NATIONAL TREATMENT AGENCY REVIEW
The National Treatment Agency for Substance Misuse released its Review of the effectiveness of treatment for alcohol problems. It is mostly excellent and a great reference tool – but some conclusions have led to a judicial review being explored by at least one provider. Deirdre Boyd hones in on the key issues
This article was first published in Addiction Today journal, January 2007.
2007 starts with the publication of the NTA’s Review of the Effectiveness of treatment for alcohol problems by lead authors Dr Duncan Raistrick of Leeds Addiction Unit, Northumbria University emeritus professor Nick Heather and University of York health-economics professor Christine Godfrey. “This publication is a key reference tool to facilitate the development of local alcohol-treatment systems… I have no hesitation commending this review to service providers, commissioners and anyone else with an interest in alcohol treatment,” states NTA chair Baroness Massey.
The Review’s 212 pages – 29 of which are devoted to valuable research references – are a mine of information which should save professionals in this field much time and effort seeking, while also giving them reassurance that their choices are based on evidence leading to best practice.
That said, the reliability of the bulk of the Review might lead readers to unquestioningly accept some confusions about residential treatment which are as useful as a chocolate teapot, whose scalding conclusion could sear the lives of desperate addicts for whom this is the only effective solution.
“The Review is a ‘must read’ for everyone in the alcohol-treatment field – but when deciding treatment of addicts/dependents, as opposed to those who misuse/abuse substances, this article/blog is a requirement intrinsic to it”
I recommend this document as required reading for professionals making decisions on how to treat people who abuse/misuse alcohol – but warn them about conclusions or recommendations which do not apply to people who are dependent on/addicted to alcohol. That different conclusions apply to different groups of people should be specified throughout the Review for accuracy – and save lives. They are not.
When I highlighted to NTA CEO Paul Hayes that page 144 of the Review states that “Conclusion: 12-step residential treatment confers no added benefit compared with other forms of treatment and is less cost-effective than outpatient treatment”, his immediate response was “but it is necessary for certain types of clients”. He is, of course, correct – but this qualification is eight chapters, almost 100 pages, away. In any case, that statement about cost effectiveness is open to argument: it can cost more to keep someone on methadone for a year than send them to four weeks of rehab, for instance.
The danger is that commissioners of treatment might see only the conclusion, be misled by thinking it applies to all clients, and thus deny vital treatment to people who would benefit most from it. This article gives those people, their advocates and providers, a tool to obtain appropriate treatment.
One of the first experts I asked to comment on the Review was John Finney PhD, who was on the advisory board of the US government’s National Institute on Alcohol Abuse and Alcoholism, is director of the Research & Development Center for Health Care Evaluation in Palo Alto, and was a lead researcher on Project Match, the world’s most extensive and expensive research into the effects of treatment for alcoholism.
“The key issue is that the conclusions need to be taken in their totality,” he explained. “Chapter 4 states that ‘some kinds of alcohol misusers may need inpatient treatment’.” He agrees with the authors’ conclusions on page 55 (chapter 4.4.6), which are:
The evidence base for determining the optimal treatment setting is weak because treatment has usually been delivered in what has been considered the safest and, to a lesser extent, cheapest setting. Service user choice may change these considerations, and
There is a need to have residential treatment facilities for selected groups of service users.
COUNT COST FACTORS
“Any conclusion about cost cannot be correct, if it does not take into account the physical, organ damage of the clients coming to residential treatment who are at the most critical end of the health scale,” added Peter McCann, chairman of Castle Craig Hospital in Scotland.
I also turned to Professor Carlo DiClemente of Project Match, co-author with Prochaska of the acclaimed Stages of Change model. “The data on inpatient and outpatient comparisons and cost effectiveness is varied. And there are not many studies randomly assigning to these modalities,” he said. “One that was well done and demonstrated differences was by Robert Rychtarik.”
Rychtarik, a professor at the Research Institute on Addiction in Buffalo, led a $788,000 study which showed that outpatient care can help many – but inpatient programmes could be “the referred treatment setting for individuals with more severe alcohol problems and/or cognitive impairment”.
PSYCHIATRIC SEVERITY: 1
According to Rychtarik, “efforts to cut healthcare costs – and prior research suggesting no differences between inpatient and outpatient treatment – resulted in a sharp reduction in the availability of inpatient alcoholism treatment”. This is the last thing we need in the UK where we already have providers with empty beds and a bottleneck of commissioners preventing the needy getting them.
Rychtarik’s 2000 study, Outpatient alcoholism treatment does not work for everyone, found no overall difference between inpatients or outpatients. “But when we took individual client characteristics into account, clients with more severe drinking problems had more voluntary abstinent days and averaged lower alcohol consumption when treated as inpatients,” he wrote.
Clients with low drinking-problem severity benefited most from outpatient care, regardless of intensity. His research also indicated that people with cognitive impairment benefited more from inpatient care.
“During the follow-up, inpatients spent fewer days incarcerated and/or in residential substance-abuse treatment combined than outpatients. This suggests that cost savings from outpatient care might be offset to some extent by higher costs of re-admissions and incarcerations after treatment,” Rychtarik concluded.
MET vs CBT vs TSF: TRIAL CONDITIONS.
Another inaccuracy which providers should note is on page 39 of the Review, which states that “Project Match found that a less intensive and less costly treatment (Motivation Enhancement Therapy) resulted in similar outcomes to two more intensive and expensive treatments (Cognitive Behavioural Therapy and Twelve-Step Facilitation).”
A statement contradicting this comes from another Project Match researcher, Richard Longabaugh, professor of psychiatry and human behaviour, and training director, at the Brown University School of Medicine.
“The cost implication where TSF produces 16.1% more abstinent days than MET is very important,” he stated. As I wrote in Addiction Today as long ago as 1998, that has vital cost implications.
MET vs CBT vs TSF? REAL-LIFE PRACTICE.
There also seems to be a lack of understanding in the Review about what forms current treatment for dependency. It is inaccurate to talk about MET, CBT and TSF as if they they are mutually exclusive. Good-practice “12-step treatment” centres use all of them, and more. So-called 12-step treatment is not so much rigorous TSF or even Minnesota Model – which itself has been adapted and updated, with the latest version defined in a book by Hazelden’s Valerie Slaymaker and Kirk Brower – as that it is SO eclectic in practice.
“TSF is seen as one of the best practices and is part of our best-practice guidelines. Psychodynamic therapies along with behavioural approaches which embrace TSF is the model we both use and teach at Duke University Medical Centre,” clinical director Jeff Georgi told me. “This is to say that we deal with family-of-origin issues and patient emotions which are often ‘dysregulated’ and can lead to further use.
“MET is also a large part of my practice and is completely congruent with this approach. The combination of MET and TSF is the direction which well-respected clinicians are taking in US.”
So ‘12-step linked’ might be a better phrase than 12-step or 12-step based, emphasising its complementary nature. The concept might also help to reduce prejudice.
“The cost implication where 12-step facilitation therapy produces 16.1% more abstinent days than motivation enhancement therapy is very important”
Professor Richard Longabaugh, Project Match
“An offshoot of AA has been the growth of private, profit-making treatment for alcohol problems based on 12-step principles,” states the Review on page 143. This, too, might build prejudice against providers so it is important to note that, if the authors had gone to the Directory of Treatment Centres in the back of Addiction Today journal they would have immediately seen that the vast majority are run by charities, to meet a gap in service provision. The authors then refer to Hazelden-type programmes – but Hazelden is a not-for-profit company.
The same page in the Review could lead to another misleading prejudice. It refers to Chris Cook’s 1988 definition of the Minnesota Model, saying that “the programme involves… confronting the alcohol misuser’s [editor’s note: the Model is for dependents not misusers] supposed denial… there is no evidence that confrontation is effective treatment for alcohol problems and some evidence suggests it is counterproductive”. Researcher George Christo of St Mary’s Hospital in London argues this.
“It seems the Review author/s focus on ‘confrontation of denial’ and found a problem with that one element, the ‘evidence’ being only Cook’s outdated description of Minnesota Model treatment as it used to be 20 years ago. That does not reflect current 12-step treatment”.
Christo updated the description of treatment in 2003, under the heading of Myths and misunderstandings in 12 Step Residential Treatment and Rehabilitation: what it is and how it works, a research summary. “Treatment programmes have evolved to incorporate developments in substance-misuse research,” he wrote. “But many inaccurate beliefs persist based on outdated observations and selective interpretations of language written in the 1930s whose meaning may have changed in the light of recent developments in psychology and biopsychosocial approaches to psychiatry (Miller and Kurtz, 1994)”.
Two decades ago, treatment centres did have a perhaps-justifiable reputation for being harshly confrontative. Today, it remains crucial to give feedback to clients about unhelpful attitudes, behaviours and beliefs – but qualified professional staff ensure that this is done in a respectful way. “Most staff are familiar with Motivational Interviewing (Miller & Rollnick 1991) and have incorporated many of its elements into their work,” Christo added. “The authors’ conclusion is not a fair summary of the body of the text.
“And not only is Cook’s reference out of date but Cook himself said a lot more than that it is just about confronting denial.”
PSYCHIATRIC SEVERITY: 2.
Page 39 states that in Project Match “a less intensive and less costly treatment (MET) resulted in similar outcomes to two more intensive and expensive treatments (CBT and TSF)”, which has been disputed in this article. It then says that “This applied to all levels of severity of the clients’ alcohol problems and to all levels of alcohol dependence”. In fact, from month 15 onwards, TSF produced the best results for patients with some, lower psychiatric severity.
The best argument for ‘12-step treatment’ – in even our broadest sense – could be the UKATT Alcohol Treatment Trial which set out to mimic Project Match with a pivotal difference: in Project Match, all clients could attend 12-step fellowships but UKATT excluded anyone who wanted to use 12-step support. Using only MET and its own creation of a ‘social behaviour and therapy network’, its abstinence rates, according to lead researcher Jim Orford, were: “at 12 months follow-up, 16.8% had been totally abstinent for three months, 15.5% in the MET group and 18.8% in the SBNT groups” [ the one-year follow-up showed only 10% abstinent]. Compare that to the Project Match results or even the average results in practice of roughly 66% abstinence in ‘12-step’ treatment centres.
This is only one outcome measure for UKATT: its researchers concluded that problem drinkers were better off for receiving its treatment than if they had received none, reducing alcohol-related problems.
Providers should show page 24 of the Review to any reluctant commissioners. It urges that “If a service user shows a preference for total abstinence for whatever reason and at whatever level of dependence, this should be immediately accepted”.
Let’s leave the final word to DiClemente. “There is a role for AA and 12-step programmes in the treatment array offered to clients,” he advised. “It is clear that AA mutual-support groups have been a significant catalyst for change for many alcohol-dependent people.” So let them complement therapy, and vice versa.
I had only a day or two to examine the Review before going to press, but hope I have done justice clarifying the differing needs of misusing versus dependent drinkers.
Readers can access a summary of research on the effectiveness of abstinence-based treatment here.