EFFECTIVENESS BANK BULLETIN 7 November 2008

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Benefits of residential care preserved by systematic, persistent and welcoming aftercare prompts ...

Internationally proven community alcohol crime and harm reduction programmes feasible in Britain ...

Brief contact and written advice as effective as a longer talk for heavy drinking hospital patients ...

International review and UK guidance weigh merits of buprenorphine versus methadone maintenance ...

Benefits of residential care preserved by systematic, persistent and welcoming aftercare prompts

A US inpatient treatment centre has shown that systematically applying simple prompts and motivators can substantially improve aftercare attendance and help sustain progress made during initial treatment. The findings offer a way to preserve the benefits of the investment made by patients, services, and funders.

FINDINGS The Salem Veterans Affairs medical centre offers a 28-day residential rehabilitation programme to its alcohol and/or drug dependent ex-military patients. To sustain sobriety, staff stressed the importance of aftercare but attendance was poor. A unique series of studies¹ had previously shown that attendance radically improved as step by step researchers added enhancements, culminating in a report which suggested But the samples were small and results barely significant. that there were consequent reductions in drinking and related problems.

A further study² has now tested the impact of the entire package Plus further enhancements, termed in the study Contracting, Prompting and Reinforcing (CPR) continuing substance abuse treatment. on aftercare attendance and more robustly assessed changes in substance use. 150 eligible patients agreed to join the study and were randomly allocated to the centre’s standard procedure or to the enhanced package. During the final days of their stay, standard procedure patients were encouraged to attend the centre’s aftercare groups and individual sessions, as well as mutual aid groups such as NA and AA. Initial appointments and/or attendance schedules were agreed and listed in an aftercare 'contract' handed to the patient, who was also shown a motivational video.

For the enhanced version, the contract was strengthened by asking patients to commit in writing (witnessed by the therapist) to over the next eight weeks The aim was to retain patients for at least three months of treatment overall, the minimum associated with improved outcomes in this population. attend weekly groups and AA/NA meetings and monthly individual sessions. Veterans Affairs’ data showing that aftercare attendance was associated with abstinence was used to motivate agreement. Therapists also explained the reminder system and showed patients the awards (see next paragraph) for attendance specified in the contract. After eight weeks patients were invited to re-contract to continue in aftercare for eleven months in total.

Letters from the therapist, Saying they were pleased the patient had chosen to join their group and that they looked forward to seeing them. appointment cards Which also tallied the patient’s attendance to date. and automated telephone reminders prompted patients to attend the next session in a few days time. Non-attendance was followed by a letter and phone call from the therapist. Awards consisted of medallions and certificates handed out during individual aftercare sessions. Further reinforcement took the form of a handwritten letter congratulating the patient on initiating aftercare followed by another after three sessions.

Researchers Unaware of to which procedure patients had been allocated. were able to re-assess around 80% of patients two, five and 11 months after they left treatment, reassuring them that their responses Urinalysis results confirmed the accuracy of their answers regarding substance use. were confidential. Compared to the standard procedure, the enhancements led 12% (95% v. 83%) more patients to initiate aftercare and nearly 30% more (75% v. 45%) to attend at least two sessions a month over the first two months. Attendance tailed off until after five months just 20–25% remained continuously in aftercare and after 11 months 12–13%. Nevertheless, nearly twice as many intervention patients attended some form of aftercare (including mutual aid groups) during the last three months of the follow-up (40% v. 22%).

This persisting attendance advantage appeared to account in part for impacts on substance use. Eleven months after leaving treatment, nearly 20% more (57% v. 37%) enhanced patients had been abstinent In contrast, the average intensity of substance use did not differ between the two sets of patients and nor generally did the severity of related problems. from alcohol and drugs for the past three months. The difference had grown over the preceding six months as more of these patients stopped using.

IN CONTEXT Because the centre served ex-military personnel there were very few women. All the studies excluded participants who would have had significant difficulty Due to distance, lack of transport or work commitments. Eliminating these practical barriers probably allowed the influence of the interventions to show through so clearly. attending an aftercare centre.

The highest attendance gains were observed while contracting and rewarding procedures were also at their height (the first two months) and for the type of aftercare provision (the centre’s own sessions) most explicitly targeted. From the prior studies, we know that each of the elements in the package added to its impact. Involving the patients themselves in formulating the contract seems likely to have deepened their commitment to fulfilling it. By signing it they acknowledged research indicating that aftercare tripled the chances of staying sober. Refusing would have meant admitting to themselves and to their therapist that they did not wish to improve their chances in this way. Phone calls and personal, handwritten letters from therapists signified individual attention and that someone cared enough to notice the patient’s achievements and to bother when they went missing.

The pattern of abstinence outcomes suggests that intervention patients, systematically encouraged and prompted to stay in or return to aftercare, felt more inclined to seek help after they lapsed or relapsed. A welcoming, non-punitive (‘Come back – we’d like to see you.’) attitude would have made it easier. The result it seemed was that more resumed abstinence over the last months of the follow-up.

Gains from the enhanced package might have been greater still if awards had been made in front of peers This was trialed in one of the earlier studies but in the featured study the opportunity had to be foregone because some of the patients in each group would have been from the standard care set. at group therapy sessions and if it had replaced typical procedures. Even the standard comparator was an advance on the most basic procedure tested in an earlier study and probably also on what typically happens to encourage aftercare attendance.

Earlier studies from Salem and related work were reviewed by Drug and Alcohol Findings in parts one³ and two¹ of the Manners Matter series. These concluded that treating the patient as an individual, being welcoming, and showing respect and caring persistence, are among the hallmarks of services which retain clients. The reviews argued that there is no conflict between these qualities and efficient administrative procedures of the kind used to deliver reminders in the featured study. Such procedures are needed to give practical expression to the qualities and values which motivate them. In turn, these procedures will not have the desired impact unless they express these qualities; a cold or standardised reminder letter signifies that the sender cares little about the individual and whether they turn up or not. Personal approaches are more effective.

PRACTICE IMPLICATIONS The interventions are practical In terms of low staff time and resource commitment and simplicity of implementation. and probably also widely acceptable because they involve neither material rewards nor material or other sanctions. Behind them is the principle of prompting and rewarding attendance directly and immediately rather than expecting this to be motivated entirely by the patient’s interest in their long-term recovery.

If (strongly argued in some quarters) Britain is to re-balance its treatment system to offer more residential treatment slots, aftercare provision and encouragement of the kind trialed in the study will be crucial to help avoid or overcome relapse and to sustain support for services which might otherwise be seen as costly revolving doors. Residential settings radically alter the patient’s environment, enabling residents who would otherwise be unable to do so to attain abstinence. By the same token, relapse is likely when they return to the environment in which they were previously unable to stop using, unless steps have been taken to alter this, or to sustainably alter how the patient reacts to it. For heroin dependent patients in particular, aftercare is needed to reduce the risk of overdose due to relapse at a time when the patient has lost their tolerance to opiate-type drugs. In the English NTORS study,⁴ within a fortnight of leaving residential or inpatient care, half the former heroin users had returned to the drug. In other⁵ studies⁶ the consequence has been extremely high post-discharge death rates.

Guidance⁷ for England stresses the need for aftercare following residential rehabilitation and continued treatment following detoxification. Arrangements are often complicated by the fact that residents return to their home areas, beyond the reach of direct aftercare provision by the initial service. However, the principles behind the featured intervention could be applied in the home area. Most services do make some arrangements, but in a survey⁸ 4 in 10 residents were at best unclear who was to coordinate their aftercare, and care plans appeared to rely on mutual aid groups for ongoing support. Valuable as they are, arranging and monitoring attendance and responding to missed meetings is less feasible than with formal aftercare arrangements.

Thanks for their comments on this entry in draft to Steven Lash of the Salem Veterans Affairs Medical Center and Bill Puddicombe, Chair of the European Association for the Treatment of Addiction (EATA). Commentators bear no responsibility for the text including the interpretations and any remaining errors.

1 Ashton M. Can we help? Drug and Alcohol Findings: 2005, 12, p. 4–7, 16–19. For an analysis of the entire series see the panel on p. 17.

2 FEATURED STUDY Lash S.J. et al. Contracting, prompting, and reinforcing substance use disorder continuing care: a randomized clinical trial. Psychology of Addictive Behaviors: 2007, 21(3), p. 387–397.

3 Ashton M. et al. The power of the welcoming reminder. Drug and Alcohol Findings: 2004, 11, p. 4–7, 16–18.

4 Gossop M. et al. Factors associated with abstinence, lapse or relapse to heroin use after residential treatment: protective effect of coping responses. Addiction: 2002, 97, p. 1259–1267.

5 Best D. et al. Overdosing on opiates parts I and II. Drug and Alcohol Findings: 2000, issues 4 and 5.

6 Davoli M. et al. Risk of fatal overdose during and after specialist drug treatment: the VEdeTTE study, a national multi-site prospective cohort study. Addiction: 2007, 102, p. 1954–1959.

7 Bradbury C. et al. Improving the quality and provision of tier 4 interventions as part of client treatment journeys: a best practice guide. National Treatment Agency for Substance Misuse, September 2008.

8 Abdulrahim D. et al. The 2007 user satisfaction survey of tier 4 service users in England. National Treatment Agency for Substance Misuse, May 2008.

LINKS Background notes | The power of the welcoming reminder | Can we help? | Nuggets 14.7 13.1 11.7 | Nuggette 10.5
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Internationally proven community alcohol crime and harm reduction programmes feasible in Britain

Though unable to securely document outcomes, three projects have shown that British communities can generate the kind of coordinated action which new reports from the USA and Sweden have shown curtail alcohol-related violence and injury, creating substantial cost-savings for society.

FINDINGS Rather than targeting risky drinkers, all the projects targeted high-risk neighbourhoods, aiming to modify features of the social and physical environment which generate alcohol-related violence and disorder.

UK From 2004, parallel projects Jointly known as the UK Community Alcohol Prevention Programme. in Glasgow, Cardiff and Birmingham sought to generate action locally to promote responsible service of alcohol in bars and shops, enforce licensing and allied laws, limit alcohol outlets, and to modify the environment and transport services to improve safety. Awareness-raising initiatives aimed to stimulate support from residents, politicians, licensees and local services. The projects were among only five in the UK found to meet international criteria¹ for ‘multi-component’ programmes which simultaneously bring a range of influences to bear on alcohol problems.

The featured report² documented how all three were able to generate activity of the kind they sought. In the absence of a systematic evaluation, official statistics and data gathered by the projects themselves was used to assess whether this activity had reduced alcohol-related problems – problematic, because the projects’ effects could not easily be isolated and the figures fluctuated due to factors other than the real levels of crime or injury.

Perhaps clearest was the impact in Birmingham, where in the targeted area (a transport corridor crossing three suburbs) the project started with a clean slate in terms of existing community organisation. Birmingham too seems to have had the strongest enforcement component, shown by research ( In context) to be the greatest single influence. Trading standards staff visited all the area’s alcohol outlets, alerting staff to their responsibilities and warning of future ‘sting’ operations to test whether outlets would sell to underage youngsters. Police recorded reports of licensing infringements, followed up with an advice visit, and mounted highly visible operations similar to those used in relation to illicit drugs.

Possibly as a result, offences such as vehicle crime, domestic burglary and robbery in the area fell by over a third compared to just 9% in a neighbouring area, and public place wounding fell by 30% compared to 17%, though the numbers involved were small. Unlike elsewhere, after the project was established few premises sold to underage test purchasers and most asked for proof of age.

USA The US project targeted two poor neighbourhoods relatively crowded with alcohol outlets and blighted by crime and alcohol-related problems. A robust Staggered implementation at the two sites and before and after measures benchmarked against the rest of the city offered multiple checks on whether the interventions were responsible for any improvements.evaluation³ documented reductions in violent crime and injuries, among the priorities for UK projects.

Local community organisations prioritised control of alcohol outlets to tackle underage drinking and alcohol-related violence. Training in responsible beverage service was taken up by 40–70% of outlets after personal and persistent approaches by project staff and police. Shop managers were warned that police would mount test purchases by underage youngsters. An accompanying officer immediately initiated proceedings against offending outlets. Given this backing, there was a clear reduction in sales, prompting replication city-wide. Similar operations were not undertaken in bars where, without enforcement backing, staff training on its own did not lead more premises to refuse service to drunk patrons. The bottom-line finding was that across both sites, the interventions were followed by significantly greater falls than in the rest of the city in assaults According to both police and medical records. and injuries Before the waters were muddied by city-wide implementation, there was also a greater reduction in injuries specifically related to drinking or drug use. due to traffic accidents. Some of the relative reductions were substantial – over a third for assaults and traffic accidents. Given the social costs imposed by such incidents, the project was likely to have been cost-beneficial.

SWEDEN The Swedish report⁴ showed that such programmes can indeed save society money. It attached monetary values to an earlier finding⁵ that a city-centre programme targeting licensed premises reduced violence Represented by reports to the police. by 29%. The resulting estimate was that it saved society 39 times more than it cost, primarily due to reduced criminal justice expenditures. The calculations were subject to potential error but even when savings were limited to police work, the most securely estimated element, they were seven times greater than costs. A dip in quality of life after being the victim of a crime meant that the interventions also gained one quality adjusted life year (QALY) for each 3000 Euros spent, well within the Swedish yardstick of 54,000 Euros.

After an upsurge in violence when on-licence outlets expanded, Stockholm County Council initiated the programme to curb serving of drunk patrons in the central district. Test purchases by apparently drunk actors generated support for responsible beverage service training, later made a condition of licence renewal for late-night venues. Liquor law enforcement (especially the ban on serving drunk patrons) was stepped up by police and the licensing board, largely in the form of warning letters rather than formal proceedings. Resulting reductions Inevitably the calculations incorporated arguable assumptions, but the magnitude of the gains were such that substantial benefits seem certain. in violence were estimated on the basis of before and after trends in the intervention district compared to the next most similar area. Benefits grew in line with the unfolding of the programme, reinforcing the case that this was an active ingredient. Once again, enforcement was thought to have been the main influence. Even in the comparison area, underage sales fell after activists organised test purchases and notified offenders to the police, who banned some from selling alcohol.

IN CONTEXT Reviewers⁶ have concluded that the ‘environmental’ approach⁷ (controlling the geographic, retailing and social environments in which alcohol is distributed, sold or consumed, and stepping up enforcement) tested in these studies can be more effective than trying to affect individuals through education or persuasion. However, impacts sometimes remain modest, partly because the scope for local action is limited by national or regional laws.

Police or licensing authority action backed by ultimate legal sanctions can on its own have a major impact, but requires other components to amplify and sustain its effects. Publicity makes authorities aware of the need for action and licensees aware of the potential consequences of failing to comply, while local lobbying helps gain support for the required intensity and persistence of effort.^{8 9} Possibly enforcement works because it stimulates defensive management actions¹⁰ such as firm and clear policies on adhering to regulations and a system for monitoring staff compliance. Commercial considerations often mitigate against such policies, but can also generate them if otherwise the business faces closure or costly restrictions.

British research includes a landmark study¹¹ based on test purchases by underage youngsters which suggested that many vendors’ primary concern was not to avoid underage selling as such, but to avoid successful prosecution for selling to children who were clearly underage. In Cardiff,¹² the main lessons of a programme to curb alcohol-related city-centre violence and disorder seemed to be that intensive implementation is needed to have a major impact. Planning and licensing decisions which increase the density of drinking outlets, and competitive and financial pressures driving the policies of large club or pub chains, can counter the benefits. However, benefits remained and were probably enough to create substantial cost-savings for society. Though not formally evaluated, similar enforcement-led programmes¹³ stimulated by the 2004 English national alcohol strategy have encouraged licensee compliance and appear to have reduced alcohol-related crime and disorder. Sales to underage youngsters have also been curbed by recent test purchase¹⁴ operations¹⁵ allied with trading standards and/or police follow-up.

PRACTICE IMPLICATIONS The UK report argued for environmentally-based community projects on the grounds that these probably represent the best chance for minimising harm in the face of national deregulation and promotion of alcohol consumption. Yet the leverage local projects can exert depends partly on the tools made available by national laws and policies to the projects and to the authorities they seek to influence, tools abolished or weakened or by deregulation. Given adequate powers, local lobbying and coordination can maximise their potential and tackle factors beyond the reach of the law.

So a crucial issue is how far national UK frameworks provide the required support and legislative tools. New British alcohol strategies and laws and attendant funding do provide a basis for projects similar to those featured, particularly the powerful tool of test purchases to expose underage service. But at the same time (less so in Scotland) they limit the scope for licensing authorities to respond to community concerns. Click here for summaries of the situations in England, Wales and Scotland.

Flexibility is essential because the impacts of commonly used tactics depend on the environment with which they interact; a different mix works best in different situations.^{1 10} The ideal¹⁶ is when national support and regulations afford localities the required tools within an accountability framework which motivates effective action, but which also gives localities discretion on what to target and how.

There are however some general principles. Regardless of the interventions built upon them, test purchasing and the construction of a database linking untoward incidents to particular premises are important in motivating and targeting action and assessing its impact. The visible and credible possibility of enforcement action against alcohol outlets must be persistently maintained if it is to have anything but a fleeting impact. Attention should be paid both to alcohol consumption and the factors¹⁷ (such as crowding, transport problems, divorcing alcohol from food, poorly kept or managed premises, glasses easily transformed in to weapons, inadequate training and monitoring of staff) which potentiate violence and disorder.

In the UK guidance on local strategies¹⁸ is available and a new database¹⁹ features examples. International lessons on community alcohol interventions have also been usefully encapsulated.²⁰ These include: devolve decision-making to the community while supplying research-based knowledge; rapid feedback of results motivates participants and keeps projects on track; recruit influential and respected local leaders; considerable lead-in time is needed to build the social and organisational infrastructure for community action, and projects need a few years to fully deliver; project staff must expect and permit adaptation not just of methods but also aims in response to the community’s strengths and self-perceived needs; success comes easier in communities where the project’s aims are already high on the agenda; community norms and alcohol availability restrictions have their greatest impacts in self-contained, stable communities whose residents and businesses cannot easily escape their impact; a key element is the surer detection and sanctioning of transgressors brought about by the more intensive use of existing legal powers; however, these legal powers must in the first place have the potential to be effective.

Thanks for their comments on this entry in draft to Willm Mistral of the University of Bath. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

1 Thom B. et al. Multi-component programmes: an approach to prevent and reduce alcohol-related harm. Joseph Rowntree Foundation, 2007.

2 FEATURED STUDY Mistral W. et al. UKCAPP: an evaluation of 3 UK Community Alcohol Prevention Programs. Final report for the Alcohol Education & Research Council. University of Bath and Avon & Wiltshire Mental Health Partnership NHS Trust, 2007.

3 FEATURED STUDY Treno A.J. et al. The Sacramento Neighborhood Alcohol Prevention Project: outcomes from a community prevention trial. Journal of Studies on Alcohol and Drugs: 2007, 68(2), p. 197–207.

4 FEATURED STUDY Månsdotter A.M. et al. A cost-effectiveness analysis of alcohol prevention targeting licensed premises. European Journal of Public Health: 2007, 17(6), p. 618–623.

5 Wallin E. et al. Alcohol prevention targeting licensed premises: a study of effects on violence. Journal of Studies on Alcohol: 2003, 64(2), p. 270–277.

6 Giesbrecht N. Alcohol, tobacco and local control: a comparison of several community-based prevention trials. Nordisk Alkohol- & narkotikatidskrift (Nordic Studies on Alcohol and Drugs): 2003, 20(English suppl.), p. 25–40.

7 Holder H.D. Prevention of alcohol problems in the 21st century: challenges and opportunities. American Journal on Addictions: 2001, 10, p. 1–15.

8 Holder H.D. Community prevention of young adult drinking and associated problems. Alcohol Research & Health: 2004/2005, 28(4), p. 245–249.

9 Toomey T.L. et al. Environmental policies to reduce college drinking: an update of research findings. Journal of Studies on Alcohol and Drugs: 2007, 68, p. 208–219.

10 Grube J. et al. Preventing impaired driving using alcohol policy. Traffic Injury Prevention: 2004, 5(3), p. 199–207.

11 Willner P. et al. Alcohol sales to underage adolescents: an unobtrusive observational field study and evaluation of a police intervention. Addiction: 2000, 95(9), p. 1373–1388.

12 Maguire M. et al. Reducing alcohol-related violence and disorder: an evaluation of the ‘TASC’ project. Home Office, 2003.

13 Home Office. Alcohol Misuse Enforcement Campaign 2: communications toolkit. Home Office, 2004.

14 Department of Health [etc]. Safe. Sensible. Social. The next steps in the national alcohol strategy. HM Government, 2007.

15 Local Government Association. Unfinished business: a state-of-play report on alcohol and the Licensing Act 2003. LGA, 2008.

16 Giesbrecht N. Community-based prevention of alcohol problems: addressing the challenges of increasing deregulation of alcohol. Substance Use & Misuse: 2007, 42(12–13), p. 1813–1834.

17 Plant M.A. et al. Safer bars, safer streets? Journal of Substance Use: 2007, 12(3), p. 151–155.

18 London Drug and Alcohol Network and Alcohol Concern. Local alcohol strategy toolkit. LDAN and Alcohol Concern, 2004.

19 Alcohol Concern. HubCAPP: Hub of Commissioned Alcohol Projects and Policies.

20 Graham K. et al. Community action research: who does what to whom and why? Lessons learned from local prevention efforts (international experiences). Substance Use and Misuse: 2000, 35(1&2), p. 87–110.

LINKS Background notes | Just say, 'No sir' | Nuggets 13.10 11.10 10.9 5.12 4.13 1.10 | Nuggette 13.6
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Brief contact and written advice as effective as a longer talk for heavy drinking hospital patients

In Scotland, handing heavy drinking medical inpatients a guide to sensible drinking led to declines in consumption as great as more extended advice, seemingly demonstrating the impact of being professionally identified as a risky drinker and the suggestion (even if conveyed by a minimal intervention) that you should consider cutting back.

FINDINGS Over six months the featured study¹ recruited 215 adult patients from among the 2307 admitted as inpatients to 16 wards in a general hospital. Steps were taken Though there was no upper limit on how much patients could drink before being excluded from the study, none of the wards dealt specifically with substance dependence and (along with other criteria) patients with a history of drug or alcohol dependence or mental illness, or who had been admitted primarily for treatment of alcohol-related complaints, were excluded from the study. to exclude patients known to have serious drinking problems. Among the 819 not excluded for these or other reasons, screening tests identified 215 who had drunk excessively Operationalised as over 21 UK units for men and 14 for women, 168gm and 112gm alcohol respectively. over the past week. In two-week blocks (to reduce ‘cross-contamination’ between patients), they were allocated to one of three alcohol advice options.

About a third (the control group) were left to the wards’ usual care. Another third met a mental health nurse who handed them a written guide to sensible drinking.² The same nurse engaged the remaining third in a roughly 20-minute discussion³ intended to bolster confidence in their abilities to control drinking and to lead them to the point where they set their own change goals.

Six months later 172 of the 215 were reinterviewed. Typically men in their 40s, before being admitted half had drunk at least 35 UK units 280gm alcohol. of alcohol in the past week. Those allocated to either intervention had on average cut their weekly drinking by 14 or 15 UK units. 112–120gm alcohol. Compared to assessment and normal care, both interventions had led to a further reduction of 10 units 80gm alcohol. a week, highly unlikely to have occurred by chance. However, the interventions still left the patients drinking heavily; on average they still consumed perhaps Based on the average consumption in the full initial sample minus the reduction seen in those retained in the study in the intervention groups. about 30 units a week.

IN CONTEXT There are some concerns over the reliability of the findings (notably, many control group patients could not be reinterviewed), but none threaten the conclusion that the interventions led to equivalent drinking reductions relative to screening, research assessment and normal care only.

Accepting this, a key question becomes why such a well structured brief intervention, delivered by an apparently highly skilled interventionist, to patients in the relatively conducive (the very ill were excluded) environment of an inpatient ward, had no greater effect than handing them an alcohol advice booklet.

Since the same interventionist handed over the booklet, one possibility is that this entailed some discussion which, though presumably shorter, drew on the same skills and content as the longer intervention. Another is that this mistakenly targeted confidence in ability to cut down when this was not the decisive obstacle, Both active interventions led to increased confidence, particularly the discussion specifically designed to enhance confidence. Yet this (not quite statistically significant) extra boost in confidence had no effect on drinking itself, suggesting perhaps that ability to control drinking was not the main issue, rather, the resolve to do so. If this was the case, then an intervention more thoroughly focused on enhancing motivation might have had a greater impact. or perhaps muddied the water⁴ by asking patients to rehearse what for them were the benefits of drinking and by not giving clear advice.

Given other studies (detailed in the background notes), perhaps the most likely explanation is that being identified as a risky drinker and professionally advised (as the offer of the booklet would probably have been interpreted) to consider cutting down, was sufficient to trigger such drinking reductions as there were going to be. The limits of what can be achieved by unsought advice in situations where drinking is neither implicated in the patient’s condition, nor a natural topic for clinicians to raise, are typically quite low. Compared to assessment only, often no significant impact is observed,⁵ even after fully fledged brief interventions.

A recent analysis⁶ pooled results from studies Several concerned hospital patients. of written advice on drinking accompanied by at most one face-to-face discussion with patients identified by screening. The whole package of screening, assessment and intervention led to substantial drinking reductions, but there were major falls too after just screening and assessment, leaving a small (but still statistically significant) extra benefit from intervention. Its magnitude varied across studies, suggesting that even modest extra benefit was not guaranteed. Where this had been tested, sometimes very brief interventions were just as effective as longer ones.

Focusing on the UK, the picture is similar. Two studies of non-emergency hospital patients tested fully fledged brief interventions against a minimal intervention based on handing over an advice booklet with⁷ or without⁸ a warning about the patient’s drinking. In the first, relative to assessment only, both interventions led patients This study included some primary care patients. to cut drinking by on average 2–3 UK units Around 20gm alcohol. a day. In the second, neither intervention significantly improved on assessment only; all the groups reduced their drinking to roughly the same degree.

Beyond the UK, studies have also found more extended brief interventions offer no advantage over briefer ones.^{9 10 11} The exception was an Australian study¹² of psychiatric inpatients which found greater reductions in drinking after a 45 minute intervention than after handing over a booklet. In the context of substantial falls in both groups, the difference was modest, and did not translate in to fewer hospital admissions over the next five years.¹³ Similarly, at GP practices,¹⁴ more extended interventions have led to only slight and statistically non-significant extra reductions in drinking.

A second key issue is whether any form of brief intervention, longer or shorter, is likely to reduce drinking in the non-emergency hospital setting. Compared to merely being assessed, one UK study⁷ found modest extra reductions, two⁸ found¹⁵ none, and in another,¹⁶ the gains were questionable.

All these studies concerned the general run of patients. Two further UK studies concerned patients whose complaints meant that being talked to about drinking might have seemed a natural part of their medical care. Compared to assessment only, both found substantial drinking reductions after intervention. The most convincing study¹⁷ concerned young male outpatients with facial injuries after drinking. The second,¹⁸ of patients with high blood pressure, trialed a four-session intervention rather than the more usual one-off, compared it to perverse advice to carry on drinking, and the follow-up period was just eight weeks.

With the featured study, this work seems to show that in hospital patients, drinking reductions of the order of two or three UK units a day can be achieved by screening and brief intervention. However, none of the UK studies showed that longer and more sophisticated interventions were any more effective than being identified as a heavy drinker and given very brief advice and/or an advice booklet. On this issue of whether more is better, evidence from elsewhere is also unconvincing.

PRACTICE IMPLICATIONS Among hospital patients, screening for risky drinking and, if indicated, offering very brief advice reinforced by written material seems a worthwhile preventive intervention, but there is no convincing case for more extended (if still brief) intervention. Gains might be greater in clinics or wards whose specialism makes enquiring about drinking integral to the core business of responding to the patient’s complaint, but even on general wards, the proportion of heavy drinkers seems sufficient to justify screening and intervention. In the featured study, even after eliminating known problem drinkers, over a quarter of patients screened as excessive drinkers. Similarly, in the general wards of a London hospital,¹⁹ 28% of screened patients had a current substance misuse problem, for three quarters involving alcohol.

Screening and intervention is likely at best to lead to modest reductions but enough, in a few studies which looked at this issue, to reduce the future load on health services. The rate of alcohol-related hospital admissions is an optional local indicator²⁰ for English health authorities, relating to the national ambition²¹ to reduce that rate. Conceivably, hospital based screening and brief intervention could contribute to that objective as well as to national priorities to curb alcohol-related violence and disorder and to prevent or mitigate alcohol-related²²chronic diseases such as cancer, mental illness, heart disease and diabetes.

These gains are potential rather than certain, but the cost of attempting to secure them is also low because the simplest, quickest and least costly interventions seem as effective as the more sophisticated and extensive. Given this, such programmes might be considered a worthwhile investment⁶ in public health terms and to provide an opportunity to identify individuals who need further treatment.

Current alcohol screening policy in England²³ and Scotland²⁴ focuses more on primary care and accident and emergency departments than general hospitals, but the Department of Health’s programme of improvement²⁵ for alcohol misuse interventions saw hospitals as one of the sites for such work, particularly clinics dealing with complaints often related to drinking.

Though aimed at other medical settings, practical guidance is available from a UK web site²⁶ developed by leading researchers and an officially published US guide²⁷ from the American College of Surgeons.

Thanks for their comments on this entry in draft to Aisha Holloway of the University of Nottingham, Robert Patton of the National Addiction Centre, and Eileen Kaner of Newcastle University’s Institute of Health and Society. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

1 FEATURED STUDY Holloway A.S. et al. The effect of brief interventions on alcohol consumption among heavy drinkers in a general hospital setting. Addiction: 2007, 102(11), p. 1762–1770.

2 Health Education Authority. That’s the limit: a guide to sensible drinking. London: Health Education Authority; 1994.

3 Holloway A.S. et al. How do we increase problem drinkers' self-efficacy? A nurse-led brief intervention putting theory into practice. Journal of Substance Use: 2006, 11(6), p. 375–386.

4 Ashton M. The motivational hallo. Drug and Alcohol Findings: 2005, 13, p. 23–30.

5 Emmen M.J. et al. Effectiveness of opportunistic brief interventions for problem drinking in a general hospital setting: systematic review. British Medical Journal: 2004, 328:318.

6 Apodaca T.R. et al. A meta-analysis of the effectiveness of bibliotherapy for alcohol problems. Journal of Clinical Psychology: 2003, 59(3), p. 289–304.

7 Babor T.F. et al, eds. Project on identification and management of alcohol-related problems. Report on phase II: a randomized clinical trial of brief interventions in primary health care. World Health Organization, 1992.

8 Watson H.E. A study of minimal interventions for problem drinkers in acute care settings. International Journal of Nursing Studies: 1999, 36, p. 425–434.

9 WHO Brief Intervention Study Group. A cross-national trial of brief interventions with heavy drinkers. American Journal of Public Health: 1996, 86(7), p. 948–955.

10 Forsberg L. et al. Brief interventions for risk consumption of alcohol at an emergency surgical ward. Addictive Behaviors: 2000, 25(3), p. 471–475.

11 Burge S.K. et al. An evaluation of two primary care interventions for alcohol abuse among Mexican-American patients. Addiction: 1997, 92(12), p. 1705–1716.

12 Hulse G.K. et al. Six-month outcomes associated with a brief alcohol intervention for adult in-patients with psychiatric disorders. Drug and Alcohol Review: 2002, 21, p. 105–112.

13 Hulse G.K. et al. Five-year outcomes of a brief alcohol intervention for adult in-patients with psychiatric disorders. Addiction: 2003, 98(8), p. 1061–1068.

14 Kaner E.F.S. et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database of Systematic Reviews: 2007, 2.

15 Chick J. et al. Counselling problem drinkers in medical wards: a controlled study. British Medical Journal: 1985, 290, p. 965–967.

16 Rowland N. et al. Standardized alcohol education: a hit or miss affair? Health Promotion International: 1993, 8, p. 5–12.

17 Smith A.J. et al. A randomized controlled trial of a brief intervention after alcohol-related facial injury. Addiction: 2003, 98, p. 43–52.

18 Maheswaran R. et al. Effectiveness of advice to reduce alcohol consumption in hypertensive patients. Hypertension: 1992, 19, p. 79–84.

19 Canning U.P. et al. Substance misuse in acute general medical admissions. JQ J Med: 1999, 92, p. 319–326.

20 DH/NHS Finance Performance & Operations. Operational plans 2008/09–2010/11. Department of Health, 2008.

21 HM Government. PSA delivery agreement 25: reduce the harm caused by alcohol and drugs. HM Government, 2007.

22 London Drug and Alcohol Network and Alcohol Concern. Local alcohol strategy toolkit.

23 Department of Health [etc]. Safe. Sensible. Social. The next steps in the national alcohol strategy. Department of Health [etc], 2007.

24 Scottish Government. Changing Scotland’s relationship with alcohol: a discussion paper on our strategic approach. Scottish Government, 2008.

25 Department of Health and National Treatment Agency for Substance Misuse. Alcohol misuse interventions: guidance on developing a local programme of improvement. Department of Health, 2005.

26 Newcastle University Institute of Health and Society. Brief interventions - alcohol and health improvement.

27 American College of Surgeons Trauma Committee. Alcohol screening and brief intervention (SBI) for trauma patients. US Department of Health and Human Services, 2007.

LINKS Background notes | How brief can you get? | Investing in alcohol treatment. Brief interventions | Nuggets 12.6 9.5 2.8
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International review and UK guidance weigh merits of buprenorphine versus methadone maintenance

An analysis of the most clinically relevant studies of buprenorphine versus methadone maintenance treatment of opiate dependence has confirmed that buprenorphine has slightly less ‘holding power’, but that among patients who are retained, there are equivalent reductions in the illegal use of opiate-type drugs. The findings informed new UK guidelines on the treatments.

FINDINGS The comparison between flexible-dose sublingual (absorbed under the tongue) buprenorphine and oral methadone was one of several made in the updated review¹ for the Cochrane Collaboration, one of the world’s most trusted sources. Where possible, results of relevant studies were statistically pooled. The analysis is important because studies which allow clinicians to adjust the dose depending on how the patient reacts more closely reflect actual and recommended clinical practice² than fixed-dose studies.

Across the eight studies (see background notes for citations and further information), 18% more methadone than buprenorphine patients remained in treatment for time periods The periods assessed by the studies and included in the Cochrane analysis were: 24 weeks; 17 weeks; 6 months; 13 weeks; 12 months; 6 weeks; 16 weeks; 16 weeks. varying from six weeks to a year. This means, for example, that if 60 out of 100 patients were retained on buprenorphine, had they instead been prescribed methadone, typically another 11 would have stayed in treatment. Retention over at least these periods is key because when patients leave, relapse to dependent illicit opiate use is the norm.

Among the studies which provided this data, numbers of positive urine tests (indicative of continuing illegal opiate use) only slightly and non-significantly favoured buprenorphine. The same was true for the patients’ own accounts of their heroin use. There were also no significant differences in use of cocaine or benzodiazepines or in crime.

IN CONTEXT The analysts’ verdict was that given adequate doses, methadone was the more effective treatment, but not by an overwhelming margin. However, limitations in their analysis and in the source studies it relied on introduce considerable uncertainty.

Some of these (fuller discussion in background notes) may have meant that methadone’s advantage would be greater in everyday practice. Even when they could have got methadone elsewhere, patients were prepared to accept allocation to an unfamiliar medication. Possibly they were keen on trying a new medication with less strong opiate-type effects. In all but one of the studies they were (compared to UK caseloads) either early in their addiction or treatment careers, relatively young, or relatively socially included. One of the questions marks over buprenorphine is its suitability for more dependent, high-dose heroin users.

Also perhaps disdavantaging methadone was the way the urine test comparison was calculated. This appears to have ignored missed tests rather than treating them as positive (shorter retention means buprenorphine patients probably missed more) and to have credited to buprenorphine results from patients who avoided positive tests by switching to methadone.

On the other hand, buprenorphine patients too might have been disadvantaged. The drug permits non-daily dosing and perhaps an earlier shift to unsupervised consumption. For many patients, this offers a more attractive regimen than daily supervised methadone. However, most studies sacrificed these advantages to ‘blind’ patients and staff to which drug was being taken. Blinding also (because the patient might have been on methadone) caused unnecessary delays in reaching optimal doses of buprenorphine. Both considerations may have diminished retention on buprenorphine.

Since it drew on this data, these sources of uncertainty were also incorporated in a recent assessment3 for the UK’s National Institute for Health and Clinical Excellence (NICE), which itself added adding further layers of uncertainty. It found that methadone’s retention advantage in flexible-dose studies translated in to slightly greater improvements in (largely health-related) quality of life. Since methadone also resulted in lower health care costs, it was more cost-effective than buprenorphine. However, the analysis did not explore all the ways in which buprenorphine’s costs might be (and are being⁴) reduced such as unsupervised dosing, nor all the ways in which it might enhance quality of life. Neither did it fully account for the benefits of greater retention on methadone.

PRACTICE IMPLICATIONS For clinical guidance on how to use buprenorphine see UK prescribing guidelines² and a review from three leading US researchers.⁵

For the Cochrane team their findings meant methadone should be the default maintenance medication, with buprenorphine reserved for environments or patients where high dose methadone is not possible. Their reasoning was that at high or flexible doses, "methadone is associated with better suppression of heroin use", yet their review concluded this was not the case for flexible dose programmes. They added that in some settings, buprenorphine may be advantaged by its relative safety and alternate-day dosing option, a rider which opens the door for the drug when daily supervised consumption would otherwise be required or take-home doses are desirable, and perhaps in some primary care practices.

Experts and advisers convened by the UK’s National Institute for Health and Clinical Excellence (NICE) put a different spin⁶ on largely the same evidence. Their advice was that the choice between the medications should be made "case by case", based on issues like whether buprenorphine’s safety was a priority in that individual case, whether the patient was aiming to withdraw from opiate-type drugs altogether (easier with buprenorphine), and patient preference. When for an individual the medications were equally appropriate, methadone might take precedence because it cost less and on average extended the benefits of being in treatment. UK prescribing guidelines² take a similar line.

Neither assessment fully accounted for the cost-savings and convenience possible due to buprenorphine’s extended effects and relative safety, the latter (as Scottish guidelines⁷ point out) particularly applying to tablets which combine buprenorphine and naloxone. This formulation reduces the risk of the tablets being crushed and injected. The result could be to facilitate more primary care-based treatment and to reduce the need to control diversion to the illicit market by insisting on supervised consumption.

Uncertainty about overall advantage, allied with differences in the safety and effects of the drugs and possible dispensing arrangements, suggest that the most defensible conclusion is that some patients will be most suited to methadone, others to buprenorphine. Unfortunately, there is little in the research to indicate who will be in which camp. Buprenorphine possibly helps depressed patients more than those not suffering depression and patients dependent on large doses of opiates may find it inadequate because there is a ceiling beyond which higher doses do not augment opiate-type effects. Patients who value the ‘wrapped in cotton wool’ feeling typical of heroin may prefer methadone, those who value a clearer mind might prefer buprenorphine.

In England around the years 2005 and 2006 buprenorphine accounted for over a quarter of patients prescribed opiate substitutes, having rapidly gained ground over the previous years. Though dispensed more often as take-home doses, surveyed⁸ patients were less likely to use other opiate-type drugs ‘on top’ than with methadone and were also more likely to be satisfied with their treatments. Methadone is likely to remain the mainstay of maintenance prescribing due its wider appeal to patients and lower cost, but the case for considering buprenorphine is strong and may get stronger if potential cost savings are realised and if methadone’s major advantage – greater retention – comes to be seen as an impediment to successful treatment exit.

Thanks for their comments on this entry in draft to Tom Carnwath, consultant psychiatrist, Tees, Esk & Wear Valleys NHS trust. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

1 FEATURED STUDY Mattick R.P. et al. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews: 2008, 2.

2 Department of Health (England) and the devolved administrations. Drug misuse and dependence: UK guidelines on clinical management. Department of Health [etc], 2007.

3 Connock M. et al. Methadone and buprenorphine for the management of opioid dependence: a systematic review and economic evaluation. Health Technology Assessment: 2007, 11(9).

4 Best D. et al. National prescribing audit: an assessment of prescribing practices for opioid substitution treatment in England, 2004–2005. National Treatment Agency for Substance Misuse, 2007.

5 Johnson R.E. et al. Buprenorphine: how to use it right. Drug and Alcohol Dependence: 2003, 70(2, suppl.), p. S59–S77.

6 National Institute for Health and Clinical Excellence. Methadone and buprenorphine for the management of opioid dependence. NICE technology appraisal guidance 114. National Institute for Health and Clinical Excellence, January 2007.

7 Scottish Medicines Consortium. Buprenorphine/naloxone 2mg/0.5mg, 8/2mg sublingual tablet (Suboxone). Scottish Medicines Consortium, 2007.

8 Gordon D. et al. The 2007 user satisfaction survey of tier 2 and 3 service users in England. National Treatment Agency for Substance Misuse, May 2008.

LINKS Background notes | There is an alternative: buprenorphine maintenance | Nuggets 10.3 6.2 4.6 2.4
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