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General Conclusions
Alcohol-related injury can be prevented
Most physicians and nurses meet patients who consume hazardous levels of alcohol. Well-documented scientific studies show that ‘mini-intervention’ – based on identifying hazardous consumption and providing information, motivation, and support – leads to a reduction in alcohol consumption and alcohol-related problems.
This simple but effective method to prevent the physical and psychological damage caused by alcohol is, however, not used to the extent possible.
Effective methods are available to treat abuse and dependence on alcohol and drugs
Many specific psychosocial treatment methods and pharmaceuticals have been scientifically documented as effective means to treat abuse and dependence on alcohol and drugs. Several other methods currently used to treat alcohol and drug abuse and dependence have no documented effects, or are shown to be ineffective in scientific studies.
Consequently, care for substance abuse can be improved by: (a) shifting resources away from ineffective treatment methods and into treatment methods that have been documented as effective and (b) committing more resources to treatment programs that apply evidence-based methods.
Information, education, and research are needed
Programs to treat substance abuse should rest on a foundation of evidence-based knowledge. This requires a commitment to information, education, and research. Informational and educational efforts should encompass the findings presented in this report and should be pursued by all appropriate healthcare and social service providers in the public and private sectors.
Important research areas include:
• the effectiveness of psychosocial and pharmacological methods to treat the abuse of cannabis and amphetamines,
• integrated psychosocial and pharmacological treatment,
• optimal intensity and duration of different treatment interventions,
• studies on substance abuse during pregnancy,
• the cost-effectiveness of different treatment methods.
Alcohol – Hazardous Consumption, Abuse, and Addiction
• Short-term preventive interventions by healthcare providers that target hazardous levels of alcohol consumption are shown to be effective in reducing alcohol consumption for up to 2 years.
• Many psychosocial treatment methods with a clear structure and well-defined interventions have favorable effects on alcohol dependence. These methods include cognitive behavioral therapy, 12-step treatment, structured interactional therapy, structured modern therapy with dynamic reference frameworks, motivation-enhancing treatment, partner therapy, and strategies that involve the family in treatment.
• The effects of many psychosocial treatment methods (eg, general counseling) have not been scientifically documented.
• Benzodiazepines are the most thoroughly documented medication for alcohol withdrawal. The routine practice of supplementing this treatment with antiepileptic therapy does not have satisfactory scientific support.
• In long-term treatment of alcohol addiction, acamprosate (Campral) and naltrexone (Revia) have confirmed effects, as does disulfiram (Antabuse) if delivered under supervision.
• The scientific evidence shows that treatment with antidepressants and buspirone (BuSpar) relieves depression and anxiety in alcoholics, but it does not show any positive effects on alcohol dependence.
Narcotics – Dependence and Abuse
• Relearning therapies targeted at the behaviors of substance abusers are the most effective among the psychosocial methods for treating heroin and cocaine dependence. These methods are generally based on behavioral therapy. Dynamic psychotherapy appears to have a positive effect on heroin abuse. Nonspecific, supportive therapy is often used in Sweden to treat drug abuse, but its effectiveness has not been confirmed.
• The psychosocial therapies that have been used to address other drugs have no proven effects (eg, cannabis) or are insufficiently studied (eg, amphetamines, etc).
• Clonidine can be used successfully to treat heroin withdrawal, and it does not cause addiction. Morphine-like substances, ie, methadone and buprenorphine (Subutex), have effects that are similar to clonidine.
• Methadone and buprenorphine (Subutex) used in maintenance therapy for heroin addiction reduces heroin use and improves participation in treatment programs. Naltrexone also reduces abuse (Revia, not approved for this indication in Sweden).
• No well-executed, controlled studies have shown that medication is effective in treating cocaine, amphetamine, or cannabis dependence.
SBU Summary
Introduction
Alcohol-related problems are common in society. Large population studies from the United States have shown that 10% to 15% of all men and approximately 5% of all women suffer from chronic alcohol dependency. In these groups, approximately one fourth are in a phase of active abuse.
Dependence results from consuming hazardous levels of alcohol for a prolonged period. Alcohol dependence often leads to severe social and economic consequences for individuals and their families. Suicide, violence, drunken driving, social isolation, and criminal acts often follow dependence and abuse. Alcohol abuse often leads to serious health disorders that mainly affect the brain and nervous system, but also cause serious damage to the liver, muscles, heart, and blood vessels. A large part of the total healthcare expenditure is used to care for alcohol-related disorders. The social services allocate substantial economic and human resources toward managing the social and economic consequences of alcohol-related problems.
The economic costs of alcohol and drug dependence and abuse have been calculated in numerous studies from many countries, and the estimates range between 2% and 8% of GNP. In Sweden, this translates into a cost between 30 billion and 120 billion Swedish kronor (SEK) annually. Substance abusers and their families account for nearly one half of these costs. These figures illustrate the catastrophic social and human impact that substance abuse has on the family.
Drug addiction and abuse is a less common, but not less serious, problem in Sweden. Addiction to narcotics is becoming more widespread, particularly among young people. The use of narcotics in Sweden is illegal, with the exception of narcotics used in medical treatment. The most commonly used narcotics include heroin, cocaine, amphetamines, and cannabis. Each of these agents can lead to psychological problems, anxiety, and depression, and some drugs can create long-term or incurable brain disorders. In recent years, several other substances have appeared which some people claim are relatively harmless. This is not the case. Many studies have documented the serious effects of, eg, ecstasy, which can damage the neurotransmitter system in the brain.
The use of both alcohol and drugs may result in physical dependence and greater tolerance levels, ie, increasingly greater doses are needed to become intoxicated. The nervous system adapts to the intake level, and withdrawal may cause extreme suffering and in some cases may be life-threatening.
Alcohol and drug dependence and abuse often become chronic conditions, even though longer periods of sobriety are common. The dependent individual may often suffer from other physical and/or mental disorders. Hence, treatment must aim both at the dependency itself and at concurrent disorders, and may need to be repeated to prevent relapse and reduce injury. This goal is similar to the goals applied in treating chronic somatic diseases, eg, diabetes and cardiovascular diseases.
This report presents the methods available to intervene against harmful levels of alcohol consumption, and the methods used to treat and prevent relapse of alcohol and drug dependence and abuse. Furthermore, it presents the findings from scientific studies concerning the effectiveness of different treatment methods.
Definitions
Dependence
Dependence implies that alcohol or drugs have come to play a major role in an individual’s life, to the point that these substances lead to substantial functional impairment or suffering. The internationally accepted criteria for dependence are, eg, that the individual loses control over intake, that withdrawal problems develop, and that a higher intake is needed to become intoxicated.
Most of the studies reviewed in this report have used a system of diagnostic criteria for dependence that was developed in the United States, ie, the Diagnostic and Statistical Manual of Mental Disorders (DSM system). The DSM system includes the following 7 criteria, 3 of which must be met for a period of one year to establish a diagnosis of dependence:
1) Increased tolerance, eg, a marked increase in consumption is needed to achieve intoxication.
2) Withdrawal symptoms when use is discontinued.
3) Substances often taken in larger amounts or over a longer period than intended.
4) Persistent desire or unsuccessful efforts to cut down or control substance use.
5) Much time is spent acquiring and consuming alcohol and drugs, or recovering from their effects.
6) Important social, occupational, or recreational activities are neglected.
7) Continued substance use despite physical or psychological problems.
Abuse
Many of the reviewed studies based their definition of substance abuse on criteria from the DSM system mentioned above. According to DSM-IV, an individual who meets one or more of the following 4 criteria for a period of one year is defined as suffering from substance abuse:
1) Repeated use of alcohol or drugs that leads to problems fulfilling ones obligations at work, school, or at home.
2) Repeated use of alcohol or drugs in risk situations, eg, driving or working with mechanical equipment.
3) Repeated contact with the judicial system as a result of substance abuse.
4) Continued use despite recurring problems.
Hazardous alcohol consumption
There is no scientifically established definition of hazardous alcohol consumption, but there is general agreement on a definition within the research community. It suggests that one glass of wine per day for women and two glasses of wine per day for men do not carry a risk, but may have some protective effect against cardiovascular disease. The following limits have often been applied in studies of hazardous alcohol consumption:
• Three bottles of wine per week, or 9 to 12 cans of strong beer per week, or 75 centiliters of hard liquor per week for men.
• Two bottles of wine per week, or 6 to 9 cans of strong beer per week, or 50 centiliters of hard liquor per week for women.
Project Design and Scope
This project is limited to reviewing the methods used to intervene against hazardous levels of alcohol consumption and methods used to treat established alcohol and drug abuse and dependence. Dependence on benzodiazepines and other sedatives was not investigated, nor does the report address preventive work, eg, campaigns, information directed at different target groups, legislation, pricing policies, and other primary prevention.
The report was prepared by a project group of 11 experts. The group identified relevant scientific studies by searching databases covering the international scientific literature in the field. The literature search covered all studies published from the 1950s until the summer of 2000. The MEDLINE database alone yielded 23 000 studies on alcohol problems.
The project group selected studies of high scientific quality. The selection focused on randomized controlled trials (RCT), ie, studies that randomly assign patients to different types of treatments to analyze which treatments yield the best results. This assessment approach is the most reliable, but is often conducted under relatively ideal conditions. Hence, not all of the conclusions are directly applicable to routine, day-to-day healthcare delivery. Ultimately, the group identified 641 relevant studies, most of which were randomized controlled trials.
The report presents an assessment of numerous methods and combinations of methods, including medications. It covers pharmacological treatment for alcohol and drug dependence and alcohol detoxification. It also covers psychosocial treatment of alcohol and drug problems, the long-term course of alcohol dependence, and the cost-effectiveness of different treatment methods.
The project group considered the following questions to be fundamental:
• Does a particular treatment have a better effect than no treatment?
• Are there treatment methods that are more effective than others?
• Does a particular treatment work better in a particular type of patient?
• Is special treatment needed for substance abusers with mental illness?
• Is inpatient care more effective than outpatient care?
• How cost-effective are the different treatment alternatives?
The following summary presents the main results of the report.
Preventive Interventions Against Hazardous Consumption of Alcohol
The intent of various types of interventions is to detect and treat, at an early stage, individuals with excessively high alcohol consumption to prevent them from developing dependence and damaging the different organs in the body. The interventions are simple but relatively effective. Most of the methods are based on the following principles:
1. To identify hazardous alcohol consumption by asking a few simple questions.
2. To provide information about the risks and empathetically challenge, advise, and motivate people to reduce or cease alcohol consumption.
In total, nearly 500 studies were identified in this area, 25 of which met the standards for high scientific quality and relevance. These studies are presented in detail in Chapter 1 of the report. In most of the studies, primary care physicians and nurses carried out the interventions described above. Many of the studies reported similar outcomes, regardless of whether a physician or a nurse managed the intervention. Generally, those who perform the intervention should participate in a brief educational program (1 or 2 days).
The overwhelming majority of studies reported significantly better results with active intervention against hazardous alcohol consumption. Approximately 30% in the group who received advice/counseling reduced their alcohol consumption to risk-free levels compared to approximately 20% in the control group.
This is a substantial effect compared to the interventions required for other preventive programs. A comparative example would be that in 18 patients treated by medication for 4 years for an enlarged prostate it is possible to avoid surgery in 1 individual. In 128 middle-aged patients treated with medication for 5 years for moderately elevated blood pressure, it is possible to avoid cardiovascular disease in 1 individual. In 10 persons who are given counseling and motivation to reduce their alcohol consumption, 1 individual will cease or lower their consumption to a risk-free level.
Psychosocial Treatment of Alcohol Dependence
The wide range of treatment methods covered by the concept of psychosocial treatment can be classified into the following categories:
1) Methods intended to motivate change.
2) Methods aimed at changing the abusive behavior itself.
3) Methods that focus on the presumed factors that lead to abuse.
4) Methods that offer general support.
5) Methods that focus on partners and family.
This section of the report identifies 139 randomized controlled trials, whereof 14 compared psychosocial treatment to no treatment. The outcomes were generally favorable and were comparable with results achieved in treating other health problems and diseases within the healthcare system.
A comparison of different types of psychosocial treatment reveals that several specific treatment methods have similar effects. These treatment methods are distinguished by a clear structure and well-defined interventions that are often based on detailed protocols. Examples include different types of cognitive behavioral therapy such as a 12-step treatment program (eg, the Hazelden Minnesota model) often combined with self-help programs (eg, Alcoholics Anonymous) and motivational programs. Several studies have shown that structured interactional therapy and structured modern therapy with psychodynamic reference frameworks have effects similar to cognitive behavioral therapy. The studies on partner therapy and family intervention show positive results.
Several studies use the term "standard treatment", when referring to the control group. This concept is often poorly defined. Standard treatment usually refers to supportive discussions in combination with input from social services. In the studies reviewed, such treatment showed no effects when compared to specific treatment methods. Furthermore, this type of treatment does not focus as clearly on abusive behavior as specific therapies do.
The evidence that a specific treatment method has better effects in certain categories of patient is weak. In patients with less serious alcohol dependence it appears that limited treatment has the same effects as more comprehensive treatment. However, people with more severe alcohol problems have better results with more comprehensive treatment. Although a few treatment programs have been aimed specifically at women, several studies have analyzed the effects of treatment in both genders without finding any distinct differences.
The scientific evidence shows that treatment of psychologically disturbed substance abusers and homeless substance abusers must concurrently address both the psychological problems and other lifestyle problems. Positive effects in treating homeless substance abusers have been achieved when applying behavioral methods and structured, consistent patient support. Supportive housing and inpatient care do not appear to yield better results than outpatient treatment.
Medications for Alcohol Dependence
Since the 1950s, many psychopharmacological drugs have been used to treat alcohol dependence. Earlier drugs were less specifically targeted at alcohol dependence compared to the drugs developed in recent decades.
In total, 104 published and 16 unpublished randomized controlled trials assessed the effects of medication on alcohol dependence. Essentially all drugs used at different periods to treat alcohol dependence are covered by these assessments.
The agents approved by the Swedish Medical Products Agency to treat alcohol dependence (acamprosate - Campral and naltrexone - Revia) have well-documented effects. Acamprosate significantly increases the rate of complete recovery while naltrexone significantly reduces alcohol abuse when the drug is combined with effective psychosocial interventions such as cognitive behavioral therapy. Antabuse (disulfiram), which causes nausea and discomfort during alcohol consumption, is also documented as an effective method to reduce alcohol intake, but only when used under supervision.
Drugs (antidepressants / buspirone) are effective in treating depression or anxiety in alcoholics. However, they have no confirmed effects on alcohol dependence.
Scientific studies have not confirmed the effects of other medications on alcohol dependence.
Medications in Alcohol Withdrawal
The main goal with this treatment is to prevent and treat life-threatening delirium tremens, epileptic seizures, and other withdrawal symptoms. The most common agents used for this purpose in Sweden are benzodiazepines and chlormethiazole (Hemineurin).
The literature search identified 82 randomized controlled trials of medications for alcohol withdrawal. An additional 13 studies assessed treatment of manifest delirium tremens.
These studies show that benzodiazepine treatment is the most well-documented. This treatment reduces the risks for developing both delirium and withdrawal seizures. It also reduces symptoms of hyperactivity, eg, perspiration, tremors, and palpitations. Differences between short-acting and long-acting benzodiazepines have not been confirmed. There is no scientific evidence to support other drugs alone as treatment for withdrawal seizures or delirium tremens.
The documentation for chlormethiazole – which has more potentially serious side effects than benzodiazepines – is substantially weaker even though 3 smaller studies found similar effects for benzodiazepines and chlormethiazole.
In treating severe cases of alcohol withdrawal, a common intervention is to combine benzodiazepines or similar agents with specific agents for treating epilepsy to prevent withdrawal seizures. Scientific support for this routine is inadequate.
Psychosocial Treatment of Drug Addiction
In total, 112 randomized controlled trials were found on the psychosocial treatment of drug addiction. These studies can be classified into the following categories:
1. Supportive treatment, which is often based on attempts to organize a functioning network among patients, caregivers, and family members. The treatment is not based on protocols, and the structure is usually inadequately described in the studies currently available.
2. Relearning, which usually includes behavioral therapy to change the behaviors behind abuse. This usually involves common behavioral therapy or behavioral interventions targeted at the abuse itself. Hence, this approach requires uniform standards for adequate education of the caregiver. Some relearning treatment methods, eg, to prevent the relapse of substance abuse, are based on written protocols and can be administered by individuals without special qualifications.
3. Psychotherapy methods that include family therapy, cognitive therapy, and dynamic-oriented treatments. In Sweden, these therapies require specially licensed practitioners.
Interventions that involve relearning are effective in treating heroin and cocaine addiction. However, all of the studies involved patients who were also treated with methadone.
Dynamic psychotherapies are effective in treating heroin, but not cocaine, abuse. They are also the only methods shown to have the effect of keeping people in treatment, a primary measure of treatment effectiveness.
Supportive interventions have not been effective in treating addiction or keeping people in treatment.
The negative findings on supportive therapy and the positive findings on relearning therapy have many similarities with the corresponding findings on psychosocial treatment methods in alcohol dependence. In the latter case, the scientific literature shows positive effects for specific treatments (which correspond to relearning therapy in drug dependency) and a lack of positive effects for standard, nonspecific treatment (which corresponds to supportive therapy in drug dependency).
Seven randomized controlled trials assessed the effects of different psychosocial treatment methods on cannabis dependency. None of the methods tested had any confirmed treatment effects.
Amphetamines represent the most commonly abused narcotic in Sweden. There are no randomized controlled trials of psychosocial treatment methods for amphetamine dependence.
Medications to Treat Drug Addiction
Long-term treatment of heroin addiction
Many randomized controlled trials (70) have assessed different types of drugs to treat heroin addiction.
The four studies that assessed the effects of methadone treatment, compared to an untreated control group, reported significant positive effects: reduced heroin abuse and good compliance with treatment. One of the studies also reported a lower mortality rate in the treatment group compared to the control group. The dose of methadone is important. Studies show that doses exceeding 50mg to 60mg are usually required to achieve favorable treatment results.
An alternative to methadone is buprenorphine, which was compared to placebo in only a single study. This study shows significant positive effects from buprenorphine in treating heroin addiction. Another agent, which can be used to treat heroin addiction is the methadone derivative, levomethadyl acetate hydrochloride (ORLAAM). This drug has not been assessed in relation to placebo.
Comparative studies show similar treatment effects from methadone, buprenorphine, and ORLAAM. The effects have been measured in terms of reduced addiction and continued participation in treatment programs. Buprenorphine is generally described as having certain advantages, eg, less addiction and lower risk for overdosing, but these effects were insufficiently documented in the studies reviewed.
Another alternative is naltrexone, which blocks the receptors for heroin, ie, the drug user does not experience a “high” from the narcotic. In contrast to what is commonly reported, this review clearly shows that naltrexone has an effect on heroin abuse. However, naltrexone has not been approved in Sweden for treating heroin addiction.
It is common for heroin addicts to suffer from depression in conjunction with methadone treatment. Six controlled studies have been conducted on the effects of antidepressants. Two of these studies reported definite effects on depression but not on narcotic addiction.
Long-term treatment of cocaine addiction
Forty studies have evaluated the effects of several different drugs on cocaine addiction. No effects were documented in these studies.
Long-term treatment of amphetamine and cannabis addiction
No studies have been able to demonstrate that pharmaceuticals are effective in treating amphetamine or cannabis addiction.
Pharmacological Therapy in Heroin Detoxification
The pharmaceuticals used in heroin detoxification have been assessed in 33 randomized controlled trials.
Detoxification can be achieved with some antihypertensive drugs or with morphine-like agents such as methadone and buprenorphine.
Among the antihypertensive drugs, clonidine is the agent that has been most studied. Clonidine is more effective than placebo and demonstrates the same effects as morphine-like substances in most of the studies. The effects of methadone treatment are similar to treatment with other morphine-like substances, including buprenorphine. Using naltrexone in combination with clonidine or buprenorphine can shorten the withdrawal period.
Inpatient and Outpatient Treatment
In 1999, the National Swedish Board of Health and Welfare surveyed the structure of care for substance abuse in Sweden. The overwhelming majority (nearly 90%, whereof 70% were men and 30% were women) of people with substance abuse problems were treated as outpatients. Most care is provided at the municipal level or in conjunction with the county councils. The county councils provide treatment for detoxification and short-term care for alcohol and drug abuse at hospital clinical departments. Foundations or private providers manage approximately 30% of all units for substance abuse. Within institutions, various types of environmental therapies are the dominant methods.
The studies that compare the effects of different types of care show that no confirmed conclusions can be drawn on the value of institutional treatment for alcohol dependence, even though the care setting should be appropriate to the level of dependence. In drug addicts, institutional care has effects on social functioning and continued participation in treatment, but such effects are temporary. However, superior results are reported for some drug abuse groups, specifically those who are mentally ill and/or homeless. Among these groups, institutional care results in lower alcohol and drug use and fewer mental symptoms compared to treatment delivered by psychiatric outpatient care or general social services.
Pregnancy and Substance Abuse
There is growing knowledge about the injury to the fetus that can be caused by a mother's use of alcohol and drugs. However, there are no controlled trials that show the effects of prevention or treatment interventions.
Economic Analysis
Using “costs” and various combinations of alcohol/ drug problems as keywords, a literature search of several databases (such as MEDLINE, EconLit, PsychLit, and Current Contents) identified approximately 1200 studies. The overwhelming majority of these studies do not include economic assessments, but mention and discuss the costs and benefits of, eg, different treatment methods. Twenty-four studies contained formal economic analyses, whereof eight were based on randomized controlled trials.
Approximately one half of the 24 economic analyses that were reviewed in this report were found to be of low scientific quality. The remaining studies address a wide range of aspects of treatment for alcohol and drug problems, which means that for each treatment investigated only isolated studies offer potential support in one direction or the other. The scientific evidence is too weak or contradictory to permit conclusions about the cost-effectiveness of different treatment methods.
Overview of the Effects of Different Methods
The following table gives an overview of several of the important findings from the literature review. With few exceptions, this study is based on randomized controlled trials of high and moderate scientific quality. Hence, only treatment methods whose effects are supported by several studies, or treatment methods where the lack of effect is supported by several studies, are reported here.
| Intervention Against: |
Is treatment effective? |
Which therapies
are best? |
No.
studies
|
| Hazardous alcohol consumption |
Yes |
Identify hazardous consumption, inform about risks, give advice and motivation on how to cut back or quit
|
25 |
| Alcohol dependence |
- |
- |
- |
| Pharmacological treatment |
Yes |
Acamprosate
Naltrexone
Disulfiram (treatment under supervision) |
80 |
| Psychosocial treatment focused on addiction |
Yes |
Specific methods |
139 |
| Withdrawal treatment |
Yes |
Benzodiazepines |
95 |
Nonspecific supportive treatment
|
No |
- |
-95 |
| Heroin dependence |
- |
- |
- |
| Pharmacological treatment |
Yes |
Methadone
Buprenorphine
ORLAAM
Naltrexone |
70 |
| Psychosocial treatment |
Yes |
Relearning therapy |
68 |
| Withdrawal treatment |
Yes |
Clonidine
Buprenorphine
Methadone |
33 |
| Nonspecific supportive treatment |
No |
- |
|
| Cocaine dependence |
- |
- |
- |
| Pharmacological treatment |
No |
None |
40 |
Psychosocial treatment
|
Yes |
Relearning therapy |
44 |
Amphetamine dependence
|
Not studied |
Not studied |
0 |
| Cannabis dependence |
- |
- |
- |
| Pharmacological treatment |
Not studied |
Not studied |
0 |
| Psychosocial treatment |
No |
No |
7 |
|