Improving alcohol treatment saved lives in Sweden

[Annie]

Early treatment for women with alcohol addiction (EWA) reduces
mortality: a randomized controlled trial with long-term register
follow-up.
Gjestad R., Franck J., Lindberg S. et al. Request reprint
Alcohol and Alcoholism: 2011, 46(2), p. 170–176.

Compared to usual treatment, over the next 27 years introduction of a
comprehensively serviced female-only alcohol treatment unit in Sweden
substantially extended the lives of its patients – a uniquely
convincing demonstration that improving treatment can save lives.

Summary Alarmed by rising numbers of alcohol dependent women and their
high death rate, in the 1980s Sweden established a female-only unit at
a hospital alcohol treatment centre in the capital Stockholm. Compared
to 'treatment as usual' wards and clinics, the Early Treatment for
Women with Alcohol Addiction (EWA) unit was better staffed with more
doctors and psychologists, and it focused more on the women's
psychiatric symptoms and relationships with their (often also
alcoholic) partners. It offered individualised treatment including
detoxification, inpatient stays, psychotropic medications, disulfiram
(a drug which deters drinking due the aversive physical consequences
of mixing the two), women-only group therapy two or three times a
week, regular contact with a key worker for up to two years, work
training, and physiotherapy. A child psychiatrist helped with family
and child issues and the woman's partner was invited to participate in
the treatment. Abstinence was the intended goal, though social
drinking was considered when abstinence was not possible, and proved
to be by far the most feasible option. Treatment lasted on average
three months longer (eight v. five months) than the mixed-gender usual
treatment, which consisted mainly of regular contact with nursing
staff and detoxification followed by a disulfiram-based relapse
prevention regimen.

In 1983 and 1984, 200 not previously treated women were consecutively
allocated to the new unit or to the centre's mixed gender usual
treatment. On average they were in their early 40s. From an earlier
paper it is known that around 90% were employed, they presented well,
were not seriously physically ill, and most were settled with a live-
in male partner of whom nearly half were also problem drinkers. Six in
10 had been treated for psychiatric problems and one in four had
attempted suicide. Typically they had experienced one of the main
indicators of alcohol dependence (loss of control over drinking) for
seven years and on average were drinking 15 UK units (120g) of alcohol
a day. For most, treatment started with inpatient detoxification, an
indicator of the severity of their dependence. The main issue
addressed by the study was whether the new unit curbed the worrying
death rate among such women despite their being treated for their
drink problems in the usual programme. To test this, mortality records
were matched to the former patients over the 27 years since they
entered the study.

Main findings
Over 27 years, inevitably the proportions of women in the two groups
who died would even out; by the end, 38% of the EWA women and 45%
formerly in treatment as usual had died, not a statistically
significant difference. The main issue was whether the EWA women had
survived longer, and they had. The effect was significant overall but
concentrated among younger women. Those already 50 when they started
EWA treatment died at about the same annual rate as usual treatment
patients, but EWA treatment starters aged 30 to 40 survived longer
over the first 15 to 20 years than those treated without the EWA
enhancements. For example, among 30-year-olds, about 97% were still
alive 15 years later compared to about 81% of treatment-as-usual
patients. Among 40-year-olds, the gap was about the same. Over the
first ten years, survival was extended by EWA treatment regardless of
whether the patient had been considered severe enough to be treated as
an inpatient. This mainly reflected the impact on younger women and
older women not considered severely dependent enough to require
inpatient treatment.

Surprisingly, attainment of a social drinking pattern (abstinence was
rare) in the two years after treatment – much more common (48% v. 19%)
among the EWA women – was unrelated to death rates over the 27 year
follow-up. But among short-term treatment 'failures' who relapsed to
non-social drinking, those formerly treated in the EWA unit had a
significantly lower death rate than treatment-as-usual patients.

The authors' conclusions
That over the next 20 years younger women treated in the EWA unit
lived longer indicates that enhanced treatment had the intended effect
and was more effective than treatment as usual. It seems likely that
this was at least partly because the unit offered a more comprehensive
service which addressed factors related to mortality among female
alcoholics and the general population. Among these are early treatment
drop-out, severity of drinking and alcohol dependence, medical and
mental health problems, coping strategies and relapse prevention, and
interpersonal stressors such as work-related problems and living with
a partner who is also a heavy drinker. A longer treatment programme
(in theory and on average in practice) may also have helped, aided by
the unit's willingness to work with each individual's drinking goal
without insisting on total abstinence as the only acceptable outcome.
So too may have long-term stable contact with treatment staff.
Generally lacking from treatment as usual were specific interventions
targeting psychiatric co-morbidity, an important influence on
outcomes. This greater intensity and extensity of treatment took place
in a women-only programme, making it impossible to disentangle which
were the active ingredients. However, the EWA women saw meeting other
women with drinking problems as the most important positive influence.

Some findings were difficult to interpret. The apparent impacts on
inpatient versus outpatients were confounded by missing data and by
differences between the EWA unit and the other units in criteria for
inpatient treatment and the availability of beds. The finding that a
good drinking outcome in the first two years after treatment was
unrelated to mortality could mean these outcomes were not reliably
reported, or that over the long follow-up drinking patterns changed
sufficiently to make earlier patterns poor predictors of mortality.
Interpreting the finding that EWA treatment improved survival among
non-social drinkers is complicated by the fact that poorer prognosis
women were less likely to be included in this analysis if they had
been treated as usual.

The featured study comes as close as any, and closer than most, to
securely establishing that effective treatment for alcohol dependence
appreciably extends the lives of the patients, with what must be
consequent benefits for families, employers and the state. Random
allocation to enhanced versus what is now known to be relatively
ineffective treatment goes part way to the methodologically ideal –
but ethically unacceptable – random allocation of dependent drinkers
seeking help to 'real' versus 'placebo' treatment. Though less
methodologically adequate, other studies have been able to relate the
quantity of treatment to trends in deaths from alcohol-related causes,
notably liver disease, showing that benefits for patients can cumulate
(and perhaps spill-over) to benefits noticeable across a community. To
get to this result treatment must reach a high proportion of the heavy
drinking population and (the featured study suggests) not just be
treatment, but good quality treatment. However, even in relatively
rich nations, any realistically conceivable expansion and improvement
of treatment is unlikely to match potential public health gains from
non-treatment measures applied more or less inescapably across the
entire population such as price rises and restrictions on the
availability of alcohol. Details below.

About the featured study
The impression from the two-year follow-up report is of a set of
patients who are socially integrated, settled and relatively
conventional, but very stressed, depressed and distressed, and coping
with this through drink. For many too, their married lives probably
revolved around heavy drinking. Unlike some other female caseloads,
there is no mention of treatment being forced on them due to child
care concerns and 85% were self-referred. As the researchers
commented, they seem a previously hidden population of publicly well
functioning alcoholics, possibly attracted to services by the
availability of specialist woman-only treatment. The implication is
that they represented a relatively promising set of patients whose
motivation levels were high as in some respects was their 'recovery
capital' – they had things worth keeping which they risked losing if
their drinking got much worse.

Nevertheless, they needed the extra attention they received in the EWA
unit to maximise their progress. Over the next two years it helped
normalise relations with partners and children, improve psychological
well-being, and prevent relapse requiring inpatient care, needed by
31% of treatment-as-usual patients but just 16% treated in the EWA.
Underpinning these gains was a substantial extra reduction in heavy
drinking and a more widespread return to social drinking reflected in
a variety of measures. Most directly, "alcohol abuse" featuring daily
or near-daily drinking was reported by 8% of EWA patients compared to
around 30% treated as usual. Already in these two years, a lower death
rate was apparent; one former EWA patient died compared to three after
usual treatment, all from clearly or possibly alcohol-related causes.
There is reason to believe these recorded outcomes understated the
benefits of the EWA unit because treatment-as-usual patients doing
particularly poorly could not be followed up.

One doubt over whether these findings would be replicated outside the
context of a randomised study arises from the assumption that the
women were attracted to treatment by the existence of the EWA unit.
The half who found themselves randomly denied access to it may have
fared worse partly due to disappointment and demoralisation rather
than simply to lower service levels in the usual wards and clinic. The
'treatment as usual' comparator raises a different question over
whether the findings would be replicated in other treatment
environments. Detoxification plus disulfiram is now known generally to
be (except for closely monitored or supervised patients with much to
lose from non-compliance) a relatively ineffective treatment. It seems
unlikely that the often alcoholic partners were well placed to ensure
the women took their disulfiram, and there is no mention of
supervision being organised by the treatment service.

Around the same time as the featured study selected its samples,
another two samples of women treated at the EWA unit were recruited
for a study which in 2007 (from 13 to 26 years later) compared their
survival rates against local women from the general population matched
for age, marital and socioeconomic status, and educational level, but
not known to be problem drinkers. Over twice as many of the treated
alcoholics died and on average they died four years earlier, shortly
before their sixtieth birthdays. Chronic alcohol-related diseases
played their part, but the greatest cause of excess and early deaths
was what the report described as "external" factors. Possible or
actual suicide was also much more frequent. The unusually intensive
and comprehensive treatment the EWA women received could be why the
excess death rate in this study was, as the authors commented,
"substantially lower than [in] almost any other treatment study". The
excess death rate compared to the general population was greatest
among younger women; 17–39-year-old former EWA patients were four
times as likely to have died as their comparators, and their deaths
tended to happen in the first five years of the follow-up period while
they were still young. It was also the case that in the featured study
the life-extending impact of EWA treatment was most noticeable among
these younger women, suggesting that without the EWA, the death rate
would have been even more excessive.

Alcohol treatment extends lives
Research has confirmed the featured study's assumption that extended
life is indicative of a good overall outcome from addiction treatment.
With less socially integrated and more deprived populations, in the US
context stable abstinence has been the only pattern of post-treatment
drinking substantially associated with extended life. In contrast, the
featured study's patients were relatively advantaged, post-treatment
abstinence was rare, and the social and treatment environment were
'friendly' to non-abstinence-based recovery. In this context,
continued drinking seemed no barrier to realising the lifesaving
potential of alcohol dependence treatment.

Attempts to assess this potential have been complicated by the fact
that some forms of treatment (such as inpatient detoxification) are
indicative of poor outcomes. The more of this kind of treatment
someone has undergone, the less their chances of survival – not
necessarily because the treatment has been counterproductive, but
because the repeated need for it is a marker of severe and intractable
dependence. Methodologically, the ideal solution is to randomly deny
treatment to some severely alcoholic would-be patients, and to offer
it to others, but such an experiment would be unethical. The featured
study goes part way to this ideal by randomly allocating patients to a
relatively ineffective treatment (closer along the quality spectrum to
no treatment at all) or to one designed and expected to be much more
effective. Its finding that 'more' treatment means more years of life
saved – in pharmaceutical terms, a dose-related response – is a strong
indication that treatment can be an active ingredient in saving lives.

Random allocation makes the featured study a possibly unique advance
on studies which have simply related the quantity of treatment (marked
by availability, funding or numbers of patients) to trends in the
death rate. Despite attempts to statistically eliminate confounding
influences like changes in alcohol price and availability, these still
complicate the attribution of death rate changes to treatment
expansion. Nevertheless, together these offer persuasive evidence that
provided on a large enough scale, treatment (even 'treatment as
usual') benefits patients and perhaps also their associates and others
sufficiently for the impact to be noticeable in alcohol-related death
rates across the entire population.

A notable example took advantage of the considerable state-funded
expansion of alcoholism treatment in the US state of North Carolina in
the early 1970s to show that treatment extended the lives of heavy
drinkers who would otherwise have died sooner of cirrhosis of the
liver – a condition related to heavy prolonged drinking but which can
be stabilised by stopping drinking, and whose precursors can be
reversed by the same tactic. A review of similar studies has assessed
the evidence that at a community level (city, state or country)
treatment's impacts cumulate into worthwhile reductions in alcohol-
related problems. Evidence (mostly from North America) was strongest
for cirrhosis of the liver. At varying time lags, greater
participation in conventional treatment and in AA were associated with
fewer cirrhosis cases and deaths. There was also some evidence for an
impact on accidents and drink-driving incidents. Importantly, these
benefits could not be explained by changes in the availability and
overall consumption of alcohol. Mathematical models suggested that
increased participation in treatment/AA alone could have accounted for
all the reductions in cirrhosis deaths in the USA and Ontario in the
1970s and '80s.

Another review focused on the area where the previous review found the
evidence less convincing – the impact of treatment and allied
interventions with problem drinkers on injuries and deaths due to
accidents. The search uncovered 19 relevant randomised controlled
trials, seven of which compared intervention to no intervention (as
opposed to another intervention). In nearly all cases, intervention
reduced injuries, in some cases substantially. This was true whether
the recorded outcomes were fatal injuries, non-fatal injuries,
violence, or motor vehicle crashes and injuries. The authors'
conclusion that "interventions to reduce problem drinking could have
an important effect on the incidence of injuries and deaths" was
expressed tentatively because of the poor quality of many of the
studies and small sample sizes.

Not the main lever at a population level
Though treatment can extend the lives of the patients, and on a large
enough scale and in sufficient quality may also affect alcohol-related
deaths across a community, it is generally accepted (1 2) that it is
not the major policy tool for improving health and avoiding early
deaths across an entire community. Globally, injuries account for the
largest portion of the alcohol-attributable burden of ill health. Many
result from accidents caused by periodic intoxication not susceptible
to or not considered appropriate (by the drinkers and by the wider
society) for treatment interventions; for a given amount of drinking,
the risk is actually higher among people who do not usually drink
heavily rather than more treatment-appropriate heavy drinkers. Chronic
disease too can be caused or aggravated by drinking levels well below
those typical of treatment caseloads.

The World Health Organisation has concluded that in countries such as
the UK, with a high prevalence of hazardous drinking, raising alcohol
tax rates would have the greatest yet least resource-intensive impact
on public health. Next most cost-effective were licensing controls
which reduced hours of sale and advertising bans. Applying this model
across the Australian population, it has been calculated that health
gains in terms of disability adjusted life years would be greater from
population-wide interventions (taxation, advertising or licensing
controls, random breath testing, and drink-driving campaigns) than
from interventions which target risky (brief advice) or dependent
drinkers (residential treatment with or without naltrexone-based
aftercare).

Assessing all the available evidence, alcohol policy experts judged
that the most effective, evidence-based policy approaches to reduce
alcohol-related harm are measures restricting the affordability,
availability and accessibility of alcohol. Among these are alcohol tax
rises and limiting the opening hours, locations and density of alcohol
outlets, and enforcement of a minimum purchase age. What these
measures have going for them is their financial feasibility and their
more or less inescapable application (to the degree that the
regulations can be enforced) across the entire population. In contrast
and despite its effectiveness for the patients, alcohol treatment can
be expensive to implement and maintain, and benefits are focused on
individuals who volunteer for or are identified and directed in to
treatment. Nevertheless, as the studies cited above confirm, the
experts added the rider that treatment can curb population levels of
alcohol consumption and resultant harm if implemented and accessed on
a large enough scale.

Last revised 21 June 2011