Addiction Treatment Outcome Evaluation

Although there are hundreds of published studies on what treatment methods are most (and least) effective in treating alcohol use disorders, this literature is not very accessible to practicing clinicians.  I decided early in my career that one service I could provide for the field was to summarize the findings of this large body of clinical research, to make it available and useable for those who provide treatment.  With the very earliest of these reviews (Miller & Hester, 1980), it became obvious that there was a very large gap between the treatment methods most strongly supported by research and those commonly used in practice.  This well-documented science/practice gap eventually led to the international “evidence-based treatment” movement in addiction treatment and other fields.

As the treatment outcome literature grew, we restricted our reviews to controlled clinical trials, and eventually dubbed the project “Mesa Grande” because of the huge table that it produced.  Four generations of this “What works?” review were published (Miller et al., 1995, 1998, 2003; Miller & Wilbourne, 2002), and the project and files were turned over to Dr. Paula Wilbourne when I retired.

In the 1970s and 1980s, inpatient programs were a popular mode for treating alcoholism, and consumed the lion’s share of treatment resources.  We conducted a review of the available studies comparing outcomes of residential, day treatment and outpatient treatment programs (Miller & Hester, 1985), concluding that treatment setting showed no significant impact on overall treatment outcomes.  The “managed care” movement soon thereafter began restricting the use of residential/inpatient treatment, leading ASAM to develop placement criteria.  The vast majority of treatment for alcohol problems is now delivered on an outpatient basis.

This in turn led to a broader interest in the relationship between cost of treatment and its effectiveness.  Our initial review (Holder et al., 1991) found, if anything, an inverse relationship between the cost of delivering a particular treatment method and evidence for its efficacy.  Subsequent analyses within Project MATCH found similar outcomes for longer versus shorter treatments, and thus at least a modest cost-effectiveness advantage for the briefer treatment (in this case, motivational enhancement therapy).

Our analyses of the treatment outcome literature led to some interesting larger questions.  How much has the treatment of alcoholism actually changed over the course of 40 years (Miller, 1992)?  If you wanted to stack the deck in your favor when evaluating alcoholism treatment, how could you do it (Miller & Sanchez-Craig, 1996)?  How effective is alcoholism treatment on average, as delivered in the United States (Miller, Walters & Bennett, 2001)?  Why are clinicians often unimpressed by clinical studies, and how large does a treatment effect have to be before it matters to treatment professionals (Miller & Manual, 2008).

Studies and Articles on Addiction Treatment Outcome Evaluation

(in chronological order)

Miller, W. R., & Hester, R. K. (1980).  Treating the problem drinker:  Modern approaches.  In W. R. Miller (Ed.), The addictive behaviors: Treatment of alcoholism, drug abuse, smoking and obesity (pp. 11-141).  Oxford: Pergamon Press.

Miller, W. R. (1982).  Treating problem drinkers: What works?  The Behavior Therapist, 5, 15-18.

Miller, W. R., & Hester, R. K. (1986).  The effectiveness of alcoholism treatment methods: What research reveals.  In W. R. Miller & N. Heather (Eds.), Treating addictive behaviors: Processes of change (pp. 121-174).  New York: Plenum Press.

Miller, W. R., & Hester, R. K. (1986).  Inpatient alcoholism treatment: Who benefits?  American Psychologist, 41, 794-805.

Miller, W. R. (1988).  Follow-up: Purposes, practicalities, and pitfalls.  Drugs & Society, 2, 93-107.

Miller, W. R. (1989).  Follow-up assessment.  In R. K. Hester & W. R. Miller (Eds.), Handbook of alcoholism treatment approaches: Effective alternatives (pp. 81-89).  Elmsford, NY: Pergamon Press.

Miller, W. R., & Hester, R. K. (1989).  Inpatient alcoholism treatment: Rules of evidence and burden of proof.  American Psychologist, 44, 1245-1246.

Miller, W. R. (1989).  The effectiveness of alcoholism treatment modalities: Testimony to the U.S. Senate Committee on Governmental Affairs.  In Causes and consequences of alcohol abuse, Part 2 (pp. 158-185).  Washington, D.C.: U.S. Government Printing Office.

Miller, W. R. (1989).  Treatment modalities: Process and outcome.  In Committee to Identify Research Opportunities in the Prevention and Treatment of Alcohol-Related Problems, Prevention and treatment of alcohol problems: Research opportunities (pp. 169-213).  Washington, DC: National Academy Press.

Holder, H., Longabaugh, R., Miller, W. R., & Rubonis, A. V. (1991).  The cost effectiveness of treatment for alcoholism: A first approximation.  Journal of Studies on Alcohol, 52, 517-540.

Miller, W. R. (1992).  The effectiveness of treatment for substance abuse: Reasons for optimism.  Journal of Substance Abuse Treatment, 9, 93-102.

Miller, W. R. (1992).  The evolution of treatment for alcohol problems since 1945.  In P. G. Erickson & H. Kalant (Eds.),  Windows on Science: 40th anniversary scientific lecture series (pp. 107-124).  Toronto: Addiction Research Foundation.

Miller, W. R., Brown, J. M., Simpson, T. L., Handmaker, N. S., Bien, T. H., Luckie, L. F., Montgomery, H. A., Hester, R. K., & Tonigan, J. S. (1995).  What works? A methodological analysis of the alcohol treatment outcome literature.  In R. K. Hester & W. R. Miller (Eds.), Handbook of alcoholism treatment approaches: Effective alternatives (2nd ed., pp. 12-44).  Boston, MA: Allyn and Bacon.

Miller, W. R., & Sanchez-Craig, M. (1996).  How to have a high success rate in treatment: Advice for evaluators of alcoholism programs.  Addiction, 91, 779-785.

Miller, W. R., Andrews, N. R., Wilbourne, P., & Bennett, M. E. (1998).  A wealth of alternatives: Effective treatments for alcohol problems.   In W. R. Miller & N. Heather (Eds.), Treating addictive behaviors: Processes of change (2nd ed., pp. 203-216).  New York: Plenum Press.

Miller, W. R., Walters, S. T., & Bennett, M. E. (2001).  How effective is alcoholism treatment?  Journal of Studies on Alcohol, 62, 211-220.

Miller, W. R., & Wilbourne, P. L. (2002).  Mesa Grande: A methodological analysis of clinical trials of treatments for alcohol use disorders.  Addiction, 97, 265-277.

Wilbourne, P. L., & Miller, W. R. (2002).  Treatment for alcoholism: Older and wiser?  Alcoholism Treatment Quarterly, 20, 3/4, 41-60.

Miller, W. R., Wilbourne, P. L., & Hettema, J. E. (2003).  What works? A summary of alcohol treatment outcome research.  In R. K. Hester & W. R. Miller (Eds.), Handbook of Alcoholism Treatment Approaches: Effective Alternatives (3^rd ed., pp. 13-63).  Boston, MA: Allyn & Bacon.

Miller, W. R. (2005).  Are alcoholism treatments effective?  The Project MATCH data: Response.  BMC Public Health, 5:76. (http://www.biomedcentral.com/1471‑2458/5/76).

Miller, W. R., & Manuel, J. K. (2008).  How large must a treatment effect be before it matters to practitioners?  An estimation method and demonstration.  Drug and Alcohol Review, 27, 524-528.