Alex Copello

Addiction in the family is a major but neglected contributor to the global burden of adult ill-health

This paper offers a conceptual overview of a neglected field. Evidence is presented to suggest that, globally, addiction is sufficiently stressful to cause pain and suffering to a large but uncounted number of adult affected family members (AFMs), possibly in the region of 100 million worldwide. A non-pathological stress-strain-coping-support model of the experience of AFMs is presented. The model is based on research in a number of different sociocultural groups in Mexico, England, Australia and Italy and aims to be sensitive to the circumstances of AFMs in low and middle income countries and in minority ethnic and indigenous groups as well to those of majorities in wealthier nations. It highlights the social and economic stressors of many kinds which AFMs face, their lack of information and social support, dilemmas about how to cope, and resulting high risk for ill-health. The public sector and personal costs are likely to be high. Attention is drawn to the relative lack of forms of help designed for AFMs in their own right. A 5-Step form of help aiming to fill that gap is briefly described. Family members affected by addiction have for too long been a group without a collective voice; research and action using the model and method described can make a contribution to changing that state of affairs.

A preliminary evaluation of integrated treatment for co-existing substance use and severe mental health problems: Impact on teams and service users

Aim:u2003This study sought to develop a methodology to measure the integration of substance use treatment within five existing assertive outreach (AO) teams in Birmingham, UK. Changes in the way teams approach and discuss drug and alcohol problems amongst clients with severe mental health problems were anticipated. This was assessed at team meetings, through clinical sessions and case notes. The impact of change in team practice was also measured at the level of service users by assessing psychiatric symptoms, engagement, amount of substance used, and conviction ratings of positive substance-related beliefs. Method:u2003Each team were provided with training and supervision to deliver cognitive behavioural integrated treatment (C-BIT). This aimed to increase awareness of the relationship between psychosis and problem substance use and provide skills to manage these difficulties. Data was collected at intervals over a 36 month period. Results:u2003Staff within teams increased in self reported confidence and skills to deliver C-BIT and these gains were maintained over time. Findings suggest that following training, integration was achieved to a degree and changes in teams practice were observed. Improvements in client engagement and reduction in alcohol intake and positive alcohol-related beliefs were also noted but occurred regardless of team training. Conclusions:u2003Training and supporting AO staff to use an integrated treatment approach is well received and produces lasting changes in confidence and practice. Whether this can go on to impact upon client outcome is yet to be established.

Exploring Treatment Attendance and its Relationship to Outcome in a Randomized Controlled Trial of Treatment for Alcohol Problems: Secondary Analysis of the UK Alcohol Treatment Trial (UKATT)

AIMSnTo identify client characteristics that predict attendance at treatment sessions and to investigate the effect of attendance on outcomes using data from the UK Alcohol Treatment Trial.nnnMETHODSnLogistic regression was used to determine whether there were characteristics that could predict attendance and then continuation in treatment. Linear regression was used to explore the effects of treatment attendance on outcomes.nnnRESULTSnThere were significant positive relationships between treatment attendance and outcomes at Month 3. At Month 12, these relationships were only significant for dependence and alcohol problems for those randomized to motivational enhancement therapy (MET). There were significant differences between groups in attendance, with MET clients more likely to attend than clients allocated to social behaviour and network therapy (SBNT). MET clients were also more likely to attend all sessions (three sessions) compared with SBNT (eight sessions). MET clients with larger social networks and those with confidence in their ability not to drink excessively were more likely to attend. SBNT clients with greater motivation to change and those with more negative short-term alcohol outcome expectancies were more likely to attend. No significant predictors were found for retention in treatment for MET. For those receiving SBNT, fewer alcohol problems were associated with continuation in treatment.nnnCONCLUSIONnAttending more sessions was associated with better outcomes. An interpretation of these findings is that, to improve outcomes, methods should be developed and used to increase attendance rates. Different characteristics were identified that predicted attendance and continuation in treatment for MET and SBNT.

Social network support for individuals receiving opiate substitution treatment and its association with treatment progress.

Background/Aims: Social networks have been hypothesized to protect people from the harmful effects of stress, but may also provide dysfunctional role models and provide cues associated with drug use. This study describes the range, type and level of social support available to patients engaged in UK opiate substitution treatment (OST) programmes, and explores the association between network factors and continued use of illicit heroin. Methods: A cross-sectional survey of a randomly selected sample of OST patients (n = 118) utilised measures of current substance use and social network structure and support. Results: More than half of the participants had used heroin in the previous month, and most described networks that were both supportive and positive about treatment. Multivariate analysis showed that the substance use involvement of network members was higher in those patients still using heroin, even when other treatment factors were controlled for. Conclusion: There was a strong association between ongoing contact with other drug users and continued use of illicit heroin in this treatment sample. Whilst there is potential for the involvement of social networks in treatment, future research needs to ascertain the exact nature of the relationship between social support and drug use.

Barriers and enablers to implementation of family-based work in alcohol services: A qualitative study of alcohol worker perceptions

Aims: Despite research evidence and clinical guidelines, family work is rarely delivered systematically in community alcohol services in the UK. This study explored clinicians’ perceptions of implementation of family-based approaches in community alcohol services and included the investigation of factors that clinicians perceived to either impede or enable family work. Method: Participants were recruited from seven community alcohol services within the UK. A total of 18 clinicians participated in semi-structured interviews using an adapted version of the theory-based implementation interview which were audio-taped, transcribed and used for analysis. Findings: Analysis of the interviews identified barriers and enablers to family-based work at three different levels: clinician; problem drinker and family; and the organization. Clinician perceptions of family-based work were identified as enabling or impeding depending on the clinicians interpretations of family-based work. Conclusions: The study demonstrated the importance of challenging narrow perceptions of family-based work so that it included more flexible interpretations of it (i.e. brief low intensity family interventions as well as more formal family therapies). This would help to increase family-based work; more accurate measurement, and help reduce resistant attitudes in clinicians towards family work.

Pilot study of a social network intervention for heroin users in opiate substitution treatment: study protocol for a randomized controlled trial.

AbstractBackgroundResearch indicates that 3% of people receiving opiate substitution treatment (OST) in the UK manage to achieve abstinence from all prescribed and illicit drugs within 3 years of commencing treatment, and there is concern that treatment services have become skilled at engaging people but not at helping them to enter a stage of recovery and drug abstinence. The National Treatment Agency for Substance Misuse recommends the involvement of families and wider social networks in supporting drug users’ psychological treatment, and this pilot randomized controlled trial aims to evaluate the impact of a social network-focused intervention for patients receiving OST.Methods and designIn this two-site, early phase, randomized controlled trial, a total of 120 patients receiving OST will be recruited and randomized to receive one of three treatments: 1) Brief Social Behavior and Network Therapy (B-SBNT), 2) Personal Goal Setting (PGS) or 3) treatment as usual. Randomization will take place following baseline assessment. Participants allocated to receive B-SBNT or PGS will continue to receive the same treatment that is routinely provided by drug treatment services, plus four additional sessions of either intervention. Outcomes will be assessed at baseline, 3 and 12 months. The primary outcome will be assessment of illicit heroin use, measured by both urinary analysis and self-report. Secondary outcomes involve assessment of dependence, psychological symptoms, social satisfaction, motivation to change, quality of life and therapeutic engagement. Family members (n = 120) of patients involved in the trial will also be assessed to measure the level of symptoms, coping and the impact of the addiction problem on the family member at baseline, 3 and 12 months.DiscussionThis study will provide experimental data regarding the feasibility and efficacy of implementing a social network intervention within routine drug treatment services in the UK National Health Service. The study will explore the impact of the intervention on both patients receiving drug treatment and their family members.Trial registrationTrial Registration Number: ISRCTN22608399nISRCTN22608399 registration: 27/04/2012Date of first randomisation: 14/08/2012

Assertive Community Treatment for alcohol dependence (ACTAD): study protocol for a randomised controlled trial

BackgroundAlcohol dependence is a significant and costly problem in the UK yet only 6% of people a year receive treatment. Current service provision based on the treatment of acute episodes of illness and emphasising personal choice and motivation results in a small proportion of these patients engaging with alcohol treatment. There is a need for interventions targeted at the population of alcohol dependent patients who are hard to engage in conventional treatment. Assertive Community Treatment (ACT), a model of care based on assertive outreach, has been used for treating patients with severe mental illnesses and presents a promising avenue for engaging patients with primary alcohol dependence. So far there has been little research on this.Methods/DesignIn this single blind exploratory randomised controlled trial, a total of 90 alcohol dependent participants will be recruited from community addiction services. After completing a baseline assessment, they will be assigned to one of two conditions: (1) ACT plus care as usual, or (2) care as usual. Those allocated to the ACT plus care as usual will receive the same treatment that is routinely provided by services, plus a trained key worker who will provide ACT. ACT comprises intensive and assertive contact at least once a week, over 50% of contacts in the participants home or local community, and comprehensive case management across social and health care, for a period of one year. All participants will be followed up at 6 months and 12 months to assess outcome post randomisation. The primary outcome measures will be alcohol consumption: mean drinks per drinking day and percentage of days abstinent measured by the Time Line Follow Back interview. Secondary outcome measures will include severity of alcohol dependence, alcohol related problems, motivation to change, social network involvement, quality of life, therapeutic relationship and service use. Other outcome variables are treatment engagement including completion of assessment, detoxification and aftercare.DiscussionResults of this trial will help clarify the potential beneficial effects of ACT for people with alcohol dependence and provide information to design a definitive trial.Trial registration numberISRCTN: ISRCTN22775534

Muslim faith healers' views on substance misuse and psychosis

It has been found that the Muslim population in the UK seek spiritual advice from traditional faith healers for psychiatric and related problems. The important role that religious beliefs may have on perceptions of mental illness and substance misuse warrants further investigation. The aims were to examine the views of Muslims faith healers on symptoms and changes in behaviour commonly described as “psychosis” and “substance misuse”. Eight semi-structured interviews were conducted with Muslim faith healers from various backgrounds. Data were analysed according to the conventions of qualitative research using grounded theory methods. Religious conceptualisations played a key role in the understanding of both the disorders and consequently the guidance given. There were similarities and differences in the narratives given for psychosis and substance misuse. Healers expressed doubt towards other faith healers and the methods utilised by scientific means. The findings suggest a need for close collaboration between faith healers and mental health workers in order to achieve a culturally sensitive health care system.

Pilot randomised trial of a brief intervention for comorbid substance misuse in psychiatric in‐patient settings

This proof of principle study evaluated the effectiveness and feasibility of a brief motivational intervention, delivered in mental health in‐patient settings, to improve engagement in treatment for drug and alcohol misuse.

A pilot study to assess the feasibility and impact of a brief motivational intervention on problem drug and alcohol use in adult mental health inpatient units: study protocol for a randomized controlled trial

BackgroundSubstance misuse in those with severe mental health problems is common and associated with poor engagement in treatment and treatment outcomes. Up to 44% of those admitted into psychiatric inpatient facilities have coexisting substance-misuse problems. However, this is not routinely addressed as part of their treatment plan. A mental health admission may present a window of opportunity for inpatients to reevaluate the impact of their substance use. This study will aim to evaluate the effectiveness of a targeted brief motivational intervention in improving engagement in treatment and to assess how feasible and acceptable this intervention is to inpatients and staff as a routine intervention.Methods/DesignThis randomized controlled trial will use concealed randomization; blind, independent assessment of outcome at 3 months; characterization of refusers and dropouts; and be analyzed according to the intention-to-treat principle. After baseline assessments, eligible participants will be randomized either to the Brief Integrated Motivational Intervention plus Treatment As Usual, or Treatment as Usual alone. Eligible participants will be those who are new admissions; >18 years; ICD-10 diagnosis of -schizophrenia or related disorder, bipolar affective disorder, recurrent depressive disorder, and DSM-IV diagnosis of substance abuse or dependence over the last 3 months. The primary outcome is engagement in treatment for substance misuse, and secondary outcomes include readiness to change substance misuse together with a cost-effectiveness analysis. Qualitative interviews with staff and participants will assess the acceptability of the intervention.DiscussionThis pilot randomized trial will provide the first robust evidence base for inpatient care of people with severe mental health problems and co-morbid substance misuse and provide the groundwork for confirmatory trials to evaluate a potentially feasible, cost-effective, and easy-to-implement treatment option that may be readily integrated into standard inpatient and community-based care.Trial registrationISRCTN43548483 Date of ISRCTN assignation: 4/17/2014.