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ABSTRACT: AIMS: To estimate the cost-effectiveness and resourcing implications of universal alcohol screening and brief intervention (SBI) programmes in primary care in England. METHODS: This was a health economic model, combining evidence of the effectiveness and health care resource requirements of SBI activities with existing epidemiological modelling of the relationship between alcohol consumption and health harms. RESULTS: Screening patients on registration with a family doctor would steadily capture ∼40% of the population over a 10-year programme; screening patients at next primary care consultation would capture 96% of the population over the same period, but with high resourcing needs in the first year. The registration approach, delivered by a practice nurse, provides modest cost savings to the health care system of £120 m over 30 years. Health gains over the same period amount to 32,000 quality-adjusted life years (QALYs). This SBI programme still appears cost-effective (at £6900 per QALY gained) compared with no programme, under pessimistic effectiveness assumptions. Switching to a consultation approach, delivered by a doctor, would incur an incremental net cost of £108 m, with incremental health gains equivalent to 92,000 QALYs, giving an incremental cost-effectiveness ratio of £1175 per QALY gained compared with current practice. CONCLUSION: A universal programme of alcohol SBI in primary care is estimated to be cost-effective, under all but the most pessimistic assumptions for programme costs and effectiveness. Policymakers should ensure that SBI programmes are routinely evaluated and followed up, given the substantial uncertainty over the effects of many of the implementation details.
Alcohol and Alcoholism 09/2012; · 2.95 Impact Factor
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ABSTRACT: Changes in per capita alcohol consumption are temporally linked to changes in rates of alcohol-related harm. Methodological approaches for analysing this relationship have been suggested, however, the problem of time lags is not well-addressed. This study provides a review of time lag specifications, looking at (a) time to first effect on harm, (b) time to full effect and (c) the functional form of the effect accumulation from first to full effect to inform modelling of the relationship between changes in aggregate alcohol consumption and changes in rates of harm.
Bibliographic databases were searched and citation and reference checking was used to identify studies. Included studies were time series analyses of the relationship between aggregated population alcohol consumption and rates of alcohol-related harms where time lag specifications had been derived or tested.
36 studies were included with liver cirrhosis, heart disease and suicide dominating the evidence base. For a large number of alcohol-related harms, no literature was identified. There was strong evidence of an immediate first effect following a change in consumption for most harms. Recommended lag specifications are proposed for a set of alcohol-attributable harms.
Research on time lag specifications is under-developed for most harms although we provide suggested specifications based on the findings of the review. Greater methodological attention needs to be given to the rationale for choosing or applying lag specifications and the inherent complexity of the time lag process. More consistent and transparent reporting of methodological decisions would aide progress in the field.
Drug and alcohol dependence 12/2011; 123(1-3):7-14. · 3.60 Impact Factor
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Petra S Meier
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ABSTRACT: This paper aims to contribute to a rethink of marketing research priorities to address policy makers' evidence needs in relation to alcohol marketing.
Discussion paper reviewing evidence gaps identified during an appraisal of policy options to restrict alcohol marketing.
Evidence requirements can be categorized as follows: (i) the size of marketing effects for the whole population and for policy-relevant population subgroups, (ii) the balance between immediate and long-term effects and the time lag, duration and cumulative build-up of effects and (iii) comparative effects of partial versus comprehensive marketing restrictions on consumption and harm. These knowledge gaps impede the appraisal and evaluation of existing and new interventions, because without understanding the size and timing of expected effects, researchers may choose inadequate time-frames, samples or sample sizes. To date, research has tended to rely on simplified models of marketing and has focused disproportionately on youth populations. The effects of cumulative exposure across multiple marketing channels, targeting of messages at certain population groups and indirect effects of advertising on consumption remain unclear.
It is essential that studies into marketing effect sizes are geared towards informing policy decision-makers, anchored strongly in theory, use measures of effect that are well-justified and recognize fully the complexities of alcohol marketing efforts.
Addiction 03/2011; 106(3):466-71. · 4.31 Impact Factor
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ABSTRACT: Crack cocaine injecting is associated with a higher prevalence of sharing behaviours, increased rates of hepatitis C infection and a higher likelihood of homelessness. The limited available evidence on snowballing (co-injecting of heroin and crack cocaine) suggests that this is associated with an increase in risky injection practices. This study sets out to explore the views and experiences of a group of drug users who 'snowball', with a view to inform the improvement of harm reduction services for such clients.
This is a qualitative interview study of 18 male and female homeless drug users attending a needle exchange service in Nottingham, UK.
For all those interviewed, snowballing represented a communal activity which affected peer injection practices. The individual perceptions of the terms 'sharing' and 'splitting' affected the levels of concerns when snowballs were used with others. The study highlighted the importance of knowing current vaccination and screening history of injecting partners in order to manage risk behaviour when drugs are used communally.
Harm reduction services need to target information so it is meaningful and appropriate to those who engage in communal drug use.
Drug and Alcohol Review 05/2010; 29(3):256-62. · 1.55 Impact Factor
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ABSTRACT: Although pricing policies for alcohol are known to be effective, little is known about how specific interventions affect health-care costs and health-related quality-of-life outcomes for different types of drinkers. We assessed effects of alcohol pricing and promotion policy options in various population subgroups.
We built an epidemiological mathematical model to appraise 18 pricing policies, with English data from the Expenditure and Food Survey and the General Household Survey for average and peak alcohol consumption. We used results from econometric analyses (256 own-price and cross-price elasticity estimates) to estimate effects of policies on alcohol consumption. We applied risk functions from systemic reviews and meta-analyses, or derived from attributable fractions, to model the effect of consumption changes on mortality and disease prevalence for 47 illnesses.
General price increases were effective for reduction of consumption, health-care costs, and health-related quality of life losses in all population subgroups. Minimum pricing policies can maintain this level of effectiveness for harmful drinkers while reducing effects on consumer spending for moderate drinkers. Total bans of supermarket and off-license discounting are effective but banning only large discounts has little effect. Young adult drinkers aged 18-24 years are especially affected by policies that raise prices in pubs and bars.
Minimum pricing policies and discounting restrictions might warrant further consideration because both strategies are estimated to reduce alcohol consumption, and related health harms and costs, with drinker spending increases targeting those who incur most harm.
Policy Research Programme, UK Department of Health.
The Lancet 03/2010; 375(9723):1355-64. · 38.28 Impact Factor
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ABSTRACT: Background: There is growing evidence that the therapeutic alliance is one of the most consistent predictors of retention and outcomes in drug treatment. Recent psychotherapy research has indicated that there is a lack of agreement between client, therapist and observer ratings of the therapeutic alliance; however, the clinical implications of this lack of consensus have not been explored. Aims: The aims of the study are to (1) explore the extent to which, in drug treatment, clients and counsellors agree in their perceptions of their alliance, and (2) investigate whether the degree of disagreement between clients and counsellors is related to retention in treatment. Methods: The study recruited 187 clients starting residential rehabilitation treatment for drug misuse in three UK services. Client and counsellor ratings of the therapeutic alliance (using the WAI‐S) were obtained during weeks 1–12. Retention was in this study defined as remaining in treatment for at least 12 weeks. Results: Client and counsellor ratings of the alliance were only weakly related (correlations ranging from r = 0.07 to 0.42) and tended to become more dissimilar over the first 12 weeks in treatment. However, whether or not clients and counsellors agreed on the quality of their relationship did not influence whether clients were retained in treatment. Conclusions: The low consensus between client and counsellor views of the alliance found in this and other studies highlights the need for drug counsellors to attend closely to their clients' perceptions of the alliance and to seek regular feedback from clients regarding their feelings about their therapeutic relationship.
07/2009; 11(1):73-80.
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ABSTRACT: Background Counselling is one of the most common treatment options in drug services, and recent research has convincingly demonstrated its effectiveness if certain quality parameters regarding intensity and qualifications of those providing it are observed. However, there is a remarkable paucity of literature on the nature of counselling provision in UK drug treatment. Aims To describe the extent and nature of counselling provision in UK drug treatment services. Method A national survey of specialist drug services in England and Wales was carried out, and information was obtained from 326 services. Results Levels of counselling provision were very similar in nonstatutory, community‐based, residential day care and statutory, community‐based services (around 90%), with slightly lower levels in inpatient services (78%, difference not significant). In the majority of services (74%), individual sessions were provided by drug workers without counselling accreditation. In 32% of agencies, counselling was provided only by drug workers, whereas 36% of agencies employed both drug workers and accredited counsellors. In 17% of agencies, sessions were run by accredited counsellors only. Volunteers without formal training provided one‐to‐one sessions in 27% of agencies, mostly in agencies also employing counsellors and drug workers. Most agencies (66%) operated a schedule of weekly sessions; 12% of agencies offered fortnightly or less frequent sessions, whereas 15% of agencies offered several sessions a week. More than three‐quarters of all sessions were scheduled to last between 50 and 60 minutes. Conclusion Typically, counselling is provided on a weekly to fortnightly basis by drug workers without formal counselling qualifications. In‐depth research is needed to examine whether and how sessions provided by drug workers differ from sessions provided by counsellors, as past research has only demonstrated the effectiveness of counselling in studies using highly trained counselling staff.
07/2009; 9(1):44-51.
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ABSTRACT: This paper describes the effects of the adoption of a systems approach to alcohol service delivery by four previously separate organisations in Manchester, UK that commenced in 1997. The study examined a database of 5542 admissions for in-patient detoxification between 1995 and 2003, which permitted the analysis of changes occurring in the composition of the client group after the adoption of the new model. Findings suggest that working with the systems approach resulted in more effective targeting of people with higher levels of alcohol dependency towards in-patient detoxification. Females and people in stable housing also benefited from increased access in the new system. Increases in planned discharges were observed across all demographic variables, although alcohol-dependent males without stable accommodation found it more difficult to access in-patient detoxification after the new model was introduced. We conclude that in comparison to a loose network of services a co-ordinated and managed service system can improve targeting for in-patient detoxification for most people with severe alcohol dependence but may not do so for all who need access.
Drug and Alcohol Dependence 11/2006; 85(1):28-34. · 3.38 Impact Factor
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ABSTRACT: The aim of this study was to predict retention in residential rehabilitation (RR) services for drug users, focusing on service provider factors. A national postal survey of RR services in England and Wales was carried out and information was obtained from 57 of 87 services identified (65.5%). Service managers were asked to complete a questionnaire asking about treatment philosophy, treatments provided, staff characteristics and staffing levels, as well as overall service size and funding. Services also provided information on the number of clients admitted and the number who had completed, dropped out and been asked to leave in the past year. Completion rates varied widely, from 3% to 92%, with an average of 48%. Higher completion rates were associated with lower counsellor caseloads, fewer beds, single rooms, shorter scheduled treatment durations, higher fees per client and provision of what could be termed a balanced treatment programme containing adequate amounts of individual counselling and programme-free time, and with only moderate demands for domestic duties. Programmes with more drug than alcohol users had lower completion rates, but the proportion of dual diagnosis or criminal justice referred clients did not appear to affect retention. Completion rates varied as a function of a number of service factors that are amenable to manipulation. To retain clients successfully, programmes should not be too large and should have adequate levels of therapeutic staff, a well-developed treatment schedule which is not too demanding for the client in terms of duties or overall time spent in structured activities, and which incorporates sufficient levels of individual counselling. [Meier PS, Best D. Programme factors that influence completion of residential treatment. Drug Alcohol Rev2006;25:349 - 355].
Drug and Alcohol Review 08/2006; 25(4):349-55. · 1.55 Impact Factor
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ABSTRACT: To investigate the role of the therapeutic alliance in predicting length of retention in residential drug treatment.
The study recruited 187 clients starting residential rehabilitation treatment for drug misuse in three UK services. Counsellor and client information was assessed at intake, and the average total scores of client and counsellor ratings on the WAI-S (obtained during weeks 1-3) were use as the alliance measure. Length of retention and treatment completion (stay beyond 90 days) were used as measures of retention.
Clients with weak counsellor rated alliances dropped out of treatment significantly sooner than clients with strong counsellor rated therapeutic alliances, whether or not the model adjusted for individual counsellor effects and potential confounders including psychological well-being, treatment motivation and readiness, coping strategies, and attachment style. The client rated alliance did not predict length of retention. Apart from the alliance, pre-treatment crack use, secure attachment style and better coping strategies were associated with shorter retention, whereas greater confidence in treatment, older client age and better education predicted treatment completion. Counsellors with greater experience of delivering drug counselling retained clients longer.
The findings of this study stress the importance of treatment professionals attending to the therapeutic alliance in drug treatment, as counsellors' alliance ratings were found to be amongst the strongest predictors of dropout. Using alliance measures as clinical tools may help treatment practitioners to become aware of the risk of disengagement early on. Prospective studies are needed to evaluate whether strategies of reallocating clients with poor alliances to different counsellors lead to improvements in retention.
Drug and Alcohol Dependence 07/2006; 83(1):57-64. · 3.38 Impact Factor
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ABSTRACT: To predict the early therapeutic alliance from a range of potentially relevant factors, including clients' social relationships, motivation and psychological resources, and counsellors' professional experience and ex-user status.
The study recruited 187 clients starting residential rehabilitation treatment for drug misuse in three UK services. Counsellor and client information was assessed at intake, and client and counsellor ratings of the alliance were obtained during weeks 1, 2 and 3.
The intake assessment battery included scales on psychological wellbeing, treatment motivation, coping strategies and attachment style. Client and counsellor versions of the Working Alliance Inventory (WAI-S) were used for weekly alliance measurement. Hierarchical linear models were used to examine the relationship between alliance and predictor variables.
Clients who had better motivation, coping strategies, social support and a secure attachment style were more likely to develop good alliances. Findings with regard to counsellor characteristics were not clear cut: clients rated their relationships with ex-user counsellors, experienced counsellors and male counsellors as better, but more experienced counsellors rated their alliances as worse.
The findings offer important leads as to what interventions might improve the therapeutic alliance. Further work will need to establish whether the therapeutic alliance and ultimately treatment outcomes can be enhanced by working on improving clients' motivation and psychosocial resources.
Addiction 05/2005; 100(4):500-11. · 4.31 Impact Factor
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ABSTRACT: In the past two decades, a number of studies investigating the role of the therapeutic alliance in drug treatment have been published and it is timely that their findings are brought together in a comprehensive review.
This paper has two principal aims: (1) to assess the degree to which the relationship between drug user and counsellor predicts treatment outcome and (2) to examine critically the evidence on determinants of the quality of the alliance.
Peer-reviewed research located through the literature databases Medline, PsycInfo and Ovid Full Text Mental Health Journals using predefined search-terms and published in the past 20 years is considered. Further papers were identified from the bibliographies of relevant publications.
A key finding is that the early therapeutic alliance appears to be a consistent predictor of engagement and retention in drug treatment. With regard to other treatment outcomes, the early alliance appears to influence early improvements during treatment, but it is an inconsistent predictor of post-treatment outcomes. There is relatively little research on the determinants of the alliance. In studies that are available, clients' demographic or diagnostic pre-treatment characteristics did not appear to predict the therapeutic alliance, whereas modest but consistent relationships were reported for motivation, treatment readiness and positive previous treatment experiences.
The therapeutic alliance plays an important role in predicting drug treatment process outcomes, but too little is known about what determines the quality of the relationship between drug users and counsellors.
Addiction 04/2005; 100(3):304-16. · 4.31 Impact Factor
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ABSTRACT: To compare the relative frequency of eight indicators of problem drug use and potentially adverse social circumstances in drug-using parents and non-parents and to explore whether a profile based on these characteristics differs according to whether or not dependent children live with their drug-using parent.
The study utilizes a 5 year national UK treatment monitoring system data set.
61,425 users with, and 105,473 without dependent children accessing drug treatment services in England and Wales between January 1996 and December 2000.
Information about parenthood and children's residence was routinely collected. Drug use and social circumstance indicators were daily heroin use, daily alcohol use, regular stimulant use, sharing of injecting equipment, living with another user, living alone, unstable accommodation, and criminal justice referral.
There were clear differences between drug-using parents according to where children live. Parents with children at home and non-parents showed fewer of the indicators than parents with children in care or elsewhere. Sixty-five percent of parents with none of the indicators lived with their children, compared with only 28% of those with three indicators and 9% of those with six or more indicators. Parents with children in care or living elsewhere showed the highest prevalence for each individual indicator.
Drug-using parents demonstrate a range of potentially unfavourable drug use behaviours and social circumstances, but those whose children live with them use drugs less frequently and live in more favourable conditions than those whose children live elsewhere. Protective factors may operate in family situations, while severe drug use and adverse social circumstances may result in a breakdown of family structures.
Addiction 09/2004; 99(8):955-61. · 4.31 Impact Factor
