National Treatment Outcome Research Study Research Articles

PMH45 - MODELLING THE BUDGETARY IMPACT OF TREATING OPIOID ADDICTION IN THE ENGLISH MUNICIPAL SETTING

Our model estimated budgetary impacts in terms of direct treatment costs and other services provided by local communities, including criminal justice, welfare, child safeguarding and healthcare. We modelled a large town in England across a one-year timeframe. Patients were assumed to receive opioid agonist treatment (OAT) and psychosocial support. Direct OAT costs (medicine acquisition, dispensing and supervised consumption) were based on published sources. Non-pharmacological intervention costs (e.g. counselling) were based on local expert opinion. Wider societal costs were based on published analyses of the National Treatment Outcome Research Study and published references. Expert opinion informed child safeguarding estimates. Two main clinical parameters drove costs: i. retention in treatment and ii. Proportion of urine samples which are free from illicit opioids (i.e. no ‘use on top’), these came from published trial data. 875 patients (50% of local opioid users) received OAT, 60% methadone and 40% buprenorphine. Treatment costs were £821,305. Indirect healthcare costs were £2.34m (£1.6m in users not seeking treatment). Crime costs were £13.4m (£9.1m for users not in treatment). The cost of children in care following parents dropping out of OAT, or not entering OAT at all, was £7.1m although this estimate was based on conservative assumptions. Potential additional cost of child safeguarding was explored in sensitivity analysis. Total cost associated with opioid-using population was £28.9m. If an additional 10% of patients were treated, this annual cost would be reduced by £1.7m. Our model shows that treating opioid addiction with OAT delivers a net cost saving to communities. New treatment approaches should address the issues that prevent users from seeking OAT. The model has potential to be adapted to local settings using locally-gathered evidence.

Commentary on Metrebian et al (2015): What is addiction treatment research about? Some comments on the secondary outcomes of the Randomized Injectable Opioid Treatment Trial.

Keywords: Addiction treatment policy; addiction treatment research; heroin assisted treatment; randomized controlled studies; risk factors; cost-effectiveness; treatment objectives

Alcohol, still the forgotten drug

Alcohol, still the forgotten drug

What future for the Therapeutic Community in the field of addiction? A view from Europe

What future for the Therapeutic Community in the field of addiction? A view from Europe

Reductions in criminal convictions after addiction treatment: 5-year follow-up

Changes in criminal convictions were investigated among 1075 clients admitted to 54 drug misuse treatment services across England as part of the National Treatment Outcome Research Study (NTORS). Convictions data during the year prior to treatment, and at 1 year, 2 years, and 5 years after treatment intake were collected from the Home Office Offenders’ Index, a national database of all convictions in adult and youth courts. Clinical data were collected by face-to-face interviews at intake to treatment, and at follow-up 1 year, 2 years, and 4–5 years after admission to treatment. During the year prior to treatment, 34% of the sample had been convicted of at least one offence. Conviction rates at all follow-up points were significantly lower than at intake. During the year prior to the 5-year follow-up, 18% of the sample had been convicted of at least one offence. Statistically significant reductions in the mean number of convicted offences were also found between treatment intake and 5-year follow-up. Reductions in convictions were found for acquisitive, drug selling, and violent crimes. Reductions in crime were associated with reductions in regular heroin use, age, and with stable housing. The results replicate previously reported findings of crime reductions among the NTORS cohort as indicated by self-reported measures of offending behaviour. The observed reductions in crime among drug misusers after treatment represent substantial changes in behaviour and have considerable personal, social and clinical significance. Reduced criminality also provides substantial economic benefits to society.

Economic analysis of costs and consequences of the treatment of drug misuse: 2-year outcome data from the National Treatment Outcome Research Study (NTORS).

Some economic costs and consequences of drug misuse and treatment were investigated among clients recruited to the National Treatment Outcome Research Study (NTORS). This was a longitudinal prospective cohort design comprising 549 clients recruited from 54 residential and community treatment programmes: data were collected from interviews conducted at treatment intake, at 1 year and at 2-year follow-ups. Treatment costs included index and other drug treatments. Costs were estimated for use of health and social care services, criminal activity and the use of criminal justice resources. Costs were based upon self-reported data collected by structured face-to-face interviews combined with unit cost estimates taken from a variety of sources. Addiction treatment was costed at pound 2.9 million in the 2 years prior to index treatment, and a further pound 4.4 million in the subsequent 2 years. Economic benefits were largely accounted for by reduced crime and victim costs of crime. Crime costs fell by pound 16.1 million during the first year, and by pound 11.3 million during the second year. Health-care costs were relatively small but approximately doubled during the course of the study. The ratio of consequences to net treatment investment varied from 18 : 1 to 9.5 : 1, depending on assumptions. This is likely to be a conservative estimate of the benefit-cost ratio because many potential benefits were not estimated. The data showed clear economic benefits to treating drug misusers in England.

Introduction to 5-year followup treatment outcome studies

National evaluations of drug treatment outcomes and processes over the past 30 years have been an important source of ‘‘real-world’’ evidence for the effectiveness of treatment in the U.S. While they are more limited than experimental protocols in their capacity to establish scientific causality, they excel in documenting naturally occurring patterns of treatment delivery and patient recovery. The Drug Abuse Treatment Outcome Studies (DATOS) is the third national evaluation of community-based treatment effectiveness funded by the National Institute on Drug Abuse (Flynn, Craddock, Hubbard, Anderson, & Etheridge, 1997) following the Drug Abuse Reporting Program from the 1970s (see Simpson & Sells, 1982, 1990) and the Treatment Outcomes Prospective Study from the 1980s (see Hubbard, Marsden, Rachal, Harwood, Cavanaugh, & Ginzburg, 1989). The National Treatment Outcome Research Study (NTORS) has followed the same general model to provide the first large-scale evaluation of its kind in the United Kingdom (Gossop, Marsden, Stewart, & Kidd, 2003). Sets of papers focused on 1-year outcomes and treatment process from DATOS and NTORS have been published in special issues of Psychology of Addictive Behaviors (Simpson & Curry, 1997) and Drug and Alcohol Dependence (Simpson & Brown, 1999), and evaluations of treatment for adolescents in DATOS were reported in a special issue of the Journal of Adolescent Research (Grella & Hser, 2001). Overviews of 1-year and 5-year treatment outcomes for adult cocaine users were also reported in Archives of General Psychiatry (Simpson, Joe, Fletcher, Hubbard, & Anglin, 1999; Simpson, Joe, & Broome, 2002), along with 1-year treatment outcomes for adolescents (Hser et al., 2001). Bullet reports and charts that summarize findings of 75 publications from DATOS are available on its website at www.datos.org. Outcome evaluations reported in this issue and previously were conducted by the four collaborating research cen-

Alcohol use outcomes and heavy drinking at 4–5 years among a treatment sample of drug misusers

This paper investigates alcohol outcomes and heavy drinking among 418 drug misusers from the National Treatment Outcome Research Study who completed followup interviews at 1, 2, and 4–5 years. About a quarter of the sample were drinking heavily at intake. Alcohol consumption at followup was predicted by drinking prior to intake, and about a quarter of those who were classified as alcohol abstainers, medium-level drinkers, or heavy drinkers at intake, remained in the same drinking category at all assessment points. Drinking outcomes were not related to opioid use. Heavy drinkers at followup were more likely to be using non-opioid drugs. The poor drinking outcomes are a matter for concern. Drug misusers with concurrent alcohol problems may require special treatment provision. The extent of heavy drinking among drug misusers both before and after treatment indicates a need to develop and strengthen programs and interventions to tackle alcohol-related problems in this patient group.

Reduction or cessation of injecting risk behaviours? Treatment outcomes at 1-year follow-up

This paper investigates changes in injecting and shared use of needles and syringes among 732 drug misusers recruited to residential and community treatment programmes as part of the National Treatment Outcome Research Study (NTORS). Specifically, it investigates whether reductions in these behaviours were due to a move away from injecting among drug users or whether they could be accounted for by drug users becoming abstinent. Injecting and sharing of injecting equipment were substantially reduced after treatment. Outcomes were due to reduced sharing among injectors, reduced injecting among continuing users and to users becoming abstinent. Clients from residential programmes were more likely to be abstinent at follow-up: methadone clients were more likely to be injecting but not sharing. Abstinence and intermediate risk reduction outcomes were achieved by many drug injectors from both treatment settings. Both outcomes confer benefits, though the benefits of abstinence are greater. Users who were injectors at intake but who had stopped injecting at follow-up consistently achieved superior outcomes across a range of problem behaviours.

Treatment process components and heroin use outcome among methadone patients

The study proposes and tests an integrative and directional (structural equations) model to explain how pre-treatment motivation, frequency and content of counselling services, programme perceptions, and methadone dose are related to 1 and 6 months heroin use outcomes among opiate addicts receiving outpatient methadone treatment. Data were collected as part of the National Treatment Outcome Research Study (NTORS). The sample comprised 262 patients who were admitted to, and retained in methadone treatment programmes at 6 months. Structural equation models showed several relationships between treatment process variables and heroin use outcomes at 1 and 6 months follow-up. Programme perceptions and methadone dose were related to reduced heroin use at 1 month; early engagement with treatment services was related to reduced heroin use at 6 months. Pre-treatment motivation and engagement with treatment services were indirectly related to reduced heroin use at 1 month through their association with programme perceptions. Short-term (1 month) heroin use was strongly related to heroin outcome at 6 months. In addition to direct effects, treatment factors may have important indirect effects upon subsequent outcomes through their influence upon short-term outcomes.

The National Treatment Outcome Research Study (NTORS): 4-5 year follow-up results.

The National Treatment Outcome Research Study (NTORS) is the first prospective national study of treatment outcome among drug misusers in the United Kingdom. NTORS investigates outcomes for drug misusers treated in existing services in residential and community settings. The study used a longitudinal, prospective cohort design. Data were collected by structured interviews at intake to treatment, 1 year, 2 years and at 4-5 years. The sample comprised 418 patients from 54 agencies and four treatment modalities. Measures were taken of illicit drug use, injecting and sharing injecting equipment, alcohol use, psychological health and crime. Rates of abstinence from illicit drugs increased after treatment among patients from both residential and community (methadone) programmes. Reductions were found for frequency of use of heroin, non-prescribed methadone, benzodiazepines, injecting and sharing of injecting equipment. For most variables, reductions were evident at 1 year with outcomes remaining at about the 1 year level or with further reductions. Crack cocaine and alcohol outcomes at 4-5 years were not significantly different from intake. Substantial reductions across a range of problem behaviours were found 4-5 years after patients were admitted to national treatment programmes delivered under day-to-day conditions. The less satisfactory outcomes for heavy drinking and use of crack cocaine suggest the need for services to be modified to tackle these problems more effectively. Despite differences between the United Kingdom and the United States in patient populations and in treatment programmes, there are many similarities between the two countries in outcomes from large-scale, multi-site studies.

Changes in use of crack cocaine after drug misuse treatment: 4–5 year follow-up results from the National Treatment Outcome Research Study (NTORS)

Crack cocaine outcomes at 4–5 years are reported for 496 drug users recruited from UK treatment programmes. About one-third used crack at intake and at 4–5 years. The results show different outcome profiles. For crack users at intake, use was more than halved at follow-up. Among non-crack-users at intake, about a quarter used crack during follow-up, of whom about two-thirds had never used crack before. Polydrug use and use of other stimulants were associated with using crack. Crack users reported worse acquisitive crime and psychological health outcomes. About 10% reported injecting crack. The reductions in crack use are encouraging, but the onset of crack use among many non-users at intake suggests the need to develop more effective treatment interventions.

Reduced injection risk and sexual risk behaviours after drug misuse treatment: Results from the National Treatment Outcome Research Study

This paper investigates injecting, shared use of needles/syringes and sexual risk behaviours at intake to treatment and at one-year follow-up among 753 drug users recruited to the National Treatment Outcome Research Study (NTORS). Injecting, sharing and having unprotected sex were substantially reduced among clients admitted to methadone programmes and among those admitted to residential treatments. The overall levels of risk fell after treatment, and the majority of those who were engaged in high risk behaviours at intake had stopped at follow-up. The results also show the variability of individual outcomes. A minority persisted with their risk behaviour, and others who were not at risk at intake who had started to engage in risky behaviours at follow-up. The behaviour of these clients creates a focal point for risk as well as being a threat to public health. Several social and psychological factors were predictive of health risk behaviours. These included frequency and duration of heroin use, polydrug use, alcohol use, gender, ethnicity, having a drug-using partner, anxiety and depression. The results indicate the important role that can be played by treatment services in helping to reduce the risk of blood-borne infections. We suggest that risk reduction interventions are an important and effective component of treatment programmes.

Reductions in non-fatal overdose after drug misuse treatment: results from the National Treatment Outcome Research Study (NTORS).

Few studies have reported changes in rates of overdose after drug misuse treatment. This paper investigates changes in non-fatal overdose between treatment intake and 1 year follow-up among a sample of 753 clients recruited to the National Treatment Outcome Research Study (NTORS). A relatively high rate of overdose (15%) was reported during the 3 months prior to treatment. Variables predictive of overdose at intake to treatment included injecting, frequency of benzodiazepine and cocaine use, quantity of alcohol consumption, and levels of anxiety. At 1 year follow-up, the rate of non-fatal overdose had fallen to 6%. Reduced rates of non-fatal overdose were found for clients treated in both residential and community treatment settings. Reductions in overdose were linked to improvements in frequency of drug use and lower rates of injecting. Clients who overdosed at follow-up showed no improvements in their substance use, except for frequency of crack cocaine use. The risk of non-fatal overdose at 1 year was associated with injecting and multiple drug use. These findings support the view that treatment an important role can play in reducing deaths among drug misusers.

Change and stability of change after treatment of drug misuse: 2-year outcomes from the National Treatment Outcome Research Study (UK).

The National Treatment Outcome Research Study (NTORS) is a longitudinal, multisite, prospective cohort study that assesses changes in illicit drug use and other problems after treatment in national (UK) drug misuse treatment programmes. Clients were recruited from 54 residential and community-based drug treatment programmes throughout England. Four modalities were studied: inpatient drug dependence units, residential/rehabilitation programmes, methadone maintenance, and methadone reduction programmes. Data on substance use behaviours and physical and psychological health were collected by structured face-to-face interviews at intake, 1- and 2-year follow-up. Data are presented for 549 clients. A majority of clients achieved widespread improvements across a range of outcome measures after treatment in existing treatment services. For most outcomes, reductions in problem behaviours at the group level occurred within the first year and were maintained at 2 years. Considerable stability of outcomes at the individual level was also found. Abstinence from illicit drugs was substantially increased among clients from both residential and community programmes, and there were also substantial reductions in frequency of use of heroin, nonprescribed methadone, benzodiazepines, and crack cocaine. Injecting and shared use of injecting equipment was also reduced. Heavy drinking was common at intake and was not reduced at follow-up. Psychological and physical health problems were reduced on both groups at follow-up. These changes represent important clinical benefits to the individual clients, to their families, and to society.

Outcomes after methadone maintenance and methadone reduction treatments: two-year follow-up results from the National Treatment Outcome Research Study

This paper provides a detailed analysis of the 2-year outcomes for 351 drug misusers allocated on an intention-to-treat basis to methadone maintenance or methadone reduction treatments. Both groups showed substantial reductions in their use of illicit drugs and in other outcome areas. However, whereas most methadone maintenance patients received maintenance, only about one third of those allocated to methadone reduction received methadone reduction, and many actually received a form of methadone maintenance. Reduction patients were more likely to receive low doses of methadone, and were less likely to remain in treatment. For maintenance patients, higher doses and retention in treatment were both associated with improvements in illicit heroin use at 2 years. For the reduction patients, the more rapidly the methadone was reduced, the worse the heroin use outcomes. For patients in both treatment conditions, reductions in heroin use were associated with improvements in other outcome areas. The more severely dependent patients showed better outcomes in methadone maintenance. Methadone reduction treatment processes were associated with poor outcomes, and many patients who were allocated to methadone reduction treatment did not receive reduction treatment as intended. This calls into question the appropriateness of either the initial treatment planning process or the treatment delivery process, or both. A clearer distinction should be made between methadone maintenance and methadone reduction. Treatment goals should be made explicit both to the patient and to the clinical staff at the start of treatment. We suggest the need for a reappraisal of the goals and procedures of methadone reduction treatment.

Patterns of improvement after methadone treatment: 1 year follow-up results from the National Treatment Outcome Research Study (NTORS)

One year outcomes for substance use behaviours, health and criminal behaviour, and variation in treatment response, are reported for patients recruited to methadone maintenance and methadone reduction treatment programmes as part of NTORS. Significant reductions in the use of all illicit target drugs were found at follow-up for patients recruited to the methadone maintenance and methadone reduction modalities. Because of similarities in the treatments received by clients in the two modalities we caution against interpreting these findings as showing that methadone maintenance and reduction treatments lead to similar outcomes. At this stage, it is suggested that these outcomes be regarded as reflective of exposure to some general methadone substitution treatment. Further investigation of the outcomes for the two modalities will be conducted. Cluster analyses were used to classify patients according to level of improvement in drug use. Four groups were identified. Two groups (59% of cases) showed substantial reductions in their illicit drug use and criminality as well as reduced physical and psychological symptoms. Twenty two percent of cases showed poor outcomes across a range of measures. Results for alcohol consumption were less satisfactory for patients in all groups. A majority of patients achieved widespread improvements across a range of outcome measures after treatment in existing methadone treatment services. These changes represent important clinical benefits to the individual clients, to their families and to society.

Patterns of drinking and drinking outcomes among drug misusers. 1-year follow-up results.

This article investigates patterns of drinking and drinking outcomes among 753 drug-misusing clients recruited to the National Treatment Outcome Research Study (NTORS). More than one third of those who were drinking at intake reported problematic or highly problematic patterns of alcohol consumption. About one third of the sample were abstinent from alcohol at intake and at follow-up. Some improvements in drinking behavior were found at 1-year follow-up, especially among the heaviest and most problematic drinkers. Improvements were specifically related to patterns of preintake drinking behavior. The majority of clients made little change to their pattern of pretreatment drinking behavior and the continued heavy drinking of many drinkers at follow-up is a disappointing finding. Drinking problems have been given insufficient attention in the treatment of illicit substance misuse problems, and efforts should be made to develop and strengthen the assessment and treatment of drinking problems among drug misusers.

Drug selling among drug misusers before intake to treatment and at 1‐year follow‐up: results from the National Treatment Outcome Research Study (NTORS)

AbstractDrug misusers recruited to the National Treatment Outcome Research Study were interviewed at intake to treatment programmes throughout England (n = 1075), and after 1 year (n = 753). Data were collected on self‐reported involvement in and frequency of drug‐selling activities and other crimes during the 90‐day periods prior to each interview. A huge number of drug‐selling offences (39 153) was reported prior to intake. Fewer than one‐third of the clients (29%) reported selling drugs during the 90 days prior to intake, and among those clients who had sold drugs, drug selling was an infrequent and occasional activity. Most clients reported not selling drugs. A small minority (7%) committed the majority (89%) of drug‐selling offences. These high‐rate drug sellers reported different patterns of substance misuse to other drug sellers, including more frequent use of heroin but less severe dependence upon heroin, and less frequent drinking. The involvement of these high‐rate drug sellers may reflect a more ‘professional’ approach to dealing. Reductions in dealing were found for clients from both residential and methadone programmes. Overall, the number of dealing offences at 1 year was reduced to a less than one‐fifth of intake levels and the rate of involvement in crime was also reduced to less than two‐thirds of intake levels. Reductions in drug selling were associated with reductions in regular heroin use.

Treatment outcomes of stimulant misusers: One year follow-up results from the national treatment outcome research study (Ntors)

There are substantial gaps in knowledge about treatment outcomes for stimulant misuse. This paper investigates patterns of stimulant use and outcomes of stimulant misusers one year after starting treatment at 54 agencies within United Kingdom national services. In a prospective, longitudinal cohort study of 1,075 drug misusers, 637 were current users of stimulant drugs at intake to treatment. Most of the clients were multiple drug users. Stimulants were the main problem drug for 13% of the sample. The two most frequently used drugs were crack cocaine and amphetamine sulphate. The most frequently reported pattern of stimulant use was among heroin dependent clients who also used stimulants. The clients for whom stimulants were the main problem drug were most likely to approach residential rehabilitation programs for treatment. Overall, the stimulant users showed satisfactory outcomes with marked reductions in substance use and other problem behaviors at follow-up. Many clients with stimulant misuse problems were able to achieve substantial improvements after treatment within existing services.