Drug and Alcohol Findings home page. Opens new window Effectiveness Bank bulletin 30 May 2014

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

First two entries are respectively about helping vulnerable children avoid and exit problems with substance use. Next two are important guidelines which face the issue of how to ‘scale up’ interventions to match need – in one case, treatment for the large prison problem-drinking population, in the other, injecting equipment abundant enough to prevent injectors sharing.

Vulnerable children benefit from promising prevention programme ...

Treat the family, not just the child ...

WHO guidelines on identifying and treating problem drinkers in prison ...

Aim is more than enough fresh equipment for every injection ...


Differential impact of a Dutch alcohol prevention program targeting adolescents and parents separately and simultaneously: low self-control and lenient parenting at baseline predict effectiveness.

Koning I.M., Verdumen J. E., Engels R. C. et al
Prevention Science: 2012, 13(3), p. 289–297.
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 Koning at i.koning@uu.nl. You could also try this alternative source.

An alcohol prevention intervention that combined adolescent and parent components was found to be effective at delaying the onset of regular drinking only among children with low self-control or whose parents were lenient.

Summary The featured report derives from an evaluation conducted in the Netherlands of an intervention aimed at reducing drinking in adolescents by educating pupils and helping their parents set rules. This further report sought to discover whether the intervention’s impact varied among children with differing levels of self-control or parents with more or less strict attitudes to and rules about drinking.

As the Findings analysis of the earlier report discusses in detail, the intervention combined a parental rule-setting intervention based on the Örebro programme (first developed and tested in Sweden), with a classroom-based education programme providing the children with information and training around alcohol. When, and only when, these two interventions were combined, was there a restraining influence on the adolescents’ future regular drinking and regular heavy drinking that Findings judged to be “several times greater and more consistent than those typical of alcohol prevention programmes applied universally to the entire youth population ... even in respect of programmes recognised as effective and usually far more costly and difficult to implement”.

Reasoning behind the featured analysis was that knowing how the impact of the intervention varied in children and parents with different characteristics might provide evidence for focusing on these characteristics in the first place, and allow interventions to be targeted at people most likely to benefit. Previous research had suggested the two chosen characteristics (adolescent self-control and parental rule-setting) were important. Low self-control appears a good predictor of onset of alcohol use in adolescents, and is a frequent and sometimes effective target of alcohol interventions, whilst the children of parents who have stricter rules and attitudes about drinking have been found less likely to drink heavily. Researchers hypothesised that, in general, interventions are more likely to be effective among high-risk groups. Extrapolating to the featured study, this would imply that adolescents with low self-control and whose parents were more lenient should have benefited most from the intervention.

The original study had randomly assigned participating schools to receive either just the parent intervention, just the adolescent intervention, both interventions, or to act as control schools which simply carried on with the normal alcohol education content of the Dutch curriculum. Further details in our analysis of the original study.

Two main outcomes were assessed 34 months after the baseline assessments: how many children started (ie, had not been doing so before the intervention but started to do so after) drinking at least weekly; and how many children started drinking heavily each weekend – defined as usually consuming at least five glasses for boys and four for girls. To measure adolescent self-control and parental rule-setting, adolescents were given a series of statements like, “I have trouble saying no”, or “I am allowed to have one glass of alcohol when my parents are at home”, and asked to rate how much they thought these applied to them. Parental attitudes were measured by asking the parents questions about how acceptable they found adolescent drinking.

From an original total of almost 3500 students, some were excluded because they were already drinking weekly or because their answers to the questions were inconsistent, leaving just over 2900 students and just under 2400 parents in the analysis. Children were typically 12 or 13 years old, half were boys and half girls, and more than half had no religion. The parents were mostly women aged between 35 and 49.

Main findings

As expected, in respect of preventing weekly drinking, the combined adolescent and parent intervention was effective among the half of the children with the lowest self-control, but not the half with higher self-control. Also as expected, on the same measure the combined intervention restrained the onset of weekly drinking among the half of the children whose parents were most lenient about alcohol, but not the half with stricter parents. These characteristics did not, however, affect impacts on heavy weekly drinking. Though given separately the adolescent and parent interventions were also most effective in the same sets of children, these results did not achieve statistically significance. As opposed to their strictness about drinking as perceived by their children, the parents’ self-reported attitudes to adolescent drinking did not significantly affect the impact of the interventions.

The authors’ conclusions

That the intervention delayed the onset of weekly drinking in adolescents with low self-control or lenient parents, but not those with high self-control or strict parents, underlines the importance and appropriateness of targeting these characteristics and is consistent with the hypothesis that young people at greater risk of starting to drink early stand to benefit more from interventions designed to delay this development.

Parental attitudes did not affect intervention impact, but parental rule-setting did, perhaps because as states of mind rather than actions, attitudes do not have the same concrete link to changing behaviour. Also, setting rules may also require more parental effort [Editor’s note: so presumably act as a marker of parents prepared to exert some effort to prevent their children drinking].

The fact that the separate parent and adolescent interventions did not significantly affect drinking even among the half of adolescents at highest risk, emphasises the importance of using the combined intervention.

In contrast to weekly drinking, neither child not parental characteristics affected intervention impact on heavy weekly drinking. This may have been because parents and children were more uniform in their attitudes and actions to this more severe form of youth drinking, leaving little variation between them to influence the effects of the interventions.

Note that this study was based only on self-reported drinking assessed at a single follow-up point. The Netherlands is considered to have a lenient culture around drinking, and the findings may not translate to countries with different drinking cultures.


Findings logo commentary For a full discussion of the intervention and its relevance to the UK context, see the previous Finding commentary, which concluded that the parental intervention could be “a worthwhile addition to alcohol use prevention lessons as long as parents can effectively be reached and persuaded to be stricter about their children’s drinking”. This further analysis tells us more about who would be most likely to experience benefits from the intervention, and in what ways, enabling the intervention to be more sharply targeted. However, targeting may have limited ability to augment potential public health gains and impacts on disorder related to ‘binge’ drinking, since intervention impact on heavy weekly drinking did not differ between children and parent with differing characteristics.

The influences that were found are consistent with the researchers’ understanding of how and why the combined intervention worked – by encouraging parents to be stricter and by increasing self-control in the students. If this theory is correct, it makes sense that students already relatively self-controlled and with relatively strict parents would have less to gain. A plausible narrative explaining the mechanisms at play, that was expected in advance, and with which findings were consistent, suggests these are not simply chance findings.

Whether this actually means that the intervention should be performed any differently is less clear. The researchers’ hope that their new-found knowledge about for whom the intervention works would enable better targeting may not prove practical or desirable in real school settings. Given that both the student and parent components were delivered to many people at once (in school lessons and in parents’ meetings respectively), it is not clear that significant savings could be made by reducing the number of people offered the intervention. It would also be necessary to weigh such targeting against any possible negative effects from singling out the adolescents perceived as being low in self-control and with lenient parents, even before they have actually begun to drink regularly or harmfully.

For more research and analysis on alcohol prevention interventions among young people, run this Findings search, and see in particular this summary of the findings of three authoritative reviews of alcohol prevention programmes. The National Institute for Health and Care Excellence has published guidelines for schools-based interventions on alcohol, which recommend adopting an inclusive approach that involves parents as well as pupils.

Thanks for their comments on this entry in draft to research author Ina Koning of Universiteit Utrecht. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 02 June 2014. First uploaded 14 May 2014

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STUDY 2011 Long-term effects of a parent and student intervention on alcohol use in adolescents: a cluster randomized controlled trial

STUDY 2015 Effects of a combined parent-student alcohol prevention program on intermediate factors and adolescents’ drinking behavior: a sequential mediation model

STUDY 2010 The effectiveness of a school-based substance abuse prevention program: 18-month follow-up of the EU-Dap cluster randomized controlled trial

STUDY 2010 Why target early adolescents and parents in alcohol prevention? The mediating effects of self-control, rules and attitudes about alcohol use

STUDY 2008 Substance use outcomes 5½ years past baseline for partnership-based, family-school preventive interventions

REVIEW 2012 Universal alcohol misuse prevention programmes for children and adolescents: Cochrane systematic reviews

STUDY 2002 Growth in youth drinking curbed by correcting 'normative' beliefs

STUDY 2000 Education's uncertain saviour

STUDY 2011 Effects of a school-based prevention program on European adolescents' patterns of alcohol use

REVIEW 2014 Interventions to reduce substance misuse among vulnerable young people





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

Baldwin S.A., Christian S., Berkeljon A. et al.
Journal of Marital and Family Therapy: 2012, 38(1), p. 281–304.
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 Baldwin at scott_baldwin@byu.edu.

Review assesses the effectiveness selling points of four largely ‘privatised’ brand-name family therapies for troubled and delinquent teens. Yes, they work better than usual or individualised approaches, but not much and not always, and most of the research has been done by people who stand to gain from positive findings.

Summary The featured review used advanced meta-analytic techniques to amalgamate results from studies of four family therapy approaches which have shown considerable promise for treating youth delinquency and substance use problems. The four approaches (Brief Strategic Family Therapy; Functional Family Therapy; Multidimensional Family Therapy; and Multisystemic Therapy) share a focus on changing dysfunctional family patterns or ‘systems’ which contribute to the onset and maintenance of adolescent delinquency and substance use. In practice, typically they help parents and adolescents communicate better and reduce conflict, improve parenting skills (eg, limit-setting), and help adolescents become better integrated with the systems they are involved in outside the family, such as the school.

Analysts sought published and unpublished reports of the outcomes of trials which randomly allocated children aged 11–19 or their families to these approaches implemented as ‘standalone’ therapies, versus a comparison approach which might be an alternative therapy also organised by the researchers, treatment as usual (eg, court referral to a juvenile delinquency treatment centre), or no particular help. Primarily at issue was whether at the first post-treatment follow-up point (usually when treatment had finished) these approaches improved on the comparators in reducing indicators of delinquency and substance use, the main targets of the interventions, though other outcomes too were assessed. In all 24 such studies were found, half testing Multisystemic Therapy and from three to five each testing the other three approaches.

Main findings

All but one of the 11 studies where the comparator was treatment as usual concerned Multisystemic Therapy. Across all 11, family therapies registered modestly but significantly better outcomes, amounting to a small effect size of 0.21, though results were heavily influenced by one study in which Multisystemic Therapy performed unusually well. Excluding this, the extra improvement in outcomes was even more modest (effect size 0.12). The advantage gained by Multisystemic Therapy was similarly reduced, from an effect size of 0.22 to 0.13. In both cases, though reduced the impact remained statistically significant. Specifically in respect of delinquency and substance use combined, outcomes were significantly better than treatment as usual, amounting to a statistically significant effect size of around 0.30 regardless of whether the ‘outlier’ study was included.

Another 11 studies compared outcomes from the four family therapies versus alternative research-organised treatments not based on these approaches, such as group therapy, individual counselling for the child, or groups for parents. Across all the approaches, family therapies led to statistically significant extra benefits, amounting to a small effect size of 0.26. Each of the four approaches accounted for from two to four studies. With so few studies, the extra gains made by each of the approaches did not differ to a statistically significant degree. In the lead though was Multisystemic Therapy with an effect size of 0.57, but this was possibly due to chance and derived from just two studies led by the same researcher, and involving the programme developer. [Editor’s note: The most important of the two seems best seen as a contrast between the well structured family therapy and a comparator “selected to represent the usual community treatment for juvenile offenders”. Rather than an equally well structured alternative approach, this is described as an eclectic variety of interventions dependent on the preferences of the therapists, sharing only that they focused on the individual adolescent rather than the family system.] Delinquency and substance use were the main targets of the interventions. When these outcomes were combined, they registered a statistically significant aggregate effect size of 0.43, verging on what is conventionally considered a medium-sized impact, and one greater than their impacts on more secondary outcomes. However, studies focused on treating substance use problems had significantly worse outcomes than studies that focused on treating delinquency – a result possibly influenced by the fact some of the delinquency studies recruited their samples entirely from the justice system, among whom outcomes were relatively good.

Just four studies compared outcomes from one of the family therapies against no particular help, registering a relatively large aggregate effect size of 0.70, greater than when the comparison was against an active treatment.

The authors’ conclusions

Confirming earlier research syntheses, for 11–19-year-olds impacts of the four family therapies included in this analysis appear to modestly improve on those from treatment as usual or from other therapies in respect of substance use and delinquency, and to a lesser degree other outcomes too. However, with few studies it was not possible to securely identify which approach had the better record. Among the limitations of the analysis was that it analysed only outcomes from the first follow-up point, typically at the end of treatment.


Findings logo commentary Britain’s National Institute for Health and Clinical Excellence (NICE) has recommended this family of programmes, all of which integrate intervention in to several aspects of a child’s life and environment, for children and young people who misuse alcohol and who also have other major problems and/or limited social support. A later meta-analytic synthesis of research on the treatment of substance use in young people (in this case, aged 12–20) judged, “The most convincing and consistent comparative effectiveness finding was for family therapy, which showed relatively large positive effects relative to other treatments”. Though all sorts of family therapies were included, most studies were of ‘brand-name’ programmes, including those investigated in the featured review.

There seems no doubt that these approaches can improve on typically less well organised and less extensive usual practices, but it also seems this is not always the case, that evaluations conducted independently of the programme developers have been (but not always) unconvincing, and overall results are not as impressive as the investment in these programmes might be seen to require, especially if they must be costed as add-ons to legally or socially required procedures rather than replacements. A major impediment to their use is the expensive training and supervision and considerable skills required to implement them in ways which have been associated with good outcomes. See below for more on these themes.

Cost is a barrier

Within the article, a clinician from the same US institution as the lead author commented that the findings seemed to confirm the superiority of treating young people in the context of their family systems. With no statistically significant differences between the approaches in their degrees of superiority, decisions on which to implement can be taken on practical grounds. Benefits stretch across behavioural problems (eg, sexual offences, serious drug use, bullying), an advantage for real-world services which try to help youngsters who typically present with multiple problems.

The main impediment to extending these approaches is, he suggested, that training is not readily accessible. It is expensive, time-consuming, and usually not available for individuals as opposed to teams. Making this considerable investment is deterred by high staff turnover. In a vicious circle, training organisations have little incentive to invest in training for these approaches when there are few job opportunities for their trainees. Once trained, practitioners are expected to work intensively with small caseloads and to go beyond the focal client to the wider systems they interact with, extensions some funders do not recognise. When money is tight, there is a temptation to cut back on these high-cost approaches.

In a rational system cost would be weighed against results to test whether extra cost was worth the investment. Such analyses have however not found that the extra costs of the types of programmes included in the featured analysis warrant their returns in terms of impacts on substance use and delinquency or extra benefits overall for society (1 2 3).

Concerns over researcher allegiance

The commentator dealt at length with a controversial issue – that researchers in to these family approaches are usually not disinterested examiners, but have themselves developed the approaches, and often have a financial stake in their success as well as an intellectual affiliation to the approach.

Three of the four models have, as he put it, been ‘privatised’, training being provided on a for-profit basis which allows retention and ownership of intellectual property by programme developers. While this enforces the developer’s stipulations for how the programme should be implemented, it means that the fruits of the “millions of taxpayer dollars ... used directly and indirectly in the discovery, development, and refinement of these approaches ... are not readily accessible to clinicians and educators in the public arena”.

There is, he observed, little evidence that these approaches work well outside the context of a tightly controlled trial usually overseen by the experts who developed the approach – a reference to the so-called ‘researcher allegiance’ effect of concern in several social research areas (1 2 3), where programme developers and other researchers with an interest in the programme’s success have been found to record more positive findings than fully independent researchers.

Why this happens is unclear. A possibility is the general finding that expectations (eg, of teachers of their pupils) affect performance via unintended influences on how research participants are treated; programme developers and other researchers affiliated to the intervention may transmit such expectations to participants via their influence on trainers and practitioners. Another is that investigators committed to the intervention are less rigorous in their testing and analysis methods and effectively look for ways to show it works – for example, by assessing many outcomes, gifting the programme they developed many chances to succeed, but not correspondingly raising the bar for what counts as a statistically significant success. It also seems likely that the involvement of the developer in a study will permit an implementation of the programme which adheres to its principles and methods more thoroughly than could be expected in routine practice.

Such issues came to a head recently in respect of Multisystemic Therapy, which dominates the research record. At the heart of the dispute between the programme’s developer and reviewers for the Cochrane Collaboration, known for the rigour of its analyses, were results from a Canadian trial which the reviewers saw as particularly important, because it was the only one of eight trials conducted fully independently of the developers of the approach, and for which results from all the randomised participants could be included over a defined follow-up period. It found no significant extra benefits from Multisystemic Therapy compared to usual juvenile justice services. Where similar outcome measures were available from this and from other trials, generally impacts in Canada were not just non-significant, but virtually zero, a contrast with trials in which the programme developers had been involved.

Including this study, Cochrane’s reviewers concluded that Multisystemic Therapy has not been shown to have clinically significant advantages over usual services or other interventions for youngsters with social, emotional or behavioural problems. Though tending to favour the approach, results from the eight trials did not aggregate to statistically significant advantages in terms of children being removed from home, crime, arrests or convictions, child psychiatric symptoms or family functioning. When all the sample was included in the analysis, no study found significant differences in substance use.

Based on this review, its lead author constructed a methodological critique of Multisystemic Therapy studies and previous more positive reviews. For scientific discourse, it elicited a vitriolic response from the approach’s developers and researchers, who took it as evidence of a “particularly insidious strategy ... to camouflage the commitment to the status quo with what appears to be a methodological and statistical critique of the forces challenging it”. The critic’s motivation was, they suspected, to sustain the “‘cottage industry’ of mental health treatment and services” which Multisystemic Therapy among others challenges with a view to improving the prospects of troubled youth. In turn a rejoinder from the reviewer contested the criticism of her work in detail and denied any such motivations, beginning with the implication that if anyone had a reason for bias, it was the programme’s developers, who “apart from their hard-won professional pride in their achievements ... have a financial interest” in the programme. She ended by pointedly querying whether the evidence for the programme is free of allegiance bias, is replicable in independent evaluations, or is “built on selective use of evidence by people who developed and profit from it ... has there been some mixture of science and sleight of hand in the making and successful marketing of [Multisystemic Therapy]?”

The featured review referred to this controversy, and made its own contribution by asserting that both in terms of its methodology, and how its results compared with other trials, there was no reason to single out the Canadian trial as a particularly poor or atypical test of the programme, and that even if implementation was poor compared to developer-led trials, this was to be expected in normal practice. Also relevant is that in Canada, how well the programme was implemented bore no relation to its results. The trialists there also pointed to the risk of bias in developer-led trials, asking, “When profit is at stake, is it safe to assume that research is value neutral? The potential for conflict of interest should be considered when selecting evaluators and when interpreting results”.

Thanks for their comments on this entry in draft to Michael L. Dennis of Chestnut Health Systems in the USA. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 29 May 2014. First uploaded 25 May 2014

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

REVIEW 2011 Evidence-based therapy relationships: research conclusions and clinical practices

STUDY 2010 A randomized pilot study of the Engaging Moms Program for family drug court

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

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

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

REVIEW 2014 Interventions to reduce substance misuse among vulnerable young people

REVIEW 2006 Motivational arm twisting: contradiction in terms?

DOCUMENT 2009 Management of cannabis use disorder and related issues: a clinician’s guide

STUDY 2010 Long-term effect of community-based treatment: evidence from the adolescent outcomes project





Alcohol problems in the criminal justice system: an opportunity for intervention.

Graham L., Parkes T., McAuley A. et al.
World Health Organization, 2012.

Based largely on prior research analyses and guidelines from the UK, these international guidelines offer an integrated model of best practice care for problem-drinking prisoners, grounded in research specific to prisons and in potentially applicable research in other settings.

Summary From a team based in Scotland and drawing on UK experience and guidelines as well as international research, these guidelines based on a literature review aim to help prison authorities focus more closely on prisoners with alcohol problems and thereby prevent re-offending after release. They are designed primarily for prison staff, related policymakers, and staff in the community helping prisoners to reintegrate into society after release. This account is taken from the document’s own summary.

Despite the limited evidence base on effective interventions to date, the very high prevalence of alcohol problems in the prison population is in itself an opportunity with the potential to deliver a wide range of positive outcomes in addressing alcohol problems in prisoners.

Alcohol problems are best detected with a validated screening tool. There is, however, limited evidence of the effectiveness of screening tools in prison populations, with alcohol problems often subsumed into wider substance misuse and with heterogeneity across studies. Nevertheless, the WHO Alcohol Use Disorders Identification Test (AUDIT) screening tool appears the most promising option in busy settings, given its increasing use in criminal justice settings and its ability to differentiate between different patterns of drinking behaviour.

The evidence base for effective alcohol interventions in prison populations has also been limited. There has been conflation with other substance misuse as well as issues of heterogeneity and the poor quality of studies. An increasing amount of high-quality research has, however, recently been published, particularly relating to women prisoners and young offenders. Overall, the strongest evidence to date relating to alcohol is for brief interventions and motivational interviewing, though variability in length and content of these interventions across studies makes it difficult to be specific about recommendations for implementation.

The essence of a brief intervention is that it is a short, opportunistic intervention delivered in an empathic manner, with motivational elements, by a suitably trained member of staff. This would make brief interventions a suitable option for prisoners who may not have time to access other prison-based alcohol services, either because of the short length of their stays or the nature of their problems. Recent research on brief interventions in other criminal justice settings (such as probation) has shown reductions in alcohol consumption and re-offending. Although there are caveats in generalising these findings to the overall prisoner population, they do suggest brief interventions are promising.

Tiers of intervention

1 Alcohol-related information and advice; screening; simple brief interventions; referral.
2 Open access, non-care-planned, alcohol-specific interventions.
3 Community-based, structured, care-planned alcohol treatment.
4 Alcohol specialist inpatient treatment and residential rehabilitation

Drawing extensively on work in the United Kingdom, particularly Scotland, an integrated model of care for alcohol problems in prisoners is described together with elements for best practice. The model is built on the principle that health care in prisons should be equivalent to that in the community, and proposes three levels of assessment. Firstly, screening (with AUDIT) followed by triage which helps direct individuals to the most appropriate tier for intervention. Triage should determine the presence of other co-occurring health or social problems as well as risk, and can also prioritise those most in need of intervention when demand is high. Those drinking at hazardous or harmful levels (AUDIT scores of 8–19) would generally be offered one or more tier 1 and 2 interventions. These could include brief interventions and motivational interviewing.

Those with AUDIT scores of 20+ are more likely to be dependent and should undergo comprehensive assessment. They can then be offered more intense interventions at tiers 3 or 4, such as psychological therapies. At this third level of assessment, each person’s alcohol problem should be assessed individually, treatment goals discussed with them, and wider health and social needs identified. It is equally crucial to ensure continuity of treatment in the community for those who have begun treatment in prison, or referral to community-based services for those identified with a problem but for whom there are constraints (such as length of incarceration) on the delivery of interventions.

Implementation issues

The model presented in this publication has been designed from Scottish research and is based on a UK model of care for the community population. There may, therefore, be questions of translatability when considering its implementation in other cultural contexts. Adequate resources are needed (such as staff for delivery and to enable accessibility) at a time of widespread financial constraint.

Alcohol services have generally been under-resourced both in prisons and in the community, despite overwhelming evidence for their effectiveness. They are one of the recommended areas of effective alcohol policies in the WHO European action plan to reduce the harmful use of alcohol. The prison regimen itself can be both a help and a hindrance. The (general) policy in prison of no alcohol enforces an environment of abstinence. It is, however, artificial and does not, for example, enable prisoners to practise their newly acquired knowledge about drinking in moderation or coping skills for preventing relapse. In addition, the production of illicit alcohol can be harmful to health and result in disorder and unrest. While some prisoners may be unwilling to admit to an alcohol problem, for others prison is a welcome opportunity to do so.


Findings logo commentary Featured report cover These international guidelines were drafted by a team from Scotland and drew extensively on UK experience, so can double as a good-practice guide for the UK. The report’s cover poses the key dilemma. Its subtitle (“An opportunity for intervention”) seems belied by the forbidding, barbed wire-topped concrete wall, raising the question of how this environment could host productive intervention, and even if it did, whether the benefits would last beyond the walls. Yet the walls create the ‘dry space’ in which intervention seems possible.

After acknowledging this seeming contradiction, the guidelines usefully package current thinking about alcohol interventions and apply these to the prison population. The result is a well grounded and coherent basis for prison health services to arrange their alcohol programmes, an advance on more ad hoc arrangements less likely to identify prisoners who could benefit and/or to offer them an intensity and style of intervention suited to their needs. However, the authors admit they had to make recommendations from a very narrow evidence base specific to prison alcohol treatment, and often drew instead on studies conducted in other settings and populations not under criminal justice supervision.

At the base of the pyramid of need and probably most applicable to the greatest number of prisoners were brief interventions – usually one or two brief face-to-face sessions, often based on motivational interviewing. Evidence of effectiveness meant these were considered promising. They also recommend themselves on feasibility grounds for prisoners on short sentences or who may be moved to another prison, and because they demand less learning, skills and time from prison and healthcare staff than fully-fledged therapies. The combination makes brief intervention a candidate for forming the bedrock of prison alcohol programmes, the reason why the evidence is examined further below.

Brief interventions

Results from the sole randomised prison-based brief intervention study cited in the guidelines, though not entirely negative, were overall unconvincing. Conducted in a US prison complex for women, generally the prisoners continued to frequently drink heavily after release, but at the three-month follow-up, somewhat less frequently if they had been allocated to the two brief intervention sessions. These were, however, the only statistically significant results. There were no such differences at the one-month follow-up and by the six-month follow-up the gap in the proportion of non-drinking days had narrowed to an insignificant 66% among advised women versus 62% in the comparison group not offered brief intervention.

Also unconvincing were the major studies of brief interventions for offenders under community supervision in England and Scotland. The remit for the Scottish study was to establish feasibility – whether brief interventions could be implemented in ways which gave them a chance of working. Staff were ambivalent, often feeling the pilot was not suited to their client groups who faced more serious issues such as money problems and housing. Some said if drinking was a priority, it needed more than a few minutes of brief advice, that their clients were often too extreme in their drinking to be suitable for a brief intervention, and that excessive drinking was too intertwined with other problems to be dealt with in isolation. The AUDIT screening tool was generally seen as easy to apply and by some as a useful way to broach the issue of drinking, while other staff thought it was inappropriate to have to complete it when drink was clearly not a relevant issue. Few staff felt offenders generally had engaged well with the brief intervention.

For the English study in 20 probation offices, only informally presented results are available, but it was by far the largest UK controlled study of alcohol advice/counselling for offenders. As in Scotland, staff scepticism was apparent. Of the nearly 200 staff in the trial, about a fifth did not recruit any offenders to the study, and only about a quarter were able to implement screening and brief intervention as intended without extra help from researchers and specialist alcohol workers. Compared to staff in the two other settings (GPs’ surgeries and emergency departments), screening and brief intervention was felt to meld more naturally with routine probation work, but staff were less convinced these procedures would be useful and tended to feel they were best reserved for offenders with obvious drinking problems.

The English study also investigated effectiveness. Results in probation offices were similar to those in the other settings: no great differences between how well the screening methods identified risky drinkers, nor in drinking reductions after three interventions of varying intensity, ranging from a very brief warning to an additional 20 minutes of counselling at (in the probation arm) a further appointment with a specialist alcohol worker.

Probation was, however, a partial exception. At the six-month follow-up and among particularly heavy-drinking offenders offered counselling, there was a fleeting extra reduction in the proportion still drinking at risky levels – one possibly chance positive finding among many negatives. Conceivably, more intense drink problems among offenders than patients in the other arms of the study afforded scope for them to respond better to extended counselling. In turn this may have caused what preliminary results say were significantly fewer reconvictions registered in police records and a relative reduction in health and crime costs associated with counselling – even though only 41% of offenders offered it attended the appointment. But without a no-intervention comparator, there is no way of knowing whether any of the interventions were better than doing nothing.

Thanks for their comments on this entry in draft to report author Lesley Graham of the Scottish NHS National Services Information Services Division. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 17 April 2014. First uploaded 10 April 2014

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

STUDY 2012 Alcohol screening and brief intervention in probation

STUDY 2014 Alcohol screening and brief interventions for offenders in the probation setting (SIPS trial): a pragmatic multicentre cluster randomized controlled trial

STUDY 2011 Prison health needs assessment for alcohol problems

STUDY 2011 Delivering alcohol brief interventions in the community justice setting: evaluation of a pilot project

DOCUMENT 2009 Management of cannabis use disorder and related issues: a clinician’s guide

REVIEW 2014 Interventions to reduce substance misuse among vulnerable young people

STUDY 2010 A brief alcohol intervention for hazardously drinking incarcerated women

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

STUDY 2009 Evidence-based practice? The National Probation Service's work with alcohol-misusing offenders

STUDY 2011 Scoping study of interventions for offenders with alcohol problems in community justice settings





Needle and syringe programmes.

National Institute for Health and Clinical Excellence.
National Institute for Health and Clinical Excellence, 2014.

The UK’s health advisory body recommends high coverage and if need be, 24-hour needle exchange to combat HIV and the hepatitis C epidemic. The aim they say is for every injector to have even more sterile injecting equipment than they need for every single injection.

Summary These guidelines replace those issued in 2009 which resulted from a request by the Department of Health for the National Institute for Health and Clinical Excellence (NICE) to produce public guidance on the optimal provision of needle and syringe programmes for injecting drug users. Unlike the original guidelines, the update covers children as well as adults and extend to users of image- and performance-enhancing drugs. The remit was to consider what constitutes optimal provision. In other words, they were about what makes programmes more effective, not whether they are effective in the first place. However, the committee did express an opinion on the latter issue, concluding that “Evidence from systematic reviews shows that [needle and syringe programmes] are an effective way to reduce many of the risks associated with injecting drugs”.

NICE’s Public Health Advisory Committee developed these recommendations on the basis of an updated overall effectiveness review (see the Findings analysis of the original review), an economic analysis, expert advice, stakeholder comments and fieldwork, reports on which are available on NICE’s web site.

Particularly significant recommendations are listed below.

Coverage is the priority

• Commissioning bodies and public health practitioners should assess the percentage of injections in their areas for which sterile needles and syringes were available among different user groups, including people who inject image- and performance-enhancing drugs, who inject occasionally and under-18s, as well as more traditional injector populations. They should also know what proportion of injectors were supplied more sterile needles and syringes than they needed (over 100% coverage) and what proportion are in regular contact with a needle and syringe programme.
• This and other information should be used to ensure services meet local need with a view to increasing the proportion of injectors who have more than one sterile needle and syringe available for every injection (over 100% coverage) and the proportion in contact with a needle and syringe programme.
• Commissioning bodies should ensure needle and syringe programmes aim to offer information on and referral to other harm reduction services, and to services (for example, opioid substitution therapy) which encourage people to stop using drugs or to switch to non-injecting methods, and those which address visitors’ other health needs.

Services for young people

• Commissioning bodies and service providers should develop and implement a local, area-wide policy on providing needle and syringe programmes and related services to meet the needs of different groups of young people aged under 18 (including those under 16) who inject drugs.
• They should ensure the policy details how local services will achieve the right balance between the imperative to provide young people with sterile injecting equipment and the duty to protect (safeguard) them and provide advice on harm reduction and other services.
• The policy should emphasise the need to provide young people with sterile injecting equipment which where possible should be provided as part of a broader package of care to meet their other health and social care needs.
• Parental or carer involvement should generally be encouraged, with the consent of the young person. Where this is not possible (or appropriate), the policy should include strategies to address their needs.

Mix of services

• The local service mix should include three levels of service providing:
1 Injecting equipment either loose or in packs with written harm reduction information.
2 ‘Pick and mix’ injecting equipment supply plus health promotion advice and referral to specialist services.
3 Level two plus provision of or referral to specialist services (for example, specialist clinics, vaccinations, drug treatment and secondary care).
• Links and referral pathways between these different levels of service should promote integration and the sharing of learning and expertise and services should be coordinated to ensure injecting equipment is available at times, and in places, that meet the needs of people who inject drugs.
• Services offering opioid substitution therapy should also make needles and syringes available to their patients.

Injecting equipment

• Needle and syringe programmes should distribute equipment numbers and types according to need rather than subject to a pre-set limit.
• They should also allow service users to take equipment for other injectors (‘secondary distribution’), but ask them to encourage those people to use the service themselves.
• Disposal bins/advice for used equipment should be provided plus a means for safe disposal of used bins and equipment.
• Programmes should facilitate the use by injectors of other services including those which aim to reduce harm from injecting, promote switching to safer drug use methods, to stop drug use, and to address other health needs.

Services to be provided

• Pharmacy programmes should ensure staff are competent to provide the level of service offered and can and do refer customers to other healthcare services, including drug treatment services, and offer wider health promotion advice as relevant.
• Specialist services operating at level 3 (see above) should offer comprehensive harm reduction services including advice on safer injecting practices, assessment of injection site infections, advice on preventing overdoses, help to stop injecting, and referral to opioid substitution clinics and other drug treatments.
• Specialist services should also offer or help people to access: opioid substitution and other drug treatments; treatment of injection site infections; vaccinations for hepatitis A and B and tetanus; testing and associated counselling for hepatitis B and C and HIV; services for image- and performance-enhancing drug users; psychosocial interventions; primary care services (including condoms and general sexual health services, dental care and general health promotion advice); specialist substance misuse services and specialist youth services for young people; secondary care services (for example, treatment for hepatitis C and HIV); welfare and advocacy services (for example, advice on housing and legal issues).

Services for people who inject image- and performance-enhancing drugs

• Commissioners, providers and public health practitioners should ensure needle and syringe programmes are provided at times and in places that meet the needs of people who inject image- and performance-enhancing drugs, for example, outside normal working hours, or at gyms.
• They should also ensure level 2 and 3 programmes whose caseload includes a high proportion of these injectors provide specialist services for this group, including: specialist advice about the drugs and their side effects; advice on alternatives (such as nutrition and physical training); information about and referral to sexual and mental health services and (if available) specialist clinics for user of image- and performance- enhancing drugs.


Findings logo commentary In making its recommendation on coverage, the committee responsible for the guidance noted the need to balance the number of people who have sterile injecting equipment for each injection with the number in direct contact with needle and syringe programmes. Their thinking seemed to be that allowing people to take equipment for their associates who do not visit exchanges might increase coverage (how much sterile equipment is available to injectors in relation to the number of times they inject), but do little to encourage attendance. Because coverage is the biggest predictor of sterile needle and syringe use, they felt that how injectors get their sterile equipment was less important than that they get it in sufficient numbers, making coverage the priority. For this reason they recommended that it be considered acceptable to knowingly provide equipment for service users to pass on to others (‘secondary distribution’), but did add the rider that those users be asked to encourage their associates to themselves become needle and syringe programme users.

From a coverage point of view this makes sense, but once in the hands of someone the exchange has no direct relationship with, the service loses any control of the disposal of its used equipment. On balance exchanges probably help prevent unsafe disposal of used equipment, and it can be argued that if (as intended) a secondary relationship with the exchange encourages non-service users to become users, that will extend the exchange’s ability to prevent unsafe disposal. Nevertheless, exchange managers will be acutely aware of the potentially damaging impact of equipment originating with the service being found on the streets or other public places.

With an eye to the national drug strategy’s focus on recovery from dependence – not excluding but de-emphasising harm reduction – the committee “noted that a focus on recovery (that is, encouraging people to stop taking drugs completely) should not compromise the provision of needle and syringe programmes and any associated harm-reduction initiatives”.

The previous NICE report reached its conclusions partly on the basis of a cost-effectiveness analysis which was not updated for the current version of the guidance. In estimating benefits, this took in to account the potentially important role exchanges can play in bringing people who inject drugs in contact with a range of services. Though the contribution made by this ‘gateway’ function was uncertain, the conclusion was that providing sterile injecting equipment is cost-effective for the NHS and personal social services and for society as a whole.

There has however been an updated ‘costing statement’ based on the earlier analysis, taking in to account the extension of the guidance to services for people who inject image– and performance– enhancing drugs and injectors aged under 18. It reiterates the earlier cost-benefit argument that for “a relatively small investment there is the potential to avoid significant healthcare and societal costs in the future”. The cost of supplying injecting equipment for someone who injects drugs like heroin and cocaine of £200 per year and for an injector of image– and performance– enhancing drugs of £6 per year (plus dispensing) is contrasted to the cost of treating someone infected with hepatitis C (£22,000 to £41,000 a year) or HIV (£10,000 to £42,000).

The earlier economic analysis also suggested that while increasing the coverage of syringe distribution and the recruitment rate in to substitute prescribing programmes are sufficient to control HIV, they are not sufficient to reduce the prevalence or incidence of hepatitis C infection; only multi-faceted interventions including for example these interventions and treatment of hepatitis C infection can achieve substantial decreases in new hepatitis C infections.

Thanks to Steve Taylor of Public Health England for alerting us the costing statement.

Last revised 28 April 2014. First uploaded 27 February 2009

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