The impact of and interaction between motivation and coercion for drug misuse treatment seekers in England

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The impact of and interaction between motivation and coercion for drug misuse treatment seekers in England

Jones A

PhD

2013-12

University of Manchester

553

Chapter 1 Study context 271.1 Background 271.1.1 UK Drug Scene 271.1.2 Official responses to drug use 291.2 Review of Existing Literature 321.2.1 The Effectiveness of Treatment 321.2.2 Impact of legal pressure 331.2.3 The relevance of motivation at treatment onset 351.3 Existing study limitations and comparability 391.4 Importance of the research area 401.5 Relevance of study to research area 411.6 Hypotheses and study objectives 42Chapter 2 Introduction to the Study 432.1 Introduction and summary 432.2 Background 432.3 Study design 442.3.1 Sampling 442.3.2 Interviews 452.3.3 Fieldwork 452.3.4 Instrument development 452.4 Description of baseline sample 512.4.1 Social Context 512.4.2 Drug Use 522.4.3 Offending 532.4.4 Treatment Experience and Referral 542.4.5 Validation of self reported data 552.4.6 Comparison of baseline characteristics to previous studies 56Chapter 3 Reliability tests for the CMR scale 573.1 Introduction 573.2 Background 573.3 Methods 583.3.1 Factor analysis 583.3.2 Use of Alpha scores as further evidence of intra-scale consistency 613.3.3 Note on predictive validity 623.3.4 CMR scale item reference list 633.4 Results 643.4.1 Dimensionality of scale items 643.4.2 Cronbach’s Alpha scores 693.4.3 Inter scale correlations 703.5 Conclusion 71Chapter 4 Data Weighting 734.1 Introduction 734.1.1 Possible approaches 734.2 Follow-up non-response weights 754.2.1 First Follow-up 754.2.2 Second Follow-up 784.3 Population weights 804.3.1 Case matching 804.3.2 Fields rejected for use 814.3.3 Fields accepted for use 844.3.4 Agency throughput weight 854.4 Conclusion 86Chapter 5 Data preparation and approaches to analysis 875.1 Introduction 875.2 Coercion and motivation measures 875.2.1 Derived variables 875.2.2 Use of CMR sub-scales 915.2.3 Binary conversion of CMR scores 915.3 Regression preparation 945.3.1 Outcome measures 945.3.2 Covariate inclusion for multivariate models 975.3.3 Collinearity 995.4 Selection criteria 1035.4.1 Selection of cases – time in treatment 1035.4.2 Sub-sample analysis 1045.5 Sample size calculations 1055.6 Software 106Chapter 6 Motivation at Baseline 1076.1 Introduction 1076.2 Methods 1086.2.1 Univariate analysis 1086.2.2 Multivariate Models 1086.2.3 Sub-sample Analyses 1096.2.4 Sensitivity analysis 1106.2.5 Alternative analysis 1106.3 Results 1116.3.1 Primary analysis - Association between coercion level and CMR scores 1116.3.2 Supplementary analysis 1166.3.3 Sensitivity analyses 1246.3.4 Alternative analyses 1276.3.5 Summary of primary and supplementary results - associations with CMR scores 1306.4 Discussion 1316.4.1 Discussion of primary findings 1316.4.2 Supplementary analysis - Factors other than coercion 1366.4.3 Supplementary analysis - Sub-samples 1376.5 Conclusion 141Chapter 7 Treatment Engagement 1437.1 Overview 1437.2 Background 1437.2.1 Clinical/political relevance 1447.3 Methods 1477.3.1 Correlations between CMR scores and retention 1477.3.2 Logistic regressions 1477.3.3 Survival analysis 1487.4 Results 1537.4.1 Treatment Uptake 1547.4.2 Treatment retention 1557.4.3 Summary of results: treatment uptake and retention, multivariate models 1787.5 Discussion 1797.5.1 The CMR scale and treatment engagement 1797.5.2 Referral and coercion 186Chapter 8 Treatment Outcomes 1918.1 Introduction 1918.2 Methods 1928.2.1 Distribution of follow-up interviews 1928.2.2 Selection of covariates 2008.2.3 Selection of cases 2008.2.4 Outcome measures 2018.2.5 Regression models 2078.2.6 Interactions 2098.2.7 Propensity score matching 2118.2.8 Conclusion 2128.3 Results 2148.3.1 Association between coercion levels and outcomes 2148.3.2 Associations between CMR scores and outcomes 2308.3.3 Combined models - coercion and CMR scores included 2378.3.4 Examination of supplementary outcomes 2478.3.5 Propensity score matching 2478.3.6 Summary of results 2508.4 Discussion 252Chapter 9 Conclusion 2659.1 Introduction 2659.2 Summary of results and conclusions 2659.2.1 Association between motivation and coercion 2659.2.2 Treatment engagement 2679.2.3 Outcomes 2719.2.4 Synthesis 2749.3 Policy relevance 2779.4 Limitations 2789.5 Areas for future research 280References 283Chapter 10 Appendices 29510.1 Statistical Output 29510.1.1 CMR reliability testing 29510.1.2 Data Weights 29610.1.3 Motivation at Baseline 30010.1.4 Treatment Engagement 35610.1.5 Outcomes 371Appendix 2 CMR Circumstances, Motivation and Readiness Scale 463Appendix 3 Study Instruments – Baseline and Follow up 465

Background: Referral from the Criminal Justice System (CJS) is a key, common route into drug misuse treatment. It is important to know whether, and how, it impinges on treatment outcome, particularly in relation to motivational states that may influence behaviour change.Aim: To assess the association between motivational state and level of treatment coercion, and the effects of these on treatment engagement and outcome, among a sample of drug misuse treatment seekers in England.Setting: Patients were sampled from 342 community and residential drug misuse treatment services within 94 (of 149) commissioning areas in England during 2006-07. All patients seeking drug misuse treatment at these services were eligible for inclusion.Methods: The Circumstances, Motivation, and Readiness scale provided measures of propensity for treatment including specific sub-scores for circumstances, motivation and readiness for treatment. The degree of referral coercion was categorised according to the level of CJS involvement: CJS referral with a condition of attendance; voluntary CJS (no attendance condition); non-CJS. Predictors of propensity were examined using linear regression, with particular emphasis on level of coercion. The predictive nature of coercion and propensity in relation to treatment uptake and threshold points for duration of treatment retention was examined using logistic regression models. Cox proportional hazard models examined associations with linear measures of treatment duration. Analysis of treatment outcome focussed on changes in: the value of drugs used; severity of dependence score; and level of offending. Relationships between these measures and coercion and propensity were examined using quantile, linear and logistic regression models. These were further supported by longitudinal models, incorporating instrumental variables for continuous outcomes to account for potential time related confounding. Results: No negative association was observed between level of coercive referral and levels of motivation or readiness for treatment and conditional referral was positively associated with motivation at the point of treatment entry. Both readiness for treatment and coercion predicted treatment retention for three months, although previous treatment experience treatment and use of heroin were the most consistent predictors of retention. Increasing pre-treatment motivation predicted greater reduction in the value of drugs used but not changes in the level of offending. Neither propensity sub-scores nor coercive referral predicted change in dependence severity. However, coercion was associated with cessation of offending among opiate /crack users. Conclusions: Propensity and coercion have mutually exclusive effects on different aspects of behaviour change. Coercion can positively affect treatment retention but changes in drug taking behaviour are more strongly associated with level of intrinsic motivation. Assessment of propensity, including its motivational components, at treatment entry could inform treatment delivery but its importance should not overshadow that of other factors, which may exert more important effects. Coercive CJS referral is not detrimental to treatment success and may have particular benefits for specific populations, but the cost effectiveness of diversionary schemes should be considered.

• Coercion, motivation, treatment, outcomes

• Jones, Andrew

• Faculty of Medical and Human Sciences
• Institute of Health Sciences

uk-ac-man-scw:261616

Jones, Andrew

25th March, 2015, 09:29:24

Jones, Andrew

25th March, 2015, 09:29:24