Drug treatment outcomes and employment - National Treatment ...

Drug treatment outcomes and employment A Rapid Evidence Review January 2016

Ash Patel Dave Simmonds Sandra Vegeris Connor Stevens

In January 2016, NIACE and the Centre for Economic and Social Inclusion merged to form Learning and Work Institute

Learning and Work Institute Patron: HRH The Princess Royal | Chief Executive: David Hughes A company limited by guarantee, registered in England and Wales Registration No. 2603322 Registered Charity No. 1002775 Registered office: 21 De Montfort Street, Leicester, LE1 7GE

Acknowledgements The authors are grateful to Paul Anders and Pete Burkinshaw at Public Health England for their continued support throughout this project. We are also grateful to the anonymous reviewers for their valuable feedback on the report. Our thanks are extended to the wider research team from the Learning and Work Institute and in particular Professor Dan Finn, Tony Wilson, Alexander McCallum and Hannah Murphy who have all made a significant contribution to the delivery of project.

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Contents Acknowledgements .....................................................................................................2 1

Abstract ...............................................................................................................4

2

Aims & Objectives................................................................................................5

3

Methodology ........................................................................................................6 3.1

Research Strategy .................................................................................................. 6

3.2

Search strategy....................................................................................................... 6

3.3

Search results ......................................................................................................... 7

3.4

Quality assessment ................................................................................................ 7

3.4.1 3.5 4

Reliability of assessments ................................................................................ 9

Caveat on literature ................................................................................................ 9

Results...............................................................................................................11 4.1

Employment and its influence on drug treatment .................................................. 11

4.2

Employment Outcomes ........................................................................................ 13

4.2.1

Entry into employment and sustainability of employment outcomes .............. 13

4.2.2

Employment outcomes by model of support .................................................. 15

4.3

Other outcomes .................................................................................................... 18

4.4

Participant groups ................................................................................................. 18

4.4.1

Offenders ....................................................................................................... 19

4.4.2

Mental Health ................................................................................................. 19

4.4.3

Gender ........................................................................................................... 20

4.4.4

People with multiple barriers .......................................................................... 20

4.5

Stigma .................................................................................................................. 21

4.6

Contingency management .................................................................................... 21

4.7

Cost Effectiveness ................................................................................................ 22

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Conclusions .......................................................................................................23

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Annex A .............................................................................................................25

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Annex B .............................................................................................................33

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Annex C .............................................................................................................44

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Annex D .............................................................................................................61

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Annex E ..........................................................................................................63

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1 Abstract It is widely believed that a relationship between problem drug use and unemployment exists. This Rapid Evidence Review seeks to explore the evidence base regarding the relationship between drug treatment outcomes and employment. A comprehensive and systematic search of academic and gray literature was conducted identifying literature published between 1995 and 2015 focusing on the extent to which drug treatment alone influences employment outcomes, the role of employment in influencing drug treatment outcomes and what works in terms of supporting drug users to achieve employment outcomes. In total 83 papers were included within this review. The evidence indicates a strong relationship between drug treatment and employment. This relationship appeared to work in two directions with successful drug treatment improving the likelihood of achieving positive employment outcomes, and employment moderating drug misuse. Specifically, the evidence suggests that for many, offering appropriate employment support as part of, or alongside drug treatment may increase post treatment employment. Being in employment or having increased employment stability was correlated with more positive drug treatment outcomes, including increased periods of abstinence, reduced relapse, and improved engagement with drug treatment though this did not apply to everyone. However, a lack of UK-based evidence limits the transferability of findings from the identified literature, highlighting the need for further UK specific research that explores the longer-term impacts of drug outcomes and employment as well as capturing the full range of benefits and costs.

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2 Aims & Objectives The Learning and Work Institute (formerly the Centre for Economic and Social Inclusion) was commissioned by Public Health England in October 2015 to conduct a Rapid Evidence Review of the relationship between employment, employment support and drug treatment outcomes. This review sets out to address the following research questions which were defined by Public Health England (PHE): To what extent do social determinants and other services affect which drug treatment outcomes can be achieved, and for whom? 1. To what extent does drug treatment alone influence employment and social inclusion/integration outcomes? 2. To what extent does employment/employment support intended to improve social integration and inclusion influence drug treatment outcomes? 3. What does the evidence base tell us about: i. Optimal timing and sequencing of interventions ii. Optimal interventions iii. What does the evidence tell us about the cost and effectiveness of labour market interventions for this population and its sub-populations? The first two sub-questions refer to the direction of causation; the effect of drug treatment on employment and social outcomes (question 1) and the effect of employment intervention on drug treatment outcomes (question 2). For this review it is recognised that when the intervention combines drug and employment treatments it may not be possible to separate the interdependencies of the treatment effects (unless controlled for in the study). The third question refers to the mechanisms of the ‘causal links’ (i. and ii.), and iii. only applies to studies where cost-effectiveness information was considered.

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3 Methodology 3.1 Research Strategy The review adopts a rapid, time-bound systematic approach to searching, identifying and synthesizing existing research evidence. The approach involves a number of stages, starting with question refinement and identification of search terms, conducting the searches, and then a two stage sift (at the title level, and then at the abstract level). Selected titles are then fully reviewed and assessed. Finally, findings are synthesized to draw conclusions from the evidence. The approach is outlined in a review protocol (see Annex A) which was agreed with PHE. Following a process of question refinement using a Population, Intervention, Comparator, Outcome, Context (PICOC) framework, key search terms and strings were identified (see Annexes A and B).

3.2 Search strategy Searches were conducted on six databases: PUBMED; ERIC; Web of Science; ProQuest; OpenGrey; and EBSCO (Criminal Justice Abstracts and E-journals). Databases were selected to ensure coverage across healthcare, the social sciences, psychology, and criminology. ERIC and OpenGrey were included in order to identify relevant grey literature. Searches were supplemented by bibliography searches. As a contingency in the event that few studies were identified through these databases, an option to conduct searches using Google Scholar was retained. However, the volume of search results made this unnecessary. As well as needing to be relevant to the focus of the review, prescribed inclusion and exclusion criterion were applied to the search. First, both academic and grey literature were included in the review. Second, in order to capture evidence drawn from a range of disciplines, inclusion was not limited by research methodology, provided they were empirically grounded. Third, a twenty-year reference period (1995-2015) was selected for academic material, to ensure that all evidence was sufficiently relevant to the current environment, whilst still allowing for enough coverage to account for changes in the political and economic cycle. Four, only English language publications were considered within the scope of the review. Five, research had to originate within the UK or from countries with similar labour market conditions e.g. Western European Union countries, North America, Australia, and New Zealand. Specific search terms and strategies, including the use of thesaurus tools, wildcard searches, Booelean and proximity operators, were agreed for each database in order to maximise the efficacy of the literature search according to the respective resource (see Annex B).

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Searches were run against each database, according to their selected search terms with search tools used to exclude non-English language, pre-1995 literature. Once each search was complete, the resulting literature was imported into Mendeley, the referencing tool used in this review to gather and manage the located literature.

3.3 Search results The search yielded 19,260 titles after de-duplication; Figure 1 provides the number of publications excluded at each stage. A sift of titles was conducted by the review team. For consistency across the team and to provide necessary guidance, the first 200 titles screened by team members were peer reviewed by the lead researcher. Following the title sift, 788 publications were retained, with 18,832 excluded. The next stage of the process was the abstract review of the 788 studies. Screening at this point left 138 potential documents to go to full review. These papers were supplemented by a further 20 publications drawn from bibliography searches and expert suggested publications. A list of publications taken to full paper review can be found in Annex C.

Figure 1. Search results and title sifting

3.4 Quality assessment Given that a large proportion of the studies were non-experimental, it was necessary to establish a systematic approach for assessing the evidence which takes into account its technical execution and the methodological domain (e.g. quantitative, qualitative, mixed method, economic).

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Based on guidance from the Joanna Briggs Institute,1 quantitative, qualitative and mixed method studies were assessed separately, according to their purpose. Quantitative studies can provide information on intervention effects: impacts, changes and prevalence. Qualitative studies can provide valuable context on intervention characteristics and processes, in addition to study subject views and experiences of the intervention. Mixed method studies draw on the merits of the quantitative and qualitative approaches and, optimally, triangulate the findings. Therefore, the procedure classified quantitative, qualitative and mixed methods studies separately and assessed the execution of the study on six criteria, adapted from CASP2:      

appropriateness of design choice sampling/recruitment adequate description of intervention data collection data analysis conclusions and recommendations adhere to findings.

A binary indicator whether individual criteria were sufficiently detailed was used to assess publication against each criteria. Providing insufficient detail against a criteria did not necessarily result in its exclusion from the full review; indeed it was often the case that publications addressed a criteria superficially, without the level of detail required to make a full and transparent assessment. However, where fundamental flaws in the research were apparent within any of these criteria, reviewers were able to recommend the exclusion of the paper. Papers were summarised directly into an Excel spreadsheet (see Annex D). Following the full review of the 138 papers, 83 were deemed to be of sufficient quality to have findings included as part of this evidence review. Details of the papers included as part of the full review can be found in Annex E. All papers were assessed using a six-point scale. Papers rated as less than 2 were assigned as low quality, papers rated between 3-4 were assigned as of moderate quality, and those scoring 5 or higher assigned as high quality. While it is acknowledged that assigning papers on this scale may not be a highly sensitive measure of quality of the

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Joanna Briggs Institute (2014) Methodology for JBI Mixed Mixed Methods Systematic Reviews http://www.joannabriggs.org/assets/docs/sumari/ReviewersManual_Mixed-Methods-Review-Methods-2014ch1.pdf; Joanna Briggs Institute (2013) New JBI Levels of Evidence http://joannabriggs.org/assets/docs/approach/JBI-Levels-of-evidence_2014.pdf 2 http://www.casp-uk.net/#!casp-tools-checklists/c18f8

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research, it does provide useful scale to consider papers relative to other studies included in the review. 3.4.1 Reliability of assessments While it would have been preferable to have all of the papers reviewed by a second reviewer, time constraints made this impractical. In order to therefore test for inconsistencies in assessment quality across the four reviewers, two senior researchers re-assessed a selection of 20 reports drawn from the other reviewers. As presented in table 3.1, ten papers from each review team member were reassessed accounting for just under half of all studies included in the review, leaving 43 papers being assessed by a single reviewer. Table 3.1 Reliability assessment of papers by reviewer Moderator Reviewer 1 Reviewer 2 10 10 5 5 5 5 20 20

Reviewer Reviewer 1 Reviewer 2 Reviewer 3 Reviewer 4 Total

Unmoderated 12 15 2 14 43

In instances where differences in quality assessments were noted, scores were reviewed and moderated. The distribution of quality assessments achieved is presented in Table 3.2. Table 3.2 Quality of evidence by method* Methodological approach Quantitative Qualitative TOTAL

High

Moderate

Low

TOTAL

21 1 22

34 10 44

16 4 20

71 15 86*

*Mixed methods studies are separated within qualitative and quantitative strands. Of the 83 included as part of this review, 3 were sufficiently strong mixed method studies and were therefore assessed in terms of both qualitative and quantitative elements, hence the total number presented in this table is higher than the number of studies included in the review.

3.5 Caveat on literature The quality of the evidence identified is highly variable. Limitations were: small sample sizes; selection and implementation bias; and corruption of the counterfactual or control

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group. Further, as observed by Vanderplasschen et al (2007), there was a notable lack of consistency and clarity about terms commonly used to describe interventions, in particular those seeking to address employment and social issues. Whilst the majority of publications reviewed provided a brief description of the interventions, few went into sufficient detail about the form and content of delivery. Even when looking at ostensibly similar employment support interventions, there are likely to be significant unobservable differences. Similar observations were also made with regards to defining the research participants whereby levels of detail about study participants’ characteristics varied, often reducing the external validity of research. Furthermore, there is very little evidence addressing the research question originating within the United Kingdom. Of the 83 reviewed studies, 79% originated in the US, 17% in the UK and the remaining 4% in other countries. It is therefore important to note that the research presented in this review is subject to national and regional differences which may limit applicability to the UK context. Given the paucity of relevant high quality research and the breadth of the research questions this review seeks to address, analysis sought to synthesise findings across all studies included as part of this review irrespective of the quality assessment. However, statistics are presented only for studies identified as high quality and utilising appropriate methodological and analytical approaches.

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4 Results 4.1 Employment and its influence on drug treatment This section presents the broad relationship between employment and drug treatment. It presents findings on: how employment can effect drug treatment outcomes; the correlation between employment and drug dependency/abuse; and the effect of post-treatment employment on drug treatment outcomes. Employment rates in the drug user population are low and in line with other employment disadvantaged groups (Fisher 2011; Hay & Bauld 2010; Kemp & Neale 2003). It has been suggested that employment can be a positive mediator for increasing drug abstinence or reduction (see for example London Drug and Alcohol Network (LDAN) 2014). Whilst it is challenging to determine the causal relationship of entering and maintaining employment (controlling for other factors) and drug treatment outcomes, a number of studies have indicated a relationship. Drawing together longitudinal data from several US studies, Prendergast et al (2008) found that post treatment employment increased at around 10% per year for all population subgroups included in the study over the 5 year period (B=0.1; p