Change and stability of change after treatment of drug misuse: 2-year outcomes from the National Treatment Outcome Research Study (UK)

The National Treatment Outcome Research Study (NTORS) is a longitudinal, multisite, prospective cohort study that assesses changes in illicit drug use and other problems after treatment in national (UK) drug misuse treatment programmes. Clients were recruited from 54 residential and community-based drug treatment programmes throughout England. Four modalities were studied: inpatient drug dependence units, residential/rehabilitation programmes, methadone maintenance, and methadone reduction programmes. Data on substance use behaviours and physical and psychological health were collected by structured face-to-face interviews at intake, 1- and 2-year follow-up. Data are presented for 549 clients. A majority of clients achieved widespread improvements across a range of outcome measures after treatment in existing treatment services. For most outcomes, reductions in problem behaviours at the group level occurred within the first year and were maintained at 2 years. Considerable stability of outcomes at the individual level was also found. Abstinence from illicit drugs was substantially increased among clients from both residential and community programmes, and there were also substantial reductions in frequency of use of heroin, nonprescribed methadone, benzodiazepines, and crack cocaine. Injecting and shared use of injecting equipment was also reduced. Heavy drinking was common at intake and was not reduced at follow-up. Psychological and physical health problems were reduced on both groups at follow-up. These changes represent important clinical benefits to the individual clients, to their families, and to society.

Changes in use of crack cocaine after drug misuse treatment: 4-5 year follow-up results from the National Treatment Outcome Research Study (NTORS)

Crack cocaine outcomes at 4-5 years are reported for 496 drug users recruited from UK treatment programmes. About one-third used crack at intake and at 4-5 years. The results show different outcome profiles. For crack users at intake, use was more than halved at follow-up. Among non-crack-users at intake, about a quarter used crack during follow-up, of whom about two-thirds had never used crack before. Polydrug use and use of other stimulants were associated with using crack. Crack users reported worse acquisitive crime and psychological health outcomes. About 10% reported injecting crack. The reductions in crack use are encouraging, but the onset of crack use among many non-users at intake suggests the need to develop more effective treatment interventions.

Reduced injection risk and sexual risk behaviours after drug misuse treatment: results from the National Treatment Outcome Research Study

This paper investigates injecting, shared use of needles/syringes and sexual risk behaviours at intake to treatment and at one-year follow-up among 753 drug users recruited to the National Treatment Outcome Research Study (NTORS). Injecting, sharing and having unprotected sex were substantially reduced among clients admitted to methadone programmes and among those admitted to residential treatments. The overall levels of risk fell after treatment, and the majority of those who were engaged in high risk behaviours at intake had stopped at follow-up. The results also show the variability of individual outcomes. A minority persisted with their risk behaviour, and others who were not at risk at intake who had started to engage in risky behaviours at follow-up. The behaviour of these clients creates a focal point for risk as well as being a threat to public health. Several social and psychological factors were predictive of health risk behaviours. These included frequency and duration of heroin use, polydrug use, alcohol use, gender, ethnicity, having a drug-using partner, anxiety and depression. The results indicate the important role that can be played by treatment services in helping to reduce the risk of blood-borne infections. We suggest that risk reduction interventions are an important and effective component of treatment programmes.

Dual dependence: assessment of dependence upon alcohol and illicit drugs, and the relationship of alcohol dependence among drug misusers to patterns of drinking, illicit drug use and health problems

AIMS

The study investigates severity of alcohol dependence among drug misusers. Specifically, it investigates the inter-relationship of alcohol and drug dependence and associations with alcohol consumption, drug consumption and substance-related problems.

DESIGN, SETTING, PARTICIPANTS

The sample comprised 735 people seeking treatment for drug misuse problems, who were current (last 90 days) drinkers.

MEASUREMENTS

Data were collected by structured face-to-face interviews. Dependence upon illicit drugs and upon alcohol was measured by the Severity of Dependence Scale (SDS).

FINDINGS

Three groups of drinkers were identified: non-alcohol-dependent drug misusers (63%); low-dependence (19%); and high-dependence (18%). Many drug misusers were drinking excessively and alcohol dependence was related to patterns of alcohol and drug consumption. High-dependence drinkers were more likely to drink extra-strength beer; they were less frequent users of heroin and crack cocaine but more frequent users of benzodiazepines, amphetamines and cocaine powder; they reported more psychological and physical health problems. The SDS was found to have good reliability and validity as a measure of alcohol dependence. SDS scores for alcohol and drug dependence were unrelated.

CONCLUSIONS

Alcohol use is an important and under-rated problem in the treatment of drug misusers. A comprehensive assessment of alcohol use among drug misusers should include separate assessments of alcohol consumption, alcohol-related problems and severity of alcohol dependence.

Reductions in non-fatal overdose after drug misuse treatment: results from the National Treatment Outcome Research Study (NTORS)

Few studies have reported changes in rates of overdose after drug misuse treatment. This paper investigates changes in non-fatal overdose between treatment intake and 1 year follow-up among a sample of 753 clients recruited to the National Treatment Outcome Research Study (NTORS). A relatively high rate of overdose (15%) was reported during the 3 months prior to treatment. Variables predictive of overdose at intake to treatment included injecting, frequency of benzodiazepine and cocaine use, quantity of alcohol consumption, and levels of anxiety. At 1 year follow-up, the rate of non-fatal overdose had fallen to 6%. Reduced rates of non-fatal overdose were found for clients treated in both residential and community treatment settings. Reductions in overdose were linked to improvements in frequency of drug use and lower rates of injecting. Clients who overdosed at follow-up showed no improvements in their substance use, except for frequency of crack cocaine use. The risk of non-fatal overdose at 1 year was associated with injecting and multiple drug use. These findings support the view that treatment an important role can play in reducing deaths among drug misusers.

The relative impact of waiting time and treatment entry on drug and alcohol use

One hundred and twenty-three treatment-seeking substance misusers were recruited to a study assessing the early impact of treatment. Participants were interviewed at treatment entry and 3 and 6 months later, regardless of their treatment status (i.e. including those who had dropped out of treatment), while additional data were obtained from the two assessment interviews carried out prior to the initiation of treatment. Three consistent observations can be applied to both the opiate misuser (n = 61) and problem drinker samples (n = 62): (1) the period of pre-treatment wait (mean of 8 weeks) was characterized by stable patterns of substance misuse with no significant 'spontaneous' improvement in indices of severity of drug or alcohol problems; (2) the period immediately following initiation of treatment was associated with substantial reductions in the quantity and frequency of substance use, an effect not influenced by the length of time for treatment initiation; (3) these benefits are maintained to 6 months after treatment initiation. The waiting period for treatment initiation does not seem to be characterized by significant changes in drug or alcohol use patterns, at least among those who made it into treatment, with clear and sustained improvements irrespective of the length of treatment wait.

A Short Alcohol Withdrawal Scale (SAWS): development and psychometric properties

The measurement of alcohol withdrawal symptoms is important for the assessment of the alcohol withdrawal syndrome and for the evaluation of the effectiveness of withdrawal treatment interventions. There continues to be a need for an instrument for the measurement of alcohol withdrawal severity which is short, easy to understand (especially by respondents who may feel anxious, confused or physically ill) and easy to administer (for example, within clinical services with limited time and resources).This paper describes the development and psychometric properties of the 10-item Short Alcohol Withdrawal Scale. The SAWS includes five items which represent psychological symptoms (anxious, confused, restless, miserable, memory problems) which accounted for 47% of the variance. A further five items represent physical symptoms (tremor, nausea, heart pounding, sleep disturbance, sweating) and accounted for 11% of the variance. The procedures leading to the development of the scale are described and results are presented showing that the SAWS has high internal consistency, and good construct and concurrent validity.

A prospective study of mortality among drug misusers during a 4-year period after seeking treatment

AIMS

The opportunity to study deaths as they occur within the framework of a prospective cohort study is relatively uncommon. This study investigates deaths among drug misusers over a 4-year period, with specific attention to the circumstances and causes of death, and risk factors for mortality. The study also critically examines the recording of drug-related deaths.

DESIGN, SETTING, PARTICIPANTS

Prospective cohort study of 1075 drug misusers recruited to 54 treatment programmes during 1995.

MEASUREMENTS

Data derived from interviews conducted with clients at intake, death certificates and post-mortem examinations.

FINDINGS

The annual mortality rate was 1.2%, about six times higher than that for a general, age-matched population. Fourteen per cent of the deaths were due to self-inflicted injuries, accidents or violence and 18%, were due to medical causes. The majority of deaths (68%) were associated with drug overdoses. Opiates were the drugs most commonly detected during post-mortem examinations. In the majority of cases, more than one drug was detected. Polydrug use and, specifically, heavy drinking, and use of benzodiazepines and amphetamines, were identified as risk factors for mortality. Anxiety and homelessness were also predictive of increased mortality.

CONCLUSIONS

We suggest that drug misusers and those working with drug misusers need to be more alert to the risks of polydrug use, including the combined use of alcohol with illicit drugs. The study revealed inconsistencies in the recording of drug-related deaths on death certificates. The routine recording of all substances detected during toxicological examination would improve the accuracy of death certification.

A double-blind randomized placebo-controlled trial of lofexidine in alcohol withdrawal: lofexidine is not a useful adjunct to chlordiazepoxide

Lofexidine is an alpha-adrenoceptor agonist which has proved useful in opiate withdrawal and which, through its attenuation of noradrenergic activity, might be a valuable adjunct in the management of alcohol withdrawal. The objective of this study was to compare the clinical effectiveness and patient retention with adjunctive lofexidine versus placebo in the treatment of alcohol withdrawal under chlordiazepoxide cover. This was done in a prospective double-blind randomized placebo-controlled trial with 72 alcohol-dependent adults referred and admitted for in-patient alcohol detoxification. The adjunctive lofexidine group experienced significantly more severe withdrawal symptoms, greater hypotensive problems, more adverse effects, and no better rates of retention in treatment. Lofexidine provides no discernible benefit as an adjunctive medication (to chlordiazepoxide) in alcohol detoxification and, on the basis of our study, appears to be contra-indicated.

Are the Twelve Steps more acceptable to drug users than to drinkers? A comparison of experiences of and attitudes to Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) among 200 substance misusers attending inpatient detoxification

The present study is a cross-sectional interview-based investigation comparing experiences of and attitudes towards Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) in a sample of 200 patients attending inpatient substance misuse detoxification services. Two hundred consecutive admissions were recruited; 100 each from one drug and one alcohol in-patient treatment service in which attendance at AA/NA was a voluntary adjunct to a generic treatment programme. Although there were no differences in the history of AA/NA attendance, the drug users (who were on average younger) reported significantly more positive attitudes towards AA/NA, more willingness to attend during their in-patient treatment and greater intention to attend following completion of their detoxification. In particular, despite no differences in spiritual/religious orientation, the drug users reported more positive views of the Twelve Steps. As AA/NA remain popular and accessible forms of substance misuse support, it is critical that we develop a clearer understanding of their impact and of the scope for their integration with generic forms of substance misuse treatment.

Outcomes after methadone maintenance and methadone reduction treatments: two-year follow-up results from the National Treatment Outcome Research Study

This paper provides a detailed analysis of the 2-year outcomes for 351 drug misusers allocated on an intention-to-treat basis to methadone maintenance or methadone reduction treatments. Both groups showed substantial reductions in their use of illicit drugs and in other outcome areas. However, whereas most methadone maintenance patients received maintenance, only about one third of those allocated to methadone reduction received methadone reduction, and many actually received a form of methadone maintenance. Reduction patients were more likely to receive low doses of methadone, and were less likely to remain in treatment. For maintenance patients, higher doses and retention in treatment were both associated with improvements in illicit heroin use at 2 years. For the reduction patients, the more rapidly the methadone was reduced, the worse the heroin use outcomes. For patients in both treatment conditions, reductions in heroin use were associated with improvements in other outcome areas. The more severely dependent patients showed better outcomes in methadone maintenance. Methadone reduction treatment processes were associated with poor outcomes, and many patients who were allocated to methadone reduction treatment did not receive reduction treatment as intended. This calls into question the appropriateness of either the initial treatment planning process or the treatment delivery process, or both. A clearer distinction should be made between methadone maintenance and methadone reduction. Treatment goals should be made explicit both to the patient and to the clinical staff at the start of treatment. We suggest the need for a reappraisal of the goals and procedures of methadone reduction treatment.

The impact of naloxone/lofexidine combination treatment on the opiate withdrawal syndrome

Clinical studies in opiate-dependent patients suggest that detoxification treatment with opiate antagonists may accelerate the resolution of the opiate withdrawal syndrome, permitting early induction onto naltrexone maintenance treatment. The present open study compared the clinical efficacy of daily naloxone injections in conjunction with lofexidine, with conventional lofexidine monotherapy, in 49 polysubstance-misusing opiate-dependent patients. Overall, the addition of naloxone did not confer substantial benefit over lofexidine monotherapy, although area-under-the-curve analysis showed that withdrawal severity in the naloxone/lofexidine combination group was significantly less than in the lofexidine monotherapy group, who experienced more severe withdrawal symptoms on days 4, 7, 9 and 13 of treatment. There were no significant differences in rates of completion of detoxification. Blood pressure remained within normal limits in both groups. Naltrexone maintenance treatment acceptability was low; only four patients continued with treatment for 5 or more days. The modest benefit of adding naloxone to lofexidine compared to the findings of previous opiate antagonist detoxification treatment studies is discussed in the context of the hypothesis that a critical level of opiate receptor occupancy is required to accelerate resolution of opiate withdrawal; the neurochemical mechanisms which may promote this are discussed.

Health care professionals referred for treatment of alcohol and drug problems

This study reports on 62 health care professionals referred to a specialist drug and alcohol treatment service. Most patients used more than one type of substance. Health problems were common, but were seldom reasons for referral. Self-referral was infrequent. Referral was often subsequent to intoxication at work or persistent absenteeism. Just over half of admissions completed treatment. Multiple drug use was a poor prognostic indicator with fewer multiple drug users engaging with, or completing, treatment.

High dose cocaine use in São Paulo: a comparison of treatment and community samples

This cross-sectional study investigates patterns of drug use and associated problems among 332 cocaine users from treatment and community samples in São Paulo, Brazil. Data were collected using a structured questionnaire and the Severity of Dependence Scale (SDS). The majority were regular users of high doses of smoked cocaine. After controlling for severity of cocaine use, users in the community were found to be more involved in illegal activities, more likely to report adverse effects of cocaine, to be involved in prostitution, and to have lived on the streets. Better methods are required to provide interventions to tackle the problems and risk behaviors of these cocaine users.

Patterns of improvement after methadone treatment: 1 year follow-up results from the National Treatment Outcome Research Study

One year outcomes for substance use behaviours, health and criminal behaviour, and variation in treatment response, are reported for patients recruited to methadone maintenance and methadone reduction treatment programmes as part of NTORS. Significant reductions in the use of all illicit target drugs were found at follow-up for patients recruited to the methadone maintenance and methadone reduction modalities. Because of similarities in the treatments received by clients in the two modalities we caution against interpreting these findings as showing that methadone maintenance and reduction treatments lead to similar outcomes. At this stage, it is suggested that these outcomes be regarded as reflective of exposure to some general methadone substitution treatment. Further investigation of the outcomes for the two modalities will be conducted. Cluster analyses were used to classify patients according to level of improvement in drug use. Four groups were identified. Two groups (59% of cases) showed substantial reductions in their illicit drug use and criminality as well as reduced physical and psychological symptoms. Twenty two percent of cases showed poor outcomes across a range of measures. Results for alcohol consumption were less satisfactory for patients in all groups. A majority of patients achieved widespread improvements across a range of outcome measures after treatment in existing methadone treatment services. These changes represent important clinical benefits to the individual clients, to their families and to society.

Randomized trial of supervised injectable versus oral methadone maintenance: report of feasibility and 6-month outcome

AIM

To assess the feasibility of a randomized clinical trial of supervised injectable versus oral methadone maintenance and to assess medium-term treatment outcomes.

DESIGN

Randomized clinical trial of supervised injectable versus supervised oral methadone maintenance treatment (MMT). Trial participants were dependent illicit opiate injectors allocated at intake to supervised injectable or oral methadone maintenance treatment.

SETTING

Specialist addictions treatment centre in South London.

SUBJECTS

Forty dependent illicit opiate injectors seeking methadone maintenance treatment.

INTERVENTIONS

Daily supervised injectable and oral methadone maintenance, delivered at the treatment centre.

MAIN OUTCOME MEASURES

Frequency of illicit heroin use and frequency of illicit drug injecting during 30 days before intake to treatment and prior to 6-month follow-up.

SECONDARY OUTCOME MEASURES

frequency of use of illicit methadone, crack cocaine, benzodiazepines and alcohol, physical and psychological health symptoms and acquisitive crime.

RESULTS

Injectable and oral MMT were both generally acceptable to the study participants: there was a high level of agreement to enter the randomized trial, and subsequent retention in treatment was good. The average number of days of illicit heroin use reduced from 22.2 to 7.6 for the injectable MMT group and from 22.4 to 8.7 for the oral MMT group. The average number of days of illicit injecting reduced from 25.7 to 10.8 days for the injectable group and from 20.1 to 11.9 days for the oral group. Patients' physical and psychological health symptoms and involvement in acquisitive crime also reduced in both groups. Treatment satisfaction ratings at follow-up were higher among patients in the injectable MMT group. The ratio for the actual medication costs between injectable and oral MMT was 6.8:1, and for the direct operational costs was 4.7:1. There was some evidence of a differential patient response with greater reductions in heroin use occurring among patients who were daily illicit injectors and had poorer psychological and physical health (at entry) who were allocated to injectable MMT.

CONCLUSIONS

Conduct of the trial has demonstrated that it is feasible to implement supervised injectable methadone maintenance treatment in the context of (although separate from) a specialist oral methadone maintenance service. Patients assigned to receive either supervised injectable or oral MMT had broadly equivalent, positive during-treatment outcomes at 6-month follow-up. Future studies should seek to identify patient characteristics which are linked to good outcome in injectable MMT. Practical evidence-based guidance to physicians about determining which patients are more suitable for injectable MMT is urgently needed.

Changes in cigarette smoking among alcohol and drug misusers during inpatient detoxification

Smoking prevalence and changes during inpatient detoxification were examined among 135 admissions to an inpatient alcohol and drug detoxification unit, of whom 83 (61.5%) were re-interviewed one week later. Ninety-two per cent of the initial sample were currently smokers; 87% of alcohol misusers, 97% of drug misusers and 100% of drug/alcohol misusers. Smokers consumed a daily mean of 27 cigarettes before admission. Those classified as heavy smokers (smoking 40 or more cigarettes prior to admission) decreased their smoking levels by an average of 10.5 cigarettes during detoxification. Light smokers (1-19 cigarettes per day) increased by a daily average of 8.6 cigarettes and intermediate smokers (20-39 cigarettes) by 4.9 cigarettes. The findings suggest a dose-dependent relationship between cigarette smoking and inpatient detoxification that requires further study. Over three-quarters of the sample expressed a desire to change their smoking behaviour, many of whom felt they would like help to tackle this change. Given the high smoking prevalence and reported interest in smoking cessation/reduction, there is an opportunity to address the smoking behaviour of drug and alcohol misusers entering inpatient care, whether during or after their detoxification.

Variation between and within drug treatment modalities: data from the National Treatment Outcome Research Study (UK)

This paper describes treatment practices in 54 drug treatment programmes taking part in the National Treatment Outcome Research Study (NTORS). Programmes were representative of the 4 main treatment modalities in the UK: in-patient, residential rehabilitation, methadone maintenance and methadone reduction. Distinguishing features of these forms of treatment were identified. Substantial variations in treatment practices were also observed within each modality, particularly for detoxification and prescribing arrangements, counselling and non-drug treatment services, and planned duration of treatment. Many programmes reported extensive waiting lists. These findings are discussed in the context of the growing international evidence of the association between patient outcome and the manner in which programme services are delivered.

Price, cost and value of opiate detoxification treatments. Reanalysis of data from two randomised trials

BACKGROUND

Treatments in different settings have different costs. A dilemma arises if expensive treatments lead to better outcomes.

AIMS

To investigate conflicts between the priorities of cost minimisation, clinical effectiveness, and cost-effectiveness in the detoxification of opiate addicts.

METHOD

Cost and clinical effectiveness were examined using published outcome data. The main outcome measures were: achieving a drug-free state on completion of detoxification; the economic costs of treatment.

RESULTS

In terms of simple cost, in-patient detoxification is much more expensive than out-patient treatment (ratio, 24:1). With adjustment for successful outcome, the costs are almost identical (ratio, 0.9:1). Comparison of specialist and general psychiatry in-patient settings showed that even when adjusted for clinical outcomes, the specialist setting is more costly (ratio, 1.9:1), although the outcomes are better.

CONCLUSIONS

Naïve adherence to cost and cost-containment considerations is dangerous. Discussion of treatment costs is misleading if not informed by, and adjusted for, evidence of effectiveness. This is especially important where marked differences in outcome between treatment options exist.

New European instruments for treatment outcome research: reliability of the maudsley addiction profile and treatment perceptions questionnaire in Italy, Spain and Portugal

This report describes the field testing of two recently developed instruments for treatment evaluation research - the Maudsley Addiction Profile (MAP) and the Treatment Perceptions Questionnaire (TPQ) - in Italy, Portugal and Spain. The MAP and TPQ have been developed in the United Kingdom as brief instruments which contain measures of high face validity for research applications with the adult psychoactive substance use disorder population. The present study assesses the application of these instruments in the continental European context and assesses the internal and test-retest reliabilities of the items. A total of 206 subjects participated in the study (124 subjects participated in the MAP test-retest study, and 95 clients completed the TPQ). Thirteen subjects completed both the MAP and the TPQ questionnaires. Results of the study indicated that the MAP can be administered to clients in 15 min or less. The internal and test-retest reliabilities of the MAP and TPQ are satisfactory. Both instruments are suitable for treatment evaluation and other relevant research purposes in the European Union.