Drug and Alcohol Findings home page in a new window EFFECTIVENESS BANK BULLETIN 10 September 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.


Contents

Therapy add-ons to detox and maintenance; new prevention tactic

Two syntheses of research conducted for the Cochrane collaboration offer an instructive contrast between the non-impact of structured psychosocial therapy as an add-on to methadone maintenance and its positive impact when added to detoxification programmes based on reducing doses of the same drug. For the reviewers, a testament to the power of basic methadone maintenance. At the other end of the intervention spectrum, a team of US researchers has been trying to make universal youth drug use prevention more feasible for schools and colleges by targeting use of the most common substances and other health-relevant behaviours in one package delivered face-to-face in less than half an hour. The interventions embody sound psychological principles, contrasting risky behaviour with desired self-image, but effects have been patchy and sometimes short-lived, perhaps as much as can be expected from a one-off brief session.

Extra therapy does not improve on methadone plus counselling ...

Therapy means more complete opiate detoxification ...

Substance using pupils cut back after health promotion session ...

Few sustained gains from health promotion session with college students ...


Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of opioid dependence.

Amato L., Minozzi S., Davoli M. et al.
Cochrane Database of Systematic Reviews: 2011, 10, Art. No.: CD004147.

Update of Cochrane review of rigorous studies surprisingly finds that adding psychosocial therapy to opiate substitute prescribing makes no difference to retention or substance use – a testament to the power of the routine treatment and a blow (but not a fatal one) to hopes that extra therapy would aid recovery and treatment exit.

Summary Maintenance treatments with pharmacological agents which substitute for heroin can reduce the risks associated with use of street drugs for addicts unable to abstain from drug use. Methadone retains patients in treatment and reduces heroin use, but re-addiction remains as a substantial challenge. Opiate addicts often have psychiatric problems such as anxiety and depression and may not be able to cope with stress. Psychosocial interventions including psychiatric care, psychotherapy, counselling, and social work services are commonly offered as part of maintenance programmes. Psychological support varies from structured psychotherapies such as cognitive-behavioural therapy and supportive-expressive therapy to behavioural interventions and contingency management. This review addressed whether these specific psychosocial interventions create any additional benefit relative to usual pharmacological maintenance treatment, which itself routinely includes counselling.

The reviewers sought trials which randomly allocated patients to opiate substitute prescribing with and without extra therapy or used some other procedure to ensure comparability between the sets of patients. In the event all 35 studies (involving in total 4319 participants) randomly allocated patients either as individuals or groups. The USA accounted for 31 studies and one each was conducted in Germany, Malaysia, China, and Scotland. Most often they tested therapies from the behavioural family which generally assume drug dependence is a learnt behaviour which can be unlearnt, and focus on changing behaviours rather than for example developing insights in to why those behaviours might have come about.

Main findings

Without psychosocial therapy 68 of 100 patients were retained in treatment to the end of the study; with therapy this rose to 70, a difference which might have occurred by chance. Similarly the three studies which reported retention to the end of the follow-up period also together found no significant difference, though here the balance was actually in favour of standard treatment (71 versus 64 in every 100 retained).

Eight studies documented how many patients remained abstinent from non-prescribed opiate-type drugs as confirmed by consecutive urine tests over at least three weeks. Though in favour of therapy patients (on average 12% Editor's note: according to the main text (based on eight studies), though a tabular summary of findings (based on seven studies) says 19%. more abstinent) this difference was not statistically significant so might reflect chance variations. Results were similar across the three studies reporting abstinence at the end of the follow-up period.

Across the three studies to have reported on these variables, there were no statistically significant differences in treatment session attendance or in symptoms of psychological problems and specifically depression.

Neither were there any statistically significant improvements in these outcomes when the different types of psychosocial therapies were considered separately. Of these, the most often evaluated were therapies from the behavioural family, across which retention and abstinence were virtually identical regardless of whether therapy was offered. In relation to retention, the same was true of contingency management A behavioural treatment based on the systematic use of incentives to promote abstinence or compliance with treatment, such as (in the reviewed studies) material rewards for drug-free urines or methadone dose increases. studies in particular.

The authors' conclusions

The previous version of this review found that therapy improved both retention and opiate abstinence; with more studies at its disposal, this update found neither to be the case. Though larger and further studies with longer follow-ups and rigorous, wide-ranging assessments may yet record benefits, as things stand the evidence does not indicate that adding psychosocial therapy improves the effectiveness opiate substitute prescribing programmes. This means that methadone maintenance treatment should be provided even if additional psychosocial therapies cannot be funded.

It should be however be remembered that that these therapies were compared not with substitute drugs only, but these plus routine counselling. The results reflect the added value of structured psychosocial interventions implementing specific therapies, not whether any kind of psychosocial intervention helps.

The results of this review contrast with those of a companion review of adding psychosocial therapy to 'detoxification' programmes which prescribe substitute drugs on a reducing schedule with a view to patients becoming entirely free of these and street drugs. Across these studies, adding therapy did improve retention as well as reducing opiate use during and after treatment. The difference between impacts in these two types of treatments may arise because maintenance treatments have robust effects in themselves and counselling is usually offered along with methadone. Possibly too, detoxification patients are less stable – usually a personal crisis precipitates detoxification – and have more issues to deal with. If psychosocial interventions help with these issues, it seems reasonable to expect improved outcomes.


Findings logo commentary An expert group convened for the Department of Health on how to enhance the recovery potential of methadone treatment saw psychosocial therapies as one way Though structured therapies of the kind assessed in the reviewed studies were seen as just one of several ways to improve treatment. forward. Their report sought to further ambitions in British national drug policies (England; Scotland) to make methadone maintenance in Britain more recovery-oriented. The featured review suggests that across the entire caseload, explicit psychotherapies do not in fact help. That they do not extend retention may be dismissed in an era when the emphasis has shifted to treatment exit. However, this emphasis is softened by the expectation that exit will be of 'recovered' addicts no longer using street drugs; it seems in that respect too that structured psychosocial therapies have offered no added value across researched caseloads.

Methadone treatment: powerful in itself

Sometimes denigrated as 'merely' substituting one drug for another, the review's findings are a testament to the power of routine methadone maintenance. The impact of a legal supply of a more 'normalising', smoother and longer acting drug like oral methadone on patients, many of whom previously had to offend several times a day to sustain the roller-coaster of repeated daily heroin injections, is in itself typically rapid and powerful. From this and other research it seems that an specific programme of psychological therapy is less important than the basics identified in a review conducted for an expert group convened for the English Department of Health: a structured treatment with clear objectives (cessation of heroin use, the key to recovery), involving an adequate dose of methadone, long-term treatment with no hurry to withdraw, and an accepting, non-judgmental therapeutic alliance. Below some examples of the power of methadone treatment in its own right.

The impact of basic methadone treatment was visible in a study in Baltimore where for the first four months crisis counselling only was provided to randomly selected patients. Over this period they did as well as patients offered standard weekly or more enhanced counselling and the improvements were substantial, heroin use falling from on average virtually daily to two to four days a month. That kind of finding has been replicated in other studies of 'interim' methadone arrangements which accelerate treatment entry by for a time doing without standard counselling. Particularly instructive was a different kind of trial in San Francisco which randomly allocated patients to methadone-based detoxification, or to six months of methadone maintenance with just 15 minutes of counselling a month or at least two sessions a month and more if needed. What made the difference to both heroin use and drinking was being on methadone. Additional counselling led to no further reductions or any other statistically significant differences in outcomes.

In Britain too questions have been raised about the benefits of and therefore the need for regular counselling. Finding itself overwhelmed with referrals, a prescribing service in Scotland introduced a 'low threshold' methadone programme which provided counselling and other forms of help only when the client actively sought them. The 'chaotic' caseload was typically unemployed and recently or currently homeless and injecting several times a day. The effect was to widen treatment access, the impact on retained patients was beneficial, and many went on to the full prescribing programme or to GPs. 69 of 101 patients were retained long enough to complete the eight-week follow-up. They reported dramatic reductions in injecting and sharing injecting equipment. The proportion involved in crime fell and depression receded. Discharged patients had typically stayed for 4.5 months, longer than envisaged, partly because many did not want to transfer to the more comprehensive programme with standard counselling.

Also a testament to the power of methadone maintenance, one conclusion reached by the review was that on average psychosocial therapies add little or nothing to this treatment but do bolster other treatments, specifically those which use the same drug but on a reducing detoxification schedule. It was also one finding of a US study of intensive case management support for welfare applicants with substance use problems. Providing this helped in terms of achieving abstinence, but only among applicants not already managed in substitute prescribing programmes. For those who were, case management made no significant difference. Again it is important to remember that in the US context the methadone patients would already have been being counselled regularly and seeing clinic staff virtually daily.

Not an argument against counselling

The review's findings do not however mean psychosocial support is useless. First, the therapies tested did not exhaust the possibilities. Second is the point made by the reviewers that counselling was provided to comparison patients. It can be added that since most studies were from the USA, they would also usually have been required to attend the clinic almost daily to take their methadone – more potentially therapeutic staff contact than many British patients experience – and that generally patients volunteered to be randomly allocated to therapy or not. If they did so because they did not care much either way, it comes perhaps as no surprise that on average they did as well with as without.

Evidence that counselling does help in some circumstances comes from for example a US study which for the first 24 weeks randomly assigned 100 patients starting methadone maintenance either to monthly counselling, three sessions a week, or seven sessions a week plus medical, psychiatric, employment and family therapy services. More support led to better drug problem, crime and health outcomes. Though it cost more, the three times a week option was actually more cost-effective than monthly counselling in terms of the cost of services actually delivered per patient abstinent from heroin and cocaine.

Psychotherapy benefits only patients who need it

For research purposes, commonly studies exclude psychologically unstable patients, the very ones who some US studies described below suggest might have benefited from psychotherapy.

These studies found extra benefits from psychotherapy for methadone patients with psychiatric problems but not for those without. Benefits were apparent in some ways (but not in substance use) among patients with moderately severe problems, but more clear cut for the high severity patients who consistently improved more after being randomly allocated to professional psychotherapy, including a greater reduction in days of opiate use. Without psychotherapy, among these patients opiate use remained virtually unchanged. Clinical records showed that the two groups of patients with appreciable (mid or high) psychiatric severity had more drug positive urines when offered drug counselling alone without psychotherapy and had required higher doses of methadone, typically a response to continuing problems.

Later the study was broadly replicated among patients selected for severe psychiatric symptoms attending three more typical methadone programmes. In all 123 were sufficiently severe to be randomly allocated to an extra therapy session a week for 24 weeks of either supportive expressive psychotherapy, or drug counselling of the kind they were already receiving. On nearly every measure, by the final follow-up psychotherapy patients were doing better than those given drug counselling, though usually the differences were modest. After the initial impacts of being on methadone had evened out, patients given psychotherapy evidenced somewhat better psychiatric adjustment and a move towards a more conventional and law-abiding lifestyle. However, in some respects the effects were not as substantial as in the previous study and were not seen at the initial follow-up, perhaps partly because both groups of patients were offered an extra therapy session a week. This was intended to eliminate concerns that the earlier findings might have reflected the amount of therapeutic contact rather than its type. Given the relative findings of the two studies, it seems these concerns were at least partly valid – that perhaps amount was an important active ingredient.

But is it the therapy or the quality of the interaction?

These studies cast some doubt over the implicit assumption tested by the review that it is the structured, theory-driven nature of psychosocial therapy which is important. An alternative is that it is instead the quality and quantity of therapeutic contact with staff whether or not this features 'brand name' therapies. If this is what counts most, it makes sense that offering a little extra therapy to what is already intensive staff contact would make no difference. The answer is probably a mix of both but perhaps more weighted to the quality of the interaction whether or not it adopts a specific therapeutic programme or philosophy.

This seemed the message of a rare British study which found that offering cognitive-behavioural therapy to methadone patients in addition to routine keyworking led to reductions in the severity of addiction and heroin use, and improved compliance with prescribed methadone. But with a small sample, the differences were not statistically significant so may have occurred by chance. If they were real it was generally not because cognitive-behavioural therapy led to the intended psychological changes any more effectively than routine treatment. The findings suggest that extra therapeutic contact did help stabilise patients who were prepared to accept it, but whether this needed to be cognitive-behavioural or a recognised therapy of any kind seems questionable, particularly since in addiction treatment in general, cognitive-behavioural therapy is no more effective than other similarly extensive and coherent approaches, even when these amount simply to well-structured medical care.

As described in these Findings notes, the quality of counselling seemed decisive at a US methadone clinic where patients were allocated in a virtually random fashion to four drug counsellors. Two were moderately effective, the third very effective and the fourth not effective at all. The most effective counsellor was able to bring his clients to a point over a six-month period where their drug use and unemployment were significantly reduced when compared with the prior six months, while at the same time reducing their use of both methadone and ancillary psychoactive medications. By contrast, the clients of the least effective counsellor showed increased unemployment, drug use and criminal activity, and needed more methadone and ancillary medication. When the case notes were examined in detail, it became clear that the most effective counsellor was able to help clients anticipate their problems and assist them in developing ways of dealing with them before they arose. This was the quality which most clearly distinguished this counsellor from the moderately effective ones who were similarly qualified.

Other issues

In respect of contingency management, the review's findings differ from those of another synthesis of the research published in the year 2000. It found 30 relevant studies across which the systematic application of incentives led to more drug-free urine tests. Though effects were significantly smaller than in non-randomised trials, this was also the case among the 17 trials which randomly allocated patients, but effects were modest and even more so when urine tests were conducted less than three times a week.

According to the featured review, only 1 of 27 studies in itself found a statistically significant improvement in retention at the end of the study. In fact it was even worse – a remarkable clean sweep with no finding in favour. The one apparently positive finding seems to have been a mistake The relevant table in the review records 20 of 42 comparison patients has having been retained but in fact there were only 24 patients. by the reviewers and that study too found no significant difference.

Thanks for their comments on this entry in draft to James Bell of the National Addiction Centre in London, England. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 06 September 2012

Comment/query to editor
Back to contents list at top of page
Give us your feedback on the site (one-minute survey)
Open Effectiveness Bank home page
Add your name to the mailing list to be alerted to new studies and other site updates


Top 10 most closely related documents on this site. For more try a subject or free text search

HOT TOPIC 2016 Are the drugs enough? Counselling and therapy in substitute prescribing programmes

REVIEW 2009 Efficacy of opiate maintenance therapy and adjunctive interventions for opioid dependence with comorbid cocaine use disorders: a systematic review and meta-analysis of controlled clinical trials

STUDY 2011 How does cognitive behaviour therapy work with opioid-dependent clients? Results of the UKCBTMM study

REVIEW 2011 Psychosocial and pharmacological treatments versus pharmacological treatments for opioid detoxification

STUDY 2010 Is heroin-assisted treatment effective for patients with no previous maintenance treatment? Results from a German randomised controlled trial

STUDY 2010 Using enhanced and integrated services to improve response to standard methadone treatment: changing the clinical infrastructure of treatment networks

STUDY 2012 Randomized trial of standard methadone treatment compared to initiating methadone without counseling: 12-month findings

REVIEW 2010 A review of opioid dependence treatment: pharmacological and psychosocial interventions to treat opioid addiction

STUDY 2013 A randomized trial of cognitive behavioral therapy in primary care-based buprenorphine

REVIEW 2011 A systematic review and meta-analysis of interventions to prevent hepatitis C virus infection in people who inject drugs





Psychosocial and pharmacological treatments versus pharmacological treatments for opioid detoxification.

Amato L., Minozzi S., Davoli M. et al.
Cochrane Database of Systematic Reviews: 2011, 9, Art. No.: CD005031.

Review of controlled studies finds that offering therapy and incentives alongside drugs which ameliorate withdrawal symptoms increases the numbers who complete detoxification from heroin and allied drugs and who stay opiate free, but still most do not do either.

Summary People who abuse opioid drugs and become dependent on them experience social issues and health risks. Medications such as methadone and buprenorphine are substituted to help dependent drug users detoxify and return to living drug free, by reducing physiological withdrawal symptoms (pharmacological detoxification). Yet psychological symptoms can occur during detoxification and may be distressing. Often a personal crisis led to a drug user deciding to detoxify. Furthermore the psychological reasons why a person became addicted are important. They may not be able to cope with stress and have come to expect that using mood-modifying illicit substances helps. Even after successful return to a drug-free state, many people return to heroin use and re-addiction is a substantial problem. The physiological, behavioural and social conditions in an individual's life that made them an opiate addict may still be present when physical dependence on the drug has been eliminated. These considerations suggest that psychosocial therapy should be an important component of detoxification programmes. These interventions include behavioural treatments, counselling and family therapy.

To test this propositions, the review authors searched the medical literature and found eleven studies involving 1592 adults which randomly allocated opioid-dependent patients to pharmacological detoxification with versus without psychosocial interventions. All but one study was from the USA. Psychosocial interventions tested in these studies were: contingency management; A behavioural treatment based on the systematic use of incentives to promote abstinence or compliance with treatment, such as (in the reviewed studies) material rewards for drug-free urines or methadone dose increases. community reinforcement Significant others in the patient's life are mobilised to provide incentives for desired behaviours such as not using drugs or doing things incompatible with drug use. In the reviewed studies during individual sessions patients were provided with relationship and employment counselling, instructions on antecedents and consequences of their opiate use, and help to develop new or reinstate old recreational activities. structured counselling of various kinds; Psychotherapeutic counselling; intensive role induction with or without case management; counselling and education on high risk behaviour; therapeutic alliance intervention. or family therapy

Main findings

Meta-analytic 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. synthesis of the findings showed that adding psychosocial interventions to withdrawal-ameliorating substitute drugs significantly improved the number of patients who completed treatment (from about 64 in every 100 dropping out the number was reduced to 45), reduced the proportion who continued to use opiate-type drugs during (from about 79 in every 100 down to 65) and after (from about 80 in every 100 down to 53) treatment, and halved the number of times patients failed to turn up at treatment sessions.

For the different types of psychosocial intervention, it was possible to pool data only for contingency management and psychotherapeutic counselling. Combining contingency management with pharmacological treatments significantly reduced drop-out rates, opiate use during treatment, and missed appointments. Only the latter could be assessed for psychotherapeutic counselling, and was also significantly reduced. Three other outcomes were reported only in one study (engagement in further treatment; use of other drugs; and mortality), so it was not possible to pool the data.

The authors' conclusions

The results of this review show that psychosocial adjuncts to pharmacological detoxification treatments improve completion rates and reduce opiate use during and after treatment. Their effects seems stronger than when such interventions are added to maintenance treatments which prescribe substitute opiate-type medications on a long-term and non-reducing basis. This may be because maintenance treatments have robust effects in themselves and counselling is usually offered along with methadone. Possibly too, detoxification patients are less stable – usually a personal crisis precipitates detoxification – and have more issues to deal with. If psychosocial interventions help with these issues, it seems reasonable to expect improved outcomes.

The main limitation is that nearly all the studies were from the USA, a particular social and cultural context. Context can affect treatment outcomes, so it impossible to sure the same results would be found in other countries.

Outpatient opiate detoxification is a quick, inexpensive and common procedure that helps by ameliorating withdrawal symptoms and temporarily reducing health risk associated with illegal drug use. It also constitutes the first point of contact of many addicts with the various treatment services available, and may facilitate transition to long-term care. Given that methadone-based detoxification is so widely used, it is reasonable to attempt to try to develop more effective techniques, of which adding psychosocial interventions seems an example. Particularly interesting are the findings of improved attendance, providing extra opportunities to counsel patients in psychiatric, employment and other drug and non-drug related areas.

It is important however to remember that there is no evidence that detoxification can substitute for long-term treatment in the management of opiate addiction. Relapse to opiate use is not entirely due to avoidance of or escape from withdrawal symptoms, so a treatment which only addresses these symptoms can be at best partially effective. Many if not most of the physiological, behavioural and social conditions prevailing during an individual's life as an opiate addict will still be present when physical dependence has been eliminated. Furthermore, once methadone prescribed during detoxification (the typical medication used) is no longer active, opiates will regain the reinforcing properties which previously sustained self-administration. Under these conditions, relapse is probable.


Findings logo commentary In Britain successful completion and exit from the treatment system of patients no longer dependent on drugs or using heroin or crack is now an important criterion of success on which some funding also hinges. This review suggests that for opiate users, the bulk of the treatment caseload, the opiate-free state and treatment completion essential to meeting this criterion is more likely to be achieved if drugs to ameliorate withdrawal symptoms are accompanied by systematically applied incentives geared to these objectives and/or counselling and therapy to help patients build a new and stable life without resort to opiate-type drugs. Conducted under stringent Cochrane collaboration procedures, the review focused on studies which should have virtually eliminated bias due to different types of patients opting for or being given different treatments by randomly allocating patients to the different programmes. It means the resulting estimates can be relied on as indications of the impact of the extra support in these studies, but also that very few studies made it in to the analysis, reducing the extent to which their results can be taken as indicative of what would happen in routine practice with different caseloads and in different countries.

Of those studies which did get through, just one was not from the USA. It was a British study published in 2002 which supplemented gradual methadone detoxification with family therapy for patients willing to have their partners or families involved and to join the study. On a variety of measures, family therapy patients were doing better six and 12 months later, when 22% and 15% were not using street opiates or being prescribed methadone, compared to at both times 8% of patients also withdrawn from methadone on a fixed schedule but with minimal psychosocial support, and just 5% and 0% of a 'standard' treatment group offered normal counselling and reduced at the discretion of the service, typically over 12 months compared to the six to 12 months on the fixed schedule. The patients who qualified for and joined the study were however just 119 of the 423 who sought treatment at the clinic, and family therapy was most clearly beneficial for those in a couple relationship. One year after starting treatment two of the 41 patients allocated to family therapy had died but none from the other treatments. With such small numbers this might be pure chance, but it might also reflect the greater risk faced by patients who relapse after having completed detoxification and become for a time opiate-free, during which time their tolerance to opiate-type drugs will have waned to the point when previously taken doses could be fatal. This will remain an important consideration as long as the relapse rate – in this study even with family therapy support – remains so high that return to opiate use is the norm after detoxification. As the featured review confirms, the extra support it evaluated is often the icing on what remains a very unsatisfactory cake, usually offering a short-lived respite which most patients do not complete.

British guidance for clinicians treating drug misuse and dependence on how to detoxify opiate-dependent patients draws on an appraisal of evidence and expert opinion published in 2007 by Britain's National Institute for Health and Clinical Excellence. In respect of psychosocial adjuncts, it was faced with a narrow set of research studies heavily weighted to the contingency management regimens favoured in recent US studies. Unable on the basis of the generally lacking scientific evidence to pronounce on other interventions, its recommendations on specific types of programmes were limited to contingency management, which it saw as a cost effective option when wider economic, social and public health consequences of drug misuse are considered. The result was a recommendation for phased and evaluated introduction of these regimens to see if they work as intended in Britain. However, this aspect of NICE's recommendations was downplayed by the clinical guidance which instead called for a "full programme of psychosocial support" during detoxification and "access to a range of drug-free support services" afterwards.

Last revised 31 August 2012

Comment/query to editor
Back to contents list at top of page
Give us your feedback on the site (one-minute survey)
Open Effectiveness Bank home page
Add your name to the mailing list to be alerted to new studies and other site updates


Top 10 most closely related documents on this site. For more try a subject or free text search

REVIEW 2009 Efficacy of opiate maintenance therapy and adjunctive interventions for opioid dependence with comorbid cocaine use disorders: a systematic review and meta-analysis of controlled clinical trials

REVIEW 2011 Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of opioid dependence

STUDY 2011 Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence

REVIEW 2003 Lofexidine safe and effective in opiate detoxification

STUDY 2011 Transitioning opioid-dependent patients from detoxification to long-term treatment: efficacy of intensive role induction

HOT TOPIC 2016 Are the drugs enough? Counselling and therapy in substitute prescribing programmes

HOT TOPIC 2016 Should we offer prizes for not using drugs?

DOCUMENT 2013 Rewarding virtue

STUDY 2011 How does cognitive behaviour therapy work with opioid-dependent clients? Results of the UKCBTMM study

STUDY 2012 Randomized trial of standard methadone treatment compared to initiating methadone without counseling: 12-month findings





A brief image-based prevention intervention for adolescents.

Werch C.E., Bian H., Moore M.J., et al.
Psychology of Addictive Behaviors: 2010, 24(1), p. 170–175.
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 Werch at cwerch@hhp.ufl.edu. You could also try this alternative source.

Across the sample, a brief face-to-face consultation highlighting how substance use might stop them becoming the sort of young adults they wanted to be generally did not prevent substance use among US high school pupils, but those already using substances were significantly more responsive, suggesting a selective if not a universal prevention role.

Summary The Behavior-Image Model approach to health promotion is based on the principle that portrayals of people attractive to the participant and their own improved possible future selves can integrate and motivate change in a range of activities which result in better health. Change is motivated by providing feedback on the participant's current health-related activities and their self-images, highlighting the discrepancy between them to foster commitment to setting goals to narrow this gap. Such interventions might prove more feasible for schools than single-target or lengthy programmes because in a short time they target multiple commonly used drugs and positive health promoting and personal development habits.

Two previous studies (1; 2) evaluating image-based prevention interventions among adolescents found improved substance use and other outcomes particularly among those already using substances at the start of the studies.

The featured article reports outcomes three months later in a third study. For the study 416 students (nearly two thirds girls) at a US school in grades intended for 15—17-year olds completed baseline questionnaires and were randomly assigned to the image-based intervention or to a 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. group who were simply given commercially available health promotion materials commonly used in schools. Of the 416, 87% completed the three-month follow-up.

The image-based intervention called Planned Success delivered scripted messages which illustrated how health-promoting behaviours support positive social and self-images of a successful young adult attractive to the student, while behaviours which risk health do the opposite. Content was tailored to the individual's current health behaviours and the images most attractive to them. At the end they were given a 'goal plan' against which to make progress after the session. Sessions were delivered to individual pupils face-to-face by specially trained nurses and health educators and lasted about 20 minutes. Starting a week later, parents and guardian were sent three weekly mailings of five parent–youth cards with messages parallel to those given the children.

Main findings

Of the nine measures of drinking, smoking and cannabis use and one of substance use problems, just one (frequency of smoking) was reduced by the intervention to a statistically significant degree after adjusting for the risk that with so many tests some might have met this criterion purely by chance. However, children who had been through the intervention were more active in setting goals for health-related behaviour.

Results differed between the 28% of pupils who were using Had used in past 30 days. either tobacco, alcohol or cannabis before the start of the study. Compared to the bulk of non-using pupils, the intervention had led to stronger positive trends in the amount they drunk and smoked and on the number of problems related to substance use they experienced, but not in cannabis use.

The authors' conclusions

This study reinforces previous work suggesting that image-based messages, delivered in potentially cost-effective and translatable brief intervention formats, may foster health behaviour goal setting and reduce substance use, particularly among the older drug using adolescents in greatest need of an effective preventive intervention. These findings suggest that brief interventions targeting positive images linking health-promoting behaviours with avoiding substance use might have a role as 'selective' interventions to curb the drug use of adolescents who are already drinking, smoking or using illicit drugs.


Findings logo commentary The findings of this study in relation to youngsters already using substances indicate that the effect of the intervention was for them significantly greater than among non-users, but not necessarily that there had been significant effects among the users themselves. It is also a concern that in each case where significant differences were found, substance users in the intervention group started the study using more or more often than control group users. This raises the suspicion that what we are seeing is at least partly the 'regression to the mean' phenomenon of relatively extreme scores normalising over time regardless of intervention. Some other studies of a similar intervention ( final paragraph) raise the issue of whether the significant results seen at three months would have survived to say a year.

The study did however avoid very common methodological flaws. Unusually and commendably it set stricter criteria for statistical significance in light of the number of outcomes being tested. If as many studies do it had not been so diligent, it could have claimed another significant result in relation to drinking. It also seems to have decided in advance of seeing the results to test whether these differed among substance users, rather than capitalising on the results to segment the sample in ways which would produce a significant difference. Finally, though rarely significant, all the differences in the sample as a whole were in favour of the intervention.

In respect of drinking, the findings seem in line with the conclusion commonly reached by policy analysts that interventions based on education and persuasion have a minor place in the prevention armoury compared to the much greater role of interventions which directly affect the availability of drink through restricting outlets and/or increasing price.

One of the previous school-based studies of a similar intervention included a specific alcohol component as well as one based on sport and fitness (the latter including how alcohol would impede these objectives). In no case did this focus on alcohol lead to better alcohol-related outcomes, and the presumed predisposing factors to drinking targeted by the alcohol component actually improved more when the focus was on sport. Another school study found that a sport and fitness image-based intervention curbed drinking and smoking not just three months but also 12 months later. However, a similar intervention trialled among US university students had only fleeting effects. The students at first cut back their drinking and cannabis use in response to a brief face-to-face fitness consultation, but the gains were no longer apparent a year after intervention. Still at that time they had at least experienced more positive trends in how well they felt than students who had just read a fitness brochure.

Last revised 06 September 2012

Comment/query to editor
Back to contents list at top of page
Give us your feedback on the site (one-minute survey)
Open Effectiveness Bank home page
Add your name to the mailing list to be alerted to new studies and other site updates


Top 10 most closely related documents on this site. For more try a subject or free text search

REVIEW 2015 Prevention of addictive behaviours

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

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

STUDY 2010 The effectiveness of a school-based substance abuse prevention program: 18-month follow-up of the EU-Dap cluster randomized controlled trial

REVIEW 2014 Interventions to reduce substance misuse among vulnerable young people

STUDY 2010 Does successful school-based prevention of bullying influence substance use among 13- to 16-year-olds?

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

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

STUDY 2010 Project SUCCESS' effects on the substance use of alternative high school students

STUDY 2004 Family check-up builds on teachers' abilities to identify problem pupils





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

Werch C.E., Moore M.J., Bian H. et al.
Preventive Medicine: 2010, 50, p. 30–34.
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 Werch at cwerch@hhp.ufl.edu. You could also try this alternative source.

At a US university students at first cut back their drinking and cannabis use in response to a brief face-to-face fitness consultation, but the gains were no longer apparent a year after intervention. Yet still at that time they had at least experienced more positive trends in how they felt than students who had just read a fitness brochure.

Summary The Behavior-Image Model approach to health promotion is based on the principle that portrayals of people attractive to the participant and their own improved possible future selves can integrate and motivate change in a range of activities which result in better health. Change is motivated by providing feedback on the participant's current health-related activities and their self-images, highlighting the discrepancy between them to foster commitment to setting goals to narrow this gap.

An initial study evaluated three brief face-to-face, image-based interventions for college students conducted by fitness specialists. Over the following month several health-related activity domains and health-related quality of life significantly improved.

The featured article reports outcomes 12 months later from a second such study which at three months found that a brief image-based intervention had led to reductions in various measures of drinking and cannabis use, improved exercise and sleep patterns, and enhanced spiritual and social health-related quality of life.

For the study 18–21-year-old students at a public US university were recruited by adverts and announcements and paid for their participation. Of the 303 who volunteered, nearly all (299, of whom 60% were women) completed baseline questionnaires and were randomly assigned to then immediately participate in the image-based intervention or join a 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. group asked by a fitness specialist to read a standard brochure on fitness in a private office.

Sample messages

I see that you engage in at least 30 minutes of moderate physical activity on most days of the week. Congratulations, you are physically active!

Young adults who engage in regular physical activity tend to feel energetic, sleep better, and look more attractive, slim and physically fit. Regular physical activity can reduce your stress level making you more relaxed, happy and unworried.

Meanwhile, using too much alcohol and smoking cigarettes interferes with creating a physically active lifestyle. Alcohol misuse can get in the way of your fitness goals by decreasing your energy level, and directly harming your fitness level and compromising your goals of being in-shape, looking good and feeling strong.

Regularly engaging in moderate physical activity, while avoiding too much alcohol and cigarettes, will help you continue to be a physically active young adult, and reach your fitness goals of keeping slim and trim.

The same office was used for the 25-minute image-based intervention by the same specialists. This delivered scripted messages which illustrated how health-promoting behaviours support positive social and self-images attractive to the student, while health risk behaviours do the opposite. Content was tailored to the individual's current health behaviours and which images were attractive to them box for examples. At the end they were given a brief written 'goal plan' and asked to select at least one goal from each of four domains Physical activity and exercise; drinking; smoking; other fitness-related behaviours including nutrition, stress management, and sleep. to make progress towards over the following week.

Main findings

In calculating the outcomes the available data was used to estimate what the responses would have been of the 23% of students who did not complete the 12-month follow-up, though results were similar when this was not done. 'Heavy' use of alcohol was defined as five or more drinks in a row for men or four or more for women, while heavy use of cannabis was "getting really high or stoned". Students were usually asked to report on their behaviour and health over the past month.

The general pattern was that post-intervention relative improvements seen at three months had decayed by 12 months to the point where they were no longer statistically significant, partly due to the control students 'catching up'. Though several had been significantly affected at three months, on none of the measures of alcohol or cannabis consumption had intervention students sustained improvements to a statistically significant degree. However, the increase in the number of days on which the student had driven after drinking seen among control students was not seen in intervention students, resulting in a statistically significant difference. There were also sustained, consistent and usually significant relative gains in how well the students felt reflected in measures of health-related quality of life. One of the five measures of physical exercise (moderate exercise over the past month) had been significantly improved at three months and this had been sustained, but improvement in sleep patterns had not.

Given these findings it was decided to assess how closely the quality of life measures were related to actual health-related behaviour. The relationships were all weak, suggesting that how well the students felt did not simply reflect how 'well' in health terms they behaved.

The authors' conclusions

Initial improvements three months after a brief image-based intervention among college students were partially sustained at 12 months – in particular, there were generally small gains in health-related quality of life, moderate exercise, and drink-driving. However, relative reductions in alcohol and cannabis use and sleep patterns were not sustained (a pattern in respect of the drugs also seen with school pupils after a similar intervention), suggesting that it is worth investigating booster re-interventions. Regardless of changes in behaviour, improvement in health-related quality of life is an important goal in itself.


Findings logo commentary Though not statistically significant, on four of the eight measures of alcohol or cannabis consumption, students who had participated in the image-based intervention had moved in the 'wrong' direction relative to students just given a fitness brochure to read. Three of these four measures related to cannabis, a drug not targeted in the standard messages included in the intervention. Smoking tobacco was targeted, but there were no significant effects at three months and presumably none at 12 months. This pattern effectively amounts to no reliable reductions in substance use over the year of the follow-up. In contrast, after three months, six of 14 measures of substance use or problems had been significantly curbed by the intervention, including heavy (or 'binge') drinking and becoming intoxicated on cannabis. At three months omnibus tests of impacts on drinking and cannabis use indicated a significant impact but not in respect of smoking. At this time point too nearly all the students were reassessed.

These findings suggest that the short-term effects on substance use were real but could not be sustained. In respect of drinking, the findings support the conclusion commonly reached by policy analysts that interventions based on education and persuasion have a minor place in the prevention armoury compared to the much greater role of interventions which directly affect the availability of drink through restricting outlets and/or increasing price.

A similar intervention has been trialled among US secondary school pupils, with generally no significant effects at the three-month follow-up, though there were indications that the minority of pupils already using substances at the start of the study had cut back in response to the intervention.

Last revised 06 September 2012

Comment/query to editor
Back to contents list at top of page
Give us your feedback on the site (one-minute survey)
Open Effectiveness Bank home page
Add your name to the mailing list to be alerted to new studies and other site updates


Top 10 most closely related documents on this site. For more try a subject or free text search

REVIEW 2015 Prevention of addictive behaviours

STUDY 2011 Cluster randomised trial of the effectiveness of motivational interviewing for universal prevention

REVIEW 2011 Effectiveness of motivational interviewing interventions for adolescent substance use behavior change: a meta-analytic review

STUDY 2010 A brief image-based prevention intervention for adolescents

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

REVIEW 2014 Interventions to reduce substance misuse among vulnerable young people

STUDY 2013 Alcohol assessment and feedback by email for university students: main findings from a randomised controlled trial

STUDY 2014 Web-based alcohol screening and brief intervention for university students: a randomized trial

STUDY 2010 Brief physician advice for heavy drinking college students: a randomized controlled trial in college health clinics

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





L10 Web Stats Reporter 3.15 LevelTen Hit Counter - Free PHP Web Analytics Script
LevelTen dallas web development firm - website design, flash, graphics & marketing