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Changing behaviour, changing practice
Editorial
Science Photo Library
Changing behaviour, changing practice
For the UK guidelines see http:// www.nta.nhs.uk/areas/clinical_ guidance/clinical_guidelines/ docs/clinical_guidelines_2007.pdf For the NICE guidance see http://guidance.nice.org.uk/ CG51/niceguidance/pdf/English/ download.dspx
Treatment options for drug misuse are to increase across the UK, following the publication of two new documents—Drug misuse and dependence: UK guidelines on clinical management, released on Sept 28, and the National Institute for Health and Clinical Excellence’s Guidelines on psychosocial interventions for drug misuse, published in July. For the first time, the guidelines recommend an intervention called contingency management. The technique involves providing incentives in the form of shopping vouchers, privileges (eg, take-home methadone doses), or modest financial incentives (around £2) to a patient to modify their drug-taking behaviour. The reward is given on the condition that they produce a negative urine test for illicit, non-prescribed drugs. For the technique to work, the type of reward has to be agreed with the patient beforehand and it needs to be provided soon after the positive behaviour. Studies have shown that it is not the size of the reward that is important but the recognition of progress, and that reinforcing positive behaviour is more likely to be effective than penalising negative behaviour. News of the intervention has caused controversy. On Oct 18, the mainstream media picked up on evidence of
bad clinical practice, such as drug rewards (eg, increases in methadone doses) in return for clean urine samples. Some mistakenly view contingency management as rewarding illicit drug use. For others the problem is ethical. They see contingency management as “bribing” patients. However, it would be unethical not to consider contingency management as an option for an illicit drug user seeking help, since it has shown efficacy in more than 25 trials involving over 5000 participants in the USA, Europe, and Australia. Addressing staff concerns about contingency management and changing clinical practice presents a substantial challenge to the UK’s National Health Service. It is sensible that contingency management is being introduced to drug services in a phased-implementation programme led by the National Treatment Agency, in which staff training and service-delivery systems are being evaluated. The intervention is a welcome addition to psychosocial treatment options in the UK, which has some of the highest rates of recorded illegal drug misuse in the western world and where only between a quarter and a third of illicit-drug users entering drug treatment achieve long-term sustained abstinence. ■ The Lancet
2007 United Nations World Food Programme
Global poverty and medical journals
See Comment pages 1467 and 1468 See Special Report page 1471 See Perspectives pages 1475 and 1477 For the global theme issue see http://www.fic.nih.gov/news/ events/cse.htm
1460
This week The Lancet is one of the 235 journals from 37 countries, covering every region of the world, which participated in the Council of Science Editors’ global theme issue on global poverty and human development. Collectively, nearly 750 articles were published representing 110 countries, and The Lancet’s contribution, which includes a Special Report on the World Bank, is published in this week’s issue. The statistics on global poverty are appalling: over 1 billion people throughout the world still live on less than US$1 a day. And despite the fact that the world is generally richer and there is enough food in the world to feed the global population twice over, the number of people living in absolute poverty has actually increased by 200 000 over the past 10 years. Such figures are shocking. They are a shameful indictment on the international community. But as highlighted by 20 years of the UN International Day for the Eradication
of Poverty—on Oct 17 every year—drawing attention to global poverty is not enough. During the past 4 years, since our first child survival series in 2003, The Lancet’s focus on global health issues, such as maternal survival, sexual and reproductive health, and global mental health, has sought to act as an advocacy tool—to make science the catalyst for political change. The global partnerships and initiatives that have been formed after each series aim to enhance evidence-based policymaking and bring about lasting improvements in human health. But there is no room for complacency. By the end of today, 30 000 more people will have died from povertyrelated illnesses. We should never let the familiarity of the statistics dull the outrageousness of this situation. There is much to celebrate in the astounding feat of cross-journal partnership. We can, and should, do a great deal more. ■ The Lancet www.thelancet.com Vol 370 October 27, 2007
Science Photo Library
Changing behaviour, changing practice
For the UK guidelines see http:// www.nta.nhs.uk/areas/clinical_ guidance/clinical_guidelines/ docs/clinical_guidelines_2007.pdf For the NICE guidance see http://guidance.nice.org.uk/ CG51/niceguidance/pdf/English/ download.dspx
Treatment options for drug misuse are to increase across the UK, following the publication of two new documents—Drug misuse and dependence: UK guidelines on clinical management, released on Sept 28, and the National Institute for Health and Clinical Excellence’s Guidelines on psychosocial interventions for drug misuse, published in July. For the first time, the guidelines recommend an intervention called contingency management. The technique involves providing incentives in the form of shopping vouchers, privileges (eg, take-home methadone doses), or modest financial incentives (around £2) to a patient to modify their drug-taking behaviour. The reward is given on the condition that they produce a negative urine test for illicit, non-prescribed drugs. For the technique to work, the type of reward has to be agreed with the patient beforehand and it needs to be provided soon after the positive behaviour. Studies have shown that it is not the size of the reward that is important but the recognition of progress, and that reinforcing positive behaviour is more likely to be effective than penalising negative behaviour. News of the intervention has caused controversy. On Oct 18, the mainstream media picked up on evidence of
bad clinical practice, such as drug rewards (eg, increases in methadone doses) in return for clean urine samples. Some mistakenly view contingency management as rewarding illicit drug use. For others the problem is ethical. They see contingency management as “bribing” patients. However, it would be unethical not to consider contingency management as an option for an illicit drug user seeking help, since it has shown efficacy in more than 25 trials involving over 5000 participants in the USA, Europe, and Australia. Addressing staff concerns about contingency management and changing clinical practice presents a substantial challenge to the UK’s National Health Service. It is sensible that contingency management is being introduced to drug services in a phased-implementation programme led by the National Treatment Agency, in which staff training and service-delivery systems are being evaluated. The intervention is a welcome addition to psychosocial treatment options in the UK, which has some of the highest rates of recorded illegal drug misuse in the western world and where only between a quarter and a third of illicit-drug users entering drug treatment achieve long-term sustained abstinence. ■ The Lancet
2007 United Nations World Food Programme
Global poverty and medical journals
See Comment pages 1467 and 1468 See Special Report page 1471 See Perspectives pages 1475 and 1477 For the global theme issue see http://www.fic.nih.gov/news/ events/cse.htm
1460
This week The Lancet is one of the 235 journals from 37 countries, covering every region of the world, which participated in the Council of Science Editors’ global theme issue on global poverty and human development. Collectively, nearly 750 articles were published representing 110 countries, and The Lancet’s contribution, which includes a Special Report on the World Bank, is published in this week’s issue. The statistics on global poverty are appalling: over 1 billion people throughout the world still live on less than US$1 a day. And despite the fact that the world is generally richer and there is enough food in the world to feed the global population twice over, the number of people living in absolute poverty has actually increased by 200 000 over the past 10 years. Such figures are shocking. They are a shameful indictment on the international community. But as highlighted by 20 years of the UN International Day for the Eradication
of Poverty—on Oct 17 every year—drawing attention to global poverty is not enough. During the past 4 years, since our first child survival series in 2003, The Lancet’s focus on global health issues, such as maternal survival, sexual and reproductive health, and global mental health, has sought to act as an advocacy tool—to make science the catalyst for political change. The global partnerships and initiatives that have been formed after each series aim to enhance evidence-based policymaking and bring about lasting improvements in human health. But there is no room for complacency. By the end of today, 30 000 more people will have died from povertyrelated illnesses. We should never let the familiarity of the statistics dull the outrageousness of this situation. There is much to celebrate in the astounding feat of cross-journal partnership. We can, and should, do a great deal more. ■ The Lancet www.thelancet.com Vol 370 October 27, 2007