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How many drinkers should be in treatment?

How well are we doing in getting people who need this help into treatment for their drinking problems? It’s a question whose importance was signified by an estimate for 2004 that there would have been 794 fewer deaths had one in five dependent drinkers been treated with medications versus a zero treatment rate. Numbers avoiding illness would have been considerably greater. As we’ll see, depending on where you draw the line, England’s performance in ensuring needy drinkers enter treatment can look anywhere from an abysmal 7% to an excellent 44%. Line-drawing is a matter of judgement and perhaps too of motivation – of how you want to portray performance, and in turn whether you want to argue for more services or that need is already largely being met. But at least we can be as clear as possible about the facts on which these judgements are made.

The following analysis focuses on England which has both the best figures and dominates the UK population; Scotland seems to doing much better at meeting treatment need. The analysis also glosses over complicating factors including trends in dependent and harmful drinking since 2007, conflating estimates for different years. It is presented as a ball-park indication not necessarily of absolute numbers and proportions, but of the degree to which these alter under different assumptions of what counts as being ‘in need of treatment’.

How many in need of treatment?

The proportion of drinkers in England in treatment of those in need of treatment under different assumptions

Let’s start with how many are in treatment, using England as our example. There about 115,000 adults were in specialist alcohol treatment during 2013/14. Based on a 2007 survey which still seems the latest source, this amounts to about 7% of all 1.6 million drinkers experiencing harm from their drinking.

We can narrow this down further to the approximately 1 million adults who according to NICE, Britain’s official authority on health interventions, also score as at least mildly dependent on alcohol. On this basis, numbers in treatment represent about 11% of dependent drinkers who might need this help. One serious concern over this estimate is that by design, the questionnaire used to assess dependence was not based on clinical criteria.

Putting that concern to one side, results from this questionnaire can be used to narrow down further to the numbers who perhaps really ought to be in treatment. In 2011 NICE calculated that in England 260,000 adults were not just ‘mildly’ dependent or drinking in ways which were harming them, but were moderately dependent or worse. Accepting this figure as the in-need population suggests that numbers in treatment represent 44% of those whose condition ‘really’ justifies intensive help.

Now we have a range from treatment capturing numbers equivalent to just 7% of harmful drinkers to capturing nearly half of those also at least moderately dependent. The lower figure can be justified as the percentage of all those who might need help, the higher as perhaps closer to those who really do need treatment to overcome their dependence. That higher figure gains support from US findings that three-quarters of dependent drinkers remit without treatment and just 10% most clearly need and most often access this kind of help. NICE also appears to draw the line nearer to (and perhaps even above) the moderate dependence level, which would imply that England has the capacity to treat over 40% of the in-need population.

We might further constrict the population in need of treatment if we accepted the view that diagnosing an alcohol use disorder requires not just harm from drinking, but evidence that rather than having freely chosen this penalty, the individual is pathologically impaired in their ability to control their drinking. Compared to standard clinical criteria for dependence, applying this ‘harmful dysfunction’ diagnosis to US figures slashed the numbers calculated as potentially in need of treatment, and the proportion whose need had not yet been met by treatment services – the latter from 34% over their lifetimes to just 4%.

All these estimates of unmet need are based on access to specialised treatment for drinking problems. One reason why unmet need is not necessarily as large as it appears is that structured specialist treatment is not the totality of support available to problem or dependent drinkers nor the only way out of even severe drinking problems.

What is a reasonable target?

Fortunately we have specific guidance on what counts for Britain as good record for getting in-need drinkers into treatment; less fortunately, its provenance makes it of doubtful validity.

In 2009 the UK Department of Health estimated that provision should be made for 15% of dependent drinkers to access specialist treatment, a figure accepted by NICE. The origin of this figure was a Canadian model of treatment demand based on a model published in 1976 and developed for the US state of Nebraska.

Though perhaps of local applicability, this model does not seem to warrant elevation to an international guide. Its denominator for the population in need of specialised alcohol treatment was derived not from an assessment of harm or dependence, but purely of consumption – the number aged 15 or over who drank at least 475g of alcohol a week, about 59 UK units. The top part of the fraction – the target number for treatment during a year – was not based on an assessment of the proportion of these drinkers who might profit from treatment, but on the relapse rate (defined as return to drinking) after treatment and the annual increase in the prevalence of alcohol dependence, in the source study estimated respectively as two-thirds and 10%. To keep pace with relapse of treated alcoholics and the expanding population of newly dependent drinkers, it was estimated that 15% of the population in need of treatment would have to be treated each year.

‘Need’ is not the same as ‘demand’

So while we may suspect that capturing 115,000 of England’s problem drinkers in treatment is not enough, there is no clear way to determine whether and the degree to which this is the case. Good waiting time figures have (in respect of drug addiction treatment) been used as an indicator that treatment supply is keeping up with demand. Good waiting times for alcohol treatment may mean the same, but perhaps only because need is not reflected in demand because dependent drinkers are divorced from routes to treatment – much as a hungry population may not result in demand for bread if they can’t find their ways to the bakers or don’t like the bread they bake.

Alcohol treatment referral sources in England 2008/09 to 2013/14

That this is at least partly the case was suggested by a report on alcohol treatment in England in 2011/12. It expressed concern at how few people had successfully been referred to specialist treatment by GPs or accident and emergency departments, despite the fact that around one in five people seeing a GP is drinking at risky levels, and an estimated 35% of emergency attendances are alcohol-related: “An aim for the coming years is that these two key routes will become more active in identifying and referring people who need treatment for harmful drinking and alcohol dependency”.

If there was cause for concern then, there was even more cause in subsequent years. Referrals from GPs fell from 14,330 in 2011/12 to bottom at 13,541 the following year, only partially recovering to 13,864 in 2013/14 chart. From 22%, since 2008/09 the proportion of all treatment entrants accounted for by GPs seems to have fallen each year, ending at 17% in 2013/14. Accident and emergency department numbers and proportions are both up, but from a very low base, peaking in 2013/14 at 1268 patients, equating to 1.6% of all referrals – still a small proportion of the potential. From a peak of 15,900 in 2009/10, in 2013/14 these two sources accounted for 15,132 treatment starts in 2013/14; as a proportion of all treatment starts, the trend has consistently been down from 23% in 2008/09 to 19% in 2013/14.

For more on how many of the in-need population are in treatment run the full search on all countries or limit to the UK.

This entry was based on cell E2, one of 25 cells in the Alcohol Treatment Matrix constructed by Drug and Alcohol Findings for the Substance Misuse Skills Consortium. 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.

Last revised 03 January 2016. First uploaded 24 June 2014

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