Gillian Tober

Social behaviour and network therapy: Basic principles and early experiences

The present paper reports on the basic principles of a treatment approach currently being used in a National Multicentre Randomised Controlled Trial of Alcohol Treatments in the United Kingdom (UK Alcohol Treatment Trial). The treatment: Social Behaviour and Network Therapy (SBNT) is novel as a package but has been developed by integrating a number of strategies found to be effective in other treatment approaches. The intervention is based on the notion that to give the best chance of a good outcome people with serious drinking problems need to develop positive social network support for change. A brief review of the evidence supporting social treatments for alcohol problems is followed by an outline of the feasibility work and the basic principles that guided the development of SBNT. Process data from the first 33 trial cases and 2 case vignettes are described and discussed. It is concluded that SBNT is a feasible and coherent treatment approach that can be delivered by a range of therapists in the alcohol field.

Validation of a Scale for Rating the Delivery of Psycho-Social Treatments for Alcohol Dependence and Misuse : The UKATT Process Rating Scale (PRS)

AIM The aim of this study was to describe the development and validation of the UK Alcohol Treatment Trial Process Rating Scale (UKATT PRS), a manual based method for monitoring and rating the delivery of psychosocial treatments of alcohol dependence and misuse. METHODS Following adaptation and further development of a validated rating scale, the ability of the UKATT PRS to rate the delivery of video-recorded treatment in the UK Alcohol Treatment Trial (UKATT) was tested. RESULTS Tests of the validity and reliability of the UKATT PRS show that it is valid and reliably able to detect the two treatments for which it was designed and to discriminate between them. CONCLUSIONS The UKATT PRS is a valid and reliable method of rating the frequency and quality of therapeutic style and content in the delivery of two psycho-social treatments of alcohol use and dependence.

The effectiveness and cost-effectiveness of opportunistic screening and stepped care interventions for older hazardous alcohol users in primary care (AESOPS) – A randomised control trial protocol

BackgroundThere is a wealth of evidence regarding the detrimental impact of excessive alcohol consumption. In older populations excessive alcohol consumption is associated with increased risk of coronary heart disease, hypertension, stroke and a range of cancers. Alcohol consumption is also associated with an increased risk of falls, early onset of dementia and other cognitive deficits. Physiological changes that occur as part of the ageing process mean that older people experience alcohol related problems at lower consumption levels. There is a strong evidence base for the effectiveness of brief psychosocial interventions in reducing alcohol consumption in populations identified opportunistically in primary care settings. Stepped care interventions involve the delivery of more intensive interventions only to those in the population who fail to respond to less intensive interventions and provide a potentially resource efficient means of meeting the needs of this population.Methods/designThe study design is a pragmatic prospective multi-centre two arm randomised controlled trial. The primary hypothesis is that stepped care interventions for older hazardous alcohol users reduce alcohol consumption compared with a minimal intervention at 12 months post randomisation. Potential participants are identified using the AUDIT questionnaire. Eligible and consenting participants are randomised with equal probability to either a minimal intervention or a three step treatment approach. The step treatment approach incorporates as step 1 behavioural change counselling, step 2 three sessions of motivational enhancement therapy and step 3 referral to specialist services. The primary outcome is measured using average standard drinks per day and secondary outcome measures include the Drinking Problems Index, health related quality of life and health utility. The study incorporates a comprehensive economic analysis to assess the relative cost-effectiveness of the interventions.DiscussionThe paper presents a protocol for the first pragmatic randomised controlled trial evaluating the effectiveness and cost-effectiveness of stepped care interventions for older hazardous alcohol users in primary care.Trial registrationISRCTN52557360

AESOPS: a randomised controlled trial of the clinical effectiveness and cost-effectiveness of opportunistic screening and stepped care interventions for older hazardous alcohol users in primary care

BACKGROUND There is clear evidence of the detrimental impact of hazardous alcohol consumption on the physical and mental health of the population. Estimates suggest that hazardous alcohol consumption annually accounts for 150,000 hospital admissions and between 15,000 and 22,000 deaths in the UK. In the older population, hazardous alcohol consumption is associated with a wide range of physical, psychological and social problems. There is evidence of an association between increased alcohol consumption and increased risk of coronary heart disease, hypertension and haemorrhagic and ischaemic stroke, increased rates of alcohol-related liver disease and increased risk of a range of cancers. Alcohol is identified as one of the three main risk factors for falls. Excessive alcohol consumption in older age can also contribute to the onset of dementia and other age-related cognitive deficits and is implicated in one-third of all suicides in the older population. OBJECTIVE To compare the clinical effectiveness and cost-effectiveness of a stepped care intervention against a minimal intervention in the treatment of older hazardous alcohol users in primary care. DESIGN A multicentre, pragmatic, two-armed randomised controlled trial with an economic evaluation. SETTING General practices in primary care in England and Scotland between April 2008 and October 2010. PARTICIPANTS Adults aged ≥ 55 years scoring ≥ 8 on the Alcohol Use Disorders Identification Test (10-item) (AUDIT) were eligible. In total, 529 patients were randomised in the study. INTERVENTIONS The minimal intervention group received a 5-minute brief advice intervention with the practice or research nurse involving feedback of the screening results and discussion regarding the health consequences of continued hazardous alcohol consumption. Those in the stepped care arm initially received a 20-minute session of behavioural change counselling, with referral to step 2 (motivational enhancement therapy) and step 3 (local specialist alcohol services) if indicated. Sessions were recorded and rated to ensure treatment fidelity. MAIN OUTCOME MEASURES The primary outcome was average drinks per day (ADD) derived from extended AUDIT--Consumption (3-item) (AUDIT-C) at 12 months. Secondary outcomes were AUDIT-C score at 6 and 12 months; alcohol-related problems assessed using the Drinking Problems Index (DPI) at 6 and 12 months; health-related quality of life assessed using the Short Form Questionnaire-12 items (SF-12) at 6 and 12 months; ADD at 6 months; quality-adjusted life-years (QALYs) (for cost-utility analysis derived from European Quality of Life-5 Dimensions); and health and social care resource use associated with the two groups. RESULTS Both groups reduced alcohol consumption between baseline and 12 months. The difference between groups in log-transformed ADD at 12 months was very small, at 0.025 [95% confidence interval (CI)--0.060 to 0.119], and not statistically significant. At month 6 the stepped care group had a lower ADD, but again the difference was not statistically significant. At months 6 and 12, the stepped care group had a lower DPI score, but this difference was not statistically significant at the 5% level. The stepped care group had a lower SF-12 mental component score and lower physical component score at month 6 and month 12, but these differences were not statistically significant at the 5% level. The overall average cost per patient, taking into account health and social care resource use, was £488 [standard deviation (SD) £826] in the stepped care group and £482 (SD £826) in the minimal intervention group at month 6. The mean QALY gains were slightly greater in the stepped care group than in the minimal intervention group, with a mean difference of 0.0058 (95% CI -0.0018 to 0.0133), generating an incremental cost-effectiveness ratio (ICER) of £1100 per QALY gained. At month 12, participants in the stepped care group incurred fewer costs, with a mean difference of -£194 (95% CI -£585 to £198), and had gained 0.0117 more QALYs (95% CI -0.0084 to 0.0318) than the control group. Therefore, from an economic perspective the minimal intervention was dominated by stepped care but, as would be expected given the effectiveness results, the difference was small and not statistically significant. CONCLUSIONS Stepped care does not confer an advantage over minimal intervention in terms of reduction in alcohol consumption at 12 months post intervention when compared with a 5-minute brief (minimal) intervention. TRIAL REGISTRATION This trial is registered as ISRCTN52557360. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 17, No. 25. See the HTA programme website for further project information.

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)

AIMS To 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. METHODS Logistic 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. RESULTS There 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. CONCLUSION Attending 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.

Leeds Dependence Questionnaire: New Data from a Large Sample of Clinic Attenders

The main aim of this study was to examine psychometric properties of the Leeds Dependence Questionnaire (LDQ) in a different and larger sample from that on which the instrument was developed. Data were taken from routine intake assessments (n=1681) of referrals to two UK addiction treatment services during an 18 month period. Principal components analyses for the total sample and for three substance category subsamples (alcohol, opioids, “other drugs”) each yielded a single, major component on which all LDQ items loaded highly and positively. The LDQ had high internal consistency in the total sample and in the substance category subsamples. In a multiple regression analysis in the total sample, age (younger), gender (male), higher score on the General Health Questionnaire (GHQ) and substance category (opioid or other drugs vs. alcohol) were independent predictors of higher LDQ scores. The LDQ was shown to give a robust and psychometrically sound measurement of a general factor of dependence across a range of psychoactive substances among attenders at addiction treatment services. Norms are presented to enable clinicians to compare levels of alcohol or opioid dependence shown by individual clients presenting for treatment with those obtained from a large sample of clinic attenders.

Service user, family and friends’ views on the meaning of a ‘good outcome’ of treatment for an addiction problem

Aims: The aim of this study was to investigate the views of service users (SUs), family and friends on what constitutes a good outcome for the treatment of substance misuse problems. Methods: Six focus groups were arranged to explore and identify important elements of good outcome. Transcripts of the focus groups were analysed using thematic analysis. The content of the main theme, good outcome, was cross checked with SUs and the four authors. The main theme was analysed further into sub-themes. Findings: Participants were 24 SUs and 12 family and friend members recruited from specialist drug and alcohol services. The participants represented a broad range of treatment journey experiences in a variety of treatment modalities. A total of 20 outcome elements were elicited and categorised into seven sub-themes: abstinence, health, activities, relationships, social circumstances, self-awareness and wellbeing of family and friends. Conclusions: The focus of this study was on the ideal outcome rather than intermediate outcomes that might be valuable as individual treatment goals. Considerable weight was placed, by both SUs and their family and friends, on abstinence and ways of maintaining abstinence.

Arrest ReferralÂa proactive multi-agency approach

A multi-agency approach to arrest referral is described. While such schemes are now widely accepted within a range of measures designed to break the drug/crime link, there exists great variation in terms of the type of scheme, the setting, management and resourcing. The Leeds Arrest Referral Scheme is part of a multi-agency initiative designed to provide access to treatment for individuals detained in police custody with the ultimate goal of reducing drug-related harm and drug-related offending. Three arrest referral addiction therapists work in six police divisions and have direct contact with arrestees. They are able to refer directly into drug and alcohol services, including detoxification services, in the city. Monitoring and evaluation procedures provide measures of effectiveness. In the year ending April 2000, 66.3% of individuals seen were referred into treatment and 34.7% attended for initial appointment. The scheme meets Home Office recommendations and Drug Prevention Advisory Service (DPAS) guid...A multi-agency approach to arrest referral is described. While such schemes are now widely accepted within a range of measures designed to break the drug/crime link, there exists great variation in terms of the type of scheme, the setting, management and resourcing. The Leeds Arrest Referral Scheme is part of a multi-agency initiative designed to provide access to treatment for individuals detained in police custody with the ultimate goal of reducing drug-related harm and drug-related offending. Three arrest referral addiction therapists work in six police divisions and have direct contact with arrestees. They are able to refer directly into drug and alcohol services, including detoxification services, in the city. Monitoring and evaluation procedures provide measures of effectiveness. In the year ending April 2000, 66.3% of individuals seen were referred into treatment and 34.7% attended for initial appointment. The scheme meets Home Office recommendations and Drug Prevention Advisory Service (DPAS) guidelines for arrest referral schemes.

Measuring Outcomes in a Health Service Addiction Clinic

The aim of the study was to identify a method for the routine monitoring of outcomes in a busy city centre health service addiction clinic. The setting for the study was a health service addiction clinic serving a population of seven hundred and fifty thousand people. Study participants were two hundred and thirty consecutive attenders for treatment of alcohol and heroin dependence and misuse. A brief interview to obtain demographic and use data and a short battery of self completion questionnaires measuring dependence, psychological health and social satisfaction were administered at three data collection points. Different methods of follow-up were explored. The instruments used were capable of measuring change in levels of consumption, degrees of dependence, psychological health and social satisfaction over a three month period in over sixty-five per cent of the original sample while over eighty per cent of the original sample were accounted for. It was concluded that routine monitoring of outcomes of a busy National Health Service can provide meaningful clinical data for an acceptable sample of patients within a realistic resource limit.

Attitudes of healthcare professionals in a general hospital to patients with substance misuse disorders

Abstract Aims and method: To repeat a survey (reported 2007) of the attitudes of staff in a general hospital setting towards working with people who have substance misuse problems. Therapeutic attitude and the frequency of undertaking tasks related to dealing with substance misuse problems were measured using a modified version of the Alcohol and Alcohol Problems Perception Questionnaire (AAPPQ). The questionnaire was given to staff on wards in general hospitals where people with substance misuse problems are commonly admitted. Results: The questionnaire return rate of 24% was lower than 2007 and the possible reasons are discussed. Doctors, nurses and healthcare assistants all reported low levels of therapeutic commitment and lower than 2007. Older doctors scored the lowest and younger doctors highest. Brief training seemed to have a positive effect. Implications: The authors conclude that there should be a policy shift away from trying to “piggy back” care of people with substance misuse problems onto practitioners in other clinical specialties. Although addiction problems are found in most areas of health and social care, the role of staff in treating addiction is limited – effective substance misuse treatment is best delivered by trained addiction practitioners.