Drug and Alcohol Findings home page in a new window EFFECTIVENESS BANK BULLETIN 21 June 2012

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


Contents


A new bulletin has collated the latest additions to the Effectiveness Bank. Included is a new entry showing how in Belgium a simple feedback intervention dramatically improved treatment retention. Also alcohol treatment medications (forefronting naltrexone, newly licensed for this role in Britain), safeguarding pub/club-goers, and a Scottish verdict on computer-based alcohol interventions.

Simple feedback intervention dramatically improves treatment retention ...

Half century of evidence on which drugs aid alcohol treatment ...

Community involvement and law enforcement safeguard pub/clubgoers ...

Scottish health service cautious about computer-based alcohol advice and therapy ...


The effect of using assessment instruments on substance-abuse outpatients' adherence to treatment: a multi-centre randomised controlled trial.

Raes V., De Jong C.A.J., De Bacquer Dirk. et al.
BMC Health Services Research: 2011, 11:123.
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 Raes at veerle.raes@fracarita.org. You could also try this alternative source.

Young adult multi-drug users in Belgium who often soon dropped out of treatment were much more likely to stay in counselling when their therapists structured sessions by feeding back assessments of their motivation and recovery resources.

Summary At issue in this Belgian study was whether offering regular feedback on assessment results to inform and structure counselling means patients stay for more sessions, the presumption being that if they do, they will also benefit more. The study was conducted at five outpatient drug treatment centres from the same parent organisation which treat people commonly using several drugs and who often attend treatment patchily. In this trial the researchers provided a manual for the feedback programme and trained the centres' staff in its use, but had no direct influence over the intended or actual duration of treatment, which was left to the discretion of staff and patients.

For all patients, initial assessment of the severity of drug and related problems was measured by the European Addiction Severity Index (EuropASI) interview schedule, covering: physical and psychological health;, education, work, and income; drinking and drug use; and legal and relationship problems. Patients randomly allocated to the control A group of people, households, organisations, communities or other units who do not participate in the intervention(s) being evaluated. Instead, they receive no intervention or none relevant to the outcomes being assessed, carry on as usual, or receive an alternative intervention (for the latter the term comparison group may be preferable). Outcome measures taken from the controls form the benchmark against which changes in the intervention group(s) are compared to determine whether the intervention had an impact and whether this is statistically significant. Comparability between control and intervention groups is essential. Normally this is best achieved by randomly allocating research participants to the different groups. Alternatives include sequentially selecting participants for one then the other group(s), or deliberately selecting similar set of participants for each group. group simply carried on with treatment as usual, not even Because of standing agreements to the data collection required. being asked to participate in the trial. The other roughly half of the patients were asked to join the trial and allocated to the feedback programme, involving making assessments and feeding the results back at the next counselling session, procedures which replaced the usual content of the sessions. Assessments were made of the patient's readiness to change their substance use, and later of the resources The personal resources scale provided the appreciation of both the clinician and the patient, the wish to change scale only the patient's appreciation in 16 important life areas: everyday life situation, living situation, financial situation, legal situation, work situation, health status, health behaviour, substance use, self-esteem, self-realisation, self-control, contact with reality, partner relation, family relations, social relations, social cultural situation. available to them (assessed by both counsellor and patient) to improve their lives, akin to the 'recovery capital' thought important in overcoming addiction. Also assessed were their wishes to change these areas of their life. Assessments and feedback were repeated over treatment, offering opportunities to promote and assess therapeutic and personal progress.

In all 111 control group patients attended for initial assessment and 116 in the feedback programme, but 16 of the latter refused to participate in the feedback programme. Nevertheless their outcomes were included in the main analyses. Patients were typically young single men in their late twenties using cannabis, stimulants, and/or opiates, nearly half of whom were living with their parents.

In theory all the feedback assessments could be completed at least once in seven sessions, so the first yardstick was how many patients stayed for at least one further session – eight in all, not counting the initial assessment. In practice however, 90% of the assessment and feedback activities took place within the first 12 sessions, so completion of at least this number was chosen as the second outcome measure.

Main findings

On both yardsticks, 60% more feedback than control patients (53% v. 34% for eight sessions; 34% v. 21% for 12) were retained in treatment. For eight sessions this was also the case when the 16 who refused the feedback option were excluded from the calculations; for 12 sessions, excluding these patients meant feedback's advantage rose to 70%. All these differences were statistically significant.

The authors' conclusions

The use of assessment instruments with feedback directly to patients enhanced adherence in routine practice in the treatment of substance use disorder. Especially in the care of chronic conditions and mental health, this finding may inspire the broader field of health care to further elaborate continued measurement and outcome-feedback in daily practice.


Findings logo commentary It is not clear whether in order to complete the feedback programme, counsellors extended treatment and/or took more care to retain patients, or whether the impact of the feedback programme meant patients were keener to attend further sessions. Either way, the result was a substantial increase in the treatment 'dose' which together with a focus on personal and social resources had the potential to improve the young patients' prospects of overcoming their drug use problems.

Last revised 19 June 2012

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

STUDY 2011 Extended telephone-based continuing care for alcohol dependence: 24-month outcomes and subgroup analyses

STUDY 2010 Gender differences in client–provider relationship as active ingredient in substance abuse treatment

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

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

STUDY 2012 The first 90 days following release from jail: Findings from the Recovery Management Checkups for Women Offenders (RMCWO) experiment

STUDY 2010 A randomized controlled study of a web-based performance improvement system for substance abuse treatment providers

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

STUDY 2011 How does cognitive behaviour therapy work with opioid-dependent clients? Results of the UKCBTMM study

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

REVIEW 2012 Meta-analyses of seven of the National Institute on Drug Abuse’s principles of drug addiction treatment





Medical treatment of alcohol dependence: a systematic review.

Miller P.M., Book S.W., Stewart S.H.
International Journal of Psychiatry in Medicine: 2011, 42(3), p. 227–266.
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 Miller at millerpm@musc.edu. You could also try this alternative source.

With from 2011 naltrexone licensed for this purpose, Britain now has the full suite of major medications authorised for the treatment of alcohol dependence. Largely from a primary care perspective, this US review examines a half century of evidence for whether these and other drugs aid recovery and which work best.

Summary Funded by the US government's alcohol institute, this review of drug-based treatment for alcohol dependence aimed to express the evidence base in such a way as to underpin the expansion of these treatments to medical settings including primary care and specialist clinics. It searched for research published in English from 1960 to 2010 which involved randomly allocating adult patients to medication versus either no treatment, a placebo, or some other treatment. The aim was to focus on studies which offered either no accompanying psychosocial therapy or only brief therapies of the kind which might be undertaken in general medicine as well as specialist clinics. Only drugs in at least two trials were included.

The reviewers found 85 eligible trials involving nearly 19,000 patients. Of these, 11 studies concerned disulfiram, a drug which blocks the breakdown of alcohol in the body, producing unpleasant reactions in response to even low levels of drinking and acting as an aversive deterrent. Other pharmacotherapies for alcohol dependence are generally thought to work by blocking the rewards experienced from drinking or by stabilising body systems disrupted by chronic alcohol intake. Among these, most researched was naltrexone, tested in 33 trials. By blocking the body's own opiate-type chemicals, the drug is thought to reduce the rewarding feelings patients gain from drinking. Next most extensively researched with 24 trials was the anti-craving medication acamprosate. SSRI antidepressants were investigated in seven trials, while the anticonvulsant topiramate was the subject of four. Various other medications were less extensively researched.

Main findings

One study with the highest score for methodological rigour found no advantage for disulfiram over placebo when administration of the medication was not supervised. However, most other studies found supervised disulfiram reduces drinking more than a placebo, and there was some evidence that it may be more effective than naltrexone, acamprosate, and topiramate. Compliance is a problem with disulfiram; daily supervision of ingestion appears essential to clinical success.

Though based on few studies, topiramate seems effective in the treatment of alcohol dependence. There is, however, little evidence to support the use of antidepressants (either SSRIs or tricyclics), though one recent randomised trial found the combination of sertraline and naltrexone more effective with depressed alcoholics than naltrexone alone.

Acamprosate may promote abstinence, although studies have had mixed results, and some larger multi-site US studies found no advantage over placebo. European studies are more favourable, possibly due to differences in subject populations, including fewer patients still drinking when they entered the studies. Taken as a whole, this review suggests that on average the drug does have a modest impact among patients able to abstain for at least a few days beforehand.

Most relevant studies have found oral naltrexone is effective relative to a placebo, including 12 of the 15 most methodologically rigorous. Just two studies evaluated long-acting monthly injections of depot naltrexone, both finding it more effective than a placebo.

Whether brief psychosocial or supportive interventions enhance the impact of medications was investigated by 11 trials. Some found patients do better when medication is supplemented by extensive rather than no or minimal psychosocial support, others that brief support can be as effective as longer and/or more sophisticated therapies. The latter included three of the more methodologically rigorous studies which tested supplements appropriate in most medical settings: medical management – a supportive, compliance-focused intervention; low intensity support for primary care patients; and infrequent consultations with a doctor.

The authors' conclusions

This corpus of work shows that pharmacotherapy for alcohol dependence is feasible in primary as well as specialist medical settings, and that overall effects on drinking are on average positive, though modest. Though it is clear that some alcohol dependent patients benefit from pharmacotherapy, what type of patients do or do not is unclear.

In medical settings, current research suggests initially considering either oral naltrexone, topiramate, or (with abstinent patients) acamprosate for patients without contraindications to their use. If daily supervision of ingestion is feasible, disulfiram can be considered for motivated, abstinent patients. Medication should be accompanied by brief support aimed at making it more likely that patients will comply with treatment. Some patients may require more extensive psychosocial intervention, but it is unclear which categories this applies to. Even when intensive psychological help is unavailable, medication plus brief support from medical carers can lead to clinical improvements.

While these conclusions are based on a comprehensive search of the literature, it should be noted that non-English language articles and unpublished papers were excluded. Also, drawing conclusions is hampered by differences between patients in the studies, which may influence their responses to treatment, and by the typically short-term follow-up of the studies, many of only three to six months duration. In particular, data is lacking on long-term effects on illness and death. Often accompanying psychosocial therapies and supports are inadequately described, and these have not been sufficiently researched.


Findings logo commentary These comments focus on the review's conclusions regarding the relative benefits of the major medications it reviewed. For discussion of the absolute efficacy of these substances relative to no treatment or to a placebo, see these Findings analyses of reviews of disulfiram, naltrexone and acamprosate, and this freely available 2009 review of topiramate.

The featured review comes at a time when naltrexone (in the form of a 50mg tablet marketed as Adepend) has recently been licensed in the UK for the treatment of alcohol dependence, supplementing acamprosate and disulfiram as the major medications licensed for that purpose. The delay seems merely to have been due to no company seeking a licence rather than any misgivings on the part of the authorities.

With the field now opened up, naltrexone may in this guise (as opposed to its established role in the treatment of opiate dependence) gain a greater UK profile, commensurate with the more positive UK and to a degree international findings compared to the main alternative, acamprosate. Whatever the balance between these two medications, disulfiram continues to have different role as an enforcer of abstinence rather than to promote reduced drinking, playing a major part in the pharmacotherapy offered by specialist centres in particular.

Which medication to choose?

The review seems to have interpreted findings that disulfiram may be superior to other major medications in the light of the nature of the studies and the patients concerned, ending with the reverse recommendation that these other medications be preferred to disulfiram as the default option, unless the taking of the tablets can effectively be supervised. While this seems an appropriate reading of the evidence (details below), it perhaps understates the role disulfiram can play, especially in specialist centres and situations where patients have come seeking help to stop drinking, and when clinicians are available to take on supervision in the absence of suitable relatives or other associates of the patient. In these circumstances disulfiram can be the main option. As well as or instead of supervision, an associate can take on a less onerous monitoring role, feeding back to the doctor whether the patient is taking the tablets while the doctor does the persuading. Allied with intensive support, disulfiram has also successfully been used as a fallback option for patients who have not done well in less radical and risky therapies such as acamprosate.

Evidence for disulfiram's superiority rested largely on three Indian trials comparing the drug with acamprosate, naltrexone, and topiramate. Though each found significant differences, some were small, and other measures did not significantly differ. Nevertheless, the cumulative impression is that in this context disulfiram was on average preferable to medications which permit drinking, but are intended to moderate it. However, the context was both uniform and, in UK and European terms, atypical. Virtually complete compliance with medication and with the studies suggests that the family influences (wives and parents supervised consumption), resources and motivations of these typically employed married men detoxified at a private hospital were stronger than in typical UK and European treatment populations. Nevertheless, for their longer term sobriety, it was perhaps worrying that in all three Indian studies, on average disulfiram patients ended with more intense craving for drink than patients on other medications. The remaining study from Finland was able to complete the follow up of just 17 of 81 patients allocated to disulfiram and even fewer allocated to naltrexone or acamprosate. More did return postal surveys, but still just 42% of all the randomised patients, and by the end about half the patients were considered to have dropped out of the study.

The choice between acamprosate and naltrexone is complicated by contrary considerations. Head-to-head trials (1 2) have found naltrexone somewhat more effective in reducing drinking. Naltrexone may also be the better option for people who are not aiming for or find it hard to stop drinking altogether, and for those with a strong desire to drink in order to achieve what they experience as a pleasurable state of intoxication. However, side effects are more common and more severe (though usually few patients have to stop taking the drug) than with acamprosate, and the drug is contraindicated in patients with certain liver problems or who are also dependent on opiates. There is also the complication that in a medical emergency, patients who have recently taken naltrexone will find that opiates fail to control pain, one reason why some prefer not to take the drug.

British studies

Disulfiram

British experience and studies suggests disulfiram can have a broader and more frontline role than the featured review envisages. A major UK trial at seven specialist clinics found the drug effective at least in the first months of treatment when daily consumption was supervised mainly at home by the patient's female partner, and both knew the consequences of drinking while taking it. Over the six months they were followed up, disulfiram patients reduced their drinking days and amounts drunk by significantly more than patients prescribed a vitamin, though by the end the extra reduction had evened out, as had the time they had lasted without drinking.

In this trial nearly half the patients (but no more so on disulfiram) effectively rejected or dropped out of treatment, but this was less than in studies of other medications, perhaps because many patients had active intervention at home on a daily basis centred on ensuring the tablets were taken, and others were in regular clinical contact for medication supervision. Follow-up interviews were completed with 8 in 10 of all the patients, an acceptably high rate, lending confidence that the findings do reflect the impact of the medication, and were not an artefact of selective drop-out.

Findings of an audit of a service in Leeds show that given strong clinical support from a specialist multidisciplinary team, disulfiram can successfully be prescribed to most patients who qualify for outpatient detoxification. As for many patients in the trial described above, in this service clinicians took on the supervision role which might otherwise to be shouldered by families, presumably extending effective treatment to patients without someone in their lives willing and able to make sure they took the tablets and acceptable to the patient.

Naltrexone and acamprosate

Without being conclusive either way, in line with the international literature, another two major British studies provided greater support for naltrexone than for acamprosate. Both suffered high drop-out rates and poor compliance with treatment, but in the naltrexone study, patients who did complete the study and largely comply with treatment drank substantially less on naltrexone than on placebo tablets. As with the disulfiram trial, one lesson from both seems to be that among typical British alcohol clinic caseloads, the support available from the staff and/or from families and friends is often insufficient to enable patients to sustain their commitment to treatment.

Across six centres, the naltrexone trial found that compared to a placebo, the drug did not delay a return to drinking or to heavy drinking, but did (non-significantly) tend to reduce the amount drunk in the last month of the study, a trend partially reflected in biochemical markers of heavy drinking. Patients on naltrexone also experienced significantly less craving for alcohol and by the end of the study nearly two-thirds were judged by their doctors to have improved, about 20% more than in the placebo group. Possible side-effects seen more often in the naltrexone group included nausea and pain, but adverse effects did not result in noticeably more naltrexone patients having to terminate treatment. However, the study excluded patients with serious physical illness, medicated psychiatric conditions, or who also abused other drugs.

These results assumed that the nearly 60% of patients who were lost to the study had resumed heavy drinking. When the analysis was confined to the 70 who completed the study and had largely complied with the treatment, the reduction in the amount subsequently drunk (on average half that in the placebo group) was statistically significant and corroborated by biochemical markers.

A different treatment regimen might have further improved outcomes. Naltrexone was introduced only after patients had been abstinent for on average 10–11 days, yet the drug seems to work mainly by reducing the experienced rewards of drinking, a mechanism which can only be activated if drinking occurs. Consistent with this theory, the study found that drinking was not delayed but (presumably because they 'got less out of it') patients on naltrexone went on to drink less than those receiving a placebo.

In contrast, a similar study of acamprosate found no impact on drinking, even among patients who took the drug. At least a week after detoxification at one of 20 British alcohol treatment units, the study randomised 581 alcohol dependent outpatients either to acamprosate three times a day or to placebo tablets, each supplied for six months. High drop-out and non-compliance rates meant that just a third of the sample completed the study, and by the end fewer than 30% were taking at least 90% of their tablets. Subjects lost to follow-up were assumed to have relapsed.

Acamprosate did not improve abstinence rates among patients as a whole, nor among types thought to respond well to the drug. Even among those who at least took the tablets for the first two weeks, there was no added benefit. Whether taking acamprosate or placebo, both groups drank on most days. Neither did acamprosate prevent relapse to heavy regular or binge drinking by over 80% 12% and 11% abstinent plus 3% and 6% controlled drinking = 15% and 17% one or the other = 85% and 83% presumed or known uncontrolled drinking. of each group, though there was evidence of reduced craving and anxiety. About a month after medication ended, researchers interviewed 385 of the 581 patients. Abstinence rates had remained similar to those seen at the end of the medication period.

In contrast to some earlier research which provided high quality care characteristic of academic centres, apart from the tablets, patients received 'treatment as usual'. For many this seems to have been insufficient to prevent a high rate of pre-medication relapse and subsequent drop-out, making it much harder for acamprosate to demonstrate its worth. Nearly a third 155 + 33 for whom no data and assumed to be drinking. of patients did not remain abstinent for the week before being randomised into the study, a requirement in some other studies. Outcomes in the British study may also have suffered from not starting It was commenced on average 24 days after the start of detoxification, with an interval of over five weeks in some patients. the drug in the immediate post-withdrawal period, when theory suggests its effectiveness should be at its height.

UK policy and practice

On the basis of the evidence, acamprosate, disulfiram and naltrexone are all endorsed in national guidance for Scotland and England and Wales. The guidance envisages a more routine and/or first-line post-detoxification role for acamprosate than for disulfiram, the latter coming with the caution that total abstinence is required to avoid unpleasant and potentially dangerous reactions, and that the positive evidence derives from situations where consumption has been supervised. Naltrexone is seen as fulfilling a similar role to acamprosate, but at the time the guidance was drafted it had no UK licence for the treatment of alcohol dependence, so the Scottish advisers felt they could not commend it for use in the NHS.

Though the positive US trials are acknowledged in the guidance for England and Wales, and despite its authorisation in the USA, injectable long-acting naltrexone is not recommended in either that or in the Scottish guidance. Greater risks due to administration by injection and its irreversibility, higher costs, and especially its non-approved status in the UK, mean this option will for the time being best be seen as a possible reserve for patients who have not done well with other therapies and who cannot be supported to consistently comply with oral naltrexone, especially if when they have taken the tablets, they have responded well to the medication.

Statistics for England in 2012 show that doctors in general have forefronted acamprosate, prescribed 117,405 times compared to 60,842 for disulfiram, figures dominated by GP prescribing. However, in hospitals disulfiram is prescribed slightly more often. In these settings patients are likely to be so severely dependent that at least initial abstinence is the preferred objective, and there is the support for patients and the expertise to handle the risks of prescribing disulfiram.

Thanks for their comments on this entry in draft to Jonathan Chick and Colin Brewer. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 15 July 2013. First uploaded 18 June 2012

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

REVIEW 2009 The state of pharmacotherapy for the treatment of alcohol dependence

STUDY 2005 'Real-world' studies show that medications do suppress heavy drinking

STUDY 2010 Naltrexone and combined behavioral intervention effects on trajectories of drinking in the COMBINE study

STUDY 2012 Audit of alcohol detoxification at Leeds Addiction Unit

MATRIX CELL 2016 Alcohol Matrix cell A3: Interventions; Medical treatment

STUDY 2004 Naltrexone helps GPs and practice nurses manage alcohol dependence

MATRIX CELL 2016 Alcohol Matrix cell B3: Practitioners; Medical treatment

REVIEW 2011 The efficacy of disulfiram for the treatment of alcohol use disorder

STUDY 2006 Naltrexone aids primary care alcohol treatment

STUDY 2010 Review of treatment for cocaine dependence





Alcohol and drug prevention in nightlife settings: a review of experimental studies.

Bolier L., Voorham L., Monshouwer K. et al.
Substance Use & Misuse: 2011, 46(13), p. 1569–1591.
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 Bolier at lbolier@trimbos.nl.

In pubs and clubs, especially for young patrons, out-of-control intoxication is sometimes the aim rather than an undesirable outcome to be prevented. How in these circumstances to reduce use and harm has been investigated in the 17 studies analysed in this review.

Summary Alcohol and drug use is considerably more common than average among people who frequently patronise night-time entertainment venues, and can cause serious problems such as life-threatening alcohol intoxication, overheating and dehydration after ecstasy use, and long-term risks such as addiction, depression, and memory loss. Substance use can also lead to related problems such as traffic accidents, risky sex, sexual assault, and violence.

Offering promising opportunities for intervention, the nightlife environment and its stakeholders play a major role in the exacerbation or reduction of alcohol- and drug-related problems. They affect these problems by, for example, whether they sell drink to minors, serve intoxicated patrons, tolerate drug use, or even, as some door staff have done, supply drugs. Also the physical environment – such as ventilation, ease of access to free water, adequacy of emergency services and equipment, and bar design – greatly affects whether visitors are entering safe and healthy venues.

The featured review aimed to assess the impact of alcohol and drug interventions in licensed premises and nightlife environments, primarily in terms of substance use, but also substance-related problems. It was limited to studies in peer-reviewed journals which mounted and scientifically evaluated an intervention, but embraced research designs which fell short of the 'gold standard' randomised controlled trial, such as those which relied on before and after measures.

In all 17 studies were found reported in 21 papers. All but two concerned alcohol use. Three studies were conducted in Europe, 11 in North America, and three in Australia. The review categorised the interventions as:
community interventions, all of which involved the wider community through for example media campaigns and advocacy for policy changes, plus training staff in venues and improving law enforcement;
alcohol server interventions, limited to training venue staff and managers in their legal and other responsibilities for their patrons and giving them the information and skills to fulfil these responsibilities;
educational interventions, seeking to inform patrons about the general risks of substance use related to leisure-time venues, or the particular risks they faced as individuals; and
policy interventions, involving heightened and more highly publicised enforcement of relevant laws and regulations and the establishing and implementation of related policies by venue managements.

Main findings

Community interventions

Four studies sought variously to mobilise communities to prevent drug use in nightlife settings, stop underage or drunk patrons being served alcohol, and to reduce alcohol related injuries and traffic crashes.

In one study featuring staff training, enforcement and media advocacy, the proportion of doorstaff who denied access to patrons pretending to be 'high' on drugs increased from 7.5% to 27%. The interventions targeting drinking variously reduced high-risk drinking, alcohol-related injury from traffic accidents and assault, violent crimes, and supply to underage or intoxicated patrons. An analysis of Swedish studies found the interventions cost-effective in reducing violent crime and improving/saving lives. However, these positive findings were not universal.

In summary, it seems that community interventions can reduce substance-related harm and that this potential remains apparent in the higher quality studies.

Alcohol server interventions

Six studies investigated alcohol server training interventions in nightlife settings without attempting to bolster these through other components such as enforcement or community mobilisation. Aims are primarily to prevent serious intoxication and service to minors or to already intoxicated patrons. Over from three hours to a day, trainees were taught about the effects and risks of alcohol, relevant laws, and how to serve alcohol responsibly.

Results were mixed. Most studies reported significant effects on knowledge, some on the servers' own accounts of their behaviour, and others on more objective outcomes such as observed server behaviour and road accidents. However, probably due to poor support from management and poor implementation, one study found no positive effects on the blood alcohol levels of patrons, number of drink-driving offences, and whether pretend underage patrons were served. Likewise, in two other studies effects were small or lacking.

In summary, results are mixed and studies have mainly reported subjective outcomes. One study with the highest quality rating and which tested compulsory server training reported positive effects on an objective measure – road accidents.

Educational interventions

Just two studies trialled patron education interventions, one concerned with drugs, the other, alcohol. The drug-focused intervention distributed leaflets and info-cards to inform club visitors about the risks of ecstasy and GHB and to encourage them to use less or at least more safely. In comparison to a control A group of people, households, organisations, communities or other units who do not participate in the intervention(s) being evaluated. Instead, they receive no intervention or none relevant to the outcomes being assessed, carry on as usual, or receive an alternative intervention (for the latter the term comparison group may be preferable). Outcome measures taken from the controls form the benchmark against which changes in the intervention group(s) are compared to determine whether the intervention had an impact and whether this is statistically significant. Comparability between control and intervention groups is essential. Normally this is best achieved by randomly allocating research participants to the different groups. Alternatives include sequentially selecting participants for one then the other group(s), or deliberately selecting similar set of participants for each group. group, before and after measures revealed neither health promotion effects nor any adverse effects among either users or non-users of 'club drugs'. After reading the leaflet or info-card, non-users became more negative about GHB, and after reading the info-card, less positive in their expectations about the consequences of using the drug. An important finding was that reading information intended for drug users did not have counterproductive effects on non-users.

Compared to before the intervention, 12 months later a brief intervention offered in bars and taverns and intended to reduce harmful alcohol use and binge drinking led to a significant decrease in drinking and related problems, including 'binge' drinking. The intervention involved assessing the severity of the drinker's alcohol problems using the brief AUDIT questionnaire and a blood alcohol test, the results of which were fed back to the drinker. Effects were possibly partly due to the intervention attracting people who were already considering cutting back on their drinking.

In summary, educational interventions produced small effects on negative attitudes and drinking, but studies were scarce and low quality.

Policy interventions

Five studies reported the effects of alcohol policy interventions, the elements of which included risk assessment, training and consultation, enforcement checks, provision of tailored policy manuals and information, and promoting an alcohol prevention strategy at licensed premises via phone contacts, media, and publications. In two studies the intervention directly aimed to promote responsible service, especially in respect of minors and drunk patrons. Other interventions took a step back to develop and implement policies in the nightlife setting which promote responsible alcohol service, or to widely disseminate such a policy.

Such interventions proved effective across a number of outcomes. In one study, after regular enforcement visits bartenders were less likely to serve seemingly drunk patrons. In another, combined enforcement checks and management training restrained service to underage patrons. Policy interventions focused on implementation led to more alcohol policies being formulated and used by club owners after they underwent intensive training, and more licensed premises in a region adopting a responsible service policy. But some studies found that in the absence of enforcement checks, management training had no significant effects on sales to obviously intoxicated patrons. Furthermore, the effects of enforcement checks have been found to decay over time.

In summary, studies were of mixed quality and results, registering some positive effects in respect of responsible alcohol service, but no significant effects in the highest quality study.

The authors' conclusions

In general this review of 17 studies of the prevention of harmful alcohol and/or drug use in nightlife settings found that interventions which include community mobilisation elements can have preventive effects on alcohol use, reducing high-risk consumption, related injuries and violent crimes, and reducing access to alcohol by minors and drunk customers. An enforcement element in policy-based interventions increases the chances of success. Alcohol server training too can foster responsible alcohol service, provided it is embedded in the community and, again, bolstered by regular enforcement visits. Little research has been conducted on educational interventions in nightlife settings, and, in contrast to alcohol, preventive drug interventions have rarely been formally evaluated.

Taking these results and the quality of the studies into account leads to the conclusion that server training and policy interventions have the potential to reduce alcohol-related problems in nightlife settings. Community interventions combining these elements seem particularly promising, and the chances of a positive outcome are improved by an enforcement element.

Implications for research are that cost-effectiveness and some widely used preventive interventions such as pill testing and education by experienced peers need further evaluation. Implications for practice are that a nightlife prevention programme has a greater chance of success when embedded in the community, and that enforcement of regulations should form a major part. As effects can decay, server training should be mandatory and both this and enforcement activities maintained. Educational elements have little impact, so should not be the sole element in a programme; crowded settings, noise, use of substances, and expectations of a good night out rather than a 'lecture', may act against them.

Young people often start their night out and their substance use at a friend's place before visiting a bar or club, and drinking beforehand is associated with higher alcohol consumption and a higher likelihood of incidents involving aggression. For these and other reasons, nightlife interventions are best seen as part of a wider drug and alcohol prevention strategy including schools and parents. Moreover, other substance-related issues such as violence and sexual health should also be part of a healthy nightlife strategy.

Beyond specific evidenced interventions, common sense factors contributing to a safe environment should be considered – factors such as the layout of the bar, ventilation, free water availability, and the style and sound level of the music.

The findings of this review should be interpreted in the light of the inclusion of several studies which did not feature a control A group of people, households, organisations, communities or other units who do not participate in the intervention(s) being evaluated. Instead, they receive no intervention or none relevant to the outcomes being assessed, carry on as usual, or receive an alternative intervention (for the latter the term comparison group may be preferable). Outcome measures taken from the controls form the benchmark against which changes in the intervention group(s) are compared to determine whether the intervention had an impact and whether this is statistically significant. Comparability between control and intervention groups is essential. Normally this is best achieved by randomly allocating research participants to the different groups. Alternatives include sequentially selecting participants for one then the other group(s), or deliberately selecting similar set of participants for each group. group, leaving open the possibility that the results were due to something other than the intervention, such as the motivation of the people who chose to participate in the study. Few studies reflected the European context.

Last revised 10 June 2012

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Computer based alcohol interventions.

McAuley A.
NHS Health Scotland, 2012.

Worth trying but unproven for the UK and the general population and need evaluating, was the message of this review for the health service in Scotland of computer-based alcohol interventions as possible ways to extend the reach of treatment and of the national brief intervention programme.

Summary In 2012 NHS Health Scotland published the featured review of computer-based alcohol interventions as possible ways to extend the reach of treatment and of Scotland's national brief intervention programme to people drinking at hazardous or harmful levels, in particular those unlikely to attend traditional health care services but who might turn to the internet for advice and information, such as women and young adults. The review was a rapid assessment which limited its scope to English language reviews and meta-analyses A study which uses recognised procedures to combine quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually. published between 2001 and 2011.

Potential or actual advantages are that computer-based alcohol intervention content can be delivered consistently across users, and accessed in users' own time and at their own pace. Tailored personal feedback can also be provided, based on information generated by the user themselves. They can also be delivered consistently without a therapist, and so have the potential to be more cost-effective over time. Programmes can also be updated centrally and quickly, to reflect advances in technology or theory relevant to delivery. Other facilitators for web-based tools include the convenience of 24-hour availability (provided there is internet access), with no waiting times for an appointment and no geographical constraints. In addition, they can offer the user privacy, anonymity and flexibility, allowing individuals a greater sense of control and involvement in their treatment and protecting them from any fears of stigmatisation. The confidentiality afforded by such a delivery method is also potentially attractive to those deterred by face-to-face appointments which characterise most community-based alcohol support services.

Main findings

The report found evidence that computer-based alcohol interventions are more effective than no treatment or assessment only and just as effective as conventional approaches including brief interventions. But it also found this evidence insufficient to sustain a definite conclusion on the impact among non-student samples and in the British context, or whether such interventions truly are cost-effective.

The key points were that:
• Process research suggests that computer-based alcohol interventions have potential, and that sizable demand exists for them. They could be particularly useful for those less likely to access traditional community-based alcohol services, such as women and young people.
• Reviews suggest these interventions can be effective in reducing alcohol consumption and frequency of drinking.
• Reviews suggest these interventions are more effective than no treatment or assessment only, and equally as effective as other 'conventional' alcohol treatments (including brief interventions). This conclusion is highly debatable given the limited amount of evidence available to date.
• Web-based alcohol interventions would seem to be the most viable approach, given their breadth of reach.
• Single-session personalised feedback interventions have been identified as one of the methods that computer-based technologies may be most effective at utilising.
• Self-administered computer-based cognitive-behavioural interventions are effective, but are enhanced by some degree of therapist involvement.
• Most computer-based alcohol intervention studies have been conducted in student populations. It is difficult to apply their results to the general population.
• Most have also been conducted in the USA, with very little UK-based research.
• Most too have used inappropriate statistical measures of central tendency, thus weakening conclusions derived from the results.
• Also most studies have relied on self-report measures, which challenge the reliability and validity of some of the results.
• There is a lack of evidence on long-term impacts.
• There are clear differences across the computer-based alcohol intervention literature in relation to both outcome measures and intervention content.
• Most studies have been characterised by small sample sizes, high attrition rates, limited consideration of bias, participant self-selection and a lack of 'pure' control A group of people, households, organisations, communities or other units who do not participate in the intervention(s) being evaluated. Instead, they receive no intervention or none relevant to the outcomes being assessed, carry on as usual, or receive an alternative intervention (for the latter the term comparison group may be preferable). Outcome measures taken from the controls form the benchmark against which changes in the intervention group(s) are compared to determine whether the intervention had an impact and whether this is statistically significant. Comparability between control and intervention groups is essential. Normally this is best achieved by randomly allocating research participants to the different groups. Alternatives include sequentially selecting participants for one then the other group(s), or deliberately selecting similar set of participants for each group. groups.
• It has been suggested that computer-based alcohol interventions are a cost-effective alternative to existing treatment options. However, these claims remain unproven as there have been no rigorous cost-effectiveness studies.

The author's conclusions

Computer-based alcohol interventions (either stand-alone or web-based) have potential, but further research is required to fully establish whether they offer a viable and cost-effective alternative to conventional treatment and support options. In particular, evidence indicates that they could be effective in certain groups, notably women, students and young adults. However, students are unlikely to be representative of the wider community, especially in their motivation, alcohol consumption levels, internet access, and IT literacy. More research is needed to establish feasibility and efficacy in general populations.

In addition, cost-effectiveness of this type of approach in relation to alcohol needs to be incorporated into any future evaluation to validate as yet unproven claims. Recruitment strategies to web-based interventions also need to be researched, as these could involve costs that far outstrip the set-up costs of the intervention.

Single-session personalised feedback interventions have been identified as potentially one of the most effective approaches, but the elements of personalised feedback that are key to outcomes and those needed to engage low and high risk drinkers are still unknown. Interventions that include brief intervention principles have also been proposed, as have those incorporating cognitive-behavioural elements. Techniques for delivering face-to-face brief interventions can also be incorporated into computer-based tools, and efforts to produce such resources have been increased in recent years. However, their quality and credibility has yet to be fully established. Evidence of effectiveness for internet-based cognitive-behavioural programmes is also limited in the alcohol field, often characterised by small sample sizes, lack of control groups and other methodological limitations. Where they have succeeded is in attracting users to the intervention, and those who are attracted generally report satisfaction with this method of delivery.

In Scotland, internet access is least available to people who are older, poorer, less well educated, unemployed, long-term disabled or ill, or living in the most deprived areas. Among these are groups most affected by alcohol-related harm, meaning that establishing an intervention modality which they are least likely to access could increase rather than decrease health inequalities.

Any computer-based alcohol intervention should ensure it has measures in place to identify and signpost those requiring additional support into appropriate services as effortlessly as possible.


Findings logo commentary Worth trying but unproven for the UK and the general population and need evaluating was the core message of the featured review. While the UK deficit remains as it was when the review was done, the findings of another analysis focused on non-student general adult populations might in this respect at least have helped firm up the featured review's conclusions. But even that analysis was limited to comparisons with effectively doing nothing rather than computer-delivered therapy as an alternative to face-to face therapy for people attending alcohol treatment services. For this role they remain virtually untested.

See other Findings analyses for a review of computer-delivered self-help interventions for drinking and smoking and a review focused on drinking. Both analyses include further commentary on the role of computer delivery and on UK findings.

Last revised 03 May 2012

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

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