Introduction
The aim of the HTA Programme is to ensure that high quality research information on the clinical effectiveness, cost-effectiveness and broader impact of healthcare treatments and tests are produced in the most efficient way for those who plan, provide or receive care from NHS and social care services. The commissioned workstream invites applications in response to calls for research on specific questions which have been identified and prioritised for their importance to the NHS, patients and social care.
Research Question
What is the clinical and cost-effectiveness of facilitating access to mutual aid for people with problem alcohol and drug use in England?
Intervention
- A brief manualised Facilitating access to mutual aid (FAMA) intervention, which should be adapted from the Intensive Referral Intervention (for example, Timko et al 2006). Mutual aid is described in the government guidance on recovery support services as the social, emotional and informational support provided by, and to, members of a group at every stage of recovery. The most common mutual aid groups in England are Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Cocaine Anonymous (CA) and SMART Recovery.
- Applicants to define and justify the exact content and delivery, but it is intended that the intervention should be delivered: early in the treatment pathway; primarily one-to-one and face-to-face (although it could include some remote delivery); by specialist drug and alcohol staff as part of keywork.
- Applicants should also give consideration to how the intervention will be introduced to workers who will be delivering the intervention.
Patient group
- Adults who are receiving structured treatment in drug and alcohol services for problem alcohol and/or drug use. The target group includes those who have received any number of structured treatment episodes and those who have attended a mutual aid group before or not.
- Applicants to note that participants should be representative of adults across drug and alcohol services.
- Applications are encouraged which include recruitment from geographic populations with high prevalence of problem alcohol and drug use including dependence, which have been historically underserved by research activity in this field.
Comparator
- Standard care. Applicants to define and justify.
Setting
- Drug and alcohol treatment services. Applicants must include community-based services but can include hospital-based services as well.
Study design
- A development phase to adapt the Intensive Referral Intervention for delivery in drug and alcohol services in England.
- Applicants should clearly define and justify any adaptions to the intervention, appropriate success criteria for judging adaptation of the intervention to warrant a full evaluation, and assess acceptability to all parties as well as uptake and adherence by people receiving the intervention.
- A randomised controlled trial with an internal pilot phase to test key trial processes such as recruitment and adherence.
- Applicants should give consideration to: issues of adherence to the intervention throughout all stages of the study, and the Medical Research Council’s framework on the development and evaluation of complex interventions.
- Stop/go criteria should be provided to inform progression between the development stage, the internal pilot stage, and the full trial.
- Findings to be subgrouped by type of substance (for example opiates, non-opiates and alcohol, alcohol only and non-opiates only); length of time in treatment; previous experience of a mutual aid group; sex; setting (if relevant).
Important outcomes
- Engagement with a mutual aid group (for example, number of meetings attended, participation in meetings); continued remission of problem alcohol and/or drug use; cost effectiveness.
Other outcomes
- Measures of recovery capital, for example; personal (such as physical and mental health, employment, education and training and housing status); social (such as accessing and giving peer support, supportive family and friends, re-engagement with families); community (such as being part of recovery communities).
- Any treatment re-engagement (for example, number of times re-engaged with treatment).
- Total days of treatment.
- Use of other support services (days/number of times).
- Acceptability of the intervention to recipients.
- Self-reported improvement in health and wellbeing.
- Improved coping skills and reduced cravings and urges.
- Adverse events.
- Existing Core Outcomes should be included amongst the list of outcomes unless a good rationale is provided to do otherwise.
- Applicants are encouraged to report recruitment and findings disaggregated by sex (and other demographic factors where relevant).
- Minimum duration of follow-up is 1 year.
Longer-term follow up
- Researchers should obtain consent to allow for future follow up through efficient means (such as routine data) as part of a separately funded study, for example, to measure rates of mutual aid group attendance, and continued remission of problem alcohol and drug use.
Rationale
In England between April 2021 and March 2022 there were 289,215 adults in contact with drug and alcohol services. Many of these people will have multiple treatment episodes and, as acknowledged in the UK government’s 10-year drugs plan, ‘recovery is a process that often takes time to achieve and effort to maintain’.
As part of this recovery process, the UK guidelines on clinical management of drug misuse and dependence state that mutual aid approaches have been found to be highly effective for some individuals in supporting recovery. The government’s new guidance on recovery support services includes mutual aid as a type of recovery support service and describes it as ‘the social, emotional and information support provided by, and to, members of a group at every stage of recovery’. The most common mutual aid groups in England are Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Cocaine Anonymous (CA) and SMART Recovery.
The combination of mutual aid attendance and treatment is associated with better outcomes. Participation in mutual aid groups is also associated with improved long-term recovery rates, improved functioning across a range of domains, and a reduction in post-recovery costs to society. The UK guidelines state that the likelihood of a person engaging with a mutual aid group is increased if they are actively linked in a structured way to it as opposed to being passively linked (for example, by just being given a leaflet). Active linking is referred to as facilitating access to mutual aid (FAMA).
Although the importance of FAMA is acknowledged and recommended in the UK guidelines, a survey of local authority commissioners in England found that while a majority reported that FAMA was available in their locality, it was likely that this provision was overstated. Their descriptions of FAMA were often of more general efforts to signpost people to mutual aid or of hosting mutual aid groups rather than of structured sessions with keyworkers. However, while there is guidance on how to facilitate access to mutual aid there has not been a robust evaluation of a FAMA intervention in England.
Research suggests that only a third of people in drug and alcohol treatment in the UK have ever attended a mutual aid group. There appears to be potential to increase the number of people that attend, engage and benefit from mutual aid through a more consistent and evidence-based approach to facilitating access to it. The HTA programme therefore wishes to commission the trial outlined above.
Additional commissioning brief background information
A background document is available that provides further information to support applicants for this call. It is intended to summarise what prompted the call and the existing evidence base, including relevant work from the HTA and wider NIHR research portfolio. It was researched and written on the basis of information from a search of relevant sources and databases, and in consultation with a number of experts in the field. If you would like a copy please email htaresearchers@nihr.ac.uk.
Making an application
If you would like to apply for this funding opportunity, you can begin your application via the funding opportunity page.
Your application must be submitted online no later than 1pm on the 24 July 2024. Applications will be considered by the HTA Funding Committee at its meeting in September 2024.
Guidance notes and supporting information for HTA Programme applications are available.
Shortlisted Stage 1 applicants will be given eight weeks to submit a Stage 2 application. The Stage 2 application will be considered at the Funding Committee in January 2025.
For commissioned topics, the Programme strongly discourages the practice of the same co-applicant joining more than one competing team, other than in unusual circumstances (for example, a lead from a named charity or a unique national expert in a condition).
For such exceptions, each application needs to state the case as to why the same person is included. The shared co-applicant should not divulge application details between teams, and both teams should acknowledge in their application that they are aware of the situation, and that study details have not been shared.
Should you have any queries please contact htacommissioning@nihr.ac.uk.