Drug and Alcohol Findings home page. Opens new window Effectiveness Bank bulletin 15 July 2013

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


First two of these additions to the Effectiveness Bank are about unintended consequences of no-drinking laws – for underage drinkers and drivers and the victims of their drink-driving, and for street drinkers. Perhaps some of this harm could have been prevented if school-based prevention had focused on reducing harm rather than preventing substance use. Lastly, high buprenorphine doses help keep opiate-addicted patients in treatment – but in the 'recovery' era, is this what we want?

Driving to avoid minimum drinking age costs lives ...

Winners and losers from street drinking bans ...

More support for harm reduction education on drinking ...

Higher buprenorphine doses work better but individualisation is key ...

The fatal toll of driving to drink: the effect of minimum legal drinking age evasion on traffic fatalities.

Lovenheim M.F., Slemrod J.
Journal of Health Economics: 2010, 29, p. 62–77.
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 Lovenheim at mfl55@cornell.edu. You could also try this alternative source.

This meticulous analysis reveals that increasing the legal drinking age can cause traffic accident deaths if underage drinkers can drive to a nearby jurisdiction with a lower age limit to legally buy and drink alcohol, returning too intoxicated to drive safely. The message is that such limits need to be uniform to have the maximum beneficial impact.

Summary Introduction of the uniform 21 years minimum legal drinking age in the United States has generated much controversy and research over its impact on traffic fatalities among teenagers. An important but unexamined dimension in this debate is the degree to which cross-state differences in the age limit rather than the national level induce teenage drunk driving, the other side of which is the extent to which imposing a uniform national age has reduced deaths not just by raising the age, but also by equalising drinking ages across most localities in the country.

This issue arises because the presence of nearby lower-age localities might induce teenagers to avoid local restrictions by crossing a border to buy alcohol. Driving to get the alcohol and, more importantly, driving back often under the influence, makes alcohol-related accidents more likely. Depending on its extent, cross-border evasion of the local age limit can substantially undermine the main objective of state alcohol policies – preventing alcohol-related accidents, especially among young drivers.

To evaluate the effect of state polices on minimum legal drinking ages, from 1977 to 2002 for each US county the featured analysis mapped the distance to the nearest place where an 18, 19, or 20-year-old could legally buy alcohol. This data was then related to records of the number of people in those counties who died in a traffic accident. Accidents among drivers over 25 also vary with the minimum drinking age, so the approach taken was to compute the likelihood that an 18, 19 or 20-year-old driver is involved in a fatal accident relative to older drivers, then to relate this to changes in the minimum age and distances to lower age jurisdictions. The intention is to eliminate factors common to all drivers and to isolate the impact of those impinging only on young drivers, the main one presumed to be the inducement to drive to a place where they can legally buy alcohol. To focus on alcohol-related causes, the analysis concerned only accidents occurring at night.

Main findings

All else being equal, the analysis found that the presence of a nearby jurisdiction with a lower drinking age increases the number of youth driving fatalities. Specifically, in counties within 25 miles of a lower-age jurisdiction, raising the legal drinking age actually increases the chances that an 18 or 19-year-old (but not a 20-year-old) driver will be involved in a fatal accident, relative to drivers over 25 years old. In contrast, in counties over 25 miles from a lower-age jurisdiction, raising the drinking age reduces the risk of a teenage driver being involved in a fatal accident.

Based on these relationships it is possible to estimate how much of the reduction in teen-involved traffic fatalities from 1977–1988 to 2002 was due to due to states equalising the minimum age rather than due to states raising the age. From the late 1970s and early 1980s, about 23% of the decline in traffic fatalities involving an 18-year-old driver was due to equalisation, and for 19-year-olds about 16%. These estimates imply that previous studies which ignored evasion effects significantly underestimated the reduction in teenage drink-driving and related deaths which can be achieved when teenagers' access to alcohol is completely restricted, not just in the state where they live, but also in neighbouring areas.

The authors' conclusions

While determining the full costs and benefits of a given minimum legal drinking age is outside of the scope of the analysis, the results imply that unequal drinking age restrictions across states in the United States results in significant loss of life. The effect of changes in the age limit depends substantially on the fraction of a state's population who need not travel far to reach a state with a lower age limit. Other things being equal, these results argue for setting a standard minimum legal drinking age across all states.

Cross border evasion of regulations and pricing/tax policies is common, but being able to drink legally across a border has special implications, because the act of drinking and then driving home drunk can be dangerous, even fatal, both to the cross-border consumers and to other drivers and pedestrians.

Thanks for their comments on this entry in draft to featured study author Michael Lovenheim of Cornell University at Ithaca in the USA. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 11 July 2013. First uploaded 10 July 2013

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

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

STUDY 2011 Achieving positive change in the drinking culture of Wales

REVIEW 2010 The effectiveness of tax policy interventions for reducing excessive alcohol consumption and related harms

STUDY 2010 Social host liability for minors and underage drunk-driving accidents

REVIEW 2010 Polarized drinking patterns and alcohol deregulation. Trends in alcohol consumption, harms and policy: United Kingdom 1990–2010

STUDY 2008 Independent review of the effects of alcohol pricing and promotion

REVIEW 2010 Effectiveness of policies maintaining or restricting days of alcohol sales on excessive alcohol consumption and related harms

REVIEW 2010 Effectiveness of policies restricting hours of alcohol sales in preventing excessive alcohol consumption and related harms

STUDY 2015 Four nations: How evidence-based are alcohol policies and programmes across the UK?

REVIEW 2010 Effects of alcohol tax and price policies on morbidity and mortality: a systematic review

DOCUMENT 2012 The government's alcohol strategy

Prohibiting public drinking in urban public spaces: a review of the evidence.

Pennay A., Room R.
Drugs: Education, Prevention and Policy: 2012, 19(2), p. 91–101.
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 Pennay at amy.pennay@turningpoint.org.au.

So-called 'alcohol-free zones' have proliferated across the UK, preventing an individual drinking in public if police believe their drinking is causing a problem. This review of such measures finds they do reassure communities, but at the expense of further marginalising street drinkers.

Summary Policies which restrict where alcohol can be consumed are widely implemented, but not often discussed and little studied. The featured review was concerned with 'street drinking bans' – as distinct from bans on public drinking across entire communities and bans in specific places such as car parks, beaches, shopping centres, churches or schools. The aim was to find and assess studies which evaluated their impacts, particularly on alcohol-related harm and on the community.

Street drinking most often comes to attention when it involves marginalised populations such as homeless people and indigenous or other visible minority groups. Often they benefit on-premise licensed premises, because they restrict opportunities to consume alcohol bought in off-licenses. The advent of 'footpath trading' – restaurants and pubs selling alcohol to drink on designated pavement areas – starkly poses the contrasting treatment of drinkers, often of different social classes: street drinkers on one side of the street, outside the law; those on the other side, within the pub or restaurant's permitted use of public space, within the law.

One reason for the bans is that many citizens fear street drinkers. A survey before the first street drinking ban enacted in the UK in Coventry in 1988 found that thought that though in the past year just 9% of respondents had been insulted or bothered by strangers who had been drinking, up to 60% feared such incidents, and over 60% said they avoided areas where street drinkers congregated. Two-thirds felt "unruly groups of young people" were a problem and over half felt the same of people drinking in public. An analysis of attitudes towards street drinking in Lancaster, England, reported that community members constructed street drinking as disrupting the socio-spatial order, and thus a morally offensive activity. In this context, street drinking bans can serve to bolster perceptions of safety and restore perceptions of moral order.

Despite recent widespread implementation of street drinking laws in urban areas, research in terms of effectiveness or community impact is limited. The featured review found no academic literature, so largely drew on research published as reports, of which 16 were identified across 13 locations. These included two reports from the UK (Lancaster and Winchester); the remainder were from Australia and New Zealand. A major obstacle to understanding the effectiveness and impacts of street drinking bans was the lack of methodological rigour in all these evaluations.

Main findings

The most common theme identified across the evaluations (in at least seven of the 13 locations) was that street drinking bans resulted in negative impacts on marginalised groups, particularly homeless and indigenous people, and the young. This theme was identified in both UK evaluations and all but one from Australia. Impacts included these drinkers being unable to congregate in the same space with the same people they had been drinking with, aggravating their social marginalisation; being over-represented among those fined, aggravating economic marginalisation; and receiving less medical, health and welfare services because community health workers were unable to locate them, aggravating health-related marginalisation.

Unsurprisingly, displacement was also a common theme across the evaluations, identified at seven of the 13 locations. In at least three cases, drinkers moved to more covert and less safe places to drink. Displacement was particularly common in Australia, but was also noted in the UK and New Zealand.

In at least six of the locations community members' perceptions of safety improved following imposition a street drinking ban, though this was not the case in three of the evaluations, where poor perceptions of safety remained. Improvements were particularly common in the UK and New Zealand (the latter related to increased police presence rather than fewer drinkers) but not in Australia.

Five of the evaluations recorded concerns about police under-enforcing the law and targeting certain groups, particularly in Australia and New Zealand.

In one location each in the UK and Australia and two in New Zealand, residents, traders and police reported environmental improvements after implementation of a street drinking ban, notably less litter and broken glass. At two locations including one in the UK, community members and traders praised improvements in the 'look' and 'feel' of either the town square or a busy street due to the absence of a group of street drinkers who had previously gathered there.

Across the evaluations interviews revealed a high level of support for street drinking bans, particularly among police and traders. In Winchester, 10 of 14 service providers interviewed supported the law from a treatment and service perspective. In Lancaster and in another non-UK evaluation there was a moderate to positive degree of community support for the laws, but around a quarter of community members opposed them. In general, supporters cited increased feelings of safety, reduced litter and other amenity problems, and being able to use space previously occupied by day-time drinkers. Critics wanted to be able to drink alcohol in public themselves, were concerned about the negative impacts on themselves and on marginalised groups, or felt the law violated human rights.

Findings were mixed on whether there was a reduction in the visibility of street drinking following implementation of a street drinking ban. Five evaluations documented a noticeable reduction in visibility, but in another five (including Winchester) there was no impact.

Some reports noted a reduction in crime following a street drinking ban, but generally this could not be causally attributed to the ban. In three evaluations, alcohol-related crime increased following a street drinking ban.

Awareness of street drinking laws was mixed, with up to 60% of survey respondents in some communities either not knowing the law existed or being confused about its provisions, such as which areas were included and during which hours.

The authors' conclusions

None of the 16 evaluations of urban street drinking bans had been translated into a peer-review publication, a surprising absence of an academic dialogue on their impacts. All 16 lacked methodological rigour, making it difficult to understand whether the bans had been effective or not. It was also unclear how 'effectiveness' was and should be measured; none of the evaluations prioritised an outcome or outcomes against which success could be measured. Like any other public measure that intrudes on individual autonomy, alcohol policies should be formulated on clear ethical principles and with solid evidence concerning effects and side-effects. But street drinking bans have proliferated across urban areas despite the lack of an evidence base.

The most common themes were that street drinking bans result in negative impacts on marginalised groups, often result in displacement, and often improve perceptions of safety among the community. Less common themes were concerns about police enforcement and consistency, improvement in the local environment, and variation between stakeholder groups in support of street drinking bans, ranging from strong support from police, traders and older people, through equivocal support from general community members, to disapproval from young and indigenous people. There was little or no evidence that street drinking bans reduced congregations of drinkers, reduced alcohol-related crime or harm, or were understood and adhered to by the community.

This range of impacts should be carefully considered by local governments when making decisions about such bans. Street drinking laws are likely to impact marginalised groups who prefer to drink outside or have limited alternatives. On the other hand, bans are in the interest of community members who feel unsafe around groups of drinkers, as well as police and traders who value street 'cleanliness' and preventing public drunkenness. Decision-makers might also consider the inequity of allowing cafes, restaurants, bars and hotels to obtain 'footpath' trading licenses, meaning people who can afford to drink in licensed venues are allowed to drink on the street, while others are not.

Findings logo commentary The featured review commented that none of the evaluations prioritised an outcome, but it is clear that in the UK the primary purpose of 'alcohol-free zones' is to address nuisance and annoyance to other people in the area arising from public drinking. On this count the limited evidence the review was able to uncover suggests that generally, and in the UK in particular, they achieve this objective, but often at the cost of further marginalising the drinkers concerned.

Designated public place order sign By November 2010 820 areas in England and Wales had been made subject to designated public place orders. Home Office guidance explains that the law underpinning these enables local authorities to designate places where police have the discretion to require an individual to stop drinking. It also stresses that "this power is to be used ... for addressing nuisance or annoyance" and that therefore "it is not appropriate to challenge an individual consuming alcohol where that individual is not causing a problem". Orders should be imposed only "in areas that have experienced alcohol-related disorder or nuisance". Drinking as such is not an offence in these areas but it is an offence to continue to drink without reasonable excuse if directed to stop by a police officer. These are not then alcohol-free zones, but are commonly signed as such illustration.

Local byelaws can be and have been used to create similar zones. In Scotland local authorities can impose byelaws to prohibit drinking in designated public places under provisions contained in the Local Government (Scotland) Act 1973, subject to confirmation by the national government. According to the Scottish government, these powers are meant to address the fact that "public drinking can often be a nuisance to local communities and can greatly hamper the quality of life for residents in a particular area". An example was the decision in Edinburgh in 2010 to designate two squares 'no drinking of alcohol' zones. Over 480 towns and villages across Scotland, together with built up areas in Glasgow and Edinburgh, have such byelaws.

An alternative or complementary approach to street-drinking bans is to set up day centres where street drinkers can congregate and continue to drink, but not on the streets. Such centres will attract only a sub-section of street drinkers, but for these they can be valuable and also reduce public nuisance.

Last revised 05 July 2013. First uploaded 01 July 2013

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

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

STUDY 2014 Model-based appraisal of minimum unit pricing for alcohol in Wales

STUDY 2011 Achieving positive change in the drinking culture of Wales

STUDY 2013 An evaluation of the implementation of, and compliance with, the objectives of the Licensing (Scotland) Act 2005: final report

STUDY 2011 An evaluation of the implementation of the objectives of the Licensing (Scotland) Act 2005; first interim report summary

DOCUMENT 2016 Modern Crime Prevention Strategy

DOCUMENT 2012 The government's alcohol strategy

REVIEW 2010 Drugs, crime and public health: the political economy of drug policy

STUDY 2010 The impact of a lockout policy on levels of alcohol-related incidents in and around licensed premises

STUDY 2008 Internationally proven community alcohol crime and harm reduction programmes feasible in Britain

HOT TOPIC 2015 Controlling alcohol-related nuisance and disorder

Alcohol prevention: What can be expected of a harm reduction focused school drug education programme?

Midford R., Cahill H., Ramsden R. et al.
Drugs: Education, Prevention and Policy: 2012, 19(2), p. 102–110.
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 Midford at richard.midford@cdu.edu.au.

In Australia, alcohol outcomes from a secondary school harm reduction curriculum covering legal and illegal drugs strengthened the case that such education can not only curb harms, but also reduce consumption. Results suggest this approach might offer a more fruitful focus for education about commonly used substances than simply promoting non-use.

Summary The featured report documented post-programme alcohol-related outcomes from a small study evaluating a harm reduction model of drug, alcohol and tobacco education in Australian secondary schools. Three schools were allocated to the tested programme and a fourth to act as a control A group of people, households, organisations, communities or other units who do not participate in the intervention(s) being evaluated. Instead, they receive no intervention or none relevant to the outcomes being assessed, carry on as usual, or receive an alternative intervention (for the latter the term comparison group may be preferable). Outcome measures taken from the controls form the benchmark against which changes in the intervention group(s) are compared to determine whether the intervention had an impact and whether this is statistically significant. Comparability between control and intervention groups is essential. Normally this is best achieved by randomly allocating research participants to the different groups. Alternatives include sequentially selecting participants for one then the other group(s), or deliberately selecting similar set of participants for each group. school which carried on with normal lessons. All schools had pupil populations within the average range of socioeconomic status.

Of 930 year-eight pupils (typically 13 years old) in the schools, 521 completed a baseline assessment after approval had been obtained from the pupils and their parents. Later that school year the first set of 12 harm reduction lessons was implemented by the schools' own teachers, after which pupils completed a follow-up assessment. Another ten lessons were delivered the following year after which 318 pupils completed the final follow-up, typically when they were aged 14–15 years. Programme teachers were trained for two days in each year of the programme.

The tested curriculum incorporated learning strategies which aimed to: enhance knowledge; enhance negotiation skills; involve participants in rehearsing problem-solving and problem-prevention strategies; and engage them in deconstructing social pressures and perceived norms about levels of drug use. The curriculum was also informed by research which has identified social competence, problem-solving, autonomy and a sense of purpose as key attributes of resilient young people, and which has highlighted the importance of interactive and applied learning strategies in social and emotional learning.

Main findings

At issue was whether compared to the control school, pupils in schools which implemented the harm reduction lessons improved more (or deteriorated less) in respect of their alcohol-related behaviour, attitudes and knowledge between the baseline and the final assessments. Knowledge scores in relation to alcohol, tobacco, cannabis and other illicit drugs improved by 33% among programme pupils but only 18% in the control schools, a statistically significant advantage for the programme schools. Similarly there was a statistically significant advantage in respect of changes in the frequency of talking to parents about alcohol, which increased by 46% in the programme schools but fell slightly in control schools. The great majority of programme pupils recalled receiving more than one lesson on alcohol, but only a third of control pupils. However, the already highly responsible attitudes to drinking in both programme and control schools changed little and no more in the programme schools.

The proportion of pupils who had drank at least one full drink increased by slightly less in the programme schools (from 16% to 33% versus 20% to 43%), but this difference was not statistically significant. Neither was there any significant difference in the rise in the proportions who had drunk at least 50g or just over 6 UK units at one sitting. However, estimated total yearly consumption increased little in programme schools (from 148g to 205g) but rose significantly more steeply in the control school (from 79g to 308g). Similarly with the increase in the proportions who had drank in order to get drunk and in the number of times pupils had experienced alcohol-related social or health harms; average harm scores increased from 1.6 to 3.6 in programme schools but from about 1 to 5.2 in the control school.

The authors' conclusions

The programme is most appropriately evaluated against its harm reduction objectives. On average it curbed the age-related increase in total alcohol consumption but not the increase in the proportion who risked harm by drinking heavily on a single occasion. The reason for this seemed to be that the curriculum exerted its greatest impact on pupils who usually drank in a low-risk manner at the start of the programme: their consumption increased by 131%, whereas the consumption of the low-risk control drinkers increased by 302%. In contrast, the programme did not persuade pupils who had already drunk heavily on a single occasion to curb their consumption any more effectively than usual lessons. Relative to the control school, the programme did however reduce drinking with a view to getting drunk and the average number of alcohol-related harms experienced by the pupils.

Judged instead against traditional abstinence objectives, the programme would not have been considered a success since it did not curb the increase in the proportion of pupils who drank.

The programme was also better at enhancing knowledge and encouraging pupils to talk to their parents about drinking, but did not lead to relatively more responsible attitudes to drinking.

These results however derived from a few schools and relatively few pupils, and many pupils did not join the study. Nevertheless the findings are consistent with studies that have shown school drug education which focuses on harm reduction can reduce consumption, risk and harm. The study also suggested that this can be achieved with a curriculum that does not focus solely on alcohol, even when it does not deter pupils from starting to drink. A curriculum covering all drugs may be easier for schools to find the time for than several focusing on different substances.

Findings logo commentary The curriculum tested in the featured study was based in part on the Australian alcohol harm reduction curriculum SHAHRP. Like the featured curriculum, in both Australia and Northern Ireland SHAHRP curbed the growth in alcohol-related problems and also meant pupils drank less. These results further strengthen the promise of harm reduction education on drinking noted by a research review associated with guidance on alcohol education from the National Institute for Health and Clinical Excellence issued in 2007. For commonly used substances like alcohol in Australia and in the UK, harm reduction may offer drug education a more realistic and culturally appropriate target for its limited classroom time and one which now has some solid research support. Such issues were addressed in the NICE guidance, which stressed that education should be adapted to its cultural context. For the UK the most salient point was that "alcohol use is considered normal for a large proportion of the population [and] a 'harm reduction' approach is favoured for young people".

One possibly significant finding in the featured study is the increase in the times pupils spoke to their parents about alcohol after the harm reduction lessons. An abstinence-oriented approach would have posed these 14–15-year-olds the choice of hiding their drinking (and even their interest in drinking) or risk being seen to have contravened the no-drinking rule. Harm reduction opens up opportunities for discussion which admit to drinking, making it possible to enrol parents in helping such drinking as does occur, occur more safely.

The same study has produced similar results in respect of smoking. Compared to pupils in the control school, pupils in the three schools which implemented the harm reduction curriculum were no less likely to take up smoking, but those who did smoked fewer cigarettes and experienced fewer associated harms. Over the previous 12 months, smokers in the harm reduction schools had smoked 37% fewer cigarettes at the final follow-up than they had at the start of the study, while smokers in the control school had smoked 268 times more. Corresponding figures for numbers of harms experienced were 28% fewer versus seven times more.

In the absence of random allocation of schools, it remains possible that the results of the featured study were due to differences between programme and control schools and pupils. Against this is the coherence in the findings suggestive of the intended harm reduction impact. Another major limitation is that barely more than half the pupils in the schools joined the study and only a third could be followed up, leaving a sample presumably characterised by parents willing to have their children receive special education on drinking and drug use, also willing to have them repeatedly questioned about substance use in the context of a study, and whose children tended to be available for and willing to be followed up. How the programme would have fared among the other two thirds of pupils is unknown. Finally, at this stage we do not know what happened in respect of the other substances covered by the curriculum.

For more on harm reduction education and on the UK policy and practice context see the most recent Findings analysis of the SHAHRP curriculum.

Thanks for their comments on this entry in draft to research author Richard Midford of Charles Darwin University in Australia and to Blaine Stothard, Independent Consultant in Health Education based in London, England. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 09 July 2013. First uploaded 05 July 2013

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

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

STUDY 2015 Alcohol prevention and school students: findings from an Australian 2-year trial of integrated harm minimization school drug education

STUDY 2014 The differential impact of a classroom-based, alcohol harm reduction intervention, on adolescents with different alcohol use experiences: a multi-level growth modelling analysis

STUDY 2012 Reducing the harm from adolescent alcohol consumption: results from an adapted version of SHAHRP in Northern Ireland

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

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

STUDY 2005 School programme successfully revised to focus more on harm reduction

STUDY 2006 Harm reduction education successfully extended to illegal drugs

STUDY 2004 School lessons reduce alcohol-related harm

STUDY 2000 Everyone is NOT doing it - important prevention message for early teens

STUDY 2001 Initial outcomes from Australian alcohol harm reduction curriculum for secondary schools

Effect of buprenorphine dose on treatment outcome.

Fareed A., Vayalapalli S., Casarella J. et al.
Journal of Addictive Diseases: 2012, 31(1), p. 8–18.
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 Fareed at ayman.fareed@va.gov. You could also try this alternative source.

How much buprenorphine does it take to keep patients in treatment and suppress illicit use of heroin or other opiate-type drugs? This review concludes that on average higher is better than lower, but that individualising dose and a preparedness to go high if needed are the keys to effective treatment.

Summary As an alternative primarily to methadone, buprenorphine has many qualities which make it an effective treatment for opioid dependence. There is less of a build up of tolerance to the drug, it is safer in overdose, and it may help relieve negative mood. Induction is easy, even for physicians with limited experience with opioid maintenance treatment. Several studies have found buprenorphine a safe and effective medication for primary care-based treatment.

Most of the initial studies of buprenorphine reported that lower doses (8mg or less per day) were not as effective as higher doses (8–16mg) in suppressing illicit opiate use and retaining patients in treatment. Such findings led to studies of yet higher doses which have found 16–32mg safe and more effective than lower doses in reducing illicit use and craving for opioids.

Doses greater than 24 to 32mg per day do not directly increase the risk of overdose death due to respiratory depression but may increase risk when other depressant drugs are taken at the same time. The aim is to achieve the best treatment outcome without jeopardising safety.

As a contribution to this objective, the featured review looked for studies which would enable a comparison between retention and substance use outcomes among patients prescribed less than 16mg When doses in a study were flexible, the average dose was used to classify the study as higher or lower dose, or if there was a range, the upper limit. per day versus those prescribed 16mg or more. The search was restricted to randomised controlled trials of buprenorphine maintenance treatment, the results of which were published in English-language articles between 1960 and 2010. Fifty such articles were found of which the results reported in 21 could be included in a synthesis of the findings. These studies were divided in to those which prescribed 16mg or more of buprenorphine per day versus those which prescribed less than 16mg per day.

Main findings

The raw figures were that in the higher dose studies 69% of patients completed treatment compared to 51% in lower dose studies. This difference remained statistically significant when other influences on retention were taken in to account. Among these was a negative relationship between retention and the proportion of urine tests the study found positive for illicit opioids.

In higher dose studies patients were less likely to test positive for illegal opioids. Positive tests were also less likely in studies which retained more patients in treatment, but more likely in studies with relatively high rates of cocaine-positive tests. When all these influences were considered together, dose was no longer related to opioid-positive urine tests but the other associations remained statistically significant.

The authors' conclusions

This analysis provides strong evidence based on 21 randomised trials that doses of 16mg or more a day can improve retention in buprenorphine maintenance treatment. Retention is in turn associated with less frequent use of illicit opiate-type drugs. These results suggest that dose may play an important role in improving treatment outcomes for buprenorphine maintenance patients. Clinicians should consider prescribing 16mg or more per day to patients who do not do well on lower doses, especially if they express an intense craving for opioids. Some may be reluctant to do so for fear that certain patients will 'divert' some of the dose to the illicit market. In these cases they could first order a urine test to confirm whether the patient is taking their buprenorphine. The cost of this test and the cost of the higher doses may be barriers to high-dose provision for some patients and some treatment providers, but not prescribing a high enough dose could increase the risks of relapse and of dropping out of treatment, increasing social costs overall.

The results of the review should however be placed in the context of the caseloads being prescribed to. Most earlier studies involved patients addicted to illegally obtained heroin, but modern caseloads include patients addicted to opioids prescribed in the course of legitimate medical practice. For the latter, lower doses may be as effective as higher doses among the former. In other words, what is an ineffectively low dose for one patient may not be for another. Not just the final dose but also the speed of dose adjustment during buprenorphine induction needs to be individualised to improve treatment outcome without jeopardising safety. Because of this the results of different studies may reflect not just the final stabilisation dose, but also how quickly this was reached.

Findings logo commentary The pattern of the findings suggests that higher dose suppresses illegal use of opiate-type drugs largely because it improves retention in treatment. However, the article does not specify whether missed tests were treated as if they had indicated illegal use. If they were, more missed tests due to shorter retention on lower doses would automatically tend to worsen the urinalysis record, even if tests actually taken by patients while they remained in treatment indicated that illegal use was no more likely.

Rather than comparing high- and low-dose patients in the same studies, the featured analysis compared results from studies which prescribed high doses with those which prescribed low doses. As the authors comment, this confounds differences due to dose with differences due to other features of the studies. An alternative approach is not to compare absolute levels of retention and illicit substance use at different doses, but the degree to which these better a placebo. This was the approach taken in the relevant review for the Cochrane collaboration, which found that across all relevant studies, only doses of 16mg or more a day convincingly improved suppression of heroin use relative to a placebo. In this analysis it seems missed tests were simply ignored rather than treated as if they had indicated illegal use.

'Completion' in the studies included in the featured analysis meant staying in treatment for at most just under a year and usually six months or less. Up to this point it is generally accepted that patients are still consolidating the lifestyle changes made possible by maintenance. If high doses extend retention well beyond this point, the question arises more sharply whether on balance this is a good thing because it prevents relapse to regular illegal use of opiate-type drugs and stabilises lives, or a bad thing because it keeps patients dependent on their legal supplies instead of 'moving on' and out of treatment, even if for some this will mean life-threatening relapse. See this Findings analysis for more on this issue and how an expert UK group sought to reconcile the tensions.

UK guidance says 12–16mg of buprenorphine daily is sufficient for most patients, but acknowledges that some need up to 32mg. Based on limited research, World Health Organization guidelines say higher doses are likely to result in better retention and less heroin use than lower doses, with minimal adverse consequences other than cost. If patients are continuing to use illicit opioids, consideration should, the WHO experts said, be given to increasing doses up to 32mg daily.

Individualisation of dose is essential as the effective dose varies widely. For example, in one Australian study which adjusted the dose to how well patients responded, some were adequately maintained on 2mg a day, while others required 32mg. A similar range was found in a US study which adjusted dose in response to patients' scores on a systematic assessment incorporating their illicit opiate use, clinic attendance, withdrawal symptoms and signs of toxicity. Best practice is not necessarily high-dose buprenorphine, rather titrating dose to the lowest which prevents cravings and use on top, maximising efforts to help patients change their lifestyles for the better.

Policies which go further and encourage across-the-board dose restrictions undermine the effectiveness of buprenorphine maintenance as they do of methadone maintenance. These policies may reflect a lingering aversion to maintenance prescribing, and associated prioritisation of getting patients off opioids, or they may reflect cost considerations. Patients too sometimes resist the doses they actually need to avoid illegal use because of an ambition to cease opioid use altogether or because of feared side effects. When these desires lead relapse-prone patients to take low doses, the result is likely to be continued risk from illicit opiate use and early drop-out from treatment. In respect of buprenorphine, the concerns which motivate low doses are less salient because high doses do not correspondingly increase the risk of overdose and because the medication is relatively easy to withdraw from. After being stabilised on adequate doses, patients who want to attempt treatment termination do not face a hurdle has high as that posed by withdrawal from high-dose methadone.

Thanks for their comments on this entry in draft to Duncan Raistrick of the Leeds Addiction Unit in England. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 12 July 2013. First uploaded 08 July 2013

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

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

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

REVIEW 2014 Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence

REVIEW 2008 International review and UK guidance weigh merits of buprenorphine versus methadone maintenance

REVIEW 2012 The effectiveness of opioid maintenance treatment in prison settings: a systematic review

DOCUMENT 2013 Community loses from failure to offer maintenance prescribing in prisons

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

STUDY 2010 Risk of death during and after opiate substitution treatment in primary care: prospective observational study in UK

STUDY 2010 Unobserved versus observed office buprenorphine/naloxone induction: a pilot randomized clinical trial

REVIEW 2013 Maintenance agonist treatments for opiate dependent pregnant women

STUDY 2010 Home- versus office-based buprenorphine inductions for opioid-dependent patients

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