Effectiveness Bank Bulletin 14 February 2008

EFFECTIVENESS BANK BULLETIN 14 February 2008

The entries below are our accounts of documents selected by Drug and Alcohol Findings as particularly relevant to improving outcomes from drug or alcohol interventions in the UK. Entries were drafted after consulting related research, study authors and other experts and are © Drug and Alcohol Findings. Permission is given to distribute these entries or incorporate passages in other documents as long as the source is acknowledged including the web address http://findings.org.uk. Links to source documents are in blue. Hover mouse over orange body text for explanatory notes.

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High risk of death for opiate detoxification completers ...

Female drinkers also benefit from couples therapy ...

Harnessing peer interaction in school-based prevention can backfire ...

Needle exchange coverage key to reducing infection risk ...

High risk of death for opiate detoxification completers

Completion and opiate-free discharge are considered the markers of successful detoxification from drugs such as heroin, but in this case 'success' can carry a much higher risk of death than failure. New findings from Italy and Australia highlight the need to carefully select and prepare detoxification candidates and to invest in aftercare if patients are to survive loss of protective tolerance to opiate drugs after discharge.

Over 18 months the Italian VEdeTTE study tracked 10,454 heroin users starting treatment in 1998–2001.¹ During the same length of time, patients who had completed outpatient detoxification were four times as likely to die from overdose as those who had failed to complete. Six of the seven deceased were detoxification completers, just one a drop-out.

The importance of robust rehabilitation and aftercare was apparent in the fate of patients who entered residential therapeutic communities. There it was the drop-outs who tended to die, resulting in a post-treatment death rate of over 2 per year for every 100 former residents, the highest in the study. Like the detoxification completers, these patients will have lost their tolerance to opiate-type drugs, but drop-out indicates that rehabilitation was incomplete.

Across the whole study, overdose deaths per month were three times more frequent in the 30 days after leaving treatment than later, suggesting that relapse after treatment which had reduced tolerance but failed to foster a sufficiently resilient drug-free life was the major risk. Whatever the treatment, while patients were still in it, deaths were rare.

Even at the peaks death rates in this study were lower than in others. This may be partly because in a UK context the programmes were extraordinarily extended, potentially giving patients time to construct a stable opiate-free life. Residents spent on average 15 of the 18 months of the study in their therapeutic communities and outpatient methadone detoxification lasted nearly a year, very different from the short sharp detoxifications typical elsewhere.

Some of the highest death rates ever seen were recorded in Australia. There patients who completed detoxification and tried to avoid relapse by taking the opiate-blocking drug naltrexone faced what could have been a 1 in 12 chance of being dead within three months. This estimate came from a study which combined national treatment and prescription records for 2000-2003 with coroners' records of deaths related to naltrexone, buprenorphine or methadone.

An estimated 1 in every 100 episodes of naltrexone treatment ended in overdose death, nearly all in the fortnight after treatment terminated.² During this post-treatment period former patients died at an annualised rate of 22 in every 100. In comparison, there was just one death related to buprenorphine and methadone deaths per episode were just a quarter as frequent and very rare in the immediate post-treatment period.

An earlier research report³ previously analysed in Findings attempted to compensate for the fact that deaths related to naltrexone treatment are harder for coroners to spot because typically they occur after the drug has been cleared from the body. In contrast, methadone would normally be implicated by autopsy and other reports. As a result, the naltrexone figures were "certainly a substantial underestimate".

How great that underestimation might have been was calculated from an independent set of figures for one Australian state which suggested that 6 out of 7 deaths were missed by coroners. If this was the case nationally, 8% of patients starting naltrexone would have died within three months of starting their treatment (two months on naltrexone plus the immediate post-treatment period). This scaling up rests on several unproven assumptions, but wide variations in these would still leave a worryingly high risk.

Internationally opiate detoxification is associated with a high death rate compared to other treatments.⁴ An earlier UK study confirms the risk of completing the treatment.⁵ In 2003 a report on 137 opiate detoxification patients discharged from the Bethlem's inpatient unit found that all three overdose deaths in the following four months were among the 37 who had 'successfully' detoxified and completed the programme. There were none among non-completers. The annualised death rate among completers was 24 in every 100. The longer patients had stayed on the unit, the more likely they were to die after leaving.

Such findings imply that concern to meet many patients' ambitions to stop taking opiate-type drugs must be tempered by awareness of the risks. Programmes which achieve high rates of completed withdrawal through isolation (such as inpatient programmes and those which precipitate withdrawal under sedation) seem particularly likely to lead patients who are not yet ready for an opiate-free life to lose their protective tolerance. Ironically, outpatient programmes which test the patient's resolve in real-world conditions may be safer because relapse is more likely to occur before tolerance is eliminated.

UK national guidelines⁶ caution careful selection of patients fully committed to the process and who will have supportive and stable social environments available after discharge, among which may be seamless entry in to residential rehabilitation. The preparation phase and the detoxification interlude itself should be used to bolster psychological resilience and social supports. Patients whose attempt at abstinence is not working out should be offered immediate access to alternative treatments such as buprenorphine and methadone programmes. For patients who do complete withdrawal, a full programme of aftercare is vital to help avoid relapse and to identify when further support or alternative treatments are advisable. The general message is that detoxification without preceding stabilisation and preparation and succeeding aftercare including the construction of a resilient post detoxification life is too often a band-aid measure which risks more harm than good.

Thanks for their comments on this entry in draft to Ed Day of the Queen Elizabeth Psychiatric Hospital. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

1 FEATURED STUDY Davoli M. et al. Risk of fatal overdose during and after specialist drug treatment: the VEdeTTE study, a national multi-site prospective cohort study. Addiction: 2007, 102, p. 1954–1959.

2 FEATURED STUDY Gibson A. et al. Mortality related to pharmacotherapies for opioid dependence: a comparative analysis of coronial records. Drug and Alcohol Review: 2007, 26(4), p. 405–410.

3 Gibson A. et al. Mortality related to naltrexone in the treatment of opioid dependence: a comparative analysis. [Australian] National Drug and Alcohol Research Centre, 2005.

4 Best D. et al. Overdosing on opiates part I: causes. Drug and Alcohol Findings: 2000, issue 4.

5 Strang J. et al. Loss of tolerance and overdose mortality after inpatient opiate detoxification: follow up study. British Medical Journal: 2003, 326, p. 959–960.

6 Department of Health (England) and the devolved administrations. Drug misuse and dependence: UK guidelines on clinical management. London: Department of Health (England), the Scottish Government, Welsh Assembly Government and Northern Ireland Executive, 2007.

Last revised 14 February 2008
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Female drinkers also benefit from couples therapy

The latest in what family therapy experts have called an "impressive"¹ series of US studies on behavioural couples therapy for substance misuse found that the benefits extended to female drinkers. The approach differs from other family therapies in its focus on concretely changing behaviour so that the couple respond positively to each other, in particular so that every day the substance misuser's partner rewards behaviour conducive to sobriety.

As previously documented in Findings (Nugget 10.2), the approach has benefited (both in terms of substance use problems and family life) men using alcohol, and men and women using primarily opiates or cocaine, but until this latest study had not been tested on female drinkers.

For the study 246 married or cohabiting women starting outpatient alcohol treatment were approached. Along with their male partners, 138 agreed to participate and matched the study's requirements.² Nearly 90% met criteria for alcohol dependence. They were randomly assigned to three treatments each consisting of 32 one-hour sessions. The first included 12 sessions of behavioural couples therapy during which both partners actively participated. The remaining sessions involved the female partner only in 12-step based counselling. The second was similar except that during the 12 joint sessions the couples listened to lectures about problem substance use. In the third, all 32 sessions were individual 12-step based counselling. This design effectively tested whether engaging the couples in couples therapy added value to instead spending the same time passively being lectured to or using it to reinforce individual counselling.

The answer was affirmative. While outcomes from the other treatments differed little, women whose treatment included couples therapy drank or used drugs on fewer days during the year after treatment (by the end the difference neared 20%) and both partners reported better relationship quality. Similar results were found for heavy drinking. From the woman's point of view, interpersonal problems related to drinking also declined more after couples therapy and both partners reported fewer days marred by threats or violence from the other partner.

High follow-up rates and consistency of outcomes across substance use and problems and relationship quality give confidence that, though the other treatments also were associated with substantial gains, these were greater if the mix included couples therapy. Extra gains were undiminished a year after treatment ended.

With earlier similar results the study makes a strong case for a couples component in substance misuse therapy where this is appropriate. Often, however, it is not appropriate. Behavioural couples therapy is applicable only to patients with an intact live-in relationship with a relative or partner not also experiencing substance use problems and where the relationship is sufficiently supportive for both to agree. This will be the case for many (especially male) drinkers but usually not for long-term dependent users of cocaine or heroin. In the featured study this limitation meant that nearly 4 in 10 of the women were not eligible. In such cases similar approaches drawing on a broader social network³ may be applicable.

Another major limitation is the availability of family therapy of any kind. The dominant paradigm sees addiction as a disorder of the individual and treats it accordingly. Few drug misuse professionals have been trained in family approaches and in the UK there is no appreciable national drive to widen their perspective. The recent increasing emphasis on treatments which address not just substance use but also other recovery-relevant issues in the patient's life may alter this situation. Services which wish to pioneer this approach can obtain one of several versions of the manual⁴ (including an abbreviated six-session version) and adapt it to their needs but should also expect to invest in training and supervision.

1 Rowe C.L. et al. Substance abuse. Journal of Marital and Family Therapy: 2003, 29(1), p.97–120.

2 FEATURED STUDY Fals-Stewart W. et al. Learning sobriety together: a randomized clinical trial examining behavioral couples therapy with alcoholic female patients. Journal of Consulting and Clinical Psychology: 2006, 74(3), p. 579–591.

3 Smith J.E. et al. Take the network into treatment. Drug and Alcohol Findings: 2004, issue 10.

4 Fals-Stewart W. et al. Behavioral couples therapy for drug abuse and alcoholism: a 12-session manual. Addiction and Family Research Group, 2004.

Last revised 14 February 2008
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Harnessing peer interaction in school-based prevention can backfire

Small group work based on friendship networks and pupil-selected peer leaders is likely to foster highly interactive learning which harnesses influential peers and embeds social norms in networks active outside the classroom. Overall a US study found this augmented the preventive impact of a substance misuse curriculum, but the reverse was the case when a pupil's closest class friends used substances relatively frequently.

This finding emerged from a trial¹ of the 12-session version of the Project TND (Towards No Drug Abuse) curriculum in 'continuation' secondary schools in California. Continuation schools take pupils who are falling behind in mainstream schools. By age 16–18 most smoke, drink and use cannabis at least monthly and a substantial minority use cocaine or other drugs.²

As documented in Findings, a predecessor curriculum had retarded growth in substance use in the same kind of schools.³ Later results showed long-term impacts.⁴ Another study suggested this would only be the case if the curriculum was delivered by a trained health educator in the highly interactive manner (based on the Socratic method of asking questions) intended by the developers rather than in a self-instruction format.⁵

The featured study took interactivity further by dividing classes of on average 16-year-old pupils in to activity/discussion groups consisting of the three to five who most wanted to work together, led by pupils they nominated as the best leaders – a format based on the pupils' in-class social networks. Health educators trained in the curriculum delivered the lessons. In other classes they delivered the same curriculum but in a whole class format. Another set of classes underwent education as normal. 75 classes in 14 schools were randomly assigned to these three conditions.

In this study the whole-class format did not improve on education as usual but the network format did. Over the following year it curbed growth in the frequency of cannabis and cocaine use and smoking and drinking. Impacts on the two illegal drugs and on a composite all-substances measure were statistically significant.

While harnessing peer networks curbed substance use overall, this was not the case for pupils whose class friends used substances most frequently (also the pupils who themselves used most often). Here the network option actually increased use relative to the other options. Among these pupils, the diminished effectiveness of the network lessons was consistent across the two illegal drugs (cannabis and cocaine) and the composite measure. In contrast, among these high risk pupils the non-network options were at least as effective as among more typical pupils.

The network format's counterproductive impacts were apparent among youngsters who on average were using daily or more often. They were significantly less likely to quit if they had been grouped with like-minded friends, but the same grouping strategy led to higher quit rates among less frequent users.

As the authors comment, the network format appears to have reinforced peer influences, resulting in negative impacts when the friends shared elevated substance use patterns, while lessons which randomly mixed pupils seemed to counter the influence of high-use friendship groups.

'Deviancy training' is a recognised risk⁶ of grouping high-risk youngsters together, one which can overwhelm even the most well-constructed and well implemented curricula. It may work partly by reversing the intended impact of pupils' being made aware of how much their peers actually do use. Normally, education about typical use levels corrects misperceptions that 'everyone's doing it' and diminishes social pressure to use, but when the youngster's closest social circle (the group they are most likely to reference themselves against and who matter most to them) actually are relatively heavy users, the result may not be as intended.

While the negative impact on a subset of pupils is the headline finding, it should not be forgotten that overall (and among pupils likely to be more representative of mainstream school populations) the network format was more effective at curbing substance use than the same lessons delivered in a whole class format. Studies in mainstream schools analysed in Findings have suggested that the network method curbs smoking at least as well as the same curriculum taught conventionally,⁷ with some combinations of pupils and curricula, much more effectively.⁸

The potential for peer influence to reinforce substance use was apparent in the featured study's finding that popular pupils increased substance use most, while those who felt well supported by schoolmates increased their drinking most. These findings add to a body of literature indicating that in some situations, socially advanced (socially competent, confident and popular) teenagers are also likely to be advanced in their experimentation with substances.

Thanks for their comments on this entry in draft to Thomas Valente of the University of Southern California. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

1 FEATURED STUDY Valente T.W. et al. Peer acceleration: effects of a social network tailored substance abuse prevention program among high-risk adolescents. Addiction: 2007, 102, p. 1804–1815.

2 Sussman S. et al. Project Towards No Drug Abuse: a review of the findings and future directions. American Journal of Health Behavior: 2002, 26(5), p. 354–365.

3 Limitations on access to pupils and the ability to recontact them for follow-up raise questions over whether the results would apply to the entire school population, and significant use reductions were not observed across all the targeted substances. This also applies to the featured study whose pupils were mainly of Hispanic or Latino descent.

4 Sun W. et al. Project Towards No Drug Abuse: long-term substance use outcomes evaluation. Preventive Medicine: 2003, 2006, 42(3), p. 188–192.

5 Sussman S. et al. Project Towards No Drug Abuse: two-year outcomes of a trial that compares health educator delivery to self-instruction. Preventive Medicine: 2003, 37, p. 155–162.

6 Werch C.E. et al. Iatrogenic effects of alcohol and drug prevention programs. Journal of Studies on Alcohol: 2002, 63, p. 581–590.

7 Wiist W.H. et al. Peer education in friendship cliques: prevention of adolescent smoking. Health Education Research: 1991, 6(1), p. 101–108.

8 Valente T.W. et al. The interaction of curriculum type and implementation method on 1-year smoking outcomes in a school-based prevention program. Health Education Research: 2006, 21(3), p. 315–324.

Last revised 14 February 2008
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Needle exchange coverage key to reducing infection risk

Findings' in-depth review¹ of needle exchange and hepatitis C highlighted the importance of coverage – the extent to which exchanges approach the ideal of making a sterile set of equipment available for every injection. Two reports^{2 3} from researchers in California have confirmed that liberal exchange policies improve coverage which in turn reduces visitors' risks of contracting or spreading blood-borne diseases.

Both derive from a study of 24 of the 25 exchanges operating in the state in 2001. Each service's policies and activity levels were explored in interviews with their directors, while 1577 injectors recruited between 2001 and 2003 as they were leaving the exchanges were asked about their use of the service and their infection risk behaviours.

The number of syringes each injector had available to them over the past month was estimated on the basis of their visits during that time and how many syringes for their own use⁴ they picked up last time. This was divided by the number of times they injected during the month to construct an index of the adequacy of their supplies. On average exchange visitors (who mainly injected heroin and stimulants) needed nearly 90 syringes/needles in the past month to be able to use a fresh set each time.

Needle exchange policies affect the extent to which visitors are adequately supplied which affects their risk behaviour The first report² showed that the less restrictive was the distribution policy of their exchange, the greater were the chances of reaching this level. Most restrictive was strict one-for-one exchange of new syringes for old with a cap on the quantity issued per visit. Compared to these services, exchanges which simply provided as much as was needed were five times more likely to achieve adequate coverage. Not far behind were services which implemented uncapped one-for-one exchange supplemented by a few extra sets. Further behind were those which did this but capped quantities, then came the strict one-for-one exchanges, bottomed out by the two which also capped quantities.

An analysis which statistically evened out caseload differences confirmed that uncapped needs-based distribution was associated with the highest proportion of visitors (61%) receiving adequate supplies and the lowest receiving less than half their needs (19%). Corresponding figures for the next best option (uncapped one-for-one plus extras) were 50% and 34%. Bottom was capped, strict one-for-one exchange, which left most visitors with less than half their needs met. In exchanges which fell short of needs-based distribution, giving extras on top of one-for-one or not imposing caps made significant improvements to coverage. Visitors who received adequate supplies were significantly more likely to supply sterile syringes to other injectors who did not visit the exchange.

A second report³ linked coverage to the proportion of injectors who in the past month had risked spreading infection by injecting with a syringe already used by someone else, or by letting someone else inject with their used syringe. On both measures, the more adequately the individual's needs had been met by the exchange, the less likely they were to have incurred these risks. For example, when less than half their needs had been met, 38% had re-used after someone else. This proportion progressively reduced as coverage improved to just 9% of injectors who had received at least 50% more than they needed.

Adequate coverage was also associated with fewer injectors re-using their own equipment (which heightens the risk of damage at the injecting site) and fewer sharing implements used to heat drug solutions. On all these variables there were some statistically significant differences between coverage levels. More adequately supplied injectors were also more likely to always safely dispose of used syringes by returning them to the exchange, though this fell short of statistical significance once other factors had been taken in to account.

These results were relatively clear cut, possibly because so few injectors made up for shortfalls by purchasing syringes from pharmacies, which at the time could be supplied only on prescription.

Another important finding was that injectors in treatment were twice as likely to be adequately supplied as those who were not. As in other studies,^{1
5} this probably reflects a synergistic impact, with exchanges facilitating treatment entry and treatment stabilising lives and reducing injection frequency, making it easier for exchanges to meet patients' remaining needs.

The implications of these findings can already be found in guidelines endorsed by the National Needle Exchange Forum for England and Wales.⁷ These advise allowing injectors "to take all the injecting equipment they need for themselves and the people they inject with" without capping supplies or routinely tying distribution to returns.

There is some way to go to meet this standard. In 2004/5 a survey found that exchanges in England rarely operated a strict one-for-one policy, but also that amounts returned were commonly taken in to account in deciding how much to supply.⁸ A minority had fixed quantity caps. More common was a variable cap, often depending partly on returns. Around 30-40% had no upper limit. The result was wide variation in how much each exchange gave to the average client. Overall this was one syringe every two days, meaning that many customers must have been under-supplied. At the same time in Scotland (where there are legal caps on the quantity which can be supplied at a single visit) the picture was similar, though there the average distributed per client was less.⁹ Policies on how much to distribute per visit are not the sole reason for shortfalls; opening hours and other accessibility issues also play a role.

The featured study concerned itself with only one element of coverage – adequacy of supply of exchange users – not with the extent to which all injectors in the area were adequately supplied.⁶ In 2000/1 exchanges in Brighton and Liverpool supplied enough equipment for just over 1 in 4 injections in their areas and in London 1 in 5,¹⁰ if anything less than a national estimate for England in 1997.¹¹

Thanks for their comments on this entry in draft to Ricky Bluthenthal of the RAND Corporation and Helen Wilks, co-chair of the National Needle Exchange Forum. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

1 Ashton M. Hepatitis C and needle exchange: part 4 • the active ingredients. Drug and Alcohol Findings: 2004, 11, p. 25–30.

2 FEATURED STUDY Bluthenthal R.N. et al. Examination of the association between syringe exchange program (SEP) dispensation policy and SEP client-level syringe coverage among injection drug users. Addiction: 2007, 102(4), p. 638–646.

3 FEATURED STUDY Bluthenthal R.N. et al. Higher syringe coverage is associated with lower odds of HIV risk and does not increase unsafe syringe disposal among syringe exchange program clients. Drug and Alcohol Dependence: 2007, 89, p. 214–222.

4 As opposed to those they intended to pass on to someone else.

5 Van Den Berg C. et al. Full participation in harm reduction programmes is associated with decreased risk for human immunodeficiency virus and hepatitis C virus: evidence from the Amsterdam Cohort Studies among drug users. Addiction: 2007, 102, p. 1454–1462.

6 Burrows D. Rethinking coverage of needle exchange programs. Substance Use & Misuse: 2006, 41(6–7), p. 1045–1048.

7 UK Harm Reduction Alliance, National Needle Exchange Forum, Exchange Supplies. Reducing Injecting Related Harm: consensus statement on best practice. London: UKHRA, 2006.

8 Abdulrahim D. et al. The NTA's 2005 survey of needle exchanges in England. National Treatment Agency for Substance Misuse, 2007.

9 Griesbach D. et al. Needle exchange provision in Scotland: a report of the National Needle Exchange Survey. Scottish Executive, 2006.
This reports (p.24) that 3,553,911 syringes were distributed to 31,955 (14,229 + 17,726) clients which equates to about 1 every 3 days, but many services were unable to estimate the number of clients, suggesting that this is an over-estimate.

10 Hickman M. et al. Injecting drug use in Brighton, Liverpool, and London: best estimates of prevalence and coverage of public health indicators. Journal of Epidemiology and Community Health: 2004, 58, p. 766–771.

11 Parsons J. et al. Over a decade of syringe exchange: results from 1997 UK survey. Addiction: 2002, 97, p. 845–850.

Last revised 14 February 2008
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