Washington, D.C. The National Institute on Alcohol Abuse and Alcoholism today announced main findings from the largest and most statistically powerful clinical trial of psychotherapies ever undertaken. Designed to test whether different types of alcoholics respond differently to specific therapeutic approaches, the eight-year, multisite trial confirmed one hypothetical "match" and did not confirm ten others, leading researchers to conclude that patient-treatment matching does not substantially alter outcomes.
"The hypothesis that patients who are appropriately matched to treatments will show better outcomes than those who are unmatched or mismatched is well founded in medicine, behavioral science, and alcoholism treatment," according to NIAAA Director Enoch Gordis, M.D. "These findings challenge the notion that patient-treatment matching is necessary in alcoholism treatment."
About nine percent of U.S. adults meet diagnostic criteria for alcohol dependence (alcoholism) and the less severe medical disorder alcohol abuse. Of these, more than 500,000 Americans were treated in 1993 in more than 8,000 inpatient and outpatient alcohol treatment programs in the United States. While some of these patients have experienced or eventually will experience lasting remission, authoritative studies report relapse rates of more than 50 percent or more at two to four years after treatment. A recent meta-analysis of past alcohol treatment outcome studies estimates that more than 50 percent of treated patients relapse within the first 3 months after treatment.
Researchers during the 1980s saw promise for improving alcohol treatment outcomes in reports from more than 30 small-scale studies indicating that patient characteristics interact with behavioral treatments to affect results. At the end of the decade, when the National Academy of Science's Institute of Medicine (IOM) recommended further research on patient-treatment matching, potential benefits were seen not only as improved treatment outcomes but also as increased cost-effectiveness and improved resource utilization.
NIAAA initiated "Matching Alcoholism Treatments to Client Heterogeneity" (Project MATCH) in 1989 to provide a rigorous test of the most promising hypothetical matches.
Project MATCH investigators selected three behavioral treatments that differed markedly in philosophy and practice: 12-step facilitation therapy (based on the principles of Alcoholics Anonymous but an independent treatment designed to familiarize patients with the AA philosophy and to encourage participation), cognitive-behavioral therapy (based on social learning theory and designed to provide skills for avoiding relapse), and motivational enhancement therapy (based on motivational psychology and designed to help patients mobilize personal resources to effect change). The treatments were selected in part for their distinctiveness and in part because each had demonstrated effectiveness, the potential to reveal matching effects, and the potential to be incorporated into standard alcoholism treatment programs. Many patients in the three treatments also participated in community meetings of Alcoholics Anonymous, a mutual support fellowship rather than a formal treatment.
Patient characteristics, chosen on the basis of research and theory, included severity of alcohol involvement, cognitive impairment, psychiatric severity, conceptual level, gender, meaning-seeking, motivational readiness to change, social support for drinking versus abstinence, sociopathy, and typology of alcoholism. The Project MATCH research group predicted 16 contrasts in patient responses to the treatments, to be measured as percentage of abstinent days and average number of drinks per drinking day during the year following treatment.
The researchers recruited 1,726 patients for two parallel study arms--one with alcohol dependent patients who received outpatient therapy and one with patients who received aftercare therapy following inpatient or day hospital treatment--that involved identical matching hypotheses and identical randomization, assessment, and followup procedures. Twenty-five therapists administered the therapies over a 12-week period in individual counseling sessions that adhered strictly to manuals developed for the trial.
The single confirmed match reported today is between patients with low psychiatric severity and 12-step facilitation therapy. Such patients had more abstinent days than those treated with cognitive-behavioral therapy.
Overall, Project MATCH participants showed significant and sustained improvement in increased percentage of abstinent days and decreased number of drinks per drinking days, with few clinically significant outcome differences among the three treatments in either treatment arm. For example, there was no difference in sustained abstinence among treatments in the aftercare arm. However, outpatients who received 12-step facilitation were more likely to remain completely abstinent in the year following treatment than outpatients who received the other treatments.
Patients who participated in Project MATCH also showed decreased use of other drugs, depression, and alcohol-related problems as well as improved liver function--improvements that were maintained throughout the 12 months following treatment, the period during which most relapses typically occur.
The Project MATCH patients probably did well because the treatments were of high quality and well delivered, according to Thomas F. Babor, Ph.D., Department of Psychiatry, University of Connecticut Health Center and principal investigator for the Project MATCH Coordinating Center: "The striking differences in drinking from pretreatment levels to all followup points suggest that participation in any of the MATCH treatments would be associated with marked positive change."
Gerard Connors, Ph.D., chairperson of the Project MATCH Steering Committee and principal investigator at the Research Institute on Addictions in Buffalo, New York, noted that today's findings do not rule out the possibility that other patient-treatment matching effects may be clinically important. "The MATCH data do not speak at all to matching patients types to different treatment settings, therapists, psychotherapies other than those studied, or pharmacological treatments," he said.
"A logical next step for alcoholism treatment research is to test our quite excellent behavioral treatments in conjunction with promising pharmacological treatments for alcoholism," said Richard K. Fuller, M.D., Director of NIAAA's Division of Clinical and Prevention Research, which oversaw Project MATCH.
The Project MATCH findings may surprise but should not dismay those who foresaw a revolution in alcohol treatment delivery based on patient-treatment matching, said Dr. Gordis. "These findings are good news for treatment providers and for patients who can have confidence that any one of these treatments, if well-delivered, represents the state of the art in behavioral treatments."
"Research attention now must focus full force on illuminating the complex biochemical mechanisms of alcoholism, including the abnormal appetite for that leads to impaired control over intake, tolerance--drinking ever greater amounts to achieve a desired effect--and the discomfort of abstinence known as craving. Our best pharmacologic and behavioral treatments await that understanding."
"Matching Alcoholism Treatments to Client Heterogeneity: Project MATCH Posttreatment Drinking Outcomes" appears in the January 1997 issue of the Journal of Studies on Alcohol , the oldest journal in the field of alcohol research.
Other NIAAA news releases and materials are available on the Internet via the NIAAA home page address: http://www.niaaa.nih.gov.