Michael Donmall

The EMCDDA/Pompidou Group Treatment Demand Indicator Protocol: A European Core Item Set for Treatment Monitoring and Reporting

Over the last decades inside and outside of Europe, treatment-based data have been used in epidemiological research on drugs and drug abuse. They offer information on hidden populations and allow to follow socially stigmatised behaviour. As this type of research can be done on rather low budgets, there are long-term projects run in many countries. Experts from the national systems in several EU member states have been working together to develop a common standard on the basis of the Pompidou Group (PG) Definitive Protocol. The items and basic definitions of the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA)/PG Treatment Demand Indicator Protocol are described, which plays an important role in the process of harmonisation of data collection for the EMCDDA. Implementation strategies are described, and future steps are discussed.

The effectiveness and cost-effectiveness of diversion and aftercare programmes for offenders using class A drugs: a systematic review and economic evaluation

BACKGROUND The societal costs of problematic class A drug use in England and Wales exceed £15B; drug-related crime accounts for almost 90% of costs. Diversion plus treatment and/or aftercare programmes may reduce drug-related crime and costs. OBJECTIVES To assess the effectiveness and cost-effectiveness of diversion and aftercare for class A drug-using offenders, compared with no diversion. POPULATION Adult class A drug-using offenders diverted to treatment or an aftercare programme for their drug use. INTERVENTIONS Programmes to identify and divert problematic drug users to treatment (voluntary, court mandated or monitored services) at any point within the criminal justice system (CJS). Aftercare follows diversion and treatment, excluding care following prison or non-diversionary drug treatment. DATA SOURCES Thirty-three electronic databases and government online resources were searched for studies published between January 1985 and January 2012, including MEDLINE, PsycINFO and ISI Web of Science. Bibliographies of identified studies were screened. The UK Drug Data Warehouse, the UK Drug Treatment Outcomes Research Study and published statistics and reports provided data for the economic evaluation. METHODS Included studies evaluated diversion in adult class A drug-using offenders, in contact with the CJS. The main outcomes were drug use and offending behaviour, and these were pooled using meta-analysis. The economic review included full economic evaluations for adult opiate and/or crack, or powder, cocaine users. An economic decision analytic model, estimated incremental costs per unit of outcome gained by diversion and aftercare, over a 12-month time horizon. The perspectives included the CJS, NHS, social care providers and offenders. Probabilistic sensitivity analysis and one-way sensitivity analysis explored variance in parameter estimates, longer time horizons and structural uncertainty. RESULTS Sixteen studies met the effectiveness review inclusion criteria, characterised by poor methodological quality, with modest sample sizes, high attrition rates, retrospective data collection, limited follow-up, no random allocation and publication bias. Most study samples comprised US methamphetamine users. Limited meta-analysis was possible, indicating a potential small impact of diversion interventions on reducing drug use [odds ratio (OR) 1.68, 95% confidence interval (CI) 1.12 to 2.53 for reduced primary drug use, and OR 2.60, 95% CI 1.70 to 3.98 for reduced use of other drugs]. The cost-effectiveness review did not identify any relevant studies. The economic evaluation indicated high uncertainty because of variance in data estimates and limitations in the model design. The primary analysis was unclear whether or not diversion was cost-effective. The sensitivity analyses indicated some scenarios where diversion may be cost-effective. LIMITATIONS Nearly all participants (99.6%) in the effectiveness review were American (Californian) methamphetamine users, limiting transfer of conclusions to the UK. Data and methodological limitations mean it is unclear whether or not diversion is effective or cost-effective. CONCLUSIONS High-quality evidence for the effectiveness and cost-effectiveness of diversion schemes is sparse and does not relate to the UK. Importantly this research identified a range of methodological limitations in existing evidence. These highlight the need for research to conceptualise, define and develop models of diversion programmes and identify a core outcome set. A programme of feasibility, pilot and definitive trials, combined with process evaluation and qualitative research is recommended to assess the effectiveness and cost-effectiveness of diversionary interventions in class A drug-using offenders. FUNDING DETAILS The National Institute for Health Research Health Technology Assessment programme.

Validation of the University of Manchester Drug Misuse Database.

OBJECTIVE: The study was conducted to assess the validity and quality of data held by one of the UK regional drug misuse databases (DMD). DESIGN: The research was multi-centred and used retrospective analysis to assess the validity of data held on the database. SETTING: The Regional Database is managed at the University of Manchester Drug Misuse Research Unit and uses data returned by medical and non-medical services within the UKs former North Western Regional Health Authority. MATERIAL: The research was largely based on analysis of the reporting or non-reporting to DMD of 1526 presentations by drug users to four community drug teams (CDTs) during the course of 1993. Two datasets were used: the DMD dataset, based on returns to the regional database from the agencies in question; and agency client records. Additionally the data included on a random sample of 300 database forms returned by these CDTs were compared with information contained in client records. MAIN OUTCOME MEASURES: The study reports on how well DMD is functioning in relation to the correct reporting of episodes of problem drug use and the quality of data held. RESULTS: A very high level of agreement (0.875 +/- 0.017, 95% CI, kappa coefficient 0.728) was established between reports sent in to the database and those expected by examination of agency records. The database figures underestimated the total number of episodes that should have been reported by a factor of 0.008. It was also established that 0.906 (+/- 0.018, 95% CI) of the reports made to the database were made correctly, that 0.178 (+/- 0.030, 95% CI) of eligible presentations were not reported, and that 0.166 (+/- 0.030, 95% CI) of ineligible presentations were mistakenly reported. Lastly, it was established that data were unnecessarily missing or inaccurately recorded in 0.027 of cases and that data entry errors occurred in 0.015 of cases. CONCLUSIONS: The validation project showed that the DMD system is very reliable, providing accurate measures of the extent and nature of presenting problem drug use in the region under study.

The Endocrinology of Male Puberty

Over the last 10 years there have been a number of reports of the endocrinological events that occur during normal puberty. These studies, some cross-sectional and some longitudinal in design, have recently been the subject of reviews by Sizonenko (1978) and Tanner (1980). In the majority of these studies a variety of different hormones have been the subject of the subject of the investigation but they have usually included luteinising hormone (LH), follicle stimulating hormone (FSH) and prolactin (PRL) representing the pituitary peptide hormones, and a great variety of adrenal and gonadal steroids. Mostly the changes in hormone concentrations have been related to chronological age and pubertal stages as formalised by Tanner (1962). Only rarely have bone-age data been available. The auxological data for comparison with the hormonal data has, in general, been skimpy, depending mostly upon the puberty stages and measurement of height or weight.

Drug spend and acquisitive offending by substance misusers

AIM The need to generate income to fund drug misuse is assumed to be a driver of involvement in acquisitive crime. We examined the influence of drug misuse expenditure, and other factors, on acquisitive offending. METHODS Clients (N=1380) seeking drug treatment within 94 of 149 Drug Action Teams (DATs) across England completed a comprehensive survey, incorporating validated scales and self-report measures, such as levels of drug and alcohol use and offending. RESULTS Forty per cent (N=554) had committed acquisitive crime in the previous month. Regression analysis showed that acquisitive offending was associated with the presence of problematic use of crack cocaine, poly-drug use, sharing injecting equipment, unsafe sex, overdose risk, higher drug spend, unemployment, reduced mental wellbeing, and younger age. CONCLUSIONS Rates of acquisitive crime among drug users are high. Drug using offenders can be distinguished from drug using non-offenders by problematic crack cocaine use, younger age, income-related factors, and indicators of a chaotic life style and complex needs. Behavioural and demographic factors were associated more strongly with acquisitive crime than drug use expenditure, suggesting that the need to finance drug use is not necessarily the main factor driving acquisitive offending by drug users.

Prevalence and factors associated with sex trading in the year prior to entering treatment for drug misuse in England

BACKGROUND This study estimates the past year prevalence of and factors associated with sex trading (offering sex for money, drugs or something else) among 1796 men and women presenting to 342 drug misuse treatment agencies in England, and identifies service development and delivery implications. METHODS Secondary analysis of baseline data from a prospective cohort was conducted. Short Form-12 measured mental and physical wellbeing, psychiatric diagnoses were self-reported and the circumstances, motivation and readiness tool assessed readiness for/pressure to enter treatment. Logistic regression models determined associations with sex trading separately by sex. Inverse probability population weights were calculated, utilising demographics from the National Drug Treatment Monitoring System and agency specific data collection windows. RESULTS The estimated prevalence rate of sex trading in the past 12 months was 5.1% (15.0% for women and 2.1% for men). For women, adjusted models identified crack use (aOR 1.83, 95% CI 1.22-2.74, p=0.004), previous treatment (aOR 3.00, 95% CI 1.31-6.86, p=0.010) and greater readiness for treatment (aOR 1.12, 95% CI 1.01-1.24, p=0.027) as independently associated with sex trading. For men, lower mental wellbeing (aOR 0.97, 95% CI 0.94-0.99, p=0.030) was independently associated and marginal effects were identified for syringe sharing (aOR 2.89, 95% CI 0.94-8.86, p=0.064) and unprotected sex (aOR 2.23, 95% CI 0.95-5.26, p=0.065). CONCLUSIONS Sex trading among drug misusers is associated with additional health risks and specific treatment needs. Given the scale of the problem it is important that treatment providers have the competencies to adequately address the issue and provide accessible and appropriate services.

The dynamics of heroin use; implications for intervention

STUDY OBJECTIVE To use a readily available dataset to detect periods of epidemic change and to examine the progression of heroin epidemics in different geographical areas. To consider the implications of epidemic change for strategies to tackle drug misuse. DESIGN Comparison of trends in new treatment demand, observed incidence, and age specific population rates for treated heroin users in two geographical areas. PARTICIPANTS Heroin users recorded to have sought treatment. MAIN RESULTS The areas studied seem to show differences with respect to trends in new treatment demand, incidence of heroin use and distribution of age specific population rates; indicating that they may be at different epidemic stages. CONCLUSIONS These analyses show how areas may differ with respect to epidemic progression of heroin use. It is essential that government strategies, and local responses to these, should be cognisant of these dynamics.

Cocaine misuse treatment in England

Three methods were used to identify the treatments given to cocaine misusers in England, and to make a preliminary assessment of effectiveness. First, a postal survey of all known drug misuse treatment services ascertained approximate numbers of cocaine misusers presenting and receiving a specified range of treatments. Secondly, staff at selected services were interviewed regarding treatment policies, and asked to subjectively rate short-term and long-term effectiveness. Thirdly, a cohort of individuals in treatment were studied prospectively to assess changes in drug usage and associated problems. Fifty percent of services responded to the survey, but there was known to be significant duplication in service listings and it is considered that a representative pattern of clinical activity has been detected. Approximately half those services had recently treated cocaine misusers, mainly using counselling, residential rehabilitation, and pharmacological treatments, in which 32 different medications were identified. Acupuncture was prominent in a minority of services. Staff interviews suggested several principles in managing cocaine misusers, while all treatments were rated as being more effective in short-term relief of withdrawal features than in enabling longer-term abstinence. The treatment cohort were mostly in residential rehabilitation, and marked reductions in drug use and related clinical and social problems were demonstrated.

UK monitoring of problem drug users: the drug misuse database - a system based on regional centres.

UK drug treatment policy aims to reduce the harm to individuals and communities resulting from drug misuse through multidisciplinary community services, prescribing, detoxification and rehabilitation facilities. Drug Misuse Databases (DMD) were set up in England, Wales and Scotland in 1990 to monitor treatment demand; that in Northern Ireland is under development. The regional base of these DMDs provides good local context and data specificity, while periodic collation of regional data by the Department of Health provides national analyses. DMD will be able to deliver the TDI dataset with only minor adjustments, following harmonisation between the constituent UK countries.

How well do trends in incidence of heroin use reflect hypothesised trends in prevalence of problem drug use in the North West of England

This study investigates whether hypotheses about trends in the prevalence of problem drug use (PDU), prompted by capture--recapture based age-specific prevalence estimates, are corroborated by estimates of trends in incidence. Lag correction techniques were used to provide incidence estimates adjusted for the time-lag between onset of drug use and its first recorded treatment for heroin users seeking treatment in three areas of North West England between 1986 and 2000 (n = 4142). The incidence trends indicated geographical variation in the progress of heroin ‘epidemics’ in the areas studied and corroborated previously estimated prevalence rates that suggested PDU has passed its peak and is declining in some areas, but continues to increase in others. The lag correction method is capable of producing estimates that will improve our understanding of changes in the size and composition of the population targeted for drug misuse treatment and may provide a basis on which to forecast the direction of future trends.