Drug and Alcohol Findings home page in a new window EFFECTIVENESS BANK BULLETIN 19 September 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.


Contents

First two items offer authoritative guidance, first on the harm reduction benefits of prescribing the heroin substitute methadone to opiate-addicted patients, and then on the clinical use of the main alternative medication, buprenorphine, specifically as combined with naloxone to deter misuse by injection. Methadone is the preferred of the two in UK guidance, but the balance could be shifting as concern grows over methadone-related deaths, and its once valued power to retain is seen as a hindrance to treatment exit. Then two counselling/therapy approaches, one which surprisingly had no impact, another which probably did work. In both cases, the explanation may be the common factors which transcend what the counsellor does in terms of specific approaches and have more to do with how they do it – thing like optimism, structure, caring, concern – and not least, the impetus from the patient.

Cochrane review confirms methadone maintenance prevents spread of HIV ...

Canadian guidelines on prescribing buprenorphine/naloxone for opioid dependence ...

Brief intervention makes no difference to heart disease risk ...

Arranging an abstinence-promoting social life aids Spanish cocaine users ...


Substitution treatment of injecting opioid users for prevention of HIV infection.

Gowing L., Farrell M., Bornemann R. et al.
Cochrane Database of Systematic Reviews: 2011, Issue 8, Art. No.: CD004145.

Updated review conducted for the respected Cochrane collaboration finds that methadone maintenance and allied treatments for opioid dependence consistently and significantly reduce the risk of transmission of blood-borne viruses and curb the spread of HIV.

Summary Drug injectors are vulnerable to infection with HIV and other blood borne viruses due to the collective use of injecting equipment as well as sexual behaviour. This review aimed to assess the degree to which this risk is affected by the prescription of drugs such as methadone to be taken by mouth which substitute for the opiate-type drugs the patient is dependent. It assessed impacts on behaviours which place people at high risk of viral transmission and on actual rates of HIV infection. With one exception, it considered all sorts of studies, not just randomised trials, as long as the treatment and outcomes were relevant and participants were opioid dependent drug users, most of whom were currently or recently Last three months. injecting. The exception was studies which required patients in treatment to at the same time recall their past risk behaviour before and after starting treatment. Non-English language studies were included. The studies were expected largely to relate to methadone, but evidence relating to other oral preparations (buprenorphine, LAAM, codeine and slow release morphine) was also considered.

A search discovered 38 studies involving about 12,400 participants. Just two randomly allocated patients to substitute prescribing versus other treatments. In the remaining studies, findings would have been complicated by influences other than substitution treatment resulting in potential bias. All but six were solely concerned with methadone treatment, 32 with treatment in a service specialising in addiction treatment, and 26 were set in the USA. Due to differences between the studies, no attempt was made to combine their findings in to an overall quantitative assessment of the impacts of the treatments. Instead the reviewers assessed whether effects were consistent across the studies and across different types of studies.

Main findings

Overall studies consistently find that after entering oral substitute prescribing treatment (generally involving methadone), patients move to being at substantially lower risk of HIV infection due to behaviours linked to their drug use, but less consistently in respect of their sexual behaviour.

Across 17 studies it was consistently found that starting oral substitution treatment was associated with significant falls in the proportion of patients who continued to inject and in the frequency of injecting. These reductions typically occurred in the first one to three months of treatment and were sustained for at least the first year. However, reductions were not necessarily sustained after treatment ended, particularly if termination had been involuntary.

Treatment was also consistently associated with a significant decrease in the sharing of injecting equipment, possibly due to reduced injecting. These benefits were sometimes sustained after treatment ended, though not in a study in which patients were forced to leave due to subsidised treatment no longer being available. In some studies similar reductions in sharing were achieved by other treatment modalities.

Like another Cochrane review, the featured review also found that illicit opioid use (injected or not) significantly decreased after entering treatment and did so consistently across all relevant studies.

Since there were few studies, it was difficult to be conclusive, but the data also suggested that sex-related risks of viral transmission were also reduced due to fewer people having multiple partners or exchanging sex for drugs or money, though condom use was affected little if at all. In six of the seven studies to assess this, the overall drug-related risk of HIV infection assessed by composite scales was significantly reduced. The same was true of the seven studies which assessed risk due to drug use or sexual behaviour.

Four studies assessed relationships between the proportions of people who became HIV positive (seroconversion) and their participation in methadone treatment. All found that participation as such, or more extended or continuous participation, was associated with a lower rate of seroconversion. This suggests that reductions in risk behaviour do translate in to actual reductions in cases of HIV infection. Substitution treatment may also protect individuals already infected with HIV against further infection with other strains of HIV, or other blood-borne viruses.

The authors' conclusions

The reviewers concluded that oral substitution treatment for injecting opioid users reduces drug-related behaviours with a high risk of HIV transmission, but has less effect on sex-related risk behaviours. On this basis, provision of this treatment should be supported in countries with emerging HIV and injecting opioid use problems as well as those with established populations of injecting opioid users.

Most of the studies in this review simply observed what happened after people started maintenance treatment, though some also recruited comparison groups of patients who did not enter, had left, or had less treatment, against which to benchmark the findings. Just two minimised possible bias by randomly allocating patients. This lack of data from controlled studies leaves the findings open to bias and limits the strength of the evidence. However, these findings supplement stronger evidence from other reviews of the effectiveness of substitution treatment in retaining patients and reducing illicit drug use. Whether risk-reduction improvements persist after patients leave treatment is unclear; many relapse to illicit opioid use, but it is not clear whether they nevertheless continue to practice risk reduction strategies.


Findings logo commentary Any review is limited by the studies available to it. In this case substantial methodological limitations meant results could not be combined to assess their strength and statistical significance, taking in to account sample sizes and other features of the studies. In particular, the review was unable to offer guidance on how to optimise risk reduction. The consistency of the results is reassuring, but is no substitute for rigorous studies. Nevertheless, the key findings of reduced injecting and probably associated with this, reduced sharing of injecting equipment, is both the intended and logical result of substituting an oral drug for an injected one; it 'makes sense', lending credence to the interpretation that the consistency of the findings reflects a real and consistent impact of making substitute prescribing programmes available.

In fact there are reasons to believe that the findings may be an underestimate of overall benefits across a local population of opioid injectors. Much of the data derives from treatments provided in the previous century, so may underestimate the impacts of improved procedures. Also, the review started at the point where injectors have entered substitute prescribing programmes, and asked what the impact was on their risk of becoming infected. But there is another major feature of these programmes which might be crucial to risk reduction – their ability to engage large numbers of opioid users in treatment. The risk-reduction benefits identified by the analysis may or may not be greater than those associated with other treatments, but they are likely to be extended to far greater numbers in areas with widely accessible substitute prescribing programmes. Across an entire population of opioid injectors, the result (identified for example in Barcelona) is likely to be reduced HIV-related mortality.

In 2005 the World Health Organization added methadone (and buprenorphine) to its List of Essential Medicines, partly because "The accumulated data demonstrate that methadone maintenance treatment is a major public health tool in ... HIV/AIDS prevention" – the effectiveness issue dealt with in the featured review – but also because it is capable of widespread implementation and the engagement of a large proportion of the at-risk population in treatment. This conclusion was boosted by an analysis for the European Union which found methadone maintenance cost-effectively prolongs and improves the lives of a population of opioid injectors by averting HIV infections, and that the cost of doing so is typically below the cost of treating the infections, creating health service savings. Such findings led joint guidance from Europe's drug and infection control agencies to itemise opioid substitution treatment among the seven key intervention components which should be applied and combined to achieve maximum prevention from infection.

Importantly, the mathematical model used in the analysis for the European Union showed that as the proportion of local drug users engaged in treatment increases, costs per averted infection dramatically decrease, and benefits across all drug users in or out of treatment escalate. This is because the treatment is capable of removing a large proportion of drug users from networks of injecting equipment sharing, leading to a form of 'herd immunity'. This analysis and others find that benefits in respect of hepatitis C infection are much less convincing, and likely to be substantial at a population level only in very high quality programmes which reduce equipment sharing to very low levels and prevent relapse to injecting drug use.

To a lesser extent, these qualities have a similar influence on HIV prevention, spotlighting the importance of features of the programmes and the regulatory environment within which they operate which can undermine their infection-prevention potential. Among those described for a US think-tank are limited implementation, regulations restricting the import and supply of methadone, restrictions on the types of patients who can enter the programmes (eg, to those who have been failed by other treatments), under-dosing, and counterproductive rules and disciplinary procedures which deter patients and lead to high throw-out rates.

Another benefit not reflected in the analysis is the relatively stable platform substitute prescribing provides for engaging patients in the treatment of HIV or hepatitis C infection and for completing the therapy. By definition this cannot reduce the proportion HIV positive among these already infected patients (so its impact will not be reflected in the featured analysis), but it should help prolong their lives and reduce the risk that they will infect others.

For all Findings analyses related to the reduction of infection risk behaviour by methadone maintenance run this search.

Thanks for their comments on an earlier version of this entry to Linda Gowing of the University of Adelaide, Australia and Roy Robertson of Edinburgh University. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 07 September 2012. First uploaded 02 July 2009

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

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

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

DOCUMENT 2014 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations

DOCUMENT 2011 Prevention and control of infectious diseases among people who inject drugs

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

DOCUMENT 2014 Time limiting opioid substitution therapy

REVIEW 2012 Opiate substitution treatment and HIV transmission in people who inject drugs: systematic review and meta-analysis

DOCUMENT 2014 Needle and syringe programmes

STUDY 2004 Opiate antagonist treatment risks overdose

STUDY 2011 Benefits of concurrent syringe exchange and substance abuse treatment participation





Buprenorphine/naloxone for opioid dependence: clinical practice guideline.

Handford C. et al.
[Ontario, Canada] Centre for Addiction and Mental Health, 2011.

Though tailored for Canada, these guidelines from an internationally respected centre offer valuable guidance to clinicians in Britain and elsewhere on a form of the main alternative to methadone for the maintenance treatment of addiction to heroin and allied drugs, one whose greater safety counterbalances greater cost.

Summary The following account broadly reproduces the document's summary with the addition (because not dealt with in the summary) of the section from the main text on withdrawing patients from the treatment.

These Canadian guidelines provide clinical recommendations for the initiation, maintenance and discontinuation of buprenorphine/naloxone maintenance treatment for opioid Drugs derived from the opium poppy with opiate-type effects like heroin and morphine and synthetic drugs with similar effects such as methadone and buprenorphine. dependence in Ontario. The focus is on the combination product (marketed as Suboxone) because this is the only sublingual Taken by dissolving under the tongue. buprenorphine product available in Canada for maintenance treatment. The addition of naloxone is intended to deter injection because if taken in this way the naloxone is active and could precipitate withdrawal in people dependent on drugs like heroin and methadone. Buprenorphine is the active ingredient. By substituting for the opiate-type drugs the patient is dependent on, it is intended to safeguard them from harm related to injecting and use of illegally acquired drugs, stabilise their lives, and to bring them in to a setting where their addiction can be treated.

The guidelines were developed by a multidisciplinary committee, including specialists in addiction medicine, family medicine and pharmacy, who had available to them the results of a systematic review of the literature which formed the evidence base for the guidelines. Recommendations were assigned levels of evidence depending on the methodological rigour of the supporting studies, and grades which reflect the level of evidence plus expert clinical opinion.

The background to the guidelines is that opioid dependence is an increasing clinical and public health problem in Canada, yet only an estimated 25% of people dependent on opioids are enrolled in a methadone programme. Methadone uptake is limited by issues of access, especially in non-urban areas, as well as patient disinterest. Due in part to its demonstrated effectiveness and safety in the primary care setting, buprenorphine/naloxone has the potential to improve access to evidence-based treatment for opioid dependence.

Selecting buprenorphine maintenance treatment

• Buprenorphine/naloxone is an effective medication for the maintenance treatment of opioid dependence. It improves outcomes compared to detoxification and, with the exception of retention in treatment, appears to be of equal efficacy compared to methadone.

Clinical assessment

• Contraindications to initiation of buprenorphine/naloxone are:
– allergy to buprenorphine/naloxone;
– pregnancy (for buprenorphine/naloxone combination product specifically);
– severe liver dysfunction;
– acute severe respiratory distress;
paralytic ileus; A partial or complete blockage of the bowel that results in the failure of the intestinal contents to pass through.
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001306/

– decreased level of consciousness;
– inability to provide informed consent.
• Exercise caution if baseline liver enzymes are elevated above 3–5 times the upper limit of normal.
• The clinical assessment will include the establishment of the diagnosis of opioid dependence, an estimation of degree of the patient's physical dependence on opioids and their level of psychosocial functioning, an appreciation of other concurrent medical and psychiatric diagnoses and an understanding of the patient's treatment goals. Urine drug testing and a small but important selection of other laboratory tests are also essential components of the assessment.

Preparation

• Ensure a clinical assessment has resulted in a diagnosis of opioid dependence, a urine drug test has been interpreted and is positive for opioids, and that there has been a consideration of the contraindications to initiating buprenorphine/naloxone.
• Ensure the patient has provided informed consent to buprenorphine maintenance treatment, is aware of the possible long-term nature of this treatment and has been made aware of other treatment options. A written consent and treatment agreement may be useful.
• Ensure that there are no concurrent substance use disorders, psychiatric illnesses or medical disorders that should be stabilised prior to induction of buprenorphine/naloxone.
• Tell the patient how long to remain abstinent from opioids to maximise the likelihood that at the start of induction on to buprenorphine/naloxone they are already experiencing at least moderate opioid withdrawal. This minimises the likelihood that buprenorphine/naloxone will precipitate withdrawal during the induction.
• Ensure the patient has no plans to drive a vehicle or operate heavy machinery during the early induction period.

Induction

• Patient presents in moderate opioid withdrawal to the physician's office as early in the day as possible.
• After an assessment to establish the severity of opioid withdrawal, the physician prescribes an initial induction dose of 2–4mg of buprenorphine/naloxone (though it could be as high as 6mg), to be administered sublingually.
• The ingestion of the dose is observed by a pharmacist or other health care professional to ensure the tablet has dissolved completely.
• Consideration is given to reassessing the patient one hour after the dose to assess for precipitated withdrawal.
• If necessary, the patient is reassessed after approximately three hours to assess effectiveness of the initial dose and consider prescribing an additional observed dose (to a maximum of 8mg total on the first day). If after this re-assessment the prescriber is unsure about the need for another buprenorphine/naloxone dose, the prescriber may also consider prescribing one or two 2mg tablets of buprenorphine/naloxone for the patient to take home on that first induction day in case withdrawal symptoms emerge later in the evening (not exceeding 8mg total on the first day).
• The prescriber either asks to see the patient the next day or writes a prescription for observed once-daily dosing of buprenorphine/naloxone for the next one to two days for the total amount taken by the patient on day one. At the follow-up appointment the patient is assessed for the effectiveness of the dose and any side effects. The patient is made aware they can present for reassessment earlier than the suggested day if they are feeling the dose is very inadequate or they are having side effects from the dose.
• At each follow-up visit, the buprenorphine/naloxone dose is titrated, generally by 2–4mg at a time, until an optimal maintenance dose is reached. An optimal dose is one where, among other things, the patient is free of opioid withdrawal symptoms for the full 24-hour dosing interval without experiencing intoxication or sedation from the medication.

Maintenance

• Once at the maintenance dose and more clinically stable, patient visits become gradually less frequent. However, even a highly stable patient should be assessed at least every 12 weeks. Visits will again be more frequent during periods of instability.
• At follow-up visits, clinical stability is ascertained using the clinical assessment and urine drug testing.
• Areas to cover at follow-up visits include adequacy of the dose and side effects, substance use, psychiatric symptoms, employment, social relationships, and participation in counselling/mutual aid groups.
• Once the patient is at a stable maintenance dose, consideration can be given to alternate-day dosing. Double the dose on Monday, Wednesday and Friday and a single dose on Sunday.
• Patients should not receive a dose of buprenorphine/naloxone if they appear intoxicated or sedated upon presenting for their dose.
• The prescriber should have a structured approach to missed doses.
• The prescriber should have a structured approach to deciding about initiating and increasing the number of take-home doses once the patient achieves clinical stability.

Take-home doses

• Prescribing of take-home doses of buprenorphine/naloxone is a therapeutic intervention with benefits and risks.
• Take-home doses should not be initiated until the patient exhibits features of clinical stability. Exercise caution if the patient has recently been suicidal, is injecting, is cognitively impaired or is unstably housed.
• Generally, tighter boundaries should be loosened as the patient displays increased clinical stability rather than tightening initially looser boundaries in response to instability.
• There should be a gradual increase in the number of weekly take-home doses up to a suggested maximum of one to two weeks of consecutive take-home doses dispensed between observed doses.
• Health Canada states that all doses are to be observed, with the exception of weekends and holidays, for at least the first two months on buprenorphine/naloxone. If the prescriber feels that a patient is eligible for additional regular take-home doses earlier than two months, this should be justified in the clinical record and the patient needs to have explicitly consented to this 'against label' prescription.
• When about to receive their first take-home dose(s), all patients should be made aware of the risks to themselves, their family and the public.
• Take-home doses should be reduced or eliminated in response to a loss of clinical stability. If high levels of take-home doses are eliminated all at once and if misuse or diversion of the take-home doses is suspected, the prescriber should strongly consider reducing the buprenorphine/naloxone dose by 25–50%. This would reduce the likelihood of opioid toxicity once the patient starts ingesting their buprenorphine/naloxone doses on a daily basis.

Adverse events and safety

• Buprenorphine's partial mu agonist It has a lower intrinsic activity at opioid receptor sites in the brain than full mu opioid agonists such as heroin, oxycodone or methadone. Clinically, this means buprenorphine has a 'ceiling effect': once a certain dose is reached, opioid effects plateau and do not become more intense even if the dose is increased. pharmacodynamic properties suggest that there is less risk of overdose and short-term mortality compared to full mu agonists such as methadone. Population-level studies appear to consistently and robustly support that hypothesis.
• There is evidence that this medication can be prescribed as safely and effectively by appropriately trained or experienced practitioners in a primary care clinic as it can be in a clinic which specialises in prescribing opiate-type drugs in the treatment of addiction.
• Risk of harm with buprenorphine does still exist, including risks due to injecting the drug, so practitioners must be systematic and thorough in their approach to diagnosing opioid dependence, determining eligibility for buprenorphine/naloxone and inducting and maintaining patients on buprenorphine/naloxone maintenance therapy.

Tapering stable patients

• Buprenorphine/naloxone maintenance treatment is generally considered a long-term treatment with no predetermined end point. That said, there will be patients for whom gradual withdrawal (a 'taper') from buprenorphine/naloxone maintenance has been agreed upon by the patient and prescriber.
• Ideally, patients taper off buprenorphine/naloxone maintenance while drug-free, functioning well and with ongoing psychosocial support. In some circumstances patients may choose to taper off under less than ideal circumstances (eg, ongoing drug use or ongoing social instability).
• Regardless of the clinical circumstances, buprenorphine/naloxone should be tapered gradually, perhaps by 2mg per week initially, and the rate should be adjusted based on the patient's experience of the taper.
• Throughout the taper patients should be monitored carefully for withdrawal, cravings, and lapses to drug use. If clinical stability is lost during the taper, re-titration of the buprenorphine/naloxone dose should be recommended to the patient.


Findings logo commentary Though tailored for Canada, these guidelines from an internationally respected centre offer valuable guidance to clinicians in Britain and elsewhere. Uniquely they focus on the buprenorphine/naloxone product rather than buprenorphine, but the recommendations are usually appropriate to both. Realistically they admit that the anti-injection properties of the combination product – its main claim to being preferred to alternatives – are not 100%. Non-dependent opioid abusers, they say, still get a 'buzz' from injecting the product as do some patients maintained on buprenorphine/naloxone, and there is substantial evidence that the combination product finds an illicit market.

Such considerations are important, because they mean that if supervised consumption is thought necessary at least initially to prevent buprenorphine being diverted on to the illicit market, the same is true of the combination product. This undermines its anticipated advantages as a medication potentially prescribed widely from GPs' surgeries in regimens which reduce supervision costs and the restrictions supervision places on patients' working and family lives. However, buprenorphine with or without naloxone lends itself to being taken every other day, meaning that even if supervision is thought necessary, the attendance burden is halved compared to methadone.

An international review and UK guidance have contrasted the virtues of methadone versus buprenorphine. Like the featured guidance, these found little in the research to indentify who would do best on one drug rather than the other. The Findings analysis tentatively offered the indications that buprenorphine possibly helps depressed patients more than those not suffering depression, while patients dependent on large doses of opiates may find it inadequate because there is a ceiling beyond which higher doses do not augment opiate-type effects. Patients who value the 'wrapped in cotton wool' feeling typical of heroin may prefer methadone, while those who value a clearer mind might prefer buprenorphine.

Britain's National Institute for Health and Clinical Excellence suggests that when for an individual the medications are equally appropriate, methadone might take precedence because it costs less and on average extends the benefits of being in treatment. With the emphasis in Britain shifting from retention to treatment exit and concern over recently increased numbers of methadone-involved overdose deaths, buprenorphine with or without naloxone could find a greater profile, especially if the cost savings of alternate day dosing, less need to supervise consumption, and primary care rather than clinic-based treatment, are fully realised to counter the greater cost of the drug and the greater time required for each supervised consumption.

For other guidelines offering advice on buprenorphine maintenance run this search on the Findings site.

Last revised 24 September 2012

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

REVIEW 2014 A review of buprenorphine diversion and misuse: the current evidence base and experiences from around the world

DOCUMENT 2011 Guidance for the use of substitute prescribing in the treatment of opioid dependence in primary care

DOCUMENT 2009 Buprenorphine: a guide for nurses

STUDY 2015 Risk of mortality on and off methadone substitution treatment in primary care: a national cohort study

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

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

REVIEW 2009 Pharmacotherapies for the treatment of opioid dependence: efficacy, cost-effectiveness and implementation guidelines

DOCUMENT 2009 Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence

STUDY 2010 Were the changes to Sweden’s maintenance treatment policy 2000–06 related to changes in opiate-related mortality and morbidity?





Improving lifestyle and risk perception through patient involvement in nurse-led cardiovascular risk management: a cluster-randomized controlled trial in primary care.

Koelewijn-van Loon M.S., van der Weijden T., Ronda G. et al.
Preventive Medicine: 2010, 50, p. 35–44.
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 Koelewijn-van Loon at M.Koelewijn@HAG.unimaas.nl. You could also try this alternative source.

Dutch general practice patients at risk of cardiovascular disease did not further reduce their risks (including drinking and smoking) in response to motivational counselling from the practice nurse. Why did a well worked out, multi-session intervention fail to better usual care? The probable answer is among the common factors which transcend therapies.

Summary Most patients at risk of cardiovascular diseases could benefit from various non-pharmacological risk-reduction options such as giving up smoking, exercising more, eating more healthily, and cutting their alcohol intake. However, it is not clear if programmes intended to foster these lifestyle changes are effective in the primary prevention of cardiovascular diseases. A systematic review of trials found no significant effects, though a recent trial showed that a nurse-coordinated programme achieved healthier lifestyle changes among patients at high risk.

The IMPALA Improving Patients' Adherence to Lifestyle Advices. study used a new intervention to reduce cardiovascular risk, in which general practice nurses play a central role. Key elements are risk assessment, risk communication, use of a patient decision support tool, and adapted motivational interviewing. Risk communication and the patient decision support tool inform patients about their risk of cardiovascular disease and options for risk reduction, and are also used to correct inappropriate risk perceptions. Motivational interviewing is used to help patients articulate their views and personal values regarding cardiovascular risk reduction and to build motivation for lifestyle change. In this study the intervention was delivered by practice nurses trained over two days and occupied two 20-minute face-to-face consultations (intended to give patients time to reflect on the information received in the first consultation) plus a further 10-minute telephone or face-to-face consultation to initiate the follow-up.

An earlier study found no impact a year after intervention but it was thought there might have been some shorter-term impacts, a possibility tested by the featured study. The study randomly allocated 25 general practices to the IMPALA 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 whose nurses were trained for just two hours in risk assessment and apart from this merely applied usual care. One practice had to leave the study leaving 13 allocated to the intervention and 11 to the control group. Altogether they recruited 615 adult patients to the study who were eligible for cardiovascular risk assessment due to their blood pressure, cholesterol level, smoking, diabetes, family history or obesity. All but 67 were followed up 12 weeks later. They averaged about 57 years of age and 45% were men.

Main findings

The study assessed whether trends in cardiovascular risk from baseline to 12 weeks differed for patients in practices implementing the IMPALA intervention compared those which did not. Though both sets of patients reduced their risk, no statistically significant differences between them were found on any primary outcome including fat, fruit and vegetable consumption, physical exercise, smoking and drinking. In particular, in both groups the proportions drinking within Dutch national guidelines remained virtually unchanged at around 90%.

The authors' conclusions

Patients in both intervention and control groups improved their lifestyles, but there were only a few small and non-relevant significant differences between them. Some relevant effects of the intervention were found on the secondary outcomes of the appropriateness of their perceptions of the risk they faced of cardiovascular disease and the appropriateness of their anxiety about their risk.

A possible explanation for the lack of added impact from the intervention is that nurses in both groups were highly motivated and gave high quality care, making it difficult to improve more after just one short course. More extended training and supervision seems needed for motivational interviewing. However, another analysis was confined to patients who actually received the intervention as planned, and yet again it found no extra risk reduction. The engagement of the nurse with the patient and their concern seem the key active ingredients, whether or not the nurse followed the structured advice stipulated by the IMPALA intervention.

Last revised 15 September 2012

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DOCUMENT 2015 Alcohol-use disorders

STUDY 2010 Routine alcohol screening and brief interventions in general hospital in-patient wards: acceptability and barriers

STUDY 2012 Alcohol screening and brief intervention in primary health care

STUDY 2013 Effectiveness of screening and brief alcohol intervention in primary care (SIPS trial): pragmatic cluster randomised controlled trial

REVIEW 2011 Barriers and facilitators to implementing screening and brief intervention for alcohol misuse: a systematic review of qualitative evidence

REVIEW 2015 Prevention of addictive behaviours

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

STUDY 2012 Text-message-based drinking assessments and brief interventions for young adults discharged from the emergency department

STUDY 2013 Screening and brief intervention for alcohol and other drug use in primary care: associations between organizational climate and practice

STUDY 2008 The effectiveness of a brief intervention for illicit drugs linked to the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in primary health care settings: a technical report of phase III findings of the WHO ASSIST randomized controlled trial





Community reinforcement approach (CRA) for cocaine dependence in the Spanish public health system: 1 year outcome.

Secades-Villa R., Sánchez-Hervás E., Zacarés-Romaguera F. et al.
Drug and Alcohol Review: 2011, 30, p. 606–612.
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 Secades-Villa at secades@uniovi.es.

Emerging from its US home, the community reinforcement approach aiming to rearrange a patient's life outside the clinic to reinforce abstinence has been trialled for cocaine users at a Spanish drug treatment centre. Though therapeutic contact was equalised, patients did better than in standard treatment based on cognitive-behavioural principles.

Summary Often trialled in combination, contingency management approaches, which systematically apply incentives and sanctions, and the community reinforcement approach are recommended psychological interventions for addiction to cocaine and other stimulants.

Community reinforcement involves behavioural skills sessions intended to rearrange personal and community resources and develop alternative social activities to reinforce recovery from substance use problems. Though supported by research, there are questions over cost and feasibility in usual community contexts, especially outside the USA.

The featured study assessed the approach in a Spanish city at a public outpatient facility specialising in substance use problems, following up patients for a year after the intervention started. Patients selected for the study were adults without severe psychopathology who were seeking treatment for their dependence on cocaine. Nearly 9 in 10 of the 82 who joined the study were men. They averaged 31 years of age, had used cocaine for on average 10 years, and about three quarters were in full-time employment.

They were assigned at random to standard treatment or the community reinforcement approach, both offered for six months and with the same weekly frequency of sessions and total amount of therapeutic time. Following no set protocol, standard treatment included family sessions as appropriate and was based on cognitive-behavioural, relapse prevention principles. In contrast, community reinforcement was applied in line with a structured protocol With five components: drug avoidance skills; lifestyle change; relationship counselling; other substance abuse; and other psychiatric problems. Intensity of application of each module was adapted to the individual. To make implementation more feasible the vouchers subcomponent (material rewards for desired behaviour) was omitted and there was only one session a week instead of two. During the first three months, only two urine tests were carried out per week instead of the three indicated by the original protocol; two tests yielded the necessary objective data on cocaine abstinence. setting the content for each session plus written 'homework' assignments, and therapists (different staff from in the standard treatment) had been intensively trained and were supervised weekly.

A year after treatment started, 34 patients (41% of the initial sample and 85% of those who completed treatment) could be reassessed, including 37% of those assigned to standard treatment and 44% community reinforcement.

Main findings

Though not always to a statistically significant The following account identifies which were. When not specified, the result was not statistically significant. or large degree, in general community reinforcement patients fared better than those offered standard treatment in terms of retention and cocaine use and their wider problems, especially in family-social and drinking domains.

Treatment was completed by 55% of community reinforcement patients but 40% in standard treatment. Abstinence from cocaine was assessed at one year for the 34 patients who could be reassessed. Of the 21 who had been offered community reinforcement, 95% were no longer using cocaine compared to 69% of the 13 reassessed after standard treatment, a statistically significant difference. On the assumption that those not followed up were still using cocaine, the gap was 43% versus 26%, no longer statistically significant. Continuous abstinence throughout the follow-up year was attained by 27% versus 21%.

Substance-related and other life problems generally improved more after community reinforcement and to a statistically significant degree in the family-social and alcohol domains.

The authors' conclusions

Cocaine use abstinence and life in general improved more among patients offered the same amount of therapy but following a community reinforcement protocol. Notably this protocol included modules lacking from standard treatment on relationships and other substance use, the areas where (apart from cocaine use) community reinforcement patients improved significantly more. Based on these results, community reinforcement can be considered a promising programme which can be adapted to community contexts with good results.

That there were not clearer or greater gains from community reinforcement may have been due to the comparison treatment sharing some of the same cognitive–behavioural therapeutic principles, and to the omission of contingency management elements from the protocol.


Findings logo commentary The authors' "promising" verdict seems about right given a small sample, most of whom could not be followed up. Less promising was the major relevant UK trial, which incorporated community reinforcement elements in its social behaviour and network therapy option for alcohol dependent patients. Like community reinforcement, this was intended to bolster the incentives for sobriety in the patient's social life outside the clinic. Though offered and on average delivered over more sessions, this option did not improve on a brief therapy based on motivational interviewing principles. However, both were just part of the treatment patients were given, not the sole inputs, perhaps masking any benefits of community reinforcement.

In Spain and applied largely to employed male cocaine users, community reinforcement led to at least 43% of patients no longer using cocaine a year later, and probably more. This creditable result again shows that cocaine addiction can effectively be managed and overcome through generic psychosocial therapies, even though there is no specific psychological or pharmacological option such as methadone for heroin dependence.

In the featured study it may have been relevant that the therapist(s) assigned to community reinforcement had recently been specially trained in this new approach and then supervised weekly. The optimism of a new scientific approach, extra support, and clearer structure afforded to community reinforcement therapists may in itself have accounted for the somewhat better outcomes, regardless of the content of the therapy.

For more run a search on the Findings site for all our analyses of family and social network therapies. The results include this review of community reinforcement studies.

Last revised 12 September 2012

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