EFFECTIVENESS BANK BULLETIN 31 December 2010
EFFECTIVENESS BANK BULLETIN 31 December 2010The 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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Supervising consumption cut UK methadone death rate ...
Extended methadone prescribing needed to save lives ...
Clues to what to say and not to say in motivational interviewing sessions ...
Impact of supervision of methadone consumption on deaths related to methadone overdose (1993-2008): analyses using OD4 index in England and Scotland.Strang J., Hall W., Hickman M. et al.
BMJ: 2010, 341, c4851
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Introduced in Scotland and England in the mid-late 1990s to prevent overdose, did supervised consumption of methadone really make methadone maintenance safer? After accounting for increased prescribing, this analysis concludes that it did curb methadone-related deaths.
Summary Concern over overdose deaths in which methadone was implicated led in the mid-late 1990s to tighter controls on methadone maintenance in both Scotland and England. These were intended primarily to prevent patients diverting their supplies to the illicit market, risking the lives of non-patients, but also to protect patients themselves by ensuring they took their medication, could not 'hoard' supplies, and by greater supervision over the relatively risky initial weeks of prescribing. Instead of several doses being dispensed at once, clinics more often arranged for only one dose a day to be dispensed, and instead of patients taking these away to consume at home, doses were more often consumed at the clinic or (more usually) at the pharmacy where staff could supervise the process. This study aimed to assess whether these changes really did prevent methadone overdose deaths. Its innovation was to account for the tendency for deaths to rise simply because more methadone was being prescribed to more patients by calculating an index of the number of deaths per million doses. In other words, it was interested in whether on average each dose of methadone was less likely to result in a death after controls were tightened.
Separately for Scotland and England, over the period from 1993 to 2008 the study obtained coroners' records of the numbers of drug-related deaths in which methadone was implicated. Over the same period, records were obtained of the quantity of methadone Incidentally these confirmed that over the 16-year study period methadone prescribing expanded dramatically, in Scotland, from fewer than 0.1 million doses per million of the population in the early 1990s to 1.8 million by 2008. In England the corresponding figures were about 0.1 million in 1993 rising to just over 0.5 million by 2008. prescribed for the treatment of substance dependence by the NHS in the two countries. From this could be estimated the number of doses prescribed on the assumption In fact, average doses in the UK were slightly lower: for example, 47mg in 1995 and 56mg in 2005. that each dose averaged 60mg, the minimum recommended for maintenance prescribing. The next step was to combine deaths and doses to calculate for each year the number of deaths per million doses. This was done separately for deaths in respect of which methadone was the only drug recorded by the coroner, and those in which it was one of several.
The key issue was whether these indices of deaths per million doses dipped after controls were tightened. If they did, this would at least be consistent with the argument that, as intended, daily dispensing and especially The authors note that the "increase in daily dispensing was modest by comparison with the very substantial expansion of supervised methadone consumption in both countries". supervised consumption saved lives. In both countries this was the case; the index dipped substantially over the period when controls were being tightened and then remained at a historically low level.
Supervised consumption began in Scotland in 1992. It became the norm in Glasgow, the major conurbation, by 1995, and nationally by the year 2000. Before widespread adoption of the practice, each million doses of methadone was associated with about 19 methadone-only deaths a year. By the time it had become the national norm in 2000, the death rate had fallen to about 2 per million doses and then remained in low single figures for the rest of the study period. A similar though less pronounced trend was seen with methadone-plus-other-drugs deaths chart.
England introduced supervised consumption in 1996. In 1999 national guidance recommended it during the first months of treatment, and it spread slowly to account for 36% of all pharmacy dispensing by 2005. Before the issuing of national guidance, each million doses was associated with over 25 methadone-only deaths a year. This index then fell steadily to plateau at between 5 and 7 per million from 2003 until the end of the study period. As in Scotland, a similar trend was seen with methadone-plus-other-drugs deaths chart.
In both countries, when the 16 years of the study were split in to four-year blocks, all but two of the changes in the methadone-only index and all those in the methadone-plus-other-drugs index were statistically significant. The net result of safer per dose dispensing was that though in both countries the amount of methadone in circulation rose steadily and substantially, associated deaths did not. In Scotland they peaked in 1996–1997 then fell; in England, the peaks were a year later, after which the number of deaths fell for six years, rising again later but still not to peak levels.
Given the coincidence in death trends and policy changes, and the absence of any convincing alternative explanations, the authors cautiously accepted the inference that the decline in the per-dose rate of deaths due to methadone overdose was the result of the spread of supervised consumption, and that this was the main reason for a remarkable improvement in the safety of methadone prescribing, particularly over the period from 1995 to 2004.
The key to this study is its attempt to account for the 'natural' inflation in methadone-related deaths due to increased prescribing. Its conclusion that per dose methadone prescribing has become safer seems (as the authors suggest) a testament to the impact of the major anti-diversion measure – supervising the consumption of methadone to ensure that it does not leak in to the illicit market. To show that the most serious 'side effect' of a medical treatment has been controlled is important to its clinical justification, but from society's point of view, this is only part of the story. The more pertinent issue is not whether each dose of methadone has become safer, but whether each opiate user in or out of treatment has become more likely to survive. This is not an inevitable consequence of the anti-diversion measures highlighted by the study; in some ways, supervised consumption and other anti-diversion measures might save lives overall, but in other ways, they might have the reverse impact. Summary below. For details see these fully referenced notes.
On the plus side is the fact that most forms of diversion undermine treatment because the patient is not taking their medication as intended in their care plan. Some forms also threaten patient welfare through the injection of unsuitable preparations such as oral methadone with potentially contaminated injecting equipment, by creating a breach in the medication 'shield' which helps block a return to illegal opioid use, and through overdoses. Diversion also risks the lives of other people who acquire the medication, particularly those not as tolerant to opioids as the patient. Especially when illicitly manufactured supplies are scarce, diverted medications can fuel the spread of dependent opioid use. In a climate of antipathy to agonist maintenance, the consequences of poorly controlled diversion can threaten a particular service or the modality as a whole; effective anti-diversion measures may be essential simply to keep the service running so patients can benefit from its life-saving potential.
On the minus side, too restrictive a regimen can reduce the extent to which opiate addicts access the treatment, costing lives which might otherwise have been saved. Even when controls are relatively lax, making maintenance treatment widely available can save more lives than it costs. Patients generally dislike supervised consumption and the need for frequent pharmacy or clinic visits. As a result, some will be deterred from entering treatment or leave prematurely. Anti-diversion controls are cumbersome and costly, using up resources which could have been used to extend the treatment to more patients. Diverted medications are often taken by people already dependent on opioids who would otherwise be using illicitly produced drugs. Many take this medication for purposes similar to those promoted by treatment services – to maintain stability, prevent or manage withdrawal, and reduce use of illegal substances. These consumers risk death due to overdose and other causes, but perhaps less so than if they had used only illicit products. Successful anti-diversion measures also rob them of the wherewithal to self-manage their dependence. Patients who hoard doses or inject non-injectable preparations are arguably better off retained in imperfect treatment than deterred from treatment to avoid diversion. Where illicitly manufactured supplies are plentiful, a small amount of leakage from treatment services will have little impact on the extent of opioid addiction. Given these conditions, supervised consumption might reduce methadone-related deaths, but only at the expense of increasing deaths due to illicit opiates.
The inference that supervised consumption actually caused per dose death rates to fall rests on several assumptions which somewhat reduce confidence in its validity without fatally undermining it. Most serious is the implicit assumption that the vulnerability of the addict population, and in particular the methadone caseload, remained unchanged over the 16 years analysed by the study. Yet the early years of this period saw a considerable expansion in injecting drug use in England, and across Britain the methadone caseload expanded dramatically. The study notes that "Rates of prescribing increased dramatically over the study period (1993-2008) in both countries. In Scotland, it increased from fewer than 0.1 million defined daily doses per million population in the early 1990s to 1.8 million by 2008. In England, methadone prescribing increased from approximately 0.1 million defined daily doses per million population in 1993 to just over 0.5 million by 2008." It seems possible that this expansion was accompanied by a trend for the average patient to become less atypical, less disturbed and damaged, and to retain more of the supports in life which aid survival. If so, this trend to the 'normalisation' of opiate use across a less risk-prone population could account for part of the improved per-dose safety of methadone prescribing.
Other minor concerns include the fact that the average dose of methadone was higher The authors say: "We used the World Health Organization's definition of defined daily dose as 'the assumed average maintenance dose per day for a drug used for its main indication in adults.' This provided an estimate of consumption in a fixed unit of measurement that is independent of price and formulation and so enabled assessment of trends in methadone use. We used a methadone daily dose of 60mg as the defined daily dose because this was the lower point of the recommended dose range and was close to the average dose prescribed in the UK over the period of study – namely, 47.3mg in 1995 and 56.3mg in 2005." in the later years of the study period; the assumption of a fixed dose throughout would have slightly lowered the per dose death rate during those years relative to the earlier years. Also the fuzzy timeline of the spread of supervised consumption complicates the attempt to attribute changes in the per dose death rate to changes in the extent of the practice.
Last revised 06 January 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
Preventing unauthorised use of medications prescribed for the treatment of opiate addiction NOTES 2010
Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence DOCUMENT 2009
Low threshold methadone extends life expectancy in Barcelona STUDY 2006
Opiate antagonist treatment risks overdose STUDY 2004
Naltrexone implants compared to methadone: outcomes six months after prison release STUDY 2010
The Drug Treatment Outcomes Research Study (DTORS): final outcomes report STUDY 2009
The National Drug Related Deaths Database (Scotland) report 2009 STUDY 2010
Risk of death during and after opiate substitution treatment in primary care: prospective observational study in UK.Cornish R., Macleod J., Strang J. et al.
British Medical Journal: 2010, 341:c5475.
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This British study concluded that it takes extended opiate substitute prescribing to realise the treatment's life-saving potential. The implication is that the current push to get people off methadone sooner could cost lives.
Summary This study sought to quantify the degree to which prescribing opiate substitutes has extended the lives of opiate-dependent primary care patients in Britain, whether deaths were more common at different stages of the treatment process, on different opiate substitutes, or among certain types of patients, and to probe whether longer treatment was more effective.
It drew on a large database The General Practice Research Database (www.gprd.com). of records of about 3.5 million patients attending over 460 UK general practices, affording a reasonably representative sample of primary care patients. With minor exceptions, Patients were excluded if they were aged 60 or over when first prescribed buprenorphine or methadone, were prescribed injectable drugs, opiates specifically for pain, buprenorphine patches, or where there was insufficient data. the researchers analysed records of all patients with a diagnosis of substance misuse who had been prescribed methadone or buprenorphine between 1990 and 2005 inclusive, tracking their fate through prescription records until the end of this period or until they left the practice. Patients who left treatment were tracked until a year after the expiry of their last prescription. The sample numbered 5577 patients largely aged in their 20s and 30s, of whom 7 in 10 were men. 88% had been prescribed methadone with or without other substitute medications (including for many dihydrocodeine) and 25% buprenorphine. Typically, during the 16 years analysed by the study patients had been prescribed opiate substitutes once or twice Treatment episodes were assumed separate if there was over 28 days between them. Restricting the analysis to the last treatment episode for each patient (where the date of last treatment was clear) gave similar results to those based on this assumption. for just over two months each time. Some had however been in treatment much longer, extending the average episode to nearly eight months. On buprenorphine durations averaged just under six months, over two months less than on methadone. A quarter of treatment episodes included at least one daily dose at or above the recommended maintenance thresholds of 60mg methadone, 12mg buprenorphine, or 600mg dihydrocodeine.
In all 178 patients died while being tracked by the study. Of these, 62 were still in treatment, defined as up to the expiry of the last prescription Breaks of 28 days or less were not considered to represent a real end of one treatment episode and start of another. It was considered unlikely that a patient would genuinely stop and restart treatment in general practice within a four week period. they received during that treatment episode. Death rates were standardised as equivalent to the number of deaths which at the observed rates would have been seen during a year among 100 patients ('per 100 person years'). To level the playing field, they were then adjusted for any differences between the age or sex breakdowns of the patients, the dates they were in or out of treatment, and the degree to which the number of non-substitute medications they were prescribed indicated that they suffered from other complaints – a rudimentary 'comorbidity' index. After these adjustments, the death rate while out of treatment was over twice as high (229%) as while in treatment. Compared to the general population of the same sex and age range, while in treatment patients were about five times more likely to die, but while out of treatment, nearly 11 times more likely.
While death rates were much lower in than out of treatment, the relative gains varied substantially across a treatment episode and its aftermath chart. Safest of all was being in treatment after the first four weeks, when patients have had time to stabilise their lives and their dose of substitute medication. Compared to this period, most risky of all was
the four weeks
The study assessed the first and second two weeks after treatment during which death rates were similar. Other specific post-treatment periods were not assessed.
after leaving treatment, when the death rate was 8–9 times higher. Beyond these four weeks, being out of treatment was much less risky, but still nearly twice as risky as the 'stabilised' treatment period. The death rate was also elevated during the first four weeks of treatment, when doctors and patients may have been feeling their way towards a safe but effective dose, and some patients may not yet have adjusted to life without heroin. Compared to later in treatment, the death rate during this induction period was 2–3 times higher. Fortunately its brevity meant this elevation was overshadowed by later treatment, so that overall being in treatment was safer than not being treatment.
The analysis of whether the duration of treatment affected risk attributed deaths in the four weeks after treatment to the treatment period. This in-treatment death rate was then compared to the rate which would have been found without treatment, assumed to be the rate from four weeks after leaving treatment. On this assumption, around nine months was the 'break even' point. Shorter treatment durations were associated with similar or progressively worse death rates than without treatment and a less than 50-50 chance that lives were saved. Longer durations were associated with lower death rates than without treatment, and at least a 50-50 chance that treatment saved lives, rising to a better than 8 in 10 chance after around a year and to virtual certainty About a 95% chance. after another four months, a level sustained at least up to nearly two years of treatment.
Also of interest was what death rates were not significantly related to. Given its safer pharmacological profile, surprisingly deaths were not significantly less frequent on buprenorphine than on methadone, even during the relatively risky induction period when buprenorphine's advantages should have been most evident. Overall death rates were lower after 1990–1994, but then did not improve over the next 12 years. Whether the treatment episode featured at least one dose at or above recommended levels 60mg, 12mg, and 600mg respectively for methadone, buprenorphine, and dihydrocodeine. made no substantial difference to overall death rates. One in ten methadone treatments but nearly half on buprenorphine ended with a presumed attempt to ease treatment exit by gradually reducing doses to very low levels, For methadone 10mg or less and buprenorphine 4mg or less. but this made no significant difference to the excess mortality in the four weeks after leaving treatment.
Compared to the general population, opiate users in this study had a substantially higher risk of death. The overall risk of death during opiate substitution treatment was lower than the risk of death out of treatment and this net benefit increased with the duration of treatment. However, relative to their remaining time in treatment, in the first month patients were at two to three times higher risk of death; in the month after leaving treatment, the risk was eight to nine times higher. There was no strong evidence that these findings differed whether methadone or buprenorphine was prescribed, whether doses at least matched recommended thresholds, or whether treatment exit seems to have been planned for by tapering doses.
Informed speculations can be made about reasons for the findings. Respiratory depression is the main cause of opiate overdose deaths, and this risk is heightened when the body's 'tolerance' to opiates – the degree to which it has become used to high doses – has faded due to reduced use. This is commonly the case after the end of treatment, making the patient vulnerable to overdose until tolerance has been re-established. This together with the fact that relapse is common after treatment could explain the high post-treatment death rate. Induction on to opiate substitution treatment, especially with methadone, also poses risks if the initial dose is too high or if patients continue to use non-prescribed opiates, and the change to methadone may be distressing. Closer supervision of induction alongside more effective post-treatment anti-relapse strategies should mitigate these risks. Otherwise the heightened risk of death at either end of treratment may negate any protective effect, unless treatment is prolonged. In the featured study, the average duration of treatment was 34 weeks, not necessarily associated with a net reduction in deaths.
At a time when the the national policy emphasis in the UK is on limiting the duration of substitute prescribing, this study suggests relatively extended treatment is required to realise the treatment's life-saving potential. This is partly because the short but risky induction and treatment exit periods are counter-balanced by the relatively safe period in between, when patients and dose have presumably been maximally stabilised. The longer this period of relative stability, the greater the net benefit. This finding applies to the treatment system as implemented up to 2006 by general practitioners. Findings might be different – and there might be less need for extended treatment to save lives – if induction were handled better, there were more robust support structures for patients leaving treatment, or the caseload mix changed to patients (perhaps intercepted earlier in their addiction careers) more compliant with treatment from the start and then able to securely overcome their dependence in a shorter time. But until 2006 and probably even now, it seems that British GPs were unable to prevent elevated risk at the two ends of methadone/buprenorphine prescribing programmes. Whether specialist hospital-based addiction treatment clinics were doing any better is not known.
The finding that being in an opiate substitute prescribing programme is associated with half the risk of death compared to not being in such a programme mirrors international findings which amalgamate to a similar ratio. But the featured study leaves open the question of just what the comparator was; some former patients might have moved to other treatments, others will not have been in treatment at all. Nor does it mean that dependent opiate users who did not opt for substitute prescribing would – had they changed this minds – have experienced the same benefits. What it does suggest is that opiate users considered suitable for substitute prescribing, and who seek or at least accept this treatment, are likely to live longer if this treatment is made available than if it is not, and that as recently provided in the UK, the longer they are in these programmes, the greater the life expectancy dividend. Even this conclusion might be challenged if the kind of people with (at least at that time of their lives) the kind of resources and supports which enable them to stick with treatment would in any event have been at lower risk than less promising patients. That may account for part of the apparent life-saving dividend, but from other studies (1 2 3 4) we know it is not the whole story; substitute prescribing does have a real life-saving impact.
The greatly elevated death rate in the immediate post-treatment period is a surprise though not unprecedented details below. It highlights the need for post-treatment monitoring and support, though this may be difficult to engineer for patients who simply drop out. This need is likely to become even greater given the emphasis in the current drug strategy on enabling drug users in treatment to progress to becoming drug free rather than remaining for many years on substitute medication.
Once again the study demonstrated that most opiate maintenance patients in Britain are prescribed doses below recommended levels. The finding that recommended doses did not save more lives must be seen in the context of the fact that just one instance was all it took to categorise a treatment episode as featuring recommended doses; patients consistently prescribed these doses may well have been better protected from overdose death. Given its safer pharmacological profile, another apparent surprise is that deaths were not significantly fewer on buprenorphine than on methadone, even during the induction period, when buprenorphine's safety advantages should have been most evident. However, the numbers were very small. For example, the no-difference finding during induction was based on just one buprenorphine death and seven on methadone. In Australia, of the 121 deaths during the first two weeks of opiate prescribing programmes, just one occurred on buprenorphine and the remainder on methadone, creating the expected statistically significant advantage However, the two drugs were associated with similar death rates overall, and in particular during the immediate post-treatment period. for buprenorphine.
While substitute prescribing generally extends the lives of its patients, the featured study confirms that this is not inevitably the case. Other reports have highlighted deaths among non-patients who have obtained methadone on the illicit market. Whether lives are on balance saved depends on achieving the right balance between access and control, flexibility and regulation. Get this right, and methadone and 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.
An elevated death rate during induction is expected and in line with prior research (for example, 1 2 3). The worrying surprise in the study was the greatly elevated death rate immediately after leaving treatment. Just these four weeks saw 41 of the 178 deaths – nearly a quarter – recorded by a study which on average The 5577 patients contributed 17,732 person years of follow-up. tracked patients for over three years. Fatal overdose seems the only conceivable primary cause of an elevation of this size over such a short period. Why this might have happened among patients who left treatment after dose reductions is clear: like patients exiting detoxification or who stop taking opiate-blocking medications, they would probably have lost most of their tolerance to opiate-type drugs, leaving them vulnerable to overdose if (as many would have done) they relapsed to illegal heroin use. But they were the minority. All we know of the remaining patients is that they died shortly after their last prescription for methadone or buprenorphine expired. Had they immediately relapsed to heroin, they should have retained the protection of the tolerance maintained by the prescribing. The assumption must be that some had to, or tried to, do without opiates for a short time, but within the next few days relapsed to illegal opiate use when their tolerance would have faded.
Though most clearly shown in the featured study, such an effect is not unknown in other countries. In Australia the death rate in the first two weeks after leaving (mainly) methadone treatment was about three times that during the stabilised treatment period, and might have been higher still except that the first six days after leaving were considered part of the treatment period. Overdoses were the main cause of death. An Italian study (previously analysed by Findings) found that methadone maintenance patients and former patients were at substantially lower From table 1 it is possible to calculate that the unadjusted death rate for methadone maintenance patients was 2.8 and for other patients 3.9. risk of fatal overdose than patients from other treatment modalities and that, if less so than during treatment, they remained at lower risk after leaving. But in this study too, the overdose death rate after leaving methadone maintenance was much higher than during treatment, probably Immediate post-treatment death rates are not detailed for different modalities, but all the methadone deaths were among treatment-drop-outs, and across all modalities the death rate was over three times higher in the first month after leaving treatment than in subsequent months. due to deaths shortly after patients had dropped out. Echoing the featured study, the researchers commented that in any modality, short treatments might fail to save lives because risks were concentrated at the start and immediately after the end, counterbalanced by the time in between. Contrary to these studies, no post-treatment rise in the death rate was recorded in Amsterdam, possibly because most opiate users there do not inject, so overdose death rates were low overall, and/or because the definition of when treatment ended excluded the first three days, and might also have left the patients with some prescribed methadone still to take.
Thanks for their comments on this entry in draft to the lead researcher Matthew Hickman of Bristol University and to Neil McKeganey of the University of Glasgow. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 14 December 2010
Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
The SUMMIT Trial: a field comparison of buprenorphine versus methadone maintenance treatment STUDY 2010
Opiate antagonist treatment risks overdose STUDY 2004
Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence DOCUMENT 2009
International review and UK guidance weigh merits of buprenorphine versus methadone maintenance REVIEW 2008
The Drug Treatment Outcomes Research Study (DTORS): final outcomes report STUDY 2009
Guidance for the use of substitute prescribing in the treatment of opioid dependence in primary care DOCUMENT 2011
Naltrexone implants compared to methadone: outcomes six months after prison release STUDY 2010
Methadone maintenance as low-cost lifesaver STUDY 2004
From in-session behaviors to drinking outcomes: a causal chain for motivational interviewing.Moyers T.B., Martina T., Houcka J.M. et al.
Journal of Consulting and Clinical Psychology: 2009, 77(6), p. 1113–1124.
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This substudy from the seminal US Project MATCH alcohol treatment trial found evidence for the appealingly simple and plausible conclusions that "What therapists reflect back, they will hear more of," and that promoting talk about change promotes change itself.
Summary This analysis micro-analysed audio tapes of initial motivational interviewing sessions in the US Project MATCH alcohol treatment trial. The aim was to identify whether 'change talk' – client statements explicitly indicating that they are ready, willing and/or able to curb their drinking – really did play the pivotal role in fostering actual change posited by motivational interviewing's originators, and whether how the therapist behaved could promote this kind of talk. If both links were found, the study would support the expected route from skilful motivational interviewing which subtly encourages clients to self-generate pro-change statements, through to the expression of these sentiments, and finally to the intended change in drinking. In the process, clues should emerge about how therapists can maximise the desired changes.
Therapist and client statements during the first of the intended four therapy sessions were categorised using a system developed to characterise exchanges between motivational interviewing therapists and clients. At the broadest level, therapist comments were classified as consistent Affirm, reflect, open questioning, emphasising control, seeking permission, and offering support. or inconsistent Such as advising without permission, confronting or directing the client, raising concern without permission, or delivering warnings. with the principles of motivational interviewing, or as not directly related to the therapy.
In all 118 tapes were analysed. The first step was to identify how clients responded to different kinds of remarks from the therapist. As expected, the more often therapists made comments in line with the principles of motivational interviewing, the more often their clients talked positively about curbing their drinking – the supposedly crucial change talk Identified by statements expressing commitment to change, desire, ability, reason, need, or taking steps to change, and other comments which favoured change. indicative of movement towards the desired changes in drinking. The reverse was also the case; the more therapists behaved in ways contraindicated by the therapy's tenets, the more often their clients made 'counter-change talk' comments indicative of clinging to pre-treatment drinking patterns. Muddying the waters slightly was the fact that motivationally consistent therapist comments were also associated with these negative client statements, though to a much lesser degree.
The next steps related An attempt was made to eliminate the possibility that a relationship between these therapist/client comments and drinking was not due to one causing the other but because, for example, clients who were more motivated before treatment were more likely to 'change talk' in the first therapy session and also later more likely to curb their drinking. Specifically, pre-treatment alcohol involvement, alcohol abstinence self-efficacy, and readiness for change were controlled for in the analysis. both therapist and client comments during therapy to the client's drinking. This was expressed as the number of drinks per week during the fifth week of treatment, and trends in weekly drinking since just before treatment started. During this time clients in the analysis would all have had an initial therapy session in week 1 – the one on which the analysis was based – and those who returned would also have had a session in week 2. As expected, the more often clients had expressed change talk, the less they later drank and the more they had reduced their drinking. Similar Except that the simple linear downward trend in drinking was not related to therapist comments but the curved element of the downward trend was significantly related. links with drinking were found in respect of the frequency with which therapists had made comments in line with the principles of motivational interviewing. In both cases the associations were minor but statistically significant.
Finally, these links were integrated in to single model of how the therapy had curbed drinking. As expected, one (but not all) of the ways of testing this suggested that the therapists' adherence to the principles of motivational interviewing curbed later drinking partly by promoting client change-talk.
So far the analyses have concerned only global frequency counts of client and therapist comments. Another analysis dug deeper to expose Among other sequences. which therapist comments were responded to with change talk or its opposite. The aim was discover clues to how therapists might generate higher levels of change talk and thereby As suggested by the previous analyses. greater reductions in drinking. Particular attention was paid to reflective listening – times when the therapist signified their attention and understanding by selectively echoing back to the client (with or without elaboration) some of what they had said. A potentially important extra dimension was whether these comments reflected back (and hopefully reinforced) the client's change talk, or whether they reflected back the opposite – counter-change talk indicative of unabated drinking. Also separated out in the analysis were questions asked by the therapist, divided in to those probing what for the client may be the positive aspects Such as any positive consequences of continuing to drink heavily, negative consequences of curbing drinking, or positive feelings toward heavy drinking. of their heavy drinking, versus those probing negative aspects. Such as negative consequences of continuing to drink heavily, positive consequences of curbing drinking, or client dislikes regarding their heavy drinking.
What the analysts looked for was pairs of sequential client-therapist comments which occurred significantly more often than expected by chance; in these cases, the possible Only 'possible' because for example both may have been the result of prior interactions or of client characteristics like compliance with therapy or motivation to reduce drinking. implication is that the first element in the sequence helped generate the second. What they found was that when therapists reflected the client's change talk back to them, the next statement was very likely to be further change talk. Change talk was also a likely response when therapists asked about the negative aspects of the client's drinking. Asking about the positive aspects of the client's drinking also appeared to stimulate change talk to minor degree, but was much more likely to generate counter-change talk. Riskier still it would seem is reflecting back to the client their own counter-change talk. This appeared to suppress change talk and stimulate further counter-change talk. Other therapist comments in line with the principles of motivational interviewing did not significantly stimulate change talk but did significantly suppress counter-change talk. Change talk was less likely to occur when therapists behaved in ways incompatible with the motivational interviewing principles.
The findings support the theory that client change talk mobilised by therapists during motivational interviewing would promote reduced drinking, and that change talk in general is important, not just (as found by some other studies) the kind which specifically expresses commitment to change. The implication is that in similar therapeutic encounters, therapists should work to elicit and reinforce all types of client statements in support of change, and do so by attending carefully to client language about change and responding with the tactics recommended by motivational interviewing theorists. Among these are asking questions about the negatives of the client's drinking and reflecting back change talk when it occurs. The study also offers clues to what therapists should not do if they wish to hear change talk. They should avoid confrontation, giving advice, raising concerns without permission, or telling clients what to do – yet these are common tactics in substance abuse treatment. Though only loosely related to later drinking, the amount of change talk stimulated in a motivational interviewing session is probably a useful indicator of how well therapy is going.
Among the tactics recommended by motivational interviewing theorists, reflective listening emerges in this study as the most potent in eliciting change talk, especially when it reflects prior change talk. Reflecting back counter-change talk is a risky tactic because on balance it stimulates more of the same. In sum, what therapists reflect back, they will hear more of. The amalgam of other motivational tactics tested by the study seemed less influential, though sub-tactics within this mix may have been more potent. Often change talk was embedded For example: "I don't need to change my drinking. Well, I mean, I need to cut down for sure, but no way am I a problem drinker like they say I am." in counter-change talk. The findings suggest that therapists should learn to selectively reinforce the change talk elements while avoiding the temptation to reflect back, attempt to suppress or challenge the less promising elements, which are best seen as the expected background 'noise' for more favourable comments.
Reflective listening is emerging as possibly the key active ingredient in psychosocial interventions based on motivational interviewing. In this respect the findings of this study broadly parallel those of a study of a very different sample of heavy drinkers – young male Swiss army conscripts generally devoid of severe drink problems who were not seeking treatment, but were identified through screening and mandated to attend a single brief motivational session to reduce alcohol-related risks. In both studies, the reflective listening which was related to change talk occurred in the early stages of the intervention; in the Swiss study there was just one brief session, and the featured study focused on the first session of four. It is at these stages that motivational interviewing's originators say this core but challenging skill should form a substantial proportion of counsellor responses. The featured study adds the refinement that not just reflective listening itself, but what is reflected, determines the frequency of change talk and, by extension, the degree to which therapy achieves the intended behaviour changes. Reflecting change talk generates further change talk in a virtual cycle, while reflecting back its opposite is usually counterproductive. There is some evidence that these mechanisms are also active in therapy sessions not based on motivational interviewing.
As the authors point out, the appealingly simple and plausible conclusions that "What therapists reflect back, they will hear more of", and that promoting talk about change promotes change itself, are suggested but not proven by the study. Possibly of least concern is the small size of some of the links in the chains of associations which led to these conclusions. This is only to be expected when the focus is on one therapy session among the multiple influences on patients, including for some The analysed tapes came from both the outpatient and the aftercare arms of Project MATCH. In the latter arm patients entered the MATCH therapies after at least a week of inpatient or intensive day-hospital treatment. immediately prior intensive treatment and for many a second therapy session. Also the extensive training and monitoring of MATCH therapists reduced variation in their implementations of motivational interviewing which might have made it clearer that these variations affected the degree of change talk and of later drinking.
Of greater concern is the possibility that the associations did not reflect causal relationships, such as motivationally consistent theorist comments causing increased change talk which then cause less drinking, or reflecting back change talk causing more change talk. It could be that these links are simply signs of an underlying change process which would have happened anyway, and/or that both sides of the link are related to something else such as the client's character or motivation. Similarly at the micro-level of moment-to-moment interactions in the therapy session, in this and in the Swiss study referred to above, change talk by the client was likely to be followed by further change talk (change talk 1 > change talk 2). It could be that the counsellor's reflective comments stimulated by change talk 1 had no impact on whether change talk 2 would or would not follow, but simply neutrally intervened between a pair of comments which would have happened anyway. If the presumed causal relationships identified by the study were in fact artefacts of this kind, then nothing would be gained by attempts to 'artifically' raise the level of change talk by for example, selectively reflecting it back to the client. That the counsellor's comments were entirely uninfluential seems implausible, but this possibility could only securely be eliminated by a study which, for example, trained some therapists to selectively reinforce change talk and others to do the opposite, to see what impact this had on change talk and subsequent drinking.
Nevertheless these and some other findings are consistent with the proposition that the principles and techniques of motivational interviewing stimulate change via the generation of self-motivational statements and the voicing by the client themselves of an intention (or the precursors of an intention) to change. The theoretical grounding and plausibility of this proposition, and the experiences of many counsellors and clients, mean that this possibility has to be taken seriously, even if the research is not as yet conclusive. In particular, there is backing for the proposition that both in brief interventions for risky drinking and in the treatment of alcohol dependence, skilful reflective listening is a key element stimulating change, though one which perhaps has to rely on less directly potent ingredients, such as the ability to forge a trusting relationship within which the client will be prepared to give the counsellor opportunities to reflect back change talk statements. Advice to follow the principles of motivational interviewing does not rule out departures from these principles by socially skilled counsellors, found in one study to deepen engagement with therapy, and is very different from advocating adherence to a set, manualised programme, which has proved counterproductive.
Last revised 27 November 2010
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Style not content key to matching patients to therapeutic approaches STUDY 2008
Adjust therapist directiveness to client resistance STUDY 2006
Therapist directiveness is an important influence on outcomes STUDY 2005
Patient reactance as a moderator of the effect of therapist structure on posttreatment alcohol use STUDY 2009
What process research tells us about brief intervention efficacy STUDY 2010
The motivational hallo FINDINGS REVIEW 2005
Evidence-based therapy relationships: research conclusions and clinical practices REVIEW 2011
Counselor skill influences outcomes of brief motivational interventions STUDY 2009
