Hot topics archive
Our back-catalogue of current and/or traditionally 'hot' topics which arouse debate and comment due to their importance and sometimes also due to significant differences of opinion over the facts or over their interpretation. Click the GO buttons or the Blue titles to trigger a customised search for relevant 
documents. Click HERE for the current selection of hot topics.
Contingency management: incentive-based therapy ...
Relieving the population-wide burden of alcohol-related harm ...
Promoting recovery through employment ...
Controlling alcohol-related crime, nuisance and disorder ...
It's magic: prevent substance use problems without mentioning drugs ...
Residential rehabilitation; the best route to recovery? ...
No reason for pessimism over treating cocaine problems ...
Brief alcohol interventions: can they deliver population-wide health gains? ...
The therapeutic potential of patients and clients ...
'Everyone's not doing it' message offers new hope for preventive education ...
Ever controversial: prescribing opiates to opiate addicts
Alcohol licensing, price and taxation ...
Matching alcohol treatments to the patient ...
Drug education yet to fulfil its presumed potential ...
Individualising treatment: an obviously good thing? ...
Coping with mental illness ...
Motivational interviewing – the Swiss army knife of substance use counselling ...
Acupuncture: popular but ineffective therapy? ...
Why are some treatment services more effective than others? ...
Wrap-around services treat the whole person ...
12-step mutual aid promises to plug the recovery resources deficit ...
Get them early: seems to make sense, but does it work? ...
What about evidence-based commissioning? ...
Harm reduction flood needed to extinguish the hepatitis C epidemic ...
Reintegration and recovery objectives stretch UK drug treatment services ...
Computerised therapy and advice growing in acceptance and research backing ...
Contingency management: incentive-based therapy
Contingency management is a psychosocial therapy based on the systematic application or withdrawal of incentives or sanctions Such as money, shopping vouchers, prizes, onerous treatment requirements, desired treatment options such as take-home doses of methadone, and in some cases housing or employment. in response to substance use and/or engagement in therapeutic activities. The aim is to 'nudge' the client's behaviour in a pro-therapeutic direction much as the usual gamut of approbation, disapproval and good or bad consequences shapes how we behave in everyday interactions, but according to a consistent and codified schedule. Contingency management was one of only two The other was behavioural couples therapy. psychosocial therapies recommended by Britain's National Institute for Health and Clinical Excellence (NICE) for the treatment of problems related to illicit drug use and is being tested in UK trials.
But promising results over typically 12-week trials must be set alongside ethical concerns (including aggravation of health inequality if only promising patients qualify for and feel the therapeutic effect of the prizes), professional and public resistance, the common finding that that in-treatment gains do not persist, and some evidence that intrinsic motivation may be undermined if patients see themselves as 'just doing it for the prizes'. The key message of one particularly probing US cannabis treatment trial was that these procedures do not produce lasting change simply by mechanically reinforcing the habit of non-use. More important is whether the experience fosters confidence that one can resist relapse, along with the motivation to transform 'can' in to 'will', and strategies to effectively implement this resolution. In other words, what the patient makes of their spell on the contingencies and how they interpret it determines whether it will result in a transient, reward-driven spell of reduced substance use, or more lasting change.
As this review of cocaine dependence treatment suggested, possibly material rewards can help initiate abstinence while cognitive-behavioural therapy or community reinforcement help sustain it by teaching enduring skills, changing thought patterns, and altering how the user's social circle responds to them. Be that as it may, it would be a surprise indeed if offering often destitute patients housing, employment, money or goods, and the more despised among our population recognition and rewards, did not have powerful effects, at least while the contingencies are in place. Realising and making the most of this potential while avoiding unintended consequences is the task facing the researchers and clinicians who devise the programmes. Run this search for what Findings has made of the results.
Last revised 02 May 2012
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Relieving the population-wide burden of alcohol-related harm
At 2001 rates alcohol-related death, illness and crime was estimated to cost England about £20 billion and at 2006/7 rates to cost Scotland £2.25 billion. In tangible costs only excluding intangible costs such as human suffering. In 2005–06 costs borne by the NHS across the UK totalled about £3 billion and deaths 31,000. One in ten disability adjusted life years are lost to alcohol. This massive public health burden both reflects and calls in to question the embededness of drinking in British society, a conflict which generates controversy over how to reduce the burden. Universal prevention programmes, price rises, widespread screening and brief advice in surgeries and hospitals, and treating the worst cases, are all in the mix. Each has their enthusiasts and sceptics. After surveying the field, experts convened by Britain's National Institute for Health and Clinical Excellence prioritised national policy initiatives to restrict alcohol availability by making it less affordable, available in fewer outlets for less time, and promoted less visibly. Perhaps the most promising approach is setting a per unit price in such a way that strong drinks cost more, an approach being pursued in Scotland and considered for the rest of the UK. Brief interventions have tremendous public health potential but consistently realising that potential is a challenge yet to be overcome in the UK. The studies thrown up by this search address one of the most pressing of Britain's public health issues.
Last revised 29 February 2012
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Promoting recovery through employment
Just about wherever you look among Britain's national drug policies (England, Scotland and Wales), employment is seen The English policy stresses the clinical and fiscal need to move the estimated 400,000 substance-dependent benefit claimants through treatment and rehabilitation to sustained employment. Scotland's core treatment objective is that patients "move on from their addiction towards a drug-free life as a contributing member of society". For Wales, employment is among the life changes "essential to assist and sustain recovery". In contrast, in alcohol strategies employment is more likely to feature as a benefit of alcohol and allied leisure industries. as both a bulwark against relapse to dependent drug use and an obligation on drug users who can work and contribute to society rather than living on benefits. But how realistic is competitive paid employment for addicts who have spent a decade or more not honing their CVs, but chasing drugs and in the process often gaining a criminal record? – especially now when the economy is shedding labour. From Scotland evidence that treatment services may be able to help, but not very much. Another approach trialled in England is to place treatment staff in job centres to facilitate referral to treatment which will help ready them for employment. In three high drug use urban areas in it did raise the treatment entry rate, but not enough to recommend a national roll out. Perhaps acknowledging that in recessionary times, finding a job just may not be feasible, and despite its policy prominence, this has been omitted from national payment-by-results criteria which determine how treatment services in some areas will be funded.
Generally across the world the evidence for employment-promoting initiatives is at best patchy. Among the latest studies is one from New York which found that even though it helped welfare applicants overcome substance use problems, intensive case management support did not help men find a job; women did benefit to a small extent. The traditional 'gradualist' approach taken in this study has been contrasted with appropriate support targeted at rapid competitive employment, among which the most prominent is the Individual Placement and Support model. It has some important supporters in Britain and has helped substance users find competitive employment in the open labour market rather than sheltered placements.
So though it may shade towards the dark, the employment picture is not entirely bleak. Run this search to pick out the bright spots and, perhaps as importantly, get a feel for what does not work and what it is reasonable to expect.
Last revised 29 February 2012
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Controlling alcohol-related nuisance and disorder
Combating alcohol-related crime, disorder and nuisance was a major theme in the last English national alcohol strategy and remains a priority in for the current UK government, which has declared itself "committed to ensuring that alcohol is no longer the driver of crime and disorder that it has been over the last decade". The Welsh national substance misuse strategy has similar ambitions as does Scotland, though there crime and disorder objectives are not as high on the agenda. Policy prominence has, however, yet to be matched by UK-based research; what there is (for example, from Cardiff) has found it difficult to securely attribute improvements to interventions. Though internationally hours of sale in licensed promises have been found to affect crime and disorder, the 2003 licensing act which permitted sales 24 hours a day in England and Wales lacked a clear and consistent impact on this or on overall levels of drinking. Stronger and more immediate enforcement powers in the corresponding act in Scotland which came fully in to force in 2009 are felt to have helped prevent public nuisance and crime and disorder but this has yet to be confirmed by an evaluation. Such powers were among those commended by Britain's National Institute for Health and Clinical Excellence, which prioritised national policy initiatives to restrict alcohol availability by making it less affordable, available in fewer outlets for less time, and promoted less visibly. Perhaps the most promising approach is setting a per unit price in such a way that strong drinks cost more, an approach being pursued in Scotland and considered for the rest of the UK. Interventions focused on licensed premises such as training bar staff and improving management can work but are best seen as ways of dealing with 'hot spots' rather than achieving population-wide change. Run the search to get the full picture.
Last revised 29 February 2012
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It's magic: prevent substance use problems without mentioning drugs
Not magic at all of course, but a consequence of the fact that substance use problems are closely related to other problems which often develop at early ages when substance use is just not on the agenda. Breaking with previous versions, the 2010 English national drug strategy and also public health plans focused attention on early years parenting in general, and particularly in vulnerable families. Though studies are few compared to approaches such as drug education in schools, this renewed emphasis on the early years has strong research backing. Child development and parenting programmes which do not mention substances at all (or only peripherally) have recorded some of the most substantial prevention impacts. There was for example the classroom management technique implemented in the first years of primary schooling. Well and consistently implemented, by age 19–21 it was estimated that this would cut rates of alcohol use disorders from 20% to 13% and halve drug use disorders among the boys. Then there was the family and parenting programme which so impressed British alcohol prevention reviewers. Granddaddy of them all was the Dutch drug education study of the early '70s which had a profound impact in Britain. For the practitioners of the time, it was a warning about the dangers of the dominant 'scare them' approach, but it might as well have been a lesson about the approach which outperformed the warnings – classroom discussions which simply gave pupils a structured chance to discuss the problems of adolescence. Isolating these and other similar studies is not possible via our normal search facilities, so we have specially identified and coded them.
Last revised 28 February 2011
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Treatment staff matter
For most research the impact of the therapist is 'noise in the system' to be eliminated so it can focus on the therapy. We think this risks eliminating what matters in order to focus on what generally (see for example this verdict on alcohol therapies) does not. So we have stretched our hot topics to an issue which arguably ought to be sizzling in the research. The search combines documents relating to the development and recruitment of the workforce and of how they treat patients, rather than the treatment. In it you will find some of our own Manners Matter series devoted to the importance of sensitivity, helpfulness, and the systematic implementation of a personal, welcoming response. Other highlights include the most wide-ranging investigation ever of the organisational health of British treatment services. It found staff working in an atmosphere of support, respect, and concern for their development, tended to have clients who also felt understood, respected, supported and helped. Also from the UK, the intriguing possibility that non-conformist drug workers who value hedonism and stimulation help marginalised clients most because their values match those of their clients. The importance of the counsellor stretches even to the very brief encounters characterising alcohol or drug interventions with people not seeking help at all but identified through screening in general medical services or by other methods (see for example: 1 2 3). Running this search takes you straight to all our workforce-related analyses.
An important footnote: there is no shortcut to good relations with clients by assigning therapists of the same race or sex; to narrow in on these studies run this search. Among the hits will be these unpublished notes on relevant studies.
Last revised 02 May 2011
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Residential rehabilitation; the best route to recovery?
"I would like to ... try to provide – difficult though it will be given the shortage of money we have been left – more residential treatment programmes. In the end, the way you get drug addicts clean is by getting them off drugs altogether, challenging their addiction rather than just replacing one opiate with another." These comments made by the Prime Minister in August 2010 reflect and promise to embed in policy the current emphasis on treatment which explicitly aims for recovery, reintegration and abstinence, trends which in turn have focused attention on what has traditionally been seen as the royal route to all three – residential rehabilitation. Add the claim that these programmes have been sidelined in the pursuit of 'manage the problem' objectives, and the fact that they are among the most expensive options at a time of financial cutbacks, and you indeed have a combustible mixture. So concerned are British residential services that they have banded together to promote their cause. In 2011 a survey of residential rehabilitation services in England highlighted the lack of referrals meaning that "All but four of the respondents reported that their service was under threat of closure for 2010/11". A contrary line of argument is that non-residential rehabilitation in the area where the client is going to have to live may be harder, but is more realistic and more likely to stick than 'recovery' achieved in a protected environment far removed from the temptations and pressures which helped sustain the client's addiction.
Get the facts by running this hot topic search – but beware that no conclusive answer to the residential v. non-residential question can be found. Non-randomised studies are generally confounded by differences between clients who find their way to residential services, and those who do not, while randomised studies can only ethically include people who will accept and can safely be allocated to either. Not surprisingly, they also tend to do equally well in either. Our reading of the research is that while non-residential care is sufficient for many clients, residential care has particular benefits for the minority who are most severely affected. For this topic we are also making available these unpublished notes on studies comparing residential and non-residential care.
Last revised 29 February 2012
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No reason for pessimism over treating cocaine problems
In 2005/06 about 32% of patients in drug treatment in England were there primarily to address problems involving cocaine; Powder or crack, the latter usually in association with opiates. by 2009/10, the figure had risen to 40%. Reflecting general population trends, among 18–24-year-olds in treatment the proportion with primary cocaine powder problems doubled from 6% to 13%. Among those starting treatment, the latest figure was 15%. All these figures were slightly down on the year before but still represent a historic shift in the nature of the treatment population towards cocaine. In the absence (despite decades of searching) of a recognised drug-based treatment, and with no specific psychosocial therapy, services have turned to acupuncture, yet studies show that too fails to help. Serial disappointment might lead some to conclude that when it comes to cocaine and crack, 'nothing works'. Run this hot topic search and you will find that is far from the case. Just about any bona fide counselling or therapeutic approach helps some people some of the time, often many much of the time. It doesn't have to be very sophisticated, though severe cases may need continuing support and residential care (1 2). In the latest English national drug treatment study, crack seemed easier to give up than heroin. This is not to say that controlling your crack use is easy – just that is not uniquely difficult.
Last revised 28 February 2011
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Brief alcohol interventions: can they deliver population-wide health gains?
Not so long ago, virtually universal screening of adult primary care patients, followed by a few minutes of advice for risky drinkers, was seen as a major way to reduce the burden of alcohol-related harm. Now the ambition in England and in Scotland has been scaled back to screening new patients and/or those thought in advance to possibly be at risk, diluting the hoped-for public health benefits of a mass programme. Still this strategy remains important. In England, directors of public health are expected to include it among attempts to address the population-wide determinants of ill health, in line with recommendations from Britain's National Institute for Health and Clinical Excellence (NICE). Scottish national policy prioritises screening and brief intervention, backed by a health service target for 2008/09–2010/11 to deliver 149,449 brief interventions supported by dedicated funding.
The route from screening nearly everyone to today's less ambitious plans was punctuated by heated arguments over whether it was appropriate or feasible to ask GPs And other primary care workers, especially emergency department staff. to question patients about their drinking, when this was not why they came to see the doctor and there was no apparent reason to raise the issue. Controversy peaked when in 2003 a review in the British Medical Journal concluded that on average 1000 patients have to be screened to gain just two or three no longer drinking to excess. It was not necessarily that brief advice was ineffective, but that so few patients got to the point of receiving it. Critics hit back, but British studies (referred to in this Findings analysis and detailed in these background notes) confirmed that very low rates of screening and intervention were the norm. Even among patients who do receive brief advice, it remains unclear whether impacts found in research projects will be replicated in normal practice. But it is also the case that low rates of intervention can cumulate over the years to a high-coverage programme, and that minor gains per individual can sum to appreciable public health gains. Brief interventions have tremendous public health potential; consistently realising that potential is today's challenge. Get the latest on the state of play by running this hot topic search.
Last revised 27 April 2011
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The therapeutic potential of patients and clients
Hard times and thoughts turn to ways to make dwindling resources go further. Ally this with the new recovery agenda and the emphasis on getting people out the other end of treatment, and it is no surprise that mutual aid groups feature in new commissioning guidance from England's National Treatment Agency for Substance Misuse, nor that the agency's last two yearly plans (2009–10; 2010–11) saw promoting mutual aid networks as a key way to achieve its objectives. Local service commissioners are being called on ensure that the treatment system is better integrated with the wider supportive services, among which mutual aid organisations are seen as the most prominent, offering members support to overcome substance misuse problems, reintegrate into the community and sustain recovery.
The message has got through and is being reflected in local treatment strategies. Mutual aid groups seem to offer a way to promote the stable recovery and provide the 24/7 continuity of aftercare support which might help keep discharged patients safe while freeing up treatment slots, services unaffordable on a professional basis. Though such considerations may lie behind the current raised profile, mutual aid also appeals for its empowering and philosophical foundations. User involvement is now also more firmly on the agenda, driven by broader developments in health and social care. And for as long as there have been needle exchanges, so too have current and former drug users been at the forefront of providing a harm reduction safety net. Does all this actually work to benefit the client and patient, or is it just politically correct posturing and a more acceptable face for cost-cutting? Run this hot topic search to see our analyses of research on peer support, mutual aid and user involvement.
Last revised 27 April 2011
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'Everyone's not doing it' message offers new 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'. (See this presentation from John McAlaney of the University of Bradford for an introduction to social norm theory and research.)
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 surveys. 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.
Part of the reason for the inconsistency 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 be encouraged to hear that the 'typical' student is more restrained. And many college students actually 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 03 May 2011
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Ever controversial: prescribing opiates to opiate addicts
Previously we featured residential rehabilitation among our hot topics. Now we turn to the opposite treatment pole – prescribing opiate-type medications to opiate addicts on a long-term 'maintenance' basis. Both act as a focus for political and professional controversy, poles to which differing and often opposing treatment philosophies pin their colours. The divisions were reflected in the policies of parties contesting the May 2010 election. For the Conservatives, methadone was "drug dependency courtesy of the state". Labour responded to such criticism, but without abandoning the mass methadone programme which it believed had cut crime and curbed infectious disease. Dismayed by attacks on methadone, in April 2010, 41 British and international experts came together to defend "this life-saving treatment", an unprecedented alliance which shows how seriously they took moves to curtail it. In the event, the national drug strategy of the Conservative/Liberal Democrat coalition which took power rowed back from pre-election rhetoric, offering sometimes contradictory sentiments among which both poles of the treatment debate could find comfort. One short, key sentence "Medically-assisted recovery can, and does, happen." brought substitute prescribing in from the cold and under the umbrella of 'recovery', a safer political haven. But at the same time the strategy heralded a determined attempt (for most but not all patients) to eliminate the distinguishing feature of 'maintenance' prescribing – its indefinite and often long-term nature, bringing it within the ambit of a preparation for "full" recovery rather than a complete recovery option in itself. Picking up the baton, the 2010–11 yearly plan from England's National Treatment Agency for Substance Misuse heralded the end of maintenance prescribing for all but a minority of patients. The bulk would be offered "a time-limited intervention that stabilises them as part of a process of recovery, not as an end in itself". The agency recognised this would be a "radical reform" with risks evident in several studies, notably a US experiment which allocated patients at random to either minimal-support methadone maintenance or enriched-support but more time-limited detoxification.
On the ground, oral methadone is the workhorse, buprenorphine is behind but catching up, while injectable methadone and heroin now play a minor role. The UK arrived at this point after decades when it alone permitted heroin for the treatment of heroin addiction, resting on freedoms afforded doctors and patients by the 1926 Rolleston report. Having restricted heroin prescribing to a few hundred specialists, in the 1970s Britain moved decisively to the more 'normalising' oral methadone regimens pioneered in the USA. From the mid-'90s, mainland European countries trialled and then adopted the heroin prescribing option the UK had largely abandoned, adding supervised consumption to the regimen, an approach which has cycled back to Britain via the RIOTT trial.
Arousing visceral opposition and passionate defence, prescribing opiate-type drugs to opiate addicts for as long as needed on the discretion of the doctor treating the patient has for decades been the mainstay of heroin addiction treatment in Britain. Because opposing camps value different things, evidence alone will not decide whether it stays that way, but research does reveal what we and the patients stand to lose or gain from a change in policy.
To help you narrow in on your main interests we offer three custom-made searches:
• Run the featured search for UK-based reports and studies.
• Run this search for relevant studies from other countries.
• Run this search for what happens what happens when patients leave substitute prescribing programmes, including times when treatment has been curtailed for reasons other than the patient's wishes.
Last revised 27 April 2011
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Alcohol licensing, price and taxation
The cost of alcohol misuse to the UK economy has been estimated at up to £25.1 billion a year. One in ten disability adjusted life years are lost to alcohol. In recent years Britain has woke up to the scale of the problem but has yet to grasp the scale of the required solutions. Prime amongst these are market levers not available to curb the illicit drugs market, principally tax or other regulatory changes to increase price and licensing regulations to reduce availability.
Support for such moves include guidance from the World Health Organisation, whose possible impact was recently modelled for Australia. That exercise confirmed that in countries such as the UK where hazardous drinking is common, raising alcohol taxes has the most yet least resource-intensive impact on public health. Next most cost-effective were licensing controls. Britain has substantially contributed with modelling exercises based on data from England and Scotland which on public health grounds supported setting a relatively high minimum price per unit of alcohol. With these analyses available to them, Britain's National Institute for Health and Clinical Excellence (NICE) argued that price rises and licensing changes to reduce the number of outlets were the key public health levers.
But such moves face formidable industry, public and political opposition. As described in this Findings analysis, Scotland came closest to breaching the barriers, and may yet do so. The commitment in its 2009 alcohol strategy to set a minimum price per unit of alcohol was rejected by the Scottish parliament, but following the May 2011 elections is to be re-introduced by the ruling party, and this time the parliamentary arithmetic is more in its favour. In contrast, the UK government which sets policy for England hedged its bets on the impact of across-the-board price rises. Policy initiatives so far reveal a preference for action at the level of the individual or of drinking cultures and environments rather than national taxation and availability – a mix consistently evaluated as less effective, but one less likely to alienate the bulk of drinking voters, who will be unaffected by measures focused on young 'binge' drinkers.
While tax and unit pricing have been at the forefront of political debate, regulating availability and minimising harm through licensing are also major tactics. The Licensing Act 2003 seemingly has not made things much worse, but as detailed in this Findings analysis, neither did it give local authorities in England and Wales the power to make things much better, though in Scotland licensing authorities have greater scope. Current plans for England do however include giving local health bodies the power to make representations to licensing authorities, and do not rule out a key change already made in Scotland – including prevention of health harm among the objectives of licensing decisions.
One fly in the ointment rarely highlighted in public health studies is that health – the basis of most research-based policy recommendations – has little to do with why most Britons drink. The 'benefits' drinkers themselves feel they get are rarely valued in to cost-benefit calculations.
Still the prize in purely public health terms – health improvement among the largest achievable by any feasible means – is great, but so too are the obstacles, not least a British public wedded to cheap drink and politicians who need their votes. Run this hot topic search to see what we may be missing if we fail to grasp these opportunities.
Last revised 01 July 2011
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Matching alcohol treatments to the patient
It was the great hope for alcohol treatment: even if it seemed that overall one type of therapy was just as good as another, surely this was just because certain therapies worked best with certain patients. Getting the matching right was seen as a key way to advance alcohol treatment effectiveness. The huge US Project MATCH trial was designed to be the definitive test. It was followed by the British UKATT trial, for which testing matching was a secondary but important role. After pitting deliberately distinct psychosocial therapies against each other, both studies concluded that the outcomes differed little overall, and that there were few indications that certain types of patients benefited more from one therapy than another. But from the disappointment of Project MATCH emerged more fine-tuned analyses which (along with other studies) revealed that while the specific therapeutic programme may not be directly relevant, some programmes are more conducive to certain interpersonal styles than others, and these styles do matter: certain styles suit some patients more than others. So matching lives on, but more in the form of how someone is treated in the conventional meaning of the term, rather than what they are treated 'with' in the form of the brand of therapy applied to their addiction wounds.
In this respect addiction is catching up with and contributing to the trend in psychotherapy in general to focus on the match between how patient and therapist relate to other people. A high-level task force of the American Psychological Association has explored the candidate dimensions and found that adapting psychotherapy to four (patient preferences, tendency to reactance/resistance, culture, and religion/spirituality) demonstrably improved effectiveness. Of these the match between the patient's tendency to react against being led (or 'directed') and the directiveness Clients who need 'a push' or like to be led respond well to directive therapists; those who react against being led, respond badly. True-to-type motivational interviewing, when not unduly constrained by a set, manualised programme, encourages a non-directive style; cognitive-behavioural therapy, with its emphasis on training and skills, encourages greater directiveness. In the large US Project MATCH alcohol treatment trial, motivational therapists were significantly less directive than those implementing cognitive-behavioural therapy, and it was this difference in style which accounted for how different types of patients reacted. Complicating this formulation is the fact that whether therapists feel the need to be and/or come across as directive depends at least partly on what feels 'natural' in that culture. of the therapist has the greatest grounding in addiction-related research (as Findings discovered in this review) and makes a big contribution to how well patients do in psychotherapy in general. It takes the form of submissive patients doing better when given direction, 'in control' patients doing better when allowed to at least share the lead. A Dutch study has added the intriguing finding that patients who differ from their therapists on this dimension are drawn during treatment to become more like their therapist.
Matching remains a fascinating and fertile research topic which, despite setbacks, has thrown up meaningful messages for therapists and services seeking to maximise their impacts. See what you make of it by running this hot topic search.
Last revised 02 July 2011
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Protecting the children
There can hardly be a more emotive and now also – as a US-inspired project has come to Britain offering to pay drug users to be sterilised – contentious issue: how to protect the children of problem substance users. It is certainly a huge and pressing problem. Well over a million children in Britain have parents with a drug or alcohol problem. Across the UK, national targets, service standards and policy statements have recently embodied the perspective that their welfare is a core concern for services in contact with problem drug users, a contention featuring strongly in the latest Scottish and English drug strategies. In England it forms a specific workstream of the National Treatment Agency for Substance Misuse (NTA), which has produced guidance on how authorities responsible for drug and alcohol services can work more closely with children and family services.
Establishing what works for those at risk among these children is difficult because it would be unethical to deliberately deny services in order to determine whether they really do help. However, the potential for interventions to do serious harm as well as create major benefits makes evaluation vital. Evaluations of specialist British services in Wales and Middlesbrough found they prevented the need for permanent placement of children in care and reduced time in temporary placements. Such services attempt to help families already at the brink of losing care of their children. Before that point there is a strong case for offering parenting and child welfare interventions to all problem substance users in contact with treatment and harm reduction or other services. Because these offer positive support without implying parental failure, they often have a good uptake and can reduce the numbers who reach crisis point. But when the child is already deeply in trouble with drugs and/or crime, placing them in an alternative, long-term and more settled family environment can be better for them than continuing to try to make a dysfunctional substance-abusing family work.
Despite the issue's profile, truly informative studies are few. Run this hot topics search to see the full list.
Last revised 02 July 2011
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Overdose prevention
In recent years satisfaction in the UK at meeting addiction treatment targets has been tempered by concern about rising toll of drug-related deaths. In England and Wales drug poisoning deaths totalled 2747 in 2010, of which 1784 were linked to drug misuse and 791 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 three cases slight reductions from the peaks of 2008.
Scotland in 2010 recorded 485 drug-related deaths, of which 312 were considered to have been caused by drug abuse and 254 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. These were all appreciable downturns from the peak figures of respectively 574 (in 2008), 380 (in 2009) and 324 (in 2008). However, analyses of trends Trend analysis is complicated by the fact that instructions to pathologists were changed for 2008. They were asked to report any drug found in the body as well as those they thought might have been involved in the death, and the wording for the second category was revised. However, heroin/morphine totals seem only to have been slightly affected. revealed by averaging annual fluctuations, smoothing out atypical peaks and troughs, suggested that it was too soon to be confident that long-term upward trends had reversed. Deaths for which the underlying cause was registered as drug abuse had risen from an average of 189 a year in 1996–2000 to 328 in 2006–2010. A more detailed analysis highlighted the fact that 60% of cases had been in contact with drug treatment services, nearly 40% in the past six months, suggesting there had been chances to intervene which for these patients had been insufficient to avoid death.
Across the UK there is concern that methadone – prescribed partly in order to save lives at risk from untreated heroin addiction – is itself implicated in many deaths: in 2010 in Scotland, just over a third of drug-related deaths, and in England and Wales, about a fifth of drug misuse deaths. In both cases until the stabilisation or (in England and Wales) fall registered in this latest year, the numbers had markedly increased, but not because methadone services have become less safe. In fact, the reverse has happened; as supervised consumption has become the norm, the death rate per million doses has plummeted. Instead it seems that the expansion in methadone treatment is the main cause, and this will itself have saved many lives. Nobody has credibly worked out the balance sheet (difficult to do since it is impossible to count deaths which have not happened due to treatment) but the World Health Organization was convinced enough of methadone's public health credentials to place it on the international list of essential medicines.
Only time will tell whether 2009 and 2010 will prove a turning point in drug deaths in the UK. Looking back, the UK's long-term increase in deaths related to drug misuse presents an uncomfortable contrast with falls in some other comparable European nations.
Naloxone, a drug which rapidly reverses the effects of opiate-type drugs, including the respiratory depression which causes overdose, became the main new hope for curbing the death rate after in 2005 the law was amended to permit emergency administration by any member of the public. The first large-scale UK follow-up study of naloxone-based overdose prevention training found that this can successfully be delivered to drug users in treatment, resulting in substantially improved knowledge and competence. Though relatively few times, naloxone was used to save lives even within the study's short three-month follow-up period. This is however far from a total solution. Causes of overdoses and possible strategies to prevent them were reviewed by Findings in a two-part series which remains the most thorough analysis of the literature. Run this hot topic search for these and other reviews and studies with important messages about causes and solutions.
Last revised 21 December 2011
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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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Focus on the families
The list of documents retrieved by this search will include some on family therapies (if this is what you want, run this search instead), but the aim is to focus on the welfare of the families of problem drinkers and drug users themselves, rather than on their roles in promoting the welfare of the problem user. Among the list is our related hot topic on protecting the children of substance using parents. UK studies include the Middlesbrough project which won Drug Team of the Year award in 2008. Their intensive short-term support meant that children of problem drug users on the verge of being removed from the family were safely able to stay with their parents or other relatives. A similar project funded by the Welsh Assembly to work with the families of parents with drug or alcohol problems reduced the need for the long-term removal of children from the home. At more or less the other extreme of intensity, a British pilot study demonstrated the feasibility of a short (up to five sessions) intervention to relieve stress and improve coping among primary care patients affected by a relative's problem drug or alcohol use. Among the overseas studies is one from the USA which showed that relatives can learn how to engage a problem drug user in treatment without resort to confrontation, and that even if the user continues to resist, the relatives feel better and healthier. It was one of the studies included in a review which found this was the typical result and that the approach engaged drug users more effectively than popular alternatives. Run this search for more on arguably the neglected sufferers from problem substance use – the families.
Last revised 23 August 2011
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Individualising treatment: an obviously 'good thing'?
In treatment individualisation implies that each individual is treated differently and that this is a deliberate policy, not just a by-product of the interaction between the service and the patients. It might seem an obvious and basic prerequisite, but in fact services have often striven for the opposite: uniformity of provision. The early heroin addiction treatment clinics in Britain sought to homogenise their prescribing in order to avoid patients arguing for alternatives (like injectables) on the grounds that other patients were being prescribed them. Therapeutic communities used to rigidly enforce their traditions, procedures and hierarchies, seeing any attempt to tailor these as denial or avoidance. In some ways the advent of HIV loosened up these policies, but in other ways the need to achieve high caseloads in order to contain the disease led to further homogenisation. Individualisation also faces strong opposing forces in the form of the (sometimes perfectly justified) fear of stepping beyond professional guidelines and accepted practices to meet the patient's needs and preferences.
In prescribing services one simple way to individualise treatment is to let the patient set their own dose of substitute drugs, a tactic successfully tried several times. But results were equally good when staff retained control yet were flexible and patient-oriented, illustrating the importance of empathic, understanding and caring staff. These qualities can be expressed in simple ways like individualised, handwritten reminder letters, or in more sophisticated attempts to ensure the client's preferences and characteristics are acted on in ways which improve the effectiveness of talking therapies. So important has this become that a high-level US psychology task force has comprehensively reviewed what works best not just for substance using clients, but for psychotherapy clients in general. Visit this Findings analysis as a gateway to all eight reviews, each focusing on a particular client characteristic.
Access all our analyses relating to this fascinating and complex aspect of treatment by running this hot topic search.
Last revised 23 August 2011
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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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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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Why are some treatment services more effective than others?
As British treatment services struggle to survive in a cash-strapped environment keener than ever on extracting concrete outcomes, they will be forced to pay increasing attention to what makes some services dramatically more – or less – effective than others. The answers will be a mix of generic messages familiar from the broader organisational functioning literature and quirks more particular to addiction treatment. Among the former are the findings of a British study that clients engaged best when services fostered communication, participation and trust among staff, had a clear mission, but were open to new ideas and practices. Perhaps more particular to the addiction caseload is the possibility that at least in Britain, non-conformist drug workers who value hedonism and stimulation help socially excluded clients improve most because their values match those of their clients. Of course, services do not operate in a vacuum; in the USA, being constrained by funders in terms of the services they can offer and their ability to individualise treatments was the clearest negative influence, quality accreditation the clearest positive, both not entirely under the control of a single treatment service. But in the end it does come partly down to caring enough to take care – take care for example that patients are not abandoned because they fail to turn up but are persistently and warmly encouraged to return, initiatives which transformed aftercare attendance at a US service. Run this search for evidence that the organisation does matter, and for clues to how to make it more effectively service its therapeutic objectives.
Last revised 23 August 2011
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Wrap-around services treat the whole person
At the moment in Britain it seems unclear whether treatment services will be pared to the bone to cut costs while delivering narrow drug-focused objectives, or flower in to holistic providers of (or gateways to) the constellation of services ('wrap-around care') which seem demanded by reintegration and recovery agendas. For the Effectiveness Bank, the main issue is – does it really make a difference where services are on this dimension, and what kind of differences does it make? A consequent issue is how to construct services which find out what the client needs and can organise wrap-around care if this is what it takes. If for you these are live issues, run this search to discover what the world literature has to say. Most recent in the retrieved list is experience in California of developing and implementing a system for assessing patients' needs and matching to appropriate services. This carefully worked out strategy offers an unusually fully developed model for promoting recovery and judging the outcomes achieved by a service in the light of its patient profile. At the other end of the list is the classic 1999 study of US methadone services which suggested that increasing availability of counselling modestly buys more abstinence per dollar than offering more frequent daily access plus other services. In between much more, including a study which addressed the crucial question of whether providing appropriate wrap-around services aids or detracts from the core addiction treatment mission; for patients most in need of these services, it was the former, helping them control their illegal drug use. If there are answers to how to how wrap-around care affects the balance between costs, addiction outcomes, and reintegration outcomes, it is to be found among these studies.
Last revised 23 August 2011
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12-step mutual aid promises to plug the recovery resources deficit
Paralleling the rise in the profile of abstinence-based recovery from addiction in UK national drug strategies (1 2) has been a rise in the profile of what worldwide is probably the best-known and most widely implemented programme for achieving this goal – the 12 steps of the various 'anonymous' mutual aid fellowships and allied treatment programmes. They don't suit everyone and – as this expert Findings review makes clear – other mutual aid models less reliant on a 'higher power' and abstinence have filled the gaps, but 12-step approaches remain by far the dominant model. These and other approaches have been meticulously documented by William White in his encyclopaedic handbook on peer-based recovery.
For administrators in the UK, mutual aid spearheaded by 12-step fellowships offers a way to reconcile diminished resources with the desire to get more patients out of treatment, yet avoid life-, health-, and crime-threatening relapse. But the US record where the 12 steps are deeply engrained and widely accepted is not necessarily a guide to their impact in more 'secular' societies like Britain. For example, from the huge US Project MATCH alcohol treatment trial came the seemingly puzzling finding that 12-step therapists had been no more directive than therapists who implemented a motivational approach. Presumably as a result, unexpectedly these therapies had similar impacts on angry patients who react against direction. How could it be that practitioners of a codified set of steps with prescribed beliefs about addiction and prescribed activities and ways to recover which patients must adhere to, were no more likely to lead, teach and instruct their clients than practitioners of a method designed above all to avoid being explicitly directive? Possibly the answer is that in the US context and in particular with these patients, 12-step based therapy was 'second nature'. There would be little need to direct and teach; generally they were already convinced and practising adherents.
Running this search will enable you to test whether the worldwide popularity of the steps is matched by evidence of effectiveness. One thing to look out for is the basis on which 12-step approaches are compared with others. When abstinence is the criterion the gap is sometimes more apparent than when drug use reduction or problem resolution are the yardsticks. Abstinence-focused evaluation plays to the 12 steps' aims and strengths but abstinence does not tell the whole or only story about recovery.
Last revised 02 May 2012
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Get them early: seems to make sense, but does it work?
The English national drug strategy sees early years support for disadvantaged or vulnerable families as an important way to reduce risks of a variety of problems including substance use. Initiatives include preschool education and 'Family Nurse Partnerships' to develop the parental capacity of mothers and fathers through intensive and structured support from early pregnancy until the child is two years old. The Scottish drug strategy also focuses on the development of an "early years framework" to build parenting and family capacity to raise children less vulnerable to substance use problems among others. By 2011 this approach had been incorporated in government-initiated proposed legislation scheduled to be implemented in 2013.
Whatever their other positive effects, the evidence that such programmes can affect later substance use is thin. Step up to primary school and some bright spots appear, notably the Good Behaviour Game classroom management strategy for the first years of schooling and an educational booster programme for the same ages which also included classroom management techniques. These are not the only successes – others are noted in this Findings review. Is it enough to at least partially justify the 'Get them early' commonsense assumption? Make your own mind up by checking the findings thrown up by this hot topic search.
Last revised 31 October 2011
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What about evidence-based commissioning?
Often seen as the weak link in Britain's response to drug and alcohol problems, 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. Tucked away at the bottom of the Findings subject search page is the filter term "Commissioning services". Ticking this narrows down the main search (for treatment evaluations for example) to just those documents concerned with commissioning. Generally it leaves just a few analyses left in the list. The reason is that the usual ways of evaluating services are generally not feasible when it comes to evaluating local patterns of services. Large numbers of communities cannot 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 nature of the commissioning is impossible, because commissioning structures grow organically from the community. It leaves this crucial process relatively lacking in evidence that one type of process or approach consistently achieves better results than another.
But that does not mean commissioning is an evidence-free zone – just that the evidence is complex and in short supply. That makes what we have all the more precious. In respect of the UK, 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.
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.
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 November 2011
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Harm reduction flood needed to extinguish the hepatitis C epidemic
It was in the early '90s when an article in (what is now) DrugScope's Druglink magazine alerted Britain's drug workers to the until 1989 invisible "sleeping giant" of hepatitis C infection. Before a test was available to identify it, the virus had already infected a much larger proportion of drug injectors than HIV ever would. "It may be wise to let sleeping dogs lie, but not sleeping giants," warned the authors. Since then Britain, if not letting the virus lie, has not mounted an attack commensurate to the dimensions of the epidemic.
Consistent participation in methadone maintenance treatment plus adequate access to fresh injecting equipment can impede the spread of the virus, but these and other initiatives (especially early detection and treatment of infection) have not been sufficiently abundant to reverse an epidemic which in 2009 infected over a fifth of injectors within three years of their starting injecting, prompting the Health Protection Agency to warn that "transmission of hepatitis C among younger [injecting drug users] and recent initiates is probably higher than it was a decade ago".
The problem is that the transmissibility and prevalence of the virus mean that only a flood of harm reduction services can be expected to bring it under greater control. As comprehensively detailed in a four-part Findings series, coverage is the key – leaving no chinks in the form of the sharing of potentially contaminated injecting equipment for the virus to slip through. It has for example been estimated that to get to the point where less than 1 in 10 injectors in London are infected with hepatitis C would require the average injector to cut their sharing of used syringes from 16 times a month to one or two times, and that the impact of even this kind of achievement would be jeopardised unless sharing reductions extended to very recently initiated injectors.
How did we get to this point and how might we move forward to control hepatitis C as well as we have controlled HIV? Such answers as there are will be found among the research retrieved by this hot topic search.
Last revised 01 November 2011
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Reintegration and recovery objectives stretch UK drug treatment services
Reintegration and recovery are at the heart of the treatment themes in Britain's national drug In contrast, in alcohol strategies employment is more likely to feature as a benefit of alcohol and allied leisure industries. policies. Both the English and the Scottish strategies feature the word 'recovery' in their titles. The Welsh strategy committed the nation to "focus our efforts on helping substance misusers to improve their health and maintain their recovery." 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 strategy puts 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.
When it came to making these objectives concrete enough to be used for outcome funding English services, recovery as envisaged in the national strategies was notably lacking. Employment and whether the patient was active and contributing to society were put aside in favour of more readily measured and achieved elements like feeling OK and not offending. It was perhaps a recognition that implementing the transformational vision in the strategies would be a stretch in an era where conventional routes to a normal life through employment and stable 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. Hopes are pinned on a change of heart among services to supplement or replace a 'keep them safe' mentality with more risktaking, optimism and dynamism, and in the capacity of dependent drug users and ex-users themselves to bootstrap their ways to recovery via mutual support, along the way challenging the stigma which impeded recovery, and led those in recovery to hide from view.
If that is broadly the strategy and the task, what does the evidence say? This omnibus search gathers together all the analyses on our site assigned the keywords recovery or reintegration or both as objectives or outcomes of drug treatment. Instead run this search to restrict the hits to studies conducted in the UK or UK-originated documents.
Last revised 30 October 2011
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Computerised therapy and advice growing in acceptance and research backing
In this most intimate, personal, emotional and difficult of endeavours, the idea that an automated response driven by silicon chips could help retrieve addicted patients from often desperate situations seems not just unbelievable, but somehow 'wrong' – a denial of the humanity (in terms of compassion and also real bodies) due to them. And that is part of the problem – that such therapies would fail to meet a basic criterion for effective psychosocial treatment – that to the patient, it looks like 'treatment' – like what you do in that culture to get better. But as web services penetrate more of life including social and health-related, they too may take their place among culturally accepted routes to overcoming unhealthy substance use. Self-help web sites particularly attract people who retain a stake in mainstream society in the form of relationships, jobs, families, and a reputation to lose. These populations have more of the 'recovery capital' needed to themselves do most of the work in curbing their substance use without therapist intervention. Stepping down, and particularly in relation to alcohol, are non-dependent but clearly excessive drinkers and potentially harmful drinkers, typically targeted by brief advice offered after they have been identified by screening tests. Here a computerised response has a clearer role, because they are unlikely to seek face-to-face help, their needs are probably not so complex and problems so deeply ingrained that only an individualised response could be expected to work, and, commensurate with the size of the problem, an inexpensive and short intervention would be considered acceptable and affordable.
So much for the theory. Run this search to find the facts about what has been found to work in these early days of computerised advice/therapy. Prominent among the studies is a set from the Netherlands which have systematically mapped and examined the whole territory, at least in relation to drinking. These authors have both reviewed the evidence, and contributed to it by testing a computer-delivered therapy involving 'text–chat' conversations with a real therapist for problem and often dependent drinkers, an on-line cognitive behavioural programme for excessive drinkers, and, at the lowest level of intervention intensity and problem severity, a 10-minute web-based brief intervention for risky drinkers. They have also devised a mathematical model which simulates the health gains and costs of incorporating these new technologies in a health care system for alcohol use disorders. For the Netherlands, the results suggested national health would improve and/or costs be reduced if on-line brief interventions and therapy were added to or replaced conventional alcohol-related health care. Nobody is yet suggesting that computers can replace therapists for typical treatment populations, but further down the severity and complexity scale, the evidence is growing that the silicon chip may add substance use reduction to its accepted competencies.
Last revised 02 May 2012
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