Drug and Alcohol Findings home page. Opens new window Effectiveness Bank bulletin 21 January 2014

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

Studies on naloxone for overdose prevention, brief alcohol interventions, private versus public alcohol treatment provision, and whether parents should introduce their underage children to alcohol. Plus updated entries on the UK expert group report on methadone as a recovery aid and 2012/13 statistics on drug treatment in England.

More naloxone needed to cut opiate overdose deaths ...

Brief alcohol advice might help with emergency department overload ...

‘Empathy gap’ in private alcohol treatment, poor NHS systems? ...

Should parents introduce their underage children to drink? ...

Crucial UK report aims to rehabilitate methadone as a recovery tool ...

Fewer patients but improving treatment outcomes in England ...


Consideration of naloxone.

Advisory Council on the Misuse of Drugs.
[UK] Advisory Council on the Misuse of Drugs, 2012.

The UK’s official drugs law and policy advisory body recommends that alongside training, the opiate-blocker naloxone be made more widely and easily available to enable drug users and those who work and associate with them to prevent opiate overdose deaths.

Summary The UK’s Advisory Council on the Misuse of Drugs was established under the Misuse of Drugs Act 1971 to keep under review the drugs situation in the UK and to advise government ministers. This report from the council offers advice to government on the evidence regarding the opioid Drugs with opiate-type effects (including analgesia and the capacity for producing euphoria and dependence) derived from the opium poppy like opium, heroin, and morphine (known as opiates) and synthetic drugs with similar effects like methadone and buprenorphine. antagonist naloxone and whether to make the drug more widely available to prevent overdose deaths. Naloxone rapidly, but temporarily, reverses the effects of heroin and other opioids, preventing overdose progressing to a fatality. For several years it has been distributed in emergency kits to heroin users worldwide including in England, Scotland, and Wales, and in New York State, Los Angeles and Chicago in the USA. It has also been distributed over the counter in pharmacies in Italy. International and UK research has found that naloxone provision may be effective at preventing opiate-related deaths. Wider benefits around engaging with drug users and empowering family members and carers have also been reported.

Executive summary

Naloxone is a safe, efficacious drug for reversing the effects of opioid overdoses.

In the UK there are hundreds of deaths related to heroin use every year and a lesser number due to the abuse of other opioids. Preventing drug-related deaths has been, and continues to be a government priority.

Naloxone is already used by emergency services personnel to reverse heroin and other opioid overdoses. In 2005 it was made available under UK law to be administered by anyone for the purpose of saving a life. However, naloxone remains a prescription-only drug, and is only licensed for use in injectable form. This means that at present it is not able to be distributed to anyone without a named prescription. Because it is prescription-only, non-medical services which may experience frequent opiate-related overdoses are not able to legally hold stocks of naloxone to use in an emergency.

There is evidence that giving take-home naloxone to drug service users, and that training carers or peers how to administer naloxone, can be effective at reversing heroin overdoses. Wider provision of naloxone could result in a reduction in overall drug-related deaths in the UK.

However, wider provision of naloxone alone is not sufficient to prevent drug-related deaths. The council considers itself aligned with UK and worldwide research indicating that, alongside naloxone provision, training service users, peers and carers in all aspects of how to respond to an overdose is important.

Through its 2011 Lord Advocate’s guideline, Scotland has already made provisions to make naloxone more widely available. This promotes the availability of naloxone to approved services without prescription for use in an emergency. It also protects medical professionals supplying naloxone in cases of liability.

Conclusions

There are more than one thousand fatal opioid overdoses in the UK each year, which could be prevented by naloxone. Evidence shows that providing naloxone has benefits that include, but are not limited to, a reduction in opioid-related deaths.

Opportunities to assist unnamed individuals in an overdose situation with naloxone are limited by its prescription-only status. It cannot be supplied directly to individuals who may have a good opportunity to intervene in an overdose, such as hostel staff.

Given the opportunities for reversing overdoses and saving lives, the benefits of providing naloxone are greater than any potential risks. Risks and concerns around malicious use of naloxone, or the potential for users to be more reckless with their drug use, are not supported by evidence.

The council commends the Lord Advocate’s guideline and the Care Inspectorate guidance, which are already allowing wider provision of naloxone in Scotland. It would be timely to review the marketing authorisation of naloxone by the Medicines and Healthcare Products Regulatory Agency as a prescription-only medicine.

Training carers in naloxone administration may be beneficial, but training all those likely to encounter an overdose would have a greater impact on overdose rates. Naloxone availability to a wider group of people will further highlight the risks of opioid overdose, and have educational and public health benefits.

Naloxone provision is just one of several tools in a package of interventions to prevent opioid overdose, including basic life support training. It is important that individuals possessing naloxone are given suitable training in how to respond to an overdose, as well as how to administer naloxone.

Recommendations

To tackle the high numbers of fatal opioid overdoses in the UK, naloxone should be made more widely available.

Government should ease the restrictions on who can be supplied with naloxone.

Government should investigate how people supplied with naloxone can be suitably trained to administer it in an emergency and to respond to overdoses.


Findings logo commentary Since this report was published, in May 2013 Prenoxad, the world’s first licensed naloxone product for use in opioid overdose emergencies by non-medical personnel, became available in the UK after approval by the Medicines and Healthcare Products Regulatory Agency. The naloxone comes as part of a kit including a pre-filled syringe, a leaflet containing product instructions, and first aid guidelines appropriate to managing opioid overdose. This approval is seen as an important step to widening availability as recommended by the featured report. It means GPs across the UK can prescribe the naloxone injecting kits to suitably trained drug users and with their permission to their associates and family. Patient Group Directions also enable doctors to authorise pharmacists and nurses to supply the kits to drug users at risk, such as those who might be seen at needle exchanges. This development still leaves the prescription-only restrictions which the featured report wanted reviewed.

For background on the promise and limitations of naloxone see this analysis of a British study of the impact of training opiate-using patients in overdose prevention and providing them with a take-home supply of naloxone. Further guidance is available in the appendices to a study of the training of the carers of opiate users conducted by the English National Treatment Agency for Substance Misuse. In 2008 staff from one of the English NHS trusts which piloted naloxone training for families and carers produced a UK-focused practical guide to naloxone prescribing, training and use. The Scottish Drugs Forum runs a web site offering resources, advice, guidance, information and news on naloxone programmes and administration. This international web site offers advice and practical assistance on starting a take-home naloxone programme. Guidance on overdose prevention in general with an emphasis on the role of naloxone has been produced by the Eurasian Harm Reduction Network. In the USA the Chicago Recovery Alliance has produced a freely available training video. The manufacturers of the naloxone preparation Prenoxad licensed for emergency use in the home or other non-medical setting by appropriate individuals for reversing opioid overdose offer advice on its use. For more Findings analyses on naloxone in overdose prevention run this search, and for more on overdose prevention in general and developments in the UK see this 'hot topic' entry.

Last revised 17 January 2014. First uploaded 17 January 2014

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

STUDY 2011 The NTA overdose and naloxone training programme for families and carers

DOCUMENT 2014 Community management of opioid overdose

HOT TOPIC 2015 Overdose prevention

STUDY 2011 Impact of training for healthcare professionals on how to manage an opioid overdose with naloxone: effective, but dissemination is challenging

STUDY 2008 Overdose training and take-home naloxone for opiate users: prospective cohort study of impact on knowledge and attitudes and subsequent management of overdoses

STUDY 2012 The impact of take-home naloxone distribution and training on opiate overdose knowledge and response: an evaluation of the THN Project in Wales

MATRIX CELL 2014 Drug Matrix cell C1: Management/supervision: Reducing harm

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

STUDY 2016 Effectiveness of Scotland’s National Naloxone Programme for reducing opioid-related deaths: a before (2006–10) versus after (2011–13) comparison

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





A systematic review and meta-analysis of health care utilization outcomes in alcohol screening and brief intervention trials.

Bray J.W., Cowell A.J., Hinde J.M.
Medical Care: 2011, 49(3), p. 287–294.
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 Bray at bray@rti.org.

Screening for risky drinking and offering brief advice slightly reduces later emergency department visits was the main finding of this review, suggesting these programmes can help ease pressure on overloaded departments. Adding to their attraction, some of the evidence comes from studies in the services set to benefit.

Summary Alcohol screening and brief intervention programmes typically ask a few questions to identify risky drinkers among patients attending for medical care unrelated to their drinking and offer brief advice intended to reduce risks to their health and other adverse consequences. The featured review was the first to systematically assess whether (presumably due to health benefits) following such interventions patients less often need to attend for medical care.

The analysts sought English-language publications reporting relevant trials, excluding those focusing on alcohol-dependent populations [Editor's note: commonly thought an inappropriate target for such brief interventions]. The 29 reports they found were published from 1962 to 2010. Of these, 21 reported studies conducted in primary care, four in emergency departments, and four in another hospital setting. All the reports were from studies in western economically advanced nations, including 17 from the USA and six from the UK. Results were analysed on the assumption that (given differences between the trials) there was no single 'true' effect of the interventions from which trial results deviated just by chance, but that different results might reflect real differences in impact. The analysts selected results from the longest follow-up point in each study, usually a year but in some studies several years.

Main findings

From trials conducted in primary care, 11 reports assessed the use of outpatient medical services following intervention; results were generally not statistically significant and fairly evenly split between increased and decreased use, suggesting that overall there was no appreciable impact. The picture was similar with respect to impacts on inpatient stays. However, emergency department visits were more consistently reduced – seven of 11 reports; a non-significant decrease was the typical finding, though in two US reports from the same trial the fall was significant. Reports which combined all three categories of medical care found no significant impacts.

Results from interventions tested in emergency departments and other hospital settings were generally inconclusive. However, the three reports which documented emergency department visits found decreases, two of which were statistically significant. In respect of interventions actually in emergency department, one British study found subsequent emergency visits were fewer when risky drinkers had been referred for counselling, but across these studies inpatient care and outpatient care were either unaffected or impacts were mixed. In other hospital settings, one trial found a statistically significant decrease in subsequent inpatient stays. Three other reports documented mixed or no effects on outpatient and emergency care.

After describing the results of the trials the analysts attempted to amalgamate them using meta-analytic techniques, but just 11 of the 19 reports provided usable data from distinct trials. With so few it was decided not to divide the trials according to the type of setting in which they were conducted. Findings from the analyses were in line with the descriptive account of the trials. Compared to control patients, across all 11 trials outpatient visits actually increased among patients allocated to a brief intervention, but this finding narrowly missed statistical significance, and the variation between trials was such that it could not be relied on as an indication of the general impact of brief interventions. Results were similar for inpatient stays. Emergency department visits fell relative to control patients and there was relatively little variation across the trials. However, this result was not statistically significant, and even if it was nevertheless real, the effect was marginal.

The authors' conclusions

Both the descriptive review and the meta-analyses suggest that alcohol screening and brief intervention in primary care and in emergency departments slightly reduce the need for later emergency department visits, but there is little or no effect on later inpatient or outpatient medical care. Because emergency care is generally very expensive, interventions in these settings may reduce overall health care cost. Interventions mounted in non-emergency hospital settings appeared to have no effect on later health care utilisation. However, there were too few studies to generate robust policy implications.

In the context of there having been no impact on inpatient stays, the small increase in outpatient care found in the meta-analysis may reflect a desired effect of brief advice – to prompt further help among drinkers whose problems are not so severe as to require admission to hospital.


Findings logo commentary This analysis speaks to an important issue in brief intervention policy – whether the health services generally responsible for mounting these programmes can expect a pay-off in improved patient health which in turn relieves the load on their services. With this kind of possibility in mind, Britain's national health intervention advisory body has commended screening and brief intervention to NHS and local authorities as an essential strand in an "invest to save" strategy to prevent problem drinking. The only real hope the featured review holds out is that screening for risky drinking and offering brief advice in GPs' surgeries and in emergency departments may mean slightly fewer emergency visits in the future. Given the pressure on emergency departments in Britain, this may seem a worthwhile potential addition to any other benefits to the patients and their associates from reduced drinking. However, this hope rests mainly on two studies which did not duplicate how brief interventions would usually be implemented. Details below.

The finding in the meta-analysis that brief interventions may cut later recourse to emergency departments appears to rely largely on two US trials. Rather than attempting to approach all relevant patients in the emergency department, the first study recruited inpatients admitted for at least 24 hours to a trauma centre. The 30-minute intervention was delivered not by the hospital's medical staff but by a psychologist trained in brief interventions, and was followed up a month later by a handwritten letter. Given the nature of the injuries sustained by these patients (falls and traffic accidents accounted for about half), it seems likely that many were related to recent heavy drinking, a persuasive hook for the intervention. Nearly half the patients had previously been counselled about their drinking, further indication that this was not a usual emergency department sample. In a second study, the 'brief' intervention was unusually extensive – two advice sessions with a family doctor and two follow-up calls from a nurse – and the control intervention which it outperformed could not be considered acceptable medical care. Control patients were merely handed a general health advice booklet which would not have signalled to them that they had a drinking problem, and their doctors were not told that screening had indicated heavy drinking, depriving them of an opportunity to address the issue during the routine medical consultation.

A third study which found reduced emergency care (in another three trials, results were in the 'wrong' direction) came from the UK. Based on their own accounts, over the following 12 months patients randomly allocated after screening to an appointment with an alcohol adviser had made slightly fewer visits to an emergency unit than those simply handed an alcohol advice leaflet and told by emergency staff that their drinking might be harmful. The difference of on average 0.90 attendances versus 0.97 per patient was statistically insignificant, and the number of times patients had needed an ambulance was virtually the same regardless of intervention. This data (which was included in the featured review) was based on fewer than half the patients in the study. However, the unit's own attendance records revealed that patients allocated to advice had returned nearly 30% fewer times than patients simply handed the leaflet – a difference which was statistically significant. Though not reliant on following patients up, this finding too suffered from loss of patients to the study; of those who had screened positive for risky drinking, only about half entered the trial. Notably these results reflected the impact of adding an offer of further advice (which only a minority took up) to the potentially powerful warning from unit staff, itself a (presumably very) brief intervention. Without this systematically applied warning the advantage gained by the offer of advice might have been greater.

What about injuries?

If the impact on emergency department visits is real, presumably a major mechanism is the reduction of injuries. For the evidence we can turn to a Cochrane review which investigated injury reductions after interventions targeting problem drinking. When the analysis narrowed in on brief interventions, five of the seven relevant trials were found to have recorded fewer injuries after intervention than in a control group, and in two the differences were statistically significant. Interestingly, these two trials did not find reductions in drinking; across all the studies, injury reductions often did not parallel drinking reductions and vice versa.

From emergency departments in particular there is little evidence, and findings are patchy though on balance positive. Among studies which compared brief against no intervention, one review which focused on injured patients found two studies in which injuries were further reduced by intervention, and one in which they were not. Another similar review did not confine itself to injured patients, but excluded studies where the intervention was conducted during follow-on inpatient care. Combined findings showed that six to 12 months later, interventions patients were about half as likely as comparison patients to have suffered an alcohol-related injury. The three studies on which this estimate was based were all from the USA. Two (1 2) involved only teenage patients whose drinking would have been illegal in that country. The third did recruit adults, offering a one-hour motivational interview plus for some patients a further session a week or so later, which nearly 70% attended. Only those offered (and especially those who attended) this 'booster' experienced significantly fewer injuries than control group patients who received no special intervention.

In GP-based primary care the main feature is the lack of studies. The US study referred to above which featured an unusually extensive intervention did find this was followed over the next four years by fewer traffic accidents causing death or injury compared to the record of patients offered no alcohol-focused advice by the study. Apart from this, the evidence bank seems empty. Absence of evidence is also the main feature for studies based in general hospital wards.

Last revised 28 December 2013. First uploaded 19 December 2013

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

STUDY 2003 Family doctors' alcohol advice plus follow up cuts long-term medical and social costs

STUDY 2011 Randomized controlled trial of a brief intervention for unhealthy alcohol use in hospitalized Taiwanese men

STUDY 2012 Alcohol screening and brief intervention in emergency departments

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

STUDY 2005 Heavily drinking emergency patients cut down after referral for counselling

STUDY 2003 Injury rate cut in heavy drinking accident and emergency patients

STUDY 2006 A&E units save health service resources by addressing drinking

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

REVIEW 2013 Interventions for reducing alcohol consumption among general hospital inpatient heavy alcohol users: a systematic review

REVIEW 2010 Alcohol-use disorders: Preventing the development of hazardous and harmful drinking





Delivering service quality in alcohol treatment: a qualitative comparison of public and private treatment centres by service users and service providers.

Resnick S.M., Griffiths M.D.
International Journal of Mental Health and Addiction: 2012, 10, p. 185–196.
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 Resnick at sheilagh.resnick@ntu.ac.uk. You could also try this alternative source.

This small English study poses fundamental questions about alcohol treatment services: whether private services suffer from an ‘empathy gap’ and NHS services from poor systems; whether opening up treatment choice to patients with a record of bad decision-making is a good thing; and whether there can be universal criteria for what counts as quality provision.

Summary Organisation of alcohol treatment in Britain is very fragmented both in numbers of services and treatment approaches. The NHS offers programmes to help patients control their drinking, but many private and voluntary (mainly charitable) sector services are based on the 12-step model which mandates abstinence. Specialist NHS alcohol treatment units are organised to deal with complex cases of problem drinking and are funded by public health commissioning bodies, whose primary purpose is to implement national health priorities within the context of the local community. Voluntary alcohol treatment agencies can provide services for a range of problem drinkers, and receive funds from various sources such as local authorities, funding charities, and public health commissioning bodies. These bodies may also fund places for NHS-referred patients at private alcohol treatment services, which also cater for patients who arrange or provide their own funding.

The result is a diverse and fragmented service environment which invites competition for funding and within which problem drinkers may lack the capacity to make appropriate choices. Numerous choices of treatment services allow movement from one to another and back again, creating a ‘revolving door’ which also shapes service expectations based on previous experiences.

To investigate these and other issues, 17 patients and 13 healthcare staff at an NHS and 25 and 15 at a private alcohol treatment clinic in the same town in the English Midlands were interviewed in depth, guided by a framework of topics What does a quality service mean to you?
What do you think are the criteria for a quality service in the clinic?
Who do you think decides whether the service is good or not?
Who do you think judges whether a good service has been delivered?
Are systems in place to deliver a quality service? What are these?
Are practices in place to deliver a quality service? What are these?
What are the gaps in the service provision?
Who is important in the service delivery process?
What do you think about the service overall?
probing their understanding of what ‘quality’ means in alcohol treatment and how it can be achieved. Interviews were recorded and coded around the same topics, and further themes were identified. The NHS clinic focused on day care and aimed at controlled drinking; the private unit was residential and aimed for abstinence. The latter’s 16 beds included seven publicly funded for NHS-referred patients.

At the NHS clinic 88% of patients were unemployed. Of the 17 patients, 10 had previously attended the same service and 15 other alcohol treatment services. Staff were mainly men and averaged 12 years at the service. Patients at the private service were about equally split between being private and publicly funded. They stayed at the unit for on average 17 days. About a quarter had previously attended the same service and over 60% other alcohol treatment services. Around a third were in active employment. The staff sample were mainly women and averaged two and a half years at the unit.

Main findings

Four key themes emerged from the analysis of the tapes: how service quality delivery is defined; funding of services; choice in alcohol treatment services; and service delivery processes and their measurements. All are explored in the featured article but not all in the account below.

Patients and staff at the NHS clinic saw quality as an empathic relationship between the two and good clinical care. Patients defined quality by their personal relationships with the healthcare team, the care they received, the attitude of the staff towards their problem drinking and the way they felt personally supported – for example, staff being “interested in you as a person”. Staff saw quality as meeting patients’ needs, which was achieved through training, their professionalism in building relationships with patients, and through “Providing a professional service, founded on evidence and best possible treatment to clients ... warmth, flexibility, accepting, humanistic”.

Patients at the private clinic defined service quality in terms of achieving recovery from problem drinking and receiving a professional service. ‘Professional’ too was the term used about how service quality is delivered at the clinic though expertise, training, the structure of the treatment programme, and the physical delivery of services. Staff too described themselves as ‘professional’ and referred to qualifications, training, guidelines and knowledge as ways they deliver quality.

The study city hosted up to 23 alcohol treatment services competing for patients and for funding. Patients could move between them and return to the same services. Several at the NHS treatment clinic were on their fifth treatment attempt, having accessed other alcohol treatment services en route. NHS clinic staff said, “People can buzz around between different services ... they can sometimes bump into what suits them but at other times the number of services makes it more complex”, but also said the diversity “Makes it easy for the patients ... there is always an alternative for them”.

Of the 15 patients at the private clinic who had accessed other treatment services, nine had experienced the NHS controlled drinking programme, but many said it had not worked for them.

At the NHS clinic, auditing and measurement of service delivery appeared vague and inconsistent and there was little emphasis on measurement as a core or meaningful activity. In comparison, the private unit had a pre-admissions process for NHS-funded patients, a patient feedback process, and processes for auditing and monitoring practices. Performance monitoring took place at six-monthly intervals. For NHS-funded patients the admissions process established by the funding health authority required a waiting time of at least six weeks, which staff saw as “healthy ... it proves motivation by the patient”. Patients did not share this view, and saw the wait as too long compared to the few days private patients had to wait, who faced no such admission criteria. The funding authority also limits NHS patient access to private sector clinics to two attempts.

The authors' conclusions

An overarching theme was the differing meanings of ‘service quality’ to the different stakeholders. Patients at the NHS service interpreted this as delivered through a good standard of clinical care and an empathic relationship with their service providers, characterised by trust, helpfulness, understanding, responsiveness, reliability, and non-judgmental attitudes. Of lesser importance were the tangible physical environment and facilities of the clinic.

Processes to monitor and promote quality were relatively lacking at the NHS service. In contrast, the private unit had a defined set of processes, systems and outcomes that has produced service provision based around process, professionalism, and profit. Patients expressed service quality expectations of achieving sobriety, recovery, and receiving a professional service. The unit appears to satisfy many of the NHS’s quality criteria in terms of evaluation capabilities and performance measures, not in evidence at the NHS service. Although private clinic patients appreciated the professionalism of the staff, perhaps these emphases, coupled with mainly group rather than individual therapy, distanced staff from patients, impeded the forging of one-to-one relationships, and created an ‘empathy gap’ not apparent at the NHS service.

Another prominent factor was the range of services problem drinkers can access. Not only is there a choice of services, but these offer a choice of treatment methods and aims including an abstinence approach, specifically the 12-Step approach, and controlled drinking. Such choice legitimises patients moving from one service provider to another and back again “seeking the magic solution”, as an NHS clinic manager put it, yet there is no evidence that one approach is generally more effective than another. Fragmentation is aggravated by the lack of ways to record and share patient progress through these different services, and by the fact that in alcohol treatment, GPs do not perform their traditional role of gatekeeper to specialist services.

People often become problem drinkers because of the bad choices they have made in their lives; providing extensive choices in treatment services may not help them or service providers. Choice creates a ‘revolving door’ practice enabling problem drinkers to move from one treatment service to another and back to the same services again; the NHS service believed it had a moral duty to keep its doors open. Whether choice can improve quality in healthcare is debatable, and it could undermine equity, as there will always be people better equipped to make choices than others. This revolving door has emerged partly because responsibility for services is fragmented; no single agency has either the power or the purse strings to effect or organise change.

There were also a number of inconsistent practices and systems, such as the stringent criteria for NHS patient access to the private clinic, contrasted to no such criteria for the NHS service or for private patients at the private clinic, for whom ability to pay was the prime criterion.

These findings suggest that alcohol treatment needs a grass-roots assessment of local services, a system for commissioning all treatment services, and a framework for health service funders to plan local services more effectively and to determine an appropriate level of funding. Measurements of performance need to be introduced into NHS services, focusing on the appropriateness of the treatment and tracking the progress of the patient through the treatment system. Private sector healthcare staff need to look beyond the treatment process and develop more awareness of a patient’s individual needs. The study also identified a need for local services to work constructively together rather than seeing themselves as in competition for vulnerable patients.

Limitations of the study include its being conducted at just two treatment centres in one UK city, and the subjectivity of research based on the perceptions of participants rather than independent objective measures, though the latter are difficult to formulate.


Findings logo commentary We should take seriously the limitation of the study to just two services. For example, though not the case for the studied service, other NHS services have a strong record of developing systems capable of monitoring and acting as the basis for improving performance and efficiency. Also one service was residential and the other non-residential; some differences between them might have been due to this rather than the private versus public split.

Caring and professionalism

Nevertheless the study unearthed themes which might be of broader relevance. The NHS service was seen as a holistic carer centred on the patient, while at the private clinic patients appear to have seen themselves as buying a professional service which they expected to deliver the results they were paying for. It would have been good to know whether this attitude was equally expressed by the publicly funded patients at the private clinic. Looking to the future, if more publicly funded patients are given credits to purchase their own service mix, they too might come closer to the attitudes of the private patients in the study. With customers and purchasers to satisfy and a marketing job to do, while it came second on developing strong relationships with the patients, the private clinic won out in terms of processes which could monitor – and therefore act as the basis for improving – performance and efficiency.

Ironically, if the private clinic’s staff had systematically and professionally assessed the evidence, they and their patients might have had to agree with this review that the clinician’s professional characteristics have generally been unrelated to how well their alcohol patients do. According to the reviewers, the most consistent factor has been the clinician’s ability to build a positive relationship with patients, the strength of the NHS service.

The importance of interpersonal warmth at NHS services was apparent in data gathered from patients at the Mount Zeehan alcohol treatment unit in Kent and from the nurses who assessed them. Though the six nurses were all well trained and supported and experienced, at one extreme fewer than the a fifth of their patients went on to engage with treatment, at the other, over three quarters. This was strongly related to the nurses’ commitment to working with this set of patients, in turn related to their patients’ experiences: “There is a strong sense that clients experience committed interviewers as interpersonally warm and less committed ones as interpersonally cold”. Interpreting this data in the light of patients’ comments, it was argued that the patient was actually assessing the worker, and that their main concern was, “How does the worker see me? Does the worker like me? Do they accept me? Are they critical of me?” Coming to the clinic in a fragile state with low self-esteem, their sensors were tuned for signs of rejection. When they sensed this, they tended to reject back and not engage with treatment.

The themes of interpersonal warmth and patients “sensitized to rejection” were also apparent at Massachusetts General Hospital in the late 1950s. A study there found emergency doctors’ responses to the question, “What has been your experience with alcoholics?” were closely related to how many of their alcoholic patients had a year before followed through on a referral to the treatment clinic. The more a doctor evidenced personal (rather than coldly professional) concern in tone as well as words, the more likely their patients had been to treat the encounter as the start of a therapeutic relationship they wished to continue.

As at Massachusetts, ideally these virtues would be combined, a caring attitude to patients providing the motivation for developing strong systems which in turn enable caring to be consistently and effectively expressed in practice. For example, clinicians and services who care if some of their patients are falling behind and want to improve their prospects will be motivated to create and make good use of feedback from systematic and regular assessments of patient progress.

Freedom to make the wrong choice – or the more doors the better?

Another major issue explored by the study was patient choice in services and treatment approaches. By no means everywhere will have the ‘problem’ of up to 23 alcohol treatment options, but where there is this range, the study identifies possible plusses and minuses. Among the concerns seemed to be that patients will rather aimlessly transfer, never fully committing to gaining recovery through one service because another can always be tried or re-tried, and that patients will not make the choices that are best for them in the longer run. An example might have been the private clinic patients who tried the controlled drinking programme at the NHS service but relapsed and were now trying the abstinence-oriented regimen at the private residential unit.

These concerns might be alleviated if local services cohered in to a network through which patients could move sequentially or in parallel or be allocated based on systematic criteria. This was not the case, a national concern for Department of Health support teams which visited hundreds of areas to investigate provision. Neither did GPs act as guide to which services patients should start with and provide continuity and coherence to the treatment journey. The consequences seem apparent in national statistics for England, in which referrals from GPs in to alcohol treatment fall well below the possible caseload.

But as some study participants pointed out, choice at least means there is likely to be some starting or returning point which suits the patient and which may have a chance of success. Researchers responsible for the huge US Project MATCH alcohol treatment study stressed that treatment was not a 'technical fix', but a door through which patients can pass to actualise their impetus to get better. For them the implication of their findings were that “access to treatment may be as important as the type of treatment available to people with alcohol problems. If most treatments are similar in their effectiveness, the real value of having an array of treatments available is to promote healthy competition for the wide variety of people who would benefit from any treatment, but who would be more attracted to one because of reputation, convenience, or personal preference” (italics added).

From British studies we know that at least in the medium term, patients who opt for abstinence or to moderate their drinking usually do about equally well, even when the results are adjusted for differences in the severity of their problems and other factors associated with their choice. Eliminating or restricting one of these options risks deterring patients who prefer that choice from entering or completing treatment, without improving the effectiveness of treatment for the remainder.

Thanks for their comments on this entry in draft to research author Sheilagh Resnick of the Nottingham Business School in England. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 17 January 2014. First uploaded 10 January 2014

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STUDY 2011 Performance-based contracting within a state substance abuse treatment system: a preliminary exploration of differences in client access and client outcomes

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Changing parental behaviour to reduce risky drinking among adolescents: current evidence and future directions.

Gilligan C., Kypri K, Lubman D.
Alcohol and Alcoholism: 2012, 47(3), p. 349–354.
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 Gilligan at conor.gilligan@newcastle.edu.au. You could also try this alternative source.

Should parents introduce their underage children to alcohol, and if they give their children alcohol, is it important that they supervise its consumption? Opinions and guidelines differ as do research findings, perhaps because much depends on the context.

Summary The featured article review research and makes suggestions regarding the pros and cons of parents supplying alcohol to their children (in particular, those below the legal alcohol purchase or drinking age), sometimes thought a way to inculcate healthy drinking habits.

It starts with the observation that children are exposed to and learn about alcohol from an early age from their parents and families, the wider community and the media. Early offers of drink to their children is one way parents affect their drinking; other influences (either direct or via choice of peer group) include positive family relationships and parenting behaviours.

Guidelines and policies in many countries encourage parents to delay their children's initiation in to drinking or to closely supervise their drinking to dampen progression to problem use. These guidelines are, however, based on limited evidence and mixed research findings which, in some cases, contradict the laws regarding purchase and supply. Epidemiological evidence supports the notion that a lower age of initiation in to drinking is associated with a higher risk of alcohol-related problems, but it seems that the risk factors for drinking per se differ from those for drinking at risky levels and developing alcohol-related problems. Some evidence suggests that the age of first drunkenness is more important than the age of first drink in predicting progression to heavy drinking, and the number of episodes of intoxication prior to age 16 has been found strongly related to adult alcohol problems.

Research on the impact of parental supply of alcohol

Research on whether parental supply of alcohol increases or decreases the risk of alcohol-related problems is limited to some studies which have assessed these relationships at the same point in time, and some which have followed up the children to assess the later effect of parental choices. [Editor's note: The implication is that no study has deliberately assigned families to early parental initiation of the child versus another approach to alcohol-related parenting, and that from the studies which have been done, it will be difficult to establish cause and effect.]

The literature to date presents inconsistent information about the impact of parental supply of alcohol, age of initiation and patterns of use. One Dutch follow-up study found no differences in progression to problem drinking among children whose parents provided high versus low levels of supervision of the child's drinking. [Editor's note: The study also found that children who drank at home or outside were equally more likely to later drink in a problematic way than children who did neither, and that there was no further increase in risk from actually drinking with parents inside or outside the home.] The conclusion was that adolescent alcohol consumption increases over time, regardless of the setting or who they drink with. Another follow-up study sampled families in an Australian and a US state. It found that children who drank under adult supervision [Editor's note: not necessarily the parents] were more likely to later drink and experience alcohol-related harms. As with many others, this study did not ask how much alcohol had been consumed, just how often "more than a few sips" had been drunk.

Other studies have related children's drinking to parental behaviour at the same point in time. One large US study found that supervised rather than unsupervised parental supply was associated with less alcohol being consumed per drinking episode, another that young female college students who had been allowed to drink at home later drank heavily more often, but those allowed to drink with friends drank more alcohol on each drinking occasion. Though the Dutch study referred to above found no effect of drinking at home versus outside the home on later problem drinking, it did find that at the same point in time, drinking at home was associated with lower alcohol consumption than drinking outside. Similarly, an Australian survey found that young people who reported drinking alcohol supplied by their parents, or drinking at home, drank less than those who sourced alcohol from friends or elsewhere and drank outside the home.

Studies by the review authors suggest there are important differences between parents supplying alcohol to drink under their supervision, versus under the supervision of another adult or no supervision. In Australia the latter was found to be linked to risky drinking, but parental supply per se was not, suggesting that its impact depends on how and if consumption is supervised.

Caution should be taken in the interpretation and comparison of results from these studies. Their relevant outcomes range from problem drinking and alcohol-related harms to the frequency and volume of alcohol consumed. Even in follow-up studies, failure to explore interactions between variables over may limit the interpretability of results. Most provide limited information about who was present during drinking occasions, and thus the potential influence of parents, other family members and peers in different circumstances.

Role of parental social networks

Parental decisions about introducing their children to alcohol and their attitudes towards alcohol consumption are fundamentally social phenomena but have not been studied as such. Correcting parents' misperceptions regarding the permissiveness of other parents may lead to them to re-evaluate their stances or adopt more effective rules in relation to drinking.

In relation to stopping smoking and other behaviour change, even individuals not directly in contact are able to influence each other through their common social links. For example, parents may be influenced by what their child tells them parents of their friends are doing. In this way, a network of children may be able to influence an entire more distal network of parents by feeding inaccurate information into that network. If the parents can be connected, information is likely to travel directly between them and maintain its integrity. How to do this is unclear; after their children reach a certain age, parents may be reluctant to intervene in their social lives or to contact other parents to discuss concerns.

The potential to intervene with parents

Few families participating and many dropping out have plagued efforts to address adolescent alcohol consumption through parents and families. Some studies have found that dropouts tend to be the parents most likely to have lenient attitudes to underage alcohol consumption. High dropout is also likely to be partly due to programmes not being acceptable to the parents involved. Those trialled to date are largely high intensity interventions requiring active and sustained parental involvement. Less intensive interventions based on parents' existing resources might be more acceptable and cost-effective. Among these may be web-based approaches, through which parents can engage with guidance and educational materials in a safe environment in their own time.

The authors' conclusions

Parental supply of alcohol and parental monitoring have been linked to initiation to drinking as well as levels of later use, and are likely to be influenced by the practices of other parents and their perceptions of social norms. Sufficient evidence already exists to indicate that intervening with parents, possibly via parental social networks, may be effective in reducing adolescent risky drinking. Future research might profitably explore the volume and contexts of parental alcohol supply, the structure of parent and adolescent social networks, and the existence of 'pluralistic ignorance' among parents, who may be unaware of how other parents handle alcohol-related issues with their children.

Thanks for their comments on this entry in draft to review author Conor Gilligan of the University of Newcastle in Australia. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 27 November 2013. First uploaded 23 November 2013

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Medications in recovery: re-orientating drug dependence treatment.

Strang J. et al.
[UK] National Treatment Agency for Substance Misuse, 2012.
Unable to obtain a copy by clicking title? Try this alternative source.

On behalf of the UK government an expert group has developed and documented a clinical consensus on how prescribing-based treatment for heroin addiction can be made more recovery-oriented in line with national strategy. Their report will be the main reference point in tussles over what recovery means for methadone services and patients.

Summary Acting on behalf of the UK Department of Health, in August 2010 the National Treatment Agency for Substance Misuse – a special health authority which aims to improve treatment for drug problems in England – asked Professor John Strang to chair a group of experts (the Recovery Orientated Drug Treatment Expert Group) to guide the drug treatment field on the use of medications to aid recovery from drug addiction and on how patient care can be more fully orientated to optimise recovery, objectives consistent with the 2010 English national drug strategy.

That strategy expressed concern that "for too many people currently on a substitute prescription, what should be the first step on the journey to recovery risks ending there", and wanted to "ensure that all those on a substitute prescription engage in recovery activities". The group's task was to reach a clinical consensus which would guide clinicians and agencies in helping opioid substitution Editor's note: The use of legally prescribed medications like methadone and buprenorphine with effects similar to those of heroin (sometimes heroin itself is also prescribed) to substitute for the illegal heroin or other opiates patients have become dependent on, ideally releasing them from the experienced need to obtain and use illegal supplies and providing the stability and therapeutic contact which can promote lasting recovery from addiction. patients achieve their fullest personal recovery, improve support for long-term recovery, and avoid unplanned drift into open-ended maintenance prescribing. The group sought to reflect the evidence and contextualise it within the current UK environment and the ambitions of the 2010 English drug strategy.

In framing its recommendations the expert group had available to it a review of the evidence which combined research findings on evidence-based practice with humanitarian, recovery-based considerations based on values such as responsibility, choice, and empowerment.

The authors' conclusions

This account is based on the summary in the main report.

Heroin users are the largest single group in treatment and use an especially tenacious, habit-forming drug in the most dangerous ways. The main task of the Recovery Orientated Drug Treatment Expert Group was to describe how to meet the national strategy's ambition to help more heroin users recover and break free of dependence.

Entering and staying in treatment, coming off opioid substitution treatment, and leaving structured treatment, are all important indicators of an individual's recovery progress, but do not in themselves constitute recovery. Leaving substitution treatment or any treatment prematurely can harm individuals, especially if it leads to relapse, which is also harmful to society. Recovery is a broader and more complex journey that incorporates overcoming dependence, reducing risktaking behaviour and offending, improving health, functioning as a productive member of society, and becoming personally fulfilled. These recovery outcomes are often mutually reinforcing.

The ambition for more people to recover is legitimate, deliverable and overdue. Previous strategies focused on reducing crime and drug-related harm to public health, in respect of which society benefited from people being retained in treatment as much from completing it. This allowed a culture of commissioning and practice to develop that gave insufficient priority to an individual's desire to overcome his or her drug or alcohol dependence, particularly for heroin users receiving substitution treatment, where the protective benefits have too often become an end in themselves rather than a safe platform from which users might progress towards further recovery.

Overcoming drug or alcohol dependence is often difficult, and especially so for dependence on heroin. US studies suggest that over 30 years, half of all dependent users will die, a fifth will recover, and the remainder will continue to use opiates, some at a lower level. An accessible, evidence-based, drug treatment system in every part of England affords an excellent opportunity to improve on the past, seeing international, historical evidence as the floor for current ambition, not its ceiling.

England has lower rates of drug-related deaths and blood-borne virus infections than most of Europe and North America. Most people who enter treatment want to recover and break free of their drug dependence. More can be helped to realise this ambition if safe, evidence-based, recovery-orientated practice can be allied with the public health and wider social benefits already accrued from treatment.

Research, the international track record, and clinical experience, show that not everyone who comes into treatment will overcome their dependence, but that it is not possible or ethical to predict who will eventually do so – why we are obliged to create a treatment system which makes every effort to provide the right package of support to maximise each individual's chances of recovery.

Fewer young people are now coming into treatment for dependence on the most damaging drugs such as heroin, but there is an ageing cohort of drug dependent and ex-dependent individuals who will experience an increase in morbidity and mortality as they develop multisystem diseases that need complex treatment. Primary and secondary care services will be needed to treat them.

Well-delivered opioid substitution treatment provides a platform of stability and safety that protects people and creates the time and space for them to move forward in their personal recovery journeys; it has an important and legitimate place in recovery-orientated systems of care. The drug strategy is clear that medication-assisted recovery can and does happen. We need to ensure this treatment is the best platform it can be, but focus equally on the quality, range and purposeful management of the broader care and support it sits within.

Sticking closely to the compelling evidence for effective opioid substitution treatment and existing guidance based on that evidence will deliver many of the improvements needed, but more can and should be done. A determined assessment of the shortfalls in provision, followed by remedial action, is a priority if treatment is to fulfil its potential in supporting recovery. It is not acceptable to leave people in opioid substitution treatment without actively supporting their recovery and regularly reviewing the benefits of their treatment, as well as checking, responding to, and stimulating their readiness for change. Nor is it acceptable to impose time limits on their treatment that take no account of individual history, needs and circumstances, or the benefits of continued treatment. Treatment must be supportive and aspirational, realistic and protective.

Some people have the personal and other resources ('recovery capital') which enable them to stabilise and leave treatment more quickly than others. Many others have long-term problems and complex needs, meaning their recovery may take much longer and they require help to build their recovery capital. Treatment given over this time scale must maintain its recovery orientation.

Arbitrarily or prematurely curtailing opioid substitution treatment will not help the patient sustain their recovery and is not in the interests of the wider community. It risks losing any advances because it is externally imposed and so has no meaning; the individual does not own the decision. This would likely lead to an increase in blood-borne virus rates, drug-related deaths, and crime. However, clear and ambitious goals, with time scales for action, are key components of effective individualised treatment, especially when the individual collaborates in planning them. The expert group strongly supports continued reference and adherence to NICE drug misuse guidance and to the more practitioner-orientated 2007 clinical guidelines.

The more ambitious approach outlined will sometimes lead to people following a potentially more hazardous path, with the risk of relapse (or at least occasional lapse) as they seek to disengage from the opioid substitution treatment that has supported them. Individuals (and their families), clinicians, and services need to understand this potential risk. They need to approach the change with careful planning and increased support, and provide a 'safety net' in case of relapse.

Opioid substitution treatment will improve as a result of changes at a system, service and individual level. These include:
• treatment systems and services having a clear and coherent vision and framework for recovery visible to people in treatment, owned by all staff and maintained by strong leadership;
• purposeful treatment interventions that are properly assessed, planned, measured, reviewed and adapted;
• 'phased and layered' interventions that reflect the different needs of people at different times;
• treatment that creates the therapeutic conditions and optimism through which people, and especially those with few internal and external resources, can meet the challenge of initiating and maintaining change;
• programmes that optimise the medication according to the evidence and guidance;
• measuring recovery by assessing and tracking improvements in severity, complexity and recovery capital, then using this information to tailor interventions and support that boost an individual's chances of recovering and promote progress towards that goal;
• treatment services that are not expected to deliver recovery on their own but are integrated with, and benefit from, other services such as mutual aid, employment support and housing; and
• treatment that works alongside peers and families to give people direct access to, or signposts and facilitated support to, opportunities to reduce and stop their drug use, improve their physical and mental health, engage with others in recovery, improve relationships (including with their children), find meaningful work, build key life skills, and secure housing.

Supplement on reviewing treatment

Following the publication of the report the Chief Medical Officer asked the same expert group for further advice on:
• the frequency at which an individual receiving treatment for addiction should be reviewed (to determine the benefit of the treatment and thus whether alternative treatments should be tried);
• the structure of the review meetings (what should be considered, how to assess the benefit a patient is receiving, tools for decision making, etc).

The group’s response was published in 2013. It recommended:
• care planning, with its ongoing and planned reviews of specific goals and actions, should be part of a phased and layered treatment programme;
• a strategic review of the client’s recovery pathway will normally be necessary within three months (and no later than six months) of treatment entry, and will then usually be repeated at six-monthly intervals;
• a strategic review should always revisit recovery goals and pathways (to support clients to move towards a drug-free lifestyle);
• drug treatment should be reviewed based on an assessment of improvement (or preservation of benefit) across the core domains of successful recovery.

To enable this to happen, the group said commissioners will want to ensure that the services they support: have the resources (sufficient staff, with appropriate competences and the time) to conduct ongoing, specific and strategic reviews; monitor a range of recovery outcomes to understand and demonstrate the benefits being derived from treatment; have access to a diverse range of interventions, intensities and settings (including residential) to optimise treatment and care.


Findings logo commentary The featured report can be understood as facing two ways. Firstly it faces forward to show that methadone maintenance and allied treatments can be part of the new recovery agenda, despite that agenda's associations in some quarters with abstinence from all drugs including legal substitutes (no methadone) and with leaving treatment (no or curtailed maintenance). At the same time it faces backward to protect previously accepted views critiqued and threatened by this agenda: acceptance of the need for long-term and even indefinite prescribing in the face of the tenacity of heroin addiction and the vulnerabilities of its sufferers; the legitimacy in recovery terms of staying in as well as leaving treatment; and the value of harm reduction objectives and achievements short of what it accepts is the abstinence ideal.

In particular, it draws a 'line in the sand', rejecting the imposition of time limits or treatment exits other than those decided between clinician and patient "When they are ready", with specifically engineered safety nets to respond to actual or impending relapse through treatment re-entry. It accepts the government's vision of more people successfully leaving treatment, but rejects as life-threatening and counterproductive any attempt to enforce this from outside the therapeutic relationship. In this respect it continues the tradition most notably established by the 1926 Rolleston report, which protected the privileged doctor-patient relationship in the treatment of addiction from encroachment by penal drug control regulations.

The report's commitment to the new vision of recovery and how much this means services will need to change is most visible in the passages which stress links with local mutual aid networks and other peer-based recovery support groups such as Narcotics Anonymous, and the need to help support and create such networks. For many prescribing services, this kind of community inreach and outreach will not even have been peripheral, let alone central, to their work. To foster recovery as understood by the national drug strategy, they are now expected to: identify and appoint local strategic, therapeutic and community 'recovery champions'; integrate with peer support structures; link with key contacts in the various local mutual aid and peer support groups and services; undertake related staff training; ensure all patients have access to a recovery coach or can speak to people who are in recovery through local peer support services; invite mutual aid representatives in to their services to address patients and staff; offer their premises for meetings; and maximise attendance at mutual aid meetings by their patients, including making the initial contact for them, organising travel, and accompanying them to their first meeting.

Pre-recovery origins

The report traces its impetus to the 2010 English drug strategy formulated by the new Conservative-led UK government, but its origins date back to the preceding Labour years. Before the discovery of recovery as an overarching rationale, the emphasis had already shifted to getting patients to the point where they could leave treatment as a counter to the previous emphasis on retention. Since long-term retention in continuous treatment is characteristic of opioid substitute 'maintenance' programmes, the sometimes unspoken challenge was to the dominance of this approach in the treatment of heroin addiction.

In 2005 an "efficiency" strategy developed by the National Treatment Agency for Substance Misuse complained of the "lack of emphasis on progression through the treatment system" leading to "insufficient attention ... to planning for exit". Foreseeing a time when funding would be less available, the agency's board was told that "Moving people through and out of treatment" will create the space for new entrants "without having continually to expand capacity". This trend was given what at the time was an unwelcome boost when in 2007 the crime-reduction justification for investing in treatment was challenged by the BBC on the grounds that treatment should be about getting people off drugs, leading to the admission that in England in 2006/07 just 3% of patients had completed treatment for drug problems and left drug-free.

The shock of that challenge fed through to Labour's 2008 English national drug policy, in which the word 'recovery' in the sense of recovering from addiction was used just once and incidentally. Instead the emphasis was on components (in particular those which would relieve the burden on the state at a time of when policy sought to rein in public spending) later to be subsumed under recovery – leaving treatment, getting off benefits, and going back to work: "In return for benefit payments, claimants will have a responsibility to move successfully through treatment and into employment". Announcement of a three-year standstill in central treatment funding until 2011 while numbers were expected to rise, further focused attention on squaring the circle by more patients leaving as well as coming in to treatment.

The featured report extracts what the experts on the group saw as the positives (in therapeutic terms) from these challenges, in the form of a renewed emphasis on patients progressing in treatment towards what for them and for society are more satisfactory and fulfilling lives – which mean more can stop drug use and leave treatment sooner – while rejecting extensions to this ambition which pose moving out of treatment as a must do step in the process of moving forwards to what has been dubbed 'full' recovery marked by abstinence from drugs and from legal substitutes. Neither leaving treatment in general, nor withdrawing from prescribing-based treatments in particular, are seen in the report as essential to recovery.

That supplementary advice was called for may be indicative that government concern over patients ‘getting stuck’ in maintenance programmes was not assuaged by the initial report. Those concerned over this issue may gain reassurance from the group’s advice that six-monthly reviews should “revisit recovery goals and pathways” with a view to supporting clients “to move towards a drug-free lifestyle”. However, the group maintained the initial report’s opposition to “arbitrarily or prematurely curtailing opioid substitution treatment”, its insistence that such decisions are for the individual patient and clinical team, and that both will need to balance risk and maintenance of gains with the ambition to move on: “Balancing support for optimistic, abstinence-based recovery steps – and fully-informed risk-taking to achieve this – and supporting reduction of risk of premature drop-out and avoidable harm and death, is an important contextual issue within which strategic reviews of care always take place, and need to be addressed with the patient”.

Challenges to the challenges

The report's challenging agenda itself faces challenges from outside the world of humane and patient-centred medical practice within which its recommendations were framed. The economic forces and moral (or in some eyes, moralistic) values which predated recovery and helped elevate it to an overarching principle remain. Falling per-patient spending in addiction treatment allied with austerity threatening general support for the poor and vulnerable will make it harder to build the 'recovery capital' the report saw as often the prerequisite to safe treatment exit. At the same time, health service funding restrictions and the possible diversion of addiction treatment funding to other public health objectives will make it harder to fund continued treatment.

The temptation will be for commissioners and services to make non-patient centred limitations on the length and intensity of treatment journeys, and to focus on simple and clear 'recovery' outcomes like end-of-treatment abstinence and treatment exit, in lieu of more nebulous and harder to evidence outcomes like a more satisfying and productive life and the prevention of disease, or those much more difficult to engineer like a job and a house and the resumption of family life.

Another option is to find the resources to implement the spirit of the report's recommendations and ambitions by cutting patient numbers. The report might be seen as justifying increased investment in building the 'recovery capital' of the subset of actual or potential methadone patients committed to recovery in the form of abstinence and social reintegration and for whom these are feasible aims – transitioning methadone from a mass but relatively low intensity public health intervention for the many, to more of a Rolls Royce option for the few. The result may be more complete recovery for those who qualify, but also to jeopardise the crime reduction benefits which in economic terms justify services, and to weaken the lifesaving impact of mass treatment entry resulting in heroin use reductions seemingly unavailable on this scale from other treatment modalities. In April 2010 the chair of the group which produced the featured report was among 41 experts who came together to defend "this life-saving treatment", an unprecedented alliance which shows how seriously they took moves to curtail methadone. It should, they said, "be readily available to every person using heroin that seeks help, accepts this option and meets national criteria." Those who agree with this sentiment might not want a 'recovery-oriented' service if this means making methadone less available and cutting patient numbers. For the time being treatment funding allocations largely based on numbers in treatment will it is thought restrain this tendency. The saving grace which might rescue services from this dilemma is the retreat from heroin use across the population, automatically reducing patient numbers.

Any form of patient-centred treatment, whether or not under the umbrella of recovery, is threatened by 'payment by results' schemes which pre-set the treatment destination in detail without reference to what the individual patient wants, and in a way services cannot afford to ignore because their financial survival depends on meeting the criteria for payment. Some local schemes have created a space for the patient's ambitions in their payment criteria, but this is not a required element, or one which sits easily within a system predicated on observable outcomes the public and their representatives recognise and are willing to pay for.

At the same time the upheaval caused by these developments and the loosening of central control both force and permit innovative ways of working by new players, which some treatment systems and some patients may be able to take advantage of to breach the boundaries of custom and risk aversion which have limited productive change.

The editor of Drug and Alcohol Findings who drafted this analysis was a member of the expert group responsible for the featured report.

Thanks for their comments on this entry in draft to John Strang of the National Addiction Centre in London who chaired the expert group, and to Jon Derricot. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 15 January 2014. First uploaded 30 July 2012

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Drug treatment in England 2012–13.

Public Health England.
Public Health England, 2013.

Agency responsible for addiction treatment in England argues that efforts to put recovery at its heart are paying off in the form of patients successfully completing treatment and not having to return, but warns that the older caseload is getting harder to move on. One concern: is treatment being de-individualised to generate a 'good news' story?

Summary Within its brief to protect and improve the nation's health and address inequalities, Public Health England aims to promote addiction treatment by offering support, information and practical assistance to the local authorities with executive responsibility for local treatment systems. This report documents the nation's progress in respect of the treatment of adults (over 18) receiving treatment for problems related to their use of illegal drugs; another report deals with the treatment of alcohol-related problems. This account draws on the featured report and the data on which it was based, derived from the National Drug Treatment Monitoring System.

Main findings

Drug treatment caseload in England

Against a backdrop of falling use of illicit drugs in the general population, the number of people in structured treatment Structured drug treatment follows assessment and is delivered according to a care plan, with clear goals, which are regularly reviewed with the client. for drug problems in England fell by 2% to 193,575, slightly deepening the fall since 2008/09 chart. Among these were 69,247 patients who started treatment in 2012/13, either for the first time or having relapsed after previous treatment – again, slightly deepening the fall since 2008/09.

The drop in treatment starts reflects a continuing fall in the numbers starting treatment primarily for problems related to heroin and/or crack cocaine, down from 64,288 in 2005/06 to 45,739. In turn this was largely due to a sharp decrease in the number of newly presenting opiate users aged 18–24, from 11,309 in 2005/06 to 3536 in 2012/13; among newly presenting clients in this age group, the proportion whose problems primarily related to opiate use dropped from 61% in 2005/06 to 29% in 2012/13.

In contrast, the number of people starting treatment for problems relating to cannabis use continued to rise, from around 7500 in 2005/06 and 2006/07 to 11,280 this year. Many more people are also seeking treatment in relation to their use of new psychoactive substances Specifically GHB/GBL, ketamine, ecstasy, methamphetamine or mephedrone. or 'legal highs' and certain 'club' drugs. Nevertheless they accounted for just 5% of new treatment journeys this year, and recovery rates for these users remain good. The number with problems primarily relating to cocaine powder (ie, not crack) was 7372, having peaked in 2008/09 at 8522.

The upshot of these trends is a dramatically changed drug profile of treatment starters. In 2005/06 there were almost three times the number of heroin users starting treatment for the very first time compared to all other users (47,811 versus 16,778). Now the number of other users entirely new to treatment outstrips heroin users by two to one (16,220 versus 8318).

Another trend to emerge in recent years is that people new or returning to treatment are on average getting older. Totalling 38,485 in 2005/06, by 2012/13 the number of treatment starters aged under 30 had fallen to 25,027. In contrast, the number aged over 40 rose from 12,678 to 17,148; these now constitute 25% of all treatment starters compared to 15% in 2005/06. Trends in treatment starts mean the treatment population is gradually ageing. In 2005/06, 32,406 people aged 40 and above were in treatment at some time during the year, 18% of the total; by 2012/13 these figures had risen to 65,339 and 34%.

Waiting times have improved a little; 98% of referrals waited under three weeks for their first appointment, and the average waiting time was five days.

Before treatment setting/modality codes changed on 1 November 2012, at least 79% of all patients in treatment (new or continuing) were recorded as being prescribed medications, usually methadone for the treatment of opiate addiction. The coding system changed from 1 November 2012, after which 61% of patients were recorded as having started a prescribing intervention. In 2012/13, a quarter of all patients being prescribed medications and the same proportion of opiate users (representing just under a fifth of all patients) had been in this treatment without a break for at least five years, about a third for less than a year. The proportion of people in treatment going into residential rehabilitation has remained static at around 2–3%.

The proportion of patients who had been in treatment for at least 12 weeks or completed free of dependence has remained at 94% since 2011/12 and there has been a general upward trend from 82% in 2005/06.

In 2012/13, 29,025 patients 'successfully completed' their treatment – leaving free of dependence, judged no longer in need of treatment, and not using heroin or crack cocaine. Nearly three quarters were not using any illegal drug. At 15%, the proportion of patients successfully completing during 2012/13 was the same as the previous year but a considerable advance However, in 2009 a new discharge coding system was introduced which clarified the coding of referrals within the treatment system, and tightened the way 'treatment completed' was recorded. These changes mean it is not possible to directly compare treatment exit data from 2009/10 with previous years. on the 6–7% recorded in 2005/06 and 2006/07. Another 18,253 patients dropped out or otherwise left treatment without completing it, 9% of all patients in treatment that year, a proportion which has dropped from 21% in 2005/06.

Because it often takes people more than a year to recover from their drug problems, we need to take a longer view when judging the success of drug services. Adding data for 2012/13 to the figures for previous years reveals that since 2005, 31% of the 390,883 people who had come into treatment had successfully completed it and were no longer in treatment at the end of 2012/13; 36% had left without completing; and 32% were still or back in treatment, among whom were 12% who had remained in treatment without an appreciable break. These figures include patients who started treatment before 2005/06. A more contemporary analysis focuses on the 304,811 who entered treatment for the first time since April 2005, of whom 56% were treated for their use of opiate-type drugs like heroin. By the end of 2012/13, 34% were no longer in treatment after having successfully completed, 39% after leaving without successfully completing, and 27% were still in treatment, either because they had stayed continuously or left and returned.

The authors' conclusions

Drug treatment services in England continue to do well. They are getting the right people into treatment and helping many thousands recover. But they face increasingly apparent and urgent challenges. The treatment population is shrinking, but also getting tougher to treat.

The key issue is that many have been with treatment services a long time and are finding it difficult to move on. Local services, backed by the national support system, need to continue and in some cases intensify their efforts to help them make a sustained recovery from dependence – not an easy task. Many are older with entrenched problems and failing health. So as well as supporting them in their recovery, services need to address their health problems and help them stay safe; for many treatment is a source of stability which gives structure to their lives. Services also need to remain watchful and respond effectively to the needs of the wider treatment population, such as those who need help with new substances and prescription or over-the-counter medicines. More detailed commentary below.

The total number of people in drug treatment in England has been falling since 2008/09 because fewer have been starting new treatment journeys, and more have successfully completed and not returned. Explanations include the recent shift in focus from ensuring that all those who need treatment get it quickly, to helping those in the system recover and leave. The decline in heroin and crack use has also had a big impact. Services in England developed to respond to the many people who started using these drugs in the 1980s and 1990s, but now these drugs have fallen out of favour among young people, so we see far fewer new cases. The result is that the pool of heroin and crack users is gradually shrinking.

A quarter of people in treatment for opiate problems have been in substitute prescribing (generally methadone) for five years or more, reflecting the entrenched nature of heroin addiction, the benefits of being on a prescription, and an ageing population finding it difficult to overcome dependence and experiencing wider health problems. It is getting harder to help this group, and this has begun to show in the successful completion figures.

Younger people today are much more likely than in the past to enter drug treatment for problems with cannabis, even though cannabis use among the general population is down. This may be because treatment services have in recent years become much more aware of and open to people who are running into trouble with the drug, and because the fewer users are using stronger strains more often.

New drugs have surfaced (such as mephedrone), but not with anywhere near the impact of heroin in the 1980s and 1990s. Still, new substances and new patterns of use are a concern, and the fast pace of change makes it difficult to predict trends or to develop knowledge about the harm these drugs might cause. There is also the problem of addiction to prescription and over-the-counter medicines, which specialist treatment has an important part to play in tackling.


Findings logo commentary If we accept successful completion of treatment as (within these statistics) the closest indicator of successful treatment, the year by year figures tell a tale of an improving treatment system in England, the success rate more than doubling from 6% to 15% over seven years.

Extending these within-year figures, the eight-year analysis indicates that since April 2005, 31% of all patients had successfully completed and were not back in treatment at the end of 2012/13, a 'success' rate of nearly a third. The other side of the coin is that two thirds remained in need of treatment or beyond its protection without having successfully completed. Many ( below) will actually be successes, having left and done well without completing, or having stabilised in treatment. The clearest 'failures' are the 20% of patients who had been in treatment before but had returned and were still in treatment at the end of 2012/13, presumably because their prior treatment had not worked and/or they had relapsed. Though their previous treatment was followed by a return to problem drug use, even for these patients, re-engagement in treatment can be seen as a positive event.

If successful completion is that important, also important is understanding exactly what it means. For the recording system, 'successfully completing' treatment means that as reported by the service from which the patient last exits, they are no longer seen as requiring structured drug treatment, and have left treatment (not just that service, but the system as a whole) no longer dependent on any drug, and not using opiates or crack cocaine (1 2). They may be using other illicit drugs in a non-dependent manner (though few are recorded as doing so) and may be drinking and smoking to any degree.

This system is critically dependent on the integrity and accuracy with which treatment services record the status of their departing patients. In 2007/08 the BBC exposed the tiny proportion of patients who within a single year left treatment drug-free, intensifying a national policy emphasis on successful completion. Since then commissioners and services have been under reputational pressure to produce more successful completions, and in recent years, under financial pressure too. Allegations have surfaced that this has led services to bend the figures or to pressure patients to leave treatment or to discharge them before they are ready. Some service contracts now include a financially backed target for treatment exits. If exits are indeed being arranged to meet national or local needs and ambitions rather than those of the patient, this de-individualisation of treatment would make the increased completion rate less of a 'good news' story.

Longer view reveals 'stickiness' of heroin-addicted patients

Year-by-year statistics can only show that someone was in treatment that year, and if they left, whether they returned the same year. The eight-year analysis adds a further rider to the indicator of success – that whenever the patient started treatment and whenever they successfully completed, they should not be in treatment at the end of the period covered by the analysis, 31 March 2013.

This analysis confounds the passage of time over which treatment success rates may have improved, with the time the patient had to recover or relapse. Patients entering treatment in for example 2005/06 had eight years, those entering in 2012/13, less than a year. More informative is what proportion of patients succeed over a given time period, and whether this has improved in recent years. It can be calculated that five years later, 35% of patients new to treatment in 2007/08 were no longer in treatment having successfully completed. Another 42% had left without completing; the remaining 23% were still or back in treatment. Corresponding figures for the five years after patients started treatment in 2005/06 were 20%, 42%, and 38%. If successful completion and not being in treatment five years later is a proxy for successful treatment, then the success rate increased from 20% for patients new to treatment in 2005/06, to 35% for those who started two years later.

The same analysis shows how few treatment starters are totally new to treatment, a figure which has fallen steadily from 64,589 in 2005/06 to 24,538 in 2012/13. It means that the great majority of the 193,575 patients seen in 2012/13 were continuing in or returning to treatment. In turn that helps explain why despite the changing drug profile of patients (re)entering treatment, the proportion of the entire treatment population whose problems primarily related to opiates (with or without crack) has remained at around 80% since 2005/06. These primarily heroin-addicted patients are the ones who stay in or relapse and have to return to treatment; 42% did so after entering treatment between 2005/06 and 2012/13 compared to 8% of patients not treated for opiate use. The 'stickiness' of the heroin-addicted patients also helps explain why since 2005/06 almost exactly a half of all patients in treatment were being prescribed drugs such as methadone, in turn probably partly the cause of their retention or willingness to return to treatment.

Success not limited to treatment completers

The argument that increasing numbers of successful completions is evidence of increasingly successful treatment rests partly on an analysis of patients leaving treatment for drug problems in 2005/06. Over the next four years, 57% who left having successfully completed avoided being officially recorded as problematic users of illegal drugs, neither being picked up by criminal justice system nets intended to identify problem drug users, nor returning to treatment on their own initiatives. This record of 57% seemingly staying recovered from their dependence contrasted with 43% among patients who left without having successfully completed treatment. The 14% difference of is appreciable, but not as large as would be expected if successful completion correlated strongly with successful treatment in terms of lasting recovery. Nevertheless it is enough to justify conclusions based on the assumption that successful completion is a better outcome than patients leaving treatment before the service considers them free of dependence and/or use of heroin or crack cocaine.

Whether successful completion is also a better outcome in terms of crime and health than staying in treatment – the usual situation within each year – is less certain. In terms of reduced convictions and presumably reduced crimes, another report from National Treatment Agency for Substance Misuse records that for patients convicted in the two years before starting treatment, the greatest reductions were among those continuously in treatment for the next two years, though successful treatment leavers were not far behind (47% v. 41%). However, these figures combine big differences in the types of patients who stay and leave treatment early. When the focus was narrowed to opiate/crack users, among whom successful completers and retained patients had a virtually identical pre-treatment conviction rate, the gap widened to 10% (46% v. 36%).

Thanks for their comments on this entry in draft to Tim Murray of Public Health England. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 08 January 2014. First uploaded 14 November 2013

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