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Introduction and Summary
As an aspect of its general responsibility for the health of the American people,
the U.S. Congress has been concerned about the treatment of persons with alcohol
problems. From time to time Congress has sought information on such treatment to guide
its legislative activities. In 1983, for example, the congressional Office of Technology
Assessment (OTA) responded to a request from the Senate Finance Committee with a
report entitled The E,ffecti`~eness and Costs of Alcoholism T~meM (Saxe et al., 1983~.
During the course of its deliberations in 1986 on the extension of the expiring
authorization of appropriations for alcohol an-d drug research programs, Congress noted (in
the words of the report of the House Committee on Energy and Commerce) that the
availability of these treatment services "is becoming increasingly important to the nation's
health care system. Accordingly, it authorized the present study on the treatment of
alcohol problems in Section 4022 of Public Law 99-570, the Alcohol, Drug Abuse, and
Mental Health Amendments of 1986, enacted on October 17 of that year. Section 4022
required the secretary of health and human services, acting through the director of the
National Institute on Alcohol Abuse and Alcoholism (NIAAA), to arrange for a study to
carry out the following charge:
(a) critically review available research knowledge and experience in the United
States and other countries regarding alternative approaches and mechanisms
(including statutory and voluntary mechanisms) for the provision of alcoholism and
alcohol abuse treatment and rehabilitative services;
(b) assess available evidence concerning comparative costs, quality, effectiveness,
and appropriateness of alcoholism and alcohol abuse treatment and rehabilitation
services;
(c) review the state of financing alternatives available to the public, including an
analysis of policies and experiences of third-party insurers and state and municipal
governments; and
(d) consider and make recommendations for policies and programs of research,
planning, administration, and reimbursement for the treatment of individuals
suffering from alcoholism and alcohol abuse.
Congress further specified that the study be carried out by the National Academy
of Sciences. In transmitting the congressional request to the Academy, the director of
NIAAA, Dr. Enoch Gordis, summarized those topics that might be viewed as having
especial importance for potential inclusion in the forthcoming study:
(1) the validity of outcome measures; (2) the role of minimal intervention as a
treatment modality; (3) better definition of patient types and treatment modalities;
(4) determining feasibility and potential benefits of matching patients with
treatments; (5) defining for whom an inpatient setting is appropriate; (6) the
controlled drinking issue; (7) getting better data on the costs of alcoholism and on
who pays and benefits; (8) choosing among the better of existing studies for more
rigorously designed replication.
1
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BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
In 1987, the National Academy of Sciences accepted responsibility for conducting
the study. The Academy is a private, nonprofit corporation chartered by Abraham Lincoln
in 1863 to provide independent advice to the government on matters of science and
technology. Over the years, components of the Academy have developed an interest in
dealing with issues relating to alcohol and drug problems.
a
For example, in 1981 the
Academy's Assembly of Social and Behavioral Sciences published a report entitled Alcohol
and Pub tic Policy: Beyond the Shadow of Prohibition (Moore and Gerstein, 1981~. Although
concerned with prevention rather than treatment, the report detailed a number of concepts
that are germane to the development of this study, including the use of alcohol problems
as an inclusive framework for consideration of the subject and the importance of attending
to those individuals with less severe alcohol problems as well as to those with more severe
difficulties.
As the component of the Academy devoted to the improvement of health care, the
Institute of Medicine (IOM) was assigned responsibility for conducting the study mandated
by Congress. IOM has a history of interest in this field and in the treatment of alcohol
and drug problems. At the request of a prior director of NIAAA, for example, IOM
produced the 1980 report entitled Alcoholism, Alcohol Abuse and Related Problems:
Opportunities for Research (IOM, 1980), which outlined a possible research agenda for the
next few years. Subsequently, the administrator of the Alcohol, Drug Abuse, and Mental
Health Administration (ADAMHA) asked IOM to review research opportunities in its
tripartite portfolio (which includes alcohol problems); the resulting document, entitled
"Research on Mental Illness and Addictive Disorders: Progress and Prospects, was
published in 1985 in the American .Iourrzal of P~ychi~ry (Board on Mental Health and
Behavioral Medicine, Institute of Medicine, 1985~.
More recently, NIAAA requested an update of the 1980 report. The initial portion
of the update, which deals with basic research, was published in May 1987 as Causes and
Consequences of Alcohol Problems: An Agenda for Research (IOM, 1987~. The final portion of
this study (IOM, 1989), which covers research opportunities in the treatment and
prevention of alcohol problems, was conducted at the same time as the present study on
the treatment of alcohol problems. To ensure coordination of the two efforts, a liaison
member serving on both committees was appointed. That coordination did in fact occur
is indicated by the appearance of a chapter of the research opportunities study as an
appendix to this report (Appendix B).
. . .
~ A ~
In addition, during the same period, IOM conducted a third relevant study (also
mandated by Public Law 99-570) on substance abuse coverage. Its overall purpose was to
assess the extent and adequacy of financial coverage for the treatment of drug abuse.
Again, to ensure coordination of the two studies, a liaison member belonging to both
committees was appointed. Although each of the three simultaneous studies was an
independent effort, a productive cross-fertilization occurred among them. Several outside
experts, for example, served as consultants for more than one study. IOM staff interacted
to ensure coordination of activities and the exchange of information.
Yet the three studies have had rather different emphases. The research
opportunities study and this study on the treatment of alcohol problems shared a common
general interest in treatment. The interest of the former, however, lay more in the area
of treatment research opportunities for the future; this study concerned itself with what
might be done to improve treatment in the near term and is based largely on current
knowledge. In addition, the research opportunities study dealt equally with prevention and
treatment. The financial aspects of treatment proved a common interest in the substance
abuse coverage study and this study; nevertheless, the interest of the former focused on
drugs other than alcohol and on mechanisms of insurance coverage, whereas the treatment
study committee concerned itself with more general aspects of the financing of treatment
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INTRODUCTION & SUMMARY
3
and the issue of cost-effectiveness. These congruities and disparities reflect the differing
questions posed to each committee.
The Study Process
IOM studies are carried out by steering committees appointed by the institute's
president. Because of the many contributions of the behavioral and social sciences in the
area of alcohol problems, in this instance, concurrence of the Commission on Behavioral
and Social Sciences and Education (CBASSE), a component of the National Academy of
Sciences, was also required for appointments. The membership of the steering committee
reflected the wide range of disciplines active in prevention, treatment, and research activities
in the field of alcohol problems and was required to be responsive to the questions raised.
Each member of the committee was understood to have not one but two special
roles to fulfill in the work of the group. First, each was to bring the benefit of his or her
professional experience in dealing with alcohol problems. Second, every member also had
a duty to function as an informed and responsible citizen in carrying out the committee's
work. It was hoped that such an emphasis would encourage committee members to rise
above special interests, current controversies, and loyalties to particular constituencies. The
reader must judge whether the committee as a whole enacted this dual role successfully but
may rest assured that such duality was diligently pursued.
Staff for the study were drawn from IOM's Division of Mental Health and
Behavioral Medicine. The role of staff was technical and supportive; the content of the
report is the responsibility of the committee. In addition, a project officer from NIAAA
subserved important liaison functions and provided invaluable information throughout but
did not participate in executive sessions of the committee when recommendations were
formulated. A list of committee members and staff follows the title page of this report.
Studies conducted by the IOM are not experimental in nature, and no primary data
are collected. Frequently, however, secondary analyses of existing data are made, and the
present study contains a number of examples of this sort of analysis (e.g., the material on
the availability of treatment in Chapter 7~. Fundamentally, IOM studies consist of the
assiduous assembly of available data relevant to the charge of the committee, followed by
the consideration and interpretation of the data by the committee as it formulates its
recommendations.
In keeping with its legislative charge, this report focuses exclusively on alcohol
problems. There is value in retaining such a focus; without it, the magnitude of these
problems in our society and the difficulties that arise in dealing with them might be
obscured. The committee recognizes that the interest of Congress in directing its attention
to alcohol alone reflects the public interest in distinguishing between illegal drugs and all
other drugs. Other manifestations of this interest are the existence of separate
constituencies, and of separate structures within the executive branch of the federal
government, for alcohol and drug problems.
The committee is aware of the widespread impression among clinicians that many
persons who are currently seeking treatment for alcohol problems, and especially younger
persons, have problems with other drugs; the opinion is also held, conversely, that many
persons seeking treatment for drug problems have problems with multiple drugs including
alcohol. Longitudinal data are lacking to document a trend toward polydrug problems in
populations that are presumptively at risk for them, but this lack may reflect more
accurately the paucity of longitudinal data rather than the reality of the phenomenon.
Should the trend prove to be widespread and persistent, a reevaluation of the inclination
to deal separately with alcohol and drug problems might be in order. However, although
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BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
the committee appreciates the potential importance of these issues, their consideration is
beyond the scope of this report.
Also in keeping with its legislative charge, this report focuses largely on treatment
rather than on prevention. The committee recognizes that prevention and treatment are
closely related and that primary prevention practices, which are directed at populations that
have not yet developed problems, may nevertheless have a significant effect on individuals
who have developed problems. The research opportunities study (IOM, 1989), conducted
at the same time as the present study (see above) has dealt extensively with primary
prevention, which accordingly is not discussed further here. Secondary prevention is
considered in both the research opportunities report (Chapter 10) and in the present report
(Chapters 3 and 9~.
The work of the committee was conducted primarily in a series of six general
meetings that were held over the course of the study in various locations. Four task forces
were constituted to elaborate critical concepts in particular areas; these groups included but
were not limited to members of the committee and held separate meetings. Each task force
developed a written report, on which much of the material in the final report is based.
Some of the task forces, such as the Task Force on Assessment and Treatment Assignment,
developed literally volumes of original written resource materials, some of which are cited
as references at appropriate places in the report text. Membership lists of the various task
forces appear in Appendix ~ In addition to their work on the task forces, committee
members also carried out functions for the committee as a whole (e.g., report review and
agenda specification).
To expand the range of information available for its deliberations, the committee
commissioned three papers on specific areas of interest. Staff and consultants of the World
Health Organization in Geneva, Switzerland, prepared an international review of treatment
practices, which appears as Appendix C of the report. Kaye M. Fillmore of San Francisco,
California, and her colleagues were commissioned to prepare a report on improvement in
alcohol problems outside of formal treatment (so-called "spontaneous remissions). This
report is a significant source for the text of the report, especially in Chapter 6. (Its authors
have revised and extended the paper and are seeking publication elsewhere.) Henrick
Harwood, at the time a staff member of the Research Triangle Institute, was commissioned
to explore aspects of the financing of treatment. His analyses revealed that a number of
these avenues of exploration were unfruitful; other aspects of his work have been
incorporated into Section V of the report.
Another source for Section V was a draft paper prepared by members of the Task
Forces on Financing and on Treatment Outcome Evaluation working together under the
direction of Harold D. Holder. The draft attempted to deal with the specific
cost-effectiveness of particular kinds of treatment. At the conclusion of the study it was
incomplete; its authors plan to continue their work and will seek publication of the paper
elsewhere.
The appendices also contain two additional reports that were felt by the committee
to be highly relevant to the study. As noted earlier, Appendix B is Chapter 9, "Treatment
Modalities: Process and Outcome," from the research opportunities study. It reviews
critically and summarizes the literature on the outcome of treatment for alcohol problems.
Although the committee for the research opportunities study took the lead in developing
this material, it was considered to be of central importance to both studies. Consequently,
rather than duplicate efforts, a joint project was undertaken, with many committee
members, task force members, and staff from the Study on the Treatment of Alcohol
Problems participating actively in the development of Chapter 9. Appendix B is a
significant source for Chapter 5 of this report, although it is generally relevant to the report
as a whole. Appendix D is a paper entitled "Coercion in Alcohol Treatment,n which was
authored by committee member Constance M. Weisner. The paper principally reflects her
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INTRODUCTION & SUMMARY
s
understanding of this complex area, although other committee members and staff
contributed to its development as well. It is a significant source for Chapter 6 of the
report.
Widespread solicitation of viewpoints on all issues was made by mail, telephone,
and personal interview. A day-long public meeting was held to hear testimony from many
of the groups with particular interests in the field. Numerous site visits were carried out
by committee members and staff. Relevant congressional hearings as well as meetings of
professional societies were scrupulously attended. Current and past literature was reviewed.
If despite these efforts every relevant viewpoint failed to receive its due, the failure stems
not from lack of effort but from the complexity of the subject matter.
In preparing its report, the committee attempted to keep several potential
audiences in mind. Because the report was prepared at the behest of Congress, a primary
goal was to respond to the congressional mandate and to provide information that would
be useful in developing a legislative agenda at both the federal and state levels. Many
other federal, state, and local governmental agencies are significantly involved in the
support of treatment efforts for alcohol problems, and it is hoped the report will also be
useful to these organizations. Another very important audience for the report is what those
who are in it often refer to as The field" those indispensable persons and organizations
whose work focuses on the understanding and treatment of alcohol problems.
Finally, because the use of alcohol and the domain of alcohol problems and their
consequences touch all members of our society, we have tried to prepare a report that
will be understandable and useful to all. In attempting to serve many masters, we may have
succeeded in serving none as well as they individually might wish. We can only hope that
these few words about the committee's intentions, although not an excuse for its
shortcomings, will nevertheless explain their origin.
The report discusses those issues pertinent to the charge of the committee that
were thoroughly reviewed by the committee as a whole; it presents the consensus of the
group. As such, it constitutes an achievement rather than an initial "given." In a group as
diverse as the committee, working in an area as complex and difficult as the treatment of
alcohol problems, disagreement was expected and, indeed, materialized. Points of
contention were put forward and discussed in professional and agreeable exchanges. Where
such disagreements proved to be significant, the chairman played an active role in working
out a satisfactory resolution. Compromise was usually effected through this process. In
the few instances in which disagreements persisted, they are noted in the text.
The following section is a summary of the contents of the report. A common
practice is to accompany each portion of such a summary with succinct, discrete
recommendations for action, often set off by typographical ~bullets." The committee gave
this approach due consideration and ultimately rejected it, not only for the report as a
whole but for various sections of the report. For example, the committee actively
considered including a fully specified assessment battery in Chanter 10 but decided this
degree of specification would prove counterproductive; the committee believes such batteries
might most appropriately emerge from a consensus process that draws on a much wider
base of opinion and interests than could be found in the committee. It did, however,
provide guidelines for the construction of an assessment battery, as well as a general outline
of what such a battery might look like.
As another example, much effort was expended to provide careful financial
estimates of the cost of implementing the approach advocated by the committee, the cost
benefits that were likely to ensue in comparison with alternative methods of procedure, and
the mechanisms whereby the costs might be met. Ultimately, however, such specification
seemed more illusory than real, because the data on which to base reasonable estimates
of costs and benefits are simply not available (see Chapters 8, 19, and 20~. There are many
potential funding mechanisms, and preferences for their differential use vary widely. The
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BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
committee considered it appropriate to confine its contribution in the area of financing to
a more general discussion, expressing its opinion, for example, that there seemed likely to
be a rough parity between the costs of the changes it advocated and the cost benefits that
were likely to arise. The available data do not allow the committee to go beyond a general
discussion.
In sum, the committee made a deliberate and conscious choice in many instances
not to be prescriptive. It did not believe that it could be prescriptive because many of the
relevant data were not available. Neither did it believe, however, that it ought to be
prescriptive; evolution toward the treatment systems it sees as desirable is best accomplished
through a broadly based process of consensus involving the field as a whole and all of its
diverse elements-indeed, a process involving society as a whole. In the balance of this
report the committee presents what it has called its vision of the direction in which it
believes and hopes treatment will evolve, as well as a number of guidelines on how to
negotiate the terrain of the future. What the committee has presented is not a finely
detailed map: it considers the drawing of such a map to be the future task of the many
rather than the present task of a few.
A Summary of the Text
To summarize the large volume of information it received and the conclusions it
reached, the committee has proceeded by (1) describing its vision of the endpoint toward
which it believes treatment is evolving and toward which it ought to evolve; (2) providing
its answers to a series of fundamental questions about treatment; (3) discussing in detail
particular aspects of the treatment process that it believes require special attention; (4)
reviewing the issue of special populations in treatment; (5) examining the financing of
treatment; and (6) evaluating the opportunities for leadership in the treatment area for the
future. The numbers of the points in this paragraph correspond to the six sections of the
report. A brief summary of their contents follows; full details are contained in the text.
Our Vision
During its deliberations the committee was guided by its vision of the probable
structure toward which treatment for alcohol problems seems to be evolving. That
structure is a treatment system in which a broad community-wide treatment effort is
coupled closely with a comprehensive specialized treatment effort. The role of community
agencies in treatment would include the identification of individuals with alcohol problems,
the provision of brief interventions to a portion of those identified, and the referral of
others to specialized treatment. Specialized treatment would emphasize comprehensive
pretreatment assessment, the matching of particular individuals to specific treatment
interventions, and the regular determination of the outcome of treatment. Assuring the
continuity of care and providing for the feedback of outcome results in the reformulation
of matching guidelines are also viewed as important functional elements of the emerging
treatment system. The most fundamental recommendation of the committee is that this vision
be shared, tested, refeed, and implemented.
Some Fundamental Questions
what Is Being Treated? The committee has elected to refer to the target of treatment
throughout the report as alcohol problems. This terminology is intentionally broad and
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INI'RODUCIION & SUMMARY
7
reflects the committee's view that the focus of treatment needs to be expanded. While
maintaining and, indeed, increasing its present concern for individuals with severe problems,
treatment must also address the vast and heterogeneous spectrum of problems that are of
less than maximum severity. The committee defines alcohol problems as those problems
that may arise in individuals around their use of beverage alcohol and that may require
an appropriate treatment response for their optimum management. "Alcohol problems" is
felt to be a more inclusive definition of the object of treatment than such current
alternatives as "alcoholism" or "alcohol dependence syndrome," but it is nevertheless
compatible with these widely used conceptual frameworks.
Chat Is Treatment? In keeping with its broadened definition of the focus of treatment, the
committee believes that the definition of treatment itself needs to be broadened. Treatment
is herein defined as those activities that must be undertaken to deal with an alcohol
problem and with the individual manifesting such a problem. A comprehensive continuum
of interventions is required to cope with the expanded focus of treatment the committee
is proposing. In specifying the elements of this continuum, the committee uses a
framework that includes the treatment philosophies of providers, the settings in which
treatment takes place, and the specific modalities used in each of the stages of
treatment-acute intervention, rehabilitation, and maintenance.
Who Provides Treatment? Recent years have seen a broadening of the programmatic contexts
rif tr~.q.tm~nt and of the kinds of experience and training that are considered appropriate
~ - · = · ___1_.~1 :~1~:~ ~h~To;^iq^~
for treatment personnel. A variety or a~sc~p~nes Is now ~vo~v`;u, IlI~lUUlil~ ~,
social workers, counselors, and psychologists. Alcoholism counselors, many of them
"recovering persons" who have experienced difficulties with alcohol themselves, have become
the major providers of treatment in all organized settings. Of particular note has been the
growth in nontraditional treatment settings and in the provision of care through private
funding sources. Alcoholics Anonymous continues to be the best-known source of care, and
its approach is embodied in programs beyond its own, including professional programs.
However, the evolving network of service providers, both individual and programmatic, has
not been adequately described and studied. The committee sees a need for expanded efforts
to obtain more detailed, timely information regarding the provision of treatment.
Does Treatment Work? The committee has expanded this frequently asked question to the
following: Which kinds of individuals, with what kinds of alcohol problems, are likely to
respond to what kinds of treatments by achieving what kinds of goals when delivered by
which kinds of practitioners? Although the answer to this reframed question is still being
developed, the committee feels that its general outlines are clear. There is no one
uniformly effective treatment approach for all persons with alcohol problems. Providing
appropriate specific treatments, however, can substantially improve outcome.
Is Treatment Necessary? The committee considers the answer to this question to be a
qualified "yes." The complexities of treatment necessitate that such activities be approached
cautiously and on an individualized basis; thus, treatment is usually but not invariably
necessary for alcohol problems. The committee's response is constrained by several
considerations , ~--r ~~~~~~~ ~~~^ ~ 4 ~
First improvement in alcohol problems can occur wl~nou~ lU1111~11
treatment. Second, although treatment is often helpful, it can sometimes be harmful.
Third, the growing use of coercion in bringing people into treatment for alcohol problems
is of concern to the committee. Although some positive outcomes may be achieved, the
results of coerced treatment are by no means uniformly positive. The committee believes
that additional study is required to determine who does not need treatment, who will be
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BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
harmed by treatment (especially when coerced into undertaking it), and who will benefit
from treatment only under coercion.
Is Treaimer~ Available? Treatment for alcohol problems is not equally available throughout
the United States. There is wide variability among jurisdictions in total available treatment
capacity, and there are major differences in the availability of each of the types of care and
in per capita expenditure of funds. The cause or causes of this variability are unknown
(and largely unstudied), but it does not seem to reflect differences in the prevalence of
alcohol problems. Careful study of the reasons for differences in treatment availability is
a necessary prelude to effective action to bring about a more equitable distribution of the
broad spectrum of required treatment resources.
Who Pays for Treatment? Private health insurance is now the largest single source of
funding for the treatment of alcohol problems across jurisdictions. State and local
government contributions are next in aggregate size; federal funding for treatment, now
provided through the alcohol, drug abuse, and mental health services block grant, represents
a substantial component of state funding. Direct patient payments and federal insurance
programs (primarily Medicare and Medicaid) provide a lower proportion of funding; an
expected growth in coverage by Medicare and Medicaid has not occurred. Overall, there
has been a steady increase in the number of public and private sources of financing. Yet
although there have been some improvements in coverage, it does not appear that the goal
of obtaining nondiscriminatory coverage equivalent to that provided for other illnesses has
been reached. Consistent, precise reporting is required from providers and the states on
their expenditures for treatment services to persons with alcohol problems in order to
understand the financing of treatment fully, both at present and in the future.
Aspects of Treatment
The Community Role Although some persons have many alcohol problems and are suitable
candidates for specialized treatment, most persons with alcohol problems have a small
number of such difficulties. Because there are many more persons with fewer problems,
the burden that alcohol problems constitute for society arises principally from this group.
There is a need for a comprehensive effort to identify persons having few but significant
alcohol problems and to deal with them effectively and efficiently outside of the context of
specialized treatment and within the community itself. Fortunately, suitable methods of
identification and readily learned brief intervention techniques with good evidence of
efficacy are now available. The committee recommends that consideration be given to the
broad deploying, in a wide variety of community settings, of identification and brief
intervention capabilities, coupled with the referral of appropriate individuals to the
specialized treatment system for alcohol problems.
Assessment Specialized treatment for alcohol problems should begin with a comprehensive
assessment. The assessment should be carried out prior to the selection of a particular
treatment intervention, and it should be designed to provide the information necessary to
determine which kind of treatment is likely to be most appropriate for each individual.
Multiple dimensions of both the problem and the individual manifesting the problem should
be assessed in an efficient process that proceeds in a series of logical stages. Care needs
to be taken to ensure that the assessment process is a positive experience and that its
objectivity is maximized. In addition to its benefits for the individual entering treatment,
the gathering of compatible assessment data across treatment settings would contribute
greatly to our understanding of many aspects of the treatment process.
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INTRODUCTION & SUMMARY
9
Matching Because no treatment is universally effective but some treatments are effective
for some persons, it is necessary to match individuals to particular treatments. Less is
known about how this should be done than is desirable; however, potentially appropriate
matching guidelines can be developed in a number of ways. If guidelines are made explicit
and are tested by determining the outcome of treatment, they can be appropriately modified
to produce increasingly positive outcomes. Effective matching will also require increased
specification of treatment interventions (to complement the specification of individuals and
problems through assessment) and the specification of treatment outcomes. Because it
views the process of matching as central to the treatment of alcohol problems, the
committee recommends that conferences of clinicians and researchers be regularly convened
to explore what is currently known and to identify promising directions for the future.
Outcome Determination For a variety of reasons it is rapidly becoming untenable to provide
treatment in the absence of knowledge of its outcome. There is a tendency to rely on
randomized controlled trials (RCTs) to evaluate treatment outcome. Although the RCT
is a powerful tool with many advantages and its more widespread use is to be commended,
its application in many clinical settings is problematic. As an alternative, outcome
monitoring is more readily applicable and importantly complements information gained
from RCTs. Yet although outcome monitoring data may be consistent with treatment
efficacy, positive results following treatment may be due to factors other than treatment.
The external examination of treatment outcome (by those not connected with the provision
of treatment) provides protection against bias and is in general to be preferred; however,
internal examination of treatment outcome can provide important guidance for program
decision making.
Implementing the Piston Implementing separately each of the aspects of treatment discussed
above (the community role, assessment, matching, and outcome determination) is of value
to the treatment enterprise. But the committee's preference is for the simultaneous
implementation of all of these aspects of treatment, together with the addition of
mechanisms to assure continuity of care and the feedback of outcome data into the
treatment process in a meaningful manner. Some treatment programs have accomplished
this implementation to varying degrees, but a much more determined effort to implement
and evaluate comprehensive treatment systems embodying all of these functions is now
indicated. The committee recommends that four or five model comprehensive treatment
systems be implemented as demonstration projects in the immediate future, with provision
for full, objective evaluation of all aspects of their functioning and of their treatment
outcomes.
Special Populations in Treatment
Overview am Deft rat ons Special population groups are defined in legislation, research, and
practice not only in terms of their unique biological and sociocultural characteristics but
also in terms of extant concerns regarding access to services. The committee has
concentrated on those subgroups that have been seen as needing specifically tailored,
Culturally sensitive" treatment programs. Since the early 1970s women and youth have
received the most attention, but interest in each of the identified special populations has
waxed and waned. There have been no systematic evaluations to determine whether access
is improved and treatment outcome positively affected when special population treatment
programs are implemented.
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BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
Populations Def tied by Structural Characteristics Some special population groups tend to be
defined primarily in terms of relatively fixed characteristics-principally gender, race,
ethnicity, and age. Yet the members of populations so defined vary on other important
dimensions that have implications for treatment outcome (e.g., socioeconomic status,
employment status); hence, the cogency of such a classification is problematic. Structural
characteristics are widely believed to have an important effect on access to treatment.
Although there is some evidence for this belief, it is confounded by financial considerations;
minority group members, for example, are less likely to be able to pay for treatment
themselves or to have insurance coverage. In addition, biomedical and psychosocial
approaches to treatment across ethnic and cultural groups in the United States seem to be
essentially similar, even in the hands of treatment personnel of differing characteristics.
Because most persons will continue to be treated in mainstream programs, taking structural
characteristics into account in assessment, matching, and outcome determination is
important for determining how effectively these subgroups are being served. For racial and
ethnic minorities, the degree of acculturation to the majority culture may be a crucial
variable to examine.
Populations Deft nod by Functiorlal Characteristics Other special population groups are defined
by less fixed characteristics, such as their common social, clinical, or legal status. For some
of these functionally defined special populations (e.g., the drinking driver, the public
inebriate), specifically targeted treatment programs have been developed. The conclusions
that emerge from the committee's consideration of populations defined by functional
characteristics are not very different from those reached in looking at the groups defined
by structural characteristics. Members of functionally defined special populations also vary
on other important dimensions that have implications for treatment outcome-including
those structural characteristics discussed earlier. Again, the cogency of the classification is
problematic. The same lack of evidence favoring the application of specific treatment
approaches for populations defined by structural characteristics holds for those special
populations defined by functional characteristics.
Conclusions and Recommendations Regarding Special Populations The committee recommends
a dual approach to the issue of culturally relevant treatment for special populations. One
aspect of this approach is to look more closely at those programs that provide such
treatment. The lack of evidence as to their particular efficacy may be due in large measure
to a lack of testing. The committee has concluded that there is evidence that access has
been improved by these programs. It recommends that funding for them be continued,
together with funding for discrete evaluations of treatment for each of the major special
populations. These evaluations should compare culturally specific and mainstream programs
for the special population in terms of treatment processes and outcomes. At the same
time, because many members of special populations will continue to be treated in
majority-staffed, mainstream programs, a major effort is recommended to train staff working
in mainstream programs in the skills required to deal most effectively with members of
special populations. The committee has concluded that special populations, as commonly
defined, are actually heterogeneous. It can foresee the possibility that a variety of both
"culturally sensitive" and mainstream programs may be required to deal successfully with
members of these populations, as well as with people in the "general" population who
manifest alcohol problems.
Aspects of Financing
Me Evolatior' of Financing Policy Over the past 20 years, there has been a partially
successful effort to develop adequate funding mechanisms and structures for financing
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INTRODUCTION & SUMMARY
11
treatment for alcohol problems. Such financing is now accepted, albeit not without
reservations, as the conjoint responsibility of state and local governments, of the federal
government acting on behalf of selected poor, elderly, and chronically disabled individuals,
and of private insurers acting on behalf of employers and individuals who purchase health
insurance. Inconsistencies in financing policy remain; funding varies considerably among
jurisdictions and between the public and private treatment efforts within jurisdictions. In
the light of current concerns over rapidly rising health care costs, the major question now
being raised is whether current financing and reimbursement policies promote access to the
most cost-effective treatments. The committee recommends the development of a common
framework of criteria for matching individuals to the most appropriate treatment as a
significant contribution to this effort. Better data on expenditures, expanded research on
the impact of financing policies on treatment, and a detailed understanding of the
cost-effectiveness of alternative treatments are also required if a truly nondiscriminatory
financing policy is to be realized.
Cost-Effectiveness The justification of increased insurance coverage for the treatment of
alcohol problems has often been based on studies of cost offset (i.e. the decline in health
care expenditures to be expected if alcohol problems are successfully treated). Review of
the recent literature suggests that, although studies demonstrating cost offset have been
methodologically flawed, there is some indication, although not conclusive evidence, that
spending money on treatment for alcohol problems today does lower medical costs
tomorrow. The question that must be answered now is the cost-effectiveness of alternative
forms of treatment. We do not know whether more costly treatments provide additional
benefits sufficient to offset their greater cost. Accordingly, the committee recommends an
intensive program of research to compare the costs of alternative treatments relative to
their benefits. In addition, studies of matching and of treatment effectiveness should
include the consideration of cost-effectiveness questions.
Paying for the Treatment System The committee considered the changes that would be
required in the methods used to pay for treatment for two scenarios: first, to improve the
current system and second, to pay for the ideal comprehensive treatment system.
Given the lack of adequate cost-effectiveness studies comparing alternative
treatments, it is not possible to say definitively to what degree particular treatments should
or should not be covered. Although committee members held different opinions regarding
the criteria that should be used for admission to intensive treatment, as a whole the
committee considered a significant redistribution of resource utilization from more intensive
to less intensive treatments to be desirable. The committee anticipates that such a
redistribution would take place if alternative programs, guidelines for their use, and
outcome monitoring were available. To facilitate this redistribution, public and private
insurance coverage should be available for a broad variety of treatment options. Given the
current state of knowledge, medical supervision should not necessarily be required for the
provision of insurance benefits. At the same time, however, medical consultation should
be readily available when required for the diagnosis and treatment of medical and
psychiatric disorders in all treatment programs.
Implementing the new treatment system proposed by the committee will require
comprehensive and flexible benefit plans offered by all payer sources. Underlying the
development of all such plans is the principle that public and private insurance financing
should cover effective care that is worth the cost. The committee is aware of the fears its
recommendations may evoke that, in suggesting the development and implementation of
treatment systems, it is at the same time recommending vast increases in funding. There
is not an adequate data base on which to develop projections of any additional costs that
may arise. Nevertheless, the committee believes that, to a significant extent, the additional
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BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
costs incurred by recruiting more people into treatment through the establishment of a
widespread community role will be offset by future savings in medical costs and by more
efficient and effective treatment through the use of assessment, matching, outcome
determination, feedback, and continuity assurance. Should a net increase in the cost of
treatment ensue, the committee is confident that it would not be excessive and that the
total costs of treatment would continue to represent only a small fraction of the social costs
of alcohol problems.
Guiding the Ongoing Effort
Although it is tempting to charge a single designated leader individual, a federal
agency, an advocacy group, a profession, Congress-with ongoing stewardship of the
treatment of alcohol problems, realistically the base of leadership must be broad. The
committee believes that, to ensure progress, community and voluntary organizations,
government agencies, treatment providers, professional organizations, employers, insurance
companies, consumers of treatment services, and other interested parties will need to
evaluate its recommendations and take appropriate and concerted action. The committee
has offered suggestions on how each of these groups can provide leadership. Alcohol
problems are sufficiently pervasive, sufficiently complex, and sufficiently massive in the
aggregate that dealing with them effectively requires multifocal leadership representing
society as a whole.
REFERENCES
Board on Mental Health and Behavioral Medicine, Institute of Medicine. 1985. Research on mental illness and
addictive disorders: Progress and prospects. American Journal of Psychiatry 142(Suppl.):1-41.
Institute of Medicine. 1980. Alcoholism, Alcohol Abuse, and Related Problems: Opportunities for Research.
Washington, D.C.: National Academy Press.
Institute of Medicine. 1987. Causes and Consequences of Alcohol Problems: An Agenda for Research. Washington,
D.C.: National Academy Press.
Institute of Medicine. 1989. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington,
D.C.: National Academy Press.
Moore, M. H., and D. R. Gerstein, eds. 1981. Alcohol and Public Policy: Beyond the Shadow of Prohibition.
Washington, D.C.: National Academy Press.
Saxe, lo, D. Dougherty, K Esty, and M. Fine. 1983. The Effectiveness and Costs of Alcoholism Treatment.
Washington, D.C.: U.S. Congress, Office of Technolgy Assessment
Representative terms from entire chapter:
specialized treatment
