MATCH This

Stanton Peele

The results from Project MATCH, an 8-year, $25 million dollar plus comparative study of alcoholism treatments, are in. The study didn't prove what it set out to — that matching individuals with alcohol problems to appropriate treatments — enhances treatment outcome.

But the NIAA brass are making the best of a busted egg. According to NIAAA head Enoch Gordis, and now Margaret Mattson, a MATCH organizer, this study shows that all treatments for alcoholism work well, so we can just continue on our merry way in American alcoholism treatment.

The conduct of the project

The one qualification Mattson offered is that the treatments must be delivered "with skill and as they were conducted in Project MATCH." Is there any reason to suspect this won't happen? Well, aside from the $27 million that were spent, consider these aspects of how MATCH was conducted:

1. CLINICAL TRAINING AND SUPERVISION. A good amount of the $27 million Project MATCH price tag was devoted to clinical development and supervision. Approximately 130 clinical professionals were involved in the project. Those delivering treatment were highly trained and supervised. For example, ALL SESSIONS WERE VIDEOTAPED and the tapes were monitored for quality control. Is it likely that this replicates the care and quality of standard alcoholism treatment in the US? Jon Morgenstern and Barbara McCrady have observed actual alcoholism treatment encounters, and they find quite the opposite to be true. As I wrote, "The care and quality control of Project MATCH therapy differs so substantially from standard treatment provided for alcoholism patients in the U.S. that the two bear almost no relationship."
2. SUBJECT VOLUNTEERS. The study began with 1726 subjects out of 4,481 who were screened for participation. Almost 500 eliminated themselves after first volunteering because they felt treatment was inconvenient. Others were discarded for "failure to complete the assessment battery; residential instability; legal or probation problems, etc." In other words, subjects were socially stable volunteers with the motivation to participate in an elaborate screening procedure. Project MATCH itself acknowledged: "The overall effect of being part of Project MATCH, with extensive assessment, attractive treatments, and aggressive follow­up may have minimized naturally occurring variability among treatment modalities and may, in part, account for the favorable treatment outcomes."
3. OUTCOME MEASUREMENT. Subjects substantially reduced drinking intensity and frequency of drinking across all treatments, but relatively few did not drink at all. About 20 percent of the outpatient group and slightly over a third (35%) of the hospital aftercare group abstained throughout the year follow­up. However, only 40% of aftercare and 46% of outpatient subjects drank heavily for three straight days during the year follow­up. In other words, a third of outpatient alcoholics drank without bingeing, compared with a fifth who abstained totally. By an alternate measure, according to the publication Science Times, "before treatment, volunteers drank on 25 days out of 30 days, a number that fell to 6 days of drinking per month by the end of the follow-up."

These results are summarized at Project MATCH: What It Was and What It Found

How are we doing treating alcoholism in the US?

Project MATCH says nothing about alcoholism treatment as delivered in the U.S. today. It was an experimental treatment program, developed with a care and expense and scientific direction unmatched by any actual treatment providers, like those in strapped and understaffed public agencies or those in private centers striving to maximize profits.

1. ALCOHOL DEPENDENCE IS INCREASING. If treatment were having a major beneficial impact, might we see alcohol dependence reduced? In fact, as alcoholism treatment has become commonplace in the U.S., important research groups -- including the Alcohol Research Group (ARG) of Berkeley and the Epidemiological Catchment study -- have noted alarming upturns in youthful reports of alcohol dependence. For example, between 1967 and 1984 (a period when alcoholism treatment in the US had its largest growth spurt), the number of young men (23-29) reporting an alcohol dependence symptom over the prior year jumped from 14 to 31 percent (according to ARG surveys). For young women, the jump was from 10% to 18 percent. In 1991, John Helzer and colleagues reported that the NIMH's Epidemiological Catchment Area (ECA) study found that 27 percent of men age 18 to 29 qualified for either alcohol abuse or dependence by DSM at some point in their lives, compared with 21 percent of men age 45 to 64 and only 14 percent of men age 65 and up.

2. TREATED ALCOHOLICS DO WORSE THAN UNTREATED, ACCCORDING TO NIAAA RESEARCH. But we can turn to the NIAAA's own research to find something less than support for Gordis's and Mattson's assertions that alcoholism treatment in the U.S. is dandy as is. The NIAAA has conducted its own longitudinal study of alcohol dependent subjects, with results NIAAA researcher Deborah Dawson reported in 1996. This is the National Longitudinal Alcohol Epidemiologic Survey (NLAES), designed and sponsored by the NIAAA with interviews conducted face-to-face by the U.S. Census Bureau. The key data were:

   NLAES Data on Alcohol Dependent Subjects

   Outcome categories	Treated (n=1,233)	Untreated (n=3,309)
   < 5 years since onset dependence
   abuse/dependence	70%	53%
   abstinent	11%	5%
   drinking w/o abuse/dependence	19%	41%
   20+ years since onset dependence
   abuse/dependence	20%	10%
   abstinent	55%	30%
   drinking w/o abuse/dependence	24%	60%
   Source: Dawson (1996)

   The NIAAA's actual data on Americans who are or have been alcohol dependent and who have received treatment or not are quite at odds with the optimistic results of Project MATCH projected by Gordis and Mattson, i.e.,:

   1. The large majority of alcohol dependent Americans do not enter treatment.
   2. But by not entering treatment, ALCOHOLICS ACTUALLY FARE BETTER IN OVERCOMING ALCOHOL DEPENDENCE. Unlike Project MATCH subjects, 70 percent of alcohol dependent Americans recently treated (within last 5 years) are still drinking alcoholically, compared with just over half of those who did not seek treatment. After 20 years of an alcohol dependence diagnosis, while those who have been treated generally fare okay (discarding, of course, those who have died or are not available for study), still twice as many are actively alcoholic as those not receiving treatment.
   3. The principal reason for the poor performance of those in treatment is their inability to reduce their drinking compared with untreated alcoholics, 6 in 10 of whom eventually appear to stabilize their drinking (although a fifth of those recently treated and a quarter of those whose alcohol dependence appeared over 20 years ago are now drinking without abuse or dependence).

   Dawson reported that those who went untreated on average had lower levels of alcohol dependence. But we need to be aware that all subjects were diagnosed as alcohol dependent and all would be welcomed for treatment anywhere in the United States.

   These data are reviewed in The Results for Drug Reform Goals of Shifting from Interdiction/Punishment to Treatment

Conclusion — Alcoholism treatment in the U.S.

ARG, ECA, and NIAAA surveys of actual alcohol dependent Americans indicate alcohol dependence is increasing, particularly among the young, and that American treatment as actually practiced reduces alcohol dependence less than does not receiving treatment. Meanwhile, giving in to the inevitable, the NIAAA and its directors now say that American alcoholism treatment is fine. This is, of course, to say that we can continue to place people into 12-step programs and expect the best (as Mattson explicitly claims), since 93 percent of American alcoholism treatment programs are based on the 12-Step, abstinence model. Thus, American treatment will continue to have people "work the steps" of alcoholism treatment, such as (Step 2)" [We] came to believe that a Power greater than ourselves could restore us to sanity," and (Step 3) "[We] made a decision to turn our will and our lives over to the care of God as we understood God." This is alcoholism treatment in the U.S. today, now officially sanctioned by the NIAAA.

While it is difficult to compare the treated and untreated groups in the NIAAA/NLAES study, simply stating the results for each of the two groups separately blows away assertions made about MATCH and assumptions about alcoholism and alcoholism treatment almost universally accepted in the U.S., to wit:

1. Of all alcoholics treated within five years of onset of alcohol dependence, 70% are still drinking alcoholically and 90% are drinking, albeit 20% are drinking without a diagnosis of abuse/dependence. This is not the picture of treatment you get from MATCH or popular claims about the success of alcoholism treatment. Furthermore, even among this treated group, twice as many alcoholics reduce their drinking as abstain.
2. Of people diagnosed as alcohol dependent within the past five years who do not seek treatment, almost half achieve remission, but only 5% are abstinent (@ 40% are drinking without an abuse/dependence diagnosis). The possibility of reduced drinking would seem to be an important treatment option for even alcohol dependent patients, considering only about 10% of treated alcoholics abstain.
3. Twenty years after a diagnosis of alcohol dependence, a solid majority of untreated alcoholics are drinking without an abuse/dependence diagnosis (60%), twice as many as abstain, and only 10% continue to drink alcoholically for longer than 20 years. This group, comprising the solid majority of alcoholics, shows just how self-limiting (as opposed to progressive) alcohol dependence is.

A principal investigator of Project MATCH retorts

I am a Project MATCH P.I., who has followed much of the correspondences on this list server regarding Project MATCH results.

Contary to Stenton Peele's conclusion, the results of Project MATCH are far from concluded. There are at least two more papers (one under review, and one in preparation) focusing on the primary match of findings. That should be digested. Only then do I think we will have a sufficient view of the finding's to evaluate MATCH's contribution. To the alcohol treatment knowledge base, I'd say publications of these results are about a year away.

On the other hand, discussion is "livelier" without the facts.

Richard Longabaugh

To which Stanton replies

Dear Dick:

Gosh, the summaries I have seen published by Mattson and the interviews I have read with Gordis have strongly affirmed the result that MATCH shows, overall, that alcoholism treatment is beneficial.

In Science News (January 25, 1997), Gordis was quoted as saying: "The good news is that treatment works. All three treatments evaluated in Project MATCH produced excellent overall outcomes."

Gordis continued by characterizing the matching results in the study fairly decisively as well: "For now, Gordis contends, it appears that individual therapies based on a variety of philosophies make approximately the same dent in alcohol use."

Mattson, in her summary of Project MATCH in the government newsletter EPIKRISIS (March, 1997), wrote, again fairly decisively, "The main result of Project MATCH challenges a popular theory that it is necessary to match patients to treatment to achieve better results.... based on the main findings of Project MATCH, matching seems to add little to improving treatment results."

She further summarized, "The results indicate that the Twelve Step model, which is the most widely practiced treatment in the US, is beneficial," after having earlier concluded, "Patients in all three treatment conditions demonstrated major improvements in drinking." Coming where this article did, it suggests an official NIAAA position on the results.

As I understand your comment, you feel it is better that any critiques or revisionist interpretations should be withheld until a year or more from now, while summaries like these sink in. Is this a kind of unilateral disarmament proposal?

Ironically, although you have an official position in this study, you make this recommendation to those viewing it from the outside, but don't seem concerned with pronouncements from those officially connected with the study. Your statement, "on the other hand, discussion is 'livelier' without the facts," is fairly insulting. In fact, in this case, I like to think that I have brought to the forefront a number of factual and methodological issues in Project MATCH not aired elsewhere.

Regards, Stanton