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Services for alcohol use disorders 

Services for alcohol use disorders
Chapter:
Services for alcohol use disorders
Author(s):

D. Colin Drummond

DOI:
10.1093/med/9780199696758.003.0060
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date: 25 August 2019

The alcohol treatment field has seen considerable change over the past 30 years. Some of this has been evidence based, and some has been largely politically driven, particularly in the pursuit of containing health care costs. On the positive side, a shift in policy from a limited number of treatment services catering only for the small minority of severely dependent drinkers, to more community orientated services with a greater emphasis on early identification and intervention, is to be broadly welcomed. However, in some places a move towards services catering for early stage ‘at-risk’ drinkers has been at the expense of losing services for those with more severe alcohol problems. While the evidence in favour of matching treatments to individual needs is still at a relatively early stage of development, and clear evidence of matching effects is not yet available, clinical practice needs to be guided by pragmatic principles by which more intensive treatments are provided to more complex patients, and/or in a stepped care paradigm. It must be concluded that, despite a large research effort in evaluating intensive versus less intensive alcohol interventions, there is still a long way to go in developing pragmatic clinical trials that evaluate effectiveness and cost-effectiveness of treatment in a way that can best advise practitioners in the typical treatment setting. On the positive side, research has begun to address fundamental health economic issues that are highly relevant to the rational funding of treatment services. Important in this is the development of health economic analysis in randomized controlled trials. The assessment of the impact of treatment availability on the prevalence of alcohol-related harm also represents a significant advance. Nevertheless, treatment research cannot occur in a vacuum. Research needs to take account of the funding environment in which treatment takes place. Further, treatment research needs to provide answers to the key issues facing commissioners of health care. With the gradual improvement in the quality of treatment research over the past three decades and the development of more advanced health economic methods to evaluate treatment, the treatment research community is in a much better position than ever before to provide evidence to guide the rational development of treatment services for alcohol use disorders. While many differences between health care systems exist in different countries, the evidence points to the need for a wide spectrum of services to cater for different needs. The development of low-threshold community-based services should not occur at the expense of more specialized services for more severe alcohol use disorders. Similarly, a treatment system that provides only specialist services for the minority of severe cases misses a significant public health opportunity to reduce the prevalence of alcohol use disorders through early, brief interventions.

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