Hot topics Jan/Feb 2012
Our selection of important issues or interventions which sometimes generate heated debate over the facts or over their interpretation. Click the GO buttons or the Blue titles to trigger a customised search for relevant 
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Acupuncture: popular but ineffective therapy? ...
Coping with mental illness ...
Motivational interviewing – the Swiss army knife of substance use counselling ...
Drug education yet to fulfil its presumed potential ...
Acupuncture: popular but ineffective therapy?
What do you do if there is no accepted medication and no specific psychosocial therapy for the particular problem presented by your client(s)? Those dependent on cocaine are usually considered a case in point, though in fact just about any bona fide therapy helps some of these clients some of the time. One popular solution has been to offer complementary therapies, among which acupuncture is by far the most widely used in substance use treatment. It is also commonly used to ameliorate withdrawal symptoms from drugs including alcohol and heroin. But the faith placed in it by services and patients is matched by scepticism justified by research which generally finds that whether the needles are placed where they are supposed to be or at sham sites makes little or no difference. In other words, if acupuncture works, it doesn't work in the way it is supposed to, casting doubt on whether we are seeing anything more than a placebo effect. However, that effect may itself be valuable. Offering something concrete like acupuncture (even if it is a 'sham' procedure) may attract people to services, and some studies have suggested that doing something clients and staff believe is worthwhile can help retain patients in treatment. If this is the case, acupuncture could indirectly improve outcomes by increasing the patient's exposure to treatment's active ingredients. Just such a role was specified in guidance from England's National Treatment Agency for Substance Misuse. Such considerations may explain why despite no convincing evidence of efficacy, acupuncture continues to feature in many of the treatment plans As revealed in March 2009 by a search for term 'acupuncture' on the web site of the National Treatment Agency for Substance Misuse, http://www.nta.nhs.uk. developed by local partnerships responsible for commissioning treatment services in England. It will take more and different kinds of studies to determine whether even if all they are buying is a possible placebo effect, it remains a worthwhile investment. For the evidence to date run this hot topic search.
Last revised 01 January 2012
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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 may 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. But in the case of depression, it also seems likely that an appreciable number of patients would benefit from addressing mental health directly. This relates to another perennial issue – which to tackle first, substance or mental health problems? Experts disagree about the best general approach, though in the case of an 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 01 January 2012
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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. The approach'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; the answer seems to be, not much, but they do usually take less time. For people identified through screening, the key issue is whether having an intervention 'seek them' is better than doing nothing; and here the answer is yes, it is better. 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. Among the results you will find our own insightful analyses of motivational interviewing as a preparation for addiction treatment and of the possible counterproductive impacts among patients who welcome explicit direction or who are already committed to a way out of their problems.
Last revised 01 January 2012
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Drug education yet to fulfil its presumed potential
School-based drug education was and for many remains the great hope for preventing unhealthy or illegal substance use. Across almost an entire age group it offers a way to divert the development of these forms of substance use before they or their precursors have taken root. The promise is clear, the fulfilment less so. The issues can be divided in to at least two possibly interrelated domains: contradictions in principle, shortfalls in practice. Among the first is the contradiction between the objectives of education and those of prevention: the former seeks to empower children to think for themselves and open up new horizons, the latter to channel thoughts, attitudes and actions in ways intended by programme developers and teachers. Then there are potential contradictions within prevention programmes themselves. Some aim to limit young people's autonomy in their choice of friends and substances by extending autonomy in decision-making, to encourage conformity to non-drug use values by discouraging conformity to other young people, to develop team work and social solidarity without accepting that youngsters may express this by going along with their peers as well as deciding not to. The practical issue is that (perhaps because of such contradictions) impacts of drug education on drug use are usually at best minor and short-lived. But perhaps the newer normative education approaches, a change in objective to harm reduction rather than absolute prevention (1 2 3), or some other innovation, will see drug education live up to its presumed potential. Alternatively we may see prevention steering away from drug education and towards general early-years character development, for which promising results have been found. Decide for yourself by running this hot topic search.
Last revised 01 January 2012
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