Drug and Alcohol Findings home page in a new window EFFECTIVENESS BANK BULLETIN 24 October 2011

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


Bad news for counsellors

This issue has what may be seen as bad news for counsellors: in the USA, 1 in 6 non-specialists typically ended up with clients whose substance use problems were worse, while specialists in methadone clinics may be dispensable. Also two UK studies dealing with critical issues: child protection and how to tame the hepatitis C epidemic.

1 in 6 therapists make substance use problems worse ...

Counselling not essential to initial impact of methadone maintenance ...

Hepatitis C can be prevented by methadone plus needle exchange ...

Promising results from pilot UK family drug and alcohol court ...

Therapist effectiveness: implications for accountability and patient care.

Kraus D.R., Castonguay L., Boswell J.F. et al.
Psychotherapy Research: 2011, 21(3), p. 267–276.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Kraus at dkraus@bhealthlabs.com.

1 in 6 US therapists (mainly not specialising in substance use) typically ended up with clients whose substance use problems were significantly worse than when they started therapy, an indication perhaps that social workers and mental health counsellors find these issues especially hard to deal with.

Summary Some counsellors and therapists achieve on average outstanding results, while others leave many patients worse than when therapy started. While this is known to happen, how great this variation is in normal practice and what proportion of therapists fit in these categories is unclear. Across all types of patients including those being treated for substance use, the featured study is the first to assess the pervasiveness of positive versus harmful therapist effects in normal practice. It also asks whether therapists tend to be good/bad across the board, or have strengths or weaknesses with respect to some types of problems but not others.

The data for this study came from clinicians or clinics who had contracted an outcomes management company to process assessment and outcome data from patients as a way of monitoring their performance. From this dataset were selected records on adult outpatients which included a standard pre-therapy assessment of wellbeing and functioning in 12 domains, Work functioning, sexual functioning, social conflict, depression, panic (somatic anxiety), psychosis, suicidal ideation, violence, mania, sleep, substance abuse, and quality of life. plus a repeat assessment near the sixteenth week of treatment, by when most improvements will normally have become apparent. Of these 15,217 patients seen by 3222 therapists, the sample was further limited to therapists with at least 10 patients and to just the first 10 patients. The final dataset included 6960 patients and 696 therapists, the latter being quite similar to the larger group of 3222 clinicians. Both patient and therapists were mainly female and the therapists were primarily social workers and mental health counsellors. Just 5% were licensed drug and alcohol counsellors.

For each patient it was calculated whether in each of the 12 domains they had reliably improved (ie, more than could be attributed to assessment error), reliably deteriorated, or were somewhere in between, neither definitely improved nor definitely worse. These patient progress assessments were then used to assess the therapists. In each domain, 'effective' therapists were defined as those whose average patient reliably improved on that measure, 'harmful' therapists as those whose average patient reliably deteriorated. In between ('unclassifiable/ineffective') were those whose patients on average neither improved nor deteriorated or who had too few patients with such problems for an assessment to be made.

Main findings

Of the 696 therapists, the proportion assessed as effective (ie, their average patient reliably improved) ranged from a low of 29% in treating sexual dysfunction to a high of 67% in treating symptoms of depression. Exactly half were effective in treating substance abuse. In contrast, at 16% substance abuse (along with violence) topped the ranking of the proportion of therapists assessed as harmful. Bottom of the range at 3% was treating depression. In the treatment of substance abuse, therapists overall achieved on average a medium degree of improvement in their patients (an effect size A standard way of expressing the magnitude of a difference (eg, between outcomes in control and intervention 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 how much the outcome varies 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. of 0.47), but effective therapists on average recorded a very large positive effect (effect size of 1.14) and harmful therapists a large negative effect (effect size of -0.98).

The next question addressed was whether therapists who were effective (or the reverse) in one domain also tended to be the same in others. Generally this was only modestly the case; often therapists excelled at relieving one type of problem but failed with others. With respect to substance abuse, the correlation between how high a therapist ranked in this domain and how they ranked in others ranged from near zero up to (for suicidal ideation) a modest 0.24, including just 0.11 for quality of life and 0.10 for work functioning.

The authors' conclusions

On average, the findings from this study suggest that therapists are quite effective, but these global findings mask tremendous variability in therapist performance and in the symptom types they effectively address. In particular, the data indicate that harmful therapists are more widespread than previously thought. Depending on the symptom type, the average patient of 11% to 38% of therapists ended initial treatment worse off (but some within the margin of measurement error) than when they started, including 20% whose average patients left more suicidal and 36% more violent. On the more stringent criterion of reliable deterioration beyond the margin for error, again depending on the symptom type (substance abuse and violence topped the list), the average patient of up to 16% of therapists ended initial treatment significantly worse, justifying the label 'harmful' in these cases.

The study also found preliminary evidence that therapist effectiveness is not a global construct; therapists skilled in one domain may be harmful in another. Just from 1–9% of the variation in how therapists rank in each domain can be accounted for by their global competence. The bulk of the variation between therapists is symptom-specific. No therapist in this study was found effective in every clinical domain.

These findings can be set against the common finding that therapists overestimate their performance. The contrast suggests that standards of ethical practice may require therapists routinely to measure their outcomes and focus their practices where they are most likely to succeed, or obtain supervision or continuing education to improve in weaker areas. From the patient's point of view, an ideal system would enable them to find appropriate therapists not just in terms of gender, ethnicity or other currently used variables, but also their track record of helping patients with similar issues.

The findings also have important training implications, including the provision of regular and systematic feedback to students and trainees about their impact on different aspects of their clients' functioning. Solid evidence that clients tend to get worse on specific aspects of their functioning should prompt the trainee and their supervisor to consider remedial strategies.

The importance of these implications mandates an awareness of the limitations of the study on which they were based. Notably, rather than being based on a random national sample of therapists, the contributors were a convenience sample who were concerned enough (or whose employers were) about being aware of their performance to pay for their client outcome data to routinely be analysed.

Findings logo commentary Importantly this study found, not that a high proportion of therapists were globally harmful, but that a substantial minority had patients who got worse in some areas of their wellbeing or functioning. Though the featured study was unable to pinpoint what made some therapists counterproductive, this issue has been addressed by experts including some of the authors of the featured study. Among the candidates are inflexible application of guidelines and techniques, inappropriate use of techniques which arouse anxiety or resistance, lack of awareness of when things are going wrong and of insight in to the causes, inadequate familiarisation with the client's strengths and vulnerabilities, and failure to establish a solid therapeutic relationship. Given the therapist's injunction to above all do no harm, the training implications are profound, and given findings that some therapists are simply unsuitable by nature, so too are the implications for staff recruitment and retention. As the authors acknowledge, such implications mandate a thorough probe of whether the findings can be relied on. While there are the concerns detailed below, these do not undermine the study as an indicative if not definitive assessment of the extent of harmful practice, nor the implications the authors draw for therapist selection and training.

At 10% to 15%, previous estimates of deterioration among clients seeking help with substance use problems exceeded the 3% to 10% range reported for psychotherapy in general. In the featured study, deterioration in substance use problems was one of the two most common ways therapists seemed to harm their patients, a finding which may reflect lack of training and difficulties faced by some generic mental health and social work practitioners in addressing substance use. Non-specialist workers vary in effectiveness even in the very brief encounters characterising alcohol or drug interventions with people not seeking help at all, but identified through screening in general medical services or by other methods (see for example: 1 2 3).

It is also well established that specialist substance use counsellors and therapists differ in effectiveness. Some of the reasons for these differences have been explored in Findings' Manners Matter series, devoted to the importance of sensitivity, helpfulness, and the systematic implementation of a personal, welcoming response. Since those reviews the most wide-ranging investigation ever of the organisational health of British treatment services has found that staff working in an atmosphere of support, respect, and concern for their development, tended to have clients who also felt understood, respected, supported and helped – a finding which supports the possibility that the featured study might partly reflect organisational variation, not just differences between individual therapists.

Also from the UK, another study has thrown up the intriguing possibility that non-conformist drug workers who value hedonism and stimulation help marginalised problem drug users most because their values match those of their clients. In line with the featured study's finding that therapists are often good with some problems but not others, it seems likely that such workers, while doing well with drug use problems and clients, would not so readily help more socially conventional mental health clients.

Do the findings stand up to scrutiny?

The representativeness of the samples of patients and therapists is the major limitation of the study as a barometer of the national US picture. Only the records of patients who stayed in treatment for around 16 weeks were included in the analysis, the results of which might conceivably have differed if early drop-outs had been included. The major way in which the 3222 therapists in the starting sample were whittled down to 696 was the elimination of those with fewer than ten recorded patients. Though the retained sample of therapists seemed generally typical of the full sample, it seems likely that there were some systematic differences which meant they saw more patients, retained them for long enough for them to be included in the analysis, or were more diligent in documenting these patients than the other nearly four fifths of therapists not retained in the analysis. But these influences seem most likely to have resulted in an under- rather than an over-estimation of harmful practice.

The fact that deterioration was not uniform across all symptom groupings raises the question of the importance of these issues to the patient. There is no indication in the study of which were the problems which led the patient to seek help and/or constituted their primary diagnosis, or which were less focal and severe issues on which some deterioration might be considered a price worth paying. Similarly, it is not known whether the problem areas therapists failed on were those they were employed and/or aiming to deal with. It would, for example, be of great concern if the patients of a substance misuse counsellor – presumably seeking and expecting help with severe substance use problems – generally got even worse in their substance use problem scores, but perhaps less of a concern if this happened with depressed people seeking mental health counselling and whose substance use, though more of a problem than before, remained unremarkable, especially if at the same time their core concern had been effectively treated. The caveat that rather than therapy causing deterioration, some of the patients might have got worse (and perhaps more so) even without therapy does not explain why deterioration in some aspects of their patients' welfare was characteristic of some therapists. It can also be countered by the speculation that some clients who improved might have done even better without therapy.

Other limitations are that the categorisation of therapists was made on the basis of just ten patients each, though in many cases this will have been most or all their relevant recorded caseload. It is also unclear whether the findings reflected variation between therapists, or variation between clinics or whole service-provider organisations. To some degree they may bear witness to the impact of excellent versus poor management and therapeutic environments rather than excellent versus poor therapists. The 'outcomes' assessed by the study were in-treatment progress rather than sustained post-treatment recovery.

Another concern is that the lead author is or was associated with a company which stands to benefit from the monitoring implications of the findings. However, similar implications have been drawn (1 2) by independent academics and therapists. The implication that the performance of psychotherapists, and with it the welfare of their patients, would benefit from in-treatment feedback on how the client is doing and on their relationship with the therapist has been confirmed in studies which have randomly allocated patients to feedback-based versus non-feedback-based therapy. Benefits were most apparent in preventing patients doing poorly going on to end up significantly worse than when they started – in the featured study's terms, also preventing their therapists from falling in to the "harmful" category.

Last revised 19 October 2011

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REVIEW 2011 Evidence-based therapy relationships: research conclusions and clinical practices

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

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

STUDY 2009 The alliance in motivational enhancement therapy and counseling as usual for substance use problems

REVIEW 2011 Evidence-based psychotherapy relationships: Collecting client feedback

REVIEW 2011 Integration of treatment innovation planning and implementation: strategic process models and organizational challenges

REVIEW 2011 Evidence-based psychotherapy relationships: Goal consensus and collaboration

DOCUMENT 2013 Sometimes best to break the rules

REVIEW 2011 Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence

STUDY 2005 How does motivational interviewing work? Therapist skill predicts client involvement within motivational interviewing sessions

Interim methadone treatment compared to standard methadone treatment: 4-month findings.

Schwartz R.P., Kelly S.M., O'Grady K.E. et al.
Journal of Substance Abuse Treatment: 2011, 41, p. 21–29.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Schwartz at rschwartz@friendssocialresearch.org.

Is regular counselling really essential to the effectiveness of methadone maintenance treatment, or are treatment entry and the power of high-dose methadone enough in themselves for many patients? At least in the first four months, this US study suggests the latter.

Summary These are the outcomes in the featured study four months after patients started treatment. See this later analysis for 12-month outcomes.

This US study addresses the issue of whether regular counselling improves initial outcomes from methadone maintenance treatment. The context is that federal regulations require regular counselling except under special authorisation and then counselling can be omitted only for up to 120 days – hence the term "interim" for this stripped-down provision. By forcing counselling provision, the regulations limit the number of methadone slots which can be provided under current funding and inhibit access for patients who have to pay all or some programme costs. Previous studies had shown that compared to the alternative of waiting for a standard methadone treatment slot, interim provision substantially reduced opiate use and crime and led many more patients to eventually start regular methadone treatment. But these studies left open the issue of whether offering rapid access to standard programmes would be even more effective than offering rapid access to interim programmes.

To investigate this issue, at two methadone clinics in Baltimore, new patients were randomly assigned to start (usually within three days) an interim programme or standard treatment. As per regulations, the interim programme could last only up to 120 days, offered crisis counselling only, required patients to take all their methadone under supervision at the clinics, and at least three tests for illegal drug use. In the standard regimen, patients were expected to attend weekly group and/or individual counselling sessions (with some room for adjustment to patient needs), permitted take-home doses depending on time in treatment and progress, were subject to more frequent drug testing than in the interim programme, and were able to benefit from care planning and other psychosocial inputs. At one of the clinics patients were also randomly assigned to a third option – the standard programme plus enriched counselling provision by a highly regarded counsellor with a low caseload who was instructed to see patients as often as they wanted or the counsellor thought appropriate. Dosing protocols did not differ, and patients ended up on doses averaging from 68mg to 79mg a day across the three groups, the highest average being among the interim patients.

Main findings

The 230 patients recruited to the study and successfully assigned to one of the three treatment regimens were typically unemployed single black men in their early 40s who used heroin daily. All but a few were followed up by researchers four months later when the interim programme had to have stopped or been replaced by standard provision (on average the patients were in the interim stage nearly all the 120 days). As expected, during this time the interim patients received virtually no counselling sessions, the standard patients about one a fortnight, and the enhanced patients about one per week.

The first important finding was that interim patients were no less likely to have stayed in treatment; 92% did so compared to 81% of standard and 89% of enhanced patients. Over this time heroin use declined substantially and cocaine use more modestly, both to roughly the same degree in all three treatments. Heroin use fell from on average virtually daily to two to four days a month according the patients' own accounts, broadly confirmed by urine tests which were 97% positive at first but fell to 41% to 51% positive. Self-reported drug, legal and family problems all declined too, and to roughly the same degree across the three treatments. Crime indicators Past 30-day self-reported days of criminal activity, money spent on drugs, and illegal income. actually fell slightly more steeply among interim than standard programme patients. These results generally indicative of no differences in outcomes across treatments were broadly replicated in a comparison of the interim patients with all remaining study participants assigned to more frequent counselling.

The authors' conclusions

While across the board there was significant improvement, being assigned to scheduled counselling versus the interim regimen did not further improve retention, illicit drug use and related problems, or criminal activity. The study found no evidence that interim patients were substantially disadvantaged by the four-month period during which only emergency counselling was available.

However, even the most frequently counselled group in the study were seen on average once a week. More intensive or different forms of counselling and other forms of support might have made more of a difference. Conceivably too, the benefits of extra counselling would be seen in more sustained improvement following the four-month break point imposed by regulations.

The findings are consistent with other studies conducted at typical US community-based methadone clinics. They strongly suggest that the regulation of opioid agonist treatment should allow for provision of additional services where these are both helpful to patients and wanted by them rather than making such services obligatory. As well as increasing costs by imposing services that may or may not be needed, mandating these services has the unintended consequence of denying access to more basic treatment which is demonstrably valuable to patients and the society in which they live.

Findings logo commentary Together with this latest study, similar studies (including some in the UK) reviewed in detail by Findings have shown that subject to sufficient assessment and monitoring to ensure clinical safety, starting prescribing in the absence of regular counselling or other psychosocial supports is preferable to simply leaving patients waiting, even for a few weeks. Patients reduce their drug use, health risks and criminal activity, and more go on to enter the main programme. For some patients, little more may be needed and such programmes can form a longer term alternative to more intensive support. These patients might be identified by how well they do on the interim programme.

It is, however, important to remember that this (and the same applies to other studies of interim arrangements) was far from a 'contactless' programme. Every day of the week over the entire period, interim patients had to attend the clinic to take their methadone under supervision – more staff contact than many British patients experience. It also clear that multiply problematic clients benefit from regular counselling and well targeted ancillary services, and without these will suffer repeated crises, in the end demanding more intensive and expensive intervention. Cost-effectiveness is probably maximised by making more intensive and extensive services available for those who feel they need them, or where referral to such services seems advisable. However, it would be widely considered unacceptable to leave patients on minimal programmes without regular review probing for and seizing opportunities to make yet further improvements in their welfare and recovery from addiction, including ways to solidify their recovery sufficiently for them to safely leave methadone treatment. In turn this raises what in Britain is a key current issue of whether more intensive counselling, even if it seems to add little to the powerful effect of entering methadone treatment, might help people get sufficiently on their feet to more to leave this treatment and leave it earlier.

One caveat to the findings mentioned by the authors is worth emphasising – that the difference counselling makes will depend on the quality and nature of that counselling and also on the quality and nature of the counsellor. Perfunctory brief encounters focused on dose, prescribing and dispensing arrangements, attendance records, and regulatory and disciplinary issues are unlikely to engender step change in the client's recovery, yet are characteristic of the keyworking service offered by some British criminal justice teams to offenders on opiate substitute prescribing programmes.

Last revised 02 September 2013. First uploaded 20 October 2011

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

STUDY 2009 The Drug Treatment Outcomes Research Study (DTORS): final outcomes report

STUDY 2010 Is heroin-assisted treatment effective for patients with no previous maintenance treatment? Results from a German randomised controlled trial

STUDY 2006 Stripped down methadone prescribing better than leaving patients to wait

STUDY 2002 The grand design: lessons from DATOS

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

STUDY 2005 Addressing medical and welfare needs improves treatment retention and outcomes

REVIEW 2012 New heroin-assisted treatment: Recent evidence and current practices of supervised injectable heroin treatment in Europe and beyond

STUDY 2015 Understanding the costs and savings to public services of different treatment pathways for clients dependent on opiates

STUDY 2004 Methadone maintenance as low-cost lifesaver

The impact of needle and syringe provision and opiate substitution therapy on the incidence of hepatitis C virus in injecting drug users: pooling of UK evidence.

Turner K.M.E., Hutchinson S., Vickerman P. et al.
Addiction: 2011, 106, p. 1978–1988.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Hickman at matthew.hickman@bristol.ac.uk.

Together studies recently conducted across the UK suggest that consistent participation in methadone maintenance treatment plus adequate access to fresh injecting equipment has prevented many hepatitis C infections, supporting calls for needle exchange to be expanded and methadone treatment sustained.

Summary For drug injectors, opiate substitution therapy reduces drug dependence and the frequency of injecting while providing hygienic injecting equipment through needle and syringe programmes reduces unsafe injecting using shared syringes. These interventions have been shown to reduce self-reported injecting risk behaviour, but there is little direct evidence of impact on the incidence of hepatitis C infection. By pooling data from studies across the United Kingdom, this study aimed to determine whether opiate substitution therapy and needle and syringe programmes, singly or in combination, can reduce the transmission of hepatitis C among drug injectors.

The analysts searched for studies conducted in the UK and published since the year 2000 which related hepatitis C infection among injectors outside prison to their participation in opiate substitution therapy and/or needle and syringe programmes. Six such studies were found of 2986 injectors in total, conducted in Birmingham, Bristol, Glasgow, Leeds, London and Wales. Two of the studies were follow-up studies which directly assessed the incidence of new infections by retesting To test whether they were HCV antibody-negative or positive. injectors a year later. The other four which took measurements at a single point in time used a laboratory test Individuals who tested HCV RNA-positive among those who tested HCV antibody-negative. to identify which injectors were relatively newly infected. For the follow-up studies injectors were considered to have been in opiate substitution treatment if this treatment occupied at least six of the 12 months of the follow-up period. For the remaining studies the definition was currently being in treatment. Injectors were considered to be 'highly covered' by needle and syringe programme provision if from these sources they had obtained at least enough sterile injecting equipment to have used a fresh set for each injection. These categories were then combined to form three levels of harm reduction coverage:
full coverage by both consistently being in opiate substitution therapy and high coverage needle and syringe programmes;
partial coverage by consistently being in opiate substitution therapy or high coverage needle and syringe programmes;
minimal coverage, neither consistently accessing opiate substitution therapy nor obtaining high coverage of injecting equipment needs from needle and syringe programmes.

Main findings

Across the six studies the proportions of injectors infected with hepatitis C ranged from 70% in Glasgow to 26% in Wales. The estimated proportions who became or were newly infected ranged from 5% to 40% per year. 57% had recently been or were (as defined by the study) in opiate substitution therapy and 67% were highly covered by needle and syringe programmes.

Interest centred on the 1457 injectors who (for the follow-up studies, initially) tested negative for hepatitis C antibodies. Only these injectors could be shown to have become newly infected, either by a retest a year later in the follow-up studies, or by a further hepatitis C RNA test in the studies conducted at a single point in time. Missing data and the exclusion of people who had not injected during the relevant periods reduced the numbers in each analysis to around 1000.

In three of the six relevant studies, being or having been in opiate substitution treatment was associated with a lower risk of becoming newly infected with hepatitis C. Though there were inter-study differences in the strength and direction of this link, these were not statistically significant, meaning the results of the studies could be pooled. These pooled results revealed that across the six studies there was a statistically significant association between opiate substitution treatment and a lower risk of becoming infected. Similarly across the five relevant studies, high coverage participation in needle and syringe programmes was also linked with a lower risk of becoming infected. In both cases the effect size A standard way of expressing the magnitude of a difference (eg, between outcomes in control and intervention 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 how much the outcome varies 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. indicated a medium-strength effect.

A finer grained analysis assessed whether injectors were at lower risk of infection when they were partially covered by either opiate substitution treatment or high coverage needle and syringe programmes, but not both. After differences in risk profiles That is, whether the injector was a woman, had recently been homeless or injected crack, or had injected for over 2.5 years. had been accounted for, in both cases the odds of becoming infected versus remaining uninfected were halved relative to the risk faced by injectors who had not adequately participated in either type of harm reduction service. However, in neither case was the risk reduction statistically significant. When injectors had used both types of services, their risk of infection was just a fifth of that faced by injectors who had used neither to the degree set by the featured study, and this time the risk reduction was statistically significant. The raw numbers were 8 of 392 fully covered injectors becoming infected versus 13 of 120 who had used neither service to the set degree.

Instead of actual infections, similar analyses assessed the links between harm reduction coverage and behaviour which put the injector at risk of infection: specifically, sharing needles over the past month and frequent injecting. Injectors who had used both opiate substitution treatment and high coverage needle and syringe programmes to the degree set by the study were on both counts at lower risk than those who met neither service access criterion. They were half as likely to have shared versus not shared and they injected 21 times fewer per month. Among the partially covered injectors who used one service but not the other, the only statistically significant result was a reduction in the frequency of injecting amounting to 13 times a month among opiate substitution patients.

The authors' conclusions

By pooling UK data the study showed that opiate substitute treatment (in Britain, mainly using methadone) and high coverage needle and syringe programme participation can reduce the transmission of hepatitis C among injectors. After adjusting for important influences on the risk of infection (such as gender, homelessness and crack use), access to either type of service approximately halved the risk of infection, and the combination of both could reduce risk by up to 80%. The true effect of opiate substitute treatment may have under-represented, since most of the studies recruited only current injectors, missing the risk reduction achieved by those helped to stop injecting altogether by treatment. In line with previous evidence, the study also showed that this combination of services was associated with lower levels of infection risk behaviour in the form of injecting and the sharing of injecting equipment.

The analyses did not assess the impact of using needle and syringe programmes as such, but use at a level adequate to meet the injector's need for fresh equipment. In areas where hepatitis C is very common among injectors, even infrequent infection risk behaviour is enough to sustain transmission. Preventing it requires not just use, but high levels of use of needle and syringe programmes, preferably allied with opiate substitute treatment. Under these conditions, these harm reduction interventions are effective in intercepting transmission of the virus. How much more will be required to actually drive down levels of infection across the injecting population remains to be determined.

Findings logo commentary The featured analysis bolsters the contention (details below) that fully implemented and multi-pronged harm reduction services can dent the transmission of hepatitis C, and supports calls for current services (especially needle exchange provision) to be upgraded to meet this challenge.

One of its strengths is that as well as demonstrating a link between new infection and service use, it also showed how this link might operate by reducing the frequency of injecting and the proportion of injectors who continue to share injecting equipment, reducing opportunities for the virus to be transmitted. Completing the expected causal chain from service use, through behaviour change, to actual infection, adds credibility to the assumption that the links between service use and infection found by the study are due to an effect of the interventions.

It remains the case however that this conclusion is based on an association which could have been due to other factors. Conceivably, for example, injectors concerned and stable enough to stay in treatment and to make regular use of needle exchanges would have found other ways to avoid infection, even if exchanges and treatment were unavailable. In this scenario, it would not be the services which were the essential factor, but the characteristics of the injectors who tended to use them most.

For example, of the six studies on which the featured analysis was based, one in Wales was important because it was one of the two to follow-up uninfected injectors and see if later (in this case, a year later) they had become infected with hepatitis C, and because its results contributed considerably to the positive findings on opiate substitution treatment. However, the researchers admitted that "it is possible that we failed to identify differences between those in and out of treatment. Of particular concern is that being in [treatment] might arguably reflect more care seeking and lower risk behaviour ... rather than an effect of treatment per se." Also this study was able to follow up just 286 of the 516 injectors who initially tested as uninfected.

Another study in Bristol contributed considerably to the positive findings on needle exchange provision. Its findings were based largely on just 14 individuals who showed evidence of recent infection. The sample was asked about their exchange use over the past week, but the infection could have occurred months before. It may be the case, as the authors say, that "their service use will probably have changed little over this relatively short period", but the salient issue is whether they had attended exchanges with sufficient regularity and diligence to get all the equipment they needed to use a fresh set for each injection, a condition presumably easier to dip in and out of than attending versus not attending. But the major unanswered question is in what ways the high coverage exchange users differed from those who did not get enough for a fresh set each time, and whether their diligence would have led them to protect themselves in other ways such as effective cleaning, re-using only their own equipment, or sharing only with trusted infection-free associates.

In line with other research

The findings confirm research reviewed by Findings which indicated that in respect of hepatitis C, "Trickle-feed needle exchange does not work, or not well enough. It has to be nearer a flood. Hepatitis C demands strategies which aim to eliminate even occasional risky sharing and which extend to all the equipment directly or indirectly in contact with an injector’s blood, and all the ways this might happen."

As in the featured study, the review also found evidence that treatment and needle exchange exert a synergistic impact on risk. By reducing the frequency of injecting, oral opiate substitution programmes also reduce the opportunities for sharing equipment and for viral spread. Meantime, the role of exchanges is to see that uncontaminated equipment is used for each remaining injection and to remove potentially contaminated equipment. By reducing the number of injections, treatment should make it easier to meet the reduced demand for injecting equipment. Treatment can also address the lifestyle and psychosocial factors which thwart the efforts of exchanges. Prescribing injectable drugs too may help. Even if it does not reduce injecting frequency, sourcing injectable drugs from a doctor divorces injectors from the shared drug procurement and consumption arrangements which characterise illegal drug use, making it less likely that they will also share injecting equipment. Evidence for a synergistic impact was apparent in the early years of needle exchange in Britain, when injectables were more widely prescribed than today. Facilitating access to this treatment was probably one of the main ways exchanges reduced infection risk. In the USA, studies have found that by reducing the frequency of injecting, treatment augments the risk reduction impact of attending exchanges, whose main effect is not to reduce injecting, but the sharing of injecting equipment.

Findings from the featured study parallel those from Amsterdam, where over the decade from 1985 to 2005 injectors who had more fully implemented harm reduction (were being prescribed at least 60mg daily of methadone and had either stopped injecting or injected only with needles from needle exchanges) were less likely to become infected with HIV or hepatitis C than continuing injectors who did not use exchanges and were not in methadone treatment. In contrast, less complete harm reduction access – lower doses of methadone and/or not fully relying on exchanges for one's syringes – did not significantly reduce the rate of new infections. Similar findings have also emerged from Baltimore in the USA, where syringe exchange participants who entered treatment reduced their drug use, crime and injecting more than syringe exchange alone was able to achieve.

Policy implications

The findings of the featured study were fed in to a simulation model for the UK. This extrapolated back to a hypothetical zero access to substitute prescribing and adequate needle exchange, leading to an estimate that current service provision levels may have reduced what would have been a 65% infection rate among injectors to 40%. But to make further substantial progress would it was calculated require scaling up these interventions so that both reach not half the injectors in the UK, but at least 8 in 10. To do this would probably require both considerably more injectors to start using these programmes and for them to stay considerably longer.

Among the implications of these findings is that needle exchange services and commissioners should prioritise adequate provision of injecting equipment, an objective known to be furthered by liberal rather than restrictive distribution policies. Another is that exchanges can make their provision more effective by finding ways to promote treatment entry by their clients, like co-location with treatment services and active referral. These were among the recommendations made in 2009 by Britain's National Institute for Health and Clinical Excellence, in a report which saw a triumvirate of services – high coverage needle exchange, substitute prescribing, and the treatment of hepatitis C infection – as the foundation of an anti-infection strategy.

How far England (and probably even more so other UK nations) is from implementing such a strategy was revealed by an audit of the impact of the national hepatitis C action plan launched in 2004. At the end of the first decade of the 2000s hepatitis C was spreading more rapidly than in the early 2000s, infecting a quarter of injectors within three years of their starting to inject.

This means that the reduction Down across Britain from about 60% in the past month in the early 2000s to 37% in 2009 and 40% in 2010. in the sharing of injecting equipment seen among drug injectors surveyed at drug services has been insufficient to dent the spread of the highly transmissible hepatitis C virus. It has been estimated that to get to the point where less than 1 in 10 injectors in London are infected with hepatitis C would require the average injector to cut their sharing of used syringes from 16 times a month to one or two times, and that the impact of even this kind of achievement would be jeopardised unless sharing reductions extended to very recently initiated injectors.

Such a scenario is currently well beyond the capacity of available services. Exchange services in Britain and elsewhere are commonly patchily provided, under-funded and hampered by formal or informal restrictions on their abilities to 'flood the market' with hygienic injecting equipment. In the mid-2000s, in England access to sterile injecting equipment from needle exchanges fell well short (on average just one syringe per exchange user every two days) of the level needed to permit use of a fresh needle each time, and only a minority provided some other equipment such as sterile water. At about the same time in Scotland, syringe supplies from exchanges were even more limited – at best an average of one per user every three days, though since then distribution may have modestly increased.

When the entire population of injectors is considered whether or not they attend exchanges, the shortfall is bound to be greater still. For example, in 2000/1 exchanges in Brighton and Liverpool supplied enough equipment for just over 1 in 4 injections in their areas and in London 1 in 5, if anything less than a national estimate for England for 1997.

Last revised 25 October 2012. First uploaded 14 October 2011

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The family drug and alcohol court (FDAC) evaluation project: final report.

Harwin J., Ryan M, Tunnard J. et al.
Uxbridge: Brunel University, 2011.
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The first family drug and alcohol court in Britain offers intensive specialist support to parents of children at risk due to parental substance misuse; the result in this small-scale pilot study was better parental and child outcomes at lower cost.

Summary The first family drug and alcohol court in Britain was piloted at an inner London family court initially for three years to the end of 2010, later extended to March 2012. Aiming to improve children's outcomes by addressing the entrenched difficulties of their parents, it takes a new approach to proceedings to protect children from parental neglect or abuse where parental substance misuse was a key element in the local authority's decision to bring proceedings. The catalysts for the pilot were encouraging evidence from such courts in the USA and concerns about the response to parental substance misuse through ordinary care proceedings in England: poor child and parent outcomes; insufficient coordination between adult and children's services; late intervention to protect children; delay in reaching decisions; and the soaring costs of proceedings, linked to the cost of expert evidence.

Working with the court is a unique, specialist multi-disciplinary team of practitioners provided by a partnership between a local NHS trust and a children's charity. The team carry out assessments, devise and coordinate an individual intervention plan, help parents engage and stay engaged with substance misuse and parenting services, carry out direct work with parents, get feedback on parental progress from services, and provide regular reports on parental progress to the court and to all others involved in the case. Attached to the team are volunteer mentors to support parents.

Cases are heard by two dedicated district judges, with two further judges as back-ups. Cases are dealt with by the same judge throughout. Guardians for the children are appointed immediately. Legal representatives attend the first two hearings after which there are fortnightly court reviews which they attend only if there is a particular issue requiring their input. The reviews are the problem-solving, therapeutic aspect of the process. They enable regular monitoring of parents' progress and give judges the opportunity to engage and motivate parents, speak directly to parents and social workers, and find ways of resolving problems. In contrast, in ordinary care proceedings there are no dedicated judges or magistrates and little judicial continuity, no specialist team attached to the court, assessments may be ordered from a range of different experts and can take months to be delivered, lawyers attend all hearings, guardians are not immediately appointed, and there is little coordination of services for parents.

To evaluate this initiative, parents seen by the court between January 2008 (the start of the pilot) and the end of June 2009 were invited to join the study. In all 55 families with 77 children joined. Their progress was compared to that of 31 families with 49 children subject to care proceedings due to parental substance misuse brought by two other local authorities during the same period, but which did not send cases to the family drug and alcohol court. Cases were followed up for six months from the first hearing. It was also possible to track 41 family drug and alcohol court and 19 comparison cases to the final order imposed by the court. Interviews were held with 37 parents adjudicated by the family drug and alcohol court and with the court's judges, specialist team, and staff and commissioners involved in the set-up and implementation of the court. Focus groups were also held with parent mentors and with professionals involved in cases over the first 18 months of the pilot.

Main findings

Official records were used to assess the nature and progress of the specialist court and comparison samples and the services they received. Both samples consisted generally of entrenched cases of parental drug and alcohol (rarely alcohol alone) problems and most mothers had previously been treated for these problems. In each sample there were high rates of domestic violence, mental health problems, criminal convictions, housing problems, a history of parents being in care, and contact with children's services. However, in some respects the specialist court saw more difficult cases. Mothers had longer substance use histories more often involving heroin, and more families had previously had children removed in care proceedings.

Records showed that parents seen by the specialist court received more help more quickly than the comparison sample, in particular substance misuse treatment. The specialist court ensured parents accessed its core services within three weeks, coordinated access to community services, and more of its parents were helped by finance, housing and domestic violence services, probably because the court had developed a dedicated link with such services in each pilot local authority area. However, there was no difference in the range and type of services received by the children. Assessments conducted for the specialist court uncovered more unmet needs in relation to substance misuse, domestic violence and maternal mental health than had been identified by the local authorities applying for care proceedings.

Among cases tracked through to the final court order, more specialist court parents engaged with substance misuse services and more remained engaged throughout the proceedings. Probably as a result, by the end 48% of mothers seen by the specialist court and 36% of fathers were no longer misusing substances compared to 39% and none at comparison courts. Associated with this, more mothers at the specialist court (39%) than in the comparison sample (21%) were living at home and reunited with their children. More specialist court than comparison children had improved well-being at the end of proceedings, but this may have been due to their relative youth.

On average it took a few weeks longer for specialist court children to be reunited with their parents but less time for them to be placed in a permanent alternative home, possibly reflecting the common view that time in proceedings was used more constructively in the specialist court but that when reunification was not considered advisable, action was taken sooner to stabilise the children's lives.

Costs calculated for 22 specialist court families and 19 comparison families whose cases had reached final order by the end of May 2010 indicated savings in relation to court hearings and days spent by children in out-of-home placements (specialist court children averaged 153 days compared to 348 days for comparison cases). The expert reports, assessments and testimony of the specialist team also saved money in the cost of independent experts. It is likely that shorter hearings, and fewer hearings with legal representation, also produce savings.

These quantitative findings based on records were illuminated by the views of parents and officials gathered through interviews and focus groups. Parents were overwhelmingly positive about the specialist court team for motivating and engaging them and for their non-judgemental attitude and practical assistance. Judicial praise and encouragement was motivational and judges were seen as 'treating you like a human being'. Judicial continuity was appreciated.

Unanimously both parents and staff saw the specialist court as preferable to ordinary care proceedings. Staff valued the specialist team for the speed and the quality of its assessments, ability to engage parents, efficient coordination of an often complex intervention plan, speed and reduced cost of drug and alcohol tests, its role in getting feedback from adult substance misuse and other services, and its active promotion of partnership work and reflective practice. Judicial continuity too was widely valued, partly because it enabled more efficient use of court time, and because the judges were able at the same time to be friendly, supportive and motivating of parents, but also to give clear messages about the consequences if they failed to comply. The direct and usually lawyer-less communication between judges and parents and social workers resulted in less conflict and antagonism than in ordinary care proceedings and greater involvement of parents, while frequent reviews ensured any problems (some outside the normal remit of the court, such as housing, finance, or the delivery of services) were identified and responded to quickly.

Over the pilot the specialist team developed a 'fair test' approach to assessing parents: an initial period where parents are supported to control their substance misuse; a second stage to see whether recovery can be sustained; a third stage focused on parenting; and a fourth stage of supported rehabilitation. The approach affords parents every support to overcome their drug and alcohol problems so they can show they can safely look after their children. Such an approach might however lack credibility if cases have to revert to ordinary care proceedings. Initial concerns that children suffered from the time parents were given to sort out their problems receded as the pilot progressed.

The authors' conclusions

These findings suggest that the specialist family drug and alcohol court is a promising approach to the protection of the children of substance misusing parents subject to care proceedings. More parents seen by specialist than comparison courts had controlled their substance misuse by the end of proceedings and been reunited with their children. They were also engaged in more substance misuse services over a longer period. There is evidence of cost savings in relation to court hearings, out-of-home placements, and fewer contested proceedings. Parents and staff felt this was a better approach than ordinary care proceedings.

Given the similarity in specialist and ordinary court families, it is reasonable to infer that the specialist court's distinctive problem-solving approach combined with the expertise of the multidisciplinary team played an important part in these results. What makes the court distinctive includes: the alacrity of assessment and treatment; the extent and continuity of support to motivate parents; a multidisciplinary team committed to tackling the wide range of parents' problems and promoting inter-agency coordination, care planning and service delivery; a transparent process promoting honesty; an approach that conveys a sense of hope that change is possible whilst remaining focused on the child's need for permanency; judicial continuity and regular court reviews without lawyers, leading to improved case management, problems being identified and responded to quickly, less antagonism and improved parental engagement in the proceedings; and a supportive and reflective learning culture to keep motivation high when team members are dealing with hard cases.

The evaluators argue that the pilot court should continue so that it can consolidate progress, tackle some of the challenges, and test out the contribution of an expanded pre-trial and aftercare service below. Similar courts should be set up in one or two further sites to develop learning on implementing the model in different circumstances and test whether its results can be replicated in different areas with different staff.


The evaluation identified challenges, some of which are likely to be addressed over time, while others will need wider system changes. Recruiting mentors to support the parents is not questioned in principle but was poorly implemented. Lessons are that such schemes need adequate funding and support and sufficient development time. The specialist court is already building up a group of parents who have been through the programme and are interested in becoming mentors. Where parental progress in controlling substance misuse is poor, planning early for the possibility of an out-of-home placement for the child might reduce delays if this is the final outcome. Greater coordination with ordinary family courts would also aid transfer of cases between the two systems. Increasing the capacity of the court and the its judges to continue to deal with cases that have exited the family court would also reduce delays. This would require changes to the working arrangements of district judges.

Despite good inter-agency working overall, there were some tensions between adult substance misuse and children's services, and difficulties in resolving housing problems. Continued attention to joint planning and commissioning and to 'whole family' approaches will be important in addressing these issues. In both samples, more parents continued to misuse than regained control of their addiction, demonstrating the importance of identifying misuse earlier and supporting parents whilst remaining realistic about the prospects of change, so that very young children are given the best chances of a secure childhood. Earlier identification and support requires a workforce equipped with the skills and knowledge to work effectively with parental substance misuse, and a network of family-focused treatment services.

Finance is likely to remain tight. Funders should however consider that the family drug and alcohol court model has the potential for improving outcomes while saving costs, and that in the long term, not only local authority children's services could benefit, but also adult services, health services, probation, the courts and the Legal Services Commission.

Developing the model

Engaging the court's problem-solving approach earlier when cases are less entrenched might increase the chances of good outcomes; court action should not always be seen as a last resort but, but sometimes as an early intervention. Similarly, a pre-birth assessment and intervention service provided by the court's specialist team is being trialled in the three pilot local authorities in the hope that earlier provision of support will increase the chances of controlling substance misuse and of family reunification, and if this fails, result in alternative permanent care at for the child at an earlier age.

A short-term aftercare service for families living together at the end of the case might increase the sustainability of family reunification outcomes. However, at present, the court has no role after proceedings finish. It would be possible to incorporate continuing support from the specialist team in supervision orders on a case-by-case basis.

Findings logo commentary There can hardly be a more emotive and now also – as a US-inspired project has come to Britain offering to pay drug users to be sterilised – contentious issue than how to protect the children of problem substance users. It is certainly a huge and pressing problem. Well over a million children in Britain have parents with a drug or alcohol problem. Across the UK, national targets, service standards and policy statements have recently embodied the perspective that their welfare is a core concern for services in contact with problem drug users, a contention featuring strongly in the latest Scottish and English drug strategies. In England it forms a specific workstream of the National Treatment Agency for Substance Misuse (NTA), which has produced guidance on how authorities responsible for drug and alcohol services can work more closely with children and family services.

Establishing what works for those at risk among these children is difficult because it would be unethical to deliberately deny services in order to determine whether they really do help. However, the potential for interventions to do serious harm as well as create major benefits makes evaluation vital. Evaluations of specialist British services in Wales and Middlesbrough found they prevented the need for permanent placement of children in care and reduced time in temporary placements. These services offered intensive support to the parents in much the same way as the specialist court team but on a short-term basis and without the authority of the court behind them. As the featured report commented, such services attempt to help families already at the brink of losing care of their children. Before that point there is a strong case for offering parenting and child welfare interventions to all problem substance users in contact with treatment and harm reduction or other services. Because these offer positive support without implying parental failure, they often have a good uptake and can reduce the numbers who reach crisis point.

A later report from the same study with a longer follow-up of more families reinforced the earlier findings. More family drug and alcohol court parents had stopped misusing substances and dealt with other problems, and more mothers had been reunited with their children, but this 36% v 24% gap was not statistically significant.

The main weakness of the featured study is that in some known respects and perhaps in others not known, the comparison families differed from the family drug court families in ways which might have affected child welfare outcomes, regardless of the type of court proceedings. Also, through a preceding feasibility study the researchers had been involved in developing the programme they evaluated, raising the possibility of their somehow favouring the new court, a risk endemic The so-called ‘researcher allegiance’ effect. In several social research areas,1 programme developers and other researchers with an interest in the programme&‘s success have been found to record more positive findings than fully independent researchers, possibly an instance of the general finding2 that expectations (eg of teachers of their pupils) affect performance via unintended changes in how the individual is treated. Such overlaps between developers and researchers are endemic3 in drug problem and other social research areas.

1. http://dx.doi.org/10.1007/s11292-009-9071-y
2. http://dx.doi.org/10.1037/0003-066X.57.11.839
3. http://dx.doi.org/10.1016/j.evalprogplan.2007.06.004
in much substance use research.

Three NHS professionals who helped develop the court evaluated by the featured study have explained that it differs from normal family courts in its multi-disciplinary assessment and intervention team made up of both child workers (child protection social workers and a child and adolescent psychiatrist) and adult workers (substance misuse workers and an adult psychiatrist), plus volunteers with personal experience of overcoming substance misuse, some of whom are court ‘graduates’. Court proceedings form an integral part of the treatment process. The family works with the same judge throughout and the court takes a less-adversarial approach to care proceedings, the parent speaking directly to the judge in the absence of lawyers.

Similar courts have opened in Gloucestershire and Milton Keynes and as reported in 2015, more were due to open in 2015/16 in areas including East Sussex, Kent and Medway, Plymouth, Torbay and Exeter, and West Yorkshire, funded by the Department for Education. Despite this significant expansion, as in London, these courts will sit once a week and hear a relatively small number of cases.

An Effectiveness Bank hot topic has explored the issues involved in protecting children and offers one-click access to all Findings analyses relevant to child protection.

Last revised 21 May 2015. First uploaded 08 October 2011

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