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