Drug and Alcohol Findings home page. Opens new window Effectiveness Bank bulletin 17 January 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.


Research for straitened times

Three additions to the Effectiveness Bank question whether in these straitened times we really need to do as much as we've been used to, while the fourth evaluates a way reduce Britain's partly alcohol/drug fuelled welfare and crime costs. First of the three is a way to screen for drink problems which is surely as brief as it gets – a single question. Then a very brief (half an hour) way to help repeat drink drivers, and finally a Scottish trial whose results challenge the need to continue to make methadone patients take medication under supervision. Fourth study evaluates an extended and intensive intervention to tackle what the UK sees as a huge problem – its unemployed, lone-parent and in childbearing, crime and welfare spending terms, most prolific families, a third each of whom have drink and drugs on their extensive problem menus.

Single question identifies most problem drinkers ...

Half-hour of advice may cut drinking in repeat drink-driving offenders ...

Scottish randomised trial tests need to supervise methadone ...

Troubled families improve after family intervention ...

A comparison of two single-item screeners for hazardous drinking and alcohol use disorder.

Dawson D.A., Pulay A.J., Grant B.F.
Alcoholism, Clinical and Experimental Research: 2010, 34(2), p. 364–374.
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 Dawson at ddawson@mail.nih.gov. You could also try this alternative source.

Can you get away with asking just a single question to identify risky drinkers and even dependent drinkers? When the thresholds are suitably adjusted, asking either about frequency of heavy drinking or maximum single-occasion consumption worked remarkably well in the US general population.

Summary Financial pressure on primary care providers to minimise the length of appointments and obtain necessary medical information as economically as possible has increased interest in ways to screen patients for alcohol problems which consist of a single question. Generally this question has been about how often or whether in a given period the patient has consumed over a certain amount of alcohol, in the USA generally five standard drinks for men and four for women, equivalent to about nine and seven UK units respectively. Depending on the precise criteria, these can identify a large proportion (around 8 in 10) of people which more extended tests show have alcohol use disorders (abuse or dependence) or who drink at hazardous levels, while also correctly identifying most who do not – measures known respectively as sensitivity The proportion of people with a condition who have a positive test result. and specificity. The proportion of people without a condition who have a negative test result.

An alternative approach tried to date only once is not to how often someone as drunk heavily, but how much as a maximum they drank in standard drinks or some other unit of alcohol, and then to find a quantity which most acceptably identifies problem drinkers while not falsely identifying non-problem drinkers.

In both cases it is important to test whether the performance of the tests is as good for men as for women and whether criteria need to be adjusted. Similarly for different age groups, especially since young people often 'binge' drink yet do not meet criteria for alcohol use disorder, while older people may not and yet still be problem drinkers.

This study tested these two approaches as screening methods in a representative sample of 43,093 US adults. Its two questions were:
Frequency "During the last 12 months, about how often did you drink [five for men, four for women] or more drinks in a single day?"
Maximum "During the last 12 months, what was the largest number of drinks that you drank in a single day?"

The questions were embedded in a survey which included other questions about drinking in the last 12 months, plus a 33-item interview which enabled a diagnosis of alcohol dependence A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
• Tolerance, as defined by either of the following:
a need for markedly increased amounts of the substance to achieve Intoxication or desired effect;
markedly diminished effect with continued use of the same amount of the substance.
• Withdrawal, as manifested by either of the following:
the characteristic withdrawal syndrome for the substance;
the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms.
• The substance is often taken in larger amounts or over a longer period than was intended.
• There is a persistent desire or unsuccessful efforts to cut down or control substance use.
• A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.
• Important social, occupational, or recreational activities are given up or reduced because of substance use.
• The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
or abuse A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:
• Recurrent substance use resulting in a failure to fulfil major role obligations at work, school, or home (eg, repeated absences or poor work performance related to substance use; substance-related absences, suspensions or expulsions from school; neglect of children or household).
• Recurrent substance use in situations in which it is physically hazardous (eg, driving an automobile or operating a machine when impaired by substance use).
• Recurrent substance-related legal problems (eg, arrests for substance-related disorderly conduct).
• Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (eg, arguments with spouse about consequences of intoxication, physical fights).

The study also diagnosed abuse when at least three of the seven dependence criteria were present.
according to US criteria. Also identified was past-year hazardous drinking was defined as in excess Men were positive for hazardous drinking if (i) their past-year average daily volume of alcohol intake exceeded 1.2 fluid ounces, ie, two US standard drinks or 3.5 UK units; (ii) they consumed five or more drinks (nearly nine UK units) at least once in the past year; or (iii) their frequency of drinking this much was unknown but their usual or maximum quantity of drinks was five or more. For women the criteria were the same except that the amounts were 0.6 ounces and four or more drinks. of national US low-risk drinking guidelines. At issue was how well at various thresholds the single questions identified any problem drinking (hazardous, abuse or dependence), alcohol use disorder (abuse or dependence), or specifically dependence. Optimal thresholds were defined as those resulting in the best combination of sensitivity (identifying problem drinkers) and specificity (identifying non-problem drinkers).

Main findings

Across the entire sample, the best frequency thresholds for dependence were heavy drinking at least three times (but seven for men and once for women) a year, and for any abuse/dependence disorder or any problem drinking, at least once a year (but three times for disorders among men). For the maximum drinks question, the best thresholds were for dependence at least five drinks Nearly nine UK units. (but seven for men and four for women), and for any disorder or any problem drinking, at least four drinks Seven UK units. (but five for men). In all but one case these thresholds correctly identified over 80% of the relevant category of drinkers and over 80% of people not in this category.

At these thresholds, in respect of dependence the two questions performed equally well. That is, there were no statistically significant differences in either sensitivity or specificity. But the maximum drinks question identified more of the disorder/problem drinkers (sensitivity) while the frequency question was better at correctly identifying people without these drinking problems and not falsely identifying them as disorder/problem drinkers (specificity).

Optimal thresholds varied for different population subgroups. Variations for men and women are displayed in the previous paragraph. As age increased (the categories were 18 to 34, 35 to 64, and 65 and older), in respect of both questions and all three categories of problem drinkers, optimal thresholds got lower. Other than in the most elderly, given optimal thresholds, both questions performed well. Among the elderly the frequency question did not at whatever threshold identify an acceptable proportion (in each case below 80%) of the three categories of drinkers. In contrast, on this criterion the maximum drinks question performed well, as it did (though not as well as the frequency question) in correctly identifying elderly people without these drinking problems. Optimal thresholds were generally higher for native Americans, white people and Hispanics, than for Asians and black people. They were also slightly higher among people who had drunk at all in the past year or visited an emergency department, due to higher thresholds correctly identifying more non-problem drinkers.

The authors' conclusions

The study provided clear support for single-question screening instruments for problem drinking, and demonstrated that the maximum drinks question is a worthy alternative to the frequency or recency of heavy drinking. Both performed very well in predicting problem drinking.

Rather than favouring one type of screening question over the other, the results highlight the value of an arsenal of screening tools which contains an alternative single-item screening test, and the importance of using one which yields a wide range of responses. This not only facilitates the selection of different screening thresholds for different subgroups, but also gives room for flexibility in the relative importance assigned to sensitivity and specificity in the selection of optimal thresholds. This decision should reflect the expected prevalence of the drinking problems being identified and the costs associated with a positive screen in terms of further action such as brief interventions, counselling or treatment.

Optimal screening thresholds varied substantially across population subgroups and should be matched to these subgroups to maximise screening performance. These results provided strong support for the common gender-specific definitions of risky drinking. Similarly, they also support a lower risk drinking threshold for people aged 65 and older and for black people, the latter possibly because they consume more alcohol per drink than other racially or ethnically defined groups.

Notably this study did not find a single instance where a frequency threshold defined in terms of exceeding this at least once a month was optimal, strongly suggesting that such questions should ask about the number of heavy drinking occasions over the past year.

The same dataset has been used to test the AUDIT-C screening questionnaire to identify dependence and dependence/abuse. This tool confined to questions about drinking provides an alternative to brief screening instruments which ask about alcohol-related problems. It consist of the first three questions To do with frequency of drinking, typical quantity, and frequency of heavy drinking. of the ten-item AUDIT questionnaire, a widely accepted and researched screening tool. In respect of identifying (or not) dependence and dependence/abuse, at optimal thresholds the single questions in the featured study were of comparable power. However, among past-year drinkers they identified a slightly higher proportion of dependent drinkers but a slightly lower one of non-dependent drinkers.

Findings logo commentary For busy primary care and other staff tasked with screening patients for risky drinking, these results will come as good news, offering a rapid and relatively non-intrusive way to sift patients for further testing and/or intervention.

The findings can be compared with those from the SIPS project in England, which tested screening (and brief interventions) in primary care, emergency departments, and probation offices. Screening results from SIPS have been amalgamated in conference presentations ( 1 Coulton S. "What is the most efficient method for screening for alcohol use?" Presented at Alcohol Screening and Brief Interventions: from Research into Practice, London 5 March 2012. 2).

One of the screening methods was a variation on the frequency question in the featured study, a single question asking: "How often do you have [eight for men, six for women] or more standard drinks Each drink is roughly a UK unit of 8gm alcohol. on one occasion?" Monthly or more was considered a positive screen. The main alternative was the FAST Alcohol Screening Test. It began with the single frequency question and registered a positive screen if the response was weekly or more often. Otherwise three further questions How often in the last six months the respondent has been unable to remember what happened during the previous night's drinking, failed due to drink to do what was normally expected of them, or experienced concern over their drinking from a relative, friend, or health professional. about drink-related problems were asked. Scores in response to the four questions were summed So that, for example, people who have (even if in all cases less than monthly) drunk excessively, and forgotten what happened and failed to meet obligations would screen positive, as would someone who said they had never drunk excessively yet had either forgotten or failed to meet obligations at least weekly, or experienced concern on more than one occasion. to determine whether to proceed with intervention.

Except in emergency departments, generally the FAST test was best in terms of identifying (it spotted over 8 out of 10) risky drinkers who would have been picked up by the longer AUDIT questionnaire. In primary care in particular, FAST was preferable, identifying 89% of risky drinking patients compared to 81% for the single question. It was also significantly better at identifying people whose AUDIT scores indicated a medium severity of alcohol problems, the range thought appropriate for brief interventions. Though it consists of four questions, generally only the first (about frequency of excessive drinking) had to be asked, offering perhaps an acceptable compromise between speed and accuracy.

This draft entry is currently subject to consultation and correction by the study authors and other experts.

Last revised 14 January 2013. First uploaded 14 January 2013

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STUDY 2014 The effectiveness of alcohol screening and brief intervention in emergency departments: a multicentre pragmatic cluster randomized controlled trial

STUDY 2011 Achieving positive change in the drinking culture of Wales

STUDY 2008 Universal screening for alcohol problems in primary care fails in Denmark and no longer on UK agenda

STUDY 2011 An evaluation to assess the implementation of NHS delivered alcohol brief interventions: final report

REVIEW 2012 Behavioral counseling after screening for alcohol misuse in primary care: a systematic review and meta-analysis for the U.S. Preventive Services Task Force

The role of demographic characteristics and readiness to change in 12-month outcome from two distinct brief interventions for impaired drivers.

Brown T.G., Dongier M., Ouimet M.C. et al.
Journal of Substance Abuse Treatment: 2012, 42, p. 383–391.
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 Brown at thomas.brown@mcgill.ca. You could also try this alternative source.

Can repeat drink-driving offenders be swayed by just 30 minutes with a therapist, and would those minutes best be spent in motivational interviewing or providing information on alcohol? This Canadian study hints that 'Yes' is the answer to both questions – but only hints.

Summary The featured report was based on a study which tested the effectiveness of a brief face-to-face counselling intervention based on motivational interviewing offered to drink-driving offenders living near Montreal in Canada. It aimed to test whether certain types of drink-drivers had responded best to the intervention. This account also includes findings from an earlier report from the same study evaluating whether motivational interviewing improved outcomes overall.

Participants were recruited via adverts and via letters from the province's licensing authority asking recipients to help clarify how best to convey information on the risks of alcohol misuse. 184 people joined the study and provided baseline and follow-up data. They completed baseline measures and at least one of the two follow-ups. Of these 11 completed only one follow-up; their outcomes for the missing point were estimated. They were selected to be adults convicted of at least two offences of driving while impaired by alcohol or drugs in the past 15 years and whom the AUDIT questionnaire administered by the researchers showed had in the past six months still been drinking at problem levels. They were also selected to currently not be engaged with any other intervention targeted at drink-driving. Typically they were single men in their 40s. Around half currently met criteria for being dependent on alcohol and two thirds scored on a standard questionnaire as feeling some degree of ambivalence about the need to change their drinking.

Participants were randomly allocated to one of two half-hour interventions delivered face to face by the same therapists, who were trained and monitored to ensure they stuck to the respective manuals and approaches. The motivational interviewing approach involved an empathic interviewing style attempting to resolve client ambivalence to facilitate the desired behaviour change without arguing with the client or confronting resistance. Though manualised for the study, the therapists could adapt the content to suit the client. The comparison intervention lacked motivational interviewing's specific therapeutic; therapists simply delivered a prepared script covering the risks of excessive drinking and drink-driving, non-specific advice about alcohol misuse, and substance use treatment options.

Main findings

Six and 12 months after the interventions researchers repeated their baseline assessments of the participants. A key measure was the percentage of days over the past six months when their alcohol intake would have placed them at greater risk of accidents, set at 42g Just over five UK units. or more for men and 28g 3.5 UK units. for women. According to their own accounts, on this measure at both six and 12 months the offenders were less often at risk than before the interventions (risky drinking days down from nearly 50 to 39 and 37), but the trends did not significantly differ between the two intervention groups. Nor did the groups significantly differ in the risk levels they ended up with.

However, there was a significant difference in trends between the two follow-ups. Twelve months after intervention those counselled using a motivational interviewing style had continued to reduce their risk (drinking at risky levels on 25% fewer days than at baseline) while those given the information script had fallen back somewhat. It meant that by 12 months what had been a greater risk reduction in the information group had reversed and become greater among the motivational interviewing group, though neither difference was statistically significant.

Blood tests suggested The trend was statistically significant in just one of the four tests and then only at the six-month follow-up. that at six months (but not at 12 months) heavy drinking might have receded more after motivational interviewing than after the information session, a suggestion reinforced by a similar result on an alcoholism questionnaire particularly predictive of drink-driving.

A questionnaire assessing readiness to change to less risky drinking revealed no significant difference in trends and there was none either in the time the two groups spent in treatment for substance use over the follow-up year. The two groups were equally satisfied with their interventions, though those who experienced the motivational approach were significantly more likely (96% vs. 76%) to agree it had helped them deal with their problems.

These findings from the first report were extended by the featured report, which drew on the same data to assess whether the relative impact of the two interventions differed for offenders of different ages, sex, education level, number of drink-driving offences, severity of substance use problems, and readiness to address their risky drinking. Generally this was not the case, meaning that the relative impact of the interventions was not dependent on the type of offender.

An exception was a blood test for the consequences of heavy drinking, the same one which ( above) had fallen most steeply at six months after motivational interviewing. On this measure at six months, the advantage of motivational interviewing was significantly greater among offenders not thinking of changing their drinking, though just two fell in this category. On the same measure, these types of offenders also responded best, whatever the intervention.

Among the other findings from this analysis was that (regardless of intervention) participants with more severe drinking problems made the greatest reductions in their risky drinking days, and younger participants responded best to the interventions as assessed by two blood tests indicative of heavy drinking.

The authors' conclusions

Findings add weight to the contention that brief motivational interviewing interventions can reduce the negative health consequences of risky drinking in drink-driving offenders, and warrant further applied study of their feasibility and impact in venues where these offenders may be targeted, such as at court following a charge or in frontline health settings, particularly when the offenders will not be subject to a formal drink-driving intervention programme.

Various measures suggest the brief motivational interviewing session led to a significantly greater and longer lasting reduction in risky drinking. Only this intervention resulted in continued reduction in risky drinking days (ie, when the amount of alcohol consumed could pose a danger if coupled with driving) between the six- to 12-month follow-ups, consistent with significantly greater reductions in a blood test for heavy drinking and scores on a questionnaire reflecting problem drinking and the likelihood of recidivism.

There was no evidence that motivational interviewing gained its advantage by bolstering readiness to change drinking or use of treatment services. However, more participants said it had helped them cope with problems than said this of the information sessions, hinting at the possibility that the motivational approach had improved self-efficacy.

Expectations of greater responsiveness to motivational interviewing in certain types of patients were not convincingly supported. However, both types of brief intervention seemed to work best among recidivist offenders with greater ambivalence regarding the need to alter risky drinking, who were relatively young, had experienced more negative consequences of their drinking, and among men, suggesting that these interventions can reduce risky drinking among high-risk male offenders.

Findings logo commentary While there were hints that motivational interviewing led to greater remission in drinking and drink problems than the information session, statistically significant results were confined to two out of the 12 tests At each of two follow-ups: risky drinking days; four blood tests indicative of heavy drinking; and a questionnaire intended to reveal drinking problems. which gave the approach a chance to demonstrate its advantage. One was a single blood test result, which the authors say would carry more weight had it been confirmed by at least one other blood test. The other rested on a problem drinking questionnaire which does not mention drinking but attempts to tap personality and attitudinal characteristics which commonly distinguish individuals with such problems from those without. This 'covert' measure might have been critical had the desire to cover up one's drinking been greater among the motivational interviewing patients, but according to the study's measures, it was not.

In these circumstances, and given that they were talking to researchers who presumably assured them of confidentiality, perhaps more weight can be placed on the explicit accounts from the offenders of how much they actually did drink. On this measure there were no significant differences between motivational interviewing and information session patients in the degree to which they cut back their risky drinking, only in the trends between the two follow-up points. The decision to test this inter-follow-up trend was made post hoc, that is, after the results of the study were known, rendering them at best suggestive because the findings are vulnerable No suggestion is made that this was the case in respect of the current study, only that this possibility cannot be eliminated. to researchers choosing which outcomes to report depending on what happens.

That a minority of recipients felt the motivational approach was helpful when the other approach was not was a clear difference, suggesting the encounter with the therapist – when they were permitted to act like a therapist – offered something participants valued, even if it did not lead to significantly fewer risky drinking days. This finding is relevant to the feasibility of engaging people who have not sought therapy for their drinking. Even if in controlled studies motivational approaches are no more effective than straightforward didactic approaches, they might in routine practice be more feasible to implement because they are more acceptable to the recipients than approaches which assume they have a problem and/or which lecture or confront them.

What the participants meant when they said the motivational approach helped could be that it helped curtail their drink-driving if not their drinking as such, an issue to be addressed by later reports on the study. If this was the case, it would be in line with the findings published in 1999 of an attempt to garner all the available evidence from studies of interventions which assessed impacts on alcohol-related injuries. It came to the tentative conclusion that interventions with problem drinkers can reduce injuries and deaths even when this is not the aim and when drinking itself seems unaffected. This was also the case specifically in respect of traffic accidents.

No clear superiority of a motivational versus an alternative well structured approach was also found in two recent syntheses of research (1 2) on brief and longer therapies and across treatment-seeking and non-treatment seeking caseloads. Both analyses however found motivational approaches preferable to doing nothing. Whether this was the case in the featured study cannot be established. Without a no-intervention group, it is not possible to say whether any the improvements noted would have happened anyway, even without brief intervention.

Thanks for their comments on this entry in draft to Thomas G. Brown of McGill University in Canada. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 14 January 2013. First uploaded 11 January 2013

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STUDY 2012 Alcohol screening and brief intervention in primary health care

STUDY 2012 Alcohol screening and brief intervention in probation

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STUDY 2012 Summary of findings from two evaluations of Home Office alcohol arrest referral pilot schemes

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

STUDY 2012 Alcohol screening and brief intervention in emergency departments

STUDY 2011 Achieving positive change in the drinking culture of Wales

REVIEW 2012 Assessing the effectiveness of drug courts on recidivism: a meta-analytic review of traditional and non-traditional drug courts

STUDY 2014 Alcohol screening and brief interventions for offenders in the probation setting (SIPS trial): a pragmatic multicentre cluster randomized controlled trial

STUDY 2010 Screening, Brief Intervention, and Referral to Treatment (SBIRT): 12-month outcomes of a randomized controlled clinical trial in a Polish emergency department

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

Holland R., Matheson C., Anthony G. et al.
Drug and Alcohol Review: 2012, 31(4), p. 483–491.
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 Holland at r.holland@uea.ac.uk. You could also try this alternative source.

What happens when opiate-addicted patients are suddenly no longer required to take their methadone under supervision but can take it away from the pharmacy? In Scotland this was tried in the first UK randomised trial; patients stayed longer in treatment and there was no dramatic escalation in heroin use.

Summary Prescribing opiate-type drugs such as methadone to substitute for illegally obtained heroin and similar drugs is intended to safeguard the health of the patient, help them address their addiction, and safeguard the community, particularly from revenue-raising crime to pay for illegal drugs. However, because these prescribed drugs have opiate-type effects they can be dangerous in overdose or when taken by people unused to them, and they have a 'street value' which can tempt some patients to sell them or give them to other people – dangerous for the recipients, and also meaning the patient may return to illegal heroin use with all its risks.

To prevent these unwanted consequences, since 1999 UK guidance has advised that patients be observed while taking their medication to ensure it is taken as intended, known as supervised consumption. The advice is that this should be continued for at least three months. Regular daily contact with pharmacy or clinic staff possibly enhances treatment, but also implies a lack of trust, and imposes on patients the burden of daily visits to take their medication.

This small scale Scottish pilot study conducted in Glasgow, Aberdeen and the Highland region was the first UK randomised trial of supervised consumption. Rather than testing the need for the initial three months recommended in national guidance, it recruited patients who had complied with those recommendations, but then for the next three months randomly allocated 60 to either continue to be supervised typically six days a week at the pharmacy ('daily'), only twice a week, or not at all. On non-supervision days the last two groups still had to collect their medication daily from a pharmacy. Patients were being treated by nine different doctors at various clinics. Prolonged supervision is the norm in Scotland, so effectively this feasibility study was intended to pave the way for testing the benefits and drawbacks of relaxing current Scottish practice. The sample was too small it was considered for the study to act as a test in itself of those practices.

Of 102 patients approached to join the study, 60 did so; 29 effectively rejected entry to the study and seven were judged clinically unsuitable Typically they were unemployed men in their 30s being treated in Glasgow. At the start of the study, 25 tested positive for continued use of illegal opiate-type drugs, and 15 (often the same people) for benzodiazepines. Despite randomisation there were some appreciable differences between the profiles of the patients in each group.

Of the 60, 46 could be reassessed at the end of the randomisation period. Among the losses were two out of the 19 unsupervised patients whose risky behaviour led to them being returned to supervision.

Main findings

Differences in retention and most of those in substance use between patients allocated to the three supervision regimens were neither substantial nor statistically significant.

Unsupervised patients were however non-significantly most likely to still be in treatment at the end of the study (six months after they started their treatment), those supervised daily, least likely. When the analysis took account of the two patients who changed supervision status, all but one of the 17 unsupervised patients were still in treatment but just 16 of the 22 supervised daily.

Among the 46 who could be reassessed at the end of the study, according to their own accounts to researchers, illicit heroin use was rare at the start of the study ( typically Median figure. one or two days a month) and remained rare at the end, though with slight reductions (from one to zero days) among the supervised patients and a slight increase among the unsupervised (two to 2.5). Their own accounts also revealed no differences in use of other illicit drugs. However, the proportion who were drinking problematically fell from 47% to 33% in those supervised daily but increased or remained the same in the other two groups, creating a statistically significant difference. Urine test results indicated a decrease in use of illicit drugs and in heroin in particular, which was most marked (but not significantly different) among those supervised daily.

Psychological health improved in the twice-weekly supervision group while staying the same or worsening in the other two groups, a statistically significant difference. No significant differences were recorded in physical health, social functioning, crime, quality of life or overall satisfaction with treatment, and no adverse events were recorded in any group. Though with so few patients involved this would not have in any event been expected, patients said there had been no changes in the availability or price of illicit methadone between baseline and follow up; at both times most saw methadone as quite or very easy to access.

There was however a clear and statistically significant divide in patient reactions to their allocation to the groups. Two-thirds of those relieved of the need to take their medication at the pharmacy were happy about their allocation, but only 30% subject to twice-weekly supervision and 14% daily. Given the chance to express their views in their own words, the unsupervised patients highlighted reduced stigma, the supervised patients, the continued stigma of being exposed as a methadone patient at the pharmacy.

The authors' conclusions

Recruitment was slower than anticipated, but this pilot showed that it is possible to conduct a randomised trial of supervised consumption in the Scottish context. Though too small to support anything other than tentative implications, the findings suggest that increasingly frequent supervision shortens retention but may also reduce problem drinking and illicit heroin use – indicative of a dilemma between a harm minimisation approach favouring retention (promoted by relaxing supervision) and a recovery approach where eliminating heroin use is the key objective (which benefits from tighter supervision).

These suggestions were in some respects consistent with the patients' own views. Universally they were happy or did not mind not being supervised, but over 4 in 10 of those supervised did not like this. Many patients would it seems rather take their methadone in private. It was clear that stigmatisation in pharmacies remains a major problem. Some may prefer to be dispensed long-term from their drug treatment centres, or to use a pharmacy more distant from their homes.

These results should be interpreted in the light of the fact that all patients still had to attend their pharmacies nearly every day, a less clear change in regimen than for example offering weekly dispensing. Also this study explored the effects of being supervised on the individual patients, yet supervision was initiated in the late 1990s also for its community-level effects of reducing diversion and wider access to illicit methadone. Interestingly however, the results indicated that the price of methadone in Glasgow is approximately half that in Grampian or Highland, despite Glasgow's high supervision rates.

Findings logo commentary The persistence of unsupervised methadone prescribing in England and Wales (less so in Scotland) is unusual internationally and is also where the preferences of patients (generally against) and national guidance (in favour at the start of treatment) most obviously diverge, setting the stage for a trial of whether despite patient preferences, supervised consumption is worth imposing. The featured study takes a welcome initial step in this direction, but one which still leaves this core feature of modern UK practice unsupported by a rigorous large scale trial.

The authors' cautions that this was not an adequate test, but primarily a test of whether such a study was possible, are well taken. Apart from the factors they mention, there seems a strong chance that doctors 'cherry-picked' patients they were prepared to invite in to the trial and risk their being suddenly switched to totally unsupervised consumption. The trial's protocol allowed them to exclude any they thought too severely ill. The facts that recruitment was slow, that typically patients were on their own accounts using heroin very infrequently at the start of the study, few were heavy drinkers, just two had to be switched back to supervision, and that in the absence of supervision six-month retention was almost 100%, all seem suggestive of a relatively stable set of patients. Additionally, 28% of patients who were approached by their doctors decided not to enter the trial or did not turn up, adding self-selection to selection by their doctors.

Given these considerations, the results could signify not what might happen if all patients switched to unsupervised consumption, but what happens when requirements are relaxed on those who have already 'survived' three months of near-daily supervision, and whom their doctors and themselves consider well and stable enough to risk ending supervision. Another consideration is that the sometimes considerable differences between patients in the three groups were not taken in to account in the analysis of outcomes, so it is possible that these reflect pre-existing differences rather than the impact of the supervision changes. Also, with many variables tested for, even the few statistically significant differences might have been chance occurrences.

The findings on which we can place most reliance are the (still not statistically significant) improved retention among such patients when they are relived of the need to take their medication under the eyes of pharmacy staff and possibly too their customers – who could be the patient's neighbours – and the strong preference patients expressed for not having to do this.

In comparison, the findings in respect of substance use are usually minor and at best suggestive. There is however a clear 'non-finding'; that from their own accounts to researchers corroborated by urine tests, among this possibly cherry-picked set of patients, and in a context where illicit methadone was not in short supply, allowing them to take their medication away from the pharmacy did not precipitate escalation in heroin use, as it might have done had they chosen en masse to sell their methadone in order to buy heroin.

Other UK studies

Even after this trial supervising consumption has not been subject to large scale evaluation in Britain, yet this was one of the intentions of the NTORS study of addiction treatment in England, which recruited its patients in 1995. The closest the study came to reporting the findings was a comparison between seven GP-led methadone services and eight specialist clinics. The major difference in their prescribing practices was that three quarters of the clinics required patients to take their methadone under supervision, but just one of the GP programmes. Two years after entering treatment, GP and clinic patients had improved substantially and to roughly the same degree, but what differences there were favoured the GPs. GP patients had made significantly greater reductions in use of stimulants and non-prescribed benzodiazepines and greater gains in psychological health. They also tended to stay in treatment longer.

An important reason for supervising consumption is to prevent methadone being sold on the illicit market or otherwise 'diverted' to people other than the patient for whom it was intended, with possibly fatal consequences in the form of opioid overdose. A study of methadone overdoses in Scotland and England suggests these concerns are valid and that supervision does have the desired impact. It concluded that declines in the per-dose rate of deaths due to methadone overdose were due to the spread of supervised consumption, the main reason for a remarkable improvement in the safety of methadone prescribing from 1995 to 2004.

However, the study was unable to determine whether each opiate user in or out of treatment had become more or less likely to avoid overdose on opiate-type drugs as a whole – heroin as well as methadone – as a result of the introduction of supervised consumption. As well as preventing diversion, supervision should help prevent elevated death rates in the first few weeks of treatment because clinicians can monitor the patients more closely and directly control their methadone intake. It also means the prescriber can be sure that the drug has been taken and that therefore the patient has built up the required tolerance to make such doses safe, and helps assess whether higher doses are required and would be safe. The structure and contact it imposes can also be therapeutic.

Set against this, to the degree that (as some clinicians believe) the supervision requirement causes dependent opiate users to avoid treatment, it would prevent substitute prescribing realising its lifesaving potential. In line with the featured study, other studies have reported that patients who do start treatment find it difficult to comply with long-term attendance or supervision requirements, leading to reduced compliance with treatment and premature drop-out or discharge, impacts which would again reduce the treatment's benefits via reduced retention. How these contrary influences balance out to affect overdose on opiate-type drugs as a whole is unclear.

Practice in Britain

In 2009 some of the same authors conducted a survey of all 42 clinical leads in substance misuse in Scotland to establish the extent and nature of supervised consumption at specialist drug dependence treatment centres. Of the 32 respondents, 20 said they required supervised consumption of new patients for at least three months. For new patients, all but five required supervision six days a week. About half the clinicians said they relaxed these requirements gradually, though it was not unusual for clinicians to support long-term or indefinite supervision. Safety was highlighted as the key reason for supervising consumption, particularly preventing methadone being taken unsafely by people other than the patient.

Based on data from the mid-2000s, another report has related a survey of usual prescribing practices at NHS community drug teams in England and Wales (which treat addiction to drugs including heroin) to a companion survey of the opinions on these policies of patients from one area. All but 3% of the services which responded could arrange supervised consumption of methadone, but 22% said fewer than half their methadone patients starting treatment were supervised. Patients at four community drug teams in South East England were asked if they agreed with guidance that methadone should be taken in front of a pharmacist for three to six months; 52% disagreed, 34% agreed.

The same authors had also phoned 1000 pharmacies throughout England and discovered that a third of patients were supervised and twice as many – two-thirds – were prescribed methadone to take away. Historical practice and the reluctance of many British pharmacies to provide the required facilities make routine supervised consumption of methadone difficult to provide. Since service users too tend to be opposed to supervised consumption, community drug teams may be under pressure from patients to permit methadone to be dispensed to take away.

In 2006 a national survey of Scottish pharmacies found that 91% which dispensed methadone for addiction treatment provided supervised consumption. Of the methadone patients they served, 57% were supervised, nearly 24% higher than in England.

For a summary of research on these and related issues see this Findings review. Other analyses related to supervised consumption can be found by running this search.

Thanks for their comments on this entry in draft to Richard Holland of the University of East Anglia in Norwich in England and Catriona Matheson of Aberdeen University in Scotland. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 16 January 2013. First uploaded 09 January 2013

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Monitoring and evaluation of family intervention services and projects between February 2007 and March 2011.

Lloyd C., Wollny I., White C. et al.
[UK] Department for Education, 2011.

Family interventions were at the heart of the UK government’s ambition to ‘turn round’ the lives of 120,000 troubled families in England. In respect of drink and drug problems, substantial remission was seen, but the featured study could not show whether this was due to the interventions, and a report on a successor programme found no significant impacts.

Summary This report from the National Centre for Social Research evaluates family interventions set up to work with highly troubled and challenging families to tackle anti-social behaviour, youth crime, inter-generational disadvantage and worklessness. Though commissioned by the pre-2010 Labour government, its findings reflect work undertaken under the Conservative-Liberal coalition administration since May 2010 and the impact to March 2011 of its commitment to ‘turn round’ the lives of the estimated 120,000 most troubled families across England by March 2015.

The 159 local authorities which contributed data to the study made 12,850 referrals to a family intervention service during the study period, of which a fifth were in relation to adult substance use with or without other problems. Most common reasons for referral were anti-social behaviour (58%) and poor parenting (43%).

The family interventions typically lasted around a year and involved at first an average nine hours a week contact time between family and worker tailing down to six to seven hours. The core work was undertaken by key workers assigned to work intensively with about six families at any one time, building a close and trusting relationship. Their approach was assertive and persistent yet supportive, working with all members of a family so as to address the inter-connectedness of their problems. They managed the family’s problems, coordinated delivery of services, and used a combination of support, rewards and the possibility of sanctions to motivate families to change their behaviour. Persistence and assertiveness was critical to keeping families engaged and ensure they followed their agreed contract or support plan. Family intervention activities included: anger management; one-to-one and group based parenting sessions; educational support and advocacy; and organising activities for family members such as sports and arts-based activities for children and family outings/activities.

Well over 8000 families engaged with the family interventions during the study period. Typically they were highly disadvantaged. Two thirds were lone parent families and in three-quarters no adult was in employment. Of these families, 3675 had left their interventions by the time the study ended, enabling an assessment of the outcomes of the process based on official records completed by family workers. Based on their own continued contact with the family or information from other agencies, the same workers were asked to complete another set of assessments of the 775 of these families who had finished their intervention at least nine and up to 14 months previously. Of these families, 470 were assessed. They tended to be the ones most likely to have achieved successful outcomes.

Main findings

Based on official statistics, by the time the intervention had ended the 32% of families experiencing drug problems had shrunk to 20% and the 29% with drink problems to 15%. These falls compared well with less steep falls in the proportions of families experiencing mental or physical health problems, but were in the same range as remissions in other behavioural problems such as poor parenting, relationship or family breakdown, and domestic violence.

No specific data was presented in the report about whether the remissions in alcohol and drug problems were sustained nine to 14 months later. Instead these were subsumed under the health domain. Within this domain, 61% of families who had problems before intervention, but had overcome these when they left, were still judged to no longer be experiencing these problems at follow-up. This was the lowest proportion among the domains, topped by education at 89%.

Generally it was not possible from these figures to say how much improvement was due to the family interventions and how much would have happened anyway, because there was no comparison group of families not offered family interventions. However, in respect of families targeted for anti-social behaviour, information on a comparison group of 93 families who would have qualified for family intervention was obtained from 11 local authorities which did not in fact offer these interventions. Of these, 56 could be followed up nine months later, indicating how such families would fare in areas without family intervention projects. In respect of crime and anti-social behaviour, 33% of comparison families were judged to have improved, compared to 63% of matched families who had been offered family intervention in other areas. The results suggested that compared to usual practices, family intervention led to another 30% of families improving. In respect of education and employment and family functioning, there was similar (but because numbers were smaller, less convincing) evidence of added value from family interventions. However, in respect of the health domain which included drug and alcohol problems, the number of comparison families experiencing these problems at the start (just 20) was too small for any conclusions to be drawn.

The authors’ conclusions

This report builds on the compelling evidence endorsing the role and value of family interventions. The outcomes reported at the point of exit have remained consistently high since the projects were first set up despite the increasing number of families being worked with. In the current economic climate it is very encouraging that family interventions appear to be achieving a similarly impressive set of results in a shorter time duration (from 13 months in 2010 to 11 months in 2011). However, as there is a link between the length of intervention and success we will need to wait to assess the impact of a shorter duration of intervention in the longer term.

The findings from the families compared with those in areas without family interventions provide the first indication that the positive outcomes achieved by families can be attributed to a family intervention. There is also further encouraging evidence that the outcomes are sustained nine to 14 months after leaving an intervention.

Findings logo commentary The family interventions evaluated by the featured report became a core part of the Troubled Families Programme launched in April 2012 to take forward the UK goverment’s commitment to turn around the lives of the estimated 120,000 “troubled” families in England. Published five years later in October 2016, a final government-commissioned evaluation report on the programme integrated evidence collected between January 2013 to September 2015 from national administrative datasets, a large-scale face-to-face survey of families which compared families going through the programme with a matched comparison group, longitudinal case study research with 20 local authorities, and ‘snapshot’ telephone interviews with a further 50 local authorities. The report also drew on self-reports from 143 local authorities at three points in time during the evaluation, and a survey of local authorities conducted during the early stages of the programme to map the broad characteristics of local Troubled Families programmes.

Its crucial advance on the featured report was the construction of comparison sets of families not in the programme against whom its impacts could be benchmarked, helping to clarify whether any improvements really were due to the programme. Across the range of outcome measures that the programme aspired to improve including employment, benefit receipt, school attendance, safeguarding and child welfare, analyses of administrative data did not reveal consistent evidence of any significant or systematic impact. Observed outcomes for Troubled Families Programme families were very similar to the outcomes for a matched comparison group of families. The vast majority of impact estimates were statistically insignificant, with a very small number of positive or negative results.

Relative to comparison families, the separate analyses using survey data also found no significant or systemic impact on outcomes related to employment, job-seeking, school attendance, or anti-social behaviour. The measures included:
• GP and emergency department visits in the previous three months;
• self-reported general health of the respondents and young people interviewed, plus proxy data on partners;
• life satisfaction of the respondents and young people interviewed;
• use of non-prescription drugs in previous three months by the respondents and young people interviewed;
• alcohol use in the previous three months by the respondents and young people interviewed, plus proxy data on partners;
• assessments of the well-being and depression levels of the main carer respondent;
• how well parents got on within the family and physical, verbal, emotional and sexual domestic violence.

There was no statistically significant evidence of any impacts of the programme across all of these health and well-being measures.

The final report also had what it considered an important message for commissioners considering payment-by-results schemes, used by the programme to incentivise local authorities to achieve desired outcomes. Evaluators emphasised the need for these schemes “to be structured in such a way that they incentivise those responsible for delivery to improve outcomes relative to ... a counterfactual, rather than simply claiming ‘results-based’ payments for outcomes which would have been likely to occur in any event”.

Last revised 20 October 2016. First uploaded 08 January 2013

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