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Drug treatment

This page refers to the current evidence on the effectiveness of the available drug treatment for improving the employability of drug users. Information on the methodology used and the definition of terms can be found on the methodology page.

Date of last update: 05.2017     Next update: 10.2017

Available evidence for drug treatment

Summary: Contingency management (employment-based or not) helps people to obtain more paid working days than employment-only interventions. Residential treatment and therapeutic workplaces improve attendance at work.

Beneficial

No interventions met the criteria for this category.

Likely to be beneficial

Contingency management to improve the Addiction Severity Index (ASI) employment scores

Contingency management, including voucher-based incentives to coping skills and motivational enhancement and social model programmes, were found to be effective in one RCT (n = 60; Budney et al., 2000, cited in EMCDDA, 2012 - Online appedix) in:

  • increasing significantly the ASI employment scores.

The finding was confirmed by one observational study (Room, 1998, cited in EMCDDA, 2012 - Online appedix) in which it was shown that social model programmes produced improvements of 34 % and 28 %, respectively, in ASI employment scores from baseline to follow-up. ASI scores also show decreases in employment problems among social model clients.

ASI employment item relates to the number of paid working days.

Employment-based reinforcement of cocaine abstinence contingency management

Employment-based reinforcement of cocaine abstinence contingency management was found to be effective in one RCT (n = 51; DeFulio and Silverman, 2011, cited in EMCDDA, 2012 - Online appedix):

  • at follow-up more participants reported earning some money from employment compared with the baseline measurement;
  • 40 % earned money from employment during the year after employment in the therapeutic workplace;
  • a lower percentage of study participants were on welfare or living in poverty during the year of follow-up compared with study intake; and
  • participants’ social, employment, economic and legal conditions were similar in the two groups across all phases of the study.

It was also found to be effective in one CBA (n = 319; Donlin et al., 2008, cited in EMCDDA, 2012 - Online appedix):

  • the percentage of minutes worked in the induction period was significantly correlated with the percentage of cocaine-negative urine samples in the intervention period.

Residential rehabilitation to improve employment performance

Residential treatment was found to be effective in one BA (n = 212; Slaymaker and Owen, 2006, cited in EMCDDA, 2012 - Online appedix):

  • decreasing significantly problems at work (of the past 30 days) from an average of 5.20 days at baseline to 0.14 days at the 12 months;
  • 65 % were retained by their original employer;
  • decreasing significantly any unplanned absence during the 12 months preceding treatment as compared with the 12 months after treatment from 77.7 % to 29.6 %; and
  • decreasing significantly the rate of unplanned absences from work, from an overall mean of 9.19 days in the year before treatment entry to 1.33 days in the year after treatment.

Therapeutic workplace with voucher reinforcement to promote consistent and reliable attendance

Therapeutic workplace with voucher reinforcement contingencies was found to be effective in one CBA (n = 40, consisting of 20 individuals in the intervention group and 20 in the control group; Silverman et al., 2002, cited in EMCDDA, 2012 - Online appedix):

  • 12 (60 %) of the participants maintained periods of sustained attendance (i.e. interrupted by no more than occasional brief absences) of 6 months or more;
  • three (15 %) of the participants initiated their longest period of sustained workplace attendance after their initial invitation to attend the therapeutic workplace; and
  • on average, participants attended the workplace on 43 % of the 780 weekdays in the 3-year period. At the end of the 3-year period, 9 of the 20 participants were attending the workplace consistently.

Trade-off between benefits and harms

No interventions met the criteria for this category.

Unknown effectiveness

Employment-based reinforcement vs. employment-only cocaine abstinence contingency management

Employment and employment-only cocaine abstinence contingency management were compared and results showed no significant effects.
One RCT (n = 51; De Fulio et al., 2009a, cited in EMCDDA, 2012 - Online appedix) showed that:

  • the abstinence-contingent employment and employment-only groups attended the workplace at similar rates and most participants in both groups were retained throughout the year of phase 2;
  • participants in both groups earned similar hourly wages on average and showed similar levels of accuracy in data entry; and
  • the abstinence-contingent employment group had a higher mean rate of work output than the employment-only group, but this difference was not significant.

A second RCT (n = 56; Silverman et al., 2007, cited in EMCDDA, 2012 - Online appedix) showed that:

  • abstinence-and-work and work-only participants had high rates of attendance at the workplace at baseline (85 % and 82 % of days, respectively);
  • work-only participants continued high rates of attendance throughout the intervention; and
  • attendance by abstinence-and-work participants decreased during the intervention when the cocaine urinalysis contingency was arranged, although most participants continued to attend intermittently.

Residential rehabilitation for pregnant women to improve the ASI employment scores

Residential treatment showed no significant effect in one RCT (n = 85; French et al., 2002, cited in EMCDDA, 2012 - Online appedix) on:

  • employment measures (ASI, income received from employment) between treatment programme types.

ASI employment item relates to the number of paid working days.

Therapeutic workplace for pregnant women to promote reliable attendance and improved work performance

Therapeutic workplace (upon providing negative urine samples) on treatment outcomes including employment showed no evidence of effectiveness in one RCT (n = 40; Silverman et al., 2002, cited in EMCDDA, 2012 - Online appedix):

  • on average, 45 % of participants attended the workplace per day; and
  • 40 % of all therapeutic workplace participants maintained high rates of attendance throughout most of the 24 weeks.

In another RCT (n = 20, phase 2 of the above study; De Fulio et al., 2009b, cited in EMCDDA, 2012 - Online appedix):

  • trainees completed tasks and maintained at least two consecutive weeks of abstinence, consistent attendance, punctuality and professional behaviour; and
  • the trainees who were hired as a data entry operator in phase 2 maintained an overall accuracy of 99.6 % and entered data at a rate of 2 515 characters per hour.

Therapeutic workplace providing training under simulated work conditions to promote consistent and reliable attendance

Therapeutic workplace providing training under simulated work conditions to prepare participants for entry-level office jobs together with contingency management showed no significant difference in one RCT (n = 47; Knealing et al., 2006, cited in EMCDDA, 2012 - Online appedix):

  • rates of full-time employment (> 20 of past 30 days; assessed on the basis of ASI interviews) were universally low at intake, throughout the treatment period, and at the follow-up time point;
  • rates of part-time employment (> 20 of past 30 days), although higher than for full-time employment, were consistently low across time for both groups of participants, and there were no significant differences between groups at any of the time points; and
  • a higher percentage of therapeutic workplace participants than usual care control participants had ‘any employment’ (defined as having full-time, part-time or therapeutic workplace employment) during treatment. That difference was marginally significant, yet was not maintained at the follow-up time point, when employment within the therapeutic workplace was no longer available.

Evidence of ineffectiveness

No interventions met the criteria for this category.

References and definitions

List of references

Explanation of terms used

Below you can find definitions and further explanation for some of the terms used in this section of the Best practice portal. A more general glossary for the best practice portal is also available.

Affective-focused prevention intervention

A type of prevention intervention which aims to they aim to modify inner qualities (personality traits such as self-esteem and self-efficacy, and motivational aspects such as the intention to use drugs).

BA

Before-after (BA) study design

BAL

Blood alcohol level (BAL)

Beneficial

Interventions for which precise measures of the effects in favour of the type of intervention were found in systematic reviews of relevant studies. An intervention ranked as ‘beneficial’ is suitable for most patients/contexts. See the relevant module methodology page for further information.

CBA

Controlled before-after (CBA) study design. UCBA stands for Uncontrolled before-after study design.

CBT

Cognitive behavioral therapy is an individual based intervention occurring in three stages. Phase 1 is aimed at determining and prioritizing the patient’s problems and constructing the treatment contract. Phase 2 is aimed at increasing coping competence and reducing risky behaviors. Phase 3 focuses on relapse prevention. Each session is administered once per week over a period of 4-6 months with 60- to 90-minute sessions (Beck AT, Wright FW, Newman CF, Liese B. Cognitive Therapy of substance abuse. New York: Guilford Press, 1993).

CCT

Controlled clinical trials (CCT)

Cohort study

A cohort study is a type of observational study that follows a group of people (i.e. a cohort) over time. In a prospective cohort study, the cohort is formed and then followed over time. In a retrospective cohort study, data is gathered for a cohort that was formed sometime in the past.

Confidence Interval (CI)

The Confidence Interval (CI) is a measure of the precision (or uncertainty) of study results. It is the interval that most likely includes the true value of the parameter we are calculating, where 'most likely' is taken by common usage to be a 95% probability. Thus the current expression of '95 % CI'. A wide CI indicates less precise estimates of effect and vice versa.

Practical interpretation

  • If the RR (the relative risk) = 1, or the CI (the confidence interval) = 1, then there is no significant difference between treatment and control groups
  • If the RR > 1, and the CI does not include 1, events are significantly more likely in the treatment than the control group
  • If the RR < 1, and the CI does not include 1, events are significantly less likely in the treatment than the control group
CPS

Current population survey (CPS)

Cross-sectional study

A cross-sectional study is a study employing a single point of data collection for each participant or system being studied.They are usually conducted to estimate the prevalence of the outcome of interest for a given population at a given point in time.

Evidence of ineffectiveness

Interventions that gave negative results if compared with a standard intervention or no intervention, for example. See the relevant module methodology page for further information.

Additional information for prevention
For ethical reasons this category in prevention should be considered as interventions with negative and undesired (iatrogenic) effect.

IP

Individual psychotherapy is a standard individual treatment based on counseling and motivational interviewing and focused on substance use triggers and strategies for relapse prevention. It includes elements of cognitive-behavioral therapy (CBT).

IQR

Interquartile range (IQR) - also called the midspread or middle fifty - is a measure of statistical dispersion. It is a trimmed estimator, defined as the 25% trimmed mid-range, and is the most significant basic robust measure of scale.

ITS

Intermittent time series design (ITS)

Knowledge-focused prevention intervention

A type of prevention intervention which aims to to enhance knowledge of drugs, and drug effects, and consequences.

Likely to be beneficial

Interventions that were shown to have limited measures of effect, that are likely to be effective but for which evidence is limited. An intervention ranked as ‘likely to be beneficial’ is suitable for most contexts/patients, with some discretion. See the relevant module methodology page for further information.

Number Needed to Treat (NNT)

The Number Needed to Treat (NNT)indicates the number of patients that needs to be treated to obtain one respondent patient. Numerically the NNT is the reciprocal of the difference between the proportion of events in the experimental and the comparison group (absolute risk reduction). Taking into consideration that the ideal NNT would be 1 (the unreal situation in which every single patient succeeded) it is easily understood that a NNT value close to 3 or 4 would be very good.

Adjusted Odds Ratio (AOR)

The Adjusted Odds Ratio is a way of comparing whether the probability of a certain event is the same between two groups, yet they are calculated adjusting for or controlling for other possible contributions from other variables (tipically demographic variables) in the model. An AOR equal to 1 implies that the the event is equally probable in both groups. An AOR greater than 1 implies that the event is more likely in the first group. An AOR less than 1 implies that the event is less likely in the first group.

Odds Ratio (OR)

The Odds Ratio is a way of comparing whether the probability of a certain event is the same between two groups. Like the Relative Risk, an OR equal to 1 implies that the the event is equally probable in both groups. A OR greater than 1 implies that the event is more likely in the first group. A OR less than 1 implies that the event is less likely in the first group. In medical research, the odds ratio is commonly used for case-control studies, as odds, but not probabilities, are usually estimated. Relative risk is used in randomized controlled trials and cohort studies.

p value

A p-value is a measure of how much evidence we have against the null hypothesis. The null hypothesis represents the hypothesis of no change or no effect. The smaller the p-value, the more evidence we have against the null hypothesis thus it is more likely that our sample result is true. Traditionally, researchers will reject a null hypothesis if the p-value is less than 0.05.

RBS

Responsible beverage service (RBS)

RCT

Randomised controlled trial (RCT)

Relative Risk (RR)

The Relative Risk (RR) is used to compare the risk in the two different groups of people, i.e. treated and control groups to see if belonging to one group or another increases or decreases the risk of developing certain outcomes. This measure of effect will tell us the number of times an outcome is more likely (RR > 1) or less likely (RR < 1) to happen in the treatment group compared with the control group.

Practical interpretation

  • If the RR (the relative risk) = 1, or the CI (the confidence interval) = 1, then there is no significant difference between treatment and control groups
  • If the RR > 1, and the CI does not include 1, events are significantly more likely in the treatment than the control group
  • If the RR < 1, and the CI does not include 1, events are significantly less likely in the treatment than the control group
Trade-off between benefits and harms

Interventions that obtained measures of effects in favour of the intervention, but that showed some limitations or unintended effects that need to be assessed before providing them. See the relevant module methodology page for further information.

 
Unknown effectiveness

Interventions for which there are not enough studies or where available studies are of low quality (with few patients or with uncertain methodological rigour), making it difficult to assess if they are effective or not. Interventions for which more research should be undertaken are also grouped in this category.

Additional information for prevention
For prevention interventions,  this  is also known as 'zero effect'.

Skill-focused prevention intervention

A type of prevention intervention which aims to enhance students’ abilities in generic skills, refusal skills and safety skills.

Standardised Mean Difference (SMD)

The Standardised Mean Difference (SMD) is the difference in means divided by a standard deviation. Note that it is not the standard error of the difference in means (a common confusion). The standardized mean difference has the important property that its value does not depend on the measurement scale. It may be useful if there are several trials assessing the same outcome, but using different scales.

z score (Standard Score)

The z-score (aka, a standard score) indicates how many standard deviations an element is from the mean of the population.

Definition

According to the EMCDDA Treatment demand protocol 3.0, ‘Drug treatment is defined as an activity (activities) that directly targets people who have problems with their drug use and aims at achieving defined aims with regard to the alleviation and/or elimination of these problems, provided by experienced or accredited professionals, in the framework of recognised medical, psychological or social assistance practice. This activity often takes place at specialised facilities for drug users, but may also take place in general services offering medical/psychological help to people with drug problems’.

Barriers to social inclusion

Personal level:
limited or no qualifications, including low levels of literacy and numeracy; poor employment histories; criminal records precluding certain careers (e.g. police, teaching, working with children, financial institutions); chronic mental and physical ill health; insecure housing circumstances; limited interpersonal skills; complex personal needs; lack of confidence; chaotic lifestyles (e.g. poor timekeeping); family problems; low expectations of themselves and of life in general.

Structural level:
requirement to attend treatment on a daily basis; inadequate opening hours of treatment services that are incompatible with working hours; lack of interagency coordination; stigmatising and discriminative views, actions and procedures; inability to open a bank account to receive wages; increased likelihood of temporary or insecure work; shortage of suitable employment opportunities; perceived ‘benefit trap’ whereby an (incorrect) belief is held that the loss of welfare benefits as a consequence of employment will result in a reduction in income that is not compensated by the salary; criminal record checks required by employers.

Interventions

Substitution treatment

Substitute prescribing is the controlled prescribing of medication (usually opioids) to illicit drug users, usually heroin users, as part of an overall care plan. The aim of substitute prescribing is to reduce or eliminate illegal drug use and/or to reduce negative health and social consequences of use.

Psychosocial interventions

Psychosocial interventions may include a range of different interventions, such as structured counselling, motivational enhancement, case management, care coordination, psychotherapy and relapse prevention.

  • Case management approach - Case management includes those strategies for which a single case manager is responsible for linking patients with multiple relevant services. Basic activities include assessment, planning, linking, monitoring and advocacy.
  • Residential treatment and rehabilitation - Residential treatment and rehabilitation programmes are inpatient services, i.e. those for which participants are required to live in a hostel, home or hospital unit. They usually provide a range of (intensive) psychosocial interventions, group work, practical and vocational activities and structured programmes of daily activities which residents are (usually) required to attend.
  • Contingency management - Contingency management (CM) is an intervention model whereby particular client behaviour is reinforced (rewarded or punished) in accordance to a treatment plan. For drug treatment, this may include monetary incentives (in cash or vouchers) for negative urine toxicology.
  • Community reinforcement approach - The Community Reinforcement Approach (CRA) is a comprehensive behavioural treatment package that focuses on the management of substance-related behaviours and other disrupted life areas. It provides a range of skills training, including problem solving and assertiveness, family relationships, and vocational and employment counselling.

Outcomes

The main outcomes considered as proxy of social reintegration were employment-related outcomes.

Primary outcomes

  • Employment rate
  • Employment attendance
  • Average income

 

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The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) is the reference point on drugs and drug addiction information in Europe. Inaugurated in Lisbon in 1995, it is one of the EU's decentralised agencies. Read more >>

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Page last updated: Thursday, 18 May 2017