EFFECTIVENESS BANK BULLETIN 23 December 2009
EFFECTIVENESS BANK BULLETIN 23 December 2009The 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.
If you have not found what you want you could:
● Try a subject or free text search instead. Searches include bulletin entries and all other documents on this site.
● Try browsing other bulletins or back issues of the magazine.
● Try searching the libraries of
Alcohol Concern or
DrugScope (opens new window).
● Documents are regularly added. Use the e-mail update service to monitor additions.
● Return to the home page.
Click HERE and enter e-mail address to receive alerts of new bulletins
English national evaluation fails to support drug education programme ...
Primary school behaviour and parenting programme curbs teenage substance use ...
Holistic family therapy helps younger teens and their families get back on track ...
Long-acting naltrexone holds heroin at bay more effectively than pills ...
Blueprint drugs education: the response of pupils and parents to the programme.Blueprint Evaluation Team.
Blueprint Evaluation Team, 2009.
In the British context, it was expected to decide whether an evidence-based, well structured and well resourced drug education programme could contribute to reducing youth substance use, yet the multi-million pound Blueprint study never got near fulfilling its promise.
Abstract The Blueprint drug education programme was piloted in 23 schools in the North-West and East Midlands regions of England during the spring terms of 2004 and 2005. Funded by the Home Office, at its core were 15 lessons delivered across the first two years of secondary schooling when children were generally aged 11 and 12. Teachers received six days' training and were supported by school drug advisers and other local professionals. Through interactive teaching methods, the lessons aimed to equip pupils with the knowledge and experiences to make informed choices about drug use. This work was reinforced by information for the pupils' parents intended to promote effective communication about drugs with their children. Parents were sent fact sheets and communication advice and invited to parenting skills workshops. The wider community was involved through a media relations programme raising understanding and awareness of Blueprint, through funding enabling local authorities to work with other agencies to reduce underage sales of alcohol, tobacco and solvents, and through an attempt to develop shared principles for drug education across local prevention practitioners.
Originally it was intended to recruit a comparison sample of schools against which the impact of Blueprint could be assessed. However, it was calculated that this would require at least 50 schools, a number beyond the scope of the evaluation. So instead an evaluation led by the Open University and the Institute for Social Marketing (ISM) at the University of Stirling focused on how well the programme was implemented in the 23 Blueprint schools and the reactions of target groups such as pupils and parents. Another six local schools not assigned to the programme provided some context, but did not act as a comparison group. An attempt was made to follow up about 3000 pupils before they received the lessons until the year after they had finished, when pupils were in year 10 and aged 15–16. Surveys assessed pupils' drug use, attitudes, beliefs and reactions to the lessons. Their parents or carers were also surveyed to gauge awareness and opinions of Blueprint.
The evaluation found that pupils enjoyed the lessons, in particular active teaching methods such as role-play, had good recall of drug knowledge, and gained experience of how to deal with drug offers. The vast majority said the lessons were an important source of information about drugs. Parents approved of their children being taught about drugs, were engaged by the Blueprint materials, and said the programme had increased their knowledge and helped them communicate with their children about drugs. As expected, as pupils grew older, smoking, drinking and drug use all became more common. Drugtaking was associated with previous use, truancy and exclusion. Many pupils overestimated Important because correcting such overestimations was a core prevention tactic. This finding shows that there was scope for this tactic to work. how many of their peers smoked and drank, but fewer overestimated drug use. Pupils with relatively high estimates of peer substance use tended to be girls, older, and to have been truant and/or excluded from school. Pupils considered drinking more acceptable than smoking or drug use.
But pupils from the six schools which did not implement Blueprint were also positive about their drug education, nearly half saw these lessons as an important source of information, they demonstrated high recall of drugs knowledge and, again, their parents approved of their children receiving drug education at school.
The evaluators concluded that while most Blueprint components were successfully implemented, engaging parents in workshops proved difficult, suggesting that more effective methods are needed to make the most of the important influence parents have on their children. Other suggestions were that future programmes might focus more on the pupil and parent components and on coordinating these, and less on community, health policy and media components. This type of initiative could benefit from being implemented earlier. Most children who take drugs start to experiment from age 11; introducing drug education in primary school could pre-empt this stage in their development.
The great store set in the featured study's potential to "trigger a fundamental assessment of the place of drug education" in UK drug policy has led to equally great disappointment that it was unable to fulfil this promise. This final report argued that methodological limitations meant no conclusions on Blueprint's preventive impacts could be drawn from the study. Though undoubtedly true, the study can still be examined for signs that the programme might have had an impact; details below. That such signs were lacking reinforces the view that drug education in secondary schools makes little contribution to the prevention of problems related to drinking and illegal drug use
(NOTE),
The cited review supports the modest effectiveness of school programmes in preventing cannabis use. However, of the four studies on which this verdict was based, one was a primary school programme not focused on substance use at all but on classroom management, education and parenting, another was conducted only among pupils for some reason excluded from mainstream education, and the programme studied in a third has since failed in a more real-world study conducted by researchers not associated with its development. The remaining study was conducted in secondary schools but the impact on cannabis use was not statistically significant.
though the evidence in respect of smoking is stronger.
Given that just 30 One later withdrew from the study. schools were available, the study decided against splitting them evenly, arguing that the samples would be too small This conclusion has been contested and it is the case that several other studies have produced what are widely accepted as useful results with samples no bigger than those available to the Blueprint study. The report (http://www.mrc-bsu.cam.ac.uk/Publications/PDFs/SampleSizeCalculations2002.pdf) cited as indicating that at least 50 schools would be needed to detect any impacts of the Blueprint programme did so largely on the basis that the impacts would be very small. to detect the programme's impacts even if in reality these existed. Instead it opted to test whether the programme could be implemented in a large set of schools, leaving just six schools which did not implement Blueprint. Though not randomly selected or formally matched, these six seem sufficiently like the 23 Blueprint schools to be used to discern any signs that Blueprint might have had an impact which would have been confirmed by a larger study. Indeed, this seems to have been the initial expectation.
In each of the three Derbyshire, Cheshire and Lancashire. study areas the two non-Blueprint schools were selected to be on more or less opposite ends of a scale of socioeconomic deprivation. The result was a sample very similar on a range of social, economic and other indicators to the children in the Blueprint schools. In 2005 a Blueprint leaflet Blueprint in practice. UK government, 2005. described the six schools as "control" schools which would be used to "assess and examine the impact that the Blueprint Programme has had on ... prevalence of drug use among the Year 7 cohort until they reach Year 10". Describing the study's design shortly after the lessons had been completed and before the results were known, the Department of Health's lead on the project still saw the six schools as "comparison schools", and while describing the trial as exploratory rather than definitive, was still hoping it would assess "impacts on ... prevalence and harm" and "identify any potential for Blueprint to impact on behaviour change". Given the similarity of the six schools to the Blueprint schools in the same areas, this last ambition does not seem unrealistic.
The study provided at least five measures of recent or frequent substance use for which the numbers are large enough to look for signs of an impact on more serious forms of substance use: smoking in the past week; similarly with drinking; drinking at least once a week; using any drugs in the past month; using cannabis in the past year. By the end of the study, on none of these measures did fewer Blueprint pupils use than non-Blueprint pupils chart. Since before the lessons the pupils started at very similar use levels, this also means there was no sign that Blueprint retarded growth in substance use any more effectively than the usual lessons in the non-Blueprint schools.
Many more Blueprint than non-Blueprint pupils felt their drug education lessons were an important source of information, but this did not mean that as a result they were better informed. Even before the lessons, slightly more (2%) pupils in Blueprint schools answered five out of six questions correctly, a gap which remained virtually unmoved by the lessons (3% at years 9 and 10). For example, by year 10, 58% of Blueprint pupils remained unsure whether, or actually believed, that cannabis is more dangerous than heroin, compared to 53% in the non-Blueprint schools. Such a fundamental knowledge gap persisting towards the end of compulsory schooling seems to cast doubt on the educational as well as the preventive performance of the Blueprint programme.
Encouraging conclusions about the ability of schools to implement programmes like Blueprint must be tempered by the fact that the 23 schools were selected for their ability and willingness to take on this work. Only schools relatively well advanced and well organised They had to have a named health or drug education coordinator and an established drug policy, and to be engaged in the National Healthy School Standard programme, a long-term initiative promoting a whole-school approach to health and well being. in their health and drug education work were invited to join the study, yet despite financial inducements, of the 122 invited, just 45 applied. It cannot be assumed that the majority which did not apply would have been as well placed to deliver the lessons, let alone those which did not qualify to be invited to join the study.
Of the possible reasons why Blueprint appears to have had disappointing impacts, the most likely is that no matter how well structured, school-based drug education generally has at best minor prevention impacts. Among the other possibilities are that Blueprint's lessons largely displaced lessons timetabled for personal, social and health education, which may themselves (as perhaps in the six non-Blueprint schools) have been an effective intervention. Also Blueprint relied on so-called 'normative education' comparing survey data on actual adolescent substance use levels with what are usually overestimates made by pupils. However, some teachers did not understand or adequately implement this core component, and even when they did, more often than not, In most of the observed lessons at least some pupils questioned the validity of the answers and, in some cases, these doubts were raised by the majority of the class. some pupils simply did not believe the survey data, particularly in respect of the ubiquitously 'normal' activity of drinking. Also the lessons were seen as overly prescriptive by some teachers; there may have been inadequate tailoring to the varying substance use knowledge, attitudes and use patterns of pupils in different classes, and too little scope for responding to how the pupils' themselves responded to the lessons.
Mixed and generally inconclusive findings of a prevention impact from school programmes targeting substance use do not negate the possibility that general attempts to create schools conducive to healthy development will affect substance use along with other behaviours, nor do they relieve schools of the obligation to educate their pupils on this important aspect of our society.
Thanks for their comments on this entry in draft to Martine Stead of the University of Stirling in Scotland. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 11 December 2009 Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Education's uncertain saviour KEY STUDY 2000
It's magic: prevent substance use problems without mentioning drugs HOT TOPIC 2010
Drug prevention best done by school's own teachers not outside specialists NUGGETTE 2005
Family programme improves on school lessons NUGGET 2003
Doing it together strengthens families and helps prevent substance use KEY STUDY 2004
Communities that Care aims for science-based community action NUGGETTE 2005
Growth in youth drinking curbed by correcting 'normative' beliefs NUGGET 2002
Prevention is a two-way process KEY STUDY 2001
Evaluating mediators of the impact of the Linking the Interests of Families and Teachers (LIFT) multimodal preventive intervention on substance use initiation.DeGarmo D.S., Eddy J.M., Reid J.B. et al. Request reprint
Prevention Science: 2009, 10(3), p. 208–220.
Again an early schools programme which does not mention substance use at all but focuses on overall child development has later impacts on substance use (plus other benefits) as great as targeted drug education is typically able to produce.
Abstract As described in an earlier paper, the primary school LIFT intervention does not directly address substance use, but instead targets child and parent behaviours thought most relevant to the development of teenage delinquency and violence, including children's opposition, defiance, and lack of social skills, and parental disciplining and monitoring.
Interventions are tailored to each school year spanning ages six to 11, but follow a common model. For an hour twice a week for 10 weeks, LIFT instructors join classroom teachers to promote good behaviour and relationship and group work skills through demonstration and role-play. At playtime this learning is reinforced through a version of the Good Behaviour Game. At the start of the programme children in each class will have been divided into small groups. Children who during play behave well towards their peers are praised and their behaviour recognised by an armband. Collectively these can cumulate in to a special privilege reward for the class as a whole. Children observed to behave badly lose points for their small group from a 'good faith' total renewed at each playtime. Groups which retain a certain number of points are recognised by each member receiving a sticker. Retained points can cumulate to the level where each group member can select a small prize.
During the same 10-week period, LIFT parent instructors meet groups of 10 to 15 families once a week for six weeks. Lecture, discussion, role plays and videotaped scenarios are used to convey parenting issues and skills to be practised at home, and the results of last week's home practice are reviewed. The focus is on creating situations where children are likely to interact well with their peers and on fostering cooperative rather than competitive play by not singling 'winners' and, by implication, 'losers'. Parents unable to attend To encourage attendance, free childcare is provided and a prize draw is held at the end of each session. are offered sessions at home or sent written materials. In the featured study parental participation was unusually high; thought only 28% attended all the meetings, any given meeting was attended by on average 6 in 10 families and just 5% refused to participate in any form. Extra sessions are arranged as needed for specific problems affecting a family. Additionally parents are involved via weekly LIFT newsletters and a dedicated phone/answering machine in each classroom which carries messages from teachers about class activities and homework assignments, and on which parents can leave messages for the teacher. LIFT parent instructors also call each family weekly to check on progress on home exercises and to address questions or concerns.
The programme was developed in a medium-sized US town after a year of piloting and feedback from parents and teachers. Then it was evaluated in the same town, in neighbourhoods in the top half for the proportion of households whose children had been arrested for juvenile crime. These also tended to be relatively poor and ethnically mixed areas. In each of three successive school years in the early '90s, four primary schools in these areas were randomly selected for the study. Within these, two were randomly allocated to LIFT and two to carry on as usual (the comparison schools). Schools were further randomly allocated to involve either their first (ages 6–7) or fifth grade (ages 10–11) classes in the study. Across the three years, the result was three LIFT and three comparison schools which tested LIFT as a first-grade intervention, and another three pairs which tested it as a fifth-grade intervention. Among the younger children, trends in substance would not yet have been sufficiently developed, so the featured report concerns only the six fifth-grade schools, involving 351 children in 17 classrooms. These pupils and their families were surveyed annually through secondary school to their twelfth grade or equivalent, when typically pupils would been aged 17 or 18.
Outcomes were based on pupils' answers about how often they had used substances the past six months, so represented more or less current use levels. Initiation of smoking, drinking and (but not to a statistically significant degree) illicit drug use were delayed by the intervention, amounting to 7–10% fewer children trying these substances. However, the greatest impacts were on how often substances were used. Over the years after the intervention ended, the average frequency of use of all three types of substance was lower in LIFT than comparison children, most noticeably in respect of drinking. Though overall the intervention did not retard the year-by-year growth in average frequency of use, it did do so for the girls in the sample in respect of smoking and illicit drug use, though not drinking.
Further analyses probed what might have led to these effects. Smoking uptake, frequency and growth were retarded seemingly partly because the intervention improved These interactions were directly observed before and after the intervention period and the change measured. Parents and children were asked to choose topics from a checklist of common parent-child conflicts, and were asked to attempt to resolve the 'hottest' issues. how the family resolved parent-child conflicts, and partly because it affected the aggression As directly assessed during school play periods shortly after the intervention ended. shown by the child to their peers. Growth in drinking and illicit drug use were also influenced via family conflict resolution improvements and child aggression respectively.
The authors cautioned that effect sizes A standard way of expressing the magnitude of a difference (eg, between outcomes in control and experimental groups) applicable to most quantitative data. Enables different measures taken in different studies to be compared or (in meta-analyses) combined. Based on expressing the difference in the average outcomes between control and experimental groups as a proportion of the variability in the outcome across both groups. the most common statistic used to quantify this difference is called Cohen's d. Conventionally this is considered to indicate a small effect when no greater than 0.2, a medium effect when around 0.5, and a large effect when at least 0.8. were small as was the sample, the study was limited to one type of neighbourhood in one town, and the probe for how the intervention worked was limited by the available survey and observation measures. Despite these limitations, they argued that the study showed that a relatively low-cost intervention lasting only a few months during late primary school can lead to significant effects on childhood aggression and family functioning and, partly as a result, also curb the growth of substance use through to the late teenage years.
The study exemplifies a stream of substance use prevention which instead of tackling the issue 'head-on' through later years' education, addresses it early through generic socialisation measures and/or fostering attachment to school, and which also sometimes reach beyond the school to parenting and the family environment. The development of 'risk' and 'protective' factors in the child's life is diverted before manifest in substance use and other adolescent problems. Typically this is done not through authoritarian discipline but by parental and teaching approaches which both model and foster involvement and cooperation. The immediate target is not the individual child, but the overall school/class environment which shapes the behaviour of all the children. The study joins a small set suggesting that such approaches impact on later substance use at least as much and as (in)consistently as school-based interventions actually aimed at substance use. Patchy impacts, with many not statistically significant, are not unusual in school substance use prevention programmes, and have also been observed of the kind of programme tested in the featured study.
This itself had patchy though promising outcomes, most consistently on the average frequency of use over the years after the intervention. Though parenting was the major target for LIFT, when initiated in early primary school the Good Behaviour Game has itself been shown to have substantial impacts on early adult problem substance use. The featured study initiated it several years later and the follow-up was to late teenage years only, possibly accounting for smaller impacts. Though the research programme's inputs were time-limited, their repercussions may have persisted through the learning of the teachers who partnered LIFT's instructors, through parenting improvements, and through persisting positive peer influence. A major plus is that such programmes are intended also to improve child development across the board, not just substance use. An earlier report of outcomes up to grade eight (age 13–14) found that the LIFT children were already drinking less often, and also were less likely to have been arrested. The study has some major methodological strengths but also some important limitations and possibly too some shortcomings; details below.
Few families Of the 762 families with children enrolled in all 12 study schools, l2% declined to participate, resulting in a sample of 671 families. refused to participate in the study, all but ten of the 361 children in the fifth-grade classes had the required baseline data, and follow-up rates were high, Nearly 90% of families missed at most two of the seven assessments. giving confidence that the families and children were representative of all those in the selected neighbourhoods. In case the parents' drinking affected their children, this was statistically 'evened out' in the analyses. A similar procedure sought to statistically eliminate the impact of associating with deviant peers. As judged by the teachers and parents. If part of the way it worked was to curb such friendships, in theory this would have disadvantaged the LIFT intervention. In fact, Personal communication from David S. DeGarmo, November 2009. LIFT's impacts on friendships with deviant peers were independent of its impacts on substance use. Some of the LIFT classes were combined fourth and fifth grade classes. Though the average age was very similar to comparison schools, many more LIFT children (20% v. 5%) were just nine years of age when the study started. Being earlier in their development, they can be expected to take longer to develop substance use and other problems, possibly biasing outcomes in favour of the LIFT schools. Reassuringly, an earlier report on substance use and other outcomes to grade eight (age 13–14) found no significant indication of such a bias. No similar test is mentioned in the featured report, and neither was the grade level of the children or their age statistically 'evened out' in the analyses, raising the possibility that some degree of bias might have affected the comparison between LIFT and non-LIFT children. Surprisingly, which class or school the child was in bore little relation to outcomes, so was ignored the analyses. However, purists might insist that since it was schools which were randomly allocated to the intervention, the analysis of outcomes should also have been at school level. With just six schools, the chances of a statistically significant finding would have been drastically reduced. Also it is unclear whether adjustments were made for the multiple outcomes tested in the study to reduce the possibility of chance findings. There were nine tests Initiation, growth and accelerated growth of each of smoking, drinking and illicit drug use. of various kinds of substance use outcomes of which across the whole sample five were statistically significant and four were not, though other methodological considerations might have reduced the positive tally. In particular, it is unclear whether the way statistical significance was tested effectively doubled the chances of a positive finding by assuming that LIFT could not have negative impacts. It is unclear whether the frequency of use outcomes included (as 0 use) pupils who had not used The questions on frequency all assumed some degree of use. that substance at all, or only averaged frequency rates over users. An earlier report was based on past-year substance use. The featured report instead chose to report use in the past six months, a goalpost-shifting which requires justification. While the authors admit that substance use impacts were small, the report does not give 'raw' data on substance use levels in LIFT and comparison schools, making it impossible to assess the clinical significance of the findings.
The Good Behaviour Game school component in the featured intervention has been found feasible and effective in terms of classroom behaviour control in British schools. In broader form, these principles are embodied in the strand of personal, social, health and economic education (PSHE) which aims to create a climate in the classroom within which sensitive issues (including disruptive and aggressive behaviour) can be explored openly and honestly without fear of ridicule or betrayal of confidence, based on standards which the children themselves have helped generate. They can also be found in the SEAL (social and emotional aspects of learning) curriculum widely used in British primary schools.
Where these UK initiatives differ from the Good Behaviour Game is in their rejection of approaches based purely on a mechanical system of rules, rewards and sanctions, seen as failing to encourage pupils to learn social and emotional skills or take responsibility for their own behaviour. LIFT too fits the game within a broader approach to promoting good behaviour. Parent involvement mechanisms in British primary schools are underdeveloped compared to those deployed in LIFT and the national focus is on academic attainment and school attendance rather than overall child development and parenting. The family of studies of which the LIFT study forms a part focus attention away from specific programmes to deal with particular behaviours like substance use or bullying, towards generic and more sustainable inputs based not on subject knowledge but on the teacher's understanding of social and communication skills and child and adolescent psychology. In turn this demands a greater and more consistently implemented focus on developing this understanding.
Thanks for their comments on this entry in draft to Blaine Stothard, Independent Consultant in Health Education of the Institution. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 23 December 2009 Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Early teaching boost pays off six years later NUGGET 2004
Confident kids ... like to party NASTY SURPRISES 2004
It's magic: prevent substance use problems without mentioning drugs HOT TOPIC 2010
Prevention is a two-way process KEY STUDY 2001
Secondary school DARE ineffective without interactive extensions NUGGET 2003
Family check-up builds on teachers' abilities to identify problem pupils NUGGET 2004
Education's uncertain saviour KEY STUDY 2000
Multidimensional Family Therapy for young adolescent substance abuse: twelve-month outcomes of a randomized controlled trial.Liddle H.A, Rowe C.L., Dakof G.A. et al. Request reprint
Journal of Consulting and Clinical Psychology: 2009, 77(1), p. 12–25.
Holistic family therapy helped younger teens and their families get back on track before problems escalate, but was substance use really their focal problem?
Abstract Multidimensional Family Therapy addresses problem drug use and related problems among adolescents not through a set regimen, but by applying principles and a therapeutic framework to the individual young person situated within a particular set of environmental influences and constraints. It can be centre- or home-based or both, residential or non-residential, and can be delivered from one to three times a week over three to six months, depending on setting, problem severity, and family functioning. What distinguishes it from some other family therapies is that therapists see substance use as potentially a problem in its own right, and that the intervention extends beyond To address substance use and other problems, therapists intervene simultaneously across four interdependent domains They aim to engage the young person in treatment, to help them communicate, relate to parents and other adults, and to develop social competence and alternatives to drug use. A parallel attempt is made to engage parents in the therapy, to deepen their involvement with their child, and to improve parental monitoring and limit-setting. Family sessions with parents and children address interaction patterns, aiming to reduce conflict, strengthen emotional attachments, and improve communication and problem-solving. Lastly there is a focus on improving how the family relates to all the social systems in which the child is involved, such as school, the juvenile justice system, and recreational opportunities. Therapists work just with the adolescent, with the parent(s), or with both, depending on the problem being addressed. the child and family to all the social systems (school, juvenile justice, etc) in which the child is involved, according to the particular vulnerabilities and strengths of the child and their family.
Research on such approaches has mainly targeted teenagers around 16 years of age. The featured study extended this down to 11–15-year-olds referred (mainly by juvenile justice or schools) for outpatient substance use treatment at a treatment agency in Miami, whose problems were not so severe as to require intensive or inpatient care, and who lived with a parent or parent-figure who could participate in their treatment. The 83 children were mainly boys from poor African-American or Hispanic families whose substance use problems fell short of dependence; nearly half were on probation or awaiting a court hearing.
With family consent they were randomly assigned to Multidimensional Family Therapy or group therapy based on cognitive–behavioural principles. The latter differed from the family therapy by treating groups of four to six youngsters together and working exclusively with them rather than directly Though these were addressed indirectly as risk factors and through seeking to develop the youngsters' self-esteem, values and identity, decision-making, personal control, and interpersonal communication. with their families and social environments. Both treatments were manual-guided, conducted by trained and supervised therapists from the treatment agency twice a week for 12–16 weeks, and supplemented case management services. Family therapy was conducted mainly in the home, group therapy at the clinic, and the family option involved about half an hour a week more contact time, a difference adjusted for in the analyses.
Nearly all the family therapy children completed treatment as did three quarters in group therapy, unusually high. Outcomes were assessed during treatment, at discharge, and six and 12 months after treatment started. Trends across this period consistently Not just across the different outcomes but also in that there were no significant signs that family therapy was more or less beneficial for boys or girls, different ages or racial groups, or children referred from different sources. favoured the family therapy children and tended to be sustained in the post-treatment period. Before treatment, 72% of children assigned to family therapy admitted substance use in the past month compared to 45% in group therapy. The number who abstained increased more rapidly in and after family therapy until 12 months later just 13% said they had used in the past month compared to 54% in group therapy. Among those who did use at some stage, The analysis was based on that used in another study (http://dx.doi.org/10.1037/a0014160) which explained that this so-called 'continuous' measure "represented the frequency of substance use, given that some use had taken place ... substance nonuse within each time period was treated as missing data ... Thus, students who reported nonuse of a particular substance throughout the study contributed little information to growth parameter estimates...; however, any and all information related to positive substance use was incorporated in the derivation of growth parameters." frequency of use also declined faster among the family therapy children. These statistically significant differences were accompanied by a greater decline in children's accounts of the frequency with which they experienced substance-related problems, associated with delinquent peers, Though in both groups this declined. or committed delinquent acts, Among those who did commit such acts the frequency fell in family therapy but increased in group therapy. confirmed by court records showing that over the 12 months of the follow-up, fewer family therapy children were arrested (23% v. 44%) or placed on probation (10% v. 30%). Family therapy children also improved more in psychological health and reported greater and sustained improvements in the quality of family interactions. Both more positive interactions and fewer negative. These improvements "include core relationship characteristics (such as parental involvement and acceptance) as well as parenting practices (such as monitoring and consistency in discipline and limit setting)". Improvements were absent in the group therapy children. Finally, school records indicated that academic (but only slightly) and disciplinary grades improved in and after family therapy but declined in group therapy.
Another report on the same study concluded that better relations with parents gained during both treatments helped curb post-treatment substance use. What partly made the difference between them was that (to judge by the child's accounts) during treatment, family therapy parents started to monitor their children more closely. This seemed to account for more of their children becoming or remaining abstinent than after group therapy.
This latest study extends a series often demonstrating greater positive impacts from Multidimensional Family Therapy than from alternative treatments for teenage substance use problems. Compared to other non-residential therapies for youth problem substance use, family-based therapies which (like the featured intervention) also intervene in the child's life beyond the family have been relatively rigorously tested against alternatives and emerged with a good record – presumably, and sometimes demonstrably, because they alter critical aspects of the environment within which the child's behaviour is generated, which on their own these children and families are relatively powerless to alter. A bonus is that these alterations can also lead to wider benefits (eg, delinquency, school record, psychological health) and also improve the prospects for other children in the family (1 2).
Multidimensional Family Therapy in particular has distinguished itself by the sustainability (and even the growth; for example, 1 2) of the gains made during treatment; typically the reverse is the case in adolescent substance use treatment. A plausible explanation is that the therapy initiates a mutually reinforcing set of interactions between the child, their family and the wider environment.
Promising as it is, Multidimensional Family Therapy has not always outperformed well structured alternatives. In one study, it was slightly (but not significantly) less effective at promoting recovery from substance use problems than two other therapies Motivational interviewing plus group cognitive-behavioural therapy and a family/individual therapy based on reinforcing pro-social behaviours incompatible with substance use and skills training related to relapse prevention and problem solving. and substantially less cost-effective. Unlike most other studies of the therapy including the featured study, this study was led by an executive team which did not involve its developers; fully independent studies are an important test of whether an intervention's impacts can be maintained in routine practice. This and some other methodological issues are detailed below.
Strengths of the study include random assignment, a very high follow-up rate, sophisticated analyses controlling for extraneous influences on outcomes, careful data collection from children and parents separately by researchers unaware which treatment they had been assigned to, and the use of the clinic's own therapists treating the usual run of normally referred cases. These last points are an important indication that the findings might translate from the research across to 'real-world' conditions. For example, an allied therapy was found far more effective when delivered by specially hired and closely supervised graduates than in less controlled conditions with usual staff. However, as the authors acknowledged, the study was conducted at a single clinic and among a very particular caseload of poor minority children selected
not to have very severe
39 out of 130 referrals to the study were excluded because their problems warranted more intensive treatment.
substance use problems – hence its designation as an 'early intervention' trial intended to forestall rather than treat serious problems. Again as the authors acknowledged, the study was not fully independent but led by the researcher
who developed
In several social research areas (see http://dx.doi.org/10.1007/s11292-009-9071-y, http://dx.doi.org/10.1177/0193841X06287188, http://dx.doi.org/10.1093/clipsy.6.1.95), these and other forms of 'allegiance' have been found to favour more positive findings than fully independent research.
the family intervention and who is based at a centre which sells related training and certification. Recently a similar US-based therapy did not sustain its performance in fully independent replication studies in other countries (1 2). Proportionately, almost twice as many family therapy (22 out of 40 or 55%) as group therapy (12 out of 43 or 28%) children claimed not to have used substances over the month before starting treatment, a difference in their starting points which weakens confidence that later differences were entirely due to the treatment which followed. No adjustment was made for the multiple outcomes tested in the study in order to reduce the possibility of chance findings, though the
pattern of outcomes
Seven statistically significant differences out of nine. The primary outcomes were described as: “Substance Use, Substance Use Problems, Delinquency, and Internalized Distress”. These were represented by the following variables of which (x) were statistically significant:
Substance use problems: continuous(x)
Any problems: categorical
30-day substance use frequency: continuous(x)
Any use: categorical(x)
Delinquency self-report: continuous(x)
Any delinquency self-report: categorical
Arrests(x)
Probation(x)
Internalized distress(x)
makes it highly likely that there was a true beneficial impact from the therapy. The treatment which family therapy outperformed, though typical of much youth drug treatment, was perhaps a weak comparator. Group therapy for adolescent drug users has a poor record compared to other structured approaches, possibly partly because grouping high-risk youngsters together tends to reinforce their delinquency. While this may not overwhelm a well constructed and skilfully implemented therapy, it may weaken its impacts when compared to therapies which do not involve such grouping. Compared to another non-group approach, Multidimensional Family Therapy has led to more persistent gains on some measures of substance use/problems (problem severity, overall minimal use levels, and use of drugs other than cannabis or alcohol) but not in drinking or cannabis use.
Such therapies require a high level of competence on the part of the therapist, who has to be able to exercise judgement and flexibility in working with highly stressed families and to intervene simultaneously in several aspects of the child's life. In turn this mandates a high level of support in the form of training, supervision and opportunities for sharing experiences with other therapists. Though the featured therapy is time-limited, any such therapy is resource-intensive. Perhaps the biggest practical issue raised by the study is whether such expenditure was warranted by the current substance use problems of the children and the risk that these might mushroom in to severe problems, when there are older/other children and families which already have severe problems. At intake, 47% of the participants met criteria for substance abuse but just 16% met criteria for substance dependence, leaving over a third without any such diagnosis. Most denied any substance use over the past month, and those who did use, did so on average just over once a week. Among 13–14-year-olds in their neighbourhoods, such behaviour may not have been exceptional. Their general trajectory of delinquency, trouble with criminal justice and other authorities, and poor educational progress within economically stressed (and usually single parent) families, may have been a more appropriate target for intervention by child and family social work teams. Importantly though, Multidimensional Family Therapy has the flexibility to address substance use indirectly if a head-on approach seems for the time being inadvisable or impossible, and the approach it takes has relevance for troubled teens in general, whether or not substance use is a prominent feature.
Recent child drug treatment caseloads are such that many British health areas could justify the kind of service investigated in the study. Family therapy providers and services for children with multiple needs would be the most appropriate locations. Multidimensional family therapists engage systems which should already have been engaged by a coordinated multidisciplinary team, so the approach may have particular relevance where such coordination is imperfect and where a single person orchestrating the various systems may have more success. There seems considerable scope for developing this work. Though commending family work, an audit by the English National Treatment Agency for Substance Misuse found that family therapy is very much a minority Though many interventions were unspecified, just 3% were identified as involving family work. response to youth drug and alcohol problems. In Britain, Glasgow has been piloting the feasibility, acceptability and effectiveness of Multidimensional Family Therapy training in changing clinician practices and clinical outcomes in young people's alcohol and drug services.
For more on Multidimensional Family Therapy see the research project's own web site, the therapy's entry in the US government's directory of evidence-based therapies, or download the manual used in one of the US studies. For more on family therapy in general see this US expert consensus document.
Thanks for their comments on this entry to Howard Liddle of the University of Miami. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 21 December 2009 Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Motivational arm twisting: contradiction in terms? THEMATIC REVIEW 2006
Holistic family therapy preferable to less comprehensive therapy for troubled teens NUGGET 2002
Continuing care research: what we have learned and where we are going REVIEW 2009
Brief 12-step therapy can work for children too NUGGET 2000
The Drug Treatment Outcomes Research Study (DTORS): final outcomes report STUDY 2009
Behavioral couples therapy (BCT) for alcohol and drug use disorders: a meta-analysis REVIEW 2008
Aftercare calls suit less relapse-prone patients NUGGET 2005
Psychosocial interventions for people with both severe mental illness and substance misuse REVIEW 2008
Toward cost-effective initial care for substance-abusing homeless STUDY 2008
Improving clinical outcomes in treating heroin dependence: randomized, controlled trial of oral or implant naltrexone.Hulse G.K., Morris N., Arnold-Reed D. et al. Request reprint
Archives of General Psychiatry: 2009, 66(10), p. 1108–1115.
The first trial of implanted versus oral naltrexone found that the implants' extended opiate-blocking action helps avoid relapse to regular opiate use – but the action was not as extended as hoped, non-opiate use was greater, and there were more unpleasant side-effects.
Abstract Naltrexone blocks the effects of opiate-type drugs, in theory helping to prevent post-detoxification relapse to heroin and allied drugs. As a medication taken daily by mouth, its potential has not been realised because patients generally refuse to take the pills or quickly discontinue. New longer-acting formulations in the form of a depot injection or an implant surgically inserted under the skin avoid the need to take medication daily, promising to improve retention on the medication and outcomes.
This Australian study compared the oral form of naltrexone with a naltrexone implant thought to block the effects of heroin and allied drugs for several months. Of 236 people referred to the study or who responded to ads, 70 were assessed as heroin dependent and met safety and other criteria for inclusion the study. Typically they were men in their late 20s and early 30s who had on average been using heroin regularly for nearly ten years. Following outpatient detoxification they were randomly allocated to an active implant and inactive placebo pills, or the reverse. Neither they nor the researchers knew who had been given the active implant and who the active pills. Trial treatments lasted six months, during which patients were dispensed monthly supplies of the pills. Arrangements were made for their consumption to be supervised and encouraged by a non–drug using associate such as a family member or partner. All patients were encouraged to attend weekly individual, group, or family therapy sessions and were regularly monitored by researchers including blood samples to check on naltrexone levels and urine samples to test for drug use.
By the end of the six months of treatment a range of alternative measures confirmed that the implants had helped prevent relapse to heroin use. Just two of the 34 One patient assigned to implants was later known not to have been heroin dependent and was excluded from the analyses, leaving 34 implant patients and 35 oral. patients originally One later requested transfer to buprenorphine and another had to be switched to the oral form of the drug. prescribed active implants had been withdrawn from the study and offered alternative treatments due to relapse to daily heroin (and often other drug) use; in contrast, this rescue procedure had to be applied to 13 of the 35 originally Two later requested transfer to methadone. prescribed active oral medication. Just six of the 35 patients prescribed implants either could not be followed up (4) or had according to their own accounts relapsed to frequent At least 4 days a week. heroin use. In contrast, this was the norm (21 out of 34, of whom five could not be followed up) among patients prescribed oral naltrexone, creating a statistically significant difference between the groups. Abstinence from opiate-type drugs throughout the six months could be confirmed by urine tests for half (17) the implant patients but just a fifth (7) of the oral naltrexone patients. Oral naltrexone patients who returned to heroin use generally relapsed to regular use, not the case among those prescribed implants. Though both groups typically used non-opiate drugs, this was more common (94% v. 76%) among the implant patients; all but two had used other drugs, of whom 11 had used cannabis daily (versus seven oral patients) and four stimulants (versus one oral patient).
Greater desistance from heroin use in the implant group was related to the longer period they maintained blood levels of naltrexone sufficient to at least partly block opiate-type drugs. However, this new implant did not maintain these levels for as long as the earlier product not subject to the same manufacturing standards. In men an accepted therapeutic level was maintained for on average just under two months and among women for six weeks. A partially effective level was maintained for just over three months and four months respectively. Three Just two are noted in the relevant section in table 4 but another seems to have been wrongly placed in the section of the table devoted to oral patients. of the 35 implant patients experienced complications around the injecting site and a few others experienced diarrhoea, nausea, and vomiting, experiences absent in the oral group. No opiate overdoses were noted. Altogether a fifth of the active implant patients had implants removed though three of the seven later had them reinserted.
The authors concluded that, compared with oral naltrexone, implants effectively reduced relapse to regular heroin use and were not associated with major adverse events. Often patients appear to have 'tested' the implant by using heroin but found the effects unrewarding and did not carry on using. Though at the cost of a minor surgical procedure, the featured implant has the advantage over other formulations of sustaining partially effective naltrexone levels for three to four months, providing an extended period during which the patient can make significant life changes, and/or reducing the frequency of repeat implantations.
The featured study seems the first to have randomised patients to an implant or to the oral form of the drug. It convincingly demonstrated the superiority of the implant version in the limited but important area of short-term reduction in use of opiate-type drugs. It was also the first trial to use implants manufactured in accordance with an international code which aims to ensure medicines meet certain production quality standards. This more controlled manufacturing process seems to have accounted for the dramatically
shortened duration of action,
Though the study argues that partial blockade was maintained for longer, the pre-result trial registration document makes it clear that 2 ng/ml or more was considered to be "above therapeutic levels" – see http://www.anzctr.org.au/trial_view.aspx?ID=1462.
meaning that implants would have to be repeated every six to eight weeks to sustain the blockade. Briefer duration increases the risks and expense and offers more opportunities for patients to return to opiate use, possibly before their lives have stabilised in other ways. In the study
at least 14
17 were recorded as opioid-free but these may have included the three who were reimplanted.
of the 34 implant patients had no signs of a return to using opiate-type drugs, despite the fact that for the last half of the six months the implants would have partially or altogether lost their potency. However, the study offers no indications of how far this opiate-abstinent period was used to create a life sustainably free of regular drug use. All of these 14 could have been among the patients who resorted to regular use of non-opiate drugs, an unintended impact also seen in other Australian reports (1 2). Gains from the implant were also bought at the cost of a higher incidence of unwelcome side-effects, one of which was a case of MRSA infection, potentially a very serious incident, though in this highly monitored research study, one quickly resolved. One methodological concern is that recruitment was partly through newspaper ads, possibly meaning the patients were not typical of usual caseloads. Another is that reduced craving for heroin was to have been one of the primary measures of effectiveness, yet these results were not reported. A big gap is the absence of data on drinking, clearly a possible route to continued intoxication for patients on implants denied the effects of opiate-type drugs.
Other randomised trials (see below) have tested implants as a supplement to medication-free psychosocial support. Presuming that patients join these studies primarily for the chance of receiving a long-acting implant or injection, they suggest that patients motivated for this radical treatment do considerably better when they receive it than when offered just modest outpatient aftercare support, even if this includes support to keep taking oral naltrexone. As yet untested is whether such patients would do better if maintained on opiate-type drugs such as methadone or buprenorphine. In all randomised trials to date, more active and structured aftercare (for example, regular monitoring, continued well organised care from the initial service, or active referral to support groups) might have narrowed the advantages gained by supplementing aftercare with implants or depot injections. However, motivated patients and imperfect aftercare arrangements probably reflect the conditions in which implants would be deployed in normal practice. The featured study's findings are consistent with those from Britain (1), and elsewhere (1 2 3 Maksoud N.A. "Experience with detox and naltrexone implants in Egypt." Abstracts from 7th International Conference 2002. Stapleford Trust. 4 5) tentatively suggesting that long-acting naltrexone can be used to create an opiate-free period which extends beyond the initial blockade, sometimes aided by further administrations and sometimes too by resort to non-opiate drugs (1 2).
A trial in Norway tested an earlier form of the implant used in the featured study, one whose blocking effects typically last nearly six months. Staff at inpatient drug clinics invited opiate-dependent patients on abstinence–oriented programmes to participate in the study. The 56 who joined the study were told that for the first six months they would be randomly allocated to the implant or to usual aftercare arrangements, after which all would be offered (re)implantation. Over the six months of the follow-up, implanted patients used opiate-type drugs far less often, and at the six-month follow-up assessment, 18 out of 27 usual-care patients but just 9 of the 29 implant patients continued to meet criteria for opioid dependence. In this study implants supplemented relatively weak The usual aftercare against which the implants were compared does not appear to have been a continued service from the clinics, but external counselling and other services which (if necessary with help from the clinics) patients would have had to arrange for themselves. aftercare arrangements.
Another randomised trial conducted in the USA tested a long-acting form of naltrexone administered by injection which blocks opiates for about four weeks. Compared to placebo, this nearly doubled the time heroin dependent patients were retained in aftercare following inpatient detoxification. On the credible assumption that drop-outs relapsed, there was a similar impact on heroin use. At the four-week choice point when the naltrexone patients could have refused the second set of injections, few did so, most committing themselves to another period without (or with reduced) opiate effects. Though encouraging, multiple exclusions (such as psychiatric conditions or dependence on other drugs) and the recruitment procedures (partly through newspaper ads) meant the patients may not have been typical of usual caseloads. In this study all the patients were offered twice weekly relapse prevention therapy and monthly psychiatric consultations.
Patients will only opt for such procedures if they are prepared (irreversibly in the case of depot injections) to commit to weeks or months without the effects of heroin or other opiate-type drugs, or with severely attenuated effects requiring higher than usual doses, an unusual degree of commitment. In the featured study for example, despite responding to ads or agreeing to a referral, of 129 people screened by the study who might otherwise have qualified to join it, nearly half (59) declined. But from the control groups in naltrexone implant/depot studies, we know that motivation alone is usually insufficient; without long-acting medication, even among these caseloads, treatment drop-out and relapse are common. Long-acting naltrexone helps these highly motivated patients sustain their resolve. The clearest candidates for the treatment are patients who are motivated to return to a life without opiate-type drugs (including prescribed substitutes), have the resources, stability and support to sustain this, are unlikely to simply use other drugs instead, but who when free to experience heroin and allied drugs cannot resist using them, possibly reflected in their poor compliance with oral naltrexone regimens. The treatment may also be considered for unstable patients at very high risk of overdose, but who will not accept or do poorly in substitute prescribing programmes.
In the UK, neither implants nor depot injections of naltrexone have been licensed for medical use; they can still be (and have been; 1 2 Revill J. "A Comparative study of the protective benefits of oral and implanted naltrexone in a British NHS general practice." Abstracts from 7th International Conference 2002. Stapleford Trust. 3 Daly M. "Implant progress blocked." Druglink: September/October 2004, p. 12–13. 4) used, but patient and doctor have to accept the added responsibility of a product which has not yet been shown to meet the safety and efficacy requirements involved in licensing. Some possible safety concerns are outlined below.
As with any abstinence-based treatment, overdose due to lost tolerance to opiate-type drugs is a serious concern. However, the few studies to date suggest these products protect against overdose while they are active, and that in caseloads prepared to undertake these procedures, opiate overdose reductions can outlast the active period of the implants, possibly because opiate use too remains suppressed. Another potential problem is that implants impede opiate-based pain relief. To cater for this, at least one study gave patients a card to carry which specified the presence of a naltrexone implant, its expected duration, possible pain relief options, and contact details for study staff. Without this (as reported in Australia) hospital staff sometimes make futile attempts to relieve pain using opiate-type medications. The same report of hospital admissions after implantation identified severe withdrawal symptoms after rapid detoxification to the point where hospitalisation was required. Long-acting naltrexone means the most effective way of relieving these symptoms (using opiate-type drugs) is denied to the patient. As the featured study illustrates, any surgical procedure carries risks. No implant has yet been through the safety tests required for registration as a medical product. See background notes to an earlier Findings analysis for more on adverse effects and overdose protection.
Last revised 16 December 2009 Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Naltrexone implants after in-patient treatment for opioid dependence: randomised controlled trial STUDY 2009
Naltrexone implants prevent opiate overdose NUGGET 2006
Rapid opiate detox guarantees completion, but abstinence depends on what follows NUGGET 2002
High risk of overdose death for opiate detoxification completers NUGGET 2008
Naltrexone implants could reduce the early relapse rate after detoxification NUGGETTE 2003
Opiate antagonist treatment risks overdose NUGGET 2004
Prescription of heroin for the management of heroin dependence: current status REVIEW 2009
Rapid opiate detoxification feasible at home NUGGET 2003
