Drug and Alcohol Findings home page. Opens new window Effectiveness Bank bulletin 27 September 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 first entry is a rare study of the featherweight end of treatment for drug problems – a quarter of an hour of light-touch counselling. Then we lurch to the heaviest end, prescribing heroin to opiate addicted patients unable to manage on methadone, and to the difficult issues entailed in treating psychotic patients. Finally to prevention, with an intriguing series of US studies which shows once again that you don't always get what you want from media campaigns; sometimes you get the very opposite.

Positive but puzzling results from brief intervention trial for drug problems ...

Can heroin remedy the problems it helped to create? ...

UK guidance on services for psychotic substance misusers ...

Guilt- or shame-inducing responsible drinking ads backfire ...

A randomized controlled trial of a brief intervention for illicit drugs linked to the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in clients recruited from primary health-care settings in four countries.

Humeniuk R., Ali R., Babor T. et al.
Addiction: 2012, 107(5), p. 957–966.
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 Humeniuk at rachel.humeniuk@adelaide.edu.au;rachel.humeniuk@health.sa.gov.au. You could also try this alternative source.

Orchestrated by WHO, across all four countries this rare attempt at screening and brief intervention for problems arising from illegal drug use identified at front-line health care centres found modest reductions in use/risks, but there was a puzzling opposition between particularly positive results from Australia and seemingly negative ones from the USA.

Summary Results of the featured study are also available in a research report previously analysed by Findings. Both this and the featured journal article are drawn on in the following account.

There is good evidence that brief interventions (usually one or two face-to-face counselling sessions) can reduce tobacco and alcohol use identified by screening tests in primary health care settings, particularly when they capitalise on the results of the test. However, there is only suggestive evidence of similar effects in respect of illicit drug use, only recently has a culturally neutral screening questionnaire for all psychoactive substances, including illicit drugs, been available for use in primary care, and most studies were conducted in the USA, UK or Australia, limiting the international generalisability of the findings.

To address these gaps the World Health Organization (WHO) developed the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). Through a series of interview questions it screens for problem or risky use of tobacco, alcohol, cannabis, cocaine, amphetamine-type stimulants, sedatives, hallucinogens, inhalants, opioids like heroin, and "other drugs". It first asks whether the patient has ever used these substances, then for those they have, how often in the past three months. Further questions in relation to each used substance ask about adverse consequences, urges to use, whether the individual has tried but failed to cut down, and whether others have shown concern over their substance use. Finally the patient is asked if they have injected drugs, if so when, and if recently, how often.

A risk score is calculated for each substance and categorised as low, moderate (harmful but not dependent use) or high (actually or probably dependent), in turn indicating whether no intervention is needed, a brief intervention to encourage the patient to cut back, or a brief intervention encouraging them to seek further and/or specialised treatment. ASSIST was primarily intended to identify patients at moderate risk who may otherwise go undetected and deteriorate.

To test this strategy, in 2003 to 2006, 845 potentially suitable patients were assessed by researchers and/or clinicians at health centres and other front-line medical care settings In Australia, participants were recruited at a free, walk-in sexually transmitted disease clinic. In Brazil, recruitment was at 30 primary health care units, two health centres that specialise in sexually transmitted diseases and one out-patient setting linked to a general hospital. In India, participants were recruited from community health centres. In the United States, participants were recruited from a community clinic, a walk-in health clinic associated with a drug treatment programme, and from general medicine clinic and a dental clinics, particularly one of the latter primarily seeing poor patients in an emergency. in Australia, India, the United States and Brazil. After completing the ASSIST interview, 731 adults were found to meet the study's criteria and agreed to join the study; another 51 refused. To join they had to have scored as at moderate risk due to their use of either cannabis, cocaine, amphetamine-type stimulants, or opioids, but not at high risk High-risk patients or frequent injectors were instead referred to specialist drug and alcohol treatment services. from any substance except tobacco. Two thirds of study participants were men and 72% were employed. They averaged about 31 years of age.

Following assessment patients were randomly allocated to wait for three months before intervention (the control A group of people, households, organisations, communities or other units who do not participate in the intervention(s) being evaluated. Instead, they receive no intervention or none relevant to the outcomes being assessed, carry on as usual, or receive an alternative intervention (for the latter the term comparison group may be preferable). Outcome measures taken from the controls form the benchmark against which changes in the intervention group(s) are compared to determine whether the intervention had an impact and whether this is statistically significant. Comparability between control and intervention groups is essential. Normally this is best achieved by randomly allocating research participants to the different groups. Alternatives include sequentially selecting participants for one then the other group(s), or deliberately selecting similar set of participants for each group. group), or to participate (they all did) in a single brief advice session offered by the same clinician/researcher who had conducted the assessment, focused on the drug which posed the greatest risk to the patient and/or over which they were most concerned. In a motivational interviewing style, during this session patients were offered written feedback on their ASSIST scores and the implications (eg, health risks) were explored. They left with a self-help guide on reducing substance use. On average ASSIST screening took eight minutes and the brief intervention 14 minutes.

86% of the patients were followed up about three months later when the ASSIST test was re-applied. At issue was whether the risk scores of those who participated in the brief intervention three months before had decreased relative to the control group. How they might have scored at the follow-up was estimated for the patients who could not be re-assessed.

Main findings

In general across all countries and in each separately, the brief intervention resulted in greater risk reduction, particularly in respect of the substance on which the intervention had focused.

Total ASSIST risk scores for substances other than alcohol and tobacco fell for both sets of patients, but significantly more so for patients who had been allocated to the brief intervention. Their scores fell from an average 36 to just under 30, while those of the control group fell from 36 to 32. In % terms this meant a fall of 18% compared to 11%. This global picture was replicated in each of the countries (most sharply in Australia) except the USA, where control patients actually reduced their risk more than brief intervention patients, though not to a statistically significant degree. Patients who scored in the upper half of the moderate risk range reacted about as well to the intervention as those who scored lower; when the sample was divided in this way, neither intervention effect was statistically significant, though both neared this criterion.

For just over half the patients their main problem substance was cannabis, and this was the focus of the brief intervention for those allocated to this procedure. Among these patients, risk reduction in relation to the targeted drug (cannabis) was significantly greater among patients allocated to the brief intervention. In each country too risk reduction was greater among intervention patients, except again for the USA, where the order was reversed. Only the results for Brazil and India were statistically significant. For cannabis, only patients at the higher end of the moderate risk spectrum further reduced their ASSIST scores following intervention.

Across all countries, patients whose primary problem substance was a stimulant (cocaine or amphetamine-type drugs) also reduced their risk related to these substances more if they had been through the brief intervention. None were recruited in India and the country-specific statistically significant results were from Brazil and Australia. In respect of these drugs, only patients at the lower end of the moderate risk spectrum further reduced their ASSIST scores following intervention.

Only in India were there appreciable patients whose main problem substances were opioids. Opioid-related risk reduction was significantly greater among brief intervention patients than among control patients.

Finally the analysts explored whether there was any evidence that while on average patients reduced their cannabis use in response to the cannabis-specific brief intervention, they 'compensated' by increasing use of other substances. No statistically significant effects on other substances were found, and there was actually some reduction in risk related to drinking. Similarly, when the intervention targeted substances other than cannabis, cannabis use was unaffected.

The authors' conclusions

This study has shown that a brief intervention lasting on average a quarter of an hour and linked to the results of the ASSIST screening test reduced illicit substance use and associated risk significantly among non-dependent patients identified across a range countries in different types of front-line health care settings. Risk related to the target drug was reduced without patients 'compensating' by increasing their risky use of other substances. Except for the USA, the pattern of extra risk reduction after brief intervention was maintained in each of the four countries. It was also apparent in patients with both a moderately high and a moderately low risk.

In both developing and developed countries, there is a compelling need for a comprehensive approach capable of addressing use of a range of illicit drugs and of tobacco and alcohol in primary care settings. The findings from this project indicate that the ASSIST screening test and linked brief intervention can at least partly meet this need, promising to help reduce the burden of disease associated with substance use and substance use disorders.

Why results differed in the USA is unclear. Possibly the relatively lengthy (10–15 minutes) interview required to establish the patient's consent to join the study 'overwhelmed' the intervention. Possibly too the patients, around 30% of whom had been treated for drug or alcohol problems, were less responsive to a brief intervention. The authors also point out that screening and intervention was generally conducted by specially trained clinical research staff rather than the centres' usual staff, and that these same staff also generally conducted initial and follow-up assessments, raising the possibility of bias.

Findings logo commentary The puzzling divide between the prominence of research on brief interventions for drinkers, and the lack of similar investigations among users of other drugs, makes this rare large-scale study particularly welcome. Especially in the Australian (so perhaps too in the UK) context, it holds out the prospect that this divide is not due to differing efficacy, but a prospect clouded by questions over real-world applicability and impacts on health.

Though the study recorded statistically significant reductions in drug use severity after research procedures and screening, and significant extra reductions from the intervention, questions have been raised about the clinical significance of the findings. After the entire package overall illicit drug use risk fell by 6.6 points on a scale whose maximum was 336, only 2.6 points greater than the decline in the control group. Similarly for cannabis, on a scale reaching 39 the overall reduction was 3.1, just 1.4 greater than in the control group. Among patients whose drug use may or may not According to the ASSIST manual (http://whqlibdoc.who.int/publications/2010/9789241599382_eng.pdf), the patients selected for the trial scored in a range indicative of "moderate risk of health and other problems and may be experiencing some of these problems now. Continuing use in this way indicates a likelihood of future health and other problems." have put them at risk of health problems, the impact of such small reductions on their future health is unclear. The study excluded the highest risk patients most likely to be identified by doctors and of greatest concern, so could say nothing about how well the recommended brief intervention plus referral procedure works among these priority patients.

As in some alcohol studies (1 2), a very minimal intervention, such as handing over the booklets Though minimal, this entails the potentially powerful message that the patient has been professionally identified as at risk from their substance use, a realisation which the current study's participants commonly highlighted as instrumental in their improvements. used in the current study, may have led to as great a reduction in drug use/problems as the motivational-style interview.

The fact that patients usually saw the same person for intervention and follow-up assessment means not only could the assessors know whether the patient had been in the brief intervention group (ie, they were not 'blinded' as recommended in such trials), but also that often they were assessing the results of their own work. No biochemical tests were conducted to objectively test for substance use. This raises the serious possibility No implication of bias is meant, merely that bias cannot be ruled out and seems a serious possibility. that both parties had the opportunity and the motivation to amplify the impacts of their interaction. Given the overall small impact of the intervention, this could account for an appreciable part of its apparent effectiveness. In the USA about half the participants were instead re-interviewed by a different person, perhaps one reason why their responses did not indicate extra risk reductions from the intervention.

Some of the biggest effects were seen among opioid users in India, where nearly 10 points were sliced from opioid use severity scores (maximum 39) by the whole package, over twice the decline in the control group. Half the patients targeted for their opioid use were daily or near daily users and all but a few were recruited in India. Where, as in parts of that country, regular opioid use is normalised among socially included populations with family and work responsibilities, it seems that in certain cultures it is susceptible to even quite brief intervention. It seems possible however that participants were motivated to deny continuing drug use (especially in the case of brief intervention patients, to their counsellors), which compared to other countries they tended to see as contravening personal and family responsibilities.

As the authors hint, screening of this kind will probably be reserved for medical and other settings likely to attract unusually many illegal drug users. How willing they will be to own up to their use is unclear. In the validation studies for the ASSIST screening questionnaire, patients were interviewed by researchers and assured of confidentiality, even in respect of their doctors – important to at least some of the patients. In routine practice these doctors or their colleagues would be the ones asking the screening questions. Another departure from routine practice was that the study largely relied on specially trained clinical research staff rather than the centres' usual staff, meaning the results may not apply where clinical research staff are not available.

Assuming the results do translate to everyday practice, there remains the issue of which type of practice. Among the settings were sexually transmitted disease clinics, a health centre associated with a drug treatment programme, a dental clinic primarily seeing poor patients in an emergency, as well as primary health and community health clinics. At best pooling these results reveals the impact of the intervention at settings with the characteristic they shared – being front-line medical services. At worst it jumbles apples with pears, perhaps one reason why there was a highly significant variation in results from different countries.

Puzzling opposition in results from Australia and USA

British readers may be most interested in the somewhat opposing results from the two westernised developed nations in the study, Australia and the USA. It should be stressed however that results from individual countries are subject to the idiosyncrasies of the study site, population and procedures in that country, variations partly ironed out in the amalgamated results. Results from Australia were particularly promising, but derived from STD clinics rather than generic primary care, and the unexplained variation between these two countries closest to UK conditions makes it impossible to predict what the consequences might be of a similar study in the UK, especially in GP surgeries and emergency departments, where brief intervention work is concentrated. Details below.

In Australia, three quarters of the largely young single population recruited at clinics for sexually transmitted diseases were identified as primarily having problems with what seems to have been mainly recreational Once a week or less often. stimulant use. Despite of all the nations averaging the highest risk score in relation to illegal drug use and the shortest intervention (typically just eight minutes), this country also recorded the strongest intervention effects. Possibly this was a particularly health-conscious population not representative of usual primary care patients in Britain.

The USA was the other westernised developed nation, and here results were at the opposite end of the scale – in the 'wrong' direction for illicit drugs in general and for cannabis and stimulants, in each case nearly to a statistically significant degree. This could simply be chance variation but the consistency of the findings suggests otherwise. If it did reflect a real and counterproductive effect, this pattern does not square with the intervention being overwhelmed by the consent procedure or by the patients' previous experiences of treatment, influences which would have merely nullified the intervention. Adding to the puzzle is that according to their own accounts at the follow-up interviews, the US patients' feelings about the brief intervention do not seem to explain why they failed to react to by reducing their substance use risks. For example, almost 80% who received the brief intervention reported attempting to cut down as a result, similar to other countries.

For more see the WHO ASSIST web site where you can download the research report on the featured evaluation, manuals for the screening tool and the brief intervention, and the written self-help guide given to patients in the study.

Thanks for their comments on this entry in draft to research author Rachel Humeniuk of Drug and Alcohol Services South Australia and to Richard Saitz of the Boston Medical Center in the USA. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 20 September 2013. First uploaded 05 September 2013

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STUDY 2008 The effectiveness of a brief intervention for illicit drugs linked to the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in primary health care settings: a technical report of phase III findings of the WHO ASSIST randomized controlled trial

STUDY 2014 The effectiveness of alcohol screening and brief intervention in emergency departments: a multicentre pragmatic cluster randomized controlled trial

STUDY 2008 Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: comparison at intake and 6 months later

STUDY 2012 Alcohol screening and brief intervention in emergency departments

STUDY 2012 Alcohol screening and brief intervention in primary health care

STUDY 2013 Effectiveness of screening and brief alcohol intervention in primary care (SIPS trial): pragmatic cluster randomised controlled trial

STUDY 2012 Brief intervention for drug-abusing adolescents in a school setting: outcomes and mediating factors

REVIEW 2015 Prevention of addictive behaviours

STUDY 2013 Screening and brief intervention for alcohol and other drug use in primary care: associations between organizational climate and practice

REVIEW 2016 Emergency department-based brief interventions for individuals with substance-related problems: A review of effectiveness

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

Strang J., Groshkova T., Metrebian N.
Lisbon: European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), 2012.
Unable to obtain a copy by clicking title? Try this alternative source.

Prescribing oral methadone to heroin addicts divides opinions, but prescribing injectable heroin elevates the controversy to another level. Fortunately we now have six randomised clinical trials involving over 1500 patients to ground us in the evidence – and this European Union review to pull it all together.

Summary The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) established by the European Union aims to be the central source of comprehensive information on drugs and drug addiction in Europe. In the featured report freely available from its web site it collates all major contemporary studies on treatments based on prescribing pharmaceutical heroin ('diamorphine' or 'diacetylmorphine') to heroin addicts, addressing two key questions:
• Does the evidence support the use of supervised injectable heroin treatment for those who have failed to respond adequately to other approaches?
• And if so, what are the clinical management issues necessary to ensure this option can be delivered in a manner that avoids the associated risks?

The following account of this 170-page report is based on its executive summary with minor editorial changes and links where appropriate to Findings analyses or original studies.

Supervised Meaning that all injectable doses are taken under direct medical or nursing supervision. injectable heroin treatment has emerged over the last 15 years as a potentially important intensive second-line treatment for entrenched heroin addicts for whom previous orthodox treatments have produced little benefit. We now have results from a series of well-designed randomised clinical trials from Europe and Canada which have been peer-reviewed and published in scientific journals, as well as accumulating clinical experience of the development and provision of this treatment. For this report all findings from randomised controlled trials published in academic papers and project reports have been examined to gauge the efficacy (against a range of outcomes) as well as the cost and cost utility of this form of treatment.

Context and history

Supervised injectable heroin treatment was developed and initially introduced in Switzerland during the 1990s after a century of prescribing heroin for the treatment of addiction without direct supervision, mostly in the United Kingdom. Since the 1990s the approach has been tested as a new clinical practice, sometimes in the context of randomised clinical trials, in several European countries and in Canada.

Two common features characterise the new approach to heroin treatment:
• It is not a first-line treatment, but an option for patients who have not responded to standard treatments such as oral methadone maintenance treatment or residential rehabilitation.
• All injectable doses (typically about 200mg of diamorphine per injection) are taken under direct medical or nursing supervision, ensuring compliance, monitoring, and safety, and preventing the medication being diverted to the illicit market; this requires clinics to be open for several sessions per day, every day of the year.

Scientific evidence base

Over the past 15 years, six randomised clinical trials have been conducted involving more than 1500 patients. They provide strong evidence, both individually and collectively, in support of the efficacy of treatment with fully supervised, self-administered injectable heroin, when compared with oral methadone, for long-term heroin-dependent individuals who have proved refractory to previous treatment. These trials have been conducted in six countries: Switzerland; the Netherlands, for which also see this Findings analysis; Spain, for which also see this Findings analysis; Germany, for which also see this Findings analysis; Canada, for which also see this Findings analysis; and England.

Across the trials, major reductions in the use of 'street' heroin occurred in those receiving heroin-based treatment compared with 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 patients, who were usually being prescribed oral methadone. Reductions occasionally amounted to complete cessation; more often there was continued but reduced irregular use of street heroin, at least through the trial periods ranging from six to 12 months. Lesser reductions also occurred in the use of a range of other drugs such as cocaine and alcohol.

Patients receiving injectable heroin treatment achieved gains in physical and mental health and social functioning, though in different trials improvements were not consistently or significantly superior to those in the control groups, particularly in relation to psychosocial functioning. Reductions in criminal activity were also evident and substantially greater than those made by control group patients. Retention in treatment varied substantially across the trials.

This evidence suggests that for long-term, treatment-refractory opioid users, supervised injectable heroin treatment plus supplementary methadone does add value, a verdict corroborated in respect of several outcomes including retention and mortality See commentary below. by a systematic review conducted by the Cochrane Group. However, it is important to note that more serious adverse events See commentary below. have been reported to occur in patients receiving supervised injectable heroin than oral methadone. This suggests that heroin treatment may be less safe, and therefore require more resources and clinical attention in order to manage the risks.

Finally, countries that have conducted longer term (up to six years) follow-up studies have seen a high retention in supervised injectable heroin treatment (55% at two years and 40% at six years), with patients sustaining gains in reduced street heroin use and marked improvements in social functioning (eg, stable housing, drug-free social contacts, and employment).

Cost and economic evaluations

In the trials the reported cost per patient per year of a supervised injectable heroin maintenance programme was between €12,700 and €20,400. These costs were consistently and substantially higher than the cost of oral methadone maintenance at €3500 in Germany and €1600 in the Netherlands, partly due to the higher cost of pharmaceutical heroin, but largely due to more staff being required for the heroin-based treatment. At least two staff members must be present at all times and no 'take-home' injectable heroin doses are permitted, so clinics need to open daily and for extended hours.

This higher cost was compensated for by extra significant savings to society. In particular, a greater reduction in the costs of criminal procedures and imprisonment arising from criminal behaviour was seen with supervised injectable heroin than with oral methadone treatment. It should be noted that the provision of a more standard treatment to a patient who derives little benefit cannot be cost-effective, no matter how cheaply it may be delivered.

Impact, clinical practice and challenges

At the time of writing there are about 1000 injectable heroin patients in the European Union and a further 1400 in Switzerland. In the United Kingdom heroin has been used in clinical practice since it was first synthesised, both for the relief of terminal pain and (rarely recently) for the treatment of opioid dependence. In recent years, four other countries (Denmark, Germany, the Netherlands and Switzerland) have granted approval for diamorphine to be used as a medicinal product for treatment-refractory heroin addicts. In these countries, injectable heroin clinics are now integrated into local addiction service networks, and appear to successfully deliver important benefits to a small number of severely affected chronic heroin addicts. For these addicts, this new treatment delivers tangible benefits, for themselves, for their families and for society.

One Spanish clinic continues to provide treatment to participants enrolled in their trial, now operating under legal exemption, and Canada has approved diamorphine for research trials only.


Supervised injectable heroin has developed in to a useful addition to the treatment toolbox for opiate addicts, but seems unlikely to become the solution to the heroin problem. The objective to provide a second-line intervention for hard-to-reach and highly problematic heroin users is reflected in the small number of patients – in 2011 across Europe, about 2500 or ½% of all patients in substitution treatment. Where the heroin treatment is already well established, proportions were stable at between 5% and 8%.

Across countries, almost uniformly supervised injectable heroin treatments are strongly structured, with the patient having to attend the clinic to take all injected doses under medical supervision. The treatment is also embedded within wider psychosocial support and rehabilitation, with attention to family reunion, criminal charges and debt, etc, as well as to outstanding health and psychological disorders. Patients themselves see the prescribed heroin as one perhaps important part of their treatment, but just one part nevertheless, and the wider therapeutic engagement and rehabilitative effort is considered equally important.

Clinical precautions remain vital since, though rare (one in every 6000 injections), life-threatening and often unpredictable adverse events are seen – in particular overdoses, often for reasons not immediately apparent and sometimes very hard to predict, even with a carefully applied testing procedures. This means it is important for clinical teams to be appropriately trained and resourced to deal with such emergencies and for clinical protocols, training and facilities to be established in advance.

The high costs of this treatment and the potentially controversial status of the medication may limit its implementation. However, it must be remembered that diamorphine is a medicinal product prepared by the pharmaceutical industry in accordance with all the usual quality and safety controls. Also, the costs have to be compared with the gains; notwithstanding their relative cheapness, oral opiate substitution treatments can never be cost-effective for this selected group of heroin addicts if they do not derive the expected benefits.

Another challenge will be to make this form of treatment available to severely affected heroin addicts in such a way that it does not inadvertently undermine the commitment of other patients to more orthodox forms of opiate addiction treatment.

Findings logo commentary As the body of report makes clear, the Cochrane review which it cited found fewer deaths among heroin than methadone patients or (more broadly) other comparison patients, but these statistically insignificant findings might have been due to chance fluctuations, and the randomised trials covered by the review were it said "not appropriate for measuring this outcome". Also, for methodological reasons the calculations excluded two studies where neither heroin nor comparison patients died. Had these been able to be included, the gap in the death rate would have been less. Given these considerations, it remains probable, but far from conclusive, that prescribing heroin to the types of patients recruited to the trials does help keep them alive.

On the other side of the equation is the greater incidence among heroin patients of serious and potentially fatal adverse events. That more of these (and especially more that were related to prescribed medications) were recorded among the heroin patients was almost certainly largely due to the fact much of their injecting – and any resultant immediate complications – was observed at the clinics, while any injecting by methadone patients would have taken place elsewhere. That for the patients in the trials it was in fact safer to prescribe heroin is suggested by the difference in the death rate.

In line with the featured report, UK national clinical guidelines and guidance issued by England's National Treatment Agency for Substance Misuse recommend that injectable prescribing should be considered only for the minority of patients with persistently poor outcomes despite optimised oral programmes, and that the priority should be improving the effectiveness of oral maintenance treatment for the majority. Later (in 2009) an expert group of clinicians, service users, commissioners from England agreed that a "sustained attempt" at optimised oral prescribing programmes should precede injectable treatment. Only if this proved unsuccessful should injectables be considered, and they should continue to be prescribed only if in fact they gained greater benefits than the oral programme. Though for new patients "total supervision of injectables was the ideal", the group stopped short of recommending this be mandatory. They also recommended that patients doing well in the traditional non-supervised British model should be allowed to continue.

Apart from the issues of cost and controversy mentioned by the featured report, there is a major logistical problem in extending heroin prescribing programmes based as recommended on supervised consumption at the clinic. Studies in continental Europe and Britain have shown that requiring on-site injecting or smoking of heroin several times a day is feasible. However, this can only work for patients who can easily and quickly get to the clinic. Unless the network of heroin prescribing centres is greatly expanded, on-site consumption will leave large parts of Britain unserved, especially rural areas. The inconvenience of on-site consumption can be tempered by allowing patients to skip visits and take oral medication instead, an opportunity most took advantage of in Swiss trials and which was also implemented in all three clinics in the English trial. If supervision is primarily to prevent prescribed injectable drugs being diverted to the illicit market, insisting instead on the return of used ampoules may be a less intrusive and less expensive way to achieve this objective – a tactic used with seeming success at a clinic in London which did not routinely require ongoing supervised injecting.

English trial

The English trial's finding that (in patients previously failed by oral methadone) injectable heroin suppressed illegal heroin use much more effectively than oral methadone, was in September 2013 supplemented by a cost-effectiveness analysis. Though in itself heroin prescribing was the most expensive option, taking all costs in to account (of which the most decisive was the cost of crime committed by the patients), over the first six months of treatment it and the prescribing of injectable methadone registered lower costs Though the differences were not statistically significant. overall than oral methadone. Since all three treatments led to roughly the same improvements in the health-related quality of life of the patients, the injectable options (and especially injectable methadone) were calculated to be the most cost-effective.

Results of the English trial helped secure a future for supervised injectable treatment as a supplement to the traditional less structured injectable prescribing practices in UK addiction clinics. In 2012 the Department of Health issued a £5.5 million competitive tender for services to "develop a cost-effective model" for supervised injectable opioid treatment. The contract was awarded Personal communication September 2013 from John Strang. to the groups running the trial clinics in south London, Darlington and Brighton, which had been continuing their treatments after the trial ended. A network of 'micro-sites' is intended to help cover the London area.

For more on substitute prescribing for heroin addiction see this Findings hot topic. For heroin prescribing studies in particular run this search on the Findings site, and especially see this Findings review and a later review which paid careful attention to the context of the studies and the details of the treatments. The Findings analysis of the Cochrane review cited by the featured report also includes an extended commentary.

Thanks for their comments on this entry in draft to review authors John Strang and Nicola Metrebian of the National Addiction Centre in London, England, and to Sarah Byford of the Institute of Psychiatry in London, England. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 20 September 2013. First uploaded 12 September 2013

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

REVIEW 2009 Prescription of heroin for the management of heroin dependence: current status

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

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

REVIEW 2017 An evidence review of the outcomes that can be expected of drug misuse treatment in England

REVIEW 2011 Heroin maintenance for chronic heroin-dependent individuals

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

REVIEW 2003 Role Reversal

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

STUDY 2011 Interim methadone treatment compared to standard methadone treatment: 4-month findings

Psychosis with coexisting substance misuse: assessment and management in adults and young people.

National Collaborating Centre for Mental Health and National Institute for Health and Clinical Excellence.
[UK] National Institute for Health and Clinical Excellence, 2011.

Psychosis plus harmful substance use is a toxic mixture which worsens the prospects of recovery from mental illness. How should it be dealt with, and what are the respective roles of mental health and substance use services? This UK guideline developed by an expert group has some of the answers.

Summary This account is largely an abridged version of the introduction and key priorities sections of the guidance. See the freely available original for the recommendations in full and their rationale and genesis.

This guideline covers the assessment and management of people aged 14 and older with a clinical diagnosis of psychosis plus coexisting substance misuse. It aims to help healthcare professionals guide these people to stabilise, reduce or stop their substance misuse, to improve treatment adherence and outcomes, and to enhance their lives. In this guideline, substance misuse is defined as the harmful use of any psychotropic substance including alcohol and legal or illicit drugs. Such use is usually seen as a problem if there is evidence of dependence. However, substance misuse can be harmful without dependence, especially among people with psychosis.

People with psychosis commonly take non-prescribed substances to cope with their symptoms; in a third this amounts to harmful or dependent use. At some time in their lives, about 40% misuse substances, at least double the rate in the general population. They also have a higher risk of relapse and hospitalisation, and higher levels of unmet needs, compared with other inpatients with psychosis who do not misuse substances. Substance misuse among individuals with psychiatric disorders is associated with significantly poorer outcomes than for individuals with a single disorder. Coexisting substance misuse worsens outcome for people with psychosis partly because the substances used may exacerbate the psychosis, and partly because they often interfere with pharmacological or psychological treatment.

Person-centred care

People with psychosis and coexisting substance misuse should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If they do not have the capacity to make decisions, professionals should follow the Department of Health's advice on consent and the code of practice that accompanies the Mental Capacity Act. In Wales, healthcare professionals should follow advice on consent from the Welsh Assembly Government. If the person is under 16, healthcare professionals should follow the guidelines in Seeking consent: working with children.

If the person agrees, families and carers should have the opportunity to be involved in decisions about treatment and care. Families and carers should also be given the information and support they need. Care of young people in transition between child and adolescent mental health services (CAMHS) and adult services should be planned and managed according to the best practice guidance described in Transition: getting it right for young people. Adult and CAMHS healthcare teams should work jointly to provide assessment and services to young people with psychosis and coexisting substance misuse. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Key priorities for implementation

When working with adults and young people with known or suspected psychosis and coexisting substance misuse, take time to engage the person from the start, and build a respectful, trusting, non-judgemental relationship in an atmosphere of hope and optimism. Be direct in your communications, use a flexible and motivational approach, and take into account that:
• stigma and discrimination are associated with both psychosis and substance misuse;
• some people will try to conceal either one or both of their conditions;
• many people with psychosis and coexisting substance misuse fear being detained or imprisoned, being given psychiatric medication forcibly or having their children taken into care, and some fear that they may be 'mad'.

Healthcare professionals in all settings, including primary care, secondary care mental health services, CAMHS and accident and emergency departments, and those in prisons and criminal justice mental health liaison schemes, should routinely ask adults and young people with known or suspected psychosis about their use of alcohol and/or prescribed and non-prescribed (including illicit) drugs. If the person has used substances, ask them about all of the following:
• particular substance(s) used;
• quantity, frequency and pattern of use;
• route of administration;
• duration of current level of use.

In addition, conduct an assessment of dependency (see these NICE guidelines on opioid detoxification and alcohol use disorders) and seek corroborative evidence from families, carers or significant others, where this is possible and permission has been given.

Healthcare professionals working within secondary care mental health services should ensure they are competent in the recognition, treatment and care of adults and young people with psychosis and coexisting substance misuse.

Do not exclude adults and young people with psychosis and coexisting substance misuse from age-appropriate mental healthcare because of their substance misuse, nor from age-appropriate substance misuse services because of a diagnosis of psychosis.

For most adults with psychosis and coexisting substance misuse, treatment for both conditions should be provided by healthcare professionals in secondary care mental health services such as community-based mental health teams. These services should consider seeking specialist advice and initiating joint working arrangements with specialist substance misuse services for adults and young people with psychosis being treated by community mental health teams known to be:
• severely dependent on alcohol; or
• dependent on both alcohol and benzodiazepines; or
• dependent on opioids and/or cocaine or crack cocaine.
Adult community mental health services or CAMHS should continue to provide care coordination and treatment for the psychosis within joint working arrangements.

Healthcare professionals in substance misuse services should be competent to:
• recognise the signs and symptoms of psychosis;
• undertake a mental health needs and risk assessment sufficient to know how and when to refer to secondary care mental health services.

All inpatient mental health services should ensure that they have policies and procedures for promoting a therapeutic environment free from drugs and alcohol that have been developed together with service users and their families, carers or significant others. These should include: search procedures; visiting arrangements; planning and reviewing leave; drug and alcohol testing; disposal of legal and illicit substances; and other security measures. Soon after admission, provide all service users, and their families, carers or significant others, with information about the policies and procedures.

Those providing and commissioning services should ensure that:
• age-appropriate mental health services are available for young people with psychosis and coexisting substance misuse; and
• transition arrangements to adult mental health services are in place where appropriate.

Findings logo commentary For more on the care of psychiatrically ill problem substance users see this Findings hot topic.

Last revised 24 September 2013. First uploaded 24 September 2013

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Emotional compatibility and the effectiveness of anti-drinking messages: a defensive processing perspective on shame and guilt.

Agrawal N., Duhachek A.
Journal of Marketing Research: 2010, 47(2), p. 263–273.
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 Agrawal at nidhi-agrawal@kellogg.northwestern.edu. You could also try this alternative source.

US students already burdened by these emotions reacted to shame or guilt-inducing anti-drink ads by intending to and actually drinking more, the opposite of what was intended. This intriguing series of studies may reinforce the feeling that the ways anti-substance use ads can backfire are so various, the safest option is not to try them.

Summary This series of US studies using university students as subjects explored how people already experiencing or prone to shame or guilt respond to anti-alcohol adverts which induce the same unpleasant emotion. Unlike other aversive emotions, shame and guilt involve a conscious and negative perception of oneself as being seen to violate social norms and one's ideal self (shame), or having unacceptably caused harm to others (guilt). Especially if already feeling bad about oneself in these ways, people may guard against and resist information (eg, 'That won't happen to me') which would otherwise aggravate these uncomfortable feelings. The result could be to negate and even reverse the intended impacts of adverts which arouse these emotions. A case in point might be ads warning that the consequences of one's over-drinking may be witnessed by friends and family (shame-inducing) or cause them serious inconvenience or harm (guilt-inducing).

Shame-inducing ad Guilt-inducing ad

To investigate this theory, in a pilot study an ad from a public service responsible-drinking campaign was modified to convey either shame or guilt due to the impact on "those you love" of a drink-laced "Best night of my life" illustrations.

By random allocation, one or other ad or none were shown to 75 students, who then rated the degree to which they were feeling guilt or shame. As expected, the shame-inducing ad did lead to the greatest feelings of shame, while the guilt-inducing ad led to the greatest feelings of guilt.

Having established that the ads aroused the intended emotions, the researchers then investigated this effect's impact on how students responded to the ads, in particular their intended or actual drinking.

Study 1 randomly allocated 478 students to describe in writing an episode during which they had experienced either extreme shame or extreme guilt, or to simply describe their typical day. Again ratings indicated that the intended emotions had been aroused. Then the students were asked to evaluate either the shame-inducing anti-drinking ad or the guilt-inducing version. After a break they then completed a survey of the "habits of college students" which included the question, "Compared to last year, how often do you plan to binge drink this year?" A similar question asked their views about the intentions of the average student.

Students primed by the first task to feel shame, and then shown an advert inducing the same emotion, planned to binge significantly more often than the other students, including shame-primed students shown a guilt-inducing ad. The pattern was the same for the guilt variants of the preceding task and the ad. In contrast when, the individual was no longer themselves 'threatened' by the question, the combination of shame-inducing task and ad led them to make the lowest estimate of how often other students would binge-drink.

In other words, it was not the ads' induction of negative emotions as such which generated a counterproductive impact on drinking intentions, but the 'piling on' of the same unpleasant emotion previously aroused, and then only when the viewer's own drinking was at issue. The process of defending themselves from yet further shame (or further guilt) seemed to lead the students to reject the ad's message, so that compared to seeing another ad, they planned to drink more. The opposing impacts on their ratings of their own versus other students' intentions proves they had not simply 'switched off' in response to the ads – they were switched on and processing the messages, but not as the ads' developers might have wished.

Study 2 extended the findings of study 1 from intentions to actual drinking. It recruited 71 students and followed a similar procedure to study 1 – a shame- or guilt-arousing recall task followed by viewing the shame- or guilt-arousing ad. Then the students were asked to evaluate the ad, and after a break, told they would be sampling and rating a new alcoholic drink mixer, of which they could drink as much they wanted. Among other questions, they were then asked to rate how likely they would be to shame themselves (or for students assigned to the guilt-arousing task, do something they felt guilty about) after having had a couple of drinks at a party, an attempt to assess whether they really had been provoked by the ads in to being defensive about their drinking.

When a shame- or guilt-inducing ad followed a task intended to arouse the same emotion, students drank more than when task and ad had been intended to arouse different emotions. They also saw themselves as less likely to get in to a situation causing the same feelings after drinking at a party. It seemed that piling on the same negative emotion led them to deny the link between their drinking and possibly behaving in ways which cause shame or guilt, a defensive posture which led them to actually drink more than if these emotions had not been serially provoked.

Unlike the previous studies, study 3 used ads to prime shame or guilt, more like what might happen in real life. The first ads shown to 182 students were unrelated to alcohol, but explicitly sought to generate shame about cheating, or guilt about the environmental consequences of buying bottled water. A test confirmed the intended effects. Then they were shown one of the two anti-drinking ads, and after a break asked to rate the likelihood that during the next two weeks they would patronise a bar, or consume three or more drinks in one evening. Combining these answers created a single measure of drinking intentions.

As expected, when a shame-inducing anti-drink ad followed another shame-inducing ad, students expressed firmer intentions to go out and drink heavily, but not because they had ignored the anti-drink ad – in fact, they recalled the ad better than the other students. Moreover, even though they had serially been exposed to shame-inducing ads, these students felt less shame at the end than other students in the study (but not less guilt). Similarly for the guilt-inducing ads. This pattern was consistent with the students successfully resisting the alcohol ads' attempts to generate yet more of the same uncomfortable emotion already generated by the preceding ad, and as a result also resisting its anti-drink message.

The assumption was that students exposed to the shame-inducing adverts ended up feeling less shame than before, and similarly with guilt – but with no pre-ad measures of shame and guilt, this was just an assumption which fit the evidence. Study 4 rectified this by replicating study 1 with another 64 students, but this time taking before-and-after measures of guilt and shame.

As before, first the students described a shame or guilt-inducing incident from their lives. This time they were then asked to rate their feelings of shame and guilt, measures repeated after they later watched one of the two anti-alcohol adverts. When the advert was intended to arouse the same emotion as the preceding task, the opposite happened – feelings of that emotion actually fell from before to after watching the ad, relative to watching one intended to arouse a different emotion. In contrast, students primed to feel shame did feel more guilt after seeing the guilt-inducing ad. When processed defensively by people already burdened by these emotions, it seemed that a message designed to induce shame or guilt actually reduced the intended emotion.

The preceding studies had 'artificially' induced feelings of guilt or shame before exposing students to the anti-alcohol ads. Study 5 instead investigated the effects of the ads on people naturally prone to feel either guilt or shame. A questionnaire was used to assess these propensities among 233 students, who after a break were then shown one of the two anti-alcohol adverts. As in study 1, they were then asked, "Compared to last year, how often do you plan to binge drink this year?" The results were similar to the other studies. Shame-prone students were more likely to plan to drink heavily more often if they had been shown the shame-inducing advert, but not the other. For guilt-prone students there was a corresponding finding.

The authors' conclusions

In relation to 'irresponsible' drinking, these studies show that when emotions which entail an uncomfortable perception of oneself are further stimulated in ways which threaten to heighten this discomfort, viewers tend to convince themselves that the message does not apply to them ('defensive' processing), leaving them freer to do what the message warned against than if it had never been received. In particular, shame-laden consumers exposed to messages which asserted that drinking might lead to additional shame-inducing situations, believed that their own drinking would not lead to those consequences, and similarly for guilt. In contrast, when there was no threat to the self and the viewer was asked to think about the behaviour of others, the warnings had the intended impacts.

The findings also suggests that people 'repair' negative mood states not in general but in relation to the specific mood they are experiencing; shame-laden consumers resist messages that might lead to greater shame, but are open to messages that lead to guilt, and vice versa.

In some of the studies effects were not large, but much larger in study 2 which assessed actual drinking, suggesting that guarding against the 'piling up' of negative emotions might strongly influence health-related behaviour.

Public service health promotion messages often highlight how friends or others might see you if you behave in the way the ad is seeking to deter. In relation to binge drinking, commonly ads arouse concern over 'making a fool of oneself' or 'losing control and doing something bad'. Commonly these ads also highlight emotions which play on these concerns (eg, 'Avoid the shame and embarrassment of a drunk-driving arrest') and the consequences of one's actions on others (eg, 'Think about those you may harm if you cause an accident while driving drunk').

The featured research suggests that emotional appeals such as these playing on guilt or shame should be used cautiously, and that attention should be paid to the broader milieu within which the ad will be embedded. For instance, a guilt-inducing message may not be optimal if inserted in a guilt-ridden television drama. However, such appeals may work as intended if the viewer is directed to the behaviour of others rather than themselves, as for example in the popular public service message, 'Friends don't let friends drive drunk'.

Findings logo commentary This intriguing series of studies might well reinforce a feeling that the ways anti-substance use campaigns can backfire are so various, the safest option is not to mount them. Describing the implications of the findings, one of the featured article's authors warned that "public health and marketing communities expend considerable effort and capital on [anti- or 'responsible' drinking] campaigns but have long suspected they were less effective than hoped. But the situation is worse than wasted money or effort. These ads ultimately may do more harm than good because they have the potential to spur more of the behaviour they're trying to prevent."

It can happen, he said, because "Advertisements are capable of bringing forth feelings so unpleasant that we're compelled to eliminate them by whatever means possible. This motivation is sufficiently strong to convince us we're immune to certain risks." The implication for health promoters was that "If you're going to communicate a frightening scenario, temper it with the idea that it's avoidable. It's best to use the carrot along with the stick."

The mechanism the authors propose for this effect is distinct from the 'reactance' thought partly to underlie counterproductive reactions to the anti-drug messages of the US National Youth Anti-Drug Media Campaign. Seeing these ads, some young viewers may have resented being (as they saw it) 'told what to do', and reacted by moving in the opposite direction. Another way these ads may have backfired is by implying that drug use was so common and so hard to resist that the government had to warn young people about it. Ads which contradict personal experience may also be counter-productively discounted by viewers. Yet another mechanism is that ads can generate discussion between young people, which may be dominated by the more voluble risk-takers among them who tend to favour substance use. Another proposed mechanism is that ads which generate too much emotion lead recipients to 'shut down' and simply not process the message. One way to avoid these reactions is to end on a more positive note after presenting a warning, relieving the negative emotion and defusing defensiveness – found in a Spanish study to lead students to say they were less likely to drink excessively than a totally negative anti-drinking message or no message at all.

For the authors of the featured article, none of these explanation account for their findings. Instead they deduce that the students did pay attention to and process the messages of the two anti-alcohol ads, but in such a way as to defensively divorce themselves (if not others) from the risks portrayed. If this, as they persuasively argue, was the case, it may however have been due to the situation. The students had 'signed up' (sometimes in return for course credits) to participate in a study which involved assessing the ads; they may not have considered themselves at liberty not to 'process' them – that the situation and their obligations demanded they do not simply ignore them. To avoid further unpleasant emotions, perhaps they were left with little option but the 'defensive processing' hypothesised by the researchers. In real-life situations, viewers normally can simply turn over the page, look the other way, or stop paying attention to the TV, reactions which might neutralise the ad's messages but not lead to counter-productive reactions.

All the studies involved young people in the USA, who below the age of 21 are not permitted to legally buy alcohol and usually also forbidden to drink. All too were students, a group newly liberated from parental control and known to in some quarters value excessive drinking. Rather bluntly, in some of the studies they were asked "Compared to last year, how often do you plan to binge drink this year?" Their reactions to the ads and to this loaded question may not transfer to other sub-populations in the USA or to students in the UK.

Another limitation is that only the pilot study compared the ads to no ad at all; in all the others, students were allocated to see one or other of the two anti-alcohol ads. None of the studies tell us whether, compared to no ad at all, the ads led students to intend to drink excessively or actually do so. All we know is that in certain circumstances, seeing one ad was counterproductive vis-à-vis seeing the other; it may nevertheless have been better (or at least, no worse) than no health promotion at all.

Also, both adverts look amateur and seem to give not very persuasively framed messages, the content of which may easily be discounted. Better expressed and produced ads may have lent themselves less easily to 'defensive processing', and produced a different reaction.

However, the general ineffectiveness of anti-drinking advertising campaigns suggest that the featured studies' results are not merely due to context or ad quality. When experts assessed the full panoply of strategies to prevent or minimise alcohol-related harm, they could find no media campaign strategies to recommend: "Media campaigns prepared by government agencies and non-governmental organizations (NGOs) that address responsible drinking, the hazards of drink-driving and related topics are an ineffective antidote to the high-quality pro-drinking messages that appear much more frequently as paid advertisements in the mass media". In respect of illegal drugs too, in controlled studies anti-drug adverts have if anything bolstered intentions to use these substances.

Last revised 26 September 2013. First uploaded 19 September 2013

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