How useful is abstinence alone in understanding the effectiveness of SUD treatment?

Alcohol Resistance

The following article was recently published on the research page of the Recovery Research Institute website. It reports that abstinence from alcohol and other drugs is commonly perceived as a defining feature of recovery and has been widely used as a marker by which to evaluate the success of substance use disorder (SUD) treatment. Efforts have been made to define recovery more broadly by incorporating indices of functioning and well-being, but even within such broader definitions, achieving abstinence (as opposed to drinking at low-risk levels) is noted as an important milestone. This research presents three-year outcomes of persons who participated in outpatient treatment for alcohol use disorder, where treatment outcomes are defined in terms of both alcohol use and functioning.

WHAT PROBLEM DOES THIS STUDY ADDRESS?

A focus on abstinence in defining recovery from an alcohol or other substance use problem has a long history in the field of addiction. More recently, however, efforts have been made to broaden the definition of recovery so as to align more closely with the variety of actions one can take toward health and wellness for those with substance use disorder. This broadening of the definition has largely focused on incorporating indices of functioning and well-being, which, of course, are of great relevance to individuals with SUD, both inside and outside the treatment context. When it comes to substance use, however, most definitions of recovery continue to focus on abstinence rather than also considering drinking patterns that do not result in a re-occurrence of substance use disorder symptoms or other harms. Clinically as well, patients are often advised to choose abstinence as their treatment goal. Increasingly, however, it is being questioned if abstinence is a necessary treatment goal for all persons with substance use disorder. To shed further light on this issue, Witkiewitz and colleagues looked at the outcomes of 806 alcohol use disorder outpatients over the course of three years after they started alcohol use disorder outpatient treatment.  

HOW WAS THIS STUDY CONDUCTED?

This study was a secondary data analysis of the well-characterized and frequently analyzed dataset stemming from Project MATCH, a multi-site project conducted in the 1990s in the United States. This analysis used a subsample of these study participants who were followed for up to three years following the initial Project MATCH treatments.  In this subsample, 952 individuals with alcohol use disorder were randomized to receive one of three individually-delivered outpatient treatments (i.e., cognitive behavioral therapy, motivational enhancement therapy, or Twelve-Step facilitation). Of these, 806 (85%) provided data on their drinking during the three years following treatment and were included in analyses. Assessments were conducted prior to treatment, during the 12 weeks of treatment, immediately following treatment, and 6, 12, and 36 months after treatment end. In addition to reporting on their drinking and negative consequences they experienced due to their drinking, participants also provided information on their experiences during the past 30 days, using four yes/no items (“employed,” experienced “serious depression,” “trouble understanding, concentrating, or remembering,” “serious anxiety or tension”), and completed several items measuring to what degree they engaged in problematic social behaviors and to what degree they felt satisfaction with their life.   

Witkiewitz and colleagues then conducted two types of analyses. First, they simply defined three groups of participants in terms of their drinking based on cut-off values of public health interest and described their outcomes over time. The three groups they defined were abstainers, low-risk drinkers (i.e. non-abstinent individuals with no heavy drinking days) and heavy drinkers. A heavy drinking day was defined using nationally-defined standards as consuming four or more drinks in a day for women, or five or more drinks in a day for men. Then, they used an exploratory technique called “latent profile analysis” to identify groups of patients based on their reports of alcohol consumption and life functioning (i.e., as described above) over the three years following entry into outpatient treatment. 

WHAT DID THIS STUDY FIND?

When outcomes were defined by public health relevant cut-off values, low-risk drinkers were not significantly different from abstainers (i.e., differences were not greater than could be explained by chance alone) on almost all non-drinking outcomes, with one exception: abstainers were significantly unhappier with life. This may because these individuals tended to have the heaviest drinking and most severe problems prior to treatment and these individuals’ lives can continue to be detrimentally affected for many years even after remission has been achieved.  

In defining groups that emerged by considering participants’ data over time, Witkiewitz and colleagues identified four profiles: 

Witk Fig 1

Figure 1. Four drinking categories identified by researchers.

By far the largest group is ‘high-functioning infrequent non-heavy drinking’ (51.2%), which is good news in and of itself. Among these, only 49% were completely abstinent from alcohol, demonstrating that both abstainers and individuals who experienced at least some low-level re-exposure to alcohol were able to achieve high-functioning. Of note, all of these patients were able to refrain from heavy drinking.   

For the remaining three groups, whether or not someone remained abstinent was also not a very informative datapoint: a third of these participants were high–functioning despite at least some heavy drinking. Note also that achieving infrequent drinking or abstinence did not guarantee higher functioning: roughly 25% of those achieving infrequent drinking had very poor functioning (i.e., the ‘low-functioning infrequent heavy drinking’ group, which comprises 25% of all participants who were able to refrain from occasional or frequent heavy drinking). Of note, this group also seemed to be worse off at the beginning of the study, as they reported higher levels of depression, tension, and difficulties concentrating at the onset of the study, suggesting that this group was struggling to overcome greater psychosocial challenges than the other groups.    

More generally, the study also made observations about how baseline characteristics of patients related to outcomes three years later: 

  • Higher functioning: Patients who at baseline were found to have better mental health, greater purpose in life, and social support from family and friends were more likely to be high–functioning three years after treatment. 
  • More frequent heavy drinking: Patients who at baseline had more high-risk social networks that actually supported continuing to consume alcohol were more likely to engage in frequent heavy drinking three years after treatment.  
  • Achieving high-functioning heavy drinking: Patients who had lower alcohol dependence severity at baseline were more likely to achieve high-functioning despite at least some heavy drinking. Note that high-functioning patients who engaged in occasional heavy drinking were more likely to be White, and at study entry drank fewer drinks per drinking day and experienced fewer consequences due to their drinking than those high-functioning patients who engaged in infrequent non-heavy drinking. 

WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?

The findings from this secondary data analysis project of a large, multi-site trial delivering outpatient treatment (in the 1990s) to more than 800 alcohol use disorder outpatients lend further weight to recent calls reconsider how the effectiveness of SUD treatments ought best to be measured. It builds on a previous report from the same research group that has highlighted the shortcoming of existing Food and Drug Administration guidance to use heavy drinking as indicative of treatment “failure,” as it fails to acknowledge substantial psychosocial improvements made by individuals who continue to occasionally drink heavily post-treatment. As Witkiewitz and colleagues argue, patient variability (i.e., heterogeneity) has long been acknowledged as an important factor to consider; it may now also be time to acknowledge that there is considerable variability in how some individuals may function following treatment for alcohol use disorder. That said, whereas it is becoming clearer that abstinence is a relatively uninformative indicator of treatment success, engaging in heavy drinking in and of itself confers harm, given that alcohol is a known Group 1 carcinogen – it has the potential to cause cancer. It is also a major cause of liver disease. Thus, while it is possible to engage in heavy drinking occasionally and still function at a high level, such toxicity–related risks need also to be considered. For this reason, perhaps other characterizations of alcohol consumption may be more informative, such as staying within national “low-risk” drinking guidelines. Drinking guidelines, such as those of the American Cancer Society, seek to prevent not only alcohol use disorder, but also the harms posed by both toxicity from alcohol, and recommend that women and men should drink no more than one and two drinks per day respectively, to limit harm due to alcohol’s toxicity-related effects. Beyond broadening our perspective of how alcohol consumption should be considered in terms of defining treatment “success,” the results of this study raise additional intriguing questions surrounding the broad definition of “recovery” that most agree should encompass both indices of functioning and a range of alcohol use indices.  

Also of note, roughly half of those who are low-functioning after outpatient treatment show vulnerability to intermittent alcohol exposure, and continue to struggle psychosocially, underscoring the importance of continuing care that can help address these challenges over the longer term. LIMITATIONS

BOTTOM LINE

This new analysis of a large, multi-site trial with more than 800 alcohol use disorder outpatients showed that some individuals who engage in at least some occasional heavy drinking following treatment may function as well as those who are mostly abstinent with respect to psychosocial functioning, employment, life satisfaction, and mental health. Such individuals tend to have lower addiction severity and fewer alcohol-related consequences prior to treatment, suggesting a more favorable prognosis overall.  

  • For individuals and families seeking recovery: An incidental finding of this study, but good news that deserves highlighting nevertheless, is the finding that more than half of the alcohol use disorder outpatients examined in this study had a positive outcome for at least 3 years following treatment, both in terms of drinking (i.e., no heavy drinking days) and functioning (i.e., low probability of reporting problematic social behaviors, unemployment, other drug use, or life dissatisfaction). This positive finding is in line with other recent findings highlighting that roughly half of the people seeking to recover from a substance use problem need only two recovery attempts.     
  • For treatment professionals and treatment systems: This paper provides further empirical support to move beyond a reliance on abstinence as the ultimate indicator of treatment success, and instead to move towards a broader range of drinking as well as psychosocial functioning. See our previous Bulletin article on broader definitions of recovery. Patients with higher addiction severity at treatment entry are less likely to achieve high-functioning with occasional heavy drinking. Moving beyond abstinence as the indicator of treatment success may help decrease barriers to treatment–seeking amongst those who do not wish to abstain from alcohol entirely but may otherwise welcome support in achieving low-risk drinking and higher functioning.   
  • For scientists: The present study, as well as similar reports, are based on older datasets, and thus replication in more modern-day datasets would help clarify if observed findings generalize to present day alcohol use disorder treatment contexts and recovery supports. Note also that “functioning” may be defined in a number of ways, but in the present study was limited to the indices used in Project MATCH. As Witkiewitz and colleagues highlight, further research should examine the role and impact of heretofore understudied correlates in this context, such as cognitive functioning/executive control, medical health and chronic pain, and misuse of prescription drugs.  
  • For policy makers: An increasing body of research points to the downfalls of relying on abstinence as a marker of alcohol use disorder treatment success. Far beyond being a simple matter of treatment goal preference of a substantial number of treatment seekers, current evidence, including this paper, suggests that alcohol consumption by itself does not necessarily equate to “treatment failure.” Guidance used to evaluate alcohol use disorder treatment, including FDA regulations, may need to be updated in light of this emerging evidence, with perhaps measures of diagnostic remission status and/or drinking within the national low-risk drinking guidelines being the optimal outcomes.  

CITATIONS

Witkiewitz, K., Wilson, A. D., Pearson, M. R., Montes, K. S., Kirouac, M., Roos, C. R., . . . Maisto, S. A. (2018). Profiles of recovery from alcohol use disorder at three years following treatment: Can the definition of recovery be extended to include high functioning heavy drinkers? Addiction, 114(1), 69-80. doi:10.1111/add.14403 

Individuals can get help for alcohol use and PTSD at the same time: A movement toward integrated treatment approaches

Puzzle3

The following article was recently published on the research page of the Recovery Research Institute website. The study indicates that individuals with post-traumatic stress disorder (PTSD) are at increased risk of having co-occurring alcohol use disorder. However, it is not known whether the first-line treatment for PTSD (i.e., prolonged exposure therapy) is also effective in reducing problematic drinking. This study replicated prior findings suggesting prolonged exposure therapy is superior in treating PTSD symptoms, but was not more effective in reducing heavy drinking days than an intervention intended primarily to increase coping skills. However, findings from this study do challenge the notion that alcohol use disorder may be a barrier to receiving gold-standard treatment for PTSD. 

WHAT PROBLEM DOES THIS STUDY ADDRESS?

Individuals with PTSD are more likely to have an alcohol use disorder than individuals in the general population. One representative survey of adults in the United States found individuals with PTSD were 1.2 times as likely to have an alcohol use disorder in their lifetime than those without PTSD. PTSD is also associated with a more problematic course of alcohol use, including greater difficulty quitting, briefer abstinence periods, and more associated medical, legal, and psychological consequences. These disparities in alcohol use outcomes in individuals with PTSD underscore the need to identify treatments that are effective in treating both symptoms of PTSD as well as problematic alcohol use. To address this need, Norman and colleagues studied the immediate, 3-month, and 6-month outcomes among 119 adult veterans with co-occurring PTSD and alcohol use disorder who received one of two competing treatment approaches. The table below outlines key components of each treatment approach. The first treatment, called Concurrent Treatment for PTSD and Substance Use Disorder Using Prolonged Exposure, or “COPE,” was integrated with prolonged exposure therapy that involves 1) helping individuals gradually approach trauma-related memories, feelings, and situations, and 2) relapse prevention for alcohol use disorder using cognitive and behavioral therapeutic techniques. The second tested treatment, called Seeking Safety (an empirically-supported treatment for co-occurring PTSD and substance use disorder), was a present-focused coping intervention that aimed to teach individuals skills to cope with both symptoms of PTSD and alcohol use disorder. The ultimate goal of this research study was to determine which treatment modality was most effective in supporting the recovery of individuals living with both PTSD and alcohol use disorder. 

Norman Fig 1

Figure 1. Chart comparing the features of both the COPE and Seeking Safety treatment approaches, including general timeframe of treatment, and specific therapy techniques.

HOW WAS THIS STUDY CONDUCTED?

Study authors examined 119 adult veterans (90% male, average age of 41 years, 66% White) with current symptoms of PTSD who were receiving care at the San Diego Department of Veterans Affairs (VA). While individuals were encouraged to avoid other treatment for their PTSD, they were able to receive standard mental health treatment at the VA while participating in this study. For example, 65% were taking psychotropic medication during the study. Participants also needed to have current alcohol use disorder, at least 20 days of heavy alcohol use (see below for heavy drinking definition) in the past three months, and a stated desire to quit or cut back on alcohol use. Participants were randomly assigned to receive either 12-16 90-minute sessions of COPE (i.e., integrated prolonged exposure therapy) or Seeking Safety (i.e., coping skills–focused therapy). Sessions were administered preferably once to twice per week on consecutive weeks, but could span across a 6-month period of time. 

Participants completed assessments of PTSD symptoms and problematic drinking behavior after treatment and at 3- and 6-months posttreatment, and these assessments were administered by study staff who were not aware of (i.e., “blinded” to) the treatment received.The Clinician Administered PTSD Scale for DSM-5 (CAPS-5) was the primary measure used to quantify PTSD symptoms and diagnosis, with scores >=12 suggestive of a PTSD diagnosis (range: 0-80). Frequency and quantity of alcohol use were ascertained via a calendar-based interview (i.e., Timeline Follow-Back), which was used to deduce A) the percent of heavy drinking days defined as the number of days in which 5 or more drinks for men or 4 or more drinks for women were consumed since the last assessment, and B) percent days abstinent for alcohol. A breathalyzer was administered to any participant who appeared intoxicated. 

WHAT DID THIS STUDY FIND?

PTSD symptoms declined more in veterans who received integrated prolonged exposure therapy compared to the present-focused coping intervention.

PTSD symptoms improved over time regardless of therapy assignment; however, the COPE group improved more than did the Seeking Safety group. Immediately after treatment, over 20% of individuals went from having a PTSD diagnosis to no longer meeting criteria for the condition (“remission”), compared to only 7% in the present-focused coping intervention. The advantage for the COPE group became slightly weakened over time but was nevertheless maintained; the greater PTSD symptom gains for the COPE group were still present 6 months after completing treatment.

Norman Fig 2

Figure 2.

Drinking outcomes improved similarly across treatment groups.

All participants showed reductions in the percent of heavy drinking days over time, though the extent of decrease was similar in those who received integrated prolonged exposure and the present-focused coping intervention. Findings were similar – both groups displayed similarly improved drinking – when the outcome was percent days abstinent as well.

Norman Fig 3

Figure 3.

Norman Fig 4

Figure 4.

WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?

This study is responsive to the urgent need to identify treatments that are effective in mitigating both symptoms of PTSD and alcohol use disorder, the co-occurrence of which is both highly common and linked with greater negative outcomes compared to either disorder alone. Findings from this study build upon a robust literature suggesting that prolonged exposure therapy is the gold standard for mitigating PTSD symptoms. Importantly, this study demonstrates that prolonged exposure therapy is effective even among individuals with an active alcohol use disorder. This study, plus a growing body of literature, challenges a commonly held belief that individuals with alcohol use disorder cannot tolerate exposure-based approaches, addressing the notion of alcohol use disorder as a potential barrier to receiving widely–supported, evidence–based therapy for PTSD.

Contrary to the authors’ hypotheses, however, prolonged exposure therapy was no more effective in reducing problematic alcohol use than the present-focused coping intervention. The fact that this PTSD reduction benefit did not translate into lower problematic alcohol use suggests that, whereas some PTSD patients may have initially drunk (and still drink) alcohol to help “medicate” the distress caused by PTSD, for many others, the alcohol use may persist fairly independently of PTSD. Although group differences were not found with regard to drinking use, it is notable that both groups showed significant reductions in drinking over time, suggesting that simultaneous treatment for alcohol use disorder can be integrated into the framework of PTSD treatment without interfering with the treatment of PTSD itself. Future studies are needed to determine which PTSD treatment modalities may have the most beneficial impact on drinking behaviors. Some findings from other groups provide promising preliminary support for approaches that involve teaching individuals to challenge and modify maladaptive beliefs (cognitive processing therapy and cognitive behavioral therapy) and guided eye movements with the goal of diminishing negative feelings associated with traumatic events (eye movement desensitization and reprocessing therapy).LIMITATIONS

BOTTOM LINE

  • For individuals and families seeking recovery: This study demonstrated that the simultaneous attention to both PTSD symptoms and alcohol use disorder is possible, and attention to both disorders in an integrated treatment approach is linked with improved functioning. Therefore, patients with both conditions should feel empowered to have both PTSD symptoms and problematic drinking behavior as treatment targets that can be addressed in tandem rather than in parallel. This is comparable to other studies that find integrated approaches to be successful in cases of co-occurring substance use and other neuropsychiatric disorders such as depression and ADHD. 
  • For treatment professionals and treatment systems: Patients with PTSD and alcohol use disorder benefitted from integrated treatment approaches. Findings suggest that individuals with comorbid PTSD and alcohol use disorder should not be excluded from receiving front-line PTSD treatment on account of their untreated alcohol use. Rather, alcohol use should be identified as a core treatment target and addressed in tandem with PTSD. Further work is needed, though, to determine the most effective treatment modality for addressing problematic alcohol use in the context of PTSD.  
  • For scientists: Findings point to the efficacy of prolonged exposure therapy, even in the presence of co-occurring alcohol use, in mitigating symptoms of PTSD. While findings suggest a reduction in heavy drinking days, this effect was not specific to the therapeutic approach of prolonged exposure therapy. This finding does not align with “self-medication” as a maintaining condition for alcohol use disorder, at least for some. While more work is needed to determine the most effective approach for reducing alcohol use among PTSD patients, this study represents an important first step in decreasing barriers to access to empirically-validated and integrated treatments. Additionally, while prolonged exposure therapy is commonly viewed as a gold standard approach for trauma treatment, retention particularly in real-world settings is often low. Co-occurring substance use has been found to be one patient factor robustly associated with dropout. Therefore, future studies aimed at enhancing engagement and retention, especially among patients with co-occurring disorders, is critical for the widespread dissemination of this approach. 
  • For policy makers: Findings lend preliminary support for the efficacy of integrated treatment approaches, which runs contrary to the outdated, yet still pervasively present notion, that substance use disorders need to be fully remitted prior to the treatment of co-occurring other mental health concerns (e.g., PTSD, depression, anxiety disorders). Integrated treatment approaches that allow for substance use disorders and other mental health disorders to be addressed simultaneously will undoubtedly decrease barriers to treatment access for the large proportion of patients seeking recovery from multiple conditions. Therefore, it is imperative that clinician trainees and all patient-facing staff in mental health facilities receive proper education and training in issues related to substance use disorders. Such training may involve early identification of problematic substance use and management of acute signs of overdose. Additionally, as demonstrated in this study, it remains unknown which integrated treatments are optimally effective in treating substance use disorders in the context of PTSD and other co-occurring mental health conditions. Therefore, the field would benefit from continued funding to support research on novel treatment development and evaluation.  

CITATIONS

Norman, S. B., Trim, R., Haller, M., Davis, B. C., Myers, U. S., . . . Mayes, T. (2019). Efficacy of integrated exposure therapy vs integrated coping skills therapy for comorbid posttraumatic stress disorder and alcohol use disorder: A randomized clinical trial. JAMA Psychiatry, (Epub ahead of print). doi: 10.1001/jamapsychiatry.2019.0638 

The Council on Recovery is the leader in providing a wide range of prevention and education resources aimed reducing alcohol use, especially among adolescents and young adults. We also offer therapeutic counseling and an intensive outpatient treatment program (IOP) for those affected by alcoholism. For more information, please call 713-942-4100 or contact us online.

What would alcohol sales look like if excessive and problem drinkers drank in moderation?

alcohol sales

The following article was recently published on the research page of the Recovery Research Institute website. It reports a novel new study focusing on the alcohol industry’s public support of moderate drinking amidst speculation that a large portion of alcohol industry profits come from alcohol sales to excessive drinkers and individuals with drinking problems. The research explored what percentage of alcohol sales are accounted for by heavy drinkers, and what the alcohol industry stands to lose financially if everyone drank in moderation (within government health guidelines).

WHAT PROBLEM DOES THIS STUDY ADDRESS?

The alcohol industry has long faced a difficult public relations dilemma. Though many individuals enjoy using alcohol with little or no consequence, for many others, alcohol causes significant emotional, physical, and interpersonal harm. At a population level, alcohol use has a prodigious, adverse social and economic impact. In order to mitigate the perception that the alcohol industry is profiting from suffering, and at times because of government pressure, in many countries major alcohol producers have voluntarily funded public awareness campaigns about the harms of excessive alcohol use. Critics, however, have argued that such voluntary measures are doomed to fail because they involve companies engaging in activities and policies aimed at reducing the harmful behaviors on which their profitability depends. In essence, these companies have a major conflict of interest. 

The alcohol industries in England and the United States have often played down the extent to which profits are driven by excessive use of their products, in spite of evidence from several countries that alcohol consumption is concentrated within a minority of heavier drinkers. The present study explored whether such findings are also true for England. Specifically, the authors asked: 1) What proportion of alcohol sales revenue is accounted for by people drinking more than government recommended guidelines for low-risk drinking (in the UK no more than 14 standard drinks per week, where a standard drink is equal to 7.9g of pure alcohol. This is considerably less than in the U.S. where a standard drink is equal to14g of pure alcohol – almost twice as much). 2) How does financial dependence on heavy drinkers vary between different sectors of the alcohol industry? 3) How would alcohol sales revenue be affected if everyone’s consumption fell to within guideline levels? 

This research has implications not just for public health policy, but for the millions of these heavy drinkers with alcohol use disorder in England, and countries like the United States.

HOW WAS THIS STUDY CONDUCTED?

This paper uses data from the UK Office for National Statistics’ Living Costs and Food Survey and the National Health Service’s Digital Health Survey for England. The Living Costs and Food Survey is distributed to households on a continuous basis throughout the year and asks each individual aged 16 years and over to keep a detailed diary of their daily expenditure over a 2-week period. For alcohol, the survey provides transaction-level data on beverage type (e.g., beer, cider, wine, spirits), price paid, and volume of product purchased. The survey also asks where the alcohol was purchased; either in a hotel, restaurant, or bar (known in the UK as on-trade sales), or from an alcohol retailer like a liquor store (referred to in the UK as off-trade sales). The authors pooled data from the 2013 and 2014 iterations of the survey, comprising a total of 9,975 households. 

The Health Survey for England is a large, nationally-representative survey of 16,872 individuals (2013 and 2014 pooled) which records self-reported ‘typical’ consumption by beverage type. Coverage of total alcohol purchases relative to estimates from more robust national accounts and sales data is approximately 60% (compared to 40% for the Living Costs and Food Survey), suggesting people markedly under-report their alcohol use. 

Drinking groups were defined according to UK government guidelines. ‘Moderate’ drinking is consumption below or equal to 14 standard drinks per week for both sexes, with a standard drink in the UK equaling 7.9g or 10ml of pure alcohol. ‘Heavy’ drinking refers to consumption above this level. Within the ‘heavy drinking’ category, the authors further distinguished ‘hazardous’ (15–35 units for women, 15–50 for men) from ‘harmful’ (36+ for women, 51+ for men) drinking, based on government guidelines.

WHAT DID THIS STUDY FIND?

The authors found that on the whole, the bulk of alcohol sales in England in 2013/14 were to individuals drinking excessively. An estimated 77% of alcohol was sold to drinkers consuming above guideline levels: 30% to harmful drinkers and 48% to hazardous drinkers. Further, alcohol consumed in excess of the guideline levels (i.e., those drinking 14 or more standard UK drinks per week) accounted for 44% of all sales.

Moderate drinkers (i.e., those drinking 14 or fewer UK standard drinks per week), who represented an estimated 59% of the population, were estimated to consume only 23% of all alcohol and accounted for only 32% of all revenue (Figure 1). The 21% of the population who were hazardous drinkers consumed an estimated 48% of all alcohol and accounted for an estimated 45% of all revenue. A relatively small group of harmful drinkers, comprising 4% of the total population, consumed almost a third (30%) of all alcohol sold in England, and accounted for nearly a quarter (23%) of all alcohol sales revenue.

Batt Fig 1

Figure 1. Source: Bhattacharya et al., 2018.

Figure 1. Volume and value of alcohol sales by consumption level in England, 2013/14. The first column represents the makeup of the entire English population by drinking behaviors. The second column shows what percent of alcohol consumed in England was accounted for by each category of drinker. The third column shows the percentage of alcohol revenue accounted for by each category of drinker. As illustrated in this figure, in spite of making up only 25% of the population, hazardous and harmful drinkers accounted for 78% of alcohol consumption and 68% of alcohol revenue. 

In terms of differences between on-trade (i.e., in a hotel, restaurant or bar) and off-trade (alcohol retailors), 81% of off-trade revenue was estimated to come from those drinking above guideline levels (Figure 2). The corresponding amount was substantially lower (60%) for on-trade sales, although heavy drinkers also still accounted for the majority of sales revenue, highlighting the fact that hazardous and harmful drinkers accounted for the majority of both retail and bar/restaurant sales.

Batt Fig 2

Figure 2. Source: Bhattacharya et al., 2018.

Figure 2. Proportion of revenue from harmful, hazardous and moderate drinkers by beverage types and retailer in England in 2013/14. On-trade refers to hotel, restaurant, or bar sales; off-trade refers to alcohol retailors. 77% of beer expenditure was estimated to come from drinkers consuming above guideline levels, compared to 70% for cider, 66% for wine and 50% for spirits. Hazardous and harmful drinkers accounted for the majority of on-trade and off-trade alcohol sales. 

The authors also report that should alcohol consumption be reduced to low-risk levels suggested by the UK government (i.e., 14 or less standard drinks per person, per week), the alcohol industry would stand to lose 38% of their current revenue (Figure 3). In absolute terms, this implies that the industry’s market value would fall by £13 billion (approximately US$17 billion).

Batt Fig 3

Figure 3. Source: Bhattacharya et al., 2018.

Figure 3. Predicted percentage decline in alcohol revenue in England if alcohol consumption were to fall to government guideline levels for low-risk drinking (i.e., 14 or less standard drinks per person per week). Percentage declines in revenue are broken down by point of sale (on-trade versus off-trade), and alcohol category (beer, wine, etc.), as well as point of sale type crossed with alcohol category (in box, bottom right of figure). Altogether, the alcohol industry in England would stand to lose 38% of its revenue if everyone drank in accordance with government guideline levels for low-risk drinking.

WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?

Findings indicate the alcohol industry in England derives a large portion of its profit from excessive and/or problem drinkers. Given the consistency of this finding with similar research in Australia and Brazil, it seems likely that such a study conducted in the United States would find similar results. These findings raise serious questions about the conflicts of interest arising when an industry reliant on hazardous and harmful drinking is allowed to self-regulate and manages its public image with largely ineffective ‘safe drinking’ mantras (e.g., “Drink responsibly”). These findings also reinforce the need for strong alcohol sales policy, which has been shown to have real impact on problem drinking. Moreover, in so far as they suggest that a financially successful alcohol industry of its current size and form depends upon harmful drinking, the UK government’s economic support for alcohol producers, for example through tax cuts and trade negotiations, appear more problematic. These findings may also have relevance for ongoing debates about whether to restrict alcohol sales to state monopolies or open them up to commercial enterprises.

LIMITATIONS

  1. The authors’ analysis is taken from self-reported survey data, which tends to underestimate alcohol consumption. Their approach assumes implicitly that all sections of the population under-report their drinking in the same proportion. If anything, this probably underestimates the alcohol industry’s full reliance upon the heaviest drinkers, who are less likely to be represented in surveys.
  2. The analyses do not distinguish between specific companies. The degree to which any individual company benefits from sales to heavy drinkers is therefore unclear.

BOTTOM LINE

  • For individuals and families seeking recovery: Harmful and hazardous drinkers drive the bulk of English alcohol sales; a finding observed in other countries and presumed to be the same in other Western countries like the Unites States.
  • For treatment professionals and treatment systems: Harmful and hazardous drinkers drive the bulk of alcohol sales in England, and presumably other Western countries as well. Allowing the alcohol industry to design and self-monitor its own public health messaging regarding harmful/hazardous drinking represents a major conflict of interest. An industry that is financially reliant on harmful/hazardous drinking is unlikely to implement measures sufficient to curb problematic alcohol use.
  • For scientists: Harmful and hazardous drinkers drive the bulk of alcohol sales in England. The questions addressed by this research need to also be asked in the United States. Further, more research on the extent to which the alcohol industry has, in the past, mitigated volume declines by raising prices and selling more premium products would provide an indication of how sustainable such a strategy is likely to be in the long term. A further possible extension would be to explore the tax revenue generated by the government from excise duty on harmful drinkers, and the extent to which that tax revenue helps address some of the consequences of alcohol use disorder (e.g., funding publicly available treatment and recovery support services).
  • For policy makers: Alcohol use and alcohol use disorder cost Western economies hundreds of billions of dollars annually and cause tremendous personal and societal harm. The alcohol industry profits directly from this problem. The alcohol industry’s conflicts of interest highlighted in this paper should be considered when creating and enforcing alcohol policy.

CITATIONS

Battacharya, A., Angus, C., Pryce, R., Holmes, J., Brennan, A., & Meier, P. S. (2018). How dependent is the alcohol industry on heavy drinking in England? Addiction, 113(12), 2225-2232. doi: 10.1111/add.14386

The Council on Recovery is the leader in providing a wide range of prevention and education resources aimed reducing alcohol use, especially among adolescents and young adults. We also offer therapeutic counseling and an intensive outpatient treatment program (IOP) for those affected by alcoholism. For more information, please call 713-942-4100 or contact us online.

How Does Spirituality Change the Brain?

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The following article by Dr. Mark Gold, recently published on the Addiction Policy Forum Blog, explores the growing body of research about what regions of the brain are changed during a person’s spiritual practice. It presents compelling ideas for how fellowship and treatment programs can empower individuals in recovery to use spirituality as a proven tool to improve their mental health.

Spirituality can be an important component of recovery from addiction, as it can be a key way for a person seeking recovery to connect to something outside themselves – spiritual practices have long been cornerstones of mutual aid groups, such as Alcoholics Anonymous. Recently, researchers and those looking at trends have concluded that Americans are becoming less religious but at the same time identify as more spiritual. Spiritual engagement can be a way to find, as the authors in the study write, a “sense of union with something larger than oneself.” In a recent study of the brain done at Yale directed by Dr. Mark Potenza, Neural Correlates of Spiritual Experiences, scientists used functional Magnetic Resonance Imaging (fMRI) to examine exactly how spirituality activated or deactivated, certain regions of the brain, changing how people perceive and interact with the world around them.

Dr. Christina Puchalski, Director of the George Washington Institute for Spirituality and Health, defines spirituality as “the aspect of humanity that refers to the way individuals seek and express meaning and purpose and the way they experience their connectedness to the moment, to self, to others, to nature, and to the significant or sacred.” Importantly, the authors of the study encouraged diverse, personally-motivated definitions of spiritual experience, examples of which included participation in a religious service at a house of worship, connection with nature, mindfulness meditation, and contemplative prayer.

How do we Measure the Effect of Spirituality?

Spirituality and religious practices are a key part of many people’s lives – 81% of U.S. adults describe themselves as spiritual, religious, or both. Despite the majority of American adults engaging in some form of spiritual practice, little is known about what happens in certain parts of the brain during these spiritual experiences. Although studies have linked specific brain measures to aspects of spirituality, none have sought to directly examine spiritual experiences, particularly when using a broader, modern definition of spirituality that may be independent of religiousness. This study used a special kind of brain imaging, functional magnetic resonance imaging (fMRI), to examine neural structures and systems that are activated when we engage in spiritual practice. By detecting changes in blood flow to certain regions of the brain, the fMRI is able to detect activity in the brain when participants were asked to recall spiritual experiences.

Methodology

A potential challenge in this study is the wide variety of spiritual experiences that individuals can find personally meaningful. The authors of the study sought to address this by using a personalized guided-imagery fMRI procedure in which participants were asked to describe a situation in which they felt “a strong connection with a higher power or a spiritual presence.” Their accounts were turned into a script, which was recorded and played back to the participant during fMRI. The brain activation measured during the participant’s recall of a spiritual moment was compared to measurements taken while participants listened to narrations of their neutral and stressful experiences.

Key to this study was that the accounts were completely self-directed by the participants — which enabled the researchers to identify commonalities in brain activity among diverse spiritual experiences.

How Does Spirituality Change the Brain?

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The area highlighted in blue is the Inferior Parietal Lobe, which is associated with perceptual processing

Spiritual experiences were associated with lower levels of activity in certain parts of the brain:

  • The inferior parietal lobe (IPL), the part of the brain associated with perceptual processing, relating to the concept of self in time and space
  • The thalamus and striatum, the parts of the brain associated with emotional and sensory processing

This study furthers a growing body of research about spirituality and its connection to brain processing. These findings tell us that spiritual experiences shift perception, and can moderate the effects of stress on mental health. This study saw decreased activation in the parts of the brain responsible for stress and increased activity in the parts of the brain responsible for connection with others. A sense of union with someone or something outside of oneself and community engagement have been found to support a robust recovery from substance use disorders as well as other behavioral health issues. 

Looking to the Future

Marc Potenza, MD, PhD is an expert in Psychiatry, Behavioral Addictions, and his work at Yale in this important area is a welcome addition to the investigators working in this field. Neural Correlates of Spiritual Experiences has positive implications for instituting spiritual engagement in prevention, treatment, and recovery for substance use disorders. Importantly, participants were scanned while they recalled their own, individualized spiritual experience, but the results were consistent between participants. This means that a person does not have to participate in a certain type of spiritual practice to see the benefits, but can engage in whatever version of engagement is most compatible with their personal beliefs. This encourages treatment and recovery programs to encourage patients to pursue diverse means of spiritual engagement.

This study found a way to measure and visualize what many recovery and treatment communities have understood for years—that spirituality can reduce stress and create feelings of connectedness. By understanding what regions of the brain are changed during a person’s spiritual practice, fellowship and treatment programs can empower individuals in recovery to use spirituality as a proven tool to improve their mental health.

References:

  1. Smith, G., Van Capellen, P., (2018, March 7) Rising Spirituality in America [Audio Podcast]. Retrieved from https://www.pewtrusts.org/en/research-and-analysis/articles/2018/rising-spirituality-in-america.
  2. Lipka, M., Gecewicz, C., (2017, September 6). More Americans now say they’re spiritual but not religious. Retrieved from https://www.pewresearch.org/fact-tank/2017/09/06/more-americans-now-say-theyre-spiritual-but-not-religious/

Rx Take Back Day at The Council Nets 400 Pounds of Unused & Expired Prescription Drugs

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The Council’s drive-through Rx Take Back site made Rx med disposal quick & convenient
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DEA agents collected over 400 lbs. of unused & expired Rx prescriptions for disposal

The Council on Recovery was a busy collection site for the DEA’s 16th National Rx Take Back Day this past Saturday. Nearly 100 people stopped by The Council’s drive-in location on Jackson Hill Street to dispose of their unused and expired prescription medications. By the end of the four-hour collection period, DEA agents had collected more than 400 pounds of Rx drugs.

This is the first time The Council has participated in the DEA’s National Take Back Day. The national initiative was launched after Congress enacted the Disposal Act in 2014, which amended the Controlled Substances Act, that gave the DEA authority to collect unused pharmaceutical controlled substances for disposal in a safe and effective manner.

The Council views unused or expired prescription medications as a public safety issue that contributes to potential accidental poisoning, misuse, and overdose. Proper disposal of unused drugs saves lives and protects the environment. As a Rx Take Back Day collection site, The Council provided a secure, convenient, and anonymous way for its constituency to clear their homes of old or unneeded Rx medications in a responsible manner.

As one of nearly 350 collection sites across the state, The Council provided an easily accessible and central location for residents in the Heights, Rice Military, Montrose, River Oaks, Midtown, and near-Downtown areas to dispose of their medications. During the last Rx Take Back Day in October, over 67,000 pounds of Rx prescriptions were collected in Texas, according to the Drug Enforcement Administration Diversion Control Division. The Council on Recovery is pleased to contribute 400 pounds to this Spring’s total haul and plans to participate in future Rx Take Back events.

If you missed Rx Take Back Day at The Council, you can still dispose of unused or expired prescriptions at DEA authorized collection sites, many of which are located within national and local pharmacies. To search the DEA’s website for a collection site near you, click here.

The Council Taking Back Unwanted Prescription Drugs Saturday, April 27

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On Saturday, April 27, from 10 a.m. to 2 p.m., The Council on Recovery and the U.S. Drug Enforcement Administration will give the public its 17th opportunity in nine years to prevent pill abuse and theft by ridding their homes of potentially dangerous expired, unused, and unwanted prescription drugs.

Bring your pills for disposal to The Council at 303 Jackson Hill Street in Houston. (We cannot accept liquids or needles or sharps, only pills or patches). This drive up/drop-off service is free and anonymous, no questions asked. The Council’s drive-through covered portico will keep everyone dry in the event of rain. Additional security personnel will also assure the safety of everyone who participates in the event.

Last fall Americans turned in nearly 460 tons (more than 900,000 pounds) of prescription drugs at more than 5,800 sites operated by the DEA and almost 4,800 of its state and local law enforcement partners. Overall, in its 16 previous Take Back events, DEA and its partners have taken in almost 11 million pounds—nearly 5,500 tons—of pills.

This Take Back initiative addresses a vital public safety and public health issue. Medicines that languish in home cabinets are highly susceptible to diversion, misuse, and abuse. Rates of prescription drug abuse in the U.S. are alarmingly high, as are the number of accidental poisonings and overdoses due to these drugs. The Substance Abuse and Mental Health Services Administration’s National Survey on Drug Use and Health shows year after year that the majority of misused and abused prescription drugs are obtained from family and friends. These include someone else’s medication being stolen from the home medicine cabinet.

In addition, Americans are now advised that their usual methods for disposing of unused medicines—flushing them down the toilet or throwing them in the trash—both pose potential safety and health hazards.

For more information about the disposal of prescription drugs or about the April 27 Take Back Day event, go to www.DEATakeBack.com or call The Council at 713-942-4100 or contact us online.