Drug and Alcohol Findings home page. Opens new window Effectiveness Bank bulletin 26 March 2013

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.


The proportion of dependence-free, non-returning treatment completers is one of the few substance use-specific indicators in the new English public health framework. Next three entries raise important questions about the treatment effort: should we do more to involve families; are substances really the core problem for troubled substance using youngsters; and can straightforward educational approaches do as well as sophisticated and more costly therapies?

New public health objectives for England including drugs and alcohol ...

Engaging partners in treatment aids patient and family ...

Gains fade from specialist youth therapeutic community ...

Nurse-led hepatitis education cost-effective way to curb drinking in methadone patients ...

Improving outcomes and supporting transparency part 1: A public health outcomes framework for England, 2013–2016.

Department of Health.
[UK] Department of Health, 2012.

Sets out the structure and objectives of the public health system for England effective from April 2013 and how progress against these objectives will be measured, including addiction treatment completions, alcohol-related hospital admissions, and prisoners identified as needing treatment for alcohol/drug problems.

Summary This document sets out the structure and objectives of the public health system for England effective from April 2013 and how progress against these objectives will be measured. At the apex ( figure) are the overarching aims of:
• increased healthy life expectancy;
• reduced differences in life expectancy and healthy life expectancy between communities.

These outcomes reflect a focus not only on how long people live but also on how well they live – healthy life expectancy, at all stages of the life course. The second focuses attention on reducing health inequalities between people, communities and areas.

Public health outcomes framework for England

Public Health England will be the new national delivery organisation of the public health system. The NHS will remain critical to protecting and improving the population's health. It will be charged with delivering some public health services, and with promoting health through all its clinical activity, striving to use the millions of patient contacts that take place each day as opportunities to promote healthier living.

Outside the clinical arena, the key responsibility for improving the health of local populations, including reducing health inequalities, will rest with democratically accountable upper tier and unitary local authorities. Each will have the duty to "take such steps as it considers appropriate for improving the health of the people in its area". They will set up statutory health and wellbeing boards to drive local commissioning and integration of all health services based on local needs.

Local authorities will commission public health services on their populations' behalf, resourced by a ring-fenced grant, and put health and wellbeing at the heart of all their activity. Public Health England will support and advise directors of public health and local authorities to help ensure consistency and excellence across the public health system, for example through a single authoritative web portal on public health information and evidence. In this new system, the Secretary of State for Health sets the strategic direction, through this, the first-ever Public Health Outcomes Framework, and through leading for health across government.

Substance use indicators

The featured document sets out the indicators which will be used to measure improvements in public health, defined in greater detail in the part 2 technical specification. Many relate to substance use even though this is not the focus. Among these are for example the sickness absence rate, deaths and serious injuries on the roads, domestic abuse, violent crime and re-offending, preventable deaths, and deaths from liver disease and communicable diseases.

Indicators specific to substance use are:
• [Mother's] Smoking status at time of delivery [of baby]. Defined as rate of smoking at time of delivery per 100 maternities.
• Smoking prevalence – 15 year olds. Defined as the number of persons aged 15 who [in surveys] are self-reported smokers as a proportion of the total number of respondents with valid recorded smoking status aged 15.
• Smoking prevalence – adult (over 18s). Defined as the number of persons aged 18+ who are self-reported smokers in the Integrated Household Survey as a proportion of the total number of respondents with valid recorded smoking status aged 18+. Smokers are defined as those responding "Yes" to the question, "Do you smoke at all nowadays?"
• Successful completion of drug treatment. Defined as the number of drug users who left drug treatment successfully (free of drug(s) of dependence) who do not then re-present to treatment again within six months, as a proportion of the total number in treatment in a year.
• Alcohol-related admissions to hospital. The preferred option would be based on just alcohol-related primary diagnoses, to minimise the risk of perverse consequences from any changes in coding practice.
• People entering prison with substance dependence issues previously not known to community treatment. Defined as the number of individuals entering prison who are provided with a substance misuse triage assessment to determine dependence on drugs or alcohol, who then require structured treatment and who have not already received it in the community, as a proportion of the total number of people entering prison.

Last revised 21 March 2013. First uploaded 20 March 2013

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DOCUMENT 2010 The Patel report: Reducing drug-related crime and rehabilitating offenders

STUDY 2008 Reducing alcohol harm: health services in England for alcohol misuse

STUDY 2011 Supporting partnerships to reduce alcohol harm: key findings, recommendations and case studies from the Alcohol Harm Reduction National Support Team

DOCUMENT 2013 Community loses from failure to offer maintenance prescribing in prisons

STUDY 2014 Drugs: international comparators

DOCUMENT 2014 Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations

DOCUMENT 2012 The government's alcohol strategy

MATRIX CELL 2014 Drug Matrix cell E1: Local and national systems; Reducing harm

STUDY 2014 Monitoring and evaluating Scotland’s alcohol strategy. Fourth annual report

STUDY 2016 Monitoring and evaluating Scotland’s alcohol strategy: Final annual report

Behavioral couples therapy for substance abusers: where do we go from here?

Klostermann K., Kelley M.L., Mignone T. et al.
Substance Use & Misuse: 2011, 46, p. 1502–1509.
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 Klostermann at kklostem@odu.edu.

Problem drinkers and drug users in a persisting if distressed relationship with a partner do better when the focus is at least partly shifted from the patient to working with the couple to foster sobriety-encouraging interactions. Benefits for patients and the broader society can be remarkable.

Summary Of the psychosocial interventions available to treat problem alcohol and drug use, it could be argued that partner-involved treatments are the most broadly efficacious, not just in terms of substance use and relationship adjustment, but also other dimensions of public health significance including domestic violence and cost–benefit and cost-effectiveness.

A presentation from one of the originators of behavioural couples therapy offers a taste of how the therapy looks in practice and reference to a book including practice guidance. See also these guidelines on the therapy.

Behavioural couples therapy is one of these approaches, based on the insight that distressed couples engage in mutual punishment rather than mutually rewarding behaviours which improve the relationship. Developed as a marital therapy, in the past three decades it has also been shown effective for alcoholism and drug problems.

The 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. It features a 'recovery contract' which 'bans' mention of past substance use and fears of future relapse, and instead involves the couple in a daily ritual to reaffirm and reinforce the user's intention to that day stay drug-free/sober, together with techniques for increasing positive activities and improving communication. A calendar kept by the couple records their progress and 'homework' activities, providing a focus for therapy sessions. Towards the end a continuing recovery plan is agreed for how the couple will tail off therapy-associated activities. A usual requirement for the therapy is that the partner of the problem substance user does not themselves have the same sort of problem.

Main findings

Compared to alternative therapies, research has shown that behavioural couples therapy results in equal or greater likelihood of clients stopping substance, and usually also better relationships between the couple. For women in particular, relationships appear to play a critical role in the maintenance and exacerbation of substance use, suggesting that couples therapy would be a valuable approach. In line with this expectation, a study found behavioural couples therapy more effective than individual therapy for female problem drinkers in terms of both abstinence and heavy drinking days. Among the relationship improvements found in a study of male problem substance users and their non-using female partners was a substantial reduction in domestic violence compared to pre-treatment levels.

It is however important for a therapy to be cost-effective as well as effective, and ideally to benefit society (when those benefits have been translated in to financial terms) more than it costs. Two studies have investigated these issues. One found that over the next two years behavioural couples therapy plus individual counselling resulted in cost savings in alcohol-related hospital inpatient and residential treatment and time in prison amounting to $6700 per case. The result was a saving of $8.64 for every dollar spent on supplementing individual counselling with behavioural couples therapy, a ratio not apparent with a different form of supplemental couples therapy.

The second study compared pre- and post-treatment (one year in both cases) health and legal service costs associated with for behavioural couples therapy for alcoholics and their spouses, with or without additional couples relapse prevention sessions. Adding relapse prevention sessions led to less drinking and better marital relationships but net cost savings were lower. The benefit-to-cost ratio decreased from $5.97 for every dollar spent on behavioural couples therapy to just $1.89 for the combined programme. Lower cost meant that behavioural couples therapy alone was more cost-effective in producing abstinence from drinking, though no more cost-effective in improving marital adjustment.

Despite its efficacy, behavioural couples therapy is not yet widely implemented in substance use treatment. In US services it was found to be one of Along with contingency management and pharmacotherapies. the evidence-based practices staff felt least ready to adopt. Barriers may include perceived relevance, difficulty of implementation, distance from preferred or familiar approaches, and cost.

Typically partners who have both been diagnosed with a substance use disorder have been excluded from behavioural couples therapy trials. Treating dual-using couples is a serious challenge for both men and women, but especially for women because of social and gender norms. Experience is that generally neither achieves abstinence, and that when one partner does, this seems to change the dynamic in a way which ends the relationship. Behavioural couples therapy has not been sufficiently researched with these couples, though contingency management (providing voucher incentives for attendance and abstinence by both partners) has had some success.

Other research gaps include trials for gay and lesbian couples, identifying how behavioural couples therapy works – in particular which components are positive active ingredients and which may be counterproductive – whether supplementary components like parent skills training and partner violence reduction strategies add value, and developing and testing interventions whose intensity and type adapt to the patient's response, potentially conserving resources and making these approaches more acceptable.

Findings logo commentary As previously noted by Findings (1 2 3), for the minority of patients for whom it suitable, acceptable and safe, behavioural couples therapy seems a good option relative to other therapies, one whose benefits are more likely to extend to the whole family and to persist because an altered family dynamic embeds positive sobriety interactions and incentives in to the 24-hour a day joint life of couples who despite their troubles have stayed together. For such couples, joint therapy could profitably replace some of the counselling targeted on the problem substance using partner, creating better lasting outcomes but not necessarily at greater cost. The results are better outcomes for patient and partner and greater benefits for society per unit cost of treatment.

Despite its widely accepted standing as an evidence-based practice, behavioural couples therapy has a narrow support base in terms of the approaches with which it has been compared and the researchers doing the comparing. In particular, trials conducted by people who did not themselves develop the therapies are few and their results among the least convincing; details below.

Strengths and limitations of the evidence base

A review of family interventions for mental health problems found behavioural couples/family therapy much the best supported in terms of its performance vis à vis individual-oriented therapies in reducing substance use and improving relationships. Most notably, effects eroded more slowly than after individually-oriented treatment. However, the analysts noted that eight of the 11 trials of behavioural couples therapy had been conducted by the same research team. The remaining three were still supportive of the therapy, but this limitation led the analysts to consider the evidence as "moderate" rather than any stronger.

A similar mixture of strengths and limitations emerged from a meta-analytic 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. review aggregating findings from trials available up to early 2007 which had randomly allocated problem substance users to treatment with or without supplementary behavioural couples therapy, or to this therapy versus an alternative approach.

Across the studies there was a clear advantage for treatment incorporating behavioural couples therapy versus solely individual-based treatment. Effects were slightly greater for the adverse consequences of substance use and relationship satisfaction than for the frequency of substance use, but this pattern varied with time. Immediately after treatment, couples therapy was superior to comparison treatments only in respect of relationship satisfaction, later, in respect of all three types of outcomes and to roughly the same degree. The conclusion was that when married or cohabiting couples seek help for substance dependence problems confined to one of the partners, behavioural couples therapy results in better substance use outcomes than more typical individual-based treatments. Benefits extend to related problems and the quality of the relationship. Immediate improvements in relationships seem to pave the way for later relative gains in substance use outcomes.

Of the 12 trials on which these verdicts were based, eight dealt solely with drinking problems, and in all but two couples therapy had supplemented other approaches. Eight of the studies compared couples therapy with cognitive-behavioural therapy. One assumption underlying the analysis – that the studies were entirely independent of each other – was certainly violated because eight of the 12 involved one or both of the developers of the therapy. Another (1 2) involved the developer of a similar couples therapy which was tested in the trial. Among the remaining three were the least convincing results across all follow-up points, raising the issue of whether outcomes depend on who is organising the study. Research conducted by teams linked in some way to the intervention they are testing has been found to produce more positive findings than fully independent research. In relation to psychosocial therapies for drinking problems, an analysis of relevant studies concluded that therapies were generally equivalent, and that when they were not, the researcher's 'allegiance' to the therapy accounted for This analysis restricted itself to drinking outcomes assessed immediately after therapy ended; the cited review suggests that the benefits of behavioural couples therapy go beyond drinking itself, and in respect of substance use, emerge only several months later. a significant portion of the differences.

However, in one of these independent tests, equivalent treatment-end outcomes had diverged six months later as behavioural couples therapy did better at sustaining improvements. In another, involving spouses in alcohol treatment did improve drinking outcomes, but not to any greater extent when behavioural couples therapy replaced the half of the sessions otherwise devoted to jointly participating in lectures on alcohol and health. This was perhaps because both relationship distress and drinking were relatively mild in this study whose programme was advertised as "not designed for alcoholics". The third was a randomised but otherwise relatively 'real world' Dutch trial, in which the couples treatment and the comparator 'standard' individual cognitive-behavioural programme were delivered by addiction counsellors who were not highly experienced in these approaches, and as few patients as possible were excluded from the trial. Though patients did well in both approaches, neither at the end of treatment nor six months later were there any significant or substantial extra drinking reductions, and at the final follow-up relationship satisfaction too had not improved significantly more as a result of couples therapy.

In one respect the research base has broadened from that reflected in the featured review; there is now a study of behavioural couples therapy with gay and lesbian couples. In this study of treatment for drinking problems, couples therapy replaced 12 of 32 individual counselling sessions. In the year after treatment ended, including couples therapy resulted in significantly more sustained drinking reductions and improved relationships amongst both the male and female couples.

Cost versus benefits

Along with other studies of behavioural couples therapy, a review of the cost-effectiveness of family-based substance use treatment included the two studies cited in the featured review. It found a more mixed picture than that portrayed by the featured review. Analysing the studies in greater detail ( background notes), it seems that when behavioural couples therapy replaced individual counselling sessions (and therefore did not greatly increase costs) it was the most cost-effective in reducing substance use. But when it was in whole or part additional (meaning greater costs), it might be more effective, but not more cost-effective. The practice implication for cost-benefit conscious service planners is that for people in stable relationships, where possible including behavioural couples therapy instead of counselling focused on the substance using partner is likely to net more benefit per unit cost, but this is unlikely to be the case if the couples therapy is additional.

UK guidance

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 the treatment of problems related to illicit drug use. In particular, NICE said it should be considered for problem users of stimulants or opioids who are in close contact with a non-drug-misusing partner. Among other therapies, NICE guidance on the treatment of alcohol problems also recommends behavioural couples therapy for service users with a regular partner willing to participate. An update to that guidance cited a review by family intervention experts working in Britain which concluded that couples therapy results in positive drinking and marital adjustment outcomes and that behavioural couples therapy in particular "clearly ... out-performs the comparison individually oriented treatments". Experts reached a similar conclusion after reviewing the alcohol treatment literature for England's National Treatment Agency for Substance Misuse.

All these documents noted the therapy's limited applicability: 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. This will be the case for many (especially male) drinkers, but usually not for long-term dependent users of cocaine or heroin. Care will also be needed to exclude the risk that such therapies, particularly when they engage women in the treatment of male substance users, might perpetuate or aggravate victimisation by abusive partners.

Another major 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 drug misuse professionals have been trained in family approaches and in the UK there has been no appreciable national drive to widen their perspective, though the recent emphasis on addressing not just substance use but also other recovery-relevant issues in the patient's life may alter this situation.

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 on alcohol treatment 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.

Thanks for their comments on this entry in draft to Timothy O'Farrell of the Harvard Medical School Department of Psychiatry at the VA Boston Healthcare System, based in Brockton in the USA. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 21 March 2013. First uploaded 18 March 2013

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REVIEW 2008 Behavioral couples therapy (BCT) for alcohol and drug use disorders: a meta-analysis

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

STUDY 2011 Extended telephone-based continuing care for alcohol dependence: 24-month outcomes and subgroup analyses

STUDY 2011 Treatment of adolescents with a cannabis use disorder: Main findings of a randomized controlled trial comparing multidimensional family therapy and cognitive behavioral therapy in The Netherlands

STUDY 2009 Therapist behavior as a predictor of black and white caregiver responsiveness in multisystemic therapy

STUDY 2009 A randomized trial of individual and couple behavioral alcohol treatment for women

STUDY 2012 The forgotten carers: support for adult family members affected by a relative's drug problems

STUDY 2009 Multidimensional Family Therapy for young adolescent substance abuse: twelve-month outcomes of a randomized controlled trial

REVIEW 2011 Implementing evidence-based psychosocial treatment in specialty substance use disorder care

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

Long-term effect of community-based treatment: evidence from the adolescent outcomes project.

Edelen M.O., Slaughter M.E., McCaffrey D.F. et al.
Drug and Alcohol Dependence: 2010, 107, p. 62–68.
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 Edelen at Maria_Edelen@rand.org. You could also try this alternative source.

The title speaks of long-term effects but in fact there were none from sending young US substance users to a youth therapeutic community specialising in substance use problems compared to non-specialist group homes; early gains had all eroded, an instance of the general difficulty of sustaining youth treatment outcomes.

Summary Few studies have reported on the long-term impacts of substance use treatment for adolescents, and those which have provide at best limited evidence that impacts persist. In particular, no such study has yet assessed long-term outcomes for drug-involved juvenile offenders receiving treatment outside custody, the majority of adolescent treatment admissions.

This US evaluation offers the first assessment of long-term effects nearly nine years after offenders had been referred by the juvenile justice system either to a drug-specialist residential therapeutic community for adolescents (the Phoenix Academy), or to other residential group living programmes of similar size and structure, but which did not offer specialised Though they did offer some less intensive services such as drug education classes and the availability of drug and alcohol self-help groups. substance use treatment.

Relative to the group homes, the community had previously been shown to result 12 months after referral in significantly better substance use and psychological functioning. This report sets out to establish whether these improvements persisted and even 'snowballed', or were eroded by time and other influences.

In 1999 and 2000, 449 young people aged 13–17 joined the study after being contacted at a juvenile court; all were legal wards of the court. Of these, 175 were initially admitted the specialist community where they stayed for on average just over five months, about the same time as other young people stayed after being sent instead to one of the six comparison group homes.

The featured report drew its data from the 412 youngsters who completed any of the long-term follow-up interviews about three, seven and eight and a half years after the baseline interviews; of these, nearly 90% had completed the final interview. Typically they were 15–16-year-old Hispanic/Latino boys who by the final follow-up would have averaged about 24 years of age. At study intake nearly 8 in 10 had met criteria for substance abuse and 55% for dependence. For about half their main substance was cannabis. Despite extensive substance use, 59% did not feel they needed treatment.

There were some appreciable differences between those sent and not sent to the Phoenix Academy, notably in motivation for treatment, extent of recent cannabis use, and substance use problems. An attempt was made to adjust outcomes for differences on these and other (totalling 88) dimensions as assessed before starting treatment. Then estimates were made of how well the young people would have done had they all been sent to Phoenix, or all to the other centres.

Main findings

Variables tested included substance use, crime, imprisonment and institutionalisation, physical and psychological health, education and employment. After adjusting for the risk that with so many outcomes, one might test significantly different purely by chance, neither over the period from three months after baseline to eight and half years after, nor at the final follow-up itself, were there any statistically significant differences between youngsters sent and not sent to Phoenix. Generally too the differences were insubstantial. The apparent benefits of being sent to the community seen one year after baseline had evaporated due to trends between that time and seven and half years later.

Most notably, the relative suppression in crime seen a year after starting treatment disappeared because the Phoenix cohort increased or sustained their criminal activity while those sent to other centres began to commit fewer crimes. At the 12-month point psychological health too had improved more among the Phoenix cohort, but in the next two years the other children caught up leaving no significant differences. Similarly, abstinence from drug or alcohol use became less common as the years progressed but the decline was steeper after leaving the Phoenix Academy, leaving former residents at roughly the same level as the other children. Early gains in non-smoking eroded even more quickly.

The authors' conclusions

The question posed by the study of whether initial 12-month benefits from specialist substance use treatment would persist, snowball or erode, was decisively answered; all eroded. Relative to youngsters referred from juvenile court to other group home settings, those referred to a residential therapeutic community had not progressed better when evaluated up to eight and half years after referral.

Though the findings are disappointing, society may still have benefited from the cost savings associated with the temporary extra decreases in adolescent crime and substance use after specialist treatment; these may even have saved lives by reducing drinking and drug use at a time when adolescents may be at highest risk of harming themselves and others. Other analyses of the same dataset revealed that on many counts, how well the youngsters were doing a year after referral did not predict how they would do later, suggesting that early outcomes had been overwhelmed by the many and substantial changes in the lives of adolescents as they become young adults.

Extending initial gains may require structured aftercare and/or multiple treatment episodes. Without this it may be unrealistic to expect one dose of treatment to have long-term effects, especially on high-risk adolescents such as those in this study, who confront multiple risk factors on return to their original environments, including family, peers, and neighbourhood.

Results from this study are vulnerable to differences between the children sent and not sent to Phoenix which the study may not have been able to fully adjust for, and may not generalise to other young people, especially those not required to enter treatment by the juvenile justice system.

Findings logo commentary The featured study's findings are a reminder that especially for young people, good results seen on leaving treatment (such as those in England) often do not persist. This is also the case for young cannabis users in particular – the main caseload in the featured study – where the effects of treatment overall are modest and then become even more so with time.

Less so than adults, children cannot build on treatment by altering the environments they are returned to; resources, occupations, homes, relationships, parents, neighbourhoods, siblings, schools and other important influences are beyond their reach or beyond their control, and largely beyond that of the treatment service. Another difference from most adults is that teenagers typically enter treatment under pressure from or directed by families, courts, schools or welfare services (1 2). These unwilling, sometimes angry and uncooperative youngsters often (like those in the featured study) see no need for treatment for their substance use.

Youngsters who have got in to such serious trouble early in their lives often face daunting difficulties and live with families unable to effect positive changes for them. With escape routes constricted, the periodic drug use or under-age drinking which typically brings them into trouble with the law may to them seem a valued way of coping; the downsides may be hard to identify, the upsides more salient. For some their assessments that substance use is not for them a core or pressing problem may have some validity; even the youngsters sent for specialist substance use treatment in the featured study told researchers they had drunk or used drugs on just six of the last 90 days at the start of the study.

If we make the assumption that many of these youngsters were right in downplaying the centrality of their substance use, it becomes easier to understand why a treatment focused on this non-central issue failed to have more persisting impacts than regimens which were not. It and the comparison regimens may nevertheless both have had positive lasting impacts – a speculation suggested by a study which exploited the limitations of the US health insurance system to conduct a rare quasi-random test of whether (in this case, 12-step based) substance use treatment is more effective for adolescents than merely being placed on a waiting list. Twelve months after completing treatment, 44% of the treatment groups had barely touched alcohol or drugs in the past year and on average each had cut their substance use by a quarter. Those on the waiting list continued to use drugs on average at the same rate as a year before and just 27% maintained near abstinence.

If the return environment is the key to post-treatment relapse for young substance users, one way to alter it is to engage the family and especially the parent(s) in the treatment, presumably not an option for many of the children in the featured study. Multidimensional Family Therapy tries to do this and also to intervene in other influential areas of the child's life without requiring them to admit they need substance use treatment. This approach in particular has distinguished itself by the sustainability (and even the growth; for example, 1 2) of the gains made during treatment. A plausible explanation is that the therapy initiates a mutually reinforcing set of interactions between the child, their family and the wider environment. However, not all implementations have succeeded.

Thanks for their comments on this entry in draft to author Maria Orlando Edelen of the US RAND Corporation. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 22 March 2013. First uploaded 19 March 2013

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REVIEW 2006 Motivational arm twisting: contradiction in terms?

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

DOCUMENT 2010 Drug Strategy 2010. Reducing Demand, Restricting Supply, Building Recovery: Supporting People to Live a Drug Free Life

STUDY 2011 Treatment of adolescents with a cannabis use disorder: Main findings of a randomized controlled trial comparing multidimensional family therapy and cognitive behavioral therapy in The Netherlands

STUDY 2012 Using pay for performance to improve treatment implementation for adolescent substance use disorders

STUDY 2011 Using a cross-study design to assess the efficacy of motivational enhancement therapy-cognitive behavioral therapy 5 (MET/CBT5) in treating adolescents with cannabis-related disorders

REVIEW 2012 The effects of family therapies for adolescent delinquency and substance abuse: a meta-analysis

STUDY 2009 Therapist behavior as a predictor of black and white caregiver responsiveness in multisystemic therapy

STUDY 2012 The effectiveness of Prisoners Addressing Substance Related Offending (P-ASRO) programme: evaluating the pre and post treatment psychometric outcomes in an adult male category C prison

STUDY 2009 Multidimensional Family Therapy for young adolescent substance abuse: twelve-month outcomes of a randomized controlled trial

Effect of motivational interviewing on reduction of alcohol use.

Nyamathi A., Shoptaw S., Cohen A. et al.
Drug and Alcohol Dependence: 2010, 107(1), p. 23–30.
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 Nyamathi at anyamath@sonnet.ucla.edu. You could also try this alternative source.

At Californian methadone clinics, group education sessions led by a nurse and focused on the risks of aggravating hepatitis infection led to the same substantial reductions in drinking as one-to-one or group motivational interviewing conducted by highly trained counsellors, offering a cost-effective means to reduce alcohol-related risks.

Summary Many methadone-maintained patients drink excessively, a particular concern among those infected with hepatitis C for whom drinking may accelerate disease progression. Motivational interviewing is the most popular counselling approach found to reduce drinking, but so far no studies have tested it among patients treated for opioid dependence in methadone maintenance programmes.

The featured study aimed to start to fill this gap in the research and at the same time (given the dominance of group counselling in US treatment services) compare one-to-one motivational interviewing with the less familiar group version, and with a nurse-led group education programme focused on the relation between drinking and disease related to hepatitis C infection.

Each of the three approaches occupied three fortnightly one-hour sessions over the first six weeks after patients started methadone treatment. Interventions were guided by set protocols and delivered by staff trained in these approaches and supervised to help ensure they delivered them as intended. Patients were paid $5 for each session they attended.

Group and individual motivational sessions were generally conducted by different counsellors. Sessions explored the impact of drinking on health and risky behaviours and while focusing on life goals, worked through ambivalence about cutting drinking. Sessions were open, meaning that patients who had not completed three sessions in their original group could join a later one. Instead of a motivational approach, the nurse-led (assisted by a hepatitis-trained research assistant) hepatitis health promotion programme adopted an educational format. Sessions focused on the progression of hepatitis infection and culturally-sensitive strategies to prevent liver damage. Content included the dangers of drinking while infected with hepatitis, strategies for avoiding drinking and drug use, diet, the dangers of reinfection with hepatitis C if patients inject, other infection routes, consistently looking after one's health, and seeking social support and building self esteem.

After these sessions patients suitable for this started a course of hepatitis A and B vaccinations, concluding at the same time as a six-month follow-up interview.

Participants in the study were 256 adult drinkers starting methadone treatment at five Californian clinics who scored as moderate or heavy drinkers on a baseline questionnaire. They were randomly allocated to the three approaches to reducing drinking. Typically they were black or Latino men. On entering treatment about half had drunk at least 90 US standard drinks About 156 UK units or just over five units on average each day. in the past month. On average 87% of the patients completed all three of the study's counselling/education sessions and 91% completed the six-month follow-up.

Main findings

The main outcome tested by the study was the proportion of patients who cut their drinking by half from the month before they started treatment to the month before the six-month follow-up. On this yardstick, and on the yardstick of total abstinence, there were not only no statistically significant differences between patients allocated to the three interventions, but also no substantial differences. In each group about half the patients halved their drinking, ranging from 54% after group motivational sessions to 49% after hepatitis education and 47% after one-to-one motivational sessions, and from 20–23% had not drunk at all in the past month.

Once other variables had been taken in to account, across the three sets of patients the strongest predictor of which patients would halve their drinking was how much they drank before treatment; the more they drank, the more likely they were to halve it. Women were more likely to halve their drinking than men as were better educated patients and those who took at least one dose of vaccine, while less likely were those whose partners were also drug users or who had recently used cannabis.

The authors' conclusions

The major finding of this study was that all three interventions were followed by roughly equally substantial reductions in drinking at the six-month follow-up. Delivered by trained therapists, group and one-to-one motivational interviewing sessions neither differed in effectiveness from each other nor from a nurse-led group hepatitis education programme focused on reducing drinking.

For services the implications are that the cost-saving group format can be used without detriment to effectiveness and that costs may also be saved by implementing programmes led by nurses rather than therapists, with the potential added benefit that such programmes can be integrated within more comprehensive health promotion. Research nurses also administered the vaccines, receipt of which was associated with drinking reductions, perhaps partly because of the extra time and attention required to explain the vaccine.

It should be acknowledged that any differences between the interventions may have been obscured by differences between the staff implementing them, and that patients had volunteered for a research study rather than being counselled during routine practice.

Findings logo commentary Half the patients halving their drinking seems an impressive result. However, the patients were extremely diligent in attending their sessions and completing the follow-up, suggesting that self-selection in to the study and the small financial incentive may have created a better platform for these kinds of intervention than would normally be the case.

It should also be stressed that the study lacked a no-intervention 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 which to benchmark these results. It could be that simply starting methadone treatment, the regularisation of one's life the treatment requires and enables, the medical setting and contact, being asked about one's drinking, and the clinics' usual hepatitis testing and care procedures, had a substantial impact on drinking. To avoid possible overdose, it is not unusual for methadone clinics to administer methadone only if patients test free of alcohol, another possible incentive to cut back. This was one of the reasons why it was thought patients in Germany required to test free of alcohol several times a day before heroin was administered cut their drinking more than patients on methadone, required to test free of alcohol just once a day.

Set against this speculation is a review of the effects of methadone maintenance treatment on drinking, which found that 'no change' was the usual result. Given this context, it seems more likely that the interventions in the featured study did contribute to drinking reductions than that they did not.

Another report from the featured study focused on use of drugs other than alcohol. It reported that the two motivational approaches were followed by statistically significant reductions in substance use, while the reduction after the nurse-led approach was not statistically significant. However, once again there were no statistically significant differences between the three interventions. The authors concluded that on this yardstick too, group motivational interviewing had shown itself equivalent to the one-to-one format, and that this time there was some indication that the perhaps more alcohol-focused educational approach had less of a 'spillover' impact on non-alcohol drug use. As with drinking, it was the most severe users (the recent injectors) who made the greatest reductions in their drug use.

For further evidence that other well structured approaches are usually as effective as motivational interviewing see this Effectiveness Bank hot topic.

Motivational interviewing has also been used to try to reduce the drinking of methadone patients at a clinic in England. Reflecting the featured study's conviction that nurses could play a role, the intervention was conducted by a specialist nurse. Among patients identified by screening as heavy drinkers, 14 of 22 attended all five sessions and 11 markedly reduced their drinking. Again there was no no-intervention control group, but in this case the patients were not necessarily new to methadone treatment, so 'spontaneous' drinking reductions of the order seen in this study are an unlikely explanation for the findings.

Thanks for their comments on this entry in draft to author Adeline Nyamathi of the University of California. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 20 March 2013. First uploaded 15 March 2013

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