Drug and Alcohol Findings home page in a new window EFFECTIVENESS BANK BULLETIN 7 January 2008

The entries below are our accounts of documents selected by Drug and Alcohol Findings as particularly relevant to improving outcomes from drug or alcohol interventions in the UK. Entries were drafted after consulting related research, study authors and other experts and are © Drug and Alcohol Findings. Permission is given to distribute these entries or incorporate passages in other documents as long as the source is acknowledged including the web address http://findings.org.uk. Links to source documents are in blue. Hover mouse over orange body text for explanatory notes.

Patchy performance of UK offender treatment initiatives ...

Botched DTTO response to crack using offenders ...

Treatment on bail makes little discernable difference ...

Testing on arrest scatter gun nets some extra treatment entrants ...

Testing children pointless but arrest referral offers early intervention opportunities ...

‘Most promising' alcohol prevention programme tried with poor black US families ...

Self-financing resident-run houses maintain recovery after treatment ...

Concern over abstinence outcomes in Scotland's treatment services ...


Patchy performance of UK offender treatment initiatives

In 2007 a clutch of government-commissioned reports shed light on the now superseded drug treatment and testing order and on new criminal justice initiatives under the Drug Interventions Programme (DIP) umbrella. Though phrased more diplomatically, verdicts ranged from pointless and botched through worthwhile but limited to distinctly promising, though the latter could only be said of the least drug-focused of the initiatives – arrest referral for under-18s.

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Botched DTTO response to crack using offenders

Most worrying of the recent crop of reports on coerced treatment in Britain was a report not released until 2007 on how in 2003 and 2004 three English DTTO teams handled their crack using caseloads.1 For two of the sites no outcome assessment was possible because the most basic of records were lacking. Though there too much data was missing, the third (in London) was able to provide records for 70 relevant offenders. At most five may (we only know the rest did not) have completed their court orders and remained free of crack or heroin use or heavy drinking.

Administrative confusion was apparent from the start when the researchers found central authorities mistakenly thought the teams saw large numbers of primary crack users. In fact there were few; even if using crack, most offenders saw themselves as primarily heroin users.

Though what happened to most of the offenders is unclear, the inflexibility of the court orders and of the treatments combined with poor management and inter-agency working suggest any successes would have been as much in spite of as because of the DTTO process Each site failed to invidualise the treatments they offered and relations between partner agencies were strained.

Staff knew things needed to change and changes were afoot. Confidence that things really did improve after the research ended is diminished by the fact that several years earlier the first DTTO schemes had suffered similar problems.2

1 Turnbull P.J. et al. Supervising crack-using offenders on drug treatment and testing orders. National Treatment Agency for Substance Misuse, 2007.

2 Ashton M. First test for the DTTO. Drug and Alcohol Findings: 2001, issue 6.

Last revised 07 January 2008

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Criminal justice responses to drug related crime in Scotland STUDY 2013

First test for the DTTO STUDY 2001

Treatment and testing orders should make a substantial dent in drug-related social costs STUDY 2001

The family drug and alcohol court (FDAC) evaluation project: final report STUDY 2011

Testing children pointless but arrest referral offers early intervention opportunities STUDY 2008

Flexible DTTOs do most to cut crime STUDY 2005

The impact of treatment on reconviction for drug-related offences STUDY 2012

Review of the Glasgow & Fife drug courts STUDY 2009

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

Treatment with drug testing promises to cut national burden of drug-related crime STUDY 2000



Treatment on bail makes little discernible difference

Imposing treatment earlier in the judicial process than prosecution and conviction may be one way to improve outcomes. In 2004 and 2005 three areas in England piloted a court order which made attending an assessment and if indicated participating in treatment a condition of non-custodial bail. For defendants suspected of an offence motivated by drug use (identified by a positive test after arrest), it offered rapid access to help if they needed it and the chance (they could turn it down) to avoid a spell in a remand prison.

The evaluation found that implementation had been remarkably smooth.1 Over 18 months 2229 defendants were deemed eligible for the order and for 59% it was actually imposed. Over on average the next eight weeks on bail, generally they were rapidly assessed and started treatment which most were not receiving before the order was imposed. About a third breached the conditions of their order, unexpectedly low and mainly due to disorganised lives which obstructed appointment-keeping.

Among defendants already in treatment, at 87% the 12-week retention rate was high. But when the order prompted treatment entry, barely more than half made it through to 12 weeks. Comparison bail samples indicated that making treatment a condition of bail had not improved retention. A small and possibly unrepresentative sample of defendants were enthusiastic about the rapid treatment access the bail condition had offered them.

The order did not mean fewer defendants were jailed while on remand. Instead an extra condition was imposed on defendants who would otherwise have been granted unconditional bail. Neither did rapid pre-trial treatment entry mean the sentence when it came was less likely to be custodial. No impact was apparent on offending while on bail but none was expected.

The conclusion was that a relatively small but possibly worthwhile number of defendants had entered treatment due to the bail order who would not otherwise have done so, but that impacts on retention, offending and imprisonment could not be demonstrated.

1 FEATURED STUDY Hucklesby A. et al. The evaluation of the restriction on bail pilot final report. Home Office, 2007.

Last revised 07 January 2008

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Criminal justice responses to drug related crime in Scotland STUDY 2013

Testing on arrest scatter gun nets some extra treatment entrants STUDY 2008

Evaluation of the mandatory drug testing of arrestees pilot STUDY 2009

Arrest referral tackles drug-driven crime STUDY 2003

Testing children pointless but arrest referral offers early intervention opportunities STUDY 2008

Barriers to implementing effective correctional drug treatment programs REVIEW 1999

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

Drugs: international comparators STUDY 2014

Coerced arrest referral as early intervention STUDY 1999

Offenders do better in treatment if sanctions credible and clear STUDY 2005



Testing on arrest scatter gun nets some extra treatment entrants

Testing and offering treatment before court proceedings aims to capture more drug users earlier than would be captured by waiting until later in the process. Advanced first to testing on charge with a 'trigger' offence (mainly revenue-raising crime), from April 2006 testing further advanced to the arrest stage and arrestees positive for heroin or cocaine were required to attend an assessment of their drug problems and treatment needs.

One concern is that some will not be convicted of the trigger offence yet forced to undergo testing and assessment or face conviction for refusing. Set against this is the possibility that a wider net will capture more people who benefit from treatment. Both seem to have happened.

In 2007 a Home Office study tracked the progress of positive-test arrestees in England who already had a criminal record, about 70% of those testing positive.1 Its main purpose was to compare testing on charge with the later testing on arrest regime.

Making assessment mandatory raised the proportion assessed from 67% to 82%. As a result, the proportion not already in the DIP system who went on to start structured (tier 3 or 4) treatment rose from 8% to 11%, about 400 people a month. However, they were less well 'gripped' meaning that only an extra 30 a month were retained for the 12 weeks thought important for therapeutic progress. Despite testing on arrest and mandatory assessment, fewer (8 versus 9 per month) offenders with the most prolific criminal records were retained for 12 weeks than under the earlier regime.

In pilots about half the tests were positive.2 With these new figures this suggests that 5% to 6% of tested arrestees start structured treatment who might not otherwise have done so and about 1% stay for 12 weeks. 'Might' because there was no comparison group not processed through DIP, and because as many arrestees went on to start structured treatment apparently (but not necessarily) on their own initiative as after being referred through DIP. More may have started tier 2 'treatment' – mainly ongoing contact with DIP staff, suspect the evaluators.

These gains were bought at the cost of considerable net-widening. Across both periods 30% of positive testers had no criminal record and under the later regime 15% of the rest were unconvicted in the past three years, indicating that about 40% of those identified through on-arrest testing had no recent conviction.

The evaluators' analysis confirmed that on-arrest testing captured more relatively low level offenders. On-charge testing netted an average 1932 positive tests per month. Testing on arrest raised this to 3672, suggesting that many who never get charged are now required to undergo test and assessment. 62% of the on-arrest cohort were classified as 'low crime causing' compared to 49% previously. The proportion 'high' on this scale decreased from 24% to 17%, but extended testing meant the number rose from 460 to 610 a month.

Drawing in low-level offenders seems to do little to reduce crime. The test on charge regime (only one for which data was available) identified 2172 heroin or cocaine users with no convictions for offences committed in the past six months. In the six months after encountering this regime, they committed crimes which resulted in 2492 convictions.3 Overall the conviction rate was either unchanged or increased for over half (53%) the offenders.

These less desirable outcomes were outweighed by conviction decreases concentrated among the higher rate offenders, meaning that overall the number of convicted offences fell by 26%. By (very rough) comparison, in the NTORS study of mainly voluntary treatment entrants in England there was a 24% reduction in convictions from the year before treatment started to the year after.4

In both cases it is impossible to say to what degree testing and/or treatment contributed to the changes, especially so for the DIP process whose participants were also influenced by being arrested and charged.

Though no practice recommendations were made by the evaluators, there seems a clear case for sharper targeting towards offenders with a proven record of repeated revenue-raising crime related to drug use.

1 FEATURED STUDY Skodbo S. et al. The Drug Interventions Programme (DIP): addressing drug use and offending through 'Tough Choices'. Home Office, 2007.

2 Matrix Research and Consultancy and NACRO. Evaluation of drug testing in the criminal justice system. Home Office, 2004.

3 Calculated from table 30 of reference 1.

4 Gossop M. et al. Reductions in criminal convictions after addiction treatment: 5-year follow-up. Drug and Alcohol Dependence: 2005, 79(3), p. 295-302.

Last revised 07 January 2008

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Criminal justice responses to drug related crime in Scotland STUDY 2013

Evaluation of the mandatory drug testing of arrestees pilot STUDY 2009

Treatment on bail makes little discernable difference STUDY 2008

Testing children pointless but arrest referral offers early intervention opportunities STUDY 2008

Arrest referral tackles drug-driven crime STUDY 2003

Drug Matrix cell A5: Interventions; Safeguarding the community MATRIX CELL 2014

Drug Matrix cell B5: Practitioners; Safeguarding the community MATRIX CELL 2014

Arrest referral breaks drugs-crime cycle STUDY 1999

Coerced arrest referral as early intervention STUDY 1999

Arrest referral cost-effective way to cut drug-related offending STUDY 1999



Testing children pointless but arrest referral offers early intervention opportunities

In 2007 a three-pronged report assessed an extension to drug testing to under 18s charged with 'trigger' offences, as well as arrest referral and drug treatment and testing orders for the same age group.1

Across the five pilot sites, so few treatment and testing orders were imposed (just 11 in a year) that it was impossible to make any recommendations about their continuance.

Testing on charge along similar lines to the adult programme netted about 100 children a month but only 5% of tests were positive for opiates or cocaine and these children were often already known to services. Comparison with non-pilot sites revealed no evidence that testing curbed the youngsters' substance use. With the unit cost of a positive test ranging up to over £2000, one worker saw the process as a "very intense way of trying to throw money at an issue with very little result" while the evaluators found "insufficient evidence ... to support wider rollout".

These verdicts might have been mitigated if, regardless of the test result, the testing process had brought more services to the aid of children who, if not using cocaine and heroin, were using other substances. However, very few – perhaps 7% accepted but "the number of referrals identified by arrest referral as originating with the drug testing process (n= 69) is lower than the number of young people who accepted an offer of arrest referral during the drug testing process (n= 143)". 3%2 – accepted and acted on a referral to an arrest referral worker.

There were also serious procedural irregularities. Though mandatory, appropriate adults were recorded as present at only three-quarters of tests and just 11% involving 17-year-olds. Home Office checks elicited the questionable explanation that most such incidents were due to data entry error.

Of the three initiatives evaluated, the voluntary arrest referral scheme was the only one the evaluators could recommend for wider implementation. At the five sites, over 11 months 2327 youngsters were contacted by arrest referral workers, mainly on the 'proactive' model of being called in by the police or through cell sweeps by the workers. Possibly due to methodological limitations, the study found few concrete improvements in the children's lives or support structures compared to non-pilot sites, but the pilots did function well at bringing services to the attention of children not previously in touch with them. The vast majority were not substance misuse services but addressed the other issues the youngsters faced like accommodation and education (just 37% were in full time education).

If judged as a juvenile parallel to the adult schemes' attempts to intercept drug driven offending, arrest referral for under-18s would have to be considered a failure. But as a holistic, child-centred early intervention mechanism, it had considerable potential benefits and apart from cost (easily covered by very small crime reductions) no down sides.

1 FEATURED STUDY Matrix Research and Consultancy and Institute for Criminal Policy Research, Kings College. Evaluation of Drug Interventions Programme pilots for children and young people: arrest referral, drug testing and Drug Treatment and Testing Requirements. Home Office, 2007.

2 7% accepted but "the number of referrals identified by arrest referral as originating with the drug testing process (n= 69) is lower than the number of young people who accepted an offer of arrest referral during the drug testing process (n= 143)".

Last revised 07 January 2008

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Criminal justice responses to drug related crime in Scotland STUDY 2013

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

Treatment and testing orders should make a substantial dent in drug-related social costs STUDY 2001

Review of the Glasgow & Fife drug courts STUDY 2009

First test for the DTTO STUDY 2001

Evaluation of the mandatory drug testing of arrestees pilot STUDY 2009

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

Testing on arrest scatter gun nets some extra treatment entrants STUDY 2008

Botched DTTO response to crack using offenders STUDY 2008

Drug Matrix cell A5: Interventions; Safeguarding the community MATRIX CELL 2014



'Most promising' alcohol prevention programme tried with poor black US families

The Strengthening Families Program assessed by UK analysts as the most promising intervention over the longer-term for the primary prevention of alcohol misuse1 has gained further support from a US trial among poor black families.

The original programme has been extensively analysed in Drug and Alcohol Findings.2 As implemented in the new study, over seven weekly sessions parallel groups of parents and their 11-year-old children from about ten families develop their understandings and skills led by parent and child trainers.3 In the second half of each session parents and children come together to practice what they learned. Based on the counties they lived in, over 300 families were randomly assigned to be invited to participate in the programme or to carry on as usual and completed the study. Two years later 19% of programme-assigned children had started to drink compared to 29% of the controls, a significant difference.

A companion paper tested whether this was due to the intended effects on parenting and on the children's attitudes.4 The programme's designers reasoned that enhanced parental monitoring and collaborative but clear rule making and implementation (in particular about alcohol) would curb growth in children's active intentions to drink. There remained the possibility that the children would still drink if the opportunity presented itself. To protect against this, the designers addressed the children themselves, aiming to foster less attractive images of young drinkers. As anticipated, it was through these mechanisms that the programme exerted its restraining effect on age-related increases in drinking.

In the context of previous work on other implementations of the programme, this is an encouraging demonstration of its potential. Confidence would have improved further if improvements in parenting had been directly observed rather than inferred from the parents' own accounts. With any such intervention, getting families to participate is a major obstacle. In this study recruitment was good but may have been influenced by the fact that each of these typically very poor families stood to earn $300 from the research assessments. In normal practice the incentives might be less enticing. Even so just a third of the families invited to participate in the study ended up in the analyses, largely because many failed to respond to the initial invitation. This compromises the random allocation and means that at best the study is a test of the response of the minority of families prepared to fully participate in such a study.

The programme has been used in the UK with the organisers' believe good results.2 A UK evaluation has adapted the US materials for British families and tested their impact. Families and workers thought the approach workable in a UK context.5 A small non-randomised pilot established the feasibility of a larger study but was itself was unable to demonstrate an impact.6 Benefits beyond substance use on family relations and anti-social tendencies may improve the chances of the programme attracting funding.7 Whether high-risk families should be targeted or whether it should be provided across the board is a major practical issue.2 Firm recommendations on wider UK implementation must await a larger randomised trial.

1 Foxcroft D.R. et al. Primary prevention for alcohol misuse in young people. Cochrane Database of Systematic Reviews 2002, Issue 3.

2 Ashton M. Doing it together strengthens families and helps prevent substance use. Drug and Alcohol Findings: 2004, issue 10.

3 FEATURED STUDY Brody G.H. et al. The Strong African American Families Program: a cluster-randomized prevention trial of long-term effects and a mediational model. Journal of Consulting and Clinical Psychology: 2006 74(2), p. 356–366.

4 FEATURED STUDY Gerrard M. et al. A theory-based dual-focus alcohol intervention for preadolescents: the Strong African American Families Program. Psychology of Addictive Behaviors: 2006, 20(2), p. 185–195.

5 Allen D. et al. Cultural accommodation of the Strengthening Families Programme 10-14: UK phase I study. Health Education Research: 2007, 22(4), p. 547–560.

6 Allen D. et al. Preventing alcohol and drug misuse in young people: adaptation and testing of the Strengthening Families Programme 10-14 (SFP10-14) for use in the United Kingdom. Oxford Brookes University, 2008.

7 Spoth R.L. et al. Reducing adolescents' aggressive and hostile behaviors: randomized trial effects of a brief family intervention 4 years past baseline. Archives of Pediatric and Adolescent Medicine: 2000, 154(12), p. 1248-1257.

Last revised 07 January 2008

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Doing it together strengthens families and helps prevent substance use STUDY 2004

Family programme improves on school lessons STUDY 2003

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

Early intervention: the next steps. An independent report to Her Majesty's Government REVIEW 2011

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

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

UK reviewer identifies most promising alcohol misuse prevention programme for young people OFFCUT 2001

Family skills programmes delay adolescent drinking but recruitment is a problem STUDY 2000

Interventions to reduce substance misuse among vulnerable young people REVIEW 2014

Education's uncertain saviour STUDY 2000



Self-financing resident-run houses maintain recovery after treatment

A US recovery model yet to be tried in Europe has proved its effectiveness in a rare randomised trial of a mutual aid intervention.

Democratically run by their residents, the USA has over 1200 Oxford Houses and others operate in Australia and Canada. Each houses six to 18 same-sex residents (some also house their children) who typically have achieved abstinence from alcohol or drugs through a short rehabilitation or detoxification programme and commit to maintaining it with the aid of fellow residents. Applicants are admitted by a vote of current residents. Those judged by housemates to have failed to comply with house rules including abstinence are evicted but may be readmitted after a month sober. The self-financing structure (residents pay all expenses and repay start-up loans from public bodies) permits unlimited stays (these average just over a year) and excess demand is typically met by opening another house.

Researchers recruited 150 adults from in-patient treatment units in Illinois who agreed to be randomly allocated to usual care (the control group) or to apply to Oxford Houses. Typically they were single, black, unemployed women in their late 30s, many with a history of imprisonment and mental health problems. Two reports document this first randomised controlled trial of the houses, the first1 focusing more on describing the intervention, the second2 a fuller account of the study and its outcomes.

All 75 Oxford House applicants became residents. Over half left within six months and by the final follow-up (two years after treatment discharge) just 5% remained. Importantly this means the later results reflect the persisting effects of having been prompted by the study to seek Oxford House residency. Regardless of their location, nearly 90% of the sample completed follow-up assessments.

Compared to the control group, over the follow-up period fewer Oxford House assignees were using alcohol or drugs or charged for a recent offence and more were employed. By the end fewer than half as many (31% v. 65%) were using alcohol or drugs, a third as many were in prison (3% v. 9%), and average earnings were $550 a month higher. All these differences were Oxford House outcomesreported as statistically significant. Additionally, at two years 27% more Oxford House assignees had their own accommodation and nine more mothers had regained or retained custody of their children.

Longer stays were associated with better outcomes but residents who left within six months were still less likely than the control group to be using alcohol or drugs at the last follow-up (46% v. 65%). Though overall the houses were equally (in respect of criminal charges, more) effective for the younger half the sample (under 37), younger residents who left early did no better than the control group.

For a mutual aid intervention, this was an unusually rigorous test with convincing results, but there are some concerns. Unlike the national Oxford House population,3 nearly two thirds of the study sample were women (a function of the units where they were recruited4), raising concerns over representativeness. However, there was no significant indication that the houses benefited one gender more than another.

Presumably only people with no overriding accommodation or relationship commitments would have agreed to enter the study, confirmed by their generally single status and by the fact that just 16% of the control group exited treatment to their own homes and another 16% to a partner's. Where (as in Britain) welfare and housing safety nets are more robust, the control group may have been less disadvantaged. The study was unable to exclude the possibility that decent accommodation may in itself have raised the control group's outcomes nearer to those of the Oxford House group.

It was essential for the researchers to gain the trust of Oxford Houses over many years of collaborative working, raising the possibility of researcher allegiance influences, especially since it was difficult for interviewers to remain unaware of which group respondents had been assigned to.4

There is no indication of the severity of the sample's substance use or psychological problems at the time they entered the study, leaving an important question unanswered – whether severely dependent residents would have been able to comply with house rules. On the other hand, the fact that Oxford House assignees were aided by the researchers may mean they were less motivated than the typical resident who has to find and apply for a house under their own steam.

In the US context, for people without a home or able to move home for several months, Oxford Houses offer a way to preserve the gains achieved in short-term detoxification programmes at no cost to the wider society, which benefits from reduced substance use and criminality. In this role, they may in the UK provide an extended and accessible platform for sustaining recovery to supplement the limited supply and limited duration of expensive residential rehabilitation places.

More on Oxford Houses in the researchers' (at the time of writing) forthcoming book including residents' stories.

Thanks to Rowdy Yates of the University of Stirling for his comments on this entry in draft and to Leonard Jason for supplying further information. Neither bears any responsibility for the text including the interpretations and any remaining errors.

1 FEATURED STUDY Jason L.A. et al. Communal housing settings enhance substance abuse recovery. American Journal of Public Health: 2006, 96, p. 1727–1729.

2 FEATURED STUDY Jason L.A. et al. An examination of main and interactive effects of substance abuse recovery housing on multiple indicators of adjustment. Addiction: 2007, 102(7), p. 1114–1121.

3 Jason L.A. et al. The need for substance abuse after-care: longitudinal analysis of Oxford House. Addictive Behaviors: 2007, 32(4), p. 803–818.

4 Personal communication from Leonard Jason. Click here to visit the research team's web site.

Last revised 07 January 2008

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Concern over abstinence outcomes in Scotland's treatment services

A study of drug users starting treatment in Scotland revealed low rates of abstinence nearly three years later, findings which have been widely misinterpreted. The figures derived from the Drug Outcome Research in Scotland study (DORIS). Like NTORS in England, this sampled patients entering different types of treatments and observed their progress during and after normal treatment delivery.

The study's most significant outcome report to date documented the progress 33 months later of 695 (all who could be reinterviewed) out of 1033 people who started treatment in 2001.1 Though using other drugs, most saw their main problem as heroin. Abstinence was the sole drug use outcome reported, defined as totally avoiding drugs except alcohol or tobacco over the preceding three months. DORIS excluded from this designation anyone prescribed legal substitutes such as methadone.

On this criterion, overall just 8%2 of the sample were abstinent. For patients who had started treatment at detoxification or counselling services, it was 6%, for prison-based services, 5%, and for residential rehabilitation 25%, significantly higher than the other modalities.

No corresponding figure was presented for patients who started the study in methadone maintenance. Instead a figure was given for patients who had started methadone after their first DORIS treatment, about 3% of whom were abstinent. Another 8% confined their (non-alcohol, non-tobacco) drug use to prescribed methadone, meaning that 11% were no longer using illegal drugs. For residential rehabilitation this figure was 33%.

Abstinence was associated with positive outcomes in terms of social integration (education/employment and crime), self-perceived health and mental health. For example, 39% of non-abstinent (ex)patients had committed acquisitive crimes over the past 17 months compared to 9% who were abstinent, and 11% and 2% respectively had attempted suicide or harmed themselves.

These associations were said to underline "the benefits ... of drug users having an extended period of abstinence", implying that abstinence caused or enabled other improvements. Yet abstinence was measured over the past three months, associated " benefits" over the past 17. To establish causality, cause must be shown to come before effect. It seems equally conceivable that other life changes enabled abstinence or that there was a complex multi-way interaction. Also, an analysis based on drug use frequency or severity might have found similar improvements associated with less than total abstinence.

As DORIS researchers warned, potential caseload differences make it unsafe to assume that the various treatment modalities caused the associated differences in abstinence rates. Similar considerations led NTORS to avoid using statistical tests to compare the performances of different modalities because a level playing field in terms of caseload could not be assured.3 Since so few patients enter residential care in Scotland, and since selection procedures should ensure that this expensive option is reserved for those who could benefit most, it seems likely that they differ from the average methadone patient. Another complication is that in DORIS as in other studies, over the years patients traversed several treatment modalities, complicating the assessment of what led to the eventual outcomes.

Nevertheless the research has highlighted how few drug users enter residential rehabilitation in Scotland and how few become abstinent from illegal drugs after an episode in methadone maintenance, raising questions over the balance of investment in treatment modalities. However, for the reasons given above, it would be unsafe to reset the balance solely on the basis of these findings. Internationally, research on residential rehabilitation is sparse, methodologically weak and ambiguous about its benefits relative to less expensive treatment options, while that favouring methadone is more extensive and more convincing.4 5 6 Evidence for the special benefits of residential care is mainly confined to multiply problematic and more severe cases.7

For similar reasons it would be unsafe to assume that the findings support the diversion of methadone patients to services aimed at abstinence from illegal drugs and legal substitutes. Compared to well run methadone services, such services have been associated with an extremely high rate of relapse and resultant deaths because the short spell of abstinence has left patients unprotected by tolerance to opiate-type drugs yet failed to create the circumstances in which they could do without them.8

Rather than or in addition to rebalancing there may be a case for reviewing the resourcing of methadone treatment in Scotland and the services provided by the clinics. English figures show that nearly three times as much is spent on an episode of residential care as on an episode of methadone treatment.9 From its inception social reintegration has been a major benefit of effective methadone maintenance.10 In this and other respects, services vary widely. Among the critical factors are adequate, flexible dosing, procedures which minimise both drop-out and throw-out, sufficiently comprehensive services able to draw on wider social resources, staff committed to the welfare of patients and if indicated to indefinite maintenance, and good organisation.

In 2007 an official report on Scottish methadone services suspected that insufficient resources were devoted to rehabilitating patients, found patchy adherence to UK dosing guidelines, differing views on the desirability of long-term prescribing, and widely differing policies on supervised consumption.11 Such differences are bound to affect patient retention and outcomes and the possibilities for rehabilitation.

Thanks for their comments on this entry in draft to Neil McKeganey of the University of Glasgow, David Best of the University of Birmingham, Mike McCarron of the Scottish Alcohol and Drug Action Team Association, and the staff of Glasgow Addiction Services. They bear no responsibility for the text including the interpretations and any remaining errors.

1 FEATURED STUDY McKeganey N. et al. Abstinence and drug abuse treatment: results from the Drug Outcome Research in Scotland study. Drugs: Education, Prevention & Policy: 2006, 13(6), p. 537–550.

2 Probably fewer given the numbers not followed up. This applies also to other abstinence estimates.

3 Gossop M. et al. The National Treatment Outcome Research Study in the United Kingdom: six-month follow-up outcomes. Psychology of Addictive Behaviors: 1997, 11 (4), p.324–337.

4 Simoens S. et al. The effectiveness of treatment for opiate dependent drug users: an international systematic review of the evidence. Scottish Executive Effective Interventions Unit, 2002.

5 Drug misuse: psychosocial interventions. National Clinical Practice Guideline Number 51. National Collaborating Centre for Mental Health, 2007.

6 Mattick R.P. et al. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database of Systematic Reviews 2003, Issue 2.

7 Systematic but simple way to determine who needs residential care. Nugget 8.9. Drug and Alcohol Findings: 2003, 8, p. 13.

8 Best D. et al. Overdosing on opiates parts I and II. Drug and Alcohol Findings: 2000, issues 4 and 5.

9 Healey A. et al. Criminal outcomes and costs of treatment services for injecting and non-injecting heroin users: evidence from a national prospective cohort survey. Journal of Health Services Research and Policy: 2003 8, 134–141.

10 Ashton M. Methadone maintenance: the original. Drug and Alcohol Findings: 2006, issue 14.

11 Scottish Advisory Committee on Drug Misuse Reducing harm and promoting recovery: a report on methadone treatment for substance misuse in Scotland. SACDM, 2007.

Last revised 07 January 2008

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