1 The Effectiveness of Drug and Alcohol Treatment: A Review of the Research Literature David M. Stein, Ph.D.
2 2 Table of Contents What are Typical Outcomes for Persons Receiving Minimal or No Treatment for Clinically Significant and Chronic Alcoholism?... 7 Large Scale Surveys of Treatment Programs: Pre-to-Post Changes in Persons Enrolled in Drug and Alcohol Treatment... 8 The National Treatment Improvement Evaluation Study (NTIES)... 8 Key NTIES Conclusions... 8 California Drug and Alcohol Treatment CALDATA (Gerstein, Johnson and Larison, 1997)... 9 The Drug Abuse Treatment Outcome Study (DATOS)... 9 Key highlights of the study Major Reviews, and Recently Published Controlled Outcome Studies Miller et al Meta-Analysis of Controlled Outcome Studies on Alcohol Treatment, and More Recent Studies Interpretations of Selected Data From the Miller et al Meta-Analysis Treatments for problem-drinkers versus severe alcoholics: Brief Interventions 14 Coping and Social Skills Training Patient-treatment matching and CSST Community reinforcement approach Motivational enhancement/counseling approach Marital/Family Therapy Cognitive-Behavioral Approaches Relapse prevention Antidipsotropic medications Psychotropic medications Psychotherapy Confrontational Approaches Mileau treatments Alcoholics Anonymous Acupuncture as an adjunct to treatment for drug abuse Comments on the Miller et al Meta-Analysis The Efficacy of Treatment in Particular Settings Inpatient Versus Outpatient Summary and conclusions: Inpatient versus Outpatient Residential and Therapeutic Communities Factors Affecting Retention in Treatment in TCs Key variables relating to TC outcomes... 27
3 Residential Versus Outpatient/Day Treatment Hospital-Based Versus Community-Based VA Residential Treatment Programs Therapeutic Community Versus Community Residence Program: Homeless, Mentally Ill, Chronic Substance-Abusing Patients Summary and Recommendations Regarding Residential Programs and TCs The Effectiveness of Treatment in Particular Settings: Treatment Drug Courts Effective Treatments for Particular Drug Problems Recent Outcome Research on Opiate Treatment, and the Effects of Supplemental Components on Methadone Maintenance Factors that enhance retention and outcomes in methadone maintenance Variables that might improve retention in methadone maintenance Methadone maintenance and antidepressant medication Some Conclusions and Recommendations About Methadone Maintenance General Conclusions Conclusions Regarding Methadone Substitution during Pregnancy Cocaine and Methamphetamine Treatment Advances NTIES (1997): National data on pre-to-post treatment changes Inpatient and outpatient treatment comparisons Factors That Enhance Cocaine Treatment Effectiveness Incentives and vouchers Counseling and psychotherapy Group versus individual formats for relapse prevention in cocaine dependence Psychotherapy and pharmacological therapy for depressed cocaine addicts Treating cocaine addiction among homeless persons Combined Methadone Maintenance and Cocaine Abuse: Special Treatment Problems 46 General Program and Treatment Recommendations for Cocaine Treatment Effective Treatment Modalities and Special Treatment Populations The Effectiveness of Family/Couples Treatments Family and couples therapy literature reviews Family methods for getting patients into treatment Additional Intervention Studies Family therapies as drug/alcohol treatment Maintaining treatment effects and preventing relapse Does gender of the alcoholic relate to the effectiveness of family/couples intervention Summary and Recommendations Regarding Family/Couples Treatment Adolescent Substance Abuse Treatment: Special Issues and Guidelines... 56
4 Prominent accessory problems of adolescent substance abusers Uncontrolled pre-post changes among adolescents treated in federally-funded treatment programs The CATOR database pertaining to adolescents Some promising programs and treatment components for adolescents Family involvement and family therapy Some additional, empirically-based psychological interventions for problem adolescents Cognitive problem-solving skills training for oppositional and aggressive children and adolescents Parent management training for oppositional and aggressive children and adolescents (PMT) Multi systemic therapy for antisocial behavior among adolescents (MST) Adolescent Treatment Summary and Recommendations Gender Differences and Women s Treatment Issues Do any studies offer guidance regarding treatments that might be more helpful for women than traditional, or existing treatments? Conclusions and Recommendations on Women s Treatment Issues Effectiveness of Alcoholics Anonymous and Self-Help Programs What personal characteristics of alcoholics tend to correlate with AA affiliation? Is AA attendance correlated with client improvement? Do correlation studies adequately demonstrate that AA causes recovery? Does the amount of AA attendance relate to amount of improvement? Does AA contribute to treatment program effectiveness? Does AA represent an effective stand-alone approach to abstinence, compared available treatments? Conclusions and Recommendations Regarding AA Vocational Rehabilitation and Employment Issues of AOD Abusers Contemporary Issues That Determine Treatment Practices Cost Effectiveness Data and Managed Care Application of ASAM and other criteria for assigning patients to treatment Research examining the application of patient assignment criteria Other criteria for patient placement Key unresolved issues in use of patient placement criteria Conclusions About the Possible Impact of Managed Care Treatment Advances with Dual Diagnosis Patients and Matching Patients to Treatment Dual Diagnosis Why is it important for drug and alcohol counselors to become familiar with diagnostic systems and mental disorder paradigms
5 Research and Guidelines on Treating (Multi-Diagnosis) AOD Clients With Mental Disorders HIV infection as a concomitant condition Common Mental Disorders Associated with AOD and Recommended Treatments Recommendations regarding multi-diagnosis patients The Relationship Between Smoking and Alcoholism Matching Patients to Treatment Examples of Recent Research: Individual Studies Adolescent matching Naltrexone versus placebo and relapse prevention, versus supportive psychotherapy in treatment of alcoholism The Results of Project Match An Individualized Problem-Centered Approach to the Issue of Matching, and Helping Multi-Diagnosis Clients Justification for a problem-focussed approach to matching Empirically-based matching and the continued need for individualized treatment planning Psychological, Psychosocial and Pharmacological Approaches for Substance Abuse 100 General Conclusions and Recommendations about Matching Amount of Treatment Services or Hours of Contact, and Relationship to Improvement Planned Program Duration and Outcome in Residential Programs for Drug Abuse Does treatment outcome depend on whether clients complete treatment programs as designed and planned? Cost-effectiveness of Treatment Other cost-effectiveness data Conclusions about cost-effectiveness data Older Patients and Treatment, Service Demands, and Readmission Rates Recent HIV/AIDS Interventions in Drug and Alcohol Treatment Intensive Case Management Approach General Conclusions and Summary Monitoring Common Factors and Social Support Future Training Trends Conclusions Regarding Literature Summaries/Reviews On Effective Treatments Settings and Difficult Drug Problems On Effective Treatment Modalities and Special Treatment Populations On The Effectiveness of Other Contemporary Treatments, and Factors Impacting Practice Issues
6 Reference List Appendix A Appendix B The Effectiveness of Drug and Alcohol Treatment: A Review of the Research Literature This paper summarizes recent research on the effectiveness of contemporary treatments for alcohol and drug dependence. It primarily examines basic and applied research conducted since 1990, although older research is discussed when it is relevant to a topic. Because the question of effectiveness is highly complex, the paper addresses the treatment of specific problems, and the efficacy of particular treatments and interventions for both specific samples and populations. Major topics include 1) summaries of large-scale, national studies, and major reviews of the literature; 2) efficacy of treatment in particular settings (e.g., inpatient versus outpatient, residential and therapeutic communities, treatment drug courts); 3) effective treatments for particular drug problems (i.e., heroin/methadone treatment, cocaine treatment); 4) effective treatment modalities and special treatment populations (family/couples treatment, adolescents, Women s issues, Alcoholics Anonymous, controlled, vocational rehabilitation), and 5) contemporary practice issues that determine treatment practices (possible impact of managed care, patient placement criteria, multi diagnosis patients, patienttreatment matching, length of treatment and outcomes, cost effectiveness). In the first section of this paper, readers are reminded of the typical outcomes observed among persons with serious drug/alcohol problems who receive minimal or no treatment (e.g., detoxification). Such information on natural outcomes over time of persons with alcohol problems provides a frame of reference for evaluating the outcomes reported in large scale studies of pre-to-post changes in persons enrolled in typical treatment programs. Thus, largescale pre-to-post outcome surveys are presented next to provide readers with broad outline of the likely efficacy of general treatment approaches, as demonstrated in respected programs. Such surveys are deemed to be important, because they involve conclusions about numerous studies and/or diverse patient samples and treatment facilities. The present author suggests that such studies may offer the best available insights into what is typical in patient change over time, for different drug problems and treatment settings; such findings might be generalizable across settings and populations. Also presented are the key conclusions from panels of experts in the area of treatment and research (e.g., panels organized by professional organizations or the government). A key focus of the present paper is to report the results of recent controlled and comparative outcome research projects will be discussed. Such studies not only address the relative effectiveness of particular treatments, but also treatment-client matching issues. Where data were available, the effectiveness of particular therapy approaches alone, or added to other treatments will be presented. This information may be useful to program planners who 6
7 want to make certain that if they add a particular treatment to their program (e.g., AA) or fund a referral for a particular service (e.g., family therapy), the action will likely improve overall effectiveness. Treatment approaches for adolescents and women will be highlighted in this section as well. Following the discussion of the effectiveness of general treatment models and techniques, the question of whether certain treatments work best for particular persons is addressed. Here, patient multi-diagnosis and patient-treatment matching studies are examined, as is a summary of what we know about the validity of patient placement criteria Research on patient-treatment matching schemes is presently of keen interest, because patients certainly want the best treatment for their particular life circumstance, and government and corporate interests, such as managed health care, are continually searching for the most cost-effective solutions to drug and alcohol problems. In addition to these topics, a number of contemporary issues will likely determine what treatments may be offered in the future, and how. The possible impact of managed care, published data on cost-effectiveness of treatment, and the controversy about the length of treatment and outcomes will be discussed. Finally, summary comments and recommended practices are highlighted, and a resource of recommended treatment guides, texts, and manuals. Some of the topics in the present review were dictated largely by the amount and quality of research available in the literature. For example, an extreme paucity of quality research exists on elderly treatment or methamphetamines, and the present review has little new to offer readers on this topic. A number of principles and research paper selection criteria guided some of the decisions of the present author regarding the selection of documents to be used in the present paper. This paper focuses on patient groups that evidence close approximations to DSM-IV substance dependence disorder or significantly problematic alcoholism (which frequently was a bit more broadly defined). The author tended to not include research on AOD prevention. Further, the amount of attention paid to pharmacological treatments is limited; the present writer believes that in a few short years, a very substantial review of research in this area can be offered. Finally, the present review was limited somewhat by the failure of researchers to adequately report details of their studies. In many cases, the literature is still dominated by simple descriptions of programs and advice based on particular authors clinical judgement. This is especially true for instance, in the arena of treatments for adolescent substance abuse problems. The approach to identifying studies for the present review is worthy of mention. The author conducted methodical searches of Psychological Abstracts and Medline, and perused major government research summaries, abstracts and agency home pages on the Worldwide Web (e.g., NIDA homepage). When suitable articles were identified, the reference lists of each article were searched for additional research reports. Further, hand searches of journals commonly publishing drug and alcohol treatment studies were conducted. While the present review is likely not exhaustive, it is most certainly highly representative of the research conducted from 1990 to The present paper also provides an Appendix in which recommended treatment texts and manuals are referenced. The interested reader is directed to this section of the paper for guidance 7
8 8 regarding treatment manuals covering such topics as cognitive behavioral therapy, community reinforcement approaches etc.
9 9 What are Typical Outcomes for Persons Receiving Minimal or No Treatment for Clinically Significant and Chronic Alcoholism? Historically, some programs offered patients a detoxification regimen lasting at most, a few weeks, followed by discharge-plus-minimal follow-up. Such follow-ups might involve nothing more than a recommendation to seek outpatient services, or a few visits with a drug counselor. Presently, some programs still offer what is mainly a brief detoxification program with minimal counseling; immediately prior to discharge, patients may be apprised of social service agencies or organizations (e.g., AA). Representatives of these organizations might visit the patient before, or shortly after discharge, but no aggressive follow-up service plan is executed. Programs offering detoxification-but-little-else still produce the classic relapse profile among their patients. In a recent study of such a program, Jones and McMahon (1994) reported on abstinence rates for older male alcoholics (mean age 45), most of whom had experienced detoxification or treatment in the past, but failed. About 70% of the patients were unemployed, and only about 1/3 were married. Following discharge from a 10-day residential alcohol detoxification unit, 51% had relapsed (i.e., had consumed alcohol on at least one or more occasions) by the end of just one month; by the end of 3 months, 72% had relapsed. The authors noted that this pattern was similar to what they have observed historically, i.e., by one month about 50% of patients relapse; by three months, about half of the remaining patients also relapse; and half of those still abstain at 3 months relapse by 6 months. It appears that these outcomes correspond to data describing the natural course of significant alcohol dependency over a number of years. For example, a follow-up study of 80 halfway-house alcoholics receiving minimal, supportive services showed an approximate abstinence rate of only 22% after 10 years. In addition, about 20% of the original sample had died. The high mortality rate is probably accounted for in part, by health problems and patients tendency to engage in high risk behaviors associated with alcohol (Myerson and Mayer, 1966). Hyman (1976) found that alcoholics receiving a few outpatient visits showed an abstinence rate of about 19% after a 15 year follow-up. Also, Schuckit et al (1997) found that 35.7% of alcoholics who experienced at least one 3-month period of abstinence during their alcoholic careers (mean length of 14 years) had never been in treatment, suggesting great variability in drinking/non-drinking periods. Schuckit also found that patients who had been in any form of treatment, were twice as likely to experience at least one 3-month period of abstinence. Additionally, the Epidemiological Cachement Area Study found that the likelihood of abstaining from alcohol was only about 20% without treatment. In general treatment populations, 50% of treatment dropouts in a population occur by 1 month, and 80% of the expected dropouts will have occurred by 6 months (Miller & Gold, 1995). These outcomes, and the results of detoxification-only studies appear to be a good deal worse than those observed among patients enrolled in most treatment programs e.g., those assessed in the large-scale, pre-post studies outlined in the section that follows (i.e., NTIES, DATOS). It should be noted that long-term follow-ups of samples in these large-scale studies are still needed. Also, the widely-appreciated dictum that detoxification-alone or very minimal
10 10 treatment creates an inefficient revolving door within programs for patients with significant drug and alcohol abuse continues to be supported by empirical evidence. Large Scale Surveys of Treatment Programs: Pre-to-Post Changes in Persons Enrolled in Drug and Alcohol Treatment The first reports summarized in the present review involve studies of very large, multisite treatment programs. In these studies, clients enrolled in diverse, representative treatment programs around the country, and are assessed before, and after treatment. Changes that occur in various measures of improvement (e.g., percent of days drinking) are reported. The value of these studies is that they document large-scale, general changes in persons in treatment. They provide a general benchmark for minimal changes that should be occurring in roughly comparable programs, assuming that the study results are generalizable. They do not tell researchers or clinicians how such patients compare with matched groups who never entered treatment, or patients who followed alternative paths toward recovery. Thus, the changes reported in these studies do not provide a frame of reference for judging whether the changes are cost-effective, relative to no treatment or less-expensive approaches. The National Treatment Improvement Evaluation Study (NTIES). NTIES (1997) was a five-year, congressionally-mandated study of the (pre-to-post) outcomes of thousands of patients seeking treatment at numerous treatment facilities in the U.S. these programs received federal support dollars. Specifically, about 82% of the 6,593 clients attending 78 treatment units were interviewed when they entered treatment, when they left treatment, and at a 12-month follow-up. Information about many different outcomes, such as substance use, employment status, use of medical services, mental health problems, arrests, etc., obtained directly from patients, or cooperative informants who knew the patients well. Key NTIES Conclusions: 1. Drug abuse treatment may substantially reduce patients (primary) drug use. In the 12 months before, versus 12 months after treatment, persons using crack as their primary drug of choice reduced their use from 40% to 18%; similar data for primary cocaine users was a 39.5% to 17.8% change; and for heroin, a 23.6% to 12.6% average change in use rate occurred. Overall use of drugs dropped an average of 48.2% during this interval (n = 4,411 patients). 2. Drug abuse treatment may dramatically decrease criminal behavior Criminal arrests in the 12 months before, versus 12 months after treatment went from 48.2% to 17.2% another outcome measure, the frequency of selling drugs shifted from 64% to 13.9% (n = 4,411 patients). 3. Treatment is improved rates of employment, income, and reduced homelessness. In this same sample, 12-month before, versus 12 month after treatment changes occurred in the following: a) 18% increase in receiving some job income, and a 10.8% decrease in receipt of welfare income; b) 19.2% (before) versus 11% (after treatment) change in homelessness (for any time in past year).
11 4. Possible treatment savings on the costs of accessory alcohol/drug-related medical visits. Prevalence of patients, alcohol or drug-related medical visits dropped from 24.7%, to 11.5% of patients. 5. Treatment may decrease the need for expensive inpatient mental health visits. Prior to treatment, 6.5% of patients had an inpatient mental health visit, while following treatment, 4.7% had such visits. 6. Drug treatment may dramatically reduce the rates of high risk sexual behaviors, such as providing sex for money, having sex with IV drug users, and having unprotected sex. For example, the percentage of patients who had sex for money or drugs decreased by 56% after treatment. There was a 51% decrease in the number of patients who had sex with an IV drug user, and a 35% decrease in unprotected sex incidents. NTIES also provided more specific data on particular patient groups (e.g., women), and specific drugs, as well as cost data for particular treatment setting. Relevant data on these topics will be reported in other, sections of this paper. While it is unclear precisely how patients in the NTIES study (or a parallel, comparison sample) would have fared with less intervention or no treatment, the project provides treatment program directors with broad, benchmark outcome data against which they can compare the effectiveness of their own treatment program. NTIES provides a classic, contemporary example of the importance of examining multiple, broad outcome measures to evaluate changes in patients who have been in treatment. California Drug and Alcohol Treatment CALDATA (Gerstein, Johnson and Larison, 1997) Recently, the outcomes, benefits and costs of drug and alcohol abuse treatment were evaluated in California (CALDATA project) during Recipients of treatment were randomly selected from the overall treatment population, but they received Medicaid, state/county alcohol and drug treatment funding, public insurance, or Aid to Families with Dependent Children (AFDC). Some highlights reflecting pre-post changes in CALDATA recipients are offered below. Relative to pretreatment levels: 1. Criminal activity declined by about 2/3 after treatment among men and women patients. 2. Alcohol/drug use declined by about 40%. 3. A reduction of hospitalizations by one-third occurred. 4. Ethnic groups differed in the programs they enrolled in; Hispanics were much more likely to be in methadone programs for heroin addiction; African-Americans were primarily in residential programs, mostly for alcohol and cocaine, compared to non-hispanic Whites and with African Americans in other types of treatment. 5. CALDATA programs had little or no impact on the employment and economic situations of clients. Modest improvements in employment were correlated with staying in a program longer than one month, also a slight decrease (22%) in numbers of women with children, and on welfare was found, in terms of leaving welfare rolls. 6. Treatment resulted in increased patient access to a variety of other services, such as Medi- Cal, payments for disability, etc. In turn, this increase was correlated with improvements in health status. 11
12 12 The Drug Abuse Treatment Outcome Study (DATOS) In a NIDA-sponsored, nationwide study of drug abuse treatment outcomes (Hubbard, Cradddock, Flynn, Anderson and Etheridge, 1997), over 10,000 patients enrolled in nearly 100 treatment programs across the country were studied between 1991 and Researchers examined a random sample of this population, 3,000 patients. Approximately 33% of the patients at these treatment centers were women. The primary drug of abuse among these patients was cocaine, followed closely by alcohol. Patients were interviewed about daily drug use for the 12-month period before treatment, at the end of treatment. Attempts were also made to assess patients at 12-months post-treatment. Also evaluated were number of illegal acts, work records, and depression/suicidal ideation. Further, outcomes were evaluated across four types of programs: 1) outpatient methadone; 2) outpatient drug-free; 3) long-term residential; and 4) short-term inpatient. Key highlights of the study: 1. Programs showed reductions in rates of substance use---depending upon the drug. For example, long-term residential programs, outpatient drug-free programs, and short-term inpatient programs were surprisingly similar in reported rates of reduction of alcohol consumption (53%, 51%, and 59% reductions, respectively). On the other hand, outpatient methadone program participants were much more likely to report substantial decreases in heroin use than patients in than other types of programs (89.4% use rate before treatment versus 27.8% in the 12 months after treatment). Patients in outpatient methadone programs tended to slightly increase their rate of alcohol consumption over time; initial drinking rates were less than half those found among patients in other programs however. Average reductions in cocaine use across programs were between 48.2 and 66.7%. 2. Programs had little impact on the very poor rates of full-time work among patients; modest 10-20% improvements in full-time employment were the norm across all programs. This finding is significant, given the very high number of patients who continued to work less than 35 hours per week either before, or after treatment (i.e., 63-87% of the overall sample). Further, most programs, including methadone outpatient, avowed that vocational counseling or skills development was part of their curriculum. 3. With the exception of outpatient methadone programs, typical programs reduced suicidal ideation by 41-47%. 4. Comparatively, short-term inpatient treatment programs were associated with significant declines in drug use, despite the fact that clients were in these programs no more than 30 days. Patients in these programs did not appear to display less severe problems or symptoms than those in other programs. It is not clear whether the inpatient programs were merely an initial step in recovery for these patients i.e., whether they also participated heavily in, other outpatient programs, AA, etc. This issue will be explored by the DATOS research group in the near future. 5. Huge variability in programs ability to keep patients in treatment was found. Program predictors of this variance have not been evaluated fully by the research team. In terms of patient
13 13 characteristics however, highest drop-out rates are observed among patients who were heroinplus-crack cocaine (but not powder cocaine) abusers. Further, major predictors of staying in treatment were: 1) high motivation; 2) legal pressures to stay in treatment; 3) no prior trouble with the law; 4) getting psychological counseling while in treatment; and 4) lack of other psychological problems, especially anti-social personality disorder. Combining NTIES and DATOS data One important conclusion can be drawn by comparing the NTIES and DATOS studies, because of similarities in key questions they addressed. Figure 1 below illustrates this conclusion: Figure 1
14 Together, the DATOS and NTIES studies suggest that patients entering treatment for cocaine, heroin or a primary drug-of-choice (usually cocaine or alcohol), showed very similar reductions in use from the 12 month before treatment to about 12 months after. While different populations and treatment programs are represented in these studies, taken together, they suggest that reductions in the approximate 50% range should be expected from typical treatment programs. However, these figures do not take into account drop-outs---which remain a serious problem in the drug and alcohol treatment field. Major Reviews, and Recently Published Controlled Outcome Studies Of great utility to treatment program directors and clinicians is information regarding the general effects of treatments, as summarized by large-scale literature reviews of controlled treatment outcome studies. Such literature reviews can provide a measure of the relative effects of particular treatments versus others, across many samples of patients. These treatment effects can be correlated with various study design and patient characteristics across studies, shedding light on factors that might account for variations in outcome for different patient samples. The effects associated with treatments in such reviews can be extremely useful, because they represent changes in patients relative to a frame of reference; for example, changes for a new treatment relative to a standard approach. Systematic reviews of controlled outcome studies are especially useful, because they provide more unequivocal data on the effectiveness of treatments than studies merely reporting the before versus after outcomes of a given treatment program. While the shortcomings of controlled outcome studies will not be discussed here (e.g., introduction of substantial artificiality which fundamentally alters the treatment), the strengths of such studies are difficult to challenge. In controlled studies, patients would (ideally) be randomly assigned to treatment conditions, or steps are taken to equate treatment groups on critical variables that might account for differences in treatment outcome. Given a large enough number of patients, random assignment to treatment conditions will make it very likely that all treatment conditions being compared will have equal number of patients possessing very comparable characteristics (e.g., equal proportions of male an female clients). True randomization can rarely occur, but many researchers succeed in closely matching treatment groups on characteristics that might otherwise account for differences between treatment approaches that are found. Also, though simple before-versus-after change measures in a single treatment program can suggest impressive effectiveness for a particular approach to treatment, it is essential to compare such changes to some other frame of reference. Though there is clearly a trend in the literature for samples of substance abusers to not get better with the mere passage of time (e.g., 6 month period), it is nonetheless important to demonstrate that a given treatment is better than no treatment, standard treatment, etc. In other controlled studies, a standard treatment patient group can be compared to a group receiving standard treatment plus an innovative therapy. Such an approach allows researchers to discover whether the innovative therapy adds anything to the effectiveness of the standard therapy. Such a question bears directly on cost-effectiveness issues, and efficiency of treatment. 14
15 15 Miller et al Meta-Analysis of Controlled Outcome Studies on Alcohol Treatment, and More Recent Studies The best literature review conducted to date of controlled and comparative outcome research on alcohol treatment is by Miller et al (1995). The review includes studies published through While the procedures and decisions Miller et al used to conduct the review would no doubt stir some debate among research clinicians, the authors were diligent in applying all of their review decision rules consistently. For example, Miller et al, devised decision rules for scoring research projects on methodological quality, and comparing studies in terms of the ways they contrasted different treatments or the ingredients of treatments. All of the study ratings and evaluations assigned by particular reviewers in the research team were cross-checked with those of other reviewers; a consistent system for making decisions about methodological ratings and other study factors when disagreements between reviewers arose was also worked out. In all, 211 studies were reviewed and data from 169 of these were used to calculate various indices of effectiveness. One shortcoming of the present study was that Miller et al s decisions about managing measures of effectiveness resulted in outcome indices that were independent of the length of follow-up, making judgements about short term versus long-term effects of treatment for different studies impossible to determine. Also, the review places much emphasis on the number and proportion of studies with positive outcomes versus negative outcomes, rather than utilizing a more standard statistic the size of effect. This shortcoming is important, because some studies might have larger, relative treatment effects than other study of the same treatment, but both are given equal weight. On the other hand, this shortcoming is ameliorated somewhat because Miller et al did weight studies by their methodological quality score, which impacted their decisions about the relative effectiveness of different treatments. The key findings and comparisons reported by Miller et al are considered in the context of the following questions: What treatment approaches have the strongest weight of evidence supporting them? Which have been demonstrated to be ineffective, and which have yet to be adequately studied? Miller et al (1995) interventions with strongest empirical evidence (top 15, rank ordered ) 1. Brief Interventions 2. Social Skills Training 3. Motivational Enhancement 4. Community Reinforcement Approach 5. Behavioral Contracting 6. Aversion Therapy, Nausea 7. Client-Centered Therapy 8. Relapse Prevention 9. Self-Help Manual 10. Cognitive Therapy
16 Covert Sensitization 12. Marital/Family Therapy--Behavioral 13. Disulfiram 14. Behavioral Self-Control Training 15. Systematic Desensitization Interventions that have little or no empirical support, based on the results of more than 2 studies include (ranked from worst, to less weak): 1. Educational Lectures/Films 2. Unspecified Alcoholism Counseling 3. Psychotherapy 4. Confrontational Counseling 5. Relaxation Training 6. Metronidazole 7. Antianxiety Medication 8. Videotape Self-Confrontation 9. Unspecified Standard Treatment 10 Psychedelic Medication 11. Milieu Therapy 12. Hypnosis 13. Aversion Therapy, Electrical 14. Marital/Family Therapy, Nonbehavioral Interventions for which there are too few controlled outcome studies to yet evaluate effectiveness: 1. Sensory Deprivation 2. Developmental Counseling 3. Acupuncture 4. Exercise 5. Aversion Therapy, Apneic 6. Problem-Solving Training 7. Functional Analysis 8. Self-Monitoring 9. Antidepressant Medication 10. BAC Discrimination 11. Antipsychotic Medication 12. Alcoholics Anonymous Interpretations of Selected Data From the Miller et al Meta-Analysis
17 The results of the Miller et al review will be discussed below, along with additional, recently published studies not included in the Miller et al review. These are included in discussions of particular treatment modalities, where relevant. Treatments for problem-drinkers versus severe alcoholics: Brief Interventions. As pointed out by Miller, the treatments having the strongest empirical support, Brief Interventions are typically very short-term (1-3 sessions). Miller et al s patient severity ratings across studies show that the treatment is used by research clinicians with problem drinking and or mildly dependent persons, not severe alcoholics. Brief interventions are designed to impact drug/alcohol use. However, because they involve minimal investments of time on the part of providers, these interventions are best construed as educational approaches (Heather, 1995). To provide a frame of reference, brief interventions might involve only 2-3 "sessions". Self-help manuals may be included here. Though they may take considerable time for clients to complete, they place very limited demands on practitioners' time. The notion that some alcoholics have viable options to undergo treatment to either control their drinking (e.g., learn to socially drink), or pursue permanent abstinence, remains a controversial topic. However, formal controlled drinking (CD) programs are almost nonexistent in the U.S.; though not the norm, CD interventions are more available in Europe and Canada. One of the most obvious, though uninformed opinion about the viability of CD treatments is the widespread fact that the most common alcoholism treatment program is rarely long-term abstinence; rather, patients show relative reductions in consumption, or follow cycles of waxing and waning drinking episodes over time which may include treatment. Also, it is clear that the majority of alcoholics probably enter treatment knowing (superficially) that the program extolls and encourages a commitment to abstinence as the only suitable outcome; however, most patients almost assuredly do not truly believe this----at least until they are further along in treatment, or unless experience has taught them that many prior attempts to control their drinking have only met with failure. Clearly, the best long-term health and lifestyle outcomes seem to be associated with a commitment to abstinence. The controversy over the advisability of pursuing a controlled drinking outcome has indeed subsided in recent years. A recent, exhaustive review of the research literature by Rosenberg (1993) offers the following general conclusions about the viability of controlled drinking as a treatment goal. Controlled drinking (CD) may be workable if the person: 1) evidences relatively low dependence severity; 2) strongly believes in CD; 3) has regular, stable employment; 4) is younger (e.g., under age 40); 5) shows relative psychological and social stability; and 5) is female. Rosenberg notes that no single characteristic has been consistently predictive of success in CD. It is suggested that controlled drinking (CD) trials may be especially risky for persons who superficially appear to meet CD suitability profile but are in fact, at high risk for alcoholism. e.g., not knowing one has a strong family history of alcoholism. Obviously, certain health complications (e.g., liver disease) may make the decision to attempt CD extremely unwise. Most suited to brief interventions may be persons with minimal problems with alcohol dependence. Indeed reductions in drinking, rather than abstinence, is commonly the goal of brief 17
18 interventions. Persons who drink above the level of health guidelines for safe drinking, but who do not yet show signs of significant alcohol-related problems, are also candidates for brief interventions (Heather, 1995). It is also suggested that having a thorough understanding of the similarities and differences between DSM-IV diagnostic criteria for abuse versus dependence is essential in making a distinction between clients appropriate for brief interventions, versus those who should pursue standard treatment. Many assessment instruments are available which help identify patients with alcohol dependence. Also, Heather (1995) suggests that brief interventions may be palatable to high-dependence problem drinkers who cannot be reached by conventional treatments. What constitutes a typical, controlled drinking approach? In behavioral self-control training, clients are first assessed, via a detailed, weekly self-monitoring procedure. Clients attempt to set drinking limits for themselves. Strategies designed to help clients control their rate of consumption include requesting/mixing weaker drinks, alternating drinks with nonalcoholic beverages, or requesting drinks known to have a lower alcohol content. Also, clients can ask for a favorite drink, but then switch to a less-preferred drink---which they often drink somewhat more slowly. Self-monitoring one's commitment to sip, rather than gulp drinks is also useful. Eating food, and spacing drinks across time are additional strategies. Clients may need social skills training/practice to learn how to refuse drinks. Further, they often need to learn how to reward themselves in supplemental ways, if they meet with success in a drinking episode. Selfcontrol training also involves helping clients understand the cues that lead them to drink excessively, and learn how to cope with these internal or situational factors. As has been intimated, controlled outcome studies show that when behavioral self-control training fails, it is often because the person was seriously dependent on alcohol. Also, lowempathy therapists have been shown to have less success with BSCD (see Foy et al, 1984; Hester, 1995). Some additional points regarding treatments for less-severe problem drinkers can be gleaned from the Miller et al (1995) review. For example, the weight of evidence suggests that irrespective of the level of alcohol dependence of clients, educational/films are a poor choice as a stand-alone treatment, and though widely used and popular, probably do not add significantly to treatment program effectiveness. Also showing poor results with (typically) less severe patients is relaxation training. Coping and Social Skills Training. The outcome data for social skills training are impressive, given that the average or typical study involves the most severe alcoholics. Monti et al (1995) provide a detailed overview of Coping and Social Skills Training (CSST) which has been demonstrated through controlled studies to be an effective approach to alcoholism treatment. (It is noteworthy that a modified version of CSST was one of the three treatments compared in the widely publicized study, Project Match, which will be discussed in this paper under the topic of matching patients to treatment.) CSST involves some investment of time in assessment of client abilities e.g., coping skills; a variety of assessment approaches are offered by Monti et al, e.g., Alcohol Specific Role- Play. Assessment also plays an important role in the cue-exposure treatment (CET) 18
19 CSST also provides recipients with communication skills training. Components involve introduction, rationale, goals, sample modeling of effective and ineffective communications, group discussion and modeling practice of real-life situations. The other major modules of CSST Social Skills Training are a) Drink Refusal Skills; b) giving positive feedback; c) giving criticism; d) receiving criticism about drinking; e) conversation skills; f) listening skills; g) developing sober supports; h) conflict resolution; I) nonverbal communication; j) expressing feelings; k) assertiveness training; l) refusing requests; m) receiving criticism (general). The major modules of CSST's cognitive-behavioral mood management training are: a) managing thoughts about drinking and coping with craving; b) managing negative thinking; and c) understanding and coping with seemingly irrelevant decisions. The modules of CSST cue exposure and urge coping skills include: a) assessment/beverage exposure; b) imaginal scene exposure; c) integration of urge coping skills; and d) urge coping strategies. Patient-treatment matching and CSST. Monti et al discuss some patient-treatment matching considerations, some empirically-based, but most, related to clinical experiences in their program. These are enumerated below: 1. Screen out floridly psychotic or suicidal patients, or patients with substantial cognitive impairment. (CSST can accommodate some degree of cognitive impairment, as treatment sessions are paced with regard to cognitive improvement with continued abstinence). 2. Depressed clients seem to do as well as non-depressed clients 3. Kadden et al (1989) found that CSST was more effective with persons with significant sociopathy and psychopathology than more "standard" interactional group therapy. 4. Clients with more education and less anxiety are able to benefit more from the mood management components of CSST, than those with low education, high anxiety. However, clients seem equally likely to benefit from all other components of CSST (Rohsenow et al, 1991). 5. Careful assessment of clients' degree of "denial" regarding sensitivity to visual/sensory cues regarding alcohol is needed for the exposure/desensitization phase of CSST. High denial clients are frequently very surprised at how physiologically and emotionally responsive they are to such cues. In summary, CSST uses cognitive-behavioral and social learning theory models developed by psychologists to impact the quality of one s basic interpersonal skills, teaching clients how to manage their mood states, basic coping skills for managing daily living and dealing with stressful life events, and managing the situational cues that are associated with substance use. Such approaches probably incorporate a good deal of training in relapse prevention, and is probably a component in nearly all effective community reinforcement programs. Miller et al s data suggest that this is perhaps one of the most cost-effective therapies. The data also indicated that social skills training may be a very useful supplement to a more comprehensive treatment program. Community reinforcement approach. The community reinforcement approach (CRA) is also supported by a significant weight of evidence. CRA approaches work with clients' family, social, community, recreational and vocational sources of incentives and reinforcers to alter drinking behavior. A careful assessment is made of all of the important antecedent and 19
20 consequences associated with drinking. Also, meaningful incentives to clients are identified, and then attempts are made to rearrange consequences and sources of reinforcement in the person s world, so as to support abstinence. This approach may work best with individuals possessing adequate social support and who have much to gain by not drinking, but much to lose if they do not stop. CRA programs also involve many coping and skills training elements. For example, it may include social skills, communication skills, and problem solving skills training. Therapists may work with clients to help them practice how to refuse offers of drinks, job skills assistance, and how to incorporate stress reduction behaviors and increase pleasant events in life through recreational counseling. Where appropriate, CRAs may offer marital or family therapy, as this area of social support involves many sources of incentives to clients. A recent review of CRA theoretical underpinnings, common procedures, and an assessment of controlled outcome studies is offered by Smith & Myers (1995). They note that this approach has not been investigated extensively, but that controlled studies suggest that the approach is promising. As noted elsewhere in the present review, the CRA approach has been evaluated with cocaine dependent persons, with fairly good results (e.g, Budney et al, 1991, Higgins et al, 1991; 1993). A study of a CRA for opiate abusers reported in the section of the present review on methadone maintenance is reported; it suggests favorable effects (Abbott et al, 1998). It may be essential for families to become involved in CRAs. In one study, only family or significant other involvement predicted outcome (Higgins et al, 1994). Smith, Meyers, & Delaney (1997) randomly assigned homeless, alcohol-dependent patients to either the community reinforcement approach or a standard treatment (physical services needs, and 12 step/aa program) in a large day shelter. The community reinforcement program was significantly superior to the standard program in terms of reductions in drinking at 5 follow-up measurement periods. Both treatments were equally effective in improving employment and housing stability. Bickel et al (1997) compared the addition of a behavioral program emphasizing use vouchers plus community reinforcement program with a standard treatment lifestyle counseling approach as adjuncts to opiate detoxification using buprenorphine. The authors found highly significant differences favoring the behavioral program in terms of program completion and periods of abstinence at several follow-up periods. Motivational enhancement/counseling approach. Still another treatment approach that is supported by a reasonable body of controlled research is Motivational Interviewing and Counseling. Miller (1995) summarized his conceptualization of several hundred studies that dealt with such things as the problem of client drop-out rates, relapse, poor treatment outcomes, and their relation to client motivation. He suggests that motivation is not an emotion or state of mind of clients, but rather, something one does. Basically, motivated persons interact with their social and physical world much differently than unmotivated people. Therapists and counselor traits probably have more to do with clients' motivational status than is generally appreciated. Miller (1995) outlines several keys to motivate client change. The present writer suggests that counselor/therapist behaviors associated with these key factors can be readily implemented in any treatment program, regardless of philosophy. Miller uses the acronym FRAMES to describe the 20
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