Paul Toner

A specialized maternity drug service: Examples of good practice

This mixed-method study explores the views of professionals and service users with regard to Maternity Drugs Service provision in Bristol, UK. Findings indicate that this specialist multidisciplinary service, in many ways, can be seen as a model of good practice. Effective multi-agency and multidisciplinary working; early engagement; a service-user-centred approach; positive and non-judgemental staff attitudes contribute to good maternal and child outcomes. However, this service also experiences challenges arising from unclear management structures, differing work practices, and staffing levels. Consistency and clarity within and across complex services, and continuous service development are identified as necessary to effectively meet the needs of an extremely vulnerable population.

Initial reliability and validity of a new measure of perceived social support for family members of problem substance users

Aims: To describe the development of a questionnaire for assessment of the perceived functional social support needs of family members who have relatives with substance-related problems. To present preliminary evidence of its reliability and validity, thus completing the set of measures required to quantitatively assess the Stress-Strain-Coping-Support (SSCS) model of addiction and the family. Design: A mixed methodological approach utilising interview, cross-sectional and repeated-measurement data was adopted to operationalise social support specific to family members. Participants: Adult family members affected by the problem alcohol or drug use of close relatives in the United Kingdom. Measurements: A 75-item self-completion Alcohol, Drugs and the Family Social Support Scale (ADF SSS) was developed from interview data, and piloted with 10 family members. The resultant 58-item measure was subjected to psychometric testing with 132 family members, alongside qualitative feedback from 110. This led to a refined 25-item questionnaire whose psychometric properties are described in this article. Findings: Preliminary findings on the 25-item questionnaire indicate satisfactory levels of internal consistency for the overall measure (α = 0.812) and each of the three constituent subscales: frequency of positively perceived general (α = 0.913) and ADF-specific (α = 0.727) functional support and frequency of negatively perceived ADF-related (α = 0.851) functional support. Qualitative information from family members revealed that the measure was experientially applicable to them. Conclusions: The significance of a new social support measure is discussed, with implications for research, theory and practice in the field.

Effectiveness of Transdiagnostic Cognitive Behaviour Therapy for Anxiety and Depression in Adults: A Systematic Review and Meta-analysis.

BACKGROUND Transdiagnostic Cognitive Behaviour Therapy (CBT) seeks to identify core cognitive-behavioural processes hypothesized to be important across a range of disorders and to develop a treatment that targets these. This contrasts with standard CBT approaches that are disorder-specific. Proponents of transdiagnostic CBT suggest that it may offer advantages over disorder-specific CBT, but little is known about the effectiveness of this approach. AIMS The review aimed to summarize trial-based clinical and cost-effectiveness data on transdiagnostic CBT for anxiety and depression. METHOD A systematic review of electronic databases, including peer-reviewed and grey literature sources, was conducted (n = 1167 unique citations). RESULTS Eight trials were eligible for inclusion in the review. There was evidence of an effect for transdiagnostic CBT when compared to a control condition. There were no differences between transdiagnostic CBT and active treatments in two studies. We found no evidence of cost-effectiveness data. CONCLUSIONS Quality assessment of the primary studies indicated a number of methodological concerns that may serve to inflate the observed effects of transdiagnostic approaches. Although there are positive signs of the value of transdiagnostic CBT, there is as yet insufficient evidence to recommend its use in place of disorder-specific CBT.

ADAPTA: A pilot randomised controlled trial of an alcohol-focused intervention versus a healthy living intervention for problem drinkers identified in a general hospital setting

Highlights • No evidence of a difference in AUDIT score was seen between treatments at 6 months.• A greater proportion in the healthy living group attended all 4 treatment sessions.• Recruitment and follow up proved challenging with this non-help seeking group.• Further thought needed regarding engaging problem drinkers in a hospital setting.

Perceptions on the role of evidence: an English alcohol policy case study

This paper explores the competing influences which inform public health policy and describes the role that research evidence plays within the policy-making process. In particular it draws on a recent English alcohol policy case study to assess the role of evidence in informing policy and practice. Semi-structured interviews with key national, regional and local policy informants were transcribed and analysed thematically. A strong theme identified was that of the role of evidence. Findings are discussed in the context of competing views on what constitutes appropriate evidence for policy-making.

The Alcohol Improvement Programme: Evaluation of an Initiative to Address Alcohol-Related Health Harm in England

Aims: The evaluation aimed to assess the impact of The Alcohol Improvement Programme (AIP). This was a UK Department of Health initiative (April 2008–March 2011) aiming to contribute to the reduction of alcohol-related harm as measured by a reduction in the rate of increase in alcohol-related hospital admissions (ARHAs). Methods: The evaluation (March 2010–September 2011) used a mix of qualitative and quantitative methods to assess the impact of the AIP on ARHAs, to describe and assess the process of implementation, and to identify elements of the programme which might serve as a ‘legacy’ for the future. Results: There was no evidence that the AIP had an impact on reducing the rise in the rate of ARHAs. The AIP was successfully delivered, increased the priority given to alcohol-related harm on local policy agendas and strengthened the infrastructure for the delivery of interventions. Conclusion: Although there was no measurable short-term impact on the rise in the rate of ARHAs, the AIP helped to set up a strategic response and a delivery infrastructure as a first, necessary step in working towards that goal. There are a number of valuable elements in the AIP which should be retained and repackaged to fit into new policy contexts.

An alcohol-focused intervention versus a healthy living intervention for problem drinkers identified in a general hospital setting (ADAPTA): study protocol for a randomized, controlled pilot trial.

BackgroundAlcohol misuse is a major cause of premature mortality and ill health. Although there is a high prevalence of alcohol problems among patients presenting to general hospital, many of these people are not help seekers and do not engage in specialist treatment. Hospital admission is an opportunity to steer people towards specialist treatment, which can reduce health-care utilization and costs to the public sector and produce substantial individual health and social benefits. Alcohol misuse is associated with other lifestyle problems, which are amenable to intervention. It has been suggested that the development of a healthy or balanced lifestyle is potentially beneficial for reducing or abstaining from alcohol use, and relapse prevention. The aim of the study is to test whether or not the offer of a choice of health-related lifestyle interventions is more acceptable, and therefore able to engage more problem drinkers in treatment, than an alcohol-focused intervention.Methods/designThis is a pragmatic, randomized, controlled, open pilot study in a UK general hospital setting with concurrent economic evaluation and a qualitative component. Potential participants are those admitted to hospital with a diagnosis likely to be responsive to addiction interventions who score equal to or more than 16 on the Alcohol Use Disorders Identification Test (AUDIT). The main purpose of this pilot study is to evaluate the acceptability of two sorts of interventions (healthy living related versus alcohol focused) to the participants and to assess the components and processes of the design. Qualitative research will be undertaken to explore acceptability and the impact of the approach, assessment, recruitment and intervention on trial participants and non-participants. The effectiveness of the two treatments will be compared at 6 months using AUDIT scores as the primary outcome measure. There will be additional economic, qualitative and secondary outcome measurements.DiscussionDevelopment of the study was a collaboration between academics, commissioners and clinicians in general hospital and addiction services, made possible by the Collaboration in Leadership in Applied Health Research and Care (CLAHRC) program of research. CLAHRC was a necessary vehicle for overcoming the barriers to answering an important NHS question – how better to engage problem drinkers in a hospital setting.Trial registrationISRCTN47728072

Youth social behaviour and network therapy (Y-SBNT): adaptation of a family and social network intervention for young people who misuse alcohol and drugs - a randomised controlled feasibility trial.

BACKGROUND Family interventions appear to be effective at treating young peoples substance misuse. However, implementation of family approaches in UK services is low. This study aimed to demonstrate the feasibility of recruiting young people to an intervention based on an adaptation of adult social behaviour and network therapy. It also sought to involve young people with experience of using substance misuse services in the research process. OBJECTIVES To demonstrate the feasibility of recruiting young people to family and social network therapy and to explore ways in which young people with experience of using substance misuse services could be involved in a study of this nature. DESIGN A pragmatic, two-armed, randomised controlled open feasibility trial. SETTING Two UK-based treatment services for young people with substance use problems, with recruitment taking place from May to November 2014. PARTICIPANTS Young people aged 12-18 years, newly referred and accepted for structured interventions for drug and/or alcohol problems. INTERVENTIONS A remote, web-based computer randomisation system allocated young people to adapted youth social behaviour and network therapy (Y-SBNT) or treatment as usual (TAU). Y-SBNT participants were intended to receive up to six 50-minute sessions over a maximum of 12 weeks. TAU participants continued to receive usual care delivered by their service. MAIN OUTCOME MEASURES Feasibility was measured by recruitment rates, retention in treatment and follow-up completion rates. The main clinical outcome was the proportion of days on which the main problem substance was used in the preceding 90-day period as captured by the Timeline Follow-Back interview at 3 and 12 months. RESULTS In total, 53 young people were randomised (Y-SBNT, n = 26; TAU, n = 27) against a target of 60 (88.3%). Forty-two young people attended at least one treatment session [Y-SBNT 22/26 (84.6%); TAU 20/27 (74.1%)]; follow-up rates were 77.4% at month 3 and 73.6% at month 12. Data for nine young people were missing at both months 3 and 12, so the main clinical outcome analysis was based on 24 young people (92.3%) in the Y-SBNT group and 20 young people (74.1%) in the TAU group. At month 12, the average proportion of days that the main problem substance was used in the preceding 90 days was higher in the Y-SBNT group than in the TAU group (0.54 vs. 0.41; adjusted mean difference 0.13, 95% confidence interval -0.12 to 0.39; p = 0.30). No adverse events were reported. Seventeen young people with experience of substance misuse services were actively involved throughout the study. They informed key elements of the intervention and research process, ensuring that the intervention was acceptable and relevant to our target groups; contributing to the design of key trial documents, ideas for a new model of public involvement and this report. Two parents were also involved. CONCLUSIONS The adapted intervention could be delivered in young peoples services, and qualitative interviews found that Y-SBNT was acceptable to young people, family members and staff. Engagement of family and network members proved difficult within the intervention and research aspects. The study proved the feasibility of this work in routine services but outcome measurement based on narrow substance use variables may be limited and may fail to capture other important changes in wider areas of functioning for young people. Validation of the EuroQol-5 Dimensions for young people aged 12-18 years should be considered and flexible models for involvement of young people in research are required to achieve inclusive representation throughout all aspects of the research process. Although recommendation of a full trial of the Y-SBNT intervention compared with TAU is not supported, this study can inform future intervention development and UK research within routine addiction services. TRIAL REGISTRATION Current Controlled Trials ISRCTN93446265. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 15. See the NIHR Journals Library website for further project information.

A randomised controlled feasibility trial of family and social network intervention for young people who misuse alcohol and drugs: study protocol (Y-SBNT)

BackgroundA growing body of research has identified family interventions to be effective in treating young people’s substance use problems. However, despite this evidence, take-up of family-based approaches in the UK has been low. Key factors for this appear to include the resource-intensive nature of most family interventions which challenges implementation and delivery in many service settings and the cultural adaptation of approaches developed in the USA to a UK setting. This study aims to demonstrate the feasibility of recruiting young people to a specifically developed family- and wider social network-based intervention by testing an adapted version of adult social behaviour and network therapy (SBNT).MethodsA pragmatic, randomised controlled, open feasibility trial delivered in two services for young people in the UK. Potential participants are aged 12–18 years referred for drug or alcohol problems to either service. The main purpose of this study is to demonstrate the feasibility of recruiting young people to a specifically developed family and social network-based intervention. The feasibility and acceptability of this intervention will be measured by recruitment rates, treatment retention, follow-up rates and qualitative interviews. The feasibility of training staff from existing services to deliver this intervention will be explored. Using this opportunity to compare the effectiveness of the intervention against treatment as usual, Timeline Follow-Back interviews will document the proportion of days on which the main problem substance was used in the preceding 90-day period at each assessment point. The economic component will examine the feasibility of conducting a full incremental cost-effectiveness analysis of the two treatments. The study will also explore and develop models of patient and public involvement which support the involvement of young people in a study of this nature.DiscussionAn earlier phase of work adapted social behaviour and network therapy (adult approach) to produce a purpose-designed youth version supported by a therapy manual and associated resources. This was achieved by consultation with young people with experience of services and professionals working in services for young people. This feasibility trial alongside ongoing consultations with young people will offer a meaningful understanding of processes of delivery and implementation.Trial registrationISRCTN93446265; Date ISRCTN assigned 31/05/2013.

Involving young people in drug and alcohol research

Purpose Young people’s involvement should lead to research, and ultimately services, that better reflect young people’s priorities and concerns. Young people with a history of treatment for alcohol and/or drug problems were actively involved in the youth social behaviour and network therapy study. The purpose of this paper is to explore the impact of that involvement on the study and what was learnt about involving young people in drug and alcohol research. Design/methodology/approach The initial plan was to form a young people’s advisory group (YPAG), but when this proved problematic the study explored alternative approaches in collaboration with researchers and young people. Input from 17 young people informed all key elements of the study. Findings Involvement of young people needs to be dynamic and flexible, with sensitivity to their personal experiences. Engagement with services was crucial both in recruiting young people and supporting their ongoing engagement. This research identified a need to critically reflect on the extent to which rhetorics of participation and involvement give rise to effective and meaningful involvement for young service users. It also highlights the need for researchers to be more flexible in response to young people’s personal circumstances, particularly when those young people are “less frequently heard”. Research limitations/implications This research highlights the need for researchers to be more flexible in response to young people’s personal circumstances, particularly when those young people are “less frequently heard”. It highlights the danger of young people in drug and alcohol research being unintentionally disaffected from involvement through conventional approaches and instead suggests ways in which young people could be involved in influencing if and how they participate in research. Practical implications There is an apparent contradiction between dominant discourses and cultures of health services research (including patient and public involvement) that often do not sit easily with ideas of co-production and young people-centred involvement. This paper provides an alternative approach to involvement of young people that can help to enable more meaningful and effective involvement. Originality/value The flexible and young people-centred model for involvement which emerged from this work provides a template for a different approach. This may be particularly useful for those who find current practice, such as YPAG, inaccessible.