The role of the family in preventing and intervening with substance use and misuse: a comprehensive review of family interventions, with a focus on young people

The family plays a key part in both preventing and intervening with substance use and misuse, both through inducing risk, and/or encouraging and promoting protection and resilience. This review examines a number of family processes and structures that have been associated with young people commencing substance use and later misuse, and concludes that there is significant evidence for family involvement in young people's taking up, and later misusing, substances. Given this family involvement, the review explores and appraises interventions aimed at using the family to prevent substance use and misuse amongst young people. The review concludes that there is a dearth of methodologically highly sound research in this area, but the research that has been conducted does suggest strongly that the family can have a central role in preventing substance use and later misuse amongst young people.     

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.     

Improving services for prevention and treatment of substance misuse for Aboriginal communities in a Sydney Area Health Service

Introduction and Aims. Substance misuse among Aboriginal Australians is both a symptom of disadvantage and suffering but also a cause of health and social problems. Few data are available on how mainstream drug and alcohol services meet the needs of Aboriginal Australians. We assessed acceptability and accessibility of mainstream services for Aboriginal Australians with alcohol or drug use disorders in an urban Area Health Service (AHS). We identified priorities for improvement and an implementation plan. Methods. We collected feedback via consultation with client groups, with the Aboriginal community and community organisations, with staff of the AHS and of the local Aboriginal Medical Service (AMS) and through direct observation. We examined attendance data. Results. Aboriginal people were well represented in this mainstream service, partly because of existing collaboration with the AMS. Good points in the service were reported to be priority appointments for new Aboriginal clients, professional and caring service and collaboration with the AMS. Suggested improvements included increased cultural sensitivity of communication, more appropriate physical surrounds and printed materials, having Aboriginal staff available, peer support groups and integration of health care for individual, family and community. The action plan included increased recruitment and career opportunities for Aboriginal staff, strengthened partnerships with the Aboriginal community, including ongoing collaboration with the AMS in improving and monitoring mainstream service quality. Discussion and Conclusions. Given the adverse impact of substance use disorders, there is a pressing need for services to work with Aboriginal communities to optimise the quality of mainstream treatment services. [Teasdale KE, Conigrave KM, Kiel KA, Freeburn B, Long G, Becker K. Improving services for prevention and treatment of substance misuse for Aboriginal communities in a Sydney Area Health Service. Drug Alcohol Rev 2008; 27:152-159]     

A brief motivational intervention for substance misuse in recent-onset psychosis

Substance misuse is common in early psychosis, and impacts negatively on outcomes. Little is known about effective interventions for this population. We report a pilot study of brief intervention for substance misuse in early psychosis (Start Over and Survive: SOS), comparing it with Standard Care (SC). Twenty-five in-patients aged 18 - 35 years with early psychosis and current misuse of non-opioid drugs were allocated randomly to conditions. Substance use and related problems were assessed at baseline, 6 weeks and 3, 6 and 12 months. Final assessments were blind to condition. All 13 SOS participants who proceeded to motivational interviewing reported less substance use at 6 months, compared with 58% (7/12) in SC alone. Effects were well maintained to 12 months. However, more SOS participants lived with a relative or partner, and this also was associated with better outcomes. Engagement remained challenging: 39% (16/41) declined participation and 38% (5/13) in SOS only received rapport building. Further research will increase sample size, and address both engagement and potential confounds. [Kavanagh DJ, Young R, White A, Saunders JB, Wallis J, Shockley N, Jenner L, Clair A. A brief motivational intervention for substance misuse in recent-onset psychosis. Drug Alcohol Rev 2004;23:151 - 155]     

The influence of structured education and clinical experience on the attitudes of medical students towards substance misusers

Negative attitudes to patients with substance misuse disorders form a well-recognised barrier to the implementation of best practice. The influence of structured education and clinical experience on the attitudes of medical students towards substance misusers was investigated at an Australian university. First-year students were surveyed before and after 3 weeks of drug and alcohol education and in the same year, fourth-year students were surveyed before and after a 9-week block. Males, older students and those with prior clinical experience tended to have more negative attitudes. Attitudes improved significantly after exposure to interactive learning modules which included contact with patients with substance dependence, including individuals in remission. The level of dislike of problem drinkers significantly decreased after teaching. After fourth-year education, students reported a greater sense of responsibility towards providing intervention and less anticipation of discomfort working with these patients. In particular, confidence and attitudes towards heroin users improved near the end of training after contact with illicit drug users in the small group or individual interview setting. By the end of drug and alcohol education, less than half (42%) of students reported they could not imagine working with substance misusers as a career. Findings support the provision of structured drug and alcohol education and supported clinical experience for every medical student if appropriate evidence-based treatment is to be provided. [Silins E, Conigrave KM, Rakvin C, Dobbins T, Curry K. The influence of structured education and clinical experience on the attitudes of medical students towards substance misusers. Drug Alcohol Rev 2007;26:191 - 200]     

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: 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.     

Substance use and misuse in burn patients: Testing the classical hypotheses of the interaction between post-traumatic symptomatology and substance use

The authors aimed to test whether the three classical hypotheses of the interaction between post-traumatic symptomatology and substance use (high risk of trauma exposure, susceptibility for post-traumatic symptomatology, and self-medication of symptoms), may be useful in the understanding of substance use among burn patients. Substance use data (nicotine, alcohol, cannabis, amphetamines, cocaine, opiates, and tranquilizers) and psychopathology measures among burn patients admitted to a burn unit and enrolled in a longitudinal observational study were analyzed. Lifetime substance use information (n = 246) was incorporated to analyses aiming to test the high risk hypothesis. Only patients assessed for psychopathology in a 6-month follow-up (n = 183) were included in prospective analyses testing the susceptibility and self-medication hypotheses. Regarding the high risk hypothesis, results show a higher proportion of heroin and tranquilizer users compared to the general population. Furthermore, in line with the susceptibility hypothesis, higher levels of symptomatology were found in lifetime alcohol, tobacco, and drug users during recovery. The self-medication hypothesis could be tested partially due to the hospital stay “cleaning” effect, but severity of symptoms was linked to the amount of caffeine, nicotine, alcohol, and cannabis use after discharge. It was found that the 3 classical hypotheses could be used to understand the link between traumatic experiences and substance use explaining different patterns of burn patient's risk for trauma exposure and emergence of symptomatology.     

早期干预对脑瘫高危儿预后影响的研究

目的:探讨脑瘫高危儿的最佳干预时期,对脑瘫高危儿预后的影响。方法:在我院新生儿科住院治疗的脑瘫高危儿257例,其中98例于3个月内开始干预治疗为超早期干预组,83例于3个月后开始干预治疗为早期干预组,两干预组患儿均在医院干预治疗2个疗程(2个月)以上,另76例家属拒绝干预治疗为对照组。结果:(1)1岁(早产儿取纠正年龄)时婴儿智能测试(CDCC)量表测试结果各干预组的MDI和PDI平均值与对照组比较差异均有显著性(P<0.01),超早期干预组平均值更高(P<0.05);(2)1岁(早产儿取纠正年龄)时两干预组脑瘫的发生率均明显低于对照组(P<0.01)。结论:早期干预能减少脑瘫高危儿的脑瘫发病率,减轻障碍程度,最佳干预时期是3个月以内。     

The potential cost-effectiveness of general practitioner delivered brief intervention for alcohol misuse: evidence from rural Australia

Objective

This paper aims to model General Practitioner (GP) delivered screening and brief intervention (BI), and to identify the costs per additional risky drinker who reduces alcohol consumption to low-risk levels, relative to current practice.

Method

A decision model and nine different scenarios were developed to assess outcomes and costs of GP-delivered screening and BI on the potential number of risky drinkers who reduce their alcohol consumption to low-risk levels in 10 rural communities in New South Wales, Australia.

Findings

Based on evidence from current practice, approximately 19% of all risky drinkers visiting GPs annually would reduce alcohol consumption to low-risk levels, of which 0.7% would do so because of GP-delivered screening and BI. If rates of screening and BI are increased to 100%, 36% of these risky drinkers would reduce their drinking to low risk-levels. Alternatively, increments of 10% and 20% in GP-delivered screening and BI would reduce the proportion of risky drinkers by 2.1% and 4.2% respectively. The most cost-effective outcome per additional risky drinker reducing their drinking relative to current practice would be if all of these risky drinkers are screened alone with an ICER of AUD$197.

Conclusion

These findings indicate that increments in rates of screening and BI delivered by GPs can result in cost-effective reductions per additional risky drinkers reducing their drinking to low-risk levels, relative to current practice. They also imply that achieving substantial reductions in the prevalence of risky drinking in a community will require strategies other than opportunistic screening and BIs by GPs.     

Sociocultural determinants of substance misuse among adult Latinas of Caribbean and South and Central American descent: A longitudinal study of a community-based sample

Few studies have examined the socio-cultural determinants of alcohol and drug misuse trajectories among adult Latinas. To assess the associations between socio-cultural determinants and alcohol and drug misuse, we used a longitudinal design to follow a sample of adult Latina mother-daughter-dyads (N = 267) for ten years, and collected four waves of data. They were adult Latinas of Caribbean, South and Central American descent. Specifically, this study investigated the effects of the following factors: (1) Individual Determinants (e.g., socioeconomic conditions, mental health, and medical status); (2) Cultural Determinants (e.g., acculturation to US culture); (3) Interpersonal Determinants (e.g., interpersonal support, relationship stress, mother-daughter attachment, intimate partner violence); (4) Community Determinants (e.g., neighborhood related stress); and (5) Institutional Determinants (e.g., religious involvement, involvement with the criminal justice system). Using hierarchical modeling, we found that taking prescribed medication on a regular basis for a physical problem, religious involvement, and mother-daughter attachment were negatively associated with drug misuse, while involvement in criminal activity was positively associated with drug misuse. Regarding alcohol misuse, results showed that age at arrival in the United States, number of years in the United States, and religious involvement were negatively associated with alcohol misuse, while involvement in criminal activity was positively associated with alcohol misuse. Based on our findings, explicit implications are provided for culturally relevant interventions.     

'It was a nice day...a beautiful day': an analysis of relapse into substance misuse among Indigenous drinkers

This paper presents results from a study investigating relapse prevention options for indigenous clients of alcohol and drug intervention services. The study has 63 'stories' collected through a survey of nine substance misuse services. An adapted version of the Marlatt Relapse Prevention Model was developed to interview clients who had quit drinking but later relapsed into heavy use. The study identified situations influencing the decision to quit, obstacles and dilemmas arising during periods of abstinence, and major triggers associated with relapse into substance misuse. The paper analyses these major triggers and discusses the crucial issues of motivation to quit and maintenance of abstinence. The community environments where indigenous drinkers use alcohol strongly influence successful or unsuccessful attempts to quit. Relapse prevention should be part of a range of public health strategies for tackling substance misuse problems with Indigenous drinkers, and should be included at the minimal intervention level.     

早期护理干预对脑卒中吞咽障碍患者的影响

目的探讨早期护理干预对脑卒中吞咽障碍患者的影响。方法本研究选取2011年1月至2012年5月在本院接受治疗的脑卒中吞咽障碍的患者90例,将其随机分为实验组45例和对照组45例,对照组给予常规护理治疗,实验组在常规护理的基础上给予心理护理、进食护理、咽部功能训练护理,比较两组患者的有效率。结果两组患者在治疗期间内,实验组有效为42例,有效率为93.3%;对照组有效28例,有效率为62.2%,实验组患者的有效率明显高于对照组,差异有统计学意义（P〈0.05）。结论早期护理干预对脑卒中吞咽障碍患者有积极的意义,能够提高患者的生活质量。     

早期干预对高热惊厥复发的影响

目的研究早期干预对高热惊厥复发的影响。方法将各种原因导致的高热惊厥发作的住院患儿60例,完全随机分为观察组和对照组,各30例。对照组给予常规治疗,观察组在此基础上对发热实施早期干预治疗等措施。比较2组惊厥控制效果。结果在随诊1年中,观察组无惊厥发作者26例,占86．7％;对照组10例,占33．3％,观察组惊厥控制效果好于对照组,2组比较差异有统计学意3Z（x2=4．19,P〈0．05）。结论早期干预对防治高热惊厥再发有良好效果。     

Getting the mix right: family, community and social policy interventions to improve outcomes for young people at risk of substance misuse

Societal responses to the existence of substance misuse fluctuate between harm minimisation and prohibition. Both approaches are predominantly downstream reactions to substance misuse that focus on the supply of harmful substances and the containment of misuse through treatment, rehabilitation or punishment. Until recently, little attention has been paid to the upstream individual, family, relationship, community or societal antecedents of substance misuse (which often overlap with those for other adverse life outcomes, such as unemployment, antisocial personality disorder and mental health problems) that have operated during earlier life. A growing body of evidence highlights the overlapping biological and experiential antecedents for substance abuse and other poor outcomes as well as the trajectory-changing protective factors that can prevent risks being translated into destiny. Risk minimisation and protection enhancement embedded in family and social systems are the essential building blocks of a set of early intervention strategies that begin antenatally and continue through the developing years of childhood, adolescence and young adult life, that have been shown to be effective in improving many outcomes in development, health and well-being. Much remains to be done to enable the promise of effective universal and targeted early intervention to be translated into policies, programs and practices that could be life-changing for citizens bogged in the mire of substance misuse and their children. Realistic, timely investment, influenced by the best scientific evidence indicating what works, for whom, under what circumstances, an increased degree of collaboration within and between governments and their agencies to enable "whole of government" responses in partnership with community-based initiatives are essential along with investments in multidisciplinary program evaluation research that will enable evidence-informed policy decisions to be tailored to the needs of individual countries.     

早期干预对妊娠期糖尿病高危孕妇妊娠结局的影响观察

目的探讨分析早期干预对妊娠期糖尿病高危孕妇妊娠结局的影响。方法选取2008年12月～2012年12月本院进行早期干预的30例妊娠期糖尿病高危孕妇为观察组,并以同期未进行早期干预的30例高危孕妇为对照组,然后将两组产妇妊娠结局和新生儿情况进行比较。结果观察组剖宫产率、产后出血发生率、妊高征发生率及感染发生率均低于对照组,新生儿Apgar评分和NBNA评分优于对照组,宫内窘迫、早产、巨大儿发生率低于对照组,差异均有统计学意义（P〈0.05）。结论早期干预可有效改善妊娠期糖尿病高危孕妇的妊娠结局,对于母体及新生儿均发挥着积极的作用。     

新生儿缺氧缺血性脑病早期干预的效果

目的探讨通过早期干预对新生儿缺氧缺血性脑病(HIE)发育状况的疗效。方法将96例观察对象随机分到两组,早期干预组在新生儿期即开始接受系统的干预;晚期干预在4个月以后开始治疗,1岁时测量他们的的行为发育商(DQ)和发育年龄(DA),并进行比较。结果晚期干预组发育异常率为27.7%,高于早期干预组的10.45%(χ2=4.597,P=0.032),干预疗效与开始接受治疗的年龄(H=23.92,P<0.001)、治疗疗程(H=0.990,P<0.001)有关。结论对新生儿缺氧缺血性脑病患者早期干预治疗能有效改善智力及运动发育。     

Missed opportunities: a qualitative study of views and experiences of smoking cessation amongst adults in substance misuse treatment

Background: Smoking rates amongst people with a substance use disorder are disproportionately high. This study aimed to explore views and experiences of smoking and smoking cessation amongst people in substance misuse treatment in order to uncover novel perspectives which could assist in addressing this disparity.

Methods: A qualitative research design was employed, using individual semi-structured interviews. The sample comprised 15 smokers and ex-smokers with a history of drug misuse who were recruited from four inner city substance misuse services. Interviews were audio recorded and analysed using the Framework method.

Results: Several themes were uncovered, including the influence of the environment, peers and staff on motivation to quit and quit attempts; a complex link between smoking and substance use and the impact of substance misuse treatment experiences on attitudes towards smoking cessation. A number of missed opportunities were revealed, as well as unique factors affecting access to smoking cessation treatment for this population, demonstrating support for provision of smoking cessation treatment within both generic and specialist health services.

Conclusions: People accessing substance misuse treatment seek to apply their learning from quitting illicit substances to smoking cessation. However, despite the availability of smoking cessation treatment including pharmacotherapy within substance misuse services and interest from service users, quit attempts were not encouraged or supported by substance misuse staff. Opportunities to quit within such services are minimal, inconsistent and not aligned or sustained across services.     

住院联合家庭康复对0～1岁脑瘫及脑瘫高危儿早期干预的研究

目的 研究住院联合家庭康复,对0～1岁脑瘫及脑瘫高危儿的康复效果.方法 对60例住院联合家庭康复患儿设为治疗组,在医院住院治疗,每1个月为1个疗程,至少治疗3个月,同时根据患儿年龄不同,医生对家长每1月或每2个月指导1次,每次45 min,出院后家长继续实施家庭康复.80例只住院治疗或只家庭康复训练的患儿设为对照组.比...