Drug and Alcohol Findings home page. Opens new window Effectiveness Bank bulletin 11 September 2013

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.


First two additions to the Effectiveness Bank address the issue of how little can be done and still gain some therapeutic benefits. Next is about how to make the most of talking therapies – long or short – by improving patients' cognitive abilities. Final report extends out from treatment to the emerging recovery context in northern England.

Feasible intervention for short-sentence heavy drinkers ...

Is counselling dispensable in methadone programmes? ...

Brain exercises help clients engage with and benefit from therapy ...

Challenges faced by groundbreaking recovery projects ...

A brief alcohol intervention for hazardously drinking incarcerated women.

Stein M.D, Caviness C.M, Anderson B.J. et al.
Addiction: 2010, 105(3), p. 466–475.
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 Stein at michael_stein@brown.edu. You could also try this alternative source.

Could just two motivational interviewing sessions moderate the drinking of very heavy drinking US women prisoners? The surprise was not that there were few benefits, but that there were some, especially after the reinforcing session usually conducted after the prisoners' release.

Summary While in prison women drinking at hazardous levels can be identified by screening, and despite the high turnover of prison populations, the one or two short counselling sessions which characterise brief interventions can normally be completed. Especially if reinforced after leaving, these may prove of benefit.

This possibility was tested at the US Rhode Island prison complex by a study which recruited newly admitted female adult prisoners who on assessment by researchers were found They also had to have reported unprotected sex on at least three separate days in the three months before entering prison. to have drunk heavily (four or more US standard drinks or seven UK units) on at least three days in the previous three months, or who scored as hazardous drinkers (eight or more) on the AUDIT alcohol problem screening questionnaire.

On average the 245 women who joined the study were 34 years of age, had drunk heavily three days a week (each day consuming 25 UK units) in the three months before their imprisonment, and scored just over 20 Editor's note: considered to warrant further diagnostic evaluation for alcohol dependence. on the AUDIT questionnaire. Nine in 10 met criteria for being or having been dependent on alcohol.

They were randomly allocated to no intervention (the 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), or to two 30–45-minute motivational interviewing sessions. The first session was conducted in prison immediately after the researchers had recruited the prisoners to the study. All the participants were to be re-assessed a month later. If they had been released, for those allocated to the brief intervention this was immediately followed by their second session. If they were still in prison, the session was delayed until they were released, with the proviso that in any event it was to be scheduled before the three-month follow-up. In practice about a quarter of the women did not attend the second session; of the remainder, three quarters attended it after release.

During the first session the specially trained female clinicians were to lead the prisoner to set goals for changing their drinking, and to explore strategies to deal with any obstacles. The second session focused on the participant's progress (or on setting a goal if none had been set before) and on developing concrete strategies for meeting new goals. Recovery strategies were also discussed, with an emphasis on identifying and coping with high-risk situations.

Sessions were audiotaped and reviewed in fortnightly supervision sessions.

Nearly 8 in 10 participants completed each of the follow-ups (one, three and six months after recruitment) and 91% completed at least one.

Main findings

The following analyses ignored days when participants were not free to drink because they were in prison.

Generally the women continued to frequently drink heavily after release, but at the three-month follow-up, somewhat less frequently if they had been allocated to the two brief intervention sessions, which by then they would have completed or failed to attend.

At the three-month follow-up, on 68% of days since their baseline interview women offered the brief intervention had not drunk at all versus 57% of days among the control group, a statistically significant advantage for the intervention. This effect was much greater among the minority of women who had not been dependent on alcohol than among those who had been. Over the same period women offered brief intervention also recalled significantly fewer adverse consequences from their drinking.

These were, however, the only statistically significant results. There were no such differences at the one-month follow-up before the second session had been offered, and by the six-month follow-up the gap in the proportion of non-drinking days had narrowed to an insignificant 66% versus 62%.

Few women avoided drinking altogether (8% of controls and 9% offered brief intervention) and there was no evidence that the intervention restrained drinking on days when the women did drink; at the last two follow-ups they still averaged around 16–17 UK units on each drinking day. Neither did the intervention encourage significantly more women to start treatment for their drinking. Whether (as intended) the second motivational session had taken place after release rather than in prison made no difference to the findings, as did the time between the two sessions.

The authors' conclusions

Among these heavy-drinking female prisoners, a two-session brief alcohol intervention increased the proportion of alcohol-free days over the three months after the initial session. It also resulted in a reduction in alcohol-related problems, suggesting the impacts on drinking were clinically meaningful. These effects did not last, and the brief intervention was not enough to produce consistent or prolonged abstinence, or to moderate the intensity of drinking on drinking days. In other words, though at three months the brief intervention led to fewer days when the women started drinking, once they had started, it did not restrain consumption.

These results should be seen in the context of the nature of the caseload. Nine in 10 of the women had a history of alcohol dependence, people often excluded from brief intervention trials on the basis that such minimal help could not be expected to work. They were also selected on the basis of their pre-prison risky sexual activity. This population may have needed more intensive care than two brief sessions. Also, these results were achieved with trained and supervised clinicians doing the motivational interviewing, not routine prison staff.

Findings logo commentary For the UK the findings of this study will be of greatest relevance to the many short-term female prisoners for whom a full course of treatment (one of the main programmes runs over 20 two-hour sessions) is not feasible, especially since the cognitive-behavioural group therapy programmes common in UK prisons have so far gathered little evidence that they affect substance use or crime.

However the results offer little encouragement. In generally finding no significant positive impacts, the findings in one way accord with the major British trial of a brief alcohol intervention for heavy drinking offenders, in this case on probation. Where they differ is that the most noticeable impact in the featured study was among the less severe drinkers, while in the British study it was among the most severe. Outside a criminal justice context too, it is not unusual to find that severe drinkers, including those dependent on drinking, do benefit from brief interventions, in some cases more so than less severe drinkers.

The results presented above and the study focus on the difference the intervention made. Another way of looking at the results is the difference potentially made by the full package of research assessments, screening and intervention – an increase from 45% non-drinking days at baseline to 68% three months later and a drop from 21 UK units at a sitting to 18. This however is the maximum change the package might have made; some of this modest remission might have happened anyway.

For more on the application of motivational interviewing in criminal justice contexts see this Findings review.

Last revised 10 September 2013. First uploaded 04 September 2013

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

STUDY 2012 The first 90 days following release from jail: Findings from the Recovery Management Checkups for Women Offenders (RMCWO) experiment

STUDY 2009 Randomized controlled pilot study of cognitive-behavioral therapy in a sample of incarcerated women with substance use disorder and PTSD

STUDY 2012 Alcohol screening and brief intervention in probation

DOCUMENT 2012 Alcohol problems in the criminal justice system: an opportunity for intervention

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

STUDY 2011 Extended telephone-based continuing care for alcohol dependence: 24-month outcomes and subgroup analyses

REVIEW 2011 Motivational interviewing for substance abuse

STUDY 2011 Delivering alcohol brief interventions in the community justice setting: evaluation of a pilot project

STUDY 2010 Efficacy of physician-delivered brief counseling intervention for binge drinkers

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

Schwartz R.P., Kelly S.M., O'Grady K.E. et al.
Addiction: 2012, 107(5), p. 943–952.
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 Schwartz at rschwartz@friendssocialresearch.org. You could also try this alternative source.

Up to a year after starting methadone treatment US patients offered virtually no counselling for the first four months were still doing as well as those offered regular counselling. But there is a hint that intensive and high quality counselling enabled more to safely leave treatment.

Summary The featured article presents the 12-month follow-up results of a US study from which Findings has previously analysed the four-month follow-up results. Both articles are drawn on in this account.

At issue was whether initial regular counselling improves outcomes from methadone maintenance treatment. US regulations require regular counselling except for specially authorised 'interim' programmes, and even then counselling must start after 120 days of this stripped-down provision. Previous studies have shown that compared to waiting for a standard methadone treatment slot, rapid access to interim provision substantially reduces opiate use and crime, and many more patients eventually start standard methadone treatment. But these studies left open whether offering rapid access to standard programmes would be even more effective than offering rapid access to interim programmes.

To explore this question two Baltimore methadone clinics randomly and rapidly assigned new patients (usually within three days) to an interim programme, to a standard methadone programme, or to an enhanced programme.

As per regulations, the interim programmes could last only up to 120 days, offered crisis counselling only, required patients to take all methadone doses under supervision at the clinics, and featured at least three tests for illegal drug use.

Patients randomised instead to standard programmes were expected to attend weekly group and/or individual counselling sessions (with some room for adjustment to patient needs), permitted to take their methadone at home depending on time in treatment and progress, were subject to more frequent drug testing than in the interim programme, and were able to benefit from care planning and other psychosocial inputs.

At one of the clinics patients were also randomly assigned to the enhanced option – the standard programme plus enriched counselling by a highly regarded counsellor with a low caseload, told to see patients as often as they wanted or the counsellor thought appropriate.

The 230 patients recruited to the study and who started 248 patients could have joined the study, 244 did so and were randomly allocated to the three programmes, but only 230 actually started the intended treatments (received an initial dose of methadone), the remainder having been excluded by the clinics or by the study. one of the three types of programmes were typically unemployed single black men in their early 40s who used heroin daily. On average they had used heroin for nearly 22 years but most (53%) had never before been in methadone treatment. All but a few were followed up by researchers four months later when the interim programmes had to have stopped or been replaced by standard provision. As expected, during this time clinic records showed that the interim patients had received virtually no counselling, standard patients about one session a fortnight, and enhanced patients about one a week. Over the next eight months enhanced patients continued to receive individual counselling most frequently, averaging once every two or three weeks, former interim patients about monthly, and standard patients about one session every six weeks.

Main findings

Generally the findings suggested that patients did equally well regardless of the differing availability of counselling and the other differences between the programmes.

Dosing protocols in the three types of programmes did not differ. However, at all assessed time points from one month after starting treatment to 12 months later, patients started in the interim programme averaged the highest doses, next were standard programme patients, while doses averaged the least among patients offered enriched counselling. By the end of the 12-month follow-up doses Presumably among followed up patients still in treatment. averaged respectively 92mg, 80mg and 65mg per day, statistically significant differences.

On average interim patients stayed in that stage nearly all the permitted 120 days. Over these four months they were no more likely than other patients to have ceased treatment at the assigned clinic; 92% were still in their original programmes compared to 81% of standard and 89% of enhanced patients. Though still not a significantly different, by 12 months retention figures had diverged to 61%, 55% and 37% respectively, again meaning that patients who had initiated in the interim programme were most likely to have remained at their clinics.

By the end of the four-month interim period and (with a little 'bounce back') also at the 12-month follow-up, heroin use had declined substantially and cocaine use (far less to begin with) more modestly. Use of both drugs fell to roughly the same degree in all three treatments. Heroin use fell from on average virtually daily to a year later four to seven days a month according the patients' own accounts (the lowest figure was for the interim patients), broadly confirmed by urine tests which were 97% positive at first but fell to 46% to 51% positive. Self-reported drug, legal and family problems all declined too, Psychiatric problems (not on average severe to begin with) did not decline in any of the programmes and neither did benzodiazepine use, apparent in roughly 1 in 5 urine tests at the start of treatment and staying at about this level four and 12 months later. and to roughly the same degree across the three treatments.

Over the four-month interim period, two indicators Past 30-day self-reported days of criminal activity, money spent on drugs, and illegal income. of criminal activity and one of spending on drugs fell slightly more steeply among interim than standard programme patients. By the 12 month follow-up there remained a statistically significant difference in trends in illegal income, which had fallen steeply from an average $657 a month to just $27 among interim patients, but slightly less steeply (from $475 to $55) among standard programme patients.

Of the serious medical or other adverse events which occurred, none were attributed to the differences in counselling frequency. By the end of the 12-month follow-up, 19% of interim patients had experienced at least one such event compared to 9% of standard-programme patients and 15% offered enhanced counselling.

The general equivalence of the treatments was broadly replicated when four-month follow-up results for interim patients were compared with those for all other study participants assigned to more frequent counselling.

The authors' conclusions

Across the board there was significant improvement, but being assigned to standard/enhanced versus interim programmes did not further improve retention, illicit drug use and related problems, or make much difference to criminal activity. There was no evidence that interim patients had been substantially disadvantaged by the four-month period during which only emergency counselling was available and they could not 'earn' take-home doses by providing drug-free urine tests.

The findings are consistent with other studies at typical US methadone clinics. They strongly suggest that rather than making additional services obligatory, opioid agonist treatment regulations should allow for these when they are helpful and wanted by patients. As well as increasing costs by imposing services that may or may not be needed, mandating these services has the unintended consequence of denying access to more basic treatment which is demonstrably of value to patients and to society. The findings also raise questions over discharging patients simply because they have not attended the required number of counselling sessions.

However, even the most frequently counselled group in the study were seen on average once a week. More intensive or different forms of counselling and other forms of support might have made more of a difference. Possibly too, some counsellors were actually beneficial, but across all patients their impacts were neutralised by less effective staff. Perhaps also patients must achieve a level of stability before counselling helps, or methadone itself at the doses prescribed at the clinics has such a powerful impact that modest levels of counselling could not create additional improvement.

Findings logo commentary Together with this study, similar studies (including some in the UK) reviewed in detail by Findings have shown that subject to sufficient assessment and monitoring to ensure clinical safety, starting prescribing in the absence of regular counselling or other psychosocial supports is preferable to simply leaving patients waiting, even for a few weeks. Patients reduce their drug use, health risks and criminal activity, and more go on to enter the main programme.

What this study adds is that in this seemingly unpromising population with on average over 20 years of heroin use and over four years in jail behind them, patients who started their first four months of treatment virtually without counselling can do as well as those individually counselled about once a month, and even as well as those counselled once a fortnight by a counsellor handpicked for excellence, and this equivalence can be sustained for at least eight months after the interim programme has ended. It seems possible that over their decades of heroin use the patients had heard already experienced advice and counselling to which the study’s programmes could add little, but what most had never experienced before was being on methadone.

Long-term solution?

Rather than just a short-term introduction to facilitate rapid access, for some patients, little more may be needed These patients might be identified by how well they do on the interim programme. and programmes similar to the US interim arrangements can form a longer term alternative to more intensive support. Across all patients, evidence of the effectiveness of extra therapy is surprisingly thin.

These findings challenge guidelines and regulations which commonly see offering drugs alone as sub-standard treatment. For example, in 2009 the World Health Organization said, "Treatment services should aim to offer onsite, integrated, comprehensive psychosocial support to every patient". UK guidelines also support psychosocial adjuncts to methadone, taking their lead partly from evidence analysed by Britain's National Institute for Health and Clinical Excellence (NICE). In 2007, NICE commended some social network therapies and the systematic application In the form of contingency management regimens. of rewards and sanctions as adjuncts to maintenance, but other approaches – including cognitive-behavioural therapy, relapse prevention techniques and motivational interviewing – were not recommended, leaving the most commonly (if often only loosely) implemented methods without the backing of this official health service advisory body.

NICE's verdict was followed in 2011 by an update of an authoritative review of rigorous studies, which found that adding psychosocial therapy to opiate substitute prescribing plus routine counselling has overall made no significant difference to retention or substance use. Among the ineffective supplements was the systematic application of rewards and sanctions, which the earlier NICE report had favoured, deleting yet another psychosocial intervention from the list of effective adjuncts.

It is important to remember that these analyses were considering the impact of therapies over and above counselling, not counselling itself, though they are suggestive that the dose of 'talking therapies' is not a critical factor. That verdict does however apply to formal therapies, and the featured study's findings to formal counselling. Even without these scheduled talking sessions, methadone treatment is far from a 'contactless' endeavour. In the featured study (and other studies of US interim arrangements), every day of the week over the entire interim period, interim patients had to attend the clinic to take their methadone under supervision – more staff contact than many British patients experience.

Also, the difference counselling makes will depend on the quality and nature of that counselling and of the counsellor. Perfunctory brief encounters focused on dose, prescribing and dispensing arrangements, attendance records, and regulatory and disciplinary issues are unlikely to accelerate recovery, yet are characteristic of the keyworking service offered by some British criminal justice teams to offenders on opiate substitute prescribing programmes.

Maybe good counselling helps patients leave treatment

Guidance for Britain on how to foster recovery in methadone maintenance and allied treatments makes it clear that it would be unacceptable to leave patients on minimal programmes without regular reviews probing for and seizing opportunities to further improve welfare and progress recovery from addiction, including ways to solidify recovery sufficiently for patients to safely leave treatment. In turn this raises the issue of whether more intensive counselling, even if it seems to add little to the powerful effect of entering methadone treatment, might help patients get sufficiently on their feet for more to leave and leave earlier.

High quality and relatively intensive counselling in the featured study was focused on the 27 patients allocated to one of the clinic's "best" counsellors. This counsellor's patients managed about as well as the others despite significantly lower doses of methadone and despite many more – nearly two thirds versus just over a third of interim patients – leaving the clinic within a year. What if any support these leavers moved on to is not reported, but across all three programmes under a third were in any kind of treatment at the last follow-up. Here there may be a hint that expert and intensive counselling, though it may not improve in-treatment outcomes, may decrease the patient's reliance on methadone and on treatment in general, making it possible for more to leave safely earlier.

A further hint comes from a review which assessed the impact of psychosocial inputs in opiate substitute prescribing programmes. It found no statistically significant differences between methadone programmes with and without extra therapy, but the direction of the differences was that with therapy more patients left, but while in treatment, more managed to do at least for a time without illicit opiate-type drugs.

In the featured study an alternative explanation for the findings is that counsellors at the clinics were unduly concerned to limit methadone doses and that this counteracted any benefit from their counselling. Interim patients who were free to seek increased doses from nurses (perhaps more pro-medication) gained those increases, and continued on higher doses over the next eight months.

Even if when averaged across all patients, counselling and therapy seem to make little difference, inevitably there are exceptions, among whom may be the psychologically unstable patients often excluded from trials, and the (in the UK) minority of patients in a position to engage in family or couples therapy. Some studies have found that multiply problematic clients benefit from regular counselling and well targeted ancillary services. Without these they suffer repeated crises, perhaps in the end requiring more intensive and expensive intervention than would otherwise have been needed.

Powerful substitute

Sometimes denigrated as 'merely' substituting one drug for another, these findings are a testament to the power of routine methadone (the same applies to buprenorphine) maintenance. After the roller-coaster of repeated daily heroin injections entailing for many addicts the need to offend several times a day to sustain their use, the impact of a legal supply of a more 'normalising', smoother and longer acting drug like oral methadone is in itself typically rapid and powerful. Adding a specific programme of psychological therapy or more intensive counselling seems less important than the basics identified in the UK recovery guidance cited above: a structured treatment with clear objectives, involving an adequate dose of methadone, long-term treatment with no hurry to withdraw, and a therapeutic alliance built on an accepting, non-judgmental stance by the clinician. Cost-effectiveness is probably maximised by making more intensive and extensive services available for those who feel they need them, or where such services seem advisable.

For more on these issues see this Effectiveness Bank hot topic on counselling in methadone programmes.

Thanks for their comments on this study to Shaun Shelly of the University of Pretoria in South Africa. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 05 November 2016. First uploaded 02 September 2013

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

STUDY 2011 Interim methadone treatment compared to standard methadone treatment: 4-month findings

STUDY 2009 The Drug Treatment Outcomes Research Study (DTORS): final outcomes report

STUDY 2012 A pilot randomised controlled trial of brief versus twice weekly versus standard supervised consumption in patients on opiate maintenance treatment

REVIEW 2017 An evidence review of the outcomes that can be expected of drug misuse treatment in England

STUDY 2006 Stripped down methadone prescribing better than leaving patients to wait

STUDY 2002 The grand design: lessons from DATOS

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

STUDY 2015 Risk of mortality on and off methadone substitution treatment in primary care: a national cohort study

STUDY 2010 The Andalusian trial on heroin-assisted treatment: a 2 year follow-up

STUDY 2010 The SUMMIT Trial: a field comparison of buprenorphine versus methadone maintenance treatment

Computer-assisted cognitive rehabilitation for the treatment of patients with substance use disorders: a randomized clinical trial.

Fals-Stewart W, Lam W.K.K.
Experimental and Clinical Psychopharmacology: 2010, 18(1), p. 87–98.
Unable to obtain a copy by clicking title? Try this alternative source.

Researchers have long suspected that pre-existing or drug/alcohol-induced cognitive deficits prevent patients making the most of treatments which rely on complex verbal communications and understandings. For the first time this US study has shown that psychological exercises to remedy these deficits do improve outcomes by helping patients get to grips with treatment.

Summary Chronic abuse or dependence on psychoactive substances is associated with neuroanatomical changes that seem to cause cognitive deficits. Such deficits could significantly impair the ability of patients being treated for substance use problems to benefit from psychosocial therapies which require patients to receive, encode, and integrate new information, to organise this information into behavioural plans, and to initiate and execute these plans. Cognitive impairment is likely to interfere with the learning and using of new information and, in turn, to be associated (as some studies have confirmed) with poorer response to treatment and worse long-term outcomes.

It follows that interventions which ameliorate cognitive impairments may improve treatment outcomes. Cognitive rehabilitation – exercises designed to enhance skills such as problem-solving, attention, memory, and abstract reasoning – appears a promising approach. Rather than directly, it may improve outcomes by strengthening the patient's ability to engage with the core treatment, stay longer and complete the process. As with physical exercise, it may also benefit patients who are not cognitively impaired, broadening its applicability and easing implementation because lengthy tests would not be required to identify impaired patients. Results to date from cognitive rehabilitation studies have been promising, but limited by recruitment of atypical and highly selected patients, no long-term follow-ups, and too few patients to tease out how the interventions might work.

The featured study aimed to address these limitations. Via ads at the service, it recruited 160 out of 199 eligible adult problem substance users starting treatment at a six-month 'Minnesota Model' residential programme in the USA based on 12-step principles. Typically they were single men in their early 30s with alcohol problems. About a third tested as cognitively impaired. Additional to the service's standard programme, for the first eight weeks of therapy they were randomly assigned to three 50-minute sessions per week of cognitive rehabilitation, or to the same time learning how to type. Both were computerised programmes and sessions were overseen by research staff.

The four modules of the cognitive rehabilitation package started with foundation training in focusing, shifting, sustaining, and dividing attention; discrimination; initiation; inhibition; and differential responding. A visuospatial module taught complex attention skills, followed by a problem solving module, and finally one devoted to improving memory.

Among other variables and assessments, the patient's substance use and problems were assessed when they left the residential service and then quarterly for a year. All but 13 of the 160 completed all assessments during and after treatment. What the 14% of missing assessments might have recorded was estimated from the data that was available.

Main findings

On average both sets of patients attended the computerised training sessions, engaged in the exercises, and said they felt satisfied with the interventions.

A 45-minute battery of tests assessed cognitive functioning in terms of attention, language, memory, and visuospatial ability and the executive functions which regulate the application of these and other abilities. After completing their cognitive training, on this measure patients had improved significantly more than those assigned to typing training. They also had significantly higher scores on all three measures of engagement with treatment – two assessed by their counsellors (their therapeutic relationship with the patient and how well the patient was 'working the programme') and one the patient's own assessment of their progress. Cognitive training patients also stayed longer in treatment – 129 days versus 109 – and more successfully completed – 55% versus 38%.

% days abstinent over past 12 months

At the final follow-up one year after leaving the residential service cognitive training patients had improved more on assessments of their drug use and problems, legal difficulties, and family and social relationships. Over the 12 months they had also spent more days without using alcohol or drugs – 71% versus 54% chart. Problems in relation to employment and medical and psychiatric health were not significantly affected.

The model of how the programme worked that fit the data best suggested that cognitive rehabilitation had elevated days of abstinence because it deepened engagement with treatment and via that effect (and also directly) extended stays. Patients who were not cognitively impaired at the start of the study also benefited from the cognitive exercises, and to a degree not significantly different from the third who seemed to need them most.

The authors' conclusions

Compared to the same time spent in an equally satisfying and engaging task also demanding the patients' attention, cognitive rehabilitation exercises resulted in deeper engagement with treatment, longer stays and more patients completing the programme, and (due to engagement and retention effects) better substance use outcomes up to a year after leaving, as well as improvements in associated areas of the patients' lives.

These findings clearly support cognitive rehabilitation to enhance the effects of treatment for substance use disorders, and imply that the recovery of the significant proportion of substance use patients who are cognitively impaired can be accelerated by exposing patients to environments which promote cognitive functioning. These positive effects may generalise to various forms of psychosocial intervention for substance use, and to targeted interventions such as HIV risk-reduction training. However, more remains to be established about how this happens and whether it will remain the case with different forms of treatment, among different patient populations, and in non-residential programmes.

Though this was how the exercises were expected to work, the featured study did not examine whether patients in fact acquired new information and skills and whether this new learning caused the patients to engage more fully in treatment. Participants were drawn from one long-term residential programme. Though typical of such US programmes, most patients are treated in less intensive and less controlled non-residential programmes. With patients sheltered from drugs and other influences and already on-site, the residential setting can be considered an ideal test bed for cognitive improvement. Whether effects will survive transfer to less controlled settings requires testing.

Findings logo commentary Unusually rigorous steps were taken to ensure that in the featured study extra improvements in the patients offered cognitive rehabilitation could be attributed to the content of that programme. The point made however about whether results would generalise to non-residential settings is well taken. One thing patients have in residential settings is time – 24 hours a day. In non-residential services already hard pressed to offer more than basic counselling, the first problem will be get patients to accept this is a good use of their time at the service, and services to accept that time which could have been spent counselling patients should be diverted to indirectly improving the impact of that counselling. What would help is a demonstration that not only is time spent in cognitive rehabilitation better than time spent learning to type, but also that is better than spending the same time in directly therapeutic activities.

After this entry had been released Findings was informed that the lead author William Fals-Stewart had been found dead on 23 February 2010 after being arrested a few days before on charges arising from an attempt to rebut an accusation of scientific misconduct made in 2004. The accusation related to the alleged fabrication of data in studies undertaken as an employee at the University at Buffalo and Research Institute on Addictions. The arrest was in relation to his allegedly hiring actors to give false testimony during an investigation of the misconduct accusation conducted by the university. At the time of writing we do not know which particular study was alleged to have been falsified, nor whether other studies led by Dr Fals-Stewart are also under suspicion.

For more see the announcement of the charges made by the New York State Attorney General at: http://www.ag.ny.gov/press-release/new-york-state-attorney-general-andrew-m-cuomo-announces-charges-against-former-ub

This note drafted 30 August 2013.

An alternative approach to cognitively challenged patients or those with less well developed verbal understanding is to cater for these deficits rather than trying to rectify them. One technique which has gained currency in the UK is node-link mapping, the basis of a manual released in 2013 by Public Health England. Flow-chart style maps present worker and client with a simplified and shared visual representation of the client's needs, resources and goals, why they relapse, and how they can avoid relapse. Mapping these and other processes is intended to help maintain focus, improve communication and understanding, and offer an aide-memoire of where therapy has got to.

In its application to substance use problems, node-link mapping derives from research and development work at the Institute of Behavioral Research at the Texas Christian University in the USA, who say the maps particularly help clients with deficits in communication, attention, problem solving and decision making. Mapping was an element in the unit's project to improve substance use counselling for often poorly educated offenders unused to abstract, verbal explorations. The key innovation was not the project's therapeutic principles based on motivational interviewing, but its delivery methods based on engaging, hands-on, practical activities and 'games' requiring only basic reading and verbal skills. As expected, these tools particularly improved engagement with treatment among less well educated offenders and those averse to 'hard thinking' or thinking things through.

Last revised 30 August 2013. First uploaded 21 August 2013

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STUDY 2002 The grand design: lessons from DATOS

STUDY 2010 Gender differences in client–provider relationship as active ingredient in substance abuse treatment

STUDY 2009 Relating counselor attributes to client engagement in England

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

STUDY 2010 A randomized controlled study of a web-based performance improvement system for substance abuse treatment providers

STUDY 2008 Benefits of residential care preserved by systematic, persistent and welcoming aftercare prompts

STUDY 2008 Promoting continuing care adherence among substance abusers with co-occurring psychiatric disorders following residential treatment

REVIEW 2014 Peer recovery support for individuals with substance use disorders: assessing the evidence

STUDY 2011 Shared decision-making: increases autonomy in substance-dependent patients

STUDY 2012 A preliminary study of the effects of individual patient-level feedback in outpatient substance abuse treatment programs

Recovery innovations in Yorkshire and Humberside.

Best D., Knowles D., Morell M.
The authors, 2011.

The enthusiastic shoots of a recovery orientation emerging in treatment systems and services in northern England faced considerable challenges in gaining sufficient coverage to transform the established landscape – literally in the case of a plan to communally build an Iron Age roundhouse village.

Summary The freely available featured report documented attempts in 2010 in the Yorkshire and Humberside region of England to implement recovery-oriented systems of treatment and wider care for problem drug users. The regional team of the then National Treatment Agency for Substance Misuse (now absorbed in to Public Health England) selected eight projects for review by the researchers.

Two of the projects were identified as 'system change recovery models'.
Calderdale Recovery Partnership. Centred on the Basement recovery service, but also linked to sober-living housing, long-term social enterprise and employment and training opportunities, and the growth of a community of recovery champions.
Barnsley system re-configuration. The area put its addiction treatment system out to tender in 2009 to establish a replacement built on a recovery model. The aim was to develop a system of outcome- and recovery-focused services which could boost the social recovery capital of problem drug users. The successful bid featured 'care navigators' independent of the treatment system who provided central assessment and recovery planning for each service user throughout their recovery journey.

Merlin roundhouse village leaflet

Three further projects attempted to initiate the recovery process from within structured treatment services.
Bridge 12-step awareness. This established treatment organisation aimed to raise its staff's awareness of 12-step mutual aid organisations and principles and to encourage them to attend at least one meeting. The ultimate aim was that staff would then more actively encourage clients to become involved in Narcotics Anonymous as part of their recovery.
Sheffield ITEP mapping training. Provided psychosocial group support for 'stuck' clients been stable in treatment for at least two years and who were not engaged in active substance use, with a view to progressing their recovery.
North Lincolnshire Primary Care Trust. Two workers from the shared care team (prescribing-based primary care services) set up a 'recovery clinic' offering one-to-one psychological support for clients interested in recovery.

The final three projects focused on peer models of support.
Merlin roundhouse village. A West Yorkshire project led by service users which aimed to engage participants in community processes and build their capacity to reintegrate in to society via the communal building of an Iron Age village using past industrial skills illustration.
Doncaster Recovery Empowerment and Mentoring (DREAM). A service-user led group of people in recovery which offered therapeutic interventions, a support group, and a service user newsletter.
Project 6. This harm reduction service in West Yorkshire set up an accredited peer support training course available to service users in recovery, especially those who had come through its aftercare programme; there was also a linked recovery group.

The authors' conclusions

Each project is individually described, placed in the local context, its achievements and challenges noted, suggestions made about how it might be evaluated, and broader lessons drawn. Considering all the projects, the authors found they faced some common challenges.
• Integrating effectively with and influencing specialist treatment provision, especially prescribing treatments for long-term clients.
• As a result, several projects had problems in securing a throughput of clients from acute care services and producing graduates who could actively engage with clients at specialist services.
• Enabling culture and attitude change in service staff and commissioners.
• Establishing continuity of funding and the resulting stability to build effective programmes and essential links in the community.
• Securing 'quick wins' to inspire and engage clients who may have a more passive view of 'treatment'.
• Identifying recovery champions from among service users and staff and creating the drive and motivation to enable recovery, along with safety nets and supports.
• Ensuring that their zone of impact is sufficiently widespread that the innovations can enable system-wide early and assertive engagement with recovery supports, and ongoing support and care for people leaving treatment.
• Establishing credible measures and evaluation mechanisms for early process aspects of delivery, then linking these to recovery-focused outcomes.
• Creating a range of services that build personal and social capital across a range of clients and that provide the safety net of collective or community recovery capital.

These nine issues are what commissioners and new recovery projects need to build into their planning. They also provide the foundation for mapping their traction in local treatment systems and their ability to generate and support long-term recovery.

Findings logo commentary The lead author of the report has also provided a summary of the work and its implications.

Thanks for their comments on this entry in draft to research author David Best now of Turning Point in Australia. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 30 August 2013. First uploaded 27 August 2013

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