Drug and Alcohol Findings home page. Opens new window Effectiveness Bank bulletin 15 April 2014

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


Contents

Expert guidance and new findings on the main medical treatment for opiate dependence, possibly the main psychosocial approach to substance use problems, and the major harm reduction strategy for injecting drug use, plus important information on what it is about a school’s social and educational climate which helps protect its pupils from problem substance use.

Methadone not an obstruction on road to recovery, agree Scottish experts ...

Unique study unpicks motivational interviewing’s change drivers ...

REVISED Needle exchanges linked to fewer discarded needles and syringes on the streets ...

What makes a school excel at substance use prevention? ...


Delivering recovery. Independent expert review of opioid replacement therapies in Scotland.

Scottish Drug Strategy Delivery Commission.
The Scottish Government, 2013.
Unable to obtain a copy by clicking title? Try this alternative source.

An expert committee responds to the Scottish government’s concerns over the role of methadone prescribing in helping patients along the Road to Recovery signposted in the national strategy. On the ground, that road was often barely constructed but methadone was not the problem, rather the failure to optimise programmes for recovery.

Summary The featured report answers a request to the Scottish Drugs Strategy Delivery Commission from Scotland’s Chief Medical Officer to review the use in Scotland of ‘opioid replacement therapy’ – methadone maintenance and allied treatments which substitute legally prescribed drugs with similar effects for the illegally obtained opiate-type (opioid) drugs on which patients have become dependent. On the basis of the evidence gathered, it was also asked that the report recommend ways to maximise effectiveness.

The commission was established to offer independent expertise and challenge to Scotland’s national drug strategy, the Road to Recovery. To produce the featured report it set up a steering group from among its members which also drew in other experts, chaired by the addictions psychiatrist who also chairs the commission. Researchers were commissioned to rapidly review research and to survey the 30 Scottish alcohol and drug partnerships responsible for organising addiction services in their areas. Also consulted were relevant organisations and individuals, including service users and their families, and events were attended where views were sought and aired. The resultant draft report was commented on by international experts. The account below is based on the report’s own summary.

Background

Patterns of substance use problems are strongly associated with a wide range of social, psychological and physical issues. There is a need to ensure local systems of care take these inequalities into account to better address the high levels of morbidity and mortality experienced by this group.

Generic primary care providers – such as general practitioners and community pharmacists – have been important elements of the system of care offered to substance users, and as professional groupings have strongly supported delivery of care for this group. However, there are still huge inconsistencies across Scotland in the availability of treatment via primary care and the range or quality of care available. Despite the high risks carried by this group, contracting processes in primary care still support an ‘opt-in’ approach to delivering treatment, even in the higher risk communities.

Themes

The review makes twelve recommendations under the following six themes.

Theme 1: Social exclusion and health inequalities

The demographic characteristics of substance users who might benefit from opioid replacement therapy have changed in recent years. Average age has markedly increased, suggesting that the degree of both physiological and psychological difficulty, already high, is likely also to increase. Equally, as health inequalities continue to increase, the effects on this already multiply deprived and marginalised group will become more extreme.

These factors, further compounded by the effects of stigma, will produce a picture of increasingly complex social and medical difficulty which will require a more coordinated approach from all providers of social and medical care, especially primary care, whose involvement, whilst excellent in some areas, seems inconsistent and sometimes absent in others. This is a problem driven by the ‘opt-in’ nature of the contracting process.

Theme 2: Opioid replacement therapies in Scotland

The issue for Scotland is to ensure that the opioid replacement therapy delivery system is of the highest quality, and that staff delivering this care recognise the impetus to offer this therapy in the context of a flexible and mixed treatment system. This would ensure that service users and their families are involved in decisions regarding their treatment plans.

Theme 3: Progressing recovery in Scotland

The review found considerable variation in local delivery of even the core elements of recovery-orientated systems of care. Many areas stated their plans were at very early stages of development. There was little evidence presented by some alcohol and drug partnerships regarding a real impetus towards recovery. Stakeholder reports supported this view.

Theme 4: Governance and accountability of the delivery system

There are real concerns around the lack of progress we found in many areas regarding the delivery of recovery-orientated systems of care and quality assurance for services. The Scottish Government funds alcohol and drug partnerships to facilitate local improvement. Despite this, in many areas, basic information seemed impossible to access. Clear strategic plans and objective reports of improvement were rare in the responses received by the review. Elements of recovery-orientated services were often absent. There was not a strong sense of accountability.

In this field there is a lack of institutional memory [eg, of past mistakes and successes and the essentials of treatment] regarding an agreed understanding of the key issues and the plans which require to be put in place to address them. Without this, systems are destined to continue repeating mistakes or failing to capitalise on successes. Such inefficiency is at odds with the aspirations of the Christie Commission report.

Theme 5: Information, research and evaluation

Despite the magnitude and seriousness of its manifestations, research and academic enquiry into problem substance use has been poorly developed in Scotland. There is an urgent need to develop meaningful information systems which allow routine data to be used to support a high quality national research programme, designed to address Scottish challenges. If such a structure were in place, future assessments of the effectiveness of drug strategy would be planned and resourced as part of an on-going academic programme rather than convened in response to a perceived crisis.

Theme 6: Mechanism for change

The Christie Commission has highlighted the need for the Scottish Government and its partners to develop more efficient, effective and outcome-focused mechanisms for delivering services. In the area of substance use, recent reports have raised similar issues regarding inconsistent delivery and a lack of accountability of a dedicated system (alcohol and drug action teams; alcohol and drug partnerships). It is now important to avoid further delay and take immediate steps to use an approach which has a track record of delivering change.

Delivering recovery

The review proposes that the specific recommendations (numbers 1–11) should form the basis of an immediate improvement process – giving local and national systems a clear direction for improvement work. In the meantime, officials should be developing plans for use of the 3-Step Improvement Framework for Scotland’s Public Services, to put in place sustainable changes to address the issues identified by this review.

Recommendations

1 Consideration should be given to the development of mechanisms bringing the delivery of approaches to address health inequalities closer to those related to problem substance use.
As a minimum requirement, all local inequalities strategies should contain reference to plans to address the risks associated with substance use.

2 Primary care services – specifically general practitioners and community pharmacists – are essential elements of the delivery system and should be delivered to national standards.
It is imperative that discussions begin to consider how substance misuse treatment can best be delivered in the primary care setting. This process should be led by NHS primary care structures and discussions should include general practitioners and community pharmacists.
Actions to test service quality improvement should be initiated nationally to reduce variation in practice.

3 Opioid replacement is an essential treatment with a strong evidence base. Its use remains a central component of the treatment for opiate dependence and it should be retained in Scottish services.
In all settings, opioid replacement therapy should be delivered as part of a coherent, person-centred recovery plan with SMART (specific, measurable, achievable, realistic, time-bound) goals and based on an assessment of individual recovery capital.
The quality of opioid replacement therapy should be governed and delivery should be in line with national standards and guidance. NHS medical directors should hold this responsibility on behalf of local partnerships.
Fit-for-purpose information systems should be able to identify individuals on this care pathway and objectively demonstrate their progress.

4 A national specification for pharmacy services for problematic drug users should be developed to ensure that a high quality and consistent service can be provided. This should be supported by a nationally agreed guideline for supervised self-administration of opioid replacement therapy medications and initiation of improvement approaches to accelerate progress.
As part of this process, Prevention and treatment of substance misuse, delivering the right medicine should be updated to reflect the role of pharmacy within the national drug strategy.

5 Mechanisms which determine the reimbursement cost of methadone in Scottish community treatment systems should be reviewed to ensure they deliver best value and that in balancing the competing challenges, the benefits to problem substance users are to the fore.

6 Recovery-orientated systems of care are well described in many guidance documents. All local systems should immediately publish prioritised SMART plans to ensure they can demonstrate a process towards delivery of these systems. Elements expected in such plans include:
• All service users should be offered and actively encouraged to use Essential Care services. This offer should be recorded and repeated at regular intervals. This should become the norm in Scotland’s services.
• In all settings staff should be trained in the delivery of recovery-orientated systems of care.
• A full range of Essential Care services should be available in every locality. This should include a full range of identifiable community rehabilitation services, including: those using people with lived experience; access to detoxification and residential rehabilitation; access to a full range of psychological and psychiatric services; services addressing employability and accommodation.

7 Within the medical and other caring professions, it is everyone’s responsibility to manage drug users and their problems, which extend into every clinical speciality. All practitioners can effect change and have opportunities to address drug-related problems within their professional arenas. Local systems should have plans to ensure substance users are not excluded from generic services.

8 The Scottish Government should seriously reconsider how to better facilitate universal and effective partnerships which respond to local need and deliver consistent and measureable outcome improvement for substance users across Scotland.
The functions of alcohol and drug partnerships should be reviewed urgently and clear improvement measures developed and monitored with clear time-frames for change.
In particular, all local systems should immediately publish prioritised SMART plans to ensure they can demonstrate a valid and coherent process to evidence the delivery of recovery-orientated systems of care in line with the Essential Care report.

9 There is an urgent need to address the lack of institutional memory in the planning, delivery and governance of these systems of care. In particular, current advisory structures should be reviewed to improve impact on performance – especially with regard to lines of accountability and relationships with the Scottish Government and Scottish Parliament.

10 The Chief Medical Officer should task the Chief Scientist to consult with the academic community in Scotland and bring forward robust plans to develop a Scottish national research programme addressing the key substance use questions for Scotland. The aim should be to support and facilitate the delivery of efficient, high quality research into the natural history of problem substance use – its development and progression – as well as the effectiveness of a broad range of treatment approaches, including psychological and social approaches and novel treatments.

11 Any proposal to further develop national information systems in the area of substance misuse at national level should be subject to meaningful and accountable project management. This should include: external scrutiny of delivery; a risk assessment to identify and address the main obstructions to delivery; and publication of a realistic programme of delivery with agreed time-frames, measureable milestones, and clear lines of accountability for all elements of the proposed system.

12 The variation of practice identified across services should be addressed using the proven improvement methodology, enshrined in the 3-Step improvement framework for Scotland’s public services. This work should be given high priority by the Scottish Government and its partners. Clearly defined aims, drivers and measures should be developed for agreement at an initial national collaborative learning event organised by the Scottish Government early in 2014.


Findings logo commentary This report comes in the year after the corresponding report for England. Both were concerned with establishing and augmenting the ‘recovery’ credentials of maintenance prescribing, seen in some quarters as antithetical to the holistic life changes entailed in recovery, while retaining harm reduction benefits such as protection against disease and not least, prevention of early death. In both cases the reports were formally requested by the countries’ chief medical officers, but they acted as a conduit for political concerns and in Scotland also public concern as expressed in and/or generated by the media. The Chief Medical Officer’s foreword to the Scottish report hints at the concerns leading to his request: that methadone treatment “often simply switches one pattern of drug use for another” and “is far from risk free”, an allusion to the concern in Scotland about overdose deaths linked to the drug. It also reflected what is perhaps the core concern – that methadone has been portrayed as dominating treatment provision to the point where other options are in practice excluded.

For the committee there was more than enough evidence to indicate that methadone and allied treatments are “essential” components of treatment services whose costs are justified by “extensive impact ... on health, criminal justice, social care, costs to the economy and wider costs to society”. Yet despite these strengths, the report found “The evidence-base for effectiveness in achieving abstinence or promoting long term recovery – as opposed to reducing harm – remains much less compelling”, possibly due to inadequate research.

Though for some a key issue, for these experts treatment duration was not a problem: “for maximum long term benefit some may require to receive [opioid replacement therapy] indefinitely ... this outcome... should not be considered a failure”. Instead the main problem not lay not with maintenance prescribing itself or its duration, but with the suboptimal nature of much current provision, including the lack of ancillary inputs such as psychosocial therapy, an overloaded staff unable to do much more than prescribe medications and complete required paperwork, and under-developed links with services which could address the multiple needs of the patients.

They did accept there was underuse of and obstructed access to alternative addiction treatment programmes such as residential rehabilitation, but their recipe would entail more resources for maintenance programmes and their patients, not their constriction. These and other features of treatment commissioning and provision meant that despite national policy, recovery-oriented service provision could rarely be shown to be a reality on the ground, though in some respects (especially links with mutual aid and other peer networks) it was moving forward.

A distinctive feature of Scottish drug policy and policy debate is the centrality of income and health inequalities, apparent to the report in the multiple deprivation characterising the home areas of most drug service patients. Inequality is seen as a significant driver of negative outcomes such as drug and alcohol-related deaths. Though outside their remit, the committee warned that unless inequality is addressed, other efforts will struggle to curb the deaths, but they were not hopeful that Scotland wants to or can do enough on this front. More on these and other issues in small text below.

The Scottish Government has responded positively to the report. Aligned with the report’s themes, an “alcohol and drug quality improvement framework” is being developed to “ensure quality in the provision of care, treatment and recovery services as well as in the data that will evidence outcomes”. It is intended to set out what someone who accesses a service can expect to receive and achieve, including: “high-quality, evidence-based interventions; workers who are appropriately trained and supervised; full strengths-based assessments and person-centred recovery plans that are agreed and regularly reviewed; and, if it is helpful to the individual, the opportunity for their family to be involved”.

The review noted that “Some service elements which one would expect to be strategic priorities in a recovery environment clearly are not.” Among those lacking were making use of current or former problem drug users, the development of community rehabilitation, improved access to residential rehabilitation, and access to specialist clinical psychology services. With “a very large proportion of funding” devoted to methadone prescribing, these ‘wrap-around’ services were relatively starved of practical and financial support: “There has been little evidence supplied to this review of a meaningful local response to this resource deficit”. Not surprisingly, it was argued, in this situation opioid replacement therapy is seen as the problem, rather than “the failure to deliver this evidence-based medical treatment optimally nor the failure to effectively commission an adequate range of services in a balanced manner to best meet local needs”.

Though in most areas services and commissioners engaged with mutual aid groups, rarely were these promoted to patients in the most effective ways. In few areas were groups co-located with treatment services and very few could show they assertively linked patients to groups rather than leaving them to find (or not find) their own ways. Universally among responding areas, residential rehabilitation was seen as an option reserved for patients who had not done well in other services, not as a possible first-line option for some patients.

For the review there was no set duration for opioid replacement therapy. Instead duration would depend on the patient’s circumstances and resources and (importantly) also on the services, care and support required to help them progress. The implication is that opioid replacement treatment careers might be shortened if patients were “afforded all the services they require to meet their needs at any point in their own [recovery] journey with regular opportunities for review and, when they are ready to do so, are given the opportunity to come off [opioid replacement therapy] safely”. If they do, they should be monitored for at least a year and if needed, be able to restart therapy immediately. Instead, (ex)patients, though acknowledging that methadone maintenance was often essential to recovery, felt it had not been a ‘component’, but all they had been offered when asking for treatment. Many felt they were not reviewed regularly nor supported in their desire to reduce their methadone dose or detoxify.

The commission endorsed the views of US recovery advocate William White (who commented on their report in draft) and felt they had resonance for Scotland. He had argued that “periodic moral panics about the idea of patients being on methadone for prolonged periods ... obscures the real problem which is that most patients are not on methadone long enough, eg, high rates of early drop-out, administrative discharge and rapid resumption of opioid addiction”.

To judge by prescribing patterns, in most areas patients and clinicians were not as free to choose buprenorphine as they were methadone, the former being sidelined due to the cost of the drug and the cost or impracticality of supervising its administration (it has to dissolve under the tongue) in pharmacies.

The review accepted that services clearly aimed to deliver holistic care, but also felt many struggled to do so, due among other things to the focus on prescribing, lack of competence among staff, high caseloads and administrative burdens restricting the time available to offer anything more than basic treatment, poorly developed partnerships with other services or their inadequacy, and poor access to inputs such as specialist psychology or psychiatry services or the lack of priority given by those services to substance users. How crucial staff competence could be seemed reflected in the comment from many in recovery that one particular worker’s empathic relationship with them had made the difference.

Thanks for their comments on this entry in draft to Brian Kidd of the University of Dundee Medical School in Scotland, who chaired the group which produced the featured report. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 07 April 2014. First uploaded 31 March 2014

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

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Motivational interviewing: a pilot test of active ingredients and mechanisms of change.

Morgenstern J., Kuerbis A., Amrhein P. et al.
Psychology of Addictive Behaviors: 2012, 26(4), p. 859–869.
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 Morgenstern at jm977@columbia.edu. You could also try this alternative source.

Motivational interviewing’s originator has stressed how unexpected findings can force fruitful rethinking. This study may prove an example; designed to forefront the approach’s distinct active ingredients, other than fleetingly and non-significantly, these did not seem active at all among the stable, moderately dependent drinkers recruited to the trial.

Summary Motivational interviewing is probably the most influential and widely implemented formal counselling style in the treatment of problem substance use. How it works has been investigated, but rarely in studies which deliberately vary the mix of supposedly active ingredients (key therapist strategies that facilitate positive change) to test whether they really do affect mechanisms of change in the client (such as developing skills and making commitments to change) and finally substance use itself. This US study was the first to do so among heavily drinking clients aiming to cut down rather than stop altogether, and who sought help rather than being identified through screening programmes. Among treatment-seeking problem drinkers, also a first was its comparison of a ‘self-change’ option with therapist-led interventions.

Theory behind the study

Issues addressed by the study

The study was based on the distinction made in motivational interviewing between ‘relational’ and ‘technical’ active ingredients. The former (the ‘spirit’ of the approach) refer to elements of non-directive counselling including empathic listening, avoiding negative therapeutic interactions, and monitoring and repairing ruptures to the therapeutic relationship. Technical elements are the directive strategies and techniques geared to moving the client in the desired direction (in this case, reduced substance use), including sharpening their perception that how they actually behave is not how they wish to, the resolution of ambivalence, and securing a commitment to a behaviour change goal.

Together these active ingredients are intended to elicit statements from the client in support of the desired change – so called ‘change talk’, the sincere emergence of the client’s own reasons for change, promoted by active shaping and reinforcement of their responses by the therapist. Change talk is hypothesised to be the mechanism which in turn leads to behaviour change.

The implication is that without these directive, technical elements, non-directive counselling (motivational interviewing stripped of its specific levers of change) would be less effective, but both would be better than leaving patients to ‘self-change’ without any counselling.

How the theory was tested

To test these expectations the study recruited 89 adult problem drinkers, all but nine of those assessed after responding to ads for treatment aimed at drinking less and which emphasised client choice. As assessed in interviews with research staff, they had to be on average drinking more than 210g alcohol a week for women or 336g for men and to meet criteria for alcohol abuse or dependence, but not so severely dependent as to have experienced withdrawal symptoms. Most were mildly or moderately dependent, averaging around 434g alcohol a week and 84g on each day they drank. They had to be aiming for moderation rather than abstinence, socially stable, and not severely mentally ill or seriously involved in regular use of other drugs. About evenly split between men and women, typically they were in their 30s and 40s, employed, well educated and had never been treated for drinking problems.

Throughout the therapy phase of the study, all patients were asked each day to report their drinking and issues and situations which may have prompted drinking. For the first week this was all they did. Then all were further assessed and results fed back to them indicating the seriousness of their drinking.

The interventions

After this they were allocated at random to one of two therapies or told to try to curb drinking on their own. Effectively these options delivered the full set of motivational interviewing’s active ingredients, only the non-directive set, or none. The three options were:
• Motivational interviewing spanning four one-hour sessions over seven weeks with both the non-directive ‘spirit’ elements (see below) and more directive techniques to lead the client to commit to curb their drinking, a combination expected to lead to the greatest drinking reductions.
• Just the non-directive or ‘Rogerian’ [after the therapist Carl Rogers – see this discussion] elements over the same phasing of sessions and delivered by the same (generally) experienced motivational therapists, featuring therapist warmth, genuineness, and egalitarianism, emphasis on the client’s responsibility for change, extensive reflective listening, and avoiding therapist behaviours contrary to motivational interviewing’s spirit. More directive techniques were explicitly proscribed, extending to the use of reflective listening to reinforce change talk. Instead reflections focused on echoing and exploring the patient’s emotions and experiences.
• A self-change option in which (after the assessment feedback given to all clients) participants were told to try to change on their own over the next eight weeks, after which they would be offered treatment. They were told some people could manage this without professional help, and that monitoring their drinking and being interviewed for research purposes might help. Clients met only technical research staff, not therapists.

Primarily at issue was whether over the last half of the eight weeks before self-change clients were offered treatment, these options would be associated with progressively less steep reductions in average weekly alcohol consumption, assessed by three research interviews each completed by at least 92% of clients in the study. Patients from the start allocated to the two forms of therapy were also followed up for a further four weeks.

If these options did differ in effectiveness, what might have helped cause this was assessed by rating session videos for how often and how strongly clients committed to change (or not to change) their drinking, and related comments on, for example, their ability or desire to change. The videos also showed that therapists stuck well to their ‘scripts’, as did feedback from clients.

Main findings

The anticipated findings did not materialise. All three sets of clients reduced their drinking over the eight weeks of the therapy period, but not by significantly different degrees. Unexpectedly, such minor differences as there were favoured the spirit-only option, though (as expected) least effective was self-change. Among the two groups offered therapy over this period, drinking fell from an average of about 456g alcohol a week to 298g by the last half of the period. Over the next four weeks it fell further to average 227g, about half the pre-treatment level, but again with no significant differences between full motivational interviewing and the stripped down version.

With no advantages for any of the options needing to be explained, there was no point in looking for mechanisms to explain them. Instead the researchers probed the data for results they had not planned to look for in advance, a procedure which limits confidence in the robustness of any which emerge. None did emerge when drinking intensity or consequences replaced weekly consumption as the outcome, and such differences as there were did not favour the full motivational option. Also not found was any indication that more severely dependent participants had reacted better to this option than to the supposedly less effective alternatives.

Fleeting concordance with theory

However, during one period of the study the drinking reduction pattern did look like that expected. This was over the first two weeks of the therapy period during and after the first two sessions, when all three groups made most of their reductions in drinking. The drop was steepest among those offered full motivational interviewing and least among those left to their own devices, the expected pattern. These differences were appreciable but not statistically significant. Later the non-directive group ‘caught up’ and by the end of the eight weeks the difference had reversed, but the early pattern offered the opportunity to test whether the expected change-talk mechanism had fleetingly been at work.

The comparison was between full motivational interviewing versus non-directive counselling. Though not all the links were statistically significant, by the end of the first session the motivational option had generated stronger commitments to curb drinking, which seemed enacted in the following week when these clients’ did make extra drinking reductions. Further analysis indicated that generating stronger change talk was at least part of the reason for this advantage. In the second session a week later the motivational option also generated stronger change talk, but this was not linked to further reductions in drinking. Only the first session showed signs of the expected links.

The authors’ conclusions

Since differences were small and not in the expected direction, it seems unlikely that failure to find extra benefits from the full motivational option was due to having too few participants. This surprising outcome seems to direct our attention beyond the specific elements included or not in each of the three options, to the features they share, and to drivers of change which are not unique to therapy, but active in the self-change process which proved equal to formal therapy.

The first two sessions of motivational interviewing did (non-significantly) accelerate drinking reductions, but by the end these advantages had narrowed or reversed. Acceleration after the first session seemed due in part to the generation of stronger change talk, a finding consistent with the expected mechanism but which should be interpreted cautiously.

A plausible explanation of the findings is that motivational interviewing is uniquely effective in mobilising rapid change in the context of a one- or two-session intervention. However, in a longer treatment well delivered Rogerian therapy can achieve equivalent effects for problem drinkers. Why self-change was almost as effective as motivational interviewing might be due to daily self-monitoring of alcohol consumption, a high level of contact with research staff, and a short follow-up.

In the only previous similar study, over the following six months frequent heavy drinking was significantly less common when motivational interviewing techniques had been added to non-directive listening, but other drinking outcomes were not significantly affected. Another study has shown that (with college students concerned about their drinking) therapists can deploy strategies which increase the frequency of change talk, a finding confirmed in the current study.

Together with the current study, this work means it remains an open question whether motivational interviewing’s directive strategies augment its effects, or whether the non-directive elements alone might be equally effective.

All these studies used random allocation to different types of therapy to investigate how therapy works. Others have instead observed links between outcomes and active ingredients and mechanisms as they emerge in studies primarily designed for other purposes. It means any links they find cannot securely be attributed to cause and effect, but may have been due to other factors. Generally motivational interviewing’s stance and techniques have been found associated with increased change talk, and these commitments to change associated with reductions in drinking.

The primary limitations of this study are its relatively small sample size and short-term follow-up. Also its findings are limited to problem drinkers seeking moderation who voluntarily attend treatment with minimal coercion from outside sources. Participants with more severe drinking problems and those coerced in to treatment might respond differently.


Findings logo commentary William Miller, motivational interviewing’s originator, has observed that in science, “Failure to confirm expectations is a particularly fruitful point [which] if taken seriously, lead[s] one back to the drawing board of discovery to develop a better theory for subsequent testing”. This study may prove an example, delivering a comprehensive reversal for the expectation that motivational interviewing would prove preferable to non-directive counselling, and even more unexpectedly, failing to find it significantly better than going it alone pending therapy. On no measure of drinking were these expectations fulfilled; frequently the slight advantage was with non-directive counselling.

Not too much should be made of one small study, especially one seemingly contradicted by a predecessor, but to date this is the most rigorous test we have of whether motivational interviewing’s theory stands up and with it the approach’s intended superiority to the bedrock of substance use (and other problems) counselling – non-directive listening. Instead it turned the spotlight among treatment-seeking, stable and not very dependent drinkers, on their own impetus to change, and suggests change talk is not active in itself, but a sign of that impetus drawn out by motivational techniques. Along the way the study also demonstrated the value of offering some kind of intervention to excessive drinkers which does not deter by insisting on abstinence, and added to the substantial accumulation of research showing that well structured therapies are equivalent in their effects. It also suggested in line with other research that motivational interviewing can accelerate change and/or achieve it in a shorter time than alternatives, and partially confirmed the role techniques and activities play in forging a deeper therapeutic relationship, supporting assertions that how the therapist acts with clients cannot entirely be divorced from the content of those acts – from what they and the client do together.

Unfold supplementary text for more detailed discussion of these points.

For more on the mechanisms and processes involved in motivational interviewing run this search of the Effectiveness Bank site.

Thanks for their comments on this entry in draft to research author Jon Morgenstern of the National Center on Addiction and Substance Abuse at Columbia University in the USA, and Tim Leighton of the Centre for Addiction Treatment Studies of Action on Addiction. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 14 April 2014. First uploaded 07 April 2014

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

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

STUDY 2009 From in-session behaviors to drinking outcomes: a causal chain for motivational interviewing

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

STUDY 2009 Counselor skill influences outcomes of brief motivational interventions

STUDY 2010 Initial preference for drinking goal in the treatment of alcohol problems: II. Treatment outcomes

STUDY 2014 Influence of counselor characteristics and behaviors on the efficacy of a brief motivational intervention for heavy drinking in young men – a randomized controlled trial

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

STUDY 2013 Effectiveness of screening and brief alcohol intervention in primary care (SIPS trial): pragmatic cluster randomised controlled trial





A comparison of syringe disposal practices among injection drug users in a city with versus a city without needle and syringe programs.

Tookes H.E., Kral A.H., Wenger L.D. et al.
Drug and Alcohol Dependence: 2012, 123(1–3), p. 255–299.
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 Metsch at lmetsch@med.miami.edu. You could also try this alternative source.

A major concern about needle exchanges is that after use the injecting equipment they supply will be left unsafely disfiguring public areas, but this US study based on a comparison between San Francisco (has legal exchanges) and Miami (exchanges illegal) strongly suggests the opposite.

Summary Needle and syringe exchange programmes, which allow injecting drug users to safely dispose of used injecting equipment and receive new sterile equipment, were first established in some parts of the USA in the late 1980s, and have since 2009 been eligible for federal funding. Access to needle and syringe programmes in the USA still varies greatly: in San Francisco there are four dedicated needle and syringe programmes, and pharmacies are also able to provide up to 10 syringes without a prescription; whilst in Miami there are no needle exchanges because they are illegal, as is giving or selling syringes to people who are known to inject drugs. Researchers exploited the policy differences between these cities to test whether needle exchanges help reduce the number of used needles and syringes discarded unsafely in public places.

Unsafely discarded needles and syringes present a risk, albeit slight, to the public from blood-borne diseases including HIV and hepatitis. At issue was whether exchanges reduce unsafely discarded needles and syringes by providing a safe disposal site and a motivation – receiving sterile new equipment – to use it. Concerns have been expressed that exchanges might instead increase the number of discarded syringes; the featured study is the first to address this by comparing rates of discarded syringes in cities with and without exchanges.

Data for San Francisco derived from a 2008 study into syringe disposal and for Miami from new research conducted in 2009 using similar methods – a visual inspection of drug-affected areas for discarded syringes, and interviewing injectors to ask how they had discarded their syringes. Visual inspections involved determining which neighbourhoods in each city were assessed as being in the top quartile of drug-affected areas, as indicated in San Francisco by the number of drug-related arrests and drug treatment admissions, and in Miami by the number of drug-related arrests. The neighbourhoods were divided into blocks, and a random sample of blocks picked to be surveyed. The blocks were then inspected visually for discarded syringes, looking in all publically accessible areas including pavements, gutters, grassy areas, alleyways and car parks. In San Francisco, one side of each block was examined; in Miami, all four sides were. The number of syringes found in San Francisco was multiplied by four to compensate, and researchers used census data to calculate in each city the number of syringes found per 1000 residents of the blocks.

Just over 600 injecting drug users in San Francisco and just under 450 in Miami were interviewed about how they disposed of syringes. The sampling methods were slightly different, but have been shown to produce similar results, and researchers did not deliberately recruit from needle exchanges. Interviewees over 18 who had recently injected were asked if and how many times they had disposed of syringes in the last 30 days by discarding them in public places, giving away or selling, or by placing them in rubbish bins (‘unsafe’ disposal), versus at exchanges, hospital clinics, pharmacies, or in sharps containers (‘safe’ disposal). Most interviewees were homeless men over 40. San Francisco had relatively more non-Hispanic white respondents and Miami more Hispanics, and 15% in San Francisco and 10% in Miami reported being HIV positive.

Main findings

In San Francisco 11 discarded syringes were found, 328 in Miami. After adjusting for different sampling strategies, this equated to 44 syringes per 1000 blocks and 0.3 per 1000 people in San Francisco, compared to 371 per 1000 blocks and 4.9 per 1000 people in Miami.

In San Francisco 11% of interviewees reported having discarded any syringes in public places in the previous 30 days, compared to 69% in Miami, and the difference was statistically significant. 65% of interviewees in San Francisco reported any improper or unsafe disposal in the previous 30 days, compared to 95% in Miami. Apart from in public places, the unsafe disposal was mostly putting syringes in the rubbish (53% of interviewees in San Francisco, 66% in Miami) flushing them down the toilet (15% in San Francisco, 2% in Miami) and giving them away or selling them (13% in San Francisco, 13% in Miami). The primary safe methods of disposal reported were discarding syringes at a needle exchange (62% of interviewees in San Francisco, 0% in Miami) or at a hospital or clinic (12% in San Francisco, 2% in Miami). In Miami, none of the safe methods of disposal had been used by a sizeable proportion of interviewees in the previous 30 days.

Looking at the total number of syringes disposed of, in San Francisco 8474 out of 64259 syringes (13%) were reported disposed of unsafely, of which 718 (1%) were discarded in a public place. In Miami, 9845 out of 10379 (95%) syringes were reported disposed of unsafely, of which 4689 (45%) were in a public place. In San Francisco, 53143 (80%) syringes were reported to have been handed in at needle exchanges, compared to none in Miami. Statistical analysis showed that injecting drug users in Miami were on average 34 times more likely to discard syringes in public places than those in San Francisco. On average, homeless people in both cities were five times more likely to discard syringes in public places than non-homeless people.

The authors’ conclusions

The higher number of syringes found by inspections in Miami compared to San Francisco was corroborated by the interview data, which shows that injectors in Miami were much more likely to discard syringes in public places. Free syringes are relatively abundant in San Francisco compared to Miami, which might suggest that San Franciscan injectors possess more and therefore dispose of more syringes over a given period of time, but the majority are disposed of at needle exchanges. Exchanges are a significant means of collecting used syringes, and do not increase the amount of publically disposed syringes. From the interview results, it is clear that Miami has few options for safe disposal of syringes; the great majority are discarded in public or in the rubbish, which is a risk to refuse workers and the general public. Some public areas in Miami had large numbers of discarded syringes, with four areas having over 10 syringes. Venues where syringes can be disposed of safely, such as needle exchanges, are needed in these areas, along with education and awareness-raising.

Acknowledged limitations include the year’s gap between the inspections and the interviews in San Francisco and those in Miami. It is also possible that there were differences between the interviewees in the two cities that were not controlled for, which would introduce a risk of bias. Street cleaning and litter removal policies were similar in both cities, and the inspections were made at random times, so it is likely that the number of syringes spotted in each city was representative. Because the inspections were only conducted in a small proportion of city blocks, in areas considered to be the most drug-affected, the results cannot be generalised to areas that are not so drug-affected. The interviews rely on self-reporting of syringe disposal, which might be subject to bias. The sampling methods used to pick people for interviews were also different, although should not have produced very different results.


Findings logo commentary The results appear compelling insofar as they apply to the discarding of syringes in public places; they show that many more syringes were found discarded in public places in Miami than in San Francisco, in total, per person and per block, and that a much greater percentage of injectors reported publically disposing of a much greater number of syringes in Miami than San Francisco. Looking not just at public places, but all unsafe disposal including in the rubbish, we find that there is much less difference in the total number of syringes reported disposed unsafely; approximately 8500 from 600 injectors in San Francisco, and approximately 9800 from 450 injectors in Miami. This appears to be a less strongly positive result, but we should bear in mind that the primary aim of needle exchanges, reducing the re-use of contaminated needles and syringes and resulting blood-borne virus transmission among injectors, may work in the other direction by increasing the supply of syringes. To reduce virus transmission in injectors, it is of course desirable to provide sufficient needles and syringes so that injectors have a new one each time they inject. If the aim were only to reduce the number of syringes disposed of unsafely, it would be acceptable simply to reduce the supply of syringes, or insist on one-to-one return. Perhaps the most important finding of this study is that despite there being much greater numbers of syringes disposed of in San Francisco – a positive outcome with regard to virus transmission, assuming that the number of injections was similar – the exchanges collected so many used syringes that the number of syringes disposed of unsafely was still lower than in Miami, and of those disposed of unsafely, many fewer were in public places.

Whilst this appears to be a very positive result, we cannot securely attribute all of the differences in syringe disposal to the presence of exchanges; whilst the researchers took into account differences in sex, age and other demographic characteristics among the injectors interviewed, other differences between the cities may not have been taken into account. The concern about the limitations of self-reported interview data is also legitimate; it is possible for example that injectors in San Francisco were reluctant to admit to disposing of syringes in public places when they knew that there were exchanges available, whereas in Miami, with fewer alternatives, this might not apply. There should be concerns about the validity of comparing data that was in many ways conducted differently in each city; the Miami study counted all four sides of each block not just one, used different measures to assess which were the most drug-affected areas, and used different sampling methods to select people for interviews. Importantly for the inspection data, we have no way of knowing if the areas inspected in San Francisco and Miami had similar levels or types of drug use. They were, by slightly different measures, each in the top quartile of drug-affected areas for each city, but this may conceal many differences including but not limited to the concentration of drug users in the areas, which drugs were being used and what proportion were injected, as well as other legal or policing differences between the cities. If for example, injecting in Miami was concentrated in a few particular areas but more dispersed in San Francisco, counting syringes found in only the most affected areas might unfairly make Miami look worse even if the total amount of syringes city-wide would have been similar. In particular in Miami, the syringes that the researchers found were very bunched, with large numbers found in just a few blocks, but none in most blocks. This means that the accuracy of the selection of areas deemed to be most drug-affected was critical to the results of this part of the research.

It is not clear why the researchers did not attempt to conduct the study in Miami using identical methods to the one in San Francisco, but clearly any further research on the subject ought to assess different cities or regions at the same times and using identical methods. It would also have been helpful to obtain data directly from the needle exchanges in San Francisco, to see whether the differences they observe between the numbers of syringes distributed and collected corroborates the findings from the interviews.

The negative impact of discarded syringes is not limited just to possible health risks to the community, but can also be upsetting, diminishing the quality of the environment. This aspect is discussed in this qualitative study, along with other issues around drug-related litter. In the UK as a whole, it is not even known Source: personal communication from Jamie Bridge of the National Needle Exchange Forum, 1 April 2014. how many needles and syringes are distributed, even less the number that are discarded, making it difficult to assess the true extent of this problem. There is more detailed information available for Scotland, where almost four million were distributed in 2011/12. Separate information reported to the BBC by local authorities in Scotland shows that there were just over 3,900 discarded needles and syringes found and reported to the authorities in the two years of 2012 and 2013, of which over 2,400 were in Glasgow. The response of the community to discarded syringes, and the negative impression formed of injecting drug users, can also lead to the closure of needle exchanges. This is just what happened in one Canadian city. In this case and perhaps ironically, the closure of the needle exchange actually lead to an increase in drug-related nuisance nearby.

Needle exchanges are legal throughout the UK, and the National Treatment Agency for Substance Misuse (now absorbed into Public Health England) was confident that there is effective needle exchange provision in every local area in England. Guidance from the National Institute for Health and Clinical Excellence recommends that local areas provide a range of services, and that all programmes should as a minimum: encourage people who inject drugs to use the services on offer, provide as many needles and syringes and other injecting equipment as someone needs, provide sharps bins and advice on how to dispose of equipment safely, provide advice on safer injecting and ways to get help to stop using drugs or switch to non-injecting methods. More specialist services should include advice and services to help them stop injecting and treatment of infections and other health problems, vaccinations and housing and benefits advice (or help to access to such services). It has also recently been made legal for needle exchanges to provide foil as well as injecting paraphernalia, to encourage injectors to move toward smoking drugs on foil as a far less harmful route of administration. For more analyses of the research basis around needle exchange, try this Findings search, or this search for research specific to needle exchanges, public nuisance and litter.

Thanks for their comments on this entry in draft to Jamie Bridge of the National Needle Exchange Forum. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 15 April 2014. First uploaded 19 March 2014

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

Markham W.A., Young R., Sweeting H. et al.
Social Science and Medicine: 2012, 75, p. 69–76.
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 Markham at wolfgang.markham@warwick.ac.uk. You could also try this alternative source.

Intriguing findings from Glasgow on what it is about a school which helps protect pupils from less socially accepted substance use: in this case, engaging schools with good teacher-pupil relationships but, unlike in England, not those which (given their pupils and areas) excel academically and in eliminating truancy. Connection is it seems the key.

Summary Pupil substance use varies between schools partly it is thought due to differences in school ethos or culture rather than (or as well as) health education lessons and interventions targeted at substance use. To investigate this, the featured analysis drew data from a Scottish study which sampled over 2000 pupils at 43 randomly selected secondary schools in the Glasgow area, and followed them up from 1994 when they were ending primary school (age 11) to their last year of compulsory schooling (age 15). For the featured study, two school performance indicators were calculated for each school: the proportion of pupils who achieved five good grades in exams at the end of compulsory schooling; and the truancy rate. Researchers calculated the degree to which on each measure schools exceeded or fell below the rate expected for schools with a similar pupil mix – indices of ‘added value’. These two indices closely co-varied, so could be combined in to a single added-value index.

As found in the West Midlands of England, it was expected that the more a school ‘added value’, the fewer of its pupils would currently smoke or regularly drink, or have ever used illegal drugs. The thinking was that schools which support learning and exert behaviour controls in line with pupils’ cultural expectations should achieve relatively good exam results and lower truancy rates. Pupils at these schools were also expected to have better impressions of the school’s ethos (a mix of their perceptions of the school environment, how involved and engaged they are with the school, and how they see teacher-pupil relationships) and as a result to have more fully absorbed the school’s anti-substance use values, reflected in lower than expected levels of substance use.

The hypothesised causal chain ran from supportive schools (reflected in added value) > better pupils perceptions of school ethos > anti-substance use values > less substance use. If this was indeed the mechanism, added value should be related to less substance use, but no longer related once the school’s impact on ethos perceptions had been taken in to account. To test this, substance use assessments at ages 13 and 15 were related to added value (calculated from official records) and to perceptions of school ethos as seen by pupils at ages 13 and 15. A battery of pupil, family and social background measures were taken in to account to try to exclude other influences.

Main findings

Generally the expected relationships were not confirmed. The reverse of what was anticipated, schools which added value in the form of better than expected exam and truancy records actually had higher proportions of pupils who smoked and (non-significantly) also more pupils who had tried illegal drugs and were drinking at age 13. The only ‘right’ way round relationship was between added value and non-significantly fewer drinkers at age 15.

On most measures schools which added value and were presumed more supportive did not have pupils who felt significantly and/or substantially more engaged and positive about their schools. Neither did these perceptions account for such relationships as there were between added value and substance use.

As expected, it was the case that the better a school’s ethos as seen by its pupils, the fewer were smokers at ages 13 and 15; drinking and experience of illegal drug use were also non-significantly less common in these schools. However, these relationships became non-significant (and in the case of drinking, reversed) when the analysis took account of how far each individual pupil’s perceptions were related to their substance use. The implication was that even in a school seen as engaging by pupils generally, individuals who did not share this perception were prone to use substances. Similarly, pupils in less engaging schools but who nevertheless felt engaged seemed protected from substance use.

The authors' conclusions

Unlike the featured study, previous UK and US studies have found that pupils at high value-added schools were less likely to use substances. With alternative explanations lacking, this consistency led to the conclusion that the relationship was probably causal, a conclusion cast in doubt by the findings of the featured study.

Instead, in the Glasgow area schools which attained unexpectedly good truancy and exam results did not tend also to excel in engaging pupils. In this context, possible explanations are that a minority of pupils may rebel against or feel alienated from schools which effectively support and control the pupil population as a whole. The result may be increased substance use among this minority, even though the bulk of pupils are relatively protected against substance use. Possibly too, schools in the Scottish context which achieve relatively good academic results do so by focusing on this to the detriment of caring for pupils and ensuring all pupils feel included in the life of the school.

In contrast to added value, the degree to which an individual pupil felt disengaged from school or reported poorer teacher-pupil relationships remained significant risk factors for substance use, even after all other influences had been taken in to account. These relationships were relatively strong in comparison to other substance use risk factors recorded by research. Some schools more universally engaged their pupils, and it was this which accounted for the relationship between overall school engagement and substance use.


Findings logo commentary The variance between findings in Scotland and elsewhere in the UK highlights the importance of context in prevention research. Varying contexts (even it seems within the United Kingdom) can mean what has a preventive impact in one area, does not in another. In the case of the Glasgow area, it seemed that typically schools did not achieve good exam and truancy results by ensuring their pupils felt exceptionally well cared for and engaged with the school, breaking the expected causal chain from added value to substance use. Schools in other areas with different methods and priorities may embody this causal chain, resulting in the findings elsewhere in the UK where added value was related to less substance use.

Though statistically non-significant, schools with a good overall ethos were as a whole much less likely to have pupils who engaged in the most deviant (to judge by the proportions of pupils engaging in these behaviours) forms of substance use – early (age 13) smoking and illicit drug use. This was the case even after each pupil’s individual engagement scores had been taken in to account. In other words, it seems possible that in this sample, schools which were good at including pupils also helped prevent even relatively alienated pupils departing from local substance use norms.

The featured study turns the focus from added value in the form of academic results and truancy prevention to the school’s culture as perceived by its pupils. Because these are all-pervasive, improvements in the social climate of schools might justify themselves on a multiplicity of grounds, including academic achievement and crime prevention as well as substance use prevention, especially given the patchy track record of preventive drug education. The evidence is strong that schools which develop supportive, engaging and inclusive cultures, and which offer opportunities to participate in school decision-making and extracurricular activities, create better outcomes across many domains, including non-normative substance use. As well as facilitating bonding with the school, such schools are likely to make it easier for pupils to seek and receive the support they need.

The lessons seem to be to attend to the basics through school management, training, pastoral and administrative procedures which foster and demonstrate a caring, cooperative and participative ethos and concern for pupils as individuals, then perhaps to seek to optimise these virtues through targeted interventions.

Studies have generally documented the impacts of normal school development processes rather than randomly allocating schools to develop better cultures. The observed relationships between culture and substance use could be artefacts rather than a result of good ethos exerting a restraining influence. For example, perhaps good schools attract families whose children are less at risk of deviant substance use, or both culture and substance use reflect some other factor, such as unmeasured quirks of the neighbourhood. Even if we accept the plausible explanation that engaging schools also prevent pupils disengaging from social norms in their substance use, doubts remain over whether an add-on intervention can ‘artifically’ turn unpromising schools in to engaging schools and thereby reduce substance use problems.

The featured study and its predecessors exemplify a trend to see the most promising ways to prevent substance use (or more accurately, substance use problem) as generic and usually early processes and interventions which affect the development of the child as a whole, rather than later interventions specific to substance use.

Last revised 14 February 2014. First uploaded 07 February 2014

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