How To Write A Brief, Motivational Enhancement Intervention For Alcohol Misuse Offenders

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1 Gloucestershire Probation Area Brief, Motivational Enhancement Intervention for Alcohol Misusing Offenders S. Croft MCIM, BSc Hons March 2007

2 Acknowledgements In presenting this report the author would like to acknowledge the very valuable contributions of the following: Sarah Dryden - Gloucestershire DAAT Database John Trolan - Nelson Trust Neil Bebbington - inglos Julie Spokes - inglos Brian Lawson - inglos Sue Ellis - inglos Ted Yates - Gloucestershire Probation Area Gary Holden - Gloucestershire Probation Area 1

3 Brief, Motivational Enhancement Intervention for Alcohol Misusing Offenders Contents Page 1.0 Executive summary List of illustrations Introduction, aims and objectives Literature review Target End Service User Stepped care approach or direct referral Mapping exercise Process of screening for brief intervention evaluation of AUDIT, FAST and SADD Structure of brief intervention Evaluation of pilot scheme Closing remarks Appendix References Glossary 66 3

4 1.0 Executive Summary 1.1 Of those offenders supervised by Gloucestershire Probation Area (GPA), twice as many have a criminogenic alcohol need as have a criminogenic need relating to illicit substances. The annual Gloucestershire Drug and Alcohol Action Team s Adult Drug Treatment Plan assists agencies map and provide services for local need in relation to drug use. Substance misusing offenders can access appropriate statutory and non statutory services as well as, where suitable and eligible, the accredited substance misuse and offending programmes of Probation that include ASRO and Think First. These GPA programmes are designed for delivery to alcohol and drug misusers. Nationally however, the National Probation Service recognises that the push to meet the demands of delivering the Drug Rehabilitation Requirement has more usually seen drug misusers prioritised. (Probation Circular SUBSTANCE MISUSE MODULES REFERENCE NO: 70/2005 ISSUE DATE: 25 August 2005.) 1.2 Existing arrangements within GPA see offenders matched to appropriate interventions based upon seriousness of offence and severity of need. For offenders whose circumstances do not meet the threshold for participation in ASRO or Think First, there is a gap in provision. This gap will only partially be filled if the proposed Low Intensity Alcohol Module (LIAM) is introduced. 1.3 The evidence of the efficacy and cost effectiveness of Brief, Motivational Enhancement Interventions is well established through the Mesa Grande, Miller and Wilbourne (2002), the Project Match Research Group (US) 1997 and the UKATT Effectiveness of Treatment for Alcohol Problems: The findings of the UK randomised alcohol treatment trial (published in the British Medical Journal under reference BMJ 2005; ). The use of such interventions is promoted in Review of Effectiveness of Treatment for Alcohol Problems (NTA, Nov 2006), Models of Care for Alcohol Misusers (NTA June 2006), and the Alcohol Needs Assessment Research Project (DoH Nov 2005). 1.5 As a consequence, GPA proposes that to enhance the provision of stepped care for alcohol misusing offenders, a brief motivational enhancement intervention be introduced. This intervention will serve those given a Community Order with Supervision Requirement who do not meet the threshold for existing accredited programmes. The content of the intervention will be based upon that validated by the UKATT trial. Recommendation for the intervention will be triggered by reference to section nine of OASys (Probation s tool for assessing risk of re-offending) which addresses alcohol misuse, and the Alcohol Use Disorders Identification Test (AUDIT). 1.6 It is important to acknowledge at the beginning the differences in how treatment is defined. Probation does not see an extended brief intervention as part of provision for the Alcohol Treatment Requirement, and therefore by definition it is not in their eyes treatment. Treatment, as defined by Probation, is something aimed at dependence. However, by the definitions of Models of Care for Alcohol Misusers, an extended brief intervention based upon motivational enhancement therapy is clearly a tier 2 intervention and part of the continuum of treatment provision. 5

5 2.0 Alphabetical list of Illustrations Audit Contents of AARS session Costs of evaluation FAST Mapping exercise MESA Grande NOMS Offender Management Model Pathway into existing treatment system Probation s view of interventions Progress through brief alcohol intervention Relationship between excessive drinking, problems and dependence p.46, fig.13 p.61, app.1 p.62, app.2 p.47, fig.14 p.43, fig.12 p.27, fig.4 p.32, fig.6 p.42, fig.11 p.31, fig.5 p.33, fig.7 p.10, fig.1 Relationship between severity of problematic drinking and intervention p.37, fig.9 Results of analysis of AARS/GPA databases SADD Stage Model of Change Stakeholder and Probation Expectations Stepped Care Model p.38, fig.10 p.48, fig.15 p.51, fig.16 p.12&13, figs.2&3 p.36, fig.8 6

6 3.0 Introduction, Aims and Objectives 3.1 Introduction A large proportion of the Probation Service caseload has identified substance misuse needs linked to their offending, both alcohol and/or drug related. The development of Drug Action Teams nationally has resulted in agencies mapping and providing services for local need in relation to drug use. As members of local communities, offenders can access appropriate services in areas as well as, where suitable and eligible, accessing the substance misuse and offending related accredited programmes ASRO, OSAP and PRISM. These programmes are designed for delivery to alcohol and drug misusers, though the push to meet the demands of delivering DTTOs/DRR has more usually seen drug misusers prioritised (Probation Circular SUBSTANCE MISUSE MODULES REFERENCE NO: 70/2005 ISSUE DATE: 25 August 2005) Offenders' drug misuse needs that are not sufficient to lead to a referral to ASRO, OSAP or PRISM are adequately met via local DAT provisions. Therefore offenders whose priority needs lead to referral to other accredited programmes, who are assessed as having drug misuse needs, can already access local services without the need to develop any alternative in-house provision. Similarly, this is also the case for offenders with OGRS too low to be eligible for accredited programmes generally. In contrast, alcohol needs do not currently benefit from the same level of mapped provisions for offenders to be referred to appropriate services (Probation Circular SUBSTANCE MISUSE MODULES REFERENCE NO: 70/2005 ISSUE DATE: 25 August 2005) Data from o-deat published May 2006 identified that In Gloucestershire Probation Area (GPA), 43% of offenders had alcohol as a criminogenic need. This was approximately twice as many as had illicit drugs as a criminogenic need In Gloucestershire, approximately 1000 individuals a year receive the two session Alcohol Arrest Referral Scheme (AARS) intervention, this being from about 1400 referrals and representing about a third of the level of need. We have not previously investigated how many of GPA s offenders have received this intervention There are therefore indicators of considerable unmet need and the potential identification of a lack of provision for offenders with problematic use of alcohol This project would: (a) Enable a clear picture of need and provision for GPA offenders to be established and for the AARS and GPA provisions, particularly future commissioned provision to work in partnership (b) Provide an opportunity to address the lack of provision of alcohol interventions for offenders with problematic use of alcohol. This would complement and support the Gloucestershire Alcohol Strategy, launched 24 th November 2006, which has been prepared for the Gloucestershire Safer and Stronger Communities Partnership. 7

7 3.1.6 (c) The work fits with the commissioned provision of drug and alcohol services (for the reduction of crime and disorder) under the safer and stronger community s block of the Gloucestershire Local Area Agreement ( ). The work also fits with the GPA Reducing Re-offending Action Plan, pathway 4, drugs and alcohol. 3.2 Aims and Objectives The aims and objectives of the project are linked with the aims and objectives if the National Probation Service (NPS) Alcohol Strategy and therefore are: Aims The ultimate aim of the project is that there be fewer victims of crime, i.e. fewer crimes (reported or not) are committed because a common criminogenic need is being met to a greater degree than before. This can be broken down into the following: (a) To identify alcohol misuse and offending needs at an early stage of contact with Probation and refer offenders into appropriate interventions. Offenders will be identified via OASys and the use of the other screening tools at the start of order and then receive a brief intervention within 12 weeks of commencement or referral for care planned intervention (b) To ensure that staff are fully competent to deliver brief advice and support alcohol misusing offenders under their supervision. Staff will be trained to deliver a brief intervention using a training package that will be developed through the project (c) To improve the advice and information provided to offenders about the risks of alcohol misuse and about the help that is available locally. The risks of alcohol misuse will be a component of the brief intervention (d) To develop and promote the delivery of evidence based interventions to meet the needs of a full range of alcohol misusing offenders. The brief intervention will be based upon the evidence from the UK alcohol treatment trial and upon the three session intervention that has been evaluated by that trial (e) To increase the consistency of what is delivered across the NPS based upon evidence of best practice. The project will use the above research to develop a brief intervention that will be delivered via a partnership between GPA and local partners. 8

8 It will be evaluated by the research department attached to one of our partners the Gloucestershire DAAT Database Targeting, Screening, referral and assessment OASys scores will be used to indicate which cases require a more in depth assessment which will be done using a validated tool such as AUDIT, FAST or SADD. Those identified as Harmful drinkers will then go on to receive a brief intervention. Work outside the project will also occur to ensure a treatment pathway for those who require care planned alcohol treatment. The brief intervention will build upon the two session intervention that some offenders receive via the Alcohol Arrest Referral Scheme (AARS) Inter-agency working The AARS is operated by GDAS (Gloucestershire Drug and Alcohol Service) who already work in partnership with GPA. The project will develop close links via the sharing of information and the joint approach to brief interventions to ensure that offenders receive the appropriate level of intervention and to target those who have not received the AARS intervention. The training package will be developed utilising the experience of another partner, Nelson Trust, who are delivering a similar intervention for another Probation area. The project will be evaluated by another current partner, the Gloucestershire DAAT Database. 9

9 RELATIONSHIP BETWEEN EXCESSIVE DRINKING, RELATIONSHIP BETWEEN EXCESSIVE BETWEEN DRINKING, PROBLEMS EXCESSIVE DRINKING, PROBLEMS AND AND DEPENDENCE DEPENDENCE Acute social/health harm resulting from heavy drinking sessions Drinking at risk (e.g. over 28 units/week for males, 21 units/week for females) Cumulative social/health harm resulting from regular drinking Dependent drinking From: Chick et al (1997) Figure Objectives By 31/03/07, the project will achieve: (a) An analysis jointly by GPA and GDAS of the links between the clients who receive interventions via the AARS and those who receive a community order, and those who score three or more in section nine of OASys. The purpose of this activity is to assess: What proportion of those offenders who require further assessment are already receiving a brief intervention and thus: How many may require a top up and how many may require all three sessions (b) The development of a training package (by GPA, GDAS and Nelson Trust) for staff to deliver a three session brief intervention (based on the three session brief intervention use in the UK alcohol treatment trial) within the first twelve weeks of the community order, for those who score three or more in section nine of OASys and are further identified as harmful drinkers. 10

10 3.2.2 (c) Liaison between GPA and all other providers of alcohol treatment in Gloucestershire to ensure that any planned intervention is integrated into the whole treatment system planning and offender interventions (d) Identify which staff will be trained together with the necessary partnership arrangements (e.g. service specifications) and create the necessary capacity for them to do so (e) Create a project plan for the delivery of the brief intervention post 01/04/07 - this will include: naming of a project manager and group, a pilot phase that will be evaluated by GDD, reviewed by partners and altered in the light of the evaluation, and then rolled out in a sustained format. This will depend upon the securing of additional funding. The interests of each stakeholder in the project are summarised in figure 2 and expectations in figure Aims and Objectives Training Package Aim (a) As stated above, the aim of the project in training terms is: To ensure that staff are fully competent to deliver brief advice and support alcohol misusing offenders under their supervision. Staff will be trained to deliver a brief intervention using a training package that will be developed through the project Objectives Training objectives can be stated in terms of input, process, output and outcome (a) Input objectives, usually in the form of budgets can be stated in terms of training development. For the life of the initial programme therefore the objective is to deliver the appropriate level of man hours and consultation to produce a workable, user friendly and easily assimilated training manual. For the roll out of a pilot scheme and eventual delivery of a service, it may be necessary to have training sessions for the practitioners delivering the intervention (b) Objectives relating to process can be stated in the terminology and concepts employed in different approaches to training and development. Therefore the process objective for the life of the initial project is to have an approach to training alcohol workers that builds upon existing knowledge and skills and is delivered quickly and easily, at minimal cost. The process objective for the roll out of a pilot scheme and eventual delivery of a service can be defined in terms of theorising (reflecting on the evidence base), developing competency in accordance with Drug and Alcohol National Occupational Standards (DANOS) and reflection on the interaction with the client during sessions. 11

11 3.3.2 (c) Output objectives can be stated in terms of the levels of training and development activity. Therefore the output objective for the life of the initial project is to deliver a workable, user friendly and easily assimilated training manual. The output objective for the roll out of a pilot scheme and eventual delivery of a service can be stated in terms of numbers of trainees, trainee days, etc (d) Outcome objectives can be stated in behavioural and performance terms and therefore apply to the roll out of a pilot scheme and eventual delivery of a service. The outcomes should be that staff are competent to deliver a brief intervention and support alcohol misusing offenders under their supervision, measurable against DANOS, and display the attitudes of empathy, warmth and genuineness that are the cornerstones of brief motivational enhancement therapy (e) Evaluation would involve assessing the degree to which the project has met training outcome objectives (f) Validation would involve assessing the degree to which output objectives have been met and how far the training has achieved value for money in doing so. Figure 2 12

12 Figure Literature Review To ensure that any recommendations that emerge from this project are suitably evidence based and in context, it is necessary to review research of high academic legitimacy and Government guidance that is sufficiently contemporary to be relevant. 4.1 Key themes identified by literature review Treatment for alcohol problems is cost effective. Overall for every 1 spent on treatment, 5 is saved elsewhere in the health, social care and criminal justice systems. MoCAM identifies four main categories of alcohol misusers who may benefit from some kind of intervention or treatment: hazardous drinkers; harmful drinkers; moderately dependent drinkers and severely dependent drinkers. Simple and reliable instruments, such as the alcohol use disorders identification test (AUDIT) and derivatives such as the fast alcohol screening test (FAST) tool can be used to identify hazardous and harmful drinkers and provide an indication of the likely extent and severity of their alcohol-related problems. 43% of offenders on probation are identified as having an alcohol problem compared with 21% having a drug problem. 13

13 MOCAM distinguishes between Simple Brief Interventions in Tier 1 and Extended Brief Interventions in Tier 2 and advocates a stepped model of care. It is very possible to have a significantly beneficial effect, even if contact is very brief and it makes sense to concentrate on providing effective brief interventions. Motivational Enhancement Therapy is identified as the most evidenced, most effective, extended brief intervention and should be regarded as an essential element in the local treatment system. Nationally, our system has made a small amount of progress in cutting down reoffending with a reduction in re-offending rates of 1.3% between 1997 and Whether offenders are in prison or in the community, we need to manage them better to stop them re-offending. More than half of all crime is currently committed by people who have been through the system and have not yet changed their behaviour. The Criminal Justice Act 2003 introduced a coherent set of sentences which protect the public, punish offenders and can be used to rehabilitate them. It replaced all existing community penalties with a single Community Order, which involves offenders doing things to get themselves back on the straight and narrow. There will be a named Offender Manager for every offender, who will be responsible for making sure that they are both punished and rehabilitated properly; and who will get involved as early as possible in managing the offender. Interventions of all kinds are only effective if delivered in accordance with current descriptions of best practice and carried out by a competent practitioner. Practitioner characteristics account for around 10-50% of outcome variance Brief intervention trials can reduce weekly drinking by between 13% and 34%, resulting in 2.9 to 8.7 fewer mean drinks per week with a significant effect on recommended or safe alcohol use. The number of hazardous or harmful drinkers that need to receive brief interventions for one to reduce their drinking to low risk levels is about eight. This compares favourably with smoking cessation where twenty people need to be treated and ten if nicotine replacement therapy is included, for one to change their behaviour. Evidence suggests that hazardous and harmful drinkers receiving brief interventions were twice as likely to moderate their drinking six to twelve months after an intervention when compared to drinkers receiving no intervention. 14

14 4.2 Government (Central and Local) Strategy Papers (starting with most recent) 4.2 (a) Review of the Effectiveness of Treatment for Alcohol Problems, National Treatment Agency for Substance Misuse Nov 2006 The National Treatment Agency for Substance Misuse (NTA) produced a review of the effectiveness of treatment for alcohol problems in November 2006 to inform the commissioning and provision of local alcohol treatment systems in England. One of the key themes was that interventions of all kinds are only effective if delivered in accordance with current descriptions of best practice and carried out by a competent practitioner. Practitioner characteristics account for around 10-50% of outcome variance. Treatment fidelity and competent delivery are important elements of a successful outcome. Building a therapeutic alliance between Service User and therapist is important. The significant conclusions of the review include that; Treatment for alcohol problems is cost effective. Overall for every 1 spent on treatment, 5 is saved elsewhere in the health, social care and criminal justice systems. Simple brief interventions consisting of simple, structured advice are effective in reducing alcohol consumption and improving health status among hazardous and harmful drinkers encountered in healthcare settings. There is mixed evidence on whether extended brief interventions in healthcare settings add anything to the effects of simple brief interventions. Studies are needed of the effectiveness of brief interventions in various settings within the criminal justice system. Stand-alone adaptations of Motivational Interviewing are no more effective than other forms of psychosocial treatment but are usually less intensive and therefore potentially more cost effective. Motivational Enhancement Therapy (MET) is effective as a stand-alone specialist treatment for Service Users with moderate alcohol dependency provided the Service User accepts a less intensive treatment and there is effective follow up to check on progress. MET seems especially effective for Service Users showing a high level of anger at entry to treatment and possibly for those with low levels of readiness to change, although more research is needed to confirm the latter suggestion. 4.2 (b) Gloucestershire Alcohol Strategy Gloucestershire Safer and Stronger Community Partnership and Gloucestershire Healthy Living Partnership (Nov 2006) The Gloucestershire Alcohol Strategy identifies four local strategic drivers: 15

15 Local Area Agreements (LAAs) are currently being developed in the county. LAAs bring together all parties including the voluntary sector to agree planning for local priorities. Alcohol is a cross cutting issue that spans all the LAA blocks. These LAAs fit within the framework of the local strategic strategies. The six district Crime and Disorder reduction partnerships (CDRPs) published their strategies in April 2005 following extensive consultation with the public. Tackling alcohol misuse figured in all of the strategies. A county alcohol strategy is being developed by the National Probation Service in Gloucestershire. There are cross cutting links to the county Suicide and Self Harm Strategy, Domestic Abuse Strategy, Obesity Strategy, Children and Young People s Strategy and the Constabulary. Local statistics quoted included: The Alcohol Arrest Referral Scheme (AARS) dealt with 1381 referrals in 05/06 up from 800 in 00/01. The cost to the community of alcohol related crime is estimated at a minimum of 2m. The overall estimated cost of alcohol misuse in the county, including costs to the public sector, healthcare, criminal justice, social care, housing communities etc would approach 10 million. 43% of offenders on probation are identified as having an alcohol problem compared with 21% having a drug problem. Estimated local profiling indicates that there are within the county 427 severely dependent drinkers, 1,709 moderately dependent drinkers, 17,520 harmful drinkers and 69,655 hazardous drinkers. This is alongside 286,734 low risk drinkers and 51,279 non drinkers. Direct Local Responses include CDRP initiatives, treatment provided by CSSMS, GDAS, Nelson Trust, Stepps and Inishfree, JCG commissioned residential rehabilitation places out of county, services related to accommodation funded by Supporting People, and self help networks such as Alcoholics Anonymous. Indirect local responses include a range of initiatives and projects in education and young people s services; services provided by The Pilot Inn and GEAR, statutory services such as Probation, Police, District Councils, Adult Continuing Care (formally Social Services), and all aspects of the NHS etc. The strategic vision of the strategy is to reduce the actual and potential harm caused to people and communities by alcohol use in Gloucestershire. The aim of the strategy is that in order to meet the vision, the strategy will set a range 16

16 of outcomes and outputs that support all public sector bodies in meeting their local targets including the cross cutting Local Area Agreements. Objectives within the strategy that are directly relevant to this project include: 1(c) Continue to bring pressure to reduce alcohol related crime in line with local strategies. 5(a) Target treatment activities at key or high risk groups including Probation and Prison. although all of the objectives are relevant in that they create the environment in which this project exists. 4.2 (c) Models of Care for Alcohol Misusers (Dept of Health, National Treatment Agency for Substance Misuse June 2006) Models of care for alcohol misusers (MoCAM) provides best practice guidance for local health organisations and their partners in delivering a planned and integrated local treatment system for adult alcohol misusers. The approach described in MoCAM is consistent with, and supported by, the Department of Health guidance Alcohol Misuse Interventions: guidance on developing a local programme of improvement (2005). In the introduction, MoCAM identifies that screening and brief interventions for harmful and hazardous drinkers, as well as treatment for dependent drinkers, when delivered as part of a planned and integrated local treatment system, can offer economic benefits. Recent studies suggest that alcohol treatment has both short and long-term economic benefits. Analysis from UKATT suggests that for every 1 spent on alcohol treatment, the public sector saves 5. Between 2006 and 2008, the Department of Health will support the delivery of trailblazer projects to explore the practical applications of screening and brief interventions in various settings. The findings of these projects will serve to inform the further development of local systems. According to MoCAM there is no single concise way of categorising individuals in need of alcohol treatment. The extent to which individuals would benefit from interventions depends on a number of factors. Key factors include the level of consumption, the context in which alcohol is used, the seriousness of the alcoholrelated problems and the severity of the dependence on alcohol. MoCAM identifies four main categories of alcohol misusers who may benefit from some kind of intervention or treatment: hazardous drinkers, harmful drinkers, moderately dependent drinkers and severely dependent drinkers. The categorisation should be seen as a conceptual framework to assist commissioners in planning for a 17

17 full range of services for a local area. Individual drinkers may move in and out of different categories over the course of a lifetime. The World Health Organization (WHO) defines hazardous use of a psychoactive substance, such as alcohol, as a pattern of substance use that increases the risk of harmful consequences for the user In contrast to harmful use, hazardous use refers to patterns of use that are of public health significance despite the absence of any current disorder in the individual user. Hazardous drinkers are drinking at levels over the sensible drinking limits, either in terms of regular excessive consumption or less frequent sessions of heavy drinking. However, they have so far avoided significant alcohol-related problems. Despite this, hazardous drinkers, if identified, may benefit from brief advice about their alcohol use. The WHO International Classification of Diseases (ICD-10)11 defines harmful use of a psychoactive substance, such as alcohol, as a pattern of use which is already causing damage to health. The damage may be physical or mental. This definition does not include those with alcohol dependence. Harmful drinkers are usually drinking at levels above those recommended for sensible drinking, typically at higher levels than most hazardous drinkers. Unlike hazardous drinkers, harmful drinkers show clear evidence of some alcohol-related harm. Many harmful drinkers may not have understood the link between their drinking and the range of problems they may be experiencing. Simple and reliable instruments, such as the alcohol use disorders identification test (AUDIT) and derivatives such as the fast alcohol screening test (FAST) tool can be used to identify hazardous and harmful drinkers and provide an indication of the likely extent and severity of their alcohol-related problems. As these drinkers do not have significant evidence of alcohol dependence, advice and brief interventions are often suitable to meet the needs of both these groups. Dependence is essentially characterised by behaviours previously described as psychological dependence, with an increased drive to use alcohol and difficulty controlling its use, despite negative consequences. More severe dependence is usually associated with physical withdrawal upon cessation, but this is not essential to the diagnosis of less severe cases. In addressing the commissioning of interventions, MoCAM recommends that commissioners ensure that their plans are in line with population needs, address local service gaps, deliver equity, are evidence-based, are developed in partnership with other NHS bodies, local authorities and other partners and offer value for money. MOCAM distinguishes between Simple Brief Interventions in Tier 1 and Extended Brief interventions in Tier 2 and advocates a stepped model of care. Simple brief interventions are specific brief advisory interviews, often delivered after opportunistic screening identifies alcohol as a potential problem. Brief interventions should be followed up to ensure that Service Users have benefited from them and to identify 18

18 those for whom further, perhaps more intensive or extended interventions are required. Motivational enhancement therapy is identified as the most evidenced, most effective, extended brief intervention and should be regarded as an essential element in the local treatment system. Other brief forms of treatment should also be considered and commissioned, as appropriate to local need. In practice there are two main components to the stepped care model for alcohol misusers which are, broadly: Provision of brief interventions for those drinking excessively but not requiring treatment for alcohol dependence. Provision of treatment interventions for those with moderate or severe dependence and related problems. Hazardous and harmful drinkers without complex needs should be offered simple, structured advice to encourage reduced consumption of alcohol to sensible or less risky levels. If simple or minimal intervention does not succeed, they may be offered an extended brief intervention by a suitably competent practitioner. A small number may also be reassessed as actually needing treatment for alcohol dependence (where it was not initially identified) and would enter that part of the stepped care model. Brief interventions are effective in a variety of settings, including medical settings, such as primary care and A&E, and in generic non-specialist services. Evidence demonstrates that properly implemented brief interventions can help hazardous and harmful drinkers and some moderately dependent drinkers. 4.2 (d) Working with Alcohol Misusing Offenders a strategy for delivery. (National Offender Management Service National Probation Service May 2006 The National Offender Management Service (NOMS) produced its strategy Working with Alcohol Misusing Offenders a strategy for delivery in May 2006 with five specific aims: To establish a consistent approach to tackling alcohol related offending across the Probation Service based on evidence of best practice. To complement the Alcohol Harm Reduction Strategy for England and the Prison Service Alcohol Strategy to make a coherent NOMS strategy. To complement the Five Year Strategy for Protecting the Public and Reducing Re-offending and the National Reducing Re-offending Delivery Plan. To complement Models of Care for Alcohol Misusers. To be consistent with the developing role of Regional Offender Managers in commissioning on a regional basis. 19

19 The strategy identified that in 41 Probation areas between 1/4/04 and 31/5/05, 37% of offenders had a current problem with alcohol use and 37% with binge drinking. 47% had misused alcohol in the past, 32% had violent behaviour related to their alcohol use and 38% had a criminogenic need relating to alcohol, potentially linked to their risk of re-offending. It further identified that research has found that alcohol had been consumed prior to the offence in 73% of domestic violence cases and was a feature in 62%. Furthermore, 48% of these domestic violence offenders were alcohol dependent. The aims and objectives of the strategy included: To identify alcohol misuse on offending needs at an early stage of contact and refer offenders to appropriate interventions. To ensure that staff are fully competent to deliver brief advice and support to alcohol misusing offenders under their supervision. To improve the advice and information given to offenders about the risks of alcohol misuse and about help that is available locally. To develop and promote the delivery of evidenced based interventions to meet the needs of the full range of alcohol misusing offenders. The strategy introduces from Models of Care for Alcohol Misusers the concept that problem drinking can be broadly broken down into three categories; hazardous, harmful and dependent drinking. It recommends identification of offenders whose alcohol misuse fall into these categories using the OASys system and other specific alcohol screening tools, and that intervention should be targeted accordingly. Further, the report advises that hazardous and harmful drinkers whose criminal activity is often directly alcohol related are more likely to respond to low level advice, information and support often delivered by non specialists. Those with a habitual alcohol dependency are likely to need specialised and intensive care planned alcohol treatment. It identified that information, brief advice and support for behavioural change may, if targeted appropriately help to encourage responsible drinking and reduce risks to health. It may also help to reduce offending related to alcohol misuse. A successful intervention, it says, is one that leads to a reduction in alcohol related problems, not necessarily the number of units of alcohol consumed. 4.2 (e) Five Year Strategy for Protecting the Public and Reducing Re-offending and the National Reducing Re-offending Delivery Plan. (Home Office, Feb 2006) At the moment, our system has made a small amount of progress in cutting down reoffending with a reduction in re-offending rates of 1.3% between 1997 and 2002 but it is not nearly enough (Source: Re-offending of adults results from the 2002 cohort, statistical bulletin 25/05, Home Office). Whether offenders are in prison or in the community, we need to manage them better to stop them re-offending. More than half of all crime is currently committed by people 20

20 who have been through the system and have not yet changed their behaviour. We need to offer them the chance to change, and address the multiple problems that many of the most persistent offenders face. This is the central aim of our strategy, because it is key to reducing crime. Community sentences are tough, and getting tougher, and can be more successful at helping offenders stop offending again. All offenders coming before the courts are screened for the risks that they may pose, by looking at their background and offences. Where there is any cause for concern they will be given a fuller analysis using a structured risk assessment called OASys. It uses actuarial and professional assessment to produce a detailed analysis of risk factors. OASys assessment will be the key factor in how the offender is managed. The Criminal Justice Act 2003 introduced a coherent set of sentences which protect the public, punish offenders and can be used to rehabilitate them. It replaced all existing community penalties with a single Community Order, which involves offenders doing things to get themselves back on the straight and narrow like getting off drugs or getting a better education. There will continue to be increasingly tough enforcement and offenders who are not prepared to make the effort and who do not keep to the conditions of their community sentences will have extra conditions added, or end up in prison. Community Orders can include up to twelve different requirements, including unpaid work, drug treatment, and curfews. Sentencers can select from these twelve requirements, and advice to sentencers suggests that there should be more requirements for more serious offenders, and that minor offenders should only have one or two requirements. 51% of those commencing Community Orders in April to September 2005 had one requirement, 32% had two, 14% had three and 2% had four or five. Key action points of the strategy include: A named Offender Manager for every offender, who will be responsible for making sure that they are both punished and rehabilitated properly; and who will get involved as early as possible in managing the offender. Going Straight contracts a compact between the offender and the Offender Manager, with clear and meaningful incentives and sanctions, so that offenders committed to changing get rewarded. When offenders are committed to changing, we want Offender Managers to be able to call on support for them in a very wide range of areas including health, education and skills, employment, social and family links, housing, drug and alcohol abuse, finance and benefits. This needs strong partnership working across Government and beyond, including with Local Government, employers and the voluntary and community sector. We will learn from our successful drug treatment programmes and give offenders better access to alcohol interventions, especially where their offending is linked to alcohol. 21

21 4.2 (f) The Alcohol Needs Assessment Research Project (ANARP), (Dept of Health, Nov 2005) The Alcohol Needs Assessment Research Project (ANARP) is the first alcohol needs assessment in England conducted on a national scale. Among the key findings are: The study found a high level of need across categories of drinkers. 38% of men and 16% of women (age 16 64) have an alcohol use disorder (26% overall), which is equivalent to approximately 8.2 million people in England. There are 21% of men and 9% of women who are binge drinkers. There is a considerable overlap between drinking above sensible daily benchmarks and sensible weekly benchmarks for both men and women. The prevalence of alcohol dependence overall was 3.6%, with 6% of men and 2% of women meeting these criteria nationally. This equates to 1.1 million people with alcohol dependence nationally. The General Practice Research Database (GPRD) study found extremely low levels of formal identification, treatment and referral of patients with alcohol use disorders. In the qualitative research with DAT professionals, this group was aware of a very large gap between the provision of alcohol treatment and need or demand, however it is expressed. The gap analysis estimated the number of alcohol dependent individuals accessing treatment per annum is approximately 63,000, providing a Prevalence Service Utilisation Ratio (PSUR) of 18 (5.6% of the in need alcohol dependent population accessing alcohol treatment per annum or 1 in 18). There is clearly considerable scope for increased identification and referral to specialist care from generic services including primary care, general hospitals, mental health services, criminal justice agencies and social services. 4.2 (g) Alcohol Misuse Interventions Dept of Health, National Treatment Agency for Substance Misuse (Nov 2005) This document provides guidance on developing and implementing programmes that can improve the care of hazardous, harmful and dependent drinkers and focuses on guidance for the development of screening and brief interventions. Only 24% of referrals to alcohol services come from primary care, whereas 36% are self-referrals. This suggests: There is considerable potential for growth in the screening, identification and referral of individuals with patterns of hazardous, harmful and dependent use of alcohol. 22

22 Screening, identification and referral could be extended to agencies outside of the NHS including criminal justice agencies and social services. As part of an assessment of local need for the entire pathway, greatest impact may be made if screening and brief interventions are offered to hazardous and harmful drinkers. Consideration should be given to extending screening and brief intervention to those attending a non-nhs service, for example in a criminal justice setting. Primary Care Trusts (PCTs) and local authorities, the criminal justice agencies and voluntary agencies are key members of local and regional partnerships. Responsibility for commissioning crime-related healthcare programmes aimed at behaviour change in offenders will fall under the new National Offender Management Service (NOMS). Commissioners in PCTs may work in partnership with NOMS to commission screening, brief interventions and treatment for alcohol-misusing offenders. Research evidence on screening and brief interventions indicates that many individuals benefit from brief interventions. However, in order to strengthen the UK evidence base, trailblazer projects will be taking place to determine the impact of targeted screening and brief interventions in primary care, hospital and criminal justice settings. A recent trial found that: Brief intervention trials can reduce weekly drinking by between 13% and 34%, resulting in 2.9 to 8.7 fewer mean drinks per week with a significant effect on recommended or safe alcohol use. The number of hazardous or harmful drinkers that need to receive brief interventions for one to reduce their drinking to low risk levels is about eight. This compares favourably with smoking cessation where twenty people need to be treated and ten if nicotine replacement therapy is included, for one to change their behaviour. Evidence suggests that hazardous and harmful drinkers receiving brief interventions were twice as likely to moderate their drinking six to twelve months after an intervention when compared to drinkers receiving no intervention. The report draws on cross Government PSAs and Governmental agendas to set alcohol misuse interventions in context. 4.2 (h) Alcohol Harm Reduction Strategy for England (Prime Ministers Strategy unit March 2004) This report, produced by the Prime Minister s Strategy Unit in the Cabinet Office in March 2004 sets out the Government s strategy for tackling the harms and costs of 23

23 alcohol misuse in England. It sets out four keys ways in which Government can act, namely: Improved, and better-targeted, education and communication; Better identification and treatment of alcohol problems; Better coordination and enforcement of existing powers against crime and disorder; Encouraging the industry to continue promoting responsible drinking and to continue to take a role in reducing alcohol-related harm. Strategic interventions, it goes on to say, also need to be: Coherent, as isolated interventions are unlikely to succeed; Sustained, as short-term initiatives will have little long-term impact; Strategic, as without a coordinated strategy there is likely to be little progress; and Measured, as without ways to chart progress, the success of the strategy cannot be assessed. Expanding on these key areas the report informs us that The first step in encouraging individuals to act responsibly involves making sure that they understand the potential risks of irresponsible drinking and alcohol misuse. Consumers are generally not well enough equipped to take informed choices about their drinking behaviour. If individuals are to make informed choices about their drinking and act more responsibly, they need accurate and balanced information. The report identifies early intervention and treatment as an imperative: alcohol problems are often not identified sufficiently early, leading to later financial and human costs and promises that: Government will improve the identification and referral of those with alcohol problems by running pilot programmes to establish whether earlier identification and treatment of those with alcohol problems can improve health, lead to longer-term savings, and be embedded into mainstream health care provision. The strategy devotes a chapter to alcohol related crime and disorder and acknowledges that Alcohol misuse is a major contributor to crime, disorder and antisocial behaviour, with alcohol related crime costing society up to 7.3bn per annum. Several ways in which the failure of individuals to behave responsibly is presently dealt with are identified, including: Acceptable Behaviour Contracts - engage individuals in recognising the negative impact of their anti-social behaviour on other people and in agreeing to change it. 24

24 Although they are informal and voluntary, breach may result in an application for an Anti-Social Behaviour Order or other legal action. Anti-Social Behaviour Orders - are civil orders which aim to protect the community from behaviour which causes or is likely to cause harassment, alarm or distress to others, and can be clearly linked to alcohol misuse. For example, they can prevent an individual associating with other people with whom they commit anti-social behaviour. Breach is a criminal offence with a maximum penalty of five years imprisonment and/or a fine. The report highlights the fact that Enforcement of legislation on drunk and disorderly behaviour has dropped sharply over the last 10 years. This reflects not only falling priority but also, crucially, the sheer practicalities of policing large numbers of drunk people. Fixed Penalty Notices mean that enforcing legislation on drunk and disorderly behaviour will be easier. Also among the recommendations of this chapter is use of conditional cautions as a basis for directly targeting the offence. The report then turns to the opportunity to intervene with an offender by addressing treatment needs around alcohol misuse. Many offenders who are repeatedly arrested for alcohol-related offences will not be dependent on alcohol, although they may be drinking heavily and frequently. Evidence suggests that, in particular, many of those arrested for violence are likely to be younger and not dependent on alcohol. This group of offenders is unlikely to need extensive alcohol treatment. However, people in this group do have problems which need to be addressed: brief interventions, counselling, or referral to self-help groups may well be appropriate, depending upon the individual case. In other cases, more generic treatment may be more appropriate. By contrast, offenders who are dependent on or who have serious problems with alcohol may be helped by specialist alcohol treatment. There are currently eight referral schemes with a specific focus on alcohol: some of these are based on arrest and others on bail conditions. These have not been systematically evaluated, but available management statistics suggest that one such scheme reduced re-offending by up to half. These encouraging results suggest that it is worth looking at whether more use could be made of arrest referral schemes. The Criminal Justice Act 2003 introduced the Community Order and Suspended Sentence Order to which an alcohol treatment requirement can be added in appropriate cases. Furthermore, under the new provisions it is no longer a requirement that the offender s dependency on or misuse of alcohol caused or contributed to the offence. The report commits the Government to consider establishing pilot arrest referral schemes for evaluation with an aim of having clear emerging conclusions by Q4/2007, and to encourage Crime and Disorder Reduction Partnerships to work with Local Criminal Justice Boards to implement the conclusions of those schemes if there is a clear case for effectiveness. 25

25 4.3 Academic Research (starting with most recent) 4.3 (a) UKATT. Effectiveness of Treatment for Alcohol Problems: The findings of the UK randomised alcohol treatment trial (published in the British Medical Journal under reference BMJ 2005; ). The study built on the Matching alcoholism treatments to client heterogeneity (Project Match) study in the United States. This earlier trial examined the efficacy of cognitive behavioural therapy, twelve step facilitation therapy, and motivational enhancement therapy. Results showed substantial improvements in drinking outcomes for all three. Motivational enhancement therapy achieved outcomes essentially similar to those of the two more intensive treatments. Meta-analyses have since confirmed the effectiveness of such treatment. The UKATT study compared the effectiveness of social behavioural and network therapy, a new treatment for alcohol problems with that of the proved motivational enhancement therapy. Both interventions reported substantial reductions in alcohol consumption, dependence and problems and better mental health related quality of life over twelve months. Economic analysis concluded that both interventions offered cost effectiveness at acceptable levels. In the trial, motivational enhancement therapy comprised three, 50 minute sessions over eight to twelve weeks. It combined counselling in the motivational style with objective feedback. The trial recommended that as neither therapy emerged as significantly more effective, or cost effective, the choice of interventions should depend on other, local factors. 4.3 (b) Mesa Grande, Miller and Wilbourne (2002) What Works, A summary of alcohol treatment outcome research Miller, Wilbourne and Hettma devised a study over 10 years of 47 different treatment modalities based on analysis of 381 separate clinical trials, specialist narrative reviews, and surveys of expert opinion. The study took account of the scientific rigour in the methodology of each trial, the complexity of treatment episodes studied and differing treatment settings. The resulting tabulation of treatment modalities, dubbed Mesa Grande ranks interventions in order of strength of evidence for efficacy using a measure known as Cumulative Evidence Score (CES). The CES score can be either positive or negative. Brief Interventions emerged from the study as the modality that was by far the best supported by evidence, with a positive CES score of 390. Second of 47 was Motivational Enhancement, with a positive CES score of 189. The content of studied brief interventions designed to enhance motivation varied, but most often included personal assessment feedback ( drink diary ) and motivational interviewing. Common themes included empathic counselling style. The essential message was that it is very possible to have a significantly beneficial effect, even if contact is very brief and that it makes sense to concentrate on providing effective brief interventions. The empathic clinical style of motivational interviewing has also been shown to increase client retention in treatment. 26