EFFECTIVENESS BANK BULLETIN 26 February 2010
EFFECTIVENESS BANK BULLETIN 26 February 2010The entries below are our accounts of documents selected by Drug and Alcohol Findings as particularly relevant to improving outcomes from drug or alcohol interventions in the UK. Entries were drafted after consulting related research, study authors and other experts and are © Drug and Alcohol Findings. Permission is given to distribute these entries or incorporate passages in other documents as long as the source is acknowledged including the web address http://findings.org.uk. However, the original documents were not published by Findings; click on the Titles to obtain copies. Free reprints may also be available from the authors; if displayed, click Request reprint to send or adapt the pre-prepared e-mail message. Abstracts are intended to summarise the findings and views expressed in the study. Below are comments from Drug and Alcohol Findings. Links to source documents are in blue. Hover mouse over orange text for explanatory notes.
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Broaden access to 12-step groups by de-emphasising philosophy, emphasising social support ...
When feasible, couples therapy helps alcohol-dependent women sustain their recovery ...
Can traditional herbal remedies or acupuncture help treat addiction? ...
UN guidance on how to mount family-based prevention programmes ...
Changing network support for drinking: Network Support Project 2-year follow-up.Litt M.D., Kadden R.M., Kabela-Cormier E. et al. Request reprint
Journal of Consulting and Clinical Psychology: 2009, 77(2), p. 229–242.
Treatment services do not have to adopt, or ask patients to adopt, the belief system on which 12-step groups are founded in order to effectively encourage patients to tap in to the social support offered by these groups and improve their chances of sustained abstinence.
Abstract This account also draws on an earlier report on the same study. Media ads offering free treatment for drinking problems attracted 348 people to phone a US medical centre of whom 297 met the study's
requirements
At least 18 years old, meet criteria for alcohol dependence or abuse, willing to accept random assignment to any of the three treatment conditions. Individuals were excluded if they had acute medical or psychiatric problems requiring inpatient treatment, were dependent on drugs (except nicotine and cannabis), had injected in the past three months, poor reading ability, no reliable transportation to the treatment site or excessive commuting distance, were already engaged in substance abuse treatment or regular AA attendance, or denied drinking in the past 60 days.
and 210 joined the study. Nearly all met diagnostic criteria for
dependence
As defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM–IV): a maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
• Tolerance, as defined by either of the following:
a need for markedly increased amounts of the substance to achieve Intoxication or desired effect;
markedly diminished effect with continued use of the same amount of the substance.
• Withdrawal, as manifested by either of the following:
the characteristic withdrawal syndrome for the substance;
the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms.
• The substance is often taken in larger amounts or over a longer period than was intended.
• There is a persistent desire or unsuccessful efforts to cut down or control substance use.
• A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.
• Important social, occupational, or recreational activities are given up or reduced because of substance use.
• The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
on alcohol, most were white and employed, half were in a live-in relationship, on average they said they drank about
16–17 UK units
About 133gm
on three out of every four days, and had one prior treatment for alcohol dependence.
Participants were randomly allocated to one of three manualised treatments aiming to promote abstinence and offered over 12 weekly one-hour, one-to-one outpatient sessions. Most basic was case management during which practical, social or psychological barriers to abstinence were identified and patients directed to appropriate services. The main interest of the study was how an alternative network support therapy performed. Though derived from a 12-step based approach, 12-step philosophy was downplayed. Instead the emphasis Other social networks were also explored, and the emphasis on AA was dropped among the fifth of patients who rejected this approach. was on using affiliation with Alcoholics Anonymous (AA) as a means of changing one's social support network, avoiding drinking friends, acquiring non-drinking friends, and enjoying activities other than drinking. The third treatment added contingency management to reinforce the network support option. It offered a prize draw opportunity to patients who provided proof signed by a third-party that they had completed recovery tasks set as part of network therapy, such as attending AA meetings, having coffee with a non-drinking friend, or signing up for a further education. Patients were assured that whether they drank had no bearing on the availability of prizes. Patients were reinterviewed By the last follow-ups typically about 60 out of 70 patients in each group could be re-assessed. by researchers after treatment ended and then every three months for another two years.
All three treatments yielded sustained abstinence and substantial increases As recalled by patients over the three months before the assessment. in non-drinking days. Contrary to expectations, drinking outcomes were best when network support was not incentivised by contingency management. When network therapy was implemented on its own, once treatment had ended the improvements were greater and more sustained than in either of the other two treatments. Towards the end of the follow-up, these patients avoided drinking on about 80% of days versus just over 60% for the other two treatments, and about 40% said they had been totally abstinent versus under 30%, statistically significant advantages. When supplemented by contingency management, during treatment patients did well, but the number of days they avoided drinking fell back after treatment ended. On abstinence yardsticks, case management patients did relatively poorly from the start, but by the final nine months they were doing as well as the contingency management patients whose gains had by then faded. On days they did drink, patients in all three treatments on average drank roughly the same amount, Towards the end of the follow-up, about six UK units or about 50gm, much less than before treatment. and there were no statistically significant differences in their experiences of negative alcohol-related consequences.
The study also assessed some of the 'mechanisms' through which the treatments might have affected drinking. Consistently the network support option led to the greatest and most sustained abstinence-supportive changes In terms of the number of contacts who were non-drinkers and how strongly the most important (to the patient) among them encouraged the patient also not to drink. in the patient's social circle. By the end of the follow-up period, adding incentives to the network support option retarded these changes to the point where networks were no more supportive of abstinence than after the basic case management option, which did not even try to alter social networks. The standalone network support option also led to greater increases in patients' confidence that they could resist drinking ('self-efficacy'), and in their repertoire of strategies for doing so. Network support patients tended to add non-drinking contacts to their social networks rather than to eliminate drinkers.
Finally the study tested whether these mechanisms did indeed account for the advantage network support patients had in days without drinking. The resultant model suggested that network support improved on the other two options by more effectively (in each case, as measured after treatment had ended) increasing AA attendance, how many non-drinking friends the patient had, their confidence in resisting drinking, and their strategies for doing so.
For the authors their findings showed that a treatment focused on changing the drinker's social environment can result in long-term changes in their social networks which contribute to improved drinking outcomes. AA attendance and increasing the number of non-drinking friends were strong predictors of drinking outcomes, appearing to increase abstinence partly by reinforcing patients' confidence in their ability to resist drinking.
The messages of the study seem to be that:
1 An approach which systematically bolsters non-drinking contacts and support in a drinker's social circle can lead to greater and more sustained abstinence than typical counselling which does not include this component.
2 Incentivising this approach with material rewards may not only be ineffective, but actually counterproductive.
3 12-step philosophy can be de-emphasised during treatment, yet the non-drinking social support 12-step groups offers remains an effective ingredient.
Each is examined below.
1 The first of these messages appears out of line with Britain's UKATT trial, which found that for alcohol problems a network approach was not superior to a therapy based on motivational interviewing. Possible reasons for this discrepancy are many. For network therapies, the most fundamental is that in Britain the UKATT therapy focused on generating support from the client's existing family and friends, if possible directly involving them in therapy sessions. In contrast, the featured study's network treatment relied mainly on new contacts made via mutual aid groups, who perhaps could be relied on more to model and encourage abstinence, with fewer of the complications involved in also for example being a spouse, close friend or work colleague. In UKATT the attempt to involve these and other people was described as a "mixed blessing", attracting the highest number of "least useful" assessments in both therapist and client post-session feedback reports, though more often it was seen as among the most useful elements. This polarisation Such a split in opinion was not apparent in reactions to the study's motivational therapy option. may derive from the attempt to involve people whose close and lasting/permanent relationship with the patient carries with it the potential for seriously obstructing as well as facilitating progress. Another variant on this type of approach helps avoid such problems by selecting only patients with a suitable, supportive and willing partner.
At a deeper level, in mutual aid groups the members are the vehicles of their own recovery Findings is grateful to Tim Leighton for making this point. and that of other members. The more active this participation, the greater are the benefits (1 2). In contrast, the UKATT therapy was a therapy; it required certain actions of the patient and a degree of participation, but in the context of something being done to rather than by them. The background notes deal with the issues of whether mutual aid groups are available and supported in the UK, and other differences between the featured study and UKATT which could account for the difference in outcomes.
2 How incentivising network support with material rewards made it less effective seems reasonably clear; why, less so. Especially towards the end of the two-year follow-up period, incentives weakened the network support option's positive influences on how many non-drinking friends the patient had, their confidence in resisting drinking ('self-efficacy'), and their strategies for doing so. Since all these partly accounted for impacts on abstinence, this too was weakened. A possible reason is that external incentives to engage in social network activities distracted patients from or diluted the impact of the rewards inherent in such activities, like praise and recognition for efforts to stop drinking. The study's authors highlighted the influence of post-treatment self-efficacy. It seemed as if during treatment patients relied on (or at least, saw themselves as relying on) the incentives to keep them on track. When these ended, they were left without the strong belief in their own ability which in other patients had been built up by the experience of resisting drinking without the need for incentives. The potential for material rewards to undermine 'intrinsic' motivation for engaging in, completing, or doing well at a task is well established. Though studies are few, such an effect has also been observed in substance use treatment, during which readiness to change, motivation, or confidence in one's ability to resist substance use were held back by contingency management relative to other therapies. The most relevant of these studies found that supplementing motivational and coping skills therapy with rewards halved what without the rewards was a substantial increase in confidence in ability to refrain from smoking cannabis. Such effects are however by no means inevitable. The meaning the patient attaches to the incentives is probably critical and can be influenced by how these are integrated in to accompanying therapy. The background notes explore this important issue further.
3 The implication that 12-step philosophy can be de-emphasised during treatment is potentially important for people who find it hard to embrace this philosophy, but would benefit from repeated and extended contact with committed abstainers. For the relatively secular UK, the 'higher power' steps and references to God seem the least appreciated and most off-putting of the 12 steps, the more so in one study among drinkers in treatment (the majority held these views) than drug users. In this study almost half the drinkers said the 12 steps would deter them from attending AA/ NA meetings. Focusing instead on the social network/support offered by mutual aid groups is also in line with findings from across health and mental health sectors (for example, among the elderly) of the adverse impacts of loneliness and the positive impacts of social support networks. The social support element was also highlighted by England's National Treatment Agency for Substance Misuse in its recommendations for effective commissioning for recovery.
However, it cannot be assumed that 12-step philosophy played no part in the featured study's outcomes. It seems unlikely that these beliefs remained de-emphasised while patients participated in Alcoholics Anonymous meetings. Potentially, fostering commitment to AA philosophy was one way AA attendance and non-drinking friends helped sustain abstinence, bolstered patients' confidence they could resist drinking, and extended their repertoire of strategies for doing so – all ways network support exerted a greater impact than the other treatments. Evidence has been found for
many ways
Those listed in the cited review were:
• problem recognition and commitment to change;
• regular re-motivation to continue change efforts;
• counter-norms that buffer the effects of heavy drinking social networks and substance use promotion in the wider culture;
• sustained self-monitoring;
• increased spiritual orientation;
• enhanced coping skills, particularly the recognition of high-risk situations and stressors;
• increased self-efficacy;
• social support that offsets the influence of pro-drinking social networks;
• helping others with substance use problems;
• exposure to sober role models and experience-based advice on how to stay sober;
• participation in rewarding sober activities;
• 24-hour accessibility of assistance; and
• potentially lifelong supports that do not require financial resources.
in which mutual aid supports abstinence. Social support is one, but may itself be sustained, justified and even mandated by 12-step traditions and philosophy, much in the way that the social support gained from (for example) joining sports clubs or churches may be sustained, justified and mandated by the traditions of the sport or religious beliefs involving obligations to others and communal worship. The background notes explore these issues further, concluding that 12-step groups mainly work through mechanisms common to other therapies, among which is social support, and in particular social support for abstinence. However, this particular form of support may have been highlighted because the research has generally adopted abstinence as its key outcome measure.
Despite some methodological limitations (of which the main one was that the patients had not sought treatment in the normal way background notes), the study offers a way for services in countries like the UK to tap in to the social support offered by mutual aid groups without having to ask patients to adopt the belief system or objectives on which 12-step groups are founded. Historically the perfectionist ideal of abstinence, though it originated in the UK, took root in the USA but was sidelined and even ridiculed in Britain, which was more comfortable (and still is) with a pragmatic approach embracing controlled drinking. The consequences seemed apparent in a study published in 2000, which found that only a small minority of alcohol treatment clients in the UK attend AA. Practical tactics for increasing mutual aid uptake include emphasising the concrete benefits and mutual support available through AA rather than the spiritual aspects, escorting patients to 'taster' meetings during treatment (with the escort perhaps being a former patient now attending AA), arranging an introductory meeting at the treatment service, and inviting AA members to address patients. Patients who attend AA during treatment are more likely to continue attending in the aftercare phase.
Thanks for their comments on this entry in draft to Mark Litt of the University of Connecticut Health Center, Paul Whelan of the North West London NHS Foundation Trust, Tim Leighton of the Centre for Addiction Treatment Studies at Action on Addiction, and Luke Mitcheson of the South London and Maudsley NHS Trust. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 18 February 2010 Background notes Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Initial preference for drinking goal in the treatment of alcohol problems: II. Treatment outcomes STUDY 2010
Effective services for substance misuse and homelessness in Scotland: evidence from an international review REVIEW 2008
Style not content key to matching patients to therapeutic approaches NUGGET 2008
Attending AA: encourage but don't coerce NUGGET 2000
Recovery management and recovery-oriented systems of care: scientific rationale and promising practices REVIEW 2008
Brief interventions short-change some heavily dependent cannabis users NUGGET 2005
Review of treatment for cocaine dependence STUDY 2010
A randomized trial of individual and couple behavioral alcohol treatment for women.McCrady B.S., Epstein E.E., Cook S. et al. Request reprint
Journal of Consulting and Clinical Psychology: 2009, 77(2), p. 243–256.
Alcohol dependent women experienced more lasting improvements when couples-based therapy embedded therapeutic processes in a lasting relationship with a willing husband or partner, extending an impressive research portfolio for the therapy.
Abstract Behavioural couples therapy assumes that substance use problems and intimate relationships are reciprocally related, such that substance use impairs relationship functioning, and severe relationship distress combined with attempts by partners to control substance use may prompt craving, reinforce substance use, or trigger relapse. To break this vicious cycle and transform the relationship in to a positive force, the therapy aims to build support for abstinence and to improve relationship functioning. A major limitation on applicability has been that the partner of the problem substance user must not themselves have a substance use problem. In respect at least of drinking, the featured study tried dispensing with this requirement. It sought to further broaden applicability by combining couples therapy with components aimed at the individual patient so the combination could be deployed as a standalone approach rather than (as typical in previous studies) supplementing other therapies.
Through adverts and referrals from local alcohol treatment services, contact was made with 351 women who seemed potentially eligible for the study. Apart from alcohol abuse or dependence, the main requirements were that the women were in a committed Defined as married, cohabiting for at least six months, or in a committed heterosexual relationship of at least one year's duration with intent to continue the relationship. relationship with a male partner who met criteria Either no evidence of domestic violence in the past year, or, if there had been any physical aggression, the victim reported no fear of retribution for discussions that might occur in couple therapy, and either the violence occurred only in the presence of intoxication or had not caused injury requiring medical attention. These assessments were conducted separately with each partner when the other was not present. intended to exclude men who might respond aggressively to involvement in therapy, and that neither were physically dependent on drugs other than alcohol. A further requirement that the man was willing to participate in research and treatment meant (it was known or presumed) that a third of the women could not join the study. In the end 109 joined, of whom 102 participated in at least one treatment session and formed the sample from whom outcomes were recorded. All but three were diagnosed as dependent on alcohol. Typically they were white women in their mid-40s who were working and/or looking after the home. At entry to the study they admitted drinking heavily Over three US drinks – about 42gm alcohol or just over five UK units. on nearly 60% of days in the past three months. Their partners were on average much less frequent drinkers, less likely to be heavy drinkers, and generally in full-time employment.
At random the women were allocated to one of two abstinence-oriented cognitive–behavioural therapies Neither featured other than trivial female-specific adaptations. intended to be delivered over 20 sessions for up to six months. The first was an individual approach involving only the woman and featuring typical Self-monitoring, analysis of the functions drinking served in the woman's life, and coping skills to avoid alcohol and deal with other life problems. cognitive–behavioural components. The second involved both partners. Couples sessions were extended from an hour to 90 minutes to incorporate the individual components of the first therapy plus interventions intended to teach the man to support abstinence, decrease attention to drinking, and improve the relationship through enhanced reciprocity, communication and problem-solving. The men were free (but not required) to use the therapy's interventions to change their own drinking, and if asked for, treatment referrals were offered. On average more individual therapy sessions were attended (15 versus 12) and more women completed the course (44% versus 24%). However, longer sessions meant that in total more hours were spent in the couples therapy.
Treatment progress was tracked every three months for a year and a half, mainly by interviewing each partner separately and selecting the 'worst' report on the woman's drinking over the past three months. In the year after treatment ended, women who had been in couples therapy were slightly (but the advantage was statistically significant) better able to sustain the rapid
improvements
These improvements in proportions of days spent (heavy) drinking were not due to more women totally avoiding these activities. Neither during nor after treatment was there any difference in the proportions of women who sustained total abstinence or totally avoided heavy drinking.
in proportion of days abstinent and days of heavy drinking seen in the first months of treatment. On average they ended up not drinking on 75% of days compared to 63% after individual therapy, and drank heavily on just 13% of days compared to 22% chart.
A composite measure combined the degree to which before treatment each woman was satisfied with their relationship, it was not characterised by aggression, and the woman's drinking was not triggered by relationship issues. After treatment had ended, only women in (according to this measure) relatively healthy relationships benefited more from couples therapy in terms of reducing the proportion of days they drank heavily. Women in unhealthy relationships did just as well in individual therapy. Women whose own psychological health was relatively poor when treatment started also benefited most clearly from the couples therapy.
The authors concluded that their results were consistent with other studies supporting the relatively greater efficacy of couple rather than individual treatment when both partners are prepared to participate. Together with these studies, the featured study suggests that couples therapy is effective for women of varied backgrounds and ages either as a standalone treatment or a supplementary therapy, may not require the accompanying partner to be free of drinking problems, and remains effective (perhaps particularly so) when the female partner starts treatment in relatively poor psychological health.
In research terms behavioural couples therapy is one of the best-established family approaches and among the best established of psychosocial substance misuse therapies in general, though generally as an adjunct to other approaches. Among women, two previous studies dealing respectively with drinking and drug/alcohol problems, had demonstrated its superiority to
treatments
In one study couples viewing lectures together and/or 12-step-based individual counselling; in the other, group and individual cognitive-behavioural therapy.
not involving family-based therapy. A recent
meta-analysis
A study which uses recognised procedures to summarise quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually.
synthesising results from relevant studies found that for the minority of patients for whom it feasible, acceptable and safe, the therapy reduces substance use relative to (mainly) individual therapies, and is more likely to improve the quality of family relationships. Improvements in relationships seem to pave the way for later relative gains in substance use outcomes, meaning that in some studies improvements were better sustained than after individual therapies. Though these outcomes were not included in the meta-analysis, studies have also shown that the therapy outperforms individual-based treatments in respect of child adjustment, cost-effectiveness, and reduced interpersonal violence. Behavioural couples therapy was one of only
two
The other was contingency management.
psychosocial therapies recommended by Britain's National Institute for Health and Clinical Excellence (NICE) for problems related to illicit drug use. Experts reached a similar conclusion after reviewing the alcohol treatment literature for England's National Treatment Agency for Substance Misuse (NTA).
Both NICE and the review for the NTA noted the therapy's limited applicability: normally the patient must share an intact, live-in relationship with a relative or partner not also experiencing substance use problems, and the relationship must be sufficiently supportive for both to productively engage with the therapy. Particularly when they engage women in the treatment of male substance users, care is also needed to exclude the risk that such therapies might perpetuate or aggravate victimisation by abusive partners. The featured study dispensed with the need for cohabitation and for the partner to be free of drinking problems, but in practice The men did not drink on two-thirds of days, just 1 in 7 drank heavily (over three US drinks – about 42gm alcohol or just over five UK units), compared (as the study noted) to other samples of male partners, they were relatively free not just of substance use but also psychological problems, and just five were living apart from their female partners. these extensions applied to very few couples. As such the study can only be considered a very partial test of whether relaxing these requirements makes any difference to the therapy's effectiveness. It seems likely that the requirement that the man be willing and able to help in the therapy will always tend to exclude those with serious substance use problems or whose relationship is such that they do not share a home with the woman. Despite the systematic selection of promising and willing couples, a few women who dropped out of treatment were uncomfortable at the presence of their partner in sessions, and the logistics of getting both along to therapy were at times difficult, perhaps partly accounting for poorer retention in the couples therapy. However, the viability and value of combining individual and couples therapy components does seem to have been demonstrated, widening the potential applicability of the approach.
Another limitation is the availability of family therapy of any kind. The dominant paradigm sees addiction as a disorder of the individual and treats it accordingly. Few substance misuse professionals have been trained in family approaches. A census of UK alcohol treatment agencies conducted in 1996 made no mention of family therapy at all. Calling for greater family involvement, in 2002 an article cited a "recent survey" of one of Britain's largest non-statutory alcohol agencies. During the census period, family members were involved (as couples) in the client's therapy in just three of 174 client contacts. In 2006 guidance from the English Department of Health and the National Treatment Agency for Substance Misuse did not specifically mention family therapy, mainly At most, help with family issues was seen as an adjunct "provided in parallel with the core treatment interventions for alcohol problems". seeing the family as a beneficiary of treatment rather than a participant.
When competent therapists are available, and the patient is in a committed relationship of the kind which makes involving the partner feasible, acceptable and safe, behavioural couples therapy seems preferable to non-family therapies, and the benefits are more likely to extend to the whole family. Such advantages may not be apparent to treatment staff; in this and previous studies (1 2) of female patients, improvements during treatment have generally been the same whether or not couples therapy was employed. This may be partly because much of the initial gains are to do with having made the decision and taken steps to enter treatment, rather than treatment itself. However, once treatment ends, embedding therapeutic processes in a lasting relationship seems to mean that the gains are better sustained. Where couples therapy is not possible, it should not be forgotten that individual therapies focused on the (in these studies, male) drinker also substantially benefit not just the patient, but their partners and children.
The featured study's strengths include excellent From 98% at first falling to at the final assessment 86%. follow-up rates and sophisticated statistical analyses. Of the methodological issues affecting confidence in its findings or their wider applicability, a major one is that most The study comments: "First, although we attempted to recruit from community treatment programs, most participants entered the study in response to direct advertising. Despite the potential limitations in such a recruitment strategy, the women were quite similar to reported samples of women in treatment in terms of quantity and frequency of drinking as well as levels of comorbid psychopathology." patients did not seek treatment in the normal way, but instead responded to the study's ads. Their motivations may have been to do with joining (with accompanying financial compensation) a study rather than simply seeking help. Some other issues are dealt with below.
Participants were relatively affluent compared to other caseloads. Research assistants who gathered the outcome data knew which treatment patients had been assigned to, opening up the possibility that somehow they favoured one of the treatments. So too does the fact that it seems They described it as "our model". the authors of the study themselves developed this version of the couples intervention. This also applies to most other studies of behavioural couples therapy, and studies not conducted by the developers usually produced the least convincing results. In substance misuse and in other sectors, research conducted by teams linked in some way to the intervention they are testing has been found (1 2 3) to produce more positive findings than fully independent research. The applicability of an intervention is severely limited if effectiveness depends on the involvement of the developers.
Six couples randomly allocated to couples therapy never participated in a single session versus just one allocated to individual therapy. These seven were left out of the analysis, compromising the equivalence of the two caseloads. Though few, at the (perhaps unlikely) extremes, very bad drinking outcomes among these women would have By the final follow-up point the 50 couples therapy patients drank heavily on 12.78% of days. Assuming the six omitted women drank heavily every day this proportion would be raised to 22.1% (([12.78x50] +[6x100])/56). By the final follow-up point the 52 individual therapy patients drank heavily on 22.46% of days. Assuming the one omitted woman drank heavily every day this proportion would be raised to 23.9% (([22.46x52] +[1x100])/53). almost eliminated the couples therapy's advantage in curbing the proportion of heavy drinking days by the end of the follow-up. The study did not report how the quality of the relationships between the partners developed in response to the therapies. What is known is that six of the 52 couples in individual therapy (12%) and 10 of the 50 in the couples therapy (20%) separated during the follow-up period.
Thanks for their comments on this entry in draft to Barbara McCrady of the Center on Alcoholism, Substance Abuse, and Addictions at the University of New Mexico. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 22 February 2010 Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Initial preference for drinking goal in the treatment of alcohol problems: II. Treatment outcomes STUDY 2010
Behavioral couples therapy (BCT) for alcohol and drug use disorders: a meta-analysis REVIEW 2008
Still hard to find reasons for matching patients to therapies NUGGET 2008
Cognitive-behavioral treatment with adult alcohol and illicit drug users: a meta-analysis of randomized controlled trials REVIEW ABSTRACT 2009
Dual diagnosis add-on to mental health services improves outcomes NUGGET 2004
Style not content key to matching patients to therapeutic approaches NUGGET 2008
Female drinkers also benefit from couples therapy NUGGET 2008
Traditional medicine in the treatment of drug addiction.Lu L., Liu Y., Zhu W. et al. Request reprint
American Journal of Drug and Alcohol Abuse: 2009, 35(1), p. 1–11.
A China-North America funding and authorship collaboration has assessed the evidence for the main traditional herbal remedies in addiction treatment, and made a new assessment of the role of acupuncture; generally, 'promising' was most positive verdict it could reach.
Abstract With joint Chinese and North American funding, a Sino-US author collaboration has reviewed evidence for the effectiveness and modes of action of traditional (not just Chinese) herbal remedies and acupuncture in the treatment of addiction to alcohol or other drugs. The reviewers accessed both Chinese and English language texts and databases and examined texts from before the advent of computerised databases.
They found few clinical trials have tested the effectiveness of herbal remedies. In summary, Radix Puerariae was the most promising for alcoholism, creating aversive physical reactions after drinking similar to those caused by disulfiram (Antabuse). There is some evidence for peyote in the treatment of alcoholism among Native Americans. Evidence is lacking for ginseng and kava, and the latter can be toxic to the liver. Thunbergia laurifolia can protect against alcoholic liver toxicity. Human clinical trial evidence is also lacking for Withania somnifera and Salvia miltiorrhiza, though animal experiments suggest that respectively they can reduce morphine tolerance and alcohol intake. Selected details below.
Radix Puerariae Also known as Kudzu, this is root of a plant native to eastern Asia and used for treating alcohol-related problems almost a thousand years ago. In animals its active ingredients have suppressed alcohol consumption. Two controlled clinical trials in human beings respectively found no impact on alcohol craving or sobriety, or a reduction in beer intake among heavy drinkers. The ingredient daidzin prevents the oxidation of acetaldehyde produced in the body when alcohol is metabolised, creating unpleasant physical reactions like those due to disulfiram. Several other effects on the brain's neurotransmitter systems may also be useful in treating addiction.
Ginseng The two major types of ginseng are Panax ginseng (Asian ginseng) and Panax quinquefolium (American ginseng). Panax ginseng modulates the neurochemical effects of some drugs, but no studies have tested whether this affects the degree to which animals or human beings repeatedly consume these substances. Panax quinquefolium, and specifically PF11, an active ingredient not present in the other form of ginseng, also modulates the neurochemical effects of some drugs, and does so in ways which suggest that it might reduce relapse in methamphetamine and opiate dependence and protect against methamphetamine-induced neurotoxicity.
Withania Somnifera Commonly called Ashwagandha, this medicinal plant is popularly known as 'Indian ginseng' because its biological effects are similar to those of Panax ginseng. It is widely used within the ancient Indian Ayurvedic medical system and as a home remedy for a range of problems. In one animal study it was found to attenuate the development of tolerance to morphine's analgesic effects and to suppress certain withdrawal symptoms. It may have promise as a non-analgesic herbal medicine for stress-induced relapse in drug abuse and dependence.
Kava Kava is commonly used by Pacific Islanders and indigenous Australians and has been used as a folk medical aid to stopping smoking or drinking. Human clinical research suggests it can reduce craving and promote abstinence in drug dependent patients. Animal studies have demonstrated relaxant, anaesthetic, anti-anxiety, and anticonvulsive properties. Because widely used for a long time, kava was thought to be safe, but has recently been associated with liver toxicity.
Tabernanthe iboga and Voacanga Africana Both contain the active ingredient ibogaine, used by indigenous peoples in low doses to combat fatigue, hunger, and in higher doses as a sacrament in religious rituals. Anecdotal reports and a preliminary investigation suggest it attenuates opiate withdrawal symptoms and reduces drug cravings, but no clinical trial in drug dependent patients has yet been conducted. In animals it has been shown to curb morphine and cocaine consumption. It seems to act by affecting several of the systems which transmit signals between nerve cells, but these actions also lead to undesirable side-effects. New synthetic variants are reported in animal studies to have potent anti-addiction properties with greater safety.
Thunbergia laurifolia Linn Though an anti-alcoholism treatment in Thai traditional medicine, no published clinical trial has examined this herb's effectiveness in treating substance use problems. In animals it protects against alcohol-induced liver damage and has been shown to affect central nervous systems and mechanisms related to the effects of alcohol and other drugs, in particular those involving the neurotransmitter dopamine.
Salvia miltiorrhiza Popular in Chinese traditional medicine, 'Danshen' as it is known is a folk treatment for several physical complaints and insomnia. In animal experiments it has curbed alcohol intake, seemingly due to its active ingredient miltirone which attenuates some of the neurochemical consequences of alcohol withdrawal. This ingredient also has certain amphetamine-like effects on animal brain tissue.
Banisteriopsis caapi This Amazonian woody vine is the basis for the hallucinogenic drink known as ayahuasca, a brew which enables its hallucinogenic ingredient DMT to be active via the oral route. Some religious groups in Brazil use it to treat alcoholism. In two clinical reports it was described as a possible treatment for cocaine addiction and found to reduce the desire for drugs such as alcohol, cocaine and amphetamines.
Corydolis yanhusuo Used in traditional Chinese medicine as an analgesic, l-THP, Corydolis' primary active chemical, has in animals been found to attenuate opiate and opiate withdrawal effects and reduce cocaine consumption. In China a clinical trial involving recovering heroin-dependent patients found that l-THP reduced drug craving, withdrawal syndromes, and relapse rates. It acts on dopamine-based neurotransmitter systems in ways which suggest a potential for affecting the development of tolerance, dependence, and sensitisation to opiate-type drugs and for the 're-normalisation' of
brain function disrupted by chronic drug dependence.
Lophophora williamsii Known as peyote, this cactus grows wild in Mexico and the southern USA. It contains the hallucinogenic chemical mescaline and is commonly used by several native American tribes, among whom it is consumed as a religious sacrament. Its hallucinogenic properties have also been used in psychotherapy at a US public hospital to precipitate rapid transformations in how drinkers feel and behave toward alcohol.
Acupuncture is a traditional technique developed over two thousand years ago based on the insertion of needles or more recently electrical stimulation, based on the Chinese medical theory that diseases are caused by blockages in the flow of energy within the body. It is now widely used to treat withdrawal syndromes in substance use treatment centres across the United States and Europe. There is evidence that it is effective (and for how it is effective) in ameliorating opiate withdrawal symptoms, but also that it is relatively ineffective for alcohol and nicotine withdrawal or in preventing post-withdrawal relapse, and no large studies have supported its efficacy for cocaine addiction in well-designed clinical trials. Further details below.
In clinical studies acupuncture's utility has been best established for the amelioration of opiate withdrawal symptoms, for which it has been found superior to clonidine and to have relatively few side effects. These effects have also been shown in animals, and are presumed to be due to the technique's impact on dopamine-based neurotransmitter systems. Combining acupuncture with herbal medicine has been found to greatly attenuate heroin withdrawal symptoms. The few clinical trials of acupuncture in the treatment of cocaine addiction have produced promising but mixed results, possibly due to differences in the methodologies of the studies. Given these findings, acupuncture cannot yet be considered an effective adjunct to treatment for dependence on cocaine or other stimulants. Extensive research in the treatment of alcohol dependence has found anti-relapse impacts and improved quality of life, though the most recent study found acupuncture was not superior to aromatherapy in reducing alcohol withdrawal symptoms.
The reviewers concluded that acupuncture does ease opiate withdrawal, and that traditional herbal treatments can compliment pharmacotherapies for drug withdrawal and possibly relapse prevention with generally less expense and perhaps fewer side effects. Both acupuncture and herbal treatments need testing as adjuncts which might mean that standard pharmacotherapies can be implemented in lower doses and for shorter times.
There have been several previous reviews of the effectiveness of acupuncture (run this search in the Findings database for a selection) but fewer of herbal remedies, making this review a valuable extension to the literature, especially for the way the different preparations are separately analysed. Together with previous reviews, it suggests acupuncture may relieve withdrawal from opiates (reactions to which are strongly influenced by the patient's anticipations and fears), but probably mainly due to placebo effects related to the expectations of patients and interactions with therapists. It also perhaps helps attract and retain people in treatment. In respect of Chinese herbal remedies, the evidence from the featured study and other reviews ( below) seems greatest in respect of ameliorating opiate withdrawal symptoms, explored more fully below. Apart from the specific disulfiram-like action of Radix Puerariae when alcohol is drunk, other applications seem mainly to have only indirect scientific backing. Observed effects may reflect the common sedating and calming properties of the compounds rather than any specific impact on withdrawal or addiction. It is important to remember that no substance with such properties (or with stimulant properties) is itself immune from becoming mis-used or over-used, especially when use is not constrained by medical controls or other cultural norms.
An example
We are grateful to Liv Langberg of the Drammen Council Drug Addiction Prevention Centre in Norway for this example and for prompting us to make this general point.
is kava, introduced by indigenous Australians as an alternative to drinking primarily to avoid alcohol-related aggression and violence. It became widely used in some regions, and came to be seen as a serious substance use problem in its own right, leading to regulation and an eventual ban.
The best established impact of herbal remedies – ameliorating opiate withdrawal symptoms – should be placed in the context of alternative pharmacotherapies. Though reviewers ( below) are not entirely in agreement, it seems that some traditional Chinese herbal remedies alleviate opiate withdrawal symptoms to roughly the same degree as non-opiate drugs (lofexidine and clonidine) which subdue
some
Such as chills, cramps, and diarrhoea.
but not all of the body's reactions to the sudden absence of opiates. Experience in Britain and internationally (1 2 3) suggests that reducing doses of the opiate-type drug buprenorphine generally provides the best combination of safety and effectiveness in curbing withdrawal symptoms and completion of the withdrawal process. Since it is superior to clonidine, it is likely also to be superior to herbal remedies. These remedies and other drugs may be complementary to reducing doses of opiate-type drugs like buprenorphine, or form the major part of the therapy when opiate-type drugs are unavailable or considered unsuitable.
Despite limited findings of efficacy, the possibility remains that offering something concrete like acupuncture (even if it is a 'sham' procedure) helps attract people to services. Some studies have also suggested that doing something clients and staff believe is worthwhile can help retain patients in treatment. If this is the case, acupuncture could indirectly improve outcomes by increasing the patient's exposure to treatment's active ingredients. Just such a role was specified Complementary therapies were defined as "Any non medical intervention which regardless of therapeutic value enhances client access and retention in services, such as auricular acupuncture." in recent guidance from England's National Treatment Agency for Substance Misuse on treatment intervention costing and on treatment systems. Such considerations may explain why despite no convincing evidence of efficacy, acupuncture continues to feature in many of the treatment plans As revealed in March 2009 by a search for term 'acupuncture' on the web site of the National Treatment Agency for Substance Misuse, http://www.nta.nhs.uk. developed by local partnerships responsible for commissioning treatment services in England. This could reflect an enthusiasm among service providers greater than that among service users. Between 2001 and 2003, a survey of community-based drug services in northern England found that despite the fact that three quarters of services already provided complementary therapies, for staff these topped the list of desired service developments, mentioned by 29% of those interviewed. In contrast, in broadly the same areas complementary therapies were mentioned by just 4% of service users; topping their specifications at around 20% each were lower waiting times, more resources and staff, and more psychological/counselling services.
The featured study's conclusions can be compared against those of other recent reviews. Some of the same authors published a review in 2006 which pointed out that despite some specific actions, most Chinese medicines offer sedation, pain relief, and anti-fatigue, anti-stress and anti-shock benefits. Though less effective in ameliorating opiate withdrawal than substitute drugs like methadone, the review found them at least as effective as drugs like clonidine and lofexidine, and moderately effective with limitations in treating patients with severe addiction. One particular value may be in tackling residual withdrawal symptoms not well controlled by some other drugs, such as insomnia, anxiety, and pain. Acupuncture is the review concluded inexpensive and safe and can be used for the prevention of opiate relapse, but how it works and what the best techniques are is unclear.
Like the featured review, another published in 2009 was hampered by the lack of rigorous human trials. It searched for studies of herbal and other traditional and alternative remedies in the treatment of substance dependence including alcohol and other drugs, and did not limit itself to randomised trials. Such evidence as there was amounted to little more than a few promising preliminary studies of acupuncture, of the herbal therapies kudzu and ibogaine, and of using electroencephalograms ('brain waves' or EEG) to feedback to the patient how their body is reacting, intended to facilitate greater control over those reactions, including control over relapse-precipitants like craving, withdrawal symptoms and stress.
Perhaps because it focused on the role of Chinese herbal medicine in relieving heroin withdrawal symptoms, a meta-analysis A study which uses recognised procedures to summarise quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually. published in 2009 was more positive. It synthesised results from 21 randomised trials. Compared Across the nine highest quality studies, leaving out five low quality studies. When these were included results favoured herbal medicine from the first day rather than from only the third. to clonidine and lofexidine, after the initial three days herbal remedies gave patients greater relief from withdrawal symptoms, and possibly Depending on whether only the highest quality studies were included in the analysis. at the end of treatment, also anxiety. Additionally, undesirable side-effects were no more or less frequent. When compared instead to reducing doses of opiate-type drugs, these gave better initial relief, but after three days herbal remedies were generally equivalent. These analyses combined studies of different herbal preparations, making it impossible to determine which was (the most) effective, and all the trials were conducted in China. Covering similar ground, in 2008 a review of recent studies published in Chinese-language journals focused on three traditional Chinese patent medicines: Shenfu Tuodu, Fukang Pian, and Shifu Sheng. Basing itself on randomised trials, it found all three equivalent to clonidine or lofexidine in relieving heroin withdrawal symptoms, more effective than placebo pills or capsules, and to generally have no greater or less frequent side effects.
Too recent to be included in these reviews, in China a trial of a combination Chinese herbal product based primarily on Corydalis Rhizoma found it equivalent to lofexidine in alleviating heroin withdrawal symptoms. The same verdict was reached in a similar recent trial of Jinniu capsules, a preparation containing herbs and marine product extracts traditionally used in Chinese medicine.
Since the featured review collected its evidence, a British trial found ear acupuncture no better than a similar 'sham' procedure in relieving withdrawal symptoms or craving among opiate dependent patients being withdrawn as inpatients. The featured review's more promising conclusions seemed to derive from a single study. Perhaps partly because this study was not included, an earlier review found studies of acupuncture in the treatment of opiate addiction to have generally been unconvincing, and argued that such positive findings as there have been were due to placebo effects. The featured review's unpromising resumé of the evidence in respect of alcohol dependence was echoed by another review published in 2009 which had access to the Chinese (and other) language literature as well as English. The pattern of the findings suggested that if there are any benefits from acupuncture, they are caused not by the intended mechanisms, but by non-specific factors such as extra therapist contact time or the placebo effect of receiving what seems to be an active therapy. In 2006 a review conducted according to the rigorous Cochrane template found no evidence that ear acupuncture helps in the treatment of cocaine dependence, but commented that the quality of the studies was poor.
Last revised 02 March 2010 Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
The search for medications to treat stimulant dependence REVIEW 2008
Review of treatment for cocaine dependence STUDY 2010
Mindfulness meditation for substance use disorders: a systematic review STUDY 2009
Antabuse reduces cocaine and alcohol use among opiate maintenance patients NUGGET 2001
Rapid opiate detox guarantees completion, but abstinence depends on what follows NUGGET 2002
Prescription of heroin for the management of heroin dependence: current status REVIEW 2009
Acupuncture for alcohol dependence: a systematic review REVIEW 2009
Antidepressants curb depression but add little to strong 'talking therapies' NUGGET 2006
Guide to implementing family skills training programmes for drug abuse prevention.Kumpfer K.
United Nations Office on Drugs and Crime, 2009.
UN-commissioned guidance from international experts on how to mount prevention programmes based on family skills training involving parents and children in a joint effort to improve family dynamics and child development. Engaging parents seems the major barrier.
Abstract This review and guidance initiated by the UN Office on Drugs and Crime concerned the role of family skills training programmes in the prevention of substance use problems among children in families across the board ('universal'), or families whose children are particularly at risk ('selective'). Unless integrated with these types of interventions, the document did not include Though some of the programmes have been found effective for these individuals. programmes aimed at individuals identified as at high risk or as already experiencing substance use problems ('indicated'). A literature and website review identified 130 universal and selective programmes. Research articles and programme descriptions were solicited from the developers. Practitioners, managers, researchers and developers from these programmes throughout the world were invited to a technical consultation meeting. The guide was drafted on the basis of the discussions and the literature review. This account largely relies on its final chapter, which summarised the major points.
Families can act as powerful protective forces Strong attachments between parents and children, supportive parenting and supervision, monitoring, and effective discipline, have all been linked to less problematic and risky behaviours in adolescence. in healthy child development, in particular with regard to substance use. To bolster this process, universal and selective family skills training programmes generally aim at strengthening the protective factors in families, equipping parents with the skills to provide supportive parenting, supervision, monitoring and effective discipline, and giving entire families opportunities and skills to strengthen attachment between parents and children. These approaches are more intensive and differ from parent education, which typically limits itself to providing parents with information about substances and their effects and does not involve the children.
Such programmes have been extensively evaluated and found effective in preventing substance abuse and other risky behaviours – about three times more effective than life skills education programmes aimed only at children and young people, and with more long-lasting benefits. Conservative estimates indicate that for each pound spent, over the long term these programmes return a saving of nine pounds. They also form part of effective multi-component programmes which offer other interventions in other settings (such as schools, media and the community), and of tiered programmes which operate across several levels of prevention simultaneously according to the needs of the families (universal, selective and indicated).
Although the evidence is limited to few programmes in high-income countries, recommended principles for family skills training programmes can be identified. These include a solid theory of how the training will affect risk and protective factors based on research on factors related to substance abuse which can be addressed at the family level. Programmes should be matched to the target population, especially the age and developmental stage of the children and the level of risk or problems in the families. This makes accurate needs assessment vital. Programmes must be of sufficient intensity and duration to address the targeted outcomes. In general, universal programmes extend over four to eight sessions, selective programmes for higher risk families, 10 to 15. Sessions last about two to three hours and should be based on interactive techniques implemented in small groups of eight to 12 families. A typical and effective programme will provide parents with the skills and opportunities to strengthen positive family relationships, family supervision and monitoring, and improve the communication of family values and expectations.
Recruitment and retention of parents are significant barriers to the dissemination of such programmes. However, retention rates of over 80% can be achieved by addressing the practical (transportation, childcare) and psychological (fear of stigmatisation, feelings of hopelessness) barriers. Interventions are most effective if participants are ready for change, such as at major transition points like children starting school or a new school phase.
Often it most feasible and/or cost-effective to base a project on an evidence-based programme developed elsewhere for a similar target group, preferably one with the best prevention record. In this case, it is important to carefully and systematically adapt the programme to the cultural and socioeconomic needs of the target population. Such adaptations enhance recruitment and retention of families. However, during its initial use the programme should be implemented with only minimal For example, careful translation and the insertion of culturally appropriate activities, songs, stories, and names. local adaptations or changes. Feedback from participants and group facilitators on what worked or did not work so well can be used as the basis for further refinements. Experience with these and outcome evaluations should be used to assess whether a deeper adaptation is required.
As with other types of programmes, adequate training and ongoing support must be provided to carefully selected staff. Most evidence-based programmes require two to three days of training for 10 to 30 future group leaders. Training should give them the opportunity to practise their skills, but also discuss the theoretical foundations, evidence of effectiveness, and the values of the programme. Ongoing support by programme managers and supervisors (and, if possible and appropriate, from programme developers) is important, especially in the form of e-mail contacts and web-based networking of group facilitators across agencies. Site visits and debriefing sessions also enhance quality and fidelity of implementation, as well as the collection of monitoring data.
Programmes should include strong and systematic monitoring and evaluation components. This work contributes to the understanding of prevention strategies, indicating which programmes are effective, under which circumstances, and for which populations, and provides evidence of effectiveness which can be used to lobby policymakers and donors, potentially helping to sustain the programme.
There is no question that the family is a powerful influence on child development and on substance use and problems in particular, nor that interventions with families and parents can (see for example this demonstration from Sweden) help prevent substance use in various forms. What is questionable is whether the research, though sometimes promising, is sufficiently extensive and sound to warrant widespread implementation of these programmes. Searching for practical guidance, British reviewers found that research deficiencies mean that no clear choice could be made about what works best either for marginalised and vulnerable groups, or for families in general. The background notes focus on two of the best researched family skills interventions (the Strengthening Families Programme and the Family Check-Up) as a way of testing the adequacy of the evidence overall, and address the issue of engaging families of early adolescent children. For other relevant evidence run this search for pre-school and parenting interventions on the Findings site.
When in 2008 the US government analysed the costs and benefits of substance use prevention programmes, family skills training programmes were among those with the highest benefit to cost ratio, though they lagged behind some other school/community/family programmes, and also well behind some entirely different kinds of initiatives like enforcing laws on serving drunk customers in licensed premises. Estimates for the two relatively well researched family skills interventions focused on in the background notes rested on one or two studies, which in both cases provided a narrow and at best tentative basis for the calculations, casting doubt over the degree to which they can be relied on to guide prevention programme planning. Nevertheless, the same may be said of some of the other programmes included in the analysis. For the analysts, the major drawback of family training as a universal prevention modality was its higher cost relative to other types of initiatives, leading them to suggest that this approach be reserved for high risk schools, areas or families
A particular issue is whether by the time family skills training comes in to its own – from age six to 11, and in major studies not until the early years of secondary schooling – enough families can be involved to make these strategies a viable way of curbing youth substance use problems across the population as a whole. British experience so far suggests this is not the case, though high-risk families under pressure to attend and/or energetically and sensitively targeted can be engaged in and benefit from family skills training. As the featured review comments, one way cost and accessibility barriers are being addressed is through computerisation of such programmes so families can go though them at times convenient to them and in their own homes, a tactic trialled for example with some success among mothers and daughters in New Jersey.
Based on UK experience and the adequacy of the international evidence, family skills training programmes of the kind reviewed can be recommended for consideration for families who have come to attention because their children (age six upwards) are at risk of behavioural problems which may include risky substance use. Sensitive personal approaches from programme staff, perhaps preferably from the same communities, can recruit many to participate, stay in and benefit from the programmes. Universal application to all families seems at the moment to lack sufficient evidence (especially in the UK) to warrant the considerable investment required, a situation which may change if low-cost, accessible computer-based alternatives prove feasible, effective and capable of widespread implementation.
Thanks for their comments on this entry in draft to Karol Kumpfer of the University of Utah in the USA. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 09 March 2010 Background notes Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Doing it together strengthens families and helps prevent substance use KEY STUDY 2004
Blueprint drugs education: the response of pupils and parents to the programme STUDY 2009
Family programme improves on school lessons NUGGET 2003
Peer-based addiction recovery support: history, theory, practice, and scientific evaluation REVIEW 2009
Matching resources to needs is key to achieving 'wrap-around' care objectives NUGGET 2006
Education's uncertain saviour KEY STUDY 2000
The power of the welcoming reminder THEMATIC REVIEW 2004
