Improving substance abuse treatment outcomes for Indigenous and non-Indigenous Australians in rural, community-based health settings

June 2016
Professor Anthony Shakeshaft, NDARC
Evidence shows that rural/regional Australians experience disproportionately high rates of substance abuse, and that it is strongly associated with serious physical and mental health harms. To address these issues, we identified the Community Reinforcement Approach (CRA), a version of cognitive-behaviour therapy, adapted to optimise its relevance and acceptability to Indigenous Australians.

Research Staff

Bianca Calabria (NCEPH, ANU & NDARC), Anthony Shakeshaft (NDARC), Anton Clifford (UQ), Chiara Stone (NDARC), Phillip Clare (NDARC), Julaine Allan (Lyndon Community, NSW), Donna Bliss (Yoorana Gunya Family Healing Centre, NSW)

Background

In the context of substance abuse in rural and regional communities, sound epidemiological evidence has demonstrated that rural/regional Australians experience disproportionately high rates of substance abuse1,2, and that it is strongly associated with serious physical and mental health harms, meaning these phenomena are not independent of each other3.  It is also clear that Australia’s Aboriginal and Torres Strait Islander people (respectfully referred to as Indigenous Australians hereafter) experience a disproportionately high burden of substance abuse harms compared to the general Australian population, especially for alcohol4,5, cannabis6,7, tobacco8 and, more recently, for the growing concern about ice9,10.  Finally, epidemiological data have identified the disproportionately high substance abuse harm experienced by women: Indigenous women aged 30-44, for example, are 18 times more likely to be victims of violence or homicide than in the general Australian population5.

These descriptions of substance abuse harms make a compelling case for the need for effective interventions. Specifically, the epidemiological data highlight that to be optimally beneficial, interventions cannot simply focus on an individual substance: they need to be effective in reducing substance abuse and mental health harms; they need to be highly acceptable to Indigenous Australians; and they need to be effective on a range of substances. Despite the need for evidence for effective interventions, systematic literature reviews consistently show that there have been few evaluations of substance abuse interventions delivered in a range of settings11-13, few evaluations of interventions that have been specifically tailored for Indigenous populations in Australia14 or internationally15,16, and few evaluations of how interventions might be most efficiently delivered in the context of everyday Indigenous health services17.

Given the lack of adequate intervention evidence, our research team sought to identify a promising intervention and adapt it in collaboration with Indigenous Australians.  The intervention we identified was the Community Reinforcement Approach (CRA), a version of cognitive-behaviour therapy developed in the U.S that is ranked as one of the most effective interventions for alcohol misuse18-20.  Indigenous health care providers and community members partnered with our research team to extensively adapt CRA to optimise its relevance and acceptability to Indigenous Australians generally, rather than to the local Indigenous community (e.g. highly specific cultural references were excluded)21,22. 

What is CRA and who is it for?

The Community Reinforcement Approach or CRA is for people who:

'feel a strong need to drink so that drinking is given priority over other behaviours that they had previously found much more important. This will include people whose dependence on alcohol may range from mild to severe. People with severe dependence drink regularly at high-risk levels, often find it hard to limit how much they drink, and generally have marked tolerance to the effects of alcohol.'
(2009 NHMRC Australian Guidelines to Reduce Health Risks from Drinking Alcohol)

This means CRA is for anybody whose alcohol consumption has resulted in: diseases such as cardiovascular, cancer, diabetes, liver disease, mental health conditions, foetal alcohol syndrome, malnutrition, obesity and/or alcohol related injury such as assault, vehicle accident, drowning, violence, sports injury, falls, recreational injury, self-harm, poisoning and/or social problems such as relationship difficulties, family problems, time off work and money troubles.

The main goal of CRA is to help people whose alcohol consumption is impacting on their health and wellbeing to ‘discover and adopt a pleasurable and healthy lifestyle that is more rewarding than a lifestyle filled with using alcohol or drugs’ (Meyers, Roozen Smith 2011). The approach focuses on the elimination of positive reinforcement for drinking, and enhancing positive reinforcement for reduction or abstinence.

Source: Aboriginal-specific Community Reinforcement Approach (CRA) Training Manual, page 7
Note: the training manual in the link refers to both Community Reinforcement Approach (CRA) and Community Reinforcement Approach and Family Training (CRAFT). The current study only evaluated CRA and we will seek funds to evaluate CRAFT because it shows promise in engaging with whole families, particularly in Indigenous communities.

Our implementation of CRA

We obtained approval from the ethics committees of the Aboriginal Health and Medical Research Council of NSW and UNSW to conduct a pre- and post-intervention evaluation of CRA with clients who attended a community-based drug and alcohol treatment service in rural NSW between March and November 2013, and who were at least 18 years of age.  CRA was offered to clients individually (60 minute sessions) or in groups comprising both Indigenous and non-Indigenous clients (90 minute sessions). For individuals, the order of the intervention components was tailored to the needs of each client. Although groups comprised six sessions delivered in a prescribed order for feasibility reasons, one-on-one discussion between clients and counsellors was also accommodated when requested by clients. The first session for all clients, irrespective of the individual or group format, comprised baseline screening, feedback and brief advice to ensure all clients received at least some evidence-based intervention23, even if they did not return for any further counselling.

Principles of CRA for Indigenous communities

The CRA approach for managing the effects of alcohol in Aboriginal communities has been designed with three key principles in mind. These are:

  1. A holistic approach
  2. Primary Health Care
  3. Community Development 

Having adapted CRA to Australian rural settings and established its acceptability22, this study aimed to test the feasibility of delivering it to Indigenous and non-Indigenous clients in a mainstream rural, community-based, drug and alcohol counselling service, and pilot test its likely effectiveness.  If it proves to be feasible and the outcome data are promising, the next step would be a more rigorous evaluation of its effectiveness and costs.

Source:Aboriginal-specific Community Reinforcement Approach (CRA) Training Manual, page 8

To ensure CRA was implemented with high fidelity (ie: as it was designed), a practice manual was developed for counsellors, and a local certified training and supervision program established21,24. This supervision program required that at least one, and up to three, of the six CRA sessions were supervised, and that narrative feedback was provided to counsellors. Exposure to CRA was measured by counsellors using a standardised checklist to record the number of sessions and CRA components each participant completed.  An ancillary benefit of this project is that fully certified CRA trainers are now available in Australia to assist with the uptake of the Australian version of CRA if this study establishes that it is feasible to deliver in routine practice.

Measuring the impact of CRA

Baseline data were collected in the first session.  Follow-up data were collected one-, three- and six-months after commencement of CRA. Measures included demographics, substance use (Alcohol, Smoking and Substance Involvement Screening Test [ASSIST])25, psychological distress (Kessler-5 [K-5])26 and the Indigenous devised Growth Empowerment Measure (GEM)27. Process measures, documented at three month follow-up by CRA counsellors, were type of health services used recently, reason for this use, any drug and alcohol treatment received in the follow up period, the mode of CRA received (individual or group), the number of CRA sessions and components completed, and clients’ ratings of CRA’s acceptability and effectiveness.

Client characteristics at baseline

At entry to treatment (baseline data), clients had a median age of 33 years and were mostly male (58%) and unemployed (87%). Indigenous clients were dramatically over-represented relative to their population in the local community (44% compared to approximately 5%).  In the three months prior to baseline, tobacco use was reported by the highest proportion of clients (80%), followed by alcohol (71%) and cannabis (60%). About half the clients reported injecting drug use (46%).

Client preferences and use of CRA

The process data show that most clients opted for CRA in a group format (87%).  The median number of CRA components completed was about half (29 of a possible 56), which underscores the importance of our decision to ensure the first session was structured to provide screening and brief advice.  At three-month follow-up, half the CRA clients reported using other health services (e.g. a GP) and 25% using other drug and alcohol treatment (e.g. counselling, residential rehabilitation, detoxification and SMART Recovery).  These process data suggest treatment effects may be due to a range of services accessed by clients, one of which is CRA. From a pragmatic viewpoint, the current critical issue is to ensure that all treatment provided to clients represents best-evidence practice, so that patients can choose their preferred treatment options at any point in time and receive best-evidence care in relation to their choices, rather than the less pragmatic scenario in which clients would only ever seek one treatment option. Indeed, the sequential stages of the research process (see Box 4) highlights that optimising the economic efficiency of providing a range of evidence-based substance abuse services is important, but it represents a stage of research development that is subsequent to establishing the evidence base for different treatment options.

Summary of CRA strategies and procedures

  1. CRA Survey conducted at intake when clients enter the CRA program.
  2. Functional Analysis of Drinking Behaviour. This analysis is a procedure to assess the way clients use alcohol in their day to day lives. The functional analysis has two phases. The first phase explores the triggers and short and long term consequences of the clients drinking, while the second phase explores the triggers for non-drinking and its short and long term consequences.
  3. Sobriety Sampling, a procedure for supporting clients to give up drinking for a specific period of time and to develop a tailor made plan to achieve this.
  4. CRA Treatment Plan and its two procedures: the Happiness Scale for assisting clients to think about their level of satisfaction in ten different areas of their lives and the Goals for Counseling, used with clients to address problem areas in their lives.
  5. Skills Training, a series of strategies that aim to identify, strengthen and extend the skills that individual clients may need to better manage their lives and stop their harmful alcohol use.
  6. Relapse Prevention was also described because it is a procedure that workers may need to use with clients who give way to drinking, even though they have been participating in the CRA program.

Source: Aboriginal-specific Community Reinforcement Approach (CRA) Training Manual, page 58

Client treatment outcomes

To assess the impact of treatment, the primary outcome point selected was three months after the first treatment session.  Given 42% of clients did not complete the three-month follow-up, missing data were imputed using one-month and six-month outcomes.  The only difference between those followed-up and those not followed up was that those retained completed significantly more CRA components.  This finding suggests that CRA does not systematically discriminate against clients with any specific characteristics, such as their Indigenous status.

Relative to baseline, ASSIST scores were statistically significantly lower at three month follow-up for alcohol, cannabis, amphetamine type stimulants (including ‘ice’) and over the counter medications.  Median number of cigarettes smoked per day significantly reduced, as did psychological distress (K5 scores).  Empowerment scores (measured using GEM) significantly increased.  Although those followed-up after three months had received significantly more CRA components, we found no evidence of a correlation between the number of CRA components received and alcohol outcomes (alcohol was designated the primary outcome because it was the drug used by the highest proportion of these clients, excluding tobacco), meaning a shorter version of CRA might be just as effective as the full version designed for this study24.

The acceptability of CRA to clients

Consistent with our original acceptability data22, CRA was highly acceptable to these clients.  At three-month follow-up, 88% of clients rated the CRA program as important or very important, and at least 84% agreed or strongly agreed that CRA was highly effective in: understanding substance use; goal setting; reducing and stopping substance use; problem solving/relapse prevention; making better use of spare time; and staying in treatment.

Sequential stages of intervention research

Providing effective treatment for substance abuse harms relies on the development of high-quality research evidence across a number of sequential stages.  Although different models of these stages have been articulated, they generally identify the need to develop accurate and reliable measures of substance abuse, using those measures to precisely describe the prevalence, incidence and nature of substance abuse using sound epidemiological methods, developing promising interventions (based on new ideas or adapted ideas from other contexts), pilot testing the acceptability, feasibility and likely effectiveness of promising interventions, establishing methodologically rigorous evidence for the effectiveness and costs of acceptable, pilot tested interventions, and then identifying the most cost-efficient methods of achieving the uptake of the most cost-effective interventions into routine practice.  Delineating this process is important because it means that the focus of research ought to shift over time within different fields as new knowledge in each stage is created, and that the type of research that is appropriate at a given point in time is context specific. In this context, CRA is now at the stage where we need to test its effectiveness and costs using more rigorous evaluation methods, while CRAFT is at the stage where we need to pilot test its acceptability, feasibility and likely effectiveness.

Conclusions and next steps

This study shows the Australian adaptation of CRA is feasible to deliver in the context of routine service provision, and that it is highly acceptable to Indigenous and non-Indigenous clients.  It provides initial evidence that CRA is effective for a range of substances, for both substance abuse and mental health harms, and is of comparable effectiveness across the full range of clients seeking treatment from a rural, community-based health setting.  It reflects clear Indigenous leadership, evidenced by their willingness to partner with service providers and researchers to adapt CRA to Australian treatment settings.

The next step is a more scientifically rigorous evaluation of the effectiveness and costs of the Australian version of CRA (see Box 4).  Such a study would address the key limitations of this feasibility and pilot trial: i) the pre/post evaluation design in one setting does not provide the capacity to confidently rule out the possibility that something other than CRA was causally related to the outcomes; ii) an economic analysis is required to weigh the benefits of CRA against its costs; iii) the relatively small sample sizes and the loss to follow-up may have introduced a systematic bias into the results and precluded the option of analysing the results separately for Indigenous and non-Indigenous clients; and iv) the possibility of response bias given the reliance on self-reported data.

Although improving the scientific rigour of the evidence for the Australian version of CRA is now necessary, this step need not be done independently of usual treatment provision.  The new administrative arrangement whereby Primary Health-care Networks (PHNs) will commission substance abuse services could provide an ideal mechanism to co-ordinate the simultaneous delivery of treatment services and the evaluation of their effectiveness and costs.  We have previously worked with our colleagues to articulate practical evaluation designs that are of adequate scientific rigour28, and to establish methods of estimating intervention effects using population-level outcomes based on routinely collected data, such as hospital and crime datasets29.  Given we have a promising intervention in CRA and we have established adequate evaluation tools, grasping the opportunity to simultaneously implement CRA and its evaluation would be an innovative advance for service providers and researchers, the primary beneficiaries of which would be the clients of substance abuse treatment services.

More information about CRA and CRAFT

Please contact Professor Anthony Shakeshaft at NDARC (a.shakeshaft@unsw.edu.au) if you require any further information about CRA or CRAFT.

Key findings
  • Relative to baseline, ASSIST scores were statistically significantly lower at three month follow-up for alcohol, cannabis, amphetamine type stimulants (including ‘ice’) and over the counter medications. Median number of cigarettes smoked per day significantly reduced.
  • Psychological distress (K5 scores) significantly reduced.
  • Empowerment scores (measured using GEM) significantly increased. 
  • No evidence of a correlation between the number of CRA components received and alcohol outcomes, which suggests a shorter version of CRA might be just as effective as the full version24.
  1. Czech S, Shakeshaft A, Byrnes J, Doran C. Counting the cost of alcohol-related traffic crashes: Is the public health burden of harm greater in rural or urban environments? Accid Anal Prev. 2010;42(4):1195-98.
  2. Miller P, Coomber K, Staiger P, Zinkiewicz L, Toumbourou J. Review of rural and regional alcohol research in Australia. Aust J Rural Health. 2010;18:110-7.
  3. Roxburgh A, Ritter A, Slade T, et al. Trends in drug use and related harms in Australia, 2001 to 2013. Sydney: National Drug and Alcohol Research Centre, UNSW Australia; 2013.
  4. Australian Institute of Health and Welfare. Substance use among Aboriginal and Torres Strait Islander people. Canberra: Australian Institute of Health and Welfare; 2011.
  5. Calabria B, Doran C, Vos T, Shakeshaft A, Hall W. Epidemiology of alcohol-related burden of disease among Indigenous Australians. Australian and New Zealand Journal of Public Health 2010;34(s1):s47-51.
  6. Bohanna I, Clough AR. Cannabis use in Cape York Indigenous communities: high prevalence, mental health impacts and the desire to quit. Drug Alcohol Rev 2012; 31: 580-584.
  7. Lee KS, Conigrave KM, Patton GC, Clough AR. Cannabis use in remote Indigenous communities in Australia: endemic yet neglected. Med J Aust 2009; 190: 228-229.
  8. Australian Bureau of Statistics. Australian Aboriginal and Torres Strait Islander health survey: updated results, 2012–13. Canberra: Australian Bureau of Statistics, 2014.
  9. Degenhardt L, Larney S, Chan G, et al. Estimating the number of regular and dependent methamphetamine users in Australia, 2002–2014. Med J Aust 2016; 204.
  10. Clough AR, Fitts M, Robertson J. Recent warnings of a rise in crystal methamphetamine (“ice”) use in rural and remote Indigenous Australian communities should be heeded. Med J Aust 2015; 203 (1): 19.
  11. Calabria B, Shakeshaft AP, Havard A. A systematic and methodological review of interventions for young people experiencing alcohol-related harm. Addiction. 2011;106(8):1406-18.
  12. Havard A, Shakeshaft A, Sanson-Fisher R. Systematic review and meta-analyses of strategies targeting alcohol problems in emergency departments: Interventions reduce alcohol-related injuries. Addiction. 2008;103(3):368-76.
  13. Wood E, Shakeshaft A, Gilmour S, et al. A systematic review of school-based studies involving alcohol and the community. Australian and New Zealand Journal of Public Health. 2006;30(6):541-9.
  14. Gray D, Saggers S, Sputore B, et al. What works? A review of evaluated alcohol misuse interventions among Aboriginal Australians. Addiction. 2000;95(1):11-22.
  15. Greenfield B, Venner K. Review of substance use disorder treatment research in Indian Country: Future directions to strive towards health equity. The American Journal of Drug and Alcohol Abuse. 2012;38(5):483-92.
  16. Sanson-Fisher RW, Campbell EM, Perkins JJ, et al. Indigenous health research: A critical review of outputs over time. Medical Journal of Australia. 2006;184(10):502-5.
  17. McCalman J, Tsey K, Clifford A, Earles W, Shakeshaft A, Bainbridge R. Applying what works: a systematic search of the transfer and implementation of promising Indigenous Australian health services and programs. BMC Public Health. 2012;12:600.
  18. Meyers RJ, Smith JE. Clinical guide to alcohol treatment: The Community Reinforcement Approach. New York: The Guilford Press; 1995.
  19. Meyers RJ, Roozen HG, Smith JE. The community reinforcement approach: an update of the evidence. Alcohol Research & Health. 2011;333(4):380-8.
  20. Miller W, Wilbourne P. Mesa Grande: A methodological analysis of clinical trials and treatments for alcohol use disorders. Addiction. 2002;97:265-77.
  21. Calabria B, Clifford A, Rose M, et al. Tailoring a family-based alcohol intervention for Aboriginal Australians, and the experiences and perceptions of health care providers trained in its delivery. BMC Public Health. 2014;14:322.
  22. Calabria B, Clifford A, Shakeshaft A, Allan J, Doran CM.  The acceptability to Aboriginal Australians of a family-based intervention to reduce alcohol-related harms. Drug and Alcohol Review. 2013; 32:328-32.
  23. Navarro H, Shakeshaft A, Doran C, Sanson-Fisher R. The cost-effectiveness of GP screening and brief intervention, Addictive Behaviors. 2011; 36, 1191-8.
  24. Rose M, Calabria B, Allan J, et al. Aboriginal-specific Community Reinforcement Approach (CRA) training manual. Sydney: NDARC, UNSW, 2014.
  25. Humeniuk R, Ali R, WHO ASSIST Phase II Study Group. Validation of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) and pilot brief intervention: A technical report of Phase II findings of the WHO ASSIST Project. Geneva: Management of Substance Abuse, Department of Mental Health and Substance Abuse, 2006.
  26. Australian Institute of Health and Welfare. Measuring the social and emotional wellbeing of Aboriginal and Torres Strait Islander peoples. Canberra: 2009.
  27. Haswell MR, Kavanagh D, Tsey K, et al. Psychometric validation of the Growth and Empowerment Measure (GEM) applied with Indigenous Australians. Australian and New Zealand Journal of Psychiatry. 2010;44(9):791-9.
  28. Hawkins NG, Sanson-Fisher RW, Shakeshaft A, D’Este C, Green L.  The Multiple Baseline Design for Evaluating Population-Based Research.  American Journal of Preventive Medicine. 2007; 33, 162-8.
  29. Shakeshaft A, Doran C, Petrie D, Breen C, Havard A, Abudeen A, Harwood E, Clifford A, D’Este C, Gilmour S, Sanson-Fisher R. The Alcohol Action in Rural Communities (AARC) Project. The effectiveness of community-action in reducing risky alcohol consumption and harm: a cluster randomised controlled trial.  PLOS Medicine. 2014; 11(3).