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Outcomes for untreated individuals involved in randomized trials of alcohol treatment

  • Anne Moyer
    Correspondence
    Corresponding author. State University of New York at Stony Brook, Department of Psychology, Stony Brook, NY 11794-2500, USA. Tel.: +1-631-632-7811; fax: +1-631-632-7876.
    Affiliations
    Center for Health Care Evaluation, VA Palo Alto Health Care System, MPD-152, 795 Willow Road, Menlo Park, CA 94025, USA
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  • John W. Finney
    Affiliations
    Center for Health Care Evaluation, VA Palo Alto Health Care System, MPD-152, 795 Willow Road, Menlo Park, CA 94025, USA
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      Abstract

      Summarizing the relative effects of different treatments for alcohol use disorders is challenging because there is no standard treatment against which experimental treatments can be contrasted and comparisons to no-treatment control groups are rare. As alternative reference points, we examined outcomes and improvement for untreated participants (i.e., those in wait-list, no-treatment, and placebo conditions) in randomized trials of alcohol treatment over the last three decades. At followup, the average abstinence rate was 21% (n = 17 studies) and the mean level of alcohol consumption was 31 drinks per week (n = 29 studies). The reduction in drinking from baseline was .19 of a SD unit, or a 14% decrease from a baseline mean of 37 drinks per week (n = 17 studies). These values provide approximations of success and improvement that an active treatment for alcohol use disorders should surpass to be considered more beneficial than no treatment.

      Keywords

      1. Introduction

      Although evidence supports the benefits of an array of treatments for alcohol use disorders (
      • Finney J.W.
      • Monahan S.C.
      The cost effectiveness of treatment for alcoholism: a second approximation.
      ,
      • McCrady B.S.
      • Langenbucher J.W.
      Alcohol treatment and health care system reform.
      ,
      • Miller W.R.
      • Brown J.M.
      • Simpson T.L.
      • Handmaker N.S.
      • Bien T.H.
      • Luckie L.F.
      • Montgomery H.A.
      • Hester R.K.
      • Tonigan J.S.
      What works? A methodological analysis of the alcohol treatment outcome literature.
      ,
      • Miller W.R.
      • Andrews N.R.
      • Wilbourne P.
      • Bennett M.E.
      A wealth of alternatives: effective treatments for alcohol problems.
      ), their relative performance remains poorly understood. Summarizing the comparative effects of different treatments for alcohol use disorders is challenging for two reasons. First, because interventions are typically evaluated against other treatment modalities that vary in strength, different types of treatments have not been tested on a “level playing field,” making results difficult to interpret (
      • Finney J.W.
      Limitations in using existing alcohol treatment trials to develop practice guidelines.
      ). Second, other than investigations of pharmacologic treatments, comparisons to no-treatment control groups are infrequent (
      • Floyd A.S.
      • Monahan S.C.
      • Finney J.W.
      • Morley J.A.
      Alcoholism treatment outcome studies, 1980–1992: the nature of the research.
      ,

      Swearingen, C. E., Moyer, A., & Finney, J. W. (in press). Alcoholism treatment outcome studies, 1970–1998: an expanded look at the nature of the research. Addictive Behaviors.

      ). One potential way of dealing with the variety of reference treatments is to group studies that include the same treatment or control conditions (
      • Finney J.W.
      • Monahan S.C.
      The cost effectiveness of treatment for alcoholism: a second approximation.
      ). However, our attempt to find frequently-compared pairs of treatment and/or control conditions among 404 multiple-group studies of treatment for alcohol use disorders indicated that this was not a viable option for more than a few specific treatment modalities (e.g., brief interventions, anti-craving medications, anti-anxiety medications, and relapse prevention).
      In the absence of helpful comparative information, an alternative benchmark against which to measure treatment success is the outcome of individuals in untreated (i.e., wait list, no-treatment, placebo-only) conditions. Here, we focus on two commonly assessed and complementary drinking-related outcomes, abstinence rate and level of alcohol consumption, to characterize the typical level of followup functioning for untreated individuals. The abstinence rate indicates the proportion of those with drinking problems initially who no longer drink at followup. Level of alcohol consumption is a more sensitive continuous index of the quantity of alcohol that, on average, all individuals are drinking. Changes in consumption from baseline to followup were coded to determine to what extent excessive drinking improves or deteriorates over time without active intervention.

      2. Materials and methods

      We calculated the average abstinence rate and level of alcohol consumption at the final followup point for individuals in treatment trials randomly assigned to four types of untreated conditions: (1) no treatment (e.g., wait list, assessment only); (2) placebo (e.g., pharmacologically inert pills, sham acupuncture); (3) no treatment following a brief period of detoxification; and (4) placebo following a brief period of detoxification. We examined the no-treatment and placebo conditions separately because of the differing demand effects (expectations, reactions) that might flow from the fact that those in no-treatment groups understand that they are receiving no active treatment, whereas those in placebo groups believe that they may be receiving an effective therapeutic agent (

      Klein, D. F. (1997, September 22). Control groups in pharmacotherapy and psychotherapy evaluations. Treatment, 1, (Article 1), Retrieved from the World Wide Web: http://journals.apa.org/treatment/vol1/97_a1.html.

      ). We separated conditions that included detoxification from those that did not, to distinguish any potential, but likely minimal, salutary effects of detoxification (
      • Foster J.H.
      • Marshall E.J.
      • Peters T.J.
      Outcome after in-patient detoxification for alcohol dependence: a naturalistic comparison of 7 versus 28 days stay.
      ).
      Abstinence rate was defined as the proportion of study participants followed that were considered “abstinent” by investigators, regardless of whether any drinking (or “slips”) was allowed. Level of alcohol consumption was defined as alcohol intake over a given period of time. A common way of expressing alcohol intake is in terms of the number of standard drinks or standard ethanol content units consumed per week. Thus, when investigators assessed levels of drinking over different periods of time, such as days or months, we converted this value to number of standard drinks per week. When alcohol intake was measured in units other than standard drinks, such as ounces of ethanol, or in terms of the amount of different types of alcoholic beverages, we used the common approximations of 0.5 ounces, 15 ml, or 10–15 g of absolute alcohol, or 10 ounces of beer, 4 ounces of (12.5%) wine, or 1.25 ounces of 80 proof liquor to estimate the number of standard drinks (
      • Hester R.K.
      • Delaney H.D.
      Behavioral self-control program for Windows: results of a controlled clinical trial.
      ,
      • Miller W.R.
      • Heather N.
      • Hall W.
      Calculating standard drink units: international comparisons.
      ,
      • Scott E.
      • Anderson P.
      Randomized controlled trial of general practitioner intervention in women with excessive alcohol consumption.
      ,
      WHO Brief Intervention Study Group
      A cross-national trial of brief interventions with heavy drinkers.
      ).
      Finally, when mean and SD were presented for both baseline and outcome levels of drinking, we calculated effect sizes for the change in alcohol consumption. We used a computer software package (D-STAT;
      • Johnson B.T.
      ) to calculate within-group, pre-post effect sizes (d) for each study, to aggregate effect sizes across studies, and to test the individual effect sizes for heterogeneity and the aggregate effect size for significance.
      We drew on a database of 701 studies investigating treatment for alcohol use disorders spanning the years 1970 to 1998 (
      • Moyer A.
      • Finney J.W.
      • Elworth J.T.
      • Kraemer H.C.
      Can methodological features account for patient-treatment matching findings in the alcohol field?.
      ). The database contains studies that: (1) focused on an intervention for alcohol use disorders; (2) enrolled participants 18 years or older; (3) had at least five participants in each treatment condition; (4) assessed at least one drinking-related outcome; and (5) were published in the English language. Although studies including untreated control conditions are rare, we were readily able to locate such investigations because the 404 multiple-group projects in the database had been coded with respect to, among other variables, whether or not the study design involved a no-treatment or a minimal-treatment control condition. The studies thus identified were then examined to ascertain true no-treatment conditions, which were organized into the categories listed above.

      3. Results

      We located 17 trials with no-treatment conditions that assessed abstinence rates at followup (
      • Harris K.B.
      • Miller W.R.
      Behavioral self-control training for problem drinkers: components of efficacy.
      ,
      • Miller W.R.
      • Benefield R.G.
      • Tonigan J.S.
      Enhancing motivation for change in problem drinking: A controlled comparison of two therapist styles.
      ,
      • Borg V.
      Bromocriptine in the prevention of alcohol abuse.
      ,
      • Bullock M.L.
      • Culliton P.D.
      • Olander R.D.
      Controlled trial of acupuncture for severe recidivist alcoholism.
      ,
      • Fine E.W.
      • Steer R.A.
      • Scoles P.E.
      Evaluation of treatment program for drunk driving offenders.
      ,
      • Gallimberti L.
      • Ferri M.
      • Ferrara S.D.
      • Fadda F.
      • Gessa G.L.
      Gamma-hydroxybutyric acid in the treatment of alcohol dependence: a double-blind study.
      ,
      • Malcolm R.
      • Anton R.F.
      • Randall C.L.
      • Johnson A.
      • Brady K.
      • Thevos A.
      A placebo-controlled trial of buspirone in anxious inpatient alcoholics.
      ,
      • Malec E.
      • Malec T.
      • Gagné M.A.
      • Dongier M.
      Buspirone in the treatment of alcohol dependence: a placebo-controlled trial.
      ,
      • Ogborne A.C.
      • Wilmot R.
      Evaluation of an experimental counseling service for male skid row alcoholics.
      ,
      • Padjen A.L.
      • Dongier M.
      • Malec T.
      Effects of cerebral electrical stimulation on alcoholism: A pilot study.
      ,
      • Powell B.J.
      • Penick E.C.
      • Read M.R.
      • Ludwig A.M.
      Comparison of three outpatient treatment interventions: A twelve-month follow-up of men alcoholics.
      ,

      Regester, D. C. (1971). Change in autonomic responsivity and drinking behavior of alcoholics as a function of aversion therapy (Doctoral dissertation, University of Nebraska, 1971).

      ,
      • Senft R.A.
      • Polen M.R.
      Brief intervention in a primary care setting for hazardous drinkers.
      ,
      • Wilson A.
      • Davidson W.
      • Blanchard R.
      Disulfiram implantation: A trial using placebo implants and two-types of controls.
      ,
      • Wadstein J.
      • Ohlin H.
      • Stenberg P.
      Effects of apomorphine and apomorphine-L-dopa-carbidopa on alcohol post-intoxication symptoms.
      ,
      • Whitworth A.
      • Fischer F.
      • Lesch O.
      • Nimmerrichter A.
      • Oberbauer H.
      • Platz T.
      • Potgieter A.
      • Walter H.
      • Fleischhacker W.
      Comparison of acamprosate and placebo in long-term treatment of alcohol dependence.
      ,
      WHO Brief Intervention Study Group
      A cross-national trial of brief interventions with heavy drinkers.
      ), 29 that assessed alcohol consumption at followup (
      • Alden L.E.
      Behavioral self-management controlled-drinking strategies in a context of secondary prevention.
      ,
      • Anderson P.
      • Scott E.
      The effect of general practitioners' advice to heavy drinking men.
      ,
      • Bruno F.
      Buspirone in the treatment of alcoholic patients.
      ,

      Dimeff, L. A. (1997). Brief intervention for heavy and hazardous college drinkers in a student primary health care setting. Doctoral dissertation, University of Washington.

      ,
      • Fine E.W.
      • Steer R.A.
      • Scoles P.E.
      Evaluation of treatment program for drunk driving offenders.
      ,
      • Gallimberti L.
      • Ferri M.
      • Ferrara S.D.
      • Fadda F.
      • Gessa G.L.
      Gamma-hydroxybutyric acid in the treatment of alcohol dependence: a double-blind study.
      ,
      • Harris K.B.
      • Miller W.R.
      Behavioral self-control training for problem drinkers: components of efficacy.
      ,
      • Heather N.
      • Campion P.D.
      • Neville R.G.
      • Maccabe D.
      Evaluation of controlled drinking minimal intervention for problem drinkers in general practice (the DRAMS scheme).
      ,
      • Heather N.
      • Rollnick S.
      • Bell A.
      • Richmond R.
      Effects of brief counselling among male heavy drinkers identified on general wards.
      ,
      • Hester R.K.
      • Delaney H.D.
      Behavioral self-control program for Windows: results of a controlled clinical trial.
      ,
      • Kivlahan D.R.
      • Marlatt G.A.
      • Fromme K.
      • Coppel D.B.
      • Williams E.
      Secondary prevention with college drinkers: Evaluation of an alcohol skills training program.
      ,
      • Maheswaran R.
      • Beevers M.
      • Beevers D.G.
      Effectiveness of advice to reduce alcohol consumption in hypertensive patients.
      ,
      • Malec E.
      • Malec T.
      • Gagné M.A.
      • Dongier M.
      Buspirone in the treatment of alcohol dependence: a placebo-controlled trial.
      ,
      • Malec E.
      • Malec T.
      • Gagné M.A.
      • Dongier M.
      Buspirone in the treatment of alcohol dependence: a placebo-controlled trial.
      ,
      • Malcolm R.
      • Anton R.F.
      • Randall C.L.
      • Johnson A.
      • Brady K.
      • Thevos A.
      A placebo-controlled trial of buspirone in anxious inpatient alcoholics.
      ,
      • Marlatt G.A.
      • Baer J.S.
      • Kivlahan D.R.
      • Dimeff L.A.
      • Larimer M.E.
      • Quigley L.A.
      • Somers J.M.
      • Williams E.
      Screening and brief intervention for high-risk college student drinkers: Results from a 2-year follow-up assessment.
      ,
      • Mason B.J.
      • Ritvo E.C.
      • Morgan R.O.
      • Salvato F.R.
      • Goldberg G.
      • Welch B.
      • Mantero-Atienza E.
      A double-blind, placebo-controlled pilot study to evaluate the efficacy and safety of oral nalmefene Hcl for alcohol dependence.
      ,
      • Naranjo C.A.
      • Poulos C.X.
      • Lanctôt K.L.
      • Bremner K.E.
      • Kwok M.
      • Umana M.
      Ritanserin, a central 5-HT2 antagonist, in heavy social drinkers: Desire to drink, alcohol intake and related effects.
      ,
      • Miller W.R.
      • Benefield R.G.
      • Tonigan J.S.
      Enhancing motivation for change in problem drinking: A controlled comparison of two therapist styles.
      ,
      • Naranjo C.A.
      • Kadlec K.E.
      • Sanhueza P.
      • Woodley-Remus D.
      • Sellers E.M.
      Fluoxetine differentially alters alcohol intake and other consumatory behaviors in problem drinkers.
      ,
      • Padjen A.L.
      • Dongier M.
      • Malec T.
      Effects of cerebral electrical stimulation on alcoholism: A pilot study.
      ,
      • Pond S.
      • Becker C.
      • Vandervoort R.
      • Phillips M.
      • Bowler R.
      • Peck C.
      An evaluation of the effects of lithium in the treatment of chronic alcoholism: I. clinical results.
      ,

      Regester, D. C. (1971). Change in autonomic responsivity and drinking behavior of alcoholics as a function of aversion therapy (Doctoral dissertation, University of Nebraska, 1971).

      ,
      • Richmond R.
      • Heather N.
      • Wodak A.
      • Kehoe L.
      • Webster I.
      Controlled evaluation of a general practice-based brief intervention for excessive drinking.
      ,
      • Rohsenow D.J.
      • Smith R.E.
      • Johnson S.
      Stress management training as a prevention program for heavy social drinkers: Cognitions, affect, drinking, and individual differences.
      ,
      • Scott E.
      • Anderson P.
      Randomized controlled trial of general practitioner intervention in women with excessive alcohol consumption.
      ,
      • Senft R.A.
      • Polen M.R.
      Brief intervention in a primary care setting for hazardous drinkers.
      ,
      • Tomson Y.
      • Romelsjö A.
      • Åberg H.
      Excessive drinking–brief intervention by a primary health care nurse: a randomized controlled trial.
      ,
      WHO Brief Intervention Study Group
      A cross-national trial of brief interventions with heavy drinkers.
      ) (10 of which were included in the 17 that assessed abstinence rates), and 17 that assessed alcohol consumption at both intake and followup (
      • Alden L.E.
      Behavioral self-management controlled-drinking strategies in a context of secondary prevention.
      ,
      • Anderson P.
      • Scott E.
      The effect of general practitioners' advice to heavy drinking men.
      ,

      Dimeff, L. A. (1997). Brief intervention for heavy and hazardous college drinkers in a student primary health care setting. Doctoral dissertation, University of Washington.

      ,
      • Fine E.W.
      • Steer R.A.
      • Scoles P.E.
      Evaluation of treatment program for drunk driving offenders.
      ,
      • Fleming M.F.
      • Barry K.L.
      • Manwell L.B.
      • Johnson K.
      • London R.
      Brief physician advice for problem alcohol drinkers: a randomized controlled trial in community-based primary care clinics.
      ,
      • Gallimberti L.
      • Ferri M.
      • Ferrara S.D.
      • Fadda F.
      • Gessa G.L.
      Gamma-hydroxybutyric acid in the treatment of alcohol dependence: a double-blind study.
      ,
      • Heather N.
      • Campion P.D.
      • Neville R.G.
      • Maccabe D.
      Evaluation of controlled drinking minimal intervention for problem drinkers in general practice (the DRAMS scheme).
      ,
      • Heather N.
      • Rollnick S.
      • Bell A.
      • Richmond R.
      Effects of brief counselling among male heavy drinkers identified on general wards.
      ,
      • Kivlahan D.R.
      • Marlatt G.A.
      • Fromme K.
      • Coppel D.B.
      • Williams E.
      Secondary prevention with college drinkers: Evaluation of an alcohol skills training program.
      ,
      • Maheswaran R.
      • Beevers M.
      • Beevers D.G.
      Effectiveness of advice to reduce alcohol consumption in hypertensive patients.
      ,
      • Marlatt G.A.
      • Baer J.S.
      • Kivlahan D.R.
      • Dimeff L.A.
      • Larimer M.E.
      • Quigley L.A.
      • Somers J.M.
      • Williams E.
      Screening and brief intervention for high-risk college student drinkers: Results from a 2-year follow-up assessment.
      ,
      • Miller W.R.
      • Benefield R.G.
      • Tonigan J.S.
      Enhancing motivation for change in problem drinking: A controlled comparison of two therapist styles.
      ,
      • Naranjo C.A.
      • Kadlec K.E.
      • Sanhueza P.
      • Woodley-Remus D.
      • Sellers E.M.
      Fluoxetine differentially alters alcohol intake and other consumatory behaviors in problem drinkers.
      ,
      • Naranjo C.A.
      • Poulos C.X.
      • Lanctôt K.L.
      • Bremner K.E.
      • Kwok M.
      • Umana M.
      Ritanserin, a central 5-HT2 antagonist, in heavy social drinkers: Desire to drink, alcohol intake and related effects.
      ,
      • Richmond R.
      • Heather N.
      • Wodak A.
      • Kehoe L.
      • Webster I.
      Controlled evaluation of a general practice-based brief intervention for excessive drinking.
      ,
      • Scott E.
      • Anderson P.
      Randomized controlled trial of general practitioner intervention in women with excessive alcohol consumption.
      ). Table 1 summarizes the characteristics of these studies with respect to participants' severity of alcohol use disorders, the timing of the final followup assessment, and the stringency of the definition of abstinence used in terms of whether or not drinking (or “slips”) was allowed. Overall, although each of the three subsets of studies included both more and less severely affected samples, the majority of trials that assessed abstinence rates had samples of higher severity whereas the majority of trials assessing alcohol consumption and changes in alcohol consumption had samples of lower severity. The typical final followup point was less than a year and most of the studies assessing abstinence used definitions that did not allow any drinking “slips.”
      Table 1Characteristics of randomized trials of alcohol treatment with untreated participants
      Abstinence rates N = 17Alcohol consumption N = 29Change in alcohol consumption N = 17
      Problem severity of sample
      Lower severity samples were those obtained in studies that explicitly recruited “non-alcoholic,” “problem,” “heavy,” or “at-risk” drinkers, and excluded those with alcohol dependence or abuse, or alcohol consumption above certain levels. Higher severity samples were those obtained in studies that included “alcoholic” participants, or those meeting diagnostic criteria for alcohol dependence or abuse, and/or did not exclude those with alcohol consumption above certain levels.
      Lower42017
      Higher1392
      Length of follow-up
      Less than 12 months132111
      12 months or more486
      Definition of abstinence
      No drinking permitted15
      Some drinking permitted2
      a Lower severity samples were those obtained in studies that explicitly recruited “non-alcoholic,” “problem,” “heavy,” or “at-risk” drinkers, and excluded those with alcohol dependence or abuse, or alcohol consumption above certain levels. Higher severity samples were those obtained in studies that included “alcoholic” participants, or those meeting diagnostic criteria for alcohol dependence or abuse, and/or did not exclude those with alcohol consumption above certain levels.
      Of the 17 studies that assessed abstinence rates at followup, 8 had a no-treatment–only condition, 4 had a placebo-only condition, 1 had a detoxification-plus-no-treatment condition, and 4 had a detoxification-plus-placebo condition. The mean abstinence rates ranged from 14% to 71% for the different types of untreated conditions, with an average of 21% overall (see Table 2). Although not all reports mentioned monitoring additional unplanned treatment received during the treatment or followup periods, five of them indicated that some participants in all conditions were exposed to some kind of potentially therapeutic agent or contact (e.g., rehospitalization for detoxification, psychotropic medications, Alcoholics Anonymous) apart from the conditions under study. The average abstinence rate for the remaining 12 no-treatment conditions was 22%.
      Table 2Average abstinence rates at final follow-up point (%)
      n (studies)MeanMedianMinimumMaximum
      Type of untreated condition
      No treatment8141073
      Placebo41816635
      Detoxification plus no treatment171
      Detoxification plus placebo43527580
      Overall172117080
      Overall (no unplanned treatment)122212080
      Six of the 17 studies provided corroboration of self-reported drinking behavior. The abstinence rates were not significantly different for the studies that provided such confirmation (M = 29%, SD = 38%) than for those that did not (M = 16%, SD = 13%, t = 0.81, ns). The number of participants in individual studies ranged from 5 to 486 (M = 75). The average abstinence rate weighted by sample size was 21% (SD = 28%), identical to the unweighted value.
      Of the 29 trials that assessed level of alcohol consumption, 20 had a no-treatment-only condition, 8 had a placebo-only condition, and 1 had a detoxification-plus-placebo condition. Mean alcohol consumption ranged from 8 to 40 drinks per week for the different types of untreated condition, with an average of 31 drinks per week overall (see Table 3). The average level of consumption at followup for the 23 studies where no unplanned treatment was reported was 33 drinks per week.
      Table 3Average alcohol consumption at final follow-up point (drinks/week)
      n (studies)MeanMedianMinimumMaximum
      Type of untreated condition
      No treatment202828874
      Placebo84044972
      Detoxification plus placebo18
      Overall293129874
      Overall (no unplanned treatment)233334872
      Eleven of the 29 studies provided corroboration of self-reported drinking behavior. The number of standard drinks per week was significantly lower for the studies that provided such confirmation (M = 21.65, SD = 10.99) than for those that did not (M = 36.82, SD = 21.07, t = 2.5, p < .05). The number of participants in individual studies ranged from 5 to 486 (M = 64). The mean number of standard drinks per week weighted by sample size was 23.20 (SD = 12.55).
      The aggregate effect for the studies presenting intake and followup alcohol consumption was a significant decrease of .19 of a SD unit (p < .001). The reduction in consumption was 5 drinks per week from a baseline of 37 drinks per week, a 14% decrease. There was no significant heterogeneity among the effect sizes (Q = 8.8, ns), precluding examination of study-level moderators of changes in drinking levels.

      4. Discussion

      Overall, an average of 21% of individuals in untreated conditions in the treatment efficacy studies we examined were abstinent at followup and the average alcohol intake was 31 drinks per week. Although definitions of problem, excessive, or hazardous drinking vary by investigation, nation, and/or culture, and are often specified differently by gender, in most studies the definition involved a minimum of 20 to 35 drinks per week (e.g.,
      • Heather N.
      • Rollnick S.
      • Bell A.
      • Richmond R.
      Effects of brief counselling among male heavy drinkers identified on general wards.
      ,
      • Tomson Y.
      • Romelsjö A.
      • Åberg H.
      Excessive drinking–brief intervention by a primary health care nurse: a randomized controlled trial.
      ). Thus, in studies that assessed abstinence, about a fifth of untreated individuals were abstinent at followup, whereas in studies that assessed alcohol consumption, average levels of drinking were still in a range considered harmful by some investigators, despite a small (
      • Cohen J.
      ) significant decline from baseline levels.
      These estimates can help to put findings regarding outcomes following treatment into perspective. For instance,
      • Miller W.R.
      • Walters S.T.
      • Bennett M.E.
      How effective is alcoholism treatment in the United States?.
      , combined the results of seven diverse multisite trials conducted in the United States with individuals with a broad range of problem severity and other personal characteristics. Despite the complexities related to different samples and treatment methods, they sought to provide an indication how people fare, on average, after treatment for alcohol use disorders. They found that, at 12-month followups, the average abstinence rate was 24% and the average level of alcohol consumption was 7 drinks per week. Although this abstinence rate was only slightly higher than our estimate of 21% for persons in non-treated conditions, the level of alcohol consumption, likely a more sensitive indicator, is considerably lower for these treated individuals.
      • Monahan S.C.
      • Finney J.W.
      Explaining abstinence rates following treatment for alcohol abuse: a quantitative synthesis of patient, research design and treatment effects.
      found a higher average abstinence rate of 43% at the first followup point of three months or longer for 150 active treatment conditions drawn from 100 alcohol treatment outcome studies published between 1980 and 1992. Taken together, the outcomes found in the current review for untreated participants and the outcomes in the reports of Miller et al. and Monahan and Finney for individuals in active treatments provide informative rough parameters with which to compare specific program or study outcomes. As Miller and colleagues point out, such estimates should not be interpreted as representing the outcomes of any and all programs, but serve as helpful averages with which to compare specific outcomes. It should be noted, however, that the group of studies on which we based our estimates of abstinence typically included samples of higher severity, whereas the group of studies on which we based our estimates of alcohol consumption typically included samples of lower severity.
      Between-category statistical analyses were not appropriate because the number of studies examined is small and the means for each type of untreated condition (e.g., placebo vs. no treatment) come from different studies (see
      • Hrobjartsson A.
      • Gotzsche P.C.
      Is the placebo powerless? An analysis of clinical trials comparing placebo with no treatment.
      , for a review of the outcomes of placebo and no-treatment conditions compared within the same trials of treatments for several types of clinical condition). However, by inspection, as might be expected, placebo-only conditions had higher mean abstinence rates than no-treatment–only conditions, and both types of conditions that included detoxification had higher abstinence rates than no-treatment–only and placebo-only conditions. Yet, placebo conditions also had higher levels of drinking than no-treatment conditions.
      We can only speculate regarding the mechanisms that might have led to small proportions of untreated participants being abstinent at followup and for there to be a reduction in drinking from baseline to followup. Several factors, such as regression toward the mean, life changes, the passage of time, the benefits of simply seeking help or participating in a research study, anticipation of receiving active treatment for those in wait-list conditions, or placebo effects for those in placebo conditions, could have affected outcomes (
      • Bowen W.T.
      • Twemlow S.W.
      A follow-up study of alcoholics who failed to appear for treatment.
      ,

      Kirsch, I., & Sapirstein, G. (1998, June 26). Listening to Prozac but hearing placebo: A meta-analysis of antidepressant medication. Prevention and Treatment, 1, (Article 0002a), Retrieved from the World Wide Web: http://journals.apa.org/prevention/volume1/pre0010002a.htm.

      ). Reviews of research on pharmacological treatment of depression (

      Kirsch, I., & Sapirstein, G. (1998, June 26). Listening to Prozac but hearing placebo: A meta-analysis of antidepressant medication. Prevention and Treatment, 1, (Article 0002a), Retrieved from the World Wide Web: http://journals.apa.org/prevention/volume1/pre0010002a.htm.

      ) and child psychotherapy (
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      • Weisz J.R.
      The impact of methodological factors on child psychotherapy outcome research: a meta-analysis for researchers.
      ) have noted improvement over time in no-treatment and placebo conditions, providing evidence that these factors have some effect.
      A recent review found only limited differences in the outcomes of placebo and no-treatment conditions administered within the same studies, indicating, somewhat surprisingly, that placebo effects may not be much more powerful than effects that operate for those in no-treatment conditions (
      • Hrobjartsson A.
      • Gotzsche P.C.
      Is the placebo powerless? An analysis of clinical trials comparing placebo with no treatment.
      ; see also
      • Bailar J.C.
      The powerful placebo and the Wizard of Oz.
      ). However, placebo effects in alcohol treatment and other drug trials may be reduced by the fact that participants may often suspect correctly that they are receiving a placebo. In one of the studies examined here, 41% of participants and (79% of the research assistants conducting assessments) correctly identified their treatment group (
      • Malec E.
      • Malec T.
      • Gagné M.A.
      • Dongier M.
      Buspirone in the treatment of alcohol dependence: a placebo-controlled trial.
      ). Although 41% is below chance (50%), indicating that the blind for participants was successful, it suggests that a considerable proportion of placebo participants suspect correctly that they are not receiving active treatment. Such beliefs may affect trial and treatment adherence. In another trial examined here, those receiving placebo were significantly less likely to remain in an 8-week treatment trial (
      • Bruno F.
      Buspirone in the treatment of alcoholic patients.
      ).
      Because our findings are based on a small proportion of alcohol treatment studies, their generalizability is difficult to gauge. Participants in the studies reviewed encompassed individuals at risk for alcohol-problems, problem drinkers (who were recruited through health clinics or through the media, rather than presenting for treatment), persons diagnosed with alcohol dependence or abuse (some who were recruited when they were treated for other medical problems and some who were recruited when they sought help at alcohol treatment centers), and individuals with chronic, recidivist alcohol problems. Thus, those included had a range of problem severity and varied in terms of whether or not they were actively seeking treatment (see
      • Krupnick J.
      • Elkin I.
      • Shea T.
      Generalizability of treatment studies utilizing solicited patients.
      ).
      The definitions of abstinence used were fairly stringent, with all but one of the 17 studies coding only those with no drinking “slips” as abstinent. The date of first publication spanned a wide interval of time, from 1971 to 1998. These observations suggest that the estimates obtained are applicable to a wide range of individuals with alcohol problems in studies with stringent definitions of outcome conducted over a broad period of time. It is also true, however, that the individual estimates of outcome for each study varied widely.
      A limitation of this investigation is that it considers only two of a much larger number of possible outcomes for those with problem drinking. Changes in abstinence rates and levels of alcohol consumption are just a few aspects of the potential relevant changes in functioning that can occur, both in drinking patterns and in nondrinking outcomes (
      • Miller W.R.
      • Walters S.T.
      • Bennett M.E.
      How effective is alcoholism treatment in the United States?.
      ). Abstinence is not a goal of all treatments for alcohol use disorders, or a necessary condition of recovery for all individuals with alcohol problems (
      • Sobell M.B.
      • Sobell L.C.
      Controlled drinking after 25 years: How important was the great debate?.
      ). In addition, abstinence is a somewhat insensitive measure of success. However, the fact that improvements were seen in untreated conditions even with this crude index makes the findings more compelling. Unfortuantately, the small number of investigations included precluded helpful statistical comparisons of conceptually distinct types of untreated conditions. Finally, the level of success estimated here is probably not relevant to estimates of the percentage of persons becoming abstinent through “natural recovery,” as all individuals considered here had joined randomized trials, and so may differ from individuals who stop drinking on their own or through self-help (
      • Schwartz C.E.
      • Chesney M.A.
      • Irvine M.J.
      • Keefe F.J.
      The control group dilemma in clinical research: applications for psychosocial and behavioral medicine trials.
      ).
      In sum, at followup 21% of untreated participants with alcohol use disorders in randomized trials were abstinent and the average level of alcohol consumption was 31 drinks per week. From baseline, alcohol consumption decreased .19 of a SD unit, or 14%. Thus, a small minority of untreated individuals was no longer drinking, and levels of alcohol consumption showed a significant trend toward reduced drinking. However, levels of consumption were still at levels considered problematic by some investigators. These values provide helpful reference points regarding the approximate average level of success that can be expected without active treatment, and thus, the level which an active treatment should surpass to be considered incrementally beneficial.

      Acknowledgements

      This work was supported by National Institute on Alcohol Abuse and Alcoholism grant AA08689, the VA Quality Enhancement Research Initiative, and the VA Mental Health Strategic Healthcare Group. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. We are grateful to Keith Humphreys, Rudolf Moos, and Craig Rosen for helpful comments on an earlier version of this manuscript. A portion of this work was presented at the Society of Behavioral Medicine's Annual Meeting and Scientific Sessions, Washington, DC, April, 2002.

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