Treatment for alcohol problems saves public money

National Treatment Agency Review of Effectiveness

Evidence-based alcohol treatment in the UK could result in net savings of £5 for every £1 spent for the public sector and providing effective treatment is likely to reduce significantly the social costs relating to alcohol,whilst increasing individual social welfare.This is the view put forward in a recently-published review of the effectiveness of treatments for alcohol problems,which will be of interest tomanagers,commissioners,providers, service users and key stakeholders in the provision of alcohol treatment services.

The Review of the Effectiveness of Treatment for Alcohol Problems,written to support the implementation of the National Alcohol Harm Reduction Strategy and specifically to complement the Models of Care for Treatment of Adult Drug Misusers (MoCAM) initiative was published by the National Treatment Agency for Substance Misuse in November 2006. It is intended as a key reference tool to facilitate the development of effective local alcohol treatment systems,which can contribute to the reduction of alcohol-related harm within communities. By covering the published international research literature on alcohol interventions and treatment and by describing the effectiveness of the various interventions and treatments available, it is hoped that the Review will enable local services and partnerships to assess current provision and plan future developments to meet the needs of their populations.

At the outset, the authors, Duncan Raistrick,Nick Heather and Christine Godfrey, identify 10 key themes which inform the document. Briefly, these are:

• Drinking takes place within an influential social context.

• People move in and out of different patterns of drinking without recourse to professional treatment.

• Help-seeking usually follows prolonged alcohol-related problems, notably related to health, relationships and finances, after unassisted attempts to change drinking patterns have failed.

• Treatment effectiveness may be as much about how treatment is delivered as about what treatment is delivered.

• There is a choice of effective treatments to suit the variety of potential service users.

• Psychiatric co-morbidity is common among problem drinkers and this is likely to make treatment more challenging and of longer duration.

• Treatment for alcohol problems is cost-effective. Alcohol misuse has a high impact on health, social care and criminal justice systems, where major savings can be made.

• Interventions of all kinds are only effective if delivered in accordance with their current descriptions of best practice and carried out by a competent practitioner.

• Stepped care is a rational approach to developing an integrated service model that makes best use of a finite resource.

• The evidence base for the effectiveness of alcohol problems interventions is strong.The UK contribution is considerable and merits further financial support to research programmes.

The first part of the report sets the scene by giving the background to the review and putting it in context against current alcohol policy.This is followed by an overview of treatment and interventions to reduce alcohol-related harm and consideration of ways in which the base of treatment for alcohol problems needs to be broadened from the traditional exclusive focus on ‘alcoholics’. Summaries are then provided of the Mesa Grande project, together with three recent systemic reviews and two large multi-centre trials of alcohol treatment, known as Project MATCH and the United Kingdom Alcohol Treatment Trial.The authors then consider how treatment should be delivered rather than what treatment should be delivered, covering therapist characteristics, service user groups and settings in which to deliver services.

Before reviewing treatments themselves, the authors review commonly used screening tools, such as questionnaires, and consider the use of screening instruments in various settings, including Antenatal clinics and A & E departments, as well as looking at biological and clinical markers of alcohol misuse. It is recognised that early detection is an essential element of broadening the base of treatment to detect problem drinkers before they become helpseekers. The authors consider which evidence should beincluded in a comprehensive assessment and review commonly used assessment tools, noting that treatments are only of value if they deliver useful outcomes, and exploring some of the problems concerned with measuring outcomes.

Four chapters follow which deal specifically with core psychosocial treatments for alcohol misuse – brief interventions, less intensive treatment, alcohol-focused specialist treatment and nonalcohol focused specialist treatment. Brief interventions are described in different populations and settings; medical, non-medical and educational, and the authors identify specific barriers to the implementation of screening and alcohol brief interventions in primary healthcare. Less intensive treatments,which are still considered brief but are aimed at help-seekers andextend over a number of treatment sessions, are then considered, including condensed cognitive-behavioural therapy, brief conjoint therapy, motivational interviewing and motivational enhancement therapy.

The chapter on alcohol focused specialist treatment looks at the effectiveness of psychosocial treatments focused on the service user’s drinking and alcohol-related problems, which are mainly relevant to service users with moderate or severe alcohol dependence. Several treatment options are considered, namely the community reinforcement approach, social behaviour and network therapy, behavioural self-control training, behaviour contracting, coping and social skills training, cognitive behavioural marital therapy, aversion therapy, cue exposure and relapse prevention.The subsequent chapter on nonalcohol focused specialist treatment covers coping skills, counselling, family work and complementary therapies.

Pharmacotherapies and their interaction with the psychosocial interventions discussed earlier in the Review are then considered.These are categorised as detoxification, relapse prevention and nutritional therapy.The authors then look at how alcohol misusers can help themselves to recover from their problems without the aid of formal treatment.Distinguishing between individual self-help and collective mutual aid, the authors consider computer and web-based self-help programmes, 12-step facilitation therapy and 12-step residential treatment, amongst others.

The authors consider the prevalence of psychiatric comorbidity and note that most of the interventions described will be helpful to people with mental health problems, although they may require modification.The Review concludes that there is theoretical and anecdotal evidence to favour either an integrated or shared care approach and that there is a need to configure services and construct care pathways in such a way that people with comorbidity are not excluded from treatment and are not moved from one agency to another.

The authors then turn to the crucial question of the costeffectiveness of treatment and its relevance to the provision of treatment for alcohol problems in England, concluding that alcohol treatments are highly cost-effective in comparison with other healthcare interventions. In the final chapter, the treatment journey is put in context, and the authors point out that treatment is one of the many different influences on an individual’s drinking. Directly or indirectly, they say, treatment probably accounts for around one-third of all improvements made.UK and international research has shown that alcohol treatment can be an effective and cost effective response to alcohol problems. While there is compelling evidence for investment in alcohol treatment, the review makes clear that it will be essential to invest wisely in interventions of proven effectiveness.

The Review provides a wellorganised, systematic evaluation of the wide range of treatment options available to deal with alcohol-related problems and will be an invaluable resource for anyone with an interest in this field.