Research for Recovery: A Review of the Drugs Evidence Base
This review of the drugs evidence base was commissioned by the Scottish Government on behalf of the National Drugs Evidence Group. The main aim of the review was to show where the evidence base is already strong, what the evidence tells us and what we still need to know to support Scotland's National Drugs Strategy, The Road to Recovery: A New Approach to Tackling Scotland's Drug Problem. It examines both the published evidence base and the policy context in which the strategy sits and this provides the link between the evidence base for addictions and the wider social, health and economic context in which recovery occurs. The review set out to assess what we know about 'what works' in drugs recovery and identify the core questions that need to be answered when assessing the effectiveness and impact of The Road to Recovery.
- The evidence base on recovery is growing, demonstrating that recovery-focused approaches can augment and enhance treatment interventions, and maximise wider benefits to families and communities.
- There is little UK-based research on recovery and the international evidence base is limited by three factors - much of it is quite dated, much of it is based on alcohol or mental health rather than illicit drugs, and almost all of the evidence originates from the United States.
- In the drugs research field, there is a considerable history of treatment effectiveness cohort studies and these consistently show significant improvements for clients in treatment services across a range of indicators including health, offending, risk-taking and substance use.
- Differences in the effectiveness of different forms of abstinence-oriented treatment (such as community detoxification and residential rehabilitation) have been less consistently researched and reported.
- With the exception of one medium-term (33 month) outcome study (Drug Outcome Research In Scotland - DORIS), there is little longitudinal treatment research in Scotland and very little clinical research activity. Thus, the evidence base is largely derived from English and international findings and from 'expert' reviews and policy guidance.
- However, there is a clear need for 'technology transfer' research to determine what can be learned from other settings, particularly mental health recovery and the substance misuse recovery experience in the United States, and to test its applicability to the drugs field in Scotland.
- Findings from this review emphasise: 1) the importance of providing ongoing support to individuals following structured treatment; 2) the positive outcomes associated with mutual aid and peer support in the community; and 3) the importance of assertive follow-up support as aftercare.
- The review highlighted an evidence gap on the impact of drug treatment aftercare in Scotland and there is a need for research and evaluation on this in the future.
- The overall consensus of key experts working in the drugs field, who were consulted as part of the review, was that a clear strategy is needed for developing a Scottish evidence base that will both inform the delivery of The Road to Recovery and assess its impact.
- The findings from this research could help to inform the commissioning and delivery of services in Scotland, the establishment of recovery-focused outcomes and indicators, and the involvement of service users and communities in developing knowledge about recovery and service provision.
The main aim of this review was to show where the evidence base is already strong, what the evidence tells us and what we still need to know to support the drugs strategy. In doing so, the research mapped the evidence requirements of The Road to Recovery, reviewed the findings of existing evidence around recovery, assessed the quality of the available evidence base and identified key evidence gaps.
The research process involved two distinct phases:
1. A review of the available literature on recovery, what works in drug treatment, and the lessons that can be learned from related fields, particularly the mental health recovery movement, with a view to understanding how this evidence could inform policy making in Scotland.
2. A 'consultation' phase, in which key experts in the drugs field were interviewed about the findings of the literature review, the drugs evidence base in Scotland and internationally and the key gaps in current knowledge.
What do we know about recovery?
Although there is a limited UK recovery research base, some key conclusions can still be drawn:
- Sustained recovery is the norm, although the time to recover and the pathways involved are unique to the individual. For this reason, the evidence suggests that a narrow, 'diagnostic' definition of recovery is not advisable.
- The best predictor of the likelihood of sustained recovery is the extent of 'recovery capital'. This includes the personal and psychological resources a person has, the social supports that are available to them and the basic foundations of quality of life (i.e. a safe place to live, meaningful activities and a role in their community, however they define this).
- Barriers to recovery include psychological problems (mental illnesses and the absence of strengths, such as self-esteem), significant physical morbidities (including blood borne viruses), social isolation and ongoing chaotic substance use.
- Strengths (i.e. recovery capital) are a better predictor of long-term recovery than the symptoms of substance misuse.
- While structured treatment has a key role to play in an individual's recovery, it is only part of the support that most people will need to recover from their drug use. Ongoing support in the community is essential for maintaining and continuing the recovery journey.
- The individual is the central actor in the recovery journey and their empowerment, hope and strength are key predictors of their sustained recovery.
- Recovery is not just about the individual, but significantly it also involves - and impacts upon - families and communities.
- Switching to a recovery model is likely to require a fundamental change in culture and attitudes by many professionals and by communities.
What is the evidence for treatment outcomes?
There is a considerable history of cohort studies assessing short-, medium- and long-term outcomes for clients accessing different types of drug treatment. Findings from these studies consistently show significant improvements for clients across a range of indicators, including health, offending, risk-taking, substance use and social functioning.
Differences in effectiveness between different modalities of treatment have been less consistently reported. More recent outcome studies in the United States have switched focus from overall effects to the mechanisms of change, including service functioning and delivery, the client/worker alliance and client engagement and participation in the treatment process. This is based on findings that therapeutic relationships and overall service quality are important predictors of treatment engagement and outcomes for clients.
Other key findings have been that:
- There is a strong evidence base supporting methadone substitution treatment in maintenance settings, but this requires adequate psychosocial support and links to 'wraparound' care in addition to prescribing.
- Scottish outcome research (DORIS) has shown that while methadone maintenance leads to improved outcomes in a range of domains, it is associated with low rates of sustained abstinence.
- Continuity of care is a critical component of effective treatment systems, and there is a strong supportive evidence base around linkage to 12-step and other community 'aftercare' supports. However, the quality of current research evidence on aftercare packages is particularly poor.
- The evidence suggests that there is a problem with psychosocial interventions and that this is related to the structure of service delivery. While there is a strong evidence base available from clinical trials, there is little evidence that structured psychosocial interventions are routinely translated into everyday clinical practice.
- The issue of 'technology transfer' is part of a recent transition to assessing what allows the evidence base to be applied in real clinical settings with increased focus on the structure of services and their organisational functioning.
What can we learn from parallel fields?
Scotland has been at the forefront of the mental health recovery movement. The key underlying principles of recovery in mental health can be summarised as: the empowerment of the person in recovery; building their aspirations and expectations of recovery; focusing on the enabling role of the professional; and a much greater role for family and community engagement in recovery. This approach has changed the way that professionals engage with their clients and has required major shifts in professional cultures and workforce development. That said, much of the evidence to date in this field has been drawn from personal experiences, and systematic analysis has been more limited.
Equally important as the changing role of professionals and the empowerment of the person in recovery, is the increased role of communities. These provide the setting for recovery to occur, a foundation for supportive relationships and opportunities for vocational and personal growth, as well as a developmental platform for recovery.
Finally, there are lessons to be learned from criminal justice research, where the assumption is that desistance (or recovery) is the norm and that it is life transitions, rather than interventions, which are a key part of sustaining an individual's recovery journey.
While we should be cautious in translating lessons learned from recovery in other fields to drugs recovery, these approaches do promote some common themes:
- the central role of self-empowerment;
- the importance of the growth of self-esteem and self-efficacy and the importance of changed self-perception;
- the central role of the community and peer learning, rather than the clinic, and the benefits around communities of recovery;
- the recognition that recovery is both an ongoing and dynamic process of change.
What do we know in key areas?
Criminal Justice and Prisons
- Therapeutic Communities (TC) in a prison context are effective in reducing drug use and criminality, with outcomes further improved with follow-up aftercare. TC may be less successful among women and those with a dual diagnosis of mental health and substance use issues.
- Interventions for prisoners with a dual diagnosis of mental ill-health and substance use have shown limited effectiveness, although those receiving dual treatment are more likely to maintain contact with services. However, more research is required.
- US research suggests that interventions which take account of the multiple and complex needs of female offenders, such as post-traumatic stress disorder, can improve effectiveness and recovery, particularly where there is follow-up after release from prison.
- The evidence around the success of coerced treatment is mixed. Research from North America suggests coercion improves retention in treatment but not necessarily abstinence. Further research is required on the effectiveness of coerced treatment, especially in a Scottish context.
- Encouraging social skills, improving self-esteem and channelling substance misusing former offenders towards networks of social support have been found to help reduce reoffending.
- US research suggests that family involvement in treatment programmes may improve outcomes.
- Teaching parenting skills as part of treatment programmes can improve retention in treatment and may reduce childcare associated stresses that can trigger relapse.
- Californian research suggests that mothers are more likely to have children returned to them from care where mothers remain in treatment for 90 days or more.
- Pregnant women tend to use treatment services more and undertake more intensive treatments, suggesting that pregnancy can be a turning point in drug misuse. Abstinence outcomes tend to be improved as a result, particularly where residential programmes are used.
- Supportive parents are key to adolescents becoming abstinent. Therapeutic communities and 12-step participation have also been shown to be effective with adolescents, but it may be necessary to frame the assisted recovery process as a part of the individualisation process associated with becoming an adult.
Prevention and Education
- There is a strong link between problem drug use and deprivation, suggesting tackling poor housing and employment could have a positive impact on recovery from drugs in Scotland, although it is also important to review other factors such as mental health, recreational use and peer networks. Research evidence on the efficacy of drug prevention initiatives is lacking.
- More risk factors and the absence of protective factors increase the likelihood of a young person developing a drug problem. However, there is a research gap around whether identifying and targeting vulnerable young people is an effective method of reducing substance misuse.
- Certain drug education models can deliver modest reductions in cannabis, alcohol and tobacco consumption in the short-term. However, there is generally a lack of robust evidence on effective drug education strategies, both within educational institutions and in the community.
Treatment and Intervention
- Treatment is generally effective although the structure and context is increasingly recognised as being important. US evidence suggests that a staged approach to recovery is effective. Long-term recovery is likely to be linked to social networks and the development of recovery capital.
- The evidence around the success of treatment for those with dual diagnosis of substance misuse and poor mental health is limited. Some treatment, mutual aid and integrated care approaches show promise but more rigorous trials are required.
- Women are less likely to access drug treatment than men, but once in treatment retention and outcomes are similar. There is a need to evaluate interventions for older women and women with dual diagnosis, as well as the benefits of mixed versus single-gender treatments.
- The therapeutic alliance and level of client engagement is an important predictor of treatment outcomes, with worker motivation and efficacy central. Professional staff from similar cultural backgrounds to clients can improve treatment engagement.
- In Scotland, people from black and minority ethnic groups are less likely to access drugs treatment than the population as a whole. Further research is needed to find out whether this reflects lower prevalence of drug use, poor reporting or barriers to services. Such barriers may reflect inadequate diversity training, lack of cultural understanding, language barriers and a lack of welcoming 'symbols of accessibility'.
- Using aftercare interventions, such as relapse prevention and 12-step which aim to build self-efficacy and confidence in clients, is likely to be an important step towards recovery. While there is strong evidence of the added value of engagement in mutual aid after formal treatment, there remain barriers for both clients and professionals.
- There is clear support for effective engagement in recovery housing and training and vocational support as parts of a recovery package of care, provided that work-related pressures do not compromise recovery needs.
- Effective continuity of care is essential with an increasing international evidence base around the benefits of assertive linkage to aftercare and community support. Quarterly post-treatment recovery check-ups have been shown to be effective in reducing relapse and in returning clients to treatment more quickly where relapse does occur.
Filling the gaps in evidence
The review confirms the need for a more strategic, programmatic approach to developing the drugs recovery evidence base in Scotland.
Building on this review, the Scottish Government and National Drugs Evidence Group will work towards agreeing a Drugs Evidence Framework, setting out the key priorities for new evidence that will help inform effective recovery in Scotland.
In addition, the authors of the review also recommend new structures - perhaps in the form of a Scottish Drugs Research Forum - to lead on research prioritisation and negotiation with key bodies around sustainable funding support for research and broader evaluation and audit work within Scotland.
This document, along with full research report of the project, and further information about social and policy research commissioned and published on behalf of the Scottish Government, can be viewed on the Internet at: http://www.scotland.gov.uk/socialresearch. If you have any further queries about social research, or would like further copies of this research findings summary document, please contact us at firstname.lastname@example.org or on 0131-244 7560.