Effectiveness of community treatments for heroin and crack cocaine addiction in England: a prospective, in-treatment cohort study.

BACKGROUND: Addiction to heroin and crack cocaine is debilitating and persistent, but such disorders are treatable. We present the first effectiveness study of the main community interventions for addiction to heroin and crack cocaine in England, using data from the National Drug Treatment Monitoring System (NDTMS). METHODS: The study cohort consisted of all adults with a heroin or crack cocaine addiction, or both, who started pharmacological treatment (n=18 428 patients) or psychosocial treatment (n=2647) between Jan 1 and Nov 30, 2008, received at least 6 months' treatment or were discharged by the study endpoint (May 31, 2009), and had outcome data submitted to the NDTMS. Effectiveness was assessed from change in days of heroin or crack cocaine use, or both in the 28 days before the start of treatment and in the 28 days before review. FINDINGS: 14 656 clients-74% of the cohort eligible for analysis at review with available data-were analysed at the study endpoint. During the 28 days before review, 37% (5016/13 542) of heroin users abstained from heroin and 52% (3941/7636) of crack cocaine users abstained from crack cocaine. A higher proportion of users of heroin only abstained than did users of both heroin and crack cocaine (42% [2465/5863] vs 33% [2551/7679]; OR 1.46, 95% CI 1.36-1.56), and more users of crack cocaine only abstained than did users of both drugs (57% [295/522] vs 51% [3646/7114]; 1.24, 1.03-1.48). Overall heroin use reduced by 14.5 days (95% CI 14.3-14.7) and crack cocaine use by 7.7 days (7.5-7.9). For clients given pharmacological treatment, reduction in days of heroin use was smaller for users of both heroin and crack cocaine than for users of heroin alone (p<0.0001), but this differential effectiveness was not recorded for psychosocial treatment in heroin or crack cocaine users compared with users of both drugs. INTERPRETATION: The first 6 months of pharmacological or psychosocial treatment is associated with reduced heroin and crack cocaine use, but the effectiveness of pharmacological treatment is less pronounced for users of both drugs. New strategies are needed to treat individuals with combined heroin and crack cocaine addiction. FUNDING: National Treatment Agency for Substance Misuse.

Development of the Treatment Outcomes Profile.

AIM: To develop the Treatment Outcomes Profile (TOP), a new instrument for monitoring substance misuse treatment. DESIGN: Prospective cohort, psychometric evaluation with 7-day retest and 1-month follow-up to assess inter-rater reliability, concurrent, discriminant and construct validity, and change sensitivity. PARTICIPANTS: A sample of 1021 service users, aged 16-62 years. Recruitment from 63 treatment agencies in England, collectively providing opioid substitution treatment, psychosocial interventions, in-patient detoxification and residential rehabilitation. MEASUREMENTS: Thirty-eight frequency, rating scale and period prevalence measures, with 28-day recall, across substance use, health, crime and social functioning domains, administered as personal interview by 163 treatment keyworkers. FINDINGS: Twenty outcome measures met inter-rater reliability criteria: days used alcohol, opioids, crack cocaine, cocaine powder, amphetamines, cannabis and one other named substance; days injected and period prevalence of direct or indirect needle/syringe sharing; subjective rating of physical and psychological health; days committed shop theft and drug selling, period prevalence of vehicle, property, fraud/forgery and assault/violence offences; rating of quality of life; days worked and attended for education/training; and period prevalence of acute housing problems and risk of eviction. Intraclass correlation coefficients for scale measures and Cohen's kappa for dichotomous measures reached or exceeded 0.75 and 0.61, respectively. There were satisfactory validity assessments and change sensitivity of scale items judged by effect size and smallest detectable difference. The TOP clinical tool contains an additional 10 items for individual treatment planning and review. CONCLUSIONS: The TOP is a reliable and valid 20-item instrument for treatment outcomes monitoring.

Risk adjustment of heroin treatment outcomes for comparative performance assessment in England.

AIMS: Variability in effectiveness of treatment for substance abuse disorder (SUD) is an important and understudied issue. This study aimed to quantify the extent of outcome variability in the English SUD treatment system after adjusting for potential confounding variables. DESIGN: Prospective cohort study using data from the English national drug treatment outcome monitoring database. SETTING: All 149 administrative areas delivering publicly funded SUD services in the National Health Service and non-governmental sector. PARTICIPANTS: New adult admissions between January 2008 and October 2010 with illicit heroin-related problems in all administrative areas, with an in-treatment review conducted between 5 and 26 weeks (mean = 129.5 days; SD = 40.0) up to 30 April 2011 (n = 65 223; 75.6% of eligible clients). Individuals were divided randomly to form model developmental and internal validation samples. These were contrasted with an independent (external) sample of the same population admitted to treatment between November 2010 and April 2011 and followed to 31 October 2011 (n = 13 797; 81.4% of those eligible). MEASUREMENTS AND ANALYSIS: The outcome measure was self-reported illicit heroin use, categorized as abstinent or deteriorated (the latter by Reliable Change Index), each risk-adjusted by person-level (demographics, clinical severity and treatment complexity) and area-level (SUD prevalence, social deprivation and severity averages) covariates by multivariable logistic regression using multiply imputed outcome and covariate data. Risk-adjusted models were assessed by information criteria and discrimination (c-index). Standardized outcome rates were compared by funnel plot with 95% and 99% control limits. FINDINGS: Models of heroin abstinence (48.4%) and deterioration (3.2%) were comparable across the developmental and validation samples (c-index = 0.70-0.71 and 0.82-0.87), with 79.2 and 94.0%, respectively, of the 149 treatment areas falling within 95% control limits. At the 99% limit, seven areas (4.7%) achieved abstinence rates above the national average, and eight had relatively poor abstinence rates (5.4%). At the 99% control limit, one area achieved very low deterioration outcomes and two (1.3%) were worse that the average. Risk adjustment served to increase abstinence rates in good performing areas by 0.63% and reduce abstinence rates by 0.37% in poor performing areas, and by 0.12% and 0.18%, respectively, for deterioration. CONCLUSION: There is some exceptional variability in the apparent effectiveness of the English treatment system for substance use disorders. It is important to determine the source of this variability in order to inform drug treatment delivery and its evaluation both in England and overseas.

How best to measure change in evaluations of treatment for substance use disorder.

AIMS: To compare the performance of the Jacobson & Truax (JT) reliable change index (RCI) with three alternative methods, using data from individuals receiving treatment for substance use disorders. DESIGN: English National Treatment Outcome Monitoring Database for publicly funded specialist community pharmacological and psychosocial interventions. PARTICIPANTS: New adult admissions to treatment across England (1 January-31 December 2008), with in-treatment clinic progress review conducted after an average of 122.8 days for 18,163 individuals. MEASUREMENTS: Self-reported days using heroin, crack, cocaine powder and alcohol during the 4 weeks before admission and clinical review, recorded using the Treatment Outcomes Profile and analysed using a multi-level, mixed-linear model, with both observed and true scores to estimate the effect of regression to the mean (RTM). Differences in performance among the JT RCI and the alternative methods were assessed by the proportion assigned to a reliably 'improved', 'unchanged' or 'reliably deteriorated' category; level of agreement; difference in effect size for observed and true scores; and receiver operating characteristic parameters. FINDINGS: When compared to the alternative methods, the JT RCI was more conservative in assigning individuals to the improved category, and it showed no evidence of inferiority on any measure. For each method, all individuals categorized as reliably deteriorated and the majority of those categorized reliably improved had outcome scores which fell beyond that expected by RTM. Substituting true scores for observed scores moderated the size of the change effect associated with reduced use of the four substances, but this remained statistically significant. CONCLUSIONS: The Jacobson & Truax Reliable Change Index appears to be the optimal measure of change for evaluations of treatment for substance use disorder, in that it is the most conservative for assessing improvement and at least as accurate on all other criteria. Any evaluation of change needs to take account of regression to the mean.

Stresses and strains for family members living with drinking or drug problems in England and Mexico

Este trabajo es la primera aproximáción cualitativa al estudio de la salud, las emociones y los estresores relacionados con el uso de drogas en la familia. La comprensión de los aspectos centrales de las experiencias de los familiares que viven con un usuario de alcohol o drogas, y la manera como responden a ello, puede contribuir no sólo con el conocimiento acerca de las estrategias de enfrentamiento, sino también con el papel de la familia en los procesos de cambio. En este sentido, se consideran los aspectos transculturales al explorar y descubrir las variaciones psicológicas de cada cultura que no están presentes en otras. La información proviene de 12 entrevistas inglesas y 12 mexicanas a familiares con características semejantes, y se enfoca en las descripciones de los estresores que han experimentado, sus reacciones emocionales y los signos de estrés físico o mental. El objetivo de este trabajo es proporcionar una descripción detallada, por medio de testimonios, de los estresores y tensiones así como de los posibles vínculos que hay entre ellos. El método principal de recolección de la información que se utilizó en el proyecto fue una entrevista semiestructurada, y la principal estrategia de análisis es cualitativa (Strauss y Corbin, 1990). La hipótesis que surgierón de este trabajo se basan en el hecho de que ciertas experiencias de los familiares son universales en esas circunstancias. Estas experiencias consisten en las repercusiones negativas de vivir con el usuario; el interés por la salud y el desempeño del usuario; las dificultades económicas; los efectos dañinos del consumo en la familia y el hogar; los sentimientos de ansiedad, preocupación, desesperanza, desesperación y depresión; la manera como afecta la salud mental y los síntomas específicos que el familiar atribuye, en parte, al estrés por vivir bajo los efectos de la problemática del consumo de alcohol o drogas. Hay un gran contraste entre la ciudad de México y las áreas del sur de Inglaterra, de donde proceden los participantes ingleses. La cultura de los participantes mexicanos tiende a ser más colectivista, mientras que la cultura inglesa es más individualista. También hubo divergencias en las dimensiones urbano-rural, religioso-secular y católico-protestante