EFFECTIVENESS BANK BULLETIN 7 August 2008
EFFECTIVENESS BANK BULLETIN 7 August 2008
The 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. Links to source documents are in blue. Hover mouse over orange body text for explanatory notes.
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School-based smoking prevention: popular peers can help ...
Adequate needle exchange helps prevent bacterial as well as viral infections ...
Home visits reduce risk of 'hidden harm' to children of drug treatment patients
...
No reductions in drinking were found in a Danish attempt to implement in 'real-world' conditions the primary care screening and brief intervention protocol for heavy drinkers which emerged from World Health Organization (WHO) trials, also the origin of a model officially recommended for England. Findings suggest it was right for UK policy to turn away from universal screening but whether the favoured alternative – targeted screening – will prove effective and cost-effective or deliver public health benefits remains unclear.
FINDINGS Of the 426 GPs invited to join the featured study,1 39 did so. Each was required to have practice staff to recruit patients for the study and hand them a screening questionnaire for completion in private in the waiting room. This consisted of the 10-item AUDIT screening test plus questions about how much the patient usually drank. Patients were also given a survey to be completed at home assessing how much they had drunk in the past week.
Of the nearly 7000 patients who agreed to join the study, a randomly selected half (the control group) simply dropped their sealed screens in to a ballot-style box and saw the doctor in the normal way, who was unaware of their scores. The other half handed their questionnaires to the doctor who scored the AUDIT tests. About 1 in 6 scored high enough to be considered hazardous or harmful alcohol drinkers. Of these, about 13% were eliminated from the study because they might actually be dependent on alcohol.
The remaining risky but presumed non-dependent drinkers – about 1 in 8 of all the screened patients – were to be given the 10-minute intervention consisting of feedback on their scores, advice on cutting back, a self-help booklet, and a suggested further consultation (which fewer than a fifth returned for). Follow-up data sought a year later from these 442 patients was compared with that from their 464 counterparts in the control group to assess whether the doctor's advice had curbed their drinking. Data was collected by means of a further AUDIT test and alcohol consumption survey mailed to patients, to which about 60% responded.
On none of the several measures Usual amount, amount in previous week, reduction below excess drinking levels, ceased binge drinking, reversion to below AUDIT risky drinking score, or at least one of the last three without deterioration on the other two. of alcohol consumption or problems2 had intervention patients improved to a statistically significant degree relative to control patients. The pattern of the results makes it unlikely that findings from a larger sample would have been more decisive.
IN CONTEXT The featured study 'seamlessly' combined AUDIT-based screening with brief intervention during the same visit and was exclusively conducted in GP practices, making it a close test of the recommendations which emerged from the WHO study.3
One concern is that heavier drinkers were excluded or disproportionately lost to the study. Nearly 8 in 10 patients who did participate denied usually drinking amounts in excess of Danish guidelines. Comparison against these guidelines risked validating their drinking. Heavier drinkers might have seemed a more legitimate target and (as one review found) might also have responded better.4 On the other hand, initial drinking averaged about 26 UK units a week and patients with higher AUDIT scores did not respond better to the intervention.
The large loss to follow up (especially among intervention patients) is a significant weakness but one likely if anything to have tipped the balance in favour of the intervention.
Defensive reactions to the intervention might account for this extra loss and for the rejection of further counselling. Such reactions were noted by the doctors during 'debriefing' sessions.5 The doctors themselves seemed deeply uncomfortable with the intervention, fearing that doctor-patient rapport would be damaged by introducing drinking 'artificially' when the patient was attending for some other reason and without a naturally emerging clinical prompt. Despite the likelihood that the GPs who volunteered for the study were highly motivated, almost universally they said they would not carry on screening.
Recent meta-analyses combining the results of similar studies have concluded that once patients reach the point of being randomised to receive a brief intervention, compared to screening alone or screening plus usual care, this leads to a reduction of about 5 UK units a week in their drinking, noticeable at least a year after the intervention.4 6
However, the great majority of screened patients never reach this point because they do not score as risky drinkers, are unavailable, excluded by research criteria, or fail to participate, leading to an estimate that on average 1000 patients have to be screened to gain 12 months later just two or three who have stopped drinking excessively.7 Outside a research context when (as in the featured study) intervention can seamlessly follow a positive screen, attrition might be less.
Screening too is rarely applied to more than a small minority of patients. Initiatives like practice visits and training, especially when combined with ongoing support, do modestly improve screening rate and intervention rates,8 but these remain low.
In Britain at least two studies have found that primary care brief intervention did reduce drinking.9 10 They demonstrated the approach's potential, but not necessarily that it would work in typical practices which themselves identified patients for intervention, and with patients not subject to the multiple selection gateways applied by the studies.
Perhaps importantly, in both patients were selected explicitly on the basis of excessive consumption and either no ceiling or a very high one was set before they were excluded. The result was a sample of on average clearly excessive drinkers (the men averaged over 60 UK units or 480g of alcohol a week). Most would have been towards the far end of the national distribution against which their drinking was compared during the intervention.
Other British effectiveness studies (see background notes for citations) were either not reflective of primary care or inconclusive about the benefits of intervention. Feedback from staff and the sometimes very low rates of screening and intervention suggested lack of enthusiasm and/or of resources (such as skills, time and organisational support) for screening and intervention, but this may have been partly due to the burden of the associated research.
Further UK studies have minimised this burden, but even in willing practices offered training and ongoing support, the results confirm that attempts at universal screening (and in respect of nurses, opportunistic screening too) result in only a small fraction of risky drinkers being advised about their drinking.
Most practices never reach this point because they refuse screening or fail to implement it. As in Denmark, generally nurses and doctors are prepared to screen (if at all) only when this emerges naturally in the course of addressing the patient's complaint or because it is a logical component of a procedure applied to all patients in certain categories, such as those undergoing general health checks, new patients, and patients being monitored for chronic conditions which might be related to or aggravated by drinking.
PRACTICE IMPLICATIONS The featured study and related British studies suggest that universal screening for risky drinking is not feasible in normal primary care practice. An alternative model emerging from the research as possibly feasible and effective involves targeted/selective screening using AUDIT or shorter screens as part of overall health checks, or when the patient's complaint might be related to or aggravated by heavy drinking (either individually or routinely at clinics dealing with such complaints), and then offering brief advice to risky drinkers. What that advice best consists of is unclear.
Selective screening and typical and promising intervention approaches have been codified in a protocol called How much is too much?,11 recommended in English guidelines for commissioning such work from GPs as an enhanced service.12 'Enhanced' status means GPs are not required to undertake this work unless they have agreed to do so under contract to their local health authority, and authorities are not required to ensure its provision in their areas.
England's national alcohol charity believes this option will be taken up by only a small proportion of GPs.13 Selective screening may also mean few patients are screened. The combination seems likely to undermine the hoped-for public health benefits of a mass programme identifying 'hidden' risky drinking before it becomes noticeable in drink-related complaints, though individual patients who are screened and advised may benefit.
The enhanced service guidelines follow the commitment to selective screening and brief intervention in the 2004 English national alcohol strategy and resultant guidelines.14 15 Scotland has similar practice recommendations and policy proposals.16 17
Thanks for their comments on this entry in draft to Anders Beich of the University of Copenhagen. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
1 FEATURED STUDY Beich A. et al. Screening and brief intervention targeting risky drinkers in Danish general practice – a pragmatic controlled trial. Alcohol and Alcoholism: 2007, 42(6), p. 593–603.
2 Usual amount, amount in previous week, reduction below excess drinking levels, ceased binge drinking, reversion to below AUDIT risky drinking score, or at least one of the last three without deterioration on the other two.
3 Babor T.F. et al. Brief intervention for hazardous and harmful drinking: a manual for use in primary care. World Health Organization, 2001.
4 Bertholet N. et al. Reduction of alcohol consumption by brief alcohol intervention in primary care: systematic review and meta-analysis. Archives of Internal Medicine: 2005, 165, p. 986–995.
5 Beich A. et al. Screening and brief intervention for excessive alcohol use: qualitative interview study of the experiences of general practitioners. British Medical Journal: 2002, 325(870).
6 Kaner E.F.S. et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database of Systematic Reviews: 2007, 2.
7 Beich A. et al. Screening in brief intervention trials targeting excessive drinkers in general practice: systematic review and meta-analysis. British Medical Journal: 2003, 327, p. 536–542. The estimates were hotly contested.
8 Anderson P. at al. Engaging general practitioners in the management of hazardous and harmful alcohol consumption: results of a meta-analysis. Journal of Studies on Alcohol: 2004, 65(2), p. 191–199.
9 Wallace P. et al. Randomised controlled trial of general practitioner intervention in patients with excessive alcohol consumption. British Medical Journal: 1988, 297, p. 663–668.
10 Anderson P. et al. The effect of general practitioners' advice to heavy drinking men. British Journal of Addiction: 1992, 87(6), p. 891–900.
11 Newcastle University Institute of Health and Society. Brief interventions - alcohol and health improvement, accessed 5 July 2008.
12 Primary care service framework: alcohol services in primary care. NHS England, 2008.
13 Alcohol Concern. Addressing alcohol through the new GP contract. A briefing for primary care organisations. 2004.
14 Prime Minister's Strategy Unit. Alcohol harm reduction strategy for England. 2004.
15 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.
16 Scottish Intercollegiate Guidelines Network (SIGN). The management of harmful drinking and alcohol dependence in primary care. September 2003.
17 Scottish Government. Changing Scotland's relationship with alcohol: a discussion paper on our strategic approach. 2008.
Last revised 07 August 2008 Background notes Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Brief contact and written advice as effective as a longer talk for heavy drinking hospital patients NUGGET 2008
Injury rate cut in heavy drinking accident and emergency patients NUGGET 2003
Family doctors' alcohol advice plus follow up cuts long-term medical and social costs NUGGET 2003
The effectiveness of brief alcohol interventions in primary care settings: a systematic review REVIEW 2009
How brief can you get? OLD GOLD 1999
Emergency patients benefit from minimal alcohol intervention NUGGET 2001
Ongoing support encourages GPs to advise heavy drinkers NUGGET 2006
A&E units save health service resources by addressing drinking NUGGET 2006
Brief interventions for heavy alcohol users admitted to general hospital wards REVIEW 2009
A UK study successfully harnessed respected peers to prevent smoking, but not through classroom activities. Instead the 12-13-year-olds simply exerted their influence in normal social interactions with same-age school mates.
FINDINGS 223 Welsh and English secondary schools were approached in 2001. About half were prepared to consider participating in the featured study.1 Of these, 59 were randomly sampled and agreed Seven of the randomly selected schools did not agree. to participate. They were randomly selected to continue with their normal smoking education (the control schools) or additionally to host the ASSIST intervention.
To prepare for this, participating year 8 pupils (12-13 years old) nominated year-mates they respected or who were good leaders. In ASSIST schools only, the research project's trainers asked roughly the top 1 in 6 most nominated pupils to act as 'peer supporters', excluding only smokers who were unwilling to try to stop, or those about whom the school had serious concerns.2 Few were excluded The study approached the top 17.5% of pupils and recruited 16%. for these reasons. Nearly all the chosen pupils completed two days of out-of-school training with health promotion staff and youth workers.
Through interactive learning methods such as role play and discussion, the training aimed to equip the 835 peer supporters with the confidence, social skills and knowledge to talk informally with their peers about the effects of smoking and the benefits of not smoking. They were asked to do this for 10 weeks and to keep a log of their conversations, supported by four follow-up visits from the health promotion trainers.
In each set of schools well over 5000 pupils completed questionnaires about their smoking before and after the intervention and then about one and two years later. At first few (6%) admitted smoking in the past week, growing to 20% by the final follow-up. After adjusting among other things Differences between the sets of schools in size, private v. state, free school meals percentage, single or mixed gender, and language. for starting levels of smoking, at the one- and two-year points ASSIST schools had about a fifth fewer pupils Statistically significant at the first point, narrowly missing this at the second. who had smoked in the past week. At two years the unadjusted percentages of past-week smokers were about 19% in ASSIST schools and 22% in control schools.
Apart from (at least at one-year) a minimal impact among the few regular weekly smokers,2 the intervention was about as effective with pupils who had and had not smoked, with boys and girls, and regardless of whether the pupil had been a peer supporter. However, its impact faded slightly over the follow-up period, and was much greater in schools serving the small communities of the south Wales valleys than in towns and cities, where it failed to achieve a statistically significant impact.
IN CONTEXT The innovation in the featured study was to harness peer influence outside the classroom. Pupils could exercise judgement over who to approach, how and when, rather than teachers mandating who they interacted with and the programme they used. As might be expected of these socially advanced youngsters, they appear to have used this discretion to good effect. Feedback suggested they found it easier and thought it would be more profitable to talk to friends and to pupils who were not already regular smokers.2 Their activity levels tailed off over the 10 weeks, partly because they risked repeating the message to the same circle of contacts. For this reason, continuous intervention for more than a few weeks seems unrealistic, but, as the authors comment, impacts might have been greater had the intervention been implemented each year in each school grade.
Inevitably there are questions about whether the approach would work as well elsewhere. First, schools self-selected in to the study and were generally prepared to go along with their pupils' choices of peer leaders (thought important to their credibility) and to release these pupils for training, even when the teachers had misgivings about the choices made.3 On the other hand, school staff were not directly involved in delivering the intervention.
Secondly, impacts may be dependent on the socialisation patterns of the youngsters. The greater impact in the Welsh valleys was not due to their relative deprivation. As reflected in the proportion receiving free school meals, this was not a significant predictor of intervention impact. Instead it seems likely that in these circumscribed, stable communities, pupils were in contact not just at school but on the way there and back and during leisure time. Influential pupils at school may also have been influential out of school where smoking occurs.
The intervention benefited from external trainers and external venues. This and the nomination procedure makes it unlikely that peer leaders will be seen as having been co-opted by the school, an image unlikely to appeal to the youngsters most likely to flout adult convention by smoking. However, external help comes at a cost. Overall the intervention cost £4700 per school, a figure which would be slightly lower if local trainers were available.
It is not unusual for preventive interventions to curb smoking but not (or not as much) other forms of substance use,4 making it unsafe to assume that similar methods would work in respect of drinking and illegal drug use.
Though rarely resorted to, it seems wise to have retained a veto over peer leaders who were committed to smoking or over whom the school had serious concerns. Socially advanced teenagers likely to be chosen by their peers have also tended to be advanced in their experimentation with substance use and can have an influence opposite to that intended.
Other studies which have relied on peer-selected leaders have instead paired them with the pupils who nominated them (the so-called 'network' method) in small-group, classroom-based substance misuse prevention activities devised and overseen by adult educationalists. Typically these US studies favoured the network option over whole class teaching or randomly selected groups, but sometimes not to a statistically significant degree, and with important exceptions. See background notes and earlier Findings web and PDF Nuggets for detailed analyses.
One exception was when the minority of pupils who used substances most frequently choose like-minded friends and leaders.5 In another study the network method was preferable only when paired with a curriculum devised to reflect the cultural heritages of the largely Hispanic pupils.6 Similar variations may partly lie behind the findings of a meta-analysis which combined relevant studies.7 This concluded that peer-led school-based substance use prevention had a slightly better record than adult-led programmes, but also that the advantage is inconsistent, apparent in some circumstances but not in others.
PRACTICE IMPLICATIONS Given the potential for counterproductive impacts, if the featured study's method is tried some monitoring of outcomes would be advisable. It does have the great advantage of not occupying classroom teaching time, always in short supply. This means such initiatives can (as in the study) supplement rather than displace classroom drug education and leave this (as some teachers argue should be the case) to focus on education rather than prevention, but at the cost of funding external staff and venues. Such work could however be incorporated within existing youth work projects, reducing the costs, and usefully placing these projects in contact with the most influential youngsters in their areas. If the featured study's methodology is followed, unless this can be arranged for school holidays or weekends, schools will have to be prepared to release about 15% of their pupils for the training (thought to be the 'critical mass') and to trust the pupils as a whole to take the lead in selecting who is trained.
1 FEATURED STUDY Campbell R. et al. An informal school-based peer-led intervention for smoking prevention in adolescence (ASSIST): a cluster randomised trial. Lancet: 2008, 371, p. 1595–1602.
2 Audrey S. et al. It's good to talk: adolescent perspectives of an informal, peer-led intervention to reduce smoking. Social Science & Medicine: 2006, 63(2), p. 320–334.
3 Audrey S. et al. Commitment and compatibility: Teachers' perspectives on the implementation of an effective school-based, peer-led smoking intervention. Health Education Journal: 2008, 67(2), p. 74–90.
4 See for example the discussion of Life Skills Training in: Stothard B. et al. Education's uncertain saviour. Drug and Alcohol Findings: 2000, 3.
5 Valente T.W. et al. Peer acceleration: effects of a social network tailored substance abuse prevention program among high-risk adolescents. Addiction: 2007, 102, p. 1804–1815.
6 Valente T.W. et al. The interaction of curriculum type and implementation method on 1-year smoking outcomes in a school-based prevention program. Health Education Research: 2006, 21(3), p. 315–324.
7 Cuijpers P. Peer-led and adult-led school drug prevention: a meta-analytic comparison. Journal of Drug Education: 2002, 32(2), p. 107–119.
Last revised 07 August 2008 Background notes Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Harnessing peer interaction in school-based prevention can backfire NUGGET 2008
Secondary school DARE ineffective without interactive extensions NUGGET 2003
Education's uncertain saviour KEY STUDY 2000
Confident kids ... like to party NASTY SURPRISES 2004
Community mobilisation cuts drinking and drug use, but implementation complex and costly NUGGET 1999
Involving parents as well as children may improve drug prevention outcomes NUGGET 2002
Substance-focused initiatives not only way schools help prevent risky substance use NUGGET 2008
Growth in youth drinking curbed by correcting 'normative' beliefs NUGGET 2002
Bacterial infections at the injecting site are an everyday experience for drug injectors and a common (but not the only) cause of abscesses. A pus-filled cavity resulting from inflammation. Consequences can include loss of limbs and death if infection spreads. Findings from new US study suggest that needle exchanges which make adequate supplies of injecting equipment easily accessible not only prevent viral infections but also abscesses. More restrictive policies are less effective and may end up costing health services more than they save.
FINDINGS Conducted in Eureka, California, the featured study1 analysed records from the area's needle exchange and of abscesses treated at local health centres from the start of 2002 to the end of February 2004. This period straddled the introduction in April 2003 of a more restrictive policy at the needle exchange. Walk-in one-for-one exchange combined with advice and health care was capped to a maximum of 100 needles per visit, for which appointments were now required. Afterwards the number of visits made to the exchange and the number of needles exchanged both fell, the latter from on average 3268 a week to 471. At the same time the average number of abscesses treated rose by six a week to just over 14.
These trends were closely and highly significantly related; the fewer needles exchanged, or the fewer visits in a week, the greater the number of abscesses. Put the other way round, every extra 1000 needles exchanged or every extra eight visits were associated with one fewer abscess. The result was that the exchange's saving of about $243 a week on injecting equipment was overshadowed by at least an extra $500 a week spent elsewhere treating abscesses.
A survey of 62 former injectors recruited through local mutual aid meetings also found that the more needles they had exchanged per visit, the fewer abscesses they had suffered.
IN CONTEXT Findings at this exchange might have been so clear cut because it served a rural area. Possibly this offered few alternative sources of sterile equipment to counteract the exchange's policy switch, and made it easier to identify the rise in abscesses at neighbourhood health centres. Also, the switch was dramatic. The appointment regime seemed to cut visit numbers at the same time as the quantity cap limited per visit supplies, combining to cut supplies by 86%. Despite some shortcomings The analysis based on needle exchange and health service records seems convincing but would have been more so had there been an attempt to eliminate other potential reasons for the upsurge in abscesses. The survey of former injectors is at best a weak reinforcement of the findings. In this brief report, the economic analysis – not planned in to the study from the start – is not described in detail and seems to have accounted only for equipment costs at the exchange. in the study, the consequence seems to have been to expose a relationship between abscesses and the adequacy of needle exchange provision which might otherwise have remained hidden.
Which elements of that provision were critical is unclear. Probably frequent health checks/advice and adequate access to sterile equipment were both influential. Other research Reviewing this research comprehensively is beyond the scope of this entry. Only recent studies which specifically referred to abscesses are cited here or in the background notes. indicates that the mechanisms via which needle exchanges might prevent abscesses include reducing use of potentially contaminated equipment, reducing the re-use of one's own equipment, and improving injecting technique, particularly hygiene.
Among the risk factors identified in a review of bacterial infections in drug users were:2 injecting cocaine or heroin and cocaine mixtures (in both cases due perhaps to cocaine's vasoconstrictive effects and in the former also to very frequent injection); skin popping as an injection technique (concentrating irritants and any bacteria in surface tissue rather than directly injecting in to the blood stream); not cleaning the skin at the injection site and other forms of poor hygiene such as licking needles; repeatedly drawing blood back in to the syringe before injecting ('booting' or 'flushing'); injecting with unclean equipment; sharing potentially contaminated equipment; and contaminated or particularly irritating drug mixtures.
Recent studies (see background notes for details) have confirmed many of these risks. These include a British survey which identified increased crack cocaine injecting as a possible cause of a recent rise in the number of injectors suffering bacterial infections at injection sites.3 One particularly well constructed US study found that the only practice which seemed positively protective against abscess was cleaning the injection site with alcohol before injecting.4
Previous work in California In this study the 'raw' number (ie, unadjusted for differences in caseload) of abscesses did not differ much between different types of exchange policies, but the figures were expressed in terms of the proportion (about 40%) of visitors who had experienced any such injury in the past year, not their frequency or severity. (featured in Findings5) showed that more liberal needle exchange equipment supply policies reduce some of these risk factors by reducing sharing and the re-use of one's own equipment.
Those findings are consistent with a Scottish study which found that inadequate supplies and inconvenient access meant that re-use of one's own equipment was common.6 Beyond this, laboratory tests led the researcher to conclude that the best ways to reduce health risks were to encourage hand washing before injections and to provide acidifiers, filters and single-use vessels for heating the drug solution, with appropriate education in their use.
PRACTICE IMPLICATIONS Indicative of the scale of the problem in the UK, surveys conducted within the past three years have found that a substantial minority (around a third) of injectors attending drug harm reduction and treatment services have current or recent infected or non-infected abscesses.3 6 7 Treating these and their complications is expensive, often requiring operating theatre time and two or three days of inpatient hospitalisation.4
Subject to confirmation from other studies and other types of studies, the messages from the research seem to be that abscesses and bacterial infections should be reduced by adequate supplies of needles and syringes combined with other equipment (alcohol swabs, acidifiers, filters and 'cookers') plus well-informed, detailed and well-communicated advice on how to maintain hygiene and reduce risks.
Reliance in the UK on pharmacy-based exchanges limits the degree to which all this can be provided.8 9 Compared to exchanges in services dedicated to drug users, in pharmacies there is less likely to be the space, time, inclination or staff training required for this work. However, there is potential for allying pharmacy exchanges with drug specialist provision to ensure access across an area (if not at every exchange) to adequate preventive services.
Specialist provision itself often needs upgrading in terms of both equipment supply and assessments and advice. In England a third of the services which responded to a survey said they did not include injecting hygiene in the initial assessment and 29% did not provide face-to-face harm reduction advice.8 Access to sterile injecting equipment from exchanges of whatever kind fell well short of the level needed to permit use of a fresh needle each time (on average one syringe every two days) and only a minority provided some other equipment such as sterile water. Similarly if not more so in Scotland.9
Thanks for their comments on this entry in draft to Jenny Scott of the University of Bath. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
1 FEATURED STUDY Tomolillo C.M. et al. The damage done: a study of injection drug use, injection related abscesses and needle exchange regulation. Substance Use & Misuse: 2007, 42, 10, p. 1603–1611.
2 Gordon R.J. et al. Bacterial infections in drug users. New England Journal of Medicine: 2005, 353, p. 1945–1954.
3 Health Protection Agency [etc]. Shooting up: infections among injecting drug users in the United Kingdom 2006. Health Protection Agency, 2007.
4 Murphy E.L. et al. Risk factors for skin and soft-tissue abscesses among injection drug users: a case-control study. Clinical Infectious Diseases: 2001, 33, p. 35–48.
5 Drug and Alcohol Findings. Needle exchange coverage key to reducing infection risk. 14 February 2008.
6 Scott J. Safety, risks and outcomes from the use of injecting paraphernalia. Scottish Government Social Research, 2008.
7 National Treatment Agency for Substance Misuse (NTA). Harm reduction findings from the NTA's 2006 survey of user satisfaction in England. NTA, 2007.
8 Abdulrahim D. et al. The NTA's 2005 survey of needle exchanges in England. National Treatment Agency for Substance Misuse, 2007.
9 Griesbach D. et al. Needle exchange provision in Scotland: a report of the National Needle Exchange Survey. Scottish Executive, 2006.
Last revised 07 August 2008 Background notes Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Needle and syringe programmes: providing people who inject drugs with injecting equipment REVIEW 2009
Hepatitis C and needle exchange part 2: case studies THEMATIC REVIEW 2003
Needle exchange coverage key to reducing infection risk NUGGET 2008
Hepatitis C and needle exchange SERIES OF ARTICLES 2004
Economic evaluation of delivering hepatitis B vaccine to injection drug users STUDY 2008
Hepatitis C and needle exchange part 3: the British record THEMATIC REVIEW 2004
Hepatitis C and needle exchange part 4: the active ingredients THEMATIC REVIEW 2004
Hepatitis C is spreading more rapidly than was thought OFFCUT 2005
Addressing heavy drinking by needle exchange users could reduce infection risk NUGGET 2003
In Australia a home-based child welfare intervention for methadone-maintained parents improved parenting and decreased parental indicators of potential child abuse or neglect while offering brief parenting education classes barely improved on usual care. This type of intervention offers one way to address current concerns about the children of dependent drug users.
FINDINGS The featured study1 recruited 64 methadone patients Most of the recruited parents were mothers, typically unemployed and in their late 20s and early 30s. On average they had been on methadone for over three years. caring full time for children aged from two to eight. At the start of the study, 40 scored above the level indicative of potential child abuse or neglect on a standard assessment questionnaire.
Patients were randomly allocated either to carry on with their usual care at the clinics (the control group) or additionally to one of two parenting interventions conducted by therapists from the research project. One consisted of just two sessions of conventional parenting skills training. The other was the specially devised Parents Under Pressure programme This aimed to help parents become aware of and regulate their emotional reactions, improve parenting skills, avoid relapse to substance misuse, and gain support from other people and from welfare and community services. Outside scheduled sessions therapists were available to (and often did) support patients by accompanying them to schools, social, legal and health services and in everyday activities such as shopping. involving ten home visits over three months lasting one to two hours plus practical assistance with community services and everyday activities. Day-before reminder calls and flexibility in response to the families' vulnerability to crises partly accounted it's thought for why just one of the patients allocated to it did not engage with the programme.
All but seven patients were reassessed after the three-month intervention period and/or again six months later. On all the measures of parenting, child welfare risk, and child behaviour, patients allocated to Parents Under Pressure had improved substantially, while generally the others had not. On the key measure of risk to the child, the control group had deteriorated, while those given limited parenting skills training had improved only slightly.
By the last follow-up, a third of the Parents Under Pressure patients no longer scored as child welfare risks, twice the proportion in the parenting skills group; none of the control group reached this level. However, another third remained potential risks. Though this was not an explicit objective, only the Parents Under Pressure patients had also been able to reduce their average doses of methadone.
IN CONTEXT Previously a pilot study from the same research team had tested the programme on nine methadone-maintained patients and recorded similar improvements,2 suggesting that the featured study was not a one-off. However, this does not guarantee that the results will be replicated elsewhere. Staff were particularly skilled The two therapists were experienced in working with families with complex needs and closely supervised by a researcher who devised the Parents Under Pressure programme, a degree of expertise and possibly too commitment which may be diluted in everyday practice. The team which devised the programme also researched it and provided the therapists; independent researchers tend to record less positive outcomes. and they and the researchers were likely to be highly committed to the programme.
Its seems likely too that patients not allocated to Parents Under Pressure were disappointed and that this affected outcomes, All the patients knew the options they might be randomised to, so were presumably willing to invest up to 20 hours of their time and to open their homes to the interventionists. Ten not allocated to the Parents Under Pressure programme quickly withdrew and were not included in the study, including seven from the control group. Whilst this compromised the randomisation procedure, it did so in a way which can be expected to have favoured the control group if the most motivated parents withdrew in disappointment. Drop out of patients once they were in the study could have had the opposite effect. Again this was greatest in the control group, fewer of whom attended the six-month follow-up. If more motivated parents had dropped out, this could account for the apparent worsening in the control group, especially since in some analyses drop-outs were assumed not to have improved since their last assessment. Conceivably, too, disappointment affected the outcomes of control patients who did attend for follow-up. However, this concern applies less to the brief intervention group, which also improved little. though sometimes in ways which might have disadvantaged the programme. Disappointment leading to excess drop-out in the control group may have been one of the reasons why just two of the patients originally allocated to Parents Under Pressure could not be followed up compared to 13 (about half) of the control group.
Except for methadone dose, all the measures were based on the parent's interview responses. The questionnaire assessing potential risk to the child was designed to cater for misleading responses, but validation of the improvements by (if available) the school, close family, or by direct observation, would have given greater confidence in the results. There is also the possibility that it was not just the Parents Under Pressure programme which was influential, but also/instead the degree of contact this entailed and where (ie, the home) this occurred.
Other evaluated attempts to improve the prospects for children living with parents who are problem drug users have been few and results patchy.3 4 A fairly close parallel (including home visits) to the featured study was undertaken at two US methadone clinics.5 Take-up of the parenting programme was excellent and parenting and child behaviour/attitudes improved, though the latter not consistently. Another US study at methadone clinics trialled psychotherapy groups aimed at improving parenting.6 Again engagement was good. Data from mothers and children indicated that the intervention had reduced the risk of child abuse or neglect but improvement was not seen on all the measures, in particular when the neighbourhood context was a limiting factor.
Methadone-maintained parents provided the impetus for the US-originated Strengthening Families Programme featuring parallel and then joint weekly groups of parents and children.7 Not explicitly a child protection intervention, nevertheless the improvements seen in parenting skills, children's social skills, and family relationships can be expected to have a protective impact.
UK research on parenting interventions in drug services is scarce and not directly relevant to the approach trialled in the study.8 9 10 There are, however, descriptions of similar interventions involving home visits which appear to embody the features commended by international research.11
Directly addressing parenting is not the only way to improve life for the children of substance using patients. Counselling couples to improve their relationship (and compliance with treatment for the partner in treatment) has spilled over to benefits for children.12 In so far as it stabilises the patient and brings them in to contact with social and welfare services, addiction treatment in itself improves the prospects for the children,13 though, as the featured study among others shows, there may still be elevated risks of neglect or abuse which can be further reduced by interventions targeting these risks.
Approaches found effective with parents in general may also prove effective with problem drug users. Promising results have been found with home-based interventions which involve all the family and 'coach' parenting skills rather than didactically educating, and provide case management services to link families to sources of support in the community.14
PRACTICE IMPLICATIONS Across the UK, national targets, service standards and policy statements have recently embodied the perspective that parenting and child welfare are core concerns for addiction treatment services,15 a contention featuring strongly in new Scottish16 17 and English18 drug strategies. Interventions like the one trialled in the study are one way It is important to distinguish the type of intervention in the featured study (a preventive applied across the board to all parent-patients) from the action which should be taken if an individual patient's child is assessed as at risk of serious harm. The main role of interventions such as those trialed is to reduce the numbers that deteriorate to this point. In individual child protection cases, service protocols and legal and ethical obligations will normally dictate the action to be taken, such as involving senior managers and child welfare authorities. Such cases may be revealed during the course of interventions like those in the featured study. This possibility should be provided for in staff training and guidelines and in the information given to patients invited to participate in interventions. services (and conceivably drug action teams or service consortia working across an area) can play their part in these agendas. With no blame implied and offering positive support, in the research they seem to have been welcomed by the patients.
There are an estimated 250,000 to 350,000 children of problem drug users in the UK.13 In a typical specialist drug treatment service in England, at least 1 in 8 patients and perhaps as many as half are potentially eligible for family interventions.20 Such work should not await the resolution of the parent's substance misuse problem; much can be done before this point to benefit the entire family, in the process (research suggests) also furthering the resolution of substance use problems.
The lessons of research to date seem to be that interventions need to be relatively intensive, well targeted at the risk/resilience factors affecting the child and the issues obstructing good parenting, that staff must be able to forge trusting relationships with adults wary of authority, yet retain the child's interests as paramount, and that they and the programme they are implementing must able to adapt to the contingencies affecting the family. Roles typically combine direct parenting support with a case management function, facilitating support from other welfare and community services and intervening when pressures threaten the family's progress.
The featured intervention embodies this learning, combining flexibility with manualisation. Studies have found most parents welcome this type of help and engage well with the programmes. Home-based interventions allow for children and other carers to be incorporated in the process, resolve the need for child care, permit assessment of home safety, provide for the learning and practice of new skills in the environment where they need to be applied,14 and are possibly more likely to be taken up by the parents.5
Many drug service workers feel ill-equipped for this work. Government advisers have pointed out that the first essential step is for treatment services to ask patients about their children.13 A recent official audit of English prescribing services found that half did not have assessment procedures which systematically enquired who else shared the home.19 Current NTA National Treatment Agency for Substance Misuse, special health authority charged with improving drug treatment in England. care planning guidance refers to the need for addiction treatment services to identify child protection issues. Additionally, patients should be questioned about their children in order to submit this data to national and regional monitoring systems, including those for drug using offenders.15 In the process, patients who might be offered family interventions will be identified.
How diligently such enquiries are made is unclear. Being able to offer concrete and supportive interventions such as those in the featured study makes asking about children both more acceptable to patient and worker and more worthwhile.
Thanks for their comments on this entry in draft to Daphne Obang, Methodist church Safeguarding Officer and former director of social services, and to Lorna Templeton of the University of Bath. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
1 FEATURED STUDY Dawe S. et al. Reducing potential for child abuse among methadone-maintained parents: results from a randomized controlled trial. Journal of Substance Abuse Treatment: 2007, 32, p. 381–390.
2 Dawe S. et al. Improving family functioning and child outcome in methadone maintained families: the Parents Under Pressure programme. Drug and Alcohol Review: 2003, 22(3), p. 299–307.
3 Barnard M. et al. The impact of parental problem drug use on children: what is the problem and what can be done to help? Addiction: 2004, 99, p. 552–559.
4 Suchmann N. et al. Parenting interventions for drug-dependent mothers and their young children: the case for an attachment-based approach. Family Relations: 2006, 55(2), p. 211–226.
5 Catalano R.F. et al. An experimental intervention with families of substance abusers: one-year follow-up of the focus on families project. Addiction: 1999, 94, p. 241–254.
6 Luthar S.S. et al. Relational psychotherapy mothers' group: a developmentally informed intervention for at-risk mothers. Development and Psychopathology: 2000, 12, p. 235–253.
7 Ashton M. Doing it together strengthens families and helps prevent substance use. Drug and Alcohol Findings: 2004, 10, p. 16–21.
8 Social Care Institute for Excellence (SCIE). Parenting capacity and substance misuse. SCIE, 2005.
9 Tunnard J. Parental drug misuse – a review of impact and intervention studies. Research in Practice, 2002.
10 Keen J. et al. Keeping families of heroin addicts together: results of 13 months' intake for community detoxification and rehabilitation at a family centre for drug users. Family Practice: 2000, 17(6), p. 484-489.
11 Harbin F. et al, eds. Substance misuse and child care: how to understand, assist and intervene when drugs affect parenting. Russell House, 2000.
12 Kelley M.L. et al. Couples-versus individual-based therapy for alcohol and drug abuse: effects on children's psychosocial functioning. Journal of Consulting and Clinical Psychology: 2002, 70(2), p. 417–427.
13 Advisory Council on the Misuse of Drugs. Hidden harm: responding to the needs of children of problem drug users. Home Office, 2003.
14 Donohue B. Coexisting child neglect and drug abuse in young mothers specific recommendations for treatment based on a review of the outcome literature. Behavior Modification: 2004, 28(2), p. 206–233.
15 Advisory Council on the Misuse of Drugs. Hidden harm. Three years on: realities, challenges and opportunities. Advisory Council on the Misuse of Drugs, 2006.
16 Scottish Government. The road to recovery: a new approach to tackling Scotland's drug problem. The Scottish Government, 2008.
17 Scottish Executive. Getting our priorities right: policy and practice guidelines for working with children and families affected by problem drug use. Scottish Executive, 2006.
18 HM Government. Drugs: protecting families and communities: the 2008 drug strategy. HM Government, 2008
19 Healthcare Commission and National Treatment Agency for Substance Misuse. Improving services for substance misuse: a joint review. Commission for Healthcare Audit and Inspection, 2006.
20 Jones A. et al. The drug treatment outcomes research study (DTORS) baseline report: appendices. Home Office, 2007.
Last revised 07 August 2008 Background notes Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Doing it together strengthens families and helps prevent substance use KEY STUDY 2004
Motivational arm twisting: contradiction in terms? THEMATIC REVIEW 2006
Final report on the evaluation of 'Option 2' STUDY 2008
The Drug Treatment Outcomes Research Study (DTORS): final outcomes report STUDY 2009
Holistic family therapy preferable to less comprehensive therapy for troubled teens NUGGET 2002
Early teaching boost pays off six years later NUGGET 2004
International review and UK guidance weigh merits of buprenorphine versus methadone maintenance NUGGET 2008
