- Email: [email protected]
Relapse rates for former clients of alcoholism rehabilitation units who are drinking without symptoms
25
Drug and Alcohol Dependence, 12 (1983) 25-29 Elsevier Scientific Publishers Ireland Ltd.
RELAPSE RATES REHABILITATION SYMPTOMS
JOHN W. WELTE, Research
Institute
(Received
FOR FORMER CLIENTS OF ALCOHOLISM UNITS WHO ARE DRINKING WITHOUT
JOSEPH
P. LYONS
on Alcoholism,
and LLOYD
1021 Main
Street,
SOKOLOW
Buffalo,
NY
14203
(U.S.A.)
March 21st, 1983)
SUMMARY
A follow-up study of former clients of 17 alcoholism rehabilitation units of New York State shows that those clients drinking without symptoms at the first follow-up have higher relapse rates at the second than those who were abstaining at the first follow-up. This is true for all identifiable sub-groups of former clients.
Key words: Alcoholism
- Controlled
drinking - Abstinence
INTRODUCTION
An important controversy in the alcoholism field centers around the question of whether, and under what circumstances, alcoholics or former problem drinkers may drink in a ‘normal’ or ‘controlled’ manner. The weight of conventional wisdom and clinical experience supports abstinence as the only wise course, but longitudinal studies 11,21 have often reported apparently untroubled drinking by people who formerly had a drinking problem. Pattison et al. 133 reviewed 74 studies, mostly follow-up studies, which report some identified alcoholics who have resumed non-problem drinking. When an outcome study of treated alcoholics uses more than one followup, it becomes possible to examine the status of the clients at the later as a function of their drinking pattern at the earlier follow-up and thereby determine which earlier pattern produces the highest relapse rates. The best known use of this type of analysis has been made in the first 0376-8716/83/$03.00 0 1983 Elsevier Scientific Publishers Printed and Published in Ireland
Ireland Ltd.
26
Rand Study 143.Data from 220 former clients of 8 federal alcoholism treatment centers were analyzed. Each of these had been followed-up at 6 and 18 months after treatment. There were no statistically significant differences in relapse rates at 18 months between those who were abstaining at 6 months and those who were drinking in ‘normal’ ranges. This result became controversial because it could be construed to mean that controlled drinking is a reasonable option for recovering alcoholics, although the Rand authors did not make any such recommendations. Orford et al. 151did 12- and 24-month follow-ups of 100 male alcoholics who had been in inpatient or outpatient treatment. These men had been counselled to remain abstinent, but less than 10% remained abstinent for more than a year. In spite of this, 26 of these men had good outcomes at 2 years, equally divided between short-term abstainers and controlled drinkers. Gottheil et al. (unpublished data) followed up 305 male alcoholic former inpatients at 6, 12 and 24 months. There was no difference in relapse rates at 24 months between those abstaining at 12 months and those drinking moderately at 12 months, with relapse being defined as reported intoxication. The latest and most elaborate contribution to this line of research is the second Rand Study 161.The same Rand group has published a second report based on Cyear follow-ups of the same clients who were previously followedup at 18 months. In this second study, the authors looked at relapse between 18 months and 4 years, and found results somewhat different from those that they had found earlier. They found that the relationship between relapse rates at 4 years and drinking patterns at 18 months depended on the respondent’s age and degree of dependence on alcohol at admission. Relapse was defined as presenting any of a list of alcohol impairment symptoms at follow-up. For those clients who had no dependence or low dependence, relapse rates were higher for abstainers than for those drinking without symptoms. Likewise, for those under 40, relapse rates were higher for abstainers than for drinkers. For those more impaired or older, relapse rates were higher for non-symptom drinkers. Although these results could be construed to mean that for some non-symptom clients abstinence is not the only road to recovery, the authors of the Rand report themselves take care to state that they are not recommending that any alcoholic resume drinking. In the present study, we will use data from an outcome study of New York State alcoholism rehabilitation units to pursue the same questions. We will ask which group of clients does better at the second follow-up: those who are drinking without symptoms at the first follow-up or those who were abstaining at that time. We will also search for subgroups among which the relationship between relapse rates at the second, and drinking pattern at the first follow-up differ.
27 METHODS
The New York outcome study involves interviews of 1340 clients who were admitted to inpatient treatment at 14 state-run and three community alcoholism rehabilitation units during 1977. The duration of a normal course of treatment ranges from 1 to 3 months, depending on the policy of the unit. These clients were 62.9% male and 17.1% female. White clients comprised 72.8% of the sample, 22% black, with the remaining 5.2% a scattering of other groups. The socioeconomic status of the clients covered a wide range, from upper middle class to poor transients. The researchers attempted to interview the former clients at 3 and 8 months after treatment. At 3 months, 72% of the clients were interviewed. At 8 months, interviews were obtained with 67% of the clients including 79% of those who had been interviewed at 3 months. Our analysis was done in two stages. Firstly, we examined relapse rates at the &month follow-up as a function of drinking pattern at the 3-month one. Secondly, we attempted to find subgroups of clients who differed in the degree of success that they enjoyed in maintaining abstinence as opposed to non-symptom drinking. RESULTS
The first column of Table I shows the relapse rates at the &month follow-up. Borrowing from the Rand Study authors, we have defined nonsymptom drinkers as those who have had no episodes of shakes, blackouts, missing meals due to drinking, drinking continuously for 12 h or morning drinking during the 30 days before the interview. Relapse is defined as drinking with symptoms. Those former clients who were abstaining at the 3-month follow-up have a much lower relapse rate (12.3%) at the &month stage than those who were drinking without symptoms at the 3-month
TABLE I NEW YORK STATE OUTCOME STUDY
Relapse rates at 8 months Drinking at 3 months 30-Day abstainers 30-Day non-symptom drinkers 30-Day symptom drinkers
Overall
White
Non-White
12.3% N = 621506 31.9% N = 22169 64.6% N = 117/181
11.5% N = 461399 23.6% N = 13155 60.7% N = 821135
15.0% N = 161107 64.3% N = 9114 76.1% N = 35146
follow-up (31.9%). A x2 test of these differences is significant at the 0.001 level. Our next step was to locate subgroups of former clients who might differ in the success that they enjoyed in maintaining non-symptom drinking as opposed to abstinence. We approached this problem by using two discriminant function analyses. The first of these involved only those former clients who were abstaining at the 3-month follow-up. We used a set of 14 descriptive measures taken at intake as independent variables and attempted to discriminate between those former clients who relapsed at 8 months and those who did not. The second discriminant analysis was identical to the first except that it involved only those former clients who were engaged in non-symptom drinking at the 3-month follow-up. Our reasoning is that any descriptive measure which does not emerge from either analysis as a significant discriminator can be rejected as a possible identifier of subgroups who will be more or less successful at maintaining non-symptom drinking as opposed to abstinence. Any variable significant in one or both analyses bears further examination. The discriminating variables were: sex, age, race, years since last employment, socioeconomic status, financial status, number of times arrested, extent of drug abuse in 30 days before entering treatment, social adjustment, social stability, number of lifetime treatments for alcoholism, average alcohol consumption in the 30 days before entering treatment, and alcohol dependence in the 30 days before entering treatment. All of these variables were constructed using information from the interview obtained while in treatment. Race was coded as a binary variable, white vs. non-white. Socioeconomic status was derived from education and occupation status. The financial scale reflected salary or wages as a positive value and welfare or use of government social and medical services as a negative value. Social adjustment was based on how well the client got along with others. Social stability was computed as a function of the client’s family arrangements, employment status and other indications of stability. Our alcohol dependence scale was compiled from 15 of the 29 signs and symptoms used by Skinner and Allen 171 to define the alcohol dependence syndrome. We were particularly interested in this formulation because it has been proposed that drinkers who are high in alcohol dependence syndrome would have difficulty in maintaining non-symptom drinking. The first discriminant analysis showed that none of the independent variables had a meaningful ability to discriminate between successful and unsuccessful abstainers. Given that a client was abstaining at the first follow-up, none of the independent variables were of any use in predicting whether he would relapse at the second follow-up. The second discriminant analysis showed that only race (white vs. nonwhite) had a meaningful ability to discriminate between successful and unsuccessful non-symptom drinkers. Therefore, race is the only candidate for a variable to help distinguish subgroups of clients who will differ in their degree of success with abstinence as opposed to non-symptom drink-
29
ing. Columns two and three of Table I show the results. For both whites and non-whites, abstainers do better than non-symptom drinkers, but the difference is much greater for non-whites. DISCUSSION
We were unable to identify any sub-population of former clients who were more successful at avoiding relapse with non-symptom drinking than with abstinence. This result is consistent with the traditional wisdom of alcoholism treatment. It is also different from the results described by both Rand Reports, although there are many differences between our study and the Rand study, the most important being the difference in follow-up intervals. We interpret our result as a caution to those who advocate controlled drinking, but by no means as a refutation. For one thing, all of these clients had received treatment aimed towards total abstinence; so these results may not generalize to treatment specifically designed to achieve controlled drinking. For another, our analyses use only those clients for whom we obtained two follow-ups and who had not relapsed at the time of the first. The reduction of the original 1340 clients to those 575 surely introduced some bias, and that may also affect the generalizability of the results. Finally, some variables that we have not measured may identify a subpopulation that can profitably aim at controlled drinking. REFERENCES 1 M.B. Bailey and J. Stewart, Q.J. Stud. Alcohol, 28 (1967) 305. 2 W.B. Clark and D. Cahalan, Addict. Behav., 1 (1976) 251. 3 E.M. Pattison et al., in: E. Manse11 Pattison, Mark B. Sobell and Linda C. Sobell (Eds.), Emerging Concepts of Alcohol Dependence, Springer Publishing Company, New York, 1977. 4 D.J. Armor, J.M. Polich and H.B. Stambul, Alcoholism and Treatment, The Rand Corporation, Santa Monica, 1976. 5 J. Orford, E. Oppenheimer and G. Edwards, Behav. Res. Ther. 14 (1976) 409. 6 J.M. Polich, D.J. Armor and H.B. Braiker, The Course of Alcoholism: Four Years After Treatment, The Rand Corporation, Santa Monica, 1980. 7 H.A. Skinner and B.A. Allen, Alcohol Dependence Syndrome: Measurement and Validation. Presented at the International Conference on Treatment of Addictive Behaviors, University of New Mexico, Grand Canyon, Arizona, November 17-21, 1981.
Drug and Alcohol Dependence, 12 (1983) 25-29 Elsevier Scientific Publishers Ireland Ltd.
RELAPSE RATES REHABILITATION SYMPTOMS
JOHN W. WELTE, Research
Institute
(Received
FOR FORMER CLIENTS OF ALCOHOLISM UNITS WHO ARE DRINKING WITHOUT
JOSEPH
P. LYONS
on Alcoholism,
and LLOYD
1021 Main
Street,
SOKOLOW
Buffalo,
NY
14203
(U.S.A.)
March 21st, 1983)
SUMMARY
A follow-up study of former clients of 17 alcoholism rehabilitation units of New York State shows that those clients drinking without symptoms at the first follow-up have higher relapse rates at the second than those who were abstaining at the first follow-up. This is true for all identifiable sub-groups of former clients.
Key words: Alcoholism
- Controlled
drinking - Abstinence
INTRODUCTION
An important controversy in the alcoholism field centers around the question of whether, and under what circumstances, alcoholics or former problem drinkers may drink in a ‘normal’ or ‘controlled’ manner. The weight of conventional wisdom and clinical experience supports abstinence as the only wise course, but longitudinal studies 11,21 have often reported apparently untroubled drinking by people who formerly had a drinking problem. Pattison et al. 133 reviewed 74 studies, mostly follow-up studies, which report some identified alcoholics who have resumed non-problem drinking. When an outcome study of treated alcoholics uses more than one followup, it becomes possible to examine the status of the clients at the later as a function of their drinking pattern at the earlier follow-up and thereby determine which earlier pattern produces the highest relapse rates. The best known use of this type of analysis has been made in the first 0376-8716/83/$03.00 0 1983 Elsevier Scientific Publishers Printed and Published in Ireland
Ireland Ltd.
26
Rand Study 143.Data from 220 former clients of 8 federal alcoholism treatment centers were analyzed. Each of these had been followed-up at 6 and 18 months after treatment. There were no statistically significant differences in relapse rates at 18 months between those who were abstaining at 6 months and those who were drinking in ‘normal’ ranges. This result became controversial because it could be construed to mean that controlled drinking is a reasonable option for recovering alcoholics, although the Rand authors did not make any such recommendations. Orford et al. 151did 12- and 24-month follow-ups of 100 male alcoholics who had been in inpatient or outpatient treatment. These men had been counselled to remain abstinent, but less than 10% remained abstinent for more than a year. In spite of this, 26 of these men had good outcomes at 2 years, equally divided between short-term abstainers and controlled drinkers. Gottheil et al. (unpublished data) followed up 305 male alcoholic former inpatients at 6, 12 and 24 months. There was no difference in relapse rates at 24 months between those abstaining at 12 months and those drinking moderately at 12 months, with relapse being defined as reported intoxication. The latest and most elaborate contribution to this line of research is the second Rand Study 161.The same Rand group has published a second report based on Cyear follow-ups of the same clients who were previously followedup at 18 months. In this second study, the authors looked at relapse between 18 months and 4 years, and found results somewhat different from those that they had found earlier. They found that the relationship between relapse rates at 4 years and drinking patterns at 18 months depended on the respondent’s age and degree of dependence on alcohol at admission. Relapse was defined as presenting any of a list of alcohol impairment symptoms at follow-up. For those clients who had no dependence or low dependence, relapse rates were higher for abstainers than for those drinking without symptoms. Likewise, for those under 40, relapse rates were higher for abstainers than for drinkers. For those more impaired or older, relapse rates were higher for non-symptom drinkers. Although these results could be construed to mean that for some non-symptom clients abstinence is not the only road to recovery, the authors of the Rand report themselves take care to state that they are not recommending that any alcoholic resume drinking. In the present study, we will use data from an outcome study of New York State alcoholism rehabilitation units to pursue the same questions. We will ask which group of clients does better at the second follow-up: those who are drinking without symptoms at the first follow-up or those who were abstaining at that time. We will also search for subgroups among which the relationship between relapse rates at the second, and drinking pattern at the first follow-up differ.
27 METHODS
The New York outcome study involves interviews of 1340 clients who were admitted to inpatient treatment at 14 state-run and three community alcoholism rehabilitation units during 1977. The duration of a normal course of treatment ranges from 1 to 3 months, depending on the policy of the unit. These clients were 62.9% male and 17.1% female. White clients comprised 72.8% of the sample, 22% black, with the remaining 5.2% a scattering of other groups. The socioeconomic status of the clients covered a wide range, from upper middle class to poor transients. The researchers attempted to interview the former clients at 3 and 8 months after treatment. At 3 months, 72% of the clients were interviewed. At 8 months, interviews were obtained with 67% of the clients including 79% of those who had been interviewed at 3 months. Our analysis was done in two stages. Firstly, we examined relapse rates at the &month follow-up as a function of drinking pattern at the 3-month one. Secondly, we attempted to find subgroups of clients who differed in the degree of success that they enjoyed in maintaining abstinence as opposed to non-symptom drinking. RESULTS
The first column of Table I shows the relapse rates at the &month follow-up. Borrowing from the Rand Study authors, we have defined nonsymptom drinkers as those who have had no episodes of shakes, blackouts, missing meals due to drinking, drinking continuously for 12 h or morning drinking during the 30 days before the interview. Relapse is defined as drinking with symptoms. Those former clients who were abstaining at the 3-month follow-up have a much lower relapse rate (12.3%) at the &month stage than those who were drinking without symptoms at the 3-month
TABLE I NEW YORK STATE OUTCOME STUDY
Relapse rates at 8 months Drinking at 3 months 30-Day abstainers 30-Day non-symptom drinkers 30-Day symptom drinkers
Overall
White
Non-White
12.3% N = 621506 31.9% N = 22169 64.6% N = 117/181
11.5% N = 461399 23.6% N = 13155 60.7% N = 821135
15.0% N = 161107 64.3% N = 9114 76.1% N = 35146
follow-up (31.9%). A x2 test of these differences is significant at the 0.001 level. Our next step was to locate subgroups of former clients who might differ in the success that they enjoyed in maintaining non-symptom drinking as opposed to abstinence. We approached this problem by using two discriminant function analyses. The first of these involved only those former clients who were abstaining at the 3-month follow-up. We used a set of 14 descriptive measures taken at intake as independent variables and attempted to discriminate between those former clients who relapsed at 8 months and those who did not. The second discriminant analysis was identical to the first except that it involved only those former clients who were engaged in non-symptom drinking at the 3-month follow-up. Our reasoning is that any descriptive measure which does not emerge from either analysis as a significant discriminator can be rejected as a possible identifier of subgroups who will be more or less successful at maintaining non-symptom drinking as opposed to abstinence. Any variable significant in one or both analyses bears further examination. The discriminating variables were: sex, age, race, years since last employment, socioeconomic status, financial status, number of times arrested, extent of drug abuse in 30 days before entering treatment, social adjustment, social stability, number of lifetime treatments for alcoholism, average alcohol consumption in the 30 days before entering treatment, and alcohol dependence in the 30 days before entering treatment. All of these variables were constructed using information from the interview obtained while in treatment. Race was coded as a binary variable, white vs. non-white. Socioeconomic status was derived from education and occupation status. The financial scale reflected salary or wages as a positive value and welfare or use of government social and medical services as a negative value. Social adjustment was based on how well the client got along with others. Social stability was computed as a function of the client’s family arrangements, employment status and other indications of stability. Our alcohol dependence scale was compiled from 15 of the 29 signs and symptoms used by Skinner and Allen 171 to define the alcohol dependence syndrome. We were particularly interested in this formulation because it has been proposed that drinkers who are high in alcohol dependence syndrome would have difficulty in maintaining non-symptom drinking. The first discriminant analysis showed that none of the independent variables had a meaningful ability to discriminate between successful and unsuccessful abstainers. Given that a client was abstaining at the first follow-up, none of the independent variables were of any use in predicting whether he would relapse at the second follow-up. The second discriminant analysis showed that only race (white vs. nonwhite) had a meaningful ability to discriminate between successful and unsuccessful non-symptom drinkers. Therefore, race is the only candidate for a variable to help distinguish subgroups of clients who will differ in their degree of success with abstinence as opposed to non-symptom drink-
29
ing. Columns two and three of Table I show the results. For both whites and non-whites, abstainers do better than non-symptom drinkers, but the difference is much greater for non-whites. DISCUSSION
We were unable to identify any sub-population of former clients who were more successful at avoiding relapse with non-symptom drinking than with abstinence. This result is consistent with the traditional wisdom of alcoholism treatment. It is also different from the results described by both Rand Reports, although there are many differences between our study and the Rand study, the most important being the difference in follow-up intervals. We interpret our result as a caution to those who advocate controlled drinking, but by no means as a refutation. For one thing, all of these clients had received treatment aimed towards total abstinence; so these results may not generalize to treatment specifically designed to achieve controlled drinking. For another, our analyses use only those clients for whom we obtained two follow-ups and who had not relapsed at the time of the first. The reduction of the original 1340 clients to those 575 surely introduced some bias, and that may also affect the generalizability of the results. Finally, some variables that we have not measured may identify a subpopulation that can profitably aim at controlled drinking. REFERENCES 1 M.B. Bailey and J. Stewart, Q.J. Stud. Alcohol, 28 (1967) 305. 2 W.B. Clark and D. Cahalan, Addict. Behav., 1 (1976) 251. 3 E.M. Pattison et al., in: E. Manse11 Pattison, Mark B. Sobell and Linda C. Sobell (Eds.), Emerging Concepts of Alcohol Dependence, Springer Publishing Company, New York, 1977. 4 D.J. Armor, J.M. Polich and H.B. Stambul, Alcoholism and Treatment, The Rand Corporation, Santa Monica, 1976. 5 J. Orford, E. Oppenheimer and G. Edwards, Behav. Res. Ther. 14 (1976) 409. 6 J.M. Polich, D.J. Armor and H.B. Braiker, The Course of Alcoholism: Four Years After Treatment, The Rand Corporation, Santa Monica, 1980. 7 H.A. Skinner and B.A. Allen, Alcohol Dependence Syndrome: Measurement and Validation. Presented at the International Conference on Treatment of Addictive Behaviors, University of New Mexico, Grand Canyon, Arizona, November 17-21, 1981.