Drug and Alcohol Findings home page in a new window EFFECTIVENESS BANK BULLETIN 9 February 2012

The entries below are our accounts of documents collected by Drug and Alcohol Findings as relevant to improving outcomes from drug or alcohol interventions in the UK. The original documents were not published by Findings; click on the Titles to obtain copies. Free reprints may also be available from the authors. If displayed, click prepared e-mail to adapt the pre-prepared e-mail message or compose your own message. The Summary is intended to convey the findings and views expressed in the document. Below may be a commentary from Drug and Alcohol Findings.


Scottish drug education fell short of evidence-based practice ...

When schools prevent bullying, do they also prevent problem drinking? ...

Motivational interviewing works for teenagers as well as adults ...

Pros and cons of supervised methadone consumption in Scotland ...

Bridging the gap between evidence and practice: a multi-perspective examination of real-world drug education.

Stead M., Stradling R., MacNeil M. et al.
Drugs: Education, Prevention and Policy: 2010, 17(1), p. 1–20.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Stead at martine.stead@stir.ac.uk.

An audit of school drug education in Scotland in the early 2000s found that in key respects lessons departed from what research had shown was effective prevention and that despite national guidelines, there was no consistent national or even local approach.

Summary Conducted in the early and mid-2000s, this study sought to establish the degree to which national guidance and drug education in Scottish schools reflected what research suggests is good and effective practice. To this end research reviews were analysed and the findings compared with national guidance. To find out what was happening in schools, in 2003–2004 a postal questionnaire was sent to 1290 primary, secondary and special schools, which 73% of the eligible schools returned after completion mainly by head teachers or deputy heads. The survey was supplemented by direct on-site observation of 100 lessons in 40 schools of the 140 asked to participate in this strand of the research. After lessons, 78 teachers were able to be interviewed.

Main findings

National guidance at the time (latest published in 2004) reflected the evidence base by, for example, supporting interactive teaching methods, a 'whole school' approach involving parents, teaching at primary as well as secondary levels, and lessons based on pupils' needs and abilities. However, more explicit reference could have been made to some findings, including the effectiveness of social influence and normative education and the relative ineffectiveness of approaches based on imparting information or fostering personal development by (among other attributes) improving decision-making skills, clarifying values and enhancing self-esteem.

According to the school survey, almost all primary, secondary and special schools in Scotland taught drug education, in primary schools generally by all teachers, in secondary schools by a team of teachers specialising in personal, social and/or health education. A third of secondary schools used a variety of teachers including form tutors and teachers of subjects other than personal, social and/or health education. Most teachers completing the survey reported having received some staff development or training in drug education in the past three years, but just a third had been trained in teaching methods and just over a half teaching skills.

In just over 40% of both primary and secondary schools, drug education was also taught by external visitors or agencies, usually community police officers or officers from the Scottish Drug Enforcement Agency. Peer educators were rarely used.

Generally a wide range of legal and illegal substances were taught about, almost universally by providing information, for example, about their effects. Over 8 in 10 schools also reported covering issues like refusal and decision-making skills, and almost as many why drugs are used and opinions about drugs. In contrast, social-influence topics such as the acceptability drug use and how 'normal' drug use is were covered in fewer than half the schools. Whole-class discussion was a virtually universal teaching method. Also very common were small group work, pupil worksheets, and videos/DVDs.

These findings from the survey were partly confirmed by observations of lessons which most commonly featured structured whole-class discussion. Next most common were activities sharing and checking information, presenting information to others, open-ended discussion, and teacher-led inputs. Only in a minority of classes were pupils essentially passive recipients of information. In most there was some degree of interactive learning, though often in the service of acquiring information rather than developing skills or exploring attitudes and values. Teachers trained in personal, social and/or health education were more likely than others to be interactive in their teaching.

Somewhat in contrast to survey findings, the observed lessons rarely employed approaches found most effective by research. Most focused mainly on giving factual information about drugs and their effects. Few introduced harm reduction approaches, understanding of how various social influences impact on behaviour and attitudes towards drugs, or approaches designed to develop decision making and resistance and assertiveness skills. Despite its research backing, there were no examples of 'normative education' contrasting beliefs about how many young people use drugs with survey findings. Around a third of the observed lessons were exclusively based on a published education package based, but 27 lessons mixed resources whose origins were not always clear to observers, and in 23 teachers drew on a bank of activities, resources and packages developed or compiled in-house. In some cases teachers were observed using resources inappropriate for the age group they were teaching.

Two thirds of observed lessons were judged 'definitely clear' in their messages, but only in just over half (54%) did pupil understanding appear to have definitely been enhanced. In 60%, almost all the class were rated as engaged in the lesson, though in secondary schools this fell to 51%, and was lower when teachers rather than external agents delivered the lessons, seemingly (from pupil comments) due to their novelty value and because their greater proximity to drugs made them seem more credible.

Over half (55%) the observed lessons made no reference to reviewing previous work and the school survey too found that fewer than half the schools indicated that strong links were made to drug education taught earlier in the school, In only seven observed lessons did the teacher explain the expected learning outcomes. Content was sometimes duplicated across school years.

The authors' conclusions

The study confirms that the vast majority of schools in Scotland provide drug education covering a wide range of substances and across the age range. However, education is not as evidence-based as it could be in terms of methods, modes of delivery and learning approaches, and there is room for improvement in the continuity of drug education between school years and in the selection and use of resources. There is also scope for greater specificity in the guidance provided to schools and for better training and dissemination of evidence-based concepts and programmes.

In particular, although evidence indicates that information-based approaches are among the least effective, many of the observed teachers appeared to favour this approach, while social influences featured in only a minority of lessons, and normative education approaches hardly at all. It may be that giving information provides a safer approach for teachers who lack the confidence or knowledge to approach drug education in other ways. If so, this would highlightthe importance of training teachers not only in drug awareness but also in the evidence-based approaches that underpin good drug education teaching.

A key feature of the study was that teachers tended to describe their practice as less narrowly focused on information acquisition than the observations showed it to be, suggesting a lack of understanding of what different approaches mean in practice. Encouragingly, most observed lessons were least partly interactive in delivery style. However, there was room for greater use of interactivity. The fact that teachers trained in personal, social and/or health education seemed more likely to conduct interactive teaching again underlines the importance of training.

It was encouraging that drug education was provided across all years, though the study found considerable duplication.

Widespread reliance on visitors for delivering drug education is not necessarily inappropriate, and often they were seen to generate positive responses from pupils in terms of message clarity, engagement and understanding of drugs. It is however important to ensure that their inputs are evidence-based in terms of methods and approaches, and coherent with the school's own curriculum and teaching ethos.

Finally, the study confirmed other research suggesting that teachers vary in their use of drug education packages, even where a particular resource is encouraged across a local authority area. Worryingly, some teachers used materials of doubtful provenance without a clear apparent rationale for their selection, and some resources were inappropriate for the age, abilities and experiences of the class.

Arising from these findings were the following recommendations for closing the gap between evidence and practice:
1. Guidance should emphasise more strongly the weight of evidence behind proven effective approaches to drug education, particularly social influences and normative education approaches.
2. In-service training and resources for teachers should encourage the adoption of approaches proven to be effective, build confidence to use these methods, and explain the rationale for them so teachers understand not only what is involved in teaching a particular approach, but why it is important to do so and how it is assumed to impact on young people. Training programmes need to recognise that teachers may find it hard to 'unlearn' or transfer allegiance from previous approaches.
3. Greater continuity needs to be encouraged between primary and secondary school drug education. This may be achieved through strengthened liaison processes, joint training, and curriculum guidance stating more explicitly the principles underpinning progression and continuity of learning. This guidance needs also to take into account variations in young people's experiences as well as their cognitive development.
4. The resources used for Scottish drug education need reviewing to ensure they are evidence based, current, appealing, and appropriate to pupils' ages, abilities and experiences.
5. Finally, schools need help in making best use of the support provided by external visitors. There is a need for more specific guidance on how to use visitors best, covering understanding of visitors' particular strengths and expertise, what areas of drug education are more appropriately covered by teachers, and ensuring that visitors' inputs support and are integrated better with school provision. Developing mechanisms that bring schools and agencies together to plan a consistent approach may be particularly helpful.

Findings logo commentary A research report on the study is freely available on the Scottish government's web site.

Methodologically, the main weakness of the study as an indicator of national practice is the fact that lesson observations – the securest way to find out what actually is happening rather than what schools believe or claim is happening – were conducted in just 40 schools out of 140 approached, largely due to the fact that just 60 of these schools were willing to be observed. This procedure was adopted after the intended more structured selection procedure for schools proved impractical. How representative the 40 schools were of Scotland in general is impossible to say.

From the perspective of evidence on school-based substance use prevention of the time, the study and its verdicts on what was good and less good about teaching in Scottish schools in the early 2000s make detailed sense. From today's perspective, they can be questioned on at least two broad grounds.

First, the implicit assumption that drug education should be judged against prevention rather than educational criteria, though still widely accepted, has been contested by some British specialists (1 2). Much of the research also shares the assumption that prevention (generally of substance use as such) is the objective. Derived from this research, the yardsticks used by the study to assess drug education in Scotland partly reflect this assumption. Nevertheless, much of its critique of teaching planning and methods would apply also to drug education judged purely on educational grounds.

Second, even accepting that prevention is the appropriate yardstick, today the prevention credentials of approaches such as interactive teaching focused on social influences on drugtaking, and correcting beliefs about how 'normal' this is among one's peers, seem far less clear cut. In turn, it now seems less decisive to compare Scottish drug education against these best-practice yardsticks. More below.

The key analysis supporting the superiority of interactive teaching has been shown to depend on which method is used to analyse the results of relevant studies, while normative education, which once seemed the great hope for school- and college-based prevention, now seems a tactic of limited application and with inconsistent impacts. Important recent implementations of school-based drug education incorporating all these elements include the seven-nation EU-Dap European drug education trial and the English Blueprint trial. The former's results were patchy, the latter's, if anything, in the wrong direction.

This draft entry is currently subject to consultation and correction by study authors and other experts.

Last revised 26 January 2012

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STUDY 2003 Drug education: inspections show that tick box returns are no guarantee of quality

STUDY 2010 One-year follow-up evaluation of the Project Towards No Drug Abuse (TND) dissemination trial

REVIEW 2011 Early intervention: the next steps. An independent report to Her Majesty's Government

REVIEW 2015 Prevention of addictive behaviours

STUDY 2005 Drug prevention best done by school's own teachers not outside specialists

STUDY 2000 Education's uncertain saviour

STUDY 2001 Prevention is a two-way process

HOT TOPIC 2016 Drug education yet to match great (preventive) expectations

REVIEW 2009 School-based programmes that seem to work: Useful research on substance use prevention or suspicious stories of success?

DOCUMENT 2007 Interventions in schools to prevent and reduce alcohol use among children and young people

Does successful school-based prevention of bullying influence substance use among 13- to 16-year-olds?

Amundsen E.J., Ravndal E.
Drugs: Education, Prevention and Policy: 2010, 17(1), p. 42–54.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Amundsen at eja@sirus.no.

Intriguing suggestion from a Norwegian study that taking measures to effectively reduce bullying in schools (including improving the social climate and setting clear and consistently enforced boundaries) also curbs the development of forms of substance use most associated with disturbed child development.

Summary The possibility that effectively tackling bullying among young people might reduce substance use is suggested by the fact that both are linked to conduct disorders or antisocial behaviour. Norwegian pupils aged 10–16 who score high on psychological tests of antisocial attitudes have also been found to be significantly more likely to smoke and drink, suggesting a common root in the rejection or breaking of social norms.

One proven Evaluated several times in Norway, the USA and other countries, impacts have included large decreases in self-reported bullying, reductions in antisocial behaviour in general, improvement in various aspects of the 'social climate' in a class, improved order and discipline, more pro-social and positive relationships, more positive attitudes to school work and school, and greater pupil satisfaction with school life. way of preventing bullying is the Olweus Bullying Prevention Programme. Implemented in schools when pupils are aged 9–12 or older, it engages all the pupils, but specially targets those who bully and get bullied. It aims to work by fostering a school and possibly also a home environment characterised by positive interest and engagement from adults, combined with firm boundaries between acceptable and unacceptable behaviour signalled by the consistent application of non-physical, non-hostile sanctions when rules are broken. The programme is multi-faceted and multi-level (bully, victim, parents, class, school) and long-term – two full school years with follow-up.

The opportunity to assess impacts on substance use arose because in year 2001 Oslo primary/junior schools embarked on the Olweus programme and some also engaged in a study of pupils' substances use. The latter study surveyed pupils from age 12–13 in grade 7 up to age 15–16 in grade 10. Except for transfers between schools, over four years pupils in the lowest grade were re-assessed each year until grade 10. Pupils in higher grades at the start of the study were also followed up to grade 10 but over fewer years or, in the case of those in grade 10 at the start of the study, assessed only once.

From these schools were selected four which had implemented the Olweus programme and two control A group of people, households, organisations, communities or other units who do not participate in the intervention(s) being evaluated. Instead, they receive no intervention or none relevant to the outcomes being assessed, carry on as usual, or receive an alternative intervention (for the latter the term comparison group may be preferable). Outcome measures taken from the controls form the benchmark against which changes in the intervention group(s) are compared to determine whether the intervention had an impact and whether this is statistically significant. Comparability between control and intervention groups is essential. Normally this is best achieved by randomly allocating research participants to the different groups. Alternatives include sequentially selecting participants for one then the other group(s), or deliberately selecting similar set of participants for each group. schools which had not, chosen from areas with similar levels of drinking among young people. Altogether in each grade from 1378 to 443 pupils were assessed, representing nearly 90% of all pupils in those grades. Because the surveys were anonymous, it was not possible to track the responses of the same pupil over succeeding years.

Main findings

There were large variations in the proportions of pupils who had used substances between schools, and in the steepness of the increases in substance use from grade 7 to grade 10. Where there were differences in trends in substance use between Olweus and non-Olweus schools, mainly these emerged between grades 9 and 10 when pupils were aged 14 to 16.

Two sets of analyses tested the statistical significance of these trend differences in terms of the likelihood that each individual pupil would use substances in the ways assessed by the study. Of the 18 tests, six met the conventional criterion of being expected by chance less than 1 in 20 times, suggesting that there were real differences between the schools which in turn caused substance use trends to differ – the presumption being that the key difference was the Olweus programme. Significant trend differences took the form of less steep age-related increases in Olweus schools in the proportions of pupils who said they had frequently got drunk or used cannabis over the past year.

The evidence was particularly compelling in relation to frequent drunkenness; the gap between the two sets of schools was virtually zero in relation to trends in having been drunk in the past year, substantial in terms of having been drunk at least six times, and greater still in terms of having been drunk at least 11 times. In other words, the more worrying the drinking pattern, the more the Olweus programme appeared to have retarded its development. For example, by grade 10 just over 30% of non-Olweus pupils had got drunk at least six times in the past year compared to just over 20% in Olweus schools.

In contrast, smoking Currently either daily or not daily. was not significantly affected (though especially in respect of daily smoking, the differences were nearly significant) and nor was drinking Having drunk alcohol in the past year or drunk it at least six or 11 times. as such as opposed to having got drunk. In respect of drunkenness, the experience of having been drunk became more common among older pupils in both sets of schools; only trends in frequent drunkenness differed significantly.

Another two sets of analyses compared the schools in terms of trends in the proportions of pupils in each grade who had engaged in the substance use behaviours assessed by the study. When grades of pupils had been tracked across years, these analyses could treat each succeeding yearly survey as repeatedly re-assessing the same pupils. On this basis, none of the 18 tests for trend differences between Olweus and non-Olweus schools were statistically significant. Nevertheless, some of the trend differences were substantial, resulting in gaps by grade 10 of 6–9%.

The authors' conclusions

The Olweus Bullying Prevention Program did not reduce alcohol use as such, but may have reduced frequent drunkenness, cannabis use, and possibly current/daily smoking. If we assume that the programme had its intended effects (not actually assessed by the study), it suggests that development of forms of substance use associated with poor social development may be held back by persisting measures to create a school environment characterised by positive interest and engagement on the part of adults, firm boundaries between acceptable and unacceptable behaviour, and consequent application of non-physical, non-hostile sanctions.

The findings may not be due to lower levels of bullying only but to a better social climate in general. This speculation is in line with findings in Norway that young people who experience supportive peer relationships are more likely to drink than those who do not; in the study, drinking as such was unaffected, only frequently getting drunk.

These findings are however tentative. Apart from not assessing whether the social climate actually was better in Olweus schools, with so few schools it was not feasible to randomly allocate them to the Olweus programme, leaving the possibility that the schools and/or their pupils differed in other ways which affected the development of substance use.

Findings logo commentary It will be a welcome finding that in (as they are legally required to do) taking measures to prevent and deal with bullying, British schools may also be preventing the most worrying forms of substance use. For the reasons given by the authors – and also because of 36 tests for differences in substance use between the schools, just six were statistically significant – these findings are suggestive only and require confirmation in a more appropriately designed study. But as the authors point out, they 'make sense' in that such differences as there were largely concerned the type of substance use – frequently getting drunk – which at these ages seems likely to be indicative of disturbed social and psychological development. Forms of substance use like drinking as such which (in the Norwegian context) carry no such connotation were unaffected. Adding to the credibility of the finding is an association found in a US study between substance use among secondary school pupils and being either a bully or (more strongly) a victim of bullying.

Assuming that the findings reflected real differences attributable to the Olweus programme, they add to a body of work which has found substantial preventive impacts from school and parenting initiatives which are not about substance use at all, but about creating environments at home and in school which foster psychologically and socially healthy child development. This approach is consistent with the observation that typically children develop a constellation of mutually aggravating problems, related the further back one looks to a shared set of factors affecting children's mental and physical well-being. Among these is a positive school environment. Findings analyses of such studies can be accessed by running this search.

At the same time drug education in schools has generally failed to live up to hopes that it can substantially and reliably prevent substance use problems. Recent disappointments include two programmes which embodied the latest thinking on drug education – the seven-nation EU-Dap European drug education trial and the English Blueprint trial. The former's results were patchy, the latter's, if anything, in the wrong direction.

Non-drug focused programmes attract, not just because they may offer a substance use prevention effect not realised by drug-focused programmes, but also because they promise wide-ranging benefits in areas other than substance use such as the prevention of crime and violence and of mental health problems. Beyond specific programmes is the finding that substance use and problems are lower in schools distinguished by the high degree to which they productively engage pupils in their education and/or create a sense of being part of a valued school community – a sense promoted by warm and supportive schools with a caring, inclusive ethos, which emphasise prosocial values, encourage cooperation, show concern for pupils as individuals, allow pupils to participate in decision-making, and offer extracurricular activities.

These too are the type of schools where bullying is prevented and effectively dealt with when it happens. British schools have a legal duty to put in place measures to encourage good behaviour and prevent bullying among pupils. Guidance to schools from the Department for Education points out that schools "which excel at tackling bullying have created an ethos of good behaviour where pupils treat one another and the school staff with respect because they know that this is the right way to behave. Values of respect for staff and other pupils, an understanding of the value of education, and a clear understanding of how our actions affect others permeate the whole school environment and are reinforced by staff and older pupils who set a good example to the rest."

Last revised 18 February 2012. First uploaded

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STUDY 2011 Effects of a school-based prevention program on European adolescents' patterns of alcohol use

STUDY 2003 Substances, adolescence (meta-analysis)

STUDY 2010 One-year follow-up evaluation of the Project Towards No Drug Abuse (TND) dissemination trial

STUDY 2010 A brief image-based prevention intervention for adolescents

STUDY 2012 Does school ethos explain the relationship between value-added education and teenage substance use? A cohort study

STUDY 2008 Substance-focused initiatives not only way schools help prevent risky substance use

STUDY 2008 Substance use outcomes 5½ years past baseline for partnership-based, family-school preventive interventions

REVIEW 2015 Prevention of addictive behaviours

HOT TOPIC 2015 It’s magic: prevent substance use problems without mentioning drugs

STUDY 2005 Drug prevention best done by school's own teachers not outside specialists

Effectiveness of motivational interviewing interventions for adolescent substance use behavior change: a meta-analytic review.

Jensen C.D., Cushing C.C., Aylward B.S. et al.
Journal of Consulting and Clinical Psychology: 2011, 79(4), p. 433–440.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Steele at rsteele@ku.edu. You could also try this alternative source.

Not just for adults, but teenagers and young adults too, with this analysis motivational interviewing seems confirmed as the leading evidence-based approach to reducing possibly or actually risky substance use among non-clinical populations not seeking treatment.

Summary Evidence for the effectiveness of motivational interviewing to modify health-related behaviour in adults is strong, but evidence in respect of adolescents is just emerging. For the first time, this meta-analysis A study which uses recognised procedures to combine quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually. aimed to summarise information and synthesise data from studies of motivational interviewing interventions intended to promote changes in the substance use of teenagers and young adults.

The analysts searched for peer-reviewed, English language articles from studies which compared post-treatment outcomes from interventions described as motivational interviewing against those from control A group of people, households, organisations, communities or other units who do not participate in the intervention(s) being evaluated. Instead, they receive no intervention or none relevant to the outcomes being assessed, carry on as usual, or receive an alternative intervention (for the latter the term comparison group may be preferable). Outcome measures taken from the controls form the benchmark against which changes in the intervention group(s) are compared to determine whether the intervention had an impact and whether this is statistically significant. Comparability between control and intervention groups is essential. Normally this is best achieved by randomly allocating research participants to the different groups. Alternatives include sequentially selecting participants for one then the other group(s), or deliberately selecting similar set of participants for each group. conditions such as assessment only or an intervention not intended or expected to affect substance use. The people involved had to be (with minor exceptions) aged 21 or less, though their parents might also be involved in the intervention. With relatively few studies, the analytic method did not assume that the impact of these motivational interventions varied only by chance around one 'true' underlying figure, but that differences between the studies might have led to real differences in the impacts of the interventions.

In all 21 studies were discovered. Most documented changes in cannabis and alcohol use, a third smoking, while lesser proportions reported on other drugs. All but four studies recruited samples who were not attending treatment centres but might for example have been identified as substance users in emergency departments or doctors' surgeries, or responded to requests for substance users to join a study. In line with this sampling, 13 of the 21 studies tested brief interventions consisting of just one session of motivational interviewing, and in 17 the motivational intervention was the sole 'treatment'. Additional to or instead of measuring change shortly after the interventions ended, seven studies conducted follow-up assessments over six months later and another four within the next six months.

Main findings

Measured as effect sizes, A standard way of expressing the magnitude of a difference (eg, between outcomes in control and intervention groups) applicable to most quantitative data. Enables different measures taken in different studies to be compared or (in meta-analyses) combined. Based on expressing the difference in the average outcomes between control and experimental groups as a proportion of how much the outcome varies across both groups. The most common statistic used to quantify this difference is called Cohen's d. Conventionally this is considered to indicate a small effect when no greater than 0.2, a medium effect when around 0.5, and a large effect when at least 0.8. the degree to which the interventions affected substance use varied, but not so much that the studies had to be treated as so different that their results could not be pooled. Though in their own rights only three studies contributed statistically significant results, pooled across all 21, motivational interventions led to a small but statistically significant reduction in substance use amounting to an effect size of about 0.17.

Though still statistically significant, the impact waned when assessed over six months later (effect size of 0.13) compared to assessments less than six months later (effect size of 0.32). When (as it was in five studies) smoking was the sole target, at an effect size of 0.31 the impact was twice as large as the impact on other forms of substance use.

The authors' conclusions

The results of this synthesis of data from studies of young people are consistent with those found among adults. Pooled across all relevant studies, interventions for youth substance use based on motivational interviewing have resulted in small but statistically significant reductions in the use of substances including tobacco, alcohol, cannabis and other illicit drugs, though to a slightly lesser degree when tobacco-only studies were excluded. These results were recorded despite most interventions consisting of just a single session, and most interventionists not having received graduate-level training – features which suggest that motivational interviewing may be a particularly cost-effective approach for non-treatment samples of young substance users. Though impacts waned, they remained statistically significant over six months later, showing that just one or a few sessions can produce sustained substance use reductions.

It should be stressed that these results derived mainly from non-treatment populations and cannot be assumed to apply to young people diagnosed with substance use disorders, who might need more extended and possibly more robust interventions. Moreover, only five of the 21 studies systematically assessed whether the interventions really conformed to the principles of motivational interviewing, and no attempt was made to judge whether any of the studies might have produced biased results. This corpus of studies also offers no clear indication of the degree to which parents should be involved in such interventions.

Nevertheless, the results suggest that motivational interviewing does promote positive change in youth substance use, and that clinicians should consider using this approach as at least as one component of their interventions.

Findings logo commentary With this analysis motivational interviewing seems confirmed as the leading evidence-based approach to reducing possibly or actually risky substance use among non-clinical populations not seeking treatment not just among adults, but teenagers and young adults too. This status partly reflects the relatively intense research effort devoted to the approach, which in turn is a testament to its widespread applicability from possibly risky substance users not seeking help to dependent users attending treatment, and as a standalone treatment, an adjunct to the main treatment, or as a style pervading all client-clinician encounters.

Broadly speaking, what the featured synthesis showed is that (compared to doing nothing or nothing meant to be effective) one or just a few face-to-face counselling sessions intended to be based on motivational interviewing are followed by reductions in substance use among young people who may have been using these substances inadvisably or excessively, but have not been diagnosed as clinical cases, and whose related problems have not been so troubling or noticeable that they have attracted treatment. As the authors comment, this finding accords with that from a synthesis of studies mainly of adults.

But within each study, the impacts were rarely statistically significant and, particularly when tobacco was not the focus, in aggregate very small. With the fact that the comparators were not intended to be active interventions, this raises doubts over whether the motivational nature of the interventions was the active ingredient or whether any acceptable and feasible intervention would have been as effective – or indeed, whether what we are seeing is the pooling of subtle biases in the studies which tipped findings slightly in favour of motivational interviewing.

One riposte to such doubts is that among people not seeking help, motivational interventions (which do not confront or insist that participants accept a clinical label or a pre-determined outcome) are among the few which are acceptable to the participants and feasible – feasible partly because they are acceptable, and partly because they can be quite brief. Another is that we have evidence – from studies of young people among others – that what happens during motivational sessions does matter. In particular, from a British study of further education students and others from Switzerland, it seems that it is important to embody the overall spirit of the approach and, in finer detail, to use the skill of reflective listening to 'play back' to the client an elaborated version of their own comments.

The authors' caution that a brief motivational intervention may be inappropriate and/or insufficient as a formal treatment for young people with a diagnosed problem is supported by a review of such studies of young problem drinkers. It tentatively concluded that the most promising approaches were cognitive-behavioural therapy, family therapy and community reinforcement – the latter two engaging the young person's parents and 'significant others' in the process. These suggestions accord with those made by a review conducted for Britain's National Institute for Health and Clinical Excellence (NICE). In respect of interventions for children and young people who misuse alcohol, it recommended offering individual cognitive-behavioural therapy for those with limited comorbidities and good social support, and multi-component programmes engaging families and the wider social circle for those with significant multiple problems and/or limited social support. Multidimensional Family Therapy in particular has a good research record, but one mainly due to studies conducted by its developers.

Thanks for their comments on this entry in draft to Ric Steele of the University of Kansas in the USA. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 06 February 2012

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REVIEW 2010 A meta-analysis of motivational interviewing: twenty-five years of empirical studies

STUDY 2012 Brief intervention for drug-abusing adolescents in a school setting: outcomes and mediating factors

REVIEW 2010 Computer-delivered interventions for alcohol and tobacco use: a meta-analysis

REVIEW 2014 Interventions to reduce substance misuse among vulnerable young people

REVIEW 2011 Motivational interviewing for substance abuse

REVIEW 2012 Behavioral counseling after screening for alcohol misuse in primary care: a systematic review and meta-analysis for the U.S. Preventive Services Task Force

STUDY 2011 Fidelity to motivational interviewing and subsequent cannabis cessation among adolescents

STUDY 2010 Are effects from a brief multiple behavior intervention for college students sustained over time?

REVIEW 2015 Prevention of addictive behaviours

REVIEW 2011 Effectiveness of e-self-help interventions for curbing adult problem drinking: a meta-analysis

Methadone prescribing under supervised consumption on premises: a Scottish clinician's perspective on prescribing practice.

Anthony G.B., Matheson C., Holland R. et al.
Drug and Alcohol Review: 2011, online pre-print.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Anthony at g.b.anthony@abdn.ac.uk.

Survey responses from clinicians prescribing methadone at Scottish addiction treatment clinics show how the requirement that patients be observed taking the medication involves striking a balance between safety, individualising treatment, and attracting and retaining patients.

Summary Requiring opiate dependent patients to take substitute medication under observation at the pharmacy or clinic is a common way of improving initial safety and compliance with the treatment, and preventing medication being taken by other people or diverted on to the illicit market. Depending on the individual patient and on their compliance with treatment, UK guidance recommends consumption be supervised for at least the first three months of treatment. The featured study aimed to establish the extent and nature of supervised consumption at specialist drug dependence treatment centres (ie, not at GPs' surgeries) in Scotland by means of a postal survey in February 2009 of all 42 clinical leads in substance misuse in Scotland, of whom 32 completed and returned the forms.

Main findings

Of the 32 respondents, 20 said they required supervised consumption of new patients for at least three months and 15 said the same of returning patients. For new patients, all but five required supervision six days a week. About half the clinicians said they relaxed these requirements gradually, though it was not unusual for clinicians to support long-term or indefinite supervision. Safety was highlighted as the key reason for supervising consumption, particularly preventing methadone being taken unsafely by people other than the patient. The decision to relax this requirement was made partly on grounds of safety (including that of children in the home who might inadvertently consume take-home medication) and partly on the basis of indicators that the patient was socially and psychologically stable, complying with treatment and no longer using illicit drugs.

Twenty of the respondents indicated that they used the relaxation or imposition of supervision as a way of shaping the behaviour of the patient, most commonly to encourage the cessation of illicit drug use as confirmed by urine tests.

Eight of the 32 clinicians believed that supervised consumption deterred some people from starting treatment and 13 that it led some to drop out prematurely due (among other reasons) to inconvenience or conflicts with work, education or family obligations.

The authors' conclusions

Clinicians who responded to this survey usually required supervised consumption for at least three months and took the individual patient's needs and situation in to account when deciding to relax this requirement, balanced against a keen awareness of the danger posed to other people by 'leaked' methadone. What might be seen as the 'vagueness' of national guidelines created the space for the patient-centred approach important to many clinicians.

The Scottish drugs strategy's focus on recovery, entailing moving on in treatment and seeking employment, may require some relaxation of the requirement for supervised consumption. The ambition to increase the numbers in treatment may also require the rethinking of a requirement which imposes considerable cost and absorbs considerable staff time. These decisions would benefit from an assessment of evidence on the effectiveness and cost-effectiveness of different models of supervision, for example, no supervision versus daily or twice-weekly supervision. Such an assessment would also have to consider the wider societal implications of reverting to less restrictive approaches.

Findings logo commentary Findings analyses related to supervised consumption can be found by running this search. Among the retrieved studies is one of methadone overdoses in Scotland and England, which supports clinicians' safety concerns and beliefs that supervised consumption is an important aid to improving safety. It concluded that the recent decline in the per-dose rate of deaths due to methadone overdose was due to the spread of supervised consumption, and that this was the main reason for a remarkable improvement in the safety of methadone prescribing from 1995 to 2004.

However, the study was unable to determine whether each opiate user in or out of treatment had become more or less likely to survive as a result of the introduction of supervised consumption. To the degree that (as some clinicians in the featured study believed) it causes dependent opiate users to avoid or drop out of treatment, it could impede substitute prescribing realising its lifesaving potential. Beyond methadone patients and potential patients are the other adults and children who might risk their lives by consuming methadone stored in the home or passed on by patients. These deaths too can be expected to be curtailed by supervised consumption, but the impact on overdose on opiate-type drugs as a whole is less easy to predict. Below a summary of research on these and related issues based on a Findings review.

Research confirms that anti-diversion regimens which include supervised consumption are associated with reduced diversion and that the risk of diversion is greatest among patients yet to achieve stability, marked for example by appropriate housing, employment, and reduced illegal drug use. Research is contradictory with regard to the impact on outcomes and retention. This may be because two opposing influences are at play. Especially when it can be made convenient for the patient, supervised consumption can enhance retention by giving structure to lives newly devoid of the structure imposed by acquiring and using illegal drugs, by ensuring regular clinical contact, and by preventing patients straying back to illegal drug use. Sometimes patients are aware of these dangers and resist increased take-away dispensing. Others relapse when take-aways are extended across the board rather than restricted to stabilised patients.

On the other hand, patients find it difficult to comply with long-term attendance or supervision requirements, leading to reduced compliance and premature drop-out or discharge. Patients may understand the need for supervised consumption in the initial stages and for 'chaotic' patients, but object to its continuation when individuals have 'proved' themselves. Extended supervision is generally unpopular with patients. In some countries where consumption is at the prescribing clinic, it contributes to long queues and congestion which foster disputes, facilitate drug-based social networks, and create a counter-therapeutic environment. It also risks restricting the development of the patient's responsibility for their lives, and displacing therapeutic activities and relationships by policing and control. Patient autonomy is undermined because they are unable to control the timing and staging of their medication consumption. This freedom might be exercised to facilitate illegal drug use, but may also be used it to reduce it. Frequent clinic or pharmacy visits obstruct reintegration in to employment and family responsibilities and make it difficult for patients to keep their condition secret.

Last revised 02 February 2012

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