Hot topics for May/June 2013
A selection of important issues or interventions which sometimes generate heated debate over the facts or over their interpretation. First commissioning, the crucial process of ensuring that the pattern of services in an area meets local needs. Then motivational interviewing, a favourite for commissioners looking for evidence-based practice from local services. Next an issue commissioners will want services to address, the commonly poor mental health of their patients. Finally, to a common component of motivational approaches, but applied for preventive purposes in educational settings – the provision of feedback on how one's substance use contrasts with population norms.
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What about evidence-based commissioning? ...
Motivational interviewing – the Swiss army knife of substance use counselling ...
Coping with mental illness ...
'Everyone's not doing it' message offers hope for preventive education ...
What about evidence-based commissioning?
Commissioning is the crucial process of ensuring that the pattern of services in an area coherently and efficiently meets local needs and achieves local and national objectives – crucial, but lacking evidence and currently (April 2013) being dramatically re-formed.
How relatively unevidenced commissioning is can be appreciated by ticking the filter term "Commissioning services" at the bottom of the Findings subject search page. Ticking this narrows down the main search to just those documents concerned with commissioning. Generally it leaves just a few in the list. One reason is that the usual ways of evaluating services are not feasible when it comes to evaluating local patterns of services. Large numbers of communities cannot be easily be assigned at the toss of a coin to one type of commissioning process versus another, and finding naturally occurring comparisons where everything is the same except the commissioning is impossible, because commissioning structures grow organically from the community.
But that does not mean commissioning is an evidence-free zone – just that the evidence is in short supply and often takes the form of interpreting observations of real-world practice rather than deliberately changing practice to see what happens. In respect of the UK, the resultant reports often graphically portray the shortfalls. Examples include investigations in to alcohol services by the Department of Health's Alcohol Harm Reduction National Support Team, which reported that many areas did not have a clear shared vision for reducing alcohol-related harm and that alcohol strategies were often out of date or being rewritten. An audit of drug and alcohol services in Scotland found local service provision systems poorly informed by the problems to be addressed and what works in addressing them, and in respect of drugs, unclear about what 'value for money' consists of. Specifically in relation to the commissioning of advocacy services for drug users, in both England and Scotland, national rhetoric seems yet to be consistently reflected in commissioning decisions on the ground. Exhaustive consultations in the south west of England also revealed that the process for commissioning offender alcohol interventions was unclear and contested and badly under-resourced.
Prisons too suffer from inadequate patterns of services. In England's prisons, an inquiry found that drug treatment commissioning and funding structures have led to a "fragmented system" with limited choices in the type of treatment and broader social support available, while inspectors found that alcohol services present a "depressing picture" of "very limited" services, which leave offenders with poor prospects on release. Scottish prisons feature a range of alcohol-related interventions but health service researchers were concerned that many prisoners who could benefit from such interventions were being missed.
From the USA, however, we have evidence that shortcomings are not inevitable and can effectively be addressed by changes in the commissioning process. One national US programme halved waiting times and extended retention partly by fostering a self-sustaining inter-service improvement network and a performance analysis system linked to funding. In Delaware the state incentivised recruitment and engagement results rather than strategies leading to more and more engaging treatment, while in Washington patients given 'recovery support vouchers' to purchase recovery services stayed in treatment longer and were more likely to gain employment.
Such findings may be seen as an argument for reforming structures, and in England that has happened on a grand scale. From April 2013 national expertise, specialist national services and advice and support are being provided by Public Health England, which has absorbed the National Treatment Agency for Substance Misuse. Locally the treatment budget formerly administered by that agency has been allocated to local authorities to help fund their new public health responsibilities, including the prevention and treatment of alcohol and drug problems, while criminal justice treatment-support funding is now under the control of the new police and crime commissioners, and prison health services (including drug and alcohol treatment) have become the responsibility of NHS England, formerly known as the NHS Commissioning Board.
These new commissioners and service planners also face a potentially radical change in direction from the top which means they cannot or should not simply continue with established service provision networks. Adoption of 'recovery' as an overarching principle for addiction treatment (see this recovery hot topic) entails extending the commissioning horizon beyond treatment episodes restricted in space (as at a clinic) and time to the world within which the patient lives and must fully return after treatment, and their entire life course. At the same time the resources to commission services and forge those extended links have become more restricted. Precise definitions of 'recovery' are lacking and arguably inappropriate for such an individual achievement, but the broad themes of what for UK administrations counts as recovery are clear: some of the most marginal, damaged and unconventional of people are to become (as the Scottish drug strategy put it) "active and contributing member[s] of society" and variously abstinent from illegal drugs and/or free of dependence. In other words, they are to become not just 'normal', but close to ideal citizens.
If there are new structures and objectives for commissioners, so too is there a new mechanism in the form of payment-by-results – paying organisations not to deliver services but (via whatever acceptable service mix they choose) to achieve the objectives set by the commissioner. When it came to making these objectives concrete enough to be used to pay English drug services, recovery as envisaged in the national strategies was notably lacking, perhaps a recognition that implementing these transformational visions would be a stretch when conventional routes to a productive and stable life through employment and housing are shrinking or remain in short supply, and the resources to elevate patients from near the bottom rungs of society to at least near the average are being stripped back.
In a reciprocal process, the new payment mechanism is in turn affecting treatment objectives and structures. The concrete, measurable and collectable outcomes required by the schemes are bound to become not just proxies for what is truly the objective (recovery), but make-or-break objectives for services whose survival depends on achieving them. Practicalities if nothing else mean that the English schemes often specify in-treatment and treatment exit measures rather than post-treatment recovery indicators, and the post-treatment indicators are confined to routinely collected criminal justice and treatment records which do not require the expensive process of recontacting and reassessing the patients. Ironically, the schemes place a premium not on the long-term contact presupposed by the recovery vision and associated understandings of addiction, but on discharging patients who then are not seen again for at least a year. The individualisation stressed by recovery advocates too seems at odds with the payment mechanism. Local schemes could create a space for the patient's ambitions in their payment criteria, but this is not a required element or one included in the national outcomes schema, nor one which sits easily within a system predicated on observable outcomes the public and their representatives recognise and are willing to pay for. Instead schemes pre-set the treatment destination in detail without reference to what the individual patient wants, and in a way services cannot afford to ignore because their financial survival depends on meeting the criteria.
Structures too are changing due to the requirements that the new payment mechanism has a convincingly unbiased way of taking in to account the 'degree of difficulty' posed by a service's case-mix and of measuring and recording the results. When funding, jobs and organisational survival ride on these assessments, leaving them entirely to the people and organisations at threat may stretch their integrity too far. In UK schemes, the most visible result has been the setting up of central assessment units (or LASARS), which have a key role in setting tariffs based on patient severity and verifying outcomes. These, say the Gaming Commission, should be independent both of treatment services and the commissioners of those services, placing another step in the journey to accessing treatment during which access may falter. The plus side may be more efficient assessment, better treatment placement, and the potential for long-term case management to start at the assessment stage.
Run these hot topic searches to see what internationally or in studies confined to Britain has been discovered by evaluators about how commissioning works and how it might work better.
Last revised 01 May 2013. First uploaded 01 November 2011
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Motivational interviewing – the Swiss army knife of substance use counselling
Almost certainly the most influential approach in substance use counselling in Britain, motivational interviewing was first formally documented in 1983 when Bill Miller noted that many clients resist treatment because they reject stigmatisation as an 'addict' or 'alcoholic' and the loss of control implied by being a patient. Dr Miller developed an approach which explicitly avoided these and other deterrent interactions. Instead he relied on amplifying aspects of the client's ambivalence towards their substance use to nudge them in a seemingly non-directive manner towards finding their own reasons to change in a positive direction. In a seminal trial published in 1993, he found that among problem drinkers, when counsellors adopted motivational interviewing's non-confrontational style they reduced both resistance and drinking compared to the more typical confrontational approach.
Motivational interviewing's great advantage is its applicability across the board from risky but as yet non-problematic drinkers or drugtakers to established addicts who welcome being afforded the dignity of self-definition and self-control. It is however important to separate out these applications. The motivational state of people who decide they have a problem and seek treatment is likely to be very different from that of people intercepted by screening programmes while routinely visiting their GPs. Appropriate comparators also differ. For people seeking intervention, the key issue is whether motivational interventions are preferable to other treatments. When all relevant studies are amalgamated, the answer seems to be, not much, but they do usually take less time. A similar message emerged from the most definitive trials in the USA and in Britain, which also generally failed to find the expected synergies between different types of patients and different types of therapies.
For people identified through screening, the key issue is whether having a motivational intervention 'seek them' is better than doing nothing. Here across relevant studies, the answer is yes, usually it is better. But that depends to a surprising degree on who is doing the motivating, a finding which emerged from studies as different as one in London involving cannabis using students and one in Switzerland involving heavy drinking adult emergency department patients. In both cases how far counsellors embodied the spirit of motivational interviewing in their comments and tone, and in particular the skill of 'reflective listening', were among the factors which made a difference. Another Swiss study offered corroboration; our commentary explored the implications of these and other studies of how motivational interviewing works. One implication was confirmed by a US study: that recruiting clinicians who have not been trained in motivational interviewing but take to it naturally would be better than trying to turn round less promising recruits through training. In this study too, not only were the promising recruits better to begin with, they also gained most from training.
How motivational interviewing works was also explored in our own reviews of the approach as a preparation for addiction treatment and of findings in respect of matching counselling style to the client. We discovered that motivational interviewing has worked best when therapists have not been tightly constrained to work to a manual, and that it can be counterproductive among patients who welcome explicit direction or who are already committed to a way out of their substance use problems. One explanation is that the quality of seeming genuine, long recognised as one of the keys to effective therapy, can suffer from drilling in techniques and in withholding normal caring responses in order to adhere 100% to motivational principles.
To narrow in on treatment-seekers run this search; for non-treatment seekers identified through screening run this search. For both run this omnibus hot topic search.
Last revised 30 April 2013. First uploaded 01 November 2010
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Coping with mental illness
With as many as three quarters of their clients suffering from mental health problems, deciding how to respond is a major concern for Britain's drug and alcohol services. The issues are many, long-standing, and generally unresolved. Should substance use services take the lead in coordinating their clients' care, or should this be taken on by psychiatric services? Or are integrated services the best solution? In an ideal world they may well be, but in practice this will in many countries be a prohibitively expensive and unworkable sub-specialism.
Instead, in cases of severe mental illness British guidance advocates psychiatric services take the lead, but how realistic is that and will those services bat the ball back to substance misuse services? And what of the less severe cases not eligible for psychiatric care? Here substance misuse services are seen as taking the lead, but do they have the required competences? They can be reassured to a degree that patients often improve after usual substance-focused treatments, possibly because at least some emotional problems are generated by substance use and associated lifestyles. This was why NICE, England's official health advisory authority, recommended that alcohol services faced with morbidly depressed or anxious patients should treat the problem drinking first, and consider referring the patient for specialist mental health care only if psychological conditions persist after three to four weeks of abstinence.
If the substance use problem is the primary issue resulting in poor mental health, then the more appropriate and effective the treatment of that problem, the more fully should mental health improve as substance use normalises. This seems why in Germany, heroin-addicted patients suffering from mental disorders who had not done well on methadone benefited more from being prescribed heroin than methadone, including greater remission in psychiatric symptoms. The picture was similar in terms of improvement in psychological health in a heroin prescribing trial in Spain.
However, the pragmatic solution of treating substance use first does not work well for everyone. In the case of depression, it seems likely that an appreciable number of patients would benefit more from addressing this directly at the same time as addressing problem substance use.
This is one instance of the perennial issue of which to tackle first, substance or mental health problems. Experts disagree about the best general approach. At the level of the individual patient, the answer probably depends on which problem if any lies at the root of the others.
These practical and theoretical conundrums just do not seem to go away; the disagreements remain and so too do the gaps between mental health and addiction services through which patients suffering both kinds of problems too often fall. Let the evidence shed some light on these issues by running this hot topic search.
Last revised 29 April 2013. First uploaded 01 November 2010
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'Everyone's not doing it' message offers hope for preventive education
Science is littered with shining new discoveries which became somewhat tarnished as accumulating data forced a reappraisal. In substance misuse, 'normative education' retains some of its shine, but what seemed the great hope for school- and college-based prevention now seems a tactic of limited application and with inconsistent impacts. The approach relies on the common overestimation by pupils and students of how many of their peers use substances and how much they use and/or We are grateful to Andrew Brown of the Drug Education Forum for his suggestions about including 'injunctive' norms and about the presentation referred to at the end of this paragraph. (less commonly) overestimation of the acceptability of substance use among their peers. Corrective survey data is expected to reduce substance use because it no longer seems 'normal' and 'what everyone my age does'. For more on the thinking and research behind this strategy see this presentation from John McAlaney of the University of Bradford.
Important recent implementations include the seven-nation EU-Dap European drug education trial and the English Blueprint trial. The former's results were patchy, the latter's, if anything, in the wrong direction, perhaps partly because pupils often simply did not believe the results of the surveys of their peers they were presented with. So unconvincing have results been at US colleges that some suspect the drinks industry supports normative campaigns because they divert colleges from imposing restrictions which really would cut consumption. However, there have been notable successes (for example, 1 2) which found not just substance use reductions, but related these to normative beliefs.
As a review for NHS Health Scotland observed, normative approaches lend themselves to computerisation and have become the mainstay of web-based interventions for people concerned about their drinking, an issue addressed by another hot topic entry. Typically the site user completes a brief assessment of their drinking. This is then automatically compared with the corresponding sector of the general population and the results fed back to the user with computer-generated advice dependent on their inputs. UK-based examples include the Down Your Drink site and the drugs meter, which covers illicit drugs as well as alcohol. The same technique can be used in educational settings for students in general. Tried in British universities, the results were unconvincing, partly because so few students responded to the attempt to re-assess their drinking. More convincing was not the results of being given normative feedback, but of having one's drinking spotlighted by joining the study and completing the initial assessment.
Part of the reason for the inconsistency in findings seems to be that more distant (eg, 'Pupils of my age in this country') comparators are less influential than closer ones (eg, 'My closest friends'). Yet youngsters who drink, smoke or use drugs probably have friends who are also doing much the same. There is also the risk that cliques which pride themselves on prodigious consumption will feel validated rather than mortified to hear that the 'typical' student is more restrained. And many college students underestimate heavy drinking among their peers; telling them the truth could be counterproductive. So not a silver bullet, but also not a dud – just more complicated than it seemed at first glance. See what you think after running this hot topic search.
Last revised 01 May 2013. First uploaded 01 May 2010
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