Specialised alcohol treatment services are a luxury the NHS cannot afford

Is alcoholism an illness or merely a self-inflicted indulgence?Can we afford specialist alcohol treatment services? Do theyeven work? Should the tax payer foot the bill? Is the lackof such services `perverse'? In this lively debate Drs Carnwathand Luty weigh up the pros and cons of controlling the effectsof `our favourite drug'.

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The National Health Service (NHS) is now firmly in financialcrisis and redundancies of up to 20 000 staff are a real possibility.¹As Frank Dobson, the former health minister, stated, `Thereis no place in the modern NHS for... hanging onto outdated,ineffective, treatments.'² The NHS currently spends £75–250million annually on specialised alcohol treatment services,whose object is to reduce the excessive consumption of alcohol.^3,4 There are around 300 advice and counselling services, 100 dayprogrammes and nearly 200 residential programmes.⁵ Obviously,vastly more is spent by other parts of the NHS dealing withthe numerous complications of alcohol misuse.

Around 1 in 13 men in Britain⁶ are dependent on alcohol. Somewould regard these people as `ill'; many others would not,presumably considering alcoholism as self-inflicted.⁷ Thisargument is largely popular among academics and probably wouldbe of little interest if treatment were effective. Unfortunatelythe success of current specialist alcohol treatment is not proven.⁸ Motivational interviewing has been the flagship ofpsychological treatment of substance use problems for sometime. This involves the client, rather than the therapist,giving the reasons for abstinence and providing a list of problemscaused by their alcoholism. This seems modestly effective in opportunistic samples – that is people who did not realisethey were drinking too much.⁹ Moyer et al's meta-analysisfound no evidence for significant benefits in people from treatment-seekingpopulations (the people likely to attend specialised alcoholservices). Neither of the two largest randomised studies ofpsychological treatment for alcohol problems have shown any significant difference between the treatment modalities underreview (these included motivational interviewing, communityreinforcement, cognitive–behavioural therapy and twelve-step approaches).^10,11 The UK Alcohol Treatment Trial outcomesshowed that, on average, participants were still consuming137 units per week after 1 year – around five times therecommended drinking limits, or the equivalent of 68 pints ofbeer per week. No objective improvements in biochemical markers(such as ${gamma}$ -glutamyl transferase) were observed, although theinvestigators dismissed these outcomes in preference to self-reporteddata.

The results of pharmacological treatment of alcohol misuse havebeen equally disappointing. Despite great optimism, outcomesfor disulfiram treatment are poor¹² and the two largest trialsof acamprosate and naltrexone showed no significant benefits.^13,14 Some impressive results have been reported but these trialshave had unrealistic medication adherence rates (often exceeding80%) and are often funded by the drug manufacturers.¹⁵ Lloydand colleagues¹⁶ found that fewer than 3% of people misusingalcohol have been treated for alcohol problems. By contrast,Vaillant estimates that 2–3% of people with alcoholismabstain spontaneously each year in the community.¹⁷ Hence, demonstrating the effectiveness of pharmacological treatmentin small, highly selective or unrandomised trials could easilybe explained by patient selection bias.

Thirty years ago Edwards and colleagues¹⁸ reported no significantdifference in their 1-year trial involving a group of peoplewith alcohol problems who were randomised to receive a singleadvice session or extensive, multidisciplinary support. Todate, there has been no evidence published that significantlychanges this finding. I would like to quote Professor SimonWessely's comments on psychological debriefing, `It is inevitablethat when a cherished belief is challenged, various counterclaims are made – the evidence is for the wrong type of [treatment],the trials were not well done, elements of [treatment] couldstill "work", the testimonies of those who are certain it helpedthem cannot be discounted... There can be no doubt that thosewho are attempting to help people... have noble motives, butthat sadly is not enough.'¹⁹ For specialised alcohol treatmentservices the buck stops here!

Jason Luty

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This country cannot afford not to have a specialist alcohol service. Here are some alarming facts, recently highlightedby the Prime Minister's Strategy Unit:³

each year there are about 22 000 premature deaths due to alcoholmisuse, including about 1000 suicides;
seventy per cent ofall admissions to accident and emergencyunits at peak timesare alcohol-related;
alcohol misuse results in 17 millionworking days lost per year;
more than 1 million children areat risk because of parentalalcohol misuse, which also accountsfor a third of domesticviolence;
it is estimated that alcoholmisuse costs the NHS £1.4–1.7 billion a year;
alcohol-relatedcrime and disorder costs the country annually£7.3 billionand lost productivity £6.4 billion.

The majority of dual-diagnosis problems are caused by alcohol.²⁰If any illicit drug, or indeed any disease, caused this scaleof damage, it is unthinkable that huge efforts would not bemade to mitigate the problem. But because alcohol is, in thewords of the former Prime Minister Tony Blair, `our favouritedrug'³ a cloak of denial has descended over the eyes of ourpolicy-makers, and to some extent also the general public.In most of the country almost nothing is being done to reducethe problem or to treat its consequences.

Alcohol treatment services have for the most part disappeared,their resources transferred to general medicine or psychiatry,or to the treatment of illicit drug dependence. A recent nationalsurvey showed that in some parts of the country less than onein a hundred dependent alcohol misusers had access to appropriate treatment.²¹ It is not as if alcohol treatment does not work– Dr Luty has been somewhat selective in his use of evidence.Systematic reviews have indicated that alcohol treatment isindeed effective. These include the large Mesa Grande surveyof 381 controlled trials,²² and also studies commissionedby governments in Sweden,²³ Scotland,²⁴ Australia²⁵ and England.²⁶These studies also show that various psychological approachesproduce good outcomes, and also that medications such as acamprosate,naltrexone and disulfiram play an important supporting role,albeit in particular circumstances. There are also many promisingnew medications in the pipeline.⁹ It is true that the largestalcohol research study ever undertaken (Project MATCH in theUSA, 1997), showed that three different types of psychologicaltreatment (twelve-step facilitation, cognitive–behaviouralcoping skills and motivational enhancement therapy) were allequally effective,²⁸ but this is scarcely a justificationfor abandoning all of them. A recent UK study showed that eachpound spent on treatment saved £5 in terms of other healthand social costs.²⁹

Curiously, there are many national targets, which if approachedrationally would include alcohol treatment as a core component.These include health targets such as reducing cancer, heartdisease and health inequalities, and social targets such asreducing crime and promoting safe neighbourhoods. It is partlybecause there are few alcohol specialists locally that this intervention is too often ignored in local plans to meet thesetargets. There are strong voices shouting for more liver transplants,but none or few for preventing their need by providing basicalcohol services. By the same token medical students receiveonly 6 h of tuition concerning alcohol misuse and related problemsin the whole of their 6 years of training.³⁰

If commissioners have been interested at all in alcohol, itis by the idea of `brief interventions,' presumably becausethey are cheap. If general practitioners identify and counselpeople with alcohol problems, there is good evidence that aproportion will modify their ways, enough to make a sizeable difference in terms of population health at a small cost.³¹But brief interventions work most effectively where they arepart of a comprehensive treatment system. In 2006 the Departmentof Health commissioned Models of Care for Alcohol Misuse,³² unfortunately with no resources to implement its recommendations.It argues that comprehensive treatment should be provided infour `tiers'. Brief interventions are helpful at tiers oneand two, that is in the community and in primary care respectively.But they must be backed up by specialist treatment, both inthe community and in residential care (tiers three and four).Without specialist back-up, lower-tier interventions do notoccur, or occur only sporadically. There is little point inidentifying people with alcohol problems if there is nowhereto refer them. Brief interventions have little effect in alcoholdependence.

Specialist community alcohol teams are not very expensive, probablycosting less per health district than the total cost of puttinga child in care, or the legal and police costs associated withone fatal car crash, and nationally a fraction of the £8billion per year received from taxation on alcohol. Such servicesare hugely cost-effective by saving money and reducing social and physical harm caused by alcohol dependence.²⁹ That theyare not universally available is not only a scandal with regardto patient care, but also an example of irrational commissioningand policy development. It must not be allowed to continue.

Thomas Carnwath

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Dr Carnwath is correct in stating the damage that alcohol misusecauses and in pointing out that I have been selective in myreporting of the literature – I have chosen the largest,most powerful randomised trials available. Another trial hasnow been reported: the COMBINE study, a randomised controlledtrial of eight alcohol interventions over 1 year with 1383 participants.³³ Treatment involved combinations of 16-weeks naltrexone andacamprosate treatment and a `combined behavioural intervention'based on cognitive–behavioural therapy. The placebo medicationgroup reported 74% abstinent days over the period of studycompared with 80% abstinent days in the best outcome group(naltrexone without additional psychotherapy). All groups receivednine sessions of counselling. There was no benefit from additionalspecialised psychotherapy. Moreover, patients receiving placebo alone faired better than those receiving specialist psychotherapywithout any form of medication (74% v. 67% abstinent days respectively).Although the authors were predictably upbeat about the statisticaldifferences, the study fails to demonstrate any clinicallysignificant data considering the small size of the response(a maximum of a 7% reduction in the number of non-abstinentdays). Although brief interventions are regarded as moderately effective in opportunistic samples, there remains no convincingevidence of the effectiveness of specialised treatment fortreatment-seeking people with serious alcohol problems evenin large, independent trials with highly motivated and compliantparticipants.

Jason Luty

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Against: rebuttal and conclusion

Dr Luty is correct in pointing out that the difference between interventions for alcohol dependence is often small, even whenone of the interventions is placebo. What he fails to pointout is that most trials show very significant improvementsin all conditions of treatment, and that placebo in alcoholresearch is often in itself a very meaningful intervention.For example in the COMBINE trial Dr Luty describes, the averageimprovement in all arms of the research was from less than25% abstinent days at initiation to over 70% at 16 weeks andover 60% after 1 year of the treatment.³³ The `standard medicalmanagement' in this trial consisted of as many as nine structuredsessions initially of 45 min, then of 20 min, and research assessmentsalone consisted of up to 12 h of intensive questioning, a procedurewhich in itself can have a significant motivational effect.These were then compared with cognitive–behavioural therapyand other specialist interventions, and perhaps not surprisinglyoften performed just as well. In comparison with these standardor placebo interventions, one of the actual treatment interventionsin the UKATT trial described by Dr Luty consisted of just 4h of `motivational interviewing'.¹¹ Dr Luty seems also tohave misread the results in the UKATT trial when he stated thatparticipants were still consuming on average 137 units of alcoholper week at the end of the trial. He appears to have interpretedthe variable `average drinks per drinking day' as `averagedrinks per day', clearly a much higher figure than that actuallyfound, since a marked increase in abstinent days was also observed.In fact the average annual intake was 72 units per week afterthe specialist intervention – certainly more than ideal,but much less than the initial intake of 132 units, and witha demonstrated economic benefit of between £700 and £1000per patient per year.

We can probably agree that brief and slightly longer interventionsoften produce very positive results in terms of health andeconomic benefit, even when these masquerade as placebo. Inspite of this remarkable finding, even limited interventionsare still not widely available in this country. This is perverse.We can also agree that treatment is only one factor in any improvementachieved, with independent social and personal factors beingat least as important. One estimate is that `treatment probablyaccounts for around one third of all improvements made.'³⁴But when considering a problem as widespread as alcohol misuse,even a third is a large amount both in human and economic terms.Where people do not respond to self-help or to brief interventionsalone, longer and more intensive involvement is justified.This is demonstrated by the many independent reviews of theevidence from several hundred trials, as I described above.To challenge this widespread consensus is brave, but to doso Dr Luty needs to do more than point to features of selectedindividual trials; he needs to challenge the methodology onwhich these reviews are based.

Thomas Carnwath

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