Alcoholism treatment and evaluation: in search of methods. II. Collation of two-year follow-up studies

Male Alcoholics

Pilot data have provided tentative evidence that the degree of cognitive impairment may be a meaningful classificatory variable with respect to subsequent outcome. The purpose of the proposed study is to examine the differential effectiveness of short- and long-term intensive therapy for alcoholic subtypes defined by different levels of current problem-solving abilities. Subjects will be male alcoholic veterans participating in an inpatient treatment program at the Seattle Veterans Adminis tration Hospital. Patients volunteering to participate in thepresent study will initially be administered a neuropsychological test battery including the Wechsler Adult Intelligence Scale and tests from the Halstead battery. Scores from these tests will be used to determine the individuals' Brain-Age Quotient (BAQ), a measure of current adaptive abilities developed by Reitan. Measures of personality traits, psychosocial functioning, and drinking-related behavior will be collected on admission and at three-, six, and nine-month follow-up periods. Based on the antici pated findings of the present study, the length of the treatment program may be tailored to meet the specific needs, defined in terms of current adaptive abilities, of the individual client. Such a program would appear to maximize both the probabihty of a successful treatment outcome and mini mize unnecessary expenses.

Implementing an Ideology. A Case Study from Leicestershire, England

In the late 1970s, we established for the county of Leicestershire in England (pop. 850,000) what was then a highly innovative service for problem drinkers. It was based upon a number of core beliefs about the nature of people with alcohol problems and about what would be helpful for them. Most notably it rejected the concept of “alcoholism” and treated the clients (“customers”) at all times as being responsible and therefore able to make decisions about what would be helpful for them. It was a community based tiered service, non-abstinence oriented and client demand led.

That system of intervention generated a burgeoning referral rate and there was evidence that compared with neighbouring similar counties, the service may have had a positive impact on the long term morbidity and mortality related to alcohol use. The data available were correlational and incomplete but were encouraging.

Changes in the style of provision in the neighbouring counties and administrative and structural changes in health and social services nationally meant that it was not possible to continue the service in its comprehensive form, and tracking changes in the indirect indicators of alcohol problems became unfeasible. The natural experiment was terminated by factors beyond our control. Nonetheless, the service still exists, though in a truncated form. Its presence played a part in the development of the template for local alcohol service provision in Britain.

The Use Made of Treatment: an Alternative Approach to the Evaluation of Alcoholism Services

Despite much evaluative research on alcoholism services, the effectiveness of treatment is still an unsettled matter. The inconclusive results of empirical studies comparing different methods and extensive statistical analysis of their findings do not point a clear way forward for future evaluative efforts. Using a sample of follow-up data from an evaluation study of three residential units (not considered here) this report sets out to demonstrate that dynamics in individual drinking patterns make surveys of studies which have applied different outcome criteria very unreliable. The feasibility of the single controlled study in evaluation is also questioned and attributed to the inappropriate use of a “quality control” model. An alternative approach which avoids the methodological and practical difficulties of the conventional design examines the use made of treatment by clients. A more realistic account based on individual cases is urged which recognizes that seeking help for a drink problem is only one of a number of ways in which the treatment episode fits into the lives of problem drinkers. Some observational evidence is presented and a reinterpretation of Costello' successful and unsuccessful treatment groupings is made in support of a treatment-use approach to evaluation.

Don't wanna go through that madness no more: quality of life satisfaction as predictor of sustained remission from illicit drug misuse

Individuals who have developed a clinical dependence on drugs and/or alcohol often report that they sought help because they were "sick and tired of being sick and tired." Quality of life (QOL) remains the missing measurement in the addictions arena. The few studies conducted to date show that QOL is typically poor during active addiction and improves as a function of remission. An intriguing question bears on the role of QOL in subsequent remission status. Reasoning that higher life satisfaction may "increase the price" of future use and thus enhance the likelihood of sustained remission, this exploratory study tests the hypotheses that QOL satisfaction prospectively predicts sustained remission, and that motivational constructs mediate the association. Inner city residents (N = 289, 53.6% male, mean age 43) remitting from chronic and severe histories of dependence to crack and/or heroin were interviewed three times at yearly interval beginning in April 2003. Logistic regression findings generally support our hypotheses: Controlling for other relevant variables, baseline life satisfaction predicted remission status 1 and 2 years later and the association was partially mediated by motivation (commitment to abstinence) although the indirect effect did not reach statistical significance. Findings underline the importance of examining the role of QOL satisfaction in remission processes. Limitations of this exploratory study are discussed, including the use of a single-item global life satisfaction rating; suggestions for future studies are discussed including the need to embrace QOL as a bona fide clinical outcome and to use comprehensive standardized QOL measures that speak to individual dimensions of functioning. Implications are noted, especially the need for the addiction field to continue moving away from the pathology-focused model of care toward a broader model that embraces multiple dimensions of positive health as a key outcome.

Pathways to long-term recovery: a preliminary investigation

Recovery from addiction is a lifelong process. While there is a large body of empirical data on the short-term effectiveness (one to two years) of various treatment modalities, very little is known about the processes of recovery over time. This is particularly unfortunate as treatment gains are often short-lived and even multiple treatment episodes do not always succeed in breaking the addiction cycle. Further, treatment represents only one of the paths to recovery. This article reports on a study of individuals in long-term recovery from substance abuse (median = 12 years) and examines the factors they cite as important in establishing and maintaining their recovery status. Key factors reported were social and community support, affiliation with 12-Step organizations and negative consequences of substance use. Implications for clinical practice and future research directions are discussed.

Explaining abstinence rates following treatment for alcohol abuse: a quantitative synthesis of patient, research design and treatment effects

We examined the relationships of treatment, patient and research design characteristics to treatment outcome (i.e. abstinence rates) in a sample of 150 treatment conditions drawn from 100 alcohol treatment outcome studies published between 1980 and 1992. Treatment characteristics were related to abstinence rates: more intensive treatments had higher abstinence rates than less intensive treatments, whereas treatments with an expressed goal other than abstinence had lower abstinence rates than treatments with an abstinence goal. When the public vs. private ownership status of the treatment facility was taken into account, the presence of behavioral elements in the treatment condition also was related to higher abstinence rates. Because of inconsistent reporting in primary studies, we assessed the effects of only one patient pre-treatment characteristic; treatment conditions with a higher proportion of socially stable patients had better outcomes. Research design characteristics were also related to abstinence rates. Treatment conditions with shorter follow-ups and treatments drawn from studies that did not use criteria to exclude more impaired subjects had better outcomes. We discuss possible reasons why our findings regarding the effects of treatment intensity and the use of exclusionary criteria differ from those in previous reviews.

Treatment outcome of 600 chemically dependent patients treated in a multimodal inpatient program including aversion therapy and pentothal interviews

A sample of 600 patients treated in a multimodal treatment program using aversion therapy and narcotherapy at three Schick freestanding addiction treatment hospitals and one Schick unit in a general hospital were followed-up. Contact was made a minimum of 12 months and as many as 20 months after completion of treatment (mean 14.7 mos.). Telephone contact was made by an independent research organization with 427 of the patients (71.2%). Of these, 65.1% were totally abstinent for 1 year after treatment and 60.2% were abstinent until follow-up a mean of 14.7 months later. Fifty-two percent of the alcoholics were using or dependent on other drugs at admission. Seventy-five of these treated for cocaine dependence and 47 treated for marijuana dependence. The cocaine 12 month and "total" abstinence (mean 14.7 mos.) rates for the 49 contacted patients were 83.7% and 81.6%, respectively. The marijuana 12 month and "total" abstinence (mean 14.7 mos.) rates for the 30 contacted patients was 70.0% for both groups. Abstinence rates for alcohol and/or other drugs were also calculated including noncontacted patients who had chart documented evidence of relapse. The most powerful predictor of success was whether or not all urges to drink or use had been eliminated (presumably by aversion therapy). Of additional importance was the use of support groups and reinforcement treatments after completion of the initial hospitalization. The two most prominent factors initiating a relapse were "intrapersonal determinants" such as stress from work or marriage/family relationships and "interpersonal determinants" such as being around others who were drinking/using or being at a celebration or special event. The two factors were of equal importance in the alcoholics. However, interpersonal determinants were far more important in the cocaine and marijuana treated patients. Increased utilization of reinforcement treatments was associated with decreased urges to drink/use and increased abstinence rates. In contrast, increased frequency of support group utilization was associated with increased urges to drink/use and lower abstinence rates. This suggests the need to take seriously patient reports of "urges" in the first year after treatment and to carefully assess the cause and initiate or update an individualized plan of treatment. Such treatment may include increased reinforcement treatments, treatment of depression, and additional assistance in coping with intrapersonal and interpersonal determinants of relapse.

A comparison of predictors of treatment drop-out of women seeking drug and alcohol treatment in a specialist women's and two traditional mixed-sex treatment services

The problem of high levels of client drop-out in drug and alcohol treatment is frequently reported in the literature. In the course of conducting an evaluation of a specialist women's treatment service, the inadequacy of the data on women-specific predictors of treatment drop-out was highlighted. Using a retrospective design, the characteristics of 160 women who left treatment less than 5 days after admission were compared to the 160 women who stayed longer than 5 days and were enrolled in the evaluation study. The findings of this study suggested that women who were employed, had a history of sexual assault (especially in adulthood), nominated alcohol as their drug of choice, were not married, older than 25 years of age and had demonstrated a sympathy with the agency's treatment philosophy were less likely to drop-out of treatment. In addition, for lesbian women, women with a history of sexual assault in childhood, and those with dependent children, attendance at a specialist women's service reduced the incidence of treatment drop-out.

Long-term abstinence from alcohol in patients receiving aversion therapy as part of a multimodal inpatient program

A sample of 200 patients who had been treated for alcoholism in a multimodal inpatient program that used aversion therapy as a treatment component was selected for outcome evaluation. One hundred sixty (80%) were located. A minimum of 13 months had elapsed since treatment (mean 20.5 months) collateral reports were used to verify self-reports in 36% of the cases. Abstinence status was determined for the first 12 months since treatment, the entire elapsed time since treatment (range 13 to 25 months, mean 20.5 months), and "current abstinence" (last 6 months). The abstinence rate for the first 12 months was 71.3%; for the total period since treatment, the rate was 65% (mean 20.5 months); the current abstinence rate was 78.1%. The data was also viewed from other perspectives. The findings of this study suggest that a multimodal alcoholism treatment program utilizing aversion conditioning is at least as acceptable to patients as counseling centered programs and can be expected to yield favorable abstinence rates.

A prospective multicentre study of in-patient treatment for alcoholics: 18- and 48-month follow-up (Munich Evaluation for Alcoholism Treatment, MEAT)

In a prospective multicentre study of 1410 alcoholics (73% men) data were collected at five different times: admission, discharge, 6, 18 and 48 months after discharge. The details from the 21 treatment centres involved were acquired from staff-members; follow-up data on patients were collected by personal interviews and/or mailed questionnaires. In all, 85%, 84% and 81% of the patients could be traced, respectively. Additionally, data of patients' sick leave days and in-patient treatment were provided by the health insurance and pension insurance institutions, respectively. Outcome criteria were drinking behaviour, working and partner situation, and subjective complaints. The drinking behaviour was divided into three rough categories: abstinent, improved and unimproved. For 18 months 53% of the patients remained abstinent, 8.5% improved and 38% did not improve. For 48 months 46% remained abstinent, 12% improved and 42% did not improve. During the last 6 months prior to the 48-month data collection 66% were abstinent, 4% improved and 30% did not improve. Only 3% of patients succeeded in maintaining controlled drinking. The percentage of days of sick leave was reduced by 64% and of in-patient treatment from 34.7% to 14.6% during the 18-month period after discharge (in comparison with the 18-month period prior to treatment). Only 21% of the patients regularly attended self-help groups. Out of the patients' variables, ten for men and five for women could be identified as prognostically relevant. In the 48-month follow-up these factors were reconsidered. In men almost all, in women only three of the five factors were confirmed. The treatment variables were evaluated according to the prognosis factors (positive vs negative group). In the 48-month follow-up the treatment variables relevant in the 18-month follow-up were also reassessed. In the positive prognosis group five variables were confirmed, in the negative prognosis group only one. In addition, differentiated indication variables for the three treatment lengths were developed and applied to a model. The following appeared to be clues regarding the length of desirable treatment. For an unfavourable prognosis in both men and women no short-term treatment should be given; medium- or long-term treatment is to be preferred. For a medium prognosis men do better with short-term treatment; for women medium-treatment is preferred. For a favourable prognosis for men medium-term treatment should be avoided; long-term is preferred; for women short-term treatment may also be preferred.

An outcome study comparing refusers and acceptors of treatment for alcoholism

Fifteen matched pairs of alcoholics who had either refused or completed day treatment were reassessed sixteen months after the initial assessment. The treated group had improved significantly more than the untreated group on measures related directly to alcohol abuse, in their utilization of inpatient psychiatric services, and the use of family physician's services. The treated group had also used disulfiram for significantly longer periods of time. The treatment refusers had nonetheless achieved statistically significant, albeit modest, reduction in their consumption of alcohol compared to their pre-assessment levels. Both groups showed equal amount of change on a number of psychosocial measures, such as employment, use of minor tranquilizers and non-prescription drugs, legal problems and symptoms of depression. These findings are discussed in the context of the effectiveness of a day program, the use of disulfiram and certain pretreatment characteristics of the patient.

Day treatment of alcoholism: an outcome study

Thirty-seven (27 male and 10 female) alcoholics, treated in a brief day program, were assessed on a number of alcohol related and psychosocial variables 15 months following the initial treatment. Thirty percent (30%) remained totally abstinent, another 30% reduced their drinking to less than 10%, and 35% showed a moderate reduction of 10 to 50% in their pre-treatment drinking. Significant reduction was reported by these patients in their utilization of health services for purposes of detoxification, psychiatric treatment, visits to the family physician, and emergency department. Improvement was also reported on employment status, legal problems, general emotional state and some symptoms suggestive of depression. These findings are discussed in the light of the viability of cost effective day treatment programs for alcoholism within the context of general hospital psychiatric services.

Prospective study of alcoholism treatment. Eight-year follow-up

One hundred patients admitted for alcohol withdrawal were followed for eight years. At the eight year mark, 25 percent had achieved stable abstinence of three years' duration or more, and 29 percent had died. Only 26 percent experienced continued serious problems with alcohol. Premorbid social stability and sustained abstinence made independent contributions to good psychosocial outcome at eight years. Premorbid social stability and Alcoholics Anonymous attendance made independent contributions to sustained abstinence. Review of these data and other major longitudinal studies suggests that factors other than professionally organized treatment per se exert substantial effect upon long-term outcome.

The relationship of alcoholism and alcohol abuse to the abuse of other drugs

The abuse of drugs by alcoholics, the abuse of alcohol by drug abusers, the prevalence of alcohol abuse in polydrug clients, and the role of alcohol as a steppingstone are examined quantitatively over the past decade. The increase of drug abuse by alcoholics and the increase of alcohol abuse and alcoholism by polydrug abusers is documented. This is accounted for mainly by an increase of drug abuse in younger and/or female alcoholics. The abuse of alcohol by heroin addicts has also increased, particularly when heroin purity diminishes and when these clients cycle through methadone maintenance. However, much of the alcoholism in these patients began prior to the onset of heroin use and dependence. Methods of treatment modifications necessary to deal with problems presented by these combinations are discussed.

Outcome of alcoholism treatment among 5578 patients in an urban comprehensive hospital-based program: application of a computerized data system

The Elmhurst Alcoholism Program data system relates fraction of time patients are in remission to length of time they are know, and permits a systematic search for groups of variables which predict greater abstinence rates. Our program (inpatient detoxification ward, multidisciplinary outpatient clinic, and halfway house) sets abstinence as a goal. After initial data collection (social and demographic variables, income, education, residence, drinking and drug history, legal problems, and prior treatment), we collect data at 30 days after admission and at 2- or 3-month intervals thereafter from all patients who remain in contact. Forty-five percent of all patients are lost before 30 days. Only 32% of those still under observation at 1 yr and 27% of those still under observation at 2 yr claim continual abstinence. From among many combinations of variables examined for predictive power, a group of five was chosen as best. Patients who at their first follow-up interview reported attending AA meetings and taking Antabuse and who in addition had a job at admission, were older, and were admitted through the clinic rather than through inpatient detoxification had a greater fraction of time abstinent. Nevertheless, the best cluster of predictor variables did not account for more than 25% of the variation in rates of abstinence. Many social variables are not independent, and some may merely be indicators of duration or severity of alcoholism. Contemporary alcoholism treatment is, at best, of limited effectiveness.

Factors related to "stable" and "unstable" affiliation with alcoholics anonymous

The study suggests that A.A. affiliates who are among the more seriously impaired when they come to A.A. tend to make less stable members of this organization. Also, affiliates who are younger, male, lower in SES, have more slips, are in A.A. shorter time, and less involved in A.A. activities tend to be less stable members. Implications for treatment are suggested.

Utilization of medical services by alcoholics participating in an outpatient treatment program

Utilization of medical services by alcoholics participating in an outpatient alcoholism treatment program was examined, comparing these with alcoholics who chose not to participate.

Second-year alcoholism treatment outcome evaluation with a focus on Mexican-American patients

This is an evaluation of an Alcohol Treatment Unit with a focus on a comparison of Mexican-American and Anglo-American outcomes. Social adjustment on a target cohort of 75 was measured on a standard rating instrument (SAI) 2 years after discharge from the hospital. The overall successfulness of the program was 39%; the validity of the Treatment Difficulty Scale (a composite index of anticipated treatment difficulty) was demonstrated for both ethnic groups and both first and second year outcome results; and the average stability of first year findings of SAI components as compared to second year results was shown to be 79%. Use of a standardized index of pretreatment patient characteristics was recommended to facilitate comparative program evaluation research.

Alcoholism, heroin dependency, and methadone maintenance: alternatives and aids to conventional methods of therapy

Alcohol is one of the drugs most frequently used by heroin addicts prior to inception of heroin addiction. It is therefore not surprising that alcohol also represents the drug most frequently abused by persons on methadone maintenance. This abuse not only results in the appearance of all the previously known complications secondary to excessive alcohol intake, but is also a major factor in preventing successful rehabilitation while on methadone therapy. Conventional means of therapy, through abstinence and/or Antabuse, have not met with success or a good degree of patient acceptance. A multimodal approach utilizing controlled drinking, abstinence, and Antabuse along with identification of cues triggering excessive drinking may serve to attract greater numbers of persons with dependency for narcotics and alcohol into the therapeutic setting.

Comprehensive alcohol treatment planning, implementation, and evaluation

A descriptive overview of a developing comprehensive alcohol treatment program is presented. The influence of staffing practices and client recruitment on implementation of treatment components is reviewed. Program evaluation and current issues regarding such evaluation are discussed.