Nick Heather

Treating addictive behaviors

The Transtheoretical Model of Change: Toward a Comprehensive, Transtheoretical Model of Change: Stages of Change and Addictive Behaviors C.C. DiClemente, J.O. Prochaska. The Transtheoretical Model: A Critical Overview R. Davidson. Comments, Criteria, and Creating Better Models J.O. Prochaska, C.C. DiClemente. Understanding Change-Five Perspectives: Readiness, Importance, and Confidence: Critical Conditions of Change in Treatment S. Rollnick. Self-Regulation and the Addictive Behaviors J.M. Brown. Alcohol Motivations as Outcome Expectancies B.T. Jones, J. McMahon. Preparing for Change: Enhancing Motivation for Change W.R. Miller. Using Brief Opportunities for Change in Medical Settings N. Heather. Working Through the Concerned Significant Other R.J. Meyers, et al. Facilitating Change: Guiding Self-Change M.B. Sobell, L.C. Sobell. A Wealth of Alternatives: Effective Treatments for Alcohol Problems W.R. Miller, et al. Sustaining Change: What Predicts Success? V.S. Westerberg. Continuing Care: Promoting the Maintenance of Change D.M. Donovan. 11 Additional Chapters. Index.

Negotiating behaviour change in medical settings: The development of brief motivational interviewing

Motivational interviewing was developed in the addictions field for helping people work through ambivalence about behaviour change. This paper describes a brief form of motivational interviewing developed in a medical setting for use in brief consultations. It is based upon the assumption that most patients do not enter the consultation in a state of readiness to change their patterns of drinking, smoking, exercise, diet or drug use; therefore, straightforward advice-giving will be of limited value and will lead to the kind of non-constructive dialogue often encountered in the addictions field: the interviewers arguments for change are met by resistance from the patient. In contrast, this method aims to help patients articulate for themselves the reasons for concern and the arguments for change. Even if a decision to change is not made in the consultation, this time will be well spent since behaviour change itself could well occur in the near future. The method is based upon the use of a menu of strategi...

The effectiveness of brief alcohol interventions in primary care settings: A systematic review

ISSUES Numerous studies have reported that brief interventions delivered in primary care are effective in reducing excessive drinking. However, much of this work has been criticised for being clinically unrepresentative. This review aimed to assess the effectiveness of brief interventions in primary care and determine if outcomes differ between efficacy and effectiveness trials. APPROACH A pre-specified search strategy was used to search all relevant electronic databases up to 2006. We also hand-searched the reference lists of key articles and reviews. We included randomised controlled trials (RCT) involving patients in primary care who were not seeking alcohol treatment and who received brief intervention. Two authors independently abstracted data and assessed trial quality. Random effects meta-analyses, subgroup and sensitivity analyses and meta-regression were conducted. KEY FINDINGS The primary meta-analysis included 22 RCT and evaluated outcomes in over 5800 patients. At 1 year follow up, patients receiving brief intervention had a significant reduction in alcohol consumption compared with controls [mean difference: -38 g week(-1), 95%CI (confidence interval): -54 to -23], although there was substantial heterogeneity between trials (I(2) = 57%). Subgroup analysis confirmed the benefit of brief intervention in men but not in women. Extended intervention was associated with a non-significantly increased reduction in alcohol consumption compared with brief intervention. There was no significant difference in effect sizes for efficacy and effectiveness trials. CONCLUSIONS Brief interventions can reduce alcohol consumption in men, with benefit at a year after intervention, but they are unproven in women for whom there is insufficient research data. Longer counselling has little additional effect over brief intervention. The lack of differences in outcomes between efficacy and effectiveness trials suggests that the current literature is relevant to routine primary care.

Effectiveness of treatment for alcohol problems: findings of the randomised UK Alcohol Treatment Trial (UKATT)

Abstract Objective To compare the effectiveness of social behaviour and network therapy, a new treatment for alcohol problems, with that of the proved motivational enhancement therapy. Design Pragmatic randomised trial. Setting Seven treatment sites around Birmingham, Cardiff, and Leeds. Participants 742 clients with alcohol problems; 689 (93.0%) were interviewed at three months and 617 (83.2%) at 12 months. Interventions Social behaviour and network therapy and motivational enhancement therapy. Main outcome measures Changes in alcohol consumption, alcohol dependence, and alcohol related problems over 12 months. Results Both groups reported substantial reductions in alcohol consumption, dependence, and problems, and better mental health related quality of life over 12 months. Between groups we found only one significant difference in outcome, probably due to chance: the social network group showed significantly better physical health at three months. Non-significant differences at 12 months in the motivational group relative to the social network group included: the number of drinks consumed per drinking day had decreased by an extra 1.1 (95% confidence interval −1.0 to 3.2); scores on the Leeds dependence questionnaire had improved by an extra 0.6 (−0.7 to 2.0); scores on the alcohol problems questionnaire had improved by an extra 0.5 (−0.4 to 1.4); but the number of days abstinent from drinking had increased by 1.2% less (−4.5% to 6.9%). Conclusion The novel social behaviour and network therapy for alcohol problems did not differ significantly in effectiveness from the proved motivational enhancement therapy.

The reliability and validity of a scale to measure Hiv risk-taking behaviour among intravenous drug users

The initiation and maintenance of substantial behaviour change is required to reduce the spread of HIV infection among the intravenous drug-using population. In order to ascertain the efficacy of interventions aimed at reducing HIV-related risk-taking behaviour among this population, valid and reliable (yet preferably short) instruments for measuring such behaviour are required. The HIV risk-taking behaviour scale (HRBS) is a brief 11-item interviewer-administered scale which examines the behaviour of intravenous drug users in relation to both injecting and sexual behaviour. This paper describes the construction of the scale, in addition to data evaluating its reliability and validity. Initial analyses indicate that the scale has satisfactory psychometric properties.

The public health and brief interventions for excessive alcohol consumption: the British experience.

Widely disseminated brief interventions against excessive drinking, as part of the new public health movement, have a potentially crucial role in reducing alcohol-related harm on a national scale. However, a number of conceptual problems and practical barriers to progress in this area can already be identified. This article focuses on the British experience of research and implementation of community-based brief interventions, which is longer than that of other countries, as a means of discussing these problems. Rather than being pessimistic about the possible impact of brief interventions, the article is based on the assumption that it is only by clearly recognizing and solving such problems that the potential of brief interventions in the alcohol field will be fully realized.

Definitions of non-abstinent and abstinent categories in alcoholism treatment outcome classifications: A review and proposal.

Dispute about the relative frequencies of abstinent and non-abstinent outcomes following alcoholism treatment cannot be resolved in the absence of consensually-agreed definitions of such outcome categories. A review of influential outcome studies reveals wide differences in how controlled drinking and even abstinence have been defined and it is reasonable to suppose that this is partly responsible for striking variations in rates reported in the literature. Some requirements of a more satisfactory definitional scheme are described and a proposal made which, if accepted, might help to resolve issues relating to the frequency of non-abstinent outcomes.

Controlled evaluation of a brief intervention of HIV prevention among injecting drug users not in treatment

This study evaluated the effectiveness of a brief intervention (BI), a one-session motivational interview, in reducing HIV risk-taking behaviour among injecting drug users (IDU) not enrolled in any form of treatment for drug dependence. IDU were randomly assigned to either BI or a non-intervention control condition (NIC). One hundred and twenty-one subjects were successfully contacted for a 3-month follow-up and 88 subjects were followed up at 6 months. There were significant reductions for the sample as a whole for injecting risk-taking subscale scores on the HIV Risk-taking Behaviour Scale between pre-treatment and follow-up. There was no significant change in sexual risk-taking behaviour. There were no significant differences between groups on any measure at 3- and 6-month follow-up. There are a number of possible reasons why the sample as a whole showed significant improvements from initial to follow-up assessments. It is possible that, having had their attention directed to their risk-taking behaviour, subjects attempted to reduce their injecting risk-taking behaviour. If this is the case and subjects in the NIC condition can be considered as having received a BI, this suggests that BIs involving a personal risk assessment are effective in reducing risk behaviours associated with injecting. However, this suggestion could only be confirmed by comparison with a non-assessment control group.

Promoting brief alcohol intervention by nurses in primary care: a cluster randomised controlled trial

This trial evaluated the clinical impact and cost-effectiveness of strategies promoting screening and brief alcohol intervention (SBI) by nurses in primary care. Randomisation was at the level of the practice and the interventions were: written guidelines (controls, n=76); outreach training (n=68); and training plus telephone-based support (n=68). After 3 months, just 39% of controls implemented the SBI programme compared to 74% of nurses in trained practices and 71% in trained and supported practices. Controls also screened fewer patients and delivered fewer brief interventions to risk drinkers than other colleagues. However, there was a trade-off between the extent and the appropriateness of brief intervention delivery with controls displaying the least errors in overall patient management. Thus cost-effectiveness ratios (cost per patient appropriately treated) were similar between the three strategies. Given the potential for anxiety due to misdirected advice about alcohol-related risk, the balance of evidence favoured the use of written guidelines to promote SBI by nurses in primary care.

The Effectiveness of Alcohol Screening and Brief Intervention in Emergency Departments: A Multicentre Pragmatic Cluster Randomized Controlled Trial

Background Alcohol misuse is common in people attending emergency departments (EDs) and there is some evidence of efficacy of alcohol screening and brief interventions (SBI). This study investigated the effectiveness of SBI approaches of different intensities delivered by ED staff in nine typical EDs in England: the SIPS ED trial. Methods and Findings Pragmatic multicentre cluster randomized controlled trial of SBI for hazardous and harmful drinkers presenting to ED. Nine EDs were randomized to three conditions: a patient information leaflet (PIL), 5 minutes of brief advice (BA), and referral to an alcohol health worker who provided 20 minutes of brief lifestyle counseling (BLC). The primary outcome measure was the Alcohol Use Disorders Identification Test (AUDIT) status at 6 months. Of 5899 patients aged 18 or more presenting to EDs, 3737 (63·3%) were eligible to participate and 1497 (40·1%) screened positive for hazardous or harmful drinking, of whom 1204 (80·4%) gave consent to participate in the trial. Follow up rates were 72% (n = 863) at six, and 67% (n = 810) at 12 months. There was no evidence of any differences between intervention conditions for AUDIT status or any other outcome measures at months 6 or 12 in an intention to treat analysis. At month 6, compared to the PIL group, the odds ratio of being AUDIT negative for brief advice was 1·103 (95% CI 0·328 to 3·715). The odds ratio comparing BLC to PIL was 1·247 (95% CI 0·315 to 4·939). A per protocol analysis confirmed these findings. Conclusions SBI is difficult to implement in typical EDs. The results do not support widespread implementation of alcohol SBI in ED beyond screening followed by simple clinical feedback and alcohol information, which is likely to be easier and less expensive to implement than more complex interventions. Trial Registration Current Controlled Trials ISRCTN 93681536