case study on drugs and alcohol

Module 9: Substance-Related and Addictive Disorders

Case studies: substance-abuse disorders, learning objectives.

• Identify substance abuse disorders in case studies

Case Study: Benny

The following story comes from Benny, a 28-year-old living in the Metro Detroit area, USA. Read through the interview as he recounts his experiences dealing with addiction and recovery.

Q : How long have you been in recovery?

Benny : I have been in recovery for nine years. My sobriety date is April 21, 2010.

Q: What can you tell us about the last months/years of your drinking before you gave up?

Benny : To sum it up, it was a living hell. Every day I would wake up and promise myself I would not drink that day and by the evening I was intoxicated once again. I was a hardcore drug user and excessively taking ADHD medication such as Adderall, Vyvance, and Ritalin. I would abuse pills throughout the day and take sedatives at night, whether it was alcohol or a benzodiazepine. During the last month of my drinking, I was detached from reality, friends, and family, but also myself. I was isolated in my dark, cold, dorm room and suffered from extreme paranoia for weeks. I gave up going to school and the only person I was in contact with was my drug dealer.

Q : What was the final straw that led you to get sober?

Benny : I had been to drug rehab before and always relapsed afterwards. There were many situations that I can consider the final straw that led me to sobriety. However, the most notable was on an overcast, chilly October day. I was on an Adderall bender. I didn’t rest or sleep for five days. One morning I took a handful of Adderall in an effort to take the pain of addiction away. I knew it wouldn’t, but I was seeking any sort of relief. The damage this dosage caused to my brain led to a drug-induced psychosis. I was having small hallucinations here and there from the chemicals and a lack of sleep, but this time was different. I was in my own reality and my heart was racing. I had an awful reaction. The hallucinations got so real and my heart rate was beyond thumping. That day I ended up in the psych ward with very little recollection of how I ended up there. I had never been so afraid in my life. I could have died and that was enough for me to want to change.

Q : How was it for you in the early days? What was most difficult?

Benny : I had a different experience than most do in early sobriety. I was stuck in a drug-induced psychosis for the first four months of sobriety. My life was consumed by Alcoholics Anonymous meetings every day and sometimes two a day. I found guidance, friendship, and strength through these meetings. To say early sobriety was fun and easy would be a lie. However, I did learn it was possible to live a life without the use of drugs and alcohol. I also learned how to have fun once again. The most difficult part about early sobriety was dealing with my emotions. Since I started using drugs and alcohol that is what I used to deal with my emotions. If I was happy I used, if I was sad I used, if I was anxious I used, and if I couldn’t handle a situation I used. Now that the drinking and drugs were out of my life, I had to find new ways to cope with my emotions. It was also very hard leaving my old friends in the past.

Q : What reaction did you get from family and friends when you started getting sober?

Benny : My family and close friends were very supportive of me while getting sober. Everyone close to me knew I had a problem and were more than grateful when I started recovery. At first they were very skeptical because of my history of relapsing after treatment. But once they realized I was serious this time around, I received nothing but loving support from everyone close to me. My mother was especially helpful as she stopped enabling my behavior and sought help through Alcoholics Anonymous. I have amazing relationships with everyone close to me in my life today.

Q : Have you ever experienced a relapse?

Benny : I experienced many relapses before actually surrendering. I was constantly in trouble as a teenager and tried quitting many times on my own. This always resulted in me going back to the drugs or alcohol. My first experience with trying to become sober, I was 15 years old. I failed and did not get sober until I was 19. Each time I relapsed my addiction got worse and worse. Each time I gave away my sobriety, the alcohol refunded my misery.

Q : How long did it take for things to start to calm down for you emotionally and physically?

Benny : Getting over the physical pain was less of a challenge. It only lasted a few weeks. The emotional pain took a long time to heal from. It wasn’t until at least six months into my sobriety that my emotions calmed down. I was so used to being numb all the time that when I was confronted by my emotions, I often freaked out and didn’t know how to handle it. However, after working through the 12 steps of AA, I quickly learned how to deal with my emotions without the aid of drugs or alcohol.

Q : How hard was it getting used to socializing sober?

Benny : It was very hard in the beginning. I had very low self-esteem and had an extremely hard time looking anyone in the eyes. But after practice, building up my self-esteem and going to AA meetings, I quickly learned how to socialize. I have always been a social person, so after building some confidence I had no issue at all. I went back to school right after I left drug rehab and got a degree in communications. Upon taking many communication classes, I became very comfortable socializing in any situation.

Q : Was there anything surprising that you learned about yourself when you stopped drinking?

Benny : There are surprises all the time. At first it was simple things, such as the ability to make people smile. Simple gifts in life such as cracking a joke to make someone laugh when they are having a bad day. I was surprised at the fact that people actually liked me when I wasn’t intoxicated. I used to think people only liked being around me because I was the life of the party or someone they could go to and score drugs from. But after gaining experience in sobriety, I learned that people actually enjoyed my company and I wasn’t the “prick” I thought I was. The most surprising thing I learned about myself is that I can do anything as long as I am sober and I have sufficient reason to do it.

Q : How did your life change?

Benny : I could write a book to fully answer this question. My life is 100 times different than it was nine years ago. I went from being a lonely drug addict with virtually no goals, no aspirations, no friends, and no family to a productive member of society. When I was using drugs, I honestly didn’t think I would make it past the age of 21. Now, I am 28, working a dream job sharing my experience to inspire others, and constantly growing. Nine years ago I was a hopeless, miserable human being. Now, I consider myself an inspiration to others who are struggling with addiction.

Q : What are the main benefits that emerged for you from getting sober?

Benny : There are so many benefits of being sober. The most important one is the fact that no matter what happens, I am experiencing everything with a clear mind. I live every day to the fullest and understand that every day I am sober is a miracle. The benefits of sobriety are endless. People respect me today and can count on me today. I grew up in sobriety and learned a level of maturity that I would have never experienced while using. I don’t have to rely on anyone or anything to make me happy. One of the greatest benefits from sobriety is that I no longer live in fear.

Case Study: Lorrie

Figure 1. Lorrie.

Lorrie Wiley grew up in a neighborhood on the west side of Baltimore, surrounded by family and friends struggling with drug issues. She started using marijuana and “popping pills” at the age of 13, and within the following decade, someone introduced her to cocaine and heroin. She lived with family and occasional boyfriends, and as she puts it, “I had no real home or belongings of my own.”

Before the age of 30, she was trying to survive as a heroin addict. She roamed from job to job, using whatever money she made to buy drugs. She occasionally tried support groups, but they did not work for her. By the time she was in her mid-forties, she was severely depressed and felt trapped and hopeless. “I was really tired.” About that time, she fell in love with a man who also struggled with drugs.

They both knew they needed help, but weren’t sure what to do. Her boyfriend was a military veteran so he courageously sought help with the VA. It was a stroke of luck that then connected Lorrie to friends who showed her an ad in the city paper, highlighting a research study at the National Institute of Drug Abuse (NIDA), part of the National Institutes of Health (NIH.) Lorrie made the call, visited the treatment intake center adjacent to the Johns Hopkins Bayview Medical Center, and qualified for the study.

“On the first day, they gave me some medication. I went home and did what addicts do—I tried to find a bag of heroin. I took it, but felt no effect.” The medication had stopped her from feeling it. “I thought—well that was a waste of money.” Lorrie says she has never taken another drug since. Drug treatment, of course is not quite that simple, but for Lorrie, the medication helped her resist drugs during a nine-month treatment cycle that included weekly counseling as well as small cash incentives for clean urine samples.

To help with heroin cravings, every day Lorrie was given the medication buprenorphine in addition to a new drug. The experimental part of the study was to test if a medication called clonidine, sometimes prescribed to help withdrawal symptoms, would also help prevent stress-induced relapse. Half of the patients received daily buprenorphine plus daily clonidine, and half received daily buprenorphine plus a daily placebo. To this day, Lorrie does not know which one she received, but she is deeply grateful that her involvement in the study worked for her.

The study results? Clonidine worked as the NIDA investigators had hoped.

“Before I was clean, I was so uncertain of myself and I was always depressed about things. Now I am confident in life, I speak my opinion, and I am productive. I cry tears of joy, not tears of sadness,” she says. Lorrie is now eight years drug free. And her boyfriend? His treatment at the VA was also effective, and they are now married. “I now feel joy at little things, like spending time with my husband or my niece, or I look around and see that I have my own apartment, my own car, even my own pots and pans. Sounds silly, but I never thought that would be possible. I feel so happy and so blessed, thanks to the wonderful research team at NIDA.”

• Liquor store. Authored by : Fletcher6. Located at : https://commons.wikimedia.org/wiki/File:The_Bunghole_Liquor_Store.jpg . License : CC BY-SA: Attribution-ShareAlike
• Benny Story. Provided by : Living Sober. Located at : https://livingsober.org.nz/sober-story-benny/ . License : CC BY: Attribution
• One patientu2019s story: NIDA clinical trials bring a new life to a woman struggling with opioid addiction. Provided by : NIH. Located at : https://www.drugabuse.gov/drug-topics/treatment/one-patients-story-nida-clinical-trials-bring-new-life-to-woman-struggling-opioid-addiction . License : Public Domain: No Known Copyright

• Open access
• Published: 14 April 2011

A Research Strategy Case Study of Alcohol and Drug Prevention by Non-Governmental Organizations in Sweden 2003-2009

• Charli Eriksson 1 ,
• Susanna Geidne 1 ,
• Madelene Larsson 1 &
• Camilla Pettersson 1  

Substance Abuse Treatment, Prevention, and Policy volume  6 , Article number:  8 ( 2011 ) Cite this article

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Alcohol and drug prevention is high on the public health agenda in many countries. An increasing trend is the call for evidence-based practice. In Sweden in 2002 an innovative project portfolio including an integrated research and competence-building strategy for non-governmental organisations (NGOs) was designed by the National Board of Health and Welfare (NBHW). This research strategy case study is based on this initiative.

The embedded case study includes 135 projects in 69 organisations and 14 in-depth process or effect studies. The data in the case study has been compiled using multiple methods - administrative data; interviews and questionnaires to project leaders; focus group discussions and seminars; direct and participatory observations, interviews, and documentation of implementation; consultations with the NBHW and the NGOs; and a literature review. Annual reports have been submitted each year and three bi-national conferences Reflections on preventions have been held.

A broad range of organisations have been included in the NBHW project portfolio. A minority of the project were run by Alcohol or drug organisations, while a majority has children or adolescents as target groups. In order to develop a trustful partnership between practitioners, national agencies and researchers a series of measures were developed and implemented: meeting with project leaders, project dialogues and consultations, competence strengthening, support to documentation, in-depth studies and national conferences. A common element was that the projects were program-driven and not research-driven interventions. The role of researchers-as-technical advisors was suitable for the fostering of a trustful partnership for research and development. The independence of the NGOs was regarded as important for the momentum in the project implementation. The research strategy also includes elements of participatory research.

Conclusions

This research strategy case study shows that it is possible to integrate research into alcohol and drug prevention programs run by NGOs, and thereby contribute to a more evidence-based practice. A core element is developing a trustful partnership between the researchers and the organisations. Moreover, the funding agency must acknowledge the importance of knowledge development and allocating resources to research groups that is capable of cooperating with practitioners and NGOs.

Introduction

Alcohol and drug prevention is high on the public health agenda in most countries. The national initiatives differ, although action plans have been proposed by international organizations such as WHO [ 1 ]. Moreover, there is an increasing demand for evidence-based alcohol and drug prevention, causing an increased emphasis on research for prevention, an emphasis that this field shares with health promotion, prevention in general, and social work [ 2 – 8 ]. This means that prevention research needs to move "from basic to more and more applied research; from descriptive hypothesis-generating pilot studies to full-fledged, methodologically sophisticated, hypothesis-testing studies; from smaller to larger samples for testing; from greater to lesser control of experimental conditions; from more artificial 'laboratory' environments to real-world geographically defined communities; from testing the effects of single intervention strategies into more complex studies of multiple strategies integrated into intervention systems; and from research-driven outcome studies to 'demonstration' projects that evaluate the capacity of various types of communities to implement prevention programs based on prior evaluations" [[ 9 ], p 183]. It has also been more than 10 years since Nutbeam [ 10 , 11 ] noted the gap between the need for knowledge and the priorities among researchers.

Many years have passed since these recommendations, but still the gap between evidence and practice has not been bridged despite important achievements in implementation research [ 12 ], designs for effectiveness and translation research [ 13 ], and a series of initiatives regarding the evidence-practice gaps [ 14 – 22 ]. The call for more practice-based evidence is a challenge for policy-makers, practitioners, researchers, and funding agencies [ 17 , 23 ]. In several countries research on alcohol and drug issues has been incorporated into addiction research centres [ 24 – 28 ]. For many years much addiction research has been the product of specialized research centres rather than the contribution of standalone scientists. Moreover it is the specialist centres, in collaboration with the national funding agencies, which today assert leadership, set agendas, and help determine standards [ 24 ]. However, a common element in the missions of these centres is monitoring the substance use in the population, its causes, and courses, while prevention research is not high on the agendas. Furthermore, the establishment of national centres demonstrates the political administration's emphasis on scientific, evidence-based policies, but at the same time demonstrates the view that credible research is best performed within independent scientific bodies [ 26 ].

In Sweden in 2002 an innovative project portfolio for non-governmental organisations (NGOs) was designed by the National Board of Health and Welfare (NBHW). This included an integrated research and competence-building strategy to strengthen alcohol and drug prevention. This case study aims to describe and analyse this initiative.

AD prevention in Sweden - legislation, national action plans, resources, and actors

Sweden has a long tradition of a restrictive alcohol policy [ 29 ]. The temperance movement became a powerful actor in the Swedish alcoholic beverage policy [ 30 ]. Moreover, Sweden is one of the few countries in Europe with a narcotics policy that aims to create a society entirely free of illicit drugs [ 31 ].

The overall goal of the Swedish action plan on alcohol and narcotics is to promote public health by reducing the medical and social harm caused by alcohol and to create a drug-free society. The strategy for achieving this goal with regard to alcohol is to reduce the total consumption and prevent harmful drinking, taking into account differences in living conditions among boys, girls, men, and women. Six priority sub-goals have been adopted: alcohol should not be consumed in transport contexts, at workplaces, or during pregnancy; children should grow up in an alcohol-free environment; the age of alcohol debut should be postponed; drinking to point of intoxication should be reduced; there should be more alcohol-free environments; and illicit alcohol should be eliminated. The sub-goals in the action plan on narcotics are to reduce recruitment to drug abuse, induce people with substance abuse problems to give up their abuse, and to reduce the supply of drugs. Interventions targeting children, adolescents, and parents are of high priority [ 32 ].

Swedish alcohol policy is based on a combination of taxed-based price controls and the alcohol retail monopoly in order to limit the availability and accessibility of alcohol [ 32 ]. There is strong evidence for the preventive effects of an alcohol retail monopoly [ 33 , 34 ] and high prices on alcohol are regarded as one of the most effective ways of reducing total alcohol consumption and alcohol-related problems [ 35 ]. When Sweden entered the EU in 1995, the conditions changed and Sweden could no longer have an independent alcohol policy. For example, the availability of alcohol increased as a result of changed rules for private import, and alcohol taxes had to be adjusted. The numbers of alcohol shops as well as their opening hours have also increased remarkably since 1995 [ 29 ]. The increased movements across borders have also had an influence on the illicit drugs market. Almost all narcotics that are consumed in Sweden have been produced outside the country. A well-developed international collaboration is therefore of high importance for the limitation of illicit drugs in Sweden [ 32 ].

An effective alcohol and drug policy also requires national coordination. The Swedish government has established a national council for alcohol, narcotics, doping, and tobacco. The council consists of members of public authorities, civil society, and researchers, and is led by the State Secretary of the Ministry of Health and Social Affairs. The council is commissioned to advise the government on issues about alcohol, drugs, doping, and tobacco and to present information about research results [ 36 ].

There is a need for the different sectors in society to increase and deepen their cooperation for an effective prevention of the use of alcohol, tobacco, and drugs. In the Swedish action plan on alcohol and illicit drugs as well as in the government bill for public health the importance of the voluntary sector is emphasized [ 36 , 37 ]. In the latter document, A renewed public health policy , it is stated that cooperation between the state and the voluntary sector should be expanded and that the conditions for the voluntary sector's work should improve [ 37 ]. An agreement about the relations between the government, the voluntary sector in the social setting, and the Swedish Association of Local Authorities and Regions has recently been developed through a dialogue between the parties. The dialogue is another way for the government to call attention to the voluntary sector and to its ambition to strengthen the sector and improve its conditions. The goal of the agreement was to strengthen the independence of the voluntary sector as moulders of public opinion and to support the development of public medical service carried out by the voluntary sector [ 38 ]. The Swedish voluntary sector has a long tradition of alcohol prevention, especially the temperance movements [ 39 ].

NGOs in Sweden

The Swedish voluntary sector is both different and similar to those in other countries. A major difference lies in its history in that, for instance, as early as in the 16th century the responsibility for health and care was organized under the state instead of in the regime of the church. In parts of Europe the church still is an active actor in health and care [ 40 , 41 ]. Also, popular mass movements have played an important role in the development of Swedish society [ 41 , 42 ]. The Swedish voluntary sector is as large as in other industrialized countries, although quite different in character. It is dominated by organizations in the cultural and recreational field, mainly sports organizations. Since the early 1990s the Swedish voluntary sector has expanded, particularly in the two areas of culture and recreation, as well as in the area of social care [ 43 ]. It can also be called membership-based; almost everyone in Sweden is a member of some organization. Because of these differences in history and structure in different societies, the voluntary sector plays different roles. In Sweden, NGOs are more of a complement then a substitute for state programs, and have an important role as forerunners and innovators [ 44 ].

Previous research has shown that the Swedish voluntary sector was highly dependent on public financing, which is partly correct. Looking at the entire sector together, about 30 percent of its financing comes from government funding. However, within the health care and social service sector, public financing stands for more than 70 percent. That is quite high in comparison with other European countries, but not the highest [ 45 ].

Support to NGOs today

Organizational grants.

The National Board of Health and Welfare (NBHW) has a government commission to administer the grants to national organizations for the disabled, the elderly, and relatives of elderly persons; to national organizations in the social setting; and to national and local organizations. For the moment this amounts to about 300 million SEK to about 100 organizations. Also the Swedish National Institute of Public Health has funds to distribute to NGOs or to other organizations working together with NGOs. The Swedish State Inheritance Fund is also a possible source of funding for NGOs. They administer over 300 million SEK a year to provide grants to NGOs working with children, youth, and the disabled. In addition other governmental agencies such as the Swedish National Board for Youth Affairs also support NGOs.

Project grants

In the late 1990s a new system of awarding grants to NGOs in the arenas of alcohol and narcotics, vulnerable children and their families, and violence against women was prepared. The previous systems were from the late 1970s and early 1980s, and during the 1990s many investigations recommended a better, more structured follow-up and evaluation of the NGOs' work. One new idea that emerged during the 1990s was increased performance management, that is, the need to point out achieved results and effects of different activities. It was emphasized that the government should not interfere with the running of the organizations but does have the duty to monitor the use of the grants. There was also a desire that renewal efforts and collaborations should be encouraged and supported.

In the late 20th century grants were awarded through the Swedish National Institute of Public Health (with money from the Swedish State Inheritance Fund) to a number of alcohol and drug prevention projects. A final report and an internal evaluation were required from the applicants. There was also an external evaluator, who conducted an evaluation of 11 projects focusing on their working processes [ 46 ]. Among the lessons learned from this evaluation were that the way of working should be characterized by frequent contacts and dialogue between the funding agency and the project, and also by supervision. The evaluation report also suggested that the support to the project leaders should be reviewed with regard to the possibility of different types of need-based support. Moreover, the short-term thinking in the funding of these kinds of projects was not in line with the needed time-frame.

Setting the Scene: NGO strategy for alcohol and drug prevention

Non-governmental organizations have received grants from the NBHW to conduct alcohol and drug preventive work in a special venture since 2003 [ 47 ]. This initiative is part of the national plan of action to prevent alcohol-related harm and the national plan of action against narcotics and comes from the Ministry of Health and Social Affairs. The working committee, which decides who will get funding, consists of members of the NBHW, the Swedish National Institute of Public Health, and the Swedish National Board for Youth Affairs (previously members of the Swedish Alcohol Committee and the Swedish National Drug Policy Coordinator were included). The working committee, after consulting the research team at Örebro University, also decides which projects will be studied in-depth. NBHW's initiative represented a new way of thinking. One point of departure was to create a project portfolio with a broad combination of organizations to mobilize many forces in the alcohol and drug preventive work. The initiative also contains supervision for the project leaders, competence support through regular meetings for project leaders, and an integrated Research & Development (R&D) investment (Figure 1 ).

Integrated research and development for NGO alcohol and drug prevention .

Need for knowledge building and learning

There is an increasing trend towards promoting evidence-based public health initiatives. International expert committees have presented the state of science with regard to alcohol prevention: Alcohol Control Policies in Public Health Perspectives [ 48 ]; Alcohol Policy and the Public Good [ 49 ]; and Alcohol: No Ordinary Commodity -Research and Public Policy [ 33 , 50 ]. National authorities have presented reviews presenting evidence for practitioners and politicians [ 51 – 53 ]. However, there are important knowledge gaps to be filled. Among these is the lack of effectiveness studies where the external validity is high. If we want to see more evidence-based practice we need more practice-based evidence [ 54 ]. This means an improved emphasis on cooperation between researchers and practitioners [ 10 ].

A comprehensive perspective on the concept of knowledge, including scientific and practical knowledge as well as practical wisdom, is needed. Scientific knowledge about alcohol and drug issues needs to be complemented with knowledge about methods for alcohol and drug prevention. As in other public health fields, ethical issues and practical wisdom are important [ 55 ]. Moreover, the science, craft, and art of implementation are of utmost importance. There are many reasons besides practicalities that are significant for the implementation of programs [ 7 , 56 ]. In a recent review, 23 different factors were found that were of importance for the degree of the implementation [ 12 ] and that also have a great impact on the program effects.

Research on alcohol and drugs has often been organized in special research institutes, which often focus on basic research on alcohol and drugs [ 24 – 28 ]. This basic research is related both to basic biomedicine as well as social and behavioural studies. Another activity, which has been accorded great prominence, is the monitoring of alcohol and drug use in the population in general as well in different groups. Intervention research has been given less prominence in these often national research institutes. However, the national agencies, such as the Swedish Institute of Public Health, have been involved in the evaluation of different intervention projects. So far research on NGO-driven alcohol and drug prevention has been almost completely lacking. Research has been a more or less exclusive activity for the university. However, this has been based on the trust in the impartiality and objectivity of the university-based researchers. The downside of this position is that this type of research may lack the necessary cultural awareness and insights necessary for a proper understanding of basic factors for successfully planning intervention programs as well as evaluating research efforts. In other words the roles of the researcher in intervention studies need to be addressed. In a recent study, Holmila et al. [ 57 ] outlined three different positions for researchers in community intervention studies. The researcher can be an external observer, not taking part in the preventive activities - acting as an unobtrusive observer . The researcher assumes no responsibility for the design or implementation of the projects but acts as an independent conductor of process evaluation and observer of project outcomes. Another position is to be a researcher-as-technical advisor . In this role the researcher has responsibility for evaluation but also takes the responsibility for providing scientific advice on effective preventive strategies if asked for [ 58 – 60 ]. This could include training and technical assistance to the projects. Progress reports on findings as well as results from different on-going studies can be presented to the practitioners, which may use this information as they desire. A third type is researcher-as-designer , where the project is designed by the research team in partnership with the practitioner. The researcher is an active participant in project planning as well as the process of carrying it out and evaluating the effects. This approach is particularly useful when the goal is to test one or more designed prevention strategies under as close to optimal conditions as possible. Examples of such in Sweden are the STAD Project in Stockholm [ 61 ] and the Trelleborg Project [ 62 ]. The Örebro Prevention Program is an example of a program where all parts of the process were in the hands of the researchers [ 63 ].

The present paper aims to describe and analyse alcohol and drug prevention supported by the NBHW and implemented by NGOs in Sweden during 2003-2009 with a special emphasis on research and development for an evidence-based practice. The case study analyses also the integrated research strategy and its main components.

Three research questions will be addressed:

Which types of organizations and projects have received grants from the NBHW for AD prevention?

What types of research and development activities for an evidence-based practice have been included?

How can a trustful partnership develop between practitioners, national agencies, and researchers?

Methods and materials, case study approach.

A case study method was chosen as the intention was to understand a real-life phenomenon in depth and the contextual factors were highly pertinent to the study [ 64 ]. This method investigates according to Yin contemporary phenomenon in depth and within its real-life context, especially when the boundary between the phenomenon and context are not clearly evident. Moreover, the case study approach copes with the situation such as in this case in which there will be more variables of interest than data, which leads to the need for multiple sources of evidence, with data needing to converge in a triangulating fashion. Furthermore, benefits from the prior development of theoretical propositions to guide data collection and analysis [ 64 ]. The present research strategy case study is on an organisational level. It studies a social process in a situation in which we have little knowledge of the phenomenon, integration of research in alcohol and drug prevention run by NGOs. Case studies as a main research strategy are selected as this is a unique case in Sweden, the impossibility to isolate the process and the intention is to combine research and action [ 65 ].

An embedded single-case design was chosen for the study. All the projects run by the NGOs are seen as embedded units of analysis in the study with special emphasis on the fourteen in-depth studies.

Participants

The embedded case study includes 135 projects in 69 organisations and 14 in-depth process or effect studies. The participants in this research strategy case study are the NGOs applying for funding to the NBHW and especially those NGOs that have received funding during 2003-2009. The project leaders and managers in the NGOs as well as the members of the different target groups are also participants in this study. Moreover, staff at the NBHW as well as other stakeholders is included.

Case study questions

When the research program started a set of overall research questions were developed. In this paper the focus is in one of these, how can a trustful partnership for practice-based research be developed? Additional questions concerns: the role as a project leader in NGOs, the impact of competence development, methods for documentation of project development, and the added value of running projects in NGOs.

Case study protocol

A plan for the research and development activities was developed the first year and amended each year after the completion of the annual report to the NBHW. This plan consisted of several parts relating to the overall activities as well as the different in-depth studies. Notes were taken at meetings and as part of the strategy a series of presentations as progress reports were given to, project leaders, NGOs and the NBHW.

Development of a Case Study Database

In the present study a broad range of methods was used in the data collection. This includes six types of data.

Administrative data

The applications from the NGOs to the NBHW as well as the funding decisions were the initial data, which was complemented by bi-annual as well as annual progress reports from all funded projects. These reports, which were submitted following a format developed by the research team, gave information on implementation and goal achievement as well as reflections on barriers and facilitating factors. The research team introduced this approach at a meeting with the project leaders, and this reporting resulted in an annual report to the NBHW on the progress of the alcohol and drug prevention projects run by the NGOs.

Interviews and questionnaires to project leaders

Data was collected from project leaders and their organizations in the years when funding was received from the NBHW. In 2003, 2005, 2007, and 2009 all project leaders were invited to respond to a questionnaire containing questions on being a project leader in a non-governmental organization. If the same project leaders were responsible for a project for more than one year they responded to more than one questionnaire. Most of those who answered the 2003 questionnaire also answered the 2005 questionnaire, due to the fact that many of those projects receiving funding in 2003 also were being funded in 2005. In total, 84 persons participated in the questionnaire study over the years. Of these, 38 project leaders answered the questions more than one year.

Focus group discussions and seminars

Thematic discussions were held as a part of the meetings with the project leaders. These highlighted special issues related to the practice of alcohol and drug prevention. Moreover, a series of joint seminars with NGOs and the research team have been held at national and organizational conferences focusing on different projects.

Direct observations, participatory observations, interviews, and documentation of implementation of the in-depth studies

The research team collected information by a variety of methods during the planning, implementation, and evaluation of the in-depth studies. Part of this data has been used in the analysis, resulting in separate reports and scientific publications. However, in this context more process-related data will be used to give insights into the development of the partnerships between researchers and practitioners.

Consultation with the NBHW and the NGOs

In the present paper information retrieved during the management of the NBHW support to the NGOs will be an additional source of information. Regular meetings have taken place with the steering committee and the senior administrative officer, who have been the same persons during all years. The consultations with the NGOs were more intense for those organizations selected for in-depth studies, but several meetings have also taken place with other organizations. Apart of the in-depth studies was feedback on preliminary results from different studies; this never radically changed the interpretation of results but did add valuable information.

Literature review

A systematic review of the research strategies for alcohol and drug prevention has been carried out as an integral part of the research program. A number of publications related to collaboration between researchers and practitioners were found. Special thematic sections and series have been looked for. Among the key words are addiction research centre, alcohol and drug research, preventive research, practice-based research, and evidence-practice gaps.

Analytical methods

The analytical approach in this case study follows a common strategy used in research programs: to start with the ordinary preventive activities and then study what is happening [ 66 , 67 ]. Using a naturalistic approach, which is always practice-based, it has been important to let different actors and stakeholders into the knowledge-building program. This also has implications for the selection of research and evaluation methods, given a need for mixed-method approaches [ 68 – 70 ]. In studies of effects, quantitative approaches are essential, but important contributions can be achieved if qualitative studies are also included [ 71 , 72 ]. The mixed-methods approaches have been developed for some of the more extensively studied programs, which also will be included in doctoral dissertations [ 73 , 74 ].

The analysis starts with a quantitative description of the investment in NGOs by agencies awarding grants and an analysis of which organizations and projects that were supported. The types of organizations are analysed with regard to their main focus or mission. Then the investment in research is described including an overview of the participants in different empirical studies using a range of data collection methods. This includes a description of how the embedded units, the project in the NBHW portfolio, have been documented and presented in annual reports using a format for the written reports based on questions and answers in the case study database [ 64 ]. The two types of in-depth studies are briefly presented: effect studies and studies of process and implementation.

An analysis of the experiences of cross-project comparisons as well as using the multiple sources of evidence in the case study database follows. The different measures in the research program was developed in order to foster a trustful partnership is then presented. These measures were assessed by all project leaders in the annuals reporting to the research team, which reviewed the content of the research strategy each year in the annual report to the NBHW. The implementation of the research strategy with regard to evaluation initiatives together with the NGOs as well as in-depth studies was carefully documented over the years and used as indicator for developing a research partnership with the NGOs. In this case study the focus is on the implementation of the research and evaluation efforts and not on the outcome of the alcohol and drug prevention program. This has been reported in other publications [ 47 ]. The different types of data and perspectives included in the case study database are used for triangulation and finding key elements and mechanisms in the research strategy. In this case study a mixed-methods approach means parallel mixed data analysis, i.e. parallel analysis of qualitative and quantitative data from different sources. Moreover, integrated mixed data analysis also occurs in the analysis of the project portfolio and subsequent development of research initiatives. To grasp the complexity and inclusiveness of integrated methods the term inference has been proposed as the last and most important stage of research [ 70 ]. The inference process consists of a dynamic journey from ideas to results in an effort to make sense of data. In our case study the regular project leader meetings as well as the preparation of the annual evaluation and reporting to the NBHW are key activities in this process of drawing inferences. Key concepts in an integrative framework are inference quality, which is related to design quality, interpretative rigour, and inference transferability.

The results will be presented according to the three research questions. The calls for applications resulted in many proposals from many different organizations for a variety of projects engaging many project leaders.

Investing in the NGOs - Allocation of Grants 2003-2009

Since 2003 10-15 million SEK per year have been administered to this special venture (Table 1 ). The government's decisions have over the years differed somewhat according to which target groups are being specially addressed in the calls for grant applications. For the first period, which was a two-year period, the call was broad. For the second period, 2005, the main part of the grants went to projects from the earlier period. From 2006 to 2009 the target groups have been children, youth, young adults, and the workplace according to the national action plans. It has also been emphasized that the projects would be new or in the process of expanding existing activities.

About one in four applications were awarded a grant. The amount of funds provided to NGOs varies. The minimum amount of funding for one year was 40,000 SEK and the largest amount was 1,200,000 SEK. Many organizations have been funded for several years. Over the years 2003-2009 the NBHW has in total apportioned about 80,000,000 SEK to the NGOs. In addition a yearly grant has been awarded to an integrated Research & Development (R&D) program as well as funds for administration and information activities. The total allocation from the NBHW has been 95,000,000 SEK, covering 135 projects in 69 organizations funded during these years.

The projects differed in size. Table 2 presents these 219 project grants over the years 2003-2009. The reason for this lower number of project (135) is that 50 projects have been funded over more than one year, 26 projects over two years, 17 projects over three years, and two projects over four and five years each. The first period, which covered two years, had the highest number of large projects. Moreover, the number of funded project has increased between 2005 and 2008 and the number of large projects has remained relatively stable since 2005.

Organizations and projects

The strategy to involve a broad range of organizations has been successful. In Figure 2 the 69 organizations and the 135 projects are presented according to type of organization. The largest number of projects were run by the nine alcohol and drug organizations. More than half of these projects were run by the Swedish temperance organisation IOGT-NTO (24 of 38 projects) amounting to 15 million SEK. The majority of these were small one-year projects, except for two programs where effect studies were conducted by the research team and the organization jointly. Between 15 and 20 projects were run by organizations focusing on social work, assistance, and ethnic groups. About 10 projects were run by sports, adult education, and religious organizations respectively. Furthermore, 14 projects were set up by two umbrella organizations each consisting of a number of member organizations.

Organizations and projects in different types of organizations according to main objectives .

The projects have different primary target groups for their activities. A majority of the projects have children or adolescents as target groups. Some of these projects are focused on young girls with the aim of promoting self confidence and a positive self image. Sports organizations have been developing alcohol and drug policies including anti-doping initiatives. Projects run by ethnic groups have as their target group members of their organizations including children, adolescents, and parents. A few projects have the workplace as the arena for intervention.

During the first years, three community-based projects were funded. These aimed to reduce drugs in two parts of Stockholm and the island Gotland. The strategy included a range of activities and collaboration with different actors. A broad membership in the organizations seems to be important for the sustainability of the community-based prevention.

Only one project has reduction of availability as its focus. This project focused on following up the alcohol legislation concerning the sale of beer to minors in Sweden [ 75 ] and the effect of different strategies to influence shops to comply with the law [ 74 ].

Internet has a great potential in promotion and preventive work [ 76 ]. The majority of the organizations have their own website on the Internet and about one third have a project-specific site. The organizations used information technology as a source of health information in three projects, as an intervention medium in four, for professional development in two, and as a research instrument in one project. The use of e-screening as a tool for drug prevention is studied by researchers at Karolinska Institute. There are still very few scientific evaluations of the use of Internet in drug prevention [ 77 ].

Basic characteristics of the project leaders in the alcohol and drug prevention projects are given in Table 3 . All four years the proportion of women was larger than men; about two of three project leaders were women. Most of the project leaders belonged to the age group 41-50 years in the early periods (2003/2005) while in the later periods (2007/2009) an increased proportion of the project leaders were 50 years or older. Moreover, nearly one in ten project leaders was 30 years or younger. Many of the project leaders in volunteer work were members of the organization before being appointed project leaders (Table 3 ). In 2003 eight of ten project leaders were members compared with four of ten in 2007 and 2009. Nearly half of the project leaders were also doing volunteer or non-paid work in the organization. No gender differences were found in the prevalence of non-paid work.

Investing in Research and Development

A research and evaluation strategy was developed by the research team at the School of Health and Medical Sciences, Örebro University. This strategy rests on collaboration with the NGOs through regular meetings with all project leaders, development of systematic documentation of project objectives, activities, and results, annual reports to the NBHW, and biannual national conferences Reflections on prevention (2006, 2008, and 2010). The role of the researchers can most closely be characterized as researchers as technical advisors . In some projects the researcher had the position of an unobtrusive observer -for instance in following up some projects in which no longitudinal data collection was included. In addition, in no project did the researcher have the position of researcher as designer . Moreover, separate competence development and discussion of evaluation studies were conducted with a smaller number of organizations. The steering committee at the NBHW also decided, after consulting the research team, on a number of in-depth studies. Fourteen such studies were included in the funding from the NBHW (Table 4 ). The research team was also involved in three additional studies funded by other sources. These studies focused on policy development in the Swedish Football Confederation, evaluation of regional collaboration against illegal alcohol, and alcohol prevention in Novgorod, Russia.

This set of studies included systematic collection of data from children, parents, and actors in projects. A description of the empirical studies carried out between autumn 2003 and spring 2009 is given in Table 5 . Different methods, including questionnaires, personal interviews, telephone interviews, and focus group interviews, have been used depending on the purpose of the study. The main research questions have been related to the process or effect evaluations of these projects. The majority of the studies have been carried out with adolescents, as many of the projects receiving grants from the NBHW are targeting adolescents for the purpose of preventing alcohol and tobacco use. In three studies, data have been collected from both adolescents and parents, and two of these are longitudinal studies with adolescents and their parents. Dyads of adolescents and parents are identified and have been followed over the three years of secondary school. All youth surveys have been carried out in a school environment while the questionnaires to the parents have been sent by mail. Municipalities, schools, and organizations across Sweden have participated in the studies. There are many advantages with the partnerships that have been developed between the research team and the project leaders within the NGOs. For example, the large scale of the studies that have been carried out during the six years could not been managed without this cooperation. The project leaders have done much of the practical work locally, such as the dialogue with participating schools and organizations, distribution of questionnaires, and sometimes also feedback to participants.

What types of research and development have been included?

All projects in the project portfolio had to submit semi-annual and annual reports. These reports were analysis and synthesized into an annual report to the NBHW. This was based on a reporting format using questions for different important elements in the projects as well as key aspects of project management. The preparation of the annual reports included cross-project comparisons with regard to the case study questions, which resulted in some amendments and changes over the years in the research and development activities.

After the decision on potential projects for in-depth studies, planning meetings were convened with the project leaders and managers in the NGOs. Based on the project proposals and joint planning between the project leaders and the researchers, a plan for the in-depth studies was developed. Depending on the evaluation and research questions and available resources the focus, design, process, and outcome measures were set (Table 6 ). The overall results were positive; ten of the fourteen in-depth studies were completed. One project did not succeed in recruiting high-risk parents to a parental support program (IOGT-NTO Centro). Three projects were only partially completed: one started before the research team was organized, making the evaluation impossible (IOGT-NTO: Dare/Young and King); one was cancelled after a decision by the municipality (SMART Västernorrland); and in one it was impossible to follow up information from policy-makers due to a low response rate (Makalösa föräldrar). Eleven of the in-depth studies started during the first period (Table 4 ). There were some common research questions such as the effects of the projects. The NGOs wanted their approach to be studied in such a way that, in the event of positive results, the program could be regarded as evidence-based.

Effect Studies

Seven projects were considered for evaluation with effect studies, which were planned for all seven projects. However, one project was unsuccessful and two only partially completed due to overly limited implementation. One project was already implemented when the research group was appointed. It was nevertheless possible to plan and successfully complete effect studies even with short-term yearly funding.

KSAN "About small things"

The aim of this project was to develop and test an early intervention targeting pregnant women to prevent alcohol injuries in unborn children. The project was developed by the KSAN, an umbrella organization for women's organizations concerned with alcohol and drug issues, and the Swedish Association of Midwives. It was implemented in a maternal health centre in Stockholm. A randomized controlled study was completed with 454 mothers randomly assigned to either receiving an information folder with the message "Pregnancy is not a time for risk-taking" sent to their home after the telephone contact for booking the first visit to the midwife, or getting the folder during their first visit to the midwife. The effects of the intervention were measured by a questionnaire that the pregnant women answered at the maternal health centre before they met with the midwife.

IOGT-NTO: Strong and Clear

Strong and Clear is a parental support program targeting parents with children aged 13-16 years. It is a universal program aiming to prevent drinking among adolescents and to maintain parents' restrictive attitudes concerning adolescents and alcohol. The program is manual based and includes thirteen activities during the three years of secondary school. The parents can sign up for the program during the whole period the program is carried out. There are both group and self-administered activities divided into four types: parent meetings, family dialogues, friend meetings, and family meetings. The program was implemented in six schools.

The research program includes the effect study, which was designed as a longitudinal quasi-experimental study, and studies of parental attitudes and behaviour with regard to adolescents and alcohol [ 78 ] as well as reasons for non-participation [ 73 ]. In the longitudinal study, 706 children and 613 parents participated in the baseline questionnaire, which was followed by repeated data collection in the two following school years.

IOGT-NTO: Parents Together

The program Parents Together consists of three parents' meetings during three years in secondary schools. The intention is to motivate the class parents to come to an agreement on the following issues: "We enforce the 18-year limit for alcohol; We will not provide each other's children alcohol; We will get in touch with each other if we see a child we know who is not sober, is behaving badly, or is out at times and places where we would not want our own children to be."This agreement is used to strengthen the cooperation among parents. The idea is that this will make a difference with respect to the children's alcohol use. A parent-teachers meeting is held each year to update the agreement.

The design of the study is a cluster randomized controlled study in Swedish secondary schools with seven intervention and six control school. The study included almost 2000 pupils and their parents. The program Parents Together was carried out over three years in the seven intervention schools with a start in both school years 7 and 8 (Figure 3 ). The six control schools have been offered the program for parents whose children are in year 7 in the spring 2009 and the program will follow in the years 2010 and 2011. To reveal effects of the program the evaluation also includes a questionnaire about the prevention work in schools and implementation reports. The non-governmental organization IOGT-NTO is responsible for the program and the implementation in the seven intervention schools. To maintain the cooperation between the thirteen schools, the NGO, and the research team, an agreement has been signed. The agreement includes information about the responsibilities of each party such as that the researchers should the results of surveys, within six months after the data collection, are published on the website.

Design of the intervention and evaluation of the program Parents Together .

IOGT-NTO Centro: Parental Support

This project was planned to include before and after questionnaires to high risk parents. However, the project did not succeed in attracting this type of parents to the program.

Hassela solidaritet: Peer Support in School

This NGO works with training and assisting school children to be peer supporters in their own school. The aims of the project are to prevent social exclusion by reducing teenage alcohol consumption, experimentation with drugs, and bullying through peer support in schools, and to promote a school that is a positive, creative, and stimulating workplace for all. The program was first implemented in one part of the school, and was planned to be extended to the whole school. Subsequent implementation in a second school was planned. However, this extended implementation was only partly carried out due to limited resources. The evaluation included focus group interviews with peer supporters and repeated cross-sectional questionnaires to schoolchildren in school years 7-9 in the two schools.

National Federation SMART: SMART Västernorrland

The main objective of this NGO is to prevent or postpone alcohol, tobacco, and other drug use among children through positive reinforcement and signing of contracts. The parents sign the contract together with their child. The content of these contracts varies between local organizations. The membership gives the child positive benefits reinforcing positive behaviours. The program was implemented in a Swedish county, Västernorrland. The evaluation plan included an effect study among schoolchildren in Kramfors, a study of parents, and an interview of stakeholders in the county. The program was cancelled by the municipality of Kramfors with negative consequences for the effect study, which had been planned as a repeated cross-sectional study of schoolchildren in years 4-9. Data was collected with questionnaires and during the three years, 2,052 children answered the questionnaire. The research team decided to implement the evaluation as planned even if there was no intervention the third year.

The Swedish Youth Temperance Movement (UNF): Folk Beer Project

The Non-governmental organization UNF is a politically and religiously independent organization. They are a sister organization to IOGT-NTO (The Swedish Temperance organization), which is a part of the International Organization of Good Templars. All members are between 13 and 25 years of age. To be a member you have to be a teetotaller. The activities are of different kinds, for example arranging theatrical performances, discos, cafés, study circles, and a large number of courses. Besides dealing with alcohol regulations and politics regarding alcohol, they also work with international exchange and democracy issues. Their vision is a democratic and socially responsible world free from drugs. Although they are politically independent, their task is to act politically in letting the politicians know which issues are important to them. UNF has an almost 40-year history of conducting underage alcohol purchase attempts.

In 2003 UNF applied for funding for a new idea. They wanted to compare two different strategies that included underage purchase attempts. The first was an elaboration of their earlier method, which meant confronting the media with the results of the purchase attempts, reporting the check-out clerks who sold them beer to the police, and informing the municipalities of which stores that sold beer to minors. The other method was based on the idea to actively seek cooperation with the retail grocery sector, the municipality's alcohol administrator or drug coordinator (the municipalities are organized differently), the police, and the labour unions. The evaluation program was designed as a quasi-experimental study and as a follow up of the alcohol legislation concerning the sale of beer to minors in Sweden [ 75 ] and of the effect of different strategies to influence the shops to comply with the law [ 74 ].

Studies of Process and Implementation

Seven of the in-depth studies focussed on the working process in the projects. Three projects were community-based and had a clear geographical area where the programs were implemented. Motgift Gotland was an alliance for preventing the use of narcotics on the island of Gotland. Söder mot Narkotika was also an alliance against narcotics in a central district (Södermalm) of the capital Stockholm. A broad range of agencies and organizations collaborated in these efforts. A third community-based project was run by Verdandi Tensta Rinkeby. The three community-based projects were studied during 2005-2006 and included interviews with stakeholders and actors in the projects. A lesson learned is that community-based prevention needs to have broad support and cannot depend heavily on individual project leaders.

Verdandi: Get safe in Tensta - Rinkeby. Meet us!

An in-depth analysis was made of the third project in order to uncover their successful strategy. Verdandi, founded in 1896, is a Swedish workers' organization striving for social justice and a society free from alcohol-related injuries. From the very beginning, Verdandi - as an independent organization within the workers' movement - has aimed to improve people's social and financial situations. Today's aim is to analyse the development of society through the experiences and voices of those who are not heard otherwise. People of all ages, in all parts of the country, may participate in Verdandi's activities, which are quite different from place to place since they are based on local needs. According to Verdandi, without a local angle, the organization would soon lose touch with reality as well as lose credibility and members.

Verdandi runs activities for youth. The project includes support for children both in school and after. The youth in the organization can use a facility in the neighbourhood in their leisure time. Youth activities have focused on "the young leading the young" and the project has demonstrated young people's ability to organize and run a rewarding activity in the evenings and on weekends. The aim of this prevention program is to empower young people in their daily lives and help them empower their friends. This, according to the organization, contributes to young people avoiding drugs, and the neighbourhood has become calmer and safer. The activity has a bottom-up nature and the youth are involved in the planning. They have the opportunity to develop activities and thereby affect their daily lives. Among the success factors, according to the in-depth study, are: confidence in the organization, equality, youth involvement and power, memberships, support from the parents, training of leaders, common norms and roles, volunteer work, easily accessible premises, and a leadership that facilitates democratic processes.

IOGT-NTO: Dare/Young and King

This program is a redesigned version of the American program DARE [ 79 ], which was implemented before the research group was appointed. However, an adult education component, Young and King, aiming to strengthen parents was implemented and a follow-up study was completed of this component of the program.

IOGT-NTO:s Juniorförbund: Junis sisters

In this project, groups of schoolgirls in years 5 and 6 are organized with the objective to strengthen their self-esteem and promote meaningful leisure activities and thereby delay the onset of alcohol consumption by the girls. The evaluation focused on the group leaders, who were interviewed in focus groups. A lesson learned is that special effort must be put into recruiting and assisting group leaders to achieve sustainable programs.

Makalösa föräldrar: Single Parent with Teenagers

The project consisted of two main parts. One part focused on improving the knowledge about how it is to be a single parent with a teenager in the family. A survey of single parents was done in a part of Stockholm and a small newsletter was produced. The other part included self-help groups for single parents and summer camps. The evaluation of the self-help groups consisted of follow-up questionnaires to participants. An unsuccessful part of the evaluation was the follow-up of the newsletter, which was well planned and properly designed. It was not possible to get feedback from policy-makers on the publication, which may be due to lack of awareness of the publication and its contents.

The Swedish Ice Hockey Association: School Ambassadors

The project aimed to train top athletes to become school ambassadors in order to influence the attitudes of schoolchildren and give them the opportunity to try out ice hockey. Moreover, the project was also an attempt to improve the collaboration between schools and top ice hockey clubs. In the second year the specialized ice hockey secondary schools were included in the program. The evaluation consisted of following up the training of the athletes and studying the work of the secondary school ice hockey players by means of a questionnaire to schoolchildren.

In order to promote the development of a partnership a series of measures were implemented (Table 7 ). All project leaders were invited to regular meetings, which were held in Örebro as well as in Stockholm, Gothenburg, and Malmö. The agenda included presentation of project plans, information from the NBHW, and the research and development activities by the research team. Thematic lectures and discussion on issues such as the art of project management, measures to reach target groups, media advocacy, Internet as a tool for prevention, and planned communication were held at different meetings. The main objective of these meetings was to promote exchange of experiences and learning in order to strengthening the quality of the implementation of the projects as well as networking. Moreover, the systematic bi-annual and annual reports were introduced and discussed.

Depending on the needs of the different projects special project dialogues and consultations were held between individual projects, or a small group of similar projects, and the research teams. The results of these meetings ranged from refinement of project ideas to long-term collaborations. All in-depth studies started with such meetings. The competence development took different forms. In the first period an academic training program in alcohol and drug prevention was offered to the project leaders, of whom about 10 participated. Supervision in groups was implemented in three groups during the first two years, and thereafter one or two groups were run by independent supervisors annually. During 2009 the research team arranged more project leader meeting including training in project management as an alternative to supervision.

The in-depth studies were also an important measure to foster the partnership between the NGOs and the research team. Due to available resources, more extensive process and effect evaluation activities could only be implemented in a limited number of projects. Many more projects asked to be the focus of in-depth studies than the fourteen that were initiated.

The research team together with the NBHW arranged a national conference Reflections on prevention - Collaboration for better alcohol and drug prevention. Conferences were arranged in the spring of 2006, 2008, and 2010. Among the key issues discussed at the first conference were the role of parents in prevention, adolescents, community-based approaches, and supply-reducing initiatives. The second conference also discussed the role of civil society and how to promote more effective cooperation among the different stakeholders. The third conference focussed on evidence and evidence-based practice, which have received increased attention in Sweden in many sectors of society. A main emphasis has been setting the context for reflection and sharing of experiences among the participants at the conferences; therefore a series of seminars with project presentations and panel discussions have been part of the conferences. Moreover, plenary sessions as well as theatrical performances further set the stage for professional dialogues on alcohol and drug prevention. The conferences have been well received and have attracted actors from different sectors of society as well as national agencies and NGOs.

In the annual reports the project leaders also assess the implemented measures by the researchers. These have guided the future efforts of the research team. As an example, the assessments made in January 2005 are presented in Figure 4 . The financial support was very important, followed by the support from the NBHW, the project leader meetings, and the supervision. One third of the project leaders regarded the support for the documentation as very important. The academic training in alcohol and drug prevention was regarded as very important by one fifth of the project leaders, which is a high proportion given that only a small group participated in the distance education course. Only eight projects were at that time included in the in-depth studies, nevertheless one third of the project leaders reported this measure as very important. The case study data bank includes information for questionnaires, interview and other data sources for the assessment of the implementation of the research strategy.

Assessment by project leaders of measures to improve collaboration between NGO and research in 2006 .

The research strategy has been successfully implemented despite the fact that only some projects were running more than one year while new projects and project leaders are included every year. The first two years a focus in the meetings with the project leaders was on the in-depth studies which were presented by the organisations and the researchers. Then the focus changed to addressing common concerns among the project leaders such as how to reach target groups, use of Internet, different type of prevention projects and mass communication skills. The presentations from the research teams were more concentrated to the national conferences that were organized bi-annually. The networking between the projects also resulted in new applications jointly by two organisations.

An important element was the relationship between the NBHW and the research team at Örebro University. During this period the NGO portfolio was managed at the NBHW by the same senior official. However, the department director changed three times during this period. The members of the working committee also changes over the years. The chairman was the same during all years. The support to the research and development activities was nevertheless maintained and also renewed for another year. The continuity with regard to persons seems to be very important for such an endeavour as included in this case study.

Discussion - towards practice-based research for alcohol and drug prevention

The integration of the research and development component into the support from the NBHW resulted in a unique possibility to do comparative studies involving, among other things, project management and implementation as well as project results. The measures to promote a partnership for practice-based research also improved the quality and success of the different projects. A few of the in-depth studies were unsuccessful due to factors hindering the implementation, and in several cases these factors were related to a lack of resources on the part of collaborating partners in the municipalities or other organizations.

The research strategy has been based on the overall aim to contribute to the evidence base for alcohol and drug prevention, an emphasis that this field shares with health promotion, prevention in general, and social work [ 2 – 8 ]. The current development of practice-based research will give more relevant knowledge and our research program attempts to be a part of this trend. Moreover, the utilization of research results may also be improved if studies on efficacy, effectiveness, and dissemination are promoted [ 18 ]. The strategy that the NBHW developed in this program of governmental support to NGOs was an attempt to bridge this gap as described by Nutbeam [ 10 , 11 ]. This challenge for agencies to respond to the push from the funders and pull from the communities has been noted by Green and Mercier [ 23 ] and the public health researcher also needs to leave the university campus to get involved in more practice-based research. Our research program has developed along such lines.

The research strategy includes the use of qualitative, quantitative, and mixed methods. This means that data collection and data analysis are done using guidelines for these three traditions. The challenge is most apparent with regard to inference and integration. In the stages of inference in a study, quality issues such as internal and external validity in the quantitative approach and aspects of credibility, confirmability, and transferability in the qualitative approach are pertinent. Integration is the mixed-methods approach of working across strands and using meta-inferential issues related to the integration of findings and inferences from the two strands. Here design quality, interpretative rigour, and inference transferability have been proposed as indicators of quality [ 70 ]. In this research strategy case study, the set of research entities changed each year due to the funding of applications from NGOs by the NBHW. The present study covered a six-year period, and the stages of inference and integration were completed yearly in the preparation of the annual reports to the NBHW.

The research strategy also includes elements of participatory research. The organizations were involved in developing the main research questions in the in-depth studies. Sometimes the organizations also assisted in collecting questionnaires from school children; in making participatory observations, as in the studies of beer purchasing by minors; or in providing feedback to school staff and target groups, as in the parental support programs. Moreover, the organizations also played a role in discussing preliminary results as part of a validating process for the empirical studies. These discussions never changed the interpretations of the findings but often gave more insight into the noble art of implementation of preventive programs. Nevertheless, as in other research programs, a number of methodological challenges had to be dealt with. The resources were limited, which gave room for only a small number of in-depth studies. Therefore the research strategy included additional elements such as support to documentation as well as support to the project leaders in meetings and management training. The selection of these studies was mainly done by the steering committee at the NBHW. The research team developed a proper design for these studies based on the assessed potential for a successful implementation and possible options given the resources available for effect or process studies. Then the choice of methods for data collections was reviewed and target groups for the evaluation research selected. In this process the best choice from an academic point of view was often not possible due to limited staff and other resources. Nevertheless, the research program resulted in data collected from 9,568 children, 4,832 parents and 327 actors or stakeholders. Moreover, it was possible to carry out two large longitudinal studies of children and their parents in this research program. Even if the funding was granted annually, it was possible to think and plan on more long-term basis.

A broad range of organizations received project funding from the NBHW. Although the largest number of projects was run by the nine alcohol and drug organizations, the alcohol and drug prevention was successfully integrated into a range of organizations with other main objectives. Moreover, the project leaders also came from different societal sectors. This was an intended effect of the governmental initiative to strengthen the alcohol and drug prevention in Sweden. This led to another methodological challenge caused by the fact that the programs were so different. The research team developed questionnaires with common modules that could be used in different evaluations thus giving them access to data from schoolchildren and parents in different contexts and programs. This made it possible, for instance, to study the reasons for non-participation in parental support programs [ 73 ]. Another added value related to this was the possibility to organize a study of project management through a special study of the project leaders, which was integrated into the overall design of the support from the NBHW.

A challenge for the research team was that the funding for the research as well as for the alcohol and drug projects was decided annually by the NBHW. However, the research was planned with a longer time period in mind, which has actually led to a research program that has been running more than six years. A more long-term grant would have been beneficial for the development of a partnership between the NGOs and the research team. In order to overcome this barrier a multi-year agreement has been signed for the newer in-depth studies, but it was still signed on the condition of renewed funding the following year. Nevertheless, a trustful partnership was developed between all three partners: the practitioners in the NGOs, the national agencies, and the researchers. In many cases the planning and implementation were done jointly, dividing the responsibilities according to skills and keeping the roles clear and feasible to complete successfully. The validity of the results was also a major concern as well as an emphasis on a participatory approach to the research process.

Ethical concerns were very important, as stipulated by Swedish law. The effect studies were assessed by the regional research ethics boards. However, it is also important to analyse if the NGOs have vested interests in the research process. Government agencies as well as NGOs can also have a vested interest in scientific research, such as when science is misused to benefit a particular political agenda, ideology, or favoured interest group [ 80 ]. However, the problem of vested interests is more dangerous when key parts of the government sector are in conflict over their public health responsibilities; for instance health sector engagement in partnership arrangements with addictive consumption industries (particularly alcohol, tobacco, and gambling) entails too many risks [ 81 ]. In our case there have been shared visions and objectives between the government agency and the NGOs, which guided the developmental activities as well as the research work. Moreover, the division of responsibilities between the NGOs and the researcher was important. The NGOs had the responsibility for developing the proposals, conducting the interventions, and implementing the preventive programs or initiatives. The researchers had the responsibility for planning the effect evaluations after consulting with representatives of the NGOs, as well as for implementing the research components, analysis, and reporting of results, including dialogues about the outcomes, and presenting the findings for the NGOs.

The organization of the research program under the auspices of public health science at Örebro University was natural as the principal investigator holds a professorial chair in public health there. During the first two years, other members of the research group were formally employed by an NGO but worked at the university campus in Örebro. All members of the research team were subsequently offered employment at the university, giving the research team a formal independence from all NGOs.

The addiction research centres have mandates that are broader than the present research program. The centre in Michigan has the mission to develop new knowledge about the cause, course, and consequences of substance use disorder and to train the next generation of researchers [ 28 ]; and the Canadian centre in British Columbia to create an internationally recognized centre distributed across BC that is dedicated to research and knowledge exchange on substance use, harm reduction, and addiction [ 27 ]. The Swiss institute is primarily involved in collecting alcohol-related information and making it available to professionals and the general public. The Swiss Institute will continue to monitor substance use, while stepping up its prevention research activities and ensuring that it is able to react promptly to emerging phenomena [ 25 ]. Our small research team is attempting to fill a gap in knowledge about the NGO alcohol and drug prevention efforts as these offer unique opportunities [ 82 ].

The research strategy was successful in establishing prevention research for alcohol and drug prevention by NGOs, which previously had been lacking in Sweden. Moreover, added value came from having meetings for project leaders, and the capacity building led to new innovative collaboration between different NGOs, which resulted in new applications for funding and successful implementation of new initiatives. The administrative support for improving the documentation of the implementation and progress of the projects was also recognized as beneficial for the practitioners and the national agency as well as the researchers. The best approach is always transparency and discussion, disclosure and debate [ 83 , 84 ].

A weakness in the research strategy was that the funding was not sufficient for more than a limited number of in-depth studies. The role of researchers-as-technical advisors was suitable for the fostering of a trustful partnership for research and development. The independence of the NGOs was regarded as important for the momentum in the project implementation. It was beneficial because it gave the research team opportunities to address other issues. From a strictly research point of view it would have been of interest to see what could be achieved by researchers-as-designer , but this would have been very costly and all funds allocated to the integrated research activities would have been consumed by just one project. In other words, the present research strategy can be regarded as cost-effective.

The overall strategy for research and development includes capacity building for both the practitioners in the NGOs and the research team, and two doctoral dissertations will be finalized during the coming year. The NBHW has also noted that, given the limited duration of funding, this organization of knowledge development - as an integral part of the support to NGOs - is beneficial, which is indicated by the annual renewal of the contract with Örebro University. Moreover, the much more extensively funded projects in municipalities, regions, and counties still lack this strategic element. At present there is a trend that some larger governmental grants are given to such parties, but a mandatory linkage to universities for research is included in the call for proposals. This could lead to similar forms of trustful partnerships as found in the present research strategy case study.

The in-depth studies in this research strategy varied in content, design, and size. A common element was that they were program-driven and not research-driven interventions [ 9 ]. This may give the studies improved external validity [ 54 ]. The research strategy aimed at improving the evidence-base for alcohol and drug prevention. In our case this has meant using qualitative, quantitative, and mixed methods, as well a variety of designs to answer questions in practice-based settings. Including feedback and dialogue with the NGOs has further contributed to sustainable AD prevention in different settings. The missions of the NGOs differ, but the AD prevention has been included as an essential part of their activities, which in many cases meant that AD prevention has received increased priority. Moreover, the integrated research program has also been seen as beneficial and important for the organizations, which often wanted their programs to be recognized as evidence-based. Therefore, the demand for research by the NGOs is larger than what we can supply at present. This is a challenge to the funding agencies as well as research bodies. The addiction research centres seem to nurture creativity but often lack the networks and priorities for preventive research. It is important to go beyond the notion that a lack of evidence for a program is necessarily a sign of a lack of effectiveness. Therefore, practice-based research and collaboration between decision-makers, national agencies, NGOs, local authorities and researchers is needed. Using a combination of different and interactive measures it was possible to over the years built a trustful partnership between these parts. This research strategy case study shows that it is possible even in such a dynamic field as alcohol and drug prevention in NGOs where the organisations are competing for grants from the NBHW. There are added values in supporting a research group assigned to a project portfolio instead of having a series of smaller independent evaluations.

This research strategy case study shows that it is possible to integrate research into alcohol and drug prevention programs run by NGOs, and thereby contribute to a more evidence-based practice. A core element is developing a trustful partnership between the researchers and the organizations. Competence development is necessary for developing evidence for policy and practice. Given research groups assignments to address the knowledge development issues is better than having minor evaluation in individual projects. Moreover, the funding agency must acknowledge the importance of knowledge development and allocating resources to research groups that is capable of cooperating with practitioners and NGOs.

WHO: Handbook for action to reduce alcohol-related harm. 2009, Copenhagen: World Health Organization

Google Scholar  

Davies JK, Macdonald G, (Eds): Quality, Evidence and Effectiveness in Health Promotion. 1998, London: Routledge

Eriksson C: Learning and knowledge-production for public health - a review of approaches to evidence-based public health. Scandinavian Journal of Public Health. 2000, 28: 298-308.

Article   CAS   PubMed   Google Scholar  

Gomm R, Davies C, (Eds): Using Evidence in Health and Social Care. 2000, London: Sage

Oakley A: Experiment in Knowing. Gender and method in the social sciences. 2000, Cambridge: Polity Press

National Board of Health and Welfare: Nationellt stöd för kunskapsutveckling inom socialtjänsten. 2000, Stockholm: National Board of Health and Welfare, SoS Rapport, 12-[National support to knowledge development in social work].

Green LW, Kreuter MW: Health Program Planning. An Educational and Ecological Approach. 2005, Boston: McGraw Hill

Baum F: The New Public Health. 2002, Victoria, Australia: Oxford University Press

Holder H, Flay B, Howard J, Boyd G, Voss R, Grossman M: Phases of alcohol problem prevention research. Alcoholism: Clinical and Experimental Research. 1999, 23 (1): 183-194. 10.1111/j.1530-0277.1999.tb04043.x.

Article   CAS   Google Scholar  

Nutbeam D: Achieving best practice in health promotion: Improving the fitbetween research and practice. Health Education Research, Theory and Practice. 1996, 11 (3): 317-326.

Nutbeam D: Evaluating health promotion - progress, problems and solutions. Health Promotion International. 1998, 13 (1): 27-44. 10.1093/heapro/13.1.27.

Article   Google Scholar  

Durlak JA, DuPre EP: Implementation matters: a review of research on the influence of implementation on program outcomes and the factors affecting implementation. American Journal of Community Psychology. 2008, 41: 327-350. 10.1007/s10464-008-9165-0.

Article   PubMed   Google Scholar  

Mercer SL, De Vinney BJ, Fine LJ, Green LW, Dougherty D: Study designs for effectiveness and translation research. Identifying trade-offs. American Journal of Preventive Medicine. 2007, 33 (2): 139-154. 10.1016/j.amepre.2007.04.005.

Cook WK: Integrating research and action: A systematic review of community-based participatory research to address health disparities in environmental and occupational health in the United States. Journal of Epidemiology and Community Health. 2008, 62 (8): 668-676. 10.1136/jech.2007.067645.

Article   PubMed Central   CAS   PubMed   Google Scholar  

Evensen AE, Sanson-Fisher R, D'Este C, Fitzgerald M: Trends in publications regarding evidence-practice gaps: A literature review. Implementation Science. 2010, 5: 11-10.1186/1748-5908-5-11.

Article   PubMed Central   PubMed   Google Scholar  

Chaloupka FJ, Johnston LD: Bridging the gap. Research informing practice and policy for healthy youth behavior. American Journal of Preventive Medicine. 2007, 33 (4S): 147-161. 10.1016/j.amepre.2007.07.016.

Emshoff JG: Researchers, practitioners, and funders: Using the framework to get us on the same page. American Journal of Community Psychology. 2008, 41: 393-403. 10.1007/s10464-008-9168-x.

Flay BR, Biglan A, Boruch RF, Castro FG, Gottfredson D, Kellam S, Mo'scicki EK, Schinke S, Valenntine JC, Ji P: Standards of evidence: Criteria for efficacy, effectiveness and dissemination. Prevention Science. 2005, 6 (3): 151-175. 10.1007/s11121-005-5553-y.

Green LW: "Public Health Asks of Systems Science: To Advance Our Evidence-Based Practice, Can You Help Us Get More Practice-Based Evidence?". American Journal of Public Health. 2006, 96 (3): 406-409. 10.2105/AJPH.2005.066035. 2006

Green LW: Translation 2 research. The roadmap less travelled. American Journal of Preventive Medicine. 2007, 33 (2): 147-8. 10.1016/j.amepre.2007.04.023.

Straus S, Tetroe J, Graham ID: Knowledge Translation in Health Care. 2009, Oxford: Wiley-Blackwell, BMJ Books

Book   Google Scholar  

Tapp H, Dulin M: The science of primary health-care improvement: potential and use of community-based participatory research by practice-based research networks for translation of research into practice. Experimental Biology and Medicine. 2010, 235: 290-299. 10.1258/ebm.2009.009265.

Green LW, Mercer SL: "Can Public Health Researchers and Agencies Reconcile the Push From Funding Bodies and the Pull From Communities?". American Journal of Public Health. 2001, 91 (12): 1926-1929. 10.2105/AJPH.91.12.1926.

Edwards G: Addiction research centres and the nurturing of creativity. Addiction. 2009, 104: 687-10.1111/j.1360-0443.2009.02597.x.

Kuntsche E, Maffli E, Kuntsche S, Jordan MD: Addiction research centres and the nurturing of creativity: The Swiss Institute for the Prevention of Alcohol and Drug problems. Past, present and future. Addiction. 2009, 104: 699704-10.1111/j.1360-0443.2009.02556.x.

Stenius K, Ramstedt M, Olsson B: Addiction research centres and the nurturing of creativity: Centre for Social Research on Alcohol and Drugs (SoRAD), Stockholm University, Sweden. Addiction. 2010, 105: 402-407. 10.1111/j.1360-0443.2009.02838.x.

Stockwell T, Reist D, Macdonald S, Benoit C, Jansson M: Addiction research centres and the nurturing of creativity: The Centre for Addictions Research of British Columbia, Canada. Addiction. 2010, 105: 207-215. 10.1111/j.1360-0443.2009.02789.x.

Zucker RA: Addiction research centres and the nurturing of creativity: University of Michigan Addiction Research Center (UMARC): development, evolution, and direction. Addiction. 2010, 105: 966-97. 10.1111/j.1360-0443.2010.02904.x.

Norström T, Ramstedt M: "Sweden - is alcohol becoming an ordinary commodity?". Addiction. 2006, 101: 1543-1545.

Karlsson T, Österberg E: Sweden. Alcohol Policies in EU Member States and Norway A Collection of Country Reports. Edited by: Österberg E, Karlsson T. 2002, Helsinki: European Commission and STAKES

Chatwin C: Drug Policy Developments within the European Union. The Destabilizing Effects of Dutch and Swedish Drug Policies. British Journal of Criminology. 2003, 43: 567-582.

Swedish Government Bill 2005/06:30: Nationella alkohol- och narkotikahandlingsplaner. [National plan of actions for alcohol and drugs]. Stockholm

Babor T, Caetano R, Casswell S, Edwards G, Giesbrecht N, Graham K: Alcohol: no ordinary commodity- research and public policy. 2003, Oxford: Oxford University Press

Holder H, (Ed.): Alcohol Monopoly and Public Health: Potential effects of privatization of the Swedish alcohol retail monopoly. 2008, Stockholm: Swedish National Institute of Public Health, R, 27-

Howat P, Sleet D, Maycock B, Elder R: Effectiveness of Health Promotion in Preventing Alcohol Related Harm. Global Perspectives on Health Promotion Effectiveness. Edited by: McQueen D, Jones C. 2006, Springer

Government Office of Sweden: Förebygga för framtiden. En presentation av regeringens politik på alkohol-, narkotika-, dopning-, och tobaksområdet. 2008, Stockholm: Ministry of Health and Social Affairs

Swedish Government: En förnyad folkhälsopolitik. 2007, Stockholm: Ministry of Health and Social Affairs, [A renewed public health policy]

Swedish Government White Paper, 2008/09:207: Överenskommelsen mellan regeringen, idéburna organisationer inom det sociala området och Sveriges Kommuner och Landsting. Stockholm: Ministry of Integration and Gender Equality, [The agreement between the government, idea-driven organizations in the field of social welfare, and Sweden's municipalities and county councils]

Andréasson S, Göransson B, Lindberg J, Nycander S, Romanus G, Westerholm B: Solidarisk alkoholpolitik. 2007, Stockholm: Hjalmarson & Högberg och Alkoholpolitiskt forum, [Socially responsible alcohol policy]

Wijkström F, Lundström T: Den ideella sektorn: organisationerna i det civila samhället. 2002, Stockholm: Sober, [The voluntary sector: the organisations in the civil society].

Wijkström F: Different Faces of Civil Society. 1998, Dissertation, Stockholm School of Economics

Gougoulakis P: Studiecirkeln: Livslångt lärande...på svenska!: en icke-formell mötesplats för samtal och bildning för alla. 2001, Dissertation, Stockholm: HLS Förlag, Studies in Educational Sciences, 40-[The Study Circle: Lifelong learning ... in swedish!]

Wijkström F, Einarsson T: Från nationalstat till näringsliv? Det civila samhällets organisationsliv i förändring. 2006, Stockholm School of Economics, [From nation state to business sector? The changing organizational community of civil society]

Lundström T, Svedberg L: The Voluntary Sector in a Social Democratic Welfare State - The Case of Sweden. Journal of Social Policy. 2003, 32 (2): 217-238.

Wijkström F: The Swedish nonprofit sector in international comparison. Annals of Public and Cooperative Economics. 1997, 68 (4): 625-663.

Nygren S: Identitet och nätverk - en utvärdering av elva alkohol- och drogförebyggande projekt. 2000, Stockholm: Folkhälsoinstitutet, 2-[Indentity and Network - an evaluation of eleven alcohol and drug preventive projects]

Eriksson C, Geidne S, Larsson M, Pettersson C: Med kraft och vilja. Alkohol- och drogförebyggande arbete inom Socialstyrelsens stöd till frivilligorganisationer 2003-2009. 2010, Örebro: Örebro University; Studies in Public Health Sciences, 1-[With strength and will. Alcohol and drug prevention efforts within the National Board of Health and Welfare's support for voluntary organizations 2003-2009].

Bruun K, Edwards G, Lumio M, Mäkelä K, Pan L, Popham RE, Room R, Schmidt W, Skog OJ, Sulkunen P, Österberg E: Alcohol control policies in public health perspective. 1975, Helsinki: The Finnish Foundation for Alcohol Studies

Edwards G, Andersson P, Babor TF, Casswell S, Ferrence R, Giesbrecht N: Alcohol Policy and the Public Good. 1994, Oxford: Oxford University Press

Babor TF, Caetano R, Casswell S, Edwards G, Giesbrecht N, Graham K, Grube JW, Hill L, Holder H, Homel R: Alcohol: No Ordinary Commodity. Research and Public Policy. 2010, Oxford: Oxford Univesity Press, second

Andréasson S, (Ed.): Den svenska supen i det nya Europa - Nya villkor för alkoholprevention: en kunskapsöversikt. 2002, Stockholm: Förlagshuset Gothia, [Swedish Alcohol Culture in the new Europe - new challenges for alcohol prevention: a review].

Andréasson S, (Ed.): Narkotika i Sverige. Metoder för förebyggande arbete. 2008, Östersund: Statens folkhälsoinstitut, Rapport R, 23-[Illicit Drugs in Sweden. Methods for prevention].

Ferrer-Wreder L, Stattin H, Lorente CC, Tubman JG, Adamson L: Successful Prevention and Youth Development Programs: Across Borders. 2004, New York:Kluwer Academic/Plenum Publishers

Green LW, Glasgow RE: Evaluating the Relevance, Generalization, and Applicability of Research. Issues in External Validation and Translation Methodology. Evaluation & the Health Profession. 2006, 29 (1): 126-153.

Tones K, Green J: Health Promotion. Planning and Strategies. 2004, London: SAGE Publications

Birkeland S, Murphy-Graham E, Weiss C: Good reasons for ignoring good evaluation: The case of the drug abuse resistance education (D.A.R.E.) program. Evaluation and Program Planning. 2005, 28: 247-256. 10.1016/j.evalprogplan.2005.04.001.

Holmila M, Holder H, Andreasson S, Baklien B, Rossow I: Roles for researchers in community action projects to prevent alcohol and other drug problems: Methodological choices. Drugs: education, prevention and policy. 2008, 15 (4): 410-423. 10.1080/09687630701839149.

Wagenaar AC, Murray DM, Toomey TL: Community mobilizing for change on alcohol (CMCA): Effects of a randomized trial on arrests and traffic crashes. Addiction. 2000, 95: 209-217. 10.1046/j.1360-0443.2000.9522097.x.

Holmila M: The evaluation of the metropolitan project: Process and causality. NAT. Nordic Studies on Alcohol and Drugs. English Supplement. 2003, 22: 350-357.

Wallin E, Norström T, Andréasson S: Alcohol prevention targeting licensed premises: A study of effects of violence. Journal of Studies on Alcohol. 2003, 64: 270-277.

Andréasson S, Sjöström E, Bränström R: A six community prevention trial to reduce alcohol and drugs related problems in Sweden. Substance Use & Abuse. 2007, 42 (12-13): 2017-27. (2007)

Stafström M, Östergren PO, Larsson S, Lindgren B, Lundborg P: A community action programme for reducing harmful drinking behaviour among adolescents: The Trelleborg project. Addiction. 2006, 101: 813-823.

Koutakis N, Stattin H, Kerr M: Reducing youth alcohol drinking through a parent-targeted intervention: the Örebro Prevention Program. Addiction. 2008, 103: 1629-1637. 10.1111/j.1360-0443.2008.02326.x.

Yin RK: Case Study Research. Design and Methods. 2009, Los Angeles: Sage, Fourth

Swanborn P: Case Study Research. What, why and how?. 2010, Los Angeles: SAGE

Kazi MAF: Realist Evaluation in Practice. Health and Social Work. 2003, London: SAGE Publications

Reason P, Bradbury H, (Eds): Handbook of Action Research. Participative Inquiry & Practice. 2001, London: SAGE Publications

Creswell JW, Piano CVL: Designing and Conducting Mixed Methods Research. 2007, Thousand Oaks: Sage Publications

Saks M, Allsop J: Researching Health. Qualitative, Quantitative and Mixed Methods. 2007, Los Angelse: Sage

Teddlie C, Tashakkori A: Foundations of Mixed Methods Research. Integrating Quantitative and Qualitative Approaches in the Social and BehavioralSciences. 2009, Los Angeles: SAGE

Bonnie K, Schensul SL: Contribution of qualitative research to the validityof intervention research. Journal of School Psychology. 2005, 43: 177-195. 10.1016/j.jsp.2005.04.003.

Jack SM: Utility of Qualitative Research Findings in Evidence-based Public Health Practice . Public Health Nursing. 2006, 23 (3): 277-283. 10.1111/j.1525-1446.2006.230311.x.

Pettersson C, Lindén-Boström M, Eriksson C: Reasons for nonparticipation in a parental program concerning underage drinking: A mixed-method study. BMC Public Health. 2009, 9: 478-10.1186/1471-2458-9-478.

Geidne S, Eriksson C: Working with or against the stores? A nongovernmental organization working with purchase attempts. Health Education. 2009, 109: 259-278. 10.1108/09654280910955584.

Geidne S, Eriksson C: How do minors succeed in buying beer in Sweden?. Nordic Studies on Alcohol and Drugs. 2008, 25: 115-127.

Lintonen TP, Konu AI, Seedhouse D: Information technology in health promotion. Health Education Research. 2007, 23 (2): 560-566.

PubMed   Google Scholar  

Bewick BM, Trusler K, Barkman M, Hill AJ, Cahill J, Mulhern B: The effectiveness of web-based interventions designed to decrease alcohol consumption - A systematic review. Preventive Medicine. 2008, 47: 17-26. 10.1016/j.ypmed.2008.01.005. (2008)

Pettersson C, Lindén-Boström M, Eriksson C: Parental Attitudes and Behaviour Concerning Youth Alcohol Consumption - do socio-demographic factors matter?. Scandinavian Journal of Public Health. 2009, 37: 509-517. 10.1177/1403494809105790.

Lindström P, Svensson R: Skolungdomars attityder till droger - En utvärdering av VÅGA-programmet. 1998, Nordisk Alkohol & Narkotikatidskrift, 15: 5-19. (1998).[Attitudes to drugs among school children - An evaluation of DARE program].

Babor T, Miller P, Edwards G: Vested interests, addiction research and public policy. Addiction. 2010, 104: 4-5. 10.1111/j.1360-0443.2009.02664.x.

Adams PJ, Buetow A, Rossen F: Vested interests in Addiction Research and Policy: Poisonous partnerships: health sector buy-in to arrangements with government and addictive consumption industries. Addiction. 2010, 105: 585-590. 10.1111/j.1360-0443.2009.02815.x.

Nathan S, Rotem A, Ritchie J: Closing the gap: building the capacity of non-government organizations as advocates for health equity. Health Promotion International. 2002, 17 (1): 69-78. 10.1093/heapro/17.1.69.

Holder HD, Reynolds R: Science and alcohol policy at the local level: a respectful partnership. Addiction. 1998, 93 (10): 1467-1473. 10.1046/j.1360-0443.1998.931014673.x. (1998).

Holder H: Prevention programs in the 21 st century: what we do not discuss in public. Addiction. 2009, 105: 578-581. 10.1111/j.1360-0443.2009.02752.x. (2009).

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Acknowledgements

The authors are very grateful to all the NGOs that have shared their efforts and experiences with the research team. We would also like to acknowledge Åke Setréus for his support and encouragement during the whole period. The Swedish National Board of Health and Welfare supported the study.

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The four authors of the manuscript are presented in alphabetical order and their shares of the responsibility for the paper are equal. CE is the principal investigator for the research program integrated in the NBHW support to NGOs for alcohol and drug prevention. CE, ML, and CP were involved in all aspects of the program as well as this study. SG was involved in the planning, project implementation, and writing of the section on NGOs. All authors read and approved the final manuscript.

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Eriksson, C., Geidne, S., Larsson, M. et al. A Research Strategy Case Study of Alcohol and Drug Prevention by Non-Governmental Organizations in Sweden 2003-2009. Subst Abuse Treat Prev Policy 6 , 8 (2011). https://doi.org/10.1186/1747-597X-6-8

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'You drink at home so they can go to work safely': A case study exploring alcohol marketing during the COVID-19 pandemic

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Alcohol marketing is linked to heavy consumption. Researchers have begun to examine how the alcohol industry has adapted its marketing practices during the 2020 Global COVID-19 pandemic. In Canada, Nova Scotia's culture of heavy drinking has been identified as a cause for concern by community, health care and government. This case study examines how one alcohol company coopted the facilities, staff, logos and fundraising efforts of a local health charity to market the sale and home delivery of a 6% alcohol by volume product via social media. This case study details the marketing practices of the alcohol brand, suggests why the marketing practices are problematic and concludes with recommendations for health promotion practice as well as suggestions for future research.

Keywords: COVID-19; alcohol industry; alcohol marketing; health-care worker; heavy drinking.

© 2021 Australasian Professional Society on Alcohol and other Drugs.

• Alcohol Drinking

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Robert’s story

Robert was living with an alcohol addiction and was homeless for over 25 years. He was well known in the local community and was identified as one of the top 100 A&E attendees at the Local General Hospital.

He drank all day every day until he would pass out and this was either in the town centre or just by the roadside. In addition, Robert was also incontinent and really struggled with any meaningful communication or positive decision making due to his alcohol usage. This often resulted in local services such as police, ambulance being called in to help. He had no independent living skills and was unable to function without alcohol.

In addition, and due to his lifestyle and presenting behaviours, Robert had a hostile relationship with his family and had become estranged from them for a long period of time.

Robert needed ongoing support and it was identified at the General Hospital that if he was to carry on “living” the way he currently was, then he wouldn’t survive another winter.

On the back of this, Robert was referred to Calico who organised a multi-disciplinary support package for him, which included support with housing as part of the Making Every Adult Matter programme.

After some initial challenges, Robert soon started to make some positive changes.

The intensive, multidisciplinary support package taught him new skills to support him to live independently, sustain his tenancy and make some positive lifestyle changes which in turn would improve his health and wellbeing.

This included providing daily visits in the morning to see Robert and to support him with some basic activities on a daily/weekly basis. This included getting up and dressed; support with shopping and taking to appointments; guidance to help make positive decisions around his associates; support about his benefits and managing his money. In addition, he was given critical support via accessing local groups such as RAMP (reduction and motivational programme) and Acorn (drugs and alcohol service), as well as 1 to 1 sessions with drugs workers and counsellors to address his alcohol addiction.

After six months Robert continued to do well and was leading a more positive lifestyle where he had greatly reduced his A&E attendance. He had significantly reduced his alcohol intake with long periods of abstinence and was now able to communicate and make positive decisions around his lifestyle.

Critically he had maintained his tenancy and continued to regularly attend local groups and other support for his alcohol addiction and had reconnected with some of his family members.

By being able to access these community resources and reduce his isolation he is now engaged in meaningful activities throughout the day and has been able to address some of his critical issues. A small but significant example is that Robert is now wearing his hearing aids which means that he can now interact and communicate more effectively.

Alcohol Abuse in Society: Case Studies

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The last three chapters have demonstrated how routine data may be collected from the health service and forensic medicine. These data present a view of the occurrence of alcohol and drug abuse in society which is generated from a ‘medical model’. As useful as this approach is, it does not take into account the nature and needs of specific groups. To do this a more ‘socially appropriate perspective’ can be used. The following case studies illustrate some of the problems resulting from methodological issues in this area of investigation and, in particular, from studies undertaken in short-term projects undertaken by graduate students. Important discussions relating to: ‘what level of consumption constitutes abuse ’ ‘alcohol usage by the elderly’, and ‘the effectiveness of health education’ will be introduced.

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Anderson, P. (1984) ‘Alcohol Consumption of Undergraduates at Oxford University’, Alcohol and Alcoholism , 19:pp. 77–84.

Google Scholar  

Black, D. and Weare, K. (1989) ‘Knowledge and Attitudes about Alcohol in 17- and 18-Year-Olds’, Health Education Journal , 48 (2):pp. 69–73.

Article   Google Scholar  

Cyster, R. and McEwen, J. (1987) ‘Alcohol Education in the Workplace’, Health Education Journal , 46 (4):pp. 156–61.

Davies, J. (1991) ‘Learning to Drink’, paper presented at a national conference on ‘Alcohol and Young People’, 8 October 1991, Queen Mother Conference Centre, Royal College of Physicians, Edinburgh.

Gillies, P. (1991) ‘What Can Education Achieve?’, paper presented at a national conference on ‘Alcohol and Young People’, 8 October 1991, Queen Mother Conference Centre, Royal College of Physicians, Edinburgh.

Grant, M. (1981) ‘Aims, Form and Content: First Steps in Developing a Taxonomy of Preventative Education in Drug and Alcohol Abuse’, in L. R. H. Drew et al . (eds), Man, Drugs, and Society: Current Perspectives (Canberra: Australian Foundation on Alcoholism and Drug Dependence).

Haack, M. (1988) ‘Stress and Impairment among Nursing Students’, Research in Nursing and Health , 11:pp. 125–34.

Haack, M. and Harford, T. (1984) ‘Drinking Patterns among Student Nurses’, The International Journal of the Addictions , 19 (5):pp. 577–83.

Hopkins, R., Maussa, A., Kearney, K. and Weisheit, R. (1988) ‘Comprehensive Evaluation of a Model Alcohol Education Curriculum’, Journal of Studies on Alcohol , 49 (1):pp. 38–50.

Hutchison, S. (1986) ‘Chemically Dependent Nurses: The Trajectory towards Self Annihilation’, Nursing Research , 35 (July/August):pp. 196–201.

Maussa, A., Hopkins, R., Weisheit, R., and Kearney, K. (1988) The Problematic Prospects for Prevention in the Classroom: Should Alcohol Education Programmes be Expected to Reduce Drinking by Youth?’, Journal of Studies in Alcohol , 49 (1):pp. 51–61.

Plant, M. (1991) ‘Heavy Drinkers: Are They Distinctive?’, paper presented at a national conference on ‘Alcohol and Young People’, 8 October 1991, Queen Mother Conference Centre, Royal College of Physicians, Edinburgh.

Plant, M. L., Plant, M. A. and Foster, J. (1991) ‘Alcohol, Tobacco and Illicit Drug Use Amongst Nurses: A Scottish Study’, Drug and Alcohol Dependence , 28:pp. 195–202.

Roberts, R. (1988) ‘Hiccups in Alcohol Education’, Health Education Journal , 47 (213):pp. 73–5.

Royal College of General Practitioners (1986) Alcohol: A Balanced View (London: Tavistock).

Saltz, R., and Elandt, D. (1986) ‘College Students Drinking Studies 1976–1985’, Contemporary Drug Problems (Spring):pp. 117–59.

Wallace, P., Brennan, P., and Haines, A. (1987) ‘Drinking Patterns in General Practice Patients’, Journal of the Royal College of General Practitioners , 37:pp. 354–7.

Weichsler, H. and McFadden, M. (1979) ‘Drinking among College Students in New England; Extent, Social Correlates and Consequences of Alcohol’, Journal of Studies on Alcohol , 40:pp. 969–99.

West, R., Drummond, C., and Eames, K. (1990) ‘Alcohol Consumption, Problem Drinking and Anti-Social Behaviour in a Sample of College Students’, British Journal of Addiction , 85:pp. 479–86.

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Bonner, A., Waterhouse, J. (1996). Alcohol Abuse in Society: Case Studies. In: Bonner, A., Waterhouse, J. (eds) Addictive Behaviour: Molecules to Mankind. Palgrave Macmillan, London. https://doi.org/10.1007/978-1-349-24657-1_17

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Teen Cocaine Addiction Case Study: Chloe's Story

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Chloe’s Addiction

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Chloe scored straight As in her A levels, and accepted a place at Kings College London to study law. She was introduced to new people, and it seemed that cocaine was available at every place they went. Parties, clubs, and even her new friends were all good sources of a line of cocaine. As a self confessed wild child by this point, Chloe didn’t want to miss out.

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Coming out of Addiction Denial

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Introduction, correlations and typologies, complex interdependencies, group 1 exemplar. victim was never substance dependent, group 2 exemplar. victim was desisting from substance use, group 3 exemplar. victim was substance dependent, discussion and conclusion.

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The Dynamics of Domestic Abuse and Drug and Alcohol Dependency

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David Gadd, Juliet Henderson, Polly Radcliffe, Danielle Stephens-Lewis, Amy Johnson, Gail Gilchrist, The Dynamics of Domestic Abuse and Drug and Alcohol Dependency, The British Journal of Criminology , Volume 59, Issue 5, September 2019, Pages 1035–1053, https://doi.org/10.1093/bjc/azz011

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This article elucidates the dynamics that occur in relationships where there have been both substance use and domestic abuse. It draws interpretively on in-depth qualitative interviews with male perpetrators and their current and former partners. These interviews were undertaken for the National Institute for Health Research-funded ADVANCE programme. The article’s analysis highlights the diverse ways in which domestic abuse by substance-using male partners is compounded for women who have never been substance dependent, women who have formerly been substance dependent and women who are currently substance dependent. The criminological implications of the competing models of change deployed in drug treatment and domestic violence intervention are discussed alongside the policy and practice challenges entailed in reconciling them within intervention contexts where specialist service provision has been scaled back and victims navigate pressures to stay with perpetrators while they undergo treatment alongside the threat of sanction should they seek protection from the police and courts.

The 2019 Domestic Abuse Bill proposes to establish a statutory definition of domestic abuse that includes ‘controlling, coercive, threatening behaviour, violence or abuse’ encompassing ‘psychological, physical, sexual, economic and emotional forms of abuse’ ( HM Government, 2019 : 5). It proposes to widen the scope of Domestic Abuse Protection Orders so that suspected perpetrators of domestic abuse can be compelled to attend ‘drug or alcohol treatment’, as well as ‘behavioural change’ programmes by the family courts (if petitioned by victims or other relevant third parties, such as non-governmental organizations) and magistrates courts (where the police would normally petition) (ibid. Explanatory Note Clause 3: 128). It is proposed that compliance with such orders will be secured in part through electronic monitoring. Breaches of such orders will be a criminal offence, punishable by up to ‘five years’ imprisonment, unlimited fine or both’ (ibid. 30).

The Bill is informed by a prolonged consultation in which over 3,200 responses were received by government and expert opinion—primarily from organizations representing victims and survivors of domestic abuse and stalking—was submitted to two Home Affairs Committees ( House of Commons, 2018 ). Cross-party support for the Bill was secured: as politicians registered the volume of domestic abuse cases raised with them by constituents; amidst news that the daughter of an MP had committed suicide following a relationship in which she suffered psychological—but not physical—torment that caused her to fear that she was mentally ill ( Elgot, 2018 ); and during a campaign by David Challen to enable his mother to appeal her conviction for murdering his coercively controlling father ( Moore, 2018 ). In strengthening the prohibition of ‘coercive control’ ( Home Office, 2015 : 2)—a concept advanced by Stark (2007 : i) to explain ‘how men entrap women in personal life’ through ‘intimate terrorism’—the Bill can be read as a logical extension of three decades of Conservative party policy that conceives the criminalization of a dangerous minority of men who abuse ‘very vulnerable women and girls’ to be a key part of the solution to domestic abuse ( Heidensohn, 1995 ; Gadd, 2012 ). But this Bill was conceived within a more nuanced policy agenda than its predecessors. In the initial consultation document Transforming the Response to Domestic Abuse, which sought views on a raft of new measures, the then-Home Secretary, Amber Rudd, and Justice Secretary, David Gauke, called for policy that (1) recognizes that both ‘women and men are victims of domestic abuse’, though ‘a disproportionate number of victims are women, especially in the most severe cases’ ( HM Government, 2018 : 3); (2) ‘actively empowers victims, communities and professionals to confront and challenge’ domestic abuse; and (3) reduces regional variation in the quality of ‘services to help victims’ and ‘punish and rehabilitate offenders’ (ibid, our emphases). This receptivity to the rehabilitative ambitions of health and social care professionals derived principally from the findings of domestic homicide and serious case reviews (ibid, p21), which reveal the pertinence of a ‘toxic trio’ of domestic abuse, mental health issues and drug and alcohol problems in cases where women or children are killed ( Brandon et al., 2010 ; Robinson et al., 2018 ), and how substance use features in around half of intimate partners homicides in the United Kingdom ( Home Office, 2016 ). Transforming the Response to Domestic Abuse followed suit, highlighting the ‘complex needs’ of those living with ‘drug and alcohol misuse, offending, mental illness and poverty’ ( HM Government, 2018 : 10); domestic abuse ‘victims’ with ‘problematic drug use’ (p24); ‘survivors… who have children on child protection plans’ (p28); ‘women at risk of having their children removed’ (p28); ‘female offenders’ who have also ‘experienced domestic abuse’ (p31); and male ‘perpetrators’, who are too often depicted in terms of the ‘stereotype’ of a ‘drunk… who… loses control and assaults their partner’ (p11). Such ‘simplistic’ depictions were debunked for failing to ‘reflect… the complex reality and lived experience of victims’ and impervious to the ‘dynamics of power and control which are present in many abusive relationships’ (ibid. pp11 and 12). They had previously been challenged by official drugs policy that committed to supporting the disproportionate number of ‘intimate partner violence’ victims and perpetrators accessing substance misuse services ( HM Government, 2017 ).

This article responds to this call to redress the dynamics of power that occur in relationships where substance use and domestic abuse co-occur. We contribute to such an understanding through the presentation of three couple dyads—each comprising a male perpetrator and his female partner—interviewed in-depth for the UK National Institute for Health Research funded Advancing theory and treatment approaches for males in substance use treatment who perpetrate intimate partner violence (ADVANCE) programme 1 . Our conclusion returns to the challenges the 2019 Domestic Abuse Bill poses to policy, practice and criminological theorizing.

Evidence for the relationship between domestic abuse and drug and alcohol intoxication is plentiful in crime surveys but tends to focus, peculiarly, on the behaviour of victims more often than offenders. For example, the 2016 Crime Survey for England and Wales revealed that ‘adults aged between 16 and 59 who had taken illicit drugs in the last year’ were three times more likely to report ‘being a victim of partner abuse’ than those who had not done so ( ONS, 2016 : 25). However, using illicit drugs does not invite assault and the identification of such ‘risk factors’ in the absence of explanation of their relevance accentuates the victim-blaming some perpetrators deploy to control their victims ( Gadd et al., 2014 ). The international evidence reveals that men, but not women, tend to perpetrate more severe assaults when they have been drinking ( Graham et al., 2011 ; Reno et al., 2010 ). Women are more vulnerable to assault when they too are intoxicated, but this is at least partly because those living with abusers are less diligent at pursuing safety strategies when they have been drinking ( Iverson et al., 2013 ). Substance use features in around half of all UK domestic homicides. Since 2011, substance use has been detected among domestic homicide perpetrators more than four times as often as it has among those killed by them ( Home Office, 2016 )

In sum, the relationship between substance use and domestic abuse is not straightforward. Moreover, Different substances have different pharmacological properties. They are used in variable quantities and combinations fostering a range of effects—including docility as much as aggression—that are contingent upon the user’s experience of them, prehistory of use, mood and the context in which the consumption takes place ( Zinberg, 1984 ; Gilchrist et al., 2019 ). Laboratory research reveals that those with low levels of inhibition, empathy and self-regulation and elevated levels of sensitivity to threats and insults (‘instigative cues’) are more prone to violence when they have consumed alcohol up to four hours ahead of a perceived threat or ‘provocation’ ( Leonard and Quiqley, 2017 ). Cocaine consumption can induce similar reactions. Like cannabinoids and opiates—the effects of which are rarely studied in the context of aggression or violence—cocaine can also alleviate anxiety and exacerbate underlying problems with depression, paranoia and hallucinations ( Sacks et al., 2009 ). Consequently, regular use of such drugs, like the consumption of excessive alcohol, can impinge upon mental well-being and intimacy, generating indirect and belated relationships between victimization and substance use that extend far beyond periods of intoxication.

Feminist scholarship on domestic abuse has tended not to engage with the pharmacological impacts of substance use and has focussed instead on how some abusive men retain power over women by attributing their violence to intoxication, by insisting that their drinking caused them to act out of character, or by denying any memory of assaults perpetrated when intoxicated ( Hearn, 1998 ; MacKay, 1996 ). Evaluations of interventions for perpetrators have thus needed to be alert to the ways in which substance use is invoked to minimize violence. Women’s accounts of victimization have had to take precedence over men’s self-reported offending as measure of changes given the potential for such minimization ( Dobash et al., 1999 ). But as Stark’s (2007) review of officially reported ‘intimate terrorism’ cases illustrates, substance can also be implicated in the perpetration of ‘coercive control’ and victims’ responses to it. His analyses reveal that some victims do self-medicate to manage the depression the daily anticipation of violence engenders and that some perpetrators control victims by increasing their dependence on substances before restricting their access to them. Finally, Stark highlights that some women who have been terrorized over many years take matters into their own hands after the law has failed to protect them, mounting grievous attacks on perpetrators when they are too intoxicated to retaliate.

Typological research on men’s domestic abuse perpetration has also addressed the role of drugs and alcohol anecdotally. For example, Holtzworth-Munroe and Stuart (1994) suggest that there are three distinct types of male domestic abuse perpetrator, one of which—the ‘antisocial batterer’—is defined by their dependence on drugs and alcohol, engagement in crime and paternalistic values. The other two groups, they propose, include ‘family only batterers’ who are seemingly ‘normal’ men who are violent at home and conventional in their sexism; and ‘emotionally dysphoric batterers’ with clinically diagnosable ‘borderline personality disorders’ who tend to be overtly misogynistic, especially when their relationships are failing, or they distrust the fidelity of their partners. Yet, what the relationship is between substance use and violence for the antisocial batterer remains untheorized in Holzworth and colleagues’ tests of their typology ( Holtzworth-Munroe et al., 2000 ). This is despite clinical evidence suggesting that drug use and violence co-occur most among men with diagnosed mental health issues, poor concentration and problems understanding and remembering their pasts ( Sacks et al., 2009 ). In relation to ‘family only’ perpetrators, Johnson et al. (2014 : 65) suggest that this group is more likely to be involved in ‘situational couple’ and ‘separation-instigated’ violence that is more ‘gender-symmetrical’, and derivative of arguments over domestic matters, finances, childcare or ‘objections to the other partner’s excessive drinking’ that evolve into ‘fights’. For this subgroup of ‘family only perpetrators’, the link between alcohol consumption and domestic abuse may have more to do with everyday conflicts than personality traits, though the difference between them and intimate terrorists can be overdrawn ( Gadd and Corr, 2017 ). Sociologically speaking, control ‘is a continuum. Everyone controls their partner to some extent’ ( Johnson, 2008 : 87), begging the question as to when and why the desire to control becomes pertinent.

Answers to this question can be found in the few qualitative studies that explore how drugs and alcohol feature in the relationships of couples living with domestic abuse. These reveal that some perpetrators pose greater risks to their partners, not when they are high, but when they are irritable, withdrawing or are struggling to finance alcohol or drug purchases ( Gilchrist et al., 2019 ). One exemplar is Hydén’s (1994) study of middle-class Swedish couples reported to the police for domestic abuse. Follow-up interviews with 20 couples where alcohol consumption was noted by the police revealed that, although drunkenness and its expense were the source of many arguments that led to violence, social drinking, especially at parties, was also what held some relationships together. Afterwards, some couples reconciled on the basis that it was the alcohol that caused the conflict. They asserted that the perpetrator was normally a ‘good person’ who could be helped. Men who had caused injuries when intoxicated often claimed they could only recall feeling hurt—sometimes in ways that reminded them of painful experiences in their pasts—by female partners who criticized them or acted aggressively towards them and not the assaults they themselves had perpetrated.

Evidence of the relevance of emotional pain can also be found in Motz’s (2014) case analyses of couples in therapy. This reveals how some women who had been abused or neglected as children attempted to cope with feelings of vulnerability ‘through the creation of highly dependent relationships with men who… offer… protection, and through getting into states of mind where these feelings can be pushed away… through drugs or alcohol’ (p69). Motz depicts the emotionally impoverished lives of abusive men with whom some drug-using women cohabit, many of whom feared abandonment because of experiences of abuse, neglect or institutional care. Some of these men had ‘little capacity to tolerate emotional intimacy’ (p93) and thus found it ‘impossible to relate’ to their families or sexual partners unless ‘high on drugs’ (p93). Over time, Motz suggests, these couples became ‘doubly dangerous’, leaving their children uncared for when intoxicated, withdrawing or fighting, and unable to ‘come together safely’ in an emotionally connected way to ‘manage and contain distress’ afterwards (p158). ‘Toxic couples’, Motz argues, deny their own dependencies and instead project them onto each other, leading them to view their partners as more out of control than they are. For some men such projection amounted to ‘a fantasized attempt at creating a state of invulnerability and absolute control’ (ibid) when their own lives are in disarray.

Evidence of this kind of ‘splitting’—where good and bad, safe and dangerous, vulnerable and invulnerable, qualities in the self or other are imagined as irreconcilably polarized—upon which such projective processes rely, can also be found in Gilbert and colleagues’ (2001) focus-group study of women enrolled in North American methadone programmes. Participants described how altercations materialized rapidly when high on crack cocaine or when drunk, as intoxication induced paranoid sexual jealousy that led to hostile accusations by men who became like ‘Jekyll and Hyde’. When withdrawing from heroin, some men attacked their partners for failing to provide money for drugs, some women cited ‘irritability’ as explanations for their own use of violence towards their partners when intoxicated or withdrawing, meanwhile others emphasized that drunkenness intensified their male partners’ criticism of them for failing to fulfill household tasks. Some women described engaging in prostitution to raise money for drugs as evidence of their love and care for male partners. When the women subsequently refused to raise funds in this way or sought support from professionals to reduce their own drug use, some male perpetrators threatened further violence whereas others encouraged them to relapse back onto heroin or crack, thus entrapping stigmatized and socially isolated women in relationships with them.

In what follows, we expand the argument for a more relationally sensitive analysis of the dynamics of power that pertain in the lives of couples where domestic abuse towards a partner occurs alongside substance use. Such analyses, we argue, need to be attuned to the gendered power dynamics of drug use and domestic abuse: dynamics that may be reciprocal even while unequal; financial, emotional and pharmacological; involve violence that is perceived as ‘situational’ by one partner and ‘coercively controlling’ by the other; and recalled as involving movements between intimacy and distance among the exchange of insults and assaults, craving for drink and drugs, intoxication and withdrawal. We seek to illustrate these points by drawing on dyad interviews—with male perpetrators in treatment for substance use problems together with their current and former female partners—undertaken for the ADVANCE programme.

The ADVANCE programme seeks to develop and test an integrated intimate partner violence and substance use group intervention that will reduce intimate partner abuse perpetrated by men receiving substance misuse treatment. We report here on the programme’s preparatory workstream. This involved interviewing male domestic abuse perpetrators receiving treatment for substance use and their current or former partners about their relationships and support needs. Adult men were recruited from six community-based substance use treatment services in London and the West Midlands. The treatment services were for people who regarded themselves as ‘substance dependent’, typically because they regarded their drug and alcohol usage as ‘compulsive’, necessary to deal with problems, taking up a lot of time and energy, costing more than they could legitimately afford, and/or very difficult to stop 2 .

Seventy men were screened for lifetime domestic abuse against a partner. Men who currently had court orders preventing contact with their (ex)partners were excluded. Forty-seven of the 70 men screened were eligible, and 37 of these 47 men were then interviewed. Male interviewees were asked to provide contact details of their current or former female partners, and in 14 cases these women were interviewed. All participants were advised that there were limits to the confidentiality that could be afforded where unaddressed risks of harm and safeguarding issues were disclosed. Women and men were always interviewed by different researchers to ensure no information was inadvertently shared between participants. Participants were paid £20 to compensate for their time.

Interviews were undertaken using reflective techniques derived from the Free Association Narrative Interview Method ( Hollway and Jefferson, 2000 ), with participants being supported through active listening to tell the stories of their drug use, relationships, domestic abuse and intervention experiences. Digital recordings of the interviews were transcribed verbatim and transcriptions were checked twice for errors. Timelines were created to track the sequence of events through the life of each participant. Case studies were then written-up as ‘pen portraits’, which sought to capture the complexity revealed in each interview, including apparent contradictions, avoidances and implausible claims. In the 14 cases where both partners were interviewed, men’s and women’s accounts were compared with each other. Although all of the perpetrators interviewed could have been coded as ‘antisocial’ in Holtzworth-Munroe’s (2000) terms, given their drug use and criminal histories, such categorization would oversimplify matters. All but two of the men depicted their violence as situational and/or a product of some form of mutual combat, whereas all but one of their partners depicted coercively controlling abuse, to which around half the women responded with some degree of violent resistance. In terms of their drug use, the 14 men who were interviewed with their partners appeared to be broadly comparable with the other 23 whose partners were not interviewed ( Table 1 ). The majority used heroin with other illicit substances, notably crack cocaine and/or powder cocaine, though some also mixed benzodiazepines with alcohol. Nine out of the 14 were also heavy drinkers. Five of the 14 men also described medical or psychological diagnosis consistent with emotional dysphoria. Eight males disclosed perpetrating violence that was extra-familial in addition to their abuse of partners. Contact with children had, at some point or other, been restricted for all the men in the study.

Self-reported substance use within the sample

Given the high degree of similarity among the men on key variables, we explored if more meaningful distinctions could be drawn by distinguishing the dyads in terms of whether victims had ever used drugs and, if they had, whether they were desisting from substance use or still using. Only four of the women described themselves as substance dependent at the time of the interviews. Five had never been substance dependent, and another five were desisting from substance use, either having become completely abstinent from using or having only had temporary relapses. A three-fold distinction could thus be drawn across the dyads that revealed some important variations in terms of how domestic abuse and substance use manifested themselves.

Group 1. Victim had never been substance dependent ( n = 5)

Within the sample, there were five couples where the female partner had never been substance dependent, though all the women interviewed drank alcohol socially, and one smoked cannabis occasionally. Women in this group had almost no involvement in crime. Four of these women had never been separated from their children, but one woman had children who had been required to live with their grandfather as she would not leave her abusive partner. These non-substance dependent women were typically confused as to why relationships that had started out well had suddenly deteriorated; why their partners engaged in unexplained and peculiar behaviours; and why they had accused them of unfounded infidelities while lying about their own substance use and/or the criminal activity that generally supported it.

Group 2. Victim was desisting from substance use ( n = 5)

Within the sample, there were five couples where the female partner had abstained from using drugs or alcohol, having previously been substance dependent. None of these women had criminal convictions. The stories these desisting women told tended to be of intimacy lost. Sharing feelings and traumas that motivated drug use, and about what made it difficult to give up, had generated understanding and closeness when they had first met their partners. Conflicts had then developed when the men resumed drug use or drinking whereas the women were trying to reduce their own or abstain. Only two of the women in this group had children of their own. In both cases, these women had raised their own children, but with some intermittent professional oversight.

Group 3. Victim was substance dependent ( n = 4)

Within the sample, there were four couples where both the male perpetrator and the female victim were both currently substance dependent. All the women in this group used crack cocaine and heroin to varying degrees. Though they sometimes mentioned love, they often explained their persistence with relationships that had become abusive in terms of daily needs for protection, somewhere to live and the sharing of drugs. The women in this group had much more frequent and entrenched patterns of criminal involvement than the other 10 in the sample. Their criminal involvement activities included shoplifting, petty frauds and prostitution to finance their drug use, typically with encouragement from male partners who relied, to some extent, upon the income the women generated. All four women in this group had been separated from their children when these children were young, though two women had re-established relationships with their children in adulthood.

In what follows, we present one couple from each of these groups to further illustrate the different power dynamics that can pertain in relationships where domestic abuse and substance use co-occur. Italics are used to highlight points where the participants emphasized a relationship between substance use and domestic abuse.

Wayne (early thirties) and Rhian (late twenties) met while she was managing a pub where he drank, sometimes ‘heavily’, during the ‘daytime’. She had never cohabited with a partner before, but he already had a child with another woman and had served at least six prison sentences, two for ‘kidnap’ of his own child. By Rhian’s account, when they first met three years before, the relationship ‘progressed really quickly’: ‘within a couple of weeks’ Wayne was staying in her flat. By Wayne’s account, he and Rhian visited the grave of his grandfather before spending the night together. After that, Wayne said, he ‘couldn’t get rid’ of Rhian: he ‘loved her to bits’ and their relationship was ‘proper good’ for 18 months until he began to ‘blag’ money from her to buy heroin. Rhian’s account, by contrast, was recollected more as an unfolding nightmare, in which she did not know why Wayne was being so controlling until after their baby was born when he revealed he was getting treatment for heroin dependency.

Rhian recalled that Wayne first assaulted her within a couple of months of moving in. After a drink with friends and not knowing that she was already pregnant, Rhian felt ill and went to bed. When Wayne returned home, he became ‘very argumentative’, ‘coming right’ in her ‘face’, accusing her, without foundation, of sleeping with someone else. Rhian wanted to end the relationship then, but Wayne was profusely apologetic, convincing her to keep the baby and get their ‘own place’, explaining his life was ‘empty’ before they met. Wayne provided a detailed account of the emptiness he felt. His mother, who was separated from his father, had worked nights in a pub, leaving her children ‘home alone’ to run ‘wild’. In her absence, Wayne began smoking ‘weed’ regularly. He had ‘weird thoughts’ and would pick fights with anybody , feeling no ‘remorse’ afterwards. Wayne’s mother sought help but did not receive any. Instead, Wayne became abusive to her, ‘calling her a slag’, threatening to hit her when she took his brother’s side, and constantly ‘smashing her house up’. Invited by his cousin to ‘smoke’ heroin to ‘forget’ his grief’ after his grandmother’s funeral, Wayne claimed his clandestine usage escalated from there, Rhian erroneously assuming he was cheating on her, doing nothing to ‘help’ him come to terms with his loss, and causing him to cheat on her. As a ‘druggie’, Wayne said, he became unable to show Rhian ‘affection’ or ‘love anybody’ , including himself.

Wayne’s accusations of infidelity caused Rhian much distress while his behaviour became more erratic and threatening, ‘his jaw… going and his eyes’ being ‘wired’ . He smashed Rhian’s phone because he was ‘convinced’ that he had ‘seen someone’s name’ on the screen. Though their relationship was ‘over’ during most of her pregnancy, Rhian ‘literally couldn’t go anywhere’ without Wayne constantly ‘phoning’ and ‘texting’ her, questioning her about what money she had spent, and sometimes barricading her in the house until she asked his mother to come and get him. After a nurse overheard Wayne discussing drugs on his phone during one of the few antenatal appointments he attended, Rhian took the opportunity to ask him what it was about because she was concerned that social services would see a child protection risk for her baby. Wayne responded by calling Rhian a ‘sick’ ‘liar’ and insisted that it was she, not drugs, that was ‘driving’ him ‘crazy’ .

Wayne apologized after their son was born and claimed that holding the baby inspired him to ‘change’. He and Rhian then took, what she recalled was, a ‘perfect’ family holiday together in which he explained that he had been prescribed Subutex (buprenorphine), a semi-synthetic opioid used to treat heroin dependence . Wanting her son to be raised by two parents, Rhian agreed to let Wayne move back in, but when his drug use resumed, he became ‘physically aggressive again’ . Rhian recounted three occasions when Wayne throttled her, once asking her to put the baby in another room so the child would not see, and on another occasion putting a knife to Rhian’s throat and rationalizing, ‘You’re killing me… So, I should … make it look like you killed yourself’. Sometimes Wayne would speed off, with their baby in the back of the car, in a hurry to buy drugs. Other times, he locked Rhian in the flat for days because he suspected she was ‘cheating’ and feared she would leave him. The violence only ceased, Rhian said, when Wayne called the police on himself after pinning her down and grabbing her by the neck. Rhian said she was pressurized by the police to make a statement against Wayne, but that the case was withdrawn when he made a fraudulent counter-accusation and a friend of his posted content on Rhian’s Facebook page, as if by her, purportedly confessing. Wayne, by contrast, only recalled one assault explaining they ‘didn’t argue a lot’ partly because his ‘mind wasn’t there’ . He admitted driving off with the baby because he was in a ‘rush’ to get drugs but insisted the argument occurred only on his return when Rhian, who thought ‘she was more powerful than everybody else’, punched him ‘in the chest’ to stop him leaving again. In response, Wayne claimed, he had ‘moved’ Rhian by the ‘face’ because she ‘wouldn’t let’ him leave and was ‘kicking’ his ‘legs’ and because he knew he ‘would have ended up battering’ her as he did not always know what he was doing when ‘on heroin’ . Wayne was thus surprised to later be awoken by ‘two police officers’ who arrested him, but relieved when the courts concluded that Rhian had lied, and pleased that, post the break-up, he had been able to access some support for the mental health problems that had been troubling him since his childhood.

Mitchel (early fifties) and June (mid-forties) were in a relationship for over 15 years. They met while in residential rehabilitation for heroin dependence when they both were ‘emotionally raw’. Mitchel felt the ‘deepest love’ for June when they met. June thought she had ‘met her soulmate’: an ‘affectionate’ man with whom she had much ‘empathy’ given his ‘horrendous’ experiences of ‘child abuse’; a man who helped her overcome the death of her son’s (also heroin-using) father. As a teenager, Mitchel too had found ‘comfort’ in heroin use after he was sexually abused by his brother and his brother’s friends while their mother, was out ‘trying to find somebody to love her’ . As a child, June was repeatedly coerced into having sex by a man who threatened to report her to social services for caring for her siblings while her mother received hospital treatment. June said that as a university student, she lacked the social skills to say ‘no’ when she was introduced to heroin. When she became pregnant, she weaned herself off it but relapsed when her mother accused her of inviting the sexual abuse she was subjected to as a child. Having taken heroin to ‘bury’ the ‘hurt’ this accusation inflicted, June self-referred into drug rehabilitation for two years so she could raise her son in an environment in which her desistance from drugs was effectively managed . From Mitchel’s perspective, problems in their relationship emerged after they left the residential rehabilitation. June, he said, was ‘damaged goods’: ‘although the love was there’ she was ‘frigid’. He pursued sex with a woman called Rose and hoped that ‘the three of’ them ‘could love each other’, introducing both women to crack cocaine to facilitate this. But, according to Mitchel, the ‘resentments grew’, until June became pregnant and began ‘hounding’ him to commit to her, even though she knew he ‘loved’ Rose ‘more’, trapping him, paradoxically, in a sexless relationship by becoming pregnant. Owing money to a crack cocaine dealer, Mitchel said, he and June fled to his mother’s house for a ‘fresh start’, during which they could cease using drugs and get their own place.

June, by contrast, made no mention of a polyamorous relationship and said that she had remained ‘clean’ of drugs for a decade after leaving the rehabilitation centre while Mitchel’s drug use resumed . Thereafter, she said, Mitchel would constantly ‘put’ her ‘down and compare’ her to another woman. She said that while the heroin would ‘subdue’ Mitchel, when drunk he became ‘aggressive and arrogant, looking for a problem’ . This abusiveness heightened during her pregnancy; a time when she felt increasingly ‘isolated’ and ‘insecure’. The ‘fresh start’ she had been promised never materialized though this was partly because she started drinking heavily, blurring the line between his ‘put downs’ and her responses to them . Drinking, June said, helped her tolerate Mitchel’s ‘screaming’, but sometimes he was determined to escalate arguments, once pouring a bucket of water over her while in bed. When Mitchell returned from university, where his relationship with Rose had resumed, June said he ‘was drinking pints of vodka’ as well as using heroin while undertaking odd jobs for cash, and that she would come home from work to find him ‘asleep’ in front of ‘a plate full of heroin and needles’ while the children played unsupervised . June said that when she ‘confronted’ Mitchel, he ‘cleared’ out her bank account, leaving her reliant on money borrowed from her mother to provide food for the family. Feeling ‘depressed’, ‘trapped’ and defeated’, June began using heroin again.

Mitchel made no mention of these incidents but said June had become domineering about domestic matters when he returned from university. ‘ Violence’ became their ‘means’ of ‘communication’ at this time with him threatening to hit her ‘back’ when she ‘lashed out’. June explained that she had once hit Mitchel in retaliation, whacking him ‘with a folder’ when he lent her car to an unqualified driver and the police questioned her about it. Mitchel responded, she said, by ‘kicking’ her ‘from the head up’, breaking her jaw, causing her unforgettable pain. June said she lay on top of her son to protect him when Mitchel went ‘ballistic’ because the boy had failed to clear up the kitchen after making his own lunch. June conceded that she ‘hit’ Mitchel ‘right back’. Mitchel said he regretted hitting June ‘like a man’, clarifying that normally he would ‘just’ hit her back with an ‘open hand slap’, but that on this occasion she ‘came at’ him, creating an ‘explosion’ before having a ‘breakdown’, perplexingly ‘terrified’ of him.

The police attended but arrested neither of them as they had both been drinking . So, June said, she tried to leave for a friend’s house with the children and eyes that were too swollen to open, but Mitchel kicked and beat her again. After a period in hospital, June said June contacted a drugs and alcohol dependency team who put her on a methadone programme, but Mitchel started taking the methadone because he feared he would lose the house and his children if June recovered. June’s version was that she only succeeded in leaving Mitchel after she awoke to find him ‘forcing’ tablets down her ‘throat’, to make it look as if she had killed herself by overdose. Mitchel made no mention of this attempted murder but explained how bitter he was that June secured a court order that prohibited him from seeing the children merely because he had made the ‘ mistake’ of buying a very large ‘bag’ of heroin and despite always having done the hoovering and cooking ‘for them’.

Joe (mid-thirties) and Kate (late twenties) had been together for six years. A week after having met in the streets and gone out for a drink , Kate arrived at Joe’s house with just a suitcase and never left. Kate had been sexually assaulted both as a child and as a teenager and was estranged from her family. Joe, whose parents were both deceased, was sexually abused while in care and was estranged from his siblings. Kate’s children lived exclusively with her previous partner, their father, because of Kate’s alcoholism. Joe had been a heavy drinker since his molestation and had served multiple prison sentences: two for attacking men he had seen ‘touch up’ women without their consent and one for assaulting Kate. All but one of Joe’s many previous relationships had involved violence, some grievous and directed at him, but for which he had often been arrested, leading him to the conclusion that ‘it is really sexist out there’: ‘there’s one rule for blokes and one rule for women’.

Despite being ‘frightened of men’, Kate initially found Joe ‘really nice’. She said he ‘spoilt’ her and did ‘sweet’ things, taking her to restaurants and bringing her flowers. They both emphasized that they had loved each other, though Kate said she struggled to ‘handle’ Joe’s attention and was sometimes ‘mouthy’ and ‘hateful’ towards him when drunk, merely to elicit a different ‘reaction’ . From Joe’s perspective, however, ‘every argument’ was ‘about drugs and money’ . He understood that Kate was using drugs —something she barely disclosed in her interview—‘ to block out the pain’ of her past, but the drug use had affected their sex life , while chronic pancreatitis had left her with ‘only… a few years left to live’. Joe did not like Kate ‘clipping’ —‘robbing’ men she deceived into believing they would have sex with her—to fund their drug use and wanted her to steal from supermarkets instead. He said he worried that Kate would be raped or killed by men she had clipped and that he had lost teeth defending her from men she had tricked. Joe admitted being ‘jealous’ and afraid that Kate was ‘cheating on’ on him, though he knew she was not ‘a slag’ despite ‘acting’ like ‘one’. Joe considered himself to be no longer ‘alcohol reliant’, having given up spirits, but claimed that he became ‘addicted’ to heroin a year ago, trying it to show Kate he could ‘understand’ what it was like for her . Heroin withdrawal had been the real ‘devil’ for Joe, leaving him unable to ‘walk’ at times, ‘depressed’ and vulnerable to a descending ‘red mist’ that he claimed rendered his temper uncontrollable . Joe commenced a Subutex prescription during his most recent prison sentence which, since his release, he had shared with Kate to ‘make sure that she ain’t sick’ (i.e., suffering withdrawal symptoms), sometimes also using heroin or crack cocaine in addition to his prescription.

From Kate’s perspective, however, Joe’s protectiveness could be ‘suffocating’. She explained that although Joe initially ‘understood’ how her childhood experiences of the sexual violence affected her, his capacity for understanding was now contingent on whether she had sex with him. He now treated her like a ‘child’ and ‘as his’ property and feared he ‘could kill’ her in an ‘accidental angry’ moment. When coming down from being high or drunk, Joe was often ‘controlling’ and could ‘switch very easily with anyone’. Kate explained that previously, when Joe had been smoking crack, he assaulted a ‘pervert’ who had touched Kate ‘in an inappropriate way’. After he had finished assaulting the ‘pervert’ Joe proceeded to strangle and batter Kate, breaking some of her ribs. Hence, Kate avoided doing anything ‘sudden’ that would make Joe ‘paranoid’, despite having invited him to ‘just fucking kill’ her rather than keep ‘terrifying’ her. After ‘days’ of ‘not sleeping and just drinking’, Joe tried to provoke an argument . When Kate walked away, he mimed ‘putting bullets’ in her head, so she ‘pushed him away’ and he ‘punched’ her. While Joe was in prison for this assault, Kate twice attempted suicide. She continued to blame herself for his violence and drank alcohol ‘to feel happy’ while questioning whether it was ‘really’ her ‘fault’ that Joe was so ‘messed up’, as he has claimed. Joe, by contrast, claimed Kate had hit him ‘over the head with a hammer’ because he ‘wouldn’t buy her drugs’ and explained that the assault on her, for which he went to prison, occurred after she ‘slapped’ him ‘round the head’ because he did not ‘have… money for drugs’. It was unfortunate, he said, that the police drove past just as he was hitting ‘her back’ in ‘self-defence’. Though Kate said she ‘loves’ Joe ‘to death’ she doubted whether the ‘damage’ to their relationship could be ‘mended’. He , by contrast, was desperate ‘to get her clean’, as he imagined this would enable him to get his own ‘life back’. Joe assumed that if Kate became sober enough to see her children again, it would save his relationship with her from ‘ruin’.

In this article, we have presented three relationship scenarios where domestic abuse pertained alongside drug or alcohol dependency. These relationships diverged primarily in terms of the female partners’ histories of drug and alcohol consumption as all men were in treatment for substance dependence. All three men—like the majority of those interviewed in the ADVANCE project—considered ‘drugs’, their own and/or their partner’s use of them to have damaged or ruined their relationships. Their depictions of violence as ‘isolated incidents’ in which they were only partially culpable were consistent with perpetrators’ accounts more generally ( Stark, 2007 ; Women’s Aid, 2018 ; Gilchrist et al., 2019 ). Wayne, Mitchel and Joe all described discrete, regrettable and unplanned assaults that derived from everyday conflicts over alcohol and drug use, financial pressures, sexual jealousies and domestic chores: conflicts that were sometimes accentuated by being intoxicated. Nevertheless, the stories these men told suggested that their need to control became increasingly acute when their relationships were in crisis, when they had secrets to keep, when they felt dependent on drugs or alcohol, were afraid of losing their minds, their partners and their children, when money was scarce, and when homelessness and criminalization were distinct possibilities. As these men projected this sense of being in disarray onto their partners, the women began to feel like they were being driven crazy, in part because they did not have full knowledge of the drug and alcohol use that was consuming the men’s time and minds. As the women began to question what was happening, the men’s attempts to coercively control became more dangerous and desperate, e.g., in the refusal to let partners leave their homes or in their efforts to tempt or coerce the women into consuming drugs. Despite their unhappiness, these men, like their partners, often lacked the emotional strength and economic resources required to separate ( Walby and Towers, 2018 ). Instead, the men often blamed discrete incidents of violence, as they construed them, on drugs and/or money-related issues that could be fixed if they entered treatment and their partners were prepared to fight for the relationship, for the sake of children whose well-being had not been paramount (to the men) previously.

By contrast, Rhian, June and Kate, described steadily accumulating patterns of abuse, forgiven initially as promises of fresh starts, either in new places or after drug treatment, were made. The women’s reasons for enduring domestic abuse or for giving the men another chance began with this hope for change but often mutated as they encountered the financial and emotional difficulties of leaving homes, the prospect of losing their children (forever in Kate’s case) and the concomitant risk of criminalization when the men threatened to report them for hitting back or for using drugs. Hence, the reasons these women stayed were complexly configured around drug and alcohol use. Wayne’s abusive behaviour had proved confusing to Rhian, who knew only that he was a heavy drinker until his heroin use was confirmed after their baby was born. Then, as someone with little experience of either drugs or relationships, Rhian was persuaded to give Wayne another chance while he sought drug treatment, assuming mistakenly that this would redress his violence. June, by contrast, had some empathy with Mitchel, having relapsed with heroin herself and recognizing that her own drinking contributed to their arguments. June had been persuaded that moving might facilitate a fresh start, without drug use. However, when June sought opioid substitution treatment for herself, Mitchel found a new way of controlling her, diminishing her capacity to leave by controlling her access to her prescription and then trying to administer an overdose. The challenges for Kate were different again. She had a long history of heavy alcohol consumption and illicit drug use, the latter of which Joe had joined in with, compounding their mutual dependence on shoplifting and pseudo-sex work to maintain their supplies. Joe construed his heroin use as an attempt to empathize with Kate, though it appeared that he persisted with drug treatment partly because it legitimized his management of her drug use. Joe hoped he would get his ‘life back’ if he could facilitate a reconciliation between Kate and her children. In the interim, Kate suffered grievous violence, while living in Joe’s home: violence that was construed as part of the protection he afforded her against men she had clipped.

For the women in these relationships, criminal justice intervention was often greeted with trepidation, for it rarely provided the protection it promised. Instead, they had often concluded that it was simpler to suffer difficulties within their relationships, attribute violence to drugs use and attribute drug use to earlier traumas, of which there were many in our participants’ lives. For June and Kate, the pains of child abuse, mental health problems and bereavement were partly responsible for the solace they had sought in alcohol and heroin consumption, as well as in their relationships with men. However, as their drug and alcohol usage became complicated by domestic abuse, a range of different strategies were pursued by each couple, typically to avoid attracting the attention of social services or the police. These strategies included taking prescribed medications to minimize their need to commit crime to fund illicit drug use (Joe), moving away while also severing ties with friends and family (Mitchel, June), switching substances (Mitchel, Joe), pursuing relationships with others who use illicit drugs to avoid feeling ‘trapped’ (Mitchel, Kate), consuming drugs or alcohol to cope with the aftermath of conflict (Wayne, Mitchel and June), engaging in crime together (Joe, Kate) and tacitly encouraging partners to participate in drug use (Mitchel, Joe), compounding the risks faced by women who wished to abstain or keep their use moderate. Although drug and alcohol use could increase sociability and enhance feelings of closeness between partners, the fear of dependency also induced feelings of worthlessness—evidenced most vociferously in Wayne’s belief that he could not love anyone and the paranoid accusations this engendered, but also hinted at in Joe’s jealousy and Mitchel’s infidelity.

These cases reveal how the projective dynamics that impart blame, often through men’s claims that their female partners are ‘driving’ them ‘mad’, are easily facilitated by the nuances of sexism and reinforced by the perennial threat of violence. These dynamics were compounded as drinking and drug use generated financial pressures, which intensified conflicts that left the women, as well as some of the men, feeling that their partners regarded sustaining their substance use as more important than their relationship, avoiding criminalization and social services intervention, and the threats posed by those from whom money and drugs had been borrowed or defrauded.

For time-pressured police officers, social workers and magistrates faced with partial evidence and counterclaims, discerning the ‘truth’ of who had done what to whom in which circumstances would have been particularly difficult. Evidently, some abusive men tell highly convoluted stories to exonerate themselves. But some women who are the primary victims in such relationships do not and cannot always tell the whole truth either, not only because they fear further violence and abuse but also because of the stigma of their own drinking and drug use, the fear of child protection proceedings being instigated and the risk of being incriminated by perpetrators they have hit in self-defence or retaliated against ( Wolf et al., 2003 ; Felson and Paul-Phillipe, 2005 ). What is under-acknowledged in many serious cases of domestic abuse is that both perpetrators and victims often share in the shame associated with being abused as adults and children, of failing to protect their own children, anticipate their partner’s needs, having hit back, gotten drunk or engaged in illicit drug use.

Like many of the men in the ADVANCE programme study, the perpetrators we have depicted here dealt with feelings of trauma and grief from their pasts through drug use and by scaring their partners in ways that the women experienced as acutely controlling. While frequently terrifying, such behaviour was not only instrumental and controlling but also expressive of how painful some aspects of their pasts were and how unwilling they were to concede their dependency on both substances and partners who provided care, funds, a place to live and the support needed to maintain precarious relationships with children. Similar experiences of child abuse, mental health problems and drug dependency were sometimes part of the story of intimacy that held these couples together despite grievous domestic abuse. Then, when the risk of criminalization or estrangement presented, men who were coercively controlling sometimes used such prehistories against their partners by threatening to expose them for raising children in contexts that were unsafe. Hence, the ‘madness’ that the women in these relationships often felt was not simply symptomatic of their own mental health problems but projected onto them by men who had become desperate to impose their own versions of reality.

This imposition of the perpetrator’s reality sometimes became more forceful when the criminal justice system intervened. The risk of ‘legal systems abuse’ occurs when perpetrators adept at coercive control harness the powers of the police or the courts to further intimidate their partners ( Douglas, 2018 ). It has, to some extent, been be amplified by the advent of gender-neutral policy, which recognizes that men can be victims too, alongside incident-focussed approaches to policing that direct attention to what has just happened—such as a man being hit—rather than the history of the relationship—such as a woman being terrified or controlled by the same man over a prolonged period ( Walklate et al., 2018 ). The 2019 Domestic Abuse Bill attempts to counter this risk by prohibiting perpetrators from cross-examining victims in the family courts and providing greater recognition of the impact of the ways in which economic abuse makes it harder for many victims to leave. But compelling alcohol and drug-using perpetrators to receive treatment may introduce unforeseen possibilities for coercive use of the law. Some women will consider themselves too culpable to seek support and will ultimately be let down within a criminal justice process calibrated to identify the perpetrator of assaults at the scene and/or whether they were intoxicated, and hence be easily blindsided by the mutualizing discourses some serial offenders offer in their defence ( Tolmie, 2018 ). Others will stay under the misapprehension that the domestic abuse will cease once treatment for substance use begins. This is an unlikely outcome, though intervention is nonetheless worthwhile. There is tentative evidence to suggest that reducing drinking among perpetrators can diminish resort to violence ( Wilson et al., 2014 ) and that opiate substitution treatment can help alleviate dependence on illicitly purchased drugs and acquisitive crime and improve mental, physical and sexual health among heroin-dependent polydrug users ( Gossop et al., 2000 ; Strang et al., 2010 ; MacArthur et al., 2014 ). But, although treatment interventions can reduce the harms of substance use, where drug and alcohol use and domestic abuse co-occur, treatment needs to be part of a range of measures that include support in changes in thinking and modes of relating, securing the housing and economic resources couples need to be able to contemplate living apart, the support and empowerment of survivors, the safeguarding of children and professional help with mental health problems. These skilled forms of intervention are critical to deescalating the dynamics that sustain substance use in the lives of people enduring the worst forms of domestic abuse but are often in short supply.

By contrast, the evidence that domestic abuse perpetrator programmes—as currently commissioned by the UK government—‘work’ remains mixed ( Vigurs et al., 2017 ). Although the best interventions risk encouraging men who have been physically violent to adopt more emotionally abusive tactics ( Kelly and Westmarland, 2016 ), the UK’s Probation Inspectorate is doubtful as to whether the private Community Rehabilitation Companies currently delivering such interventions provide adequate practice in terms of safeguarding victims and their children ( House of Commons, 2018 ). Both the domestic abuse and substance use treatment sectors in the United Kingdom have suffered sustained funding cuts over the last 10 years ( Women’s Aid, 2016 ; ACMD, 2017 ), often secured through the non-renewal of local procurement contracts via competitive tendering processes that favour cheaper and less specialist provision. One danger with compelling drug or alcohol treatment is that it will place clinicians and health practitioners in the ethically compromising position of having to report those who relapse, together with those whose prescriptions have proved insufficient, or who have decided that they would be better trying to reduce their substance use gradually, to the courts where they may face further criminalization ( Seddon, 2007 ; Werb et al., 2016 ).

More generally, models of treatment for alcohol and drug use that acknowledge that ‘relapse’ is common are hard to reconcile with domestic abuse policy founded on compliance with court orders that insist upon ‘zero tolerance’ of reoffending ( Benitez et al., 2010 ). Criminalizing responses are rarely challenged in domestic abuse policy, where academic research has tended to extol the benefits of naming ‘perpetrators’ as such and victims, though sometimes recognized as ‘survivors’, are usually cast as their opposites. Such an approach runs contrary to academic conventions in substance use research where a concerted effort has been used to avoid stigmatizing terminology that reduces individuals’ identities to their drug consumption ( Broyles et al., 2014 ).

Hence, acknowledgement of complexities in the power dynamics of domestic abuse that co-occurs with drug, alcohol and mental health problems raises acute challenges, not only for the delivery of policy that attempts to reconcile safety, justice and rehabilitation but also for academics who have framed the problem of domestic abuse primarily as one of either gender or psychology. Not only do criminologists need to reconceptualize domestic abuse more dynamically but they must also ask why some men choose to secure control in coercive ways when so many other aspects of their lives appear out of control. There is a need to recognize how the interdependencies—including the prospect of economic abuse—involved in intimate relationships are intensified by poverty, stigma, co-dependency, child abuse and neglect, poor mental health and the fear of police and social services intervention. In theory and in practice, we must ensure that shorthand explanations derivative of personality disorders do not obscure what can be learnt from the more complex descriptions both survivors and perpetrators can offer of their relationships. Policymakers need also to ensure that evaluations of treatment options for substance-using perpetrators extend beyond the longstanding fixation with acquisitive crime to include measures that take stock of their impact on children and partners, whether current and former, and to recognize that establishing effective practice will require the reestablishment of expertize and service provision that is increasingly scarce.

Advisory Council on the Misuse of Drugs (ACMD) . ( 2017 ), Commissioning Impact on Drug Treatment , available online at https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/642811/Final_Commissioning_report_5.15_6th_Sept.pdf

Benitez , B. T. , McNiel , D. E. and Binder , R. L . ( 2010 ), ‘Do Protection Orders Protect?’ , Journal of the American Academy of Psychiatry and the Law , 38 : 376 – 85 .

Google Scholar

Brandon , M. , Bailey , S. and Belderson , P. , ( 2010 ), Building on the Learning From Serious Case Reviews . Dept of Education , available online at https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/181651/DFE-RR040.pdf

Broyles , L. M. , Binswanger , I. , Jenkins , J. , Finnell , D. , Faseru , B. , Cavaiola , A. , Pugatch , M. and Gordon , A . ( 2014 ), ‘Confronting Inadvertent Stigma and Pejorative Language in Addiction Scholarship’ , Substance Abuse , 35 217 – 21 .

Dobash , R. E. , Dobash , R. , Cavanagh , K. and Lewis , R . ( 1999 ), Changing Violent Men . Sage .

Google Preview

Douglas , H . ( 2018 ), ‘Legal Systems Abuse and Coercive Control’ , Criminology and Criminal Justice , 18 : 84 – 99 .

Elgot , J . ( 2018 ), ‘MPs Back Campaign to Strengthen Domestic Abuse Bill’, The Guardian , 23/05/18, available online at https://www.theguardian.com/society/2018/may/23/mps-back-campaign-to-strengthen-domestic-abuse-bill

Felson , R. B. and Paul‐Philippe , P . ( 2005 ), ‘The Reporting of Domestic Violence and Sexual Assault by Nonstrangers to the Police’ , Journal of Marriage and Family , 67 : 597 – 610 .

Gadd , D . ( 2012 ), ‘Domestic Abuse Prevention After Raoul Moat’ , Critical Social Policy , 32 : 495 – 516 .

Gadd , D. and Corr , M.-L . ( 2017 ), ‘Beyond Typologies: Foregrounding Meaning and Motive in Domestic Violence Perpetration’ , Deviant Behavior , 38 : 781 – 91 .

Gadd , D. , Corr , M.-L. , Fox , C. L. and Butler , I . ( 2014 ), ‘This is Abuse… or is it? Domestic Abuse Perpetrators’ Responses to Anti-Domestic Violence Publicity’ , Crime, Media, Culture , 10 : 3 – 22 .

Gilbert , L. , El-Bassel , N. , Rajah , V. , Foleno , A. and Frye , V . ( 2001 ), ‘Linking Drug-Related Activities with Experiences of Partner Violence’ Violence Survivors , 16 : 517 – 36 .

Gilchrist , G. , Dennis , F. , Radcliffe , P. , Henderson , J. , Howard , L. and Gadd , D . ( 2019 ), ‘The Interplay Between Substance Use and Intimate Partner Violence Perpetration: A Meta-Ethnography’ , International Journal of Drug Policy , 65 : 8 – 23 .

Gossop , M. , Marsden , J. , Stewart , D. and Rolfe , A . ( 2000 ), ‘Patterns of Improvement After Methadone Treatment’ , Drug and Alcohol Dependence , 60 : 275 – 86 .

Graham , K. , Bernards , S. , Wilsnack , S. and Gmel , G . ( 2011 ), ‘Alcohol May Not Cause Partner Violence But It Seems to Make It Worse’ , Journal of Interpersonal Violence , 26 : 1503 – 23

Hearn , J . ( 1998 ), The Violences of Men . Sage .

Heidensohn , F . ( 1995 ), ‘Feminist Perspectives and Their Impact on Criminology and Criminal Justice in Britain’, in N. Rafter and F. Heidensohn , eds., International Feminist Perspectives , 63 – 85 . Open University Press .

HM Government . ( 2017 ), 2017 Drug Strategy , available online at https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/628148/Drug_strategy_2017.PDF

———. ( 2018 ), Transforming the Response to Domestic Abuse , available online at https://consult.justice.gov.uk/homeoffice-moj/domestic-abuse-consultation/supporting_documents/Transforming%20the%20response%20to%20domestic%20abuse.pdf

———. ( 2019 ), Transforming the Response to Domestic Abuse: Consultation and Draft Bill , available online at https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/772202/CCS1218158068-Web_Accessible.pdf

Hollway , W. and Jefferson , T . ( 2000 ), Doing Qualitative Research Differently . Sage .

Holtzworth-Munroe , A. , Meehan , J. C. , Herron , K. , Rehman , U. and Stuart , G. L . ( 2000 ), ‘Testing the Holtzworth-Munroe and Stuart (1994) Batterer Typology’ , Journal of Consulting and Clinical Psychology , 68 : 1000 – 19 .

Holtzworth-Munroe , A. and Stuart , G . ( 1994 ), ‘Typologies of Male Batterers’ , Psychological Bulletin , 16 : 476 – 97 .

Home Office . ( 2015 ), Controlling or Coercive Behaviour in an Intimate or Family Relationship Statutory Guidance Framework , available online at https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/482528/Controlling_or_coercive_behaviour_-_statutory_guidance.pdf

———. ( 2016 ), Domestic Homicide Reviews , available online at https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/575232/HO-Domestic-Homicide-Review-Analysis-161206.pdf

House of Commons Home Affairs Committee . ( 2018 ), Domestic Abuse Ninth Report of Session 2017–19 , available online at https://publications.parliament.uk/pa/cm201719/cmselect/cmhaff/1015/1015.pdf

Hydén , M . ( 1994 ), Woman Battering as Marital Act . Scandinavian University Press .

Iverson , K. M. , Litwack , S. D. , Pineles , S. L. , Suvak , M. K. , Vaughn , R. A. and Resick , P. A . ( 2013 ), ‘Predictors of Intimate Partner Violence Revictimization’ , Journal of Traumatic Stress , 26 : 102 – 10 .

Johnson , M . ( 2008 ), A Typology of Intimate Partner Violence . New University Press .

Johnson , M. , Leone , J. and Xu , Y . ( 2014 ), ‘Intimate Terrorism and Situational Couple Violence in General Surveys’ , Violence Against Women , 20 : 186 – 207 .

Kelly , L. and Westmarland , N . ( 2016 ), ‘Naming and Defining ‘Domestic Violence’’ , Feminist Review , 112 : 113 – 27 .

Leonard , K. E. and Quiqley , B. M . ( 2017 ), ‘Thirty Years of Research Show Alcohol to be a Cause of Intimate Partner Violence’ , Drug and Alcohol Review , 36 : 7 – 9 .

MacArthur , G. J. , van Velzen , E. , Palmateer , N. , Kimber , J. , Pharris , A. , Hope , V. , Taylor , A. , Roy , K. , Aspinall , E. , Goldberg , D. , Rhodesm , T. , Hedrich , D. , Salminen , M. , Hickman , M. and Hutchinson , S. J . ( 2014 ), ‘Interventions to prevent HIV and Hepatitis C in people who inject drugs’ , International Journal of Drug Policy , 25 : 34 – 52 .

MacKay , F . ( 1996 ), ‘The Zero Tolerance Campaign: Setting the Agenda’ , Parliamentary Affairs , 49 : 206 – 20 .

Moore , A . ( 2018 ), ‘‘‘I Miss Him so Much’’ Why did a Devoted Why Kill the Man She Loved?’ , The Guardian , 29/08/18 , available online at https://www.theguardian.com/uk-news/2018/sep/29/devoted-wife-who-killed-husband-with-hammer-sally-challen

Motz , A . ( 2014 ), Toxic Couples . Routledge .

ONS . ( 2016 ), Compendium: Intimate Personal Violence And Partner Abuse . Office for National Statistics , available online at https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/compendium/focusonviolentcrimeandsexualoffences/yearendingmarch2015/chapter4intimatepersonalviolenceandpartnerabuse/pdf

Reno , J. , Marcus , D. , Leary , M.-L. and Samuels , J. E . ( 2010 ), Full Report of the Prevalence, Incidence, and Consequences of Violence Against Women . Department of Justice , available online at https://www.ncjrs.gov/pdffiles1/nij/183781.pdf

Robinson , A. , Rees , A. and Dehaghani , R . ( 2018 ), Findings From a Thematic Analysis of Reviews into Adult Deaths in Wales . Cardiff University .

Sacks , S. , Cleland , C. , Melnick , G. , Flynn , P. , Knight , K. , Friedmann , P. , Prendergast , M. and Coen , C . ( 2009 ), ‘Violent Offenses Associated with Co-Occurring Substance Use and Mental Health Problems’ , Behavioral Science and the Law , 27 : 51 – 69 .

Seddon , T . ( 2007 ), ‘Coerced Drug Treatment in the Criminal Justice System’ , Criminology and Criminal Justice , 7 : 269 – 86 .

Stark , E . ( 2007 ), Coercive Control: How Men Entrap Women in Personal Life . Oxford University Press .

Strang , J. , Metrebian , N. , Lintzeris , N. , Potts , L. , Carnwath , T. , et al.  ( 2010 ), ‘Supervised Injectable Heroin or Injectable Methadone Versus Optimised Oral Methadone as Treatment for Chronic Heroin Addicts in England After Persistent Failure in Orthodox Treatment (RIOTT): A Randomised Trial’ , The Lancet , 375 : 1885 – 95 .

Tolmie , J . ( 2018 ), ‘Coercive Control: To Criminalize or Not to Criminalize?’ , Criminology and Criminal Justice , 18 : 50 – 66 .

Vigurs , C. , Schucan Bird , K. , Quy , K. and Gough , D . ( 2017 ), The Impact of Domestic Violence Perpetrator Programmes on Victim and Criminal Justice Outcomes . College of Policing , available online at http://whatworks.college.police.uk/Research/Systematic_Review_Series/Pages/DA_perp_prog.aspx

Walby , S. and Towers , J . ( 2018 ), ‘Untangling the Concept of Coercive Control’ , Criminology and Criminal Justice , 18 : 7 – 28 .

Walklate , S. , Fitz-Gibbon , K. and McCulloch , J . ( 2018 ), ‘Is More Law the Answer?’ , Criminology and Criminal Justice , 18 : 115 – 31 .

Werb , D. , Kamarulzaman , A. , Meacham , M. C. , Rafful , C. , Fischer , B. , Strathdee , S. A. and Wood , E . ( 2016 ), ‘The Effectiveness of Compulsory Drug Treatment: A Systematic Review’ , International Journal of Drug Policy , 28 : 1 – 9 .

Wilson , I. , Graham , K. and Taft , A . ( 2014 ), ‘Alcohol Interventions, Alcohol Policy and Intimate Partner Violence: A Systematic Review’ , BMC Public Health , 14 : 1 – 11 .

Wolf , M. E. , Ly , U. Hobart , M. A. and Kernic , M. A . ( 2003 ), ‘Barriers to Seeking Police Help for Intimate Partner Violence’ , Journal of Family Violence , 18 : 121 – 29 .

Women’s Aid . ( 2016 ), Why We Need to Save Our Services . WAFE .

———. ( 2018 ), The Femicide Census: 2017 Findings . WAFE .

Zinberg , N . ( 1984 ), Drug, Set, and Setting . Yale University Press .

See https://www.kcl.ac.uk/ioppn/depts/addictions/research/drugs/ADVANCE.aspx

See https://www.slam.nhs.uk/patients-and-carers/health-information/addiction/drug-addiction

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• Public Health England

Parents with alcohol and drug problems: using case studies to estimate the cost-benefit of interventions

Published 10 May 2021

Applies to England

© Crown copyright 2021

This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open-government-licence/version/3 or write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: [email protected] .

Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned.

This publication is available at https://www.gov.uk/government/publications/parents-with-alcohol-and-drug-problems-support-resources/parents-with-alcohol-and-drug-problems-using-case-studies-to-estimate-the-cost-benefit-of-interventions

1. Introduction

This guidance supports local areas, organisations and providers that have collected, or intend to collect, case studies to estimate how much social and economic cost they can avoid by supporting families experiencing alcohol and drug problems.

It also shows you how to use Public Health England’s ( PHE ) Parents with alcohol and drug problems: Investing in families workbook .

The Excel workbook is made up of 3 parts:

• the social cost-benefit tool which contains a template you can use to estimate the costs in your case study and 4 worked examples
• the unit cost database contains the direct, indirect and intangible costs for each cost theme in 2020 to 2021 prices
• annexes contain HM Treasury’s gross domestic product ( GDP ) deflator, HM Treasury’s discount factors and market forces for reference

This guidance presents a worked-through example of a case study to estimate the cost-benefit of supporting families experiencing problem parental alcohol and drug use.

2. Using case studies

Case studies are a type of descriptive qualitative research typically used to gather information about an individual or a small group of people (like a family) receiving an intervention. You can then use this information to draw conclusions about the effect of the intervention in that specific context.

Using a case study approach can help you understand how and why different events and interventions might affect a family. This can provide a powerful story that can help when making a case for continuing to provide services. Compared with full-scale evaluations, case studies can be a more achievable, less resource-intensive way for commissioners and providers to show the effects of an intervention.

It is important to remember when you use case studies that the estimated costs represent potential benefits specific to that family and not the average benefits of the intervention. To estimate the latter, you would need to collect data on every family receiving the intervention.

3. Collecting case studies

When exploring the effects of an intervention, it is important to understand family dynamics and experiences before, during and after the intervention. This helps you to understand how things have changed for the family.

There are many ways to collate this type of data in a case study, and you might have your own preferred way to do so. You can download a case study template to use as an example or fill in with your own information.

Evidence of an intervention’s effects is stronger when the information comes from a variety of sources, such as an adult alcohol and drug worker, a schoolteacher and a child social worker. The family’s own experiences are an important component but should be validated using other sources.

4. Types of cost

There are 3 types of costs in the unit cost database:

• direct costs which are estimated monetary costs that directly relate to providing treatment and support – for example, costs to the local authority, NHS or criminal justice system
• indirect costs which are generally related to productivity losses from people being ill or dying prematurely
• intangible costs which represent disease burden, meaning the effect a condition has on someone’s quality of life and how long they will live – this is quantified as quality-adjusted life years ( QALYs ) and valued at £60,000 per QALY

Economic evaluations typically include wider indirect and intangible costs. Where available, we have also presented these so you can use them to estimate wider social and economic costs.

You can find more information on how to appraise and evaluate policies, projects and programmes in HM Treasury’s Green Book .

All costs have been inflated using HM Treasury’s latest gross domestic product ( GDP ) deflator and will be updated annually. Costs are rounded to emphasise that they are estimates.

The database presents most costs as annual costs. It also presents lifetime costs where these exist, along with methodological explanations such as how many years make up the ‘lifetime’. We have included references for the sources of all costs with links to the publication and an explanation of calculations and limitations.

Table 1. Examples of cost breakdown

5. example case study.

Below is a real case study, although the name has been changed. A drug and alcohol treatment provider collected the information to show how effective their service is. It tells the story of a vulnerable woman with a long history of substance misuse who seeks treatment when she discovers she is pregnant.

We will use the case study as an example of how you can use the unit cost database to estimate costs that could be avoided in the future.

Case study: Sarah

Sarah sought support to overcome her 20-year history of alcohol and cannabis use when she was 2 weeks pregnant. As well as a long history of using drugs and alcohol and a physical dependence on alcohol, Sarah had additional support needs related to depression, anxiety and childhood trauma. Sarah lived in unsuitable accommodation and was at risk of homelessness.

She received regular one-to-one psychosocial support from a family worker before entering a residential service for detox and rehabilitation. She and the father of her baby also received joint support to address interparental conflict.

Sarah gave birth at the beginning of May 2020. She is abstinent from all substances and both Sarah and her baby are doing well. Sarah and the father of her baby are no longer in a romantic relationship but are regularly communicating. She registered as homeless with a plan to move into appropriate accommodation, which will support her recovery.

Step 1: Open the social cost-benefit tool and select appropriate cost themes

Table 2 shows the different cost themes and explains when it might be appropriate to consider including certain activities, behaviours and events in a case study.

When using a case study to estimate social cost-benefit, we advise you to note the number of children or adults affected for each relevant cost theme.

Table 2: Cost themes

Of course, the above list is not exhaustive. If there are other known costs that would be helpful to include that are not mentioned above, please let us know via PHE ’s parental alcohol and drug use group (login needed).

The database is an iterative product which we will update and improved as new evidence comes to light.

The information from table 2 has been integrated into the social cost-benefit tool. Figure 1 is a screenshot from a worked example included in the tool. It shows how hovering above a cost theme displays a note explaining when the cost might be appropriate to consider.

Figure 1. Cost theme checklist from the social cost-benefit tool

The cost theme list is split into social benefits and costs. Social benefits are the positive outcomes that are measured following an intervention (for example a child no longer being on a child protection plan). Costs refer to the cost of treatment and any ongoing support from early help or social care.

The cost themes included in Sarah’s case study are:

• child protection plan
• perinatal depression and anxiety
• no risk of foetal alcohol spectrum disorder ( FASD )
• homelessness
• specialist treatment (community and residential)

Perinatal depression and anxiety: by addressing Sarah’s mental health issues now, it is likely that the lifetime costs will be greatly reduced, if not avoided altogether. However, as the amount of cost avoided is not clear, we will not include the costs avoided by managing her mental health. It is reasonable to assume that the costs associated with Sarah’s child resulting from her perinatal depression and anxiety could be avoided if Sarah’s recovery is sustained and her mental health issues are managed.

No risk of FASD : continued problematic drinking during pregnancy would have put Sarah’s baby at risk of FASD , which could result in growth impairments, developmental delays, intellectual disability and conduct disorders. All of these are associated with substantial costs to society.

Figure 2 shows a screenshot from the worked example of Sarah’s case study in the social cost-benefit tool. In this example, we found the cost themes relating to Sarah and her baby and placed a ‘1’ in the relevant yellow cells under ‘No. of children’ and ‘No. of adults’. The table then automatically populated with the relevant costs, using the latest prices contained in the unit cost database.

Figure 2. Adding number of people in case study affected

You can overwrite costs in this table to input your own costs. Figure 3 shows another screenshot from the worked example of Sarah’s case study in the social cost-benefit tool. Here cost cells with a red triangle in the top right-hand corner contain information about the cost, which is displayed by hovering above the cell.

Figure 3. Cost information

Step 2: Avoiding double counting

Avoiding double counting is the most important step of the process. The local authority costs above are all mutually exclusive as they relate to distinct costs of:

• the child protection plan
• residential care and special education associated with FASD
• housing services associated with moving from homelessness to stable accommodation
• treatment for alcohol dependency

However, not all benefits under each cost theme are mutually exclusive. For example, in Sarah’s case study, for NHS benefits, it is not clear whether any of the NHS costs for perinatal anxiety and depression are also included in the NHS costs associated with FASD and homelessness. There could be considerable overlap.

To avoid the social cost-benefit being over-estimated by double counting, you can select ‘No’ from the drop-down box when asked to state whether the categories under each cost theme are mutually exclusive. There is an example of this in figure 4, which is a screenshot from the social cost-benefit tool. The results will automatically update and present a range for these categories.

Figure 4. Selecting whether costs are mutually exclusive or not

Step 3: See your results

Once you have entered the number of people each cost theme relates to and you have decided which agency costs are mutually exclusive, you can read the summary of results table. Figure 5 is a screenshot from the social cost-benefit tool which shows the summary of results table for Sarah’s case study. The social benefits presented are those estimated to occur a year following treatment intervention.

Figure 5. Summary table

Remember, the above costs avoided are benefits associated with Sarah and her family specifically. It is unclear whether other people receiving the same intervention would see the same benefits. Also, while this calculation includes the cost of community and residential alcohol treatment it does not include any extra support Sarah may have received, for example from a midwife. You could include additional costs for a more accurate estimate. You could also include lifetime costs, which are available in the database, to make your estimate more accurate.

6. Additional considerations

6.1 including a cost that is not included in the unit cost database.

You can add costs that are not currently in the database if you know the cost value. If you do not know the cost value, you could either try to source the cost value from local partners or contact us via PHE ’s parental alcohol and drug use group (login needed) for help.

6.2 Accounting for geographical differences in labour and rent costs

The Excel workbook presents national averages for labour and rent costs. Annex 3 in the Excel workbook includes a market forces factor ( MFF ) for every upper-tier local authority. The NHS and the Department of Health and Social Care use the MFF to fairly allocate resources. You can use this to adjust national costs to local costs by multiplying the unit cost by the MFF for your local authority.

Alternatively, local partners may hold more accurate information on costs in your local authority.

6.3 The validity of using case studies to estimate social benefit

As with other research methodologies, issues of validity and reliability need to be carefully considered. As mentioned earlier in this guidance, it is important to remember that:

• estimated costs represent potential benefits specific to the case-study family, not the average benefits we can attribute to the intervention
• case studies are more robust if the information comes from a variety of corroborative sources
• you should take care to not double count benefits
• you should consider attribution where possible (see section 6.4 below)

6.4 Capturing input from other services

Attribution is an assessment of how much of an outcome is due to the contribution of other organisations. For example, specialist treatment for parents alone is rarely enough to address a family’s complex needs. Treatment providers, children and families services and other local support services all work together to help families recover. It will never be possible to get a completely accurate assessment of attribution, but it is important to note that an activity from a specific service may not be the only factor contributing to changes seen in a family.

6.5 Potential benefits might be less than the money invested

You must ensure that you include all the benefits of the interventions used in your case study, where possible.

If you have done this and you still find that costs outweigh benefits, then it is possible that this intervention will not represent value for money for that particular case study. It is important to remember that some interventions do not result in immediate benefits but can provide significant social benefit in years to come.

It is also possible that the result reflects data and evidence constraints. This is a significant limitation of using individual case studies as opposed to using wider and more detailed data on all families receiving interventions.

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• v.2022; 2022

A Case Study Using a Behavioural Contract in Alcohol Dependence within a Crisis Home Treatment Team

Andrew john howe.

South London and Maudsley NHS Foundation Trust, UK

Cholan Anandarajah

Associated data.

This paper is a case study and has no underlying data.

In this case study, we present a novel approach to care within a Home Treatment Team, using a behavioural contract. This is a signed, written agreement that targets specific behaviours for change. The concept draws on social learning theory in that it requires social interaction and a relationship to work. In psychiatric settings, the behavioural contract often finds use in Democratic Therapeutic Communities but rarely in crisis or acute services. In this case study, we attempted to use a behavioural contract within our Home Treatment Team to help a patient address his alcohol dependence and its subsequent effect on his daily living activities. The behavioural contract provided an alternative way to manage a crisis episode. We hope that other crisis service staff reading this case study may use a behavioural contract in their work to a similar beneficial effect.

1. Introduction

Crisis Home Treatment Teams were created in the 1980s but did not find their way into National Health Service (NHS) policy until 2000 [ 1 ]. They aim to reduce the number and duration of inpatient psychiatric admission and allow services to manage individuals in crisis better. As their name suggests, they do not engage in long term work but attempt to resolve and support patients through a crisis with an expected short duration of treatment. Home Treatment Teams (HTT) are cheaper than inpatient admissions and often have higher patient satisfaction ratings (Ibid.). The HTT in this case study covers a large borough of South London that has a diverse population. It treats between thirty to fifty patients between ages 18-65 at any one time with many different psychiatric diagnoses. Team members are from multiple health care professional backgrounds, including psychiatrists, mental health nurses, occupational therapists, social workers, drug and alcohol specialists, and psychologists. The HTT also signposts to relevant welfare and housing services as these are often critical precipitants to crises.

In this case study, we present a novel approach to care within a HTT, using a behavioural contract. This is a signed, written agreement that targets specific behaviours for change. The concept draws on social learning theory in that it requires social interaction and a relationship to work ([ 2 ], Chapter 6). Traditional contracts require that every statement within a contract is objectively verified and that there is an element of reward for success. Behavioural contracts have found use in multiple settings historically, including smoking cessation, hypertension control, lower serum cholesterol, appointment keeping, and adherence with brain and spine injury rehabilitation [ 3 – 6 ]. In psychiatric settings, the behavioural contract finds use in Democratic Therapeutic Communities (DTC) [ 2 ]. Here, the community and wish to belong are the underpinnings of the behavioural change in relation to contracts. Within DTC culture, choice-based contracts instead of coercion-based ones encourage responsible agency. Haigh and Pearce suggest that written contracts must contain phrases such as “I undertake to do x/not to do y” (Ibid, p211). If the contract includes a positive injunction, i.e., to do x, the contract must specify the frequency and circumstances. The person to whom the contract applies often proposes it. Within the DTC, all members, including staff and patients, will then consider and vote on the contract. If it is agreed on, then the community will hold the person on the contract to account.

Due to these factors above, behavioural contracts are less likely to be found in acute or crisis services. One can surmise that this is due to the lack of long-term relationships with healthcare professionals over time or the ability to foster a feeling of belonging. The HTT is relatively unique within acute services, be they for physical or mental health, in that treatment is intense, allowing relationships to be built up, and takes place in patients' home environments. Psychologically, one has the feeling of being taken on by a team that can help people in crisis. Given they operate on a consent to treatment basis, it is a team by which patients agree to treatment. This wish to be treated and get out of a crisis period relates to belonging to the team. The loss of the team in this context would therefore be something that patients would wish to avoid. In the following case, we attempted to use a behavioural contract within our HTT to help a patient address his alcohol dependence and its subsequent effect on his daily living activities.

2. Case Vignette

The following vignette details are anonymised and changed where not essential to the history to mask identity. The patient discussed has given his consent for the case to be shared in this anonymised format.

Mr. Y is a 58-year-old man who became known to the secondary mental health services following a presentation of low mood and suicidal thoughts in the context of difficulties dealing with his deceased partner's financial affairs with her family members.

Mr. Y was born in the UK with no complications and had no delays reaching his developmental milestones. He grew up with his parents and three siblings with no significant issues during his childhood. Mr. Y struggled academically at school but still achieved a few qualifications. After school, he completed a vocational qualification and worked in his chosen industry for twenty years before changing his profession due to needing to look after his father.

Mr. Y had been in a relationship for 16 years before his partner passed away, six months before his presentation to our team. Following a period of bereavement, Mr. Y initially returned to work. However, he started to have difficulties when they began to deal with his partner's will. As a result, Mr. Y started to become worried about being made to leave the house.

He received a letter from his partner's sister that she was unhappy with him living in the house and using her personal items, which triggered his low mood and subsequent suicidal thoughts. He went on sick leave but started to think about taking an overdose, jumping in front of a train or crashing his car at high speed. Mr. Y contacted his General Practitioner (GP) expressing thoughts of walking in front of a bus and was referred to accident and emergency. Initially, he was discharged back home with advice about counselling services and online cognitive behavioural therapy (CBT).

Mr. Y returned to A&E the following day with ongoing suicidal thoughts and had stopped eating. He reported that he had been consuming four-five cans of beer daily for the previous two weeks. He declined to work with HTT and was placed on the waiting list for informal admission. As a bed was still not available the following day, he was reassessed and he reported sleeping well overnight, and the suicidal thoughts were becoming less intense. As such, the least restrictive option of HTT was rediscussed, and he agreed on this occasion.

The following day, Mr. Y was assessed and accepted for HTT and then medically reviewed the day after and commenced on Mirtazapine. On this occasion, he reported consuming three cans of lager per night, but not on days when he had to work the following day.

He was initially seen daily by various members of HTT, and Mr. Y continued to express fleeting suicidal thoughts. This included seeing members of the psychology team where there were discussions about coping strategies and distraction techniques. He highlighted two goals for the future as getting back to work in the next one-two weeks and tolerating the uncertainty around the probate, which he was aware could take around two years in total.

Mr. Y's presentation worsened as he started to consume more alcohol. He would meet staff intoxicated, show clear signs of self-neglect, and at one point was noted to have injuries to his face from a fall. He was admitted informally to a psychiatric hospital to manage his risk and provide an inpatient alcohol detox. After this short admission, he was discharged back to HTT care. However, he relapsed shortly after discharge and became a dependent user of alcohol again. Given the increase in risk, this caused another admission to a psychiatric hospital to be considered, but we recognised that there was little overall benefit from this intervention previously, and the problem of alcohol use upon discharge would remain. While Mr. Y had contacted local drug and alcohol services, the contact was erratic, and options such as alcohol detox were not available. Transfer to a Community Mental Health Team (CMHT) at that particular time was also unlikely to address his problems. In terms of what a crisis service could offer, we had few options.

3. The Behavioural Contract

Given that Mr. Y had been with us for two months already, he was well known to the team members. We felt he wanted to work with us and wanted things to change, but lacked the structure and support. We came to the idea of using a behavioural contract to help Mr. Y reduce his alcohol intake at a rate that was considered safe based on approved guidelines, attend local alcohol services, and attend to his activities of daily living. We drafted a contract that we introduced to Mr. Y, who suggested removing attendance to Alcoholics Anonymous services as he did not wish to use these groups, but agreed to attend other alcohol services. We considered that alternate day contact would be an essential part of the contract as it would help foster a sense of autonomy. The contract (see Box 1 ) was then instigated with mutual agreement between the team and Mr. Y. We noted that for two weeks, Mr. Y was able to reduce his alcohol intake as per the contract and attend his local alcohol service for further support. He was no longer presenting to the team intoxicated and started to report on the various activities and goals he had achieved between visits. His living environment slowly improved to reflect this change in alcohol use and engagement with services. At the end of the two week contract period, Mr. Y was safe to be discharged back to the care of a CMHT and attend local alcohol services. He reported the contract to be beneficial and stated that he would recommend it to others to motivate change.

Behavioural contract.

Box 1 Behavioural contract.

4. Discussion

While the behavioural contract is not a novel creation, we believe its use at a time of crisis and within a crisis service is. Our case illustrates that HTT can develop significant relational attachments to their patients that they can then use to foster change. This contrasts with the common feedback we receive from patient evaluation forms that they see many different staff and do not form therapeutic relationships. While it is true that staff members do change, patients will see the team daily initially, and we inform them that they can call HTT if needed in working hours. Furthermore, we have handovers with the whole team daily where we discuss every patient, so all patients on our caseload are held in mind by the team.

One part of our contract that is different from the usual behavioural contract noted above is that we did not objectively observe Mr. Y's alcohol intake. Practically, this would have been impossible for a team that visits for around thirty minutes at a time. We did not monitor his contact with drug and alcohol services either, choosing to trust Mr. Y's account instead. Besides the practical limitations, we felt this was an appropriate course of action as it made it clear that we were operating from a mutual place of trust. While paternalistic approaches have their place, we supposed that our approach further fostered Mr. Y's autonomy in addressing his drinking. We hoped that this would promote a longer-lasting change in Mr. Y's life. This approach is in line with the use of behavioural contracts in some democratic therapeutic communities. We feel that the presumption of trust between Mr. Y and our team was also significant in the contract's success. There were some concerns from people in other teams that this may be a wasted exercise since we were not paternalistically checking his adherence via other sources. We consider the position of mutual trust can foster autonomy beyond the short time that we used the contract. The results suggest that Mr. Y did not mislead us in his reports about engagement with other services. His presentation also supports his adherence to the contract. When it comes to patient trust, one is reminded of statements around mental capacity that one must assume capacity unless there is evidence to the contrary.

We are working in a time of unprecedented demands on psychiatric services. In our Trust, there is constant pressure on inpatient beds and acute services as a whole. HTT are one solution to the inpatient bed problem, but at times, there is little practical work that can be done, and some patients can become stuck in a crisis episode. If we had not used the contract, then Mr. Y would have been a risky discharge in the context of not being able to meaningfully help him any further or he would have been admitted to a hospital bed. The behavioural contract provided an alternative way to manage a crisis episode. However, we recognise that it would be unreasonable to generalise their usability to every patient. In the case of Mr. Y, we knew him well as a team, and we had many weeks to build up a therapeutic relationship. This is not the case for many patients with HTT, where contact can be more sporadic, or patients do not want to engage with staff deeper than medication provision. Mr. Y's presentation, complicated by alcohol use, is seen reasonably frequently on our caseload. As a team, we will use this intervention again in select cases to see if we can make it a routine part of practice. Given its use in DTCs and their treatment of personality disorder, a behavioural contract may be used in crisis for this population. However, we must balance this with patients becoming attached to a crisis service that cannot hold them in the long term like a community mental health team can. In some cases, the eventual separation can be very distressing and precipitate a further crisis. With these caveats in mind, we hope that other crisis service staff reading this paper may use a behavioural contract in their work to a similar beneficial effect.

Data Availability

Conflicts of interest.

The authors declare that they have no conflicts of interest.

More From Forbes

Cannabis tops alcohol in daily use for first time ever, study finds.

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Cannabis is overtaking alcohol in Americans' daily consumption.

Americans are now choosing cannabis over alcohol for daily consumption, marking the first time in history that such a shift has taken place, according to a new study.

Published this week in the journal Addiction by the Society for the Study of Addiction, the data, authored by Jonathan P. Caulkins, a Professor of Operations Research and Public Policy at the Heinz College of Carnegie Mellon University, reveal a progressive trend of cannabis overtaking alcohol in Americans' daily consumption, a shift that has been ongoing since at least 2022.

The study analyzes cannabis use trends in the United States from the 1970s to 2022, with a particular focus on its relationship to alcohol consumption.

Caulkins identifies four key periods in the evolution of the U.S. cannabis policy.

Initially, there was liberalization during the 1970s, marked by the Shafer Commission report and state decriminalization efforts. This was followed by a conservative “Reagan-Bush drug war” era spanning from 1980 to 1992. Then, a 15-year phase from 1993 to 2008 witnessed state-led “medical marijuana” liberalization despite federal opposition. Lastly, from 2009 to 2022, federal non-interference was implemented, culminating in legalization in Colorado and Washington in 2012.

In order to understand the trend of cannabis consumption among Americans, the author of this study scrutinized self-reported surveys on cannabis use from U.S. national household surveys, specifically the National Survey on Drug Use and Health (NSDUH), spanning several decades, collecting data from over one million participants.

The findings of this study indicate that cannabis consumption reached its lowest point in 1992 after stringent drug policies under the Reagan and Bush administrations but began a steady climb throughout the 1990s and early 2000s.

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Since 2009, with federal non-interference in state-level legalization due to the memorandum from Deputy Attorney General David Ogden, who advises U.S. Attorneys not to allocate federal resources toward individuals who are compliant with existing state laws regarding medical cannabis use, cannabis use has surged significantly.

In fact, from 2008 to 2022, the rate of people reporting past-year cannabis use more than doubled, and the total annual days of use increased by over 200%, from 2.3 billion to 8.1 billion days.

The term "billions of days" refers to the collective number of days all users consumed cannabis in a year. This figure is determined by multiplying the number of users by their average usage days.

In 2022, the typical cannabis user reported using it 15 to 16 days per month, while the typical drinker reported consuming alcohol 4 to 5 days per month.

While alcohol consumption was more widespread, cannabis users displayed higher consumption rates, with over 42.3% of monthly users reporting daily use, compared to just 10.9% of alcohol users.

Despite daily cigarette smoking continuing to exceed daily cannabis use, consumption patterns for cannabis are becoming more similar to those of cigarettes, according to the study.

This study shows that patterns of cannabis use are linked with shifts in public policy, highlighting a rise in consumption during times of policy relaxation and a significant change in cannabis use trends in the country, where cannabis is now more frequently used on a daily basis than alcohol.

While surveys of the general population provide insights, they have their limitations because they rely on self-reported data, which lacks verification through biological samples and may exclude certain groups with unique cannabis use patterns. Furthermore, social acceptance of cannabis may lead to increased willingness to admit use, potentially inflating reported rates. Conversely, the proliferation of diverse cannabis products following state-level legalization complicates traditional definitions of cannabis use among survey respondents.

However, the findings of this study reveal a significant surge in reported cannabis consumption and seem to be linked to the relaxation of cannabis legislation.

While the study doesn't clarify whether these legal changes directly influence usage patterns or simply reflect evolving attitudes toward cannabis, regardless of the causal relationship, cannabis consumption appears to have fundamentally shifted in scale since legalization .

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Cannabis Tops Alcohol as Americans’ Daily Drug of Choice

A new study shows a growing number of people are regularly using cannabis, while frequent alcohol consumption has remained stable.

By Christina Caron

For the first time on record, cannabis has outpaced alcohol as the daily drug of choice for Americans.

In 2022 there were 17.7 million people who reported using cannabis either every day or nearly every day, compared with 14.7 million who reported using alcohol with the same frequency, according to a study, published on Wednesday in the journal Addiction that analyzed data from the U.S. National Survey on Drug Use and Health.

While far more people drink than use cannabis, drinking frequently has become slightly less common than it was around 15 years ago, the study found. But the proportion of people in the U.S. who use cannabis frequently has increased 15-fold in the three decades since 1992, when daily cannabis use hit a low point.

Cannabis legalization has also rapidly accelerated since the ’90s. The drug is now legal for recreational use in 24 states and Washington, D.C. , and for medical use in 38 states and D.C.

The sharp increase in the prevalence of high-frequency cannabis use over the last three decades might partly be attributed to a growing acceptance of the drug, said Jonathan P. Caulkins, a professor of public policy at Heinz College at Carnegie Mellon University. And because the survey data was self-reported, people may now feel more comfortable disclosing how often they use it.

Even so, “I don’t think that for most daily or near-daily users it is a health-promoting activity,” he added. “For some, it’s truly harmful.”

Several experts who were not involved in the research said the study’s findings were concerning. Those in favor of legalizing cannabis have argued that making the drug widely available would draw people away from the harms of alcohol, said Beatriz Carlini, a research associate professor in the psychiatry department of the University of Washington in Seattle.

But the study’s data, which shows only a slight decline in frequent alcohol use, suggests this has not been the case.

“It is disheartening,” she said.

Dr. Carlini and others noted that the concentrations of THC, the psychoactive component in marijuana, have increased dramatically over the years.

In 1995, the concentration of THC in cannabis samples seized by the Drug Enforcement Administration was about 4 percent. By 2021, it was about 15 percent . And now cannabis manufacturers are extracting THC to make oils, edibles, wax, sugar-size crystals and glass-like products called shatter with THC levels that can exceed 95 percent.

In the last decade , research has shown that frequent cannabis use — and particularly the use of high-potency products with levels of THC greater than 10 percent — is a risk factor for the onset of schizophrenia and other psychotic disorders.

“But that isn’t to say that use less frequent — monthly or yearly — is necessarily safe,” said Dr. Michael Murphy, an assistant professor of psychiatry at Harvard Medical School and a psychiatrist at McLean Hospital in Belmont, Mass.

“As we see higher rates of cannabis use in young people, I expect to see higher rates of psychotic disorders,” he said.

The risks of developing psychotic symptoms are higher for those who use cannabis before age 25, people who use it frequently, those with a genetic predisposition (for example, a parent or sibling with a psychotic disorder) or individuals who experienced stressful events like abuse, poverty or neglect during childhood.

In states that have legalized cannabis for recreational use, anyone 21 and over can purchase it.

Those who use cannabis frequently are also at risk of developing cannabis addiction as well as cannabinoid hyperemesis syndrome, a condition that causes recurrent vomiting, the experts said.

This latest study arrives on the heels of the Biden administration’s move last week to downgrade marijuana from the most restrictive category of drugs, known as Schedule I, to Schedule III, which includes drugs thought to have a low-to-moderate risk of abuse.

The survey did not collect information about the concentrations of THC in the products purchased by frequent users or note how often the respondents used cannabis each day.

“A lot of people go home and have a vape after work or take a gummy to go to sleep at night,” said Aaron Smith, the co-founder and chief executive of the National Cannabis Industry Association. He didn’t see that kind of casual daily use as a problem, he added.

At the same time, there may be young people who are using throughout the day “and are exposing themselves to a lot more THC than those people who are just taking a puff a day,” said Ziva D. Cooper, the director of the Center for Cannabis and Cannabinoids at the University of California, Los Angeles. “The mental health and the physical health outcomes are probably going to vary drastically when you look at those different groups of people.”

Christina Caron is a Times reporter covering mental health. More about Christina Caron

• Case Report
• Open access
• Published: 27 May 2024

A complex case study: coexistence of multi-drug-resistant pulmonary tuberculosis, HBV-related liver failure, and disseminated cryptococcal infection in an AIDS patient

• Wei Fu 1 , 2   na1 ,
• Zi Wei Deng 3   na1 ,
• Pei Wang 1 ,
• Zhen Wang Zhu 1 ,
• Zhi Bing Xie 1 ,
• Yong Zhong Li 1 &
• Hong Ying Yu 1  

BMC Infectious Diseases volume  24 , Article number:  533 ( 2024 ) Cite this article

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Hepatitis B virus (HBV) infection can cause liver failure, while individuals with Acquired Immunodeficiency Virus Disease (AIDS) are highly susceptible to various opportunistic infections, which can occur concurrently. The treatment process is further complicated by the potential occurrence of immune reconstitution inflammatory syndrome (IRIS), which presents significant challenges and contributes to elevated mortality rates.

Case presentation

The 50-year-old male with a history of chronic hepatitis B and untreated human immunodeficiency virus (HIV) infection presented to the hospital with a mild cough and expectoration, revealing multi-drug resistant pulmonary tuberculosis (MDR-PTB), which was confirmed by XpertMTB/RIF PCR testing and tuberculosis culture of bronchoalveolar lavage fluid (BALF). The patient was treated with a regimen consisting of linezolid, moxifloxacin, cycloserine, pyrazinamide, and ethambutol for tuberculosis, as well as a combination of bictegravir/tenofovir alafenamide/emtricitabine (BIC/TAF/FTC) for HBV and HIV viral suppression. After three months of treatment, the patient discontinued all medications, leading to hepatitis B virus reactivation and subsequent liver failure. During the subsequent treatment for AIDS, HBV, and drug-resistant tuberculosis, the patient developed disseminated cryptococcal disease. The patient’s condition worsened during treatment with liposomal amphotericin B and fluconazole, which was ultimately attributed to IRIS. Fortunately, the patient achieved successful recovery after appropriate management.

Enhancing medical compliance is crucial for AIDS patients, particularly those co-infected with HBV, to prevent HBV reactivation and subsequent liver failure. Furthermore, conducting a comprehensive assessment of potential infections in patients before resuming antiviral therapy is essential to prevent the occurrence of IRIS. Early intervention plays a pivotal role in improving survival rates.

Peer Review reports

HIV infection remains a significant global public health concern, with a cumulative death toll of 40 million individuals [ 1 ]. In 2021 alone, there were 650,000 deaths worldwide attributed to AIDS-related causes. As of the end of 2021, approximately 38 million individuals were living with HIV, and there were 1.5 million new HIV infections reported annually on a global scale [ 2 ]. Co-infection with HBV and HIV is prevalent due to their similar transmission routes, affecting around 8% of HIV-infected individuals worldwide who also have chronic HBV infection [ 3 ]. Compared to those with HBV infection alone, individuals co-infected with HIV/HBV exhibit higher HBV DNA levels and a greater risk of reactivation [ 4 ]. Opportunistic infections, such as Pneumocystis jirovecii pneumonia, Toxoplasma encephalitis, cytomegalovirus retinitis, cryptococcal meningitis (CM), tuberculosis, disseminated Mycobacterium avium complex disease, pneumococcal pneumonia, Kaposi’s sarcoma, and central nervous system lymphoma, are commonly observed due to HIV-induced immunodeficiency [ 5 ]. Tuberculosis not only contributes to the overall mortality rate in HIV-infected individuals but also leads to a rise in the number of drug-resistant tuberculosis cases and transmission of drug-resistant strains. Disseminated cryptococcal infection is a severe opportunistic infection in AIDS patients [ 6 ], and compared to other opportunistic infections, there is a higher incidence of IRIS in patients with cryptococcal infection following antiviral and antifungal therapy [ 7 ]. This article presents a rare case of an HIV/HBV co-infected patient who presented with MDR-PTB and discontinued all medications during the initial treatment for HIV, HBV, and tuberculosis. During the subsequent re-anti-HBV/HIV treatment, the patient experienced two episodes of IRIS associated with cryptococcal infection. One episode was classified as “unmasking” IRIS, where previously subclinical cryptococcal infection became apparent with immune improvement. The other episode was categorized as “paradoxical” IRIS, characterized by the worsening of pre-existing cryptococcal infection despite immune restoration [ 8 ]. Fortunately, both episodes were effectively treated.

A 50-year-old male patient, who is self-employed, presented to our hospital in January 2022 with a chief complaint of a persistent cough for the past 2 months, without significant shortness of breath, palpitations, or fever. His medical history revealed a previous hepatitis B infection, which resulted in hepatic failure 10 years ago. Additionally, he was diagnosed with HIV infection. However, he ceased taking antiviral treatment with the medications provided free of charge by the Chinese government for a period of three years. During this hospital visit, his CD4 + T-cell count was found to be 26/μL (normal range: 500–1612/μL), HIV-1 RNA was 1.1 × 10 5 copies/ml, and HBV-DNA was negative. Chest computed tomography (CT) scan revealed nodular and patchy lung lesions (Fig.  1 ). The BALF shows positive acid-fast staining. Further assessment of the BALF using XpertMTB/RIF PCR revealed resistance to rifampicin, and the tuberculosis drug susceptibility test of the BALF (liquid culture, medium MGIT 960) indicated resistance to rifampicin, isoniazid, and streptomycin. Considering the World Health Organization (WHO) guidelines for drug-resistant tuberculosis, the patient’s drug susceptibility results, and the co-infection of HIV and HBV, an individualized treatment plan was tailored for him. The treatment plan included BIC/TAF/FTC (50 mg/25 mg/200 mg per day) for HBV and HIV antiviral therapy, as well as linezolid (0.6 g/day), cycloserine (0.5 g/day), moxifloxacin (0.4 g/day), pyrazinamide (1.5 g/day), and ethambutol (0.75 g/day) for anti-tuberculosis treatment, along with supportive care.

The patient’s pulmonary CT scan shows patchy and nodular lesions accompanied by a small amount of pleural effusion, later confirmed to be MDR-PTB

Unfortunately, after 3 months of follow-up, the patient discontinued all medications due to inaccessibility of the drugs. He returned to our hospital (Nov 12, 2022, day 0) after discontinuing medication for six months, with a complaint of poor appetite for the past 10 days. Elevated liver enzymes were observed, with an alanine aminotransferase level of 295 IU/L (normal range: 0–40 IU/L) and a total bilirubin(TBIL) level of 1.8 mg/dL (normal range: 0–1 mg/dL). His HBV viral load increased to 5.5 × 10 9 copies/ml. Considering the liver impairment, elevated HBV-DNA and the incomplete anti-tuberculosis treatment regimen (Fig.  2 A), we discontinued pyrazinamide and initiated treatment with linezolid, cycloserine, levofloxacin, and ethambutol for anti-tuberculosis therapy, along with BIC/TAF/FTC for HIV and HBV antiviral treatment. Additionally, enhanced liver protection and supportive management were provided, involving hepatoprotective effects of medications such as glutathione, magnesium isoglycyrrhizinate, and bicyclol. However, the patient’s TBIL levels continued to rise progressively, reaching 4.4 mg/dL on day 10 (Fig.  3 B). Suspecting drug-related factors, we discontinued all anti-tuberculosis medications while maintaining BIC/TAF/FTC for antiviral therapy, the patient’s TBIL levels continued to rise persistently. We ruled out other viral hepatitis and found no significant evidence of obstructive lesions on magnetic resonance cholangiopancreatography. Starting from the day 19, due to the patient’s elevated TBIL levels of 12.5 mg/dL, a decrease in prothrombin activity (PTA) to 52% (Fig.  3 D), and the emergence of evident symptoms such as abdominal distension and poor appetite, we initiated aggressive treatment methods. Unfortunately, on day 38, his hemoglobin level dropped to 65 g/L (normal range: 120–170 g/L, Fig.  3 A), and his platelet count decreased to 23 × 10 9 /L (normal range: 125–300 × 10 9 /L, Fig.  3 C). Based on a score of 7 on the Naranjo Scale, it was highly suspected that “Linezolid” was the cause of these hematological abnormalities. Therefore, we had to discontinue Linezolid for the anti-tuberculosis treatment. Subsequently, on day 50, the patient developed recurrent fever, a follow-up chest CT scan revealed enlarged nodules in the lungs (Fig.  2 B). The patient also reported mild dizziness and a worsening cough. On day 61, the previous blood culture results reported the growth of Cryptococcus. A lumbar puncture was performed on the same day, and the cerebrospinal fluid (CSF) opening pressure was measured at 130 mmH 2 O. India ink staining of the CSF showed typical encapsulated yeast cells suggestive of Cryptococcus. Other CSF results indicated mild leukocytosis and mildly elevated protein levels, while chloride and glucose levels were within normal limits. Subsequently, the patient received a fungal treatment regimen consisting of liposomal amphotericin B (3 mg/kg·d −1 ) in combination with fluconazole(600 mg/d). After 5 days of antifungal therapy, the patient’s fever symptoms were well controlled. Despite experiencing bone marrow suppression, including thrombocytopenia and worsening anemia, during this period, proactive symptom management, such as the use of erythropoietin, granulocyte colony-stimulating factor, and thrombopoietin, along with high-calorie dietary management, even reducing the dosage of liposomal amphotericin B to 2 mg/kg/day for 10 days at the peak of severity, successfully controlled the bone marrow suppression. However, within the following week, the patient experienced fever again, accompanied by a worsened cough, increased sputum production, and dyspnea. Nevertheless, the bilirubin levels did not show a significant increase. On day 78 the patient’s lung CT revealed patchy infiltrates and an increased amount of pleural effusion (Fig.  2 C). The CD4 + T-cell count was 89/μL (normal range: 500–700/μL), indicating a significant improvement in immune function compared to the previous stage, and C-reactive protein was significantly elevated, reflecting the inflammatory state, other inflammatory markers such as IL-6 and γ-IFN were also significantly elevated. On day 84, Considering the possibility of IRIS, the patient began taking methylprednisolone 30 mg once a day as part of an effort to control his excessive inflammation. Following the administration of methylprednisolone, the man experienced an immediate improvement in his fever. Additionally, symptoms such as cough, sputum production, dyspnea, and poor appetite gradually subsided over time. A follow-up lung CT showed significant improvement, indicating a positive response to the treatment. After 28 days of treatment with liposomal amphotericin B in combination with fluconazole, liposomal amphotericin B was discontinued, and the patient continued with fluconazole to consolidate the antifungal therapy for Cryptococcus. Considering the patient’s ongoing immunodeficiency, the dosage of methylprednisolone was gradually reduced by 4 mg every week. After improvement in liver function, the patient’s anti-tuberculosis treatment regimen was adjusted to include bedaquiline, contezolid, cycloserine, moxifloxacin, and ethambutol. The patient’s condition was well controlled, and a follow-up lung CT on day 117 indicated a significant improvement in lung lesions (Fig.  2 D).

Upon second hospitalization admission ( A ), nodular lesions were already present in the lungs, and their size gradually increased after the initiation of ART ( B , C ). Notably, the lung lesions became more pronounced following the commencement of anti-cryptococcal therapy, coinciding with the occurrence of pleural effusion ( C ). However, with the continuation of antifungal treatment and the addition of glucocorticoids, there was a significant absorption and reduction of both the pleural effusion and pulmonary nodules ( D )

During the patient's second hospitalization, as the anti-tuberculosis treatment progressed and liver failure developed, the patient’s HGB levels gradually decreased ( A ), while TBIL levels increased ( B ). Additionally, there was a gradual decrease in PLT count ( C ) and a reduction in prothrombin activity (PTA) ( D ), indicating impaired clotting function. Moreover, myelosuppression was observed during the anti-cryptococcal treatment ( C )

People living with HIV/AIDS are susceptible to various opportunistic infections, which pose the greatest threat to their survival [ 5 ]. Pulmonary tuberculosis and disseminated cryptococcosis remain opportunistic infections with high mortality rates among AIDS patients [ 9 , 10 ]. These infections occurring on the basis of liver failure not only increase diagnostic difficulty but also present challenges in treatment. Furthermore, as the patient’s immune function and liver function recover, the occurrence of IRIS seems inevitable.

HIV and HBV co-infected patients are at a higher risk of HBV reactivation following the discontinuation of antiviral drugs

In this case, the patient presented with both HIV and HBV infections. Although the HBV DNA test was negative upon admission. However, due to the patient’s self-discontinuation of antiretroviral therapy (ART), HBV virologic and immunologic reactivation occurred six months later, leading to a rapid increase in viral load and subsequent hepatic failure. Charles Hannoun et al. also reported similar cases in 2001, where two HIV-infected patients with positive HBsAg experienced HBV reactivation and a rapid increase in HBV DNA levels after discontinuing antiretroviral and antiviral therapy, ultimately resulting in severe liver failure [ 11 ]. The European AIDS Clinical Society (EACS) also emphasize that abrupt discontinuation of antiviral therapy in patients co-infected with HBV and HIV can trigger HBV reactivation, which, although rare, can potentially result in liver failure [ 12 ].

Diagnosing disseminated Cryptococcus becomes more challenging in AIDS patients with liver failure, and the selection of antifungal medications is significantly restricted

In HIV-infected individuals, cryptococcal disease typically manifests as subacute meningitis or meningoencephalitis, often accompanied by fever, headache, and neck stiffness. The onset of symptoms usually occurs approximately two weeks after infection, with typical signs and symptoms including meningeal signs such as neck stiffness and photophobia. Some patients may also experience encephalopathy symptoms like somnolence, mental changes, personality changes, and memory loss, which are often associated with increased intracranial pressure (ICP) [ 13 ]. The presentation of cryptococcal disease in this patient was atypical, as there were no prominent symptoms such as high fever or rigors, nor were there any signs of increased ICP such as somnolence, headache, or vomiting. The presence of pre-existing pulmonary tuberculosis further complicated the early diagnosis, potentially leading to the clinical oversight of recognizing the presence of cryptococcus. In addition to the diagnostic challenges, treating a patient with underlying liver disease, multidrug-resistant tuberculosis, and concurrent cryptococcal infection poses significant challenges. It requires considering both the hepatotoxicity of antifungal agents and potential drug interactions. EACS and global guideline for the diagnosis and management of cryptococcosis suggest that liposomal amphotericin B (3 mg/kg·d −1 ) in combination with flucytosine (100 mg/kg·d −1 ) or fluconazole (800 mg/d) is the preferred induction therapy for CM for 14 days [ 12 , 14 ]. Flucytosine has hepatotoxicity and myelosuppressive effects, and it is contraindicated in patients with severe liver dysfunction. The antiviral drug bictegravir is a substrate for hepatic metabolism by CYP3A and UGT1A1 enzymes [ 15 ], while fluconazole inhibits hepatic enzymes CYP3A4 and CYP2C9 [ 16 ]. Due to the patient's liver failure and bone marrow suppression, we reduced the dosage of liposomal amphotericin B and fluconazole during the induction period. Considering the hepatotoxicity of fluconazole and its interaction with bictegravir, we decreased the dosage of fluconazole to 600 mg/d, while extending the duration of induction therapy to 28 days.

During re-antiviral treatment, maintaining vigilance for the development of IRIS remains crucial

IRIS refers to a series of inflammatory diseases that occur in HIV-infected individuals after initiating ART. It is associated with the paradoxical worsening of pre-existing infections, which may have been previously diagnosed and treated or may have been subclinical but become apparent due to the host regaining the ability to mount an inflammatory response. Currently, there is no universally accepted definition of IRIS. However, the following conditions are generally considered necessary for diagnosing IRIS: worsening of a diagnosed or previously unrecognized pre-existing infection with immune improvement (referred to as “paradoxical” IRIS) or the unmasking of a previously subclinical infection (referred to as “unmasking” IRIS) [ 8 ]. It is estimated that 10% to 30% of HIV-infected individuals with CM will develop IRIS after initiating or restarting effective ART [ 7 , 17 ]. In the guidelines of the WHO and EACS, it is recommended to delay the initiation of antiviral treatment for patients with CM for a minimum of 4 weeks to reduce the incidence of IRIS. Since we accurately identified the presence of multidrug-resistant pulmonary tuberculosis in the patient during the early stage, we promptly initiated antiretroviral and anti-hepatitis B virus treatment during the second hospitalization. However, subsequent treatment revealed that the patient experienced at least two episodes of IRIS. The first episode was classified as “unmasking” IRIS, as supported by the enlargement of pulmonary nodules observed on the chest CT scan following the initiation of ART (Fig.  2 A). Considering the morphological changes of the nodules on the chest CT before antifungal therapy, the subsequent emergence of disseminated cryptococcal infection, and the subsequent reduction in the size of the lung nodules after antifungal treatment, although there is no definitive microbiological evidence, we believe that the initial enlargement of the lung nodules was caused by cryptococcal pneumonia. As ART treatment progressed, the patient experienced disseminated cryptococcosis involving the blood and central nervous system, representing the first episode. Following the initiation of antifungal therapy for cryptococcosis, the patient encountered a second episode characterized by fever and worsening pulmonary lesions. Given the upward trend in CD4 + T-cell count, we attributed this to the second episode of IRIS, the “paradoxical” type. The patient exhibited a prompt response to low-dose corticosteroids, further supporting our hypothesis. Additionally, the occurrence of cryptococcal IRIS in the lungs, rather than the central nervous system, is relatively uncommon among HIV patients [ 17 ].

Conclusions

From the initial case of AIDS combined with chronic hepatitis B, through the diagnosis and treatment of multidrug-resistant tuberculosis, the development of liver failure and disseminated cryptococcosis, and ultimately the concurrent occurrence of IRIS, the entire process was tortuous but ultimately resulted in a good outcome (Fig.  4 ). Treatment challenges arose due to drug interactions, myelosuppression, and the need to manage both infectious and inflammatory conditions. Despite these hurdles, a tailored treatment regimen involving antifungal and antiretroviral therapies, along with corticosteroids, led to significant clinical improvement. While CM is relatively common among immunocompromised individuals, especially those with acquired immunodeficiency syndrome (AIDS) [ 13 ], reports of disseminated cryptococcal infection on the background of AIDS complicated with liver failure are extremely rare, with a very high mortality rate.

A brief timeline of the patient's medical condition progression and evolution

Through managing this patient, we have also gained valuable insights. (1) Swift and accurate diagnosis, along with timely and effective treatment, can improve prognosis, reduce mortality, and lower disability rates. Whether it's the discovery and early intervention of liver failure, the identification and treatment of disseminated cryptococcosis, or the detection and management of IRIS, all these interventions are crucially timely. They are essential for the successful treatment of such complex and critically ill patients.

(2) Patients who exhibit significant drug reactions, reducing the dosage of relevant medications and prolonging the treatment duration can improve treatment success rates with fewer side effects. In this case, the dosages of liposomal amphotericin B and fluconazole are lower than the recommended dosages by the World Health Organization and EACS guidelines. Fortunately, after 28 days of induction therapy, repeat CSF cultures showed negative results for Cryptococcus, and the improvement of related symptoms also indicates that the patient has achieved satisfactory treatment outcomes. (3) When cryptococcal infection in the bloodstream or lungs is detected, prompt lumbar puncture should be performed to screen for central nervous system cryptococcal infection. Despite the absence of neurological symptoms, the presence of Cryptococcus neoformans in the cerebrospinal fluid detected through lumbar puncture suggests the possibility of subclinical or latent CM, especially in late-stage HIV-infected patients.

We also encountered several challenges and identified certain issues that deserve attention. Limitations: (1) The withdrawal of antiviral drugs is a critical factor in the occurrence and progression of subsequent diseases in patients. Improved medical education is needed to raise awareness and prevent catastrophic consequences. (2) Prior to re-initiating antiviral therapy, a thorough evaluation of possible infections in the patient is necessary. Caution should be exercised, particularly in the case of diseases prone to IRIS, such as cryptococcal infection. (3) There is limited evidence on the use of reduced fluconazole dosage (600 mg daily) during antifungal therapy, and the potential interactions between daily fluconazole (600 mg) and the antiviral drug bictegravir and other tuberculosis medications have not been extensively studied. (4) Further observation is needed to assess the impact of early-stage limitations in the selection of anti-tuberculosis drugs on the treatment outcome of tuberculosis in this patient, considering the presence of liver failure.

In conclusion, managing opportunistic infections in HIV patients remains a complex and challenging task, particularly when multiple opportunistic infections are compounded by underlying liver failure. Further research efforts are needed in this area.

Availability of data and materials

All data generated or analyzed during this study are included in this published article.

Abbreviations

Hepatitis B virus

Acquired immunodeficiency virus disease

Immune reconstitution inflammatory syndrome

Human immunodeficiency virus

Multi-drug resistant pulmonary tuberculosis

Bronchoalveolar lavage fluid

Bictegravir/tenofovir alafenamide/emtricitabine

Cryptococcal meningitis

World Health Organization

Computed tomography

Total bilirubin

Cerebrospinal fluid

European AIDS Clinical Society

Intracranial pressure

Antiretroviral therapy

Prothrombin activity

Bekker L-G, Beyrer C, Mgodi N, Lewin SR, Delany-Moretlwe S, Taiwo B, et al. HIV infection. Nat Rev Dis Primer. 2023;9:1–21.

Google Scholar  

Data on the size of the HIV epidemic. https://www.who.int/data/gho/data/themes/topics/topic-details/GHO/data-on-the-size-of-the-hiv-aids-epidemic?lang=en . Accessed 3 May 2023.

Leumi S, Bigna JJ, Amougou MA, Ngouo A, Nyaga UF, Noubiap JJ. Global burden of hepatitis B infection in people living with human immunodeficiency virus: a systematic review and meta-analysis. Clin Infect Dis Off Publ Infect Dis Soc Am. 2020;71:2799–806.

Article   Google Scholar  

McGovern BH. The epidemiology, natural history and prevention of hepatitis B: implications of HIV coinfection. Antivir Ther. 2007;12(Suppl 3):H3-13.

Article   CAS   PubMed   Google Scholar  

Kaplan JE, Masur H, Holmes KK, Wilfert CM, Sperling R, Baker SA, et al. USPHS/IDSA guidelines for the prevention of opportunistic infections in persons infected with human immunodeficiency virus: an overview. USPHS/IDSA Prevention of Opportunistic Infections Working Group. Clin Infect Dis Off Publ Infect Dis Soc Am. 1995;21 Suppl 1:S12-31.

Article   CAS   Google Scholar  

Bamba S, Lortholary O, Sawadogo A, Millogo A, Guiguemdé RT, Bretagne S. Decreasing incidence of cryptococcal meningitis in West Africa in the era of highly active antiretroviral therapy. AIDS Lond Engl. 2012;26:1039–41.

Müller M, Wandel S, Colebunders R, Attia S, Furrer H, Egger M, et al. Immune reconstitution inflammatory syndrome in patients starting antiretroviral therapy for HIV infection: a systematic review and meta-analysis. Lancet Infect Dis. 2010;10:251–61.

Article   PubMed   PubMed Central   Google Scholar  

Haddow LJ, Easterbrook PJ, Mosam A, Khanyile NG, Parboosing R, Moodley P, et al. Defining immune reconstitution inflammatory syndrome: evaluation of expert opinion versus 2 case definitions in a South African cohort. Clin Infect Dis Off Publ Infect Dis Soc Am. 2009;49:1424–32.

Obeagu E, Onuoha E. Tuberculosis among HIV patients: a review of Prevalence and Associated Factors. Int J Adv Res Biol Sci. 2023;10:128–34.

Rajasingham R, Govender NP, Jordan A, Loyse A, Shroufi A, Denning DW, et al. The global burden of HIV-associated cryptococcal infection in adults in 2020: a modelling analysis. Lancet Infect Dis. 2022;22:1748–55.

Manegold C, Hannoun C, Wywiol A, Dietrich M, Polywka S, Chiwakata CB, et al. Reactivation of hepatitis B virus replication accompanied by acute hepatitis in patients receiving highly active antiretroviral therapy. Clin Infect Dis Off Publ Infect Dis Soc Am. 2001;32:144–8.

EACS Guidelines | EACSociety. https://www.eacsociety.org/guidelines/eacs-guidelines/ . Accessed 7 May 2023.

Cryptococcosis | NIH. 2021. https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-opportunistic-infections/cryptococcosis . Accessed 6 May 2023.

Chang CC, Harrison TS, Bicanic TA, Chayakulkeeree M, Sorrell TC, Warris A, et al. Global guideline for the diagnosis and management of cryptococcosis: an initiative of the ECMM and ISHAM in cooperation with the ASM. Lancet Infect Dis. 2024;10:S1473-3099(23)00731-4.

Deeks ED. Bictegravir/emtricitabine/tenofovir alafenamide: a review in HIV-1 infection. Drugs. 2018;78:1817–28.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Bellmann R, Smuszkiewicz P. Pharmacokinetics of antifungal drugs: practical implications for optimized treatment of patients. Infection. 2017;45:737–79.

Shelburne SA, Darcourt J, White AC, Greenberg SB, Hamill RJ, Atmar RL, et al. The role of immune reconstitution inflammatory syndrome in AIDS-related Cryptococcus neoformans disease in the era of highly active antiretroviral therapy. Clin Infect Dis Off Publ Infect Dis Soc Am. 2005;40:1049–52.

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Acknowledgements

We express our sincere gratitude for the unwavering trust bestowed upon our medical team by the patient throughout the entire treatment process.

This work was supported by the Scientific Research Project of Hunan Public Health Alliance with the approval No. ky2022-002.

Author information

Wei Fu and Zi Wei Deng contributed equally to this work.

Authors and Affiliations

Center for Infectious Diseases, Hunan University of Medicine General Hospital, Huaihua, Hunan, China

Wei Fu, Pei Wang, Zhen Wang Zhu, Ye Pu, Zhi Bing Xie, Yong Zhong Li & Hong Ying Yu

Department of Tuberculosis, The First Affiliated Hospital of Xinxiang Medical University, XinXiang, Henan, China

Department of Clinical Pharmacy, Hunan University of Medicine General Hospital, Huaihua, Hunan, China

Zi Wei Deng

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Contributions

WF and ZWD integrated the data and wrote the manuscript, YHY contributed the revision of the manuscript, PW and YP provided necessary assistance and provided key suggestions, ZWZ, YZL and ZBX contributed data acquisition and interpretation for etiological diagnosis. All authors reviewed and approved the final manuscript.

Corresponding author

Correspondence to Hong Ying Yu .

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The study was approved by the Ethics Committee of the Hunan University of Medicine General Hospital (HYZY-EC-202306-C1), and with the informed consent of the patient.

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Fu, W., Deng, Z.W., Wang, P. et al. A complex case study: coexistence of multi-drug-resistant pulmonary tuberculosis, HBV-related liver failure, and disseminated cryptococcal infection in an AIDS patient. BMC Infect Dis 24 , 533 (2024). https://doi.org/10.1186/s12879-024-09431-9

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Published : 27 May 2024

DOI : https://doi.org/10.1186/s12879-024-09431-9

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Study says more Americans smoke marijuana daily than drink alcohol

More Americans are now reporting daily or near-daily use of marijuana than those who drink alcohol at similar levels, marking the first time in about three decades that the everyday use of marijuana has surpassed that of alcohol, according to a new analysis released Wednesday.

The research, which was published in the journal Addiction and authored by Carnegie Mellon University drug policy researcher Jonathan Caulkins, analyzed data from the National Survey on Drug Use and Health which had over 1.6 million participants across nearly 30 surveys from 1979 to 2022. Although alcohol consumption is still more widespread, the analysis found that 2022 was the first time people reported using more cannabis daily or near daily than alcohol.

In 2022, about 17.7 million people reported using marijuana daily or near daily compared to the 14.7 million who reported drinking daily or near daily, according to the analysis. In 1992 — when marijuana use reached its lowest point — less than 1 million people said they used the drug every day while 8.9 million reported drinking alcohol daily.

"Through the mid-1990s, only about one-in-six or one-in-eight of those users consumed the drug daily or near daily, similar to alcohol’s roughly one-in-ten," Caulkins and Stanford University professor Keith Humphries wrote in the Washington Monthly about the analysis. "Now, more than 40 percent of marijuana users consume daily or near daily."

The upward trend coincides with changes in cannabis policy. Trends in cannabis have declined during "periods of greater restriction" and increased during "periods of policy liberalization," according to the analysis.

Marijuana reclassification: President Biden hails 'major step' toward easing federal rules on marijuana

Marijuana 'no longer a young person's drug'

The analysis noted that while "far more" people drink alcohol than use marijuana, high-frequency drinking is less common.

In 2022, the median drinker reported drinking alcohol on four to five days in the past month compared to the 15 to 16 days in the past month for marijuana users, according to the analysis. And from 1992 to 2022, there was a 15-fold increase in the per capita rate of reporting daily or near daily use of marijuana, the analysis found.

The analysis added that patterns of cannabis consumption have also shifted toward cigarette use patterns. But marijuana use is still not as high as cigarette use, according to the analysis, which cited a 2022 National Survey on Drug Use and Health survey that said about 58% — over 24 million people — of past month cigarette smokers smoked daily.

The analysis also found that marijuana is "no longer a young person's drug." In 2022, people 35 and older accounted for "slightly" more days of use than those under 35, according to the analysis.

"As a group, 35-49-year-olds consume more than 26-34-year-olds, who account for a larger share of the market than 18-25-year-olds," Caulkins and Humphries wrote in the Washington Monthly. "The 50-and-over demographic accounts for slightly more days of use than those 25 and younger."

Federal government takes step toward changing rules on marijuana

Earlier this month, the U.S. Department of Justice announced a historic proposal to ease restrictions on marijuana by reclassifying marijuana from a Schedule I drug to a Schedule III drug .

Schedule I drugs — such as heroin — are considered to be highly dangerous, addictive and are not accepted for medical use. Schedule III drugs are considered to have a moderate to low potential for physical and psychological dependence, and includes drugs like Tylenol with codeine and anabolic steroids.

While rescheduling marijuana does not make it legal at the federal level, the change represents a major step in narrowing the gap between federal and state cannabis laws.

As of April, recreational and medical marijuana is legal in 24 states and the District of Columbia, according to the Pew Research Center . And another 14 states have legalized cannabis for medical use only.

Reclassifying marijuana will also allow more research and medical use of the drug as well as to leading to potentially lighter criminal penalties and increased investments in the cannabis sector.

Contributing: Joey Garrison, USA TODAY; Reuters

Teen Drinking and Drug Use Is Staying Low After Historic Pandemic Drop, Studies Show

When you have teens in your home, it's normal to be concerned about what they're putting into their bodies. And when it comes to drugs and alcohol, with overdoses reaching record highs and fears of deadly fentanyl-laced pills , you're not alone in wanting to keep your kiddos as safe as possible.

The opioid crisis remains a major concern, but the numbers for teens and drug and alcohol use are actually trending in a positive direction. Surprised? It's actually continuing a trend that began in 2021, when the annual Monitoring the Future teen drug and alcohol survey recorded the largest-ever declines in use of cannabis, alcohol, and nicotine vaping. The question researchers had was whether that pandemic-fueled drop - likely due to lockdowns keeping teens away from classrooms and peers - would stick once society opened back up.

The answer, so far, is yes. The 2023 survey revealed that marijuana use has stayed at the low levels seen in 2021; nicotine vaping has continued to drop; and alcohol use, though more showing more fluctuation, remains low and dropped for the oldest teens surveyed. The number of 10th and 12th graders who have never tried alcohol, marijuana, or nicotine has also increased, to 54 percent and 38 percent, respectively.

The Monitoring the Future survey has tracked substance use in teens since 1975, surveying three different grade levels: 12th grade, 10th grade, and eighth grade (10th and eighth were added in 1991). The 2023 results come from surveying more than 22,000 students across those grade levels, from 235 public and private schools.

While alcohol, marijuana, and vaping nicotine were still the most commonly used substances among teens last year, the levels stayed much lower than they were before COVID. Over the previous 12 months of 2023, the survey showed that:

• 29 percent of 12th graders used marijuana; 48 percent used alcohol; and 23 percent vaped nicotine
• 18 percent of 10th graders used marijuana; 31 percent used alcohol; and 18 percent vaped nicotine
• 8 percent of eighth graders used marijuana; 15 percent used alcohol; and 11 percent vaped nicotine

The marijuana rates stayed mostly steady since the 2021 drop. For alcohol, eighth- and 10th grade use stayed steady while 12 grade use dropped from 52 percent; and for nicotine vaping, 12th- and 10th grade use dropped by about four percentage points each while eighth grade use stayed steady.

Elsewhere, cigarette use among teens was "at or near the lowest ever recorded by the survey since the start of the survey in 1975," the report noted. The same was true for ecstasy (MDMA), cocaine, heroin, and smokeless tobacco. Use of a prescription drug without a doctor's OK also remained at post-pandemic lows.

All in all, it's hopeful news for parents concerned about teen drug use - and a good reminder to keep that line of communication open. Talking to teens about drugs and alcohol might feel awkward, but experts actually recommend starting these conversations when your child is as young as 6. "Kids are listening - even if we sometimes don't think so," Ralph Blackman, the CEO of the  Foundation for Advancing Alcohol Responsibility , previously told SheKnows. "These talks are making a big difference on our kids' decisions to drink or not drink underage."

Before you go, shop these natural products to help your kid's cold symptoms:

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