over the 12 months. Highly skilled counsellors had good outcomes almost regardless of the patient's doubts. The less skilled were effective mainly with patients who already expressed high levels of ability to change.
While accepting the need for replication in a larger study, for the authors their results suggested that an optimal combination of motivational interviewing skills results in better drinking outcomes, regardless of whether the patient is confident (or expresses confidence) in their ability to cut back. The pattern of results across all the reports from the study implies that training should focus on developing an overall approach consistent with motivational interviewing (with a particular focus on avoiding inconsistent behaviour) rather than on the frequent use of particular 'micro' techniques. Since training was equalised in the study, it also seems important to select staff with a 'natural' ability to adhere to the spirit of motivational interviewing when counselling patients.
These comments are more fully explained and referenced in the associated background notes. This study is one of the few in substance misuse to deeply address how therapists relate to clients in ways which promote positive change. It seems the first to depth-analyse interactions during a brief intervention which (from the patient's point of view) unexpectedly addresses their drinking while they are seeking help for something else entirely. The implication is that in this situation, the impact of motivational interviewing with heavy drinkers depends on the ability of the counsellor to embody the spirit of the approach, not in minute or tick-box detail, but in broad-brush and consistent application. Given this spirit, as intended, patients in general respond not by defensively deflecting this uncalled-for advance, but by re-evaluating their drinking in ways which lead to a lasting reduction.
As intended by its creators, the findings show that true-to-type motivational interviewing can counter low motivation and doubts, elevating outcomes to near those of the most promising patients. While training doubtless played its part in developing this ability, still it left big differences between counsellors, who presumably varied in the degree to which they could implement what they learned. The more 'trainable' dimensions of the frequency of recommended types of comments were relatively uninfluential, the more nebulous 'spirit' dimensions more important. Despite expert training and supervision, the result was some therapists whose patients drank more than they did before, others whose patients drank less, a finding which turns the spotlight on staff recruitment. The implication is that without appropriate recruitment, much of the effort put in to training and supervision will be wasted.
The same message emerged from a study of motivational interviewing training which found that initial gains in skills had waned two months later. However, this was not the case for the addiction and mental health clinicians who, even before training, had been more proficient than the other trainees would be after training. Not only did these 'natural experts' start from a higher level, they went on to absorb and retain more of what they had learned.
How easy it is to find such people must be a concern. In the featured study all the counsellors were clinical psychologists educated to master degree level, trained by an experienced therapist and supervised throughout using actual client session recordings or observations. This exceptional combination of qualifications, training and ongoing support still resulted in just one of the therapists having a marked positive effect on drinking.
While these are important findings with echoes in other studies, inevitably they stand on a narrow and inadequate evidence base. Studies which probe deeply enough to make sense of what is going on in therapy require labour-intensive analyses, so tend to be limited to perhaps one site and a few therapists, by-products of studies designed to address the effectiveness not of therapists, but of therapies.
Particular caution is needed before assuming that the implications extend to substance misuse treatment. The dynamics in the emergency department are likely to be very different from those in substance misuse treatment clinics, whose patients have already acknowledged their problems and decided at least to give treatment a try. In this situation, the overwhelming influence is the strength of the patient's resolution. Therapists can still make a noticeable and sometimes substantial difference, but generally more in terms of whether clients want to extend the relationship by staying in treatment, than in whether they change their substance use.
Among several less serious concerns, the featured study's main weakness is the non-random allocation of patients to therapists, meaning varying caseloads might have influenced the therapists' performances. However, this does not seem to account for the findings. Confidence in these and in their generalisability is increased by findings from different contexts with similar implications.
Across a range of caseloads, one review of how motivational interviewing works has highlighted (as the featured study did) the importance of therapists avoiding behaviours inconsistent with a motivational approach. Most relevant however are other brief intervention studies of patients not seeking treatment. These confirm that in such circumstances, some therapists are much more able than others to realise the potential of a motivational approach. Avoiding directive and confrontational behaviour seems particularly important with people who when they attended their GP, emergency department, or college, were not expecting their substance use to be addressed at all, let alone in such terms. Even patients who, while not seeking treatment, have volunteered for a check-up of their drinking habits, have reacted badly to such approaches. As in the featured study, other studies have also found that embodying the overall spirit of the approach is related to good outcomes, while the sheer quantity of 'correct' micro-behaviours is not. In one study the least effective Their clients did not cut their drinking at all. of three therapists conducting motivational interventions for heavy drinking was also the one who most often used specific recommended techniques.
The dynamics of the therapist-patient encounter seem to differ in a treatment context. Like brief intervention studies, studies of patients actually seeking treatment for substance use problems have confirmed the importance of the overall spirit of the approach rather than micro measures of the frequency of correct therapist behaviours. However, they have been less clear about the damaging impact of behaviours inconsistent with a motivational approach. Within an overall supportive and accepting context, patients react well, or at least, not badly, to a degree of confrontation and caring concern, even if the patient's permission has not been sought. Motivational interviewing guidelines recommend seeking permission from the client before making such comments. With clients seeking help for a serious substance use disorder, there is more reason to show concern, be directive, and to warn about possible consequences. Patients who themselves are concerned and seeking direction might see the total absence of such comments from their therapists as withholding their true feelings, perhaps even as uncaring. For these patients the absence of a directive approach can be positively damaging, while those who like to see themselves as in control react badly to directive therapists.
Thanks for their comments on this entry in draft to Jacques Gaume, of the Alcohol Treatment Centre at Lausanne University Hospital. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 26 September 2009
Background notes Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
What process research tells us about brief intervention efficacy STUDY 2010
Investing in alcohol treatment: brief interventions FINDINGS REVIEW 2002
Brief interventions in dependent drinkers: a comparative prospective analysis in two hospitals STUDY 2011
Evidence-based therapy relationships: research conclusions and clinical practices REVIEW 2011
Replication and sustainability of improved access and retention within the Network for the Improvement of Addiction Treatment.Hoffman K.A., Ford J.H., Choi D. et al.
Drug and Alcohol Dependence: 2008, 98, p. 63–69.
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Placing staff in the clients' shoes was the key tactic in this national US treatment improvement programme which more than halved waiting times and increased retention without limiting patient numbers.
Summary In a joint attempt to improve the quality of substance use treatment services, the US government and a major US philanthropic foundation co-funded the Network for the Improvement of Addiction Treatment. Treatment providers bid for funding from either source to help improve efficiency and access to and engagement in their services by:
• reducing the waiting time between the client's first treatment-seeking contact and the start of treatment;
• cutting the number of missed appointments ('no-shows');
• increasing the number of clients admitted to treatment; and
• increasing the proportion of treatment-starters retained for at least four treatment sessions.
Interventions were tailored to each service but developed using the same model. It entails identifying key problems and possible solutions by involving service users through focus groups, satisfaction ratings and advisory boards, and by 'walk-throughs' during which staff role-play a client and experience existing procedures from their point of view. Possible solutions to each problem are briefly piloted and evaluated, then rapidly revised and retested until effective strategies are identified or the change cycle is abandoned, a process driven through by a suitably skilled staff member with the authority to make the required changes. Apart from substantial For each site initially $100,000 a year for 18 months or three years, and in the replication study $100,000 over 18 months for the 13 of the 15 sites awarded a full grant. grants, each site was phoned weekly and visited quarterly by a 'coach' trained (usually not specifically in respect to alcohol and drug treatment) in process improvement, who helped the service learn and apply the rapid improvement cycle. Participating services could also learn from each other via the project's web site and met annually to share successes and failures, the intention being to build a self-sustaining improvement network. Centrally developed systems helped services monitor the impacts of the changes they piloted.
The featured report provides longer term data from 15 Six services did not provide sufficient data. Services which did contribute data consisted of seven non-residential services, four intensive non-residential services, and four residential services. of the 21 non-residential and residential services awarded grants in 2003, plus data from a further 14 Two of the awarded organisations did not provide sufficient data. Services which did contribute data consisted of 10 non-residential and four intensive non-residential units. of the non-residential services awarded grants in a second round of funding in 2005. An earlier report on the initial funding round had found significant improvements over the first 15 months. By the end, treatment started a week sooner (down from on average 19.6 days to 12.4) and another 11% (up from 62% to 73%) of clients who attended an initial treatment session went on to attend at least three The proportion attending at least four sessions also improved (from 54% to 60%) but not to a statistically significant degree. in total. An appendix to the main study did not reveal any obvious trends in the numbers of admissions. Concerns that early gains might not be sustained (there were slight reversions by the end of the 15 months) were addressed by collecting another 20 months of data. Documented in the featured report, the results showed that overall The non-intensive, non-residential services actually significantly improved further on nearly all measures. the services maintained improvements in waiting time and retention; there was no significant weakening, nor any further improvements.
Results were similar when the same procedures were tested on the new set of second-round non-residential services. Over the 18-month observation period, waiting times fell from on average nearly 31 days to 19, while at each yardstick (from the first treatment session to the second, third or fourth) another roughly 10% of clients were retained. By the end of the period, nearly 68% of clients attended at least four treatment sessions compared to 57% at the start. Also reported was a near halving in the proportion of appointments missed from 22% during the first three months to 13% in the last three, and a modest increase in admissions from 21 a month per service to just over 23.
Among the first round of services, strategies to reduce waiting times included on-demand scheduling and next-day admissions. Other admission improvements included simplification of intake and assessment processes, longer openong hours, elimination of redundant paperwork, cross-training, and enhanced telephone responsiveness. Among the changes used to enhance retention in care were reminder calls, changes in appointment times, motivational interviewing training, and introducing clients to their counsellors before the first treatment session.
Beyond these specifics, reports from the services and interviews with staff suggested that networking and annual meetings built strong and persisting collaborations between services in different regions, enabling services to replicate changes found successful elsewhere. Change processes initiated by the project fostered an overall customer service culture at the agencies, to which walk-throughs (when staff role-played clients) were a major contributor. How revealing these were became apparent during the funding application process. For some of the initial grants, this required services to conduct a walk-through of their admissions process, with staff taking on the role of a prospective client and a member of their family. The results were reported back to the funding agency. An analysis of 327 such reports revealed poor staff engagement with clients and impersonal interactions, shortcomings in equipment, administrative procedures (such as poor phone systems) and premises (which often lacked privacy), inconsistent or badly communicated information, burdensome and repetitive processes and paperwork (including lengthy intake interviews focused not on the client's needs but those of the agency), failure to provide for clients with complex lives and problems, and an inability to schedule intakes in a timely manner.
The authors concluded that the changes stimulated by the initial round of funding had become embedded in the services and sustained even after funding ended, while short-term findings from second-round services enhanced confidence in the replicability of the procedures and their ability to create improvements in treatment access and retention. However, there was substantial variation between services in the degree to which they were able to engineer improvements, variations which seemed attributable to the nature of the services rather than the nature of their clients.
Projects like the Network for the Improvement of Addiction Treatment which aim to change the culture of services should help overcome the limitations of change driven purely by targets or financial incentives, which encourage services to do only what is required to satisfy target-setters or funders, rather than whatever is required to improve the service for its users. Reassuringly, improvements in waiting times and retention were not gained by simply cutting down on admissions, though the aim to actually increase these was at best achieved only modestly, partly (the authors suspect) because it would not bring extra money to the services.
The value of networks of the kind established by the project seemed evident also in another US study, which found that by far the single factor most closely related to whether criminal justice and allied treatment services adopted research-based quality improvements, was the degree to which they networked and carried out joint activities, especially with other treatment programmes. Also related were training opportunities and management stress on quality. The implication was that the most fertile ground for quality-improving innovation in the drugs/crime sector is likely to be an active network of not very large service providers and criminal justice agencies with managements committed to quality improvements.
Unfortunately the featured study was unable to test whether improved access and engagement translated in to further improvements in the resolution of substance use problems. In general people in need of addiction treatment do better if they get it and if they participate more fully in that treatment, but the relationships are often loose. Studies often find that treatment participation and retention With the notable exception of retention in substitute prescribing programmes. are unrelated or only poorly related to post-treatment substance use. Initiatives which improve engagement may have no noticeable effect on outcomes.
Another major question mark over the project is (as the researchers acknowledged) the representativeness of the services which made it through the application process. They were a small minority Across both rounds 595 applications resulted in just 38 awards being made. even of the services which felt they were close enough to meeting the criteria to apply. Successful applicants were heavily pre-selected for their potential ability to implement and document service changes and their commitment to customer-focused improvements. Ten of the 23 initial awards and all those in the second round were made partly on the basis of the service's performance in actually implementing a key improvement procedure, a walk-through of their admissions process. Despite this sifting, there remained substantial variation between the selected services in the degree to which they were able to engineer improvements. The authors remarked that agencies already under stress, with inconsistent leaderships or unstable finances, often abandoned change efforts. Even with the project's support and funding, several were unable to adequately monitor access and retention, a prerequisite for data-driven improvements. Such difficulties even after thorough sifting raise considerable doubts over whether most services would be able to profit from a similar exercise. It may also be relevant that the project was a nationwide one, meaning that services were presumably rarely in the position of offering good ideas to local competitors. Improving financial health is it seems The project' web site at https://www.niatx.net is headed "Financial Strength in a changing World" and the campaign is described as one aiming to "Improve services, reduce costs, increase revenue". a major motivator for services to engage in the project's improvement process, but one which could also impede it due to competitive pressures.
These features may have atypically enhanced the project's impact. Set against this is the probability that pre-study sifting had an opposing effect, limiting the scope for improvements because selected services were already doing relatively well. The application process was designed to identify services receptive to innovation and with the infrastructure, organisation and stability to see it through. Even without help of the kind provided by the project, in England such services were associated with greater participation in treatment by their clients.
The baseline from which the study sought to measure improvements would have been raised further among services required to conduct a walk-through exercise as part of the application process. Focused on the admissions process, this almost certainly substantially reduced waiting times even before the study started monitoring the services' performance. These services started the study with a waiting time of on average just eight days and then made no further improvements. Starting from a lower baseline, services which had not been through this exercise more than halved waiting time from 23 days to 10. The figures seem to demonstrate the power of explicitly and systematically addressing admission procedures via a walk-through, even without the funding, networking and technical assistance available later in the project. Including the pre-study walk-through, it seems a fair assumption the project as a whole actually led to something nearer a 60% reduction in waiting times rather than the 37% it was able to document.
Related to this is the degree to which even these heavily selected projects would have been able to implement all the changes targeted by the project without its substantial financial and technical support. A subsequent phase of the project will test whether services do as well with only modest or no financial awards and different levels of technical and networking assistance.
Services which want to profit from the project's experiences will find a practical guide to the process improvement procedures tested in the study at the project's web site, along with ideas for solutions to common problems.
Thanks for their comments on this entry in draft to Dennis McCarty of the Oregon Health & Science University. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 02 September 2009
Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
The Drug Treatment Outcomes Research Study (DTORS): final outcomes report STUDY 2009
Alcohol-use disorders: Diagnosis, assessment and management of harmful drinking and alcohol dependence REVIEW 2011
Abused women gain more from holistic counselling STUDY 2005
The grand design: lessons from DATOS STUDY 2002
Relating counselor attributes to client engagement in England STUDY 2009
Matching resources to needs is key to achieving 'wrap-around' care objectives STUDY 2006
Methadone programme loosens up, increases capacity, patients do just as well STUDY 2004
Wet day centres in Britain SERIES OF ARTICLES 2005
Improving public addiction treatment through performance contracting: the Delaware experiment STUDY 2008
Wet day centres in Britain part 1: planning and setting up IN PRACTICE 2005
Overdose training and take-home naloxone for opiate users: prospective cohort study of impact on knowledge and attitudes and subsequent management of overdoses.Strang J., Manning V., Mayet S. et al.
Addiction: 2008, 103(10), p. 1648–1657.
Request reprint using your default e-mail program or write to Dr Strang at j.strang@iop.kcl.ac.uk
As concern mounts about Britain's failure to reverse the recent growth in drug-related deaths, the first large-scale UK follow-up study has assessed the impact of training in overdose recognition and management featuring the opiate blocking drug naloxone.
Summary Most opiate overdoses happen in the presence of a witness and often in the user's own home. Prompt response can be crucial to avoid death due to respiratory depression. Equipping people likely to be with the user to take effective action while awaiting the arrival of emergency services could save many lives. In addition to training in recognising overdose and in resuscitation methods, enabling drug users and their associates to administer the opiate antagonist naloxone can greatly improve the immediate response to overdose. The medication rapidly reverses the effects of opiate-type drugs, including respiratory depression. In the UK naloxone programmes were hampered by the prescription-only status of the medication, but in 2005 the law was amended to permit emergency administration by any member of the public. This is the first large-scale UK follow-up study to assess the impact (including the degree to which the training was later put in to effect) of training in overdose recognition and management featuring naloxone provision.
Staff in 20 drug services across England were trained, before themselves recruiting and training 239 opiate-using patients attending their services and providing them with a take-home supply of naloxone. Nearly two thirds of the patients were attending as outpatients. A questionnaire completed by trainees before and immediately after the training revealed improvements in identification of factors The proportion who correctly recognised all seven risks listed increased from 32% to 64% and the average number of risks identified rose significantly from five to six. which heighten the risk of overdose, awareness of the signs of overdose, The number of signs correctly identified increased significantly from an average of 5.6 out of 8 to 6.7, with previously poor scores improving considerably. However, there was little improvement in awareness that some of the listed 'signs ' were false. what constitutes an appropriate response The average number of actions correctly identified increased significantly from 5.9 out of 11 to 8.6. Before training, only 3% correctly identified all the right and wrong responses; afterwards, 25% did so. to these signs, awareness of the role of naloxone Improvements were modest, perhaps because even before training 77% knew naloxone reversed opiate overdoses and more than 80% knew that it did not reverse overdoses due to cocaine, amphetamines, alcohol and/or benzodiazepines. After training, these proportions rose to 96% and between 95% and 98%. and willingness The proportion who would themselves administer naloxone in an overdose rose from 77% to 99%. to administer the drug, their confidence The proportion confident or very confident about administering naloxone rose from 68% to 95%. in their ability to do so, knowledge of how to administer it, The proportion who knew the recommended way to administer the drug via intramuscular injection rose from 65% to 99%. of how long The proportion who gave approximately correct responses (up to 4 hours) rose from 36% to 93%. naloxone remains active, and awareness that they would still need to call an ambulance. Important because of the concern that having naloxone available might lead some to consider an ambulance unnecessary. The proportion who recognised the need to call an ambulance rose significantly from 79% to 99%.
Typically just under three months later, 78% of the trainees were interviewed (mainly by their key workers) and completed a further knowledge test. Interview and test revealed retained or improved knowledge of the signs of overdose and appropriate responses, and almost universal confidence that they would be willing and able to manage an overdose situation and do what was needed to save life. Spreading the impact, 28% of the trainees had subsequently trained someone else who could administer naloxone to them in the event of an overdose. Only 9% had failed to receive the planned supply of naloxone, in each case because they had left treatment prematurely or were still in rehabilitation; 79% still had their supply. Ten out of the 172 who responded to this question had used naloxone to reverse an overdose suffered by another person, mostly encountering little difficulty during the administration and no unexpected adverse effects. Though there was no serious aggression, four recipients had been angry or complained that the medication had spoilt their opiate experience or precipitated withdrawal. These events were among the 18 overdoses either witnessed or experienced by the trainees. When naloxone was not administered, one of the overdoses ended in a death; none did so when it was used.
The authors concluded that training in overdose management can successfully be given to drug users in treatment, resulting in substantially improved knowledge and competence. Beyond the high numbers of drug users trained directly, knowledge was spread to their families and peers. Though implementation was relatively low, it was detectable even within the study's three-month follow-up period. No unexpected adverse reactions were identified. Benefits were primarily to other people to whom trainees administered their naloxone. Having demonstrated its potential, the authors recommended further studies to examine whether wider overdose management training and naloxone provision could reduce opiate overdose fatalities.
A later report from the study followed up a subsample of 70 trainees (nearly all from Birmingham) for six months after the training. The 46 recontacted at this time and three months earlier had retained much of what they had been taught. They had witnessed 16 overdoses since the training and generally responded appropriately, but none were known to have administered naloxone. For many this was because they were reluctant to carry the pre-loaded syringe around with them, partly due to fear of being identified as a drug user, and partly because some had completed treatment intended to divorce them from drug use and by extension, drug using associates, including those who might overdose.
This study comes at a time of heightened concern about the UK's failure to reverse the recent growth in drug-related deaths. In England and Wales drug poisoning deaths totalled 2928 in 2008, of which 1738 were linked to drug misuse and 897 to heroin/morphine, As heroin breaks down in the body into morphine, the latter may be detected at post mortem and recorded on the death certificate. Therefore the cited report gives a combined figure for deaths involving heroin or morphine. in all cases the highest numbers since 2001. In the same year in Scotland, drug-related deaths reached a record of 574, continuing the steady increase over the past decade. Of these, 336 involved heroin/morphine, As heroin breaks down in the body into morphine, the latter may be detected at post mortem and recorded on the death certificate. Therefore the cited report gives a combined figure for deaths involving heroin or morphine. a new record Instructions to pathologists were changed for 2008, asking them to report any drug found in the body rather than just those they thought had been involved in the death. This increased the figures for some drugs but the cited report does not include heroin/morphine among those particularly affected. after previous record figures in 2006 and again in 2007. Over the period 1996–2000, heroin/morphine deaths averaged 128 a year; in 2003–2007 they averaged 229. The long-term increase in deaths related to drug misuse in the UK contrasts with falls in some other comparable European nations.
Medications which block and (if opiates have been taken) reverse the effects of opiate-type drugs have an obvious role in preventing overdose becoming fatal. Of the opiate-blocking drugs, its rapid action and safety makes injectable naloxone the medication of choice. Recognising this, in 2005 the law changed in the UK to permit emergency administration of naloxone not just to the person for whom it was prescribed, but also to other people. See background notes for more on safety and effectiveness and the advantages of intramuscular administration.
Naloxone's lifesaving potential is now being realised in Britain, but still on a pilot basis rather than as a mass campaign. In 2002 the English drug strategy made a national policy commitment to reducing drug-related deaths, but the 2004 reduction target was missed and since then deaths have increased. The featured study was funded by England's National Treatment Agency for Substance Misuse, which in June 2009 announced that 16 sites in England will pilot overdose training involving naloxone for about 950 family members and carers of drug users. A study published in 2008 had established the need for and potential acceptability of such an initiative. It found that 31 of 147 carers of drug users attending local support groups who responded to the study's survey had witnessed an overdose, only about a quarter had received advice on overdose management, but nearly 9 in 10 would welcome such advice, including on naloxone administration.
Reducing drug-related deaths has a high policy profile in Scotland, where per head of population deaths are far common than in the rest of the UK. There a national forum is tracking progress on its recommendations for reducing deaths, including naloxone training and provision. Following successful pilots, Glasgow and Lanarkshire are extending their naloxone programmes and other areas are considering similar initiatives.
Though the literature on naloxone provision by the public is new and still scarce, it is unanimous in its support, while also highlighting issues which need to be addressed in training programmes. In 2005 a review found only "anecdotal, although promising" evidence. Published in 2008, a review of literature on overdose prevention conducted for the Scottish government found in respect of naloxone "a consensus among the reviewed papers that there is a potential to prevent many opiate overdose deaths" and recommended its inclusion among the interventions offered to people who might witness an overdose. See background notes for major US and European studies suggesting that many hundreds of lives have been saved.
While naloxone can certainly be a contributor to reducing deaths, it is clearly not the whole solution. First is the fact that fatal overdoses in particular tend to happen when the person is alone and/or out on the street. One concern is that naloxone might displace rather than supplement routine resuscitation techniques which remain important in the period before naloxone takes effect. Studies suggest too that despite training, having naloxone available might offer a further excuse for drug users who witness an overdose to avoid contact with the authorities by calling for an ambulance. There is also the prospect that people revived by naloxone might be unhappy about having an expensive heroin high reversed and/or withdrawal precipitated, deterring its use. Though such concerns cannot be dismissed, most can be addressed in volunteer recruitment and training programmes, and they do not threaten the potential for such programmes to on balance save very many lives. See background notes for details and relevant studies.
For Britain in particular the featured study advances knowledge considerably, demonstrating the feasibility of training drug users who are in treatment and its effectiveness in equipping them to recognise an overdose and act effectively to save lives. There is however an inherent contradiction between treatment which the patient hopes and expects to divorce them from drug use and drug using circles, and being provided with training and medication of direct use only if they stay sufficiently involved in such circles to witness an overdose.
This contradiction was apparent to many in the subsample from the featured study referred to above, and also to homeless drug users in England interviewed about using naloxone, making some reluctant to be equipped with the medication. It may be one reason why in the featured study, though nearly all the followed-up sample were in substitute prescribing treatment programmes, 90% continued to use heroin; some patients determined to move fully away from drugs may have refused or not been asked to join the study. To maximise coverage and achieve the greatest public health gains, naloxone programmes will (as they are) have to move beyond treatment populations to families and carers and out-of-treatment heroin users. From their pre-training responses, it seems possible too that the sample were unusually knowledgeable about and committed to overdose prevention. Such good results may not be maintained if overdose prevention training involving naloxone is implemented more widely.
Further information is available from the Chicago Recovery Alliance which has produced a freely available training video. In 2008 staff from one of the English NHS trusts which will (see above) be piloting naloxone training for families and carers produced a UK-focused practical guide to naloxone prescribing, training and use. A Scottish web site is being established to offer advice to professionals on take-home naloxone.
Thanks for their comments on this entry in draft to John Strang of the National Addiction Centre in London, UK. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 10 May 2010
Background notes Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence DOCUMENT 2009
An evaluation of a heroin overdose prevention and education campaign STUDY 2010
Overdosing on opiates part II: prevention FINDINGS REVIEW 2001
Naltrexone implants after in-patient treatment for opioid dependence: randomised controlled trial STUDY 2009
Heroin maintenance for chronic heroin-dependent individuals REVIEW 2010
The Patel report: Reducing drug-related crime and rehabilitating offenders DOCUMENT 2010
