Are alcoholism treatments effective?

Are alcoholism treatments effective? The Project MATCH data | BMC Public Health | Full Text

Overall, a median of only 3% of the drinking outcome at follow-up could be attributed to treatment. However this effect appeared to be present at week one before most of the treatment had been delivered. The zero treatment dropout group showed great improvement, achieving a mean of 72 percent days abstinent at follow-up

Effect size estimates showed that two-thirds to three-fourths of the improvement in the full treatment group was duplicated in the zero treatment group.

Outcomes for the one session treatment group were worse than for the zero treatment group, suggesting a patient self selection effect 

Nearly all the improvement in all groups had occurred by week one. The full treatment group had improved in PDA by 62% at week one, and the additional 11 therapy sessions added only another 4% improvement.

Conclusion

  1. The results suggest that current psychosocial treatments for alcoholism are not particularly effective.
  2. Untreated alcoholics in clinical trials show significant improvement.
  3. Most of the improvement which is interpreted as treatment effect is not due to treatment.
  4. Part of the remainder appears to be due to selection effects.

Background

A fundamental belief of addiction treatment is that therapy is effective

Three of the best of those methods were selected for Project MATCH, a large multicenter US trial designed to match the most effective treatment to individual patient characteristics.

The criteria used to select the three treatments used in MATCH included the following:

  • demonstrated clinical effectiveness;
  • applicability to existing treatment programs and client populations, and
  • distinctiveness from each other

Project MATCH took great care to assure that the therapy was of the highest quality.

Below are the three most effective treatments (none of which is particularly effective).

  1. Cognitive Behavioral Therapy (CBT) focused on handling thoughts about alcohol, dealing with urges, refusing drinks, avoiding situations that might lead to relapse, etc.
  2. Motivational Enhancement Therapy (MET) provided structured feedback about alcohol-related problems, and attempted to motivate commitment to change, to increase individual responsibility, and to enlist personal resources
  3. Twelve Step Facilitation (TSF) was based on principles of Alcoholics Anonymous and it introduced the first three steps of AA and promoted active participation in AA.

In some ways, the results of the MATCH clinical trial were disappointing. At the time it was concluded, in the late 1990s, it was the one of the most expensive clinical trials ever undertaken, costing 27 million dollars; it was conducted by the most seasoned alcoholism professional investigators, and it was designed to validate the top “cutting-edge” findings which had accumulated the strongest experimental support. Some 504 hypotheses were tested

The final results did not support the hypotheses.

There were essentially no matches between the therapeutic treatments and the participants above the level of random probability [6].

An analysis of the problem suggested that too many Type I errors were being made in the alcoholism literature [7]. Type I errors typically occur when an inappropriately large number of statistical tests are performed.

In announcing the disappointing MATCH results, the director of the National Institute of Alcohol Abuse and Alcoholism stated “All three treatments evaluated in Project MATCH produced excellent overall outcomes”  [this was believed at the time]

Evidence is accumulating that extensive therapy may be no more effective that brief intervention [1, 15]. Brief interventions are minimal types of therapies that can consist of simple expressions of concern about drinking delivered by a MD in a hospital trauma unit.

There is a growing literature on “natural recovery” showing that many, if not most, individuals with serious alcohol consumption problems are able to recover without treatment 

A recently published meta-analysis [17] reported a significant improvement in untreated alcoholics enrolled in clinical trials. And there have been a few published trials that have concluded that therapy is not particularly effective

The present study reports analyses of some overlooked data from Project MATCH.

The overall relationship between treatment quantity (number of treatment sessions attended) and drinking measures was analyzed.

Next, primary outcome data of participants who dropped out of treatment before receiving any therapy was compared to that of participants who attended each and every session for the full 12 weeks of therapy.

Additionally we identified one anomalous group consisting of those participants who attended only one session of therapy. The data from this unusual group provides additional clues that help in interpreting the findings.

Results

Table 2 compares our results to the Project MATCH’s published results [20] on the correlations between number of treatment sessions attended (0 to 12, or 0 to 4 for MET) and the two primary outcome measures, drinks per drinking day and percent days abstinent.

The table shows that our results are essentially identical to the official results. This indicates that the data used in the present study are correct. Additionally the results show rather low correlations between number of treatment sessions attended and outcome, particularly long term outcome.

match-study-table-2

The amount of outcome that can be attributed to attending treatment ranges from 0 to 9%, with a median of approximately 3%.

These are minuscule in light of the problem.

Table 3 displays the same type of correlations as in Table 2, but this time the drinking measures were for the weeks during treatment. The table shows that there is a relationship between drinking level at these early time points and number of treatment sessions. Note that drinking level at week one predicts the total number of weeks the participant will remain in treatment.

match-study-table-3

Outcome at follow-up is a mean of the data from 4 to 15 months. Overall the data show that the three treatments were fairly equal and that patients who attended more sessions had somewhat better outcomes

However, there was one anomalous group. Those who dropped out after one session (the 1 treatment group) had worse outcomes than those who dropped out before attending even one session.

Discussion

The results suggest that treatment was not particularly effective.

The following lines of evidence point to this conclusion. Correlations between treatment attendance and outcome were very small (as shown in Table 2). A median 3% of the variance in outcome might be attributed to treatment.

The correlations existed before most treatment occurred, at week 1 (Table 3).

We would normally infer from the correlations in Table 2 that more treatment produces better drinking outcomes, but the Table 3 correlations suggests the reverse, that better drinking levels predict more treatment.

Nearly two thirds of the long term improvement in the full treatment group was matched by the untreated rapid dropout group (Figures 1 &2 and Table 6). Only in the remaining one third could there be a subcomponent consisting of a treatment effect.

Most of the improvement was instantaneous, occurring at week 1, before the participants had received the bulk of their treatment (Figures 3 &4 and Table 6). Although the full treatment group received 11 more therapy sessions, the additional improvement was of small magnitude.

For example, at week one percent days abstinence had increased by over 60%, and the additional 11 weeks of treatment increased it by only 4%.

If treatment were the causal agent we would expect that the effect would occur over the course of weeks with the administration of treatment.

There was a similar instantaneous improvement in untreated alcoholics (Figures 3 &4 and Table 6).

The effect size estimates suggested that nearly three fourths of the instantaneous improvement in the full treatment group was matched by the untreated group.

Those who received zero treatment sessions had better outcomes than those who received one session

Improvement was maintained over time even in the no treatment group

In both groups the week 1 to week 12 improvement was lost by follow-up. These data do not support the contention that retention of clients in treatment for as long as possible increases the chances that they will derive benefit from therapy.

A more reasonable interpretation of these data is that they illustrate the importance of selection effects, i.e., participants who reduce their alcohol consumption are more likely to enter or remain in treatment and those who continue drinking are more likely to drop out of treatment

One of the best studies of alcoholism treatment outcome was conducted by the Rand Corporation in the late 1970s

They found that “it is possible that the correlation [between attendance and outcome] arises from selection effects, such that the better motivated or more successful patients continue in treatment, whereas the more intractable cases drop out. Such a pattern could result from subject self-selection or from the operation of the treatment environment in encouraging continued participation for more responsive patients.”

The decreased drinking in both untreated and treated participants can be explained by a number of factors. One factor is that part of the effect is not real; many active alcoholics underreport drinking

Underreporting can make treatment appear more effective than it actually is.

Additionally, there are a number of non-treatment effects likely to result in reduced drinking [19, 21–23].

In order to enter the trial participants had to first achieve a level of abstinence or reduced intake.

The pre-study screening procedures used in clinical trials, both the overt criteria and the subjective criteria, are designed to select participants who are motivated to reduce their drinking.

Enrolling in the trial suggests that the alcoholic has crystallized a decision to reduce or abstain from drinking. Once in the trial, the continued monitoring of drinking behavior by staff personnel may have both motivational and therapeutic benefits

Analyses were primarily limited to descriptive and simple inferential statistics. This was done because the findings are likely to be extremely controversial. We have therefore presented results that are easily replicated, and easily understood.

The authors are anticipating opposition because the data goes against the propaganda with which we’ve been inundated for years.

Although the results are essentially negative, suggesting that current treatments are not effective, we do not offer suggestions for future directions.

We feel we will have made a contribution if the data presented can be accepted as accurate. If they are accepted then implications for future research and treatment will naturally follow.

There are a large number of both positive and negative reasons why alcoholic participants drop out of clinical trials.

Positive reasons include work commitments, pregnancy, re-location to another area and remission from drinking.

Negative reasons include continued or increased drinking, abuse of other substances, attitude towards the clinical staff or environment, physical illness, hospitalization and incarceration.

Over 60 publications have been generated by Project MATCH, but, to the best of our knowledge, all have overlooked the main finding of this study, i.e., the good outcomes of the zero treatment group when compared to the full treatment group and that the improvement in all groups occurred immediately after enrollment in the trial.

Ineffective treatment would be the most parsimonious explanation for the rather surprising main findings of Project MATCH, that there was no match between patient characteristics and different types of treatment, and that all three treatments were equal.

Of some 17 studies than included placebo or no treatment conditions, with and without prior detoxification, a mean (for studies) was 21% abstinent, and the average participant was drinking 31 drinks per week [17].

Exaggerated claims of treatment effectiveness can have undesirable consequences for patients, for therapists, and for science.

Patients who fail an “effective” treatment may feel even more hopeless. This increased despair may be extremely deleterious in people with such life-threatening habits.

Therapists may feel inadequate or frustrated with repeated failures.

For science, exaggerated claims tend to shift focus into unproductive directions, and to obscure the pertinent facts that are necessary in order to move the science forward.

Conclusion

These results suggest that current psychosocial treatments for alcoholism are not particularly effective.

The improvements in drinking appear to be due to selection effects.

Alcoholics who decide to enter treatment are likely to reduce drinking. Those who decrease their drinking are more likely to remain in treatment.

Widespread acceptance of these results would have a profound influence on alcoholism research and treatment because it would shift focus away from treatment components and toward patient characteristics and beliefs.  

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