Services for Alcohol use disorders. Topics covered:
- A spectrum of disorders needing a range of services
- Location and intensity of treatment
- Specialist treatments
- Community-based specialist treatments
- Brief interventions
- Matching and stepped care
- Financial considerations
- Access and help-seeking
- Characteristics of the alcohol-misusing population
- Ethnic minority groups
- The homeless
- Young people
- Relatives and carers
- Services for individuals with comorbidity
- The availability of alcohol treatment services
A spectrum of disorders needing a range of services
The provision of services for alcohol use disorders historically has been driven by the prevailing view of their nature and prevalence. Following the Second World War, the disease concept of alcoholism gained increasing support in both the United States and the United Kingdom. (1) According to this concept, alcoholism is an all-or-nothing phenomenon affecting a relatively small subgroup of the population, and requires intensive specialist treatment. In the United Kingdom this led to the development of specialist alcohol treatment centres with an emphasis on intensive inpatient treatment over several weeks or months, and involving group therapy, often with close affiliation to the Alcoholic Anonymous (AA) fellowship. Such programmes tended to be targeted at relatively socially stable, articulate, and affluent males, and universally only catering for the more severely alcohol dependent. (2)
In the 1970s and 1980s, with the development of epidemiological and psychological research, came a recognition that there existed a much wider range of alcohol-related problems in the population than would meet the narrow criteria of alcoholism or alcohol dependence, which might nevertheless benefit from intervention. Further, research began to show that alcohol problems existed on a continuum of severity and thus might not necessarily require intensive specialist treatment with a lifelong goal of complete abstinence from alcohol. Evidence began to emerge that screening and brief intervention with presymptomatic heavy drinkers in the primary care or general hospital medical ward setting could be effective in reducing excessive alcohol consumption and alcohol-related harm. (3,4) This, combined with a degree of pessimism concerning the effectiveness of intensive treatments for more severely dependent drinkers, led to the proposal that greater benefit could be accrued from less intensive approaches aimed at the large number of hazardous drinkers, than more intensive and expensive interventions catering for the minority of very heavy drinkers: the ‘preventive paradox'. (5)
In a ground-breaking report, the United States Institute of Medicine advocated ‘broadening the base of treatment for alcohol problems'. (6) Recognizing the potential for increased prevention and treatment activity in non-addiction specialist health-care personnel (e.g. general practitioners, physicians, social workers), and the limitations of expanding specialist treatment, particularly in an era of health-care cost containment, the report emphasised the need for an expanded range of locations and methods of intervention, across the spectrum of alcohol use disorders. Importantly however, the report also recognized that alcohol use disorders are heterogeneous, and different types of disorder were likely to require different types or intensities of treatment, i.e. the need to match treatments to the nature of the presenting problem.
In the decade that has followed this report there has been some progress made towards increasing the range and accessibility of treatment. However, in some cases this has been disappointing. This chapter describes the range of treatment approaches and explores the barriers to implementation of a comprehensive system of care for alcohol use disorders. Certain groups in the population may be particularly disadvantaged in terms of access. Finally the cost implications of delivery of treatment services are discussed. The main conclusion of the research evidence is that there remain considerable opportunities to expand and improve treatment services for alcohol use disorders but this will require further training and dissemination initiatives throughout the health system fully to achieve.
Location and intensity of treatment
The main treatment response to alcohol use disorders continues to be delivered by specialists. There has been extensive research on the location and intensity of specialist treatment. An early influential study was that of Edwards et al. (7) in which 100 alcohol-dependent men referred to the Maudsley Hospital in London were randomized to receive either intensive specialist treatment, including inpatient care in an alcoholism treatment unit, or one session of counselling. At 1-year follow-up there was no difference in outcome between the two treatments. It was concluded that the reliance on intensive treatments up to that time was called into question by the findings. This controversial study gave rise to considerable debate and several studies have subsequently investigated the same issues. Another British study attempted to replicate the Edwards study and found only modest differences between advice only and extended treatment in a randomized controlled trial at 2 years's follow-up. (8) There were, however, no differences between treatments in abstinence rates or alcohol consumption level during follow-up.
In a larger study in the United States, 227 employees identified as abusing alcohol were randomized to one of three options: compulsory inpatient treatment, compulsory AA attendance, or a choice of these two options. (9) At 2-year follow-up there were no differences between the groups in terms of work-related outcome measures. However, on seven drinking-related measures the inpatient group had the best, and the AA group the poorest outcome, with the choice group having an intermediate outcome. The compulsory AA group was more likely than the others to require subsequent inpatient treatment. However, the length of inpatient treatment does not appear to influence outcome significantly. (10,11)
Studies comparing inpatient versus outpatient alcohol detoxification have generally found the two approaches to be equally effective. For example, Hayashida et al. (12) randomized 164 male military veterans to inpatient and outpatient detoxification. At 6 months's follow-up no differences in outcome were found between the two groups. Indeed, outpatient detoxification is generally regarded as the treatment of choice for the majority of patients. (13,14) It should be noted, however, that studies comparing inpatient and outpatient treatment (including detoxification) have tended to exclude patients with particularly poor prognosis (e.g. poor social circumstances, severe psychiatric or physical comorbidity, those at risk of harm to themselves or others). Hence, the clinician needs to interpret the research evidence with caution in the usual clinical setting. However, it is probably safe to assume that in ‘uncomplicated' alcohol dependence there is no evidence of an advantage of inpatient over outpatient treatment.
Another important specialist treatment approach used widely in the private or non-statutory treatment sector is residential treatment based upon the Minnesota Model originally developed in the Hazelden Clinic in Minnesota, using an approach closely allied to the AA movement. These approaches, often described as 12-step programmes after the 12 steps of AA, have not generally been subjected to randomized controlled trials. (15,16) One trial in Finland, however, found a higher rate of abstinence at 12 months's follow-up in the Hazelden treatment group compared with traditional residential psychiatric treatment not involving the Minnesota Model approach (26.3 per cent vs. 9.8 per cent). (17) However, the higher abstinence rate was not supported by corresponding reduction in markers of heavy drinking (g-glutamyl transferase, mean cell volume).
It is also important to note that the self-help movement of AA, which was founded in the United States in 1935, is a major provider of help and support for people with alcohol use disorders, with more than 73 000 groups worldwide. (18) Indeed, a higher proportion of problem drinkers attend AA than formal alcohol treatment programmes.(19) Although this approach is largely unevaluated, because of the difficulty of using conventional randomized controlled trials in this setting, there is evidence that regular AA attendance is associated with better outcomes in those with a high level of alcohol dependence. (20,21) Regular AA attenders are, of course, self-selected.
Overall, the majority of studies that have compared intensive specialist treatment with less intensive treatment have not supported the use of more intensive approaches, with a few important exceptions. However, three points are important to note. Little attention has been paid to the issue of matching effects in these studies: do patients with more severe or complex problems benefit more from intensive treatments, as would seem intuitively reasonable? Second, many of the studies have had important methodological limitations, not least being small sample sizes that increase the risk of type 2 error. Third, as noted above, more complex cases tend to be excluded from research trials, which limits the generalizability of the existing research base. With improved methodology now available and an awareness of the possibility of matching effects, this issue is far from closed.
Community-based specialist treatments
The growth of studies questioning the value of specialist inpatient treatment and a move towards cost containment in health care have led to a shift in resources aimed at treating alcohol use disorders in the community setting. One North American study, for example, found that the proportion of outpatient treatment units more than doubled between 1982 and 1990, consistent with the efforts of managed care organizations to decrease the utilization of inpatient services. (22)
Apart from the potential advantage of lower cost, community-based treatment provides the least social disruption for the individual and offers the opportunity to mobilize existing community resources to support, hopefully, sustained recovery. In the United Kingdom, the past 20 years has seen the widespread development of the community alcohol team model of treatment following the original Maudsley Alcohol Pilot Project. (23) The main principle of the community alcohol team model is that the specialist team (typically consisting of specialist medical, nursing, social work, and psychology staff) work to train and support generic teams, mainly in primary care, to manage alcohol use disorders more effectively. In practice, community alcohol teams have tended to find difficulty in avoiding becoming involved in a more traditional specialist role, often providing direct care for alcohol use disorders in the face of reluctance on the part of primary care personnel to take on this work. (24)
There has been remarkably little research conducted to evaluate the community alcohol team model. One study randomly allocated 40 problem drinkers referred to the specialist alcohol treatment clinic at the Maudsley Hospital to receive either routine specialist treatment or ‘shared care'. (25) Following specialist assessment, the shared care group was returned to the care of their general practitioner, who was then supported by the specialist community alcohol team. Shared care within this model included advice and training for the general practitioner, a shared treatment plan, regular phone contact between specialist and general practitioner, and the offer of further specialist care should the patient remain unchanged or deteriorate. At 6 months's follow-up the specialist and shared care groups both showed significant improvements, but there was no difference in outcome between the two groups.
Two other community-based treatment approaches show promise. The ‘community reinforcement approach' has been demonstrated to have benefits in the treatment of alcohol dependence. (26) This approach aims to provide reinforcers for abstinence from alcohol including positive family support, help in finding employment, and membership of an alcohol-free social club, including alcohol counselling. The specialist treatment input aims to ensure that these supports are put in place. There is some evidence from small-scale controlled trials (26,27) that this approach is effective in reducing alcohol consumption and improving social adjustment compared to standard treatment, but it has not so far been fully evaluated, and has never been tested in the United Kingdom.
Another variant on the community alcohol team approach has been the evaluation of community psychiatric nurse aftercare following specialist inpatient treatment. (28) One recent study in Northern Ireland evaluated the effectiveness of regular community psychiatric nurse follow-up consisting of weekly 1- to 2-h visits to the patient's home for a period of 6 weeks post-discharge from inpatient care, followed by less frequent visits up to 1 year. The home-based sessions involved advice, support, counselling, partner involvement, and encouragement to attend AA. This was compared to routine 6-weekly hospital appointments. The study, which involved a non-randomized design, found significant improvements in abstinence and engagement in support in the community psychiatric nurse approach compared to the routine aftercare group.
A recent study in Scotland evaluated the efficacy of a home detoxification service compared with minimal intervention in a randomized controlled trial in 95 patients referred by their general practitioner. (29) At 6 months's follow-up the home detoxification group remained abstinent twice as long after treatment than the minimal intervention group.
Overall, the community alcohol team model of alcohol service delivery has been widely implemented in the United Kingdom in advance of clear evidence of its effectiveness. Evidence is now beginning to emerge showing at least the equivalence, and in some cases, the superiority, of outcome from community-based services compared with more traditional hospital-based treatment approaches. However, the community alcohol team approach is implemented in a range of ways in the United Kingdom, and encompasses many different models and specific interventions. More research is needed to evaluate the cost effectiveness of community alcohol team approaches and to identify the specific elements and methods that contribute to treatment effectiveness.
There has been considerable research interest in the potential of brief interventions in the primary care setting, and to a lesser extent in the general hospital setting. (30) There are several potential advantages in conducting treatment interventions in the primary care setting. Patients with alcohol use disorders consult their general practitioner more frequently than other patients. Alcohol use disorders identified by screening in primary care are largely at an earlier stage in their drinking career and are potentially more likely to benefit from brief early intervention than more severely dependent drinkers. Further, the primary care setting is often seen as less stigmatizing than a specialist clinic.
Several studies have now demonstrated the efficacy of screening and brief intervention in hazardous drinkers in this setting. In a large randomized controlled trial, Wallace et al.(4) found that following screening, brief intervention was more effective than a control treatment in reducing alcohol consumption and g-glutamyl transferase at 1-year follow-up. Similar findings were obtained in a large World Health Organization multicentre trial (31) and in two recent North American studies. (32,33)
Fewer screening and brief intervention studies have been conducted in the general hospital setting. Two studies, one conducted in the United Kingdom and one in Australia, have found some benefit of brief intervention, although both studies lacked statistical power. (3,34) One study of screening in general hospital and attempted referral to a specialist alcohol service was negative, but again had a small sample size. (35)
Three meta-analyses of brief interventions have all found advantages of brief intervention over control treatments with effect sizes of 10 to 20 per cent on reduced alcohol consumption. (36,37 and 38) Effect sizes for men are greater than for women. These reviews have also reached a general conclusion that brief interventions are at least as effective as more intensive specialist treatments. This conclusion has been recently criticized on the basis that studies of opportunistic screening brief intervention are largely not comparable with specialist treatment studies that have included a brief intervention control group, as they involve populations with different characteristics.(39,40) Principally, the former include subjects with less severe alcohol problems, and are not seeking treatment at the point of screening and identification. Further, Drummond (40) has questioned the generalizability of brief intervention research findings in the typical clinical setting, given the large number of exclusions in research studies.
There are barriers to implementation of brief intervention in the non-specialist setting which may limit its effectiveness. In a United Kingdom national survey, (41,42) it was found that general practitioners and primary care practice nurses were reluctant to engage in screening and brief interventions because of a perceived lack of training and support to carry out this work. Effective implementation of large-scale screening and brief intervention programmes will require attention to the training and support needs of non-specialist personnel. Further, screening programmes will identify more severely alcohol-dependent drinkers who may not respond to brief interventions alone. Thus, effective working arrangements between generalists and specialists are needed. An ongoing World Health Organization collaborative study aims to identify the most effective ways of engaging primary care personnel in screening and early intervention in alcohol use disorders.
Matching and stepped care
The Institute of Medicine report, while drawing attention to the need for a range of interventions catering for a wider range of alcohol use disorders, also emphasized the need to match the level of intervention to the severity and nature of the presenting problems. (6) There is some empirical evidence of matching effects. (43) Indeed a later follow-up of the Edwards cohort found that more severely dependent drinkers benefited more from intensive treatment. (44) Up until recently, however, matching effects have generally been explored in post hoc analyses in studies that lacked statistical power. The recent large-scale Project MATCH study in the United States aimed to assess a wide range of matching hypotheses in a prospective design, but found no strong matching effects (45). However, it should be noted that most controlled trials, including MATCH, excluded the more severely problematic patients, including those with limited social support and those with severe psychiatric comorbidity. This tends to work against finding matching effects as the study samples lack clinical heterogeneity. (46) Further, many of the patient and treatment programme characteristics likely to mediate treatment matching and treatment effectiveness, remain largely unresearched.
Stepped care (47) is an alternative method of matching treatments to patient needs that has become accepted in the fields of smoking intervention and general medicine. Until now it has received relatively scant attention in the alcohol field. In essence, stepped care involves initially providing relatively low-intensity treatments to all patients, and only offering more intensive treatments to those who fail to respond. (48) This provides a potentially resource-efficient means of delivering treatment, and provides clinicians with clear clinical algorithms in making treatment decisions. However, stepped care in the alcohol field requires evaluation in controlled trials.
With a general move towards containment of health-care costs in industrialized societies, there has been an increase in the application of health economic research in the alcohol treatment field. The cost of treating alcohol use disorders represents a substantial burden on health-care budgets. It has been estimated that the annual direct treatment costs of alcohol use disorders by specialist treatment agencies amounted to approximately $10.5 billion in the United States and about £400 million in the United Kingdom in 1990. (49,50) Thus there is a need to demonstrate the cost effectiveness of treatments for alcohol use disorders.
Until recently, research on cost effectiveness has been largely speculative and not based on direct estimates of cost benefits. In a landmark study, Holder et al. (51) provided a ‘first approximation' of the cost effectiveness of treatment. In their analysis they used a combination of findings of efficacy from clinical trials, typical costs of different treatments, and recommendations from experts and treatment providers about appropriate treatment approaches. While noting the lack of studies directly assessing the cost effectiveness of treatments, they concluded that the treatments with greatest evidence of effectiveness tend to be less costly than those with least evidence of effectiveness. Based on their analysis the cost of care was inversely correlated with evidence of effectiveness. They also noted that those treatments with the highest cost and lowest evidence of effectiveness were amongst the most prevalent in the North American treatment system. While this review has been strongly criticised on methodological grounds, it has stimulated an important debate and has contributed to an increasing number of clinical trials including a health economic component in outcome evaluation. (52,53)
The two recent North American brief intervention primary care studies cited earlier found evidence of reduced postintervention health-care utilization, suggesting the potential of brief intervention in reducing health-care costs. Fleming et al. (32) found that, as well as reducing excessive drinking, there was a reduced length of hospitalization in men during the 12-month follow-up period. In the study by Israel et al., (33) brief intervention (involving 3 h of counselling by a nurse) led to reduced alcohol-related morbidity and a reduced frequency of physician visits. An earlier study by Kristenson et al. (54) in Sweden found that early intervention and regular follow-up by a physician led to a ‘significant reduction' in sickness absences, hospitalizations, and mortality, compared with a control group. All three studies point to the potential cost effectiveness of interventions in the primary care setting, but none of these studies examined cost effectiveness directly.
There has been relatively little research into the cost effectiveness of specialist treatments, and methodologies for examining cost effectiveness is still at an early stage of development in the alcohol field. However, some work has been done. In a 14-year longitudinal study of ‘alcoholic' employees within the United States, Holder and Blose (55) found that those who enrolled in treatment incurred 24 per cent less health care costs (including the costs of alcoholism treatment) than those who did not. In fact, there was an increase in health-care costs in treatment non-attenders. This was not a randomized study, however, and the results need to be interpreted with some caution.
The costs of treatment were examined in the trial in which employees were randomized to compulsory AA versus compulsory inpatient treatment, cited earlier. (9) They found that the higher-cost (inpatient) intervention resulted in superior outcomes and was only 10 per cent more expensive than AA referral because many of the AA group subsequently required hospitalization. Another randomized trial by Hayashida et al. (12) examined costs in a comparison of inpatient and outpatient alcohol detoxification in male veterans with mild to moderate alcohol withdrawal and found that the clinical outcome was not significantly different between the two groups. However, inpatient treatment was approximately 10 times the cost of outpatient treatment. The authors concluded that for this group, outpatient detoxification is more cost effective.
A recent analysis based on data from Project MATCH aimed to estimate the relative costs of three psychotherapy approaches. (56) Motivational enhancement therapy, 12-step facilitation, and cognitive-behavioural therapy were assessed on the basis of what they would cost per patient to implement in a typical clinical setting. It was found that although motivational enhancement therapy involved one-third of the number of sessions compared to the other two treatments, it was only approximately 33 per cent less costly to provide. Nevertheless, as all three treatments were found to be equally effective it must be concluded that four sessions of motivational enhancement therapy are more cost effective than 12 sessions of either cognitive-behavioural therapy or 12-step facilitation.
The ideal method of assessing the cost effectiveness of treatment for alcohol use disorders is in the context of a randomized controlled trial. However, the measurement of costs and benefits has so far been restricted mainly to direct treatment costs, and outcomes in terms of drinking-related outcome measures. Also important in establishing cost effectiveness will be estimates of indirect costs including patient out-of-pocket costs, lost productivity, unplanned health-care utilization (e.g. admissions with alcohol-related physical and mental illnesses, primary care utilization), criminal justice costs, accidents, premature deaths, social work involvement, child-care costs, and costs associated with illnesses in relatives and carers. (57,58)
Important in the field of cost effectiveness analysis is the estimation of quality-adjusted life years. This has not so far been adequately studied in the alcohol treatment field. The basic analysis relates the cost of a given intervention to a specific measurable outcome such as quality of life. Quality of life can be measured in a variety of ways (e.g. Euroqol, Short Form 36), but the relationship between quality of life and more typical alcohol-related outcomes, such as alcohol consumption, has not been widely studied. (59,60)
Overall, there is considerable scope for further development of health economic research in the alcohol field. This will prove important in providing health-care purchasers with appropriate information to make rational decisions in the provision of cost-effective evidence-based services for alcohol use disorders. One can expect a considerable expansion of research in this area over the next decade.
Access and help-seeking
So far we have concentrated on the effectiveness of interventions at an individual level. However, the overall population impact of treatment interventions is dependent upon the availability and ease of access to treatment programmes, as well as their effectiveness. From a public health perspective the effectiveness of the treatment response to alcohol problems will depend upon the number of people accessing and engaging with interventions. This will be dependent upon two main factors: characteristics of the alcohol-misusing population, and characteristics of the treatment service. There is also likely to be an interplay between these two factors.
Characteristics of the alcohol-misusing population
Specialist alcohol treatment services typically attract younger, male, single patients of lower socio-economic and educational background, with more severe alcohol dependence. Relative to the prevalence of alcohol use disorders in the general population, women, older people, and people from ethnic minorities are typically under-represented, as are the homeless. Further, there are few examples of specific services for young people. This is of particular concern as the prevalence of alcohol use disorders is increasing in these groups in the United Kingdom.
The factors involved in women's help-seeking have recently been the subject of increased research activity. Thom and Green have identified three main factors that may account for the underrepresentation of women in alcohol treatment. (61) Women tend to perceive their problems differently from men, less often identifying themselves as ‘alcoholic'. This may in part be related to negative public stereotypes of female drinking and negative attitudes towards female problem drinkers amongst professionals, who, in the medical profession, are still predominantly male. Women have also been found to perceive the ‘costs' of entering treatment differently from men. This is particularly in relation to the perceived social stigma as well as other costs, both financial, in relationships, and in terms of losing their children into the care system. Finally, women often find the services offered to be less appropriate in meeting their needs than do men. Often specialist alcohol services do not offer child care or ‘women-only' facilities. The latter is particularly relevant in view of the high prevalence of sexual abuse in women seeking alcohol treatment. (62) However, recent evidence suggests that an increasing number of women are seeking help for alcohol use disorders, at least in the United States, on the basis of general population surveys and surveys of treatment populations. (19,22) Nevertheless, more needs to be done to attract women into alcohol treatment by providing services that are sensitive to women's needs. Further, there is a need to develop services catering for pregnant women. (63)
Ethnic minority groups
The evidence concerning help-seeking in ethic minority groups is complex. Harrison et al. (64) have recently provided a review of the evidence. In the United States, Hispanics tend to be under-represented and African-Americans are over-represented in alcohol treatment compared with the general population prevalence. However, interpretation of the evidence is complicated by the fact that household surveys tend to under-represent socially disadvantaged individuals from ethnic minorities. In the United Kingdom, surveys such as the General Household Survey do not examine ethnicity, and estimates of prevalence tend to be based on indirect indicators of alcohol misuse such as cirrhosis mortality. For example, Marmot et al. (65) found that cirrhosis mortality rates were elevated compared to the national average for men from the Asian subcontinent and from Ireland, but lower than average for African-Caribbean men. In women, cirrhosis mortality was lower than average in Asian and African-Caribbean women but higher in Irish women. However, there were few cirrhosis deaths in total in ethnic minorities, which may lead to large errors in extrapolation to the whole population alcohol misuse estimates. Another study found that cirrhosis mortality was higher than expected in Punjabis, Gujuratis, and (perhaps surprisingly) Muslims in the United Kingdom. (66) In terms of alcohol treatment populations, studies have tended to find higher rates of admission (per 100 000 population) in Indian-, Scottish- and Irish-born people than in those born in the Caribbean or Pakistan. (67) Differences in culturally related health beliefs and help-seeking, as well as service factors such as the availability of interpreters or treatment personnel from appropriate ethnic minority groups, may account for some of these differences. There remain few specific services for people from ethnic minorities, although some examples of good practice exist in the United Kingdom. (64)
There is a high prevalence of alcohol use disorders (as well as mental and physical health and social problems) amongst the growing homeless population, a group that is not typically well catered for by mainstream alcohol services. The prevalence of alcohol problems in the homeless has been found to be as high as 38 per cent in the United Kingdom (68) and between 2 and 86 per cent in the United States; typically the prevalence is between 20 and 45 per cent in North American studies.(69) This has contributed to the development of specific alcohol services for the homeless and street drinkers, notably ‘wet' hostels. In the ‘wet' hostel, residents are able to continue drinking but are cared for in an environment that is designed to minimize the harm associated with heavy drinking and to tackle issues associated with homelessness.(70,71) Such facilities tend to be restricted to large urban centres and have restricted places compared to the prevalence of street drinking. Similarly, outreach services and ‘crisis centres' have been developed to attract alcohol-misusing homeless people into treatment facilities. (72) Often those entering ‘wet' hostels can subsequently be persuaded to undergo alcohol detoxification and progress to ‘dry' (or alcohol-free) supported accommodation.
The prevalence of alcohol use disorders is increasing in young people. The young are over-represented in alcohol-related road traffic accidents, and alcohol is a leading cause of accidental death in this group. (73) Alcohol misuse is also associated with engagement in unprotected sexual activity. (74) Nevertheless, there are few services for young people with alcohol use disorders. Most initiatives have been directed at prevention and health promotion in this group, but the evidence to support this is lacking. This has led to the proposal that individually targeted interventions, for example by the primary health care team, are more likely to be effective. (75)
Relatives and carers
Relatives and carers of people with alcohol use disorders often experience significant social and psychological problems related to the drinking of a ‘significant other'. Alcohol use disorders are associated with a high level of domestic violence and child neglect and abuse. Many specialist treatment programmes provide help and support to relatives and carers, and Al-Anon (for adult carers and relatives) and Alateen (for the young), which are affiliates of AA, provide a widely available source of self-help for these groups.
Services for individuals with comorbidity
There is an increasing recognition of the problems associated with alcohol and other drug misuse and mental illness. Often alcohol misuse is complicated by multiple substance misuse. For example, in the Epidemiologic Catchment Area Study half of all patients with schizophrenia also had a substance misuse disorder, (76) and a recent British survey of psychotic patients found that 36 per cent misused drugs or alcohol. (77) However, there is currently no consensus on the most appropriate treatment services for patients with comorbidity. (78) Substance misuse can be particularly problematic in the context of mental illness, and is associated with higher rates of violence and poor treatment outcome. Such patients are often non-compliant and disruptive in mental health services, and typically do not engage in alcohol or drug services. Assertive community outreach and integrated service models, covering both mental illness and substance misuse, have been advocated, but evidence for the effectiveness of such services is currently limited. (78,79)
The availability of alcohol treatment services
The availability of alcohol services is likely to affect the overall impact of public health measures to reduce alcohol use disorders. There is some evidence that the availability of alcohol treatment services has an effect on the prevalence of alcohol use disorders at a population level. Mann et al. (80) found that increased treatment services in Ontario, Canada, were associated with decreased hospital discharges for liver cirrhosis. A similar study in North Carolina examining the 20-year period between 1968 and 1987 found an association between increased alcohol treatment admissions and decreased cirrhosis mortality. Further, Mann et al.(81) found a relationship between AA membership and alcohol-related problems including cirrhosis rates in the United States, Canada, and other countries. They estimated that a 1 per cent increase in AA membership was associated with a 0.06 per cent decrease in cirrhosis mortality. These studies of course demonstrate associations rather than causal links between treatment availability and alcohol use disorder prevalence, but do provide support to the hypothesis that access to treatment could lead to potential cost savings in the health care system. (55)
The National Drug and Alcohol Treatment Utilization Survey ( NDATUS), which is a national census of public and private treatment programmes in the United States, provides a unique data set to study treatment availability. It has been conducted intermittently since 1979 and provides a method to study trends over time. An analysis by the Institute of Medicine found large regional variations in the availability of treatment places. (6) There was no association found between treatment place availability and prevalence of alcohol misuse across States in the United States. This points to the importance of ‘needs assessment' in the rational allocation of public resources to fund treatment services. Such an approach usually involves a variety of data sources as indicators of alcohol use disorder prevalence in a particular locality, including general population surveys, mortality statistics (e.g. deaths from hepatic cirrhosis), crime statistics (e.g. public drunkenness and driving whilst intoxicated arrests), and alcohol-related hospital admissions. Such indicators provide indirect measures of relative ‘need' in different localities, and can be used to direct resource allocation. (82)
Examining data from repeated NDATUS surveys between 1982 and 1993, Schmidt and Weisner (22) found an overall 190 per cent increase in the number of clients in treatment places. The majority of services (82 per cent) were combined drug and alcohol treatment agencies, however, making it difficult to estimate the number of individuals with alcohol use disorders in treatment. Nevertheless, in a subset of ‘alcohol-only' treatment facilities the increase in activity over this period was 147 per cent. In the United States the impact of managed care organizations, which aim to limit access to treatment on the basis of individual need and cost, has yet to be fully established in relation to overall access to alcohol services. Such measures are likely to reduce the availability of inpatient services and to reduce the rate of readmission for those with chronic problems.
In the United Kingdom the introduction of the National Health Service and Community Care Act 1990 (83) placed budgets for residential care, including alcohol treatment, under the direct control of the Treasury, with a view to limiting public spending on residential care. The initial impact of this legislation was estimated to be a 23 per cent reduction in residential substance misuse placements, and a 19 per cent reduction in the number of residential ‘beds'. (84) As budgets for residential alcohol treatment tend not to be ‘ring-fenced', it is likely that further restrictions on public spending will have an impact on the availability of treatment places, which in turn is likely to place more demand upon health-care facilities.
The alcohol treatment field has seen an enormous number of changes over the past 30 years. Some of the changes have been evidence based, and some have been largely politically driven, particularly in the pursuit of containing health-care costs. On the positive side, a shift in policy from a limited number of treatment services catering only for the small minority of severely dependent drinkers, to more community orientated services with a view to early identification and intervention, is to be broadly welcomed. However, in some places a move towards services catering for early-stage ‘at-risk' drinkers has been at the expense of losing services for the more severe cases. (40) While the evidence in favour of matching treatments to individual needs is still at a relatively early stage of development, and clear evidence of matching effects is not yet available, clinical practice needs to be guided by pragmatic principles by which more intensive treatments are provided to more complex cases. It must be concluded that, despite a large research effort in evaluating intensive versus less intensive alcohol interventions, there is still a long way to go in developing pragmatic clinical trials that evaluate effectiveness and cost effectiveness of treatment in a way that can best advise practitioners.
Also on the positive side, research has begun to address fundamental health economic issues that are highly relevant to the rational funding of treatment services. Important in this is the development of health economic methods in randomized controlled trials, although this remains at a relatively rudimentary stage. The assessment of the impact of treatment availability on the prevalence of alcohol-related harm also represents a significant advance.
Health services research that does not influence clinical practice fails in its fundamental aim. For example, while there is a now considerable evidence base in support of brief intervention in the primary care setting, there is a resistance within primary care to adopt such approaches, often despite exhortations from governments and professional bodies. Part of the problem may lie in the disparity between the priorities of public health, which is directed towards population level benefits of an intervention, and the priorities of the individual practitioner, whose first duty is to the patient in his or her care. (30) If the individual practitioner remains unconvinced about the value of a particular, usually brief, intervention for the patient, such public health policies are likely to fail even if they are supported by research evidence.
Similarly, as Holder et al. (51) have pointed out, often treatment programmes continue to provide alcohol services that are not supported by an acceptable evidence base. On occasions, but not exclusively, this criticism is levelled at private for-profit agencies, with the implication that their motivation is financial rather than being principally for the benefit of their patients. In many cases, however, the evidence base is lacking because the fundamental research has not yet been conducted. Or, as in the case of self-help organizations such as AA, the methodology necessary adequately to evaluate an intervention would be extremely complex, or perhaps impossible, to conduct to the standard typically expected in evidence-based medicine (i.e. a randomized controlled trial).
Nevertheless, treatment research cannot occur in a vacuum. Research needs to take account of the funding environment in which treatment takes place. Further, treatment research needs to provide answers to the key issues facing purchasers of health care. With the gradual improvement in the quality of treatment research over the past three decades (85) and the development of more advanced health economic methods to evaluate treatment, (57) the treatment research community is in a much better position than ever before to provide evidence to guide the rational development of treatment services for alcohol use disorders.
While many differences between health-care systems exist in different countries, the evidence points to the need for a wide spectrum of services to cater for different needs. The development of low-threshold community-based services should not occur at the expense of more specialized services for more severe alcohol use disorders. Similarly, a treatment system that provides only specialist services for the minority of severe cases misses a significant public health opportunity to reduce the prevalence of alcohol use disorders through early, brief interventions. Further, there is a need for better integration and co-ordination of statutory and non-statutory services to provide a seamless response that best meets the needs of the wide range of presenting alcohol use disorders.
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