The 5-Step family intervention in primary care: II. The views of primary healthcare professionals

Background: This is the second of two papers using qualitative methods from a study of an intervention for family members affected by close relatives’ substance misuse problems.

Participants: 168 primary healthcare professionals (PHCPs: GPs, practice nurses and health visitors) working in general practices in two areas of England, and who took part in the study.

Data sources: Recruitment and post-session forms completed by PHCPs; telephone interviews with each PHCP 12 weeks after recruitment of a family member; interviews with PHCPs at the end of the study.

Results: At the end of the project PHCPs were overwhelmingly positive about the family member intervention and about primary care as the appropriate site. Difficulties were encountered, however, in identifying and engaging affected family members, who were often excluded on grounds of the complexity of their problems or the level of their distress. Shortage of PHCP time and other practice-related factors added to the difficulty. Active work by a PHCP was often necessary in order to make the link between presenting symptoms of physical or mental ill-health and the existence of a family substance misuse problem. When family members were identified and recruited, PHCPs were usually positive about what was achieved. Nearly all were in favour of an approach that combined giving a self-help manual with some follow-up contact with a family member as needed.

Conclusions: Taken in conjunction with statistical outcome findings of significant reductions in symptoms and changes in ways of coping, plus qualitative analysis of the views of family members, the present results encourage the view that a flexible form of this intervention should be developed for use in primary healthcare, and that further work should build on existing strengths and attempt to overcome weaknesses identified.     

The 5-Step family intervention in primary care: I. Strengths and limitations according to family members

Background: Family members affected by a close relative's substance misuse constitute a large but neglected, high-risk group. Interventions for that group are now being developed and tested in trials. More use should be made of qualitative methods to study process in such interventions.

Design: Semi-structured interviews with family members 12 weeks after assignment to a full or brief 5-Step intervention. Both involved a primary care professional giving a self-help manual, and the full version also involved up to five sessions of a psychosocial intervention.

Participants: 143 patients of GPs, health visitors and practice nurses in general practices in two areas of England. Patients were the family members of close relatives with drinking or other drug problems.

Analysis: Framework analysis and grounded theory analysis of post-interview reports.

Results: There was strong support for a form of intervention that involved face-to-face discussion with a primary care professional, and those who received the full intervention were appreciative of being able to talk to a professional who had time to listen and who appeared interested, understanding and caring. The self-help manual itself was reported to contain active ingredients for change, and a number of family members described transformations in their ways of coping with the problem whether they received the full or brief form of intervention. A common constellation of changes included increased consciousness of the nature and extent of the relative's drinking or drug use and its family effects, an acknowledgement of the family member's own needs and rights, a strengthening of resolve to assert plans and expectations, and a calming effect with reduction in stress symptoms. Many participants were unable to describe changes, however, and the following principal limitations of the intervention were described: prior familiarity with the material, perception that the intervention did not go far enough, belief that it was incapable of effecting change for the substance misusing relative, and a perception that sufficient professional expertise or sympathy was not always available in primary care.

Conclusions: Findings suggest that the 5-Step family intervention has positive potential in the primary care setting, but has limitations and may need strengthening for family members whose problems are of longer standing or who have already been exposed to relevant information.     

Working with family members in specialist drug and alcohol services: Findings from a feasibility study

Background: Family members can be affected by a relative's substance misuse, but service provision is limited. A brief intervention in primary care has been shown to be effective. The application of such an intervention in other settings requires investigation.

Aims: To assess the feasibility of the development and implementation of a brief intervention for family members of substance misusers, within Specialist Drug and Alcohol Services.

Method: A before and after mixed methodology design.

Findings: Thirteen staff, from seven teams across one Mental Health NHS Trust area, worked with twenty family members. It was shown that it was feasible to: adapt the intervention for use within a specialist setting; recruit and train specialist service staff to deliver the intervention; have these staff recruit and work with family members; and for this intervention to be seen by both staff and family members as a positive and useful addition to service delivery. However, although feasible, there are still difficulties in integrating this work into routine clinical practice.

Conclusions: It is feasible, and beneficial, for specialist drug and alcohol services to deliver a brief intervention to family members. However, organizational and commissioning issues mean that routine delivery of such an intervention may not yet be possible, until full recognition is given to the view that addiction problems are best dealt with in a more holistic way that takes into account the family context within which most people live.     

Professionals' evaluation of the '5-step method' for helping family members of substance misusers in the context of the Italian Health Services

Background: A feasibility study of an intervention aimed at helping and supporting family members, affected by a relative's alcohol or drug problems, was undertaken in an Italian health services context.

Aims: To assess professionals' (Italian general practitioners and community addiction staff) views about the usefulness and applicability of a 5-step intervention for helping family members affected by someone else's substance-misuse problems.

Method: Analysis of professionals' written reports following each of 52 interventions, plus analysis of focus-group discussions with these professionals.

Findings: Forty-one professionals within southern Italy (18 Italian GPs and 23 community addiction staff) were trained and 23 of them (10 and 13 respectively) went on to recruit at least one affected family member and undertake an intervention with them. These 23 staff worked with 52 affected family members (mean, 2.3 treatments/professional). Analysis of the staff-completed intervention reports following each intervention, and of focus-group discussions with the professionals, showed that professionals rated the interventions as being effective and helpful, especially the giving of space to individual family members to discuss their problems in relation to their relative's alcohol or drug dependence. Many positive changes were noticed in families being helped, as well as some difficulties being reported by the professionals related to them using this method. A number of differences between staff from different settings were found, with community addiction service staff being more likely to consider that this intervention would be easy to incorporate into routine practice, and with Italian GPs finding the focus on the family members (as opposed to the substance misusing relative) to be more problematic.

Conclusions: The large majority (79%) of professionals from both services stated that they were planning on utilizing the 5-step intervention again. It may be feasible to implement this intervention more widely within Italy.     

The 5-Step family intervention in primary care: I. Strengths and limitations according to family members

Background: Family members affected by a close relative's substance misuse constitute a large but neglected, high-risk group. Interventions for that group are now being developed and tested in trials. More use should be made of qualitative methods to study process in such interventions.

Design: Semi-structured interviews with family members 12 weeks after assignment to a full or brief 5-Step intervention. Both involved a primary care professional giving a self-help manual, and the full version also involved up to five sessions of a psychosocial intervention.

Participants: 143 patients of GPs, health visitors and practice nurses in general practices in two areas of England. Patients were the family members of close relatives with drinking or other drug problems.

Analysis: Framework analysis and grounded theory analysis of post-interview reports.

Results: There was strong support for a form of intervention that involved face-to-face discussion with a primary care professional, and those who received the full intervention were appreciative of being able to talk to a professional who had time to listen and who appeared interested, understanding and caring. The self-help manual itself was reported to contain active ingredients for change, and a number of family members described transformations in their ways of coping with the problem whether they received the full or brief form of intervention. A common constellation of changes included increased consciousness of the nature and extent of the relative's drinking or drug use and its family effects, an acknowledgement of the family member's own needs and rights, a strengthening of resolve to assert plans and expectations, and a calming effect with reduction in stress symptoms. Many participants were unable to describe changes, however, and the following principal limitations of the intervention were described: prior familiarity with the material, perception that the intervention did not go far enough, belief that it was incapable of effecting change for the substance misusing relative, and a perception that sufficient professional expertise or sympathy was not always available in primary care.

Conclusions: Findings suggest that the 5-Step family intervention has positive potential in the primary care setting, but has limitations and may need strengthening for family members whose problems are of longer standing or who have already been exposed to relevant information.     

Substance misuse training among psychiatric doctors, psychiatric nurses, medical students and nursing students in a South London psychiatric teaching hospital

Background: Health professionals play an important role in the detection and subsequent management of individuals who misuse substances.

Aim: This article aimed to assess self-reported levels of training received by psychiatric doctors, nurses, medical students and nursing students in a South London psychiatric teaching hospital.

Method: Self-completion questionnaire assessing key aspects of training.

Findings: We found low overall levels of reported training in substance misuse. Of the reported training received, most was theoretical rather than clinical. The highest level of reported training was in alcohol misuse compared to illicit drug and tobacco misuse. High numbers of respondents reported feeling responsible for helping individuals with substance misuse difficulties but low numbers actually felt skilled to do so, indicating high levels of awareness without the requisite training.

Conclusion: Our findings suggest that more resources should be focused on teaching psychiatric doctors, nurses, medical students and nursing students the key issues in substance misuse, and that this training should be clinically grounded, to alleviate the perceived low levels of reported clinical training in this study and the resulting lack of confidence.     

Illicit drug use among Bangladeshi women living in the United Kingdom: An exploratory qualitative study of a hidden population in East London

This explorative study focused on Bangladeshi women using illicit drugs in the London Borough of Tower Hamlets, which has a large Bangladeshi population. The study was designed to: examine Bengali women's perceptions of their drug use and perception of treatment services; identify the cultural determinants of service utilization; examine the concept of izzat (honour) and its role in contributing to the secrecy surrounding Bengali women's drug use; examine the pressures that have contributed to Bengali women accessing drug treatment services in Tower Hamlets; and examine barriers to the utilization of drug treatment services.

 Eight Bengali female drug users were recruited via two treatment settings and one by snowballing methods and data gathering was through qualitative discourse.

 The findings revealed that Bengali female drug users constitute a hidden population that is engaging in high-risk behaviours, especially unsafe sex. Cultural constructs, such as shame about drug use, antipathy towards injecting and stigmatization of drug use in the community are all present in this group. Gender role expectations are particularly pronounced for this group and they face greater gender discrimination from within their community in respect of substance use and misuse than their male counterparts. They experience profound barriers to treatment, which prevent them from accessing services at an earlier stage in their drug use. Their presentation to drug services frequently involves a coercive element whether from family members or social services.

 Service provision should include targeted hepatitis- and HIV-prevention programmes.     

Substance Misuse Services in Primary Health Care

Introduction: Substance misuse remains the largest cause of preventable morbidity and mortality in the UK. As the first port of call for advice and care, the Primary Health Care (PHC) setting offers an ideal opportunity for prevention of substance misuse. The most basic activity is to ask patients whether they use specific substances.

Methods: All practices within four Health Authorities across South London were targeted. A self-completion questionnaire for PHC staff was designed for demographic information and previous training on substance misuse. Information on services provided by the practice was requested from the Practice Manager only.

Results: Twenty-five per cent (104/417) of the practices responded. Seventy-four per cent reported providing smoking, 76% alcohol and 81% drug services, and 67% reported providing all three. There was no significant association between services provided and PHC professionals' training in substance misuse.

Discussion: Less than half the practices reported screening their patients for smoking and drinking, and less than a third for drug use; a much greater number reported referring to specialist services for alcohol and drug use. This indicates that PHC professionals tend to engage with this health concern when the problem has escalated and specialist referral is required. A methodological limitation to this study is the low response rates and the possibility of a response bias in those who did respond.     

Drug issues affecting Chinese, Indian and Pakistani people living in Greater Glasgow

This paper describes research on drug issues affecting Chinese, Indian and Pakistani people living in Greater Glasgow. There were two strands: (i) a questionnaire-based survey of young people and focus groups; (ii) interviews with young people and adults. The primary aims were to gather prevalence data and to investigate perceptions about current service provision. A methodological discussion also takes place as to the relationship between the quantitative and qualitative data gathered.

Results show that use and misuse of drugs is reportedly present and increasing among young people in the three ethnic groups, with cannabis being the most prevalent drug. However, prevalence is still generally reported at lower levels than reported for the general population. Predictors of consumption include gender (male consumption higher), non-importance of religion, and higher consumption among friends from the same (self-identified) ethnic group.

Service provision was felt to be insensitive to issues affecting Chinese, Indian and Pakistani groups. Specific issues (religious, cultural, social) that need to be addressed by service providers are outlined. A general conclusion is that choices should be available, and stereotypes and general assumptions should be avoided.     

Adopting early intervention for substance use disorders: a preliminary study of primary healthcare professionals in New York State

Abstract

Aims: Research has reported a lack of practice of early intervention for substance use disorders among primary healthcare professionals, and only a fraction of patients were asked about their substance use when visiting a primary healthcare office. This study examines conditions that may influence the adoption of early intervention [i.e., screening, brief intervention and referral to treatment (SBIRT)] among primary healthcare professionals. Methods: A pilot survey was emailed to primary care physicians, nurse practitioners, and physician assistants in New York State, and 248 recipients responded to the survey. Findings: Three areas appear to be associated with the adoption of SBIRT: percentage of respondents’ patients using marijuana (β?=?0.14; p?<?0.05); perceived ability to perform intervention (β?=?0.32; p?<?0.05); and perception of early intervention as a responsibility of primary care professionals (β?=?0.29; p?<?0.05). Conclusions: Training and education to promote SBIRT for primary care workers should focus on increasing their favourable attitudes towards the intervention as a strategy of preventive medicine and include the knowledge of the infrastructure of services for substance use disorders, especially for medical providers who see large numbers of patients at a high risk for alcohol and drug misuse.     

Community health workers and the drug problem

Denial about the habitual misuse of substances is a standard feature of addictive behaviour. Denial by a collective of addicts when they form a sufficient proportion can then become a societal norm. This societal denial is a major factor in the conspiracy of silence.

Breaching denial is a necessary first step for addicted people seeking change. The community response to addictive behaviour must contain the essential steps as defined in the structured intervention technique (“Alconfrontation”) for the individual. They are: (i) definition and acceptance of the nature of the problem; (ii) education about addictive behaviour and the substances concerned, within a relevant perspective; (iii) clarification of the options and objectives; and (iv) contract making.

It is possible for communities to achieve collective change if enough significant catalytic individuals and agencies strive to do so.

In relation to drink driving and analgesic abuse there have already been significant advances. Cigarette smoking has declined rapidly and this wind of change can be fanned. Armidale in New South wales has a Bicentennial objective to be visibly free of cigarette smoking with its theme “Armidale Leads the Smoke-Free World”.

Innumerable surveys have confirmed that the major factor in society's problems is substance abuse. What is needed now is a core of catalysts to provoke change by increasing awareness, by appropriate education, by exploring tactics for change and by pushing for commitment and contract for change.     

Overview: Beyond guidelines and guidance—psychosocial perspectives on treatment interventions for young people with substance problems in the United Kingdom

Over the last two decades there has been accumulating evidence that both psychosocial and pharmacological treatment interventions can effect change in substance-misusing adults. Thus, treatment interventions implemented for young people with substance problems largely draw on the adult addiction experience and that of child and adolescent psychiatry and psychology. As young people with problematic drug use have different treatment needs, and require different interventions and services to those of adults, results of adult studies cannot necessarily be directly extrapolated to young people.

Over the last five years evidence has been rapidly mounting that treatment may potentially work in young people, but as yet it is not as extensive as that for adults. The interventions that appear most fruitful are those based on learning theory, e.g. cognitive behavioural therapy and family therapy. Outcome studies in young people demonstrate substantial variability in substance use and misuse following treatment. From the UK perspective, the evidence is almost entirely USA based, and these evaluations of non-UK treatment programmes for young people cannot be simply transferred or transported to UK healthcare settings. This has significant implications for practice and policy.

At this stage, 'guidelines' or 'guidance' that is available is either not directed at young people and/or is largely gleaned from the USA literature. In addition, it does not adequately capture the complexity of cases at front-line specialist settings. The management of young substance misusers in the UK is, in the main, 'beyond guidelines and guidance'.

The restricted treatment service network for young people in the UK makes the potential for undertaking studies on treatment effectiveness extremely limited, but because there is evidence of a growing number of young people requiring treatment, such specialist drug services require evaluation. Serious consideration of the establishment and funding of evaluation of treatment interventions to be delivered to young substance misusers in the UK is urgently needed.     

Undergraduate medical school education in substance misuse in Britain iii: can medical students drive change?

Background: Two previous studies have demonstrated the parlous state of undergraduate medical education. A third study was undertaken to evaluate any change.

Methodology: All deans, heads of psychiatry and addiction specialists working in 28 British medical schools were surveyed by questionnaire. Items included time allocated to formal training, clinical resources, training objectives, professional confidence and competence, postgraduate facilities, plans for change, opinion on the importance of addiction in the curriculum, and scientific credibility.

Findings: There was a 100%, 71% and 46% response rate from specialists, heads, and deans respectively. Medical students were receiving, on average, six hours of formal training in substance misuse over their entire course. Although there was disparity in responses between the three groups, there was a clear consensus that the addiction field had scientific credibility. However, this achievement has not been translated into more training, and there is pessimism about any likelihood of change.

Discussion: Barriers to training such as too few addiction specialists, stigma, and tensions in academia resulting from the Research Assessment Exercise, are identified.

Conclusion: Since the General Medical Council and the Alcohol Harm Reduction Strategy have explicitly stated the need for undergraduate training, ways in which medical students, as 'users' of the undergraduate training package, may be the drivers of change, are suggested.     

University student drinking: the role of motivational and social factors

Aims: To investigate UK university student drinking in terms of social and motivational factors.

Design: Quantitative and qualitative studies.

Participants: Undergraduate students at a UK university: 50 'heavy drinkers' and 49 'light drinkers', equally distributed in terms of sex and year of study.

Data: Questionnaire measures of drinking expectancies, perceived benefits and drawbacks of drinking, important people and activities; semi-structured interviews.

Findings: Heavy drinkers scored higher than light drinkers on measures of tension reduction, sexual enhancement and dependency drinking expectancies. The top three reported benefits of drinking were social life, fun/humour, and self-confidence. Heavy drinkers perceived 'a lot' of drawbacks to their finances as a result of drinking, whereas for light drinkers the main drawbacks concerned physical wellbeing. Heavy drinkers were found to interact with a heavier drinking social network, receive more encouragement to drink from important people in their lives and to participate in more heavy drinking activities than light drinkers. A tentative model was developed from the qualitative study suggesting that social factors are important influences in the maintenance of heavy student drinking, in particular subtle forms of 'peer pressure', and increased self-confidence.

Conclusions: Motivational factors, particularly the expectation of increased self-confidence, play an important role in the maintenance of heavy student drinking, but social factors are probably equally significant. The levels and patterns of heavy drinking found in the present sample are worrying and the findings have implications for attempts to reduce alcohol consumption by university students.     

What are the implications for clinical management and service development of prevalent comorbidity in UK mental health and substance misuse treatment populations?

There is limited evidence about the prevalence of mental illness and substance misuse comorbidity (comorbidity) and its current management. This hampers service development in the UK. We measured the prevalence of comorbidity in community mental health teams (CMHTs) and drug and alcohol services in four urban UK centres. We also described the patterns of comorbidity, assessed the health and social care needs of patients and described current management.

Among CMHT patients, 44% report past year problem drug use and/or harmful alcohol use. The majority of drug (74.5%) and alcohol patients (80.6%) had a past year psychiatric disorder. In each population most comorbid patients exhibit multiple disorders and have greater community care needs than non-comorbid patients. Comorbid status did not restrict access to interventions provided through the patient's allocated service, but joint management between services was uncommon.

Resources need to be deployed to enable substance misuse services to provide evidence-based interventions to a higher proportion of comorbid patients. The treatment need of comorbid CMHT patients are likely to be best met by mainstream mental health services. However, CMHTs need to develop these competencies through staff training and research into the effectiveness of novel interventions tailored to UK service contexts.     

Family interventions in the treatment of alcohol and drug problems

Alcohol and drug problems affect not only those using these substances but also family members of the substance user. In this review evidence of the negative impacts substance misuse may have upon families are examined, following which family-focused interventions are reviewed. Several family-focused interventions have been developed. They can be broadly grouped into three types: (1) working with family members to promote the entry and engagement of substance misusers into treatment; (2) joint involvement of family members and substance misusing relatives in the treatment of the latter; and (3) interventions responding to the needs of the family members in their own right. The evidence base for each of the three types is reviewed. Despite methodological weaknesses in this area, a number of conclusions can be advanced that support wider use of family focused interventions in routine practice. Future research needs to focus on (1) pragmatic trials that are more representative of routine clinical settings; (2) cost-effectiveness analyses, in terms of treatment costs and the impact of interventions on costs to society; (3) explore treatment process; and (4) make use of qualitative methods. In addition, there is a need to define more clearly the conceptual underpinnings of the family intervention under study. [Copello, AG, Velleman RDB, Templeton LJ. Family interventions in the treatment of alcohol and drug problems. Drug Alcohol Rev 2005;24:369 - 385]     

Exchange, deceit, risk and harm: The consequences for women of receiving injections from other drug users

Aims: To explore the consequences for women of being injected with illicit drugs.

Methods: In-depth interviews with 45 women injecting drug users who have been injected by other people.

Findings: Women's reliance on others to administer injections meant they had less control over their drug use. Exchanging drugs as currency for being injected was common and women had little choice but to provide the injector with drugs. Being injected by others often caused the recipient physical harm. Previous experience of deception and harm meant women became more knowledgeable about their injector's intentions and subsequently tried to reduce future damage when being injected. Women appeared to be confused about the risks associated with being injected and the perceived risks were often complex and polarized. Understanding the context and nature of being injected is important for services when working with injection recipients.

Conclusions: This work uncovered ideas about a complex area and highlights the importance for those working with drug users to pay attention to this. Increased training and awareness for drug-service staff about factors influencing being injected and the potential associated risks is recommended. Reinforcing current harm-reduction messages and providing related advice to injection recipients is also important. In improving the knowledge and awareness about being injected, women recipients may gain increased choice and agency in the injection process.     

Healthcare providers' use of brief clinical interventions for adolescent smokers

Aims: Numerous studies document the effectiveness of intensive clinical interventions to treat tobacco dependence in adult smokers. Empirical studies have provided limited support for the efficacy of such interventions among adolescent smokers, yet participation, retention, and quit rates associated with these interventions tend to be relatively low. Brief clinical interventions may be a promising alternative for promoting smoking cessation in adolescents. The purpose of this paper is to examine the efficacy and use of brief clinical interventions for adolescent smokers, healthcare providers' provision of such treatment, barriers to adoption, and policies to increase brief clinical intervention provision.

Methods: Studies were collected from the Centers for Disease Control and Prevention's Office of Smoking and Health, Medline, Psychinfo, PubMed, and the Cochrane Library. We also examined references identified from pertinent articles and books and elicited suggestions from experts in the field of tobacco control. Investigations were primarily confined to those conducted in the USA to allow ease of comparisons among studies. In addition, we chose to concentrate on research conducted in the USA because differences between the USA healthcare system and that of other countries would result in different barriers to adoption and policy recommendations.

Findings: Results showed that, although healthcare professionals appear to be screening adolescents for their smoking status, rates of counseling and follow-up are disappointingly low. Obstacles to brief clinical intervention adoption include clinicians' lack of knowledge and confidence regarding brief intervention delivery, lack of understanding regarding the unique use patterns of adolescent smokers, and focus on prevention instead of treatment. Clinician training can increase the confidence with which healthcare providers interact with their adolescent patients. Organizational changes include chart reminders, reimbursement for counseling, and staff behavior monitoring.

Conclusions: Additional studies on efficacious methods to help adolescent smokers quit smoking are critically needed. Research on ways in which to increase brief clinical intervention provision are also warranted to prevent teenage smokers from carrying this habit, along with its associated morbidity and mortality risks, into adulthood.     

12-Month follow-up after brief interventions in primary care for family members affected by the substance misuse problem of a close relative

Following the publication of initial and 3-month data from a prospective cluster randomised comparative trial [Copello, A., Templeton, L., Orford, J., Velleman, R., Patel, A., Moore, L.,?…?,?Godfrey, C. (2009). The relative efficacy of two levels of a primary care intervention for family members affected by the addiction problem of a close relative: A randomised trial. Addiction, 104, 49–58.], an opportunistic 12-month follow-up was undertaken. The trial compared two brief interventions for use by primary health care professionals with family members (FMs) affected by the problematic substance use of a close relative. Ninety out of 143 (63%) FMs in the trial were followed up at 12 months. Three validated self-completion questionnaires were re-administered: Symptom Rating Test, Coping Questionnaire and Family Member Impact Scale. At 12 months there were still no significant differences between FMs depending on which of the two brief interventions received. The initial improvements at 12 weeks on all of the measures (symptoms, coping and impact) were maintained, and further improved (FMs reported that their symptoms, their coping behaviours and the impact on them of their relatives’ substance misuse problem all continued to reduce). These improvements were unrelated to a range of demographic variables. FMs also reported a gradual improvement in their relatives’ misusing behaviour over the three time periods. In conclusion, following a brief intervention for affected FMs, either delivered in full via professional intervention or via a self-help manual following a brief introduction from a professional, both groups improve equally; there are significant and positive changes which are both maintained and further increased over a 12-month period, without any further formal delivery of the intervention.