FACTORS THAT INFLUENCE EFFECTIVENESS

5.1 The factors that affect evidence are varied and complex including intensity of treatment programme; combination of treatment modalities; infrastructure support including interventions to support participation and engagement in treatment; and variables such as gender and ethnicity.

Intensity of treatment programmes and/or supervision

5.2 Taking the term ‘programme’ to mean either a pharmacological or psychological intervention for the treatment of problematic drug use, Holloway (2005), in her review of the effectiveness of treatment programmes in reducing drug-related crime, stated that:

‘The meta-analysis showed that higher intensity programmes were 50% more likely to reduce criminal behaviour than their low intensity equivalents…..This applies to dosage levels, whether the programme is continuous or interrupted, time in treatment, whether the subject completes or terminates the programme, and whether treatments are combined in some way (e.g. detoxification plus aftercare)’.

5.3 Coviello et al. (2001) found that 12-week day treatment programme more effective (to a statistically significant extent) than six-week programme. Ghodse et al. (2002) found ‘intensive’ aftercare more effective than ‘non-intensive’.

5.4 Turner (1992) investigated the effect of intensive probation or parole for offenders versus standard supervision. She found that the intensive group secured a higher (statistically significant) rate of employment, but were returned to prison at a higher rate. The type of offences that led to breaches were of a more technical, less serious nature, suggesting to the author that this was a consequence of a higher level of probation scrutiny.

5.5 Holloway and colleagues (2005), in a systematic review of 52 studies of drug interventions for offenders, concluded that ‘The evidence for treating dependence on substances other than opioids shows very limited success to date in community settings, and is non-existent in offender settings’. The report did, however, find that ‘Higher- intensity programmes were more likely to result in reduction of criminal behaviour than low intensity equivalents’. These ‘higher-intensity programmes’ included clinical, psychological and aftercare elements, either as single discrete interventions, or any combinations of the three components.

5.6 In a follow-up meta-analysis, Holloway et al. (2008) concluded that the two most effective interventions for the reduction of crime among drug-using offenders were Therapeutic Communities and supervision.

5.7 A major meta-analysis (Prendergast 2002) of comparison group studies found treatment reduced illicit drug use and reduced crime significantly and to clinically meaningful levels.

Combining interventions and programmes

5.8 One of the criticisms of the evidence base is that it does not sufficiently recognise comparisons between different treatment modalities and the potential for there to be mutually enhancing affects on outcomes.

ii. Intensive outpatient treatment with reinforcement-based treatment (Jones 2005, Silverman 2001, Silverman 2007)

iii. Structured day treatment (Avants1999, Marlowe 2003) NICE (2007a) concluded that:

‘The evidence related to intensive outpatient treatments and day treatments (defined respectively as at least 9 and 20 hours of group work per week) does not support the notion that “‘more is better” when comparing more intensive treatments to standard outpatient treatment in relation to drug-use outcomes’.

None of the above studies related directly to prisons or probation.

5.10 There are also studies that have addressed the combination of prescribing either for substitution therapy or as an adjunct to detoxification with various other treatment modalities.

Opioid substitution plus CBT

5.11 NICE (2007a), in an analysis of four randomised controlled trails, concluded that relapse-prevention CBT (Epstein 2003; UKCBTMM 2004; Rawson 2002) and standard CBT (Woody, 1983) do not appear to be effective treatment options for people undergoing methadone maintenance treatment. They added, however that there was some evidence that: ‘Standard CBT may be beneficial for a sub-sample who experienced high levels of psychiatric co-morbidity’.

Opioid substitution plus Contingency Management

5.12 In reviewing the evidence related to opioid treatment plus CM (incorporating Petry et al. 2005; Silverman et al. 2004), NICE (2007a) concluded that contingency management for people undergoing methadone maintenance treatment is strongly and consistently associated with longer, continuous periods of abstinence during treatment and point abstinence at 6- and 12-month follow-up. These findings were consistent for studies using vouchers, prizes and privileges as reinforcers. However, NICE found no evidence to support CM for people undergoing buprenorphine maintenance treatment. Opioid detoxification plus psychosocial interventions

5.13 Amato et al. (2004), in reviewing outcomes from opioid detoxification with adjunctive psychosocial interventions against unsupported detoxification, found that stand-alone detoxification was the poorer treatment option in terms of retention in treatment, completion of treatment and average time elapsed prior to relapse. The high rates of treatment drop-out and relapse (Mattick and Hall, 1996), suggest that

complementary psychosocial interventions are indicated to sustain early recovery from opiate dependence. NICE, in reviewing 7 RCTs, found significant evidence in support of

family interventions (Yandoli 2002), Contingency Management (McCaul 1984), and social network interventions (Galanter 2002).

Complex needs (dual diagnosis)

5.14 Charney et al. 2001; Hesse 2004 and Watkins et al. 2006 all reported evidence that integrated mental health and drug interventions for people with combined drug and mental health problems can reduce their drug use. (See also ‘Opioid substitution plus CBT’ above).

Infrastructure and interventions to support participation and engagement in treatment 5.15 Amongst the factors that influence effectiveness are the infrastructure to support treatment programme delivery and interventions that are designed to support

participation and engagement in treatment. Support for carers/families

5.16 From an evaluation of three studies, (Kirby et al. 1999; Meyers et al. 2002, Copello et al. 2007) NICE (2007a) concluded that self-help interventions appear to be as effective as more intensive psychological interventions in reducing stress and improving psychological functioning for carers and families of problem drug users

Alternative therapies

5.17 Roberts et al. (2007) reviewed a Bowen 2006 study of the effect of vipassana meditation (VM) compared with a substance use treatment as usual control group (n=78). The VM group showed significantly lower levels of alcohol use after the 3 month follow up period, but no difference in re-offending was found between the groups. The authors concluded that Vipassana Meditation was effective as a treatment for alcohol- related problems, but not effective in reducing later criminal activity.

Case management

5.18 Evidence for case management as an intervention in its own right is not favourable, for example, one study assessed the effectiveness of a community-based offender case management intervention. Participants were randomly assigned to ACT (assertive community treatment) case management or to routine parole. No impact on drug use or criminality was found (Martin 1993). Also, NICE (2007a) in reviewing ten studies from the USA (e.g. Morgenstern, 2006; Needels, 2005), decided that case management has very little impact on drug use, but some effect in assisting people to access more formal treatment.

Infrastructure

5.20 Aside from modality or intensity of treatment approach, Simpson (2006) found evidence that innovation adoption based on training for improving treatment

engagement was significantly related to client self-reports of improved treatment

participation and rapport recorded several months later, suggesting that effort to change and improve programmes may have a beneficial effect on client outcomes.

Other therapeutic factors

5.21 The therapist and client’s working relationship has been shown to be significant in relation to outcomes from treatment. Orford (2008) reported that the most common positive factor attributed by UKATT (2005) clients to positive changes they had made was to relationship they had with their therapist. This was statistically superior to the clients’ assessments of the beneficial impact of either of the two studied interventions. 5.22 There is evidence from Project MATCH (Connors 2000) and from other

psychotherapy studies (Hanson, 2002; Martin 2000), that better treatment outcomes are associated with the rating of more positive ‘working alliance’ by both clients and

therapists. See also Connors et al. (2000); Martin D et al. (2000); Hanson et al. (2002) and UK Alcohol Treatment Trial (UKATT) Research Team (2005).