Drug and Alcohol Findings home page in a new window EFFECTIVENESS BANK BULLETIN 19 January 2012

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.


Group motivational interviewing works for college drinkers ...

Drink moderation strategies ineffective unless students want to cut down ...

The vital task of promoting post-detox treatment ...

Should legal heroin be reserved for methadone failures? ...

What makes group MET work? A randomized controlled trial of college student drinkers in mandated alcohol diversion.

LaChance H., Feldstein Ewing S.W., Bryan A.D. et al.
Psychology of Addictive Behaviors: 2009, 23(4), p. 598–612.
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 Feldstein Ewing at sfeldstein@mrn.org. You could also try this alternative source.

US students who broke college drinking rules and were required to undertake an alcohol programme responded better to three hours of group motivational interviewing than six of alcohol education; enhanced confidence that they could resist risky drinking was the key. For colleges it offers an effective but economical response to problem drinkers.

Summary A review of studies of interventions to reduce drinking among college students found these on average worked best when they incorporated elements of motivational interviewing, and also when some techniques often used during this approach were included – specifically, feedback to the student on how their drinking compares to the norm, feedback on what the student expects from drinking or why they drink, and exercises weighing the pros and cons of drinking.

The review also found that face-to-face interventions and those delivered one-to-one had the greatest impacts on drinking. However, such interventions are not always feasible or cost effective. Court-referred or university-based alcohol education and diversion programmes are commonly provided in a group modality, and with some success have adapted motivational interviewing to this setting with consequent drinking reductions. But how they work is poorly understood. Studies to date have highlighted the impact on social and enhancement motives for drinking but found no support for other expected mechanisms such as enhancing readiness to change one's drinking. Knowing more about the mechanisms should enable us to develop more effective interventions and/or training for interventionists.

To explore these mechanisms, at a US university the study successfully They completed baseline assessments and interventions. recruited 206 students required to attend alcohol education classes as one of the sanctions for minor underage drinking infractions of the institution's rules. They were randomly assigned to one of three small-group interventions:
• the university's standard two three-hour interactive alcohol education groups;
• one three-hour motivational interviewing session; or
• one three-hour lecture-format alcohol information session.

Responses from baseline questionnaires were used to create personal feedback handouts for students assigned to motivational interviewing on how their drinking compared to national averages. During the group, exercises conducted along motivational lines involved responses written on board so all the group could evaluate and discuss, and finally help each other develop strategies to alter high-risk drinking, substance abuse, and risktaking. Neither of the other two group options featured individualised information or collaborative harm reduction exercises and discussions.

Follow-ups which re-assessed drinking were completed via the internet three and six months later when responses were received from 80% and 76% respectively of the students.

Main findings

Questionnaires completed before and immediately after the sessions were used to assess whether they had led to the intended changes in the psychological mechanisms thought to account for any impacts on drinking.

Contrary to expectations, readiness to change drinking and estimates of how much students drink "when they party" were unaffected. However, there were differential effects on the students' feelings that they could resist drinking ('self-efficacy') under different circumstances. Whether this was when under social pressure to drink, under stress, or just when the opportunity presented itself, self-efficacy had increased most But not always to a statistically significant degree. after the motivational groups. Assessments of the risks posed by drinking also rose most after these groups, though expectations of the positive effects from drinking weakened equally after motivational or standard education groups.

At both follow-ups, all three measures of drinking risk and problems (AUDIT scores indicative of risky drinking, intensity of drinking on drinking days, and alcohol-related problems) had fallen most steeply after the motivational groups. The impacts of the other two groups were roughly equivalent or somewhat greater after the education sessions than the information lecture. Generally the advantages gained by the motivational sessions were statistically significant and substantial.

With both drinking, and some mechanisms thought to underlie drinking, changing more after the motivational sessions, the question arose whether it could be shown that those mechanisms accounted for the greater impacts on drinking of the motivational sessions. The analysis showed that students who after the interventions had relatively high self-efficacy to resist drinking, lower estimates of what partying students typically drank, and lower readiness to change Perhaps because this measure included awareness of drink problems. their drinking, drank less and less problematically (an amalgam of all three alcohol-related measures) at the follow-ups. However, only self-efficacy combined across the three types of circumstances which might promote drinking accounted at least in part for the greater impact of the motivational sessions on drinking and drink-related problems.

The authors' conclusions

Compared to extended alcohol education or information, at both follow-ups students randomly assigned to a motivational session drank less problematically in terms of symptoms of hazardous drinking, alcohol-related problems, and average drinks per drinking day, strengthening the implication from other studies that group motivational interviewing promises to offer a cost-effective response to students required to attend an alcohol programme.

For several reasons these findings are clinically significant. First, they show (contrary to some studies) that high-risk drinkers can respond well to a single motivational session, including sustained, significant and unusually substantial changes in drinking. Across each of the problem drinking measures, the motivational groups were the only ones to consistently evidence significant reductions. Also they did so in ways critical to reducing alcohol-related risk behaviours and associated problems for high-risk drinkers, changes which should reduce their risk of further infractions of college rules.

Other research has highlighted the critical role of self-efficacy in drinking reductions and its involvement in mediating the impact of motivational interventions. Confirming these findings, the featured study found that college drinkers required to undertake an alcohol programme who completed a single group motivational session developed (over and above the impacts of education or information alone) a significantly stronger sense of self-efficacy to refuse drinks across high-risk situations, including social pressure, stress, and drinking opportunities. This bolstering of self-efficacy was in turn associated with more positive drinking outcomes three and six months later.

Positive, mutually reinforcing interactions in the motivational groups may account for these findings. Unlike students in the other groups, motivational participants were asked to generate creative ideas about how they would avoid excessive drinking in typical college situations. They brainstormed ways to do so which to them were realistic and practical, created by themselves and their peers, and which they could own. They also helped each other find solutions they may not on their own have come up with or felt confident enough to mention. Armed with this real-life expertise and after seeing that fellow students in their position felt the strategies would work, they felt more confident that they could avoid 'doing too many shots', 'chugging' (consuming a whole drink in one go), or 'getting hammered'.

Given these findings, universities hoping to reduce drinking among high-risk drinkers should seriously consider group motivational interventions focused on bolstering students' confidence that they can curb their drinking.

Findings logo commentary The findings exemplify what is the most consistent advantage of interventions based on motivational interviewing – that they achieve results generally at least as good as other approaches but in less time, so potentially more economically.

Economy is also improved by the group format. The risk is that bringing heavy and/or risky substance users together will create social justifications and pressures for continued heavy use and make this seem more, not less 'normal'. But when the participants have a joint reason to collaborate in curbing their substance use – typically when they have voluntarily entered treatment with this objective in mind – in studies which directly compared them, group psychosocial therapies have been found equivalent to individual approaches in retention and substance use outcomes. However, such studies are usually limited to comparing outcomes among clients prepared to be randomised to either treatment. Those with strong preferences or practical reasons for choosing one of the formats have been excluded or excluded themselves.

Last revised 16 January 2012

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STUDY 2009 Thinking about drinking: need for cognition and readiness to change moderate the effects of brief alcohol interventions

REVIEW 2012 Efficacy of brief alcohol screening intervention for college students (BASICS): a meta-analysis of randomized controlled trials

REVIEW 2010 A review of motivational interviewing-based interventions targeting problematic drinking among college students

STUDY 2010 Clinical outcomes of a brief motivational intervention for heavy drinking mandated college students: a pilot study

REVIEW 2014 Interventions to reduce substance misuse among vulnerable young people

STUDY 2009 Dismantling motivational interviewing and feedback for college drinkers: a randomized clinical trial

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

STUDY 2010 Brief physician advice for heavy drinking college students: a randomized controlled trial in college health clinics

STUDY 2014 Web-based alcohol screening and brief intervention for university students: a randomized trial

REVIEW 2015 Electronic interventions for alcohol misuse and alcohol use disorders: a systematic review

Drink less or drink slower: the effects of instruction on alcohol consumption and drinking control strategy use.

Sugarman D.E., Carey K.B.
Psychology of Addictive Behaviors: 2009, 23(4), p. 577–585.
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 Carey at kbcarey@syr.edu. You could also try this alternative source.

What happens when instead of asking students to cut drinking, you ask them to use more moderation strategies such as spacing or avoiding heavy drinking situations? The results of this US study suggest that changes in strategy use may bear little relation to changes in drinking, and that intention to cut back is the most important factor.

Summary Studies have not consistently found that teaching college students strategies to moderate their drinking are actually followed by less drinking, and students who use these strategies more intensely do not necessarily drink less. Such strategies include spacing out drinks, drinking slowly, refusing drinks or spirits in particular, eating before drinking, finding non-alcoholic alternatives, and avoiding drink-promoting situations. Some studies have found that moderate use of such strategies is associated with less drinking than using them very little or very much. On the other hand, at least one study found that mailed feedback on their drinking did curb college student drinking, and seemingly did so because it promoted the use of protective strategies.

The featured study at a US college sought to clarify the relation between strategy use and drinking by instructing students to either use more strategies or to drink less. Issues addressed included whether using more or certain kinds of strategies would reduce drinking, and whether more and what types of strategies were used when the student was trying to cut down.

The study recruited 177 mainly female and campus-resident college student drinkers aged at least 18. At first they reconstructed the amount they had drunk over the past two weeks as a baseline against which to assess whether in the following fortnight they changed the amount they drank. During the fortnight all were asked to record each day how much they had drank and what moderation strategies they had used. Following the initial assessment, they were allocated at random to merely conduct this monitoring, or additionally to an instruction to over the next fortnight halve the amount they drank, or to double their use of a list or moderation strategies. Over 80% returned to be re-assessed at the end of the fortnight.

Main findings

At baseline, across all students the more often they used strategies to avoid drinking (like refusing drinks or spirits) on average the less they drank, while those who used more strategies to moderate the effects while actually drinking (such as drinking slowly or eating before and during drinking) drank more.

The instructions they then received did alter both drinking and strategy use as intended. Asked to cut their drinking, 68% did so to some degree but just 50% asked merely to monitor their drinking. Asked to increase strategy use, 84% did so to some degree but just 55% asked merely to monitor their drinking.

However, there were clear drinking reductions only among the students directly asked to drink less. Only they reduced their average weekly intake to a statistically significant degree, and only they did so more than the students asked merely to monitor their drinking. Also, only they reduced their estimated average and peak blood alcohol levels.

Of the different types of strategies, avoiding drinking, moderating effects while drinking, and participating in non-alcoholic leisure time activities were all increased most by the students specifically asked to do so. Only the first type – avoiding drinking – was increasingly adopted by students asked directly to drink less.

Changes in how often students deployed these strategies were however unrelated to changes in their drinking, and this was the case across all students and within the groups asked either to cut back or use more strategies.

The authors' conclusions

Instructions to reduce drinking had the intended effect, largely because students reduced how much they drank when drinking heavily. As other studies have found, this shows that college students can and will voluntarily reduce their alcohol use even in the absence of incentives to do so. More often avoiding situations where heavy drinking might occur was the way they sought to cut back, though there was no evidence that this did actually cut their drinking. Asking students instead to used more strategies to moderate or avoid drinking also had the intended effect, but no impact on drinking itself. The implication seems to be that promoting drinking control strategies alone is unlikely to reduce drinking unless the student actually intends to cut back. Instead the combination of trying to reduce alcohol use and using avoidance strategies may be more effective than exhortations to increase strategy use in general.

Last revised 13 January 2012

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STUDY 2015 Improving social norms interventions: rank-framing increases excessive alcohol drinkers’ information-seeking

STUDY 2009 What makes group MET work? A randomized controlled trial of college student drinkers in mandated alcohol diversion

STUDY 2014 Web-based alcohol screening and brief intervention for university students: a randomized trial

STUDY 2010 Brief physician advice for heavy drinking college students: a randomized controlled trial in college health clinics

STUDY 2013 Alcohol assessment and feedback by email for university students: main findings from a randomised controlled trial

STUDY 2010 Web-based alcohol prevention for incoming college students: a randomized controlled trial

STUDY 2009 Dismantling motivational interviewing and feedback for college drinkers: a randomized clinical trial

REVIEW 2014 Interventions to reduce substance misuse among vulnerable young people

REVIEW 2012 Efficacy of brief alcohol screening intervention for college students (BASICS): a meta-analysis of randomized controlled trials

STUDY 2011 Fidelity to motivational interviewing and subsequent cannabis cessation among adolescents

Transitioning opioid-dependent patients from detoxification to long-term treatment: efficacy of intensive role induction.

Katz E.C., Brown B.S., Schwartz R.P. et al.
Drug and Alcohol Dependence: 2011, 117, p. 24–30.
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 Katz at ekatz@towson.edu. You could also try this alternative source.

The drive in Britain to increase drug treatment exits will mean more patients detoxifying and in need of being linked to effective follow-on care to safeguard their lives and their recovery. Evidence from the USA that a simple counselling intervention can help make that vital link.

Summary The featured study tested two ways of promoting follow-on treatment after patients have been withdrawn (or 'detoxified') from opiate-type drugs – attempts to stabilise their abstinence and avoid the relapse which commonly follows withdrawal. Such initiatives are needed because by itself detoxification usually fails to lead to follow-on treatment. The study builds on previous work showing that involvement in long-term treatment following detoxification can be enhanced by methods including case management to coordinate care from various sources, and role induction counselling, which aims to establish a collaborative relationship within which the dependent user sees themself as a patient in need of further treatment.

Prior research from the same team had established that outpatient treatment entry and retention were promoted by a single role induction session with the counsellor who would also conduct the treatment, offered when the patient first attended to apply for treatment. Also in Baltimore, the featured study tested a similar but more extensive intervention as a means of promoting treatment engagement during and after a 30-day opiate detoxification involving stabilisation on buprenorphine/naloxone ('Suboxone') and then tapering doses. Also tested was whether adding case management would further improve engagement.

At the outpatient centre, between 2005 and 2008, 240 patients who had opted for a buprenorphine-based detoxification qualified for and joined the study. Typically unemployed and unmarried black men and women in their early 40s, all the patients tested positive for opiates and used these drugs almost every day, and 55% were also positive for cocaine. On average they had two prior detoxifications.

The day after medical assessment and their first dose of medication, patients were assigned at random to three types of counselling conducted over five weekly sessions by the counsellor who would care for them during and after detoxification:
• the clinic's usual counselling beginning later in the first week of treatment, focused on the disease model of addiction and addressing issues and concerns raised by patients;
• intensive role induction, the first session of which took place on the same day as their medical assessment; guided by a manual, counsellors educated patients about detoxification and treatment, addressed their concerns and barriers to continued treatment, and emphasised the value of continuing care beyond detoxification to solidify recovery;
• intensive role induction combined with case management, both delivered by the same counsellor in the same sessions starting on the same day as the medical assessment; the case management elements aimed to promote (through advocacy and other concrete means) access to community resources (not just those available at the clinic) which might support the patient's efforts at recovery.

To avoid obscuring distinctions between the three counselling options, different counsellors were trained in and delivered each option. All the patients were also offered intensive outpatient group therapy for the five weeks of detoxification, and afterwards at least weekly individual and group counselling for an expected six months or indefinitely if needed.

Main findings

Compared to usual care, during detoxification both the tested interventions significantly increased (from on average two to just over three) the number of counselling sessions patients attended. Patients offered intensive role induction (but not when it was combined with case management) were also significantly more likely (68% v. 49%) to complete Meaning they missed at most two medication doses. the detoxification process. However, this finding narrowly missed the study's criterion for statistical significance (though it remained a noteworthy tendency) when differences between patients had been taken in to account.

Compared to usual care, following detoxification role induction patients were non-significantly more likely to attend at least one session of follow-on treatment, though this finding failed to meet the study's criterion for a non-significant tendency after differences between patients had been taken in to account. Specifically, Personal communication from the corresponding author, January 2012. nearly 55% of role induction patients attended a session compared to 41% after usual care. Role induction patients also stayed in treatment significantly longer – on average 35 versus 16 days. Though a month in to their treatment the three groups of patients were equally satisfied with treatment, role induction patients felt significantly greater rapport with their counsellors then usual care patients. Again, all these differences were smaller and failed to meet criteria even for a non-significant tendency when role induction had been combined with case management.

The authors' conclusions

Role induction led to the greatest engagement with treatment. Compared to usual care, these patients on average attended more counselling sessions during detoxification, were more likely to complete detoxification, rated their counsellors more favourably, and remained in treatment for longer following detoxification. Role induction combined with case management was less effective, significantly improving only counselling attendance during detoxification. The intensive form of role induction tested in the study may in these ways help transform the role of detoxification from a palliative to that of preparing patients to take greater advantage of longer term treatment.

Counsellors may have found it difficult to maintain quality when combining the rather different ways of working of role induction and case management within the same limited time frame, undermining the effectiveness of both interventions. Also, case management can generate frustration when community resources the patient has been led to hope for and expect are not available, perhaps why counsellors offering this combination were not rated more favourably than counsellors offering neither.

However, the advantage gained by role induction may have been partly due to the first session being scheduled the same day as the medical assessment and first dose of medication rather than several days later. All patients offered this early session with or without case management attended at least this one, but about a third of usual-care patients did not attend any counselling sessions. This would not however account for the relative failure of the combined intervention.

In sum, the study showed that a role induction intervention which staff find easy to implement and integrate in to their programmes can enhance patient involvement in detoxification as well as their transition to longer term treatment.

Findings logo commentary The timing of the first session of counselling seems likely to at least partly account for the advantage both tested interventions had in terms of counselling attendance during detoxification. Placing this to one side, the remaining ways role induction significantly bettered usual care after differences between patients had been taken in to account were confined to an extra on average across all patients two to three weeks in post-detoxification care, or three to four weeks among those patients who actually started The corresponding author (personal communication 16 January 2012) explained that the averages quoted in the paper included 0s for non-attenders. From those and the numbers who attended at least one session (34 of 83 usual care; 44 of 81 role induction; personal communication from corresponding author 16 January 2012) it can calculated that people who did attend post-detoxification treatment stayed for 39 days after usual care and 64 after role induction. this care, plus greater rapport with counsellors than usual care patients. Both impacts are worth having, but perhaps constitute an insufficiently consistent impact to make adoption of this five-session intervention seem essential to detoxification services aiming to promote completion and aftercare. In particular, even after intensive role induction, nearly half the patients did not go on to attend a single aftercare session.

The surprise in the study is that adding case management to role induction weakened the impact of the former and possibly also of the latter. Rationalising this, we can appreciate that in the same time (an hour) other counsellors had to devote to simpler tasks, the counsellors had to undertake the usual role of counselling at the clinic, to implement the additional role induction elements, and then to seek to engage outside services via case management. Role induction can be seen as systematising what counselling tries to do anyway, building on a familiar patient education and informing role. As well as cutting time for other tasks, case management would have taken some counsellors (and perhaps patients too) beyond their comfort zones and in to direct engagement with external services, yet without the time and resources to make this work. This post hoc speculation may not be valid, but still the finding stands as a caution against attempting too varied a therapeutic agenda.

While case management did not promote engagement with services provide within the agency the patient was already attending, this is not its primary role or primary effect. It remains possible that the case management elements promoted linkage with external services and perhaps thereby promoted improvements in the patients' lives.

The need to promote aftercare

Completion rates for opiate detoxification vary considerably. In Britain for example, one study found that 60% of outpatients who chose their detoxification medication completed, as did 65% who accepted random allocation and were randomised to buprenorphine. Completion rates may have been elevated by careful pre-detoxification preparation, including elements of role induction and encouragement to reduce heroin intake, initiation by an experienced clinician, and daily clinical contact. In contrast, at another clinic just 36% of outpatients who sought detoxification from methadone maintenance completed the process, which was based on the palliative medication lofexidine, a less effective option than tapering doses of opiate-type drugs.

Completion is of course just the first phase. Without further support – and even when this is on offer – only a minority of patients can sustain opiate abstinence. In the British trials referred to above, in the first about a fifth of patients were abstinent from illicit opiates a month later without further treatment; at the same time in the second, 12% were neither using illicit nor prescribed opiates. Some form of follow-on care is especially important for patients who complete detoxification and leave devoid of the protection afforded by their previous tolerance to opiate-type drugs. Without effective support, the high rate of relapse can translate in to a high rate of overdose deaths.

Ways to promote aftercare

As the authors of the featured study point out, role induction is just one way of promoting aftercare. The various methods are not mutually exclusive and can have an additive impact, as demonstrated at the Salem Veterans Affairs medical centre in the USA. The centre offers a 28-day residential rehabilitation programme to its alcohol and/or drug dependent ex-military patients. To sustain sobriety, staff stressed the importance of aftercare but attendance was poor. A unique series of studies found that attendance radically improved as step by step researchers added enhancements, culminating in a report which suggested that there were consequent reductions in drinking and related problems. The steps included a contract asking patients to commit in writing (witnessed by the therapist) to regularly attend specified aftercare sessions plus education emphasising that this promotes abstinence, a reminder system featuring personal letters from the therapist, appointment cards, and automated telephone reminders prompting patients to attend the next session in a few days time, and awards consisting of medallions and certificates handed out during aftercare sessions. Further reinforcement took the form of a handwritten letter congratulating the patient on initiating aftercare followed by another after three sessions.

These and other methods including motivational interviewing, regular check-ups of whether how the patient is doing and whether they need further support, and incentives for therapists to promote aftercare, were among those trialled in the studies included in a US review which confirmed that promoting aftercare generally improves substance use outcomes. It found 11 studies which allocated patients at random or in a quasi-random manner to aftercare or continuing care versus minimal or no continuing care. In terms of each study's main substance use outcome measures, seven of the 11 found a clear and statistically significant advantage for continuing care. The review's conclusions were endorsed by a panel of experts convened by the US Betty Ford Institute, who argued that extended and regular monitoring of the patient's progress was the key component of continuing care and the one with the greatest evidence of effectiveness. Both review and recommendations were based largely on studies of aftercare following residential treatment.

UK guidance and policy

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

This caution may become more relevant as services respond to the national UK drive to increase the proportion of patients who leave treatment. For opiate dependent patients, this will normally be via detoxification. If these numbers increase, aftercare too will increasingly be needed to safeguard the progress made during detoxification as well as health and lives, and to promote and embed recovery. But continuing/after care provision runs up against a strong contrary trend in current UK policy, which emphasises not continuing care, but exit from the treatment system. Without denying the need for long-term care for some patients, the English strategy on drug misuse said services needed "to become much more ambitious for individuals to leave treatment free of their drug or alcohol dependence so they can recover fully". Scotland's strategy too stressed the need for more patients to "move on from their addiction towards a drug-free life as a contributing member of society", implying a corresponding shift away from extended and/or indefinite treatment.

In both countries reintegration in to mainstream society and especially in to employment are seen as the bulwarks which can help prevent relapse and relieve the need for extended care. Much will depend on the receptivity of the broader society to the relapse-preventing reintegration of problem substance users, and especially problem drug users. Without sufficient receptivity in the form for example of routes in to suitable work opportunities, decent and stable housing, and social acceptance and support, extended care may be the most realistic way The article cited first in this paragraph put it this way: "But as the task of change becomes harder (i.e. dependence is greater), and the environment is less supportive, the intervention itself must become more extensive to compensate. Put another way, if the environment lacks positive enduring features, then the intervention must become one. This is what we mean by 'extensity'". to prevent or intervene early in health- and life-threatening relapse.

Thanks for their comments on this entry in draft to Elizabeth Katz of Towson University in the USA and Wouter Vanderplasschen of the Universiteit Gent in Belgium. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 18 January 2012

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

Haasen C., Verthein U., Eiroa-Orosa F.J. et al.
European Addiction Research: 2010, 16, p. 124–130.
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 Haasen at haasen@uke.uni-hamburg.de.

Uniquely among modern heroin prescribing trials, the trial in Germany was not confined to heroin-addicted patients who had done poorly on methadone, offering the opportunity to assess whether heroin should be reserved for these patients. The conclusion was that other patients too benefit more from injectable heroin than oral methadone.

Summary This account also draws on the main report from the trial of which the featured report was a sub-study. The study trialled the prescribing of heroin for the treatment of heroin addiction at seven German clinics. Over the years 2002 and 2003 it successfully recruited 1015 patients who were continuing to regularly inject heroin and were in poor physical or mental health despite currently being in methadone maintenance treatment, or having been treated for their addiction in the past but not in the last six months. Uniquely among modern trials, because the past treatment need not have been opiate substitute prescribing, the trial was not confined to patients who had previously done poorly on methadone, offering the opportunity taken by the featured report to assess whether heroin prescribing should be reserved to these patients.

Patients were randomly allocated to either be prescribed heroin to be taken under supervision at the clinics plus oral methadone, or only oral methadone. Cutting across this allocation, they were also randomly allocated to two forms of psychosocial support: case management conducted along motivational interviewing lines and intended to flexibly coordinate an individualised care package from various services; or a more standard and directly delivered series of individual counselling and group therapy sessions. Which of these support programmes a patient was allocated to made no difference to the main outcomes, so reports have focused on the pharmacotherapy options.

Main findings

Over the next year 67% of the heroin patients remained in treatment but just 40% offered only methadone, a difference largely due to the 29% offered methadone who did not even start the treatment. Heroin enabled more patients than methadone (69% v. 55%) to substantially curb illicit heroin use without countervailing increases in cocaine use, and more heroin patients experienced improved health. If both together were considered the criterion for success, this was achieved by 57% on heroin but only 45% on methadone. However, many methadone patients also substantially cut their heroin use and experienced improved health despite previous treatment having left them still dependent on heroin.

% substantially curbing heroin use without countervailing increases in cocaine use

The main report on the trial records that the heroin option was not significantly more or less advantageous for patients recruited from methadone programmes versus those not in treatment at all for at least the past six months. The featured report took this analysis a step further by identifying who among the 'not in treatment patients' patients had never been in methadone maintenance treatment. How they responded to the offer of heroin could then be compared against the rest of the sample who had previously experienced methadone.

Around half the no-prior methadone patients stayed in treatment for the full 12 months of the follow-up regardless of whether they had been allocated to heroin or methadone. In terms of substantially curbing their heroin use without countervailing increases in cocaine use ( chart), patients with no previous experience of methadone maintenance were slightly more likely to do better if offered heroin as those previously on methadone, and on heroin they also committed crimes less frequently. Towards the end of the one-year follow-up, they also experienced non-significantly better health if prescribed heroin, and used cocaine less frequently. But it was also the case that – for the first time – trying methadone in the context of the trial also had a substantial if lesser impact on all these outcomes.

The authors' conclusions

The featured study was the first to analyse the effects of heroin prescribing treatment in patients with no previous experience of opiate substitute prescribing programmes. Its findings show that such patients benefit from both heroin prescribing and methadone maintenance to almost the same degree as patients previously in methadone maintenance treatment. Despite having no personal negative experiences with methadone, these patients also respond better to heroin prescribing than to methadone in terms of reduced illicit drug use and illegal activity, generally considered the two main goals of maintenance treatment. These differences could not be explained by greater retention on heroin, since retention was roughly the same on methadone. Possibly the prospect of either being allocated to heroin or, if not, switching to this option after a year, attracted patients in to maintenance therapy which they had previously avoided, and helped retain them even when they had been allocated to methadone. If this was the case, the possibility of heroin prescribing played a valuable role in encouraging treatment entry, and actually being prescribed heroin benefited more patients than oral methadone only.

These results call in to question whether heroin prescribing should only be implemented only as a second line treatment following the failure of methadone programmes, or whether it should be made available to all chronic, severely opioid-dependent patients, regardless of their previous experience with methadone treatment.

Findings logo commentary No studies have directly assessed how wide is the caseload who could benefit from heroin substantially more than from the best feasible oral methadone regimen. Only Britain in the 60s and 70s has experience of heroin prescribing as a truly front line specialist treatment for heroin addiction, deployed to attract addicts in to the newly established drug dependence clinics. In these special circumstances it fulfilled that role, but doctors rapidly moved patients on to the new oral methadone option pioneered in the USA, an attempt to engineer a more therapeutic and normalising regimen which made drug use, the effects of drugs, and particularly injecting, less central to patients' lives.

In those days supervised consumption was a rarity. Today with national authorities insisting on or encouraging supervision, heroin prescribing is less of an incentive to enter treatment because it entails twice-daily clinic attendance – a substantial disincentive, and one reason why trials have found it very difficult to recruit patients. On the other hand, one of the main reasons for insisting on supervised consumption – to avoid heroin being diverted on to the illicit market – is less salient because illicit heroin is so widely available that a little spillage from clinics could make little difference to the size of the addiction problem. Nevertheless, other reasons for supervising consumption and the need for clinics to sustain public and political support seem likely to continue to mandate supervision, at least initially.

A key question about heroin prescribing – whether it should be reserved to patients who have repeatedly done poorly on methadone, or used to attract patients suffering badly from their addiction but who will not engage with methadone – cannot be decided on the basis of the available research in to its effectiveness, partly because this aspect has not been adequately researched, and partly because many other important considerations influence that decision. Some of the issues are explored further below; in the current climate, the decisive factor seems likely to be cost rather than cost-effectiveness.

Only for methadone's failures?

Across all studies to date, a synthesis of findings published in 2010 found Sometimes depending on the selection of studies and sometimes not quite to a statistically significant degree. that prescribing heroin as opposed to oral methadone to patients who have generally not done well in methadone programmes promotes retention, reduces the risk of relapse to illicit heroin use, and reduces crime – consequences (which also extend to improved health and social situations) partly due to longer retention, and partly to the greater impact of heroin prescribing even among patients still in treatment. The analysts' conclusion was that heroin prescription should remain a treatment of last resort for people failed by conventional maintenance treatment. Similar conclusions are found in UK national clinical guidelines and in guidance issued by England's National Treatment Agency for Substance Misuse. In particular, the latter is clear 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.

Relatively high cost, the risk of perpetuating injecting, the heavy responsibility placed on staff to safeguard lives during the injections they supervise, and the burden on patients required to attend the clinic to take their heroin, are among the reasons why heroin prescribing is seen as a niche last resort for methadone's failures. But this also means patients are forced to suffer life-threatening failures in methadone programmes before being offered heroin, and that others who could have benefited from heroin will not be offered it because they are so averse to methadone that they have never engaged with that treatment. It is this dilemma which the featured study addresses, finding evidence which calls in to question the need to insist on prior failed methadone tretments.

However, even in this study heroin prescribing was very far from a front line treatment. It was implemented only after prior treatments had failed to create or sustain recovery from heroin addiction, for patients who injected their drugs, had been dependent on opiate-type drugs for at least five years and regularly using heroin for on average over ten, and who generally also used other drugs, including cocaine and benzodiazepines. This background had left them all with poor mental and/or physical health (a requirement for joining the study) and generally they were in a very poor state on both fronts, including eight in 10 infected with hepatitis C. In other words, even in this study heroin prescribing was a second line treatment implemented well in to the addiction careers of patients who had shown themselves willing to continue to inject heroin nearly every day despite very serious ill health and prior attempts to stop.

Though the study was not set up to test the impact of prior failed methadone treatment, random allocation should have meant that differences between patients could not account for any extra benefit of prescribing heroin compared to methadone. Confirming this expectation, on all but one of 22 variables assessed by the study, the no-prior methadone patients allocated to heroin did not significantly differ from those offered only methadone.

The most recent British trial was confined to people continuing to inject illicit heroin despite being in methadone treatment, but it too offered some evidence that heroin can attract and retain patients who would not engage with oral methadone. The questions posed by the study were whether patients who remained wedded to illegal heroin despite extensive treatment were simply beyond available treatments, whether they needed injectable medications, or whether it was just that their current oral treatments were sub-optimal. For some, each of these three propositions was true. 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, psychosocial support and treatment planning in a continuing oral methadone programme. But despite these attempts to make the most of oral methadone, nearly half the patients only did well if prescribed injectable medications. A subsidiary finding was the unacceptability of oral methadone to many patients who did not start the treatment or who did but attended poorly, a sign perhaps that addicts who reject methadone maintenance, as well as those who try it but do not do well, may benefit from being prescribed heroin. Since missed urine tests were counted as positive, the unacceptability of methadone may have accounted for much of the greater reduction in illicit heroin use when the drug was legally prescribed.

Last revised 12 January 2012

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