prospective study of alcoholism treatment: eight-year follow-up

Prospective Study of Alcoholism Treatment

Eight-Year Follow-Up

GEORGE E. VAILLANT, M.D.* WILLIAM CLARK, M.D. CATHERINE CYRUS, MS. EVA S. MILOFSKY, M.S. JEFFREY KOPP, M.D. VICTORIA WELLS WULSIN, M.D. NANCY P. MOGIELNICKI, M.P.H.

Boston, Massachusetts

From the Departments of Psychiatry and Medicine, Harvard Medical School, the Massachusetts Mental Health Center, the Cambridge and Som- erville Program for Alcohol Rehabilitation, Cam- bridge Hospital, and the Harvard University Health Services, Boston and Cambridge, Massachusetts. This work was supported by the Grant Foundation, the Spencer Foundation, Research Grants MH- 32885 and K05-MH-00364 from the National In- stitute of Mental Health, Research Grant AAOl- 372 from the National Institute on Alcohol Abuse and Alcoholism, and a grant from the Massachu- setts Division of Alcoholism. Manuscript accepted February 7, 1983. l Current address and address for reprint requests: Dartmouth Medical School, Hanover, New Hampshire 03755.

One hundred patients admitted for alcohol withdrawal were followed for eight years. At the eight year mark, 25 percent had achieved stable abstinence of three years’ duration or more, and 29 percent had died. Only 26 percent experienced continued serious problems with alcohol. Premorbid social stability and sustalned abstinence made independent contributions to good psychosocial outcome at eight years. Premorbid social stability and Alcoholics Anonymous attendance made independent contributions to sustained abstinence. Review of these data and other major longitudinal studies suggests that factors other than professionally organized treatment per se exert substantial effect upon long-term outcome.

Alcoholism is present in one quarter of patients admitted to general hospital medical services [l-3], and the estimated costs of alcoholism in the United States are greater than costs from all cancers and res- piratory diseases combined [4]. Like other chronic diseases, alcoholism leads to multiple hospitalizations, remissions, and relapses; it often ends in premature death. Unlike most chronic disease, however, alcoholism remains a disorder with a largely uncharted course. It is well known that eventually people with alcoholism disappear from sight, but it is astonishing that we do not know if this disappearance results from invalidism and premature death or from recovery.

To our knowledge, no follow-up studies have been published that include both multiple contacts with alcoholic subjects and follow-up of those subjects for more than four years. If the Rand Report [5] could assert that publicly funded alcoholism treatment centers have led to improvement in 67 percent of admissions, Gordis [6] could editorialize almost simultaneously that there has been no progress in the treatment of alcoholism in the last 25 years. In contrast to the therapeutic opti- mism of the Rand Report’s authors, Gordis suggested that “only a minority of patients who enter treatment are helped to long-term recovery.” A comparison of three studies [ 7-91 of 2 14 alcoholic patients who received no more than advice with four studies of 685 similar patients [lo] receiving inpatient treatment revealed no significant differences in outcome at the end of a two-year period. Other controlled studies have offered evidence that inpatient treatment per se [ 1 i] and compulsory inpatient treatment followed by compulsory clinic follow-up [ 121 offered no discernible two-year advantage over vol- untary outpatient treatment.

In part, the lesson is that disorders resulting from habits yield less to intensive hospital care than they do to sustained care. In alcoholism, it is not unusual for a singular act of “caring” such as a follow-up letter

or a chance encounter to somehow extend to the patient the power

September 1983 The American Journal of Medicine Volume 75 455

A’_CWBCISM TREATMENT-VAl’_t_AtJT ET A!

of a therapeutic tool. Baekeland et al [ 131 and Costello [ 141 have documented that when favorable premorbid characteristics of alcoholic patients are controlled for, then the apparent superiority of a variety of specific treatments largely disappear. Certainly, it has been repeatedly demonstrated that a majority of treated alcoholics will be functioning better and drinking less during a given month six to 18 months after treatment than they were during the month prior to admission [5,15,16]. However, in any chronic illness with a fluc- tuating course, hospitalization is usually sought during clinical nadirs; thus, some of the posthospital improvement may be viewed as the natural history of the disorder.

In part, the lesson is that if we are to understand alcoholism, we need studies of longer than two years’ duration. The therapeutic pessimism of some investi- gators [6,7] stands in sharp contrast to the optimistic

assertion that eventually alcoholism is a self-limiting

disease [ 171. To address such uncertainty, the present report is an eight-year prospective study of severely alcoholic patients who were contacted at multiple points in time with little attrition. The duration of this study is twice that of any other prospective study in the literature. The results are integrated with available published studies longer than six years that have followed-up alcoholic patients at a single point in time.

PATIENTS AND METHODS

Our sample consisted of the first 1 IO men and women who were admitted for alcohol withdrawal to the inpatient ward at the Cambridge and Somerville Program for Alcohol Re- habilitation at the Cambridge Hospital. On admission, in an- ticipation of prospective follow-up, we gathered systematic and extensive data on all patients regarding their previous social adjustment and alcohol abuse. Four patients who did not stay 24 hours were excluded from the study; the remaining 106 stayed for 5 f 4 days.

During their hospital stay, all patients received daily indi- vidual counseling, two to three hours of group discussion, and formal education about medical issues and alcoholism; they attended Alcoholics Anonymous meetings twice weekly. On discharge, patients were encouraged to attend twice weekly group meetings. All knew that they could return to the program indefinitely at no charge. Over the next eight years, a concerted effort was made to contact the 106 patients every 18 months; 80 to 90 percent of the sample was contacted on each of five occasions. On each follow-up wave, abstinent or asymptomatically drinking patients were personally interviewed by a different interviewer. Patients experiencing symptoms from alcohol were either interviewed during detoxification, or relatives were interviewed, or recent clinical charts were reviewed. Drinking history, alcohol-related problems, social adjustment, occupational history, physical health, and stability of address were assessed on each oc- casion. Corroboratory evidence was obtained from our program staff of more than 80-a network that included neigh-

borhood clinics and Alcoholics Anonymous meetings that expatients were likely to use. Since most patients had multiple contacts with Cambridge Hospital clinical services, in- formation about most patients was obtained from IO to 20 different sources. The final contact was in the spring of 1980 by an interviewer (CC.) with 10 years’ experience in the alcohol field who had also known most of the patients at first admission. At each interview, a special effort was made to assess Alcoholics Anonymous utilization. Frequent Alco- holics Anonymous attendance was confirmed by many of our large clinical staff who attended Alcoholics Anonymous. Admisslon Measures. The Straus-Bacon Scale [ 181 is a well established four-point prognostic scale that gives one point if an alcoholic person: (1) has had a steady job for the past three years; (2) had a stable residence for the past two years; (3) is currently married and living with spouse; (4) is currently not living.alone.

The psychosocial adjustment of each patient over the preceding two years was assessed-both on admission (1972) and in 1980 (or at death)-and assigned to one of four categories: skid row, unemployment more than 80 percent of time and residence in a single room, the street, or an in- stitution; marginal, a job or a stable home situation but not both and such social instability attributable to alcohol abuse; fair, unemployment due to chronic physical illness or social isolation due to psychiatric disability but not as a result of alcohol abuse; stable, a regular job (includes homemaking), a stable residence, contact with relevant family members, and no serious emotional or physical disability. (For statistical analysis psychosocial adjustment was also treated as a four-point scale.)

Although physiologic dependence on alcohol is a contin- uum, our operational definition was that the patient had required 750 mg or more of chlorodiazepoxide during detoxification or revealed signs of severe withdrawal such as sei- zures or delirium tremens during prior admissions. Outcome Measures. Psychosocial adjustment (1980 or at death) was rated as on admission. Deaths and causes of death were documented by death certificate.

Outcome drinking status was assessed by a three-point scale: 1 = stable remission; 2 = intermittent alcohol abuse; and 3 = chronic alcoholism. Stable remission indicated community residence andno known alcohol-related problems during 1977-1979 (or, if dead, during the last three years of life). Most such persons were abstinent; a few were drinking asymptomatically. Each had been interviewed by at least three different clinicians. Our operational definition of abstinence was less than one drink a month and not more than one episode of intoxication-and that of less than a week’s duration-in the past 24 months. In most cases, this meant total abstinence. lntermiftenf alcohol abuse indicated neither stable remission nor chronic alcoholism. A few such patients were institutionalized; others managed to remain abstinent for months in halfway houses or between binges; others fell in the category of improved but not asymptomatic. Chronic alcoholism indicated symptomatic heavy drinking (damage to health, occupation, or relationships) for at least six months of each of the last three years andone or more hospitalizations for detoxifications during 1977-1979 or, if dead, during the last three years of life.

456 September 1963 The American Journal of Medicine Volume 75

ALCOHOLISM TREATMENT-VAILLANT ET AL

Figure 1. Composite eight-year course of 100 alcoholic patients after discharge from the hospital. In a given year, Abs- tinent indicates more than 51 weeks of total abstention from alcohol with corro- boration from more than one source. ?Abstinent (light stippling) indicates evidence for abstinence unreliable or that the patient was abstinent for greater than 44 but less than 5 1 weeks. RTSD indicates return to (asymptomatic) “social” drinking. Such persons drank more frequently than once a month and for longer than 12 months but with no discernible alcohol- related problems. ?Alcoholic (diagonal lines) indicates symptomatic alcohol abuse for more than two but less than six months in a given year, or ambiguous evidence suggesting alcohol abuse or no contact at all of a patient who manifested clear alcohol dependence in the preceding or following year. Alcohol dependence indicates unambiguous alcohol abuse for more than six months leading to hospitalization for detoxification. Institu- tionalized indicates nursing home, prison, or chronic disease hospital residence for more than nine months of the year.

0

-__ STATUS UNKblOWN

100

80

f? 2

w 60

if

20

’ 1972 ’ 1973 ’ 1974 ’ 1975 ’ 1976 ’ 1977 ’ 1978 ’ 1979 ’ 1980 ’ ALCOHOL USE STATUS DURING EACH YEAR

RESULTS

Three fifths of our sample were high school graduates, and 19 percent attended college. Alcohol abuse of at least 10 years’ duration was noted in 87 percent, and 80 percent had previously undergone detoxification. Compared with alcoholic patients attending private hospitals or industrial alcoholism programs, our sample was significantly biased toward severity and chronicity. For example, 68 percent were rated poorly (0 to 1) on the Straus-Bacon scale for prognosis; this was true of only 18 percent of patients in Straus and Bacon’s New Haven alcoholism clinic [ 181. Thus, upon admission to Cambridge Hospital, only a quarter were working, and only a third were living with a spouse. Half of our sample lived in single rooms or “on the street.”

Over the eight-year period, six patients were lost but not until data were collected for an average of three years. At last contact, one of these patients had been abstinent for six months, and two were abusing alcohol intermittently. Three patients continued to manifest severe alcoholism; two are known to be still alive, and the limited evidence available suggests continued alcohol abuse.

Originally, we had also constructed a control group comprised of those persons who requested detoxification but were refused admission because our beds were full. Within a year, however, so many of these

control subjects had gained admission to our program as to make a controlled study impractical.

Figure 1 depicts the yearly use of alcohol by the 100 alcoholic patients whom we successfully followed. At any single point in time, classification of drinking status depended on a verbal statement by the patient or a relative; over time, however, we assembled a large number of observations (up to 100) for each person. The records on all subjects from five half-way houses, three detoxification units, and four other counseling programs were reviewed. During eight years, for the average subject, we found records of 15 detoxification admissions and at least that many emergency or clinic visits. By 1979, alcohol use data were totally absent for only five of 800 patient-years to be accounted for. The clinical categorization of 7 15 patient-years appeared relatively certain: for 80 (10 percent) patient-years, the tentative categories (possibly abstinent and possibly alcohol-dependent) were used. Prolonged follow-up, with its emphasis on psychosocial function and repeated contacts, made up in validity what any single observation may have lacked in reliability.

Figure 1 suggests an explanation of the steady de- cline in the observed prevalence of alcoholism after age 45. Over eight years, the percentage of stable remissions rose steadily to 34 percent, and 29 percent of the patients had died. One year after the index detoxifica-



percent of the same 100 patients achieved at least six months of abstinence-a criterion often used to indicate recovery. In a briefer follow-up, then, a majority of patients could have been classified as both treatment successes and treatment failures. Such apparent am- biguity disappeared with longer follow-up.

Table II answers the second question. Certainly psychosocial adjustment in 197 1 predicted psychosocial adjustment in 1979, but stable abstinence led to improved psychosocial status and chronic alcoholism led to deterioration. In 197 1, the psychosocial adjustment of 21 percent of the 29 patients with stable remissions had been classified in the “skid row” category; by 1979, none was so classified.

Table Ill addresses the third question and illustrates that association of Alcoholics Anonymous utilization with remission noted in Table I cannot be ascribed to premorbid social stability. Although premorbid psychosocial stability in 1972 predicted subsequent clinical remission (Table I), Table Ill shows that lack of premorbid social stability in 1972 predicted subsequent utilization of Alcoholics Anonymous. Furthermore, among the 32 who frequently attended Alcoholics Anonymous, there was an observed increase of “stable” psychosocial adjustment from two in 1972 to 15 by 1980. Thus, frequent Alcoholics Anonymous attendance (mean = 600 meetings) may have played a causal role in both social and clinical improvement. Multiple regression analysis reveals that if the premorbid variables in Table I could explain 46 percent of the variance in outcome psychosocial adjustment, Alco- holics Anonymous attendance (when entered last in the regression equation) explained an additional 14 percent of the outcome variance. Multiple regression also revealed that if premorbid social variables explained 10 percent of the variance in drinking status outcome, frequency of Alcoholics Anonymous attendance (when entered last in the regression equation) explained an

additional 25 percent of the variance.

Table IV assembles for the first time what we believe are the 10 longest, adequately documented follow-up studies of alcoholic patients in the literature [ 19-271. The patients are from Norway, Sweden, and the United States and reflect very different social backgrounds. Although care has been taken to tabulate the results in as uniform a manner as possible, generalizations must be tentative. Remission rates were somewhat reduced by chronicity of illness on admission; more importantly, remission rates bore a definite relationship to length of follow-up. If the percentage of good outcomes is divided by years of follow-up, 2 to 3 percent of alcoholic patients appeared to achieve stable abstinence or return to asymptomatic drinking during each year of follow-up. Remission rate was not affected by intensity of inpatient treatment. The studies by Ojesjo [26], Vaillant and

TABLE Ill Association of Admission and Outcome Social Adjustment Variables with Use of Alcoholics Anonymous

Use of Alcoholics Anonymous (1972-1979)

O-99 Meetings IOOt Meetings (n = 68) (n = 32)

Admission variables (1971) “Stable” psychosocial

adjustment “Skid row” psychosocial

adjustment Living with spouse Employed Never before detoxified Never previously in jail Straus-Bacon score 3-4

Eight-year outcome variables (1979)

“Stable” psychosocial adjustment

“Skid row” psychosocial adjustment

Living with spouse Employed Dead 300+ visits to Alcoholics

Anonymous (in eight years)

22%

40%

41% 22% l

29% 22% 25% 3 % * 29% 28% 26% 16%

24%

30%

51% 35% 37%

0%

6 % l

31%

47% *

22%

32% 58% 13 % + 60%’

l Significance p <0.05 chi-square test.

Milofsky 1271, and Goodwin et al [22] report the course of largely untreated alcohol abusers. The studies by Voegtlin and Broz [ 191, Lundquist [23], and Bratfos [24] report the course of alcoholics who received extensive inpatient treatment. Both sets of studies report similar remission rates. The problem in interpreting such results, of course, is that treated inpatient samples usually include patients with more serious disease.

The death rates depicted in Figure 1 and Table IV are roughly three times those expected for nonalcoholic men and women of comparable age. In our study, 10 percent of the patients younger than 40 years on admission were dead eight years later. This was true for 25 percent of those between 40 and 50 and for almost 50 percent of those older than 50. Death certificates reported that five deaths were from coronary throm- bosis, eight from homicide and accident, four from cirrhosis, and four from cancer of the pharynx, lung, or stomach. One of the remaining deaths was from suicide, five from infections and/or “alcoholism,” one from prostatic cancer, and one unknown.

COMMENTS

Several points deserve emphasis or clarification. First, although there are many pitfalls in contrasting outcome in unmatched clinical samples, one interpretation of our


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findings and of those in Table IV is that alcoholic patients recover not so much because we treat them, but because they heal themselves. An alternative interpretation of our findings is that if the appropriate treatment of advanced alcoholism is a sustained effort to encourage alcoholic persons to utilize Alcoholics Anonymous, then our treatment was very effective indeed.

Second, our findings may be criticized because we failed to interview relatives and to use blood alcohol levels to confirm abstinence. However, since we were able to establish not only alcohol use but also relapse to alcohol dependence in 95 percent of our sample, our methods are not insensitive. Eight years of repeated follow-up interviews with careful psychosocial as- sessment and with minimal attrition would appear to make up in long-term validity what the study lacks in cross-sectional reliability. In addition, studies reviewed elsewhere [5,7,22] reveal that, although alcoholic patients underreport how much they drink, they are fairly reliable historians regarding alcohol-related problems-the criteria that we used to define remission and relapse.

Third, our definition of abstinence (see Patients and Methods section) may not seem strict enough. However, in assessing long-term outcomes, we thought it more appropriate to equate virtual abstinence for 24 months with literal abstinence rather than with relapse or with asymptomatic drinking. A few examples will clarify the research issues and our decision process. Among the 25 patients whom we classified as stably abstinent for a collective total of 125 years, six had occasionally taken a drink and three had had one detoxification each. For example, one man once in seven years drank for two days and then sought hospitalization; by our criteria, he was classified as having a “stable remission.” In contrast, another man had been abstinent 95 percent of the time since discharge, but he had eight two-week binges and eight hospitalizations in eight years; he was classified by our criteria as having “intermittent alcoholism.” A third man with four brief episodes of detoxification in four years was classified by our criteria as abstinent with a “stable remission,” but he has had a relapse since the end of the study. Time is such an important dimension in understanding alcoholism.

Fourth, our present findings support the contention that stable abstinence is highly correlated with social remission. The alternative view (based on anecdote and short-term studies) that abstinence may be a puritanical goal bought at the price of psychosocial well-being [28,29] could not be supported. Indeed, a recent lo- year follow-up of the 20 alcoholic patients that the Sobells “taught” to resume controlled drinking reveals results identical to those in Table IV-30 percent stable abstainers, 5 percent asymptomatic drinkers, 20 per-


cent dead, and 45 percent symptomatic alcoholics

[301. Fifth, short-term study of alcoholic patients tends to

obscure the natural history of the disorder. One limita- tion is that clinic studies, because they identify alcoholic patients rather late in their illness, tend to oversample repeaters. For example, included among the 106 “first” admissions to our newly opened detoxification unit were 10 patients, frequently treated at other detoxification centers in the past, who were to comprise a majority of the Cambridge Hospital program’s most chronic repeaters-even though the program by now includes 8,000 different clients. Brief follow-up also fails to reveal whether alcoholic patients eventually disappear from sight because they recover or because they die. Finally, short-term studies do not permit the establish- ment of stable outcome categories. On the one hand, on a month-by-month basis, even severely alcoholic patients are as likely to engage in controlled drinking or to be abstinent as they are to abuse alcohol [ 5,7,3 11. Indeed, the present data suggest that abstinences of even six months’ duration reveal little about long-term outcome. Even when abstinence is prolonged, psychosocial recovery in abstinent alcoholic persons is a matter of years and not months [ 271.

Sixth, if “return to asymptomatic drinking” seems most feasible for alcoholic patients with relatively few adverse consequences of drinking [7,27], patients with severely symptomatic alcoholism often achieved stable abstinence. Admittedly, on any single admission, a history of frequent past hospitalizations is a bleak prognostic sign. However, it was a hopeful finding that six of the 29 patients eventually classified as having stable remissions had undergone 10 or more prior detoxifications. An explanation for this paradox may be that premorbid psychological vulnerability has less to do with the cause of alcoholism than previously believed [ 32-351.

Seventh, good premorbid psychosocial adjustment, especially marriage and employment, favorably affects short-term prognosis and compliance with clinic treatment [ 13,36,37]. Over the long term, premorbid psychosocial stability may play a smaller role. If alcoholic persons are identified by community, rather than by clinic, sampling methods, then multidecade follow-up suggests that remission from alcoholism is most closely associated with four quite different factors [27,38]. These factors are (1) finding a substitute dependency (e.g., meditation, compulsive hobbies, overeating, etc.) to replace alcohol; (2) experiencing a consistent aversive experience related to drinking, such as use of disulfiram or a painful ulcer; (3) discovering a fresh source of hope and self esteem; and (4) obtaining new social supports, often through a new job or marriage. In the present study, many of the patients with the best



outcomes found most of these factors through their use of Alcoholics Anonymous; 14 of the 29 such patients attended 300 or more Alcoholics Anonymous meetings. Of the remaining 15 with stable remissions, several encountered the four healing factors by other means, Four used disulfiram or were too physically ill to con- tinue drinking; two “depended” on prayer and meditation; five of the 29 with stable remissions became for- mally involved in the alcoholism treatment field. In a 12-year prospective study, these same four factors appeared important to recovery from heroin addiction [39], and fresh sources of hope and social supports are important in the amelioration of many chronic disorders [40-421. To say that alcoholics heal themselves is not to suggest that recovery is spontaneous.

Eighth, well-controlled studies of alcoholism treatment have suggested that many medical and psychiatric therapies are of limited efficacy [7,8,10,28,43,44]. This

study suggests that one of the most valuable roles that clinicians may play is to assist patients to join Alcoholics Anonymous, but such a conclusion required almost a decade of observation. Relatively few patients will turn to Alcoholics Anonymous after a single clinic visit; however, the fact that half of our patients (including many with stable remissions) received 10 or more detoxifications allowed the Cambridge Hospital program to exert sustained pressure on them to discover Alco- holics Anonymous. A study of a community sample of alcoholic persons also noted that more achieved remission through Alcoholics Anonymous than through clinic treatment [27], but this study required 30 years of prospective observation.

Finally, third-party payers have a right to ask that alcoholism treatment programs (other than those fo-

1.

2.

3.

4.

5.

6.

7.

a.

9.

462 September 1983 The American Journal of Medlclne Volume 75

cused on detoxification and the relief of the medical consequences of alcoholism) produce results better than the natural history of the disorder. On the one hand, controlled studies [ 11,451 and literature reviews [46,47] suggest that prolonged two- to four-week inpatient treatment of alcoholism achieves results identical to those obtained by competent clinical advice or brief detoxification. On the other hand, alcoholism is a chronic disease that costs the nation 50 billion dollars a year [4,48], and careful studies show alcoholic patients better off a few months after clinic intervention than they were just before treatment [ 15,161. At least 12 controlled cost-benefit studies [49,50] conclude that the expense of providing outpatient alcoholism programs in health maintenance organizations and in in- dustry is more than repaid by declines in medical care utilization, in sick days, and in sickness and accident benefit costs.

Medicine still has much to learn from studying the natural history of alcoholism. Cost-effective treatment may not be found through prolonged inpatient intervention. In the future, research on alcoholism treatment should perhaps focus upon mechanisms to maximize the natural healing processes. We wish to emphasize that staying sober in a hospital for a month is less important than staying sober in the community for years. Thus, a nonpunitive outpatient response towards the continued need for rehabilitation should be cultivated. No matter how refractory their alcoholism seems, alcoholic patients should not be excluded from medical insurance coverage, from treatment by emergency rooms and detoxification centers, or from shelters for the homeless. Eventually, stable remissions may occur among the most unlikely prospects.

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prospective study of alcoholism treatment: eight-year follow-up

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