« Previous | Contents | Next »
Listen
Drug treatment services for young people: A systematic review of effectiveness and the legal framework
PART 1
A SYSTEMATIC REVIEW OF THE EFFECTIVENESS OF TREATMENT AND CARE SERVICES FOR DRUG USING YOUNG PEOPLE
AIMS
Identify, assess, critically appraise and synthesise the existing evidence from the international research literature concerning the effectiveness of treatment and care services for drug using young people.
Key questions to be addressed
1) How effective are drugs services in reducing drug use among young drug users?
2) How effective are drugs services in reducing the physical harms associated with drug use among young drug users?
3) How effective are drugs services in improving the psychological well being of young drug users?
4) How effective are drugs services in improving the family and social relations of young drug users?
5) How effective are drug services in encouraging the up-take of other health and social services?
METHODS
Scope of the Review
The population
The review focuses on studies that are conducted with young people who are 16 years or under. Often researchers use the terms 'young people', 'adolescents' or school children and do not provide statistical data that fully describes their sample. By default these papers are accepted in the review. Other studies involve young people up to the age of 16years as well as older age groups. In these cases a paper is accepted if; a) the measure of central tendency is £ 16yrs, or b) a large proportion of the sample are £ 16yrs, or c) analyses are conducted on a sub-group £ 16years or d) is likely to contain a high number of £ 16yrs (11-19yrs).
Type of intervention
The review focuses on a broad range of settings including hospital in-patient, rehabilitation, prison, outpatient, community drug treatment services and schools. It includes interventions such as behaviour therapy, family therapy, general drug treatment facilities, Minnesota 12-step programmes, school programmes, and therapeutic communities.
Intervention effects
Studies are included if they focus on secondary prevention i.e., those aimed at reducing drug use or drug harms among young people. The questions set by the review are intent on addressing this aim. Thus studies that focus solely on primary prevention are excluded e.g., drug awareness campaigns, drug education programmes, mass media campaigns, government legislation, socio-economic interventions.
Problematic drug use
The definition of problematic drug use varies across studies. Some do not offer a definition whilst others adopt any number of those defined in formal assessments such as the Diagnostic and Statistical Manual of Mental Disorders. There are authors (particularly in the USA) who regard illicit drug use in itself as problematic. A substantial number of secondary prevention interventions aim to reduce drug use. These often take the form of school interventions. The techniques used in many comprise of skills, support and family involvement and are often targeted at high-risk groups. Studies that reduce drug use and those that reduce problem drug use are included in the review.
Search Strategy
Time period, publication type, language and countries
English language research published between 1990 and 2001 from any country is included. Primary and secondary research (systematic reviews) is included.
Publication Sources
Research Experts
A number of research experts were identified from the electronic and data base searches. Sixty three, from countries throughout the world, were contacted by letter and asked to provide a list of published and unpublished studies (1990-2001) they considered to be the most important in the topic area. 39 (62%) replied and the names of those who agreed to be mentioned appear in Appendix 2.
Assessing and appraising the evidence
The initial search for papers produced 5874 abstracts. All the abstracts were assessed using the following criteria:
relevant to young drug users;
relevant to the services that are subject of review;
the abstract indicated that the study included a control or comparison group design.
If a paper met these criteria it was selected for retrieval. On the bases of this assessment 694 full papers were retrieved. Appendix 3 presents the number of papers retrieved by year of publication. Each paper was subject to a more detailed assessment to determine whether it focussed on the appropriate age group and whether it involved secondary prevention. After this assessment 104 papers, including 34 reviews, were accepted for detailed appraisal.
Primary papers were appraised four broad areas of enquiry a) whether patients were randomly assigned, c) whether comparisons between groups were justified b) whether data were adequately collected and analysed d) and whether the findings were interpreted correctly. Review articles were also appraised in four broad areas of enquiry a) whether a comprehensive literature search was carried out b) whether an assessment of the primary paper was conducted adequately c) whether good quality papers were accepted d) whether the results of studies were corrected synthesised. On the basis of these criteria each paper was judged as good, moderate, or if the paper failed to perform these steps adequately it was graded as poor and then rejected. Most papers that were rejected failed in 3 out of 4 areas. Primary papers were also rejected if they appeared in reviews that were of acceptable quality. Primary papers and reviews that were rejected appear at the end of the reference list with the reason for rejection. The appraisal forms for primary papers and reviews appear in Appendix 4.
The review included studies that provide the strongest evidence. Only the following designs were considered for inclusion and graded according to the following hierarchy:
1) High quality experimental study of good or moderate quality
2) Low quality experimental study of good or moderate quality
3) High quality controlled observational study of good or moderate quality
30% of the primary papers and 30% of the reviews were selected and appraised by an independent reviewer. There was 87% agreement between reviewers on primary papers and 13% resolved through further discussion. There was 90% agreement between reviewers on the reviews and 10% resolved through further discussion. At the end of the appraisal 11 primary papers and 7 reviews were included in the review. This represents 10% of the 70 primary papers and 20% of the 34 reviews accepted for the initial appraisal.
Synthesising the evidence and writing the final report
It was not feasible to conduct a meta-analysis of the 11 primary papers. This small number of papers represents studies that are conducted on a wide range of interventions and different populations. Further more, there are differences in the way the primary outcomes are measured. For example, drug use is measured at different time points and with varying frequency.
The data from the papers are collated and described using a qualitative method. A standard data extraction sheet was used which allowed a full summary of each paper to be made. The completed data extraction sheets appear as tables in the review. These tables contain information about the authors; year of publication; the sample characteristics; the study design; the setting in which the study took place; the type of intervention studies; and the outcomes that were measured. The tables also provide a summary of the evidence for the effectiveness of the intervention and how the authors report the evidence. The evidence is graded and is presented on a scale of 1-5 where 1 represents a strong beneficial effect, 2 a weak effect, 3 no effect, 4 harmful effect and 5 indicates insufficient evidence to support the effectiveness of an intervention. The quality of the research is also given where 1 represents a good quality study and 2 a study of moderate quality. The lead author of the present review (LE) carried out the data extraction and grading.
The discussion of results comprises seven sections. The first section describes the interventions that have been the subject of research. Sections two to six are devoted to answering the key questions outlined at the beginning of this report. Each section begins with an overview of the interventions that have been subject to review and a summary of the findings and the strength of those findings. The details of the relevant papers appear in tables in each section. The tables are divided into reviews and primary papers and are arranged alphabetically by author. The seventh section describes the factors associated with the general success of interventions. A conclusion and discussion section completes the report.
« Previous | Contents | Next »