A pilot study to assess the feasibility and impact of a brief motivational intervention on problem drug and alcohol use in adult mental health inpatient units : study protocol for a randomized controlled trial

Background: Substance misuse in those with severe mental health problems is common and associated with poor engagement in treatment and treatment outcomes. Up to 44% of those admitted into psychiatric inpatient facilities have coexisting substance-misuse problems. However, this is not routinely addressed as part of their treatment plan. A mental health admission may present a window of opportunity for inpatients to reevaluate the impact of their substance use. This study will aim to evaluate the effectiveness of a targeted brief motivational intervention in improving engagement in treatment and to assess how feasible and acceptable this intervention is to inpatients and staff as a routine intervention. Methods/Design: This randomized controlled trial will use concealed randomization; blind, independent assessment of outcome at 3 months; characterization of refusers and dropouts; and be analyzed according to the intention-to-treat principle. After baseline assessments, eligible participants will be randomized either to the Brief Integrated Motivational Intervention plus Treatment As Usual, or Treatment as Usual alone. Eligible participants will be those who are new admissions; >18 years; ICD-10 diagnosis of -schizophrenia or related disorder, bipolar affective disorder, recurrent depressive disorder, and DSM-IV diagnosis of substance abuse or dependence over the last 3 months. The primary outcome is engagement in treatment for substance misuse, and secondary outcomes include readiness to change substance misuse together with a cost-effectiveness analysis. Qualitative interviews with staff and participants will assess the acceptability of the intervention. Discussion: This pilot randomized trial will provide the first robust evidence base for inpatient care of people with severe mental health problems and co-morbid substance misuse and provide the groundwork for confirmatory trials to evaluate a potentially feasible, cost-effective, and easy-to-implement treatment option that may be readily integrated into standard inpatient and community-based care

Substance misuse: education & prevention policy.

The purpose of the policy described in this document is to - 1. Outline the aims of the Midland Health Board in responding to substance misuse in terms of: preventing substance misuse, particularly amongst young people; and; providing interventions, including counselling, treatment and support for those with problems associated with substance misuse. 2. Provide a consultative framework for the development of a multi-agency strategy on substance misuse in the Midland Health Board region. The background to this policy is described in the context of discussions locally in the Midland Health Board (MHB), the development of the Government's overall strategy for combating substance misuse, and the health board's regional policy for health gain. The extent of substance misuse in the region is described using statistics for prosecution of drug offences, psychiatric admissions, and use of the Community and Alcohol Drug Service. The key factors involved in substance misuse are discussed: the individual; substance used; and the environment in which substance is taken. The MHB's position on effective approaches to substance misuse education is outlined. Other important elements in the policy include treatment and rehabilitation, information and research, monitoring and evaluation, and assigning responsibility for implementing the policy

A primary care, multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden of psychiatric comorbidity

BACKGROUND: Chronic non-cancer pain is a common problem that is often accompanied by psychiatric comorbidity and disability. The effectiveness of a multi-disciplinary pain management program was tested in a 3 month before and after trial. METHODS: Providers in an academic general medicine clinic referred patients with chronic non-cancer pain for participation in a program that combined the skills of internists, clinical pharmacists, and a psychiatrist. Patients were either receiving opioids or being considered for opioid therapy. The intervention consisted of structured clinical assessments, monthly follow-up, pain contracts, medication titration, and psychiatric consultation. Pain, mood, and function were assessed at baseline and 3 months using the Brief Pain Inventory (BPI), the Center for Epidemiological Studies-Depression Scale scale (CESD) and the Pain Disability Index (PDI). Patients were monitored for substance misuse. RESULTS: Eighty-five patients were enrolled. Mean age was 51 years, 60% were male, 78% were Caucasian, and 93% were receiving opioids. Baseline average pain was 6.5 on an 11 point scale. The average CESD score was 24.0, and the mean PDI score was 47.0. Sixty-three patients (73%) completed 3 month follow-up. Fifteen withdrew from the program after identification of substance misuse. Among those completing 3 month follow-up, the average pain score improved to 5.5 (p = 0.003). The mean PDI score improved to 39.3 (p < 0.001). Mean CESD score was reduced to 18.0 (p < 0.001), and the proportion of depressed patients fell from 79% to 54% (p = 0.003). Substance misuse was identified in 27 patients (32%). CONCLUSIONS: A primary care disease management program improved pain, depression, and disability scores over three months in a cohort of opioid-treated patients with chronic non-cancer pain. Substance misuse and depression were common, and many patients who had substance misuse identified left the program when they were no longer prescribed opioids. Effective care of patients with chronic pain should include rigorous assessment and treatment of these comorbid disorders and intensive efforts to insure follow up

The family drug & alcohol court (FDAC) evaluation project

This report presents the findings from the evaluation of the first pilot Family Drug and Alcohol Court (FDAC) in Britain. FDAC is a new approach to care proceedings, in cases where parental substance misuse is a key element in the local authority decision to bring proceedings. It is being piloted at the Inner London Family Proceedings Court in Wells Street. Initially the pilot was to run for three years, to the end of December 2010, but is now to continue until March 2012. The work is co-funded by the Department for Education (formerly the Department for Children, Schools and Families), the Ministry of Justice, the Home Office, the Department of Health and the three pilot authorities (Camden, Islington and Westminster). The evaluation was conducted by a research team at Brunel University, with funding from the Nuffield Foundation and the Home Office. FDAC is a specialist court for a problem that is anything but special. Its potential to help break the inter-generational cycle of harm associated with parental substance misuse goes straight to the heart of public policy and professional practice. Parental substance misuse is a formidable social problem and a key factor in around a third of long-term cases in children’s services in some areas. It is a major risk factor for child maltreatment, family separation and offending in adults, and for poor educational performance and substance misuse by children and young people. The parents’ many difficulties create serious problems for their children and place major demands on health, welfare and criminal justice services. For these reasons, parental substance misuse is a cross-cutting government agenda. FDAC is distinctive because it is a court-based family intervention which aims to improve children’s outcomes by addressing the entrenched difficulties of their parents. It has been adapted to English law and practice from a model of family treatment drug courts that is used widely in the USA and is showing promising results with a higher number of cases where parents and children were able to remain together safely, and with swifter alternative placement decisions for children if parents were unable to address their substance misuse successfully. The catalysts for the FDAC pilot were the encouraging evidence from the USA and concerns about the response to parental substance misuse through ordinary care proceedings in England: poor coordination of adult and children’s services; late interventions to protect children; delays in reaching decisions in court; and soaring costs of proceedings, linked to the cost of expert evidence.The work is co-funded by the Department for Education (formerly the Department for Children, Schools and Families), the Ministry of Justice, the Home Office, the Department of Health and the three pilot authorities (Camden, Islington and Westminster).1 The evaluation was conducted by a research team at Brunel University, with funding from the Nuffield Foundation and the Home Office

On Assessment of the Supreme Court Decisions in Tackling Substance Misuse in Indonesia

This study aims to analyse the Indonesian Supreme Court (Mahkamah Agung) decisions to the defendants of substance misuse. The data were based on the Supreme Court decisions for substance misuse cases from 2001-2009, uploaded in putusan.mahkamahagung.or.id. The database consists of 191 cases involving 218 defendants. Logistic regression and Tobin’s logistic regression (Tobit) were used in this study to estimate the probability and the intensity of various disposals. This is inline with Becker (1968) argument that the optimal deterrence effect of a disposal arose from the probability of conviction and the intensity of punishment. The types of punishment sentenced to defendants of substance misuse cases are vary, ranging from imprisonment, fines, community service, probation and even a capital punishment. The results from logistic regression analyses showed the social costs of substance misuse was used by the Supreme Court judges to consider the value of fines sentenced to offenders. the social cost that is inflicted by the defendant was only weighed in giving fines to the defendant. On the other hand, the results from Tobit regressions showed that the Supreme Court judges did not taken into consideration the social cost of substance misuse in determining the intensity of punishment sentenced to defendants. The explicit social cost caused by the defendants of the narcotics/psychotropics case was Rp 23.7 billion (about US$2.37 million), however the fines charged by the Supreme Court was only Rp 5.5 billion (about US$ 550,000). Further investigation showed that the defendants who were sentenced to pay fines by the District Courts has 51.7% more probability to be sentenced with imprisonment by the Supreme Court. On the other hand, results from Tobit regressions showed that the longer the imprisonment sentenced by the District Court, the more fines were sentenced to the defendants by the Supreme Court.Narcotics, Psychotropic, Social Cost of Crime, Financial Punishment, Deterrence Effect

The Belfast Youth Development Study (BYDS): A prospective cohort study of the initiation, persistence and desistance of substance use from adolescence to adulthood in Northern Ireland

Background: Substance misuse persists as a major public health issue worldwide with significant costs for society. The development of interventions requires methodologically sound studies to explore substance misuse causes and consequences. This Cohort description paper outlines the design of the Belfast Youth Development (BYDS), one of the largest cohort studies of its kind in the UK. The study was established to address the need for a long-term prospective cohort study to investigate the initiation, persistence and desistance of substance use, alongside life course processes in adolescence and adulthood. The paper provides an overview of BYDS as a longitudinal data source for investigating substance misuse and outlines the study measures, sample retention and characteristics. We also outline how the BYDS data have been used to date and highlight areas ripe for future work by interested researchers. Methods: The study began in 2000/1 when participants (n = 3,834) were pupils in their first year of post-primary education (age 10/11 years, school year 8) from over 40 schools in Northern Ireland. Children were followed during the school years: Year 9 (in 2002; aged 12; n = 4,343), Year 10 (in 2003; aged 13; n = 4,522), Year 11 (in 2004; aged 14; n = 3,965) and Year 12 (in 2005; aged 15; n = 3,830) and on two more occasions: 2006/07 (aged 16/17; n = 2,335) and 2010/11 (aged 20/21; n = 2,087). Data were collected on substance use, family, schools, neighbourhoods, offending behaviour and mental health. The most novel aspect of the study was the collection of detailed social network data via friendship nominations allowing the investigation of the spread of substance use via friendship networks. In 2004 (school year 11; respondents aged 14), a sub-sample of participants’ parents (n = 1,097) and siblings (n = 211) also completed measures on substance use and family dynamics. Results: The most recent wave (in 2010/2011; respondents aged 20/21 years) indicated lifetime use of alcohol, tobacco and cannabis among the cohort was 94, 70 and 45 per cent, respectively. The paper charts the development of drug use behaviour and some of the key results to date are presented. We have also identified a number of key areas ripe for analysis by interested researchers including sexual health and education. Conclusions: We have established a cohort with detailed data from adolescence to young adulthood, supplemented with parent and sibling reports and peer network data. The dataset, allowing for investigation of trajectories of adolescent substance use, associated factors and subsequent long-term outcomes, constitutes an important resource for longitudinal substance misuse research. A planned further wave as the cohort enter their late twenties and potential to link to administrative data sources, will further enrich the datasets

Pathways into multiple exclusion homelessness in seven UK cities

This paper interrogates pathways into multiple exclusion homelessness (MEH) in the UK and, informed by a critical realist theoretical framework, explores the potential causal processes underlying these pathways. Drawing on an innovative multistage quantitative survey, it identifies five experiential clusters within the MEH population, based on the extent and complexity of experiences of homelessness, substance misuse, institutional care, street culture activities and adverse life events. It demonstrates that the most complex forms of MEH are associated with childhood trauma. It also reveals that the temporal sequencing of MEH-relevant experiences is remarkably consistent, with substance misuse and mental health problems tending to occur early in individual pathways, and homelessness and a range of adverse life events typically occurring later. The strong inference is that these later-occurring events are largely consequences rather than originating causes of MEH, which has important implications for the conceptualisation of, and policy responses to, deep exclusion. </jats:p

Initial findings from a mixed-methods feasibility and effectiveness evaluation of the 'Breaking Free Health an Justice' treatment and recovery programme for substance misuse in prison settings

Reshaping substance misuse treatment in prisons is central to the UK Government’s drive to address substance dependence in the prison population and reduce substance-related offending and recidivism. Therefore, a through-care project to support prisoners released from custody to community, “Gateways”, is taking place across North-West England. Amongst support with housing, education, training and employment, Gateways incorporates the Breaking Free Online (BFO) substance misuse treatment programme. Aims: To explore BFO’s potential to provide support to prisoners’ substance misuse recovery and continuity of care post-release, and examine quantitative outcomes provided by prisoners who have used the programme. Methods: Qualitative interviews with prisoners and analyses of quantitative psychometric data collected pre- and post-intervention. Findings: Themes emerging from qualitative data around prisoners’ experiences of engaging with BFO illustrate its potential for use in prison settings and also upon release to the community. Significant quantitative improvements to quality of life, severity of substance dependence and aspects of recovery progression illustrate initial effectiveness of BFO. Conclusions: The BFO programme demonstrates potential in providing effective treatment for offenders with substance misuse difficulties, and specifically in delivering continuity of care following release to the community

An exploration of the role of group work in supporting young people affected by parental substance misuse

The Drugs and Young People Project (DYPP) is a small project working with children and young people affected by the substance misuse of their parents/carers. In 2007 DYPP developed a programme of group work in response to the particular needs of the young people with whom they were working. Individual work with these young people is well established, however group work is relatively rare and there is little research into its impact. Work with children affected by parental substance misuse has historically fallen between young people’s safeguarding services and adult treatment services so is a particularly challenging field for integrated work. This project analysed and evaluated the impact of a group work programme on young people affected by parental substance misuse and the role of integrated working in the delivery and development of this programme. A qualitative interview process, with four young people, their parents/carers and social workers, was employed. The foster carers and the parents of the children living at home were asked to take part, and all agreed. All were female. Parents of children in foster care were approached but none were successfully interviewed. The data which emerged was analysed and particular themes emerged. It was found that group work had specific benefits and that well established integrated working was critical to maximizing these benefits. The theme which emerged most strongly was the value of being a part of a group with young people you know have had some similar experiences. There are three implications of this common experience for young people: it makes it safe to be social; they know you are not the only one; and coping strategies can be shared, thus building on resilience. We hope that our findings will enable us to target and improve provision of group work for young people affected by parental substance misuse both within and beyond the Drugs and Young People Project. To this end the Drugs and Young People Project are putting together a manual or workbook which brings together the learning from this project and from the previous group work cycles and will be used with young people over the coming months