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SMART Recovery groups offer AA alternative to UK problem drinkers ...
Controversial amphetamine prescribing treatment trialled in Australia ...
Is a specific therapy needed to tackle dependence plus PTSD? ...
Macgregor S, Herring R.
Middlesex University, 2010.
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Austerity plus recovery plus curtailed treat equals more mutual aid is the formula for ways out of dependence in the post-credit crunch 2010s. But with only 12-step groups, the offer is limited. What will it take for a cognitive-behavioural alternative to flourish in England was the question for this pilot project.
Summary The SMART Recovery pilot project was funded by the English Department of Health for two years from April 2008. SMART is an acronym for 'Self Management and Recovery Training'. As applied to drinking, it offers a recovery and relapse prevention aid which like Alcoholics Anonymous (AA) relies on mutual support in small groups of people recovering from drink problems, but instead of being based on the 12 steps, sees addiction as a learned behaviour which it seeks to unlearn using cognitive-behavioural principles. The US-originated system focuses on:
• building and maintaining motivation to abstain;
• coping with urges;
• managing thoughts, feelings and behaviour; and
• balancing momentary and enduring satisfactions.
SMART Recovery UK (see web site) and the national charity Alcohol Concern joined together to establish the SMART Recovery project to pilot the model at six sites in England. It aimed to test whether non 12-step mutual aid can flourish and become self-sustaining with a view to facilitating take-up by areas across England. Such a development would in particular redress the lack of aftercare following formal treatment for patients uncomfortable with AA, but might also offer a recovery and relapse prevention option in its own right.
The featured evaluation report (for full report click title of this entry; for summary click here) was one of the project's outputs. It was not intended to quantify drinking outcomes but to determine whether the project's methods had proved a feasible way to establish new mutual aid groups of these kinds in the six areas, and whether these developments were acceptable to alcohol treatment/help services and potential group members. The researchers relied largely on analysing documents related to the project, observing its work, and on the views of those involved, gathered via interviews, focus groups, and questionnaires.
In response to the call for pilot sites, 33 applications were received, suggesting quite extensive interest in developing peer support options focused on abstinence.
At the six selected sites, the key dilemma in developing groups was the degree to which services and the central SMART office should support them, or leave them to make their own way. Project leaders were concerned that external funding would undermine SMART's mutual aid/self-help ethos, and a preoccupying issue was the degree to which the groups would involve or rely on services and professionals as opposed to being entirely user-led and operated. For its US originator, a period of professional facilitation was acceptable as long as within a few months operational control was relinquished to group members. Project leaders in England saw the groups as potentially working with treatment services (as a precursor to treatment, support during treatment, or aftercare) but were adamant The code of conduct in the project's resource manual stipulated that, "professional involvement is not an element of mutual aid and over involvement stifles group development ... A meeting run by a worker, paid or voluntary, of a professional organisation as part of its business is not a mutual aid meeting and should not be called a SMART Recovery Group". that groups should be user-led rather than becoming an arm of treatment services. Group members themselves differed on this issue. Some thought it naïve to think groups could function completely independently of treatment services, and support from the host agency remained very important to them. While trying to be available if needed, host agencies generally respected the wishes of group members in terms of how much involvement they had with the group.
Though the risks of co-option might be minimised by financial and operational distance from services, this also created problems. The attempt to set up a group at one site foundered when the local host agency wanted to co-facilitate the groups for an initial period, a strategy rejected by the project's national leadership. On the financial side, perhaps because so few group members were employed full time, it proved difficult to fund the work solely from their contributions.
In the event, 63 people attended for training to facilitate SMART groups, of whom nearly nine in ten had been or were (a quarter) in addiction treatment. About six in ten had attended AA and despite commonly severe dependence, most had been abstinent for several months.
Nearly all SMART group members the pilot areas responded to a survey. Of those responding, only 1 in 8 had never been treated for alcohol/drug problems, over a quarter were currently in treatment, and 80% had used self-help groups previously, mainly AA. Severe past problems with alcohol were the norm – for many, not far in the past; just over half had drunk within the past three months. Finding moderation did not suit them, most were committed to abstinence. Demonstrating how critical was referral from treatment services, two thirds had heard about SMART from an alcohol worker, reflecting the fact that most groups had developed via a close link with services. If groups become more widely established and better known, non-service referral routes might become more important.
Involvement with the group was a regular part of the life of most members, and a core group of longer term members appeared to developing. About two thirds attended meetings weekly, and all but a few intended to continue attending. All found the meetings helpful, generally more so than other types of self-help groups. The groups appealed to them because of their non-hierarchical structure, they could readily be understood by others with similar experiences, and other members acted as role models who had overcome their dependence and forged a 'normal' life. SMART Recovery in particular emphasised 'moving on', not repeating 'war stories'. Members liked the focus on problem solving and the practical approach to recovery. Support not to drink helped them stabilise and then move on to improve housing, employment and social integration. However, they accepted that relapse may be part of the recovery journey and saw the availability of groups as important in helping people get back on track. They felt their self esteem and confidence improved and enjoyed being able to think about new activities or rediscovering old ones. They were not hostile to AA – simply preferred SMART Recovery; it worked for them.
SMART groups addressed gaps in services and the need for an alternative to AA while offering great value for money. Overall, the mutual aid element seemed most appealing to facilitators, but self-help – working with the tools between meetings, absorbing this way of thinking, or accessing the web for support – also played its part. Training and refresher training (in use of therapeutic tools, group work and project development) were valuable, as was the right amount and kind of support from the host agency, which ideally remained a steadfast and enthusiastic supporter, but one willing to 'step back'. Successful implementation was aided by a core of keen and able activists, central office support and small seed-corn grants, a supportive environment of services locally into which SMART groups can be linked, and links to the wider social movement of recovery advocacy. It is important not to underestimate the support groups initially need from services nor to expect too much too quickly.
Practical lessons from the pilot include: secure sufficient initial and ongoing funding and make sure everyone is fully aware of the commitments involved; locate meeting venues before initial training and ensure posters and advertising are ready before training starts; check whether facilitators are following guidelines; better funding of a central SMART Recovery office to manage and monitor training; offer more training including for facilitators to themselves become trainers; have local trainers but enable them to meet and network; make advice available to new groups from existing groups. Further details below.
The project showed that it is feasible to develop mutual aid groups through partnerships between people in recovery and host agencies. Two of the six local projects could be seen as having been completely successful. Two others were still in the early stages and their development was in doubt after the pilot has ended. Most still needed a host agency within which to operate, at least to give them credibility until SMART becomes better known.
Groups got off the ground where there were energetic activists ready to take on the required tasks. A key question is what is needed to sustain this considerable commitment. In the pilot the required resources were underestimated. In particular, the idea that an autonomous recovery movement could develop without support from host agencies seems misconceived. Too much would be asked of people often in early recovery, whose social circumstances may be uncertain and fragile, and who do not have substantial financial resources. If group development is to be condensed into a short time frame, then support through training is useful, but one session is not enough; repeat visits boost morale and help deal with questions that arise. Funding was the number one issue and most agencies asked for more support to help purchase mobile phone, print more professional leaflets and publicity, or advertise in local papers and publications. While it is important to respect autonomy and to avoid dependence on services, adopting too puritan a view and having fixed and high expectations of group members and host agencies seems risky. A less ambitious agenda – encouraging mutual aid groups using the SMART tools and encouraging treatment providers to refer people to groups but not expecting too early a move towards total independence – might be more successful. Groups cannot be expected to run before they can walk, and most of the groups developed through this pilot will continue to need emotional and material support.
Factors that seemed to help sustain the activists included:
• the encouragement derived from networking between group members in different locations;
• a central coordination point offering information, resources and guidance;
• celebration of successes locally and nationally;
• recognition of the emotional labour involved and some input of resources to replenish this.
The steering committee might have played a more active development role but – meeting infrequently – it tended to act more like an advisory body. Most attention was paid to developing the groups but this always takes longer than anticipated and requires continuing supportive input from initiators, leaving less time for linking with host agencies and the wider body of professionals and commissioners. Though the final project conference helped redress this deficit, insufficient attention was devoted to encouraging the development of local champions, who would promote the brand and encourage referrals to groups. With such champions, groups have a much better chance of thriving.
At local level, thought should be given to what constitutes a nurturing environment and infrastructure of services in which groups can become embedded and grow. Such an environment features:
• service providers who understand and sympathise with the SMART approach, and in particular which offer services based on the same cognitive-behavioural principles so there is a fit between prior treatment and SMART;
• services ready to provide just the right amount of encouragement and practical support without taking over, and which have sufficient resources and experience of working with volunteers and peer support groups;
• an established partnership of appropriate agencies concerned with substance misuse willing to include the new groups within their ambit;
• recruitment to groups is encouraged by host agencies along with their partners;
• these conditions seem most likely to met through links to specialist alcohol rather than generalist services; they are more aware of the resources needed to develop peer support groups and are in a position to refer people to the groups.
Encouraging system-wide change in service networks to help create a conducive environment was one ambition of the pilot, but little was achieved, mainly because the focus was perhaps justifiably on developing the groups. Champions are commonly seen as the main change agents – people who will promote such groups at levels from ground to strategic. Uncertainty about who made the best champions – graduates of recovery programmes or treatment professionals or both – obstructing this development and needs clarification.
After being relatively ignored in policy circles, in recent years mutual aid has received a multi-pronged policy boost in Britain. The rise of the new "recovery" agenda has brought with it a greater emphasis on sustained and extensive life change including abstinence, and a greater role for the lived experience and contributions of recovering addicts and alcoholics. At the same time as treatment services are being expected to do much more, their resources are no longer increasing and probably diminishing overall. One way policymakers seek to square this circle is to move the stress from retaining patients in treatment to getting them out the other end, if possible sustainably free of dependence. Long-term, 24-hour access, frequent support meetings, offering a new social circle and a new way of life, yet free or low cost to the service – mutual aid groups seem tailor made for this new environment. It comes therefore as no surprise that they feature in recent commissioning guidance from England's National Treatment Agency for Substance Misuse, which sees SMART Recovery groups among others as providing "valuable support and positive social networks for individuals who are addressing their dependency through treatment". The advice to services is that "Details of how clients can access local recovery networks should be made available throughout their treatment journey. Services may wish to consider more active engagement with local mutual aid groups, for example making rooms within the treatment service or prisons available for meetings". The agency now sees (see annual reports for 2009–10 and 2010–11) promoting mutual aid networks as a key way to achieve its objectives. Local service commissioners are being called on to ensure that the treatment system is better integrated with wider supportive services, among which mutual aid organisations are seen as the most prominent.
The featured project has in particular kick-started the development of SMART groups in England. According to the UK organisation's interim director, as of June 2011 it had spawned 25 groups, and agreements with local services and commissioners would soon see SMART active at 40 sites. In the same month the UK organisation's web site also listed 15 meetings in Scotland. Centrally organised growth is possible because the organisation works in partnership with services and commissioners to create groups which are not necessarily peer led, rather than waiting for groups to mushroom 'bottom-up' from the uncoordinated initiatives of local drinkers and drug users. Though the featured project was focused on alcohol, drug services too are fostering the development of mutual aid groups, including SMART groups.
Fostering and supporting SMART groups is one way services can extend the support made available to their clients, and also support more problem substance users than services can manage or attract on their own. A degree of independence from services (or a mixture of independent and non-independent groups) is however desirable if groups are not to be limited to (ex)service users, are not to duplicate the work of service user groups or therapy/aftercare groups, and are to fulfil their potential to offer a recovery route to people who do not want to be associated with formal treatment.
The argument has been made that mutual aid is too valuable a resource to leave to chance. Though findings are far from definitive, studies suggest that group involvement reduces substance use and health care costs, and has additional benefits relating to self-efficacy, social support, depression, anxiety, and coping with stress. Without 'throwing out the baby' by co-opting groups, services can offer practical support and in particular act as a referral route. Advocates recommend validated methods (such as 12-step facilitation counselling or motivational enhancement) to ensure appropriate patients are referred to appropriate groups, and are more likely to act on that referral than after simply being told about their existence. The great advantage of adding SMART or similar groups to the mutual aid menu is to open the door to this type of support to people who would not be attracted to or not do well in 12-step groups – in particular, to open the door and enable a smooth transition from time-limited cognitive-behavioural type treatment to long-term, cognitive-behavioural support from compatible groups. Details below.
Even in an environment like the USA, where 12-step groups are widely known and accepted, a study found that systematic, persistent and practical referral efforts by substance use counsellors can modestly strengthen post-treatment involvement and improve outcomes. One simple and effective tactic is to offer to host mutual aid meetings for your patients at the treatment site, found in the featured study to also help groups avoid succumbing to the practical burden of finding a home. In a US study of patients who had generally not attended 12-step meetings in the past year, going to an intensive day programme with rather than without meetings on site increased during and post-treatment attendance and (partly because of increased participation in groups) post-treatment drug and alcohol abstinence rates.
Research has focused almost exclusively on 12-step approaches, and specifically on 12-step based treatments, rather than autonomous non 12-step approaches like SMART recovery groups. A unique US study compared the two approaches by alternately allocating 112 patients suffering serious mental illness and substance use problems to 12-step or to SMART Recovery groups. These were not autonomous groups, but run by counsellors at two separate intensive day treatment/partial hospitalisation programmes. The results suggested that these two types of groups might differ (but not dramatically) in their impacts. The 12-step intervention was better at quickly curbing self-reported drinking (though urinalysis results did not differ), there was a fleeting extra reduction in urinalysis-confirmed cannabis use, and the 12-step patients saw more of their friends or family. These improvements seemed to have been gained at the cost of a worsening of medical problems, health status, and employment, and more psychiatric admissions, while positive changes in health and employment were associated with the SMART intervention. How satisfied patients were with their lives was not differentially affected by the two types of groups. The implication is that substance use is more radically controlled in the short-term by 12-step's greater emphasis on abstinence, but that the cognitive-behavioural strategies and perhaps too the more empowering ethos of the SMART groups helped patients more with the rest of their lives.
That outcomes were generally similar in the two groups fits with indications that 12-step groups work in much the same way as can be expected of SMART and other mutual aid groups. Recent reviews (1 2) of how Alcoholics Anonymous works have highlighted non-specific mechanisms including self-efficacy, motivation for abstinence and commitment to recovery, coping strategies such as avoiding high-risk situations, the provision of clear goals and a coherently structured route for achieving these, abstinence-oriented norms and role models, involvement in alternative rewarding activities, and social support. Particular importance was placed on "perhaps its most potent influence" – social group dynamics in the AA meeting, the broader fellowship, and social support. In contrast to these generic mechanisms found in other approaches, there was less support for spirituality, adherence to AA beliefs and philosophy, or following recommended AA practices.
Differences in outcomes are probably minor and insignificant compared to the potential benefits of being able to point patients to some kind of support group which suits them and which they might join. What SMART offers is (in ethos and therapeutic approach terms) a potentially seamless transition from cognitive-behaviourally based treatments to a similarly based aftercare option, or a parallel supportive social environment which does not compete with but reinforces the treatment. In the USA, 12-step based services widely enjoy this kind of compatible mutual aid ally, with the result that continuing abstinence in particular (the shared target of both) is bolstered, while those exiting cognitive-behavioural programmes gain less (still some) from participating in 12-step groups (1 2 3). It seems likely that if cognitive-behavioural mutual aid were as widely available as 12-step groups, patients from cognitive-behavioural treatments too would better be able to sustain the behaviour changes targeted by the prior treatment, with resultant health care cost savings.
What type of mutual aid is most suitable is of course not just a function of prior or parallel treatment but of the individuals's preferences. Those alienated by what they see as the religious or spiritual overtones of AA and NA can find a compatible home in SMART recovery groups, without this compatibility at the same time deterring the more spiritual or religious. In contrast, the appeal of 12-step groups may be more limited to participants sufficiently spiritual or religious to accept submission to a higher power. It may also be that people who prefer to see themselves as in control of their drinking will prefer SMART's ethos.
In one US study, the more deeply religious someone was the less (but only slightly and not statistically significantly) they participated in SMART groups, but the more they participated in 12-step groups (a substantial and statistically significant relationship). What made this important was that 'clean and sober' time increased with participation, suggesting it is beneficial to match patients to groups on the spirituality dimension.
In this study any deterrent effect of the SMART ethos on religious members was at most slight, showing that it can appeal across this dimension. That seemed confirmed in another US study comparing the views of recovering alcoholics in AA as opposed to SMART groups. About half the SMART members believed in a higher power, suggesting no incompatibility with SMART's ethos. However, the AA groups were able to attract only a few dissenters from this view, and members were on average much more spiritual or religious in their beliefs. They were also more prone to see their drinking as subject to forces over which they had little control rather than as something whose control lay in their own hands.
Thanks for their comments on this entry in draft to Susanne MacGregor of the London School of Hygiene and Tropical Medicine and Richard Phillips of SMART Recovery UK. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 22 June 2011
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Longo M., Wickes W., Smout M. et al.
Addiction: 2010, 105(1), p. 146–154.
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Australian researchers trialled a new form of what is often seen as a 'controversial' treatment – prescribing (in this case, long-acting) amphetamine to stabilise amphetamine dependent patients. The patients stayed in treatment nearly twice as long and their dependence remitted more than when prescribed a placebo.
Summary For the first time this study tested the impact of a long-acting form of amphetamine Though not always specified, in this and the other studies cited in this entry, the amphetamine prescribed was dexamphetamine, the most active isomer found in illegal amphetamine and the variant of the drug used in medical practice. as medication to help control dependent use of the closely allied stimulant, methamphetamine. Prescribed more usually for the treatment of pathological sleepiness or attention deficit/hyperactivity disorder, effects of the amphetamine tablets prescribed in the study take several hours longer to emerge than normal amphetamine and last three to six hours longer, giving it a 'smoothing' profile similar to methadone for heroin users; non-rapid onset make it less intensely pleasurable, and longer duration suits it to once-daily administration. Doses in the study averaged 80mg per day and were capped at 110mg.
To ensure as far as possible that the medication was the active ingredient in the outcomes of the trial, a randomly allocated 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 was prescribed an identical placebo tablet and patients, staff and researchers gathering the data did not know who had been prescribed which. Also the requirement to attend daily for supervised tablet-taking meant researchers knew how much of the medication had actually been consumed, and all patients were offered the same psychosocial support and treatment contact. The trial started with up to a fortnight during which doses of the active tablets (with a mirror procedure for the placebos) were titrated upwards, followed by an intended 12 weeks on the stabilised dose and then four weeks when it was tapered to zero and the trial treatments ended. For about the first month patients had to go daily to the clinic pharmacy to have their tablet-swallowing supervised by staff; after this supervision was continued but at community pharmacies.
Patients were recruited from the South Australia state addiction treatment service. Among other criteria, to be included in the trial they had to be dependent only on methamphetamine and not on any other drug except tobacco, to have recently used methamphetamine regularly, and to be free of serious physical or mental illness. Of 313 screened initially over the phone, 49 started the trial, of whom 23 were allocated to amphetamine and 26 to placebo. Nearly 9 in 10 were injecting their methamphetamine, usage averaged five days a week, patients averaged 32 years of age and had been using for over ten years, half were unemployed, and half too had previously been treated for their use of the drug. Patients were assessed by researchers at the start of the trial, during the treatment period, and two months after this period ended, a follow-up giving some indication of whether impacts might persist once patients were no longer taking medication. Though many patients dropped out of treatment, at the final follow-up researchers managed to re-assess nearly 8 in 10 methamphetamine patients and nearly two thirds of the placebo patients. Patients were included in the outcome analyses regardless of whether they were able to be reassessed.
The most clear-cut and statistically significant result was greater retention among patients prescribed the active medication. Two thirds completed the trial compared to just under third prescribed placebo, they stayed in treatment for an average 86 days (out of a possible 104) compared to just 49, and placebo patients dropped out earlier.
The other statistically significant differences related to signs of dependence rather than use levels. In both groups, patients' responses to the Leeds Dependence Questionnaire revealed an easing of their dependence from the start to the end of treatment. Two months later this easing had been sustained among those prescribed methamphetamine while dependence rose (but not to pre-treatment levels) among those prescribed placebos. The gap this created at the final follow-up was statistically significant. Withdrawal symptoms too were suppressed more effectively by methamphetamine than placebo throughout the treatment period, a greater reduction which was statistically significant during the initial two weeks of treatment.
During treatment estimated consumption of methamphetamine (an amalgam of times used and amount used on each occasion over the past month) fell dramatically in both groups, a drop largely sustained at the final follow-up. However, these reductions were only slightly and non-significantly steeper among the methamphetamine patients. These results based on the patients' own accounts were broadly confirmed by testing hair samples.
Of the 23 patients prescribed amphetamine, one experienced a serious side effect – high blood pressure requiring a dose reduction. On average systolic blood pressures actually fell during amphetamine prescribing, while other measures of circulatory health were stable. No serious mental health problems were recorded, and in particular there were no reports of psychotic symptoms, though some patients did experience mild irritability, mood swings and headaches. There was an appreciable weight loss among the prescribed patients not seen in the controls.
The primary objectives of this study were to engage users in treatment and reduce methamphetamine use and dependence. The results showed that a maintenance pharmacotherapy programme of daily sustained-release amphetamine dispensing under pharmacist supervision is both feasible and safe and improves engagement with treatment as assessed by retention. Also dependence was moderated more by methamphetamine than placebo. Together with the general decreases in methamphetamine use, dependence and withdrawal symptom severity, these outcomes provide preliminary evidence that sustained-release amphetamine may be an efficacious treatment for methamphetamine dependence.
The fact that (except for retention) methamphetamine's advantages over placebo were minor and/or not statistically significant may have been due to the relatively intensive support both groups were offered including psychotherapy, medical and research appointments, and daily monitoring by pharmacy staff. Patients said this structure greatly helped reduce their methamphetamine use. However, 43% of the sample did not attend any psychotherapy sessions, suggesting that counselling alone may not be enough to engage a high proportion of methamphetamine injectors in treatment.
Methamphetamine is a potent and for predisposed individuals, highly addictive variant of the stimulant amphetamine, known in its smokable form as 'ice' or 'crystal' among other names. While blood levels of the active metabolites of cocaine fall to half their peak level in 90 minutes, methamphetamine's 'half-life' is 10 hours or more. Users tend to take the drug in 'binges' or 'runs' over one to three days, followed by abstinence, then repeated use. Because of its lengthy half-life, this pattern results in increasing concentrations of the drug which can be toxic, particularly because the body does not 'get used' to its effects as readily as with other drugs. When experts met to rank drugs in terms of their harms in the British context, they placed methamphetamine fourth after alcohol, heroin and crack cocaine, though in terms of harms to the actual user it came third, closely behind heroin and crack. On this sub-scale, amphetamine and cocaine came next after alcohol.
In England and Wales it has been estimated that 319,000 adults used amphetamines in 2009/10 and of whom 110,000 used in the past month, and in Scotland, about The corresponding proportions were 0.9% and 0.3% in an over 16 population of about 4,227,300. 3805 and 1268. Across the UK in 2009/10 or 2010, at least 12,128 people using amphetamines (including methamphetamine) were in or referred for treatment for problems with illegal drugs, just over 5% of the total of 226,302. These totals are an amalgam of differently defined statistics in the different nations. Details in background notes. How many of these patients were prescribed amphetamine is not recorded, but from the featured study and the studies summarised below it would seem a minority would both be suitable and benefit from this prescribing more than they would have done from psychosocial therapy alone.
But without prescribing on offer, many fewer patients see treatment as 'for them', so fewer put themselves in a position to benefit from psychosocial therapy. They also miss an opportunity for harm reduction advice and professional monitoring of physical and mental health, both important for amphetamine users. Prescribing also helps retain patients long enough and stabilise them sufficiently for them to gain the most from these other inputs, and has important direct harm reduction benefits associated with reduced injecting.
Controlled trials have tested stabilisation rather than maintenance programmes. Typically amphetamine prescribing programmes are likely to be shorter than those for opiate dependent patients, partly because stimulants can more easily be withdrawn; a typical untreated pattern of stimulant use includes periods when users are able (or feel they have to) stop using for a while. However, British services have prescribed long-term and observed beneficial results in terms of client stability and reduction in injecting. Concerns over cardiovascular risks from heavy stimulant use and the risk of precipitating a psychotic episode cannot be dismissed, but from the studies to date these risks are largely confined to patients who top up their prescribed doses with large amounts of illegal supplies, the risks are probably less than in untreated stimulant dependence, they can be minimised by careful monitoring, and patients' health is improved in other ways by a stabilised lifestyle, reduced injecting, and the regular medical contact associated with attending for prescribing and dispensing.
These impressions from clinical experience and studies which have observed the progress of patients have yet to be confirmed in rigorous trials which have as far as possible equalised everything (including randomising patients and the taking of 'dummy' tablets) except the prescribed amphetamine. In the three randomised trials to date including the featured study, substantial and statistically significant benefits were generally not found, but all three were as justifiably seen as stabilisation-withdrawal trials as maintenance, and probably none was representative of the usual patients and usual practice observed by less rigorous studies.
As much as to amphetamine prescribing, the dramatic improvements seen in the featured trial seem a testament to the motivation of this highly selected set of patients and to other elements of the treatment package. Prescribing did substantially extend retention, but was more the 'icing on the cake' than the main influence on continued methamphetamine use, dependence and withdrawal symptoms. Unusually for a maintenance programme, improvements were largely sustained after patients left treatment, perhaps aided by their continuing care at the service from which they had been recruited.
Where amphetamine did have a statistically and possibly clinically significant advantage was in the severity of persisting dependence two months after treatment ended. Such an advantage during treatment would have been unsurprising, since reliance on illicit supplies would have been attenuated by the prescription. That it persisted suggests the prescribing may have had an indirect effect via longer retention in treatment and the longer period when patients' lives were regulated by daily attendance, leading to a more lasting and extensive normalisation of their relationships with methamphetamine. This finding emerged from a comparison which was not planned in advance, so requires confirmation by other studies designed from the start to test this possibility.
The absence of psychotic symptoms is important given concerns over temporary psychotic states precipitated by high doses of amphetamine (so-called 'amphetamine psychosis'). In other studies, these episodes have occurred, but generally only among patients also heavily using illegal stimulants. Presumably such episodes were absent in the featured study because the methamphetamine patients did not continue to use their customary illegal doses of methamphetamine 'on top' of their prescribed amphetamine. Weight loss over this short period was quite steep among the prescribed patients, but this is not typical of similar studies or of experience in Britain.
One major benefit not reflected in the study's measures must have been that the number of injections was substantially reduced as patients cut down on their methamphetamine use, presumably greatly reducing the risks of injection-related damage and infectious diseases.
Better retention and the other more modest differences between amphetamine and placebo groups seem plausible effects of maintenance prescribing. But despite a strong randomised and blinded methodology, there are reasons to believe that these might not have been entirely due to the medication, and also reasons to query the applicability of the findings beyond the presumably highly motivated caseload attracted by the study. For more background notes.
Britain's tradition of amphetamine prescribing was deprecated in 2007 by national clinical guidelines. Partly due to limitations of the available research, these concluded that, "Even though there may be individual patients for whom existing treatment should be continued for the time being, substitute stimulant prescribing does not have demonstrated effectiveness and, accordingly, should not ordinarily be provided".
Guidelines from the British Association for Psychopharmacology were less dismissive of the message from studies to date, which despite their inadequacies consistently "suggest benefits in terms of reduction in [amphetamine] use and in injecting". Both guidelines agree that whatever the medication, it takes second place to psychosocial interventions, seen as the mainstay of treatment strategies for stimulant using patients.
In comparison with other countries, Britain has a rich history of amphetamine prescribing and of studies of this practice. Studies are summarised below – details in background notes.
The first British study Mitcheson, M., Edwards, G., Hawks, D. et al. "Treatment of methylamphetamine users during the 1986 epidemic." In: Edwards G., Russell M.A.H., Macafferty M. eds. Drugs and drug dependence. London: Saxon House Publishers, 1976, p. 155–162. concerned (mainly) injectable methamphetamine prescribed during the late 1960s in London to 23 young patients who had typically used amphetamine for less than a year. Only three stayed in treatment beyond three months. The authors' verdict that amphetamine substitution was a therapeutic failure remained influential for 20 years until the advent of AIDS and acceptance of harm reduction as a public health strategy. Local UK reports from later years involving older addicts and oral medication often dispensed under supervised consumption were more positive, and also generally reassuring on the issue (often described as "controversial") of whether such prescribing risks psychotic episodes – as one reviewer put it, "the most serious potential adverse consequence of dexamphetamine replacement therapy".
None of the studies could stand up to methodological scrutiny, but together they painted a consistent and persuasive picture of in-treatment progress, though not of whether this was sustained after treatment. Generally they reported substantial benefits in reduced injecting and illegal drug use, crime and risk of infection, though in some studies absolute abstinence and totally crime-free lives were rare. Prescribing attracted more problem amphetamine users in to treatment, so extended these benefits to a greater proportion of the potential caseload. Carefully controlled prescribing did not in itself cause psychotic episodes, though these did happen in a few patients who also took large doses of illegal stimulants, especially when they had a history of such episodes. Psychotic episodes may have been less frequent than if the patients were not in treatment and will also have been more readily identified by clinicians and treated.
In 2004 these conclusions were questioned by publication of the only UK trial to rigorously test amphetamine prescribing by randomly allocating amphetamine-dependent patients to this plus a psychosocial treatment package, or to the same package, but without prescribing. Only such a study can securely attribute any improvements to the medication, as opposed to differences between patients or other elements of treatment. It found no substantial or statistically significant benefit associated with prescribing; with or without the tablets, both groups reduced their illegal amphetamine use and their rates of injecting to roughly the same degrees. Similar conclusions emerged from the Australian randomised trial ( below), but neither was a test of what is usually considered 'maintenance' as opposed to a short, fixed period of stabilisation followed by withdrawal.
The obvious explanation for the UK results is that previously reported benefits were methodological artefacts which disappeared once the scales were more adequately evened up in a randomised trial. However, for several reasons the trial was not a definitive verdict on the (non-)value of amphetamine maintenance. Among these are that the focal and comparison treatments were not typical of normal practice, and the probability that the patients (especially the barely more than half left in the study at the final two assessments) were highly selected and not representative of potential patients.
For a slightly extended version of this section background notes. A US reviewer has usefully summarised the concerns about prescribing amphetamine to amphetamine-dependent patients. Prime among them are cardiovascular problems and psychotic episodes. As long as good psychosocial therapy was available and there was appropriate monitoring, he judged these and other risks "likely manageable" and less than the risks run by untreated stimulant users.
A team including the researcher who led the trial described below have advised that substitution therapy is most appropriate for severely dependent, daily amphetamine injectors. The most enduring benefits are likely to be achieved in combination with psychosocial intervention; prescribing attracts, stabilises and retains, while the therapy helps extend and embed lifestyle change preparatory to discharge, which seems to occur more often and earlier than in opiate substitute programmes. Screening and monitoring for psychotic symptoms are essential, and some clinicians do not consider the treatment suitable for patients with a history of schizophrenia or bipolar affective disorder. Partly to avoid diversion on to the illicit market, but also to determine whether maintenance is worth continuing with, supervised consumption, urinalysis and regular medical monitoring for side effects are advised for at least the first three-month stabilisation period.
Sydney in Australia was the location of the first trial to rigorously test dexamphetamine prescribing for amphetamine dependence by randomly allocating patients to this treatment (daily supervised consumption of oral medication for 12 weeks including a final two weeks withdrawal) plus counselling, or to counselling alone. However, at 10 weeks, this trial cannot be considered a test of what most people would consider a maintenance programme as opposed to stabilisation prior to withdrawal. There were no statistically significant differences in outcomes, but the differences that there were (in use of illegal amphetamine, spending on these drugs, injecting, and infection risk behaviour) favoured the prescribed group. Counselling attendance and retention records seemed indicative (as other studies have typically found) of the poor pulling power of counselling alone, and the potential for substitute prescribing to work synergistically with counselling by improving attendance.
Thanks for their comments on this entry in draft to Richard Pates of the Cardiff School of Health Sciences. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 16 June 2011
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Zlotnick C., Johnson J., Najavits L.M.
Behavior Therapy: 2009, 40, p. 325–336.
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Seeking Safety is a prominent therapy for the common combination of substance dependence and post-traumatic stress disorder, yet in this study of imprisoned women in the USA it did not significantly augment outcomes from the prison's own substance use treatment. Asking 'Why not?' generates interesting explanations.
Summary This US study tested the applicability and impacts among imprisoned women of the Seeking Safety cognitive-behavioural
The key principles are:
• safety as the overarching goal (helping clients attain safety in their relationships, thinking, behaviour, and emotions);
• integrated treatment (working on both PTSD and substance abuse at the same time);
• a focus on ideals to counteract the loss of ideals in both PTSD and substance abuse;
• four content areas: cognitive, behavioural, interpersonal, case management;
• attention to clinician processes (helping clinicians work on countertransference, self-care, and other issues).
The 25 topics covered in the programme are: Introduction/Case Management; Safety; PTSD: Taking Back Your Power; When Substances Control You; Honesty; Asking for Help; Setting Boundaries in Relationships; Getting Others to Support Your Recovery; Healthy Relationships; Community Resources; Compassion; Creating Meaning; Discovery; Integrating the Split Self; Recovery Thinking; Taking Good Care of Yourself; Commitment; Respecting Your Time; Coping with Triggers; Self-Nurturing; Red and Green Flags; Detaching from Emotional Pain (Grounding); Life Choices; and Termination. intended for people suffering both substance dependence and post-traumatic stress disorder – a severe anxiety disorder consequent on a highly traumatising or distressing event such as sexual abuse. Seeking Safety is a present-focused therapy which in an integrated manner aims to help these people attain safety both from the effects of trauma and from substance abuse, the latter through abstinence.
The study was open to women due to be released within 12 to 16 weeks who met diagnostic criteria for substance dependence (based on the month before they were imprisoned) and for post-traumatic stress disorder. They were recruited from a residential substance use treatment programme in a minimum security wing of a women's prison. Among the 49 who joined the trial, a history of (often childhood) sexual and physical abuse was the norm, as was prior imprisonment and alcohol dependence. They were randomly allocated to just the usual prison residential programme or additionally to Seeking Safety. In this implementation, Seeking Safety was conducted in 90-minute small group sessions, typically three times a week for six to eight weeks, and after leaving prison weekly individual 'booster' sessions were on offer for 12 weeks. It supplemented the prison's own residential treatment – an intensive group psychoeducational programme, entry to which was voluntary, though to stay in the programme women had to attend all components. These spanned 30 hours a week typically over three to six months and adopted a 12-step approach. While content was extensive, Including case management, drug counselling, and psychoeducational groups on: women's health; domestic violence; managing emotions; relapse prevention; career exploration; anger management; and parenting. no sessions specifically addressed trauma and there was no post-release continuity option.
The Seeking Safety sessions in prison were welcomed by the women. Of the 103 asked to join the study, just nine turned it down, all allocated to the programme began it, they voluntarily attended nearly 16 sessions, and satisfaction ratings were high. But largely it was thought due to a disordered post-prison life and competing priorities, on average they attended just three of the 12 post-release sessions.
The main issues were whether as well as being welcomed, this extra intervention contributed to improvements in substance use, legal problems and psychological health. The baseline for substance use was the month before being imprisoned, and for other measures, the month before the study intake interview. The women were then re-assessed shortly before release and three and six months later. These interviews revealed no statistically significant differences between the considerable gains made by the women whether or not they had been offered Seeking Safety sessions. The consistent pattern was that after both options, women improved significantly from intake to each follow-up point on each domain measured. However, exploratory extra analyses showed that after leaving prison Seeking Safety participants continued to improve their psychological health (both in general and trauma-related), while those not offered these sessions lost some of the gains made in prison. The gaps this opened up between the two groups were not wide and consistent enough to be statistically significant, but did suggest that improvements were better sustained after the extra Seeking Safety inputs.
Results from the featured study contrast to other studies comparing Seeking Safety to usual treatments, which consistently found significant and numerous relative benefits from the programme as measured at the end of treatment. However, comparing these trials is complicated by differences in what counted as 'usual treatment'. In the featured study, usual treatment had the added advantage of attendance being mandatory and the case management component of Seeking Safety was not implemented. Also, women who experienced the programme and the clinicians trained in it may have created spill over benefits for usual treatment participants with whom respectively they were housed and who they also treated. Nevertheless, particularly in relation to psychological health, there were signs of more persistent and even cumulating benefits from Seeking Safety which were not apparent after usual prison treatment. Whether these were due to Seeking Safety's distinctive features or to the offer of aftercare is unclear. It was also encouraging that among women with such intense needs, satisfaction with Seeking Safety was high and that greater attendance was associated with greater improvement in trauma-related and drug use symptoms.
The generally equally encouraging results from the prison's usual treatment and Seeking Safety must be seen in the context of the extended, intensive, and potentially powerful intervention to which Seeking Safety was added as a relatively minor and – since the core case management role was conceded to the prison programme – perhaps peripheral add-on. It also seems possible that the influence of this add-on was overwhelmed not just by the prison programme, but by the motivation of women prepared to spend months in this programme, and by a radical change of environment consequent upon the women's release from prison. The appreciation shown by of the women who attended Seeking Safety sessions at least raises the possibility that they got something positive out of these which was not adequately or perhaps at all measured by the study. And the hint of more sustained and cumulative improvement gains greater credibility because it chimes with what has been found in other studies of cognitive-behavioural therapies for substance use. These current findings do however reinforce doubts over whether Seeking Safety's focus on post-trauma distress consistently adds much to other well specified and equally extensive treatments without such a focus.
Despite its prior record in comparison with usual treatments, in one study Seeking Safety did not outshine a well structured alternative treatment focused on substance use, even in respect of the trauma-related and psychological health dimensions which the programme was designed to address. In general, supplementing substance use treatment with treatment for anxiety (including that generated by past trauma) has produced patchy results, sometimes improving substance use outcomes, sometimes the reverse or not at all, sometimes creating greater mental health gains, and sometimes not. It seems that in many cases (but certainly not all), remission of the aggravating influence of substance over-use, and perhaps too the non-specific strands of substance use treatment such as being cared for, listened to, and paid attention, are enough to mitigate depression and anxiety. For these findings and for an extended discussion of related UK policy and practice related to such patients see this Findings analysis.
Adding to the doubts about its specific effectiveness, in at least one study of trauma-affected female substance use treatment patients, Seeking Safety proved equivalent in effectiveness to another add-on (women's health education groups) not designed to affect psychological health or substance use at all, but to act as a 'placebo' offering extra attention and expectation of benefit, but no structured treatment.
Seeking Safety is one of several programmes intended for the same constellation of trauma-related and substance use disorders; for more see this US clinical guide and this review specifically addressing civilian post-traumatic stress and substance use disorders. There is some evidence that well specified and well integrated approaches of these kinds to trauma and substance use are preferable to treatments described as 'usual' in the relevant studies, but as yet is unclear which if any is the most effective.
One possibly significant advantage Seeking Safety has over some alternatives is its focus on the present; it does not require the client to recount, relive or be exposed to analogues of their past traumatic experiences. In this respect it seems unlikely to trigger greater distress. In the study referred to above which found Seeking Safety did not improve outcomes relative to women's health education groups, it was also the case that it generated no more (in terms of numbers of women and severity) adverse consequences like symptom aggravation.
The featured study provides an object lesson in the need for adequate 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 when assessing the effectiveness of interventions. An earlier study from the same researchers in what seems to have been the same prison and testing the same in-prison treatments produced 'promising' results which (with other work) suggested that "a treatment targeting [post-traumatic stress disorder] and substance abuse may be helpful for women with notable clinical severity and life problems". But this study had no comparison group of women who had not been allocated to Seeking Safety. When in the featured study this trial was replicated with a comparison group, it became clear that Seeking Safety's targeting of post-traumatic stress disorder was for these women of doubtful extra benefit.
Last revised 17 June 2011
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