Drug and Alcohol Findings home page in a new window EFFECTIVENESS BANK BULLETIN 19 August 2011

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


Contents

Preventing drinking and drug use among students in London

This bulletin highlights three attempts to prevent substance use among London school or college students. The first two used the same system to adjust counselling to the personality of the student and had at least some short-term success, even when using school staff as counsellors. The third individualised the approach via motivational interviewing but without success. From a different domain entirely is the latest from the Scottish national drug treatment evaluation focusing on the possible impact of aftercare.

Benefits of fine-tuning prevention to high risk personality traits ...

Benefits fade after fine-tuning prevention to high risk personality traits ...

Motivational interviewing leaves college students unmoved ...

Aftercare associated with better treatment outcomes in Scotland ...


Personality-targeted interventions delay uptake of drinking and decrease risk of alcohol-related problems when delivered by teachers.

O'Leary-Barrett M., Mackie C.J., Castellanos-Ryan N. et al.
Journal of the American Academy of Child & Adolescent Psychiatry: 2010, 49(9), p. 954–963.
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 Conrod at patricia.conrod@kcl.ac.uk. You could also try this alternative source.

Addressing the substance use promoting tendencies of the personality traits of London secondary school pupils at particular risk of substance misuse led to fewer drinking and, among the drinkers, fewer drinking heavily. The study showed that school staff could effectively conduct the focus group interventions.

Summary An alternative to prevention approaches applied to all children whatever their risk levels, the Preventure programme is a short intervention which targets youngsters who score highly on four personality dimensions which make different kinds of early-onset substance use and other risky behaviours particularly rewarding or hard to resist. As assessed by the Substance Use Risk Profile Scale personality questionnaire, these traits are:
Hopelessness A tendency to unhappiness, depression and feeling a failure, feelings relieved by intoxication;
Anxiety-sensitivity Fear of anxiety-related bodily sensations due to beliefs that such sensations will lead to catastrophic outcomes, for which substance use can represent a form of self-medication;
Impulsivity An inability to restrain seeking gratification in the presence of immediate rewards (such as the feelings available through substance use) despite longer term negative consequences; and
Sensation-seeking Desire for intense and novel experiences, which can be expressed as a desire to 'get high' through drugtaking or heavy drinking.

The Preventure intervention

The manualised Preventure intervention addresses these risk factors by drawing on psychoeducational approaches, motivational enhancement therapy, and cognitive-behavioural therapy, applied to real-life scenarios shared by high-risk young people in Britain. As implemented in the featured study, it occupied two 90-minute focus groups of on average six pupils led by two trained facilitators. Groups were formed of pupils who shared elevated scores on the same personality dimension, and the variant of the intervention applied to that group particularly targeted that dimension and the associated risks. In the first session participants were guided in a goal-setting exercise to enhance motivation to change behaviour, taught about the personality dimension and how it can predispose to problematic coping behaviours, and guided in breaking down personal experience according to the physical, cognitive, and behavioural components of an emotional response. All the exercises were specific to the personality risk factors identified in the children. The second session involved identifying and challenging personality-specific cognitive distortions which lead to problematic behaviours.

Preventure interventions have been found to prevent the onset and escalation of drug use over the following two years, but so far only as delivered by skilled research therapists. The featured study tested whether school staff, with moderate levels of training and expertise and competing responsibilities, could be trained to effectively deliver this unfamiliar interactive, small group intervention. Another issue was whether pupils would be open with adults who may hold disciplinary positions. On the other hand, it was possible that the teachers' familiarity with their pupils would aid participation, and provide a platform for later addressing individual problems.

The study

Across nine randomly selected London boroughs, 21 randomly selected secondary schools were asked to join the study and randomly allocated to the Preventure intervention or to act as 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. schools which simply carried on (as all the schools had to) with the drug education components Basic facts and laws about alcohol, tobacco, and illicit drugs, information about detrimental health effects from abuse and misuse, typically taught throughout the year as part of the science, citizenship and personal, social, health and economic wellbeing curricula, or as specific drug education focus days. required by the national curriculum. Three schools could not be included in the featured analyses, leaving 18 schools and 2506 of the original 3021 year nine (ages 13–14) pupils. Of these pupils, 1159 or just under half scored as high risk on the Substance Use Risk Profile Scale; their responses were the basis for the featured report. 1008 could be followed up six months later; the probable responses of the remainder were estimated on the basis of earlier assessments and other data.

School staff running the Preventure intervention were trained in a three-day workshop followed by at least four hours of supervised practice and feedback on their performance while practising the full intervention with year 10 pupils from their schools. Though broader and longer-term outcomes are being assessed, the featured report focused on drinking six months post-intervention.

Main findings

Over 8 in 10 of the school staff members in the study completed training and supervision and qualified to facilitate the intervention. Each conducted on average six intervention sessions. Researchers observed at least one session by each facilitator. They judged that two thirds of the sessions had covered most of the core components of the intervention, and that two thirds also had been delivered in ways which embodied the required counselling skills of listening, enabling, involving the entire group, and being inquisitive and empathic. Facilitators themselves were all rated as at least satisfactory as cognitive therapists.

% of drinkers and binge drinkers at baseline and follow-up

As expected, at the start of the study more of the high risk than the lower risk pupils (41% v. 32% ) had drunk alcohol in the past six months and more too had drunk heavily during that period (22% v. 12% ), defined as at least five drinks at one sitting for boys and four for girls. Six months later and compared to control schools, in schools allocated to Preventure the increase in the proportion of high risk pupils who were drinking was significantly less steep (rising from 43% to just 50% v. from 38% to 57%) chart. Narrowly missing statistical significance was a similar disparity in trends in the proportion drinking heavily across the entire population of high risk pupils; in intervention schools this rose from 22% to 25%, in control schools, from 21% to 28%.

A second set of analyses focused on the four in ten high risk pupils drinking at the start of the study. Among these drinkers, the proportion later drinking heavily actually fell in Preventure schools (from 52% to 48%) but rose in control schools (from 54% to 63%), another statistically significant difference. They were also consuming less alcohol overall, and were less likely to report drink-related problems.

These effects were comparable to those noted in previous trials of the intervention with specialist interventionists.

The authors' conclusions

The was the first evaluation of a school-based personality-targeted intervention for substance misuse delivered by trained educational professionals. Compared with controls, the intervention was associated with significantly decreased drinking and drink-related problems six months later, and with fewer 'binge' drinkers among participants drinking at the start of the study – a particularly high risk group for future substance misuse. The potential health benefits of this delayed uptake of drinking are substantial: a one-year delay can decrease the risk for future alcohol-related problems by 10%.

These results replicate findings from personality-targeted intervention trials in the UK and Canada, but within an implementation model that has a higher likelihood of being adopted in the real world. The demonstration that trained and supervised school staff can achieve results comparable to specialist therapists means the intervention has the potential to become a sustainable school-based early prevention strategy with youth most at risk for developing future alcohol-related problems. However, it remains unclear whether ongoing expert supervision and/or performance and outcome feedback is required to maintain standards.

Among baseline drinkers, this trial and others have found that just from four to six young people need to be allocated to the intervention in order to later prevent one from drinking heavily – a ratio much more favourable than typically found for 'universal' prevention programmes which target all the young people in a population rather than just those at high risk, and which are typically of much longer duration.

The possibility that it was simply a group intervention which was effective rather than the particular content of that intervention is contradicted by studies which have compared the Preventure intervention to alternative group sessions, and by general findings that few interventions decrease substance misuse. From a similar UK trial which found reduced use of illicit drugs, it also seems unlikely that Preventure pupils in the featured study substituted these for alcohol.

In sum, the evidence appears to strongly support the use of this programme in schools, whether delivered by trained clinicians external to the school or trained school staff. However, implementations should include the expert training and supervision components unless and until it is shown that schools are able to deliver the interventions autonomously and effectively.


Findings logo commentary Relative to basic education without much if any intended prevention content, this and other studies ( below) have demonstrated substantial effects in delaying the onset of and retarding the growth of substance use. Few of the usual limitations on the generalisability of the findings to the normal run of schools apply to this study. Neither schools nor pupils were highly selected, all but a small proportion of sampled pupils were followed up, and the schools' own staff conducted the intervention. As the authors comment, an impediment to widespread implementation may be the availability of expert trainers and supervisors. Another may be the willingness of schools to release four staff for three days training each followed by hours of supervision, and to let them spend many more hours addressing non-academic issues with a subset of high risk pupils. What may help convince them will be further results from the study if these demonstrate impacts not just on drinking but on mental health, other substance use, conduct, and academic achievement.

Among the findings is however the narrow failure to find a statistically significant impact on regular heavy or 'binge' drinking across all high risk pupils rather than just among those already drinking at the start of the study – a finding which seems to reflect the dilution of the results due to the inclusion of pupils unlikely to go on to drink heavily. This finding almost certainly also means no significant impact on regular heavy drinking across all the pupils in the school. Drinking as such at these ages is a concern, but in the British context, even more so is teenage binge drinking. That the intervention could not register even a short-term impact on this priority concern will lessen its appeal.

Its matching strategy above all distinguishes the featured intervention from other approaches. Plausibly, the developers argue that addressing each individual's particular personality vulnerability to substance use should more effectively reduce or prevent that use than a more scatter-gun or generic approach. However, this remains to be convincingly demonstrated ( below) in studies which have offered essentially the same intervention, but not matched to the individual's personality. It is possible that the advance made by the broad matching strategy embodied in the intervention's manuals is not sufficiently great to improve on the 'natural' and possibly more fine-tune matching which occurs as a sensitive therapist or counsellor adapts their interpersonal style and the content of the intervention to the individual. Also at issue is the persistence of the effects past the first six months.

Other studies of the featured intervention

This study is one of the latest in a series investigating the same or similar interventions co-authored by the intervention's developers. Given that allegiance A reference is being made here to the 'researcher allegiance' effect. In several social research areas,1 programme developers and other researchers with an interest in the programme's success have been found to record more positive findings than fully independent researchers. Such overlaps between developers and researchers are endemic2 in drug prevention research.

1. See articles at the following web addresses:
http://dx.doi.org/10.1007/s11292-009-9071-y
http://dx.doi.org/10.1177/0193841X06287188
http://dx.doi.org/10.1093/clipsy.6.1.95
2. See article at the following web address:
http://dx.doi.org/10.1016/j.evalprogplan.2007.06.004
to an intervention is associated with finding that it works, a fully independent demonstration by researchers with no personal investment in the intervention is desirable. Despite this, the body of work to date is methodologically sound, often convincing in its results and based on a plausible theory of how the intervention should work.

Among the British trials was another in London, but this time of a highly selected Of the 2530 pupils invited to participate, 2283 could assessed for personality risk factors of whom 1045 or 45.8% met the criteria. Applying this ratio to the invited sample, it can be estimated that 1158 might have met the criteria. Of these, the analysis was based on 347 or 30% and 19% completed the final follow-up assessment. set of 347 schoolchildren counselled by a professional psychologist rather than school staff. As in the featured study, the intervention was associated with drinking reductions six months later, but these effects dissipated to insignificance over the next six months and remained so over the remainder of the two-year follow-up. This was in contrast to drink-related problems, experience of which increased over the first six months in the control group and remained higher than in the intervention group over the follow-up period.

Another similar study in London found that over the following six months the intervention delayed the expected increase in drinking among high risk pupils over the first six months of the follow-up, though again, by a year there was no significant difference in the drinking behaviour of pupils who had or had not been allocated to the intervention. The same trial found reduced uptake of cocaine and other drug use and a reduced frequency of drug use overall (but not cannabis in particular) over the two-year follow-up. In Canada too, the intervention was found to result in at least short-term (four months) drinking reductions in secondary school pupils.

As well as these trials among schoolchildren, earlier versions of the intervention have been trialled with adults and young adults. One trial focused on female undergraduates in Canada characterised by one of the personality traits investigated in the featured study – anxiety-sensitivity. Over the next 10 weeks, drink-related problems were relatively lower (but not quite to a statistically significant degree) among women allocated to an intervention targeted to their personality profiles compared to those allocated to a 'placebo' group intervention, but drinking itself was unaffected. Another study involved largely alcohol-dependent women in Canada aged 30 to 50 recruited via ads asking them to get in contact if they were concerned about their drinking or prescription drug use. A variant of the featured intervention was compared to a control intervention involving a motivational film on substance use problems and a supportive discussion with a therapist, a combination which it fairly consistently outperformed in reducing substance use. However, there were no statistically significant findings (though there were tendencies Consistent as they were, they may have been due not to matching but to the therapists' knowledge that they were delivering what was expected to be a suboptimal conselling. in this direction) indicating that the intervention bettered another intervention similar in every other way except that the content was not matched to the individual's personality profile. These findings call in to question the matching strategy which above all distinguishes the featured intervention from other approaches.

Thanks for their comments on this entry in draft to Patricia Conrod of the Institute of Psychiatry at King's College in London. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 16 August 2011

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

STUDY 2011 Long-term effects of a personality-targeted intervention to reduce alcohol use in adolescents

REVIEW 2014 Interventions to reduce substance misuse among vulnerable young people

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

STUDY 2010 Project SUCCESS' effects on the substance use of alternative high school students

REVIEW 2011 Effectiveness of e-self-help interventions for curbing adult problem drinking: a meta-analysis

STUDY 2009 Translating effective web-based self-help for problem drinking into the real world

STUDY 2011 Internet therapy versus internet self-help versus no treatment for problematic alcohol use: a randomized controlled trial

STUDY 2009 Multidimensional Family Therapy for young adolescent substance abuse: twelve-month outcomes of a randomized controlled trial

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

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





Long-term effects of a personality-targeted intervention to reduce alcohol use in adolescents.

Conrod P.J., Castellanos-Ryan N., Mackie C.J.
Journal of Consulting and Clinical Psychology: 2011, 79(3), p. 296–306.
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 Conrod at patricia.conrod@kcl.ac.uk.

Addressing the substance use promoting tendencies of the personality traits of London secondary school pupils at particular risk of substance misuse led to less intensive drinking six months later, and there was some support for the psychological mechanisms thought to underpin the intervention.

Summary An alternative to prevention approaches applied to all children whatever their risk levels, the Preventure programme is a short intervention which targets youngsters who score highly on four personality dimensions which make different kinds of early-onset substance use and other risky behaviours particularly rewarding or hard to resist. As assessed by the Substance Use Risk Profile Scale personality questionnaire, these traits are:
Hopelessness A tendency to unhappiness, depression and feeling a failure, feelings relieved by intoxication;
Anxiety-sensitivity Fear of anxiety-related bodily sensations due to beliefs that such sensations will lead to catastrophic outcomes, for which substance use can represent a form of self-medication;
Impulsivity An inability to restrain seeking gratification in the presence of immediate rewards (such as the feelings available through substance use) despite longer term negative consequences; and
Sensation-seeking Desire for intense and novel experiences, which can be expressed as a desire to 'get high' through drugtaking or heavy drinking.

The Preventure intervention

The manualised Preventure intervention addresses these risk factors by drawing on psychoeducational approaches, motivational enhancement therapy, and cognitive-behavioural therapy, applied to real-life scenarios shared by high-risk young people in Britain. As implemented in the featured study, it occupied two 90-minute focus groups led by the same qualified and supervised therapist plus a co-facilitator. Groups were formed of pupils who shared elevated scores on the same personality dimension, and the variant of the intervention applied to that group particularly targeted that dimension and the associated risks. In the first session participants were guided in a goal-setting exercise to enhance motivation to change behaviour, taught about the personality dimension and how it can predispose to problematic coping behaviours, and guided in breaking down personal experience according to the physical, cognitive, and behavioural components of an emotional response. All the exercises were specific to the personality risk factors identified in the children. The second session involved identifying and challenging personality-specific cognitive distortions which lead to problematic behaviours.

Preventure interventions have been found to prevent the onset and escalation of drinking and drug use. The featured study aimed to test whether drinking reductions are sustained over the following two years, and whether they may be due the expected impacts on the particular motivations to drink generated by the targeted personality dimensions.

The study

Of 2530 pupils in 13 London secondary schools, just under half those tested scored as high risk on the Substance Use Risk Profile Scale. Of these, 347 joined the study and provided apparently reliable responses at the follow-up surveys. Their responses were the basis for the featured report. They had been individually allocated at random to the Preventure intervention or to a control A group of people, households, organisations, communities or other units who do not participate in the intervention(s) being evaluated. Instead, they receive no intervention or none relevant to the outcomes being assessed, carry on as usual, or receive an alternative intervention (for the latter the term comparison group may be preferable). Outcome measures taken from the controls form the benchmark against which changes in the intervention group(s) are compared to determine whether the intervention had an impact and whether this is statistically significant. Comparability between control and intervention groups is essential. Normally this is best achieved by randomly allocating research participants to the different groups. Alternatives include sequentially selecting participants for one then the other group(s), or deliberately selecting similar set of participants for each group. group who simply carried on (as all the schools had to) with the drug education components Basic facts and laws about alcohol, tobacco, and illicit drugs, information about detrimental health effects from abuse and misuse, typically taught throughout the year as part of the science, citizenship and personal, social, health and economic wellbeing curricula, or as specific drug education focus days. required by the national curriculum. Just over 8 in 10 pupils were followed up six months later. Follow-ups were also conducted at 12, 18 and at 24 months, by which time around 60% completed the survey. The probable responses of pupils not completing any particular follow-up were estimated on the basis of earlier assessments and other data.

Main findings

Six months later and compared to control schools, among high risk pupils in schools allocated to Preventure, the increase in average alcohol consumption had been significantly less steep, rising to 0.49 as opposed to 0.56 drinks a day. The average frequency of 'binge' drinking (defined as five or more drinks at one sitting for boys and four for girls) in the past six months too had risen less steeply, but this finding narrowly missed the conventional criterion for statistical significance. Both these effects had faded in to insignificance at later follow-ups and by the end on both measures the two sets of pupils scored virtually the same. In contrast, the increase at six months in the number of drink-related problems seen in the control group did not materialise in the Preventure group, and this gap in favour of the intervention remained statistically significant at all the follow-ups.

Largely due to findings among pupils characterised by anxiety-sensitivity, Preventure pupils expressed a relatively lower need to drink in order to cope with difficult feelings, a disparity which achieved statistical significance at the 12- and 24-month follow-ups. In contrast, there was no consistent impact on motivation to drink to 'get high' or otherwise experience pleasurable feelings.

The authors' conclusions

As in the first wave of the Preventure trial in London, the intervention reduced adolescent alcohol consumption and probably binge drinking in particular, but only over the following six months. However, the lasting impact on problems related to drinking suggests that the intervention may have delayed the growth of drinking sufficiently for the youngster to better be able to cope without developing problems. There was evidence for the expected mechanism among anxiety-sensitive pupils, who after the intervention felt relatively less need to drink to cope with their feelings and fears, but the same could not be said of pupils characterised by feelings of hopelessness, nor was there consistent and clear evidence of the expected mechanism among personality types motivated to drink to feel good as opposed to avoiding feeling bad.

The possibility remains that it was simply a group intervention which was effective in curbing drinking and related problems rather than the particular content of that intervention. In particular, it has yet to be demonstrated that matching intervention to personality profile exerts a greater preventive impact on drinking than non-matched interventions.


Findings logo commentary Relative to basic education without much if any intended prevention content, this and other studies ( below) have demonstrated sometimes substantial effects in delaying the onset of and retarding the growth of substance use.

The featured study involved a highly selected Of the 2530 pupils invited to participate, 2283 could assessed for personality risk factors of whom 1045 or 45.8% met the criteria. Applying this ratio to the invited sample, it can be estimated that 1158 might have met the criteria. Of these, the analysis was based on 347 or 30% and 19% completed the final follow-up assessment. set of pupils and a single therapist engaged by the study, limiting the degree to which the findings can be assumed to apply to pupils across the board and to interventions delivered by a school's usual staff. However, in another UK trial neither schools nor pupils were highly selected, all but a small proportion of sampled pupils were followed up, and the schools' own staff conducted the intervention. Still six months later, the intervention had retarded the growth in the proportion of high risk pupils who were drinkers and among drinkers, the proportion regularly drinking heavily. An impediment to widespread implementation may be the availability of expert trainers and supervisors. Another may be the willingness of schools to release staff for what in this more real-life study were three days of training each followed by hours of supervision, and to let them spend many more hours addressing non-academic issues with a subset of high risk pupils. What may help convince schools will be further results from the study if these demonstrate impacts not just on drinking but on mental health, other substance use, conduct, and academic achievement.

Among the findings in both studies was however the disappointing failure to find a statistically significant impact on regular heavy or 'binge' drinking across all high risk pupils rather than just among those already drinking at the start of the study, though both found a non-significant trend in this direction. This probably also means no significant impact on regular heavy drinking across all pupils in the school. Drinking as such at these ages is a concern, but in the British context, even more so is teenage binge drinking. That the intervention could not register even a short-term significant impact on this priority concern will lessen its appeal.

Its matching strategy above all distinguishes the featured intervention from other approaches. Plausibly, the developers argue that addressing each individual's particular personality vulnerability to substance use should more effectively reduce or prevent that use than a more scatter-gun or generic approach. However, this remains to be convincingly demonstrated ( below) in studies which have offered essentially the same intervention, but not matched to the individual's personality. It is possible that the advance made by the broad matching strategy embodied in the intervention's manuals is not sufficiently great to improve on the 'natural' and possibly more fine-tune matching which occurs as a sensitive therapist or counsellor adapts their interpersonal style and the content of the intervention to the individual. Also at issue is the persistence of the effects past the first six months.

Other studies of the featured intervention

This study is one of the latest in a series investigating the same or similar interventions co-authored by the intervention's developers. Given that allegiance A reference is being made here to the 'researcher allegiance' effect. In several social research areas,1 programme developers and other researchers with an interest in the programme's success have been found to record more positive findings than fully independent researchers. Such overlaps between developers and researchers are endemic2 in drug prevention research.

1. See articles at the following web addresses:
http://dx.doi.org/10.1007/s11292-009-9071-y
http://dx.doi.org/10.1177/0193841X06287188
http://dx.doi.org/10.1093/clipsy.6.1.95
2. See article at the following web address:
http://dx.doi.org/10.1016/j.evalprogplan.2007.06.004
to an intervention is associated with finding that it works, a fully independent demonstration by researchers with no personal investment in the intervention is desirable. Despite this, the body of work to date is methodologically sound, often convincing in its results and based on a plausible theory of how the intervention should work.

Apart from the featured study and the more real-world study mentioned above, studies of schoolchildren in London include one which found that over the following six months the intervention delayed the expected increase in drinking among high risk pupils over the first six months of the follow-up, though again, by a year there was no significant difference in the drinking behaviour of pupils who had or had not been allocated to the intervention. The same trial found reduced uptake of cocaine and other drug use and a reduced frequency of drug use overall (but not cannabis in particular) over the two-year follow-up. In Canada too, the intervention was found to result in at least short-term (four months) drinking reductions in secondary school pupils.

As well as these trials among schoolchildren, earlier versions of the intervention have been trialled with adults and young adults. One trial focused on female undergraduates in Canada characterised by one of the personality traits investigated in the featured study – anxiety-sensitivity. Over the next 10 weeks, drink-related problems were relatively lower (but not quite to a statistically significant degree) among women allocated to an intervention targeted to their personality profiles compared to those allocated to a 'placebo' group intervention, but drinking itself was unaffected. Another study involved largely alcohol-dependent women in Canada aged 30 to 50 recruited via ads asking them to get in contact if they were concerned about their drinking or prescription drug use. A variant of the featured intervention was compared to a control intervention involving a motivational film on substance use problems and a supportive discussion with a therapist, a combination which it fairly consistently outperformed in reducing substance use. However, there were no statistically significant findings (though there were tendencies Consistent as they were, they may have been due not to matching but to the therapists' knowledge that they were delivering what was expected to be a suboptimal conselling. in this direction) indicating that the intervention bettered another intervention similar in every other way except that the content was not matched to the individual's personality profile. These findings call in to question the matching strategy which above all distinguishes the featured intervention from other approaches.

Thanks for their comments on this entry in draft to Patricia Conrod of the Institute of Psychiatry at King's College in London. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 16 August 2011

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


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

STUDY 2010 Personality-targeted interventions delay uptake of drinking and decrease risk of alcohol-related problems when delivered by teachers

REVIEW 2014 Interventions to reduce substance misuse among vulnerable young people

STUDY 2010 Project SUCCESS' effects on the substance use of alternative high school students

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

REVIEW 2011 Effectiveness of e-self-help interventions for curbing adult problem drinking: a meta-analysis

STUDY 2011 Internet therapy versus internet self-help versus no treatment for problematic alcohol use: a randomized controlled trial

STUDY 2009 Multidimensional Family Therapy for young adolescent substance abuse: twelve-month outcomes of a randomized controlled trial

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

STUDY 2012 Alcohol screening and brief intervention in primary health care

STUDY 2012 Alcohol screening and brief intervention in emergency departments





Cluster randomised trial of the effectiveness of motivational interviewing for universal prevention.

McCambridge J., Hunt C., Jenkins R.J. et al.
Drug and Alcohol Dependence: 2011, 114, p. 177–184.
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 McCambridge at Jim.McCambridge@lshtm.ac.uk. You could also try this alternative source.

Compared to basic drug education, it should at least have moderated current use, but this attempt to deploy motivational interviewing as an across-the-board prevention strategy among college students in London neither did that, nor did it prevent non-users starting to use, negative findings which raise interesting questions.

Summary The evidence base for motivational interviewing in relation to substance misuse almost entirely involves people who have already started to use particular substances. Whether this counselling approach might also help people in general not to start using ('universal prevention') is unclear. This British study investigated this issue by randomly allocating whole classes of older teenage students Further education colleges typically enrol students who have not done well in school. Though classes included students of other ages, only 16–19-year-olds were included in the study. attending 12 further education colleges in London. None of the students refused the study and 416 were recruited.

Both the motivational interviewing intervention and the comparator – intended to approximate 'drug education as usual' at such institutions – were delivered mostly by the researchers, though sometimes by trained college staff. Motivational interviewing was based on a model found effective in the short term in curbing smoking, drinking and cannabis use among further education students already using stimulants and/or regularly using cannabis. As described in the main report on that study, the interventionists aimed to promote reflection on how the student's actual or potential drug use squared with their non-drug values and goals. The intention was to create an opportunity for them to think and talk about risk in ways conducive to the identification of problems and concerns, culminating in behaviour change to address those problems and concerns. This format was adapted for non-users, for example, by encouraging students to think through and discuss hypothetical situations in which they might find it difficult to refuse an offer of drugs, exploring reasons for not using specific substances, and envisaging how starting to use might affect the fulfilment of their plans.

Other classes were randomly allocated to drug awareness lessons based on a 16-item quiz on the effects of smoking, drinking and cannabis use, followed by discussion and the provision of leaflets giving accurate information on the effects of these target drugs. The package adopted the harm reduction orientation typical at these ages in Britain, and was intended to approximate 'drug education as usual' at the colleges. Unlike the motivational interviewing alternative, there was not intended to be any opportunity to discuss or heighten awareness of risks or concerns particular to each individual.

Main findings

Three months later 89% and 12 months later 84% of the students were recontacted and their substance use reassessed. The results were analysed on the assumption that the relatively few not reassessed at any point had continued to use substances as last assessed. Essentially the proportions smoking (around a quarter to a third in the past month) and drinking (around half) had remained stable. Among the motivational interviewing classes, so too had the proportions using cannabis at around a fifth. In contrast, the proportions of drug awareness students using cannabis fell slightly from 23% at baseline to 19% at three months and 15% at 12 months, creating the only statistically significant differences between motivational interviewing and comparison students as a whole – one in the unexpected direction of more persistent cannabis use after motivational interviewing. Other cannabis use measures too suggested that the drug awareness lessons had been more effective in curbing use; though numbers were small, significantly fewer drug awareness students (four v. 14) had started to use cannabis over the year of the follow-up, and there were non-significant tendencies for students using cannabis from the start to cut down their use more if they had been allocated to drug awareness. However, the degree to which either motivational interviewing or drug awareness education made any difference was called in to question by the fact that students who did not attend either changed or persisted in their substance use in much the same way as attendees.

Suggesting that the interventionist was an influence on outcomes, the two researchers differed in their results: one did better in restraining drinking and cannabis use, the other, smoking.

The authors' conclusions

The only statistically significant outcome differences favoured an approach – brief and basic drug awareness education – unlikely on past evidence to have truly been effective in preventing substance use. The most defensible conclusion is that neither approach was effective at preventing the uptake of substance use or in curbing existing use among this specific population – appreciably older than most targeted for universal drug prevention, and for whom lack of success in conventional education may have been a marker of wider resistance to intervention.

Among other possible explanations for the non-impact of motivational interviewing is that it was not delivered as intended. There was no formal quality monitoring, but recordings and supervision discussions suggested that in this setting and format it was difficult to embody the spirit of motivational interviewing as opposed to the intended structure. In particular, students could not consistently be led to work through possible or actual substance use situations of which they had no experience. It may also be that trying to prevent young people doing something they are not (ie, preventing uptake of substance use) interfered with motivational interviewing's proven capacity to moderate existing substance use.


Findings logo commentary Because this was an exploratory study, no adjustments Especially if multiple outcomes tend not to covary, the more are measured, the more likely it is that some will reach the threshold for a statistically significant difference purely due to chance variations in the samples rather than any real impact of the interventions being tested. For example, by convention, if a difference would happen only 1 in 20 times by chance, it is considered a non-chance occurrence possibly due to the intervention. But if, say, 20 independent outcomes are measured, more often than not one would cross this threshold purely by chance. To cater for this, it is recommended1 that researchers consider raising the threshold (in the example, according to some adjustment methods to as high as 1 in 400) before each of the outcomes is considered to have reflected a statistically significant difference.

1 International Conference on Harmonisation Of Technical Requirements for Registration of Pharmaceuticals for Human Use. "ICH harmonised tripartite guideline statistical principles for clinical trials." Statistics in Medicine: 1999, 18, p. 1905–1942.
were made for the multiple outcomes tested in the study to reduce the possibility that some were statistically significant purely by chance. For this reason and because of the implausibility of such basic and brief drug education having an impact, the authors dismiss findings which suggested that drug awareness lessons had prevented uptake of cannabis use and may also have curbed existing use. Another possibility they advance is that motivational interviewing encouraged students to later disclose cannabis use which remained more hidden after drug awareness education, making it look as if the latter had been relatively more effective. The final possibility is that drug awareness truly did reduce cannabis use more than motivational interviewing. Certainly (but in very different circumstances) it is not unknown for motivational interviewing's more roundabout approach to work less well than straightforward advice.

Universal prevention among people not selected to already be using (probably excessively) substances is a very unusual way to deploy the approach. Since the featured study was written, another study has been published which investigated the impact of a motivational intervention on the general population of young people. Participants were Swiss army conscripts, the intervention was one-to-one, drinking was the target, and the comparator was no intervention at all. In these circumstances, again there was no impact on young people not already engaging in the targeted behaviour ('binge' drinking), but this time the intervention did have a restraining influence on those already drinking to excess.

Thanks for their comments on this entry in draft to Jim McCambridge of the Centre for Research on Drugs and Health Behaviour at the London School of Hygiene & Tropical Medicine. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 07 August 2011

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Long-term outcomes of aftercare participation following various forms of drug abuse treatment in Scotland.

Vanderplasschen W., Bloor M., McKeganey N.
Journal of Drug Issues: 2010, 40(3), p. 703–728.
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 Vanderplasschen at wouter.vanderplasschen@ugent.be. You could also try this alternative source.

On several measures, the few drug dependent patients who accessed aftercare after treatment in Scotland in the early 2000s did better than the majority who chose to or were left to fend on their own – but could this be attributed to the aftercare, or would they have done well anyway?

Summary Aftercare is the continuation of work carried out in prison or community treatment, with a particular focus on resettlement and integrating individuals back into society. Various studies have demonstrated its protective role, but mainly among drinkers, and by observing that outcomes improve among patients who take up the offer of aftercare. In such studies it is difficult to disentangle the effects of aftercare itself from whatever led that patient to participate in aftercare, factors which may have had a similar impact even in the absence of aftercare. Some studies which have tried to overcome this difficulty (for example, by randomly allocating patients to aftercare versus no aftercare) have found positive impacts, but many have not. Despite the potential for aftercare to sustain treatment gains, few treatment systems systematically provide it, probably largely because few agencies are funded to do so.

The featured report aimed to assess the role of aftercare in improving outcomes among drug users treated in Scotland, drawing on data collected by the Drug Outcome Research in Scotland (DORIS) study. Excluding users contacted at needle exchanges, this tracked the progress of 1007 drug dependent patients starting a new Their first ever treatment or re-entry after a break of at least six months. treatment episode in 2001–2002 at one of 33 drug agencies chosen to represent a range of modalities. Patients were re-assessed by researchers eight, 16 and 33 months later. The featured report was based on the responses of the 653 (67% of the surviving baseline sample) who completed all the assessments. For over 8 in 10, heroin was their primary drug. About 39% had been recruited from a prison treatment programme, 13% at a residential rehabilitation unit, 17% from methadone maintenance, and 32% from other community-based treatment services such as detoxification, counselling, or group therapy.

Main findings

At the first eight-month follow-up, just 83 – about 1 in 8 – of the sample recalled having received throughcare or aftercare 'Throughcare' is the term commonly used for continuity of care after prison treatment. Throughcare or aftercare was understood as any type of support from the agency at which the patient was recruited additional to standard treatment (except housing, financial, employment or medical support) oriented at continued abstinence and resettlement near the end of the treatment episode. For example, aftercare after methadone maintenance treatment was the support drug users received from the index agency to withdraw from methadone or when referred to another treatment centre. The patient self-defined whether they had or had not received this support. from their initial treatment service towards and/or after the end of their treatment. Such support was most often experienced following residential rehabilitation (28% of former residents said they had received it) but significantly less so (from 8% to 13%) after prison-based treatment, methadone maintenance, or other community treatment. Patients who in the past had more often used other treatments, mutual aid or medical or social services also more often received aftercare, as did those who said their treatment goal was to become abstinent rather than reducing or controlling their drug use. In contrast, how severe or entrenched the patient's drug problems were made no difference to whether they received aftercare.

The key issue addressed by the report was whether receiving aftercare support was associated with later being drug or heroin free, defined respectively as a "substantial" period free of all drugs including prescribed substitutes, and not having used heroin in the last three months. The raw figures strongly suggested this was the case, at least as assessed eight months and 33 months after the start of treatment. At these times, 48% and 29% of aftercare participants had been drug free and 48% and 64% had not recently used heroin, respectively 21%, 11%, 15% and 20% more than their counterparts who had not received aftercare in the eight months after starting treatment. They also spent less on drugs, felt their health had improved more, were less likely to have been imprisoned, had more contact with families and with friends who did not use drugs, and were more likely by the end to live in their own house, but were not significantly less likely to have engaged in revenue-raising or property crime.

Nevertheless, rather than aftercare being an active ingredient in the patient's recovery, it could be that both aftercare participation and the patients' progress reflected underlying factors such as problem severity or willingness to engage with helping services. As far as they could, the analysts tried to adjust for other possible influences Age; gender; age when leaving school; relationship status; personal treatment objectives; treatment experience and treatment modality at baseline; heroin use and severity of dependence at baseline; attempted suicide or self-harm since last interview; whether they rated their general health much or somewhat better than a year ago; any arrest for drug possession or theft/handling of stolen goods since last interview; whether they had committed theft/handling of stolen goods since last interview; housing circumstances (homelessness, living in own or partner's home, being imprisoned since the last interview); received throughcare or aftercare from another agency; participated in a self-help group since the last interview; contact with index agency at follow-up; interaction between treatment modality and aftercare participation. on the patients' drug use in order to isolate the impact of aftercare itself, and to test whether it was still significantly associated with abstinence from all drugs or from heroin at the eight- and 33-month follow-ups.

The results were mixed. Having been completely drug free before the eight-month follow-up was still associated with having received aftercare, as was not having recently used heroin at the 33-month follow-up; in both cases the odds of a good versus a bad outcome were about twice as great in aftercare participants. But when all the other influences had been taken in to account, being heroin free at eight months and drug free at 33 months were no longer significantly associated with having received aftercare from the initial treatment agency. Among the other possible influences, at both time points having initially been in residential rehabilitation as opposed to other treatments was strongly associated with having recently been heroin free, and at the eight-month follow-up, with having been drug free for a period.

The study then probed whether aftercare was more important after some types of treatment than others. Having received aftercare following methadone maintenance or residential rehabilitation made little difference to whether patients had experienced a period of being entirely drug free. But consistently at each of the three follow-ups, aftercare following non-methadone community treatment like detoxification or psychosocial therapy was associated with about double the chance of having been drug free.

Formal aftercare from the treatment agency was not the only way patients sought to sustain their abstinence. Over the 33 months of the follow-up, nearly a quarter attended mutual aid groups like NA and AA. At each of the follow-ups, patients who had accessed aftercare and mutual aid were most likely to have been drug free for a period, generally those who accessed neither were least likely, and those who accessed one but not the other were in between; at the 33-month follow-up, the figures were 35%, 15% and 22–23% respectively.

The authors' conclusions

Few drug users starting treatment in Scotland in 2001 and 2002 received throughcare or aftercare from their initial treatment agency Those who did appeared to experience better outcomes up to 33 months later in terms of substance use, their social lives, imprisonment, and in other ways. The implication is that providing aftercare after initial treatment is extremely important and significantly increases the chance of abstinence in the short and longer term. One explanation is that aftercare helps people learn to cope better with drugs and in particular with heroin, the primary drug in this study. It also seems likely that the people who took up the offer of aftercare were more motivated to stay abstinent when they finished treatment, and to use appropriate treatment agencies and other services to help them do so.

Stronger still than the link with aftercare was the link between being heroin or drug free and having initially been treated in residential rehabilitation. Despite being most commonly accessed, aftercare following this option was unable to further improve substance use outcomes. The findings are consistent with aftercare being important following less intensive and all-embracing treatments (and especially after release from prison, a high risk period for overdose), but minimal continuity of care being sufficient to sustain clients after intensive residential treatment. The findings are also consistent with participation in mutual aid groups helping to sustain abstinence, and also reinforcing the impact of aftercare.

It seems that in Scotland at this time aftercare was not necessarily provided to or accessed by those most in need of it. Participation was not determined by the length or severity of drug use or drug-related problems, but rather by the individual's previous and recent efforts to do something about their drug problem, their intention to become drug-free, and the treatment modality first entered. Aftercare is predominantly taken up by people who are ready to do, and who have (recently) already done, something about their problems. Moreover, the likelihood of aftercare was highest after residential rehabilitation, yet after this treatment it seemed least needed to promote abstinence.

Given its potential to enhance treatment outcomes, attractive modalities of aftercare and continuing care should be provided as a standard element of treatment, and services funded accordingly. Treatment agencies should promote both aftercare and mutual aid engagement as initial treatment comes to an end.

While the study's findings are consistent with these interpretations, the fact that patients were not allocated at random to have or not have access to aftercare limits the ability to attribute improvements to this provision. However, patients who did or did not receive aftercare scored similarly on variables indicative of motivation and other characteristics.


Findings logo commentary As the authors acknowledged, the DORIS study was not designed to be able to attribute outcomes to interventions. All it could do is point out that certain interventions are associated with patients' progress, and test whether this association remains after other influences have been taken in to account. If it survives this sifting, the intervention may have been an active ingredient. This strategy relies on the identification and adequate measurement of all pertinent extraneous influences. In the featured report, it was particularly important to adjust for differences in the motivation of patients who did or did not access aftercare; since access was voluntary, there is a strong possibility that the minority of patients who accessed aftercare were those whose motivation was such that they would have done well anyway. In defence of a causal role for aftercare, the authors say the variables they measured which were indicative of motivation did not significantly differ between patients who did or did not access aftercare, but without detailing what these variables were. Some Among these may have been: personal treatment objectives; treatment experience and treatment modality at baseline; participated in a self-help group since the last interview; contact with index agency at follow-up. of the influences taken in to account in testing whether aftercare remained associated with outcomes might have reflected motivation and helped to level the playing field. Still, the suspicion remains that accessing aftercare reflected a general inclination to seek help by patients particularly committed to recovery through treatment and mutual aid. The very fact that such a small minority received aftercare suggests there was something quite distinctive about them, their situations, and/or the treatment service they first attended – a distinctiveness which could have accounted for their better outcomes.

Other factors complicate the interpretation of the findings. Among these is that, despite their possible successes, patients committed to recovery through methadone maintenance and who did well enough to stay in that treatment could neither access aftercare (because they remained in the initial treatment) nor claim to have been drug-free (prescribed substitutes invalidated that claim), meaning that on this yardstick, the study was not well placed to reflect success in this modality. Also, patients who have lived in a controlled residential setting should normally notch up at least that time free of drugs. Since no time scale seems to have been attached to the drug free period, their success in this regard might not reflect aftercare at all, but the protection afforded by the main treatment setting – perhaps one reason why aftercare seemed ineffective among patients who started the study in residential rehabilitation.

In DORIS as in other studies, over the years patients rarely confined themselves to a single modality, complicating the assessment of just what it was which led to the eventual outcomes. For example, the featured report sampled 108 patients from methadone programmes, yet 33 months later 433 of the sample had been prescribed methadone after their initial treatment. For at least 325 – over half the total sample – methadone must have followed other types of treatment. In particular, from an earlier report we know that about 44% of patients who started the study in residential rehabilitation went on to be prescribed methadone. It becomes a matter of choice whether such patients' progress is attributed to the initial non-methadone programme, whether transfer to methadone is seen as indicating that initial treatment had failed and their progress was due to the follow-on care, or whether the whole treatment journey is seen as the active ingredient.

Though the featured study was unable to determine whether aftercare actually caused improved outcomes, other studies with stronger designs have been able to address this critical issue. A US review included 11 studies which allocated patients at random or in a quasi-random manner to 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 That is, not counterbalanced by a contrary finding on another primary measure of substance use. 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 – suggesting that the finding of no benefit in the featured study may have reflected anomalies in the type of people who get residential care in Scotland, how they access or not aftercare, and perhaps the nature of that aftercare, rather than post-residential aftercare truly being ineffective.

Given this international research, and the fact that the DORIS findings were at least consistent with aftercare often being an aid to abstinence, it seems reasonable for the authors to recommend it as standard provision. But in doing so they run 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 ... We will ensure that all those on a substitute prescription engage in recovery activities and build upon the 15,000 heroin and crack cocaine users who successfully leave treatment every year free of their drug(s) of dependence". 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.

For other findings from the DORIS study see the Findings reports on abstinence and on employment outcomes, and this initial report highlighting poorer outcomes from prison-based treatment.

Thanks for their comments on this entry to Wouter Vanderplasschen of the University of Ghent in Belgium. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 15 November 2011

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

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