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Drug Treatment Services for Young People: A Research Review

CHAPTER 4 EVIDENCE FOR EFFECTIVE INTERVENTIONS

This chapter presents the findings of the first of two literature reviews which inform the overall study of treatment services in Scotland. More detailed analyses and methodological details are presented in a separate EIU report of the literature reviews.

After the introduction we present our conclusions and discuss the key issues contributing to the success of the interventions that appear to be effective. We then provide more detailed information about each type of intervention and its relative effectiveness and present some limitations of the literature review. Finally, we discuss whether the interventions identified through the literature review are transferable from their place of origin to a Scottish setting.

Introduction

Outlined below are the main findings of a systematic review of published research into the effectiveness of treatment and care services for drug using young people up to the age of 16 years in the following five key areas:

• reducing drug use;

• reducing the physical harms associated with drug use;

• improving the psychological well being of young drug users;

• improving the family and social relations of young drug users;

• encouraging the up-take of other health and social services.

The small number of papers included in the review (7 reviews and 11 primary papers) indicates that there is a lack of good quality studies on the effectiveness of drug interventions for young people up to the age of 16 years. Nevertheless, they provide useful insights into the types of interventions that have been evaluated using moderately strong research designs. As such the review provides the best available evidence for the effectiveness of these interventions for young drug users. The interventions range from in-patient treatments to school-based programmes and are aimed at reducing drug use and the problems associated with drug use. The review focuses on secondary prevention rather than primary prevention. Practically all of the studies are conducted in North America or Canada.

All 18 publications make specific mention of the design of the interventions. Journal articles restrict the amount of space available to authors, particularly published reviews. So not every article provides similar details about the crucial elements of the service design including, the content of the intervention, who delivered it and the setting in which it was provided. Even when more space is provided, such as in primary papers, the level of detail varies according to the author's preference. The intervention details that appear in this report are based on papers that allow some description but are likely to provide only partial coverage.

More complete analysis would require careful assessment of the relevant primary papers cited in published reviews and, where primary papers fail to provide sufficient detail, direct contact would have to be established with the original author. This is outwith the scope of the current review.

Key Findings

The review clearly demonstrates that some interventions are effective in reducing drug use and the problems associated with drug use whilst others are either weakly effective or have no impact on these outcomes. The interventions and their associated effect are summarised in Table 3.

In the fairly/strong effect/reducing drug use quadrant, the main drug(s) used by participants have been identified in brackets. The absence of other named drugs means that there is no current evidence that the specific intervention is effective in reducing other types of drug use. It is interesting to note that family therapy is seen to be effective in reducing drug use, psychological problems and social problems.

Apart from the evidence presented in Table 3, there is also weak evidence that therapeutic and residential treatments may lead to an increase in the use of medical services by young people and their parents. There is also weak evidence that family therapy reduces the length of stay in prison or residential treatment.

A small number of interventions may have a potentially harmful effect. These are mainly school based life skills programmes that demonstrate an increase in cannabis use and drug acceptance attitudes among those exposed to the intervention. This may be related to the influence of drug using peers or family support for drug use.

The review found no studies that demonstrated interventions effective in reducing the physical harms related to drug use. Two possible explanations for this are that good quality research studies have yet to be conducted in this area or that young drug users do not exhibit the same level of physical morbidity as demonstrated by adult drug users. There were also no studies that demonstrated the effects of substitute prescribing for young drug users, such as methadone. This may be due to the reluctance of medical practitioners to prescribe potentially addictive substances to young people or legal restrictions on the licensing of these drugs.

The review provides the best available evidence for the effectiveness of some interventions for young drug users and in addition the factors associated with their success. These factors are best regarded as broad indicators of the types of elements that might be included in successful interventions for young drug users (Table 4).

One of the success factors concerns providing separate services for 'low risk' and 'high risk' groups. The potential characteristics of these groups are shown in Table 5.

Involving parents and peers may enhance an intervention and this is why family therapy is particularly effective. However some caution should be shown when involving families, especially where there is negative family or peer pressure. The use of experienced well-trained staff is also important and multi-agency working in some instances is successful e.g., using mental health professionals in schools programmes and linking family therapy with school interventions.

The Effectiveness of Specific Interventions

Each type of intervention assessed in the literature is described below. This is followed in each case by a summary of the assessment findings for that intervention.

Behaviour therapy

Williams and Chang (2000) describe behaviour therapy as outpatient programs including group therapy of no set length. Azrin et al (1994) provide more detail: 'a typical format of therapist modelling, behaviour rehearsal, specific therapy assignments, self-recording between sessions, review of self-recordings and assignment records, and extensive praise for progress'. The major foci in this study are stimulus control, urge control and social control. Therapy is delivered on a one-to-one basis by a therapist.

Findings

There is fairly strong evidence that behaviour therapy is more effective in reducing drug use than non-behavioural support and that behaviour therapy and cognitive behaviour therapy are more effective than counselling in reducing drug use . In one study young people exposed to behaviour therapy for 12 months achieved 8.9 drug free months compared with 0.6 in the non-intervention group . Young people also respond more positively to behaviour therapy compared with adults . Another study reported by Williams and Chang (2000) demonstrates that 73% of those exposed to behaviour therapy achieved drug abstinence at discharge compared with 9% receiving counselling.

There is weak evidence that behaviour therapy improves the psychological well being of young drug users. Behaviour therapy also has a weak effect in improving schoolwork, school attendance, and family relations .

Counselling

Counselling is extremely varied. It encourages the expression of feelings, the initiation of comments, reactions to comments, self-described drug use, discussion of drug use experiences, praise, and abstinence desires (Azrin, McMahon et al. 1994). It may be delivered on a one-to-one basis or in groups (Williams and Chang 2000; Morehouse and Tobler 2000). In one study highly trained counsellors delivered culturally sensitive counselling consisting of drug prevention, wellness and drug freedom sessions to high-risk youths . It included the discussion and role-play of drug experiences, family problems, and stress, and aimed to change attitudes, culture and norms. Small interactive health education groups may also involve counselling. In Magura et als' study, for example, emphasis is placed on problem solving around HIV/AIDS, the factors leading to the initiation and continuation of drug use, and problems associated with drug use (Magura, Kang et al. 1994). Interestingly motivational counselling was not evaluated in any of the studies included in the review.

Findings

Culturally sensitive counselling is more effective than non-intervention controls in reducing drug use, and that up to 36% of those exposed to this counselling will reduce their drug use . Less intense health education counselling, however, is ineffective in reducing drug use .

Family Therapy and Other Family Interventions

Family therapy is diverse. Stanton and Shadish (1997) distinguish it from other family interventions in that it involves all relevant family members in a group (co-joint) or individual basis and includes any of the following elements:

• structural therapy which aims to alter family structure (Stanton and Shadish 1997);

• strategic approaches which focus on family interactions out with therapy sessions (Stanton and Shadish 1997);

• multi-systematic interventions which incorporate external systems such as courts and schools (Stanton and Shadish 1997; Schoenwald, Ward et al. 1996);

• contextual approaches which are described as 'psycho-dynamical-oriented and multigenerational'. (Stanton and Shadish 1997);

• Bowden Systems Therapy which is an intergenerational approach using family and individual sessions (Stanton and Shadish 1997);

• functional approach which combines strategic therapy with behavioural tasks (Stanton and Shadish 1997);

• behavioural approach which emphasises social learning principles (Stanton and Shadish 1997).

Other family or peer interventions that do not include family therapy are:

• individual counselling (Stanton and Shadish 1997);

• family counselling which encourages the discussion of health problems, family relations and problem solving (Harrington, Kerfoot et al. 1998);

• peer group therapy involving non-family members (Stanton and Shadish 1997);

• family psychoeducation which usually involves education on drugs and family dynamics (Stanton and Shadish 1997; Weir 1998);

• parenting groups which aim to improve parenting skills (Stanton and Shadish 1997);

• other interventions such as probation officer visits, court orders (Stanton and Shadish 1997).

Findings

There is fairly strong evidence that family therapy is effective in reducing drug use. The upper limit of reduction is approximately 54% of those exposed . Family therapy is also equally effective as parenting groups in reducing drug use . There is lack of evidence to establish which type of family therapy is most effective. An important factor is the involvement of parents or family in the therapeutic process . There is fairly strong evidence that family therapy is more effective in reducing drug use than other family interventions such as probation officer visits, drug education and peer education, teacher based therapy, individual counselling, and adolescent group therapy .

There is also fairly strong evidence that family therapy reduces psychological problems, including suicide ideation in young drug users . This includes non-hospital-based family therapy and the effect can last up to 14.6 months. Twelve family therapy sessions are equally effective as family therapy combined with other inputs (e.g. school) in improving psychiatric conditions. Co-joint family therapy, that involves the family and client in the same therapy session, is more effective in improving psychological status and psychiatric functioning compared with family therapy that is targeted at individuals. This includes reducing distress and impulse control problems .

Family therapy is also fairly effective in reducing family and social problems compared with parent support groups although family teaching in the community can also reduce anti-social behaviour . Co-joint family therapy is equally effective as one-to-one family therapy in improving family functioning . Linking co-joint family therapy with schools is also effective in improving family functioning .

There are other areas in which family therapy and non-family therapies are effective but the effects are generally weaker. Family problem solving marginally improves psychological well being for young people with low levels of depression who deliberately self-harm or overdose . Family therapy has a weak effect in reducing drug arrests and improving school grades . There is weak evidence that community-based family psycho-education improves school grades and decreases absenteeism . There is weak evidence that multi-systematic family therapy (MST) reduces the length of stay in prison or residential treatment services . There is no effect on the use of medical services, including mental health services, which were used by approximately 33% of the treatment and control groups .

Family interventions can at times be ineffective. Family problem solving sessions for young people who have deliberately harmed themselves or overdosed has no effect on family functioning or suicide ideation .

General drug treatment facilities

Some authors refer to general drug treatment facilities or out patient facilities (Williams and Chang 2000), but offer little else by way of description. Maisto et al suggest that this form of treatment should improve coping skills, and decrease stress. In their study, participants were recruited from psychiatric hospitals, a free standing chemical dependence programme, and an outpatient substance abuse programme. Williams describes the outpatient programmes as consisting of counselling, and occasionally family therapy (Williams and Chang 2000). Treatment tends to be longer in duration (1-2 sessions per week), but may vary from one session to 6 months.

Findings

There is fairly strong evidence that non-hospital day programmes reduce arrests and violence compared with a community integration interventions . Hospital in patient intervention does not improve anti-social behaviour .

There is weak evidence that general drug treatment programmes are effective in reducing drug use . General drug treatment services are weakly effective in improving the psychological well being of young drug users .

Minnesota 12-step programmes

Minnesota 12-step interventions are described by Williams and Chang (1997) as 'a short 4-6 week hospital inpatient programs typically offering a comprehensive range of treatment consisting of individual counselling, group therapy, medication for co-morbid conditions, family therapy, schooling and recreational programming. It often has an Alcoholic Anonymous/Narcotics Anonymous 12-step orientation and is followed-up with out patient treatment'.

Chemical dependency is treated as a disease and abstinence is advocated (Winters, Stinchfield et al. 2000). Winters et als' clients were treated on an inpatient bases for 4 weeks and an outpatient bases for 6 weeks. Treatment components included group therapy, individual counselling, family therapy, lectures, reading and writing assignments, schooling and occupational and recreational therapy. It focused on five elements of recovery 1) admitting the problem, 2) believing in hope for change, 3) learning from others, 4) taking stock of life, 5) discussing problems with peers. Families were encouraged to attend. A six-month programme was advocated with meetings 2/3 times per week.

Findings

Williams and Chang (2000) present fairly strong evidence that the Minnesota 12 step programme is effective in reducing drug use among young people. This is also supported by Winters et al who suggest that 53% of those receiving this intervention report reduced or no drug use at 12 months compared with 28% of controls .

School based programmes

These are diverse and include combinations of the following:

• Classroom teaching and skills development sessions. Teaching includes drug, risk and well-being awareness classes. Skills training includes developing, drugs resistance skills; social skills; listening skills; decision making skills; reducing hazardous behaviours such as drink driving; peer leadership and influence skills;

• Stress management; and managing human relations (Nicholas and Broadstock 1999; Tobler 1992; White and Pitts 1997; Lister-sharp, Chapman et al 1999; LoSciuto, Freeman et al 1997; Botvin 1997). Other affect based programmes involve building self-esteem, self awareness, expressing feelings and value clarification (Tobler 1992; White and Pitts 1997);

• School-based health centres or consultations with a doctor or nurse (Nicholas and Broadstock 1999);

• Academic support including basic reading skills and job skills (Nicholas and Broadstock 1999; Tobler 1992);

• Cognitive or behavioural and other counselling approaches (Nicholas and Broadstock 1999);

• Combining school sessions with after-school facilities e.g., community youth centres, drama workshops, psychosocial education (Nicholas and Broadstock 1999; Tobler 1992 LoSciuto, Freeman et al 1997; Stead, MacKintosh A et al. 2001);

• Involving parents (Nicholas and Broadstock 1999; White and Pitts 1997; Lister-Sharp, Chapman et al 1999; LoSciuto, Freeman et al 1997; Stead, MacKintosh A et al. 2001);

• Involving peers (Nicholas and Broadstock 1999; Tobler 1992; LoSciuto, Freeman et al 1997; Stead, MacKintosh A et al. 2001);

• Involving professional mental health counsellors (Tobler 1992; White and Pitts 1997);

• Involving teachers (Tobler 1992; White and Pitts 1997; Botvin 1997; Stead, MacKintosh A et al. 2001).

Findings

There is fairly strong evidence that school life skills interventions improve school grades and school attendance .

There is weak evidence that school based programmes reduce drug use (Nicholas and Broadstock 1999; Tobler 1992; White and Pitts 1997; Lister-sharp, Chapman et al 1999; LoSciuto, Freeman et al 1997; Botvin 1997). It is also clear from these studies that certain aspects of these programmes are more beneficial. These include skills development, self-esteem and confidence building, targeting high risk groups, using health professionals and peers, booster sessions, and involving parents (Nicholas and Broadstock 1999; Tobler 1992; Lister-sharp, Chapman et al 1999; LoSciuto, Freeman et al 1997; Botvin 1997; White and Pitts 1997).

School-based interventions are also weakly effective in improving psychological wellbeing. These include, joint school and community skills development interventions ; teen-leader compared with teacher led resistance interventions; and self-efficacy and life skills programmes .

School life skills interventions can improve interpersonal and communication skills . School drug resistance skills improve general social skills . There is weak evidence that school interventions improve family and social relations. School based counselling, mentoring and academic support increases school involvement . Joint school and community skills interventions are successful in reducing delinquency among young people defined as at risk of drug use .

Counter to the findings of research cited above, many school-based programmes were found to be ineffective in improving the psychological well-being of young people. This included joint community support , programmes that focus solely on psychological problems , and some skills programmes .

The school counselling and support intervention described by Nicholas et al, was not effective in reducing depression or suicide ideation. School interventions that focus solely on psychological problems do not have an effect on the psychological factors that place young people at risk of drug use . The multi-component intervention described by LoSciuto et al and designed to improve life skills and self-esteem failed to do so. This may have been due to negative peer or family pressure. The intervention described by Botvin et al, based on life skills and self-esteem, failed to improve decision-making skills. This may have been due to the lower baseline level of intentional drug use among the experimental group.

Studies also demonstrate that school interventions have no effect on young peoples' social well being including racist thoughts (LoSciuto, Freeman et al. 1997) and communication skills . This may be due to negative peer or family pressure or improved baseline skills of the experimental group (Botvin 1997). School counselling, mentoring and academic support classes also have no effect on social coping . The authors offer little explanation as to why this outcome was demonstrated, especially since the same intervention was successful in increasing school involvement and reducing delinquency . Purely education programmes are generally ineffective in reducing drug use. These include general multifaceted school programmes that include drama, class support and drug awareness classes for parents .

Some studies have discovered potentially harmful effects of school interventions. There was an increase in drug use (cannabis) among those exposed to a life skills programme and a teacher based support programme in the USA, particularly among boys . This is thought to be related to their experience of drug use or social support for drug use from friends or family. Older school children exposed to a life skills intervention in the USA demonstrated more unhealthy attitudes (acceptance) towards drugs. This was thought to be related to either their experience of drugs or the influence of other drug users and peers .

There is also insufficient evidence to demonstrate that school-based health centres have an effect on drug use .

Therapeutic community and residential care

This has been described as a specialist treatment facility consisting of between 6 months to 2 years stay (Williams and Chang 2000). These interventions tend to be highly regimented residential settings with treatment facilitated by paraprofessionals and often run by residents (Freeborn, Polen et al. 1995). Older traditional therapeutic communities for young people are rare. Some offer day programmes where recovering patients live at home with their parents . Therapeutic communities can offer assistance in enhancing coping skills, refusal skills, problem solving, personal responsibility and social network development, and many offer counselling (White and Pitts 1997; Weir 1998). Community based group-homes for offenders are also included in this category (Weir 1998).

Findings

Williams and Change (2000) suggest that residential treatment and out patient treatments are strongly effective in reducing drug use. They present fairly strong evidence that residential care also reduces school disturbance and anti-social behaviour compared with probation.

Nevertheless, therapeutic communities that offer coping and problem solving are weakly beneficial in reducing drug use and improving the psychological well being of young drug users . There is also weak evidence that those attending a specialist drug treatment service that offers counselling and residential care use more medical services during a 1.5 year follow-up compared with the comparison group . There is evidence that their parents also increase their contact with medical services. The authors conclude that service use may be determined by familiarity with health services and past positive experience of services

Review Limitations

Gaps & research design constraints

There are some limitations to the review. The first is that there may be interventions that are not yet the subject of research. Motivational counselling is an example. The second limitation is that the review contains studies that are moderately strong in design and as a result research using weaker designs is excluded. These studies may contain valuable information about the context or limitations of some interventions and the findings may be missed. Third, it was evident in reading some reviews that the original studies may have measured outcomes that are of relevance to the present review, but these were not reported (Tobler 1992). Finally, almost all of the studies included in the review were conducted in the USA or Canada. This means that the results may not automatically transfer to Scotland. For example, US drugs policy is based predominately on abstinence rather than tackling problems associated with drug use. In addition, many of the interventions studied were targeted at high risk populations, many of which include culturally diverse groups not found in the UK, e.g. African, Asian and Latino Americans.

Heterogeneity

There was some degree of variation in the findings. This was particularly evident among studies that investigated the effects of school interventions. For example, some studies indicate that school interventions are fairly effective in reducing social problems (Tobler 1992), whilst others suggest only a weak effect (Nicolas and Broadstock 1999) or no effect at all (LoSciuto, Freeman et al 1997).

This may be explained by a number of factors such as the impact of peer influences, study design (Botvin 1997) and type of intervention (Stead, MacKintosh et al 2001). Peers or significant others, such as family members, may have a potentially negative effect on young people (Botvin 1997). Study design is important in that although only well designed studies were included in the review these ranged in quality from quasi-experimental studies to controlled observational studies.

The following types of school intervention are thought to be generally more effective than purely educational interventions:

• skills development

• self-esteem and confidence building

• targeting high risk groups

• using health professionals and peers

• booster sessions

• and involving parents

(Nicholas and Broadstock 1999; Tobler 1992; Lister-sharp, Chapman et al 1999; LoSciuto, Freeman et al 1997; Botvin 1997; White and Pitts 1997).

Need and Provision in Scotland in the Light of the Literature Review

The literature review helps place the situation in Scotland in an international perspective. As remarked above, the findings display some variation and they may not necessarily be transferable from the cultures in which the interventions took place. So one should not attempt to draw conclusions for Scotland from the international studies in an overly simplistic way. Nevertheless, some of the key review findings provide support for the mapping and case study fieldwork. There are also some important similarities and differences between the interventions studied in the USA and Canada, and those mapped or researched in Scotland, worth highlighting.

Similarities with the Scottish Context

There is, for example, an interesting correspondence between the research findings on the needs of young misusers in Scotland, and the types of approach found effective elsewhere. The concept of a 'complex set of needs' (Chapter 2), many of which are not directly misuse related, corresponds well with the review finding that effective approaches are characterised by comprehensive interventions (Table 4). In the same table, multi-agency approaches are also noted as a factor supporting effectiveness, and this implies a similar need to deal with a complex of issues.

Similarly, the findings in chapter 2 on the broad spectrum of drug misuse echo the review finding that interventions need to be well targeted, especially in terms of dealing differently with high and low-'risk' groups, ie groups with differing degrees of misuse and related problems.

The review finds that well funded, longer term interventions using experienced and well trained staff, are more likely to be effective. In Scotland, there is great diversity in terms of:

• the length of time projects have been established;

• the duration and continuity of their contacts with service users;

• the training and experience of the staff;

• the adequacy of funding and staff resources, and

• the degree of strategic thinking and planning as opposed to 'ad-hoc' service development in response to local factors or funding opportunities.

The review findings suggest that there is a need to achieve more consistency in these areas in order to increase the overall effectiveness of provision in Scotland.

In comparing findings relating to specific interventions, there are some difficulties caused by the incomplete descriptions of interventions studied in the literature. The same difficulty is inherent in the mapping of Scottish provision, where (for example) it can be difficult to be sure that the term 'counselling' means the same thing in descriptions of two separate services. This reflects a wider problem, namely the lack of a nationally or internationally established and common set of terms and definitions when discussing interventions of this type.

While this means that some caution is needed in comparing interventions, one can identify a number of correspondences and contrasts between the review findings and the Scottish situation.

The review finds that behaviour or cognitive therapies are likely to be effective in reducing drug misuse. From the mapping survey, it is not clear that these therapies are widely used with children and young people in Scotland, except in a few services. For example there are instances in Dundee (Youth Drug and Alcohol Service, using cognitive behaviour therapy, and in Polmont, where a 'cognitive behavioural approach' is used in group work). Most of these tend to deal with low numbers of children and young people. This may reflect pressure on professionally qualified therapist time, and/or a lack of recognition of the effectiveness of this approach amongst referrers and other practitioners.

Counselling is found by the review to be effective in a number of senses, and this is one of the most common terms used by services in Scotland when describing their delivery methods. The intervention in Scotland appears similar to that defined in the literature, as described in some survey returns or via case study work. That is 'it encourages the expression of feelings, the initiation of comments, reactions to comments, self-described drug use, discussion of drug use experiences, praise, and abstinence desires'.

The review studies stress the need for counselling to be 'culturally sensitive', which reflects the North American links between ethnicity and misuse, but which is also likely to be relevant in Scotland when dealing with children from ethnic minority communities. It is notable that the mapping and case study work found no examples of services targeted at children in these communities, although some workers acknowledged a probable need in this area (see Chapter 3).

Contrasts and Gaps

The review identifies family therapies as a key component of effective approaches. Here there is a clear contrast between North American and Scottish interventions. The mapping survey provides little evidence that family based interventions are currently in place. The case studies provide some limited instances of work with parents or families, but there are no explicitly family focused drug treatment or care services.

Instances of services citing family involvement or parental support services include the Rushes in Lanarkshire, the Hype project in Edinburgh, and the CADS service in Bannockburn. The extent and impacts of this work are currently unclear. Having said this, there are plans in many DAT areas to develop such services, and the Lloyds TSB projects are stimulating work in this area. The literature review supports the importance of this approach.

Similarly, there are no examples from the case studies of very structured programmes like the Minnesota 12-step. (An exception may be the 21 hour group programme running at Polmont, which provides a programme for up to eight users, over 21 hours of contact time, aimed at raising awareness, changing behaviour, and harm reduction).

There may be differences between British and North American cultures which partly explain this contrast (e.g. more explicitly confessional and inspirational programmes involving group work may be less readily embraced by individuals on this side of the Atlantic). However it may simply be that lack of experience with and information on these methods are preventing their use as an effective component of programmes.

Therapeutic communities and residential care programmes for children, which focus specifically on drug misuse, are not readily available in Scotland. Small numbers of children or young people are referred to services in England. Drug treatment and care programmes are provided, where a need is identified, for children and young people in secure and residential facilities. However this is not the main focus of the service user's experience in these settings.

This comparison suggests that, of the five most effective interventions identified via the literature review, only counselling is widely delivered by relevant services in Scotland. Instances of the other four are limited in scale and distribution.

Other interventions discussed by the review (as more weakly effective) are found in the Scottish context. Services often include (usually as activities under the heading 'counselling and advice') group work involving peers, and life skills development. There are also some examples of school links examined via the case studies (for example the Rushes in North Lanarkshire, and the Fife Youth Drug Team - see Chapter 6). There may be other such links, but for clarity of definition school prevention and education services were excluded from the survey scope. There are likely to be 'grey areas' where school based services of this type shade into true treatment and care services, which have been missed in the mapping for this reason. The review findings are particularly heterogeneous in this area and suggest that further study of these approaches would be useful.

The review found no studies of physical harm reduction or substitution prescribing services. Mapping and fieldwork findings for Scotland suggest that such services, while available in some areas, are likely to be limited in their applicability to children. While some children may access them, this can be difficult to identify. For example, it can be difficult to establish the age of young people using needle exchanges and practitioners are generally reluctant to prescribe substitute drugs to young people, and do not 'advertise' the few cases where this is done (see Chapter 6).

Footnote

This is a treatment setting rather than a treatment type. The review evidence for its effectiveness suggests that both the setting and the types of treatment applied within it are important. Some detail on the treatment types is given on page 30.

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