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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
OCR for page 173
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
OCR for page 177
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
OCR for page 178
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.
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Representative terms from entire chapter:
treatment resources
