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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 entry helpfully packages major UK alcohol prevention reviews. Next two offer insights in to the use of opiate-blocking drugs for rather different purposes – harm reduction among continuing users versus to sustain abstinence. Finally, is it limitations of the research, or real failure to help, which accounts for negative findings from the cognitive-behavioural anti-offending programmes so popular in the UK?

Worth supplementing lessons with other alcohol prevention strands? ...

Why Wales mounted a national naloxone programme to curb overdose deaths ...

Opiate-blocking implant curbs stimulant as well as heroin use ...

Drink-driving course unable to cut reoffending ...

Universal alcohol misuse prevention programmes for children and adolescents: Cochrane systematic reviews.

Foxcroft D.R., Tsertsvadze A.
Perspectives in Public Health: 2012, 132(3), p. 128–134.
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 Foxcroft at david.foxcroft@brookes.ac.uk.

The reviewers here helpfully amalgamate the findings of their three authoritative reviews of alcohol prevention programmes in the school, among families and parents, and combining these and/or other components. Some programmes they say work, but why and in what contexts remains unclear.

Summary The featured review brought together the findings of three reviews conducted for the Cochrane collaboration, each concerned with the effectiveness of ‘universal’ Universal prevention interventions are appropriate when risk factors for development of a problem are not easy to identify, are diffuse in the population, and not easily targeted by an intervention. Another indication for universal programmes as opposed to selective programmes targeting high risk groups is when the ‘prevention paradox’ is a valid description of the distribution of problems – that is, more problems within a population arise from those at lower levels of risk than those at higher levels of risk. Several studies indicate that the prevention paradox is indeed relevant to youth drinking. programmes aiming to prevent the development of drinking or drink-related problems in young people aged 18 or younger. As opposed to programmes for high-risk groups, universal programmes target large groups such as an entire age range, whether or not they are known to be specially prone to substance use or problems. Each trial had to have randomly allocated participants to the evaluated programme or to a comparison group either offered no alcohol prevention intervention or an alternative approach, against which to benchmark the effects of the evaluated programme. Randomisation helps ensure that any differences in outcomes between intervention and comparison groups were not due to their being different to begin with, rather than the effects of the programme(s). All three reviews took in studies available up to the middle of 2010 in whatever language. Interventions included those targeted specifically at drinking and more generic programme intended to affect this among other outcomes, such as drug use and healthy and pro-social lifestyles.

The three component reviews have previously been analysed for the Effectiveness Bank. Readers are referred to these analyses for more detailed findings:
School-based programmes. Included trials which randomly assigned pupils (whether individually, as classes, schools or some other ‘unit of analysis’) to a curriculum or psychosocial intervention expected to affect drinking versus an alternative school and/or non-school-based programme, or just the standard curriculum.
Family-based programmes. In family settings, universal prevention typically entails developing parenting skills including providing support, nurturing, establishing clear boundaries or rules, and monitoring children’s activities. In one important respect, family-based programmes differ from those based in schools: rather than directly intervening with the young people, they intervene via their parents and family.
Multi-component programmes. These operate simultaneously in several settings. The typical combination supplements school lessons with a family-based intervention; often also included are community involvement mechanisms and media promotions and campaigns.

Based on the available reports, the methodological quality of the trials was generally poor. In particular, it was often not clear that adequate precautions had been taken in the randomisation process and to ‘blind’ assessors to which intervention participants had been allocated, or whether appropriate measures had been taken to cater for the fact that data for some of the participants was missing.

Main findings

School-based programmes Of the 53 trials, 41 were conducted in North America. Relative to a standard curriculum, six of the 11 trials of alcohol-specific interventions found some statistically significant reductions in drinking. Another 39 studies tested more generic programmes. Of these, 14 found some statistically significant reductions in drink-related outcomes relative to a standard curriculum. Some apparently positive results may have been due to inadequate adjustment for ‘clustering’ effects (eg, of children in a class and of classes in schools), and in some studies results were confined to certain subgroups and/or some measures of drinking but not others. Most commonly, significant effects related to drunkenness and binge drinking. Impacts tended to last longer after generic than after alcohol-specific or other programmes. Overall, the evidence is more convincing for certain generic rather than alcohol-specific programmes. Among generic programmes, those based on psychosocial or developmental approaches (life skills in Life Skills Training; social skills and norms in Unplugged; behaviour norms and peer affiliation in the Good Behaviour Game) were most likely to report statistically significant effects over several years when compared to standard school curricula or other types of interventions.

Family-based programmes All but one of the 12 trials were conducted in North America. Nine recorded statistically significant reductions in drinking, in some cases over longer as well as shorter term follow-ups. One study recorded apparently negative effects which may have arisen by chance or due to methodological issues. In another, though ineffective on its own, the family-based intervention was effective when combined with a school-based intervention. There is some evidence for the short to medium-term success of gender-specific interventions for daughters, typically involving their mothers. Some trials found impacts only among children already using substances at the start of the trial.

Multi-component programmes All but three of the 20 trials were conducted in the USA. Relative to comparison conditions, 12 trials reported statistically significant reductions in drinking lasting up to three years among children allocated to multi-component programmes. Six of the 20 trials found no statistically significant differences, and in another significant reductions were confined to children already drinking at the start of the trial. It was unclear whether in general adding further prevention components to an existing programme improved outcomes; reports on four trials indicated some possible benefits, but another three trials found no such indications.

The authors’ conclusions

The reviewed evidence supports the effectiveness of some but not all universal programmes for alcohol misuse prevention among young people. Given the variability in the results, particular attention should be paid to the content of programmes and the context in which they are delivered, including the setting, key personnel and target age. A programme may for example be effective where adolescent alcohol drinking is rare, but ineffective where it is the norm and reflects powerful social and cultural pressures to drink.

Specifically in the school setting, some studies found no effects of preventive programmes, others statistically significant effects. Most commonly observed positive effects were for drunkenness and binge drinking, and it seems that certain generic psychosocial and developmental prevention programmes can be effective and could be considered as policy and practice options. These include the Life Skills Training programme, the Unplugged programme, and the Good Behaviour Game.

Most of the studies in the family review reported positive effects. These were small but generally consistent and persisted in to the medium to longer term.

Overall there is some evidence that multi-component interventions can prevent alcohol misuse in young people, but insufficient evidence that interventions with multiple components are more effective than interventions with a single component. Most studies in the multi-component review found significant effects persisting in to the medium and longer term, but a notable proportion reported statistically non-significant results. Seven studies enabled an assessment of the impact of single versus multiple prevention components. Of these, only one showed a benefit from components delivered in more than one setting.

The psychosocial, developmental orientation of effective universal prevention programmes is typically designed to impact on a range of health and lifestyle behaviours (for example use of cannabis, tobacco, harder drugs, and antisocial behaviour) among young people, offering an advantage over alcohol-specific programmes.

The fact that some studies found positive effects and others none may mean that universal alcohol misuse prevention programmes are in fact ineffective, and that some studies find positive results purely by chance. Especially for family-based prevention programmes, this seems unlikely given the proportion of studies which found statistically significant effects and the sizes of their samples. It could however be that this proportion of positive results merely reflects a prevailing bias towards finding preventive effects. In all three Cochrane reviews, the nature of the evidence base makes this a plausible explanation for seemingly positive results.

Despite improvements in more recent studies, the studies remain weakened by important limitations in their methodologies and in how adequately they are reported. For example, the reviews found instances when clustering effects were not accounted for, and when it was not clear that randomisation had been adequate or that outcome assessors had been ‘blinded’ to the intervention participants had been allocated to. Several studies analysed their results for particular groups within the overall sample without making it clear whether these analyses had been planned in advance, or only after the results of the study were known. The latter possibility means the results can only be considered suggestive of hypotheses to be tested in studies designed in advance for that purpose. On the other hand, several studies may have failed to look for what would have proved to be significant effects in certain subsamples.

Findings logo commentary See the Findings analyses of the three component reviews for comments on the review of school-based programmes, and for extended commentaries on the reviews of family-based and multi-component programmes. These point out that the studies generally pitted family or multi-component interventions against no programme or a minimal one. Arguably the more meaningful question is whether with a limited prevention budget it is cost-effective to reinforce core components (generally school-based drug education) with family, community and media elements, or whether the desired outcomes are achieved just as well by core elements alone. On this issue we judged the evidence thin and not on balance in favour of extra components including family and parenting programmes.

In relation to school programmes, in line with the featured review Findings has also highlighted the effectiveness of generic prevention programmes, some which do not mention substance use at all, but instead target parenting or school affiliation and classroom management techniques which affect vulnerability to developmental problems.

It remains the case however that in respect of preventing harmful drinking, no type of psychosocial intervention has attracted as much scientific support as population-wide changes like price rises and outlet restrictions, the effects of which inescapably influence decisions about drinking across the entire population, even if for some the resulting decision is to drink just as much but to spend more or travel further or change what you drink. Both types of approaches have a place in an overall strategy, and probably one can reinforce the other, but the driving force behind widespread drinking reductions is likely to lie with factors beyond the reach of education, information or family-based approaches. The relative strength of environmental preventive interventions compared with psychosocial and educational prevention programmes is also supported by the lead author of these Cochrane reviews in recent conceptual and theoretical work that considers different types of prevention interventions (1 2 3 4 5).

Thanks for their comments on this entry in draft to review author David Foxcroft of Oxford Brookes University in England. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 30 January 2014. First uploaded 30 January 2014

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REVIEW 2011 Universal school-based prevention programs for alcohol misuse in young people

REVIEW 2015 Prevention of addictive behaviours

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

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

REVIEW 2012 An overview of prevention of multiple risk behaviour in adolescence and young adulthood

REVIEW 2014 Interventions to reduce substance misuse among vulnerable young people

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

REVIEW 2007 A review of the effectiveness and cost-effectiveness of interventions delivered in primary and secondary schools to prevent and/or reduce alcohol use by young people under 18 years old

STUDY 2004 Doing it together strengthens families and helps prevent substance use

STUDY 2008 Reducing youth alcohol drinking through a parent-targeted intervention: the Örebro Prevention Program

The impact of take-home naloxone distribution and training on opiate overdose knowledge and response: an evaluation of the THN Project in Wales.

Bennett T., Holloway K.
Drugs: Education, Prevention and Policy: 2012, 19(4), p. 320–328.
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 Holloway at krhollow@glam.ac.uk.

The evaluation which led to the Welsh national programme to distribute naloxone to opiate users and their associates to curb rising overdose deaths, one of several UK studies to give momentum to this peer-based strategy.

Summary Naloxone is a medication administered usually by injection which rapidly reverses the effects of opiate-type drugs such as heroin, including the respiratory depression which can cause what are normally referred to as ‘overdose’ deaths. In the UK, naloxone-based overdose prevention programmes remain hampered by the prescription-only status of the medication, but in 2005 the law was amended to permit emergency administration by any member of the public. A prescription is written for the opiate user at risk, but the drug can then be kept for them by other people who can legally use it in an emergency, and not just for the named patient. Group directives can also authorise medical staff other than the prescriber to supply naloxone to suitable patients.

In 2011 Wales began a national programme to distribute naloxone based on the results of demonstration schemes, focusing on areas with the highest rates of drug-related deaths. In addition, the four prisons in south Wales began to issue naloxone on release to prisoners who had attended naloxone training. The featured study reports on the evaluation of these schemes. This account also draws on a freely available research report from the same evaluation project. The project was funded and overseen by the Welsh government and conducted by researchers from the University of Glamorgan.

The demonstration schemes involved a single one to two hour session during which drug users (or in a few cases their friends or family) were trained to recognise the signs of overdose and how to respond with first aid emergency procedures and by administering naloxone. Courses were conducted mainly by drug treatment service staff as part of their routine duties. Staff generally agreed that recruitment to the courses was slow.

At the end of the sessions a take-home naloxone kit was issued to opiate users among the trainees who were at risk of overdose. The kits contained a pre-filled syringe with a single dose of naloxone plus associated equipment and instructions. In all 521 opiate users were trained. Typically they were men and currently in treatment. Nearly half had themselves overdosed, three quarters had seen an overdose, and nearly a third had seen a fatal incident. Trainees were encouraged to return for a replacement kit as needed.

Immediate impact of training

The initial issue was whether the training improved knowledge of how to intervene in overdose and readiness to take the required steps. This was assessed by questionnaires completed immediately before the start of the training session and again immediately after it had ended.

There had been improvements across all seven areas of knowledge of overdoses and the use of naloxone, and most individual questions were answered correctly by significantly more trainees after the training. For example, after training nearly all (around 95%) knew where on the body and how to inject naloxone and how generally to deal with overdose, and nearly 9 in 10 knew how to spot an impending possible emergency.

Confidence in being able to take the required steps to safeguard lives also consistently and significantly increased from on average 77% before training to 93% afterwards, most notably in relation to confidence to administer naloxone, up from 67% to 92%. Though 9 in 10 were even before training willing to take these steps, this too increased. Following training, almost all trainees were willing to put overdose sufferers in the recovery position, check airways, call emergency services, and administer naloxone, and the proportion willing to give mouth-to-mouth resuscitation increased from 79% to 88%. Except where nearly all the trainees already felt this way before training, in respect of nearly all the individual actions a significantly higher proportion were confident and willing to take these steps after training.

Post-training gains tended to be greater at training sites where the training session covered more of the intended elements of the programme, possibly a proxy for the overall quality of the training.

Later use of naloxone in managing overdose

Sample naloxone use account

On the day I used my kit I was with my then partner (CH) and we had used heroin IV together about 90 minutes before we went together to the solicitors. Whilst I was in the solicitors CH went into the back room on his own and when I went in to find him he was on the floor and his lips had turned blue; he was also breathing very slowly and shallowly. I called the solicitor immediately and he called the ambulance. I put CH into the recovery position as I was unable to rouse him by shaking him or calling his name. I then took out my kit and prepared the naloxone which I had no trouble in using. I then injected CH in the thigh through his jeans. After about three minutes CH began to come round and the ambulance crew arrived and asked me to leave the room whilst they took over. CH was taken to hospital where he survived. I found the training prepared me well for this situation and I don’t feel that I need any extra training. I would use my naloxone kit again.

The crucial issue was whether post-training improvements in knowledge, confidence and willingness actually did equip trainees to intervene appropriately over the following six months. This was assessed by means of forms completed by trainees returning to be issued with a further kit. The forms asked whether the naloxone issued previously had been used, if so how, and the circumstances and results. Of the 521 trainees, 28 returned for further supplies and indicated on the form that they had witnessed an overdose during the evaluation period.

Eight of the same questions were asked of a comparison group of drug users consecutively attending a drug treatment agency in an area of Wales without a naloxone scheme. The 50 attendees were seen during the last month of the six-month evaluation period. Of these, 39 completed an initial questionnaire; 36 indicated they had witnessed an overdose in the last six months and were asked further questions about circumstances and outcomes.

From this data it was possible to compare responses to 28 overdose incidents witnessed by the trainees, versus the 38 witnessed or experienced by the comparison group. In every instance, the trainees had used their naloxone kits; without being supplied kits, none of the comparison group had administered naloxone. Overdose sufferers attended by the trainees were much more likely to have been put in the recovery position (81% v. 40%) and ambulances were more likely to have been called (85% v. 60%). However, resuscitation techniques were more commonly used by the comparison group (53% v. 40%). For 22 incidents the trainees reported whether the overdose victim had died; just one had. Corresponding figures for the comparison group were 35 and also one.

The authors' conclusions

The benefits of the evaluated take-home naloxone schemes substantially outweigh the implementation drawbacks. Despite already being generally well advanced in these respects, training led to increased knowledge about overdose and use of naloxone and other appropriate actions, and increased confidence and willingness to take action.

Trainees’ responses on the forms they completed while obtaining replacement kits showed they were willing and able to use naloxone and that its use was generally straightforward. All except one overdose sufferer survived. There have been concerns that with naloxone available, other life-saving actions might be neglected, but in fact the reverse was usually the case.

Data on responses to overdoses was only available from trainees who returned for new kits and completed a replenishment form which was sent to the researchers. Other overdose incidents might have been responded to by trainees who did not return for a new kit, or who did so but there was no form. There was no information on how trainees or the comparison group had previously responded to overdoses, meaning than any differences between their responses might not have been due to the training, but to some other pre-existing factors. With such small samples and such rare events as overdose deaths, the study was not in a position to determine whether naloxone schemes reduce drug-related deaths.

Findings logo commentary The study was an important sign of and stimulus to the considerable momentum behind naloxone provision schemes, culminating in national programmes in Wales and Scotland, after promising evaluations in England (1 2).

Enabling these developments was a change in the law in 2005 which permitted naloxone to be administered in an emergency by any member of the public. In May 2013 Prenoxad, the world’s first licensed naloxone product for use in opioid overdose emergencies by non-medical personnel, became available in the UK after approval by the Medicines and Healthcare Products Regulatory Agency. Approval is seen as an important step to widening availability, meaning GPs across the UK can prescribe naloxone injecting kits to suitably trained drug users and with their permission to their associates and family. Patient Group Directions also enable doctors to authorise pharmacists and nurses to supply the kits to drug users at risk, such as those who might be seen at needle exchanges. This development still leaves the prescription-only restrictions which in 2012 the UK’s Advisory Council on the Misuse of Drugs wanted reviewed, after concluding that wider provision of naloxone could result in a reduction in overall drug-related deaths in the UK.

The featured study is best seen as testing the feasibility of running a training-based naloxone distribution scheme in Wales and whether at least some recipients will use the kits appropriately. The great gap in the findings is what use was made (if any) of the around 500 kits issued to drug users who did not return for a replacement. The small minority of trainees who did return for another kit may well have been those most keen and diligent. Often facing staff at services where they were being treated, they may also have been embarrassed to admit that they returned because kits were lost or damaged rather than used, or that they were used, but not appropriately. Nevertheless the study indicates that kits can be used appropriately in circumstances which could save lives. Whether this is the case as a general rule cannot be determined from the findings, nor could the study adequately investigate whether kits were not used when they could and should have been. Broadly these too were the implications of the corresponding evaluation in England, but that study did attempt to follow up all trainees, not just those seeking replacement kits.

At least in the context of a research study, recruiting drug users and their carers to UK naloxone programmes has been difficult. If recruitment is done through treatment agencies there may seem to be a contradiction between treatment which the patient hopes and expects to divorce them from drug use and drug using circles, and being provided with training and medication of direct use only if they stay sufficiently involved in such circles to witness or suffer an overdose. While welcomed by many, training can also resisted by families of drug users, who prefer to see treatment or a spell in prison as the start of a new drug-free life for their relatives. Some drug users do not want to carry naloxone kits because these identify them as drug users.

For more on the promise and limitations of naloxone see this analysis of the corresponding English study, and the Effectiveness Bank hot topic on overdose prevention.

Last revised 29 January 2014. First uploaded 21 January 2014

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HOT TOPIC 2016 Overdose deaths: crisis and response

STUDY 2008 Overdose training and take-home naloxone for opiate users: prospective cohort study of impact on knowledge and attitudes and subsequent management of overdoses

DOCUMENT 2014 Community management of opioid overdose

STUDY 2011 The NTA overdose and naloxone training programme for families and carers

STUDY 2011 Impact of training for healthcare professionals on how to manage an opioid overdose with naloxone: effective, but dissemination is challenging

REVIEW 2016 Preventing opioid overdose deaths with take-home naloxone

REVIEW 2012 Consideration of naloxone

STUDY 2016 Effectiveness of Scotland’s National Naloxone Programme for reducing opioid-related deaths: a before (2006–10) versus after (2011–13) comparison

STUDY 2013 Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis

DOCUMENT 2010 Consideration of the use of foil, as an intervention, to reduce the harms of injecting heroin and cocaine

Naltrexone implant for the treatment of polydrug dependence: a randomized controlled trial.

Tiihonen J., Krupitsky E., Verbitskaya E. et al.
American Journal of Psychiatry: 2012, 169(5); p. 531–536.
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 Tiihonen at jari.tiihonen@niuva.fi.

Would dually addicted heroin and stimulant users fitted with an opiate-blocking naltrexone implant simply escalate their stimulant use? The issue is important because multi-drug use is the norm. In this Finnish-Russian study it was the reverse – amphetamine use decreased as well as heroin use.

Summary Naltrexone is an opiate antagonist which has no psychoactive effects of its own but blocks the effects of heroin and other opiate-type (‘opioid’Drugs with opiate-type effects (including analgesia and the capacity for producing euphoria and dependence) derived from the opium poppy like opium, heroin, and morphine (known as opiates) and synthetic drugs with similar effects like methadone and buprenorphine. ) drugs. Attempts to use daily oral naltrexone as a treatment for people dependent on opiates have often been disappointing, as patients simply stop taking the drug. Previous studies have shown that longer- acting naltrexone implants or depot injections may be an effective treatment for people who use heroin alone, but many people addicted to heroin are also addicted to other drugs. It is not known if long-acting naltrexone is effective for these people, or if they might use heroin less often but compensate by using other drugs instead.

This trial in Russia (where opiate substitute prescribing using drugs like methadone is not permitted) therefore aimed to test the effectiveness of a naltrexone implant at reducing heroin and amphetamine use in people dependent on both drugs. A small capsule was surgically implanted under the skin of 50 participants living in and around St Petersburg, Russia. The capsule contained 1000mg of naltrexone to be released slowly, blocking the effects of opioid drugs for eight to ten weeks. Another 50 randomly selected patients were implanted with a placebo, forming 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 against whom to benchmark the effect of the active implant. Allocation was also ‘double-blinded’; to reduce the risk of bias, neither patients nor researchers knew who had been assigned to which group. After the implant was fitted, patients were scheduled to attend the clinic weekly to be urine-tested for heroin or amphetamine use and to complete research interviews.

Patients were typically men in their late twenties who averaged over eight years of dependent heroin use and nearly six of amphetamine use. Over half whose status was known were infected with HIV.

To be included in the trial patients had to have been diagnosed as dependent on both amphetamine and heroin for at least a year, have a stable address and telephone number, and at least one relative willing to help with the trial. Applicants were ineligible for the trial if they had drunk alcohol recently, had one of a number of serious physical or mental illnesses, were facing possible imprisonment, or were already in treatment. Though dependent on heroin, they also had to have stopped using the drug for three to four days before the implant was fitted. Whilst the criteria seem strict, only 16% of people assessed for the study were excluded, resulting in a sample assumed by the authors to be typical of people seeking drug treatment. One possible indication of the strictness of the criteria is that it took from March 2008 until February 2011, over three years, to recruit 100 patients.

Main findings

By the end of the ten week period, the group who received the naltrexone implant were significantly more likely to be retained in the study (52%) than those who received a placebo (38%), and significantly less likely either to test positive for heroin or amphetamine use or to miss a test (62% versus 84%). Separating the two drugs, naltrexone patients were significantly more likely (52% versus 20%) to deliver urine samples free from heroin; similarly for amphetamine (40% versus 24%), but not to a statistically significant degree. Those in the naltrexone group also used amphetamine less on average (4.5 times a week versus 5.7), a finding which narrowly missed statistical significance. On a measure called the Clinical Global Impression Scale, those given naltrexone (56%) were significantly more likely to rate as much improved at the end of the ten weeks than the control group (14%). The group who received naltrexone were also significantly less likely to report that use of amphetamine had its full euphoric effect (14% versus 83%). Craving for heroin and amphetamines and practices which risked HIV transmission diminished to roughly the same degree in both sets of patients.

The authors' conclusions

This study offers the first evidence of an effective pharmacological treatment for people dependent on both heroin and amphetamine. Compared to a placebo, patients implanted with naltrexone stayed in the study longer, made greater reductions in their heroin and amphetamine use, and were judged by clinicians to have experienced greater overall improvement. Concerns that patients would substitute amphetamine for the heroin they could no longer experience proved unfounded. Implants caused no serious adverse effects and there were no deaths during the study.

The ten week duration of the trial was notably short given the chronic, long-term nature of heroin and amphetamine addiction, and in clinical practice, it is likely that several successive implants would be needed.

Findings logo commentary This study clearly shows improved outcomes for the patients given naltrexone implants compared to those who only received placebos, in particular with regard to the percentage testing free from heroin, but it may most clearly show that more naltrexone patients stayed in the study. The lower level of amphetamine use for the same group is particularly encouraging, suggesting that participants are not simply using amphetamine more in order to compensate for the effect of heroin having been blocked. However, this finding is tempered by the fact that many more patients given the placebo dropped out of the study. It may be reasonable to assume that this meant worse drug use outcomes among patients who dropped out, but we cannot be sure of this. In addition, levels of alcohol and other drug use during or at the end of the programme were not measured, so it remains possible that people did compensate for heroin and amphetamine use with alcohol, cocaine, cannabis or benzodiazepines, for example. Whilst the group were tested for benzodiazepine, cannabis and alcohol use at the beginning of the programme, the researchers decided not to continue testing for use of these drugs once the programme had started. This severely limits the ability to infer that the naltrexone implants are a safe and effective treatment for this group of people, who were already addicted to two drugs, and might suffer serious health harms and yet more addiction problems if they increased use of others.

One important limitation of this study with regard to its implications for UK practice is that the comparison is between the naltrexone implant and a placebo – nothing at all. Perhaps of more relevance for UK practitioners is the unasked and unanswered question: ‘Is a naltrexone implant better than established pharmacological treatments, such as methadone or buprenorphine? ’. One study in Australia has suggested that, at least with regard to mortality rates, naltrexone implants might be better than buprenorphine. It is important to note that these results may have been influenced by the poor retention rates of those on buprenorphine. Another study in Norwegian prisons found that naltrexone implants had some advantages over methadone, including better continuity of treatment in the period when prisoners returned to the community, perhaps partly because in that country post-prison methadone treatment is hard to obtain. This period is important because there is a risk of overdose in people returning to the community after being drug-free in prison. Any such comparisons are complicated and perhaps invalidated by the fact that where both are available, different kinds of addicts or those with different treatment objectives will opt for a drug which blocks heroin versus one with similar effects. As US authorities have pointed out, naltrexone may be best suited for people who have overcome physical dependence on heroin, and want to sustain this without dependence on similar-acting medications.

It should be noted that it is unclear how and why patients found their way into this study – the applicability of the study to normal practice will be greatest if they were seeking treatment in the normal way, and least if they were responding to advertisements or inducements. The patients, although described by the authors as typical of people in drug treatment, had all been living relatively stable lives for people addicted to heroin – low alcohol use, a stable address, educated to at least high school graduate level, relatives willing to help, none of several serious mental and physical health problems, and not least the desire to engage in this treatment process. As has been noted when analysing previous research, “patients will only opt for such procedures if they are prepared... to commit to possibly weeks or months without the effects of heroin or other opiate-type drugs...Long-acting naltrexone helps these highly motivated patients sustain their resolve”. Nonetheless, only just over half given the implant were retained in the study for the ten-week period. The vital questions of what happened next are also unanswered: did those who had avoided heroin and amphetamine use at ten weeks get fitted with another implant, and if so, did they continue to avoid using? Is it expected that they be fitted with new implants every ten weeks, or will there be a transition to no pharmacological treatment at all, in which case how will the risk of relapse be managed? This point may be especially important given that after the ten weeks, the implant had not led to a greater reduction in drug cravings than placebo. Finally, and of huge importance, what can be done for the 62% of people who received the implant but were still known or assumed to be using heroin or amphetamine at the end of the ten weeks?

The clearest candidates for the treatment are patients who are motivated (perhaps due to employment or other pressures) to return to a life without opiate-type drugs including prescribed substitutes, have the resources, stability and support to sustain this, are unlikely simply to use other drugs instead, but who when free to experience heroin and allied drugs, cannot resist using them, possibly reflected in their poor compliance with oral naltrexone regimens. The treatment may also be considered for unstable patients at very high risk of overdose, but who will not accept or do poorly in substitute prescribing programmes. Other candidates might include those unwilling or unable to accept daily supervised consumption if this is a requirement of being prescribed substitute medications. Many patients will still at least initially try out the blockade by taking opioid drugs and do so perhaps repeatedly, but they are safeguarded from overdose while the naltrexone is active, and some studies (but not all) found rapidly stop wasting their time and money.

In the UK, neither implants nor long-lasting depot injections of naltrexone have been licensed for medical use; they can still be (and have been; 1 2 Revill J. "A Comparative study of the protective benefits of oral and implanted naltrexone in a British NHS general practice." Abstracts from 7th International Conference 2002. Stapleford Trust. 3 Daly M. "Implant progress blocked." Druglink: September/October 2004, p. 12–13. 4) used, but patient and doctor have to accept the added responsibility of a product which has not yet been shown to meet the safety and efficacy requirements involved in licensing.

This study is one of a growing number of recent research reports which suggest that naltrexone implants may have a positive role to play in addiction treatment. To examine the issue in general, read this hot topic article, which explains why naltrexone implants may still arouse controversy, even if their effectiveness is proven.

Thanks for their comments on this entry in draft to research author Jari Tiihonen of the Karolinska Institutet in Sweden and Colin Brewer based in England. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 10 February 2014. First uploaded 21 January 2014

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STUDY 2010 Naltrexone implants compared to methadone: outcomes six months after prison release

STUDY 2011 Injectable extended-release naltrexone for opioid dependence: a double-blind, placebo-controlled, multicentre randomised trial

HOT TOPIC 2016 Opiate-blocking implants: magic bullet or dangerous experiment?

STUDY 2009 Improving clinical outcomes in treating heroin dependence: randomized, controlled trial of oral or implant naltrexone

STUDY 2015 Opioid treatment at release from jail using extended-release naltrexone: a pilot proof-of-concept randomized effectiveness trial

STUDY 2010 Treatment research in prison: problems and solutions in a randomized trial

STUDY 2010 Favorable mortality profile of naltrexone implants for opiate addiction

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DOCUMENT 2012 An introduction to extended-release injectable naltrexone for the treatment of people with opioid dependence

STUDY 2015 Extended-release naltrexone for alcohol and opioid problems in Missouri parolees and probationers

The effect on reconviction of an intervention for drink-driving offenders in the community.

Palmer E.J., Hatcher R.M., McGuire J. et al.
International Journal of Offender Therapy and Comparative Criminology: 2012, 56(4), p. 525–538.
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 Palmer at ejp8@le.ac.uk.

This study of a cognitive-behavioural course for convicted drink-drivers in England and Wales found no evidence that it reduced the reconviction rate, another disappointing finding on this widely implemented family of crime- reduction approaches.

Summary The featured study funded by the UK Home Office was the first to evaluate the Drink-Impaired Drivers programme, intended to reduce recidivism among offenders on community sentences for drink-driving. Over 14 two-hour group sessions, a combination of education and cognitive-behavioural training and counselling methods aim to increase knowledge about alcohol and driving, help offenders plan alternatives to drink-driving, and to change attitudes which tend to support or justify drink-driving.

Central and local probation records and national conviction records were collected on 144 men in England and Wales mandated on to the programme, and on another 231 drink-driving offenders also on community sentences but without being required to attend the programme, forming 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 against whom to benchmark its impact. Typically participants were in their mid-thirties, with several previous convictions. Those who did not attend the first session or missed two sessions could retry the programme, but if they missed sessions again they were sent back to court for re-sentencing, usually to more community sanctions such as extra hours of unpaid work.

Main findings

Nearly 60% of offenders assigned to the programme completed it. They were significantly older and assessed as being less likely to be reconvicted than non-completers. Over the year after the programme ended or for the control group after being sentenced, 17 of the drink-drivers (4.5%) had been reconvicted for drink-driving offences. None of these recidivists were among the 85 offenders who completed the programme. In contrast, eight of the 59 non-completers (14%) and nine of the control group (4%) had been reconvicted.

Once other factors had been taken in to account, the reconviction rate of the non-completers was significantly higher than that of both the completers and the control group. Rates for completers and the control group did not significantly differ.

The authors' conclusions

Completing the Drink-Impaired Drivers programme did not significantly reduce the chance that convicted drink-drivers would be reconvicted of the same offence. Across the entire sample, the reconviction rate almost matched the national average, but was significantly higher among offenders who were mandated by the court to the programme but did not complete it than among offenders who either completed the programme or were not assigned to it.

Such interventions might be better targeted at higher risk offenders and among these address the factors associated with non-completion and recidivism and perhaps also directly target drinking as well as drink-driving. Efforts to increase the completion rate might include better preparation of offenders and using motivational interviewing techniques to enhance engagement.

Any conclusions that can be drawn from this study are limited by the small numbers in each group once the mandated offenders had been split into completers and non-completers, and the rarity of reconvictions among offenders judged suitable for community sentences rather than prison.

Findings logo commentary The Drink-Impaired Drivers programme is offered by several probation services in Britain and its 28-hour course and associated activities must represent a considerable investment. However, the researchers are clearly correct in their conclusion that it could not be shown to have reduced the likelihood of drink- drivers continuing to drink-drive, at least as evidenced by their chances of being re-convicted; at 6%, the reconviction rate of all the offenders assigned to the programme was actually slightly higher than of the control group not offered the programme. One way to increase the significance of the results of the study might have been to extend the follow-up period from one year to two, as one year may not have been long enough to accumulate enough recidivism for the results to be statistically significant. It is also not stated how participants were selected, and whether they were representative of all programme starters.

The authors suggest that results might be improved by targeting the intervention at the more serious drink-drivers, who would be more likely to re- offend, but the report offers no evidence that the more serious drink-drivers responded better to the programme. The suggestion that increasing the number of people who complete the programme would help increase the chance of it working should also be treated with caution. Increasing the incentives to complete the course might encourage people to complete it for the sake of the incentives or to avoid punishments, but without being motivated to avoid drink-driving or making changes in their lives to improve their ability to do so.

This programme is part of a large family of similar interventions, on which the Driving Standards Agency have produced guidance. Of possible importance is their note that the Drink-Impaired Drivers programme assessed in this study, unlike government-approved courses, does not qualify those completing in England and Scotland for a reduction in their driving disqualification period. If completion is important to effectiveness, this incentive is lacking, though there remains the more negative incentive of avoiding a return to court for possibly more punitive re-sentencing.

It is especially important that this study has not shown the Drink-Impaired Drivers programme is effective, given that it features on the HM Prison Service’s list of accredited offender behaviour programmes said to be evidence-based and congruent with ‘what works’ research.The National Offender Management Service is considering options Source: personal communication from Sarah Ascroft of the Ministry of Justice (NOMS), 26 March 2014. for the Drink-Impaired Drivers programme, which includes reviewing current evidence and research to look at the feasibility of also targeting offenders convicted of drug-driving. Dependent on the outcome of this, a pilot programme and a new evaluation study will be designed. The National Offender Management Service have argued Source: personal communication from Sarah Ascroft of the Ministry of Justice (NOMS), 3 March 2014. that this study has a number of flaws, which make it difficult to draw conclusions about the effectiveness of the programme, suggesting that even if the programme was effective, the study may not have discovered this. However, the study was Home Office funded, which suggests that at least that department were happy with the research methods.

Another assessment that examined several programmes aimed at reducing reoffending, including Drink-Impaired Drivers, carried out on behalf of the National Probation Service, attempted to compare the actual reconviction rates for people assigned to the programme with their predicted rates. It found that the actual reconviction rate, 28%, was 4% lower than the predicted 32%. However, without a control group of similar offenders not offered the programme to compare to, we cannot know whether this reduction was due to the effectiveness of the programme or simply that the predicted rates were too high. There is also evidence that either the predicted rate is too high or that something other than the programmes being measured had an effect, as even offenders not sentenced to any of the programmes were on the whole reconvicted less than predicted. The study authors also acknowledge that the predicted rate could be misleading if there are differences between offenders sentenced to different community sentences.

Other major studies that examined psychosocial programmes aimed at reducing repeat offending – not just for drink-driving, but for crime related to substance use in general – in both prisons and in the community have found limited evidence of effectiveness, underlining the difficulty of demonstrating positive results in this area.

If these interventions have not been proved effective, what can be done instead? One US programme that does appear to have achieved impressive results at reducing repeat drink-driving used a very different approach, focussing on drinking rather than drink-driving, and requiring people to test free of alcohol twice daily, with immediate 24-hour imprisonment for failed tests. Another study in Canada did hint that brief interventions featuring 30 minutes of motivational interviewing might be able to combat drink-driving among repeat offenders, although the results were far from conclusive.

A potential source of bias in this study was that the follow-up period differed for the control group and the group assigned to the intervention. For the control group, the researchers measured whether they had been reconvicted in a one-year period starting from their original sentencing. For people on the programme, it was a one-year period starting from the final session of the course. This means that those who completed the course were being assessed at least 14 weeks after their initial sentence, and more if there was a delay between sentencing and the start of the programme. This may have given them more time to respond to the initial sentence and make changes to avoid drink-driving in future, or it may have given longer for the initial shock effect of being convicted to wear off. Either way, it means that they were not comparing like with like.

Thanks for their comments on this entry in draft to Russell Webster, independent consultant on substance misuse and crime, UK and Sarah Ashcroft, Head of Interventions Services, Ministry of Justice, UK. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 31 March 2014. First uploaded 13 January 2014

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