Review of the effectiveness of treatment for alcohol problems (full

212 Pages·2006·1.66 MB·English

NFS Cover with spine 1/11/06 10:36 Page 1
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Review of the effectiveness of
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Duncan Raistrick, Nick Heather and Christine Godfrey
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National Treatment Agency for Substance Misuse
8th floor, Hercules House, Hercules Road, London SE1 7DU
Tel [phone]
Fax [phone]
Email: [email protected]
Website: www.nta.nhs.uk
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About the authors
About the authors
Duncan Raistrick
Leeds Addiction Unit, 19 Springfield Mount, Leeds, LS2 9NG
Duncan Raistrick qualified in medicine from the University of Leeds in 1971 and trained in general practice in
Nottingham, specialising in neurology in Leeds and Liverpool, and in psychiatry at the Maudsley Hospital, London. He
gained membership of the Royal College of Psychiatrists in 1977 and received an MSc from the University of London in
1978. He became a fellow of the Royal College of Psychiatrists in 1999 and was the medical adviser on alcohol to the
chief medical officer and a member of the Health Advisory Service for HM Prison Service. He was a member of the
working group on the Department of Health publication, Drug Misuse and Dependence – Guidelines on Clinical
Management. Duncan is currently a member of the NTA Research Advisory Group and co-director of the RESULT
Information Management System, and has published research papers and books including Tackling Alcohol Together.
His research interests are the nature of dependence, outcome measures and therapist characteristics. He is an
associate medical director of the Leeds Mental Health Trust.
Nick Heather
School of Psychology and Sport Sciences, Northumbria University, Newcastle upon Tyne, NE1 8ST
After ten years as a clinical psychologist in the NHS, in 1979 Nick Heather developed and led the Addictive Behaviours
Research Group at the University of Dundee. In 1987, he was the founding director of the National Drug and Alcohol
Research Centre at the University of New South Wales, Australia. He returned to the UK at the beginning of 1994 to
take up the post of consultant clinical psychologist at the Newcastle City Health NHS Trust and as director of the
Centre for Alcohol and Drug Studies in Newcastle. Nick has recently retired from salaried work and is now emeritus
professor of alcohol and other drug studies in the Division of Psychology at Northumbria University. He has published
numerous scientific articles, books, book chapters and other publications, mostly in the area of addictions, with an
emphasis on the treatment of alcohol problems.
Christine Godfrey
Department of Health Sciences, Seebohm Rowntree Building, Alcuin College, University of York, York YO10 5DD
Christine Godfrey is a professor of health economics at the Department of Health Sciences and the Centre for Health
Economics at the University of York. She has been involved in research into the economics of addiction since 1984.
She is currently a member of the Expert Committee on Drug Dependence, the World Health Organization, a non-
executive board member of the Health Development Agency and a member of the Scientific Committee on Tobacco
and Health at the Department of Health. She is one of the principal investigators of UKATT and is currently undertaking
a range of cost-effectiveness analyses on smoking, drinking and illicit drug interventions.
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Review of the effectiveness of treatment for alcohol problems
The National Treatment Agency for Substance Misuse
The National Treatment Agency for Substance Misuse (NTA) is a special health authority within the NHS, established by
Government in 2001, to improve the availability, capacity and effectiveness of treatment for drug misuse in England.
Treatment can reduce the harm caused by drug misuse to individuals’ well-being, to public health and to community
safety. The Home Office estimates that there are approximately 250,000–300,000 problematic drug misusers in
England who require treatment.
The overall purpose of the NTA is to:
• Double the number of people in effective, well-managed treatment between 1998 and 2008
• Increase the percentage of those successfully completing or appropriately continuing treatment year-on-year.
In addition to its remit on drug treatment, the NTA is also commissioned to undertake specific work on alcohol
treatment, including the development of Models of Care for Alcohol Misusers (DH, 2006) and commissioning the
Review of the Effectiveness of Treatment for Alcohol Problems (NTA, 2006).
Reader information
Document purpose To provide accessible information on the effectiveness of alcohol treatment
Title Review of the Effectiveness of Treatment for Alcohol Problems
Lead authors Duncan Raistrick, Nick Heather and Christine Godfrey
Publication date November 2006
Target audience Commissioners, managers and providers of alcohol treatment services
Circulation list See above
Description A critical appraisal of the international evidence of the effectiveness of treatments and
interventions for alcohol problems
Cross reference Models of Care for Alcohol Misusers (MoCAM) (DH, 2006)
Alcohol Misuse Interventions: Guidance on Developing a Local Programme of Improvement
(DH, 2005)
Alcohol Needs Assessment Research Project (ANARP) (DH, 2005)
Contact details 8th floor, Hercules House, Hercules Road, London SE1 7DU.
Tel: [phone]. Fax: [phone] Email: [email protected]
Website: www.nta.nhs.uk
Gateway/ROCR approval The NTA is a self-regulating agency in relation to Department of Health Gateway
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Foreword
Foreword
This timely, authoritative and comprehensive review of what research tells us about alcohol
treatment is very welcome. Alcohol misuse represents a significant burden to the NHS and
wider society.
Both The Alcohol Harm Reduction Strategy for England (2004) and the Choosing Health
White Paper (2005) identified a need for better identification and treatment of alcohol
problems. The evidence base reviewed here informed the publication of Models of Care for
Alcohol Misusers (2006), which provides clear guidance on the development of local systems
to identify and intervene with alcohol misuse problems. This review offers practitioners, as well
as commissioners and managers of services, the information they need to ensure that what
they provide reflects the best available evidence.
This review covers the published international research literature on alcohol interventions and treatment. In describing
the effectiveness of the various interventions and treatments available it will enable local services and partnerships to
assess current provision and plan future developments to meet the needs of their populations.
Our relationship with alcohol as a society is complex. A source of pleasure and enjoyment for many it is also implicated
in many of the most challenging problems we encounter. This review addresses the techniques for intervening early to
identify excessive and risky alcohol use as well as the approaches for dealing with developed problems.
UK and international research informs us that alcohol treatment can be an effective and cost effective response to
alcohol problems. While there is compelling evidence for investment in alcohol treatment, this review makes clear that it
will be essential to invest wisely in interventions of proven effectiveness.
In order to prevent harm associated with alcohol misuse and to treat people with alcohol problems effectively, local
partnerships will need to commission and deliver effective, integrated solutions. I believe this publication is a key
reference tool to facilitate the development of effective local alcohol treatment systems that can contribute to reduced
alcohol-related harm in our communities. I congratulate the authors on their achievement and have no hesitation in
commending this review to service providers, commissioners and anyone else with an interest in alcohol treatment.
Baroness Massey of Darwen
Chair, National Treatment Agency for Substance Misuse
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Review of the effectiveness of treatment for alcohol problems
The steering group
Annette Dale-Perera, director of quality, National Richard Phillips, acting chief executive, Alcohol Concern
Treatment Agency
Professor IT Gilmore MD PRCP, president, Royal College
Dr Emily Finch, clinical team psychiatrist, National of Physicians
Treatment Agency
Dr Duncan Raistrick, associate medical director, Leeds
Tim Murray, policy officer, National Treatment Agency Mental Health Trust
Professor Colin Drummond, professor of addiction Professor Nick Heather, emeritus professor of alcohol and
psychiatry, St George’s, University of London other drug studies, Northumbria University
Dr William Shanahan, lead clinician, Central and North Dr Linda Harris MRCGP, clinical director, Wakefield
West London Mental Health NHS Trust Substance Misuse Integrated Substance Misuse Services and RCGP
and Prison Services Substance Misuse Unit
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Contents
Contents
Ten key themes..........................................................9 6.1 Background.............................................69
1 The review process..........................................13 6.2 Assessment tools.....................................70
1.1 Introduction..............................................13 6.3 Routine follow-up.....................................75
1.2 Policy context...........................................14 6.4 Assessment packages.............................76
1.3 Objectives................................................14 7 Brief interventions............................................79
1.4 Terminology..............................................15 7.1 Background.............................................79
1.5 Chapter structure.....................................17 7.2 General effectiveness of
1.6 Summary..................................................17 brief interventions.....................................79
2 Broadening the base of 7.3 Brief interventions in primary
treatment and interventions.............................19 healthcare................................................81
2.1 Introduction..............................................19 7.4 Brief interventions in the
2.2 Categories of alcohol misuse...................19 general hospital........................................82
2.3 Prevalence...............................................22 7.5 Brief interventions in Accident
and Emergency departments...................83
2.4 Goals of treatment....................................23
7.6 Brief interventions in
2.5 Including family and
other medical settings..............................84
friends in treatment..................................25
7.7 Brief interventions in
2.6 Service user choice..................................26
educational establishments......................85
2.7 Increasing accessibility and
7.8 Brief interventions in other
responsiveness of treatment.....................26
non-medical settings................................86
2.8 Stepped care...........................................27
7.9 Simple brief interventions.........................86
3 Recent evidence on
7.10 Extended brief interventions.....................87
treatment effectiveness....................................31
7.11 Implementing brief interventions...............89
3.1 Background.............................................31
8 Less-intensive treatment.................................93
3.2 Equivalence of outcomes for
psychosocial treatments...........................31 8.1 Background.............................................93
3.3 The Mesa Grande project.........................32 8.2 A basic treatment scheme........................93
3.4 Systematic reviews commissioned 8.3 Condensed cognitive
by governments.......................................34 behavioural therapy..................................94
3.5 Project MATCH........................................35 8.4 Brief conjoint marital therapy....................94
3.6 The United Kingdom Alcohol 8.5 Motivational interviewing...........................95
Treatment Trial..........................................39 8.6 Motivational enhancement therapy...........98
3.7 Implications for treatment practice...........41 8.7 Training in motivational interviewing..........99
4 Delivering better treatment..............................47 9 Alcohol-focused specialist treatment...........103
4.1 Background.............................................47 9.1 Background...........................................103
4.2 The therapist............................................47 9.2 The community reinforcement
4.3 Service user groups.................................50 approach................................................104
4.4 The setting...............................................53 9.3 Social behaviour and
network therapy.....................................105
5 Screening for alcohol problems......................57
9.4 Behavioural self-control training..............106
5.1 Background.............................................57
9.5 Behaviour contracting............................107
5.2 Screening questionnaires.........................57
9.6 Coping and social skills training..............107
5.3 Settings....................................................60
9.7 Cognitive behavioural
5.4 Biological markers....................................61
marital therapy.......................................109
5.5 Clinical indicators.....................................63
9.8 Aversion therapy....................................111
Appendix 1: The AUDIT Questionnaire...............65
9.9 Cue exposure.........................................111
Appendix 2: Fast Alcohol Screening Test............66
9.10 Relapse prevention.................................112
Appendix 3: The Paddington Alcohol Test..........67
9.11 Aftercare................................................113
6 Assessment and measuring
9.12 Extended case monitoring......................115
treatment outcomes.........................................69
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Review of the effectiveness of treatment for alcohol problems
Contents
10 Non-alcohol-focused 13.2 The validity of co-morbidity
specialist treatment........................................119 diagnoses...............................................149
10.1 Background...........................................119 13.3 Estimates of prevalence.........................150
10.2 Families and significant others................119 13.4 The importance of co-morbidity.............152
10.3 Social skills training................................121 13.5 Symptoms of anxiety, depression
10.4 Counselling............................................122 and insomnia..........................................153
10.5 Self-esteem and 13.6 The concept of personality
complementary therapies ......................123 disorder..................................................154
11 Detoxification and pharmacological 13.7 Integrated treatment for
enhancements to treatment...........................127 co-morbidity...........................................155
11.1 Background...........................................127 13.8 Service models.......................................156
11.2 Detoxification ........................................128 14 Cost-effectiveness of treatment....................161
11.3 Medications for relapse prevention.........130 14.1 Background...........................................161
11.4 Anti-craving medications........................132 14.2 Economic benefits of
11.5 Nutritional supplements..........................134 alcohol treatment...................................162
12 Self-help and mutual aid................................137 14.3 Cost-effectiveness of brief
interventions...........................................164
12.1 Background...........................................137
14.4 Intensive treatments in
12.2 Individual self-help..................................137
different settings.....................................165
12.3 Computer and internet-based
14.5 Psychosocial treatments........................165
self-help programmes............................139
14.6 Pharmocotherapies................................167
12.4 Collective mutual aid..............................139
14.7 Comparisons of psychosocial
12.5 12-Step facilitation therapy.....................142
and pharmacotherapies.........................168
12.6 12-Step residential treatment.................143
15 The treatment journey....................................171
12.7 Other mutual aid groups.........................144
15.1 Cultural and societal contexts................171
12.8 Evidence................................................145
15.2 Drinking careers.....................................172
12.9 Conclusions...........................................146
15.3 Help-seeking..........................................173
13 Psychiatric co-morbidity................................149
15.4 Summary................................................174
13.1 Background...........................................149
References.............................................................177
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Ten key themes
Ten key themes
(cid:1) Drinking takes place within a social context, which has (cid:1) Psychiatric co-morbidity is common among problem
a powerful influence on the amount and the patterns drinkers – up to ten per cent for severe mental
of drinking in the community. The effectiveness of illnesses, up to 50 per cent for personality disorders
prevention and control measures will modulate the and up to 80 per cent for neurotic disorders. It is likely
total number of problem drinkers to make treatment more challenging and of longer
(cid:1) The majority of people, including dependent drinkers, duration
move into and out of different patterns of drinking (cid:1) Treatment for alcohol problems is cost-effective.
without recourse to professional treatment. Unassisted Alcohol misuse has a high impact on health and social
or natural recovery is often mediated through self-help, care systems, where major savings can be made.
family and friends, and mutual aid groups Drinking also places costs on the criminal justice
(cid:1) Help-seeking is typically a consequence of system, especially with regard to public order. Overall,
for every £1 spent on treatment, £5 is saved
experiencing prolonged alcohol-related problems and
elsewhere
stress, notably related to health, relationships and
finances, after attempts at unassisted behaviour (cid:1) Interventions of all kinds are only effective if delivered
change have failed in accordance with their current descriptions of best
(cid:1) Treatment effectiveness may be as much about how practice and carried out by a competent practitioner.
Assumptions drawn from the evidence are predicated
treatment is delivered as it is about what is delivered.
on the availability of trained practitioners
With regard to the “what”, the research evidence
indicates that cognitive behavioural approaches to (cid:1) Stepped care is a rational approach to developing an
specialist treatment offer the best chances of success integrated service model that makes best use of a
(cid:1) There is a choice of effective treatments to suit the finite resource. Stepped care can also be applied
within an agency. The only proviso is that the steps,
variety of potential service users:
which may involve a change of practitioner, are natural
– 7.1 million hazardous or harmful drinkers may steps for service users
benefit from brief interventions given by generic
(cid:1) The evidence base for the effectiveness of alcohol
workers in almost any setting
problems interventions is strong. The UK contribution
– 1.1 million dependent drinkers may benefit from is considerable and merits further financial support to
more intensive treatment given by specialist research programmes.
workers
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Review of the effectiveness of treatment for alcohol problems
ICD-10 substance misuse codes
F10.- Mental and behavioural disorders due to use of alcohol
F11.- Mental and behavioural disorders due to use of opioids
F12.- Mental and behavioural disorders due to use of cannabinoids
F13.- Mental and behavioural disorders due to use of sedatives or hypnotics
F14.- Mental and behavioural disorders due to use of cocaine
F15.- Mental and behavioural disorders due to use of other stimulants, including caffeine
F16.- Mental and behavioural disorders due to use of hallucinogens
F17.- Mental and behavioural disorders due to use of tobacco
F18.- Mental and behavioural disorders due to use of volatile solvents
F19.- Mental and behavioural disorders due to multiple drug use and use of other psychoactive substances
F1x .0 Acute intoxication
.00 Uncomplicated
.01 With trauma or other bodily injury
.02 With other medical complications
.03 With delirium
.04 With perceptual distortions
.05 With coma
.06 With convulsions
.07 Pathological intoxication
F1x .1 Harmful use
F1x .2 Dependence syndrome
.20 Currently abstinent
.21 Currently abstinent, but in a protected environment
.22 Currently on a clinically supervised maintenance or replacement regime (controlled dependence)
.23 Currently abstinent, but receiving treatment with aversive or blocking drugs
.24 Currently using the substance (active dependence)
.25 Continuous use
.26 Episodic use (dipsomania)
F1x .3 Withdrawal state
.30 Uncomplicated
.31 With convulsions
F1x .4 Withdrawal state with delirium
.40 Without convulsions
.41 With convulsions
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