Drug and Alcohol Findings home page. Opens new window Effectiveness Bank bulletin 18 March 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 additions to the Effectiveness Bank probe the differences and similarities in treatment processes and outcomes for men and women. The second of these concerns the prescribing of injectable heroin, but next in the list is a less radical alternative for patients who do not settle on oral methadone – slow-release morphine. Finally, text messaging finds its way in to the brief alcohol interventions armoury in a study with an intriguing twist in the findings.

Therapeutic relationships and meeting needs at heart of treatment process ...

Prescribing injectable heroin benefits women as well as men ...

Slow-release morphine offers alternative for methadone-intolerant heroin addicts ...

Post-emergency visit text message advice moderates drinking ...

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

Marsh J.C., Shin H-C, Cao D.
Evaluation and Program Planning: 2010, 33(2), p. 81–90.
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 Marsh at jmarsh@uchicago.edu. You could also try this alternative source.

From the comprehensive treatment process data collected by a major national US study emerges the important lesson that retention in itself is not an active ingredient in post-treatment outcomes but reflects influences such having one's needs met (especially important for women) and developing a good relationship with the service and your key worker.

Summary The US National Treatment Improvement Evaluation Study collected data between 1993 and 1995 from a nationally representative sample of treatment programmes funded by the US government, serving mainly vulnerable and underserved populations including minorities, pregnant women, young people, public housing residents, welfare recipients, and those involved in the criminal justice system. It remains one of the few treatment effectiveness studies to have collected detailed information from clients on their relationships with the treatment provider and their receipt of services.

The featured analysis used this data to test whether stays in treatment and drug and alcohol use a year after leaving were (as in other studies) related to the intensity of the following types of services/processes as reported by patients and clients when they left treatment:
Access services like child care and transportation intended to improve access to treatment.
Substance use counselling and other services (12-step meetings and medications for alcohol/drug problems) intended to directly reduce substance use.
• The service–needs ratio assessed the degree to which the needs for services Family and life skills services such as parenting, domestic violence counselling, family services, assertiveness training, life skills, family planning, and non-medical pregnancy services; health services including AIDS prevention and medical pregnancy services; mental health services; and concrete services such as schooling, job skills, housing, help collecting benefits, training in English, help getting alimony/child support. patients expressed when they started treatment were met by actually receiving those particular services.
Client–provider relationship: whether a positive therapeutic partnership had developed between the treatment service (in particular the client's key worker) and the client, assessed via ten questions, Whether client had seen a treatment plan; helped develop the plan; agreed with treatment; adhered to treatment goals; whether important provider existed; time spent with primary provider; length of sessions with primary provider; agreement with primary provider; understanding by primary provider; whether primary provider speaks preferred language. to most of which the client could indicate magnitude or degree.

The analysis aimed to unpick For example, it was expected that longer retention would help reduce later drug use because it gave more time for needed services to be received, and that receiving needed services would incline patients to stay longer. Women generally have greater needs and more need for transport and child care in order to access services so these might be more influential for women than for men. not just the presumed effects of these variables, but also how they worked, and whether effects and mechanisms differed for men and women and were affected by other characteristics of the client or service.

The source study had interviewed 6593 patients when they started treatment. Of these, the featured analysis included 3027 from 59 services who had completed all intake, treatment discharge, and follow-up interviews, were not in prisons or jails, and had expressed some need for services at treatment intake. Mainly they were problem drug users who may also have been drinking heavily. A year after leaving treatment they had told researchers the number of days in the last 30 on which they had used the five most frequently used substances: alcohol; cannabis; crack cocaine; cocaine powder; and heroin. These use days were summed to give an index of the intensity of their polydrug use. The fact that the variables presumed to influence substance use were measured a year before means that they could have had a causal influence, but the study was unable to be sure of this because other influences could not be excluded.

Main findings

Models were constructed of how mechanisms and influences interrelated to influence retention and post-treatment substance use. One was made for the full sample, but the same model could not be applied to men and to women – the processes were too different.

For the full sample, post-treatment substance use was significantly lower when a greater proportion of the patient's needs had been met during treatment, they had a better relationship with the treatment service/keyworker, and they had stayed in treatment longer. Further upstream of the causal chain model, facilitating access to treatment by providing transportation and child care led to receipt of a greater range and intensity of substance abuse counselling and other treatment services, which in turn led to an improved relationship between service and client. Improved relationships then seemed to lead to patients staying longer in treatment, and both were related to having more of one's needs met.

Among the 'fixed' factors affecting these processes were that residential treatment led to longer retention and more counselling and other treatment services being received. The more educated the client the less their post-treatment substance use, while the greater use was before treatment the greater it tended to be afterwards.

As assessed by surveying programme administrators, some other organisational factors did not emerge as influences in the model, including whether the service was accredited, the typical intensity of counselling scheduled (as opposed to actually received by each individual) for patients, and the number of extra services Academic training, vocational training, medical, psychiatric, or pregnancy services. provided on-site.

Simplified treatment process models for men and women

For men the structure of the model was very similar to that for men and women combined, with the exception that time spent in treatment was no longer related to post-treatment substance use. For women this was also the case, and there was another difference both from the full sample and from men, reflecting an apparently more pervasive influence of transportation and child care access services. These not only appeared to facilitate access to more types of substance use counselling and other treatment services, but also When the criterion for declaring a finding as statistically significant was relaxed to a one in ten rather than a one in twenty chance of it bring a chance finding. Similarly relaxing the criterion for men did not lead to the same relationships emerging in the model. led to an improved client–provider relationship and a greater proportion of needs being met. Another difference for women was that a better client–provider relationship had no direct influence on post-treatment substance use, though it did influence substance use indirectly via a greater proportion of needs being met figure.

The authors' conclusions

Several services and service delivery mechanisms – client–provider relationship, access services, substance use counselling and other treatment services, and services matched to needs – individually and collectively contributed to retention in treatment and reduced post-treatment substance use. While mechanisms affecting outcome are fundamentally the same for men and women, access services are particularly important for women, and a positive client–provider relationship is directly related to reduced substance use for men but only indirectly for women.

The study's modelling techniques helped establish not just which factor is related to another, but also which might be cause and which effect. These analyses suggested that a positive client–provider relationship leads to better matching of services to needs and to longer treatment, but not the other way round. The implication is that when providers develop a constructive relationship with clients, they are able to more effectively identify and meet service needs and encourage clients to remain in treatment. These findings are consistent with a review which concluded that in substance use treatment, client–provider relationships consistently predict retention but less consistently predict substance use outcomes.

Another question is whether the client–provider relationship is therapeutic in its own right, or primarily a vehicle for enhancing access to and impact of specific services. Modelling results suggest this relationship is both directly connected to reduced post-treatment drug use and indirectly related via greater need–service matching and longer treatment stays.

These linkages do however differ for men and women. The client–provider relationship is directly therapeutic for the total sample and for men, but among affects post-treatment substance use only via receipt of needed services, which for women more strongly predicts outcomes than the relationship and more strongly than for men. This may be because women start treatment with more needs, so addressing those is especially important.

The analysis was also consistent with receipt of transportation and child care leading to receipt of more substance use counselling/treatment services, which led to a higher quality client–provider relationship. It seems these access services may be a necessary precondition for receiving more substance use counselling, which in turn gives clients the opportunity to connect with their provider and work on treatment goal-setting, planning and bonding, which in turn means more needs are met, encouraging or enabling longer retention. For the total sample and for men, the result is to reduce post-treatment drinking and drug use.

Access services were identified in the models as especially valuable for women, perhaps because they are more likely to face barriers to treatment entry including lack of transportation and problems with child care. Not only does providing these facilitate access, it also improves treatment in ways which improve substance use outcomes.

Remaining in treatment for more than three months has been considered a robust predictor of reduced post-treatment substance use. The featured analysis found that when other variables are taken in to account and findings for men and women analysed separately, retention is no longer directly related to substance use, but acts via improved matching of services to needs. The implications are that treatment duration may in previous studies have served as a proxy for receipt of services.

These findings emerged from a resicted sample of treatment programmes and from a restricted sample of the patients who started treatment in those programmes; they may not be representative to all substance users in need of treatment. Findings from the source study derive mainly from public sector programmes serving lower-income groups and may not generalise to other programmes and caseloads. They also date from the early '90s, since when treatment services have changed, though perhaps not in ways which invalidate the core conclusions. Finally, the statistical techniques used to construct the models can eliminate some theories about how treatment works, but not confirm that the final model actually reflects cause and effect. This inherent limitation of the techniques is compounded by the fact that the main treatment process information was all collected at one time point (discharge from treatment); ideally the presumed causes would have been assessed before the presumed affects.

Findings logo commentary Logical, intuitively appealing and in line with other research as the conclusions of the analysis are, it is important (as the authors acknowledge) to remember that the most which can be said is that the cause-effect explanations are consistent with the data. It cannot definitely be said that this is in reality how the treatment process worked for these US clients and services in the early '90s. Only studies which deliberately varied, for example, the quality of the client-provider relationship (while keeping everything else constant) could confirm that directly or indirectly this relationship causes the resulting changes in retention and substance use. Such studies are however not very feasible because they would mean deliberately consigning some patients to a substandard treatment experience and possible substandard outcomes in a situation where lives are at risk from relapse. Failing such studies, careful and sophisticated analyses such as the featured study offers, based on relatively comprehensive data from real-world treatment services, can help elucidate important variables affecting the success of addiction treatment. More methodological considerations below.

Findings from this analysis were foreshadowed by an analysis from the same source study focused on receipt of services matched to needs. It found that receiving services matched to need was associated with greater reductions in illegal drug use generally and use of the drug(s) in relation to which the patient had sought treatment. This was the case for each of the needs separately (except for mental health) and for the extent to which each individual's overall needs had been addressed. The strongest links were with housing and vocational help and among patients at residential services, where these particular needs were most likely to be addressed. Matching services to needs was linked to improved outcomes partly (but not entirely) via a link with increased retention. However, these associations were confined to the half of the patients with multiple needs across at least four out of the five domains.

More generally, research is supportive of the attempt to match the intensity and type of help to patients' needs, but studies are few and usually the impacts on substance use have been moderate. Research is strongest in regard to providing inpatient care and professional psychotherapy for patients with distinct but not disabling psychiatric problems who also have fewer 'recovery resources' in the form of employment opportunities and a supportive family. The relative prominence of research on psychiatric severity and psychotherapy may be a function of the comparative lack of investment in meeting patients' needs for housing and employment, which are also more difficult to engineer. Despite the difficulties, studies do suggest that providing such services improves outcomes in the targeted areas and also in respect of substance use problems.

A Findings review has explored the impact of (among other forms of practical help) the access services found so influential in the featured analysis – transport and help with the child care. It concluded that practical help to overcome access obstacles directly improves retention and also shows that the service is responsive and caring. Transport seemed most important for impoverished populations required to attend methadone services daily for supervised consumption. Direct help in the form of a driver and vehicle worked best, probably because it provides an escort and structures the patient's day. Providing transport was found to augment efforts to link patients to external agencies such as housing and employment services. The review also noted that for many women, child care is essential if they are to be attracted to and retained in treatment, especially in long-term residential care, but may not be used if it is unfamiliar or seems to threaten the mother's custody of the child. Beyond child care and transport, flexible and realistic opening hours and attendance requirements meant patients with unpredictable lives were not set up to fail, and allowed others to maintain normal family and working lives.

Methodological limitations

It is unclear whether characteristics of the patients before they started treatment influenced both retention and outcomes and treatment processes in ways which could have created what looked like a causal relationship between processes and outcomes. This is especially relevant in respect of variables not entirely under the control of the treatment service. For example, clients who were particularly motivated or well placed to overcome their dependence might have developed better therapeutic relationships, been more diligent in attending the service's counselling sessions, and attended 12-step meetings outside the service. They may also have stayed in treatment longer and done better in terms of controlling their substance use after treatment, but perhaps mainly because of their pre-existing attributes rather than treatment processes. Similarly, the measures of child care and transportation services were measures of the receipt of those services, not just their provision by the treatment agency. Receipt may reflect not just organisational concern to help patients come to treatment, but also the eagerness of the patient to ask for these services so they can attend.

Such considerations may explain (for example) why the counselling sessions scheduled by the treatment service and whether it provided on-site access to ancillary services (reflecting the organisation's provision, not their use by the patient) had no impact on retention and substance use a year after leaving treatment, while whether the patient actually attended counselling sessions and whether they actually accessed needed ancillary services (potentially reflecting their impetus to get better) did have direct or indirect impacts.

The restricted sample is also a concern. About 85% of patients starting treatment completed intake interviews for the source study. From this interviewed sample were eliminated another 2179 who did not complete subsequent interviews or expressed no needs at intake. The remaining sample constituted about 57% of all patients starting treatment (from whom were then excluded those in prison or jail). Loss to the sample was unlikely to have been entirely random. In so far as it was related to the factors used to account for treatment outcomes, estimates of the effects of these factors will be biased. For example, assume (not unrealistically) that patients who developed a very poor relationship with their providers not only tended to leave treatment very early but also failed to complete all research interviews. In this scenario the potential impact of this relationship on retention – estimated on the basis of the patients who did complete all interviews – will have been underestimated.

See this web site for more on the National Treatment Improvement Evaluation Study including a list of papers analysing the findings. Also available is the main report on the study published in 1997.

Last revised 12 March 2013. First uploaded 12 March 2013

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STUDY 2012 A preliminary study of the effects of individual patient-level feedback in outpatient substance abuse treatment programs

STUDY 2002 The grand design: lessons from DATOS

STUDY 2002 Still little evidence for matching client with same-gender or same-race therapist

STUDY 2009 Therapist behavior as a predictor of black and white caregiver responsiveness in multisystemic therapy

STUDY 2012 Randomized trial of standard methadone treatment compared to initiating methadone without counseling: 12-month findings

STUDY 2009 Relating counselor attributes to client engagement in England

STUDY 2000 Client-receptive treatment more important than treatment-receptive clients

STUDY 2008 Organizational- and individual-level correlates of posttreatment substance use: a multilevel analysis

REVIEW 2011 Adapting psychotherapy to the individual patient: Preferences

REVIEW 2011 Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence

Effectiveness of diacetylmorphine versus methadone for the treatment of opioid dependence in women.

Oviedo-Joekes E., Guh D., Brissette S. et al.
Drug and Alcohol Dependence: 2010, 111, p. 50–57.
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 Oviedo-Joekes at eugenia@mail.cheos.ubc.ca. You could also try this alternative source.

From Canada the first study to show that among long-term, severely opiate dependent patients who have not responded well to prior treatment, women as well as men benefit more from being prescribed injectable heroin than oral methadone.

Summary In Canada between 2005 and 2008 a trial randomly allocated 251 long-term, treatment-resistant opioid-dependent patients to be maintained for a year on oral methadone, or instead on either injectable heroin or hydromorphone. The featured report analysed data from that trial to establish whether men or women benefited most from injectable heroin.

The parent study had allocated patients Aged at least 25 and dependent on opioids for at least five years, currently injecting opioids daily, treated for opioid dependence at least twice before including substitute prescribing (in which 60mg or more of methadone was received daily for at least 30 days within a 40 day period), but not in substitute prescribing for at least the past six months. to the two forms of injectable opioids (heroin and hydromorphone) in a way intended to hide which drug they were being given. The 25 who were allocated to hydromorphone were omitted from the featured analysis, leaving 111 allocated to oral methadone and 115 to injected heroin. Of these 226 patients, 88 were women and 138 men. Most were insecurely housed, supported themselves through crime (and for 42% of the women, prostitution) rather than employment, were infected with hepatitis C, and regular cocaine as well as opioid use was common. Women had a worse overall profile including higher rates of reported sexual and physical abuse, HIV and hepatitis C infections, suicide attempts, sex work, and cocaine use, and less employment.

During the 12 months of the trial heroin-prescribed patients injected themselves up to three times daily at the clinics under staff supervision, but oral methadone was dispensed daily according to recommended practice in Canada. Patients allocated to injectables could replace all or part of their prescription with oral methadone if patient and doctor agreed. After 12 months a further three months was allocated to transfer patients to other treatment modalities, primarily oral methadone.

Main findings

A year after starting treatment 65% of the women and 75% of the men were known to still be retained Retention was defined as having received study medication on at least 10 of the 14 days prior to the 12-month assessment, or confirmed to have been in any other addiction treatment programme or abstinent from opioids during this interval. Participants who could not be followed up were considered non-retained. in some form of addiction treatment or to no longer be using opioid drugs. This lower retention rate for women was evident among patients prescribed injectable heroin (83% v. 90%) but more marked among those offered only oral methadone (48% v. 59%). However, none of the differences in retention between men and women were statistically significant, so may have been due to chance variations rather than a real difference in how they responded to treatment. What was statistically significant was that both were retained much better when they had been offered injectable heroin – an extra 36% of women and 32% of men. Almost all retained patients were still in the treatments offered by the study or in other methadone programmes; just three were known to be abstinent and none in other types of treatment.

Proportions of men and women responding well to prescribed heroin v. methadone

As measured by the standard EuropASI interview schedule, a good clinical response to treatment was defined as an improvement of at least 20% in drug use/problems and/or crime and legal problems, and no greater than a 10% deterioration in all, or all but one, of the other domains, including family and economic situations, drinking, and physical and psychiatric health. On this yardstick, by the end of the 12 months of the study about the same proportions of women and men had done well (55% and 59% respectively), though fewer women than men (60% v. 71%) did well on injectable heroin. As with retention, none of the differences between men and women were statistically significant. Only among the men did significantly more patients respond well to injectable heroin than oral methadone (71% v. 46%). More women (60% v. 50%) also responded well to injectable heroin, but not to a statistically significant degree; chart.

The study also tested whether retention and response to treatment were related to sex once other variables had been taken in to account. Again there were no significant differences between men and women. There were also none related to (among other variables) housing status, age, previous methadone treatment, frequency of cocaine use, education, a measure reflecting reliance on criminal activity, sexual abuse, and sex work.

On the specific measures of welfare and functioning, both men and women generally improved between starting and ending the study treatments, including in their drug use, legal situations and health-related quality of life, and both improved significantly more on several domains if they had been prescribed injectable heroin. Where there were significant differences between the men and women, it was that men gained more from being prescribed injectable heroin, in particular in physical health, health-related quality of life, and family relationships.

One of the analyses in the featured report concerned patients prescribed hydromorphone, which another report had found responded almost identically to those prescribed heroin. With respect to these patients it was possible to confirm self-reports by urinalyses. Assuming missed tests were indicative of illegal heroin use, these showed that among both men and women illegal heroin was used significantly less often by patients allocated to hydromorphone than those offered only oral methadone.

The authors' conclusions

For the first time this report showed injectable heroin to be more effective than oral methadone for women as well as men. Although men more consistently benefited across the different outcomes, there were no significant differences between men and women in overall clinical response or retention a year after starting treatment. However, these findings emerged from a caseload of long-term opioid injectors with very poor housing, socioeconomic and medical conditions, and a broad history of addiction treatment, including oral methadone maintenance; they may not generalise to other types of patients.

Among other randomised trials of injectable heroin v. oral methadone, only the German trial [see this Findings analysis] has previously reported whether men or women benefit more. It found that men did better than women when prescribed injectable heroin but not when offered only oral methadone. Data from the non-randomised Swiss studies are also consistent with the featured study's finding that men benefited more than women from being prescribed injectables rather than oral methadone.

Findings logo commentary The general picture from this as from other studies of heroin prescribing is that long-term severely dependent patients who have not responded well to treatment (in particular, oral methadone), and are prepared to accept onerous conditions including multiple daily clinic visits for supervised consumption, do better when offered injectable heroin than oral methadone. It is also the case that a substantial number do well when offered what in the studies is often a higher quality of methadone treatment than they may have experienced in the past.

A previous report from the same study in Canada confirmed that substance use and a broad range of measures of welfare and functioning improved more among patients offered injectable heroin than oral methadone. As defined by the study ( above), 67% of heroin patients responded well versus 48% offered only oral methadone, and at 12 months the retention rate was 88% versus 54%. According to their own accounts, on average the heroin patients cut their illicit heroin use from 27 days a month to just five days, the methadone patients from 27 to 12 days, a steeper fall among the heroin patients. However, both continued to use cocaine at about the same rate as before starting treatment.

Another report from the study found that patients were unable to distinguish injectable hydromorphone (a semi-synthetic opioid analgesic widely used for postoperative pain) from heroin, and that both drugs led to equally good retention and response to treatment and were equally safe.

A further report concerned satisfaction with treatment among patients prescribed injectable heroin or hydromorphone (these did not differ in patient satisfaction) versus those offered oral methadone only. It found the former more satisfied with their treatment and that whatever the treatment, satisfaction was related to being retained in treatment and responding well, including reduced substance use.

British trial

Britain too has trialled injectable heroin (and also injectable methadone) versus oral methadone in treatment regimens similar to those in Canada in the form of the RIOTT trial conducted at clinics in London, Darlington, and Brighton between 2005 and 2008. The questions it posed were whether patients who remained wedded to street heroin despite extensive treatment were simply beyond available treatments, whether it was just that their current oral treatment programmes were sub-optimal, or whether they would only do well if prescribed injectable medications. Each of these three propositions was true for some of the patients.

A third did seem beyond current treatments even as extended and optimised by the study. For a fifth, 'all' it took was to individualise and optimise dosing and perhaps also psychosocial support and treatment planning in a continuing oral methadone programme. But despite pulling out many stops to make the most of oral methadone, nearly half the patients only did well if prescribed injectable medications, with heroin by far the better option than injectable methadone at suppressing illegal heroin use. The upshot was that the most reliable option in terms of securing a divorce from regular illegal heroin injecting was to prescribe the same drug to be taken in the same way, but legally and under medical supervision. As defined by the study, two-thirds of these seemingly intractable patients responded well to this option.

However, from a conference presentation it seems injectable medications and heroin in particular had a far less clear-cut advantage in respect of cutting crime (which fell greatly across the board) and improving health and quality of life.

Because they demand frequent attendance, heroin prescribing clinics have the potential to aggravate drug-related nuisance and distress caused to the local community, but in fact around the London clinic no such effect was noticed by local informants and police records for the area revealed no increase in crime. Clinic patients among street drinkers observed to have been causing some nuisance at the start of the study relatively rapidly disappeared from the records.

UK national clinical guidelines and guidance issued by England's National Treatment Agency for Substance Misuse recommend that injectable prescribing should be considered only for the minority of patients with persistently poor outcomes despite optimised oral programmes, and that the priority should be improving the effectiveness of oral maintenance treatment for the majority.

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

Last revised 07 March 2013. First uploaded 07 March 2013

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

STUDY 2010 The Andalusian trial on heroin-assisted treatment: a 2 year follow-up

STUDY 2009 The Drug Treatment Outcomes Research Study (DTORS): final outcomes report

STUDY 2010 Is heroin-assisted treatment effective for patients with no previous maintenance treatment? Results from a German randomised controlled trial

REVIEW 2012 New heroin-assisted treatment: Recent evidence and current practices of supervised injectable heroin treatment in Europe and beyond

STUDY 2010 Effect of motivational interviewing on reduction of alcohol use

STUDY 2012 A pilot randomised controlled trial of brief versus twice weekly versus standard supervised consumption in patients on opiate maintenance treatment

STUDY 2005 Addressing medical and welfare needs improves treatment retention and outcomes

REVIEW 2011 Heroin maintenance for chronic heroin-dependent individuals

REVIEW 2003 Role Reversal

After the randomised injectable opiate treatment trial: post-trial investigation of slow-release oral morphine as an alternative opiate maintenance medication.

Bond A.J., Reed K.D., Beavan P. et al.
Drug and Alcohol Review: 2012, 31(4), p. 492–498.
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 Bond at alyson.bond@kcl.ac.uk.

Slow-release capsules of morphine – the closest drug to heroin – might offer acceptable and effective treatment to addicts who cannot settle on methadone. In England a dozen also being prescribed heroin switched their supplementary methadone to morphine, generally experiencing the benefits they expected and cutting their average dose of heroin.

Summary Editor's note: Once in the brain heroin is rapidly metabolised to morphine, a conversion responsible for its opiate-type effects. The heroin rush is thought to be more intense than that of morphine because heroin's greater fat solubility enables it to penetrate the brain more rapidly, but otherwise the effects of heroin are effectively those of its metabolite, making morphine the closest substitute drug.

Morphine in the form of morphine sulphate is available as a capsule which when swallowed slowly releases the drug continuously over a 24-hour period, providing steady blood levels of the drug [Editor's note: a property which duplicates the main advantage of oral methadone: that it can be taken once a day and evens out the multiple daily peaks and troughs associated with heroin]. Though marketed for medical use in the UK, it is not licensed specifically for the treatment of opioid addiction. However, it is licensed and used for this purpose in some countries of continental Europe and is also used on an individual patient basis in the UK and Australia.

Problem-free transition of patients from methadone to slow-release morphine has been documented, including in Slovenia where at 12 clinics 39 methadone-intolerant patients were transferred to the drug. The featured study trialled a similar process, but among patients being prescribed oral methadone and injectable heroin within the British randomised injectable opiate treatment trial (RIOTT); those who were unhappy with methadone had this part of their prescription transferred to slow-release morphine capsules but could continue to inject legal heroin.

Patients who having completed the trial were still dissatisfied with oral methadone could not be transferred to buprenorphine because it would precipitate withdrawal since they were also taking heroin. Slow-release morphine capsules offered an alternative long-acting opiate. Transfer to this drug was tried for all 12 patients (11 men and one woman) to report intolerance or dislike of methadone. On average before entering the trial and being prescribed heroin they had been injecting 25 days per month despite being in maintenance treatment, but were now no longer taking any illicit heroin.

Based on earlier reports, the targeted dose of morphine was about 6mg for each mg of methadone. The switch between the two drugs to the full dose of morphine and zero methadone was made gradually over about five days, then for a few weeks the morphine dose was titrated up or down to suit the individual patient. Unlike the patients' prior oral methadone doses, all the medication was taken under supervision. Patients were monitored daily for any discomfort, intoxication and side-effects.

Pre-switch case notes documented the patients' reasons for wanting to switch and what they expected taking morphine would be like. Interviews 8–12 weeks later also recorded in notes documented their actual experiences at a time when they had been stabilised on morphine.

Main findings

Common themes among reasons for and expectations of the switch to morphine included seeing this as a route to reducing dose and/or number of injections of prescribed heroin, and therefore also reducing the frequency of clinic visits in order to take these doses under supervision. A few thought morphine might enable them to stop injecting prescribed heroin altogether. Commonly patients felt methadone hard to withdraw from and that it gave a poor experience compared to heroin, both of which might be improved by morphine.

After having been stabilised on morphine 10 of the 12 patients said the transition had been smooth, quick and problem-free; the other two reported only minor problems which rapidly resolved. Most experienced a noticeable peak effect from the long-acting formulation around three hours after taking it. Once the dose had been appropriately adjusted, all but two found it kept them comfortable for the full 24 hours. Generally no side-effects were noted and none were serious. Most (in each case eight to 10 of 12) said morphine induced feelings of well-being, improved sleep and reduced craving for other drugs, and that they preferred it to methadone.

On average patients ended up taking 7.5mg morphine for each mg of their prior methadone dose. Five reduced their dose of prescribed heroin by over a fifth, two patients reduced the number of days each week when they were prescribed injectable heroin, and after a break in treatment a third preferred to do without heroin altogether and take only morphine. Overall, after 10 weeks the average dose of prescribed heroin had fallen significantly from 382mg to 315mg.

The authors' conclusions

The findings suggest that the option of long-acting oral morphine, a drug more akin to illicit heroin, might help reduce the drop-out rate in methadone and buprenorphine maintenance, offering a palatable treatment continuation route for some dissatisfied with methadone. In this study, all 12 patients who chose to change from oral methadone successfully switched over a few days with no major problems and most experienced greater satisfaction with the new regimen and felt it was more effective and improved their lives. The positive impacts on mood and sleep confirm results from previous trials, and might reduce the need to prescribe sedative, anti-anxiety and antidepressant medications, with consequent improvements in safety.

Before switching, two thirds hoped morphine might provide a route to reduce their heroin doses and gradually detoxify out of opiate substitution treatment. Indeed, after 10 weeks the average daily heroin dose had fallen significantly, and two patients had at least one day a week when they were no longer prescribed injectable heroin, allowing them to be injection-free on that day, as well as freeing the day for non-clinic pursuits. Another maintained a switch away from injecting altogether. In these ways, as anticipated by the patients, transferring from methadone to morphine allowed them to progress in their treatment plans – in particular, to move away from injecting, a valuable harm reduction step for injectors who cannot achieve abstinence. Moreover, the patients' clear preferences for morphine should improve compliance with treatment and reduce illicit drug use.

One challenge posed by this new treatment is the potential for misuse; injecting the oral formulation or crushing and chewing the capsule content delivers a sudden release of several times the oral dose equivalent, risking fatal overdose. In the study patients could not do this because all doses were supervised, an essential safeguard when there are concerns about treatment compliance and diversion of medications to unintended uses.

Findings logo commentary UK guidance on addiction treatment says that "Oral opioids other than methadone and buprenorphine, such as dihydrocodeine and slow release oral morphine (SROM) preparations, are not licensed in the UK for the treatment of opiate dependence and should not normally be used in the community." British Association for Psychopharmacology guidelines say slow-release oral morphine has been found as effective as oral methadone, but caution that in Austria the product has frequently been abused and dominates the black market. Guidelines produced for the World Health Organization agree that slow-release oral morphine has been found equivalent to methadone in suppressing heroin use but found the research base too thin to make any consequent recommendations. The experts convened by WHO also warned that prescribing this product is complicated by difficulties in supervising doses and in assessing heroin use [Editor's note: the latter because the presence of morphine could otherwise be used to indicate illicit heroin use, a problem which can be overcome].

Thanks for their comments on this entry to Alyson Bond of the Institute of Psychiatry in London, England. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 20 February 2013. First uploaded 20 February 2013

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Text-message-based drinking assessments and brief interventions for young adults discharged from the emergency department.

Suffoletto B., Callaway C., Kristan J. et al.
Alcoholism: Clinical and Experimental Research: 2012, 36(3), p. 552–560.
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 Suffoletto at suffbp@upmc.edu. You could also try this alternative source.

For the first time this US study tried mobile phone text messaging as a way to moderate the hazardous drinking of young adults screened at emergency departments. Compared to merely monitoring, text-based advice did cut drinking – but why did the monitoring-only patients actually start to drink more?

Summary Though recommended for US emergency departments, few have implemented formal screening to identify risky drinkers and even fewer then offer brief interventions in the form of short sessions of advice or counselling to reduce risk. Conducting brief intervention via a standardised mobile phone text messaging procedure could help overcome resistance from clinical staff who feel they have neither the time nor the expertise to discuss substance use with patients, and permit low-cost, large-scale implementation. For young adults in particular, text messaging may be preferable to face-to-face counselling.

This pilot study aimed to test the feasibility of brief text-message interventions for young adults identified as risky drinkers in emergency departments, and to gauge the impact to help guide the design of a larger study. It was conducted at three US emergency departments and trauma centres in Western Pennsylvania, where in 2010 research assistants asked 109 (all but three agreed) 18–24-year-old patients to complete a computerised screening assessment of their drinking over the past three months based on the Alcohol Use Disorders Identification Test-Consumption Questions In the UK the questions are:
How often do you have a drink containing alcohol?
How many units of alcohol do you drink on a typical day when you are drinking?
How often have you had [6 or more units if female; 8 or more if male] on a single occasion in the last year?
(AUDIT-C). This assessment consist solely of questions about drinking, not about its consequences which may not yet be evident among young people.

About half (52) the 106 respondents screened positive for hazardous drinking, Scored at least 4 for men and 3 for women. of whom 45 met criteria Six were excluded because of they were under psychiatric care and another one did not own a mobile phone. for the study, agreed to join it, and completed further baseline assessments of (inter alia) their drinking and related problems. Nearly two thirds were women and just 15% were unemployed. Their screening responses indicated that most drank at least twice a week and nearly half drank at least six standard US drinks 10–11 UK units. on a single occasion at least once a month. All were advised they could have significant problems related to their drinking and encouraged to talk to their doctors, and were sent and encouraged to read an alcohol advice booklet after discharge.

All further intervention occurred via text messaging over the 12 weeks after the patients had been discharged. The 45 participants were randomly allocated to three groups of 15. One set (the control A group of people, households, organisations, communities or other units who do not participate in the intervention(s) being evaluated. Instead, they receive no intervention or none relevant to the outcomes being assessed, carry on as usual, or receive an alternative intervention (for the latter the term comparison group may be preferable). Outcome measures taken from the controls form the benchmark against which changes in the intervention group(s) are compared to determine whether the intervention had an impact and whether this is statistically significant. Comparability between control and intervention groups is essential. Normally this is best achieved by randomly allocating research participants to the different groups. Alternatives include sequentially selecting participants for one then the other group(s), or deliberately selecting similar set of participants for each group. group) were simply texted reminders about the final assessment to be e-mailed to them 12 weeks after they had been recruited to the study. Another 15 (the assessment-only group) were weekly texted As long as they responded to an initial prompt. Texts were sent on the day after the weekday on which they typically drank the most. two questions, one about how often they had drunk over the past week, the other about their maximum single occasion consumption.

The final 15 (the intervention group) were sent the same questions, but an automated process then responded with texts depending on their answers. Those who had not drunk were congratulated, while those who had drunk moderately were told they were not drinking at a dangerous level and offered brief information about the risks of drinking. Full intervention was reserved for the (on different weeks) roughly 10–50% whose text responses indicated heavy At least five standard US drinks for men and four for women, about nine and seven UK units respectively. single-occasion drinking over the past week. They were texted a message expressing concern over their drinking and asked if they would be willing to aim this week to drink moderately. No more than four standard US drinks for men or three for women (seven and five UK units) in a day and no more than 14 drinks for men or seven for women (24–25 and 12 UK units) across the week. Those who were willing were texted a reinforcing message followed by computer-selected strategies for cutting down, such as keeping track of their drinking, setting goals, pacing and spacing, eating at the same time, finding alternatives, avoiding 'triggers', planning ways to handle 'urges', and refusing drinks. Those unwilling to aim to drink moderately were prompted to reflect on their decision by texts such as: "It's OK to have mixed feelings about reducing your alcohol use. Consider making a list of all the reasons you might want to change."

Main findings

In the circumstances of the trial (when participants were paid for responding), 12 of the 15 allocated to the intervention group responded completely to all 12 weekly text messages, as did 11 of the 15 assessment-only patients. Half the time intervention group patients responded that they were willing to aim for moderate drinking, and if they did, just 36% failed to meet this criterion in the following week compared to 62% who were not willing.

Text-messaged drinking assessments were available for assessment-only and intervention groups, but not for the control group. These indicated that without intervention, assessment-only patients typically drank heavily on a single occasion in seven of the 12 weeks of the study, but those also offered the intervention in just two weeks. These reports closely corresponded with the final results from a standard questionnaire sent by e-mail, and the patients involved said they had responded accurately and felt comfortable reporting how much they drank by texting.

Final and more comprehensive assessments completed by e-mail were available for 39 of the 45 participants, including control group participants who were neither texted questions about how much they were drinking nor offered any advice. The general picture was that drinking reductions were greatest among intervention patients, somewhat less among those in the control group, while on average assessment-only patients actually ended up drinking more heavily than before the start of the study, and did significantly worse than intervention patients. For example, on average intervention patients drank at their heaviest 2.1 Nearly four UK units. standard US drinks less than they had done before the study, control group patients 0.6 One UK unit. drinks less, but assessment-only patients 1.1 Two UK units. drinks more.

Asked at the end for their opinions, those offered the intervention messages said they were useful in cutting down their drinking. However, few patients (just eight of 26) had read the booklet they were sent.

The authors' conclusions

This study is the first to show that mobile phone text messaging can be used to collect drinking data from young adults over a 12-week period. Response rates to texts are better than found with interactive voice response systems and the responses appear valid as benchmarked against a validated and widely used assessment.

It was also the first to show that interventions based on the same technology are feasible and may be associated with reductions in hazardous drinking among young adults discharged from emergency departments, apparently via successful prompting to set a short-term moderation goal. This automated computer system could provide message-based feedback on drinking and support encouraging moderation on a large scale at minimal cost in money and emergency department staff time.

It remains to be explained why (unlike in other studies) assessment-only patients actually increased their drinking between baseline and final assessment. One possibility is that the weekly reports on their drinking submitted by the other two groups led them to be more accurate at the final assessment.

It should be acknowledged that the research assistants may have tended to select certain types of patients for the study. The intervention group too may have learned that under-reporting their drinking avoided follow-on messages. Group imbalances in gender or other characteristics may have affected the results, and lasting impacts remain unknown. Assessment-only and intervention patients were paid an additional $30 for completing responses to at least 10 of the 12 weekly text messages. Without this incentive, real-world response rates may be lower.

Findings logo commentary As the authors explain, this study was primarily a 'proof of concept' trial of the text-messaging system. It showed that with incentives in place, a high response rate was possible, but it is easy to imagine that without incentives the messages might have been ignored as frequently as the alcohol advice booklet the patients were sent. All the questions about drinking could be answered in private and the results known only to researchers. Had hospital staff been involved the responses might have been less frank and many fewer youngsters identified as hazardous drinkers.

The surprise in the study was an apparently counterproductive impact among assessment-only patients, whose drinking trends were on average worse than patients prompted weekly to at least record their drinking. From the charts in the article it seems this was due to a few patients who started the study drinking relatively little but then substantially increased. It seems possible that for them the reports they made simply reminded them how little they were drinking. Another possibility is that this was simply a fluke result which will not be replicated and might not have been found had the study recruited more patients.

The good and expected news was that the intervention group reduced drinking more than the assessment-only group, suggesting that over and above the assessment process, offering feedback and advice had a moderating influence on drinking among patients selected to be drinking at hazardous levels. This suggestion is tempered however by the fact that these patients did not reduce their drinking significantly more than control patients simply reminded about the final assessment. Also the difference in heavy drinking days between intervention and assessment-only patients became clearly apparent by the first week of the study. Since patients were reporting on the past week, this difference seems to have occurred before drinking could have been influenced by the first intervention messages.

While text-messaging studies are too few to have been reviewed, a synthesis of nine studies of computerised alcohol interventions for adult risky drinkers found that compared to no intervention they led to a statistically significant if moderate extra reduction in drinking. A findings hot topic entry on computerised interventions has concluded that though nobody is yet suggesting these can replace therapists for typical treatment populations, further down the severity and complexity scale, the evidence is growing that they have a place in a public health response to risky drinkers. The featured study allied computerised responses to text messaging, a convenient, non-intrusive and acceptable way to reach populations in the mobile phone era, and one which lends itself to the automatic collection and processing of data on drinking and responses to other questions.

Thanks for their comments on this entry in draft to the author Brian Suffoletto of the University of Pittsburgh in the USA and to John Cunningham of the Centre for Addiction and Mental Health in Toronto in Canada. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 12 March 2013. First uploaded 08 March 2013

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