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Substance Abuse Treatment Modalities: Literature Review

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Controlled Drinking Strategies

For many years, use of reduced drinking as an explicit goal in the treatment of alcohol problems was rare, although reports of reduced drinking outcomes were common in the treatment evaluation literature (see Heather & Robertson, 1983; Miller, 1983; Pattison, Sobell, & Sobell, 1977; Rosenburg, 1993; Sobell & Sobell, 1981; Sobell & Sobell, 1982a; Sobell, Brochu, Sobell, Roy, & Stevens, 1987; Sobell & Sobell, 1982b; Sobell & Sobell, 1987). In fact, reviews of the alcohol treatment outcome evaluation literature have found more than half of the studies reviewed to report moderation outcomes (Sobell et al., 1987). This disparity between treatment goals and outcomes is one of several matters that need to be understood in order to objectively appraise the place of moderation goals in alcohol treatment.

The second thing that needs to be appreciated is that alcohol problems come in all varieties and severities. In other words, there is a spectrum of alcohol problems ranging from risky use of alcohol in the absence of any consequences, to use of alcohol that results in catastrophic health, social and psychological consequences. The concept of a continuum of alcohol problem severity is familiar to staff in CSC.

The third matter concerns the relationship between goals and outcomes. Although there have been few controlled trials comparing abstinent and nonabstinent goals, those that exist show a consistent pattern in outcomes. When persons with low severity alcohol problems have a successful treatment outcome, it most often (i.e., about 80% of the time) will involve a reduction of drinking to a nonhazardous level. When persons with high severity alcohol problems have a successful treatment outcome it most often will involve abstinence from drinking. These outcomes occur regardless of the goal advice given during treatment. For example, Sanchez-Craig et al. (1984) randomly assigned low dependence alcohol abusers to outpatient treatment involving either an abstinence or a controlled drinking goal. At two year follow-up it was found that the rate of successful outcomes did not differ between the goal groups. Furthermore, among those successful in each group, about 80% had achieved a reduced drinking recovery. That is, the goal advocated in treatment made no difference at all in the type of successful outcome. The same relationship between goals and outcomes has been found for persons with more severe alcohol problems. Foy, Nunn, and Rychtarik, (1984) randomly assigned seriously dependent alcohol abusers to inpatient treatments involving either an abstinence or controlled drinking goal. At five to six year follow-up, it was found that success rates did not differ between the goal groups, and that within each group the successes were predominantly cases of abstinence. Once again, even for severe alcohol abusers the goal used in treatment bore no relationship to treatment outcome.

The evidence reviewed above clearly suggests that the main determinant of the type (i.e., abstinent or nonabstinent) of successful treatment outcome is dependence severity, and not treatment goal. When persons with low dependence have a successful outcome, it most often involves reduced drinking. When persons with high dependence have a successful outcome, it most often involves abstinence.

This sort of evidence has led to the development of treatments for low dependence individuals that acknowledge those individuals' self-determination and the likelihood of a successful reduced drinking outcome. For example, several studies have been reported wherein primary care physicians advise patients identified to have low dependence alcohol problems to reduce their drinking to nonhazardous levels (Anderson 1994; Anderson & Scott 1992; Chick, 1993; Chick, Ritson, Connaughton, Stewart, & Chick, 1988). Nonhazardous levels tend to be set at a maximum of around 12 to 17 drinks per week, with no more than a few drinks on any given day, and some abstinent days (Moderate Drinking Alcohol Alert, National Institute on Alcohol Abuse and Alcoholism, No 16, 1992, Washington, D.C.; Moderate Drinking and Health. Joint Policy Statement of the Addiction Research Foundation of Ontario and the Canadian Centre on Substance Abuse, Toronto, 1993). A variety of other studies have reported the successful use of brief treatments that include reduced drinking goals for low dependence alcohol abusers (Babor et al, 1994; Bien, Miller, & Tonigan, 1993; Heather, 1990; Miller & Sovereign, 1989; Sobell & Sobell, 1993). Many of the aforementioned treatments explicitly ask individuals to choose their own goals, which seems realistic since the treatment outcome evidence suggests this is what occurs in any event.

For individuals with severe alcohol problems, there has been little purposeful use of moderation goals over the past decade, although previous research, such as the Foy et al. (1984) study had established that such goals were not destructive. Persons with severe alcohol problems, however, are typically seriously debilitated in several areas of life functioning (physical health, interpersonal relations, vocational history, poor self-esteem, etc.). Successful outcomes are not frequent for such cases, and the most typical outcome is one of improvement as compared to prior to treatment. In these cases, it is usually necessary to advise the individual to be abstinent because there are medical or social contraindications to any drinking. Nevertheless, they typically will engage in some drinking during (if outpatient) and after treatment.

Harm reduction means any strategy that will minimise the harm or risks related to the use of alcohol. Thus, for example, an individual can be encouraged to avoid slips and halt slips early if they do occur (e.g., not continue drinking the next day), to avoid driving if drinking, to avoid drinking with other heavy drinkers, and so on. The value of a harm reduction approach can be appreciated by realising that this approach has been very effective in combating the spread of AIDS. Although the very best way to avoid being contaminated with the AIDS virus would be to never use drugs intravenously and to only have sexual relations with a single, faithful and tested partner, the severe consequences of AIDS have led most societies to adopt a harm reduction strategy that includes measures such as encouraging the use of condoms, needle exchanges and providing addicts with instructions on how to sterilize needles that will be reused. Although harm reduction approaches are not yet in widespread use, the Addiction Research Foundation in Toronto uses harm reduction strategies with individuals who are not willing to stop drinking, the Donwood Institute in Toronto has recently adopted a public health approach that explicitly emphasizes harm reduction, and the OSAPP and Choices programs for offenders both incorporate such an approach.

References for Controlled Drinking Strategies:

Anderson, P. (1994), “Primary health care and public health approach to alcohol”, Addiction, 89, 668-671

Anderson, P. & Scott, E. (1992), “The effect of general practitioners' advice to heavy drinking men”, British Journal of Addiction, 87, 891-900

Babor, T.F., Grant, M., Acuda, W., Burns, F.H., Campillo, C., Delboca, F.K., Hodgson, R., Ivanets, N.N., Lukomskya, M., Machona, M., Rollnick, S., Resnick, R., Saunders, J.B., Skultle, A., Connor, K., Ernberg, G., Kranzler, H., Lauerman, R., & Mcree, B. (1994), “A randomized clinical trial of brief interventions in primary health care: Summary of a WHO project”, Addiction, 89, 657-660.

Bien, T.H., Miller, W.R., & Tonigan, J.S. (1993), “Brief interventions for alcohol problems: A review”, Addiction, 88, 315-336.

Chick, J. (1993), “Brief interventions for alcohol misuse”, British Medical Journal, 307, 1374.

Chick, J., Ritson, B., Connaughton, J., Stewart, A., & Chick, J. (1988), “Advice versus extended treatment for alcoholism: A controlled study”, British Journal of Addiction, 83, 159-170.

Foy, D.W., Nunn, L.B., & Rychtarik, R.G. (1984), “Broad-spectrum behavioural treatment for chronic alcoholics: Effects of training controlled drinking skills”, Journal of Consulting and Clinical Psychology, 52, 218-230.

Heather, N. (1990), “Brief intervention strategies”, In R. K. Hester & W. R. Miller (eds.), Handbook of alcoholism treatment approaches: Effective alternatives, (pp. 93-116), New York: Pergamon.

Heather, N., & Robertson, I. (1983), Controlled drinking (2nd Edition), New York: Methuen.

Miller, W. R. (1983), “Controlled drinking: A history and a critical review”, Journal of Studies on Alcohol, 44, 68-83.

Miller, W. R., & Sovereign, R. G. (1989), “The check-up: A model for early intervention in addictive behaviours”, In T. Løberg, W. R. Miller, P. E. Nathan, & G. A. Marlatt (eds.), Addictive behaviours prevention and early intervention (pp. 219-231), Amsterdam: Swets & Zeitlinger.

Pattison, E. M., Sobell, M. B., & Sobell, L. C., (eds.) (1977), Emerging concepts of alcohol dependence, New York: Springer.

Rosenberg, H. (1993), “Prediction of controlled drinking by alcoholics and problem drinkers”, Psychological Bulletin, 113, 129-139.

Sanchez-Craig, M., Annis, H. M., Bornet, A. R., & MacDonald, K. R. (1984), “Random assignment to abstinence and controlled drinking: Evaluation of a cognitive-behavioural program for problem drinkers”, Journal of Consulting and Clinical Psychology, 52, 390-403.

Sobell, L. C., & Sobell, M. B. (1981), “Outcome criteria and the assessment of alcohol treatment efficacy”, In National Institute on Alcohol Abuse and Alcoholism (Ed.), Evaluation of the alcoholic: Implications for research, theory and treatment (Research Monograph No. 5, pp. 369-382), Rockville, MD: National Institute on Alcohol Abuse and Alcoholism.

Sobell, L. C., & Sobell, M. B. (1982a), “Alcoholism treatment outcome evaluation methodology”, In National Institute on Alcohol Abuse and Alcoholism (Ed.), Prevention, intervention and treatment: Concerns and models (Alcohol and Health Monograph No.3, pp. 369-382). Rockville, MD: National Institute on Alcohol Abuse and Alcoholism.

Sobell, M. B., Brochu, S., Sobell, L. C., Roy, J., & Stevens, J. (1987) “Alcohol treatment outcome evaluation methodology: State of the art 1980-1984” Addictive Behaviours, 12, 113-128.

Sobell, M. B., & Sobell, L. C. (1982b), “Controlled drinking: A concept coming of age”, In R. Blankstein & J. Polivy (eds.), Self-control and self-modification of emotional behaviour , (pp. 143-162). New York: Plenum Press.

Sobell, M. B., & Sobell, L. C. (1987), “Conceptual issues regarding goals in the treatment of alcohol problems”, In M. B. Sobell & L. C. Sobell (Eds.),Moderation as a goal or outcome of treatment for alcohol problems: A dialogue, (pp. 1-37). New York: Haworth Press.

Sobell M. B., & Sobell, L. C. (1993), Problem drinkers: Guided self-change treatment, New York: Guilford Press.