EFFECTIVENESS BANK BULLETIN 21 October 2009

The entries below are our accounts of documents selected by Drug and Alcohol Findings as particularly relevant to improving outcomes from drug or alcohol interventions in the UK. Entries were drafted after consulting related research, study authors and other experts and are © Drug and Alcohol Findings. Permission is given to distribute these entries or incorporate passages in other documents as long as the source is acknowledged including the web address http://findings.org.uk. However, 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 Request reprint to send or adapt the pre-prepared e-mail message. Abstracts are intended to summarise the findings and views expressed in the study. Below are comments from Drug and Alcohol Findings. Links to source documents are in blue. Hover mouse over orange text for explanatory notes.

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£0.40 per unit of alcohol plus discount ban would save a life a day in Scotland ...

Intensive family support reduces need for children to be taken in to care ...

Popular community prevention process cuts adolescent smoking and drinking ...

Starting methadone in prison improves post-release treatment uptake ...

Model-based appraisal of alcohol minimum pricing and off-licensed trade discount bans in Scotland.

Meier P. et al.
University of Sheffield, 2009.

A £0.40 minimum price per unit of alcohol plus a ban on discount promotions would cut drinking by 5.4% in Scotland, saving a life every day once the policy fully takes effect, and over the first ten years saving £millions in public and private sector costs.

Abstract This study uses a simulation model developed to estimate the impacts of alcohol pricing and promotion policy options in England to estimate the impacts of plans in Scotland to prohibit discounting of alcohol and to introduce a minimum retail price per unit A UK unit is 8gm by weight or 1cl (10ml) by volume of pure alcohol. of alcohol. As well as focusing on these proposals, the simulation incorporated data on Scottish drinking levels, prices, purchasing preferences, and alcohol-related illness, crime and lost productivity. For more on the overall approach see the Findings analysis of the application of the model to England.

The calculations suggested that in Scotland a minimum per unit price of £0.25 would reduce alcohol consumption by 0.2%, rising steeply to 18.9% at £0.70 chart. At prices below £0.45, there is expected to be some switching to wine, increasing the consumption of this type of drink. If instead there were a total ban A total ban is assumed to prohibit all forms of price-based promotion, including straight discounting from list price and multi-buy offers (such as 'buy three for the price of two'). More limited types of ban were not appraised because the market research data available to the study does not differentiate between types of price-based promotion. If the Scottish implementation of restrictions to off-trade discounting excludes particular types of discounting, then the results may overestimate the effectiveness of the policy. on discounting off-licence sales of alcohol, consumption is estimated to fall by 3.0%, similar to the impact of a minimum price of £0.40 to £0.45. In terms of units of alcohol, wine sales would be reduced more than those of other beverages. Imposing a discount ban on top of minimum prices would further reduce consumption. The impact would be greatest at lower price levels, with diminishing returns at higher levels chart.

Next the analysis estimated what impact these consumption reductions might have on various forms of alcohol-related harm. Low minimum prices such as £0.25 per unit do little to reduce harm, but as price increases, alcohol-related hospital admissions and deaths rapidly diminish; for example, at £0.40, 3600 fewer Once the full effect on the risk of harm has been realised. admissions a year, at £0.50, 8900. Over a ten-year time frame, most lives are saved among the 7% of the population whose heavy drinking People regularly drinking more than the equivalent of 35 UK units per week for women or 50 UK units per week for men. clearly risks harm rather than among less heavy drinkers, and due to the impact on chronic disease among middle-aged and older age groups.

Across the spectrum of violent and acquisitive crimes and criminal damage, alcohol-related offending too steeply reduces as price increases (for example, at £0.40, 1100 fewer offences a year; at £0.50, 4200), but proportionately less so For example, at the £0.50 minimum price, alcohol-related hospital admissions at full effect are estimated to reduce by 13.5%, alcohol-related crimes by 1.5%. than health-related harms. This differential impact is because the more crime-prone sections of the population tend to drink in on-licensed premises, whose sales are less affected by minimum pricing. Absenteeism from work also falls steeply as the minimum price increases as does unemployment due to harmful drinking, though these calculations are less well founded in evidence than some of the others and may be vulnerable to the changing economic climate.

Banning off-trade discounting would reduce health harms by about the same as a £0.39 minimum price; crime, £0.45; absenteeism, £0.44; and unemployment, £0.38.

In turn these reductions in harm result in cost savings for society. They also conserve healthy years of life and prevent lives being damaged by crime, results which themselves have a value The study incorporated £50,000 as the value per year of life saved adjusted for the health-related quality of those years, and £81,000 for each year the victims of crime experience a reduced quality of life, adjusted for the degree of the reduction. for society. Expressed in financial terms, together these constitute the estimated social value of harm reductions due to alcohol policy changes. Over ten years the cumulative value of a £0.40 minimum price is estimated at £540 million, more than doubling to £1.3 billion at a £0.50 threshold. Value continues to increase steeply as price rises. A discount ban creates further value, for example, £950 million over ten years when combined with a £0.40 minimum price. Conserved healthy years of life is the largest component in the value calculations, constituting over half at a £0.40 minimum price, but there are also direct savings For example, over 10 years health and social care costs avoided due to reduced illness and hospital admissions are estimated at approximately £60 million from a £0.40 minimum price, £160 million from £0.50. for health and social care services. Crime-related savings too steeply increase with price, though the amounts are smaller.

The financial impact of the policy changes in terms of spending For example, for a £0.40 minimum price in combination with an off-trade discount ban, moderate drinkers would spend £0.21 a week more, hazardous drinkers £1.12, and harmful drinkers £2.63. on alcohol, and also the health benefits, For all minimum price scenarios, and with or without an off-trade discount ban, most of the health and healthcare benefits come from the harmful drinking group, for example, 62% of the reduction in hospital admissions due to a £0.40 minimum price. are concentrated among the harmful drinkers who buy the most alcohol. Reductions in crime and absence from work are spread more evenly across the population of drinkers. Overall, most of the estimated value due to harm reduction comes from the reduction in harms associated with harmful drinkers.

Under all the policy scenarios, and despite consumption reductions, consumer spending on alcohol and retailer revenues are estimated to rise. The combined impact on national VAT and duty receipts will however be relatively small, because duty is applied to the volume of sales (which reduces), but VAT is applied to the monetary value of sales (which increases).

In April 2010 an update to the featured report took in later data on consumption, distribution, mortality and crime. This new data led estimates of the impact of various pricing and discount policies to be very slightly reduced, but the changes did not substantially affect the policy implications of the findings.

The findings of this research will be used to determine the minimum price per unit of alcohol in Scotland. According to press reports, £0.40 is the favoured option. The administration has been keen too on a discount ban. The featured report details the probable results: a 5.4% cut in consumption concentrated among harmful drinkers, who would cut back by nearly six units a week; lives saved, building to one a day in the tenth year of the policy, when hospitals will be relieved of nearly 6300 alcohol-related admissions a year; nearly 3300 fewer offences a year, including 851 violent crimes; 1200 fewer jobs lost due to harmful drinking and workplaces benefiting from 29,000 fewer days off sick per year; over the initial ten years, the health service will save nearly £116 million; plus criminal justice and work-related costs, the total will be nearly £406 million; and plus the value of lives saved and improved, nearly £950 million; all at a cost to the Treasury of around £120 million.

The analysis focused on the impacts of policy changes on illness and other adverse consequences of drinking. The other side of the equation is that in British society people value drinking and social activities based on drinking. To the extent that, for example, price rises impede these activities, some things people value are lost, even as another thing they value, health, improves. If the impact is greatest on low income groups – and the parent review was unable to determine this – then greater social inequality may be the result even as health inequality diminishes. As the report acknowledges, in the face of price rises drinkers do not generally cut back sufficiently to avoid spending more. Again, the impact of a greater proportion of the family budget being diverted to drinking is likely to be felt most sharply among the poorest in society. Economic impacts of this kind can of course be mitigated depending on how governments choose to disperse revenues from higher taxes and/or public sector cost savings. Acknowledging these issues, the report calls for further research to "consider equity issues, such as the overall impact of the policies on people of low incomes". However, the particular policies tested in the model – a minimum price applicable across on- and off-licensed sales, and a ban on off-license discounts – would it was estimated result in a shift to drinking in pubs and other on-licensed premises, particularly in respect of beer, tipping the market towards more traditional and social drinking patterns and possibly increasing social value.

Uniquely the report, and the English version on which it drew, joined up previously unlinked dots leading from the effect of pricing, taxation and promotion policies on alcohol consumption, through to the effect of these consumption changes on alcohol-related harm, and then through to the cost savings and value for society. It is unclear however to what degree the report took in to account the probable level of 'importation' from England, which seems unlikely to set a minimum price for alcohol or ban discounts. But the major questions are not over the validity of the findings, which broadly accord with those of other analyses (1 2), but over whether governments mindful of the opinions of the drinking public, the social role of alcohol alluded to above, and the importance of drink-related industries, will do what research suggests is needed to significantly reduce alcohol-related harm. The Scottish administration seems determined to do so, but faces challenges from the Scottish parliament which in June 2010 narrowly rejected minimum pricing, and possibly too from UK devolution and European Union free trade laws. Though the original report was commissioned by the English Department of Health, and despite strong recommendations on minimum pricing from the UK government's principal medical adviser, there are no plans in England and Wales to respond by setting minimum prices. However, since then Britain's National Institute for Health and Clinical Excellence has also lent its weight to introducing a minimum price per unit of alcohol set on the basis of the health and social costs of alcohol-related harm and the expected impact of the policy on alcohol consumption.

Last revised 16 May 2010
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Final report on the evaluation of 'Option 2'.

Forrester D., Pokhrel S., McDonald L. et al.
Welsh Assembly Government, 2008

This evaluation of an intensive child protection service for children with substance misusing parents was the first in Britain to recruit an adequate comparison sample, a vital step in assessing effectiveness. Main finding was reduced need for long-term removal from the home.

Abstract Option 2 is funded by the Welsh Assembly to work with the families of parents with drug or alcohol problems to safeguard children at risk of harm and improve family functioning, reducing the need for public care. The intervention is short (four to six weeks) and intensive (workers available 24 hours a day). Among other therapeutic and practical interventions, workers use motivational interviewing and solution-focused counselling styles.

The Assembly commissioned an evaluation focused on possible cost savings. Data from local authorities established the care status of 367 children referred to Option 2 between 2000 and 2006. Averaging six to seven years of age, most were from single parent families and faced being taken in to care and/or placed on the child protection register. Parents' substance misuse problems mainly involved alcohol, though over a quarter also/instead used heroin, the next most common substance. Of the 367 children, 278 (the Option 2 group) were accepted by Option 2, though 16% were later assessed as inappropriate referrals and did not receive Option 2 services. Another 89 could not be accepted because the service was full, forming a comparison group; though in a broadly similar situation to the Option 2 children, some important differences complicated the comparison. While comparison families did not benefit from Option 2, they may have received alternative services.

Up to the end of 2006 (a follow-up period averaging three and a half years), virtually identical proportions of children (41% Option 2; 40% comparison) had at some stage been taken in to care. However, this took on average eight months for Option 2 children but just over four months for comparison children. Even accounting for this delay, Option 2 children spent two and a half months less time in care because they were more likely to be returned home (17% v. 7%). The net result was that at the end of 2006, just 24% of Option 2 children were still in care compared to 33% of the comparators, and 68% were living at home versus 56%. Taking initial differences between the groups in to account, the differences in final accommodation status and time in care were statistically significant.

This pattern held for both the local authority areas referring children to the service, but the costs of care differed. Across both and despite spending less time in care, costs per Option 2 child were greater, because the average daily cost was £46 compared to £31 for comparison children. The difference was driven by some very low cost and very high cost children in one of the areas. Cardiff was the other area and accounted for most children in the study. Here daily care costs for Option 2 and comparison children were about the same, and per child, total care costs were £3373 lower for Option 2 children. The service itself cost £2195 per child. Combining these figures, in Cardiff overall costs (including Option 2 services) were at least Actual savings were probably considerably greater, as not all the costs of care were included, and alternatives to Option 2 possibly accessed by comparison families were not costed. Moreover, fewer children in care at the end of the study probably meant continued lower costs in subsequent years. £1178 lower for Option 2 than for comparison children.

More so than among comparison children, among families referred to Option 2, certain indicators Children subject to a care order, involved in more serious referrals and whose parent(s) misused amphetamines. of heightened risk did as expected increase the chances of the child being taken in to care, suggesting that Option 2 improved decision-making. With a similar analysis of children in care at the end of the study, the implication was that (as intended) Option 2 was best at preventing the need for care among children for whom this was an imminent risk. Many of whom were already on the child protection register. It also seemed most effective in this regard when parents misused alcohol and among single-parent families.

Interviews were conducted with 11 adults and seven children from eight of the 16 families In the 12-month period prior to the commencement of the evaluation, Option 2 worked with a total of 16 families. Of the 16, addresses were unavailable for two families. The remaining 14 were visited but one had moved to an unknown address, four were not at home for a number of visits, and one family declined to participate. All interviews were conducted in the participants' homes. The children were aged 9 to 15. Option 2 had worked with over a 12-month period. Parents were uniformly appreciative and felt they got greater support and understanding from Option 2 than from social services. Children too generally felt the family had improved due to Option 2's work. Commonly remarked on were the worker's good communication and listening skills, willingness to work long or unusual hours, exceptional commitment to the family, and deep knowledge of both child care and substance misuse. Where families had fewer or less entrenched difficulties, these inputs seem to have fostered lasting improvements. Among families with complex and entrenched difficulties, improvements tended to be temporary and problems resurfaced when Option 2 withdrew. Several families would have liked longer contact. Questionnaires returned by 23 local social workers also revealed a generally positive experience of Option 2, but here too there concern over its short-term nature. These and the other data gathered by the study suggested that a great strength of Option 2 was its ability to engage every family it saw in at least an initial discussion, despite very difficult circumstances.

The researchers concluded that Option 2 had a greater impact in reducing the need for care than the combination of services (some themselves intensive, and some also long term) families are normally referred to, and that at least in Cardiff, it created significant cost savings for the social care system. Compared to the original US model, its success was striking, probably due to evidence-based interventions such as motivational interviewing and high quality management and staff. They cautioned however that they did not investigate child welfare outcomes. Option 2's primary purpose was not to reduce resort to care proceedings, but to safeguard the child, entailing removal from the home if this was advisable. Recommendations included considering longer term care for families with complex needs, targeting children who have already been or are imminently at risk of being removed from the home, and the extension of the skills and approach pioneered by Option 2 to generic child care social workers. This might improve the response to all families, and for those seen by Option 2, help prevent reversion to previous difficulties.

The parents of well over a million children in Britain have a drug or alcohol use problem. Across the UK, national targets, service standards and policy statements have recently embodied the perspective that their welfare is a core concern for services in contact with problem drug users, a contention featuring strongly in current Scottish and English drug strategies.

Establishing what works for those at risk among these children is difficult because it would be unethical to deliberately deny services which might help, in order to determine whether they really do help. However, the potential for interventions to do serious harm as well as create major benefits makes evaluation vital. Unable to randomly allocate, this rare study of child protection services for this caseload took the next best option of recruiting families referred to the service, but unable to be seen, the best comparator The study also tried to maintain comparability by including among the Option 2 families those (as some in the comparison group might have been) seen by Option 2 but not offered its services. While not a perfect way to recruit a comparison group – there may have been some prioritising or other influences beyond staff unavailability – this solution does at least mean that both Option 2 and comparison children were considered suitable for referring to the service. so far achieved by a British study.

The researchers cautioned that children are not necessarily best served by being kept out Or in this study, care being delayed and children being returned home sooner. of care, yet across the sample, care entry was all they could measure. Interviews with participants offer reassurance that child welfare and family functioning really did improve. Also, the decision to return children home was not taken by Option 2, but by social workers and courts, and generally after families had ceased contact with the service. Presumably it was taken on the basis that these homes were now acceptably safe environments for the children, a decision which could be taken more often and sooner in respect of families helped by Option 2.

That the caution was, however, well founded, is suggested by a study in London of a similar set of parents. Their substance misuse was causing concern and they had been referred for long-term social work involvement. In terms of their long term substance use and social welfare involvement, and the fact that their children were at high risk of care entry upon referral, they were in a similar situation to the parents in the featured study. In this study of routine social work processes, remaining in the home was the best predictor of poor child welfare outcomes. There was also a high rate of family break up. Two years after referral to social services, 54% of children no longer lived in the parental home. Given the trends, after three years around two-thirds might have been removed, compared to under a third of Option 2 children after on average about the same period. For the researchers it implied that "social workers were not effective ... with families in which there was substance misuse". If this is generally the case, it supports the need for services like Option 2, and the featured study's recommendations in respect of spreading their way of working to generic child protection services.

An evaluation of a similar service in Middlesbrough found that it too prevented the need for permanent placement of children in to care and reduced time in temporary placements. Though all 18 children subject to child protection measures had been at high risk of being taken in to care, by the end of the 12-month study, 16 were living in the parental home, none were in care or on the child protection register, and 15 were not subject to any form of care order.

The longer term success of such projects is highly dependent not just on the calibre of the staff, but also the availability of housing and other community resources, and the strong interagency partnerships needed to make these accessible to the families. As in the featured study in Wales, in Middlesbrough the families remained vulnerable to renewed problems, in this case due to continuing high levels of parental depression, shortage of social housing, and the lack of progress in education or employment. Option 2's methods may also need adaptation for services with case responsibility for the family; details below.

The recommendation that Option 2's methods be disseminated to generic child protection services was tested in respect of the motivational interviewing element in London, where child and family social workers were trained to use this approach with problem drinking parents, with a focus on child protection cases. Three months later motivational interviewing skill levels remained generally low, but most workers were now less confrontational with parents and better listeners with (they felt) positive results. What stood in the way of fully implementing the training was the need to quickly process cases and obtain mandated assessment data, but also the tension between the client-centred stance of motivational interviewing and the need in serious child protection cases to be clear about what was required of the parents, and if necessary to confront certain behaviours. It is neither possible nor credible in these circumstances to (as customary in motivational interviewing) give the message that whether and how they change is entirely up to the parent, and the child welfare worker is simply there to help them explore those areas. The more skilled workers felt able to handle this contradiction, but they were in the minority.

This issue also seems to have cropped up in Middlesbrough, where (like the social workers in the preceding study but unlike Option 2 staff) the workers shouldered the case responsibility for the families and could remove children from the home. Given this, they adapted the approach to defocus on motivational interviewing in favour of solution focused behavioural therapy, an approach which encourages the family to define what for them would be a better life, then with the therapist set tasks to move them towards this, and monitor progress towards this goal.

Even if truly client-centred counselling may be inappropriate or difficult to carry off in these circumstances, some of the characteristic features of effective therapies (including motivational interviewing) may help social workers glean more information from parents, defuse resistance to acknowledging problems, and gain agreement on the next steps. A study of British social workers interviewing an actor playing an alcoholic mother found that complex reflections and especially empathy promoted these desirable reactions, without sacrificing clarity over the social worker's concerns.

The featured study usefully reviewed the international literature on similar services. After initial enthusiasm, this concluded that they did not reduce the number of children being taken in to public care, so did not conserve resources. Such services attempt to help families already at the brink of losing care of their children. Before that point there is a strong case for offering parenting and child welfare interventions to all problem substance users in contact with treatment and harm reduction or other services. Because these offer positive support without implying parental failure, they often have a good uptake and can reduce the numbers who reach the point reached by the families in the featured study. British researchers who have specialised in substance misuse in families have offered recommendations based on a review of the international literature.

Thanks for their comments on this entry in draft to Donald Forrester of the University of Bedfordshire and Lorna Templeton of the Mental Health Research & Development Unit of the Avon & Wiltshire Mental Health Partnership NHS Trust and the University of Bath. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 03 October 2009
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Results of a type 2 translational research trial to prevent adolescent drug use and delinquency: a test of Communities That Care.

Hawkins J.D., Oesterle S., Brown E.C. et al. Request reprint
Archives of Pediatric and Adolescent Medicine: 2009, 163(9), p. 789–798.

With its appealing mix of science and community empowerment, the US Communities That Care prevention process has spread to the UK and other countries. This first randomised trial confirmed that given promising towns and rigorous execution, it can curb adolescent smoking and drinking.

Abstract Developed by the University of Washington, Communities That Care is a prevention system provided in the USA by the Substance Abuse and Mental Health Services Administration, and promoted in Britain by Rainer, a national charity for under-supported young people. Rather than a specific intervention, CTC offers a process aiming to generate science-based, effective prevention initiatives led by community coalitions. First step is to construct the coalition, which then uses 'diagnostic' surveys and local knowledge to assess the community's strengths and vulnerabilities (protective and risk factors) in relation to preventing substance use problems and delinquency among its children. Next steps are to formulate and implement an action plan to address these, drawing on a menu of proven interventions tackling for example drinking, drug use, smoking, violence, family conflict, life skills, HIV/AIDS risk, dating safety and anger management, depending on community need.

The Community Youth Development Study was the first to randomise communities to implement this process or to act as controls against which the results could be benchmarked. A preceding study had compared communities which according to state authorities were trying to mount prevention initiatives based (like CTC) on protective and risk factors, against matched In respect of size, poverty, diversity, and crime indices. communities not pursuing this strategy. In the event, in 13 of the 20 matched sets, none of the communities had actually implemented such an approach. Of these 13, 12 pairs of communities agreed to join the featured study. One from each pair was randomly allocated to the CTC process. Each was a relatively self-contained, geographically distinct small town.

A previous report had established that CTC and control communities rarely differed in pre-study trends and prevalences of youth substance use and delinquency. Another found equivalent progress in implementing research-based prevention activities, in cross-sector collaboration generally, and in collaboration over prevention initiatives. From this common baseline, on all three implementation measures CTC communities had made greater progress by the year after the CTC process had started. During this time certified CTC trainers had held six training sessions, and community leaders had identified or created coalitions which had selected priority risk factors and made plans to target these with on average three prevention policies/programmes The 12 intervention communities selected 13 different prevention programmes to implement during the 2004–2005 school year, 16 during the 2005–2006 year, and 14 during the 2006–2007 school year. These included school-based programmes (All-Stars, Life Skills Training, Lion's Quest Skills for Adolescence, Project Alert, Olweus Bullying Prevention Program, and Program Development Evaluation Training), community-based youth-focused programmes (Participate and Learn Skills, Big Brothers Big Sisters, Stay Smart, and academic tutoring), and family-focused programmes (Strengthening Families 10–14, Guiding Good Choices, Parents Who Care, Family Matters, and Parenting Wisely). each year over the next three school years aimed at 10–14-year-olds and their families.

The featured study tested whether this activity had made a difference to youth behaviour. Just before the activities had started, it recruited grade five (10–11-year-old) pupils, and then followed them up annually until they were aged 13–14. Nearly three years after the activities had first been implemented. The 4407 pupils While most were recruited from the start of the study, about a quarter could not be recruited until the following year, when some of the activities would already have been underway. Beyond this year, follow-up rates were around 96%. comprised just over three quarters of the relevant classes. By age 12–13, growth in delinquency had already been significantly curbed in CTC communities (and continued to be so), but only over the next year was there a significant impact on substance use. Between ages 12–13 and 13–14, fewer children in CTC towns who had not previously tried these substances had tried drinking (17% v. 25%), smoking (8% v. 12%), or smokeless tobacco (4% v. 6%). There were no such impacts on trying cannabis or inhaling solvents. Combining all these substances, there was a statistically significant reduction in substance use initiation across all the years of the study.

Also, in the final year of the study children in CTC towns were less likely to currently (past month) be using substances. Breaking this down, statistically significant impacts were seen for drinking (16% v. 21%), binge Drinking five or more US drinks at a sitting during past fortnight. drinking (6% v. 9%), and use of smokeless tobacco, but not for cannabis, smoking, solvent abuse or use of other drugs, though in all cases the proportions using these substances were lower in CTC towns.

The authors concluded that within four years of adopting the CTC system, community coalitions can curb the numbers of children starting to use alcohol, tobacco, and smokeless tobacco and committing delinquent acts. By age 14, the result is fewer children drinking or binge drinking or using smokeless tobacco, and fewer delinquent acts, with possible long-term public health benefits.

Among CTC's attractions are the empowerment of local communities to select their own priorities and responses, the possibility that this can underpin wider and lasting improvements, the alliance between localism and centrally determined scientific 'diagnostic' tools and response options, and the way it targets a range of risk factors potentially affecting several social problems. The findings of this first randomised trial should help sustain expansion from its US base to the UK and other countries.

CTC incorporates many of the lessons of international research on community drug/alcohol interventions. These include: devolve decision-making to the community while supplying research-based knowledge; rapid feedback of results motivates participants and keeps projects on track; recruit influential and respected local leaders; considerable lead-in time is needed to build the social and organisational infrastructure for community action, and projects need a few years to fully deliver; project staff must expect and permit adaptation not just of methods but also aims in response to the community's strengths and self-perceived needs; success comes easier in communities where the project's aims are already high on the agenda; a key element is the surer detection and sanctioning of transgressors brought about by the more intensive use of existing legal powers; however, these legal powers must in the first place have the potential to be effective.

Despite these strengths, there are doubts about whether the diagnostic indicators are strongly enough related to substance use to guide the targeting of interventions, and over whether some of CTC's interventions menu (for example, Project Northland, Project ALERT, Life Skills Training, the Midwestern Prevention Project) really are generally effective. Nevertheless, CTC's process is a big step up from interventions mounted without a needs assessment and chosen without regard to the evidence base.

The study's methodological qualities included a comprehensive process to establish that CTC and control communities were truly comparable, Where they differed, in all three cases trends favoured the control communities. tests of significance which did not inflate the chances of significant findings by assuming that the intervention can only improve things, and the construction of single, combined measures of substance use and delinquency, which avoid capitalising on chance positive findings from multiple tests. The main questions concern the generalisability of the findings to other areas; details below.

Possibly the study's towns were unusually well placed to take advantage of the CTC process. In these small, self-contained communities with relatively socially homogenous populations, it was probably easier to identify opinion leaders and for them to exercise widespread influence than in larger or more diverse conurbations. A commentary on the study pointed out that the populations were 90% white and teenage delinquency was relatively rare. Community norms and availability restrictions also have their greatest impacts in self-contained, stable communities whose residents and businesses cannot easily escape their impact. Within this promising type of community, those selected for the study were particularly promising. They were located in seven states identified as leaders in risk- and protection-focused prevention planning. These states in turn identified towns leading the way On inspection by the researchers they did not seem so, but this does not seem sufficient to dismiss the states' assessments. within their borders, which formed half the pool allocated to the CTC approach or to act as controls. It remains to be seen whether the findings would be replicated in severely disadvantaged communities whose very need to address pressing social problems is indicative of the difficulties they face in doing so.

The importance of the community was demonstrated by an evaluation of the first three In Barnsley, Coventry and Swansea. CTC programmes in Britain. Though drawing on the same framework and resources, in each area the approach and the results were very different. Where the areas started from was the key to whether coherent community action emerged. In one, local people were already involved in community development, and the infrastructure and experience of successful partnership working provided a platform from which the new project quickly moved forward. In the other two, poor infrastructure or tensions between professionals and local people seriously impeded implementation.

As the researchers acknowledged, the featured study was a test of rigorously implemented and monitored versions of the CTC process, conditions which may not be widely replicable. The CTC towns also had resources not commonly available. These included a series of 'diagnostic' surveys from the preceding project on which to base their programmes, and the financial and in-kind resources of the study, whose staff included the developers of the CTC process. In several social research areas (1 2 3), studies led by developers or people with other forms of 'allegiance' to the trialled programme have been found to produce more positive findings than fully independent research.

The impacts recorded in this rigorous trial were (relative to other prevention trials) substantial. It is important though to remember that statistically significant reductions in the uptake of substance use emerged only between grades seven and eight. Focusing just on this final year As the programme's US government distributors did in their media release on the study: “By the eighth grade, students in the CTC communities were 32 percent less likely to begin using alcohol, 33 percent less likely to begin smoking, and 33 percent less likely to begin using smokeless tobacco than their peers in the control communities.” http://www.drugabuse.gov/newsroom/09/NR9-07.html, accessed 12 October 2009. when the proportions of children starting to drink, smoke or use smokeless tobacco were cut by a third, gives a false impression of the impact over the entire study and over the entire cohort of children, including those who had already tried these substances before the study started. From this broader and longer perspective, it can be estimated Calculations by Findings based on figure 2 of the featured study and baseline prevalence of having tried these substances reported in table 2. Available on request from editor@findings.org.uk. that by grade eight about 14–16% fewer children had tried smoking or drinking in CTC communities, and about 6% fewer smokeless tobacco. For every 100 children in grade five, by grade eight these figures meant that respectively 8, 4 and 1 fewer would have tried these substances. Also there were no significant findings in respect of solvent abuse, cannabis, or other prescription or illicit drugs, though except for solvents, these might be expected to emerge only after age 13–14, the last follow-up in the study.

Last revised 19 October 2009
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A randomized clinical trial of methadone maintenance for prisoners: results at 12 months postrelease.

Kinlock T.W., Gordon M.S., Schwartz R.P. et al. Request reprint
Journal of Substance Abuse Treatment: 2009, 37, p. 277–285.

Starting methadone treatment in prison radically improves treatment uptake on release and reduces heroin and cocaine use over the following year, reports the first US randomised trial among formerly opiate dependent prisoners.

Abstract This report is a longer term follow-up of a study whose three-month follow-up results have previously been reported by Findings.

Researchers identified 564 male prisoners in Baltimore who (among other criteria) were within three to six months of release and had been heroin dependent or in methadone treatment in the year before they were imprisoned. Largely due to a lack of interest in receiving methadone maintenance, 353 were excluded from the study, leaving 211 who had a history of heroin dependence and were opioid-dependent immediately before imprisonment. Typically they were poorly educated African Americans aged between 35 and 45 with a history of repeated imprisonment and previous drug treatment. Before their latest spell in prison, on average they had used heroin every day and committed crimes nearly every day. Criteria for joining the study included suitability for and willingness to try methadone maintenance in prison, yet fewer than one third had previously experienced the treatment.

Over the first three months after release, without a treatment slot waiting for them few offenders started treatment, more used illegal opiates and cocaine, and more committed crimes. The extra benefits of also starting methadone in prison were increased treatment uptake and a more than halved risk of re-imprisonment. The picture remained similar at six months after release, the main exception being that days About 20 out of 180. spent back in prison were now virtually identical, regardless of the pre-release preparation.

The featured report extended the story to a year after release. As before, a clear and conclusive impact of starting methadone in prison was to promote treatment entry and retention on release. Over the 12 months, 70% of offenders prescribed methadone in prison started treatment in the community. Of those who started, on average each was in treatment for just under eight months. 70.4% entered treatment and over the entire group on average 166 days were spent in treatment. Corresponding figures for arranged transfer offenders were 54% and five to six months, 53.6% entered treatment and over the entire group on average 91.3 days were spent in treatment. and for counselling only offenders, 25% and three months. 25% entered treatment and over the entire group on average 23.1 days were spent in treatment.

Substance use outcomes were generally best after methadone in prison, worst after counselling only, with arranged transfer in between. Across all the 12-month follow-up measures including crime and employment, only in respect of urine test results Due to reimprisonment, hospitalisation, or interview by telephone or over two months after the scheduled date, tests were unavailable for 89 of the 204 participants. at 12 months were the differences statistically significant. Details below.

At 12 months after release, two thirds of urine tests on counselling only offenders were opioid positive, and over the preceding year, on average they admitted to using heroin on 167 days. Corresponding figures for arranged transfer offenders were about half and 121 days, and for methadone in prison offenders, a quarter and 106 days. With respect to cocaine, at 12 months after release three quarters of tests on counselling only offenders were positive, and over the year they admitted to using cocaine on 77 days. Corresponding figures for arranged transfer offenders were two thirds and 53 days, and for methadone in prison offenders, well under half (43%) and 37 days.

Over the 12 months, on average counselling only offenders admitted to committing crimes on 107 days, arranged transfer offenders 65 days, and methadone in prison offenders 82 days. In each category from 50–60% had been arrested, and over the last month of the follow-up year they had been employed for on average 10 days. Four counselling only offenders died from opioid overdose over the following year, but none in the other two groups. The methadone induction regimen had no serious The first two study participants felt excessively drowsy when initiated on 10mg of methadone, leading the starting dose to be cut to 5mg. After this adjustment the induction schedule was well tolerated, though constipation was common. adverse effects.

For this cohort, the authors felt the most promising results were the ability of an in-prison methadone programme allied with an awaiting post-release treatment slot to foster continuity of treatment sufficient to result in substantial reductions in heroin and cocaine use.

Compared to just having a treatment slot arranged on release, starting methadone in prison meant that within the first month nearly another 20% of offenders took up that slot. Perhaps because they started treatment earlier, on average each was in treatment for a further two months or more. The result it seems was reduced heroin and cocaine use, but over the first year no documented impact on crime or employment. Such impacts may yet emerge Many more of the methadone in prison offenders (37% versus 17% of arranged transfer offenders) stayed in treatment over the entire follow-up year. If, as some research suggests, this kind of duration on methadone embeds a turn away from an addicted lifestyle, then gains in crime reduction and social reintegration may emerge over later years. over later years. It is likely too that reduced drug use (especially injecting) protected some of the offenders from disease. There is also a strong indication that ensuring seamless transfer to methadone saved lives, one of its primary justifications in the UK. Besides post-release benefits, within prison itself methadone programmes improve the climate and reduce drug use, injecting and infection risk behaviour.

A key issue is whether starting methadone in prison perpetuated dependence among people who would have sustained abstinence on release. On joining the study, offenders had on average been in prison for 20 months and had three to six months to serve, two years or more in all. This enforced lengthy break from drugs might have been an opportunity to reconstruct lives so the 'break' could continue on release. For an appreciable minority, prison plus counselling only was indeed followed by relatively prolonged abstinence from opiates. In the three months after release, a fifth 14 of 62 counselling-only patients said they had not used opiates of whom two had been re-imprisoned and one had entered treatment (personal communication from Timothy W. Kinlock, December 2008). of these offenders said they had remained opiate free without treatment or being reimprisoned. Over the initial six months, 17% 11 of the 63. had still avoided heroin use. The risk of perpetuating opioid dependence in this minority by facilitating methadone treatment must be set against the benefits of cutting heroin and cocaine use among the general run of patients. Given good access to housing, employment, psychosocial treatment, and other forms of good quality and attractive resettlement support, the balance of benefit may be tipped against initiating methadone in prison. Such supports are however in limited supply in Britain.

Conceivably the impact underpinning all the others was that more of the offenders started on methadone in prison continued treatment immediately after release. Despite being selected for their interest in methadone treatment, nearly half the offenders who just had a slot awaiting them did not start treatment at all over the next 12 months, a figure almost entirely accounted for by their not linking with treatment on release. An optimistic interpretation is that having benefited from methadone in prison, offenders wanted to continue with their recovery on release; another is that leaving prison with a 60mg a day methadone habit, they faced an uncomfortable withdrawal Emerging after years in prison, it seems likely that for many their resources and contacts would have been insufficient to take the alternative route of quickly acquiring sufficient quantities of illegal opioids. unless they continued treatment. Even if this was the motivation, it did lead (presumably via treatment) to more advanced recovery in the form of reduced heroin and cocaine use, and the prisoners voluntarily put themselves in this position.

Prison methadone maintenance is clearly not a universally applicable treatment. Apart from other reasons for exclusion from the study, about half Of the 564 inmates potentially eligible for the trial, at various stages 72 proved or became ineligible leaving 492 who might have joined. Also at various stages, another 280 declined the study because they were not interested in receiving methadone maintenance treatment. the prisoners were not interested in receiving methadone, perhaps reflecting the questionable reputation of methadone programmes among minority Americans. Relatively long sentences in the USA allow for therapeutic communities. Together with aftercare (especially if this is required as part of the sentence) these reduce drug use and crime. Such facilities are rare in British prisons, but there are a number of other less intensive and/or shorter term programmes which have yet to be adequately evaluated. According to a UN/WHO guide on opiate maintenance in prisons, none of the alternative treatments are yet as reliably effective due to their limited attraction to prisoners and high drop-out and relapse rates.

Methodological considerations include an excellent follow-up rate, Data was obtained from 97% of people who started the study. giving confidence in the applicability of the findings to the Baltimore male prison population. However, results are likely to be highly dependent on the context. In Baltimore, Personal communication from Timothy W. Kinlock, December 2008. applicants typically have to wait several months for methadone treatment and pay fees dependent on ability to pay. Absent these hurdles, more without a pre-arranged methadone slot might nevertheless have started treatment on release. The more clear-cut findings from urine tests seem undermined by the number of missed tests, but these were missing partly because they could not be obtained from people in hospital or prison, when they were in any event not free to use drugs. Unlike the offenders' own accounts of their substance use, which spanned the entire year, urine tests were a point-in-time snapshot at 12 months after release. If, as hoped, lengthy spells in treatment had progressively embedded a drug-free lifestyle, end outcomes represented by urine tests would (as was the case) have been expected to show a more clear-cut advantage for methadone in prison patients. The possibility that treatment durations at or approaching a year distanced offenders from drug use is consistent with the finding that only at the 12-month follow-up point did patients offered methadone treatment evidence reduced cocaine use.

Following policy commitments in Scotland and in England, access to maintenance prescribing has recently increased and throughcare from prison to the community continues to be a policy priority. How throughcare arrangements for the relatively new cohort of methadone-maintained prisoners are working in practice has yet to be documented. Prisoners released on licence can be required to attend certain treatment services, but this only applies to sentences of over a year. Apart from licence conditions, methadone-maintained offenders leaving prison have no automatic and immediate access to similar treatment in the community. Further policy considerations below.

In England throughcare is a particular responsibility of the new Integrated Drug Treatment System, backed in some areas by additional in-prison resources for transition planning. Throughcare guidelines stipulate that a release plan for drug misusing offenders must be drawn up in liaison with the community teams responsible for implementing it, including prison-gate contacts with priority offenders liable to relapse. Clinical guidelines for prison treatment suggest that pre-entry opioid maintenance programmes should normally be continued in prison and that the treatment should be offered to dependent opiate users on short sentences. They also advise considering raising pre-release doses to previous maintenance levels as a form of post-release overdose protection for offenders prone to relapse. There is however no clear recommendation to consider initiating pre-release maintenance for longer term prisoners, though this was not ruled out The report recommended that to prevent accidental overdose and death, so-called 'retoxification' – a version of the methadone in prison option in the featured study – be considered for problem drug using prisoners thought likely to relapse on release. by a recent government-commissioned report on prison drug treatment.

In Scotland throughcare has improved but remains patchy. Over the next few years transfer of prison treatment to the NHS is intended to help improve the situation. Currently Scotland's Throughcare Addiction Service attempts to cater for short-sentence prisoners without a licence condition, aiming to link them to community-based resources and to work with them for at least six weeks after release. Current practice Personal communication from Stephen Heller-Murphy of the Scottish Prison Service, September 2009. in Scottish prisons is neither to continue nor to initiate opiate substitute prescribing in prison unless there is confirmation that a community prescriber will continue the treatment on release. Improved prison-community links consequent upon an expansion in the number of addiction nurses in prisons mean that continuity of treatment has substantially improved over recent years.

Thanks for their comments on this entry in draft to Timothy Kinlock of the Friends Research Institute in Baltimore, USA, who patiently corrected some errors, to Consultant Psychiatrist Thomas Carnwath, and to Stephen Heller-Murphy of the Scottish Prison Service. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 02 October 2009
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