Health-care reform provides an opportunity for evidence-based alcohol treatment in the USA: the National Institute for Health and Clinical Excellence (NICE) guideline as a model


The USA is entering an era of major change in the financing and delivery of health-care services, including a greater emphasis on evidence-based treatment. Mainstream US alcohol treatment is an amalgam of experience- and evidence-based approaches; the National Institute for Health and Clinical Excellence (NICE) alcohol guideline could provide a model for reform in the USA.

The NICE guideline [1] on the diagnosis, assessment and management of harmful drinking and alcohol dependence should be required reading for anyone concerned about evidence-based approaches to alcohol treatment. The guideline was developed to ‘improve standards of care, diminish unacceptable variations in the provision and quality of care … and ensure that the health service is patient centred’ (p. 13). Under the UK single-payer model, once a NICE guideline is published and disseminated, local health-care groups are expected to develop a plan to implement the guideline.

The guideline covers five major domains, offering a comprehensive set of recommendations that carefully distinguishes the needs of persons with harmful drinking/mild alcohol dependence from the needs of those with more severe dependence. Key recommendations focus on the therapeutic relationship; family involvement; use of standardized assessment tools; development of agreed-upon drinking goals; use of care coordination and case management; use of evidence-based treatments, such as motivational interviewing, Twelve-step facilitation, behavioral couple therapy, and pharmacotherapies; mutual help groups; treatment of comorbid psychological problems; and outcomes monitoring.

This is an excellent guideline, but could it be applied in the USA? The delivery of alcohol treatment is quite different in the USA than in the UK; these differences might limit the applicability of the guideline. In the USA, alcohol and drug problems are typically treated in the same programs, and the administration of policy and services occurs through a single state authority over both alcohol and other drug issues. There are approximately 13 000 substance abuse treatment programs in the country. Treatment is provided through private programs, funded through health-care insurance, self-payment, or endowments; and public programs, funded through sources including Medicaid (for low income individuals and those with disabilities), Medicare (for older adults) and block grants from the Federal government to each state. Each of the 50 states independently governs the system of care within that state; sometimes authority is assigned at the county level (with 3033 counties or county-equivalents in the USA). The large number of programs and decentralization of authority challenge the application of any uniform standard across the country.

The vast majority of US programs view alcohol problems from a disease perspective and incorporate Twelve-step principles into the treatment, but more than half also say they have adopted motivational interviewing, motivational enhancement therapy, and cognitive-behavioral approaches [2]. The primary goal of treatment is typically abstinence from all psychoactive drugs.

In contrast to the UK, the USA has no systematic approach to incorporating research findings into alcohol treatment, nor are there US-wide mandated standards of care. The US Preventive Task Force (USPSTF) is tasked with making evidence-based recommendations about preventive and treatment health services, leading to guidelines for clinical care that are adopted by Medicaid and Medicare. The only alcohol-related USPSTF guideline is for alcohol screening and counseling in primary care settings [3]. Various other groups have developed and promulgated practice guidelines [4]; some private insurance companies use such guidelines for the purposes of reimbursement.

The structure and delivery of health-care services in the USA is likely to change considerably with the 2008 passage of mental health/substance abuse parity legislation, and full implementation of the 2010 Patient Protection and Affordable Care Act (ACA) (upheld by the US Supreme Court in June 2012). The ACA requires that alcohol and other substance use disorders (SUD) be part of the ‘essential health benefit’ package and prohibits insurers from denying coverage for pre-existing conditions. The ACA mandates SUD/mental health screening and referral in primary care settings. It is anticipated that expanded health-care coverage will lead to a greater number of individuals with SUDs who have insurance, resulting in a greater demand for SUD services.

The guideline represents a different philosophical approach to alcohol problems than that of the current US system and there are significant differences in the systems of care, but many of the assessment and treatment recommendations are highly pertinent to the USA. Philosophically, the mainstream US treatment system takes a medical approach. A formal Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis is required, and individuals are referred to as ‘patients’ or ‘clients’ (versus ‘service users’ in the guideline) who receive ‘treatment’ (versus ‘care’). Although programs and providers aligned with the guideline perspective exist in the USA, they do not represent a majority. Views of the family also differ. The guideline recognizes family engagement and support as a central component of treatment; mainstream US programs rarely, or only superficially, include a family component in treatment.

The guideline is supposed to lead directly to changes in the delivery of services; currently the USA has no similar system to enforce change. With the full implementation of the ACA, the USA will have to develop better ways to deliver evidence-based treatments and monitor/enforce their use; the UK system could provide a model. The US integration of alcohol and other substance use services within the same programs could make it more difficult to apply the guideline in the USA. However, there are sufficient similarities in the service delivery systems in terms of levels of care and differentiation of service needs based on problem severity that many of the guideline recommendations could be adopted.

The guideline recommends the use of standardized measures to assess individuals seeking services. The US system also is moving to a standardized intake assessment model, with many states requiring the use of the Addiction Severity Index [5]. The US system would do well to consider the more alcohol-specific measures recommended in the guideline. The selection of drinking goals continues to be more controversial in the USA than elsewhere. The guideline provides a sensible, evidence-based model for working collaboratively with clients to select treatment goals; the USA should more fully embrace that model. Finally, the guideline provides an excellent blueprint for selection of treatments based on presenting concerns and the severity of the drinking problem. The research literature that underpins the recommendations represents work of US, UK and other European scientists, suggesting a knowledge base that is generalizable across cultures. More fully adopting the assessment, goal-setting and treatments recommended by the guideline could improve outcomes and efficiency in the US system.

In conclusion, the Guideline Development Group (GDG) has performed an incredible service for those affected by problematic drinking. The US system of care is in a state of change as the ACA and the attendant changes in health-care delivery are enacted across the country. Philosophical perspectives on drinking problems and approaches to treatment are evolving slowly in the USA; the perspective and recommendations of the GDG should form a blueprint for advancing efficacious treatments on both sides of the Atlantic.

Declarations of interest