Aims: To evaluate the effectiveness and cost-effectiveness of alcohol screening and brief intervention for adolescents delivered within the school setting. Method: Multi-centre, pragmatic, prospective randomised controlled trial conducted across different regions of England. We evaluated the effectiveness and cost-effectiveness of an Alcohol Screening and Brief Intervention (ASBI) in addition to Personal Health and Social Education (PHSE) compared to PHSE alone for adolescents aged 15 years in school. Our primary outcome was quantity of alcohol consumed at 12-months, assessed in units of alcohol. We also assessed alcohol-related problems, drinking motives and health and wellbeing. The trial was registered with current controlled trials (ISRCTN45691494). Results: While 60% of the study population had reduced their alcohol consumption at month 12, we found no difference in effectiveness between ASBI and PHSE for any of our outcome measures. The ASBI was not found to be cost-effective compared to PHSE. Conclusions: The results of the study suggest that it is not worthwhile implementing ASBI in a school setting. This concurs with other recent evidence of the effectiveness of ASBI for adolescent populations.

Background and aims: Alcohol use increases throughout adolescence. Emergency department (ED) attendance is an opportunity for alcohol screening and brief intervention (ASBI), which is effective for adults. This trial evaluated the effectiveness and cost-effectiveness of ASBI compared with screening alone (SA) in high-risk adolescents. Design, Setting and Participants: Multi-centre, three-group, single-blind, individually randomized trial with follow-ups after 6 and 12 months in 10 ED settings in England. From October 2014 to May 2015 we screened 3327 adolescents aged 14 to 18 years, of whom 756 (22.7%) scored at least 3 on the Alcohol Use Disorders Identification Test: consumption (AUDIT-C) and consented to participate in this trial. Mean age was 16.1 years; 50.2% were female and 84.9% were white. Interventions: Interventions were personalized feedback and brief advice (PFBA), personalized feedback plus electronic brief intervention (eBI) and SA. Measures: The primary outcome was the weekly alcohol consumed in standard UK units (8 g ethanol) at 12 months post-randomization, derived from extended AUDIT-C. Economic outcomes included quality of life and service use, from perspectives of both the National Health Service and personal social services (NHS&PSS) and society. Findings: At 12 months, mean weekly consumption was 2.99 [95% confidence interval (CI) = 2.38–3.70] standard units for the SA group, 3.56 (95% CI = 2.90, 4.32) for PFBA and 3.18 (95% CI = 2.50, 3.97) for eBI, showing no significant differences. The PFBA group consumed mean 0.57 (−0.36, 1.70) units more than SA; and eBIs consumed 0.19 (−0.71, 1.30) more. Bayes factors suggested lack of effectiveness explained non-significance. From the NHS&PSS perspective, economic analysis showed that PFBA and eBI were not cost-effective compared with SA: PFBA yielded incremental cost-effectiveness ratio of £6213 (−£736 843, £812 884), with the intervention having 54% probability of being cost-effective compared with SA at the £20 000 WTP threshold. Conclusions: In emergency departments in England, neither personalized feedback and brief advice nor personalized feedback plus electronic brief intervention showed evidence of being effective or cost-effective when compared with screening alone in reducing alcohol consumption among adolescents.

Introduction: Alcohol use by young people is associated with a range of psychological and physical harms. However, similar harms are also reported with disinhibitory conditions such as conduct problems that are said to precede and predispose to alcohol misuse. We explored whether alcohol use or indicators of underlying disinhibition predict psychological and physical harms in a cohort of young people. Methods: We used data from a randomised controlled intervention trial that identified young people who consumed alcohol (n = 756), mean age = 15.6 years, attending emergency departments (EDs) in England. Disinhibition was measured by the self-report Strengths and Difficulties Questionnaire hyperactivity and conduct problem items, and alcohol-related harms by questions from the ESPAD, a major European school survey. We conducted a mediation analysis with a primary outcome of frequency of engaging in alcohol-related harms 12 months after screening in ED, exploring for the mediating influence of alcohol consumed at six months. We included age, gender, allocated group and baseline consumption as covariates and adjusted for the multi-level nature of the study, where young people were nested within EDs. Results: Conduct problems and to a lesser extent hyperactivity predicted harms at twelve months. This effect was not mediated by alcohol consumed at 6 months. Conclusions: Among young drinkers underlying behavioural attributes predict harm independently of alcohol use. This suggests that the harms associated with alcohol use are attributable more to underlying disinhibitory characteristics than the quantity of alcohol consumed.

Cost‐effectiveness analyses of health care programs often focus on maximizing health and ignore nonhealth impacts. Assessing the cost‐effectiveness of public health interventions from a narrow health care perspective would likely underestimate their full impact, and potentially lead to inefficient decisions about funding. The aim of this study is to provide a practical application of a recently proposed framework for the economic evaluation of public health interventions, evaluating an intervention to reduce alcohol misuse in criminal offenders. This cross‐sectoral analysis distinguishes benefits and opportunity costs for different sectors, makes explicit the value judgments required to consider alternative perspectives, and can inform heterogeneous decision makers with different objectives in a transparent manner. Three interventions of increasing intensity are compared: client information leaflet, brief advice, and brief lifestyle counseling. Health outcomes are measured in quality‐adjusted life‐years and criminal justice outcomes in reconvictions. Costs considered include intervention costs, costs to the NHS and costs to the criminal justice system. The results are presented for four different perspectives: "narrow" health care perspective; criminal justice system perspective; "full" health care perspective; and joint "full" health and criminal justice perspective. Conclusions and recommendations differ according to the normative judgment on the appropriate perspective for the evaluation.

Background: Alcohol dependence is a significant issue contributing to disease burden. Changes in cortisol concentrations during alcohol withdrawal are associated with cognitive deficits and symptoms of depression. Current treatments are only successful for a small proportion of people and do not target cognitive deficits and symptoms of depression experienced by those who are alcohol dependent. The aim of this research is to determine the potential efficacy of mifepristone, a type II glucocorticoid receptor antagonist, to prevent symptoms of depression and cognitive deficits following alcohol detoxification. Methods: This was a phase 2 therapeutic use trial. It was a double-blind randomised controlled clinical trial of mifepristone versus inactive placebo treatment. The trial aimed to recruit 120 participants who met the inclusion criteria: (1) male, (2) aged 18–60 years inclusive, and (3) alcohol dependent for 5 or more years. Participants were randomised to 600 mg a day mifepristone (200 mg morning, afternoon, and evening) for 7 days and 400 mg for the subsequent 7 days (200 mg morning and evening) or the equivalent number of placebo tablets for 14 days. Primary outcome measures were cognitive function (measured using the Cambridge Neuropsychological Test Automated Battery (CANTAB)) and symptoms of depression (measured using the Beck Depression Inventory (BDI)) at 4 weeks post-randomisation. Results: Difficulties recruiting participants due to significant changes in the provision of inpatient care for alcohol dependence resulted in only 27 participants recruited to the trial, with data available for 21 participants. Fourteen participants were randomised to receive mifepristone and 13 to receive placebo. Conclusion: Larger trials would be needed to draw conclusions about the efficacy of mifepristone. Trial registration: ISRCTN registry ISRCTN54001953. Registered on 29 September 2011.

Background: Alcohol-related hospital admissions have doubled in the last ten years to >1.2m per year in England. High-need, high-cost (HNHC) alcohol-related frequent attenders (ARFA) are a relatively small subgroup of patients, having multiple admissions or attendances from alcohol during a short time period. This trial aims to test the effectiveness of an assertive outreach treatment (AOT) approach in improving clinical outcomes for ARFA, and reducing resource use in the acute setting. Methods: One hundred and sixty ARFA patients will be recruited and following baseline assessment, randomly assigned to AOT plus care as usual (CAU) or CAU alone in equal numbers. Baseline assessment includes alcohol consumption and related problems, physical and mental health comorbidity and health and social care service use in the previous 6 months using standard validated tools, plus a measure of resource use. Follow-up assessments at 6 and 12months after randomization includes the same tools as baseline plus standard measure of patient satisfaction. Outcomes for CAU+AOT and CAU at 6 and 12months will be compared, controlling for pre-specified baseline measures. Primary outcome will be percentage of days abstinent at 12months. Secondary outcomes include emergency department (ED) attendance, number and length of hospital admissions, alcohol consumption, alcohol-related problems, other health service use, mental and physical comorbidity 6 and 12months post intervention. Health economic analysis will estimate the economic impact of AOT from health, social care and societal perspectives and explore cost-effectiveness in terms of quality adjusted life years and alcohol consumption at 12-month follow-up. Discussion: AOT models piloted with alcohol dependent patients have demonstrated significant reductions in alcohol consumption and use of unplanned National Health Service (NHS) care, with increased engagement with alcohol treatment services, compared with patients receiving CAU. While AOT interventions are costlier per case than current standard care in the UK, the rationale for targeting HNHC ARFAs is because of their disproportionate contribution to overall alcohol burden on the NHS. No previous studies have evaluated the clinical and costeffectiveness of AOT for HNHC ARFAs: this randomized controlled trial (RCT) targeting ARFAs across five South London NHS Trusts is the first. Trial registration: International standard randomized controlled trial number (ISRCTN) registry: ISRCTN67000214, retrospectively registered 26/11/2016.

Aims: This study aims to estimate the prevalence and burden of alcohol disorders on Emergency Department (ED) and hospital inpatients in England through the exploratory analysis of NHS data. Methods: ED attendances and admission data were linked using hospital episode statistics. Diagnoses were preserved at a patient level to identify individuals who had an alcohol attributable diagnosis. Four groups were identified; a) individuals with no alcohol disorder (NAD), b) acute alcohol disorder (AAD), c) chronic alcohol disorder (CAD) and d) those with any alcohol disorder (AD) (b) and c) combined). Associations between ED diagnosis and alcohol disorders were examined using logistic regression adjusted for hospital provider, age and sex. Non-parametric tests were employed examining ED and hospital service use. Cost differences by group was explored using a propensity scored match sample. Results: Of the 1.2million subjects 6.7% were identified as having one or more AD accounting for 11.7% of ED attendances, 9.2% of hospital admissions and 7.2% total bed days. Bootstrapped derived means identified that hospital service use varied significantly between AAD and CAD. Whilst AAD accounted for greater attendances than NAD (2.78; 95% CI 2.680–2.879) those with CAD accounted for even greater attendances (4.33; 95% CI. 4.136–4.515), admissions (2.56; 95% CI. 2.502–2.625) and total bed days (15.14; 95% CI. 14.716–15.559). Conclusions: AD place a disproportionate impact on hospital services with CAD exerting the greatest burden on hospital utilization. The complexity and burden of CAD suggests this group should be a priority for intervention.

Aims: To explore adolescents' experiences of consenting to, and participating in, alcohol intervention trials when attending for emergency care. Methods: In-depth semi-structured interviews with 27 adolescents (16 males; aged 14–17 years (Mage = 15.7)) who had taken part in one of two linked brief alcohol intervention trials based in 10 accident and emergency departments in England. Interviews were transcribed verbatim and subject to thematic analysis Results: Research and intervention methods were generally found to be acceptable though confidentiality was important and parental presence could hinder truthful disclosures regarding alcohol use. Participants discussed the importance of being involved in research that was relevant to them and recognised alcohol consumption as a normative part of adolescence, highlighting the importance of having access to appropriate health information. Beyond this, they recognised the benefits and risks of trial participation for themselves and others with the majority showing a degree of altruism in considering longer term implications for others as well as themselves. Conclusions: Alcohol screening and intervention in emergency care is both acceptable and relevant to adolescents but acceptability is reliant on confidentiality being assured and may be inhibited by parental presence.

Background: Adverse effects from young people's alcohol consumption manifest in a range of physical and psychosocial factors, including neurological issues, cognitive impairment and risk-taking behaviours. The SIPS JR-HIGH pilot trial showed alcohol screening and brief intervention (ASBI) to be acceptable to young people and schools in the north-east of England. Objectives: To conduct a two-arm, individually randomised controlled trial to evaluate the effectiveness and cost-effectiveness of ASBI for risky drinking in young people aged 14–15 years in the school setting, to monitor the fidelity of ASBI and to explore the barriers to, and facilitators of, implementation with staff, young people and parents. Design: A baseline survey with a 12-month follow-up. Interviews with 30 school staff, 21 learning mentors and nine teachers, and 33 young people and two parents. Setting: Thirty state schools in four areas of England: north-east, north-west, Kent and London. Participants: Year 10 school pupils who consented to the study (aged 14–15 years, recruited between November 2015 and June 2016), school-based staff and parents of the young people who took part in the study. Interventions: Young people who screened positively on a single alcohol screening question and consented were randomised to the intervention or control arm (blinded). The intervention was a 30-minute one-to-one structured brief intervention with a trained learning mentor and an alcohol leaflet. The control group received a healthy lifestyle leaflet (no alcohol information). Main outcome measures: The primary outcome measure was total alcohol consumed in the last 28 days. Secondary outcomes related to risky drinking, general psychological health, sexual risk-taking, energy drink consumption, age of first smoking, quality of life, quality-adjusted life-years, service utilisation and demographic information. Results: A total of 4523 young people completed the baseline survey, with 1064 screening positively (24%) and 443 being eligible to take part in the trial. Of those 443, 233 (53%) were randomised to the control arm and 210 were randomised to the intervention arm. Of the 443, 374 (84%) were successfully followed up at 12 months (intervention, n = 178; control, n = 196). The results were that the intervention showed no evidence of benefit for any alcohol-related measure when compared with the control arm. At 12 months we found a reduction from 61.9% to 43.3% using the Alcohol Use Disorders Identification Test cut-off point of 8 and cut-off point of 4 (69.0% to 60.7%). These results were not significant. A cost-effectiveness analysis showed that the average net cost saving of the brief intervention was £2865 (95% confidence interval –£11,272 to £2707) per year compared with usual practice, with the intervention showing a 76% probability of being cost saving compared with usual practice. The interview findings showed that school was an acceptable setting to carry out ASBI among staff and young people. Limitations: Recruitment of parents to take part in interviews was poor. Only 18 ASBI sessions were recorded, making it difficult to assess internal validity. Conclusions: Although the intervention was ineffective in reducing risky drinking in young people aged 14–15 years, it was well received by the young people and school staff who participated.

Aims: There is a clear association between alcohol use and offending behaviour and significant police time is spent on alcohol-related incidents. This study aimed to test the feasibility of a trial of screening and brief intervention in police custody suites to reduce heavy drinking and reoffending behaviour. Short summary: We achieved target recruitment and high brief intervention delivery if this occurred immediately after screening. Low rates of return for counselling and retention at followup were challenges for a definitive trial. Conversely, high consent rates for access to police data suggested at least some outcomes could be measured remotely. Methods: A three-armed pilot Cluster Randomised Controlled Trial with an embedded qualitative interview-based process evaluation to explore acceptability issues in six police custody suites (north east and south west of the UK). Interventions included: 1. Screening only (Controls), 2. 10 min Brief Advice 3. Brief Advice plus 20 min of brief Counselling. Results: Of 3330 arrestees approached: 2228 were eligible for screening (67%) and 720 consented (32%); 386 (54%) scored 8+ on AUDIT; and 205 (53%) were enroled (79 controls, 65 brief advice and 61 brief counselling). Follow-up rates at 6 and 12 months were 29% and 26%, respectively. However, routinely collected re-offending data were obtained for 193 (94%) participants. Indices of deprivation data were calculated for 184 (90%) participants; 37.6% of these resided in the 20% most deprived areas of UK. Qualitative data showed that all arrestees reported awareness that participation was voluntary, that the trial was separate from police work, and the majority said trial procedures were acceptable.

Objective To estimate and compare the optimal cut-off score of Alcohol Use Disorders Identification Test (AUDIT) and AUDIT-C in identifying at-risk alcohol consumption, heavy episodic alcohol use, ICD-10 alcohol abuse and alcohol dependence in adolescents attending ED in England. Design Opportunistic cross-sectional survey. Setting 10 emergency departments across England. Participants Adolescents (n = 5377) aged between their 10th and 18th birthday who attended emergency departments between December 2012 and May 2013. Measures Scores on the AUDIT and AUDIT-C. At-risk alcohol consumption and monthly episodic alcohol consumption in the past 3 months were derived using the time-line follow back method. Alcohol abuse and alcohol dependence was assessed in accordance with ICD-10 criteria using the MINI-KID. Findings AUDIT-C with a score of 3 was more effective for at-risk alcohol use (AUC 0.81; sensitivity 87%, specificity 97%), heavy episodic use (0.84; 76%, 98%) and alcohol abuse (0.98; 91%, 90%). AUDIT with a score of 7 was more effective in identifying alcohol dependence (0.92; 96%, 94%). Conclusions The 3-item AUDIT-C is more effective than AUDIT in screening adolescents for at-risk alcohol use, heavy episodic alcohol use and alcohol abuse. AUDIT is more effective than AUDIT-C for the identification of alcohol dependence.

Aims: To compare the clinical effectiveness and cost-effectiveness of a stepped-care intervention versus a minimal intervention for the treatment of older hazardous alcohol users in primary care. Method: Multi-centre, pragmatic RCT, set in Primary Care in UK. Patients aged ? 55 years scoring ? 8 on the Alcohol Use Disorders Identification Test were allocated either to 5-min of brief advice or to 'Stepped Care': an initial 20-min of behavioural change counselling, with Step 2 being three sessions of Motivational Enhancement Therapy and Step 3 referral to local alcohol services (progression between each Step being determined by outcomes 1 month after each Step). Outcome measures included average drinks per day, AUDIT-C, alcohol-related problems using the Drinking Problems Index, health-related quality of life using the Short Form 12, costs measured from a NHS/Personal Social Care perspective and estimated health gains in quality adjusted life-years measured assessed EQ-5D. Results: Both groups reduced alcohol consumption at 12 months but the difference between groups was small and not significant. No significant differences were observed between the groups on secondary outcomes. In economic terms stepped care was less costly and more effective than the minimal intervention. Conclusions: Stepped care does not confer an advantage over a minimal intervention in terms of reduction in alcohol use for older hazardous alcohol users in primary care. However, stepped care has a greater probability of being more cost-effective. Trial Registration: Current controlled trials ISRCTN52557360. Short summary: A stepped care approach was compared with brief intervention for older at-risk drinkers attending primary care. While consumption reduced in both groups over 12 months there was no significant difference between the groups. An economic analysis indicated the stepped care which had a greater probability of being more cost-effective than brief intervention.

ABSTRACT Aims: To illustrate how Bayes Factors are important for determining the effectiveness of interventions. Method: We consider a case where inappropriate conclusions were publicly drawn based on significance testing, namely the SIPS Project (Screening and Intervention Programme for Sensible drinking), a pragmatic, cluster-randomized controlled trial in each of two healthcare settings and in the criminal justice system. We show how Bayes Factors can disambiguate the non-significant findings from the SIPS Project and thus determine whether the findings represent evidence of absence or absence of evidence. We show how to model the sort of effects that could be expected, and how to check the robustness of the Bayes Factors. Results: The findings from the three SIPS trials taken individually are largely uninformative but, when data from these trials are combined, there is moderate evidence for H0 and thus for a lack of effect of brief intervention compared with simple clinical feedback and an alcohol information leaflet (B = 0.24, p = 0.43). Conclusion: Scientists who find non-significant results should suspend judgment – unless they calculate a Bayes Factor to indicate either that there is evidence for H0 over a (well-justified) H1, or else that more data is needed.

Aims: To explore client characteristics that predict drinking outcomes using data from the UK Alcohol Treatment Trial (UKATT). Methods: Multiple linear regression was used to determine if there were any characteristics, measured before the start of treatment, that could predict drinking outcomes at three and 12 months, as measured by percent day abstinent (PDA) and drinks per drinking day (DDD) over the preceding 90 days. Results: Lower baseline DDD score and greater confidence to resist drinking predicted lower DDD at both three and twelve months following entry to treatment. In addition to baseline PDA and having greater confidence to resist heavy drinking, female gender, aiming for abstinence, more satisfaction with family life and a social network that included less support for drinking were predictors of percent days abstinent. Conclusions: Overall the strongest and most consistent predictors of outcome were confidence to avoid heavy drinking and social support for drinking. More predictors were identified for percent of days abstinent than for drinks per drinking day. For percent of days abstinent, a number of client characteristics at baseline consistently predicted outcome at both month three and month twelve.

PURPOSE We aimed to test whether 3 strategies—training and support, financial reimbursement, and an option to direct screen-positive patients to an Internet-based method of giving brief advice—have a longer-term effect on primary care clinicians' delivery of screening and advice to heavy drinkers operationalized with the Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) tool. METHODS We undertook a cluster randomized factorial trial with a 12-week implementation period in 120 primary health care units throughout Catalonia, England, Netherlands, Poland, and Sweden. Units were randomized to 8 groups: care as usual (control); training and support alone; financial reimbursement alone; electronic brief advice alone; paired combinations of these conditions; and all 3 combined. The primary outcome was the proportion of consulting adult patients (aged 18 years and older) receiving intervention—screening and, if screen-positive, advice—at 9 months. RESULTS Based on the factorial design, the ratio of the log of the proportion of patients given intervention at the 9-month follow-up was 1.39 (95% CI, 1.03-1.88) in units that received training and support as compared with units that did not. Neither financial reimbursement nor directing screen-positive patients to electronic brief advice led to a higher proportion of patients receiving intervention. CONCLUSIONS Training and support of primary health care units has a lasting, albeit small, impact on the proportion of adult patients given an alcohol intervention at 9 months.

Buprenorphine/naloxone, methadone and lofexidine are medications with utility in the treatment of opiate withdrawal. We report the first randomised controlled trial to compare the effects of these two medications on withdrawal symptoms and outcome during opiate induction/stabilisation and detoxification. A double-blind randomised controlled trial was conducted in an outpatient satellite clinic of a specialist drug service. Eighty opiate dependent individuals meeting DSM-IV criteria for opiate dependence, using ? ½ g heroin smoked/chased or ¼ g heroin injected or ? 30mg methadone, with ? 3 years of opioid dependency, underwent a short-term opiate treatment programme involving induction/stabilisation on methadone 30mg or buprenorphine/naloxone 4mg/1mg, followed by detoxification (where the methadone group was assisted by lofexidine). The main outcome measures were urine drug screens for opiates and withdrawal and craving questionnaires. There were no overall differences in positive urine drug screens and drop-outs during any phase of the study. During induction/stabilisation, withdrawal symptoms subsided more slowly for buprenorphine/naloxone than for methadone, and craving was significantly higher in the buprenorphine/naloxone group (p<0.05, 95% confidence interval ?3.5, ?0.38). During detoxification, withdrawal symptoms were significantly greater and the peak of withdrawal was earlier for the methadone/lofexidine group than the buprenorphine/naloxone group (p<0.01, 95% confidence interval 3.0, 8.3). Methadone/lofexidine and buprenorphine/naloxone had comparable outcomes during rapid outpatient stabilisation and detoxification in low dose opiate users.

Aims: The aim of the study was to explore the relative efficiency and effectiveness of targeted versus universal screening for at-risk alcohol use in a primary care population in the UK. Methods: The study was a randomized evaluation of screening approach (targeted versus universal) for consecutive attendees at primary care aged 18 years or more. Targeted screening involved screening any patient attending with one of the targeted presentations, conditions associated with excessive alcohol consumption: mental health, gastrointestinal, hypertension, minor injuries or a new patient registration. In the universal arm of the study all presentations in the recruitment period were included. Universal screening included all patients presenting to allocated practices. Results: A total of 3562 potential participants were approached. The odds ratio of being screen positive was higher for the targeted group versus the universal group. Yet the vast majority of those screening positive in the universal group of the study would have been missed by a targeted approach. A combination of age and gender was a more efficient approach than targeting by clinical condition or context. Conclusions: While screening targeted by age and gender is more efficient than universal screening, targeting by clinical condition or presentation is not. Further universal screening is more effective in identifying the full range of patients who could benefit from brief alcohol interventions, and would therefore have greater public health impact. Trial registration: Current Controlled Trials ISRCTN06145674.

Background: Adolescence is a critical developmental stage when young people make lifestyle choices that have the potential to impact on their current and future health and social wellbeing. The relationship between substance use and criminal activity is complex but there is clear evidence that the prevalence of problematic substance use is far higher among adolescent offenders than the general adolescent population. Adolescent offenders are a marginalized and vulnerable population who are significantly more likely to experience health and social inequalities in later life than their non-offending peers. There is a paucity of evidence on effective interventions to address substance use and risk-taking behaviours in adolescent offender populations but it is clear that preventative or abstinence orientated interventions are not effective. RISKIT-CJS is an intervention developed in collaboration with young people taking account of the current best evidence. Feasibility and pilot studies have found the intervention addresses the needs of adolescents, is acceptable and has demonstrated potential in reducing substance use and risk-taking behavior. Methods: The study is a mixed method, two-armed, prospective, pragmatic randomized controlled trial with individual randomisation to either treatment as usual alone or the RISKIT-CJS intervention in addition to treatment as usual. Adolescents, aged 13 to 17 years inclusive, engaged with the criminal justice system who are identified as having problematic substance use are eligible to participate. The study will be conducted across three geographical areas; South and South East England, London and North East England between March 2017 and February 2019. Discussion: The study represents an ambitious programme of work to address an area of need for a marginalized and vulnerable population.

Purpose: Globally, alcohol use is the leading cause of ill health and life years lost in adolescents, although its clinical impact is often overlooked, particularly in England where most research is based in schools. This study aims to examine the prevalence of alcohol consumption and the association between alcohol consumption and age of onset with health and social consequences among adolescents presenting to emergency departments (EDs). Methods: Consecutive attenders (n = 5,576) aged 10–17 years at 10 EDs were included. Information was collected on general health and functioning, quality of life, alcohol use, and alcohol-related health and social consequences. Results: Nearly 40% of adolescents reported the consumption of alcohol that was more than a sip in their lifetime. Age of the first alcohol consumption before the age of 15 years was associated with tobacco use (p < .001), lower quality of life (p = .003), and evidence of an alcohol use disorder (p = .002). It was also associated with general social functioning (problems with conduct p = .001 and hyperactivity p = .001) and alcohol-related health and social consequences (accident p = .046, problems with a parent p = .017, school p = .0117, or police p = .012). Conclusions: Rates of alcohol consumption in adolescents presenting to the ED were similar to those reported in schools in England and globally. Associations of alcohol consumption and earlier onset of drinking with poorer health and social functioning were observed. The ED can offer an opportunity for the identification of hazardous alcohol use in adolescents.

Introduction: Drinking has adverse impacts on health, well-being, education and social outcomes for adolescents. Adolescents in England are among the heaviest drinkers in Europe. Recently, the proportion of adolescents who drink alcohol has fallen, although consumption among those who do drink has actually increased. This trial seeks to investigate how effective and efficient an alcohol brief intervention is with 11–15?years olds to encourage lower alcohol consumption. Methods and analysis: This is an individually randomised two-armed trial incorporating a control arm of usual school-based practice and a leaflet on a healthy lifestyle (excl. alcohol), and an intervention arm that combines usual practice with a 30?min brief intervention delivered by school learning mentors and a leaflet on alcohol. At least 30 schools will be recruited from four regions in England (North East, North West, London, Kent and Medway) to follow-up 235 per arm. The primary outcome is total alcohol consumed in the last 28?days, using the 28?day Timeline Follow Back questionnaire measured at the 12-month follow-up. The analysis of the intervention will consider effectiveness and cost-effectiveness. A qualitative study will explore, via 1:1 in-depth interviews with (n=80) parents, young people and school staff, intervention experience, intervention fidelity and acceptability issues, using thematic narrative synthesis to report qualitative data. Ethics and dissemination: Ethical approval was granted by Teesside University. Dissemination plans include academic publications, conference presentations, disseminating to local and national education departments and the wider public health community, including via Fuse, and engaging with school staff and young people to comment on whether and how the project can be improved.

Aims: A pilot randomized controlled trial (RCT) to assess the feasibility and potential efficacy of assertive community treatment (ACT) in adults with alcohol dependence. Methods: Single blind, individually randomized, pilot RCT of 12 months of ACT plus treatment as usual (TAU) versus TAU alone in adults (age 18+ years) with alcohol dependence and a history of previous unsuccessful alcohol treatment attending specialist community alcohol treatment services. ACT aimed to actively engage participants for 12 months with assertive, regular, minimum weekly contact. ACT was combined with TAU. TAU comprised access to the full range of services provided by the community teams. Primary outcome is mean drinks per drinking day and percent days abstinent at 12 months follow up. Analysis of covariance was conducted using 80% confidence intervals, appropriate in the context of a pilot trial. Results: A total of 94 participants were randomized, 45 in ACT and 49 in TAU. Follow-up was achieved with 98 and 88%, respectively at 12 months. Those in ACT had better treatment engagement, and were more often seen in their homes or local community than TAU participants. At 12 months the ACT group had more problems related to drinking and lower quality of life than TAU but no differences in drinking measures. The ACT group had a higher percentage of days abstinent but lower quality of life at 6 months. The ACT group had less unplanned healthcare use than TAU. Conclusions: An trial of ACT was feasible to implement in an alcohol dependent treatment population. Trial registration: ISRCTN22775534

While the terms suicide and self-harm are often used interchangeably, it is important to be clear that they are conceptually different. Suicide is a self-inflicted act with the intention to cause death, whereas an act of self-harm may be the precedent to an act of suicide, but it can also exist as a concept in its own right as an intentional act of harm without suicidal intent. Self-harm is intentional, often repetitive, and often constitutes a coping mechanism to provide temporary relief from emotional distress. The crucial differentiation between suicidal behavior and self-harm lies in the nature of motivational intent underlying the action. This distinction makes the early identification of those who are at risk of self-harm or suicide more difficult and the screening of potential at-risk populations more complex. It has been argued that as the impact, treatment pathway, and even costs are similar for both groups, this difference is considered irrelevant for the screening of these behaviors. Skegg in 2005 suggested that self-harm and suicide should be considered as a continuum in the sense that self-harm covers a spectrum of behavior: The most serious form closely relates to suicide, while behaviors at the milder end of the spectrum range merge with other reactions to emotional pain. And it is this approach most commonly employed in the development of screening tools to identify those at risk of suicide and self-harm, whereby self-harm is defined as an act of self-poisoning or self-injury, irrespective of the purpose of the act. This entry addresses the prevalence of suicide and self-harm in offender populations, lists risk factors for offender suicide and self-harm, and provides an overview of assessment tools.

Background Alcohol consumption and related harm increase steeply from the ages of 12–20 years. Adolescents in the UK are among the heaviest drinkers in Europe. Excessive drinking in adolescents is associated with increased risk of accidents, injuries, self-harm, unprotected or regretted sex, violence and disorder, poisoning and accidental death. However, there is lack of clear evidence for the most clinically effective and cost-effective screening and brief interventions for reducing or preventing alcohol consumption in adolescents attending emergency departments (EDs). Objectives To estimate the distribution of alcohol consumption, alcohol-related problems and alcohol use disorders in adolescents attending EDs; to develop age-appropriate alcohol screening and brief intervention tools; and to evaluate the clinical effectiveness and cost-effectiveness of these interventions. Design The research has been conducted in three linked stages: (1) a prevalence study, (2) intervention development and (3) two linked randomised controlled trials (RCTs). Setting Twelve EDs in England (London, North East, and Yorkshire and The Humber). Participants A total of 5376 participants in the prevalence study [mean age 13.0 years, standard deviation (SD) 2.0 years; 46.2% female] and 1640 participants in the two linked RCTs (mean age 15.6 years, SD 1.0 years; 50.7% female). Interventions Personalised feedback and brief advice (PFBA) and personalised feedback plus electronic brief intervention (eBI), compared with alcohol screening alone. These age-appropriate alcohol interventions were developed in collaboration with the target audience through a series of focus groups and evaluations during stage 2 of the research programme and following two literature reviews. Main outcome measures Total alcohol consumed in standard UK units (1 unit = 8 g of ethanol) over the previous 3 months at 12-month follow-up, assessed using the Alcohol Use Disorders Identification Test, Consumption (3 items) (AUDIT-C). Results In the prevalence study, 2112 participants (39.5%) reported having had a drink of alcohol that was more than a sip in their lifetime, with prevalence increasing steadily with age and reaching 89.5% at the age of 17 years. The prevalence of at-risk alcohol consumption was 15% [95% confidence interval (CI) 14% to 16%] and the optimum cut-off point of the AUDIT-C in identifying at-risk drinking was ≥ 3. Associations of alcohol consumption and early onset of drinking with poorer health and social functioning were also found. In the RCT, the analysis of the primary outcome (average weekly alcohol consumption at month 12) identified no significant differences in effect between the three groups in both trials. In the high-risk drinking trial, the mean difference compared with control was 0.57 (95% CI –0.36 to 1.70) for PFBA and 0.19 (95% CI –0.71 to 1.30) for eBI. In the low-risk drinking trial, the mean difference compared with control was 0.03 (95% CI –0.07 to 0.13) for PFBA and 0.01 (95% CI –0.10 to 0.11) for eBI. The health economic analysis showed that eBI and PFBA were not more cost-effective than screening alone. Conclusions The ED can offer an opportunity for the identification of at-risk alcohol use in adolescents. A simple, short, self-completed screening instrument, the AUDIT-C, is an effective tool for identifying adolescents who are at risk of alcohol-related problems. Associations of alcohol consumption and earlier onset of drinking with poorer health and social functioning were observed in the prevalence study. The trials were feasible to implement and exceeded the recruitment target and minimum follow-up rates. However, PFBA and eBI were not found to be more effective than screening alone in reducing or preventing alcohol consumption in 14- to 17-year-olds attending EDs. Limitations and future work Only one-third of participants engaged with the application program; this is likely to have limited the effect of the intervention. We recommend that future research should focus on methods to maximise engagement with digital interventions and evaluate the effect of such engagement on clinical outcomes. Trial registration Current Controlled Trials ISRCTN45300218. Funding This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 8, No. 2. See the NIHR Journals Library website for further project information.

Background - RISKIT-CJS was a cluster randomised trial of a multi-component risk reduction programme for adolescents (aged 13-17), involved with the criminal justice system in England. Its main quantitative finding was acceptance of the null hypothesis of no effect on alcohol and substance use. Here we report on the realist, qualitative evaluation of the RISKIT-CJS programme to explore what can be learnt about how such programmes may not produce effects for their target group. Methods - the qualitative evaluation used: records of meetings and focus groups (purposive sample), practitioner interviews and observational fieldnotes of programme delivery. Data were abductively coded, using a realist framework to identify the configurations of context, mechanisms, moderators and outcomes through which the programme worked in practice. Results - This paper presents that refined realist programme theory. Relevant contexts included: geographical and institutional setting of the intervention sites (organising group work, staff ability, motivation and capacity), and the individual participant contexts (complex needs, maturity, motivation and risk profile). The intended mechanisms included: motivation to change; learning consequences; educational engagement; better communication; improved self-efficacy; and positive peer influence. The triggering of these mechanisms was affected by positive moderators (strong local programme champions, ageing out of crime for older participants) and negative moderators (disorganised, understaffed setting, and ageing into crime for younger participants). Potential negative mechanisms, included: negative peer effects and treatment fatigue. Different combinations of contexts, mechanisms and moderators led to different outcomes for different participants which are not adequately explained by an interpretation of the null quantitative result that the programme had 'no effect'. Conclusion - The paper demonstrates how realist, qualitative research can provide useful learning for policy and practice, even when the overall, quantitative result of a trial of a preventive intervention is null.