Need for interventions- Harms, Costs and context
Since the 1980s increasing attention has been paid to the growing costs of alcohol and drug use to Australian and globally communities. Research articles have estimated social costs of Australian Alcohol tobacco and other drug use; Collins and Lapsley estimated at ‘1.1 billion’ (Collins & Lapsley, 2008) dollars in both tangible and intangible costs, while the AERF have counted the cost incurred at ‘14.2 billion dollars’ (Laslett, et al., 2010). The increasing recognition of the growing burden of disease attributed to the use of alcohol and tobacco has spawned a large amount on research into interventions.
The focus for these interventions has been early intervention for ‘two of the most preventable causes of disease and death’ (Roche & Freeman, 2004) due to alcohol and tobacco use.
The changing understanding of the use and health consequences of alcohol tobacco and other drugs (ATOD) has created an atmosphere where ATOD use is now considered within a health framework. Much literature has been signified that ATOD use occurs across a spectrum from abstinence on one end through to hazardous use, harmful use, substance abuse through to substance dependence on the other end, punctuated throughout the continuum with increasing levels of psychosocial issues
The majority of the burden of disease lies at the point where people who are in the hazardous categories through to substance abuse are coming into contact with the health systems due to morbidity related to ATOD. The lower tiers of use also have the greater population density, through to dependence which has the lowest population density.
Screening is a ‘process that differentiates people who have, or at risk of having a medical condition’ (Babor & Higgins-Biddle, 2000) inclusive of harm from use and development of dependence. Due to the wide ranging nature and density of alcohol tobacco and other drug use within a population, much development work has been done on; the use of ‘screening and assessment tools’ (Dawe, Loxton, Hides, & Kavanagh, 2002) to assist with identifying problem use, formulating future treatment goals, appropriate treatment intensity, and intervening within an individual’s trajectory of alcohol tobacco and other drug use. A number of validated screening tools for ATOD-related problems are available, including: ASSIST: The Alcohol, Smoking and Substance involvement Screening Test, AUDIT: The Alcohol Use Disorders Identification Test, Fagerstrom Test for Nicotine Dependence, SDS: The Severity of Dependence Scale
The purpose of dug interventions in Australia (under the national framework harm minimisation) focus on intervene in health behaviours to achieve a reduction in problems associated with alcohol tobacco and other drug use. This strategy recognises that drug use occurs across a continuum, and that positive health outcomes can be achieved without total abstinence from use. This allows some flexibility in the outcomes of interventions dependent on need; a continuum from BI informational sessions through to protracted clinical engagements targeted at cessation for more dependent users. This also looks to balance the ‘risks and benefits among individual users and the community as a whole’ (Gowing, Proudfoot, Henry-Edwards, & Teeson, 2001)
The purpose of brief interventions is early intervention along the continuum of substance use, to reduce excessive use across a population. This incorporates screening & case identification of those classed as at risk but not dependent with their pattern of use. Sessions are generally between 5 minutes and one hour, in some cases multiple short sessions can occur. Within these sessions provision of information, brief counselling or ‘structured advice’ (Babor & Higgins-Biddle, 2000; Heather, 1996; Roche & Freeman, 2004; Heather, 2010) is given targeting the problem health behaviour.
BIs are a person centred, problem specific and solution focussed in regards to the particular set of health concerns that a person presents with. There are a few common themes identified to how BIs are conducted; ‘instructional, motivational, educational, information feedback, skill building, and referral’ (Babor & Higgins-Biddle, 2000). There has been a big focus on interventions that are client centred and based on the principles of ‘motivational interviewing’ (Miller & Rollnick, 2002). BIs are based on the Rogerian principles of a therapeutic client centred relationship, while also be directive in the nature of the ATOD content covered.
The most widely circulated and referenced articles found that effective of BIs contained; ‘Feedback’ of assessment, developing personal ‘responsibility’, ‘advice’, ‘menu’ of options, expression of ‘empathy’ (Bien, Miller, & Tonigan, 1993; Moyer, Finney, Swearinggen, & Vergun, 2002; Miller & Rollnick, 2002; Daeppen, Bertholet, & Gaume, 2010).
Interventions in this typology hope to achieve a change in the pattern of use through; Developing intrinsic motivation, education, information, brief advice about specific substances and their effects. It is surmised that giving people information at this stage increases awareness of the risks involved in the use of substances, and modifies risk assessment capacity resulting in behaviour change. A great deal of excitement was developed in the research community about the viability of BIs for the reduction of alcohol.
BIs are simple generic targeted interventions that have been specifically developed to be utilised across health and community sectors. These can be delivered by a number of professional and Para-professional staff with some basic training. And are also understood as easy to administer, fast and efficient way of earlier intervening and targeting health behaviours. Multiple Benefits have occurred from the development of BIs but trade-offs do occur at the same time; there is a trade-off between delivering high quality and intensive services at an individual level and delivering less intensive & less structured interventions which are able to be mobilised within the broader population.
Being broader ranging BI have been shown to be ’cost effective’ (Kaner, 2010; Heather, 1995; Mattick & Jarvis, 1994; Heather, 2010; Gibson & Shanahan, 2007; Cowell, Bray, & Mills, 2010) alternatives to treatment as usual. Although ‘cost estimates variation’ (Cowell, Bray, & Mills, 2010) are present due to the very nature of the interventions. The complexities of interventions typologies allow for no standardised or ‘comparable outcome’ (Gibson & Shanahan, 2007; Cowell, Bray, & Mills, 2010), which in turn make it difficult to conduct appropriate or deliver economic evaluations.
Having a simpler time efficient and contextually broad ranging intervention allows greater impact within a much larger population ‘in need’ (Heather, 1996). It allows engagement and retention for the large populations who fall within the hazardous and substance abuse continuum. This support BI as a cost effective population health intervention aimed at pro actively changing the low risk behaviour of a total population.
Reviewing the epidemiological patterns and accepting the proposition that ‘most use ceases around age 29’ (Chen & Kandel, 1995) it would appear that BI can provide useful prevention based intervention in regards to shortening a person’s use career or intensity of that career until it peters out or increases to dependence as the natural history of use would suggest.
There are different of needs across the spectrum of use, research indicates that people not dependent require different levels of interventions as they feature ‘different motivations to change behaviours’ (Connors, Donovan, & DiClemente, 2001). And in some cases those who are most dependent do not benefit from BIs. Research acknowledged that people who do not respond to BI ‘need follow up care’ to reinforce interventions and the ‘change process’(Heather, 2010; Moyer, Finney, Swearinggen, & Vergun, 2002; Mattick & Jarvis, 1994; Heather, 2011; Daeppen, Bertholet, & Gaume, 2010).
On an individual level BI outcomes have been shown to vary considerably depending on; substance, BI effect, reduce or decay over time, age, substance use career, and gender and socio economic status. (Moyer, Finney, Swearinggen, & Vergun, 2002; Heather, 1996; Roche & Freeman, 2004; Tait & Hulse, 2003; Satre, Blow, Chi, & Weisner, 2007; Heather, 2011). Many article are now critiquing the ‘implementation’, standardisation and ‘utilisation’ (Cowell, Bray, & Mills, 2010; Roche & Freeman, 2004; Heather, 2010; Kaner, 2010) of BIs across healthcare systems, even so there seems sufficient aggregated public health outcomes already achieved. Much of the research does link the need to develop systematic support from the community understandings of ATOD issues and local policy and legislative means to ensure that the environment reflects the public health interest in the reduction of harms from ATOD.
If taking a behavioural based perspective; Change is an active process that requires many psychological and social catalysts to start and then maintain the process. In addition it takes time to ‘consolidate these insights into ongoing real life behaviour’ (Sellman, 2009). This may be where the overall outcomes of brief interventions start to show less effect over time as behaviour is dropped off, as fewer reinforcing factors are involved within the micro through to macro environments which ‘maintain or facilitate’ (Moos, 2007) patterns of use.
Within understanding the process of individual change the limitations of brief interventions can be teased out in comparison to longer clinical engagements, which in the course of the engagement can vicariously act as a reinforcer of change. And the literature reflects that there is uncertainty if the content or processes of interventions are the effective element.
As people progress along the continuum of use toward the end of dependence more problematic issues arise. These issues take time to resolve and may be rooted in ‘biology, psychological, social issues, comorbidities, history, personality construct, early life developmental foundations, and disrupted attachments. Which in turn may develop into additional psychosocial issues and reinforce patterns of problematic use.
Comorbidity is now accepted as the norm for people presenting with high levels of substance use or dependence (Sellman, 2009; Alsop, 2008). Short term therapies are mostly symptomatic relief from issues and may not engender long lasting change and exploration of the psychosocial issues that frequently drive use or the problems themselves.
In the case of additional needs, more prolonged engagement may be more effective and have better outcomes through the ongoing engagement with the myriad of concurrent issues. Systematic research into the delivery of psychosocial interventions in severe comorbid populations has shown that longer term psychosocial interventions such as ‘AA groups, CBT, Motivational interviewing and skills training’ are no more effective than one another in treatment outcomes. (Cleary, Hunt, Matheson, Siegfried, & Walter, 2010).
Although one systematic review has suggested that longer term therapy achieves ‘greater follow up outcomes’ (Moyer, Finney, Swearinggen, & Vergun, 2002) the majority suggest otherwise. One caveat to this is the dearth of systematic reviews of other treatment types within the alcohol and drug research.
Research into the effectiveness of; cognitive behavioural therapy and behavioural family counselling, twelve step facilitation treatment, Motivational interviewing and contingency management and community reinforcement showed similar outcomes. Motivational interviewing had the greatest outcomes in reduction of use.
Although all six approaches shared four common themes; ‘a) support structure and goal direction, b) rewards and rewarding activities, c) abstinence oriented roles and models, d) self-efficacy and coping skills’ (Moos, 2007). These elements are described as particular mediators or protective factors in relation to the use or relapse into the use of substances.
Of particular emphasis in the research is the ‘quality of the relationship’ (Moyers, Miller, & Hendrickson, 2005; Lambert, 2001; Daeppen, Bertholet, & Gaume, 2010) determining treatment outcomes. As with all human relationships good therapeutic relationship takes time to develop sufficient depth and trust to explore interpersonal issues. For people experiencing higher psychosocial issues and higher use the longer term therapies may be more useful for; resolving attendant issues by interventions focusing on the four themes previously mentioned.
Conclusion Brief interventions are as effective as other longer term approaches commonly used in the substance abuse field for people who are not dependent. The large evidence base would suggest that these short term interventions are the most cost efficient intervention in regards to resource intensity and best large scale public health intervention in dealing with low to moderate levels of drug use. As people increase their levels and intensity of use, other protracted treatments may be more effective at reducing the concurrent attendant issues across biopsychosocial domains. Under the current evidence a stepped and tiered approach to interventions should begin with Brief interventions and be followed up with increasing intensity of treatment dependant on individual needs.
