Fast response services for those with a short history of drug use
Prepared by Catriona Matheson and Janice Ferguson for CERGA meeting January 2010.
Key Findings
No research studies/evaluations were found in the literature that focussed specifically on fast response/early interventions. There is a large volume of research into the management of adolescent drug use and brief interventions and limited research into rapid entry into services. These topics overlap with our topic of a fast response for those with a drug use short history but are not directly applicable.
The limited information available suggests the following possible factors but non of these have been testing in the UK context:
- Rapid entry to treatment may improve uptake.
- A motivational interviewing style at assessment may encourage.
- Apparent ‘readiness to change’ at treatment entry is not predictive of treatment involvement.
- The following interventions have demonstrated some efficacy in the adolescent population: Multi-dimensional family therapy and cognitive behavioural therapy.
1Introduction
A previous review of the effectiveness of methadone maintenance therapy indicated that those with a shorter history of drug use are more likely to respond to treatment (Bertschy, 1995). This brief topic review aimed to identify and, if possible, describe findings of research or evaluations of specific interventions aimed at early intervention otherwise described as a fast response treatment/service for drug users. It provides an overview and is not a comprehensive or systematic review.
2Methodology
The Medline database was searched using the following keywords: Substance abuse; drug use; services and fast response. The SCOPUS database was also searched using the following keywords: substance abuse; early intervention and services. To identify unpublished/grey literature an e mail was circulated around the drug misuse research network (DMRN).The search covered the last 20 years.
3Findings
The Medline search pulled 22 results, of which only one was considered relevant to this area. The SCOPUS search pulled 765 results, 14 abstracts from various articles were retrieved for further screening, of these, six were considered of some relevance. A further one paper was identified through the DMRN.
Literature specifically on early interventions/fast response was very limited. There was considerable literature on adolescent and young adults which clearly overlaps with early intervention/fast response but for the purpose of this brief topic guide was only included if there was something of relevance to the effectiveness of early interventions. Of the papers identified three were review papers, two RCTs, two cohort studies and one a qualitative study.
3.1Primary Research ofTypes of Treatment
Randomised Controlled Trials
Two randomised controlled trials have been conducted by the same research team in Miami, USA. One compared multi-dimensional family therapy (MDFT)with CBT (Liddle et al, 2009) and the other compared MDFT with per group therapy (Liddle et al, 2008). These studies were not testing early interventions as such but the populations all had a short history of drug use.
In the first trial 224 young people (12-17.5 years) attending a community based drug clinic for the first time were randomly allocated to received MDFT or CBT. Substance use was compared at intake, 6 months and 12 months. Findings found both treatments significantly decreased substance use problem severity. The MDFT group had significantlygreater and longer lasting treatment effects than the CBT group.
In the second trial 84 individuals (11-15 years) were randomised to either MDFT or peer group therapy. The MDFT group reported significantly fewer days of substance use and increased abstinence from drugs and alcohol than the peer group. Delinquency was also reduced in the MDFT group as was internalized distress (a measure of mental health/stress).
Again both of these trials are aimed at drug use generally in young people rather than early drug use per se but as the only robust original trials they have been included. These trials are in urban, US young population with a largely Hispanic and African-American ethnic group. Drug use was also weighted towards cannabis. Thus findings may be of limited generalisability to the UK population.
Cohort Research
Chung et al (2009) recruited 109 adolescents (14-18 years) from community based treatment sitesin the US who received one of two types of treatment those aiming to reduce substance use or those than address ‘other concerns’ e.g. mental health. In treatment aimed at reducing substance use was based on a mixture of 12 steps (approximately 60% of the training content) relapse prevention (20%), managing feelings (10%) and building self-esteem (10%). In the treatment focussed on ‘other concerns’treatment was manualised over 12 sessions covering a range of topics including mental health, anger management phases of recovery, psychiatric illness etc.Detailed data was collected at baseline and 6 months and covered detailed feedback of their experience of treatment.
Regression analysis tested whether great readiness to change and better attendance was associated with higher treatment content and reduction in substance use. Both alcohol and cannabis use reduced over time across the study group. Surprisingly, readiness to change at baseline was not associated with higher treatment involvement. At 6 months greater addictive behaviour content was associated with reduced alcohol use but not cannabis. The authors conclude that there may be different processes of change for alcohol and cannabis that should be considered in treatment planning.
Kellog at el (2009) followed a cohort of adolescent and young people in methadone maintenance treatment and report of their first year in treatment. The study lends little to the knowledge base. The retention rate was just 48% at 1 year and those using more heroin during treatment were more likely to fall out of treatment. There were some interesting papers highlighted in the discussion which would be useful to follow up if time permitted but was not possible in the timescale of this brief review.
Views of Treatment
Mason et al (2009) used qualitative methods to gain insight into adolescents’ views of treatment. This study was again of peripheral importance but in reflecting on what they had gained from treatment (which was a combined motivational enhancement and CBT based program) themes emerged around increased awareness of their drug use and the impact of that drug use and the effectiveness of treatment i.e. that it was generally a positive experience that helped reduced their drug use through various mechanisms.
3.2Review Papers
Three review papers were identified that were of some relevance to the topic. The first was in Drug and Alcohol Findings nugget 8.6 covered the topic of the importance of speed of treatment engagement. Research with cocaine users was described that found that same day appointments had twice as many attenders as though offered appointments 1-7 days later. The offer of an early appointment (and the earlier the better) was found to be key even if that appointment could not be attended. The review quoted research stating rapid treatment entry (across treatments and client groups) is associated with fewer people dropping out early. One study reviewed also found that using a motivational interviewing style in the assessment doubled first session attendance.
Review of Screening, Brief Interventions and Referral for Treatment (SBIRT)
Babor et al (2007) describe the use of screening, brief intervention and referral to treatment (SBIRT) in the drug and alcohol field. Although not focussing on early interventions then do make one relevant conclusion that brief treatments (one or two sessions of either motivational or CBT based treatment) was more effective than being on a waiting list and could benefit many clients awaiting treatment presumably by providing some form of engagement although this was not explicitly stated.
Adolescent Substance Use
Toumbourou et al (2007) summarised systematic reviews of interventions to reduce the harm of adolescent substance use. Although not directly on early interventions there were some findings of relevance. They concluded that early screening and brief interventions can be effective at reducing substance use (and a range of other outcomes) across a range of substances (alcohol, cannabis and tobacco) and in a range of settings (emergency rooms, primary & secondary care). Regarding treatment, the authors felt there was still a gap in knowledge of which type of treatment is most efficacious for which individuals. Authors conclude that rates of harmful alcohol and illicit drug use “can be reduced through concerted application of a combination of regulatory, early interventions and harm reduction approaches.” The use of the term “early intervention” here seems to relate to screening and brief interventions as early intervention per se are not specifically covered.
4Reflection onMethods and Terminology
All primary research and much of the research covered in the review paper was US based and thus of limited generalisability in the UK. Research into adolescent drug use with a short duration of substance useis not necessarily generalisable to the wider population because adolescents have different problems. Furthermore since much of the research found was in adolescents and US based the substance used by the population studies were dominated by cannabis and alcohol with little specific reference to opiates. Again due to the greater emphasis on adolescents there was less medication based treatment and more focus on psychosocial interventions.
The terminology being used is problematic because there seems to be some potentially confusing use of the term ‘brief interventions’ which are not synonymous with early interventions but brief interventions are often used at an earlier stage of drug use before a heavier pattern of use is established.
5Conclusion
This brief review has identified that there is no obvious or focussed research on fast response/early interventions. There was literature available on adolescent populations and on brief interventions which overlap to a limited extent with having a ‘short’ history’ of drug use.The only specific research found in non-adolescent populations was on rapid entry into treatment. However this was not in the UK and was non-opiate based.
What we can discern from the limited information available is:
- Rapid entry may improve treatment uptake.
- A motivational interviewing style at assessment can increase first session attendance.
- Apparent ‘readiness to change’ at treatment entry is not predictive of treatment involvement.
- The following interventions have demonstrated some efficacy in adolescent populations: MDFT, CBT. However these have not been tested in the UK context.
References
Babor, Thomas F., McRee, Bonnie G., Kassebaum, Patricia A., Grimaldi, Paul L., Ahmed, Kazi andBray, J(2007) 'Screening, Brief Intervention, and Referral to Treatment (SBIRT)', Substance Abuse, 28: 3, 7 — 30.
Bertschy G. (1995) Methadone maintenance treatment: an update Eur. Arch. Psychiatry Clin. Neurosci.;245:114-124.
Chung T. & Maisto S.Journal of Substance Abuse Treatment 37 (2009) 171–181
Drug and Alcohol Findings Nugget 8.6. Engaging crack users in treatment: time is of the essence.
Kellog S., Melia D., Khuri E. et al (2006) Adolescent and young adult heroin patients: Drug Use and Services in Methadone Maintenance Treatment. J Addictive Diseases 25(3) 15-25.
Liddle et al (2008) Treating adolescent drug abuse: a randomised trial comparing multidimensional family therapy and cognitive behaviour therapy. Addiction 103,1660-1670.
Liddle et al (2009) Multidimensional family therapy for young adolescent substance abuse: Twelve month outcomes of a randomised controlled trial. J of Consulting and Clinical psychiatry 77, 12-25.
Mason et al (2009) Urban adolescents’ reflection on brief substance use treatment, social networks and self-narrative Addiction Research and Theory:17 (5): 453-468.
Toumbourou et al (2007) Interventions to reduce harm associated with adolescent substance misuse.The Lancet, Volume 369, Issue 9570, Pages 1391 – 1401.
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