Drug and Alcohol Findings home page in a new window EFFECTIVENESS BANK BULLETIN 25 January 2012

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


Contents

Home visits cost-effectively aid alcohol treatment ...

Group therapy wins on cost-effectiveness grounds ...

Dual diagnosis patients benefit from heroin prescribing ...

Brief motivational interviewing works best for thinkers ...


Cost-effectiveness of home visits in the outpatient treatment of patients with alcohol dependence.

Moraes E, Campos G.M., Figlie N.B. et al.
European Addiction Research: 2010, 16, p. 69–77.
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 Moraes at nanemoraes@uol.com.br.

In Brazil adding home visits to a three-month alcohol detoxification and treatment programme cost-effectively increased the abstinence rate at the end of treatment.

Summary The featured report is a cost-effectiveness analysis based on a study conducted in the mid-2000s in Brazil comparing outpatient alcohol treatment with versus without additional home visits. In the trial 120 alcoholic patients starting outpatient treatment at a clinic in São Paulo were allocated to a multidisciplinary unit devised for the study. It offered a standard three-month treatment programme of detoxification plus 20 group therapy sessions based on relapse prevention techniques and motivational interviewing. A randomly selected half of the patients were also offered four home visits beginning at the start of the treatment and then weekly, during which therapists used motivational interviewing principles and techniques to enhance the patient's and family's adherence to treatment.

Main findings

The main criterion of successful treatment – abstinence during what was intended to be the last month of treatment – was achieved by 43% of patients not offered home visits and 58% offered these visits, a substantial but not statistically significant difference, so one subject to considerable uncertainty. Taking in to account the treatment itself, other medical costs, and productivity losses, the costs associated with outpatient treatment amounted to 602 Brazilian Real per patient; with home visits, costs increased to 819 Brazilian Real per patient. However, home visits led to more patients achieving abstinence. Per extra abstinent patient, the extra cost associated with home visits was 4260 Brazilian Real or 1852 US dollars, though this figure varied considerably when different assumptions were made about the success rates of the treatments.

The authors' conclusions

According to the yardstick adopted by the World Health Organization, the extra abstinence rate gained by home visits means these count as a cost-effective health intervention, and the extra costs are highly likely to be outweighed by social cost savings.


Findings logo commentary The structured nature, explicitly motivational approach, and clear objectives of the home visits in this study may have been critical to their achieving a greater abstinence rate. In one British study (details below), how visits were done made the difference between practically no patients controlling their drinking 12 months later versus a substantial minority.

A British study has suggested that what happens during home visits has a major impact on sustained success after detoxification. In this study half the patients were randomly allocated to standard home detoxification consisting of five home visits by a community psychiatric nurse who gave medication and advice to help control withdrawal symptoms and reduce discomfort. The other half were allocated to the same procedure over the same time periods conducted by the same staff, except that the advice element was structured via a manual into three phases. The first session adopted a non-confrontational style aimed at building rapport and motivation. The next two aimed to help the patient manage and accept discomfort and to develop and practice specific relapse prevention skills. The last two aimed to engage the patient's friends and family in supporting their recovery and developing new social activities.

Researchers interviewed patients three (92% contacted) and twelve (86% contacted) months after the detoxification and the results were compared with pre-treatment assessments. On every measure of drinking including abstinence and amount overall or per drinking day, patients given structured counselling had made greater reductions. In the three months before the 12-month follow-up, just three out of 40 standard detoxification patients were abstinent or drinking at relatively safe levels compared to 15 out of 38 given structured counselling. The latter also experienced greater reductions in alcohol-related problems and improved social satisfaction and self-esteem. Cost estimates suggest that even accounting for the training required, the home detoxification programme was a ninth the cost of an inpatient detoxification and under half the cost of an outpatient procedure.

Thanks for their comments on this entry in draft to Edilaine Moraes of the Federal University of São Paulo. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 24 January 2012

Comment/query to editor
Back to contents list at top of page
Give us your feedback on the site (one-minute survey)
Open Effectiveness Bank home page
Add your name to the mailing list to be alerted to new studies and other site updates


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

STUDY 2005 Structured nursing advice helps alcohol home detox patients keep staying sober

STUDY 2011 Modeling the cost-effectiveness of health care systems for alcohol use disorders: how implementation of eHealth interventions improves cost-effectiveness

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

STUDY 2009 Randomized controlled trial of a cognitive-behavioral motivational intervention in a group versus individual format for substance use disorders

STUDY 2006 UK trial bolsters case for well-supervised alcohol therapy

STUDY 2001 Brief motivational therapy minimises health care costs except among more problematic drinkers

STUDY 2008 Still hard to find reasons for matching patients to therapies

STUDY 2004 Dual diagnosis add-on to mental health services improves outcomes

STUDY 2002 Group cognitive-behavioural therapy can work well and save money

STUDY 2010 Initial preference for drinking goal in the treatment of alcohol problems: II. Treatment outcomes





Randomized controlled trial of a cognitive-behavioral motivational intervention in a group versus individual format for substance use disorders.

Sobell L.C., Sobell M.B., Agrawal S.
Psychology of Addictive Behaviors: 2009, 23(4), p. 672–683.
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 Sobell at sobelll@nsu.nova.edu. You could also try this alternative source.

For US problem drinkers and drug users not at the severest end of the spectrum, four sessions of group were as effective as four of individual therapy but took much fewer therapist hours per patient. The little research we have suggests this a common finding, commending group approaches on cost-effectiveness grounds.

Summary Despite the popularity of group-based therapies for substance use problems, just four studies have directly compared outcomes from the same treatment delivered in a group versus an individual format. Each found substance use reductions which did not significantly differ between the formats.

The featured study aimed to add to this scarce literature by randomising problem drinkers and drug users who were not severely dependent to group versus individual formats of the Guided Self-Change Treatment Model. The approach combines motivational interviewing style and techniques with cognitive-behavioural elements, and was developed as a brief treatment for low severity alcohol problems. It features personalised feedback of assessment findings to clients (eg, extent of use, health risks), decisional balance exercises weighing the pros and cons of change, and advice for clients on selecting their treatment goal.

Patients were referred to a Guided Self-Change clinic in Toronto, Canada, or self-referred after seeing an advert aimed at people "Concerned about your drinking (drug use)". Very heavy or highly dependent drinkers or drug users, injectors, and primary heroin users were screened out of the study. The 231 problem drinkers and 56 problem drug (mainly cocaine or cannabis) users who qualified for and agreed to join the study were allocated as appropriate to alcohol or drug versions of the intervention, and then randomly to group Closed groups of four to eight clients with two therapists who promoted and used group processes (eg, therapists facilitated social interactions and encouraged group members to share their experiences and provide feedback to other members) throughout all sessions. or individual formats run by the same therapists. Group and individual formats were intended to run over four sessions of one and a half to two hours and one hour respectively.

264 clients attended at least the first treatment session, forming the cohort whose outcomes were analysed by the study. Of these, all but 23 completed follow-up assessments 12 months after treatment ended. The 264 patients were typically employed men in their thirties and forties and most had never before been in substance use treatment.

Main findings

Around 80% of patients completed all four sessions in both group and individual formats. Most drinkers and cannabis users opted to moderate their consumption, most cocaine users to abstain.

As a whole, while in treatment patients treated for drinking problems significantly reduced their drinking on various measures and then further in the following 12 months. For example, in the 12 months before treatment they were drinking on around 7 in 10 days and on each of these days consumed about 89g of alcohol or 11 UK units. In the 12 months after treatment the corresponding figures were 4 to 5 days and 59g. From before treatment abstaining from their main drug 39% of days, following treatment the drug users abstained on 70% of days. Both drinkers and drug users also experienced fewer adverse consequences related to their substance use.

On none of these measures did individual and group therapy differ significantly or to any appreciable degree, and nor did they differ in terms of the patients' own assessments of the degree to which their problems had improved. Purely in terms of therapist hours per patient per session, group therapy demanded 59% of the time demanded by individual therapy so on this measure was more cost-effective.

Assessed for treatment completers after treatment ended, levels of client satisfaction with both group and individual formats were high but in some respects slightly and significantly higher for one rather than the other. Asked 12 months later which format they would have preferred, most (59%) of those who had experienced group therapy would have preferred individual attention, while few (6%) who had received this would have preferred group therapy.

The authors' conclusions

The featured study found comparable outcomes for alcohol and drug users who received the same Guided Self-Change treatment delivered in a group versus individual format. Both sets of clients reported significant improvements during treatment which were sustained to the 12-month follow-up. Group treatment, however, required 41% less therapist time for the same number of clients. When the cost of rescheduling appointments is considered, the benefits of groups become even more important (ie, groups are held even if clients miss a session). In this study retention in group therapy was about as high as in individual, perhaps aided by reminder telephone calls before sessions and information handouts on the benefits of group therapy. Because health care costs continue to increase, further development and evaluations of group therapy are warranted.


Findings logo commentary With equivalent outcomes, economy seems the key advantage of the group format. The risk is that bringing heavy and/or risky substance users together will create social justifications and pressures for continued heavy use and make this seem more, not less 'normal'. But when the participants have a joint reason to collaborate in curbing their substance use – typically when they have voluntarily entered treatment with this objective in mind – in studies which directly compared them, group psychosocial therapies (and cognitive-behavioural therapy in particular) have been found equivalent to individual approaches in retention and substance use outcomes. However, such studies are usually limited to comparing outcomes among clients prepared to be randomised to either treatment. Those with strong preferences or practical reasons for choosing one of the formats have been excluded or excluded themselves.

The first two authors have produced a book on the approach tested in the featured study offering clinicians resources, a detailed intervention framework and strategies for helping clients set and meet their own treatment goals.

Thanks for their comments on this entry in draft to Linda Carter Sobell of the Nova Southeastern University in Ft. Lauderdale in the USA. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 22 January 2012

Comment/query to editor
Back to contents list at top of page
Give us your feedback on the site (one-minute survey)
Open Effectiveness Bank home page
Add your name to the mailing list to be alerted to new studies and other site updates


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

STUDY 2011 Modeling the cost-effectiveness of health care systems for alcohol use disorders: how implementation of eHealth interventions improves cost-effectiveness

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

STUDY 2012 Motivational interviewing: a pilot test of active ingredients and mechanisms of change

STUDY 2005 Brief interventions short-change some heavily dependent cannabis users

STUDY 2010 Initial preference for drinking goal in the treatment of alcohol problems: II. Treatment outcomes

STUDY 2003 Alcohol counselling: try brief therapy first

STUDY 2009 What makes group MET work? A randomized controlled trial of college student drinkers in mandated alcohol diversion

STUDY 2001 Brief interventions help cannabis users cut down

REVIEW 2010 A meta-analysis of motivational interviewing: twenty-five years of empirical studies

REVIEW 2011 Effectiveness of e-self-help interventions for curbing adult problem drinking: a meta-analysis





Effects of psychiatric comorbidity on treatment outcome in patients undergoing diamorphine or methadone maintenance treatment.

Schäfer I., Eiroa-Orosa F.J., Verthein U. et al.
Psychopathology: 2010, 43, p. 88–95.
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 Haasen at haasen@uke.uni-hamburg.de. You could also try this alternative source.

In Germany, heroin-addicted patients suffering from mental disorders benefited more from being prescribed heroin than methadone and did so to almost the same degree as other patients, including greater remission in psychiatric symptoms.

Summary Whether heroin addicted patients also suffering from poor mental health benefit from being prescribed heroin was the question addressed by the featured report from the German heroin prescribing trial. This account draws on an earlier Findings analysis of the study, of which the featured report was a sub-study.

The parent study trialled the prescribing of heroin for the treatment of heroin addiction at seven German clinics. Over the years 2002 and 2003 it successfully recruited 1015 patients who were regularly injecting heroin and in poor physical or mental health despite being in methadone maintenance treatment, or having been treated for their addiction in the past, but not in the last six months.

Patients were randomly allocated to either be prescribed heroin to be taken under supervision at the clinics plus oral methadone, or only oral methadone. Cutting across this allocation, they were also randomly allocated to two forms of psychosocial support: case management conducted along motivational interviewing lines and intended to flexibly coordinate an individualised care package from various services; or a more standard and directly delivered series of individual counselling and group therapy sessions. Which of these support programmes a patient was allocated to made no difference to the main outcomes, so reports have focused on the pharmacotherapy options.

Earlier reports recorded that compared to methadone, the heroin option retained more patients for a year and enabled more to substantially curb illicit heroin use without countervailing increases in cocaine use. More heroin patients also experienced improved health. However, the new methadone programme was itself far from ineffective; though previous treatment had been unsuccessful, many methadone patients also substantially cut their heroin use and experienced improved health.

Main findings

The featured report was based on findings from 626 patients who completed an extended assessment of their psychological health. To do this they had to have been retained in the study for at least a month. Among these, 485 completed a year of the treatment to which they had been allocated.

Initial assessment revealed that at the start of treatment about half were 'dually diagnosed' as suffering from a diagnosable psychiatric condition, mainly a disorder of mood, neurosis, stress, or psychosomatic conditions. Regardless of whether prescribed heroin or methadone, only slightly and non-significantly fewer such patients were retained in treatment for a year as patients not suffering mental health problems (in all 75% v. 80%). Regardless of whether they were dual diagnosis patients, among those who were retained, psychological distress and psychiatric symptoms remitted more fully among patients prescribed heroin. Like patients in general, given heroin rather than just methadone, dual diagnosis patients more often substantially curbed illicit heroin use without countervailing increases in cocaine use, and more often experienced substantially improved health. However, in these respects the advantage gained by heroin was slightly less than among patients not diagnosed with a psychiatric condition.

The authors' conclusions

Among the study's caseload (continuing to regularly inject heroin and in poor physical or mental health despite prior or current treatment), as with other patients, patients with psychiatric conditions benefited more from heroin prescribing than methadone-only programmes in terms of improved health and reduced illicit drug use. However, these benefits were slightly less marked than among other patients, perhaps partly because anxiety or depressive disorders respond to methadone's sedative effects. However, the study excluded patients whose mental disorders were so severe that they jeopardised participation in the trial, accounting for the unusually low number suffering from schizophrenia-type disorders. The same limitation applies to patients with personality disorders.

The implication is that psychiatric comorbidity of the kind included in the trial need not be a reason to exclude patients from heroin-based treatment and that, more so than methadone, such treatment can help resolve their psychiatric and substance use problems. The structure and clinical contact imposed by having to visit the clinic several times a day for supervised heroin consumption may have been one reason why dual diagnosis patients responded well to this treatment.

This draft entry is currently subject to consultation and correction by study authors.

Last revised 24 January 2012

Comment/query to editor
Back to contents list at top of page
Give us your feedback on the site (one-minute survey)
Open Effectiveness Bank home page
Add your name to the mailing list to be alerted to new studies and other site updates


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

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

STUDY 2010 The Andalusian trial on heroin-assisted treatment: a 2 year follow-up

STUDY 2010 Effectiveness of diacetylmorphine versus methadone for the treatment of opioid dependence in women

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

REVIEW 2012 BAP updated guidelines: evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP

STUDY 2010 The SUMMIT Trial: a field comparison of buprenorphine versus methadone maintenance treatment

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

REVIEW 2003 Role Reversal





Thinking about drinking: need for cognition and readiness to change moderate the effects of brief alcohol interventions.

Capone C., Wood M.D.
Psychology of Addictive Behaviors: 2009, 23(4), p. 684–688.
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 Capone at Christy_Capone@brown.edu. You could also try this alternative source.

This US study found that different types of heavy-drinking college students responded best to different types of brief intervention to promote moderation; a novel finding was that the thinkers among them were most affected by being led to reflect on how their drinking compared to that of the average student.

Summary The featured report derives from a study of brief interventions to reduce drinking and drink-related problems in heavy-drinking US college students. It is concerned less with whether the interventions were effective, than with whether they were more or less effective with different types of individuals or people at different stages in their readiness to change their drinking.

Via flyers and advertisements, Inviting students to join a research project on students' beliefs about drinking the original study recruited 335 20–24-year-old students whose screening responses indicated they were heavy drinkers. They were randomly assigned to:
• Only be assessed with no intervention – the control A group of people, households, organisations, communities or other units who do not participate in the intervention(s) being evaluated. Instead, they receive no intervention or none relevant to the outcomes being assessed, carry on as usual, or receive an alternative intervention (for the latter the term comparison group may be preferable). Outcome measures taken from the controls form the benchmark against which changes in the intervention group(s) are compared to determine whether the intervention had an impact and whether this is statistically significant. Comparability between control and intervention groups is essential. Normally this is best achieved by randomly allocating research participants to the different groups. Alternatives include sequentially selecting participants for one then the other group(s), or deliberately selecting similar set of participants for each group. group against whom the interventions could be benchmarked;
• A brief (one session up to one hour) intervention based on motivational interviewing which featured feedback on how the student's drinking compared to the average, the risks it posed, and strategies to reduce these risks;
• A two-session 'alcohol expectancy' intervention which challenged beliefs about the effects of drinking. In a simulated bar students were offered alcoholic or mock alcoholic drinks and asked to identify who including themselves had drunk alcohol. Guided discussions highlighted mistaken beliefs about how alcohol affected the students and the positive and negative effects of alcohol in social (session 1) and sexual contexts (session 2);
• A combination of both the above interventions.

Follow-up assessments one, three and six months later re-assessed the drinking of from 82% to 72% of the students. Among those missing were 44 deliberately omitted because they could not attend one of the alcohol expectancy sessions. An earlier report established that (relative to assessment only) the interventions did reduce drinking and that the motivational session also reduced related problems. People who scored more ready to reduce their drinking at the start of the study made the greatest reductions.

Did certain types of students respond better to the interventions?

The featured report investigated whether three characteristics of the students affected how much they cut their drinking and related problems in response to the interventions.

The first was their need for cognition. Individuals highly endowed with this need tend to make sense of their world through reflection and inquiry and like tasks which require reasoning and problem solving. Brief interventions based on motivational interviewing which require reflection on individualised feedback on the participant's drinking seem particularly suited to this type of personality. In line with this expectation, it was thought that in response they would curb their drinking more than people less keen on thinking things through.

Another potential influence on intervention effectiveness is readiness to change, as measured along the continuum described by Prochaska and DiClemente from precontemplation (not considering change) through several stages to action (taking steps to implement a plan for change) and beyond. People who are more ready to contemplate change should be more responsive to interventions promoting change.

The opposite can be expected of people characterised by impulsivity and sensation seeking. Associated with greater alcohol use and problems, these traits can be expected to reduce responsive to interventions which try to promote control over drinking.

Main findings

As expected, compared to other students, six months later the motivational intervention was found to have had a greater impact on students characterised by a strong need for cognition. They had made greater reductions in their total consumption and in the number of times they drank heavily at a single sitting. Also as expected, the same drinking measures had been reduced more by the alcohol expectancy challenge when students had initially been more ready to change their drinking. However, readiness to change did not affect how well the motivational intervention worked, impulsivity and sensation seeking were not influential with respect to either intervention, and none of the three characteristics affected how well the interventions reduced drink-related problems.

The authors' conclusions

The findings of the featured and the earlier reports confirm and extend research demonstrating an association between readiness to change and reductions in drinking among college students, and also showed that high readiness made the alcohol expectancy challenge more effective in reducing drinking. The fact that students at whatever level of readiness to change responded equally well to the motivational intervention seems to confirm that such interventions can work, even with people who at first do not feel they need to cut down. But from this study it seems they may work less well with people who are not keen on thinking things through.

The findings have clear implications for prevention planners. In this study, individuals who tend to engage in hard thinking and reasoning benefitted more from an intervention which featured discussion of personalised feedback on their drinking and risks. On the other hand, compared to less ready students, those who endorsed a higher degree of readiness to control their drinking benefitted more from the expectancy challenge, perhaps because this approach is more attuned to the 'action' stage of motivational readiness. The particular version used in the study focused on debunking the notion that 'more is better' by showing that effects typically viewed as desirable (eg, sociability, relaxation) also occur at lower levels of drinking.

In aggregate, our results provide further support for brief motivational and expectancy challenge approaches with heavy drinking students, and identified two features of the participants (readiness and need for cognition) which should be considered in the design and implementation of future intervention efforts.

Last revised 01 February 2012

Comment/query to editor
Back to contents list at top of page
Give us your feedback on the site (one-minute survey)
Open Effectiveness Bank home page
Add your name to the mailing list to be alerted to new studies and other site updates


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

STUDY 2009 What makes group MET work? A randomized controlled trial of college student drinkers in mandated alcohol diversion

REVIEW 2010 A review of motivational interviewing-based interventions targeting problematic drinking among college students

STUDY 2010 Clinical outcomes of a brief motivational intervention for heavy drinking mandated college students: a pilot study

STUDY 2009 Dismantling motivational interviewing and feedback for college drinkers: a randomized clinical trial

REVIEW 2014 Interventions to reduce substance misuse among vulnerable young people

STUDY 2010 Brief physician advice for heavy drinking college students: a randomized controlled trial in college health clinics

REVIEW 2015 Electronic interventions for alcohol misuse and alcohol use disorders: a systematic review

REVIEW 2012 Computer based alcohol interventions

REVIEW 2012 Efficacy of brief alcohol screening intervention for college students (BASICS): a meta-analysis of randomized controlled trials

STUDY 2012 Alcohol screening and brief intervention in emergency departments





L10 Web Stats Reporter 3.15 LevelTen Hit Counter - Free PHP Web Analytics Script
LevelTen dallas web development firm - website design, flash, graphics & marketing