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Residential rehabilitation: the high road to recovery?

Should dependent drinkers always try for abstinence?

It’s magic: prevent substance use problems without mentioning drugs

Residential rehabilitation: the high road to recovery?

“I would like to … try to provide – difficult though it will be given the shortage of money we have been left – more residential treatment programmes. In the end, the way you get drug addicts clean is by getting them off drugs altogether, challenging their addiction rather than just replacing one opiate with another.”

These comments, made by former Prime Minister David Cameron in August 2010, were reiterated in February 2015 when he said he remained “committed to funding residential, abstinence-based rehabilitation, difficult though it may be in the current climate. Rather than maintaining people on substitutes like methadone, we have to help more people get off drugs and into work.” His words both reflected and promised to embed in policy the current emphasis on treatment which explicitly aims for recovery, reintegration and abstinence, trends which in turn have focused attention on what has been seen as the treatment best suited to all three – residential rehabilitation. However, add the claim that residential treatment has been side-lined in pursuit of ‘manage the problem’ objectives, and the fact that they are among the most expensive options at a time of financial cutbacks, and you have a combustible mixture.

What does residential rehabilitation have to offer?

‘Residential rehabilitation’ is the umbrella term for programmes which require residents to stay overnight at a facility to receive treatment, and typically expect residents to be drug and alcohol free before they start (though in some cases detoxification is offered by the centres themselves as the first of the treatment). Beyond these common factors, programmes may differ according to their philosophy, intensity, inclusion criteria, programme content, and duration.

One simple way to look at what residential rehabilitation has to offer is to break it down into those with rehabilitative versus supportive goals: rehabilitative programmes provide a structured, care-planned programme of therapeutic and other activities; whereas supportive programmes provide specialist drug/alcohol and related support, often following treatment in a rehabilitative programme, but no structured therapy ( illustration).

Models of residential programmes (National Treatment Agency for Substance Misuse)

Models of residential programmes (National Treatment Agency for Substance Misuse)

Characteristics of effective residential rehabilitation, according to the National Treatment Agency for Substance Misuse, include:
• Comprehensive assessments of clients
• Respecting client choice
• Planning and reviewing care (as well as departure and aftercare)
• Attention to housing, education, training, and employment support needs
• Developing social and life skills

A useful set of quality standards have been developed by the Recovery Partnership (formed in 2011 by DrugScope, the Recovery Group UK, and the Substance Misuse Skills Consortium). These are intended to help providers demonstrate the quality of residential rehabilitation to commissioners, purchasers, clients, and their families.

A good investment?

The present government remains focused on reducing public expenditure and welfare spending. Consequently, the relatively high cost residential rehabilitation is expected to show that it could save the Exchequer more than non-residential treatments dominated by opiate substitute prescribing.

Based on the 2009/10 treatment intake for England, a study was undertaken by the Department for Work and Pensions, whose then leader Iain Duncan Smith had forefronted welfare benefit constraints and backed the ‘full recovery’ drug-free rehabilitation options exemplified by residential rehabilitation, while condemning reliance on opiate substitute prescribing.

Net public sector costs or savings associated with treatment pathways for opiate users, for 2009/10 treatment starters to end March 2012. Shows that at all levels of treatment difficulty (complexity) and for residential and non-residential pathways there were net costs, and that these were greater for residential pathways

Though set up to determine whether the public purse would gain by sending more opiate-dependent clients to residential rehabilitation, in the end his department’s study declared itself unable to conclude one way or the other, but did judge it “highly unlikely” that these treatments’ extra expense would be offset by extra savings. If anything, the report suggested that non-residential, prescribing-dominated options were a better deal for society in its attempts to contain public sector costs, when these costs include the costs of treatment itself chart. It must have been a special concern that welfare spending uniformly moved in the ‘wrong’ direction after entering treatment, and the resultant losses to the Exchequer were particularly steep in respect of clients on treatment pathways which featured residential rehabilitation, presumed to be due to their stabilisation and the advice and help they received to claim their entitlements.

But if it was not clearly best for the public purse, for the patients and their families, residential rehabilitation might still have been considered a good investment. As defined by the study (entailing planned treatment exit and non-return), patients on pathways which included residential rehabilitation were consistently more likely to register positive treatment completions than those on entirely non-residential pathways. For example, 16% of very high complexity clients left residential pathways successfully with no later records indicative of relapse compared to just 6% whose treatment had not included residential rehabilitation. At the other end of the scale, for low complexity clients the corresponding figures were 31% and 21%. Beyond purely financial considerations is the argument that medical and allied treatments, including the treatment of addiction, are not primarily undertaken to save money for the public sector, but to use that money to relieve illness and distress. On this count residential rehabilitation scores relatively heavily.

One gap in the study was its limited data on the psychological differences between residential and non-residential pathway clients which might have affected their chances of recovery, regardless of the treatment option. Drawing its data from a national study of patients starting drug treatment in England in 2006–2007, an analysis examined this issue for opiate users, the same type of patients included in the study from the Department for Work and Pensions. It found that compared to those prescribed substitute drugs such as methadone, opiate users whose treatment had included residential rehabilitation were from the start more ambitious for their future and more motivated and ready to recover through treatment. The differences were not huge, but enough for the researchers to suggest that “higher treatment motivation in [residential rehabilitation] participants may account for the effectiveness of [residential rehabilitation] compared with other treatment modalities,” and that sending more patients to residential rehabilitation without ensuring they are sufficiently motivated is “unlikely to lead to an expansion of successful treatment outcomes.”

A 2010 review found that comparative studies of the cost-benefits of residential and non-residential treatments are actually few and far between. It challenged the widespread assumption that community-based treatments ‘must’ be the cheaper option, reporting that only a small number of studies had findings to this effect, and these “were less than definitive”. One study concluded that the benefits of residential treatment may be realised over a much longer time frame than accommodated in most research, advocating follow-up periods closer to six years than one or two years.

A last resort?

In 2011, concerned that they were being side-lined, British residential services banded together in a Concordat to promote their cause as “providers of full recovery”, defined as moving towards a drug-free, productive and socially integrated life. Their terminology was echoed the following year in a highly contested follow-up to the national drug strategy entitled Putting full recovery first, described by the chair of the Inter-Ministerial Group on Drugs as “the Government’s roadmap for building a new treatment system based on recovery”. What it meant by “full recovery” was never spelled out, nor how it differs from plain “recovery”, but adopting this objective was said to entail an “increased focus on abstinence-based treatment” and a relegation of “indefinite maintenance, which is a replacement of one dependency with another” to the periphery rather than the centre of opiate addiction treatment.

A survey of (16 of 28) members of the Concordat highlighted a lack of referrals, related to the common insistence (1 2) by local authority funders of residential care that prospective residents must first have exhausted other treatment options, and unrealistically proved their commitment to rehabilitation by complying with preparatory work, when the reason for their referral is precisely that they have been unable to overcome their dependence without the shelter of a residential setting. All but four respondents reported that “their service was under threat of closure for 2010/11”.

Though there was no immediate prospect of wholesale closure, a survey in 2014 of services in England and the commissioners largely responsible for funding them suggested that residential services had cause to be worried. Funding levels had yet to dramatically change, but 44% of services said adult social care funding had fallen and just 18% that it had increased, while twice as many commissioners (33%) foresaw their funding of these services falling as predicted it to rise (16%). Over two-thirds (70%) reported they had recently commissioned more non-residential abstinence-based services, while twice as many (about a third) thought their spending on residential services would decrease than increase. Just how precarious things had become was evident in the finding that six in ten services had recently felt under threat of closure. In what could become a vicious cycle, it seemed service quality was beginning to suffer, diminishing the difference between residential and non-residential provision, and offering further reasons for transferring funding to cheaper non-residential provision. Nevertheless, up to year 2013/14 occupancy levels and numbers in residential treatment held up well.

Commissioners who insist residential care should be a last resort can and do claim the authority of Britain’s National Institute for Health and Care Excellence (NICE). Based partly on not even a handful of studies recording no overall advantage for residential care over alternatives, NICE’s experts advised that residential treatment be reserved for substance users with “significant comorbid physical, mental health or social (for example, housing) problems”, who should have “not benefited from previous community-based psychosocial treatment.”

Most influential among the studies reviewed for NICE was a randomised comparison of a non-residential day therapeutic community versus a residential version for US crack users. It found no lasting anti-relapse benefits from the residential setting but – as in several other trials – the researchers had to limit the severity of their subjects so that all could safely be sent to either residential or non-residential care. The result was that nearly three-quarters of potential participants could not join the study, and those who could were the ones least likely to need and differentially benefit from residential care.

Critics of NICE’s ‘last resort’ position argue that the reason why some clients are in such poor mental, physical and/or social states is that residential rehabilitation had been denied them earlier in their drug using careers when they had a greater chance of succeeding before the deterioration became too deep. The opposing argument is that trying residential services first risks unnecessary expenditure which drains treatment resources because it is impossible to predict with any certainty who will do well and who badly after their spell at the rehabilitation centre.

NICE have briefly alluded to the success of residential rehabilitation for people further down the scale of severity in their guidance, saying that “While traditional practice in the UK has been for service users to be referred for residential treatment when they have failed a long period of community care, there is some evidence to suggest that those less well established in their drug using careers may benefit from residential care”. However, this point was not examined in any further detail, nor reflected in their recommendations.

Limitations as well as advantages

A distinctive feature of residential rehabilitation is the 24-hour-a-day sheltering of the patient in a setting away from home – a protected environment far removed from the temptations and pressures which helped sustain the client’s addiction. What might sound like ideal conditions was interpreted differently by William White, US guru of re-orienting treatment and allied systems to recovery objectives and principles. In his key work on systems of care he pointed out that the non-recovery oriented systems he seeks to transform “grew out of a tradition of isolating addicted persons from their natural physical and social environments [to] enter a closed therapeutic environment” such as a residential treatment programme or therapeutic community. As he saw it, the problem was that learning to live without drugs there is likely to be unlearnt on transfer to a different environment: “The greater the physical, psychological, social, and cultural distance between the treatment environment and the natural environment of the client, the greater will be this transfer-of-learning challenge.” Part of the solution, he argued, is a “greater emphasis on delivering home- and neighborhood-based (eg, health clinics, neighbourhood centers) addiction treatment and recovery support services” – the antithesis of the traditional model of residential rehabilitation in Britain. Considering these points in light of his experience in UK residential treatment, professional Dominic McCann said the following: “To my mind the “transfer of learning challenge” is White’s critique of the old therapeutic communities, with their highly artificial cultures and lengthy treatment programmes. But in modern/medical models of residential treatment, the patient is away from home for shorter periods, and treatment centres go to great lengths nowadays to prepare patients for reintegration and relapse prevention.”

For those who choose residential rehabilitation, follow-on treatment or support may be needed, especially due to the inherent challenges of sustaining sobriety in everyday life, and the elevated risk of overdose after leaving residential treatment. The illustration below highlights some data from a 2012 audit, showing that “when people complete their treatment at residential rehab they frequently require continued structured support from other parts of the system before they are ready to complete their treatment for drug or alcohol dependency”. The proportion of clients successfully completing treatment was defined as “being judged by a clinician to have overcome dependency on the substance for which the user is admitted to treatment, and no longer having a structured treatment need”.

The treatment journey of 3,972 residential rehabilitation residents

The treatment journey of 3,972 residential rehabilitation residents

Residential rehabilitation can have great advantages for people who need respite, shelter and wrap-around care, but is rarely a one-off solution to the deep-seated and multiple problems of the typical resident. Also for some, entering a ‘home’ may be too distressing or disruptive to countenance, particularly if it involves separation from their family. A UK report on women’s treatment needs pointed out that placing women in residential services without their children is not too dissimilar to sending them to prison, where travel costs and time may limit the amount of contact with their children. Such stressors could understandably impact on their ability and resolve to complete treatment and rehabilitation (an argument which would apply to others too). NICE states that “the needs of people with children should be considered so that children are appropriately looked after while their parents enter residential rehabilitative treatment”, which according to the National Treatment Agency for Substance Misuse could include accommodation for the whole family, as well childcare facilities while residents are in counselling or groupwork, and family therapeutic and education interventions, such as parenting education – though one would expect these facilities to be hard to come by.

Research prospects

Douglas L. Polcin examined the strengths and weaknesses of different research designs for studying residential rehabilitation treatment. He identified a “host of important factors that need attention”, in order to generate findings which “are more informative, intuitively appealing, and interpretable”. This includes research into understudied areas, and the resolution of challenges with randomised trials versus more naturalistic/real-life research methods.

Randomised trials are generally considered the ‘gold standard’ in research, but in comparing non-residential to residential rehabilitation, they are usually forced to exclude people whom it would be unsafe or unethical to leave ‘on the streets’, the very people who might benefit most from a residential option. This design can create a “false comparison”. The random allocation aspect that enables researchers to draw conclusions about cause and effect may also be obscuring or eliminating an important step in recovery: the mutual selection process between the applicant and the recovery home, where residents enter the residential environment because they are a good match, not because they were assigned there. Further research using random assignment could consider “assign[ing] individuals to a broad recovery home condition that allows individuals to pursue residence in different recovery houses rather than one specific house”, allowing for some degree of mutual selection, or “assign[ing] residents to an enhanced recovery house condition versus recovery housing as usual after they enter the house”.

Additional research would be beneficial in the following areas: residential homes for specific populations (eg, criminal justice, women with children, and sexual minority groups); architectural features that influence social interaction and neighbour perceptions; homes that can accommodate low income, inner-city residents; and good candidates for different levels of service intensity.

See what the researchers have discovered by running this hot topic search – but beware that no conclusive answer to the residential v. non-residential question can be found. Our reading of the research is that while non-residential care is sufficient for many clients, residential care has particular benefits for the minority who are most severely affected. For this topic we are also making available these unpublished notes on studies comparing residential and non-residential care.

Thanks for their comments on this entry in draft to Rowdy Yates, President of the European Federation of Therapeutic Communities. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 01 February 2017. First uploaded 29 March 2010

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It’s magic: prevent substance use problems without mentioning drugs

Not magic at all of course, but a consequence of the fact that substance use problems are closely related to other problems which often develop at early ages when substance use is just not on the agenda. The 2010 English national drug strategy and corresponding public health plans seemed to recognise this, breaking with previous versions to focus attention on early years parenting in general, and particularly among vulnerable families.

Though studies are few compared to approaches such as drug education (1) in schools (for which, see this Effectiveness Bank hot topic), this renewed emphasis on the early years has a strong theoretical rationale and some research backing. Child development and parenting programmes which do not mention substances at all (or only peripherally) have recorded some of the most substantial prevention impacts. Though mainly targeted at the early years, some extend to early teenage pupils and their families. The rationale for intervention rests partly on strong evidence that schools which develop supportive, engaging and inclusive cultures, and which offer opportunities to participate in school decision-making and extracurricular activities, create better outcomes across many domains, including non-normative substance use. As well as facilitating bonding with the school, such schools are likely to make it easier for pupils to seek and receive the support they need.

Understandably, such findings do not derive from random allocation of pupils to ‘good’ versus ‘bad’ schools, so are vulnerable to other influences the study was unable to account for. More convincing, if more limited in intervention scope, are studies which deliberately intervene and test what happens among young people randomly allocated to the focal intervention versus a comparator. An early example was a seminal Dutch drug education study of the early ’70s. So profound was its impact in Britain that we have analysed it in detail, contacting the original author. The surprising findings are outlined below.

Dutch study challenges the prevailing logic of drug education

The Dutch study involved 1035 Rotterdam pupils aged 14–16 years whose 20 schools were allocated to one of four sets. Two sets ran programmes delivered by outside experts, who attempted to ‘inoculate’ pupils against illegal drug use – one by stressing the dangers and moral dimensions of drug use, and the other by filling gaps in pupils’ knowledge which were presumed to underlie drug use. The third programme applied a person-centred approach; led by their usual teachers, pupils were given the opportunity to discuss problems of adolescence (rather than drugs specifically or exclusively) over 10 weekly one-hour classes. The fourth set formed a control group, whose pupils received no specific programme; measurements of their knowledge, attitudes, and use of drugs could be used to benchmark the impacts of the specific interventions.

Fewer pupils in the person-centred group (2.6%) went on to try drugs than those in the warning group (7.3%), the information group (4.6%) and the control group (3.6%). The results started to unravel the logic that dominated drug education in the Netherlands, the UK, and elsewhere. Educators had to face the possibility that warning of the danger of drugs could in itself be dangerous. Julian Cohen, the author of several well-known drug education packages, observed that “fear arousal was not only ineffective but sometimes counterproductive”. According to the research author Dr. Willy de Haes, who had been in touch with the Scottish Health Education Group, there was resistance to these findings informing policy change in Britain. The Thatcher government was committed to a “hard-hitting campaign featuring frightening images on the theme that ‘drug use leads to death’ ”, delivering in the 1980s an explicitly anti-drug “Heroin screws you up” campaign. Successive governments however moved away from the scare tactics exposed as ineffective in the 1970s – UK Government policy between 2010 and 2015, for example, included “supporting children in the first years of their life so that we reduce the risk of them engaging in risky behaviour (like misusing drugs) later in life” and “providing accurate information on drugs and alcohol through drug education and the FRANK service” (FRANK is a national drug education service, providing friendly, confidential drugs advice).

Teaching good behaviour can protect against drug and alcohol problems later on

Among the most prominent and promising of current approaches is the Good Behaviour Game classroom management technique for the first years of primary schooling. Well and consistently implemented, by age 19–21 it was estimated that this would cut rates of alcohol use disorders from 20% to 13% and halve drug use disorders among the boys.

Good Behavior Game rules displayed on the classroom wall and to the left a poster with names of children assigned to each team

With four simple rules ( illustration), the Game seeks to create pro-social attitudes among pupils and a positive learning environment, helping in the short-term to improve children’s behaviour and their engagement in school, and in the longer-term, improve educational attainment and increase resilience.

Mentor, a charity specialising in the prevention of drug and alcohol problems among people, is currently running a two-year trial to measure the impact of the Good Behaviour Game in UK schools. Click here to see what pupils and teachers participating in this trial think about the Game.

Findings demonstrating the success of the Game (1 2 3) appear to support the theory that early and continuing aggressive, disruptive behaviour is a precursor to the development of drug use and other externalising behaviours (such as high-risk sexual behaviour). By young adulthood the most significant impact of the Game on drug use and dependence disorders has been found among males who throughout their early–mid school career were more aggressive, disruptive. The same programme has been combined with parenting classes, leading to reductions in the uptake and frequency of substance use over the next three years.

Other examples include a study in Norway which raised the intriguing possibility that taking measures to effectively reduce bullying in schools could help prevent some of the most worrying forms of substance use, and the Positive Action programme which focused on improving school climate and pupil character development. In Hawaii and then the more difficult schools of Chicago, Positive Action had substantial and, in Chicago, lasting preventive impacts.

Strengthening the family unit may confer benefits too

In Britain perhaps the best-known programme aiming to help generate healthy family development is the version of the US Strengthening Families programme aimed at young people aged 10–14 years, which in the early 2000s impressed British alcohol prevention reviewers. It features parent-child play sessions, during which parents are coached in how to enjoy being with their children and to reinforce good behaviour. At first the accent is on building up the positives before tackling the more thorny issues of limit-setting and discipline. Though the potential seems great, later research in the US has not been wholly positive, and earlier results were derived from a minority of families prepared or able to participate in the interventions and complete the studies. A recent study in Poland (a large randomised controlled trial) also found no evidence for the effectiveness of Strengthening Families on the prevention of alcohol or tobacco use at 12- or 24-month follow-ups.

As of yet, there has been no trial of the Strengthening Families Programme in the UK – only an exploratory study of the adaptation of programme materials and approach to the UK context. These findings indicated that parents, carers, and young people enjoyed the intervention, and felt it had played a part in improving their family functioning, for example through:
• improving parent/caregiver communication;
• increasing the repertoire for dealing with situations;
• developing better positive and negative feedback;
• working more closely with mum and dad;
• learning to listen more;
• changing the code of behaviour.

Risk factors and protective factors: The bigger picture

The prevention activities discussed above ultimately seek to reduce ‘risk factors’ for harmful substance use (attributes or conditions that increase level of risk) and bolster ‘protective factors’ (attributes or conditions that mitigate risk), by intervening at an early stage to modify the immediate (personal, family, school) environment of young people and the way that they interact with it.

This focus on children and their families as the ‘site of the problem’ has shown success, but our gaze should not merely be fixed here. Poverty has an enormous burden on people’s lives, and in both direct and indirect ways is linked to the development of substance use issues (1 2). These “structural disadvantages, limited opportunities, alternatives and resources”, as academic Julian Buchanan puts it, signify another layer of preventative work for us to engage with – a broader way of preventing substance use problems, without focusing on substance use. In the US, the Strategic Prevention Framework guides substance use professionals to bring about population-level change by addressing the “constellation of risk and protective factors associated with substance misuse in [any] given community”. In this way, they argue, they “are more likely to create an environment that helps people support healthy decision-making”. Although “concentrating upon individual motivation and psychological strategies for change are helpful and important components” says Buchanan, “the discrimination, isolation and powerlessness faced by many problem drug users must be understood and incorporated within a social model of problem drug use”.

The present hot topic focused on those preventive impacts from school and parenting initiatives which are not about substance use at all, but about creating environments at home and in school which foster psychologically and socially healthy child development. Isolating such studies is not possible via our normal search facilities, so we have specially identified and coded them. They may prove to be the future for drug prevention, as traditional drug education struggles for credibility as a prevention tool. See how this future is shaping up today by running this hot topic search.

Last revised 23 January 2017. First uploaded 01 March 2010

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Should dependent drinkers always try for abstinence?

The issue of whether dependent drinkers should always be advised to try for abstinence has been central to alcohol dependence and its treatment for decades. Far from receding into a box marked ‘pointless debates’, prioritising abstinence as a treatment objective has recently returned to prominence as an essential component of influential visions of ‘recovery’. Not so long ago the issue in Britain and elsewhere was not just about what patients should be advised, but whether they should actually be denied treatment until deterioration forced them to accept the need to stop drinking altogether and forever. Here we look at the milestones in this debate, subject to the bitterest controversies ever seen in addiction treatment.

Why such heat over a seemingly innocuous decision between patient and clinician on which form of reduced drinking to go for? In part it was generated by concerns on the one hand that allowing controlled drinking would let alcoholicsassumed constitutionally unable to stop drinking once they start off the hook of non-drinking and set them up to fail, and on the other that insisting on abstinence did nothing to improve outcomes but did limit treatment to the minority of problem drinkersthe alternative being to widen interventions to, and appeal to, less dependent and non-dependent heavy drinkers prepared to countenance a life without drink. Behind this were alternate visions of dependence as a distinct category characterised by inevitable loss of control, or one end of a continuum of learnt behaviour which even at its most extreme can be replaced by learning to drink in moderation.

For more see this US account and if you can this British perspective (turn to chapter four of the book). See also this Effectiveness Bank analysis of a recent UK study (the background notes are particularly informative) and this recent review.

This entry is based on cell C4, one of 25 cells in the Alcohol Treatment Matrix. This and the corresponding Drug Treatment Matrix map treatment sectors and influences which might affect impact, and for each sub-territory (a cell) list the most important UK-relevant research, reviews and guidance.

Gentlemanly start

The controversy dates back at least to a 1962 report by British psychiatrist D. L. Davies on seven ‘alcoholic’ patients from south London’s Maudsley Hospital said to have sustained controlled drinking. In 1994, collectively they were judged to have deceived a research-naive clinician. The basis for this reassessment was a 1985 paper documenting interviews with the patients and others and a (re)examination of records, to which the original author (he had died three years before) was unable to respond. The allegations came from the prestigious figure of Griffith Edwards, who later embraced normal drinking as a goal for many patients, but maintained that (emphasis added) “abstinence is the only feasible objective” for those with a fully developed history of dependence. Among his criteria for identifying who should attempt which were those (see below) trialled by the Sobells in the USA.

That episode was relatively gentlemanly and limited to professional circles, but the following decade bitter disputes originating with US research literally hit the headlines and spread across TV networks, in one case spawning legal proceedings. One major spat centred on a 1976 report from the Rand Corporation on new government alcoholism treatment centres. It found that fairly complete remission was the norm, that most patients achieved this without altogether stopping drinking, and that as many resumed normal drinking as sustained abstinence. Aware of the storm their findings might provoke, the authors disavowed any intention to recommend alcoholics resume drinking. Nevertheless the storm broke, as holding out the prospect of controlled drinking was likened to “playing Russian roulette with the lives of human beings”. With striking prescience, the authors themselves felt the most important implication of their findings was that “the key ingredient in remission may be a client’s decision to seek and remain in treatment rather than the specific nature of the treatment received” – an insight revisited decades later after another major US study – the Project MATCH trial, highlighted in cell A2 of the Alcohol Treatment Matrix.

Sobells in the firing line

One reason the Rand authors knew their findings might be controversial was the reaction three years before to an audacious and for the time methodologically advanced experiment conducted by husband and wife team Mark and Linda Sobell. They had allocated hospitalised physically dependent alcoholics with what generally seemed a poor prognosis either to try for abstinence or for controlled drinking, the latter chosen principally on the basis that patients had asked for this, shown in the past they could manage it, and had a supportive environment to return to on discharge. Within each group, half were allocated to normal abstinence-oriented treatment and half to a radical procedure geared either to the abstinence or controlled-drinking goal to which the patient had been assigned. It entailed allowing patients to drink, showing them via videos how they looked when drunk, and training them how to manage or avoid what for them were situations conducive to drinking or over-consumption.

Over the last half of the follow-up year patients assigned to try for controlled drinking, and who had been trained how to manage this, spent nearly three-quarters of the time out of hospital and prison and not drinking heavily, though all but four of the 40 continued to drink – the best results of all the patients. Those given the same treatment but selected for abstinence did almost as well, but many more did so via not drinking at all. It seemed a clear vindication of an intervention based on seeing addiction as a learnt behaviour and of the judicious allocation of even physically dependent patients to try to learn moderation. Controlled-drinking patients had been selected partly because of their “sincere dissatisfaction with [Alcoholics Anonymous] and with traditional treatment modalities”; the study showed this rejection of US orthodoxy need not condemn them to the progressive deterioration predicted for untreated alcoholics.

Just as with Davies’ research at the Maudsley, a later follow-up of the same patients cast doubt on the validity of the findings, and led one of the authors to publicly (in the New York Times) allege scientific fraud. The Sobells were cleared by an investigation set up by their employers and by one commissioned by a committee of the US Congress, and their research (though sharing some of the flaws characteristic of the time) was judged fairly presented.

…many drinkers will not accept interventions which presuppose abstinence

In 1995 (and again in 2011) the Sobells revisited controlled drinking as a treatment objective in an editorial for the Addiction journal, which attracted eight commentaries. It accepted that “Recoveries of individuals who have been severely dependent on alcohol predominantly involve abstinence”, possibly because poor social support and lack of a stake in society in the form of a career and a job tend to go along with severity of dependence. Beyond this minority, they argued that reducing alcohol-related harm across the population demanded acceptance of the moderation goal because many (especially less or non-dependent) drinkers simply will not accept interventions which presuppose abstinence.

Their argument had been demonstrated in a Canadian trial which tried to randomly allocate drinkers to treatment aiming for abstinence or moderation. Most seemed to be drinking heavily enough to meet criteria for dependence but had yet to be severely affected by their drinking. Of the 35 allocated to abstinence, 23 either rejected it or expressed reservations, compared with just five of the 35 allocated to controlled drinking. That was at the start of treatment. After it had ended the picture was the same: whatever goal had been impressed on them by their clinicians, most in the end chose to drink moderately.

A study which similarly allocated patients to receive either abstinence- or controlled drinking-oriented treatment (albeit on a smaller scale, 24 problem drinkers compared with 70 above) found that both abstinent and ‘asymptomatic’ (still drinking, but evidently free of alcohol-related problems and dependence) drinking outcomes occurred regardless of the drinking goals assigned.

Patient choice and shared decision-making

But, how do patients fare if they opt for (as opposed to being assigned) abstinence versus moderation as an initial treatment goal? The UKATT study – Britain’s largest alcohol treatment trial – tested different forms of psychosocial therapy for 742 patients seeking treatment for alcohol problems at specialist treatment services in England and Wales. According to a secondary analysis of the results, regardless of their initial choice, patients did equally well, and among those who at first wanted to stop drinking altogether, more substantially reduced their drink-related problems while continuing to drink than did so by abstaining.

UKATT was among the studies assessed in a recent European review whose conclusions were largely in line with others from North America, though perhaps more enthusiastic about embracing moderation as a treatment goal in order to make treatment attractive to the (in various studies) 20–80% of dependent drinkers who prefer it. The review seemed to advocate shared decision-making (between patient and clinician) when selecting a treatment goal, with moderation as well as abstinence available, so the patient is engaged in making a positive choice rather than being ‘told’ what to do. This message was echoed in another review – in fact the first review to explicitly evaluate patient preferences for treatment goals and decision-making. It noted that nearly half of patients in three study groups preferred a reduction of alcohol consumption to a non-problematic amount, whereas 15% preferred to be completely abstinent; in contrast, two studies found that most patients preferred abstinence to moderate drinking. When patients with alcohol use disorders in one study were matched to their preferred treatments, no differences were found for number of drinking days and number of days intoxicated. However, in another study matched patients drank less over time than unmatched patients.

Shared decision-making has been shown to lead to patients becoming more independent and more able to stand up for themselves (reflected in their greater movement towards feelings of autonomy, control and extraversion). In practice, however, patient reliance on clinicians to help navigate through ‘confusing and unpredictable’ treatment pathways may undermine the ethos of shared decision-making, tipping the scales of power towards clinicians.

This UK-based study identified the need for treatment pathways to be more patient-friendly – better reflecting the capacity and capabilities of patients with alcohol dependence – and for health care professionals to support and build self-efficacy among patients (their belief in being able to succeed). It also highlighted some differences among patients, and between patients and clinicians, about the meaning of alcohol dependence and the treatment itself, with implications for shared decision-making. Among the 20 patients interviewed at alcohol treatment services in London, definitions of alcohol dependence varied widely – for some depending on volume or strength of alcohol consumed, and for others representing a need (as opposed to a want) to keep drinking – influencing their views about what and who treatment was for. Many saw ‘cutting down’ as an important step in being able to achieve abstinence and/or regain control of drinking – differing from their practitioners, who apparently tended to be supportive of cutting down only to the extent that it was a step towards abstinence, not a goal in itself. From the patient perspective, moderation could be both a means to an end, and the end in itself, problematising the mainstream clinical view of abstinence and drinking in moderation as mutually exclusive alternatives.

The following US study suggests that practitioners may be less inclined to support moderation as the treatment goal among patients with more severe drinking problems. The web-based survey of 913 addiction professionals revealed that the extent to which clinicians are supportive of non-abstinence goals is likely to depend on whether the patient is deemed to have alcohol problems or to be alcohol dependent. Where over half of respondents reported non-abstinent drinking patterns to be acceptable as intermediate (58%) and final (51%) outcome goals for people with alcohol problems, considerably fewer rated this as acceptable for clients with alcohol dependence (28% and 16%). As well as the severity of the problem drinking, their evaluations of the acceptability of non-abstinence goals were informed by patients’ health problems (86% deemed ‘very important’), number of previous treatment episodes (70%), presence of mental health disorders (68%), age (67%) and emotional stability (65%). Yet overall, the researchers concluded that “individuals with alcohol and drug problems who avoid treatment because they are ambivalent about abstinence should know that – depending on the severity of their condition, the finality of their nonabstinence goal, and their drug of choice – their interest in moderating their consumption will be acceptable to many clinicians, especially those working in outpatient and independent practice settings”.

Contemporary guidance

While patients may be ambivalent about abstinence as a treatment goal, the policy context means that practitioners are unlikely to be. Alcohol treatment services in the UK, for example, are advised by the National Institute for Health and Care Excellence (NICE) to guide drinkers at the more severe end of the continuum of alcohol use disorders towards one treatment goal – this being abstinence:

In the initial assessment in specialist alcohol services of all people who misuse alcohol, agree the goal of treatment with the service user. Abstinence is the appropriate goal for most people with alcohol dependence, and people who misuse alcohol and have significant psychiatric or physical comorbidity (for example, depression or alcohol-related liver disease). When a service user prefers a goal of moderation but there are considerable risks, advise strongly that abstinence is most appropriate, but do not refuse treatment to service users who do not agree to a goal of abstinence.

For harmful drinking or mild dependence, without significant comorbidity, and if there is adequate social support, consider a moderate level of drinking as the goal of treatment unless the service user prefers abstinence or there are other reasons for advising abstinence.

For people with severe alcohol dependence, or those who misuse alcohol and have significant psychiatric or physical comorbidity, but who are unwilling to consider a goal of abstinence or engage in structured treatment, consider a harm reduction programme of care. However, ultimately the service user should be encouraged to aim for a goal of abstinence.

Before NICE had pronounced on treatment goals, in 2006 the Department of Health and National Treatment Agency for Substance Misuse had issued guidance for England which promoted a similar strategy – that goal choice should not exclude drinkers from support or treatment, but did see abstinence as “the preferred goal for many problem drinkers with moderate to severe levels of alcohol dependence, particularly … whose organs have already been severely damaged through alcohol use, and perhaps for those who have previously attempted to moderate … without success”. Even for these drinkers, it continued, if abstinence is not acceptable, moderation is better than nothing, and may lead to abstinence. We know from research that no matter how physically dependent, moderation is for some feasible, especially when there are sufficient supports in the patient’s life, but the more severe the dependence, the more likely abstinence is to be the suitable strategy. On how the decision should be made, in relation to care planning in general, the guidance sees patient choice as not just an entitlement, but a strategy which improves the chances that the treatment approach will succeed because “it has been selected and committed to by the individual”.

Conceptions of alcohol use problems have changed in recent years. The American Psychiatric Association, for example, previously classified alcohol abuse and alcohol dependence as two distinct disorders in its Diagnostic and Statistical Manual of Mental Disorders, but in 2013 integrated these into a single ‘alcohol use disorder’, acknowledging a spectrum of experiences and symptoms within this ranging from mild, to moderate, to severe. This reimagining of drinking problems as a continuum throws up new questions about whether there can be a concrete point at which abstinence can become the preferable or only acceptable treatment goal.

This is how Drug and Alcohol Findings summed up the evidence: “Treatment programmes for dependent drinkers should not be predicated on either abstinence or controlled drinking goals but offer both. Nor does the literature offer much support for requiring or imposing goals in the face of the patient’s wishes. In general it seems that (perhaps especially after a little time in treatment) patients themselves gravitate towards what for them are feasible and suitable goals, without services having to risk alienating them by insisting on a currently unfavoured goal”.

Last revised 17 January 2017. First uploaded 06 March 2011

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