EFFECTIVENESS BANK BULLETIN 5 August 2009: reviews and meta-analyses
EFFECTIVENESS BANK BULLETIN 5 August 2009: reviews and meta-analysesThe entries below are our accounts of documents selected by Drug and Alcohol Findings as particularly relevant to improving outcomes from drug or alcohol interventions in the UK. Entries were drafted after consulting related research, study authors and other experts and are © Drug and Alcohol Findings. Permission is given to distribute these entries or incorporate passages in other documents as long as the source is acknowledged including the web address http://findings.org.uk. However, the original documents were not published by Findings; click on the Titles to obtain copies. Free reprints may also be available from the authors; if displayed, click Request reprint to send or adapt the pre-prepared e-mail message. Abstracts are intended to summarise the findings and views expressed in the study. Below are comments from Drug and Alcohol Findings. Links to source documents are in blue. Hover mouse over orange text for explanatory notes.
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Confirmation that tax rises are key alcohol harm reduction measure ...
Practical research-based handbook for peer-based recovery in the UK ...
Counterproductive to expect too much too soon from homeless addicts ...
Surprisingly small advantage for cognitive-behavioural therapies ...
Identifying cost-effective interventions to reduce the burden of harm associated with alcohol misuse in Australia.Doran C., Vos T., Cobiac L. et al.
University of Queensland, 2008.
Comprehensive calculations from Australia offer clues to what in countries like the UK would make the biggest dent in alcohol-related harm at the lowest cost; top of the list were alcohol tax rises, advertising bans, licensing controls, and random breath testing.
Abstract Four in five Australians drink alcohol during any given year, one in ten daily, and alcohol misuse is one of the leading causes of preventable death, illness and injury. In 2004–05, the total tangible cost Including lost productivity, health care costs, and costs related to road accidents and crime. attributed to alcohol consumption was estimated at $10.83 billion. Australian dollars adjusted to year 2003. At current (24 July 2009) exchange rates £5.38 billion. This study (also published as a journal article) aimed to provide a comprehensive analysis of the cost-effectiveness of interventions to reduce harm associated with alcohol misuse in Australia. Where possible, it contextualised results from a recent World Health Organisation study to the Australian setting using Australian data on costs, effectiveness of interventions, and health outcomes.
Intervention cost-effectiveness was evaluated over the lifetime of the Australian population eligible for each intervention in the baseline year of 2003. Costs and savings were also adjusted to 2003 rates. The cost side of the equation was the estimated cost to the health sector, including national and local government and costs borne by consumers and their families such as travel and time; costs saved by the intervention were taken in to account in calculating net cost. Effectiveness was measured in terms of how many disability adjusted life years (DALYs) an intervention saves. This measure combines the reduction in years lost due to premature death with the reduction in disability while someone remains alive. Years lost or gained due both to diseases (such as cirrhosis) and injuries (resulting for example from road traffic accidents or violence) were considered.
The interventions to be evaluated using this cost-effectiveness yardstick were selected with the help of a panel of alcohol experts from an initial comprehensive review, based on which were most effective, feasible and of highest priority. Selected interventions included:
• Volumetric taxation means setting the tax on commercially supplied alcoholic drinks solely on the basis of their alcohol content. Per unit of alcohol, tax would be identical across all types of beverages. Modelling suggested that setting this rate at
$25.25 per litre
Australian dollars adjusted to year 2003. At current (24 July 2009) exchange rates £12.5 per litre or £0.125 per UK unit.
of alcohol would result in a 1.4% reduction in consumption. This was assumed to wane only slowly due to price inflation.
• Advertising controls in the form of restrictions on all types of alcohol promotion and advertising, particularly if they reach young people. Evidence suggested this would result in a 5% to 8% reduction in consumption in the first year. This effect was assumed to weaken by 50% per year.
• Drink-drive mass media campaigns allied with enforcement action have been found to typically reduce alcohol-related crashes by 10%. This effect was assumed to weaken by 50% per year.
• Research shows that brief interventions by GPs cuts alcohol consumption among targeted patients by on average
44g
5.5 UK units.
per week over and above any reductions seen in control groups. The modelled procedure consisted of screening for risky drinking using the AUDIT questionnaire, followed if indicated by brief counselling, written materials and follow-up consultations. Additionally the effect was modelled of telemarketing and support to improve implementation rates by GPs.
• Residential detoxification for alcohol dependent individuals. The impact over and above natural remission was calculated from studies as on average
13.31g
About 1.7 UK units.
per day extra reduction in alcohol consumption, and in the first year a further 17% of patients in remission from alcohol dependence, with 50% relapse thereafter. Additionally the impact was modelled of 12 weeks of aftercare consisting of primary care counselling and pharmacotherapy with naltrexone, estimated to reduce drinking by
3.4 standard drinks
Just over 4 UK units.
a day.
• Licensing controls in the form of reduced trading hours on Sundays were estimated to reduce drinking by from 1.5% to 3%, an effect diminishing by 50% in the following years.
• Raising the minimum legal drinking age from 18 to 21 years typically results in a 12% cut in alcohol-related single vehicle night-time crashes, which was assumed to persist.
• Australian data suggested that highly visible and well publicised random roadside breath testing extensive enough to test every driver once a year permanently reduces road traffic accidents by 15%.
The impact of introducing these interventions was compared against the harm arising under recent and current practice in Australia (based most consistently on random breath testing) and against an estimate of what the level of harm would have been without any of the selected interventions, including random breath testing. The study also estimated how much more harm would be averted as investment in an intervention increased. In turn such an analysis lends itself to identifying an optimal order for introducing interventions to create the most cost-efficient package. If introducing or expanding an intervention averted loss of disability adjusted life years at a cost of no more than $50,000 Australian dollars adjusted to year 2003. At current (24 July 2009) exchange rates £24,800. per year, it was considered cost-effective.
Mathematical modelling indicated that across the Australian population, health gains in terms of disability adjusted life years ranged from 150 for increasing the minimum legal drinking age, to 11,000 for volumetric taxation. Except for raising the drinking age (which would benefit only those aged between 18 and 20 years), interventions which target risky drinkers (brief interventions with or without GP support) or alcohol dependents (residential treatment with or without naltrexone-based aftercare) would avert fewer years of disability or death than population-wide interventions (taxation, advertising or licensing controls, random breath testing, and drink-driving campaigns).
Considering both how much they would cost net of any cost savings, and how much they would reduce the national burden of disease and premature death, two interventions stood out as being both most effective, and most cost-effective: changing to volumetric taxation, and advertising bans. Compared to current Australian practice, both would on balance reduce health service costs, yet prevent more premature death and disease. Both too have a high probability of meeting the cost-effectiveness threshold of $50,000 Australian dollars adjusted to year 2003. At current (24 July 2009) exchange rates £24,800. per year of life saved adjusted for disability.
Top of the list was volumetric taxation, estimated to cost just $0.58 million but to save $57 million in health costs due to reduced drinking, leading to a net cost saving of $56 million. Australian dollars adjusted to year 2003. At current (24 July 2009) exchange rates about £28 million. Despite costing less than current practice, it would avert the loss of an extra 11,000 years of life adjusted for disability. It is also easy to implement though may face public and political opposition. Advertising bans too are feasible and opposition here would be likely to be limited to drink and advertising industry interests. Increasing the minimum legal drinking age to 21 would also save money yet avert more premature death and disease than current practice, but spread across the entire population, potential health gains would be small because limited to people aged 18–20. This measure is feasible but may face opposition not just from industry interests but also from some (especially in the affected age band) voters.
All the other interventions would cost more than current Australian practice. Nevertheless, all but one would still have a high or very high probability of cost-effectively That is, bettering the $50,000 per DALY threshold. averting premature death and disease; for example, brief interventions would avert a year of premature death or disease at a cost of just $6800. Australian dollars adjusted to year 2003. At current (24 July 2009) exchange rates about £3376. The exception was residential detoxification (with or without naltrexone-based aftercare). Though this would avert more premature death and disease than some other interventions, the costs would be by far the greatest, meaning that each year saved would cost at least $84,000 Australian dollars adjusted to year 2003. At current (24 July 2009) exchange rates about £42,000. and perhaps as much as $270,000. Australian dollars adjusted to year 2003. At current (24 July 2009) exchange rates about £134,000.
Given these estimates, the optimally cost-effective way to improve on current practice would clearly be first to change to volumetric taxation, then to ban advertising, and then (but with little to choose between them) to increase the legal drinking age to 21, extend primary care-based brief interventions, tighten licensing controls, conduct anti-drink driving media campaigns, and extend random breath testing. Clearly last on the list would be to introduce residential detoxification. Extending this with naltrexone-based aftercare and extending brief interventions through telemarketing and support were omitted altogether because they were less cost-effective than the unextended interventions. Combined as a package, these alcohol interventions could avert 26,000 years of premature death and disease at a total intervention cost of $210 million. Australian dollars adjusted to year 2003. At current (24 July 2009) exchange rates about £104 million. These costs would be partly offset by an estimated reduction of $130 million Australian dollars adjusted to year 2003. At current (24 July 2009) exchange rates about £65 million. in the costs of treating alcohol-related diseases and injuries.
For the analysts their key findings were that all the prevention interventions would reduce harm more cost-effectively than treating alcohol dependence. Compared to current practice, the optimal package could lead to a substantial improvement in population health at a cost well under the threshold figure of $50,000 Australian dollars adjusted to year 2003. At current (24 July 2009) exchange rates £24,800. per disability adjusted life year. Although random breath testing is cost-effective and is already being implemented in Australia, the $71 million Australian dollars adjusted to year 2003. At current (24 July 2009) exchange rates £35 million. it costs would, if invested in more cost-effective interventions, achieve over ten times the health gain. Additional positive effects were not included in the analysis, such as productivity gains generated by decreases in alcohol-related disease and injury, reduced road traffic accidents, violence and crime. Though the strength of the evidence underpinning the interventions was at best modest, the analysis clearly indicated that reallocating resources along the lines suggested would substantially reduce the current burden of harm alcohol imposes on Australia.
The relevance of these Australian findings to the UK lies in the similarity of drinking prevalence and patterns and of the overall societies, including health and health services and the acceptability, feasibility and likely impact of the various interventions. The major difference is the reliance in Australia on random testing of motorists. The focus on health gains and healthcare costs makes more sense for as a way of assessing medical and treatment interventions than it does for macro level interventions such as taxation and advertising bans, which have a much wider brief and much broader potential gains and losses for society. Among important missing details are the derivation of crucial
assumptions
An unsuccessful attempt was made to access the cited source for these figures.
about how consumers respond to price changes for alcohol, what the price changes would be following tax equalisation of the kind the report recommends, and why some of the assumptions were made about the degrees of uncertainty in the figures used in the model. Also it is unclear why the treatment intervention was confined to residential detoxification, an expensive treatment which was unlikely to prove cost-effective relative to the other policy options. Nevertheless the conclusions broadly replicate those of other analyses for similar countries including the UK; examples below.
The World Health Organisation study on which the featured analysis was based also concluded that in countries such as the UK, with a high prevalence of hazardous drinking, raising alcohol tax rates has the greatest yet least resource-intensive impact on public health, even after allowing for increased illicit production or smuggling. Also as in the Australian study, next most cost-effective were licensing controls which reduced hours of sale and advertising bans. Primary care brief interventions targeted at risky drinkers, though considered cost-effective, were estimated to be far less so than these population-wide preventive interventions. These conclusions were updated five years later in 2009 but not for UK-type European nations. Nevertheless the conclusion remained that tax increases (of 20% or 50%) were the most cost-effective harm-reduction policy in countries with (like the UK) a high prevalence of heavy drinking, and that population-wide measures including licensing controls, advertising bans and drink-driving countermeasures were also relatively cost-effective. Updated calculations can be seen at the World Health Organisation's web site.
Another influential international analysis reached broadly similar conclusions, arguing that due largely to their low cost, feasibility, sustainability and wide reach, tax increases, and licensing controls which restrict the physical availability of alcohol, are likely to have the greatest impact on public health. Similar arguments favoured drinking-driving countermeasures. In contrast (and as in the featured report) measures targeted at hazardous or dependent drinkers (though beneficial for the patients) had at best a moderate impact on harm across the society. School-based education and public service messages about drinking were considered the least effective harm-reduction options.
Similar conclusions were also reached for England in an analysis commissioned by the Department of Health which considered alcohol-related harm in terms of health, crime and employment. It concluded that policies which affect the price of alcohol including discount bans, taxation and setting a minimum price per unit – similar to the volumetric taxation favoured in the featured report – could save hundreds of millions of £s every year in NHS, crime and employment costs.
Such conclusions are based on what, after synthesising results from relevant studies, analysts called "overwhelming" evidence of the effects of alcohol prices on drinking across all types of beverages and across the population of drinkers from light drinkers to heavy drinkers. A commentary on this analysis also reminded us that price or tax rises have been directly linked to falls in drink-related adverse consequences such as deaths from various causes, violence, traffic and other accidents, and poor health.
Given this consensus, the major questions are not over the validity of the findings, but over whether governments mindful of the opinions of the drinking public and the importance of drink-related industries will do what research suggests is needed to significantly reduce alcohol-related harm by reducing overall consumption, with alcohol tax increases as the leading tool. This is especially the case in Britain, which compared to other European nations already has among the highest alcohol taxes, and where drink prices are relatively high compared to other commodities. Based on World Health Organisation and other findings, the call has been powerfully made for an international agreement to control alcohol-related harm along the lines of the Framework Convention on Tobacco Control. One reason why public and politicians remain unconvinced is that, because the studies are concerned primarily with harm, they fail to account for the benefits drinkers feel they get (the reason why they are prepared to pay) from alcohol. Sometimes studies do account for the (relative to overall harms) minor strictly medical benefits of low-level regular consumption, but these are not why most drinkers drink. An industry-funded review found research indicating that moderate drinkers "experience a sense of psychological, physical, and social well-being; elevated mood; reduced stress (under some circumstances); reduced psychopathology, particularly depression; enhanced sociability and social participation; and higher incomes and less work absence or disability," benefits which have "barely begun to be incorporated into epidemiologic research and analyses."
Among the nations of the UK, Scotland seems closest to breaching the political barriers to introducing more effective alcohol harm-reduction policies. Its 2009 alcohol strategy committed the government to pursue the introduction of a minimum price per unit of alcohol and included plans to ban the sale of alcohol as a loss-leader. Minimum pricing is not yet definitively ruled out in England and is strongly supported by the government's principal medical adviser. However, the prospects for minimum per-unit pricing seem slim outside Scotland. There are proposals to raise taxes, but only on high-strength drinks and those preferred by teenagers.
Thanks for their comments on this entry in draft to Robin Purshouse of the University of Sheffield. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 21 January 2010 Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Independent review of the effects of alcohol pricing and promotion STUDY 2008
Model-based appraisal of alcohol minimum pricing and off-licensed trade discount bans in Scotland ABSTRACT 2009
The effectiveness of tax policy interventions for reducing excessive alcohol consumption and related harms REVIEW 2010
Reducing alcohol harm: health services in England for alcohol misuse STUDY 2008
Alcohol misuse: tackling the UK epidemic REVIEW 2008
Drug and alcohol services in Scotland STUDY 2009
Family doctors' alcohol advice plus follow up cuts long-term medical and social costs NUGGET 2003
Primary care intervention to reduce alcohol misuse: ranking its health impact and cost effectiveness STUDY 2008
Universal screening for alcohol problems in primary care fails in Denmark and no longer on UK agenda NUGGET 2008
Peer-based addiction recovery support: history, theory, practice, and scientific evaluation.White W.L.
Chicago, IL: Great Lakes Addiction Technology Transfer Center and Philadelphia Department of Behavioral Health and Mental Retardation Services, 2009.
This monograph is likely to become the handbook for the growing peer-based recovery movement in the UK. For administrators, the approaches it reviews offer a way to reconcile decreasing per-patient resources with a policy agenda now focused on reintegration and recovery.
Abstract This seventh monograph* in a series on recovery management and recovery-oriented systems of care synthesises knowledge about the history, theoretical foundations, methods, and scientific status of peer-based recovery support for individuals with the most severe and complex alcohol and other drug problems. It was written primarily for people directly involved in planning, funding, delivering, supervising, and evaluating peer-based recovery support services, but will also be of interest to policymakers, purchasers of care, treatment programme administrators, and addiction counsellors and other service professionals. Though rigorously researched, information is presented in a clear and accessible language.
The report focuses on:After comprehensively reviewing the literature and profiling peer-based recovery support initiatives, the author reached (among others) the following conclusions:
• Peer-based recovery support services are today growing out of the failure of addiction treatment to provide a continuum of care that is accessible, affordable, and capable of helping people with the most severe and complex problems move beyond brief episodes of recovery initiation to stable long-term recovery.
• Their distinctive strategy is to improve linkage to recovery mutual aid groups and other recovery support institutions, and their value is founded in what specifically those in recovery bring to the helping process. As with any effective helpers, those in recovery relate not primarily through techniques, but through humanness. They are able to do so, not because they once experienced addiction, but because they completed their own recovery experiences and emerged as men and women committed to this demanding way of life.
• Peer-based models of care can have a
transforming effect
Peer-based recovery support services can help shift the larger treatment system from a focus on brief biopsychosocial stabilisation to a focus on the long-term recovery process. Peer-based models can inject a recovery focus – a source of renewal – in to treatment institutions whose fear of the current climate of financial scarcity has driven them into excessive preoccupation with paper, profit, and professional prestige. Peer-based recovery support specialists can help divert excessive attention from 'funding streams', 'product lines', and 'bottom lines', and refocus attention toward long-term recovery pathways and processes for individuals and families.
on larger systems of care and on our society, but can also be corrupted and devoured when integration in to these systems leads to pressure to emulate the ethos of current professional treatment models. Care must be taken not to over-professionalise the roles of peer helpers, but training, guidelines, supervision and recognising the limits of one's competence and role, are as important for services based on the power of mutual identification as for professional services.
• Rather than view peer-based and professional-based styles of knowing and doing as antagonistic models rivalling for superiority, it is more helpful to view these approaches as complementary. We need a community in which both professional and peer-based services are available as needed, and are supported and integrated into a seamless system of long-term recovery support.
• One unique quality separates the addictions field from peer models in allied fields: the growth of spiritual, secular, and religious recovery mutual aid groups, and new recovery support institutions, has gifted it the oldest and largest recovery mutual aid network in the world. New peer-based models must capitalise on these strengths rather than undermining or replacing them. The long-term goal is not to create a larger treatment system or new profession, but the establishment of recovery support relationships that are non-hierarchical, non-commercialised, and enduring in recovery-friendly communities.
• The question, 'Who is most qualified to treat the alcoholic?' is ill-framed because it assumes a homogeneity within the label 'alcoholic' and within the boundaries of particular helping roles or categories of helpers. In terms of recovery status, the question is not whether professional and peer helpers with or without a history of addiction recovery are most effective, but which helper is most effective with which person or family at a particular point in time. There are so many kinds of alcoholics and so many different kinds of alcoholism that a therapist eminently qualified to treat one type may fail completely with another.
• Recovery stages might be broadly conceived in terms of: 1 a sudden or unfolding opportunity for change; 2 a commitment to recovery experimentation; 3 recovery initiation and stabilisation; 4 recovery consolidation and maintenance; and 5 enhanced quality and meaning of life in long-term recovery. Peer-based recovery support services will probably be found most critical in stages
1,
Via outreach and engagement.
2,
Via charismatic encouragement and role modelling.
and
4.
Construction of a recovery-based identity, social network, and lifestyle.
Traditional professionals may be most effective in stages
3
Facilitation of medical/psychological crisis management and stabilisation.
and
5.
Providing psychotherapeutic support to resolve serious characterological defects and to enhance the quality of intimate and family relationships.
Every effort has been made to meticulously document sources, but many critical research questions about peer recovery support have yet to be studied and many studies suffer from methodological problems, so these findings are best viewed as probationary, pending new studies of greater methodological sophistication.
Though written by an advocate of peer-based recovery, this monograph is careful to adhere to the research (more comprehensively reviewed here than in any other publication) and to point out the limitations and risks involved in this route to recovery and the continuing role of professional treatment and other formal services. In it the British reader will find unfamiliar but potentially promising manifestations of mutual aid such as recovery social clubs, recovery community centres, and recovery homes, with profiles of how these have worked in practice and relevant research. Attention is not limited to 12-step based approaches, but extends to mutual aid based on other philosophies and understandings of addiction and recovery. For the growing peer-based recovery movement in the UK, it is likely to become an essential handbook to clarify thinking, offer practical ways forward, identify pitfalls and risks, and to encourage further research.
As the author comments, most of the reviewed research lacks the methodological safeguards of a randomised trial or some other research design capable of eliminating influences on outcomes other than mutual aid or peer support. Typically studies have recorded the degree to which substance dependent individuals participated in mutual aid activities and groups, and then assessed how closely this was associated with substance use and related problems. Such designs leave open the possibility that good outcomes encourage increased mutual aid participation rather than the reverse, or that people who are in any event Due to circumstances, motivation, psychological strengths, or other factors. going to do well also tend to participate in whatever in that society is the accepted route to doing well in terms of recovery from addiction. In the USA, where most studies originate, that route entails 12-step mutual aid.
When (as in a review for the Cochrane Collaboration) the focus is limited to the few randomised or other well controlled trials, there is no convincing advantage for 12-step mutual aid or allied services over other approaches. This review was unable to take in to account an influential later study which randomly assigned patients in formal treatment to standard versus intensive referral to 12-step groups. As intended, intensive referral improved 12-step mutual aid participation and this in turn improved substance use outcomes, confirming that participation was indeed an active ingredient. However, the effects on both participation and substance use were not great. While such studies can demonstrate the value of the extra element of mutual aid participation they 'artificially' generate, they say nothing about the value of the bulk of mutual aid participation as it naturally occurs. For this we must turn to the less well controlled studies excluded from the Cochrane review but included in the featured report, yet these are not capable of delivering convincing answers. This bind arises from the fact that mutual aid cannot be imposed or withheld by researchers and the results observed. Rather, it is generated (or not) organically by the nature of the society and of the individuals who choose (or not) to participate. It makes little sense to ask what the recovery chances of that society or those individuals would be if they did not generate or participate in mutual aid, because then they would not be the same societies or individuals. Another limitation of the controlled research is that typically it has studied mutual aid as an add-on to current treatment models, not the thoroughgoing systemic transformation called for in the featured report.
Even if given these difficulties, peer support and mutual aid struggle to demonstrate a superiority, where they can have a distinct advantage is in accessibility and (by reducing resort to public services) cost to society. For administrators in the UK, such approaches offer a way to reconcile increasing numbers in treatment, decreasing per-patient resources, increasing pressure to move patients through and out of treatment, and a policy agenda now focused on secure reintegration and recovery. Formal services seem unlikely to be able to make major advances in the availability to dependent substance users of (among other supports to reintegration and recovery) supported housing, suitable training and education opportunities, sheltered, graduated and attractive employment, and satisfying non-drug focused social and lifestyle options. Within available resources and political and public willingness to redirect these, transformations of the kind described in the featured report may be the only feasible way to create a more recovery-friendly environment which can protect greater numbers of people leaving treatment from repeated relapse.
However, risks of the kind warned about in the report are already apparent in parts of Britain where services concerned to safeguard vulnerable adults and who have clinical responsibility for patients seem reluctant to refer those patients to untried and unqualified mutual aid organisations, leading to pressure for those organisations to implement safeguards and protocols potentially antithetical to their self-help ethos. Such pressures have also been apparent in the UK mental health service-user/survivor movement. There is also a tendency for mutual aid recovery enthusiasts to see formal treatment services and their workers as 'part of the problem' rather than collaborators. The result is an imperfect interface between mutual aid and formal services which impedes beneficial complementarity and movement between them. As with other collaborations between organisations with different traditions and agendas, these difficulties will need to be carefully and respectfully worked through if patients are to benefit maximally from the potentially huge reservoir of voluntary effort represented by current and former problem substance users.
In the UK employment of current or former problem substance users in drug and alcohol services may be seriously impeded by the new requirements and powers associated with the advent in 2009 of the Independent Safeguarding Authority and of a similar scheme The Independent Safeguarding Authority extends to England, Wales and Northern Ireland, although arrangements for application and appeals may differ slightly in Northern Ireland. A separate but aligned scheme is being set up in Scotland under the Protection of Vulnerable Groups (Scotland) Act 2007. Anyone included on a Barred List in Scotland will also be barred from working with children and vulnerable adults across the UK. in Scotland. Among the criteria for banning people working with vulnerable adults (which would embrace many attending drug and alcohol services) are a history of acquisitive crime or fraud, addictive behaviour, or persistent offending. Such histories are common among drug addicted populations who have recovered through treatment and who might be employed as a paid employee or volunteer The new vetting service treats paid and unpaid work in the same way; see http://www.isa-gov.org.uk/default.aspx?page=323. to offer peer-based support to substance users in contact with services. These problems have been recognised and representations are being made to the authority.
*The same author's monograph on recovery management models of addiction treatment has also been featured by Drug and Alcohol Findings.
Thanks for their comments on this entry in draft to William L. White of Chestnut Health Systems in the USA and Mark Gilman of the National Treatment Agency for Substance Misuse (North West). Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 23 July 2009 Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Recovery management and recovery-oriented systems of care: scientific rationale and promising practices REVIEW 2008
The power of the welcoming reminder THEMATIC REVIEW 2004
Self help: don't leave it to the patients THEMATIC REVIEW 2005
Self-financing resident-run houses maintain recovery after treatment NUGGET 2008
The grand design: lessons from DATOS KEY STUDY 2002
Benefits of residential care preserved by systematic, persistent and welcoming aftercare prompts NUGGET 2008
The motivational hallo THEMATIC REVIEW 2005
My way or yours? THEMATIC REVIEW 2006
A meta-analysis of motivational interviewing: twenty-five years of empirical studies REVIEW 2010
Effective services for substance misuse and homelessness in Scotland: evidence from an international review.Pleace N.
Scottish Government Social Research, 2008.
Comprehensive and thoughtful review of the UK-relevant literature warns that services which impose rigid and unrealistic expectations of abstinence or independent living on homeless addicts would deny treatment and housing to vulnerable adults with complex needs.
Abstract A rapid evidence assessment of international literature on effective substance misuse services for homeless people was conducted to review best practice in other countries and determine if there were any lessons for Scotland. The review found that:
• There is strong evidence that experience of homelessness increases the risk of substance misuse among previously abstinent people, while entering into substance misuse also increases the risk that someone will become homeless. Also, when someone is homeless and involved in substance misuse, each problem compounds the other.
• In Scotland, England and
elsewhere,
North America
young or lone homeless people and people with experience of sleeping rough are characterised by higher rates of substance misuse than the general population. However, parents and children in homeless families are either only a little more likely, or no more likely, to be involved in substance misuse than parents and children in the general population.
• In Scotland, England and
elsewhere,
The European Union, North America and Japan.
there is a strong association between mental health problems or severe mental illness among homeless people and substance misuse problems.
• Services aimed solely at promoting abstinence among homeless substance misusers tend to meet with quite limited success. Many either cease contact with these services before treatment or rehabilitation is complete, or avoid them to begin with. Attempts to use short-stay detoxification services with homeless people have proven particularly unsuccessful.
• Rather than insisting on total abstinence, when services pursue harm reduction or harm minimisation policies, they are able to engage with homeless people with a substance misuse problem more effectively. In particular, US floating support models based on harm reduction can promote and sustain stable living arrangements and ensure contact with services.
• Homeless people with substance misuse problems have a range of needs that can include: support with daily living skills; mental health services; and support in managing substance misuse. Their needs are often complex and services which focus on any one element, be it substance misuse, mental health or housing-related support, are less successful than services designed to support all their needs.
• The three main models of resettlement for homeless people with a substance misuse problem are: 1 The Continuum of Care or Staircase approach, which uses a series of jointly occupied supported housing settings, intended to slowly progress service users towards independent living and abstinence. This model meets with limited success; 2 More successful and cost effective is the model referred to in the USA as Pathways Housing First, offers intensive floating support services to clients who have been housed in ordinary accommodation, with a strong focus on service user choice of accommodation and
services
Including help with substance misuse, but also with housing issues, employment, education, physical health and general wellbeing and emotional and practical support. Floating support is provided by staff who visit people in their homes.
and a harm reduction approach to substance misuse; 3 A package of floating support provided through case management and joint working, which is standard practice across Scotland. The evidence base on this approach is less developed than for some other models, though it follows the logic of the flexible packages of support and harm reduction methods of model 2 and of the more successful services.
• There is no strong evidence on the effectiveness of preventive services to counteract potential homelessness among people with a history of substance misuse. Most prevention models aim to counteract the risk of homelessness across many groups, including people with a history of substance misuse.
• The evidence base on alcohol misuse by homeless and potentially homeless people was very rich until the early 1980s, when street drugs started to become much more widespread among street homeless populations. Since then research has tended to cover all forms of substance misuse, rather than solely alcohol. There is some evidence that
older
Over 50.
street homeless and hostel dwelling populations are more likely to misuse alcohol rather than street drugs. Younger homeless people use of alcohol alongside street drugs and other substances.
The review offered a series of broad recommendations including:
• realistic service outcomes need to be set; these will be higher for some service users than others;
• harm reduction/harm minimisation models appear to meet with more success, though their goals are more limited;
• the evidence base suggests a need for a mixture of services;
• longitudinal monitoring of service outcomes should be undertaken where possible;
• the evidence base suggests that service interventions may need to go on for some time, creating a need for a secure funding base;
• modification of generic services may be the best option in areas with few homeless people with a history of substance misuse.
One of the messages from the review is that the pursuit of abstinence, independent living and paid work for all homeless people with a history of substance misuse may not be realistic. Some are highly vulnerable and have ongoing health, personal care and other support needs which may demand long term interventions and preclude independent living or secure paid work. Harm reduction models are also more effective at retaining engagement with homeless people with a substance misuse problem than services which insist on abstinence. However, services which pursue abstinence do succeed with at least a minority. This suggests a need for either a mixture of services, or a flexible model which can accept when harm reduction and semi-independent living are the only realistic goals, but can also pursue abstinence and independent living as appropriate, with further adaptations It may not always be practical to develop specialist services for homeless people with a substance misuse problem in every area of Scotland, because the numbers of people in this group are relatively low in some rural areas. One option may be to develop services which cover several more rural authorities, another is to modify practice in general homelessness and substance misuse services, as well as to examine joint working where appropriate. for rural areas.
Unlike some other 'rapid' reviews, this thoughtful analysis did not rely on prior reviews, but dug down to the several thousand source research documents. The focus was on relevance to the Scottish context, so the evidence was confined to studies in developed western nations.
Key passages address the debate at the heart of US policy on housing homeless substance misusers:
• On the one hand, it is argued that access to a home of their own should be contingent on the client's success (as judged by clinicians) in resolving their substance misuse and other problems and developing life skills through rehabilitation and education programmes. During this process they live in transitional and usually shared accommodation controlled by the treatment provider. Without first gaining stability and skills, the concern is that clients who are not 'housing ready' will in any event lose their tenancies and fail to pay their mortgages.
• An alternative view which has gained ground in the USA, is that a home of your own (and, within normal constraints, of your own choice) is a right regardless of whether you have accepted help with – still less succeeded in – resolving substance misuse and other problems. In this 'housing first' model, access is provided or facilitated to permanent housing usually rented by the resident, and intensive wrap-around support services are offered which they are largely free to accept or reject, without this directly affecting their housing. In the core model such support is open-ended and adjusted according to the needs of that individual at that particular time.
Though not an essential feature, in the US context the contingent housing model usually judges clinical success in terms of
abstinence,
To the degree that in some studies this requirement has been formalised in to a contingency management regimen, according to which housing (and sometimes employment too) is made available or immediately withheld depending on the results of tests for drug use. See: http://findings.org.uk/count/downloads/download.php?file=Milby_JB_6.txt.
while the housing first model is above all concerned with maintaining housing stability and is willing to accept ameliorations of substance misuse problems which enable the resident to sustain their tenancy. In all these models, typically the caseloads also suffer from serious mental health and other medical problems, partly because in the US system these open up access to welfare payments which can help fund accommodation.
A recent US review argued that enthusiasm for housing first approaches is based on research which has yet to show these work for severely addicted populations, as opposed to the substance using mentally ill caseloads recruited in to the studies. This means, it was argued, that routine application of those approaches to addicted populations would be premature and possibly risky. It was also argued that the failures of treatment-based contingent housing models to achieve long-term housing stability may be less to do with the effectiveness of those treatments, than with the failure of public and private housing sectors to accommodate former problem drinkers and drug users.
While the featured review sees a place for both traditions, variations on the housing first model are seen as generally the most appropriate and cost-effective approach for homeless substance dependent adults, and one more in line with current UK practice. In particular, insistence on abstinence as a condition for housing or continued housing is seen as excluding vulnerable populations from these services, and condemning many who do access them to failure and consequent loss of accommodation. The consequence seen in some of the studies is that housing first models particularly score in terms of improved stability of housing, even if substance misuse may be relatively unaffected. But since either type of approach, and shades in between, may be best for an individual at a particular stage, the review ends up calling either for flexibility within a service, or for a range of services built on different models. There is, however, a clear rejection of predetermined requirements or predetermined goals which risk being unrealistic for many actual or potential service users.
Whatever the approach adopted, the context is one of substantial need but restricted access to decent affordable housing. Across English harm reduction and treatment services, in 2006 a survey found that just under half the responding clients were living in their own homes and 38% had sought help with housing. Around 60% said their housing situation had improved since attending the service. The figures were similar (except that just a fifth had sought help) in 2007 at harm reduction, prescribing and counselling services. Not surprisingly, need was most acute at inpatient and residential services, where in 2007, 54% of responding clients had not been in settled or permanent accommodation before entering treatment, including 20% in temporary accommodation and 15% of no fixed abode. Among the 151 services which responded to the survey, just four were supported housing services. These surveys were dependent on services and clients choosing to respond. A more representative national sample found that before starting drug addiction treatment in 2006, 40% of patients had been living in unstable accommodation; some of the remainder were living with friends and family or in hostels rather than in a home of their own. In Scotland a similar But which included prison treatment services. national survey in 2002 recorded 26% of treatment starters as homeless; among the heroin users, 35% had recent accommodation problems.
In the context of a shortage of suitable housing, difficulties in securing national and local investment in response to these needs are seriously impeding the English national drug policy's reintegration agenda, and housing is seen as the single greatest obstacle to securing treatment gains through aftercare provision. Across the UK housing is a major barrier to reintegration of substance users through employment. Scotland has been relatively energetic in both tackling homelessness among substance users and other vulnerable groups, and in preventing homelessness, but coordination between treatment services and housing departments has remained a concern.
Thanks for their comments on this entry in draft to Nicholas Pleace of the Centre for Housing Policy at the University of York. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 29 July 2009 Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
The Drug Treatment Outcomes Research Study (DTORS): final outcomes report STUDY 2009
Recovery management and recovery-oriented systems of care: scientific rationale and promising practices REVIEW 2008
Peer-based addiction recovery support: history, theory, practice, and scientific evaluation REVIEW 2009
Matching resources to needs is key to achieving 'wrap-around' care objectives NUGGET 2006
Toward cost-effective initial care for substance-abusing homeless STUDY 2008
Addressing medical and welfare needs improves treatment retention and outcomes NUGGET 2005
Wet day centres in Britain part 2: Care Control Challenge IN PRACTICE 2005
Self-financing resident-run houses maintain recovery after treatment NUGGET 2008
Cognitive-behavioral treatment with adult alcohol and illicit drug users: a meta-analysis of randomized controlled trials.Magill M., Ray L.A. Request reprint
Journal of Studies on Alcohol and Drugs: 2009, 70, 516–527.
Cognitive-behavioural therapies are among the most widespread and influential approaches to substance use, yet this analysis found they conferred just a small advantage over other therapies. Perhaps other features are more important than the therapeutic 'brand'.
Abstract Cognitive-behavioural These therapies target cognitive, affective, and situational triggers for substance use and provide skills training specific to coping alternatives. For alcohol or illicit drug use, these approaches often include the following strategies: identifying intrapersonal and interpersonal triggers for relapse; coping skills training; drug refusal skills training; analysis of the functions substance use serves for the patient; and promoting activities related to non-use of substances. treatment models are among the most extensively evaluated interventions for alcohol or illicit drug use disorders, yet this body of work has not been synthesised using meta-analytic A study which uses recognised procedures to summarise quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually. techniques since 1999. This analysis aimed to update earlier analyses by synthesising results from randomised controlled trials of cognitive-behavioural treatment for adults diagnosed with alcohol or illicit drug use disorders, and to extend these analyses by identifying client or treatment factors which predict the magnitude of the treatment's impact. 52 studies One of the studies (Project MATCH) had two arms testing the interventions on different samples of drinkers, so contributed two results to the analysis. published in English between 1980 and 2006 were found, involving 9308 individuals. Most were conducted in the USA. 80% The remainder also enrolled individuals with a diagnosis of abuse. enrolled only individuals diagnosed as dependent on alcohol or other drugs. About two thirds did not exclude people with psychiatric problems. Other than suicidal or homicidal ideation and active psychosis. Nearly all used manual-guided programmes. An effect size A standard way of expressing the magnitude of a difference (eg, between outcomes in control and experimental groups) applicable to most quantitative data. Enables different measures taken in different studies to be compared or (in meta-analyses) combined. Based on expressing the difference in the average outcomes between control and experimental groups as a proportion of the variability in the outcome across both groups. the most common statistic used to quantify this difference is called Cohen's d. Conventionally this is considered to indicate a small effect when no greater than 0.2, a medium effect when around 0.5, and a large effect when at least 0.8. was calculated for each study to provide a common metric for expressing the strength of impact When these were available, biological tests of substance use were relied on, then assessments of substance use frequency, and when neither of these was available, proportions of the samples recorded as using substances. of the interventions.
Most of the studies compared cognitive-behavioural therapies against treatment as usual, many against other specific therapies, and a few against no treatment. Another few tested cognitive-behavioural therapies as an add-on treatment. Across all these studies, cognitive-behavioural therapies improved substance use outcomes by a small but statistically significant degree. The size of this effect meant that with cognitive-behavioural therapy, another 8% of people would do better than the typical Specifically, 58% of cognitive-behavioural patients performed better than the median for the comparison group. person in the comparison group whose treatment did not include cognitive-behavioural therapy. However, there was significant variation in impact across the studies.
As expected, the therapy's effectiveness was thrown in to sharpest relief when compared to no treatment. The large effect size across these studies meant that another 29% of people had better substance use outcomes than the typical non-treated individual in the comparison group. Once again however, there was significant variation in impact across the studies. In contrast, there was a consistent but much smaller improvement in outcomes when the comparison group received either treatment as usual, or another specific therapy.
Contradicting conclusions reached by other analysts, there was no evidence that the benefits of cognitive-behavioural therapies persisted and/or grew over time more than those from other approaches. Impacts registered in studies with post-treatment follow-ups were slightly lower than the overall impact, and the relative benefits of cognitive-behavioural therapies diminished between 6–9 months after treatment and 12 months.
Across the six studies where the main problem drug was cannabis, cognitive-behavioural therapies had a consistent moderate impact which was larger than the all-drugs average. This meant that instead of (as across all the studies) another 8% of people doing better than typical for the comparison group, in the cannabis studies the figure was 19%. Impacts remained significant and consistent but small for alcohol studies, variable and small when the problem drugs were either stimulants or opiates, but became insignificant when the participants used multiple drugs.
Among the more detailed findings were that no overall advantage was gained when cognitive-behavioural therapy was an add-on to another treatment programme. However, in most studies the core programme was a contingency management regimen rewarding patients for abstinence and/or recovery-promoting activities, and the findings were variable across the studies to the point where leaving out one outlier resulted in a significant positive impact. Whether therapy was delivered in an individual or group format, or as part of the initial treatment or as aftercare, made no significant difference to its effectiveness. There was a larger impact when the therapy supplemented other psychosocial therapies than when it supplemented medication-based treatment, but this finding was too dependent on the particular studies included in the analysis to be considered a generalisable principle. The relative benefit of cognitive-behavioural therapies was unaffected by the age of the participants or whether they suffered from mental illness, but was stronger the more women were included in the samples – possibly an artefact of other features Specifically, study sample size and the strength of the comparison condition. of the studies. Cognitive-behavioural programmes with fewer sessions tended to have greater benefits, but this might have been because the more extended programmes were compared against stronger alternative treatments. Even when these and other features of the studies had been taken in to account, there remained significant variation in the extent to which cognitive-behavioural therapies improved substance use outcomes.
The analysts concluded that cognitive-behavioural therapies had demonstrated their utility across a large and diverse sample of studies and for different types of substance use dependencies, and had done so under rigorous conditions for establishing efficacy, including comparisons with other active treatments. Effects were strongest among cannabis users and might also have been larger with women, when the therapies were relatively brief, and combined with another psychosocial therapy rather than medication. Group-based delivery was no less effective than individual.
Cognitive-behavioural approaches are perhaps the world's most commonly used and widely researched formal psychological therapies, applied often with good results to a range of psychological problems. For substance use too, these therapies have an impressive research record (for example for problem drinking), but this is partly because more good quality studies have been done than in respect of competing approaches.
Despite its prominence, theoretical pedigree, and an extensive research effort which has refined the therapy in to expert manuals (for example, 1 2), the featured analysis indicates that overall the advantage conferred by cognitive-behavioural therapies over the alternatives is minor. That verdict is all the more disappointing since in many cases the alternatives For example relaxation, education, non-directive social support group, brief motivational counselling, meditation, discussion groups, supportive counselling. seemed weak and/or not designed to be therapeutic. It is by no means clear that cognitive-behavioural therapies are more effective than other similarly extensive and coherent approaches. Studies which directly tested this proposition often found little or no difference, even when the competing therapy amounted simply to well structured medical care (1 2). Reviewers too have broadly reached this conclusion in respect of the use of substances in general, cannabis in particular (1 2), methamphetamine, and these and other stimulants, including cocaine. In respect of alcohol problems, a recent analysis has concluded that any differences between outcomes from psychosocial therapies are likely to have been due to chance or the allegiance of the researchers. Finally, a meta-analysis A study which uses recognised procedures to summarise quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually. has combined results from studies comparing cognitive-behavioural therapies only to other well structured and specified psychotherapies rather than to deliberately weaker alternatives. The review included patients with a variety of psychiatric complaints, including substance use problems. It found cognitive-behavioural therapies clearly preferable for depression and anxiety but not On the basis though of just three studies. substance use problems.
In the featured analysis, only with respect to cannabis use studies did cognitive-behavioural approaches record a major advantage. But of these six studies, three included no-treatment control groups, and when there was a comparison treatment, often it was much briefer then the cognitive-behavioural therapy, or in one case, deliberately non-interventionist. Greater impact across these studies might simply have reflected the relative weakness of the comparators.
Findings of little difference between outcomes from different therapies fit with the discovery that, despite in theory working through very different psychological processes, in practice cognitive-behavioural and other therapies create change through similar mechanisms. Studies have rarely confirmed that the theoretical mechanisms behind cognitive-behavioural therapies actually were responsible for substance use outcomes. Such findings direct attention away from the 'brand' of the therapy to 'common factors' which cut across different therapies, such as entering a setting within which the patient expects to be helped to get better, the credibility of the therapy to both patient and therapist, its ability to (for that patient) make ordered sense of the patient's 'disorder', in doing so to structure a route out of that disorder which generates optimism, its ability to provide a platform for engaging the client in their recovery, and the therapist's ability to create a supportive environment which facilitates these processes. Perhaps the greatest common factor lies in the patients and clients. Typically they have reached the point where they desperately want to get better, have realised they need help to do so, and have decided to follow a culturally sanctioned route to gaining that help – formal treatment.
Beyond the type of therapy, promising routes to improving outcomes include focusing on the interpersonal style of the therapist, including the degree to which they exercise discretion and flexibility, and dimensions of the therapies such their degree of structure, directiveness, focus on emotional content, emphasis on engineering social support, and how far these match the personality and needs of the patient. In turn, common factors and therapeutic dimensions are nurtured or obstructed by the service's organisational climate Such as its openness to change and new learning, and an atmosphere of trust in which staff can exchange views and raise issues. and the quality of its procedures. Such as whether patients are effectively encouraged to attend, adequately assessed and provided the services they need, proactively linked with other sources of support, and continue to be monitored after initial treatment. In turn these features are nested within the wider regulatory and professional environment. See these earlier Findings analyses for more on common factors (1), therapeutic styles and cross-cutting features of therapies (1 2 3 4 5 6 7), organisational climate (1) and procedures (1 2 3 4 5 6 7 8), and the wider environment (1 2).
Where cognitive-behavioural approaches sometimes have scored better than alternatives is in the persistence of their effects. Gains relative to other therapies have been found to emerge only after the end of therapy and to grow over the follow-up period. This has been observed for some psychological and psychiatric problems (1 2), for cocaine use problems (1 2), and recently in respect of cannabis dependence. The featured analysis seems to contradict this impression, but its finding of diminishing returns in the year after treatment reflects results from different sets of studies at the different time periods. Other ways the studies differed might account for this apparent waning. More convincing are results from different time points within the same study.
Recent national guidance from Britain's National Institute for Health and Clinical Excellence (NICE) recommended against cognitive-behavioural therapy as a routine treatment for drug problems, suggesting its main role was in tackling accompanying depression and anxiety. However, the analyses on which this was based did not show that cognitive-behavioural therapy was ineffective, just that it was not convincingly more effective than other well structured therapies. If this is the case, then the decision between such therapies can safely be taken on the grounds of what makes most sense to patient and therapist, the therapist's training, availability, and cost. In respect of cost and availability, cognitive-behavioural therapy may (more evidence is needed) prove to have two important advantages. The first is that effects may persist and even amplify without having to continue in therapy. The second is that it lends itself to manualisation to the point where it can be packaged as an interactive computer program and made available in services lacking trained therapists – potentially a crucial advantage for widespread implementation. In the UK implementation has been held back by the shortage of therapists, an obstacle currently being addressed by a government-funded training initiative.
Thanks for their comments on this entry in draft to Molly Magill of the Center for Alcohol and Addiction Studies at Brown University in the USA. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 28 July 2010 Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
A meta-analysis of motivational interviewing: twenty-five years of empirical studies REVIEW 2010
Behavioral couples therapy (BCT) for alcohol and drug use disorders: a meta-analysis REVIEW 2008
A randomized trial of individual and couple behavioral alcohol treatment for women STUDY 2009
Continuing care research: what we have learned and where we are going REVIEW 2009
Initial preference for drinking goal in the treatment of alcohol problems: II. Treatment outcomes STUDY 2010
Brief interventions short-change some heavily dependent cannabis users NUGGET 2005
