‘Dangerous data’: drinking after dependence part 7. Who takes the decision and how?
With both objectives on the care-planning table, shared decision-making between client and patient has become the recommended way to decide between alternative treatment objectives, informed by official and unofficial guidance. The final part of Mike Ashton’s series on the controlled drinking controversy.
The history of the controlled drinking controversy makes us face not just what decision is made about treatment goals, but also who makes that decision and how – where the power lies. If controlled drinking is to emerge from the cupboard to lie on the treatment-planning table alongside abstinence, how is the decision to be made about which to go for, and who should make that decision?
Shared decision-making between patient and clinician has been recommended, begging the question of how to engineer this in a meaningful rather than tokenistic manner. Helpfully a Dutch study showed that shared decision-making can be systematised rather than left to the uncertain initiative of the clinician. In relation to life in general, one result was that patients felt more able to make their own decisions, more in control, and less submissive – perhaps portending a more stable shift away from a dependent mind-set than could be achieved by less explicit shared decision-making. However, the lack of studies leaves it an open question whether systematic shared decision-making improves drinking outcomes.
In practice, reliance on clinicians to help navigate “confusing and unpredictable” treatment pathways may undermine the ethos of shared decision-making, tipping the scales of power towards clinicians. The UK study which identified this deficiency called for treatment pathways to be more ‘patient-friendly’ and for health care professionals to support and build ‘self-efficacy’ among patients – their belief in their own power to effect change.
Among 20 seemingly severely dependent patients interviewed at alcohol treatment services in London the study found that definitions of alcohol dependence varied widely – for some, depending on volume or strength of alcohol consumed, for others, indicating a need (as opposed to a want) to keep drinking. Complicating shared decision-making, in turn these variations influenced their views about what and who treatment was for. Many saw ‘cutting down’ as an important step towards achieving abstinence and/or regaining control of drinking, while their practitioners tended to support cutting down only to the extent that it was a step towards abstinence, not a goal in itself. From the patients’ perspectives, moderation could be both a means to an end and the end itself, diverging from the mainstream clinical view of abstinence and moderation as mutually exclusive goals.
Practitioners favour abstinence for the severely dependent
The British study discussed above and others from several countries show that for patients with relatively severe drinking problems, treatment practitioners are more inclined to support moderation as an intermediate step towards abstinence than as a goal in itself. Their input into shared decision-making would generally discourage the more problem-loaded of their patients from trying for moderation.
Surveyed in 1999/2000, two-thirds of the leaders of British substance use services fully endorsed the acceptability of controlled drinking as an intermediate outcome for non-dependent alcohol ‘abusing’ clients and only slightly fewer as a final outcome, but the corresponding figures for dependent clients were 42% and 29%. However, absolute dogmatism was relatively rare; even when rejection was at its maximum, only 23% saw controlled drinking as a “completely unacceptable” final goal for dependent drinkers, and 60% of services made such treatment available to their dependent clients.
In 2011 similar questions were put to US addiction clinicians. For people whose alcohol problems fell short of dependence, over half saw non-abstinent drinking as an acceptable intermediate (58%) and final (51%) goal, but far fewer did so for clients who were dependent (respectively 28% and 16%). As well as the severity of problem drinking, evaluations of the acceptability of non-abstinence goals were informed by patients’ health problems (86% deemed these ‘very important’), number of previous treatment episodes (70%), presence of mental health disorders (68%), age (67%), and emotional stability (65%). Of those who saw non-abstinence as an unacceptable treatment goal, 4 in 10 did so partly because “It would send the wrong message to clients,” echoing concern evident since the start of the controversy that acknowledging the possibility of moderation would undermine commitment to abstinence, no longer privileged as the only way to avoid a return to dependent drinking. The researchers concluded that overall, “individuals with alcohol and drug problems who avoid treatment because they are ambivalent about abstinence should know that – depending on the severity of their condition, the finality of their non-abstinence goal, and their drug of choice – their interest in moderating their consumption will be acceptable to many clinicians, especially those working in outpatient and independent practice settings”.
When similar questions were put to experienced addiction therapists in Poland, they too were much more likely to accept reduced drinking as a final treatment goal for the less severe diagnosis of alcohol abuse (77%) than for dependence (36%). Again, a common reason for rejecting this goal (expressed by around half the therapists who did reject it) was that it would send the wrong message to clients.
What are the consequences of a mismatch between the treatment goals of a service and its staff versus those of the patients? Possibly, it seems, less successful treatment. Published in 2016, a Swedish study investigated this issue at two non-residential services, one requiring an abstinence goal, the other accepting of low-risk drinking. Their patient intakes roughly reflected what research suggests makes patients suitable for these differing goals. Compared to the other unit, the abstinence-based service admitted relatively more men and older patients who were drinking more intensely and lacked socioeconomic resources, signalled by fewer years of schooling. Regardless of the service they attended, at the start of treatment about half the patients were aiming for abstinence (compared to other patients, they were older and had been drinking more heavily and for longer) and a quarter for moderation. When patients’ goals matched that of the service, two-and-a-half years later 94% were abstinent or drinking at low-risk levels, but just 63% when the goals had clashed.1 Overall, just over half the patients who wanted to drink at low-risk levels at the start of treatment were doing so when followed up.
While their patients may be ambivalent about abstinence as a treatment goal, UK practitioners who follow official guidance should not be. Alcohol treatment services in the UK are unambiguously advised by the National Institute for Health and Care Excellence (NICE) to guide drinkers at the more severe end of the spectrum of alcohol use disorders towards abstinence and to favour moderation lower down the scale, yet without ever ruling out non-abstinent goals if working with these is required to engage the drinker in treatment:
In the initial assessment in specialist alcohol services of all people who misuse alcohol, agree the goal of treatment with the service user. Abstinence is the appropriate goal for most people with alcohol dependence, and people who misuse alcohol and have significant psychiatric or physical comorbidity (for example, depression or alcohol-related liver disease). When a service user prefers a goal of moderation but there are considerable risks, advise strongly that abstinence is most appropriate, but do not refuse treatment to service users who do not agree to a goal of abstinence.
For harmful drinking or mild dependence, without significant comorbidity, and if there is adequate social support, consider a moderate level of drinking as the goal of treatment unless the service user prefers abstinence or there are other reasons for advising abstinence.
For people with severe alcohol dependence, or those who misuse alcohol and have significant psychiatric or physical comorbidity, but who are unwilling to consider a goal of abstinence or engage in structured treatment, consider a harm reduction programme of care. However, ultimately the service user should be encouraged to aim for a goal of abstinence.
Before NICE had pronounced on treatment goals, in 2006 the Department of Health and what was its National Treatment Agency for Substance Misuse had issued guidance for England which promoted a similar strategy. It stressed that their goal choices should not exclude drinkers from support or treatment, but did see abstinence as “the preferred goal for many problem drinkers with moderate to severe levels of alcohol dependence, particularly … whose organs have already been severely damaged through alcohol use, and perhaps for those who have previously attempted to moderate … without success”. Even for these drinkers, it continued, if abstinence is not acceptable, moderation is better than nothing, and may lead to abstinence. On how the decision should be made, in relation to care planning in general the guidance saw patient choice as not only an entitlement, but a strategy which improves the chances that the chosen treatment will succeed because “it has been selected and committed to by the individual”.
If severity of dependence is an influence on the chances of sustaining controlled drinking, the 2013 revision to the US diagnostic framework for mental disorders decisively removed what before seemed a clear dividing line in considerations of who should aim for abstinence. The American Psychiatric Association had previously classified alcohol abuse and alcohol dependence as distinct disorders in its Diagnostic and Statistical Manual of Mental Disorders, providing a line across which to favour abstinence. However, in 2013 it integrated these diagnoses under the single designation “alcohol use disorder”, acknowledging that these drinking problems do not divide in two, but range unbroken across a spectrum of experiences and symptoms from mild to severe. This re-imagining of drinking problems as a continuum throws up new questions about whether there can be a concrete point at which abstinence becomes the preferable or only acceptable treatment goal.
Notwithstanding this change, still valid are the conclusions of the British textbook Problem Drinking published in 1997, which authoritatively summed up the evidence: research shows that no matter how physically dependent, moderation is for some feasible, especially when there are sufficient supports in the patient’s life, but the more severe the dependence, the more likely abstinence is to be the suitable strategy. The 2020 review described in part 6 of this series cast doubt on severity of dependence as a factor, but not with sufficient weight to warrant deleting this part of the conclusions reached by Professors Nick Heather and Ian Robertson, whose watershed book Controlled Drinking had drawn together the strands as they stood in 1981. Then as now, neither abstinence nor controlled-drinking objectives could be said to have been proved preferable for dependent drinkers. Controlled Drinking’s original 1981 edition (illustrated to the right) featured a foreword by D.L. Davies, cycling us back to part 2 of this series and the origins of the controversy the book explored.
This is how in 2016 Drug and Alcohol Findings summed up the evidence: “Treatment programmes for dependent drinkers should not be predicated on either abstinence or controlled drinking goals but offer both. Nor does the literature offer much support for requiring or imposing goals in the face of the patient’s wishes. In general it seems that (perhaps especially after a little time in treatment) patients themselves gravitate towards what for them are feasible and suitable goals, without services having to risk alienating them by insisting on a currently unfavoured goal.”
Thanks for their comments relating to the original essay to: Dr Peter Rice, then Consultant Addiction Psychiatrist at the Tayside Alcohol Problems Service in Scotland; David J. Armor, lead author of the first Rand report, and now at George Mason University in the USA; Ray Hodgson, who commented on the controversy at the time and was at the time of his retirement Research Director at Alcohol Research UK; and to Ron Roizen, who also commented on the controversy at the time and is now an independent scholar known for his contributions to the history and sociology of drinking and the response to drinking in the USA. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
1. Calculated from tables 4 and 5; calculations exclude undecided patients.
Full essay available on the Effectiveness Bank.
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