Drug and Alcohol Findings home page. Opens new window Effectiveness Bank bulletin 28 January 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.


Contents

An international mixture in this bulletin from brief interventions in England (the very briefest seemed as good as the relatively lengthy) to in Iran the heavy end of treatment using anaesthesia to rapidly withdraw opiate addicts. Back to the UK for a call for smoking equipment to supplement the provision of injecting equipment, and then to Australia and Germany for the results of raising taxes on sweetened alcoholic drinks (alcopops) designed to appeal to the young.

First major report from crucial English alcohol screening and brief intervention trials ...

Rapid withdrawal and opiate-blockers work for Iranian addicts ...

Give injectors foil to promote smoking instead say UK advisers ...

No youth health benefits after alcopops tax hike in Australia ...

Switching erodes impact of doubling alcopops price in Germany ...


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

Kaner E., Bland M., Cassidy P. et al.
BMJ: 2013, 346, e8501.
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 Kaner at e.f.s.kaner@newcastle.ac.uk.

The primary care arm of the largest alcohol screening and brief intervention study yet conducted in Britain found that the proportion of risky drinkers fell just as much after the most minimal of screening and intervention methods as after more sophisticated and longer (but still brief) alternatives.

Summary The SIPS project embraced three trials of brief interventions in different settings in England. This account focuses on the primary care trial; see these Effectiveness Bank analyses for the trials in emergency departments and probation offices.

Key points icon

Key points
From summary and commentary

The SIPS trials were the largest real-world trials of brief interventions yet conducted in the UK. This account focuses on the emergency department trial.

In all the trials the expected extra impacts of more extensive advice and counselling did not materialise, and even in primary care practices incentivised with per patient payments, throughput seemed low and implementation sometimes required aid from research staff.

The trials seem to justify merely offering written information and a warning about the patient’s risky drinking, but more was or might have been involved.

First this account describes the common features of the three SIPS trials, based primarily on formal accounts of their methodology (1 2 3). Then results from primary care are described drawing almost entirely on the featured report and the relevant methodology report, but also occasionally on preliminary findings released by the SIPS project on its web site in the form of factsheets and conference presentations rather than peer-reviewed articles in academic journals. These were the basis of an initial Effectiveness Bank analysis of the primary care trial.

Common features of the SIPS trials

The project was funded by the UK Department of Health in 2006 to evaluate the effectiveness and cost effectiveness of different ways to identify risky drinkers through routine screening, followed by different forms of brief advice to prompt them to reduce risk. Another aim was to assess the feasibility of implementing such procedures in typical practice settings.

Conducted in three English regions (London; South East; North East), the project conducted three trials: one in emergency departments, another in general practices, and another in probation offices. All three involved random allocation of practices, departments or offender managers to different variants of screening and intervention. Staff seeing adult patients or offenders for usual purposes in these settings asked them to consent to screening and basic data collection. Those whose screening results indicated risky drinking and who met other criteria were then asked to join the study. This entailed further assessment (including a version of the AUDIT questionnaire to identify the severity of their drinking and related problems) followed by one of the three interventions. Usually these were to delivered by the same staff after training by the study.

To assess changes in their drinking and related problems, patients and offenders were re-assessed six and 12 months later. The main yardstick of effectiveness was the proportion of patients who six months later scored as non-hazardous drinkers on the AUDIT questionnaire, a figure adjusted (among other factors) for any differences in baseline scores. AUDIT scores are based on alcohol consumption and indicators of alcohol-related problems.

Screening methods

Three quick ways to identify hazardous or harmful drinkers were tested for feasibility and accuracy, the latter defined by how well they duplicated corresponding results from the AUDIT screening questionnaire.

Single question The simplest and quickest method was to ask,“How often do you have eight (or for women, six) or more standard drinks on one occasion?” Monthly or more was considered a positive screen.
FAST Alcohol Screening Test As used in the study, this begins with the question above and registers a positive screen if the response is weekly or more often. Otherwise three further questions are asked. Scores in response to the four questions are summed to determine whether to proceed with intervention.
Paddington Alcohol Test (PAT): Used only in the emergency department study.

The brief interventions

Patients and offenders identified as risky drinkers by these screening methods were all offered feedback/advice of some kind, so the study could not assess whether these options were better than doing nothing, only how their impacts differed. All were given a standard alcohol information and advice booklet, with a sticker giving contact information for local treatment services. This was supplemented by one of three different types and degrees of advice/feedback.

Brief feedback At its most basic, the booklet was accompanied only by very brief feedback from the practitioner who did the screening that the results showed the patient or offender was drinking “above safe levels, which may be harmful to you”.
Brief advice The next level supplemented booklet and feedback with five minutes of advice closely related to the booklet. This was based on a leaflet which the worker left with the drinker after working through it with them according to a set protocol which included comparing their drinking to typical drinking levels across the population. Though not always the case, ideally this would be seamlessly delivered by the person who did the screening and handed over the booklet.
Brief lifestyle counselling The longest of the interventions added what was intended to be about 20 minutes of lifestyle counselling to the brief advice described above. This too was based on a leaflet, but practitioners could adapt the intervention to the needs of the drinkers and their willingness to think about further controlling their drinking. Staff were trained to use techniques from motivational interviewing and health behaviour change counselling to lead the drinker to consider the pros and cons of their drinking and their readiness to cut down, before (if appropriate) formulating a plan for doing so and overcoming possible obstacles. This counselling was done at an appointment made after the brief advice phase of the intervention.

The primary care trial

Generally the first point of contact with health services, primary care seems an ideal screening/brief intervention venue. One in five primary care patients drink at hazardous or harmful levels, and studies have found brief interventions there reduce drinking by 4–5 standard drinks per week.

Additional to the common objectives of the SIPS trials, the primary care study tested its two screening methods in a ‘universal’ form, which involved asking all eligible adult patients about their drinking, and also in a ‘targeted’ form, which posed these screening questions only to those newly registering with the practice or whose complaints suggested excessive drinking – a strategy which might make screening more acceptable to both staff and patients, and therefore more widely implemented. Also, after screening the most extended intervention was to be delivered by specially trained practice staff rather than (as in the other settings) by specialist alcohol workers recruited for the trial.

As per the study‘s design, 24 GP practices joined the trial, evenly divided between the North East and combined London/South East regions. They were randomly allocated so that within each region, one practice was allocated to each of the possible 12 combinations of the two screening strategies, two screening methods, and three brief interventions. But patient recruitment was slow and nine of the 24 practices did not reach the target of 31 patients, so five standby practice were activated. Also, five practices which had already completed their targeted recruitment agreed to be randomly reallocated to a more intensive intervention. This meant that 34 unique combinations of practices and screening/intervention methods provided data for the study. Practices were financially compensated for the time spent on research procedures and for each patient screened and advised or counselled about their drinking, with a greater payment for the more extended counselling. Remuneration levels were in line with those expected if alcohol screening and brief intervention were among national quality criteria for general practice.

Main findings

Over 15 months, 3562 patients were approached for the study of whom 2991 were eligible to be screened. Of these, 900 (3 in 10) screened positive and 756 agreed to join the study. Typically married white men, they averaged 45 years of age and an AUDIT score of 12.7, a medium severity of drinking problems, though around a quarter scored in the more severe range and nearly a fifth did not score as hazardous or harmful drinkers at all. Around 80% were followed up six and 12 months later.

Positive screen patients were then offered different forms of intervention. Virtually all offered brief feedback or advice received this plus the alcohol advice booklet, the full intended interventions. This was not the case for those allocated to lifestyle counselling; though nearly all received the five-minute brief advice and booklet delivered immediately after screening, only 57% attended a later appointment for more extended counselling.

Despite all screening positive for risky drinking, at the start of the study about 19% of the patients scored as non-hazardous drinkers on the AUDIT questionnaire. Among those who could be followed up, six and 12 months later this proportion was overall 31% and 36% respectively. Neither on this measure nor on the other major yardsticks of patient drinking and welfare (average AUDIT scores, health-related quality of life, and alcohol-related problems) had there been significantly greater changes after one type of intervention than another. It seems too that average weekly drinking amounts were virtually identical at both six- and 12-month follow-ups. The expected extra impacts of more intensive advice and counselling had not materialised. At both follow-up points this was also the case when the analysis was restricted to the patients who had actually received their intended interventions. Neither could it be shown that one intervention was better than another for particularly heavy drinkers. Nor as measured by the AUDIT was a particular combination of screening method or approach and intervention significantly more effective than any other.

On one measure there was however a statistically significant extra improvement among patients at practices allocated to more extended counselling – the proportions who said they were at least trying to cut their drinking. Among patients just given the booklet and a very brief warning this barely changed over the course of the study, hovering around 30%, but among counselling patients it increased from 28% at baseline to 45% and then 48% six and 12 months later. Looking back 12 months later, counselling patients too were on average slightly but significantly more appreciative than leaflet/warning patients of the quality of the communication and the general manner of the interventions they had experienced.

The authors’ conclusions

The featured study strongly suggests that screening followed by simple feedback and written information may be the most appropriate strategy to reduce hazardous and harmful drinking in primary care. No significant differences between the brief interventions were found for alcohol-related problems or health-related quality of life. This study therefore does not support the additional delivery of five minutes of brief advice or 20 minutes of brief lifestyle counselling over and above feedback of screening results plus a patient information booklet.

Strengths of the study include a high follow-up rate and the fact that practices offering the less intensive interventions had no training in the more intensive alternatives, preventing them using this training to elaborate on the more basic interventions. However, consultations between patient and doctor were not monitored to check whether the interventions were delivered as intended.

Though this seems unlikely, one possibility which (without a no-intervention control group) cannot be eliminated is that reduced drinking after all three interventions was not due to those interventions at all, but simply reflected the fact that relatively atypical behaviour tends to shift over time to more typical behaviour. Instead it is likely that the cumulative impact of screening, assessment, simple feedback, and the delivery of written information overwhelmed the additional elements of the more extended interventions.

High levels of consent to this trial and the high rates of screening and immediate delivery of brief intervention indicate that routinely-presenting patients in primary care are willing to receive feedback, written information, and advice about their drinking. In addition, the high levels of patient satisfaction after brief intervention support the acceptability of this type of input. However, many patients did not come back for brief lifestyle counselling, suggesting that brief intervention should if possible be delivered directly after screening.

Nevertheless, in patients who did return there were significant positive changes in motivation to reduce drinking and in patient satisfaction. While most hazardous and harmful drinkers in primary care require minimal input after screening, some may value and benefit from additional support. Hence a ‘stepped care&’ approach might be helpful; the least intensive (and less costly) intervention used with most risky drinking patients, while further intervention is reserved for patients who do not respond or ask for more support.


Findings logo commentary The following commentary first summarises key features of the featured study, before setting these in context by exploring common themes across all three settings. Finally, policy implications are explored. These comments are expanded on in the background notes, which also offer further citations and information.

The featured study – primary care

Taking in all information available to date including preliminary reports, it seems that given financial incentives, training and specialist support, most primary health care practices can implement alcohol screening and brief intervention, but in the circumstances at least of a research trial, they screen and intervene with few of their patients. Least well implemented was the lifestyle counselling intervention, which required appointments to be made and kept, rather than seamless delivery of briefer interventions during the patient's initial attendance.

In terms of screening, FAST proved best at identifying risky drinkers. When it came to how to respond to these risky drinkers, anticipated extra benefits from the longer and more sophisticated theory-based interventions did not materialise, even for heavier drinkers.

It might be thought this was due to fewer patients actually going through the lifestyle counselling intervention, but findings were unchanged when the analysis was limited to patients who had undergone their allocated intervention – remarkable, because in this analysis not only did counselling have the intended advantage of time and its supposed active psychological ingredients, it also had the presumed advantage of being tested only on patients concerned and diligent enough to return for counselling. This seems to dash hopes that if only the counselling could have been delivered straight after screening to nearly all the patients, it would have proved the most effective intervention.

Instead the featured report argues that the study "strongly suggests" that the least intensive intervention is the best way to reduce hazardous and harmful drinking in primary care. But as the authors acknowledged, this was a suggestion the study was not set up to test because it did not feature a no-intervention or usual-care control group. Given ( below) how much control groups improve in brief intervention studies, it seems possible that doing nothing other than screening and usual care would have equalled the most effective of the interventions in the featured report, undermining the argument that at least the study showed the interventions were better than no intervention.

Messages from all three trials

Across the three settings, the general picture from formally published and from preliminary reports is that implementation often required specialist support, there were no great differences between how well the screening methods identified hazardous drinkers, and no significant differences between how well the interventions prompted them to reduce drinking and related problems. Brief feedback, consisting of an unadorned warning plus information booklet, intended as a ‘control’ condition against which scientifically developed and longer interventions could shine, turned out instead to be the better option; subsequent clinical gains were just as great but it cost the least in money and time.

Implementation often needs specialist support; throughput low

To maximise real-world applicability, in each setting usual staff were meant to undertake screening and intervention, except for lifestyle counselling, which in probation and emergency departments was delegated to a specialist alcohol worker, probably the way such programmes would be implemented in routine practice. However, usual staff also undertook the research tasks involved in recruiting patients to the trial and collecting baseline information, an extra burden which may have suppressed the numbers screened and offered intervention.

Preliminary reports indicate that while in each setting implementing the programmes was possible, researchers and specialist alcohol workers often had to help. Workload pressures, lack of knowledge, and feeling there were insufficient back-up alcohol services, were common themes. In emergency departments and in probation, inability to implement without help was the norm. Incentivised with per patient payments, most primary care practices managed to implement fully. Still, nine of the 14 practices did not recruit the targeted 31 patients over the 15 months of the trial.

These findings cast doubt over the potential for screening and intervention in these settings to make a significant contribution to public health; numbers reached may simply be too low. Reinforcing this doubt was uncertainty over resultant impacts on those who were screened and advised ( below).

Of the settings commonly associated with brief interventions, primary care has the greatest potential to reach the greatest numbers, partly because of its coverage, and partly because there are now in the various nations of the UK national requirements or expectations and/or frameworks for paying practices to undertake this work. Decisively influenced by financial incentives, Scotland’s national brief intervention programme was overwhelmingly implemented in primary care rather than other settings. In England the national requirement to offer surgeries screening and intervention contracts has generated more activity, but implementation has been patchy, and the quality and even the reality of the services has been questioned. In England from April 2015 screening for risky drinking and follow-on brief intervention are required of every GP practice for all newly registered patients, and similar work is meant to be undertaken (but often is not) in the health check for older people.

FAST screening edges it

Screening results from the trials have been amalgamated in conference presentations (1 2). Of the three methods, FAST had the broadest applicability, in all three settings virtually equalling or bettering the alternatives in terms of its ability to identify risky drinkers. Generally only the first (about frequency of excessive drinking) of the four questions had to be asked, and the test picked up 8 in 10 of the risky drinkers who would have been picked up by the longer AUDIT questionnaire.

If the yardstick is not failing to identify risky drinkers (around 4 in 10 were missed), whether screening is best implemented universally or targeted at certain patients or appointments was answered in favour of universal screening. On the assumption that a universal strategy truly would be universally implemented, not missing risky drinkers may be the decisive consideration. But if targeted screening – favoured by primary care staff – encourages more complete implementation, the balance could shift in its favour.

Minimal or extended advice – it doesn’t matter; each is equally (in?)effective

The final link examined by the studies was how best to advise risky drinkers identified through screening.

Across the three settings there was a remarkable uniformity in trends in drinking among the risky drinkers who agreed to join the trials. Compared to pre-intervention figures, six months later the proportions of non-hazardous drinkers had fallen by 11–13%, 12 months later, by 18%. With one minor and possibly chance exception, on this primary yardstick an alcohol advice booklet plus a few sentences of feedback alerting someone to their risky drinking was not improved on by adding more extended and individualised interventions.

In all three settings, even when the analysis was confined to people who had actually received their allocated intervention, still the extra 20 minutes of counselling made no significant difference to the proportions of risky drinkers. In these analyses, not only did counselling have the intended advantage of time and its supposed active ingredients, it also had the presumed advantage of being tested only on patients/offenders concerned and diligent enough to return for counselling, while the other two interventions were delivered to nearly all the intended recipients.

As the researchers have acknowledged, this does not necessarily mean the interventions were equally effective; they may have been equally ineffective. Without a no-intervention comparator, there is no way of knowing whether the interventions played any hand in the outcomes. Even before the interventions, 28% of emergency patients, 38% in primary care, and 57% of offenders in the probation study, said they were trying to reduce their drinking or had decided to do so. Reinforcing doubts over the impact of the interventions is the general finding (1 2) that many control groups in alcohol brief intervention studies who received no or minimal intervention on average reduced their drinking by amounts equal to or greater than AUDIT score reductions in the SIPS trials.

Set against this is the overall positive record of brief interventions in previous primary care trials. However, this record left considerable doubt over whether such reductions (internationally and in Britain in particular) would survive once intervention was ‘scaled up’ to practices in general, and applied by the general run of doctors to the general run of patients.

While the results seem to argue against doing more than screening plus offering a booklet and a few sentences of feedback, they did not prove this is all it takes to get whatever benefits are available. Additionally patients and offenders had for research purposes been quizzed about their drinking and related problems and their readiness to do something about these, possibly thought-provoking interventions in themselves. Also, whether brief feedback really was as terse as intended is unknown.

Cost may be decisive

Some data on costs and benefits can be found in preliminary reports, subject to confirmation when these results are formally published. Even if equally effective, it seems the interventions differed greatly in cost, likely to be a persuasive factor given equivocal or no evidence that spending more gained more. Not only did the briefest intervention directly cost least, but on the health service’s primary yardstick – quality-adjusted life years – in both probation and primary care, it gained most years for each £ of social costs incurred by the drinkers. Only in emergency departments did the longest intervention have the edge, but this was minimal, and may have been partly due to these patients starting the study with the lowest quality of life of the three intervention groups and catching up somewhat in a natural levelling process.

Policy implications

The 2012 English alcohol strategy said government was awaiting the results of the SIPS project before deciding whether to incorporate alcohol screening and brief intervention in to the national quality framework for primary care, a major national driver of practice. The strategy also encouraged accident and emergency departments and hospitals in general to check for and offer brief advice about hazardous drinking.

In general, all areas covered by the strategy are expected to implement national guidance and standards (1 2 3 4) which insist that health service staff must be given time and resources to carry out screening and brief intervention. This seems a tall order given the consistent appeal in the SIPS studies to workload pressures as a reason for incomplete implementation, and the need for specialist support.

The guidelines’ preferences for targeted screening may also need to be re-evaluated, though SIPS’s findings on this issue are probably not definitive enough to override the greater feasibility of targeting due both to workload pressures and staff preferences. It seems questionable too whether the precision of the 10-item AUDIT screening questionnaire is sufficient to warrant the guidelines’ preference for this as a first-line screening and triaging tool.

Where health service guidance is clearly at odds with the findings is in its backing for the equivalent of SIPS’s mid-level intervention and, subject to local conditions, the most extended option for heavier but probably still non-dependent drinkers. Similar guidance has been disseminated to criminal justice services. SIPS seems to favour the briefest of interventions consisting merely of a rather blunt feedback and warning. Yet for reasons outlined above, the message taken from the studies that only the very briefest contact is needed may be misleading, because even in this option much more was (and yet more may have been) done with the patients and offenders. But with no convincing reason to spend more money and time, hard-pressed staff and austerity-hit commissioners will be tempted to do the least seemingly justified by trials on which the government itself said it would base its policy decisions.

Last revised 29 July 2015. First uploaded 16 May 2012

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Ultra-rapid opiate detoxification followed by nine months of naltrexone maintenance therapy in Iran.

Naderi-Heiden A., Naderi A., Naderi M.M. et al.
Pharmacopsychiatry:2010, 43(4), p. 130–137.
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 Naderi-Heiden at angela.naderi-heiden@meduniwien.ac.at. You could also try this alternative source.

Further evidence from Iran that rapid withdrawal from opioids under anaesthesia followed by the opioid-blocking drug naltrexone can work for highly motivated caseloads with copious 'recovery capital'. For others this expensive and when not adequately controlled, potentially risky procedure generally ends in overdose-threatening relapse.

Summary Ultra-rapid opiate detoxification typically involves a day or two of hospitalisation during which patients dependent on opiate-type ('opioid') drugs like heroin are anaesthetised or deeply sedated while the opiate-blocking drug naloxone is administered by infusion in to the blood stream to precipitate sudden withdrawal. Then patients are started on prescriptions of naltrexone tablets Or in some cases long-acting implants or injections. which (as long as they are taken) continue to block the effects of opiate-type drugs, an attempt to prevent the relapse to regular opioid use which commonly follows withdrawal.

For the featured study records were analysed of 45 male patients admitted for such procedures between 2003 and 2005 to a surgical centre's department of anaesthesiology in Iran's capital Tehran. They were selected to be free of dependence on other drugs or alcohol except for cannabis, and free of severe physical or mental illness which might contraindicate general anaesthesia. For this and for other reasons they were relatively well placed to overcome their dependence via an abstinence-oriented route. Forty of the 45 were addicted to opium and just five injected. On average in their early 30s, they were committed to abstinence and had good family support. Over half were married and nearly 80% employed. They were attending an expensive private hospital so came predominantly from wealthy families, who (in the absence of a public welfare support system) can exert considerable pressure on opiate-dependent relatives, as can wives for whom such dependence is grounds for divorce. Also, in Iran familial solidarity is highly developed and can provide a high level of support and motivation for abstinence-oriented patients.

On admission patients were detoxified by means of a six-hour infusion of naloxone under general anaesthesia; medications used were midazolam, propofol, clonidine and the muscle relaxant atracurium. For 24 hours after patients woke staff documented severity of withdrawal on a standard checklist of physical signs such as runny noses, sweating, cramps and dilated pupils.

Usually discharge was scheduled for the day after detoxification. Then naltrexone (50mg/day) was prescribed for nine months with assessments every four weeks by a clinician with extensive experience in the treatment of dependence. At these consultations, naltrexone was re-prescribed and the patient's progress monitored, verified with the patients' agreement by talking to their families. For the purposes of the study, patients who missed these visits were considered relapsed.

Main findings

All the patients were successfully detoxified during inpatient stays of two days (one night) for all but two, who stayed three days. Withdrawal signs after awakening peaked within one to three hours but were generally few and mild, consisting universally of dilated pupils plus typically one other symptom. Severe symptoms were observed only in two patients, one an injector and the other dependent on cannabis as well as opioids. There were no serious adverse events, but there was one case of prolonged unconsciousness, eight of mild and transient confusion, and six of depressed mood. Monitored cardiopulmonary signs were stable during the whole treatment in all patients.

Of the 45, 36 (80%) continued naltrexone therapy and reported relapse-free status for the entire nine-month observation period.

The authors' conclusions

The primary purpose of opiate detoxification under general anaesthesia is to achieve a complete but quick and painless physical withdrawal. In this it generally succeeded. Patients typically exhibited only mild signs of withdrawal and required just one night in hospital, as reported by other studies. Propofol provides an excellent means of controlling excessive arousal of body systems caused by withdrawal, while clonidine allows for large doses of opioid antagonists to be delivered without significant changes in heart rate or blood pressure. The method used in the present study appears to be safe when performed by experienced anaesthetists and with round-the-clock care from qualified nursing staff for at least 24 hours.

Though this detoxification method ensures the initiation of long-term naltrexone treatment, its continuation might not depend on how the patient was withdrawn, but factors like ancillary drug use, family stability, and employment. The featured study's sample enjoyed relatively good personal and occupational situations and the close family support typical in Iran. Generally they did not inject, and were to a large extent free of official or legal pressure; voluntary detoxification is a positive prognostic feature in abstinence-oriented therapy. These factors might explain why 80% continued naltrexone treatment for at least nine months, though retention on naltrexone does not always mean abstinence from opiate-type drugs.

Such results contrast with those of an Australian study, in which few patients completed nine months of naltrexone treatment after rapid withdrawal. In this study patients injected heroin and sometimes also abused alcohol, cannabis and benzodiazepines. [Editor's note: also half were unemployed, around 80% single, and generally they were poorly educated.]

Naltrexone significantly reduces relapse apparently only when rigorously supervised. New long-acting injectable or implantable formulations may address this limitation. But the featured study shows that in Iran, with patients generally not dependent on other drugs and with strong family as well as continuous medical support, oral naltrexone following rapid withdrawal can be sustained by most for many months.

Together with other studies, these findings suggest that not only the individual but also cultural and economic factors should be taken in to consideration. In Europe and North America rapid detoxification and naltrexone are not first-line detoxification treatments, not just because patients differ, but perhaps also because the health-care systems in those countries generally provide for the expensive option of inpatient detoxification over several days or weeks while doses of opiate-type drugs are gradually reduced to zero.


Findings logo commentary The authors of the featured study are appropriately cautious about generalising their findings beyond Iran and the type of patients they sampled, and the absence of a 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 offered no treatment or an alternative means the results cannot securely be attributed to the studied treatment. However, with on average nearly ten years of opiate use behind them and still relatively young, it seems unlikely that the 80% completion and abstinence rate reported by the study would have happened anyway without treatment. Another gap is what happened to the patients after treatment ended and they were no longer shielded by naltrexone which their families probably ensured they took.

Relevance to other countries

An obvious difference from Britain and many other countries is the dominance of non-injecting routes of administration in Iran, but in recent years British drug users have also moved to non-injecting routes, an estimated 137,000 injectors in England in 2004/05 falling to 117,000 in 2006/07. Estimates for England in 2009/10 were that of the 306,150 opiate and/or crack users, just a third were injectors. These population trends fed in But were also partly based on data from that system. to the drug treatment system. By 2011/2012, just 18% of drug users starting treatment in England were recorded as currently injecting and over half – 55% – had never injected; in 2004–2005, the figures were 30% and 49% respectively. In Scotland the proportion of patients starting drug treatment who had injected in the previous month fell from 28% in 2006/07 to 24% in 2010/11 and by more still in younger age groups with presumably shorter drug using careers. In particular, smoking or 'chasing' (inhaling fumes) opiates – generally heroin rather than opium – has long been established in Britain.

Notwithstanding national and caseload differences, the study reinforces indications that even in countries such as Britain and the USA, similar types of patients in similar circumstances can do well on oral naltrexone. The role of rapid withdrawal is to ensure they at least start the procedure. Such patients include those committed to abstinence because considerable leverage is exerted over them by families, employers, professional bodies, or the criminal justice system, and can be exerted because the patients have much to lose (freedom, well paid jobs, reputations, careers, families, homes) by not complying. They also have the support and stability to be able to respond to that pressure by remaining in treatment and avoiding lasting relapse to opiate-type drugs.

Opiate blockers or substitutes?

For other types of patients, the majority in countries like Britain, rather than drugs which block opiates, the prescription of opiate-type drugs like methadone remains the mainstay of opiate addiction treatment (1 2). British guidelines relegate naltrexone to the minority of patients highly motivated to remain in an abstinence programme, contrasted with the more widespread applicability and more securely established effectiveness of substitute prescribing using methadone or buprenorphine. They also emphasise the need for anti-relapse support after detoxification. More promising but not without their complications and controversies are long-acting forms of naltrexone placed under the skin as implants or injected. These have yet to be licensed for medical use in the UK, but some forms have been elsewhere.

The only study to have randomly allocated patients detoxified as inpatients to continuing treatment with oral naltrexone or with an opiate-type drug (buprenorphine) was terminated early when it became apparent that buprenorphine was clearly the best option. Supplementing counselling with naltrexone only slightly and non-significantly improved treatment retention and heroin use outcomes compared to a placebo. In contrast, outcomes were clearly and universally superior for the buprenorphine patients, significantly better than placebo, and generally also significantly better than naltrexone. Conducted in Malaysia, typically the patients were poorly educated single men with a history of imprisonment who had been using heroin for on average 15 years and had used near-daily in the previous month – a much less promising caseload than in Iran, adding weight to the proposition that such patients usually do better on drugs like buprenorphine and methadone.

Safety concerns

Among caseloads not endowed with substantial resources and on whom leverage is weak or ineffective, rapid relapse is the norm even after they have been able to complete detoxification; oral opiate blocking medication does little to improve the situation. Relapse brings with it what in some circumstances is a very high risk of death due to opiate overdose, because patients coming off naltrexone have entirely lost their tolerance to opiate-type drugs; the doses they used to take all too often prove fatal. Such concerns are less salient when opioids are taken by the much safer and controllable inhalation route.

It seems that with modern-day anaesthetic techniques and high quality care, rapid withdrawal procedures can be very safe. Nevertheless, due to safety concerns, British guidelines say the more radical of these procedures entailing (as in the featured study) anaesthesia or deep sedation "must not be offered", as in milder terms did guidelines published by the World Health Organization, though these did see a non-routine role for procedures entailing minimal sedation. Similarly, a review for the Cochrane collaboration found that lighter forms of sedation ameliorate the severity of the withdrawal experience about as well as deep sedation or anaesthesia and are less risky. With no countervailing benefits but greater risk, the reviewers counselled against the more radical procedures.

For further discussion of these issues see this Findings hot topic on naltrexone implants and rapid detoxification, and earlier Findings analysis whose background notes (1 2) reviewed rapid withdrawal evidence to date. Other key sources are these Cochrane reviews on oral naltrexone and rapid withdrawal under heavy sedation or anaesthesia. For all relevant Findings analyses run these searches on naltrexone treatment for opiate addiction and on rapid withdrawal from opiate-type drugs.

Thanks for their comments on this entry in draft to Andrew Byrne of The Byrne Surgery in Sydney, Australia, and to psychiatrist Colin Brewer based in England. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 27 January 2013. First uploaded 19 January 2013

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STUDY 2011 Injectable extended-release naltrexone for opioid dependence: a double-blind, placebo-controlled, multicentre randomised trial

STUDY 2008 Maintenance treatment with buprenorphine and naltrexone for heroin dependence in Malaysia: a randomised, double-blind, placebo-controlled trial

STUDY 2015 Opioid treatment at release from jail using extended-release naltrexone: a pilot proof-of-concept randomized effectiveness trial

STUDY 2006 Long-acting depot naltrexone extends opiate abstinence

REVIEW 2011 Oral naltrexone maintenance treatment for opioid dependence

STUDY 2009 Naltrexone implants after in-patient treatment for opioid dependence: randomised controlled trial

STUDY 2002 Rapid opiate detox guarantees completion, but abstinence depends on what follows

STUDY 2010 Naltrexone implants compared to methadone: outcomes six months after prison release

HOT TOPIC 2016 Opiate-blocking implants: magic bullet or dangerous experiment?

STUDY 2010 Favorable mortality profile of naltrexone implants for opiate addiction





Consideration of the use of foil, as an intervention, to reduce the harms of injecting heroin and cocaine.

[UK] Advisory Council on the Misuse of Drugs.
[UK] Advisory Council on the Misuse of Drugs, 2010.

The evidence which led the UK government's drug policy advisers to call for the legalisation of the supply of foil by medical and drug services to drug users to promote transition from injecting to smoking heroin and crack cocaine.

Summary Some drug services in Britain supply specialist foil to drug users to encourage smoking of heroin (often called 'chasing' – inhaling fumes produced by heating the drug illustration) and crack cocaine in particular as a safer alternative to injecting. However, this is illegal under section 9A of the Misuse of Drugs Act 1971, provisions intended to outlaw the supply of 'cocaine kits' (razor blades, foil and lemon juice) being marketed in the mid-1980s. Because of benefits including reducing the spread of blood-borne diseases, an exception was made for sterile syringes and needles, and then later for other equipment used for preparing drugs and for injecting, including swabs, containers, acidifiers, filters and water ampoules. Foil, used not for injecting but for smoking, was not exempted. However, foil provision by harm reduction services is rarely prosecuted. Instead police forces warn services or explicitly agree that no action will be taken.

'Chasing' heroin

The Advisory Council on the Misuse of Drugs – an expert body set up under the Misuse of Drugs Act to advise government – considered whether there were grounds for legalising foil provision, producing in 2010 the featured report, followed in 2011 by a supp lement on possible health risks of smoking drugs from foil. Both documents are drawn on in this account.

Main findings

A major consideration was the council's earlier conclusion that, "Ultimately we need to stop injecting to reduce the risk of [hepatitis C]".

Two key UK studies provided evidence of how the provision of foil might reduce harm among injecting drug misusers. An evaluation of supplying foil packs to promote transition away from heroin injecting to inhalation analysed data from four needle and syringe programmes and interviewed injectors at one programme. It found that the packs were taken when available, that offering them could be a useful way of engaging attendees in discussions about ways of reducing injecting risks, and suggested that supplying foil could reduce injecting in areas where there was a pre-existing culture of 'chasing' heroin.

A second report Boid. A., Waldock. D. "The introduction of aluminium foil to Sidney Street Needle Exchange and Sharp Action mobile needle exchange Sheffield." Turning Point, 2008. provided feedback on a trial scheme providing foil from a site-based and a mobile exchange, which indicated that this reduced injecting behaviour and promoted less risky alternatives.

Surveys in Britain have also shown that needle exchange managers, commissioners, users and workers believe that providing foil would encourage drug users not to inject, but also that two thirds of services did not provide it because it was illegal.

The Dutch experience indicates that provision of foil can provide a platform – when coupled with harm reduction messages and appropriate service provision – for transition away from injecting. In Amsterdam the proportion of drug users sampled over several years who were or had started injecting fell steadily following the introduction of harm reduction policies, including foil provision. The study concluded that a harm reduction approach did not lead to an increase in injecting drug use.

Health risks

A review of more than 15 years of Dutch experience in switching injectors to foil reported uniformly positive public health outcomes. However, respiratory complaints are regularly seen and these can be severe, emphasising the need for public health warnings to foil users.

One concern is that users will inhale aluminium from the heated foil. However, the evidence provided to date does not indicate that levels of aluminium derived from the use of foil constitute a risk to the individual.

Other concerns are the effects of inhaling the fumes of street heroin or crack cocaine or of inhaling hot vapour. Risks include a rare but potentially fatal form of brain damage from inhaling heroin (or its contaminants), and constructed airways due to heroin or cocaine, which can be particularly severe in asthmatic patients. One study found a link between smoking heroin and shortness of breath. However, some of these results may have been partly due to a greater than usual prevalence of tobacco smoking among heroin users, particularly heroin smokers.

Long-term cocaine smoking can lead to significant damage to the lungs, resulting in a range of chronic diseases. Smoking crack cocaine can also cause intense vasoconstriction resulting in severe chest pain, difficulty in breathing and fever, which may become a chronic condition with prolonged use.

Damage may also occur due to the inhalation of chemical by-products or the products of the combustion of highly inflammable solvents used in the drug production process. Inhalation of hot drug vapour may in itself be associated with thermal damage to the lungs, but no studies were identified which had examined this in detail.

A further concern is the risk of infection such as happens with injecting. Rates of infection in non-injecting heroin users are much lower than among injectors, though in respect of hepatitis C, still higher than in the general population, particularly among older users, those with tattoos, and crack cocaine users who share inhalation implements. How this happens is unclear, but given the high boiling points of cocaine base and heroin, and the very high temperature of foil when heated, it would seem very unlikely that viral infection could occur by this route, even if the cocaine or heroin was contaminated.

The authors' conclusions

The physical harms of smoking are significantly less than those associated with injecting. On the current balance of evidence, foil should exempted as a harm reduction intervention under Section 9A of the Misuse of Drugs Act 1971.

In particular, the evidence indicates that there are no harmful effects from provision of foil and that it does not encourage use of illegal drugs. Potential benefits include: a decrease in blood-borne viruses; increased contact and engagement with drug service workers, offering opportunities to affect user behaviour and provide public health messages; fewer systemic infections; less soft tissue and venal damage; lower risk of overdose; and less litter related to drug use.

Providing foil is in itself unlikely to significantly reduce blood-borne viral infections, but may (like other paraphernalia) play an important role within a programme of interventions if used to reinforce harm reduction messages on the dangers of injecting.

Summarising its practice recommendations, the featured report argues that:
• Services should provide a range of responses that support people away from injecting which can include substitute prescribing.
• We should be mindful/aware of the signs and occasions when engaging with the service user to offer alternatives could instigate a change in behaviour.
• Harm reduction providers should supply foil as part of a holistic range of harm reduction interventions which support a hierarchy of needs to promote individualised recovery goals and general health and well being.
• Services must provide an environment affording privacy and dignity, where service users can speak confidentially and be supported by workers who are empathic and non-judgemental.
• Services providing foil should ensure staff can effectively assess someone's risktaking behaviour including injecting risk. They should be able to articulate the risks versus benefits of safer alternatives such as smoking and 'chasing'.


Findings logo commentary Supplying foil is one of a suite of 'route transition interventions' reviewed for the Global Fund to Fight AIDS, Tuberculosis and Malaria, aimed at promoting non-injecting and safer routes of administration of illegal drugs.

Although illegal, as the featured report observed, bona fide medical and drug services supplying foil in their professional capacities have very little in practice to fear from the law, and may be able to ease any remaining doubts by reaching agreements with their local police force. Foil for these purposes is openly supplied by a national UK social enterprise set up by drug workers.

However, illegality on the statute book remains a significant impediment to implementation, creating the anomaly that needle exchanges can legally supply equipment to make the most dangerous method of drug use (injecting) somewhat less risky, but not to supply equipment which might support transition to a far less dangerous method (smoking). In the late 2000s attempts were made to remove or amend legal restrictions on supplying foil and other items by medical and drug services when acting in their professional capacity. These were accepted in principle by the government of the time but fell victim to the impending May 2010 election.

Apart from illegality, another objection to foil provision may be cost, but in so far as it does reduce the number of injections, it will presumably also reduce the demand for injecting equipment from exchanges, saving money on that front.

See this Findings analysis for more on the two UK studies which did most to help persuade the Advisory Council on the Misuse of Drugs to recommend legalising foil provision. Available elsewhere is a history of changes to the relevant provisions of the Misuse of Drugs Act, and an encapsulation of the current legal situation. A national supplier of foil offers extensive practice notes, drafted in collaboration with services distributing foil.

Last revised 22 January 2013. First uploaded 22 January 2013

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STUDY 2008 Distributing foil from needle and syringe programmes (NSPs) to promote transitions from heroin injecting to chasing: an evaluation

MATRIX CELL 2014 Drug Matrix cell C1: Management/supervision: Reducing harm

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

MATRIX CELL 2014 Drug Matrix cell A1: Interventions; Reducing harm

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

MATRIX CELL 2014 Drug Matrix cell D1: Organisational functioning; Reducing harm

MATRIX CELL 2013 Drug Matrix cell B1: Practitioners; Reducing harm

REVIEW 2012 The effectiveness of opioid maintenance treatment in prison settings: a systematic review

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





Effect of the increase in 'alcopops' tax on alcohol-related harms in young people: a controlled interrupted time series.

Kisely S.R., Pais J., White A. et al.
Medical Journal of Australia: 2011, 195(11), p. 690–693.
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 Kisely at s.kisely@uq.edu.au. You could also try this alternative source.

A tax rise on 'alcopops' was on the agenda in Britain until they fell out of favour among young drinkers. Australia did however increase tax by a huge 70%. This study found no impact on short-term alcohol-related harm among the young revellers of its Gold Coast district, but probably there were broader benefits from reduced drinking.

Summary Effective from April 2008, concern about harmful drinking among young Australians led the government to raise by almost 70% excise duty on pre-mixed alcoholic beverages ('alcopops') favoured by young people, based on findings that higher taxes/prices reduce overall consumption of alcohol and, in particular, heavy drinking. However, it is unclear whether tax increases on only one type of drink, as opposed to alcoholic beverages in general, are similarly effective; young people may merely switch to cheaper and potentially more potent drinks.

Initial studies suggested the result was a substantial fall in alcopop sales, partially counter-balanced by a smaller shift to beer and spirits leading to a net reduction in overall sales, but the impact on harms related to alcohol remains unclear.

Consequently this study used administrative data from the emergency departments of two public hospitals in the Gold Coast district of the state of Queensland in Australia to measure a wide range of alcohol-related health harms before and after the tax increase. Included were common alcohol-related harms such as unintentional and intentional injuries as well as alcohol poisoning, mental and behavioural disorders due to alcohol, and blood-alcohol tests. The data was restricted to 15–29-year-olds (the main target group for alcopops) and spanned the tax change from April 2005 to April 2010.

To test more fully for any possible link to the tax change, analyses were done: including and excluding superficial injuries; including all injuries (adjusted for the fraction likely to have been due to alcohol) as well as just those recorded as related to alcohol; and confining the analysis to emergency department visits between 10pm and 6am or on weekends, when drinking was most likely to have been a factor.

At issue was the degree to which trends in emergency department visits changed before versus after the tax change. To try to eliminate the possibility that any such change was due to some other factor also affecting young people in general or older drinkers, these trends were compared to those of the same age group presenting with asthma, appendicitis, or any condition not related to alcohol and not an injury, and with 30–49-year-olds with alcohol-related harms.

Surfers' Paradise in the Gold Coast region of Queensland in Australia

It was also important to adjust the results for seasonal patterns. The Gold Coast is a tourist destination ( illustration) popular as a venue for annual end-of-school celebrations – why this high-risk area for alcohol-related binge drinking by young people was appropriate for the study. A fluctuating population also made it impossible to calculate the incidence of alcohol-related harms per young adult. Calculated instead was the proportion of emergency visits by 15–29-year-olds which were alcohol-related. This was compared to the proportions which comparison visits represented of the total number of emergency visits for the same age. If the proportion of visits related to alcohol among young people dipped after the alcohol tax increase in ways not apparent for comparison emergency visits, it would be evidence that the tax rise was having the intended effect.

Similar analyses were done for patients known to be Gold Coast residents, for whom it was possible to calculate emergency visit numbers per 10,000 of the same-age population.

Main findings

None of the analyses, whether of specific alcohol-related presentations or these plus all injuries, and across all the variations described above, indicated that there had been any statistically significant falls in actual or potentially alcohol-related emergency visits by 15–29-year-olds after the increase in the tax on alcopops compared with those by 3049-year-olds or compared to other types of emergency visits. This was also the case for males and females, for patients aged 15–19 years, and for Gold Coast residents. There was not even any evidence of a temporary post-tax dip.

The authors' conclusions

The proportion of alcohol-related emergency presentations for 15–29-year-olds on the Gold Coast did not significantly fall after implementation of the alcopops legislation when compared with alcohol-related presentations in an older age group, or with non-alcohol-related presentations in the same age group.

Given strong evidence of the effectiveness of taxation in curbing overall alcohol consumption, one interpretation is that price influences average consumption of all drinks, but not risky consumption on a single occasion. A second is that raising the price of just one type of drink may not reduce alcohol-related harms, at least in tourist destinations such as the Gold Coast, raising questions about generalising from the effects of overall increases in alcohol tax or duty to initiatives that target one type of drink.

If the findings hold across other health services and populations, more comprehensive approaches may be required, combining fiscal measures such as volumetric taxation for all alcoholic beverages, along with other supply and demand initiatives. These could include incentives to encourage mid-strength and low-strength beers, restrictions on the availability of drinks with a high alcohol content, more effective regulation of advertising, and raising the legal drinking age.

Given that the Gold Coast is a popular destination for end-of-school celebrations, the findings may not apply elsewhere in Australia. However, they were the same for Gold Coast residents – by definition, not tourists.


Findings logo commentary As the authors suggest, switching to other beverages means that raising tax on one type of product does not reduce overall consumption of alcohol as much as an across the board price rise or a high minimum unit price of the kind being planned for the UK. Presumably because switching is more likely to happen, the impact of a beverage-specific price rise is greatest on the beverage types which occupy a relatively small place in the market, such as alcopops in Australia (1 2).

Since there is nothing in alcopops except the alcohol which would cause harms of the kind the featured study monitored, switching to spirits instead (as may have occurred) would have eliminated some of the expected health benefits of the increased tax.

However, there does seem to have been an overall drop in alcohol consumption after the tax came in to effect, suggesting that switching was far from complete. Based on a different set of figures, that too was the conclusion of a team of authors including the chair of Australia's National Preventative Health Taskforce. They also cited evidence that after the tax rise fewer secondary school were drinking and fewer doing so at risky or high-risk levels. Whilst acknowledging the limitations of a single-beverage tax rise, they argued that "the alcopops tax has had a positive effect in reducing alcohol consumption." This may have been because the tax in effect raised the floor price for spirit-based drinks. Until then alcopops had been much cheaper than spirits. The tax rise equalised the excise rate with straight spirits products, meaning some switching was likely among spirits adherents to straight spirits and among alcopop adherents to wine-based alcopops, but also that access to cheap spirit-based drinks had been closed, apparently reducing consumption overall.

That still there was no health impact in the Gold Coast may, as the authors suggest, have been because the single-occasion, celebratory, and once a year 'binges' which probably accounted for much of the harm are not as price sensitive as regular drinking.

Experience in Germany

Unlike the Australian consumption records mentioned above, a study from Germany focused on the targets of alcopop taxes – young drinkers. Perhaps because of this focus, it found greater impacts on alcopop consumption, and provided direct evidence that teenage drinkers (defined as having drunk in the past week) switched to spirits in response to a specific alcopops tax rise in 2004 which nearly doubled their retail price.

School surveys either side of the tax rise in 2003 and 2007 revealed that the proportion of 15–16-year-old drinkers who consumed most of their alcohol in the form of alcopops had more than halved from 27% to 12%, while for spirits the same proportion doubled from 8% to 16%; there were also lesser increases in the proportions preferring wine and beer. The total amount of alcohol drunk by the children had not changed significantly, but its source had, consumption from alcopops nearly halving (25g down to 14g) and from spirits increasing (from 14g to 19g). There was also a non-significant increase in consumption in the form of beer, but practically no change for wine.

The authors interpreted these findings as evidence for a partial substitution of alcopops by spirits, which did not result in a significant reduction in total consumption due to a small increase in beer drinking. Increase in spirits consumption among young people was considered a "negative side effect of the alcopops tax", because a preference for spirits is associated with riskier drinking patterns and more problems. It might be thought that one positive effect would have been to partially shut a gateway to drinking for young people, but in fact across the full school samples (ie, not just past-week drinkers) significantly more had drunk in the past week in 2007 than in 2003, and the age drinkers had started drinking was virtually unchanged.

UK policy

As in Australia, concerned by alcohol-fuelled violence and disorder, before the elections in 2010 the Conservative Party in Britain was planning significant tax increases on alcopops as well as strong beer and strong cider. In the event, once in power duty was increased only on strong beers and ciders. Concern over alcopops had plummeted along with their consumption, which in 2010 the Treasury noted had fallen by almost three quarters between 2001 and 2008, until they represented only 8% of alcohol consumed by 18–24-year-old hazardous male drinkers. The Treasury's conclusion was that this category of drinks were not now "disproportionately responsible for alcohol-related harms".

The expected 0.45 or 0.50 minimum price per unit of alcohol being planned by governments for England and Scotland would hardly affect the category of drinks including alcopops, which already sell for a relatively high per unit price. Among the 18–24-year-old hazardous drinkers over which there is most concern, alcopop consumption is expected to slightly increase in response to a minimum price, while overall consumption would steeply fall as the cheaper drinks became more expensive.

More relevant to alcopops is a ban on selling the products at a discount, in Scotland expected to have a greater impact "The impact on RTD, whilst small, is greater than that seen for any of the minimum price thresholds considered." (though still small) than any level of minimum price tested in the model. In November 2012 the government for England consulted on a ban on off-licence promotions offering discounts contingent on buying several drinks at once. Scotland implemented such a ban in October 2011, with no obvious short term impacts on sales in comparison with England and Wales.

Thanks for their comments on this entry to author Steve Kisely of the University of Queensland in Australia, to Peter Miller of Deakin University in Australia, and to Andrew McAuley and Mark Robinson of NHS Health Scotland. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 27 January 2013. First uploaded 17 January 2013

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DOCUMENT 2012 The government's alcohol strategy

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STUDY 2010 Changes in alcohol consumption and beverage preference among adolescents after the introduction of the alcopops tax in Germany

REVIEW 2010 The effectiveness of tax policy interventions for reducing excessive alcohol consumption and related harms

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STUDY 2010 Policy options for alcohol price regulation: the importance of modelling population heterogeneity

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

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REVIEW 2008 Identifying cost-effective interventions to reduce the burden of harm associated with alcohol misuse in Australia

STUDY 2009 Model-based appraisal of alcohol minimum pricing and off-licensed trade discount bans in Scotland





Changes in alcohol consumption and beverage preference among adolescents after the introduction of the alcopops tax in Germany.

Müller S., Piontek D., Pabst A. et al.
Addiction: 2010, 105, p. 1205–1213.
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 Müller at mueller@ift.de. You could also try this alternative source.

Concern that sweetened alcoholic drinks ('alcopops') seduced adolescents to start drinking more and sooner led Germany to impose a tax rise nearly doubling their price. It dented their consumption among teenage drinkers, but switching to spirits and other products eroded the overall drop in alcohol consumption.

Summary In the late 1990s concern grew in Germany and other European nations that that the sweet taste of bottled or canned products mixing soft drink such as lemonade with alcohol ('alcopops') masked their alcohol content and seduced adolescents, especially girls, to start drinking at a younger age and to drink more. These concerns led the German government to impose a specific alcopops tax in 2004 which nearly doubled the retail price. The featured study focused on one of the main targets of the tax – young drinkers – and assessed how their drinking habits changed in response to the tax rise.

School surveys either side of the tax rise in 2003 and 2007 in the same six of Germany's 16 states sampled about 10,500 pupils in ninth- and tenth-grade classes aged 15 and 16. The study was confined to the roughly 4 in 10 who in their questionnaire responses said they had drunk alcohol in the past seven days – current drinkers. They were asked how many drinks they had consumed in that time of beer, wine, spirits and alcopops. These were converted to quantities On the basis that on average beer, wine, spirits and alcopops were respectively 4.8%, 11.0%, 33.0% and 5.5% alcohol. of alcohol, enabling total past-week consumption to be calculated. Which type of drink each individual 'preferred' was defined as that which contributed most alcohol to their intake.

Differences between the samples in the two years might have accounted for changes in drinking patterns which could be falsely attributed to the tax rise. To try to eliminate this possibility, results were adjusted for age, sex, school type and the state where the school was located. Additionally, 2347 pupils from the 2007 survey could be closely matched one-to-one with pupils from 2003 in terms of a range of variables including how available they perceived alcohol to be, their expectations of good and bad effects from drinking, how many of their friends drank, past-month binge drinking, smoking or cannabis use, when they started drinking, and other family and lifestyle variables. This 'matched' sample, with results also adjusted for age, sex, school type and the state, offered the securest basis for assessing the effects of the tax rise after other influences had as far as possible been equalised.

Main findings

The raw figures across the entire samples of pupils and unadjusted for differences between them showed a significant drop in average per-pupil past-week alcohol consumption from nearly 91g to just over 78g, but these figures were vulnerable to differences across the years apart from the imposition of the tax rise. After pupils had been matched and the results adjusted for differences between the samples, they revealed no significant drop in total consumption, but that its composition had changed; after the tax rise, teenage drinkers consumed less alcohol in the form of alcopops and more as spirits, but not so much more that the alcopop fall was cancelled out. A rise in consumption of alcohol mainly in the form of beer meant total consumption had not changed to a statistically significant degree.

In detail, average past-week alcopop alcohol intake had nearly halved from just over 25g to nearly 14g, while spirit alcohol had risen from 14g to just over 19g. Beer alcohol intake too had increased slightly and non-significantly from just over 43g to nearly 47g, while wine was virtually unchanged. These figures summed to an average near 89g alcohol intake in 2003 versus near 83g in 2007, not a statistically significant drop.

When these consumption figures were converted to 'preferences' in terms of the largest source of alcohol, preference for alcopops had more than halved from 27% to 12%, while spirit preference doubled from 8% to 16%; there were also lesser increases in the proportions preferring wine and in particular beer, the latter up from 44% to nearly 50%. In relation to the change in alcopop preference, all the other changes in preference were statistically significant.

In general the change in the pattern of drinking was similar for both boys and girls.

The authors' conclusions

The authors interpreted these findings as evidence for a partial substitution of alcopops by spirits in response to the tax rise, which did not result in a significant reduction in total consumption due to a small increase in beer drinking. Reinforcing this interpretation was evidence from a similar school survey in Switzerland of switching from alcopops to spirits after an alcopop tax rise, and a survey of adolescents in Germany in 2005, which found that nearly two thirds said expense was the reason they were now buying fewer or no alcopops. Increase in spirits consumption among young people was considered a "negative side effect of the alcopops tax", because a preference for spirits is associated with riskier drinking patterns and more problems.

Remaining unaccounted differences between the environments and pupils in the two years, and broader trends unrelated to the tax rise, might have caused some of the observed differences in drinking patterns. Also the measure of preference meant that as one drink became a lesser source of alcohol, others automatically moved up the scale, and not necessarily because they were actually being drunk in greater quantities. This may have been the case for beer, but the data on spirits is indicative of a real change in preferences as expressed in alcohol intake. Since the analysis was restricted to past-week drinkers, it probably mainly reflected changes in the drinking patterns of regular rather than occasional drinkers.


Findings logo commentary As the authors suggest, switching to other beverages means that raising tax on one type of product does not reduce overall consumption of alcohol at all, or not as much as an across the board price rise or a high minimum unit price of the kind being planned for the UK. Presumably because switching is more likely to happen, the impact of a beverage-specific price rise is greatest on beverage types which occupy a relatively small place in the market, such as alcopops (1 2). Nevertheless there are reasons ( below) to think that (despite not being statistically significant in the featured study) there was an overall drop in alcohol consumption among young people consequent on the alcopops tax, as would be expected if the reason for producing alcopops in the first place was to make alcohol more available and palatable to young people.

Switching to spirits from alcopops was seen by the authors as negative because of their association (as in a Swiss study) with more excessive, non-social drinking to cope with problems, though as the featured study authors caution, this may not be the case among children who would have drunk alcopops had the tax not increased.

It might be thought that one positive effect would have been to partially shut a gateway to drinking for young people, but in fact across the full school samples (ie, not just past-week drinkers) significantly more had drunk in the past week in 2007 than in 2003. Also, in the featured study the age when past-week drinkers had started drinking was virtually the same in 2007 as in 2003 in both full and matched samples.

Apart from the methodological limitations noted by the authors, it seems possible that in matching the 2007 and 2003 samples on variables like how many friends drank, past-month 'binge' drinking, and age of onset of drinking, they could also have cancelled out some of the effects of the tax rise. For example, if the tax rise led fewer young people to drink, this might also have led to lower past-week consumption among drinkers, an effect of the tax rise which might be eliminated by making sure as far as possible that the 2007 and 2003 samples were matched for number of drinking friends. The effect would have been to under-estimate the impact of the tax rise. Still, a near 5% drop in total consumption was found; not statistically significant, but, if real, across the entire population of young people perhaps significant in public health terms. The authors themselves cite evidence of a small overall drop in consumption nationally. Also it is unclear how the switch to beer/wine based alcopops promoted by the alcohol industry was taken in to account in the analysis. The questions about alcopop drinking made no distinction between spirit- and non-spirit-based drinks. If as seems likely the 2007 alcopop total included more of the latter, and that they contained less alcohol, the effect would again have been to underestimate the fall in alcohol consumption in the form of alcopops and also the total fall.

Australian studies

Beyond the European studies the featured report cites, figures from Australia (1 2) suggest that the 2008 increase of almost 70% in the tax on alcopops caused a substantial fall in alcopop sales, only partially counter-balanced by a smaller shift to cider, wine-based drinks and spirits, contributing to a small net reduction in overall sales across the population.

A further Australian study was based on data from the emergency departments of hospitals in a beach resort known as popular venue for 'binge' drinking by young people. Confined to older teenagers and young adults, it examined whether among this major target group, the tax rise had led to fewer alcohol-related injuries and other acute adverse effects of heavy drinking. No such effect was found; as the authors suggested, this may have been because the single-occasion, celebratory, and once a year 'binges' which probably accounted for much of the harm are not as price sensitive as regular drinking.

UK policy

As in Germany, concerned by youth 'binge' drinking, before the elections in 2010 the Conservative Party in Britain was planning significant tax increases on alcopops as well as strong beer and strong cider. In the event, once in power duty was increased only on strong beers and ciders. Concern over alcopops had plummeted along with their consumption, which in 2010 the Treasury noted had fallen by almost three quarters between 2001 and 2008, until they represented only 8% of alcohol consumed by 18–24-year-old hazardous male drinkers. The Treasury's conclusion was that this category of drinks were not now "disproportionately responsible for alcohol-related harms".

The expected 0.45 or 0.50 minimum price per unit of alcohol being planned by governments for England and Scotland would hardly affect the category of drinks including alcopops, which already sell for a relatively high per unit price. Among the 18–24-year-old hazardous drinkers over which there is most concern, alcopops consumption is expected to slightly increase in response to a minimum price, while overall consumption would steeply fall as the cheaper drinks became more expensive.

More relevant to alcopops is a ban on offering the products at a discount, in Scotland expected to have a greater impact "The impact on RTD, whilst small, is greater than that seen for any of the minimum price thresholds considered." (though still small) than any level of minimum price tested in the simulation model. In November 2012 the government for England consulted on a ban on off-licence promotions offering discounts contingent on buying several drinks at once. Scotland implemented such a ban in October 2011, with no obvious short term impacts on sales in comparison with England and Wales.

Last revised 26 January 2013. First uploaded 23 January 2013

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