13 Treatment and early intervention services

Alcohol policies are primarily the concern of local, regional, and national governments, which often view the provision of treatment as part of a comprehensive approach to alcohol-related problems. In addition to its value in the restoration of a person’s psychological and physical health, treatment can be considered as a form of prevention. When therapeutic interventions occur soon after the onset of hazardous drinking, it is called secondary prevention. When treatment is initiated to control the damage associated with chronic drinking, it is called tertiary prevention. As one of the first societal responses to alcohol problems, treatment interventions have been evaluated in terms of their impact on the individual drinker, but less research attention has been devoted to their ability to reduce the rates of alcohol-related problems in the general population, despite the resources they consume.

This chapter describes the scientific basis of alcohol treatment policies in terms of research on the effectiveness and costs of a wide range of treatment interventions and related services. By treatment policy, we mean governmental and civil society actions that affect the provision of treatment services, the allocation of resources, and the optimal mix of services for the management of alcohol use disorders. In some jurisdictions, alcohol and other drug services are administered separately; in others, they share the same programmes and facilities. In some countries, these services are part of the system of medical care, whereas in others, they are integrated with social work or psychiatric services. All of these arrangements have implications for the efficiency and effectiveness of alcohol treatment. Although there are descriptions and some comparisons of national and local alcohol treatment systems, there has been little research on effectiveness at the treatment system level. In this chapter, we consider the organization and functioning of treatment programmes, brief intervention services,¹ and mutual help organizations as important parts of systems of care, and whether service systems have an impact on the rates of alcohol-related problems at the population level.

While there was substantial provision of specialized treatment services for alcohol problems in several countries prior to the First World War (Baumohl and Room 1987), almost none of these services survived into the modern era. In many parts of the industrialized world, new kinds of programmes were set up after the Second World War, with many countries, especially those having a high prevalence of alcohol problems, investing in a variety of services, often in conjunction with treatment for other drug problems (Klingemann et al. 1992; Klingemann and Hunt 1998).

In the United States, a country with an extensive network of services, there were 17,808 facilities providing treatment for drug and alcohol disorders in 2019, with 90% managing clients diagnosed with alcohol use disorders (Substance Abuse and Mental Health Services Administration 2020). Most of the facilities are operated by private non-profit organizations (60% of all facilities) or private for-profit organizations (40% of facilities), although the services provided are more often than not funded by one or more levels of government. A point prevalence survey reported 205,402 clients with alcohol abuse being treated at 9123 facilities, and an additional 476,065 clients with both alcohol and drug abuse (Substance Abuse and Mental Health Services Administration 2020). Elsewhere in the world, services are often run by government agencies, usually as part of the health care system, but also as part of welfare or other social service systems. Two-thirds of services in Sweden, for instance, are provided through the welfare, rather than the health, system, though not all of the services paid for by governments are government-run.

A World Health Organization (WHO) survey (Babor and Stenius 2010) indicates that services have been organized wherever the incidence of alcohol and drug use is increasing, even in historically abstinent countries in the Eastern Mediterranean (Babor 2018). Nevertheless, treatment coverage (i.e. the proportion of persons with alcohol use disorders who are in contact with treatment services) varies substantially across WHO Member States. According to a WHO global survey of Member States (World Health Organization 2018, p. 93), only 14% of responding countries reported high amounts of treatment coverage, whereas 28% indicated limited or no treatment and many low-income countries were not able to provide data on this topic.

Health and social services for alcohol problems typically involve screening, brief interventions, referral advice, diagnostic evaluation, detoxification, therapeutic interventions, and continuing care. Numerous therapeutic approaches, called treatment modalities, have been evaluated by means of randomized clinical trials. Examples include motivational interviewing, marital and family therapy, cognitive behavioural therapy (CBT), relapse prevention training, contingency management, pharmacotherapy, and interventions based on the Twelve Steps of Alcoholics Anonymous (AA). These modalities are delivered in a variety of settings, including primary health care, freestanding residential facilities, psychiatric and general hospital settings, outpatient programmes, and more recently through digital technologies via the Internet. Treatment services in some countries have been organized at the municipal and national levels into systems, a term that refers to linkages between different facilities and levels of care and to the integration of alcohol treatment with other types of services such as mental health, drug dependence treatment, and mutual help organizations (Klingemann et al. 1993; Klingemann and Klingemann 1999).

Most treatment research and the scientific evidence derived from it is component-based, focusing on the effects of a single intervention or episode of care within a single component of the treatment system (e.g. outpatient treatment). In general, the research evidence can be organized according to three types of intervention: (1) brief interventions for non-dependent high-risk drinkers; (2) formal treatment for problem drinking and alcohol dependence; and (3) mutual help interventions.

Harmful drinking typically precedes the development of alcohol dependence, and by definition, it can cause serious medical and psychological problems in the absence of dependence. With the increased interest in clinical preventive services in both developed and developing countries, early intervention programmes have been developed by the WHO and national agencies to facilitate the management of harmful drinking in primary health care and other settings. Following an initial screening to identify risk levels, the patient is referred to either a brief intervention or more intensive specialized treatment. Brief interventions are characterized by their low intensity and short duration, consisting of one to three sessions of counselling and education. The aim is to motivate high-risk drinkers to moderate their alcohol consumption or to reduce the risk of drinking-related harm, rather than to promote total abstinence, and to refer more serious cases to appropriate treatment, typically with an abstinence orientation.

During the past two decades, numerous randomized controlled trials have been conducted to evaluate the efficacy of brief interventions in primary health care and other health care settings. Cumulative evidence from systematic reviews and meta-analyses (Kaner et al. 2018) shows that clinically significant reductions in drinking and alcohol-related problems can follow from brief interventions. Nurses and other health care providers are as effective as doctors in producing behaviour change, and the positive effects have been observed with adolescents, adults, older adults, college students, and pregnant women. Despite the evidence of benefit from this kind of intervention, difficulties are often encountered in persuading practitioners to deliver such care. Evaluations of programmes and policies to stimulate the uptake of alcohol screening and brief intervention (SBI) for risky alcohol consumption suggest limited success in implementation (Nilsen et al. 2006; Williams et al. 2011; McCambridge and Saitz 2017). The effectiveness of implementing SBI delivery increases when programmes include multiple components (Anderson et al. 2004), contain higher intensity of effort (Nilsen et al. 2006), and focus on general practitioners and mid-level professionals simultaneously (Williams et al. 2011). The ODHIN trial (Anderson et al. 2016) tested eight strategies to promote SBI in primary health care units in five European countries, finding that financial incentives to provider organizations were key although they needed to be reinforced by training and support.

Digital technologies have also been applied to improve the delivery of SBI and referral to treatment. SBI delivered via computer and phone provides effective delivery of interventions in both educational and health care settings and may prove to be more acceptable than traditional (face-to-face) approaches (Donoghue et al. 2014). With increasing use of mobile and digital technologies for treatment and brief interventions, population coverage can be increased and the cost of delivery reduced.

In countries with well-developed health care systems, the range of agencies and professional service providers involved in specialist treatment of alcohol-related problems is extensive. Some of the key issues that treatment research has addressed with increasing scientific rigor include the effectiveness of different detoxification measures, treatment settings and therapeutic modalities, as well as mechanisms of behaviour change and the role of coerciveness.

Detoxification services are mainly directed at patients with a history of chronic drinking (especially those with poor nutrition) who are at risk of experiencing withdrawal symptoms as part of an alcohol withdrawal syndrome. Such services usually involve a bed and some vigilance to watch for, and respond to, seizures but need not involve hospitalization (Fernandez 2019). Administration of thiamine and multivitamins is a low-cost, low-risk intervention that prevents alcohol-related neurological disturbances, and is typically combined with supportive care and treatment of concurrent illness. A variety of medications have been used for the treatment of alcohol withdrawal, but benzodiazepines, especially diazepam and chlordiazepoxide, have largely supplanted all other medications because of their favourable side effect profiles (Kattimani and Bharadwaj 2013); anticonvulsants, especially phenobarbitals, are equally effective (Hammond et al. 2017). There can be no doubt that monitoring of vital signs and treatment that obviates the development of the most severe withdrawal symptoms can be lifesaving.

Traditionally, residential care has been the preferred setting to manage the needs of persons with alcohol use disorders, but as services have expanded and new therapeutic techniques and technologies have been introduced, there has been a shift to outpatient settings. Residential treatment continues to be used in many countries for persons with severe alcohol dependence who do not respond to more limited efforts at rehabilitation. The term residential rehabilitation describes a multitude of programmes that differ in philosophy, intensity, client characteristics, programme content, and duration. While residential treatment can operate in a more collective fashion, for instance as a ‘therapeutic community’ (De Leon 2000), often the only common factor is that residents have to stay overnight at the facility to receive treatment and are expected to be alcohol-free when they start the programme. While a considerable body of research has evaluated residential treatment, the quality of earlier studies has been poor. A review of more recent studies published between 2013 and 2018 (de Andrade et al. 2019) found that residential treatment is an effective intervention for many adults with alcohol and other substance use problems. Overall, there was moderate-quality evidence that residential treatment is effective in reducing substance use and improving mental health, and some evidence that treatment may have a positive effect in reducing crime and adverse social outcomes. In most comparative studies, outpatient programmes have been found to produce outcomes comparable to those of residential programmes, although some patients may benefit more from residential treatment because of their medical and psychiatric problems (Finney et al. 1996; de Andrade et al. 2019).

The widespread use of computers, the Internet, and smartphones has led to the development of electronic systems to deliver screening, brief interventions, and behaviour therapies. The application of these technologies can potentially address the barriers to implementation of traditional face-to-face SBI and outpatient therapy. Because of their flexibility and anonymity, they have the potential to reach a larger proportion of the population in need of services. Systematic reviews have found Internet-based treatments and SBIs to be as effective in reducing alcohol consumption as outpatient face-to-face treatments (Donoghue et al. 2014; Riper et al. 2018).

In both residential and outpatient settings, a variety of therapeutic modalities have been adopted to treat the patient’s drinking problems, promote abstinence from alcohol, and prevent relapse. The approaches with the greatest amount of supporting evidence are behaviour therapy, group therapy, family treatment, and motivational enhancement (Babor et al. 2015). Mutual help interventions, and therapies derived from them, are considered below (see Section 13.5). Behavioural approaches include marital and family therapy, skills training, relapse prevention, and contingency management. The last-named involves repeatedly testing a patient to verify sobriety and giving them a reward or incentive so long as the test shows that they have been abstinent. Studies (Koffarnus et al. 2018) have shown that these non-pharmacological interventions are effective ways to reduce problem drinking and promote abstinence, although positive treatment outcomes have rarely been evaluated beyond 1 year after the end of treatment and relapse rates are high, even within that time frame.

Another treatment approach, often combined with behaviour therapy and group therapy, is use of alcohol-sensitizing drugs, as well as medications to directly reduce drinking and treat co-morbid psychopathology (Kranzler 2000). Alcohol-sensitizing drugs, such as disulfiram (Antabuse) and calcium carbimide, cause an unpleasant physical reaction when alcohol is consumed. These drugs may help motivated, abstinent, alcohol-dependent patients when special efforts (e.g. supervised dosing) are made to ensure compliance with taking the medication (Miller et al. 2011), but their overall effectiveness has not been demonstrated (Fuller et al. 1986).

Another class of medications, including endogenous opioids, operate on specific brain neurotransmitter systems implicated in the control of alcohol consumption. Opioid antagonists, such as naltrexone, have been found in some, but not all, studies to be superior to placebo in delaying the time to relapse and reducing the rate of relapse to heavy drinking among patients (Anton et al. 2006; Jonas et al. 2014). Acamprosate, an amino acid derivative, has been reported as having significant advantages over placebo, but some large-scale studies have been negative (Anton et al. 2006).

Despite advances in the search for a pharmacological intervention that could reduce craving and other precipitants of relapse, the additive effects of pharmacotherapies have been marginal beyond the benefits produced by medical management, standard counselling, and behaviour therapies. These medications tend to have small effect sizes, showing efficacy for only a limited number of individuals with alcohol use disorders (Litten et al. 2018). Naltrexone, which can be given once daily, reduces the likelihood of a return to any drinking by 5% and binge drinking risk by 10% (Kranzler and Soyka 2018). Because medications, even in high-income countries, are prescribed to less than 9% of patients who are likely to benefit from them (Kranzler and Soyka 2018), they are unlikely to become a substitute for counselling and behaviour therapies in most countries.

Treatment research has produced evidence of near-equivalent reductions in alcohol use, regardless of the type of counselling or therapy, making it unlikely that treatment efficacy is attributable to the ingredients of specific therapies, except for elements common to all forms of therapy (Magill and Longabaugh 2013). The investigation of mechanisms of behaviour change helps to answer questions about how and why treatment works (mediating effects) and for whom certain treatments work best (moderators). This research has taken place within the clinical ‘technology model’ of treatment efficacy and treatment matching, which postulates that patient attributes and treatment process elements, respectively, constitute mediators and moderators of change in drinking following treatment. Studies show that matching patient attributes to theoretically relevant therapeutic orientations (e.g. matching patients with low motivation to motivational enhancement therapy) does not substantially enhance outcomes, as previously believed (Babor and Del Boca 2003). They also indicate that the mediational mechanisms underlying several of the most popular therapies are different from what is suggested by their proponents. In general, the technology model of treatment effectiveness may be flawed, as it applies to alcohol dependence treatment. Instead of distinct, non-overlapping elements, therapy may work through common mechanisms such as empathy, an effective therapist–client alliance, a desire to change, mobilization of inner resources, a supportive social network, and provision of a culturally appropriate solution to a socially defined problem (Cooney et al. 2003).

Spirituality and religiosity, for example, are key components in several types of substance use interventions, including 12-step mutual aid groups. One systematic review of studies in this area (Hai et al. 2019) found evidence of effectiveness, but the findings could not be interpreted as proof that spiritual/religious components were the only active ingredients operating. Another study found that Twelve-Step Facilitation (TSF), which is designed to introduce problem drinkers to the principles of AA, was as effective as more theory-based therapies (Babor et al. 2003), but mainly because the participant is involved in social networks that support abstinence, rather than its effect on spirituality.

There is a degree of coercion in much of the encouragement or pressure from family, friends, or employers that precedes entry to treatment, even for patients who think of the eventual decision to come as their own (DuPont and Humphreys 2011; Room et al. 2020). But for much alcohol treatment, coercion is more formal, enforced by official decisions or threats. Opinion is sharply divided on the ethics and effectiveness of such official actions mandating persons with alcohol and other substance use disorders to enter treatment and to maintain abstinence after treatment. According to Vuong et al. (2019), mandatory treatment compels someone into treatment either involuntarily where the individual has no choice or say in the matter, or through coercion where there is a choice between a criminal justice sanction and a treatment programme.

There are at least five types of mandatory treatment (Vuong et al. 2019): (1) court-mandated treatment; (2) drug courts; (3) compulsory prison-based treatment; (4) civil commitment; and (5) centre-based compulsory rehabilitation (specific to East and South East Asian countries). In addition, some countries have programmes operated by professional groups, such as physicians’ and nurses’ associations, to treat and monitor members who have been threatened with licence suspension or employment terminations because of alcohol- or drug-related infractions. Physician health programmes, for example, require drug- and alcohol-impaired physicians to complete the programme and submit to frequent random breath testing for periods of up to 5 years to ensure abstinence.

A review of research findings (Vuong et al. 2019) on the effectiveness of mandatory treatment schemes indicated the following: (1) there is limited research on the effectiveness of mandatory treatment in the long term (i.e. after the period of treatment programme), but evaluations of short-term effects, particularly from court-mandated programmes and drug courts, show reduced alcohol and drug use and/or dependence; (2) some success has been found in all coerced models, particularly drug courts, in reducing reoffending for substance-related infractions; (3) coerced treatment models were found to be cost-effective in Australia, but involuntary treatment programmes were not; and (4) quasi-military detention and rehabilitation camps that seek to address problematic alcohol and drug use have little supporting evidence and have been heavily criticized for human rights abuses (e.g. Hall et al. 2012; World Health Organization 2020).

Although mutual help societies are not considered a formal treatment for alcohol dependence, they are often used as a substitute or as an adjunct to treatment. With an estimated 2,077,374 members affiliated with more than 125,000 groups in 180 countries (Alcoholics Anonymous 2019), AA is by far the most widely utilized source of help for persons with drinking problems. Parallel organizations with varying ideologies and approaches have been developed in a number of other countries such as Danshukai in Japan, Kreuzbund in Germany, Croix d’Or and Vie Libre in France, Abstainers Clubs in Poland, Family Clubs in Italy, and Links in the Scandinavian countries (Room 1998; Humphreys et al. 2004). Several large-scale, well-designed studies (Walsh et al. 1991; Ouimette et al. 1999) suggest that AA can have an incremental effect when combined with formal treatment, and AA attendance alone may be better than no intervention.

In a Cochrane Collaboration review of 27 studies containing 10,565 participants (Kelly et al. 2020), the authors concluded that manualized AA/TSF interventions are more effective than other established treatments, such as CBT, for increasing abstinence. Non‐manualized AA/TSF interventions may perform as well as these other established treatments. AA/TSF interventions, both manualized and non‐manualized, may be at least as effective as other treatments for other alcohol‐related outcomes; those who drop out of AA after the first year, rather than continuing lifelong as urged by AA, may do as well as those who continue in AA (Kaskutas et al. 2005). AA may be effective not only because it facilitates adaptive changes in the social networks of participants, but also by teaching recovery coping skills, providing recovery motivation, increasing abstinence self-efficacy, and reducing impulsivity and craving (Kelly 2017). And AA/TSF interventions probably produce substantial health care cost savings among people with alcohol use disorders.

A major policy issue with regard to feasibility and extent of brief intervention and specialist treatment is cost. In recent years, there have been significant improvements in the methodological tools used in econometric studies, although economic research in this field is still scarce and not always rigorous (Rehm and Barbosa 2018).

Barbosa et al. (2015) analysed the cost-effectiveness of delivering alcohol screening, brief intervention, and referral to treatment (SBIRT) in emergency departments (EDs), when compared to outpatient medical settings, in the United States. Alcohol SBIRT generated cost savings and improved health in both ED and outpatient settings. Limited information is available on the long-term effectiveness of brief alcohol interventions. Two studies followed patients for up to 48 months post-intervention (Fleming et al. 2002; Ockene et al. 2009) and showed modest short-term effects that faded over time. Other effectiveness studies showed that SBI in outpatient settings is superior to SBI in ED settings, in terms of both drinking outcomes and persistence of those outcomes at follow-ups beyond 6 months (Havard et al. 2008). This suggests that, compared with ED settings, outpatient SBIRT may be more cost-effective in the long term.

Similar research has been conducted to evaluate the costs and benefits of treatment for alcohol dependence conducted primarily in outpatient settings. Rehm and Barbosa (2018) reviewed studies of the cost-effectiveness of behavioural, pharmacological, and combined interventions to treat alcohol use disorders. From the perspective of a health care provider, the costs for interventions were smaller than the savings in services delivery in the years after treatment. Several studies have evaluated the cost-effectiveness of AA attendance and TSF interventions, which were found to have higher health care cost savings than outpatient treatment. In addition, total medical care costs decrease for participants attending AA/TSF treatment, especially among those with the worst prognostic characteristics (Kelly et al. 2020).

Regarding cost-effective alternatives for inpatient alcoholism treatment, reviews of this literature (Finney et al. 1996; Babor et al. 2008) conclude that: (1) inpatient alcoholism programmes lasting from 4 weeks to several months do not have higher success rates than periods of brief hospitalization; (2) some patients can be safely detoxified without pharmacotherapy and in non-hospital-based environments; (3) partial hospitalization programmes (‘day hospitalization’ with no overnight stays) have results equal or superior to inpatient hospitalization, at one-half to one-third the cost; and (4) in some populations, outpatient programmes produce results comparable to those of inpatient programmes.

Despite evidence of the effectiveness of brief interventions for hazardous drinkers and treatment for persons with alcohol dependence, little attention has been paid to how these individual-level benefits translate to the population level. Brief interventions and tertiary treatment are primarily designed to serve the needs of individual patients or clients, but there are a number of ways that these interventions may have an impact at community and population levels. The effect of treatment interventions is manifested most directly by reducing the amount of alcohol consumed by the drinker and the associated harms. By removing a source of reciprocal influence that is likely to contribute to the maintenance of heavy drinking subcultures (Skog 1985; Room et al. 2016), treatment should diminish the alcohol-related problem rates in a community in ways that go beyond just the recovery of individual drinkers. Treatment and brief intervention services may also contribute to population health by raising public awareness about alcohol problems, setting norms about the benefits of abstinence and low risk guidelines, involving health professionals in advocacy for prevention (see Chapter 14), and providing support to families and employers.

With the growth of SBI programmes and related evaluation research on implementation, a key question is whether the individual-level benefits can result in a population-level effect on alcohol-related morbidity and mortality. This question has been addressed by Heather (2012) who reviewed different empirical and modelling studies of SBI in terms of their potential to have a ‘public health benefit’, i.e. favourable effects that are detectable in population-level measures such as mortality statistics or drink-driving injuries. According to Heather’s review, the public health potential of SBI is unlikely to be realized without universal screening and widespread implementation of brief interventions, two conditions that rarely exist in communities and nations.

Much of the research on SBI to date has been organized around a narrowly focused clinical care model, rather than taking a broader, complementary public health approach that attempts to maximize its impact on population rates of hazardous and harmful drinking. Despite the growth of universal screening in health care settings to identify and refer drinkers to appropriate levels of care, the population impact of SBI programmes will be limited by the number of individuals who enter such environments. Creative strategies will be needed to implement a universal or near-universal screening programme, and any proposed programmes would need to work synergistically with both primary care and the specialized addiction treatment system. In one scenario (Babor et al. 2018), the number of individuals who access SBI services could be increased through social marketing campaigns that widely disseminate hazardous drinking guidelines and other SBI messages, as well as through measures to bring SBI services outside the clinic and into the community using digital technologies.

Beyond SBI, a related question is whether specialized treatment services in most countries have an impact on morbidity and mortality at the level of communities and nation states. As noted in other parts of this chapter, few countries have the capacity to provide alcohol treatment services to the majority of those in need. Nevertheless, there is some evidence that treatment has the potential to produce aggregate impact in countries where the treatment system is relatively well developed (Smart and Mann 2000). Several researchers have identified associations between declining liver cirrhosis rates and the growth of specialized treatment. Mann et al. (1988) found that decreased hospital discharge rates for liver cirrhosis were associated with increased treatment in Ontario, Canada. Romelsjö (1987) suggested that in addition to decreased per capita consumption, outpatient treatment may have accounted for the reduction in liver cirrhosis rates in Stockholm, Sweden. Holder and Parker (1992) found that increased alcohol treatment admissions (both in- and outpatient) over a 20-year period in North Carolina were related to a significant reduction in cirrhosis mortality rates.

Despite these findings, there is a dearth of research on the overall impact of brief intervention and traditional treatment services on population health or welfare indicators, and there has been little research on whether different system designs are more efficient or effective than others. One approach that has helped to address this need is the use of statistical modelling to estimate the impact of treatment interventions on alcohol-related mortality and morbidity. Box 13.1 describes the results of several modelling studies, suggesting that treatment and SBI services can make a substantial difference in population rates under the right conditions.

Other research has attempted to evaluate the effects of different organizational models and treatment system qualities. A comparison of the national alcohol treatment systems in Denmark and Sweden (Pedersen et al. 2004) showed that certain internal characteristics of the treatment system (i.e. accessibility, relation to drug treatment, treatment for special groups, and structured treatment) were important for getting patients into treatment (catchment), while certain external factors were relevant for the rate of treatment (i.e. a referral guarantee and a general appreciation in the surrounding systems of the nature of alcohol treatment). In a study of almost 1900 clients and patients in different parts of the substance abuse treatment system in Stockholm county, Stenius et al. (2005) found that in contrast to an organizational model where residential treatment predominated, a system organized around outpatient services was better at recruiting members of vulnerable groups into treatment, which could translate into population health benefits.

In the twenty-first century, there has been a growing awareness of the need for research on the ways in which treatment systems for alcohol problems are conceptualized and organized. There has been increased recognition that there are health and social problems from drinking not only for the drinker, but also for family members and others around the drinker (Selbekk et al. 2018) (see also Chapter 4), whereas services to deal with the problems are often financed only for treatment of the drinker. Discussion of treatment at a system level has often been limited to focusing on the health system, when other societal response systems—welfare, justice, and public housing, for instance—are highly relevant as well. Policy discourse on treatment systems is often dominated by a national focus (Klingemann 2020). Despite some initial comparative studies of national treatment systems (e.g. Klingemann et al. 1992; Storbjörk 2010), little research has evaluated their population-level impact and the system characteristics associated with it. An inquiry across ten European countries found a rather slow diffusion of innovations, a questionable trend toward ‘new public management’ methods, some regression to more moralized approaches, and continuing treatment gaps for less favoured populations (Klingemann 2020).

A set of international standards for treatment of ‘drug use disorders’, developed jointly by the WHO and the United Nations Office of Drugs and Crime (UNODC) (2020), provides a framework for building specialized treatment systems for all psychoactive substance use disorders. According to the standards, an effective national system requires a coordinated and integrated response by many actors. The aim is to deliver services and interventions in multiple settings targeting different groups at different stages of the substance use disorder. The public health system, and not necessarily the psychiatric arm of the medical care services, working in close coordination with social care and other community services, is considered to be in the best position to deliver effective treatment services. In some countries, the private sector and non-governmental organizations can play an important role, although substantial government funding will be needed.

Most treatment interventions are needed at lower intensity levels and the services need to reach beyond the health sector. Low-intensity interventions in community or non-specialized settings (such as SBIs) can prevent people from developing more severe disorders. Outpatient treatment is the recommended first choice of setting from a public health perspective, as long as it is evidence-based and can meet the patient’s needs. Inpatient and residential treatment may be required, based on an individualized assessment for those with more severe or complex substance use disorders or additional social problems (World Health Organization and United Nations Office on Drugs and Crime 2020, pp. 16–17). According to the WHO and the UNODC (2020) standards, treatment services should be available, accessible, affordable, evidence-based, and diversified enough to meet the needs of different subpopulations such as adolescents, multiple substance users, those with co-occurring psychiatric disorders, pregnant women, and the elderly.

Ultimately, policymakers and the general public want to know two things about alcohol treatment services: (1) Does treatment work well enough to alter the course of an excessive drinker’s harmful drinking behaviour?; and (2) Can the totality of social and clinical services reduce the human and financial costs to society, especially in terms of alcohol-related disease, crime, violence, traffic fatalities, and other problems?

To answer the first question, Table 13.1 provides the authors’ consensus ratings of the interventions considered in this chapter. As described in Online Appendix 1, the strategies and interventions are rated by the authors in two major areas: (1) evidence of effectiveness; and (2) amount of research support.

The effectiveness ratings indicate that the first question can be answered affirmatively, based on the research findings from 50 years of clinical research showing most treatment services for persons with harmful drinking patterns contribute to short-term abstinence or reduction in drinking and, to a lesser extent, long-term recovery. Both pharmacological and non-pharmacological treatment interventions are effective and they are considered to be moderately cost-effective, particularly when delivered in outpatient settings. Programmes operated by mutual help organizations such as Alcoholics Anonymous are rated high in terms of effectiveness, population reach, and low cost. In addition, brief interventions for non-dependent hazardous drinkers, along with referral to treatment for more serious cases, have strong research support, but implementation of these programmes remains challenging in most countries (Heather 2012).

The second question speaks to the issue of treatment systems and whether the development of a continuum of services can have a significant impact on the prevalence of alcohol-related problems in society. Progress has been made in a variety of areas related to the treatment system and its services. This includes studies of the impact of service coordination on costs and outcomes (Pedersen et al. 2004), needs-based planning (Ritter et al. 2019; Rush and Urbanoski 2019); and measurement of service system components and performance (Hirschovits-Gerz et al. 2019; Mota et al. 2019; Tremblay et al. 2019). Nevertheless, the overall impact of treatment services on morbidity and mortality has not been studied sufficiently to answer this question, although modelling studies suggest the potential for a modest impact (see Box 13.1).

The relative dearth of treatment research at the systems level suggests the need for a public health model of the structural resources and qualities of alcohol treatment systems that might explain how a collection of services could work synergistically to improve population health. Figure 13.1 presents such a heuristic model, which begins with the policy determinants of treatment services and ends with the population impact of treatment systems. Treatment policies, such as funding decisions, affect the number of services, as well as system qualities, specifying not only where services are located, but also how they are organized and integrated. System qualities include equity (the extent to which services are equally available and accessible to all population groups), efficiency (the most appropriate mix of services), and economy (the most cost-effective services). These qualities can be considered as mediators of system effectiveness, to the extent that they transmit the effects of system structures and programmes. In this conceptual model, it is postulated that structural resources and system qualities contribute significantly to the effectiveness of services (Babor 20015). As suggested in Figure 13.1, the cumulative impact of these services should translate into population health benefits, such as reduced mortality and morbidity, as well as reductions in unemployment, disability, crime, suicide, and health care costs. The model also provides for the possibility that both effectiveness and population impact of treatment systems are influenced by certain moderating factors, such as the socio-demographic characteristics of the population with alcohol use disorders (i.e. ‘case mix’), the social capital possessed by (or lacking in) these population groups (e.g. civic participation and community integration), and the cultural factors that determine patterns of substance use, as well as societal reactions to it. These moderating factors can contribute to the outcome of treatment, regardless of system qualities and types of treatment, and should be taken into account in the design and evaluation of any treatment system. For this reason, we have included a feedback loop from the moderating factors to the treatment policy box to emphasize that for optimal performance, treatment systems need to be designed to fit the characteristics of the population and its treatment needs.

Despite significant progress in the evaluation of treatment effectiveness, the history of alcohol treatment services provides several cautionary lessons for government officials and others interested in policies that support treatment programmes. One lesson is that alcohol treatment services tend to evolve more in response to tradition and to rapidly increasing problem rates, rather than in response to rational planning. Another lesson has been that services decline in times of economic downturn, in part because the stigma of addiction does not help with the recruitment of powerful allies to sustain funding. We have also learnt that services evolve in response to changing patterns of substance use, teaching us that static models of treatment planning need to be replaced with more dynamic ways to meet ever-changing trends in technology, research, culture, and demographics.

Based on the evidence reviewed in this chapter, the way forward seems clear—treatment services are primarily aimed at responding to problems after they exist. They can contribute to the mix of strategies needed to reduce alcohol problems, but they do not obviate the need for universal strategies that can have a greater impact at the population level at much lower cost.