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7 Is Trealment Available? Among the questions which the committee has attempted to address has been whether all those who wish to receive treatment for alcohol problems are able to receive the treatment of their choice. The heterogeneity of alcohol problems necessitates a variety of widely available treatment settings, orientations, and modalities so that persons with different sets and severities of alcohol problems can be successfully matched with the appropriate treatment regimens. One means of examining this question is to determine whether there is an even distribution of specialist treatment resources throughout the nation and whether alternative forms of treatment are available. Distribution of Resources for Alcohol Problems Treatment It can be assumed that, given an equal distribution of all types of care, those persons who are in need of treatment have an equal chance of being matched to the appropriate level and modality of treatment at each of the various treatment stages. Yet the committee's reviews of the literature and discussions with researchers, state alcoholism authority staff, practitioners, and federal administrators of treatment programs indicated that there have been no recent compilations of information about the distribution of treatment resources for the nation as a whole. The committee's investigation also revealed that there have not been any recent national studies of the level of available resources relative to the level of need or demand for treatment (i.e., the number of persons determined by themselves or others to require treatment for an alcohol problem). Other data areas also reveal a lack of attention. There have been few recent studies of the resources available and accessible to those in need of treatment within different sections of the country or resources available to different subgroups or special populations. A recent noteworthy exception is the work of Gilbert and Cervantes (1986, 1988), which has looked at both the availability and accessibility of treatment for Mexican Americans. These investigators conducted secondary analyses of data collected by several state alcoholism authorities on persons receiving treatment in state-funded agencies to examine the level of utilization and the types of referrals for this special population. They found a high level of service utilization related to coercive referrals. This effort provides a model for the type of studies required to investigate differential availability and accessibility of treatment resources for persons with alcohol problems. The committee's analysis focuses on availability. In health planning, the availability of treatment services typically refers to the supply and mix of health resources and services relative to the needs or demands of a given individual or community. Availability is not the same thing as accessibility. Accessibility typically refers to the degree to which the health care system inhibits or facilitates the ability of an individual or group to gain entry and to receive appropriate services, when services are available (Aday and Anderson, 1983~. Determining whether services are Appropriate is a matter of no small complexity; a judgment of appropriateness indicates that a match has been made between the specific needs of the "client" whether an individual, a group, or a community-and the services and resources available and utilized (Gunnersen and Feldman, 1978; NIAAA, 1980; Brown University Center for Alcohol Studies, 1985; Gilbert and Cervantes, 1988; McAullife et al., 1988; New York Division of Alcoholism and Alcohol Abuse, 1989~. Data on accessibility to treatment for alcohol problems are even sparser than those for availability; additional studies of accessibility are needed before a more comprehensive review can be undertaken. 163

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64 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS A benefit of addressing the question of treatment availability, however, is that it can serve as one of the indexes by which accessibility can be determined. Barriers to accessibility are usually described in terms of physical, cultural, linguistic, geographic, and financial constraints. Physical accessibility often refers to the architectural structure of the treatment setting and the limitations it may pose to the mobility of the physically handicapped; it also refers to the availability of appropriate transportation from a person's home to the facility. Cultural accessibility is most often dealt with by the use of bilingual, bicultural treatment staff within standard or traditional services; efforts to increase cultural accessibility have also stressed the need for culturally sensitive, culturally relevant treatments and for administrative control of the program by members of the cultural group that is the target population (see Section IV). Geographic accessibility implies that treatment services are located within a reasonable distance of the individual's residence. Financial accessibility implies that the cost of the service is reasonable and there is no disincentive to use needed services because of their costs or the method of reimbursement (see Chapters 8, 18, and 20~. The lack of sufficient resources to meet requests for service has been termed Programmatic barriers to accessibility and is measured by the incompleteness of the continuum of care, where some components exist and others do not (Brown University Center for Alcohol Studies, 1985~. When components are missing, backups occur in which case people must wait for treatment or treatment is terminated prematurely; in both instances there is a higher probability of relapse. Examples of missing components that have been identified in the continuum of care for treatment of alcohol problems are the lack of long-term custodial/domiciliary beds to provide maintenance services for chronically disabled public inebriates who are recycled through detoxification centers (e.g., Shandler and Shipley, 1988a,b; see Chapter 16), and the lack of formal relapse prevention programs for persons who complete primary rehabilitation and who are not good candidates for AA affiliation (see Chapter 3~. These structural constraints have also been called "program design" barriers in cases in which a program developed for one subgroup is applied to another without modifications that accommodate critical differences (e.g., the failure to provide child care services for mothers of small children who may be in need of inpatient primary rehabilitation [Beckman and Kocel, 1983; USDHHS, 1984~. The state alcoholism authorities have struggled with the issue of treatment availability from the vantage point of resource allocation. In response to the federal formula grant requirement that each state have a procedure to determine priorities for treatment resource development, several states (e.g., New Jersey, Nebraska, Massachusetts, Colorado, New York) had developed sophisticated resource allocation models based on a consideration of the different needs of individuals at different stages of treatment (Wilson and Hartsock, 1981~. Some of these states (e.g., Colorado, New York) have continued to routinely do such comparisons of needs and resources available in determining resource allocation priorities, even though the federal requirement was discontinued in 1982. However, there appears to have been a decrease in the states' overall efforts to use comparisons of prevalence indicators and utilization data in planning for treatment services. Formerly states were required to develop a comprehensive annual plan for services that included such a comparison to qualify for federal formula grant funds. With the ending of the formula grant program, many states no longer prepare an annual services plan and states vary in their perception of the need to have a formal method for resource allocation. Interest remains, however, in determining the relationship of the level of need to the treatment available, although a great deal of this effort may be driven as much by the need for a methodology to conduct certificate of need reviews (i.e., reviews required if inpatient services are to be expanded) as by the need to plan and allocate treatment funds (Brown University Center for Alcohol Studies, 1985; New York Division of Alcoholism and Alcohol Abuse, 1988~. Still, several states (e.g., Maryland, New York, Rhode Island) have

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IS TREATMENT AVAIIABLE? 165 undertaken to develop improved methods of treatment needs estimation and resource allocation (New York Division of Alcoholism and Alcohol Abuse, 1983, 1987; Sheridan, 1986; Rush, 1988~; The most recent such effort is that undertaken by Indiana (J. Mills, Indiana Division of Addiction Services, personal communication, December 15, 1987~. None of the federal agencies that operate their own treatment systems has a formal resource allocation model in place. Given the absence of recent studies on which to base judgments about the differential availability of treatment, the committee decided to use whatever published data were available to look at the distribution of alcohol problems treatment resources across the country. There are a number of problems in conducting such a national analysis because there are no consensually accepted methods for determining either the prevalence of alcohol problems or for projecting the appropriate level of treatment resources that will be required (Wilson and Hartsock, 1981; Brown University Center for Alcohol Studies, 1985; Institute for Health and Aging, 1986~. In addition, as discussed in Chapter 3, there is no consensually accepted taxonomy, or model, for describing the resources (settings and modalities of treatment) to be planned for (Saxe et al., 1983; Bast, 1984) and no agreement on the components that make up a comprehensive treatment delivery system. The current situation is much the same as that described 10 years ago in an NIAAA-sponsored guide for health planners: The terminology used to describe alcoholism service configurations varies considerably throughout the country. Generally, the terminology is descriptive of either the environment/setting (e.g., hospital, halfway house) in which treatment takes place or the service (e.g., outpatient, inpatient) provided within the environment. Often, descriptions are reliant upon the treatment modalities (therapeutic orientations, e.g., NN, aversive conditioning) implemented within a service. Occasionally the descriptions are mixed, causing environments to be confused with services and services to be confused with modalities. (Gunnersen and Feldman, 1978:45) There is also no single inventory that captures the utilization of treatment services, both in terms of the wide variety of current facilities and programs and the individual practitioners that provide treatment for alcohol problems (see Chapter 4~. The last available comprehensive review of the methods used by the individual states to estimate and plan for treatment resource needs was undertaken in 1980 by the NIAAA-sponsored Alcohol Epidemiologic Data System (AEDS) project (Wilson and Hartsock, 1981~. The study found that states and territories used many different methods of prevalence estimation, needs and demand forecasting, and resource description and allocation. AEDS project staff developed and proposed for national adoption a normative model for providing county-level estimates of persons needing treatment and the resources required (AEDS, 1982~. The AEDS normative approach produced estimates of the treatment resources needed to meet projected demand for services in a given service area or county (e.g., detoxification beds, hallway house beds, outpatient episodes). The estimates were derived, first, from the utilization history of the county captured by the NDATUS. These allocations were than adjusted, taking into account prevalence estimates; sociodemographic indexes including sex, race, and age; and local use patterns (AEDS, 1985~. In the AEDS model, prevalence was estimated through the use of two composite weighted indexes: the Chronic Health Index and the Alcohol Casualty Index (both are mortality- and morbidity-based prevalence estimators). The AEDS normative model was not adopted by the federal government or by any of the states. It was not perceived as an advance because it used primarily a demand-based

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166 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS or rates under treatment approach to project resource needs. In health planning and health economics, need is differentiated from demand. Need typically refers to an objectively determined index of the number of individuals with the particular condition, problem, or illness for which a given service is required (i.e., the prevalence or number of "casesn). Demand is used to describe the expressed desire for a particular service, which can be independent of objectively determined need, and is more related to subjective and economic factors (e.g., advertising, price of services, geographic proximity, attractiveness of facilities, stigmatization of persons identified as needing the treatment, etc.~. Utilization-senaces actually used- is sometimes considered an index of need and at other times an index of demand. In planning for treatment of alcohol problems the utilization of treatment services is often considered an index of need and has been used as such by particular states and health systems agencies to project future need for alcohol problems treatment resources (Gunnersen and Feldman, 1978; Bayer, 1980; Ford, 1980; AEDS, 1982; McGough and Hindman, 1986~. In the AEDS study, states that were reported as projecting future needs for alcohol treatment services from historical utilization included Nebraska, Connecticut, Maine, and Missouri (Wilson and Hartsock, 1981~. Although demand-based planning is commonly used by state alcohol authorities for planning and budgeting, it is not generally accepted by health planners, who prefer population-based approaches (e.g., community surveys) (MacStravic, 1978; NIAAA, 1980~. Since the AEDS normative model also has a demand-based component, its suggested use as a national standard may also be questioned. A more recent review of needs estimation methods was undertaken by the Institute of Health and Aging (1986) as part of a study to determine whether a more equitable formula could be found for allocating the alcohol, drug abuse, and mental health services block grant among the states and territories. The institute's review of the literature on the current status of prevalence estimation methods led to several conclusions: (a) there is no single, best approach to prevalence estimation; (b) the various indexes used to estimate the prevalence of mental health, alcohol, and drug abuse problems are not highly intercorrelated; and (c) the adoption and use of any model or set of measures as a national standard remains controversial within both the scientific and planning communities. Given this lack of consensus on and acceptance of a specific model for estimating prevalence (and in turn for allocating monies among the states accorded to need), the institute recommended that Congress continue to use population size, weighted by age and gender to reflect high-risk groups, as the need factor in the allocation formula, rather than ~_ introducing a more specific prevalence index. o ~ r .. Given the absence of recent research and further refinement of methods, it is likely that whatever methodology is used to assess the level of treatment resources currently available and the extent to which the prevalence of alcohol problems is the determinant of the availability of treatment, questions will be raised about the validity and appropriateness of the analysis. This is an. area in which the committee suggests further study and consensus development. A replication of the or~g~ucl AEDS resew of the methods ire use by the states for both reeds estimation and determining resource availability is indicated and would be useful for future planning and resource allocation if the states could agree on a common methodology. Despite the important gaps noted above, there are nonetheless several data sources that can provide a rough first comparison of available treatment resources and the prevalence of alcohol problems which can be used as a preliminary answer to the question: "Is treatment for alcohol problems equally available throughout the United States?" The assumptions underlying this analysis are that treatment resources should either be distributed equally throughout the nation or, if there is variation from a national rate, should be dispersed geographically to reflect the actual distribution (prevalence) of alcohol problems across the states and territories. The principle guiding the analysis is that there should be the same availability of treatment resources in each of the states and territories.

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IS TREATMENT AVAIIABLE? 167 Similar assumptions were used in assessing the level of services available throughout Pennsylvania's counties (Glaser and Greenberg, 1975; Glaser et al., 1978) and in the previously mentioned Institute of Health and Aging's 1986 evaluation of the formula for allocating the block grant funds. These are also the assumptions commonly used in many of the studies on the availability of health and mental health services where the distribution among counties or states of some resource (e.g., number of physicians or other health service providers per 100,000 persons; number of acute care hospital or nursing home beds per 100,000 persons) (see MacStravic, 1978; Bayer, 1980; Aday and Anderson, 1983; Knesper et al., 1984; Harrington et al., 1988~. There are two surveys conducted periodically by the federal and state governments specifically to determine current levels of services and funding for the treatment of alcohol problems that the committee originally thought would be useful in conducting such an analysis. The first, the National Drug and Alcoholism Treatment Utilization Survey (NDATUS), is designed to be a census of all known facilities and programs that provide a distinct organized program of alcohol and drug abuse services. The second, now known as the State Alcohol and Drug Abuse Profile (SADAP), is a survey of the funding and services provided in state supported programs. The committee found that both surveys were not achieving the level of coverage of providers contemplated in their design. Other surveys, such as those conducted by the American Hospital Association, the National Institute of Mental Health, and the National Center for Health Statistics, capture some information on services provided within general hospitals, psychiatric hospitals and clinics, and by private practitioners in office settings (e.g., psychiatrists, internists, social workers, clinical psychologists, and counselors) that may not be covered by these surveys of organized programs. However, the surveys do not use common definitions so that there is no single or aggregate source of data that can be used as a measure of the available level of services. A more complete ar~aisis of the availability of treatment for alcohol problems would also involve an. attempt to determine the availability of treatment in these specialist and nonspecialist practice settings. The committee suggests that such studies be undertaken so that future pod reviews of treatment availability can- be more complete. Recognizing these limitations, the committee initially examined data from these two sources (the NDATUS and SADAP) to determine whether the states and territories varied in the availability of treatment for alcohol problems and, in cases in which wide variation was found, to attempt to understand the determinants of such variation. The committee found wide differences among the states in both surveys; however, only that variation found in the NDATUS is reported here. SADAP is an annual survey of state resources and services which is conducted by the National Association of State and Drug Abuse Directors (NASADAD), on behalf of the Department of Health and Human Services (Butynski et al., 1987~. The SADAP was not used because of several problems. First, the SADAP data do not provide a measure of capacity but rather of utilization. A second problem with these data is that alcohol services funding information cannot be separated from the data on funding on other drug abuse services; the SADAP data are not differentiated because the majority of states has now combined what were formerly separate agencies for alcohol and drug abuse, and expenditures are not always identified categorically. In addition, the SADAP expenditure data do not differentiate among the types of activity (prevention, treatment, or administration and planning) for which expenditures are made. The SADAP is also limited to those treatment agencies that receive funding from the state alcoholism authority and does not include many private sector and federal government programs. In contrast, the NDATUS is a survey of all known treatment units and seeks to differentiate expenditures for treatment of alcohol problems from treatment for problems with other drugs. The committee also examined the American Hospital Association's annual survey of hospitals.

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168 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS The National Drug and Alcoholism Treatment Unit Survey As part of its agency mission, NIAAA has been engaged in an ongoing effort to provide state and federal policymakers with the information they require to manage the resources which are needed for providing treatment services for persons with alcohol problems. As part of this effort, NIAAA has periodically conducted surveys of known public and private treatment facilities, seeking data on such variables as capacity, staffing, funding, utilization, and services offered. Since 1979, the major survey, now known as the National Drug and Alcoholism Treatment Unit Survey (NDATUS), has been conducted jointly with the National Institute on Drug Abuse; consequently, the NDATUS surveys two kinds of units that offer services to persons with alcohol problems: (1) those that provide services only for persons with alcohol problems and (2) those that provide treatment for

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IS TREATMENT AVAIIABLE? 169 TABLE 7-1 Number of Alcohol Problems Treatment Units, Number of Persons in Treatment, Budgeted Capacity, and Utilization Rate of Units by lope of Care on October 30, 1987 lope of Care Persons in Budgeted Utilization Units Treatment Capacity Rate (5to) Inpatient/residential Medical detoxification939 6,391 10,353 62 Social detoxification390 4,015 6,154 65 Rehabilitation/recove~y2,185 37,501 50,615 74 CustodiaVdomicilia~y2,168 2,688 3,822 70 Total5,682 50,595 70,944 71 Outpatient/nonresidential3,701 287,333 345,393 83 Total inpatient and5,627 337,928 416,337 81 outpatient SOURCE: Based on data from the 1987 National Drug and Alcoholism Treatment Utilization Survey (NIDA/NIAAA, 1989) unit (i.e., the maximum number of individuals who could be enrolled as active clients given the unit's staffing, funding, and physical facility at the time of the census). Five types of care were identified: (1) medical detoxification, which was defined as involving the use of medication under the supervision of medical personnel in either a hospital or other 24-hour-care facility; (2) social detoxification, involving procedures other than medication carried out by trained personnel with physician services available when required in a specialized nonmedical facility; (3) inpatient/residential rehabilitation/recovery, a planned program of professionally directed evaluation, care, and treatment in either a hospital or other 24-hour-care facility; (4) custodial/domiciliary care, defined as the provision of food, shelter, and assistance in routine daily living on a long-term basis; and (5) outpatient/ nonresidential rehabilitation, which was any form of treatment (detoxification, rehabilitation, recovery, or aftercare) in which the person does not reside in a treatment facility. For the four types of inpatient and residential care, budgeted capacity means the maximum number of beds a facility has in operation on the survey's census date. The comparable term for outpatient capacity is "slots," that is, the number of persons who can be seen by existing staff on an outpatient basis. The figure does not necessarily refer to licensed capacity. Particularly in the case of outpatient services, the given capacity could be seen as a conservative estimate of potential availability because additional slots could easily be added if there were a demand for services and if funding was available. Future surveys should use a standard definition of capacity to determine capacity and utilization rate (e.g., the number of licensed and staffed beds and slots). An improved survey would more clearly differentiate among orientation, stage, and setting. The committee suggests that there be an effort to develop a type-of-care categorization which fully captures the range offacilities and programs available for treatment of alcohol problems. The types of care identified in the NDATUS correspond roughly to the stages of treatment outlined in Chapter 3, but the NDATUS categorization mixes settings with stages and orientation. In the NDATUS outpatient care includes all three of the major stages identified by the committee: acute intervention (detoxification), rehabilitation, and maintenance (aftercare). Inpatient care is divided into the three major stages and detoxification is further divided into the two major orientations. The outpatient slots similarly could be used for ambulatory detoxification, primary treatment and rehabilitation,

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170 BROADENING IlIE BASE OF TREATMENT FOR ALCOHOL PROBLEMS continuing treatment, or relapse prevention and supportive maintenance, as well as for treatment of those medical/psychiatric complications that can be dealt with in an ambulatory status. Because the committee was interested in variations in the availability of treatment for alcohol problems across the 50 states and two jurisdictions (District of Columbia and Puerto Rico) for which data from the 1987 NDATUS are available, the number of slots for outpatient care and the number of beds for each of the four types of inpatient care were converted into a rate per 1,000 persons for each state or jurisdiction. (The conversion used estimates of the drinking-age population on July 1, 1987~. It is assumed, for the purposes of this analysis, that the percentage of units reporting in each state does not vary significantly. The data should be interpreted with some caution because there are indications that there were differences across the states in both facilities to which the survey was sent and in the return rate. The Distribution of Treatment Capacity The results of the conversion discussed above appear in Table 7-2, which presents by state or jurisdiction, the rates per 1,000 persons in the general population for total treatment capacity, for each of the five types of care, and for total inpatient/residential care. Nationally, there is capacity for 1.7 persons per thousand to be in treatment for alcohol problems. The national rate for budgeted treatment capacity for outpatient care was 1.41 persons per thousand. The national treatment capacity rates for the four types of care identified as only taking place in an inpatient setting were as follows: 0.04 for medical detoxification, 0.03 for social detoxification, 0.21 for rehabilitation, and 0.02 for domiciliary care. The national treatment capacity rate for the four inpatient types of care together was 0.29 per 1,000 persons. The national rate for the two detoxification orientations together was 0.07 per 1,00() persons in the general population. An examination of the variation among the states for each type of care suggests that there is not equal treatment availability for alcohol problems as measured by the number of beds per 1,000 persons in the general population. Treatment capacity for what the NDATUS categorizes as inpatient/residential rehabilitation and recovery services would conform most closely to what is considered the standard treatment regimen for alcohol problems; that is, the fixed-length inpatient rehabilitation program. For this type of care the range among the states is from a high of 0.49 beds per 1,000 persons in the District of Columbia to a low of 0.07 in Puerto Rico. Other states with high rates are Alaska (0.48), Minnesota (0.43), Montana (0.39), New Hampshire (0.37), and Rhode Island (0.36~. Other states with low rates are West Virginia (0.09), South Carolina (0.10), and Georgia, Indiana, and Illinois (0.11~. Detoxification is the only type of care for which reporting is differentiated by treatment philosophy or orientation as well as by treatment stage. The range among the states for treatment using the social detoxification model is from zero to 0.10 beds per 1,000 persons. There are five states (West Virginia, Maine, Wyoming, North Dakota, and the District of Columbia) in which no units reported operating social detoxification beds. Another 28 states have rates less than the national rate (.003~. States with a high rate of social detoxification capacity are New York (0.10), Colorado (0.09) Arizona (0.08), South Dakota (0.07), and Nevada and New Mexico (0.06~. Medical detoxification has a similar range from zero to 0.14. Only one state (Vermont) has no units reporting medical detoxification beds. It should be noted, however, that medical detoxification can also take place in "scatter beds" in a general or psychiatric hospital and not be reported on the NDATUS. (Scatter beds are those beds in a either a medical-surgical ward or psychiatric ward which are used for detoxification but are not part of an organized program.) States

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IS TREATMENT AVAIIABLE? 171 TABLE 7-2 Budgeted Alcohol Problems Treatment Capacity by State and by Type of Care (rate per 1,000 persons) Inpatient/Residential Total Out- In- ~ Out patient patient Medical Social Rehab./ CustodiaV State Detox. Detox. Recovery Domiciliary Total Alabama 0.016 0.004 0.172 0.025 0.217 0.195 0.412 Alaska 0.054 0.002 0.481 0.064 0.601 0.029 3.860 Arizona 0.033 0.083 0.277 0.032 1.425 1.023 1.448 Arkansas 0.041 0.007 0.177 0.022 0.247 0.445 0.692 California 0.022 0.027 0.337 0.003 0.389 2.302 2.691 Colorado 0.018 0.089 0.166 0.027 0.300 3.338 3.638 Connecticut 0.055 0.018 0.220 0.010 0.302 0.881 1.183 Delaware 0.049 0.027 0.171 0.000 0.246 2.116 2.362 Dist. of Columbia 0.102 0.000 0.489 0.146 0.738 1.260 1.998 Florida 0.056 0.047 0.198 0.034 0.335 0.739 1.074 Georgia 0.055 0.001 0.109 0.010 0.175 0.896 1.071 Hawaii 0.002 0.014 0.260 0.000 0.275 0.514 0.789 Idaho 0.065 0.031 0.232 0.008 0.336 1.347 1.682 Illinois 0.018 0.033 0.111 0.017 0.178 0.929 1.108 Indiana 0.019 0.014 0.105 0.014 0.153 1.107 1.260 Iowa 0.026 0.011 0.283 0.029 0.348 1.216 1.565 Kansas 0.021 0.029 0.205 0.009 0.264 1.082 1.346 Kentucky 0.015 0.015 0.117 0.016 0.163 1.375 1.538 Louisiana 0.008 0.004 0.119 0.002 0.133 0.940 1.074 Maine 0.072 0.000 0.190 0.024 0.286 2.852 3.138 Maryland 0.031 0.002 0.167 0.047 0.306 2.315 2.621 Massachusetts 0.136 0.002 0.287 0.005 0.429 1.985 2.415 Michigan 0.030 0.002 0.144 0.000 0.176 1.702 1.878 Minnesota 0.039 0.017 0.430 0.020 0.506 3.390 0.896 Mississippi 0.042 0.035 0.198 0.017 0.291 1.706 1.997 Missouri 0.030 0.027 0.202 0.007 0.266 0.802 1.069 Montana 0.012 0.016 0.385 0.000 0.414 1.509 1.923 Nebraska 0.011 0.044 0.269 0.012 0.336 2.810 3.147 Nevada 0.010 0.057 0.266 0.000 0.333 0.586 0.919 New Hampshire 0.141 0.038 0.371 0.013 0.563 1.423 1.986 New Jersey 0.063 0.007 0.246 0.048 0.364 1.190 1.986 New Mexico 0.031 0.056 0.347 0.000 0.434 2.324 1.554 New York 0.052 0.101 0.143 0.008 0.303 1.882 2.758 North Carolina 0.020 0.039 0.124 0.008 0.190 0.851 2.185 North Dakota 0.107 0.000 0.336 0.000 0.570 2.862 1.141 Ohio 0.029 0.004 0.158 0.019 0.215 1.220 3.433 Oklahoma 0.008 0.014 0.153 0.001 0.176 0.834 1.010 Oregon 0.035 0.037 0.302 0.035 0.410 2.661 3.071 Pennsylvania 0.123 0.006 0.288 0.004 0.421 1.500 1.921 Puerto Rico 0.002 0.013 0.071 0.006 0.092 1.285 1.377 Rhode Island 0.081 0.020 0.364 0.012 0.478 2.996 3.473 South Carolina 0.023 0.033 0.099 0.002 0.157 3.164 3.320 South Dakota 0.040 0.068 0.306 0.095 0.510 2.144 2.654 Tennessee 0.012 0.008 0.143 0.003 0.166 0.569 0.735 Texas 0.055 0.008 0.178 0.007 0.248 0.300 0.548 Utah 0.026 0.014 0.227 0.062 0.329 2.186 2.514 Vermont 0.000 0.018 0.144 0.029 0.192 2.082 2.274 Virginia 0.041 0.011 0.151 0.017 0.220 1.185 1.405 Washington 0.059 0.006 0.197 0.006 0.268 2.365 2.632 West Virginia 0.007 0.000 0.086 0.000 0.094 0.205 0.344 TABLE 7-2 continues

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172 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS TABLE 7-2 (Continued) . . In pa tient/Residential State Medical Social Rehab./ Custodial/ Detox. Detox. Recovery Domiciliary Total Total Out- In- & Out patient patient Wisconsin 0.062 0.005 0.222 0.023 0.313 1.301 1.614 Wyoming 0.062 0.000 0.245 0.000 0.477 2.175 2.652 National Total 0.042 0.025 0.207 0.016 0.289 1.409 1.699 SOURCE: Committee analysis of data from the 1987 NDATUS (NIDA/NIAAA' 1989) with high rates of capacity for medical detoxification are New Hampshire and Massachusetts (0.14), Pennsylvania (0.12), and North Dakota (0.11~. Others with low rates are Hawaii, Puerto Rico, West Virginia, Louisiana and Oklahoma (all with rates of less than 0.01~. For all four types of inpatient care the range of beds per 1,000 persons was from a low of 0.09 in Puerto Rico and West Virginia to a high of 0.74 in the District of Columbia. The median is 0.31. Other states with high rates are Alaska (0.60), North Dakota (0.57), New Hampshire (0.56), and South Dakota and Minnesota (0.51~. Other states with low rates are Louisiana (0.13), Indiana (0.15), South Carolina (0.16), and Kentucky (0.17~. Treatment capacity for undifferentiated outpatient care among the states ranges from a low of 0.20 in Alabama to a high of 3.34 in Colorado. The median is 1.32. Other states with a high outpatient treatment capacity are Alaska (3.26), South Carolina (3.16) and Rhode Island (3.00~. Other states with low rates are West Virginia (0.21), Texas (0.30), Minnesota (0.39), and Arkansas (0.44~. There is wide variation among the states on all of these indexes, with no easily discernible pattern in the variation among the states. Certain states have a high level of one or more types of care and lesser levels of other types of care. Several states have either a higher level of overall treatment capacity (e.g., Alaska, North Dakota, Rhode Island) or a low level of capacity in all types of care (e.g., Alabama, Hawaii, and West Virginia). Pearson product moment correlations were computed to describe the extent to which the five types of care were related (Table 7-3~. The strongest relationships were found between the rehabilitation bed and medical detoxification capacities (r = .34) and rehabilitation and custodial/domiciliary care (r = .40~. Although this pattern would suggest that there were moderate positive associations among the types of care available, there were only very weak relationships between the four inpatient types and outpatient care. The correlation between the total of the four inpatient types and the rate for outpatient care is only.l7. Table 7-3 also shows a negative correlation between the rate for medical detoxification and the rate for social detoxification (r = -.17~. Every state except Vermont had specialist units that reported providing medical detoxification. Five states had no units reporting social detoxification beds. As shown in Table 7-2, the rate for total budgeted treatment capacity ranges from a low of 0.34 beds per 1,000 persons in West Virginia to a high of 3.86 for Alaska. The median is 1.7 slots and beds available per 1,000 persons. There are 25 states in which total treatment capacity exceeds the national level. In addition, total treatment capacity in eight

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IS TREATMENT AVAIIABLE? 173 TABLE 7-3 Pearson Product Moment Correlations Between Indexes for Types of Care Available in Each State (rates per 1,000 persons) Type of Care Social Rehabilitation Domiciliary/ Total Total Detoxification Recovery Custodial Inpatient Outpatient Medical detox. - .17 .34 .16 .47 .11 Social detox. .01 .01 .09 .17 Rehab./Recov. .40 .74 .14 Domic./custod. .50 .12 Total inpatient .17 Total outpatient states is greater than 3.0 per 1,000 persons (Alaska, Colorado, Rhode Island, North Dakota, South Carolina, Nebraska, Maine, and Oregon), whereas capacity reported in seven states is below 1.0 per 1,000 persons (Nevada, Minnesota, Hawaii, Tennessee, Arkansas, Texas, Alabama, and West Virginia). There is a slight tendency for the smaller states to have a higher level of treatment capacity (r = -.18~. 17'us, on the basis of this review of the 1987 NDATUS data, the answer to the initial question' of whether treatment for alcohol problems is equally available throughout the United States must be answered in the Derive. Moreover, there is rather wide variation in the capacity available among the 50 states and two jurisdictions analyzed by the committee. Using the 1987 NDATUS data it appears that any type of specialty treatment is 11 times more available in Alaska than it is in West Virginia. The pattern of wide variation among the states and territories is just as extreme for each of the types of care. Expenditure Data Another way to establish whether there are variations in capacity among the states is to review the level of funding available for treatment of alcohol problems. The 1987 NDATUS asked each treatment unit to provide data on the sources and total expenditures for alcohol and drug abuse services during the fiscal year which included the NDATUS census date (October 30, 1987) (USDHHS, 1987a). These data can also be used to provide a rough indication of the relative availability of services. Even with the limitations that can be expected when using programs' self reports of funding, the committee has assumed that the NDATUS level of expenditures can be used as another estimate of the level of effort to provide services in a given state and therefore, when expressed as a per capita rate, can serve as a comparative index for the differential availability of services. The expenditures reported by treatment units in the 1987 NDATUS have been summarized and expressed in Table 7-4 as a per capita rate for each state. Total expenditures for the treatment of alcohol problems as reported in the 1987 NDATUS were $1.712 billion (NIDA}NIAAA, 1989), which translates into a per capita expenditure for treatment in specialty units of $6.99 for the nation as a whole. There is wide variation among the states in the per capita expenditure reported for treatment for all types of care. The total per capita expenditures range from highs of $23.54 reported for Rhode Island and $22.70 for North Dakota to lows of $2.36 and $1.33 reported for Oklahoma and Puerto Rico, respectively. The median is $5.44. Thirty six states have a per capita expenditure treatment of alcohol problems that is below the national median. It should be noted that this median figure does not represent only the amount of expenditures made by the state governments to purchase services for their residents but

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174 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS rather the total expenditures within a state from all sources of funds, public and private. Also included are expenditures made on behalf of residents from other states who seek out a specific treatment center. Regardless of the determinants of the variation-, the important finding in. the committee's analysis of the 1987 NDATUS irlforrnation is the extreme variation among the states in the per capita expenditure offends for the treatment of Alcohol problems, affording that suggests that there is extremes differentu~l availability of treatment resources across the country. Of significance is the lack of recent analyses and studies of this variation. TABLE 7-4 Hospital Bed Rates, Per Capita Total Expenditures, and Problem Indexes by State Alcohol/CD Per Capita Hospital Bedsa Per Capita Age-adjusted Alcohol (per 1,000 Total Death Rate: Consumption State persons) Expenditureb CirrhosisC (gallons)d Alabama 0.12 2.23 8.85 1.91 Alaska 0.07 22.29 16.59 3.52 Arizona 0.08 9.52 11.90 3.15 Arkansas 0.11 1.98 7.09 1.64 California 0.13 15.92 15.47 3.12 Colorado 0.12 8.22 9.72 2.88 Connecticut 0.16 7.81 9.22 2.8 Delaware 0.00 5.37 9.52 3.13 District of Columbia 0.28 3.15 30.25 5.67 Florida 0.09 4.28 12.24 2.97 Georgia 0.13 6.19 10.35 2.44 Hawaii 0.02 3.60 5.76 2.89 Idaho 0.03 2.40 9.09 2.33 Illinois 0.16 4.33 11.12 2.68 Indiana 0.21 4.55 7.41 2.15 Iowa 0.24 8.35 6.22 2.05 Kansas 0.26 3.56 6.68 1.89 Kentucky 0.07 3.53 8.18 1.85 Louisiana 0.15 3.15 8.43 2.43 Maine 0.16 5.89 11.53 2.56 Maryland 0.13 7.70 8.58 2.76 Massachusetts 0.11 6.55 10.55 2.97 Michigan 0.11 4.92 12.57 2.57 Minnesota 0.34 9.79 7.02 2.56 Mississippi 0.17 2.28 6.62 2.05 Missouri 0.22 3.67 7.83 2.37 Montana 0.12 16.31 10.56 2.74 Nebraska 0.32 9.95 6.98 2.28 Nevada 0.10 3.03 14.67 5.07 New Hampshire 0.58 13.36 8.67 4.52 New Jersey 0.07 5.44 11.52 2.78 New Mexico 0.11 9.99 13.40 2.70 New York 0.09 11.40 15.33 2.55 North Carolina 0.10 4.39 9.44 2.16 North Dakota 0.52 22.70 7.25 2.40 Ohio 0.14 6.65 8.71 2.18 Oklahoma 0.15 2.36 8.62 1.81 Oregon 0.16 7.85 8.91 2.54 Pennsylvania 0.11 5.37 9.32 2.23 Rhode Island 0.07 23.54 10.70 2.87 South Carolina 0.09 5.53 8.90 2.50 South Dakota 0.17 5.63 5.00 2.24 Tennessee 0.16 2.66 7.16 1.96 TABLE 7-4 continues

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IS TREATMENT AVAIIABLE? TABLE 7~ (continued) 175 Alcohol/CD Per Capita Hospital Beds. Per Capita Age-adjusted Alcohol (per 1,000 Total Death Rate: Consumption State persons) Expenditureb CirrhosisC (gallons)d Texas 0.17 3.68 8.61 2.63 Utah 0.10 5.43 8.71 1.58 Vermont 0.16 4.49 10.84 3.18 Virginia 0.10 6.02 8.65 2.53 Washington 0.16 5.44 9.81 2.66 West Virginia 0.13 2.84 8.48 1.64 Wisconsin 0.18 6.84 7.54 3.16 Wyoming 0.24 4.60 10.37 2.64 National total 0.13 6.99 10.58 2.58 aSOURCE: Committee analysis of data from the 1986 AHA Annual Surveyor of Hospitals (American Hospital Association, 1987~. bCommittee analysis of data from the 1987 NDATUS (NIDA/NIAAA, 1989). CThese data represent age-specific death rates per 100,000 persons in a particular age group. See Table 1 Age-Adjusted Dead Rates for alcohol-Related Causes by States, 1975-1982: Chronic Liver Disease and Cirrhosis (Colliver and Malin, 1986). dData taken from Table XX Apparent Per Capita Ethanol Consumption (in gallons) by States, 1986 (Steffens et al., 1988). American Hospital Association Annual Survey of Hospitals Each year the American Hospital Association (AMA) surveys individual hospitals in the United States and its territories. In one of its special reports to Congress on alcohol and health, DHHS noted the increase in the availability of specialist treatment units in community hospitals that is documented in these surveys (USDHHS, 1987b). In addition, concern has been expressed regarding the proliferation of high-cost medical treatment which such diffusion represents (Miller and Hester, 1986; Yahr, 1988~. The number of hospitals offering treatment for alcohol and drug problems in a designated unit was reported to have increased from 465 (16,005 beds) in 1978 to 829 units (25,981 beds) in 1984 (USDHHS, 1987b). In 1986, 1,097 of the 6,296 hospitals (17 percent) responding to the survey reported either a designated unit (1,039 hospitals with 29,058 beds) or being totally devoted to the treatment of "alcoholism and chemical dependency" (58 hospitals and 3,486 beds). Hospitals with specialist programs were reported in each state except Delaware. There were 1,342 hospitals that reported that they had a specialist outpatient service for the treatment of alcohol problems (AMA, 1987~. To look at the availability of specialist treatment from a more conventional perspective, the committee converted these data to a rate per 1,000 persons. No distinction is made in the AHA survey as to stage-units could be offering acute intervention only, rehabilitation only, or both acute intervention and rehabilitation. The results of this transformation are presented in column 1 in Table 7-4. Nationally, in designated hospital units there are 0.13 specialty beds per 1,000 persons. There is wide variation among the states, ranging from no beds reported in Delaware and a rate of 0.03 beds per 1,000 persons in the general population in Hawaii and in Idaho to a high rate of 0.52 beds in North Dakota and 0.58 beds in New Hampshire. There are 24 states with a rate greater than the national rate noted in the table. The rate per 1,000 persons for specialty beds in hospitals is only moderately related to the rate for the types of care as found in the NDATUS. There is a correlation of .27 between the medical detoxification rate and the hospital rate and a correlation of .20

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176 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS between the hospital rate and the rehabilitation rate. There are small negative correlations between the hospital bed rate and the rate for social detoxification (r = -.10) and outpatient care (r = -.08~. There may be several explanations for this pattern of correlations. The AHA data do not distinguish between beds used to treat persons with alcohol problems and those used to treat persons with other drug problems. Reimbursement opportunities may determine which type of program is initiated. Differences in practice patterns and in ideological beliefs in the effectiveness of a given treatment strategy, which could be determinants in the development of units, have not been studied. Differences among communities in hospital overcapacity leading to new uses for medical-surgical beds have been discussed as a reason for the increase in the number of designated units, but there have been no published empirical studies of this hypothesis. Relationship Between Treatment Availability and the Prevalence of Alcohol Problems To assess whether there was any relationship between the distribution of treatment resources and the prevalence of alcohol problems within the various states, the committee computed Pearson product moment correlations between the treatment capacity rates and two commonly used indirect indexes of the prevalence of alcohol problems that require treatment: apparent per capita consumption of beverage alcohol (Williams et al., 1986; Steffens et al., 1988) and age-adjusted death rates for chronic liver disease and cirrhosis (Colliver and Malin, 1986) (see Table 7-5~. These indexes are readily available estimates of the prevalence of alcohol problems and can provide reliable substitutes for the more complex composite indexes or survey data that are often used to estimate the number of persons in need of treatment (Popham, 1970; Schmidt, 1977; AEDS, 1982~. These indexes are traditionally included in more complex formulas that have been used to estimate the size of the population in need of treatment services. The two indexes have been used by NINA to assess trends in evaluating the nation's efforts to curb alcohol problems (Colliver and Malin, 1986; USDHHS, 1986; Williams et al., 1986~. Apparent per capita consumption of alcoholic beverages is often used as an indirect prevalence measure in research and policy analysis. This index, which is derived from beverage alcohol sales and excise tax data, must be interpreted with a certain amount of caution, however, because the reports do not take into account such factors as alcoholic beverages purchased in one state and consumed in another, unreported sales, purchases and consumption by tourists, consumption of home-brewed beverages, and purchased but unconsumed beverages (Popham, 1970; USDHHS, 1986~. Even with these limitations, apparent per capita consumption is one of the few indirect measures of prevalence for which data are readily available for use in an interstate comparison (Williams et al., 1986~. The data on consumption included in Table 7-4 and used in this analysis are drawn from the work of Steffens and colleagues (1988) and represent the total per capita consumption of beer, wine, and spirits for the population aged 14 and older. There is wide variation among the states in apparent per capita consumption. Among the states with the highest rates of consumption are the District of Columbia, Nevada, New Hampshire, Alaska, and Vermont; those with the lowest rates included Utah, West Virginia, Arkansas, Oklahoma, Kentucky, and Alabama. Age-adjusted death rates for chronic liver disease and cirrhosis are the second commonly used index of the level of alcohol problems in a community. Cirrhosis of the liver is one of the leading causes of death in the United States and is estimated to involve alcohol in 41 to 95 percent of cases. Official reports of mortality from liver cirrhosis provide the foundation for the Jellinek estimation formula, which is the best known and, historically most widely used method for estimating prevalence of clinical alcohol problems

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IS TREATMENT AVAILABLE? 177 TABLE 7-5 Pearson Product Moment Correlations Between Alcohol Problem Indicators and Treatment Availability Indicators Problem Indicators Age-adjusted Per Capita Death Rate/ Treatment Availability Indicators Consumption Cirrhosis NDATUS Type of Care Medical detoxification .21 .15 Social detoxification .14 .05 Rehabilitationlrecove~y .35 .27 Custodial/domicilia~y .35 .48 Total inpatient .31 .26 Outpatient -.08 .00 Total .02 .04 NDATUS per capita expenditure .14 .10 AHA bed capacity .02 -.21 (Popham, 1970; Marden, 1980). In a sense, cirrhosis mortality is the most conservative estimate, because it focuses on the delineation of the subgroup with the most severe alcohol problems (Marden, 1980~. Local differences in reporting practices are of the most concern in looking at interstate comparisons. The data on the cirrhosis mortality rate included in Table 7-4 and used in this analysis are drawn from the work of Colliver and Malin (1986~. There is also wide variation among the states in age-adjusted death rates for chronic liver disease and cirrhosis. Among the states with the highest rates are the District of Columbia, Alaska, California, New York, and New Hampshire; those with the lowest rates included South Dakota, Hawaii, Iowa, Mississippi, and Kansas. For the 50 states and the District of Columbia, the correlation between apparent per capita consumption and the NDATUS rate of budgeted capacity for treatment is .02, which suggests that there is no relationship between this index and the availability of specialist treatment for alcohol problems. The correlation between the cirrhosis mortality rate and the NDATUS total per capita budgeted treatment capacity is .04, again suggesting that there is no association between treatment resources and the level of alcohol problems. However, these analyses should only be seen as preliminary; their greater value is an indication of the need to develop a regular program for monitoring the level of available treatment and for conducting detailed studies on the organization, utilization, and financing of treatment alternatives. In any realistic study of the reasons for variation among the states in treatment availability, there are many other factors that may be at work which must be attended to: the state's population size, level of poverty, taxing power, fiscal capacity, fiscal effort, regulatory climate, beverage alcohol availability, insurance mandates, citizen advocacy, ethnic composition, drinking patterns, and age distribution. Studies using multiple regression analyses will be required to determine whether there are meaningful relationships among the many variables that are currently thought to impact on treatment availability. What the literature review and this preliminary analysis highlight is the lack of such studies on the distribution of treatment resources in relation to need (i.e., prevalence), studies that

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178 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS are needed to inform the decisions of policymakers regarding the organization and financing of treatment for alcohol problems. Summary and Conclusions Concerned whether all those who wish to receive treatment for alcohol problems are able to receive the treatment of their choice, the committee attempted to determine whether there is a widespread distribution of treatment resources across the United States. Through review of the scant literature and committee analysis of the most relevant data available from the NDATUS and AHA surveys of providers, the committee found that specialist treatment is not equally distributed throughout the country. There is wide variability between jurisdictions in total available treatment capacity. There are also differences in the distribution 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. The variation does not appear to be related to the differences in the prevalence of alcohol problems among the states when prevalence is estimated by two commonly used indexes. When reviewing the level of resources available in a given jurisdiction, it is difficult to determine what constitutes overcapacity or undercapacity in any of the types of care for which NDATUS or AHA data are available, without an accepted national standard for each type of care (e.g., the number of beds and the number of outpatient slots needed per 1,000 persons in the general population, in total and for each stage of treatment). A starting point for development of such standards would be to utilize the deviation from the observed national rate for each type of care as found in the NDATUS data, or some comparable data set, and to examine the circumstances in the individual states which fall at the extremes of the distribution of rates. Such comprehensive studies of the possible causes in the variation of development of each state's treatment delivery system should be undertaken to aid our understanding of the changes required to bring about a more equitable distribution of alcohol problems treatment resources across states and across treatment setting or types of care. There has been concern in recent years that the number of beds being used in the treatment of alcohol problems is increasing inordinately (Miller and Hester, 1986; Saxe et al., 1983; Saxe and Goodman, 1988; Yahr, 1988~. Yet, the data presented earlier in the chapter would suggest that there may be an insufficient number of beds in a number of states. It should be noted that this type of analysis of survey data cannot determine whether the available beds are being used appropriately for the clinically necessary procedure and level or type of care required by a person's clinical status. Determining appropriateness of use is a critical element of studies of availability and access to treatment (MacStravic, 1978~. There are few studies of this nature, even though the appropriate use of the inpatient setting for detoxification and for rehabilitation continues to be a major policy issue for the field and for third-party payers. Several states (e.g., Colorado, Nebraska, New York, Massachusetts, Maryland, Rhode Island) have developed specific estimates of the number of beds or slots that would be required for each treatment setting, treatment stage, treatment modality, or type of care to meet the needs of their "target populations. Although usually not stated in terms of a rate per 1,000 persons, the target population estimates can be translated into such rates. Again, it should be noted that there is no consistency among the states in defining settings, types of care, and modalities, and that the types of care included in NDATUS do not conform to individual state definitions. (See Chapters 4 and 18 for the definitions used by Minnesota, Oregon, and Colorado.) There is also no consistency in the estimates of need used by the various states or in the proportion of persons with alcohol problems who require treatment at each stage in a given setting or with a given modality (AEDS, 1982; Brown University Center for Alcohol Studies, 1985~.

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IS TREATMENT AVAIIABLE? 179 The committee suggests that there should be the dereloprrzem and testing of a comprehensive modelfor describing the treatment delivery system for persons with alcoholproblems. Such a strudel should capture all of the Casting she variations for use us ongoing amasses of the availability of appropriate types of treatment. Without a consensually developed model to guide such studies, there will be little progress toward defining an appropriate level of services. Policymakers must have access to information on the treatment services being provided that is comprehensive, detailed, timely, and accurate. Currently there are very few meaningful aggregate data available for decisionmaking regarding resource needs and allocation. Improved surveys are needed that truly capture the relevant data on treatment activities, providers, and costs so that planning, budgeting, and policymaking can proceed in an appropriately informed manner (Weber, 1987; Robertson, 1988; Mintzes, 1988~. Reintroduction of the NDATUS items that were designed to collect data on persons in treatment, capacity, funding, and staffing is a step in the right direction, but the NDATUS alone is an insufficient tool for understanding the factors that determine availability of treatment. Another strategy to be encouraged is the development of uniform definitions for items in a minimal data set that can be used by the federal, state, and county governments to collect comparable data on the persons seen in treatment from the programs they fund. These data can than be easily aggregated to permit national and interstate comparisons (Lewin/lCF, 1989a,b). The development of standard demographic, diagnostic, referral source and treatment data items is currently being reviewed by the state alcohol and drug agencies and the Alcohol, Drug Abuse, and Mental Health Administration. Having such data collected in such a standardized manner across jurisdictions would make surveys like NDATUS and SADAP more useful and would allow researchers to carry out the needed in-depth studies of availability and accessibility within and across states using comparable data on the persons assigned to various treatments. It is clear that there is sufficient variation in treatment resources across the states to conclude that equal availability to specialist treatment for alcohol problems does not exist in this country. The variation does not appear to be related to the differences in the prevalence of alcohol problems among the states. The committee suggests that there be extensive study of the reasons for these differences in order to develop strategies for equalizing availabi~ of all types of care and to begin addressing questions' of accessibility. Ongoing monitoring of the availability of treatment resources should be instituted; it can then be expanded info monitoring of accessibility. REFERENCES Aday, A. L., and R. M. Anderson, 1983. Equity of access to medical care: An overview. Pp. 19-54 in Appendices: Empirical, Legal and Conceptual Studies. Vol. 3 of Securing Access to Health Care: A Report on the Ethical Implication of Differences in the Availability of Health Services, President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Washington, D.C.: U.S. Government Printing Office. Alcohol Epidemiologic Data System (AEDS). 1982. Procedures for Assessing Alcohol Treatment Needs: Administrative Document. Prepared for the National Institute on Alcohol Abuse and Alcoholism. Gaithersburg, Md.: Alcohol Epidemiologic Data System. Alcohol Epidemiologic Data System, NIAAA. 1985. County Problem Indicators: 1975-1980, U.S. Alcohol Epidemiological Data Reference Manual, Vol. 3. Rockville, Md.: U.S. Department of Health and Human Services. American Hospital Association (APIA). 1987. Hospital Statistics. Chicago: American Hospital Association. Bast, R. J. 1984. Classification of Alcoholism Treatment Settings. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism.

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180 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Bayer, A. 1980. Introduction. Pp. 1-2 in A Health Planner's Guide to Planning and Reviewing Alcoholism Services: Selected Readings, A. Bayer, ed. Bethesda, Md.: Alpha Center for Health Planning. Beckman, L. J., and K M. Kocel. 1983. The treatment delivery system and alcohol abuse in women: Social policy implications. Journal of Social Issues 38:139-151. Brown University Center for Alcohol Studies. 1985. Substance Abuse Treatment in Rhode Island: Population Needs and Program Development. Providence, R.I.: Rhode Island Department of Mental Health, Retardation, and Hospitals and Department of Health. Butynski, W., N. Record, P. Bruhn, and D. Canova. 1987. State Resources and Services Related to Alcohol and Drug Abuse Problems: Fiscal Year 1986. Prepared for the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse, Washington, D.C.: National Association of State Alcohol and Drug Abuse Directors, Inc. Colliver, J. D., and H. Malin. 1986. State and national trends in alcohol-related mortality: 1975-1982. Alcohol Health and Research World 10~3):60 64. Ford, W. E. 1980. A data-based technique for projecting alcoholism services. Pp. 24-34 in A Health Planner's Guide to Planning and Reviewing Alcoholism Seances: Selected Readings, A. Bayer, ed. Bethesda, Md.: Alpha Center for Health Planning. Gilbert, M. J., and R. C. Cervantes. 1986. Alcohol services for Mexican Americans: A review of utilization patterns, treatment considerations and prevention activities. Hispanic Journal of Behavioral Sciences 8:1 60. Gilbert, M. J., and R. C. Cervantes. 1988. Alcohol treatment for Mexican Americans: A review of utilization patterns and therapeutic approaches. Pp. 199-231 in Alcohol Consumption Among Mexicans and Mexican Americans: A Binational Perspective, M. J. Gilbert, ed. Los Angeles: Spanish Speaking Mental Health Research Center, University of California, Los Angeles. Glaser, F. B., and S. W. Greenberg. 1975. Relationship between treatment facilities and prevalence of alcoholism and drug abuse. Journal of Studies on Alcohol 36:348-358. Glaser, F. B., S. W. Greenberg, and M. Barrett. 1978. A Systems Approach to Alcohol Treatment. Toronto: Addiction Research Foundation. Gunnersen, U. and M. L. Feldman. 1978. Alcohol and Alcoholism Programs: A Technical Assistance Manual for Health Systems Agencies. San Leandro, Calif.: Human Services, Inc. Harrington, C., J. H. Swan, and L. A. Grant. 1988. Nursing home bed capacity in the United States, 1979-1986. Health Care Financing Review 9:81-97. Institute for Health and Aging. 1986. Review and Evaluation of Alcohol, Drug Abuse and Mental Health Services Block Grant Allotment Formulas: Final Report. Prepared for the Alcohol, Drug Abuse, and Mental Health Administration. San Francisco, Calif.: University of California, San Francisco. Knesper, D. J., J. R. C. Wheeler, and D. J. Pagnucco. Mental health service providers' distribution across counties in the United States. American Psychologist 1984:1424-1934. Lewin/ICF. 1989a. Analysis of State Alcohol and Drug Data Collection Instruments, vole. 1~. Prepared for the Office of Finance and Coverage Policy, National Institute on Drug Abuse. Washington D.C.: Lewin/ICF. Lewin/ICF. 1989b. Feasibility and Design of a Study of the Delivery and Financing of Drug and Alcohol Services. Prepared for the National Institute on Drug Abuse. Washington, D.C.: Lewin/ICF. Marden, P. G. 1980. Efforts to estimate the prevalence of alcohol abuse. Pp. 14-21 in A Health Planner's Guide to Planning and Reviewing Alcoholism Selvices: Selected Readings, A. Bayer, ed. Bethesda, Md.: Alpha Center for Health Planning. McAuliffe, W. E., P. Breer, N. White, C. Spino., L. Goldsmith, S. Robel, and L. Byam. 1988. A Drug Abuse Treatment and Intervention Plan for Rhode Island. Cranston, R. I.: Rhode Island Department of Mental Health, Retardation, and Hospitals.

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IS TREATMENT AVAIIABLE? 181 McGough, D. P., and M. Hindman. 1986. A Guide to Planning Alcoholism Treatment Programs. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism. MacStravic, R. E. 1978. Determining Health Needs. Ann Arbor, Mich.: Health Administration Press. Miller, W. R., and R. K Hester. 1986. Inpatient alcoholism treatment: Who benefits? American Psychologist 41:794~05. Mintzes, B. 1988. Statement presented at the open meeting of the IOM Committee for Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse, Washington, D.C., January 25. National Institute on Alcohol Abuse and Alcoholism (NLAAA). 1980. Health Planning Technical Assistance Manual for Alcohol and Drug Abuse Agencies. Rockville, Md.: U.S. Department of Health and Human Services. National Institute on Alcohol Abuse and Alcoholism (NLAAA). 1983. Executive Report: Data from the September 30, 1982 National Drug and Alcoholism Treatment Utilization Survey. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism. April. National Institute on Drug Abuse/National Institute on Alcohol Abuse and Alcoholism (NIAAA/NIDA). 1989. Highlights from the 1987 National Drug and Alcoholism Treatment Unit Survey (NDATUS). Rockville, Md.: National Institute on Drug Abuse/National Institute on Alcohol Abuse and Alcoholism. February. New York Division of Alcoholism and Alcohol Abuse (NYDAAA). 1983. Five Year Comprehensive Plan for Alcoholism Services in New York State: 1984-1989. Albany, N.Y.: NYDAAA New York Division of Alcoholism and Alcohol Abuse (NYDAAA). 1987. Five Year Comprehensive Plan for Alcoholism Services in New York State: 1984-1989, Final 1987 Update. Albany, N.Y.: NYDAAA. New York Division of Alcoholism and Alcohol Abuse (NYDAAA). 1988. Long Range Comprehensive Plan for Alcoholism Services in New York State: Long Range Plan-1988. Albany, N.Y.: NYDAAA. New York Division of Alcoholism and Alcohol Abuse (NYDAAA). 1989. Five Year Comprehensive Plan for Alcoholism Services in New York State: 1989-1994. Albany, N.Y.: NYDAAA. Popham, R. E. 1970. Indirect methods of alcoholism prevalence estimation: A critical evaluation. Pp. 678-685 in Alcohol and Alcoholism, R.E. Popham, ed. Toronto: University of Toronto Press. Robertson, A. D. 1988. Federal and state support for alcohol and drug abuse services. Testimony on behalf of the National Association of State Alcohol and Drug Abuse Directors presented to the U. S. Senate Committee on Governmental Affairs hearing regarding an overview of federal activities on alcohol abuse and alcoholism, National Association of State Alcohol and Drug Abuse Directors, Washington, D.C., May 25. Rush, B. 1988. A systems approach to estimating the required capacity of alcohol treatment services. Addictions Research Foundation Community Programs Evaluation Center, London, Ontario, December. Saxe, L., D. Dougherty, K Esty, and M. Fine. 1983. The Effectiveness and Costs of Alcoholism Treatment. Washington: U.S. Congress, Office of Technology Assessment. Saxe, L., and L. Goodman. 1988. The effectiveness of outpatient vs. inpatient treatment: Updating the OTA report. Boston University Center for Applied Social Science, Boston. Schmidt, W. 1977. Cirrhosis and alcohol consumption: an epidemiological perspective. Pp 15-47 in Alcoholism: New Knowledge and Responses, G. Edwards and M. Grant, eds. London: Croom Helm. Shandler, I. W., and T. E. Shipley. 1987a. New focus for an old problem: Philadelphia's response to homelessness. Alcohol Health and Research World 2~3):54-56. Shandler, I. W., and T. E. Shipley. 1987b. Policy, funding, resources are needed. Alcohol Health and Research World 2~3~:88. Sheridan, J. R. 1986. The extent of alcohol and drug abuse in the State of Maryland and resource allocation methods. Prepared for the Maryland Alcoholism Control/Drug Abuse Administration, Baltimore, Md., July.

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