SHORT-TERM RECOVERY FROM ALCOHOL ABUSE OR DEPENDENCE: ANY EVIDENCE OF A RELATIONSHIP WITH TREATMENT USE IN A GENERAL POPULATION SAMPLE?

JOHN A. CUNNINGHAM

Addiction Research Foundation Site, Centre for Addiction and Mental Health, 33 Russell Street, Toronto, Ontario, M5S 2S1, Canada and University of Toronto, Toronto, Canada

Correspondence: Tel.: +1416-535-8501 ext. 6701; Fax: +1416-595-6899; E-mail: John_Cunningham{at}camh.net

(Received 4 December 2004; first review notified 28 December 2004; in revised form 24 January 2005; accepted 9 March 2005)


    ABSTRACT
 TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Aims: To test whether survey respondents who report alcohol misuse in the past year are more likely to be abstinent or binge-free in the past 30 days if they have used treatment, than if they have not. Methods: Analysis of data from the 2002 US National Survey on Drug Use and Health was obtained. Results: A total of 5730 respondents scored positive for alcohol abuse or dependence in the preceding year. Fewer than 10% had used any treatment for alcohol or drugs in this period, but this was associated with a 10% increase in the past-month abstinence and past-month binge-free drinking compared with respondents who did not access treatment. Such an apparent short-term recovery appeared greater in those whose treatment had been received in a formal treatment setting, a doctor's office, or in self-help groups than in the emergency room or in prison. Conclusions: Even if part of the association between treatment and recent abstinence and non-binge drinking was causal, indicating that treatment has some impact, it is a pathway chosen only by the minority.


    INTRODUCTION
 TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
What can be learnt about the efficacy of treatment for alcohol problems from population survey data? First, it is possible to demonstrate that treatment has some impact. As an example, using longitudinal data from representative samples, Weisner et al. (2003aGo, b)Go have shown that problem drinkers who access treatment are more likely to resolve their concerns than those who do not access treatment. While the impact of treatment is modest, these findings are an important adjunct to clinical trial efficacy research (see reviews Miller et al., 1995Go; Moyer et al., 2002Go) because it demonstrates what happens to the population of individuals with alcohol problems as opposed to just those few individuals who enter treatment trials. In contrast to this finding, population research also demonstrates the fact that the majority of people with alcohol problems deal with their drinking concerns without treatment (Dawson, 1996Go; Cunningham, 1999Go). Hence, while treatment effectiveness research employing representative population samples can indicate that attending treatment accrues some advantages as far as increasing the chances of recovery, such research also demonstrates that this pathway is the less chosen one and that most people with alcohol problems deal with their concerns without ever using treatment.

What else can be learnt about treatment from population samples? Is it possible to find any indication whether some types of treatment might be more effective than others? There are limitations to which population surveys can be used to address this question. Such surveys are often cross-sectional, hence any findings are limited by the lack of longitudinal data. The incidence of treatment use in the general population of problem drinkers is also low (e.g. Cunningham and Breslin, 2004Go), hence sample sizes are often not large enough to compare different treatment modalities. Finally, population surveys are usually not designed to explore this question, so the items contained in these surveys are often not detailed enough to be of any use for this purpose. One possible approach to take, however, is to explore the short-term impact of treatment using population survey data. Population surveys usually have their focus on drinking and service use in the last year so it should be possible, given a large enough sample, to explore whether different treatment modalities are associated with short-term resolutions from alcohol problems in the last year.


    SUBJECTS AND METHODS
 TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Data from the 2002 National Survey on Drug Use and Health (NSDUH; US Department of Health and Human Services, 2004Go) were used to explore whether treatment use was associated with short-term recoveries. The 2002 NSDUH comprises a large (n = 54 079) representative sample of the US population. The NSDUH is a yearly survey that employs a stratified, multistage area probability sample of the US. The target population for the survey is civilians, 12 years or older. The interviews for the 2002 survey were conducted face-to-face and the overall response rate was 79%.

The 2002 NSDUH assessed the past-year alcohol dependence or abuse using items from DSM-IV (American Psychiatric Association, 1994Go) and asked about treatment use as well. Questions about treatment use were asked after all the sections assessed the use of different illicit drugs. Treatment was defined as accessing any treatment services for either illicit drug use or alcohol use in the past year, i.e. ‘These next questions deal with treatment for alcohol and drug problems, not including cigarettes. Please report treatment or counseling designed to help you reduce or stop your alcohol or drug use. Please include detoxification and any other treatment for medical problems associated with your alcohol or drug use. Have you ever received treatment or counseling for your use of alcohol or any drug, not counting cigarettes?’ Respondents agreeing to this item were then asked, ‘During the last 12 months, have you received treatment or counseling for your use of alcohol or any drug, not counting cigarettes?’ Both alcohol and drug treatment were included because there is some overlap in treatment modalities for all substance abuse problems (Rotgers et al., 1996Go). If respondents answered yes to these screener questions, they were asked about use of the specific treatment options identified on Table 1. For the purposes of this study, short-term recoveries were assessed in two ways. First, respondents were asked if they had ever consumed ≥5 drinks on one occasion in the past 30 days. Second, respondents were asked if they had consumed any alcohol in the past 30 days. A standard drink was defined for the respondent at the time these questions were asked. Prevalence estimates were calculated using weighted data on the online data analysis system of the Substance Abuse and Mental Health Data Archive. Sample sizes are presented as unweighted data.


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Table 1. Relation of addictions treatment use to one-month recovery in respondents with past year alcohol abuse or dependence (n = 5730)

 

    RESULTS
 TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Table 1 displays the treatment use and past-month drinking of the 5730 respondents with alcohol abuse or dependence in the past year. Less than 10% of these respondents had accessed any type of treatment for alcohol or drug concerns in the past year. Of all 5730 respondents, 10% were abstinent in the past month and 22.5% had not consumed ≥5 drinks on one occasion on any day in the past month. Inspection of the proportions of respondents who accessed treatment and displayed reduced drinking in the past month also indicated that: (i) respondents who accessed some type of treatment were more likely to be abstinent and to have not binged in the past month compared with respondents who had not accessed treatment [Abstinent (n = 5730): No treatment = 8.8%, Treatment = 22.1%; No binge (n = 5730): No treatment = 21.7%, Treatment = 29.7%; both P < 0.01]; and (ii) there was variation in the proportion of respondents who reported abstinence and binge-free drinking in the past month depending on the type of treatment they had accessed (Abstinent: proportions ranged from 18% for treatment in prison to 36% for treatment in a hospital; No binge: proportions ranged from 23% for treatment in prison to 41% for treatment at a doctor's office).


    DISCUSSION
 TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
In line with the findings of Weisner et al. (2003aGo, b)Go, the present study provides evidence that people who access treatment do better on an average compared with those who do not seek help for their alcohol concerns. This finding should be tempered by the facts that <10% of people with alcohol dependence or abuse actually sought treatment and that there was also evidence of short-term recoveries among respondents who did not seek treatment (albeit a lower proportion). Finally, there was a variation in the proportion of short-term recoveries among the subsets of treated respondents who accessed different types of services.

What can be concluded from these findings? First, it is probably true that people with alcohol dependence or abuse will do better if they seek treatment, as the present study demonstrated an ~10% increase in the past-month abstinence and binge-free rates between respondents who sought treatment compared with those who did not. However, this conclusion should be viewed with some caution because respondents were not randomly assigned to treatment, so causal statements cannot be made and it is possible that some systematic difference that covaried with treatment access could be the true explanation as to why these respondents did better as opposed to this improvement being the result of treatment use. Another alternative explanation is that the association of no binge or abstinence in the past month with treatment could occur because alcohol abusers who were formerly continuous drinkers and are now episodic heavy drinkers may be more likely to seek treatment than those who remain as continuous heavy drinkers. This might happen if the continuous abuser tried to abstain using his or her own resources, then finds he or she can only do so for periods (becomes ‘episodic’) and then, seeks help.

Caution should also be used in interpreting the results for several other reasons. First, the present study only investigated past-month drinking and provided no evidence regarding sustained recoveries from alcohol abuse or dependence. Second, while it is justified to ask about use of alcohol and drug treatment because there is overlap in the content and target population of these services, this analytic choice should be taken into consideration when interpreting the findings. Third, while the results of this study can probably be used to indicate that there is variation in the impact of different treatment modalities, it would be inappropriate to use the findings to state that one treatment modality is superior to the other. This type of analysis does not offer any information about the type of person that ends up in different treatment services. How do their characteristics vary and what impact does this variation have on drinking outcome, irrespective of the treatment used?

Moreover, these treatment sub-samples were partially overlapping because the sum of respondents who used each of the treatment modalities exceeded the total number of respondents who accessed any of the treatments. Despite these limitations, the final conclusion that can be drawn from these findings is that, while the provision of treatment services is a laudable effort that has some impact, it is still the pathway chosen by the minority of respondents in their drinking careers (Burton and Williamson, 1995Go; Cunningham and Breslin, 2004Go).


    REFERENCES
 TOP
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th edn). American Psychiatric Association, Washington, DC.

Burton, T. L. and Williamson, D. L. (1995) Harmful effects of drinking and the use and perceived effectiveness of treatment. Journal of Studies on Alcohol 56, 611–615.[ISI][Medline]

Cunningham, J. A. (1999) Resolving alcohol-related problems with and without treatment: The effects of different problem criteria. Journal of Studies on Alcohol 60, 463–466.[ISI][Medline]

Cunningham, J. A. and Breslin, F. C. (2004) Only one in three people with alcohol abuse or dependence ever seek treatment. Addictive Behaviors 29, 221–223.[CrossRef][ISI][Medline]

Dawson, D. A. (1996) Correlates of past-year status among treated and untreated persons with former alcohol dependence: United States, 1992. Alcoholism: Clinical and Experimental Research 20, 771–779.[ISI][Medline]

Miller, W. R., Brown, J. M., Simpson, T. L. et al. (1995) In Handbook of Alcoholism Treatment Approaches: Effective Alternatives, 2nd edn, Hester, R. K. and Miller, W. R. eds, pp. 12–44. Allyn and Bacon, Boston, MA.

Moyer, A., Finney, J. W., Swearingen, C. E. et al. (2002) Brief interventions for alcohol problems: a meta-analytic review of controlled investigations in treatment-seeking and non-treatment-seeking populations. Addiction 97, 279–292.[CrossRef][ISI][Medline]

Rotgers, F., Keller, D. S. and Morgenstern, J. (eds) (1996) Treating Substance Abuse: Theory and Technique. Guilford, New York.

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration and Studies, 2004. National Survey on Drug Use and Health, 2002. [Computer file]. 2nd ICSP version.

Weisner, C., Delucchi, K. and Matzger, H. (2003a). The role of community services and informal support on five-year drinking trajectories of alcohol dependent and problem drinkers. Journal of Studies on Alcohol 64, 862–873.[ISI][Medline]

Weisner, C., Matzger, H. and Kaskutas, L. A. (2003b). How important is treatment? One-year outcomes of treated and untreated alcohol-dependent individuals. Addiction 98, 901–911.[CrossRef][ISI][Medline]





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