Alcohol Treatment Outcome Research Research Articles

Implications of enrolment eligibility criteria in alcohol treatment outcome research: generalisability and potential bias in 1- and 6-year outcomes.

It has been acknowledged that participants in clinical trials differ from real-world service users, primarily due to the extensive use of research eligibility criteria (EC). Generalisability and outcome bias become pressing issues when evidence-based treatment guidelines, crystallised from outcome research, influence treatment provision. This study reports on the effects of EC on generalisability and short- and long-term outcomes among real-world treatment-seekers. Ten of the most commonly used EC were operationalised and applied to a large representative service user sample (n = 1125) from Stockholm County, Sweden, to determine the percentage of real-world problem alcohol users that would have been excluded by each EC and the extent to which EC bias the 1 and 6-year alcohol outcomes. Individual EC excluded between 5% and 80% of real-world service users and 96% would have been excluded by at least one EC. Most of the EC introduced a positive/upwards bias in 1- and 6-year outcomes. Most notably, the removal of the unmotivated/non-compliant service users caused an upwards bias that would considerably boost estimates of treatment effectiveness. Other bias effects were smaller. Six-year effects were generally higher than for 1 year. Outcome studies that exclude complex and non-compliant cases are not representative of real-world service users, and thus effectiveness estimates from clinical trials are biased by several commonly used EC. EC should be used judiciously and be taken into account in practice guidelines. This burgeoning research area should be further developed. [Storbjörk J. Implications of enrolment eligibility criteria in alcohol treatment outcome research: Generalisability and potential bias in 1- and 6-year outcomes. Drug Alcohol Rev 2014;33:604-11].

Applying Clinical Significance Methodology to Alcoholism Treatment Trials: Determining Recovery Outcome Status with Individual- and Population-Based Measures

The current analysis applies clinical significance methodology to alcoholism treatment outcome research using data available from Project MATCH. Because of its high internal validity and its inclusion of multiple measures assessing multiple outcome dimensions, MATCH was considered an ideal study to explore the utility of this methodology. Data reported here are from a total of 1,726 participants enrolled in either aftercare (n = 774) or outpatient (n = 952) arms of the study. First, a cutoff score was determined differentiating functional versus dysfunctional status on three outcome measures: percent days abstinent (PDA), mean drinks per drinking day (DDD) and negative consequences of alcohol use. Second, the reliable change in pre- to post-treatment scores on these three measures was calculated. The results reported herein support the importance of distinguishing between statistical and clinical significance of outcomes. During three months post-treatment, approximately one-half of the treated patients were "recovered" (i.e., both functional and reliably changed) with respect to both PDA (i.e., 51%) and negative consequences of drinking (i.e., 47%); however, only about one-third of individuals remained recovered throughout the full one-year follow-up period (i.e., 33% on PDA and 35% on negative consequences). These individual-based change outcomes compared similarly to a population-based indicator of heavy drinking. Alternatively, only about one-quarter of participants were recovered using two distinct criteria for mean DDD (i.e., 23-29%), and even fewer participants remained recovered on mean DDD over the full one-year follow-up period (i.e., about 14-18%). Based on study limitations, more work is required to make clinical significance methodology practically useful to alcoholism treatment trials including more precise definitions of functional status and relative change as well as better interpretation of the inter-relationship between multiple measures assessing multiple outcome domains.

Prevalence and predictors of research participant eligibility criteria in alcohol treatment outcome studies, 1970–98

To describe the eligibility criteria (i.e. study participant inclusion and exclusion rules) employed in alcohol treatment outcome research and to identify predictors of their use. The eligibility criteria of 683 alcohol treatment outcome studies conducted between 1970 and 1998 were coded reliably into 14 general categories. Predictors of the use of eligibility criteria were then examined. Patients were most often ruled ineligible for research studies because of their level of alcohol problems (39.1% of studies), comorbid psychiatric problems (37.8%), past or concurrent utilization of alcohol treatment (31.8%), co-occurring medical conditions (31.6%), and because they were deemed non-compliant and unmotivated (31.5%). The number of eligibility criteria employed in studies increased from the 1970s through the 1990s, and was positively associated with funding from the US National Institute of Alcohol Abuse and Alcoholism (NIAAA) and from the private sector, lack of an inpatient/residential treatment condition, presence of a pharmacotherapy, and use of a randomized, multiple-condition design. Principal investigators with doctoral degrees used more eligibility criteria than those with lower degrees. Participant eligibility criteria are extensively employed in alcohol treatment outcome research, and vary significantly across historical periods, funders and research designs. Researchers should report the details of subject eligibility criteria and excluded patients more fully, and, evaluate how eligibility criteria affect the cost, feasibility, and generalizability of treatment outcome research.

Maximizing patient follow‐up after alcohol treatment: The effect of a three‐step reminding system on response rates

Background Longitudinal research has many strengths, but is often compromised by attrition of participants. This is a particular problem in studies with ‘difficult‐to‐reach’ populations. Recommended techniques for maximizing retention are often impractical for routine clinical services.Aims To examine whether methods that are available in routine practice can achieve satisfactory follow‐up of a cohort of patients, 11 months after assessment for alcohol treatment.Methods Using a longitudinal cohort design, we tested the incremental effect of a simple three‐step approach with 124 consecutive patients seeking treatment for alcohol problems: first an interview appointment, then postal questionnaires and, finally, a reminder by telephone or letter. Data on treatment compliance and self‐reports of drinking behaviour during the 11‐month follow‐up period were obtained.Results Stage of contact was significantly associated with treatment compliance and treatment outcome. The final telephone reminder proved to be an important step in obtaining a sample that more accurately reflected both the treatment attendance and outcome of the original cohort.Conclusions Intensive resources, contact with multiple agencies and financial incentives were not necessary to achieve a contact rate of 75% and successful follow‐up of 67%. Alcohol treatment outcome research is feasible within services with limited time and resources.

More than a name change: editorial re‐organization at Addiction's office for the Americas

More than a name change: editorial re‐organization at <i>Addiction</i>'s office for the Americas

Bridging the gap between alcoholism treatment research and practice: Identifying what works and why.

Despite the proliferation of alcoholism treatment research over the past 2 decades, there is a continued gap between what has been shown to be promising in the extant literature and what is commonly practiced by clinicians in the alcohol treatment field. The present article is an effort to bridge this gap by examining findings from the broad body of alcoholism treatment outcome research to determine how these findings may optimally be used by treatment providers. To this end, the authors provide clinicians with a succinct review of the current alcoholism treatment outcome literature and identify hallmarks of the most empirically supported treatments. Clinical implications of this literature for practitioners working with client with alcohol use disorders are discussed, with a focus on factors underlying effective treatments and on how these factors can be transferred from research to practice.

Subject reactivity effects and alcohol treatment outcome research.

Attributions regarding alcohol treatment research protocols influencing clinical outcomes have persisted for more than 25 years. Although well-designed alcohol treatment outcome studies typically involve frequent, and often comprehensive, research assessment protocols, procedures are seldom in place to control or account for possible subject reactivity to the research protocol. This article presents a theoretical basis for a relationship between research protocols and treatment outcomes. The article reviews the relevant alcohol treatment outcome literature and presents a "weight of evidence" regarding subject reactivity effects and alcohol treatment outcome research assessment protocols. Also, the FRAMES (feedback, responsibility, advice, menu, empathy and self-efficacy) model was coupled with self-regulation theory to provide a theoretical explanation of how research assessment protocols might contribute to clinically relevant behavioral change. Researcher attributions, empirical investigations and theoretical considerations all provide evidence that is consistent with the existence of subject reactivity to research assessment protocols. Recommendations are made regarding interpretation of data collected as part of an alcohol treatment outcome study, control of potential subject reactivity confounding variables and directions for future research.

Use of exclusion criteria in selecting research subjects and its effect on the generalizability of alcohol treatment outcome studies.

Researchers have not systematically examined how exclusion criteria used in selection of research subjects affect the generalizability of treatment outcome research. This study evaluated the use of exclusion criteria in alcohol treatment outcome research and its effects on the comparability of research subjects with real-world individuals seeking alcohol treatment. Eight of the most common exclusion criteria described in the alcohol treatment research literature were operationalized and applied to large, representative clinical patient samples from the public and private sectors to determine whether the hypothetical research samples differed substantially from real-world samples. Five hundred ninety-three consecutive individuals seeking alcohol treatment at one of eight treatment programs participated. A trained research technician gathered information from participants on demographic variables and on alcohol, drug, and psychiatric problems as measured by the Addiction Severity Index. Large proportions of potential research subjects were excluded under most of the criteria tested. The overall pattern of results showed that African Americans, low-income individuals, and individuals who had more severe alcohol, drug, and psychiatric problems were disproportionately excluded under most criteria. Exclusion criteria can result in alcohol treatment outcome research samples that are more heavily composed of white, economically stable, and higher-functioning individuals than are real-world samples of substance abuse patients seen in clinical practice, potentially compromising the generalizability of results. For both scientific and ethical reasons, in addition to studies that use exclusion criteria, outcome research that uses no or minimal exclusion criteria should be conducted so that alcohol treatment outcome research can be better generalized to vulnerable populations.

Alcoholism treatment outcome studies, 1980–1992: The nature of the research

We reviewed 339 alcoholism treatment outcome studies reported between 1980 and 1992. After comparing single and multiple treatment group studies, we focus on multiplegroup studies, examining and comparing principal investigator and study characteristics, patient characteristics, treatment modalities and characteristics, and follow-up points and outcome variables in published and unpublished studies. This article provides an overview of the nature of the alcoholism treatment outcome research reported in the English language over the 13-year review period.

Educational lectures and films in the clinical treatment of alcoholism: a critique.

A recent meta-analysis of alcohol treatment outcome research concluded that educational lectures and films are an ineffective treatment modality in the treatment of persons with alcohol-related problems. This paper suggests several reasons why educational lectures and films are likely to be ineffective with alcohol misusers. Possible explanations include (a) the inability of alcoholics to appreciate and utilize (presented) information because of the cognitive deficits associated with chronic alcohol misuse, (b) the presentation of inaccurate or misleading information about alcoholism through lectures and films (i.e., unitary disease concept, faulty conceptualizations of denial), and (c) conventional alcoholism education which may undermine an individual's belief in her/his ability to make a complete and successful recovery from chemical dependence. Treatment implications and suggestions for further research are briefly discussed.

Predicting attendance at follow-up evaluations in alcoholism treatment outcome research.

The potential utility of an early-warning system involving the use of attendance at scheduled clinical appointments to predict attrition of research subjects from follow-up evaluations was investigated. Subjects (N = 92) discharged from an inpatient alcoholism treatment program into a treatment outcome study were monitored on their aftercare attendance for 1 year postdischarge. Attendance at clinical aftercare sessions during the follow-up year was correlated significantly with attendance at the research project's quarterly follow-up evaluations (p less than .001) and with total number of research evaluations completed (p less than .001). Number of weeks spent in aftercare before dropping out also improved prediction of attendance or nonattendance at quarterly follow-up evaluations during the first 6 months postdischarge (p less than .01). The findings suggest that monitoring attendance at clinical services may be a useful step in minimizing attrition of research subjects from follow-up evaluations.

The utility of self-report and biological measures of alcohol consumption in alcoholism treatment outcome studies

Despite the significant advances of the past 20 years, serious questions have been raised about the value of alcoholism treatment outcome research due to the purported invalidity of alcoholics' self-report data for which biological measures of alcohol consumption have been suggested as a solution. The literature does not support widespread skepticism of alcoholics' self-reports or the existence of a systematic underreporting bias except when alcoholics have a positive blood alcohol level. Available evidence shows good reliability and validity for reports of hospital/jail stays and frequency of drinking/abstinence; good reliability and modest agreement with collateral informants for measures of problem severity and alcohol dependence symptoms. For amount consumed, reliability is good for outpatient but not for inpatient or residential alcoholics and validity in the form of agreement with collateral reports is not good except in problem drinkers at followup. Unfortunately, currently available biological markers do not solve the problems of measuring alcohol consumption in outcome studies. Markers correlate only modestly with self-reported consumption, are affected by factors other than alcohol consumption, show large individual differences in response to variations in alcohol intake, have an overly long half-life in certain cases, provide a specific but not very sensitive indicator of poor outcome, and may present compliance problems especially among chronic alcoholics. Nonetheless, markers can be used as part of a convergent validity approach and as a measure of negative alcohol-related health consequences. Suggestions for current practices in the field and for future research directions are provided.