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21 Leadership Before discussing what needs to be done in the future to implement its recommendations and its vision, the committee wishes to acknowledge and to commend what has been accomplished in the past. The Cooperative Commission on the Study of Alcoholism was the first body that attempted to consider the treatment of alcohol problems from a national perspective; the commission was originally established in 1961 through the efforts of the North American Association of Alcoholism Programs, an organization of United States and Canadian government programs, with funding provided by the National Institute on Mental Health. In the slightly more than 20 years since the commission issued its report (Plaut, 1967), there has been a remarkable increase in the scope, quality and availability of treatment for alcohol problems. A review of some of the commission's conclusions and recommendations can be helpful in illustrating the progress that has been made in recent years. As noted in its report, the state of affairs when the commission began its work in 1967 was problematic: Public attitudes and feelings about drinking and about alcohol abuse have significantly influenced the way services for alcoholics have developed. The belief that the problem drinker cannot be helped-sometimes referred to as "therapeutic nihilisms-and the view that the condition is "self inflicted" result in the problem drinker's frequently being ignored by most helping agencies and by many professional workers. Hospitals, psychiatric agencies, public welfare departments and social agencies among others are often reluctant to provide care and treatment for problem drinkers; they tend to neglect or reject them. An understanding of the nature of problem drinking and its management is often limited in such helping agencies. Certain services generally available to patients with other disorders are frequently denied to problem drinkers by policy or practice. These include hospital insurance coverage, admission to general hospitals, assistance by public-welfare agencies, voluntary admission to mental hospitals and participation in most mental hospital after-care programs. (Plaut, 1967:53) Surveys of the general U.S. population and of care givers indicate that alcohol problems are now seen as treatable. Some pessimism, however, remains among legislators, the general public, and professionals (e.g., Skinner, and Holt, 1987), and vestiges of the attitudes encountered by the commission are still present. Yet the questions raised today are less likely to be about whether treatment is effective or whether treatment should be provided than about the relative effectiveness and cost-effectiveness of different treatment approaches with specific subgroups. There has, in a word, been considerable growth in the level of overall sophistication about alcohol problems and their management. The common distinction between the pessimist and the optimist applies in determining where we stand today as a nation in regard to the effectiveness of treatment for alcohol problems: either the glass is half empty, or the glass is half full. Based on its deliberations, the committee is optimistic. We choose to regard the glass as half full and to emphasize that great progress has been achieved in making treatment more available and in increasing favorable treatment outcomes. Our goal is now to fill the glass beyond the halfway point. 4X5
486 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Our Vision: The Committee's Recommendations To continue the progress that has been made, the committee has engaged in a lengthy process of observation and consultation. We have reviewed the literature, site-visited a number of treatment programs, and heard presentations from researchers, practitioners, and representatives of professional associations, trade associations, insurers, and citizens groups. We received written communications and copies of studies and reports from more than 200 researchers, practitioners, and administrators, many of whom provided summaries of the research and practice in a given area of alcohol problems treatment and specific recommendations. We have also drawn heavily on the experience, expertise, and creativity of the members of the committee and its task forces. During this process we have become increasingly aware of the uneasiness and deep concern that attend many of the changes that have taken place in the heath services arena. Yet we have also seen a readiness to change when a direction was identified. There is growing awareness that the structure and orientation of the service delivery system that was initiated some 20 years ago through the efforts of the Cooperative Commission and NIAAA must continue to evolve. Salutary as the historical development of treatment for alcohol problems has been, however, the committee has found reasons to recommend that further changes be made. In so complex an area as health care delivery, and even in so specialized a part of that area as the treatment of alcohol problems, it would be surprising if in the short space of a few years all that was required had already been accomplished. This report is only one of a long series of efforts, begun by the Cooperative Commission, to contribute to an incremental movement toward better treatment. There have been previous reports in recent years (e.g., Pattison, 1977; IOM, 1980; Saxe et al., 1983; IOM, 1989) and there will undoubtedly be others. I\vo basic observations have informed the development of the committee's recommendations. One is that the range of alcohol problems and of the individuals who manifest them is very broad indeed. The other is that a multiplicity of treatments have evolved over time to deal with these problems and with those who are troubled by them. Because research on the outcomes of these treatments has indicated that none is universally effective but that many are highly effective with certain individuals and certain kinds of problems, the focus of the committee's attention has been on the interactions among persons, problems, and treatments. Its recommendations have proposed how this interaction might more effectively be structured. As discussed in Chapter 10, the committee views a comprehensive pretreatment assessment as the cornerstone of a sound therapeutic approach. With the knowledge this comprehensive assessment provides, explicit guidelines can subsequently be used to match individuals seeking treatment with what is likely to be the most effective treatment for them. To employ matching a broad range of well-speciffed treatment interventions must be made available if appropriate treatment is to be offered to all who seek it. In each community, there must be an appropriate mix of services and settings that are available and financially accessible across the entire spectrum of problems. This mix must take into account the differing levels of severity and need for social supports. Moreover, matching must occur not only at the beginning of the process of treatment but throughout its course. For this reason, as well as many others, it is vitally important to have ongoing knowledge of the outcome of treatment. One crucial use of such knowledge of outcome is to modify the treatment process so that it works more effectively and efficiently in the future. Guidelines for matching individuals to appropriate treatments should be continually modified in the light of outcome information so that matching becomes increasingly precise. If this is done, the treatment process becomes self-correcting. Thus, the evolution and development of the treatment system as a whole and of its component parts must be systematically monitored through the collection of uniform data on the persons entering
LEADERSHIP 487 treatment, the specific treatments that they receive, the costs of treatment, and the immediate and long-term outcomes. The cost-effectiveness of each treatment and its active ingredients must be carefully studied. A way of summarizing these recommendations is to look toward the integration of presently existing treatment programs into a treatment system as described in Chapter 13. That system in essence is the cornerstone of our vision. Combining the resources of two or more treatment programs would enable a much more efficient conjoint implementation of such functions as assessment, matching, outcome determination, and continuity assurance. The resources required to implement these functions could arise from a broader base, and the functions themselves could be shared. Prototype examples are available in some jurisdictions in the public sector (e.g., Minnesota's consolidated fund, Ontario's independent assessment and referral centers) and in some organizations in the private sector (e.g., utilization management companies, employee assistance programs), although much is still required in the way of further development. The committee has also strongly recommended that the base of treatment be broadened (see Chapter 9~. Much evidence has accumulated that a majority of persons with alcohol problems seek various kinds of assistance from health, social service, and other agencies rather than from specialized treatment agencies. The detection of these problems has received more emphasis in recent years and the implementation of brief, low-cost interventions has been shown to be effective and should be implemented on a comprehensive basis. Although this action will not eliminate the need of some persons for specialized treatment, available information suggests it is likely to prove the most effective way of reducing the overall burden of alcohol problems on American society. In addition to broadening the base of treatment, the treatment structure must be sharpened at the apex. The foregoing recommendations may need to be modified in order to deal with the needs of special populations (see Section IV). The unique social, cultural, psychological, and biological characteristics of large subgroups of American society would not be well served by a treatment system of the type we proposed if it did not take such differences into consideration. The committee believes the proposed system is capable of accommodating such a requirement, but it also believes that special effort must be exerted to see that it does. Specifically, additional research is needed on the effectiveness of proposed but untested culturally sensitive treatments advanced for each of the special populations. Finally, there is the bottom line: all of this needs to be paid for. No pretense need be entertained that the burden of alcohol problems can be significantly eased without additional cost, and improvements in treatment could be costly. However, the current cost of treatment is, even by conservative estimates, a tiny fraction of the total monetary cost of alcohol problems (quite apart from their devastating toll of human misery and lost potential). If the improvement of treatment effectiveness results in a higher level of positive outcomes, the costs involved may be to a significant degree offset by a decrease in the cost of alcohol problems. Improved methods of financing treatment may contribute to this balance in an important way. The cost of increasing treatment availability and effectiveness through our vision could, indeed, come from the savings to be achieved by changing the emphasis on inpatient detoxification and rehabilitation to a focus on assessment, brief intervention, and outpatient treatment and by matching persons with the most effective form of treatment. There are no solid data on which to base estimates of either costs of current inappropriate use or projections of savings because of the lack of adequate surveys and cost-effectiveness studies (see Chapters 8, 19, and 20~. There is a need for greatly expanded program of research on the cost-effectiveness of alternative treatments. Such are the committee's vision and its specific recommendations, spelled out in much greater detail in the preceding chapters. One thing is certain: they will not
488 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS implement themselves. Indeed, in many regards, a total reorientation in our thinking about ~alcoholism" is required-a shift away from the conception that all alcohol problems involve a chronic progression that can only be deterred through a single treatment approach. Although there has been some movement in this direction, strong leadership will be required for any significant level of implementation. Who will provide the requisite leadership? Opportunities for Leadership It is tempting to think in terms of a single designated leader-an individual, an office, an organization who would be assigned the task of providing for the future of the treatment of alcohol problems. In this way, responsibility is clearly delegated, and an accounting can readily be demanded. Despite its advantages, the committee rejects this strategy. The range of alcohol problems is too large and too complex to yield to unitary leadership. There is no one federal agency, no one advocacy group, no one sector that can manage the job. Leadership in the future development of diversified treatment for alcohol problems must be shared. In what follows, possible initiatives that might be taken by some of the principal actors on the scene will be mentioned for illustrative purposes. The Leadership Opportunity for Congress The federal government has been, through the initiatives of Congress starting with the Hughes Act and continuing with the recent reviews of services, a keystone in the development of treatment services for alcohol problems. In recent years, Congress has shown an increasing willingness to share this role with the states through the development of the block grant mechanism to fund categorical services for the uninsured and indigent. It is also sharing the role with the employers who are the major purchasers of private health insurance by its unwillingness to pass legislation mandating a specific benefit for the treatment of alcohol problems. Congressional concern has been expressed as an unwillingness to impose mandates on purchasers when the efficacy of various treatments is still unknown (e.g., Florio, 1988~. Although, the committee focuses these comments on Congress which commissioned this study, it recognizes that the administration and each of the agencies involved in the delivery, financing, and study of treatment for alcohol problems can also provide leadership by taking the initiative to implement those parts of the committee's vision which are relevant to their operations. The federal government itself is both a major purchaser and a major provider of treatment services for alcohol problems (see Chapters 4, 8, and 18~. In the aggregate, the treatment capability operated by federal agencies (i.e., the Indian Health Service hospitals and clinics, as well as its contracted treatment programs; the Department of Defense hospitals, clinics, and freestanding residential and outpatient units; and the Department of Veterans Affairs inpatient and outpatient units and contracted halfway houses) constitutes one of the largest pools of treatment resources in the country. None of these services is currently operating in the manner envisioned by the committee. Congressional initiatives to introduce the comprehensive system proposed in this report into each of the system operated by federal agencies would create an important model for other providers to emulate. The federal government is also one of the major purchasers of all health care services. It pays (according to the best available data) more than 25% of the total cost of treatment for alcohol problems through its direct operations, grant programs, and public
LEADERSHIP 489 insurance programs. Congress has played a key role in the development of federal support for the nation's current system of treatment services for alcohol problems and retains oversight responsibility for it. The role of the federal government as a purchaser of health care has been described in terms that are quite applicable to the specific case of purchases of treatment for alcohol problems: In the federal government's role as a primary purchaser of health care, the Congress has, over time, developed a number of different programs. Each of these has been established to address the needs of a different beneficiary population, and each has viewed peer review in a different frame of reference. Although, in the abstract, and perhaps, in a public policy frame of reference, it would appear that the federal government should actively seek to develop a uniform benefit program (and a uniform cost-contain- ment/quality assurance mechanism) for all its beneficiaries, and thus, at a minimum, use its considerable purchasing power (i.e., size) and experience to ensure the most cost-effective benefit package possible-in reality, this is not what has occurred. Each of these programs come under the jurisdiction of different congressional (sub) committees and as a result, each is considerably different in philosophical orientation and benefit structure. (DeLeon et al., 1988:287) Obviously, the situation described here is not what the committee advocates. None of the federal purchase-of-care programs have mechanisms in place that require conformity to the elements of effective treatment as recommended in this report. Federal programs differentially support alternative treatment strategies without adequate, coordinated discussion and review. Medicare and Medicaid have narrow provider eligibility criteria that exclude providers who offer social model alternatives; they continue to support only a medical model of hospital-based detoxification and rehabilitation whereas the majority of states, using block grant funds, support a mixed medical and social model that also includes maintenance and extended care in nontraditional, nonhospital settings. While different oversight committees are involved for the different federal treatment programs, all could use similar or identical guidelines to review the current manner in which pretreatment assessment, referral and matching to treatment, treatment itself, and outcome monitoring are carried out. Alternatively, oversight responsibility could be restructured and perhaps consolidated so that a single committee reviews all treatment for alcohol problems paid for with federal funds. Pursuant to its review, the committee suggests that all federally operated treatment systems as well as the grant and insurance programs, should include both medical model and social model residential, intermediate (day care), and outpatient assessment, detoxification and other forms of acute intervention, rehabilitation, and maintenance activities as options in their benefit packages so that each can be used when clinically appropriate. The implementation of brief, low-cost interventions should be initiated immediately through the training of generalist health care and social services staff as well as specialist staff This recommendation is merely a restatement of the committee's advice to all purchasers of care as outlined in Chapter 20. The committee recommends that Congress using these principles as a means of demonstrating its leadership initiate a total reru~w of the programs for which it has oversight responsibility and create a uniform benefit structure. For example, programs offering inpatient hospital-based treatment in Minnesota are more expensive than a structured day program, but the intermediate care option has not been covered as fully as the hospital option by either public or private payers. After reviewing the research on the effectiveness of the two options, the Minnesota legislature adopted a consolidated approach that was designed to place persons needing treatment in
490 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS the most appropriate setting. Medicaid and the alcohol, drug abuse, and mental health services block grant are part of the current effort by the Minnesota Chemical Dependency Program to determine whether there can be cost savings with a statewide system of preadmission screening and assessment using uniform level of care placement criteria that include provisions for intermediate care. Medicare is not participating in the system. Conversely, the alcohol, drug abuse, and mental health block grant and many of the state alcoholism authorities exclude hospital-level service from their funded options because of cost. Yet there are times when such services are clinically appropriate and should be available, through the appropriate matching procedures. The Minnesota consolidated fund approach, now undergoing evaluation, represents a naturalistic study of all these modalities and can provide data to supplement the HCFA-NIAAA demonstration (Lawrence Johnson and Associates, Inc., 1986~. This effort should be closely monitored by Congress as it decides which path to follow. In short, treatment should be determined by clinical need rather than by the design of benefits or by ideological constraints. Clinical need should be determined by careful pretreatment assessment and continued reassessment as described in Section III of this report. Leadership from the major purchasers of care, including Congress, will be required for such changes in clinical practice and financing policies to occur on a nationwide basis. The importance of the federal government as a provider and a purchaser of services suggests that its initiatives would be influential guides for all purchasers and providers. Another area of alcohol problems treatment in which Congress might exercise some influence is through support for research on the organization and financing of effective treatment services. Data on the effectiveness of specific treatment approaches must be continuously available to encourage purchasers of care to include-or exclude a given procedure or type of provider. The committee stror~g, urges that Congress support an enhanced program of clinical and services research on the Moment of alcohol problems. One unintended effect of the introduction in 1982 of the block grant system of funding treatment and prevention services appears to have been a reorientation of federally funded research in the direction of basic biomedical research accompanied by a relative deemphasis of clinical and services research and a cutback in monitoring the development of the treatment system and in conducting services research. This effect will be discussed in more detail below in the section on leadership opportunities for the NIACIN) Only limited funding has been available for treatment evaluation and technology transfer. The result has been a slowing down in efforts devoted to the refinement of treatment strategies and practices through the comparative study of their cost effectiveness. Also lacking are mechanisms to transfer into practice the knowledge that has been gained about the effectiveness of specific treatments. What is needed are expanded training in the conduct of alternative approaches that have been shown to be effective (e.g., brief interventions) and funding support for programs that implement these more cost-effective approaches. Several recent developments that have occurred during the course of this study are noteworthy. NIAAA placed a renewed emphasis on its treatment research function in establishing a Treatment Research Branch in its new Division of Clinical and Prevention Research and will be funding studies for evaluating effectiveness when persons are matched to specified treatment strategies (Noble, 1989~. In addition, NIAAA received explicit authorization to fund services research projects as part of the Anti-Drug Act of 1988. Support for these activities, however, remains minimal; more substantive funding and staffing must be found and an expanded research agenda articulated if the needed studies are to be carried out using adequate experimental methods so that their findings are accepted and can lead to changes in practice. ~J
LEADERSHIP The Leadership Opportunity for the States 491 Wit}lin the current legislative framework, the states have the primary responsibility for funding, planning, implementing, regulating, and monitoring the quality of treatment for alcohol problems (e.g., USDHHS, 1986~. At present, each state now has an identifiable aPencv that is responsible for the development, maintenance, and evaluation of its service my, , _ , . , . ~ , . ~ i, ~ ~ ~ . ~ . ~ delivery system. The scope and authority of the agencies biller s~gnuy Irom awls; ~o ;, as do the components of the service delivery system. In states that have adopted the Uniform Act, the definitions of treatment and the continuum of care for alcohol problems are similar (see Chapters 3 and 4~. Generally, state alcohol agencies do not operate facilities or treatment programs (although some states do). Most state governments are the largest single purchasers of treatment for alcohol problems in their jurisdictions, either through the categorical agency which administers the federal block grant or through their Medicaid program, or using a combination of these ~ _ , _ ~ funding sources. The beneficiaries on whose behalf these services are purchased tend to be low-income persons who do not have private health insurance coverage for treatment of alcohol problems. The elements in the continuum of care supported by the benefit package in each state program differ from those of other states, although there are certain common features. Increasingly, however, state alcohol agencies are accepting the research findings that have demonstrated the effectiveness of lower cost mixed medical and social model detoxification and rehabilitation carried out in outpatient and intermediate care settings. The issue of consistency among the states in relation to treatment standards and the establishment of a continuum of care based on the best available research information continues to be of prime importance (see Chapters 3 and 7~. The Minnesota and Oregon legislatures' recent efforts constitute an important model for state action. The Oregon legislature recognized that the treatment system that had been put in place over 20 years earlier had not had a major review. It established a special committee to review the need for services in the state, the existing local service delivery system, and the administrative relationships and operations of the various state and local agencies involved in treatment funding and provision. The result of the review was a significant body of recommendations that was submitted to the legislature for adoption (Special Committee on Alcohol and Drug Abuse Policy, 1984; J. Kushner, Oregon Office of Alcohol and Drug Abuse Programs, personal communication, 1988~. The recommendations formulated in this report could be used in a similar fashion by state legislatures and state alcoholism authorities to review program standards and policies utilized by the state in funding specialist treatment for alcohol problems. Whether such funding is part of the categorical program administered under the state alcoholism authority or supplied by Medicaid, the following questions are relevant: Do the standards and policies indude a provision for comprehensive pretreatment assessment? Do the standards and policies require outcome monitoring and performance contracting? Do the standards and policies require a demonstration that particular services are either appropriate for heterogeneous groups or should be limited to those persons for which that specific level and type of care has been shown to be effective?
492 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Do the standards and policies allow alternative treatments to be offered to all persons seeking assistance? Do the standards and policies require matching of the person to the appropriate setting at each stage of treatment? Do the standards and policies provide for brief interventions with demonstrated effectiveness as part of the state-funded continuum of care? Does the state supported continuing education and credentialing program include training in brief intervention techniques, assessment strategies, and continuity assurance? Are there training opportunities for each of the key disciplines involved (physicians, psychologists, social workers, and nurses, as well as counselors)? The findings and recommendations formulated in this report could also be used to review the continuum of care in those states that have in place legislation mandating particular insurance benefits. As discussed in Chapter 19, the committee makes no recommendation per se on whether there should or should not be mandates. The committee maintains, however, that the principles for determining appropriateness of coverage for a given approach should be applied to mandates as well as to individual benefit plans. For example, does the mandate include a provision for comprehensive pretreatment assessment? Does it include the variety of settings and alternative treatments needed by the heterogeneous subgroups that require treatment? Does the mandate call for matching to the appropriate setting and intensity of treatment at each treatment stage? Does it allow for reassessment and outcome monitoring? Does it include a predeffned number of inpatient days or outpatient sessions? Does it call for outcome monitoring and continuity assurance? If there are concerns about the cost of implementing the vision of treatment presented by the committee, the states can take the lead in evaluating the feasibility of the proposed comprehensive system by conducting their own naturalistic and experimental studies. One possibility for conducting such a feasibility study involves the extensive network of dnnking-driver services that developed in each state out of the Alcohol Safety Action Program (see Chapters 4 and 16~. Questions have been raised regarding the effectiveness of DWI intervention and treatment in comparison with other sanctions (Hager, 1986~. There have been few adequate studies of the potentially positive effects of matching persons in DWI clinics to the appropriate treatment modality, typical first-offender programs involve only the options of education or limited treatment for all individuals (Wells-Parker et al., 1986~. Using the network of drinking-driver programs as test sites, some of the newer brief intervention strategies along with comprehensive pretreatment assessment and continuity assurance could be introduced and evaluated following a process outlined below. State-administered and state-regulated drinking-driver programs already have in place a prototype version of the comprehensive assessment process discussed in Chapter 10, as well as a network of probation specialists responsible to the court for reports on offenders, progress and outcome. In addition, most states now have in place an outcome monitoring system for program evaluation. However, these systems have not been formalized with regard to such matters as assessment, matching decision rules, and continuity assurance procedures. Consequently, the committee proposes adding a more sophisticated assessment and outcome monitoring capability, as well as additional alternative interventions, to the DWI referral and case-monitoring programs already in place. The augmented system should be capable of matching the DWI offender to different
LEADERSHIP 493 brief interventions and to different conditions of continuing treatment. Rather than being introduced in all DWI programs in a state, such an approach could be given a trial to determine its feasibility and effectiveness in one or more of the state's jurisdictions and outcomes compared among jurisdictions. A more elaborate, multisite study could be developed by the states working cooperatively with the NIAAA and the National Highway Traffic Safety Administration. There has been no comprehensive national study of these programs in recent years, despite their importance as one of the keystones of the nation's policy to decrease driving after drinking. Studies that have attempted to develop topologies of dnnking4river offenders through more extensive assessment suggest that treatment as a countermeasure can be made more effective in reducing both relapse and recidivism by the differential assignment of persons to brief or intensive interventions (e.g., Pisani, 1986; Scales et al., 1986; Wells-Parker et al., 1986~. Given the importance of the drinking-driver problem, such a national study merits serious consideration. The Leadership Opportunity for Employers and Private Insurers Insurers and employers are major purchasers of health care in general and of treatment for alcohol problems in particular. Similarly to the federal and state governments that also purchase these services, employers and insurers are seeking answers to questions about the effectiveness of treatment services to aid in cost containment and benefit design. Our vision provides the tools to obtain the data necessary to make informed choices among the alternative treatments which are presented to them by providers as Successful. Increasingly, purchasers of care use a variety of mechanisms to contain costs; these include preadmission certification, required second opinions when a costly procedure is being considered, concurrent and retrospective reviews of medical necessity, and case management. Increasingly, purchasers are entering into managed care and preferred provider arrangements with practitioners and facilities that incorporate these mechanisms along with discounts and other forms of risk sharing that were pioneered in HMOs. Questions have been raised regarding the effectiveness of these techniques to accomplish the dual purposes of containing costs and maintaining the quality of care (e.g., Ellwood, 1988~. A new Outcomes managements approach has been suggested; this approach is similar to the vision of a comprehensive system presented by the committee in this report. Employers as purchasers of treatment for alcohol problems (either directly through self-insurance or through commercial insurance carriers) can respond to these concerns by using the committee's recommendations to evaluate their current benefits or any new benefit design they seek to adopt. The committee has chosen to provide the schematics for an idealized comprehensive treatment system that can be used as a template to evaluate the continuum of care supported by a particular purchaser of services. The purpose of presenting this system is not to suggest that each employer, insurer, or government agency adopt this particular framework; the committee is well aware that other approaches are possible. Rather, its goal is to provide purchasers with an example of how a model comptrehensive system can be used to assess their particular approach. To assist in this evaluation we have included examples of the assessment tools and placement criteria currently available. In sum, we are suggesting that each and every government agency and business that purchases treatment services on behalf of its ~beneficiaries. review the continuum of care supported by its Benefit packager to determine whether the plan enables a person to receive the appropriate match at each stage of treatment or whether its structural features
494 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS (e.g., provider eligibility rules, Payment caps) serve as disincentives to proper matching. Leadership will require the asking of some difficult questions: . Does the benefit pay for an objective assessment to determine the appropriate match to level of care (setting) and treatment modality at each stage of treatment? Are the requisite screening and assessment and outcome monitoring mechanisms in place to allow for matching? Are those medical model and social model venders that provide the most cost-effective treatment part of the continuum and eligible to participate in the plan? Are the participating venders capable of providing the alternative treatments (e.g., brief interventions, ambulatory detoxification, day care) that should be available? Have the venders' staff had training in brief intervention techniques, assessment strategies, and continuity assurance? Do the participating venders conduct outcome monitoring? Is there a detailed description of each treatment that is part of the continuum and that is covered under the plan? Is there a mechanism to monitor the adequacy of the treatment's implementation as well as its outcome? Does the benefit plan provide incentives that motivate individuals to choose the treatment that is most cost-effective for them? Does the benefit plan provide incentives for venders to offer the most cost-effective treatment determined through assessment and matching? Employers and insurers can take the lead in the private sector in the development and testing of the vision through their already existing employee assistance programs (EAPs) and managed care activities. Like the drinking driver programs in the public sector, many of these employer-and insurer-sponsored plans have partially instituted key elements of the proposed comprehensive system; they can thus serve as testing grounds to evaluate the benefits to be gained by introducing our vision-or another variation that will allow employers and insurers to make data-based, empirically testable choices for their employees and customers, respectively, among the competing treatment strategies. Employers and insurers can carry out their own studies, introducing the comprehensive system in specific sites and not in others and then comparing outcomes. Again, like the states, employers and insurers can also design more elaborate experimental studies to test various combinations of practices; here, the participation of NIAAA and private foundations in funding multisite studies would be appropriate. In some measure as a response to the recommendations of the Cooperative Commission (Plaut, 1967), there are now an estimated 10,000 EAPs covering approximately 25% of the work force (see Chapter 18 and Appendix D). A recent survey by the Bureau of Labor Statistics found that approximately 50 percent of businesses with more than 250 employees had an EAP. Many EAPs have become caught up in their sponsoring company's efforts to cut down escalating health insurance costs, and as a result some concern has been expressed for their future as programs. The committee shares this ~__ _ ~ _ . _ . . _ . . _ _
LEADERSHIP 495 concern in the absence of any change in the basic pattern of operation of EAPs. Nevertheless, it sees this situation as a potential opportunity for leadership if the cost-containment efforts are combined with efforts to maintain and improve positive outcomes through the implementation of the committee's recommendations. In some respects EAPs are similar in form and function to the kind of mechanism recommended in this report. (See, for example, the discussion in Chapter 13.) Like DWI programs, they have in place rudimentary assessment and continuity assurance mechanisms. EAP counselors even now have informal means for evaluating treatment agencies and for matching their referrals to them. The EAP counselor already functions in some respects as a case manager, although there is ongoing debate as to whether this is an appropriate function if the emphasis is on cost containment rather than cost-effectiveness. In general, it is important to prevent Financial case managements and Clinical case managements from working at cross purposes (see Chapters 13 and 20~. Thus an opportunity exists for EAPs, working in concert with their company's top management and benefit administrators, to implement the committee's vision and to achieve a balance between cost containment and treatment quality. Recently, several companies have introduced assessment and case management systems (e.g., that introduced by General Motors and the United Auto Workers working with Family Services of America and Connecticut General Corporation [Butler, 1987~) that are quite reminiscent of this report's recommendations of this report. However, assessment and structured outcome monitoring have not routinely been undertaken in these arrangements. Employers and insurers can also provide leadership by requiring the implementation of the committee's recommendations in any managed care arrangement which they develop or with which they contract, be it an HMO or a preferred provider network The HMO or preferred provider network should include an organized system for the treatment of alcohol problems that includes screening and the opportunity for brief intervention in the generalist system before referral to the specialist system (see Chapter 9~. The managed care specialist system should include pretreatment assessment) matching at each stage of treatment, continuity assurance, and outcome monitoring. Through such activities, the private sector, without waiting for federal or state initiatives, can take the lead in modeling changes in practice that are needed to make cost- effective treatment possible. The Leadership Opportunity for Treatment Prowders According to the most recent survey, there are over 5,000 specialist treatment programs for alcohol problems (see Chapter 7~. At the time of the report of the Cooperative Commission in 1967, there were fewer than 400. This remarkable growth, in its richness and variety, offers a major opportunity for implementing the recommendations of this report in various ways and under various circumstances. As has been repeatedly noted, the majority of providers offer only a single approach to treatment. The continuation of such single-focus efforts was criticized in one recent state repon, which recommended that such programs not be eligible for third party reimbursement (New Jersey Department of Insurance, 1988~. In those instances, in which programs have the resources to offer alternative interventions within their own organization, but have not yet done so, the committee hopes that its recommendations will encourage them to proceed with such a strategy. As an alternative, treatment programs could implement arrangements by which they cooperatively over a broad panoply of interventions and jointly provide those functions (e.g., comprehensive assessment, matching, outcome determination, and continuity assurance or case management) that would be difficult for individual programs to implement.
496 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Because providers have traditionally been creative in their approaches to treatment, there is reason for optimism regarding the creativity they may bring to the forging of inoperative arrangements. It is the committee's hope that the adoption of the broad perspective on alcohol problems that it endorses (see Chapter 1) may facilitate this process. A worthy goal might be for the providers in a given area to work out cooperative arrangements in such a way that those seeking treatment in that area have a truly broad spectrum of alternatives on which to draw. Usually, large-scale arrangements of this kind are initiated by government agencies or other payers. If polycentric leadership is to become a reality, however, providers may also need to be initiators. In general, they can be expected to be much more aware of the service needs of their regions than a centralized governmental agency can be. Many communities already have in place a specialized information and referral agency that can serve as a hub for these activities (see Chapter 4~. In addition there are many independent information and referral agencies are operated by local affiliates of the National Council on Alcoholism. These organizations can work to bring providers together in this effort and create for their community a comprehensive system with objective assessment, outcome monitoring, and continuity assurance. Implementation of the committee's recommendations that there be an organized system of care in each community will require cooperation between treatment providers and third party purchasers of treatment services. Providers, individually or collectively through their associations, can approach the major sources of reimbursement in their community to support the effort to create a coordinated broad spectrum of treatments with a centralized objective assessment and continuity assurance function. Each community could work toward implementing the comprehensive spectrum of intervention responses that constitutes the vision of this committee_including the opportunity for brief intervention in the generalist system before referral to the specialist system, as well as pretreatment assessment, matching, continuity assurance, and outcome monitoring in the specialist system. The Leadership Opportunity for the Professions and Training Programs One of the focuses of the Cooperative Commission's recommendations in the late 1960s was development of enhanced services for problem drinkers within existing health, welfare, and community mental health agencies as well as on the development of a separate network of specialized services (Plaut, 1967~. The Commission's recommendation for enhancing nonspecialist services within the nonspecialist sector has not yet been implemented. This report also includes suggestions (see Chapter 9) toward the achievement of this end. Yet what was not possible earlier may now be achievable because of the impressive gains in knowledge and experience over the past 20 years. Encouragement in this area may also be drawn from the experiences of other nations: screening and brief intervention in the nonspecialist sector has become a cornerstone of the approach to treatment for alcohol problems in developing countries (see Appendix C). In its focus on enhanced generalist services for alcohol problems, the Cooperative Commission also emphasized the need for special clinical training programs. Until 1982, this recommendation was implemented through a number of training programs administered by NIACIN Since 1982, it has been continued on a reduced level by NIAAA (primarily for physicians), by many state alcoholism authorities (primarily for counselors), and a varieW of universities and professional schools (see Chapter 4~. However, as discussed earlier, the number and characteristics of the cadre of trained professionals (e.g., physicians, nurses, counselors, social workers, and clinical psychologists) who provide treatment for alcohol problems is unclear because there is a serious lack of accurate, timely work force data at the national level, and this lack of data
LEADERSHIP 497 compromises efforts to plan for future training and professional needs. A related issue is credentialing. While there is a growing consensus on the need for some external validation of the qualifications of a given individual to engage in clinical work, there is little movement toward organizing and coordinating such efforts within the various groups involved, let alone across different groups. As a result, diverse practices are now the rule. A uniform-or at least a coordinated policy of training and certification should to be considered, in large part because the characteristics of treatment personnel are significant contributors to treatment outcome (see Chapter 5~. Such a policy is also critical to the implementation of the committee's new vision of alcohol problems and their treatment. For example, the certification of counselors who work as primary therapists in the majority of specialist programs using a mixed medical and social model is an ongoing concern of the public and private funding sources that play an ever-increasing role in determining the direction in which the field Is going. The certification of treatment personnel is an important quality assurance issue for these payers. The committee suggests that a national strategy for the training, continuing education, and certification of persons who provide treatment for alcohol problems be formulated and implemented. The current division of responsibility suggests that the lead should be shared by the federal agencies involved, by the state alcoholism authorities acting through their national organization, and by the broadest possible coalition of professional associations whose members are actively engaged in the treatment of alcohol problems. As discussed in Chapter 4, there has been renewed interest and activity in the development of cumcula and training programs as well as in credentialing. However, there does not appear to be a viable mechanism for coordination and cooperation among the disciplines and agencies involved. There should be better integration of the efforts for the various disciplines. There are several sorts of training that need to be addressed. The training of physicians, because of their influence in the health care system, is crucial and developments that have taken place within this profession can serve as a model for what is needed for the other disciplines involved (psychology, nursing, social work, counseling). Training efforts can be important tools for bringing about the changes in institutions that are necessary to broaden the base in which screening and brief interventions will need to take place Many of the settings in which screening and brief intervention would occur, once the comprehensive system proposed by the committee was in place, are not now particularly conducive to dealing directly with alcohol problems. There needs to be a special effort by each of the professions to create training opportunities in brief interventions. If there is to be further evolution of treatment for alcohol problems, the overall training and certification issue cannot remain unaddressed at a national level. Because a broad scope is required to develop the requisite data and to address the policy issues, the task is beyond the capability of any existing single organization. These concerns need be addressed not only for physicians or for counsellors but for all the disciplines. Clearly, a broadly based consortium of the professions involved needs to be developed. One or more of the professional organizations can take the lead in lounging together all these groups to initiate such efforts. Ihe Leadership Opportunity for the National Institute on Alcohol Abuse and Alcoholism That there needed to be strong federal leadership, and discrete federal and state administrative entities working in close partnership, was the theme of several of the Cooperative Commission's recommendations (Plaut, 1967~. NIAAA and the state alcoholism authorities were subsequently established, and the goal of a strong federal presence was achieved for many years. The strong leadership previously exercised by the
498 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS National Institute on Alcohol Abuse and Alcoholism in the development and maintenance of treatment for alcohol problems has been described in previous chapters and is widely acknowledged Lewis, 1982,1988; Cahalan, 1987~. NIAAA's role altered profoundly, however, with the introduction in 1982 of the block grant system of funding treatment and prevention. The shift to block grants, which was intended to place major responsibility for services development and enhancement on the states, coincided with a focusing of the agen~y's mission on research. Currently, a substantial amount of NIAAA's funding is expended for basic biomedical research, reflecting a pattern that is uniform across the three institutes (NIAAA, NIDA, and NIMH) that constitute the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA). This policy rests on a belief that advances in knowledge regarding the basic biological processes underlying the three institutes' target Problems is required for advances in treatment (Goodwin, 1988~. -no-- A- ~- With this reorientation came a perception in the held that there had been a sharp cutback in staff and resources and that NIAAA was no longer able to carry out the leadership role it had originally assumed in monitoring service development, services demonstration, or clinical training (Cahalan, 1987; Lewis, 1988~. The perception is that there has been minimal financial and staff support for cooperative studies of treatment effectiveness, minimal communication about developments and refinements in treatment methodology, and the dissolution of a clinical and services surveillance and research infrastructure necessary for policymaking. There has been recognition that these areas have not been fully attended to and suggestions made for an expanded clinical and services research effort (e.g., Wallen, 1988; IOM, 1989~. Currently, only 14 percent of the intramural research budget and 12 percent of the extramural research budget are devoted specifically to treatment research (IOM, 1989~. These allocations are relatively small amounts, considering the need for research on treatment effectiveness outlined here and in the 1989 IOM report, Pr~venfion and Treatment of Alcohol Problems: Research Opportunities. Yet recently, there have also been some heartening changes: the creation of the Treatment Research Branch within NIAAA's new Division of Clinical and Prevention Research; the reestablishment of a specific services demonstration authority for NLAAA in the Anti-Drug Act of 1988 (P.L 100~90, Sec. 1922~; and the development of initiatives to study matching and financing. The recent program announcement for a cooperative agreement to study matching strategies is a major step toward implementing what should become an ongoing program to test the cost-effectiveness of alternative treatment strategies (see Chapter 19~. A similar positive initiative is the recent program announcement for research on economic and socioeconomic issues in prevention, treatment, and epidemiology. This program solicits investigator-initiated applications for studies of the existing system (e.g., examinations of the geographic distribution and availability of treatment, studies on the use and costs of various treatment services and settings). Both of these relatively small initiatives, however, are dwarfed by the need for better data. NLAAA's enhanced clinical and services research program is an important first step toward developing the body of research knowledge needed to further refine the maturing treatment system. Much more needs to be done, however. Some of the Institute's own programs can serve as prototypes. For example, NIAAA has creatively used the services demonstration grant to provide a mechanism to evaluate its projects for services to the homeless (Lubran, 1987; NIAAA~ 1987~. The committee recommends expanding this type of research, which involves both a project process evaluation and a national multisite outcome evaluation across all grantees, to other special population groups to study the comparative effectiveness of culturally relevant treatment approaches (see Chapter 18~. It could also be used generally for multisite trials of significant specific treatments that have not yet been subjected to testing. The cooperative agreement and contracting mechanisms constitute flexible vehicles for mounting studies that can supplement the traditional
LEADERSHIP 499 investigator~riginated grant submissions. These mechanism are beginning to be used by the Treatment Research Branch (NIAAA, 1989), although, their effective use, which involves a much more active partnership of the sponsoring organization with the participating test sites, depends heavily on an adequate complement of staff. The committee believes strongly in the need to affirm the visibility and priority of clinical and sconces research in NIAAA. Otherwise there is cause for concern regarding the adequacy with which the organization can carry out its portion of the shared leadership responsibility that the committee sees as necessary to implement the recommendations of this report. One must also think beyond the extensive but necessarily limited purview of the present study: there will be a readily foreseeable future need for the conduct of this kind of research as a basis for policy and practice. However, any future study will also be hampered by the lack of relevant data if the current deployment of resources is not enhanced. There Is currently only one NIAAA-funded research center, located at the University of Connecticut Health Center, that is devoted to treatment research. The Department of Veterans Affairs also funds one clinical research center at the San Diego VA Medical Center (IOM, 1989~. These two centers constitute a significant but inadequate effort. The committee sees a need for additional clinical research centers and activities, particularly if its concerns about the cost-effectiveness of existing treatment and referral patterns are to be addressed. An additional treatment research center, with a major focus on studies of cost-effectiveness of alternative treatment methods, would be a logical next step. In accord with its rwommend~ons for ~u~g matching in Chapter 11, the committee reconunends to= consideration be given to establishu~g a multisite network of researched who could conduct ~= eral~ion studies on an ongoing basis. This multisite network could complement the work of the more traditional research centers and carry out those activities that cannot be studied through the investigator-initiated research grant mechanism. Developing such a network with sites that can undertake cooperative studies of the effectiveness of specific treatment approaches with specific target groups and ensuring that these centers are dispersed around the country will significantly improve the timeliness and relevance of treatment research. For example, each of the sites could participate in multisite clinical trials organized in a manner similar to the VA cooperative studies of the efficacy of disulfiram (Fuller et al., 1986~. The protocols of the studies would be developed by the participating center or centers in cooperation with the NIAAA Division of Prevention and Treatment Research. The network would be able to use feedback designs within a multiprogram format and analyses of the treatment process within a uniform measurement framework to determine the effectiveness of various treatments and to identify their "active ingredients. The sites can also serve as Quick response. mechanisms to develop rapid information on treatments, procedures, assessment instruments, costs, characteristics of persons seeking treatment, and so forth. This type of timely information gathering could be of great value to NLAAA and other federal agencies (e.g., HCFA, the Department of Defense, the VA) in their efforts to respond to new developments in practice. A recommendation more directly tied to the implementation of its vision is the committee's suggestion that NIAAA be given the additional resources to fund clinical research consortia in several communities around the country to test the feasibility of implementing its proposed comprehensive system. Such a plan would involve the development of sites designed to undertake cooperative studies of the effectiveness of specific treatment approaches with specific target groups when assessment and outcome monitoring, including detailed cost data, are in place. These studies will not only enhance treatment research but will provide models of the vision for other programs and practitioners to emulate.
500 BROADENING DIE }lASE OF TREATMENT POR ALCOHOL PROBLEMS Each of the sites would involve a consortium of treatment agencies and include as the center of its operations a comprehensive assessment capability fully staffed by an assessment, referral, and clinical case management team supported by a data collection and analysis staff. Because most providers currently offer only one or two treatment approaches, each consortium should be associated with as many treatment programs as possible. The criteria for association should include an agreement to participate fully in the pretreatment assessment of individual patients and the posttreatment monitoring of outcome and, whenever possible, in clinical trials of specific treatments. The number of treatment programs involved in any one consortium is not as critical as having a range of treatments that represent the entire continuum of care. Beyond what can be achieved through the expansion of NIAAA's treatment research centers, investigator-initiated studies of treatment effectiveness, and specific studies to test the feasibility of the committee's vision, there is a great need for increased communication in and support of the field as a whole. At present in this country, treatment activities related to alcohol problems lack a central focus. Although much can be done by the states themselves and by other groups in cooperation with them in cooperation with them, the treatment of alcohol problems is a national effort and needs to be viewed as such. In previous chapters, there were suggestions and recommendations made that, for maximum usefulness, require the achievement of a national consensus on practices and procedures. NIAAA can play a crucial role in forging such a consensus. The attenuation of its services funding role through the block grant mechanism not only does not relieve it of responsibility for leadership in other areas but, in an important way, makes its leadership more credible (i.e., if funding is a state and local matter, NIAAA cannot be viewed as imposing its views on treatment programs under the guise of creating a consensus). NIAAA needs to expand its role as a disseminator of research findings through the development of a national technical assistance program. Local treatment programs and state agencies are in great need of assistance to identify and implement the latest developments in treatment delivery. Such mechanisms as technical assistance conferences, onsite demonstrations by practitioners experienced in a particular methodology, and the dissemination of technical advice manuals and training materials could provide this assistance. Consultant visits and like activities provide exchanges of information that break down the isolation that seems to be increasing for many programs in the field. lithe federal government, through NIAAA, could provide leadership that would end this isolation by establishing a program of technical assistance, continuing education, technology transfer conferences, consensus conferences, and consultation on matters pertinent to treatment that would be directed toward state alcohol agencies and other funders and toward providers of treatment for alcohol problems. The Leadership Opportunity for Voluntary and Community Organizations There are many voluntary and community organizations that are concerned with the prevention and treatment of alcohol problems (Matheson, 1982; Lewis, 1988~. These organizations also have a major role to play in bringing about the changes required in our current system to move away from the present emphasis on undifferentiated treatment of those individuals with the most severe alcohol problems. Creating a comprehensive system that provides cost-effective treatment for persons at all levels of alcohol problems requires action at both the local and national levels. Thus, community and voluntary organizations must be encouraged to work to work closely with governmental agencies, treatment providers, professional organizations, employers, and insurance companies to implement these recommendations.
LEADERSHIP 501 Much of the progress documented by the committee in relation to the establishment of a nationwide network of specialist treatment has been due to the assistance and, often, leadership of voluntary organizations, citizens groups, unions, service organizations, trade associations, private foundations, and church and clergy groups in the implementation of the recommendations of the Cooperative Commission on Alcohol Problems. Key roles have been played by organizations such as the National Council on Alcoholism, the Junior Chamber of Commerce, the National Congress of Parents and Teachers, the AFCCIO and the United Auto Workers (UAW), the Junior League, and the Alcohol and Drug Problems Association of North America. Over the past 20 years, these groups have frequently endorsed programs of prevention, treatment, and research; they have also helped obtain wider access to treatment for persons with alcohol problems. Similarly, recovering persons and their family members have used these local and national organizations to express their concerns about the accessibility and adequacy of treatment resources . The successful efforts of these groups can be seen in the passage of legislation at the national, state, and local levels of government, as well as in the initiation of and continuing support for individual treatment programs. In particular, the role of local churches and national religious organizations of all denominations is critical. Individuals and families often share their alcohol-related difficulties first with clergy and are counseled or referred to self help organizations or specialist treatment. Clergy and church groups also provide ongoing support in preventing relapse after formal treatment. In many instances in which no treatment programs existed, churches were active in their initiation. There is now an opportunity for them to play a leadership role again in combination with schools, service organizations, and other voluntary associations. One particularly useful course of action would be for all these erouDs to come together in each community to review the committee's conclusions and ~ , ~ ~ recommendations and to work with tile providers and funders to evaluate how closely the current treatment system and the efforts to implement them come to having a comprehensive system. Their various national associations can come together for a similar review. Frequently, the positions on various alcohol-related issues held by voluntary associations and community organizations are at variance with government policies. This divergence comes from the unique perspective these groups bring to community needs and interests and as such represent a substantial force for change in both the public and private sectors. It is the committee's hope that these groups can adopt the broad perspective on alcohol problems presented in Chapter 1 and work with the relevant government agencies, treatment providers, third-party payers, and professional associations to develop a full response in both the generalist and specialist sectors to persons at each level of the spectrum. Thus, it is not only the professionals and legislators who should be involved in the reevaluation of the nationts approach to the treatment of alcohol problems but also those community members who have an ongoing stake in the outcome of treatment. Clearly, a broadly based consortium of the relevant community organizations asking these same questions about the system of care in their community can help to provide the leadership needed to bring about the necessary changes. The Challenge for the Future In sum, much has been accomplished in the treatment of alcohol problems since the pioneering work of the Cooperative Commission more than 20 years ago. Nevertheless, it should surprise no one that much remains to be accomplished. Alcohol problems, like other so-called ~lifestyle. problems (e.g., smoking, eating habits) have increasingly risen to
502 BROADENING THE BASE OF l!REAl~MENT FOR ALCOHOL PROBLEMS national attention as further knowledge is gained regarding the attendant morbidity and mortality. Now is the time for a major increment in efforts to deal effectively and efficiently with individuals at risk of or already experiencing alcohol problems. The committee hopes its recommendations will contribute to this process. Implementing the recommendations contained in this report will require shared leadership and cooperation among those groups and agencies that have been involved since the report of the Cooperative Commission in efforts to expand the availability of quality primary treatment for alcohol problems. We have entered a period of stabilization for those gains that were achieved by the acceptance of alcohol problems as a condition that could be effectively treated. Now, those gains can be maintained only if there is a shift toward concern with the differential effectiveness of each treatment for specific individuals. The current emphasis on cost containment in all areas of health care must engender a positive response Dom those who provide treatment for alcohol problems, a response that emphasizes careful assessment of clinical status and the matching of individuals to the appropriate setting, intensity, and modality at each stage of treatment. Rather than viewing these concerns as threats to the future of the field, the committee sees them as challenges that may allow the field to take the next steps along its path to maturity as an important, vital specialty area within mainstream health services. Meeting those challenges will demand the joint efforts of a wide range of leaders who are ready to adopt a broader, yet more precise, framework for treating alcohol problems. REFERENCES Butler, J. 1987. GM's approach to substance abuse treatment. Business and Health 4(3): 12-13. Cahalan, D. 1987. Understanding America's Drinking Problem: How to Combat the Hazards of Alcohol. San Francisco: Joss~-Bass. DeLeon, P. H., J. G. Pollens, J. J. Clinton, and G. VandenBos. The role of the federal govrnment in peer review. Pp. 285453 in G. Stricker and ~ R. Rodriguez, eds. Handbook of Quality Assurance in Mental Health. New York: Plenum Press, 1988. Ellwood, P. M. 1988. Outcomes management: A technology of patient experience. New England Journal of Medicine 318: 1549-1556. Florio, J. J. 1988. Opening statement. Presented at the U.S. House of Representatives, Subcommittee on Commerce, Consumer Protection and Competitiveness hearing regarding insurance coverage of drug and alcohol abuse treatment. Washington, D.C., September 8. Fuller, R. K, Lo Branchey, D. R. Brightwell, R. M. Derman, C. D. Emrick, F. Lo Iber, K E. James, R. B. Lacoursiere, K K Lee, I. Lourenstam, I. Maany, D. Neiderhiser, J. J. Nocks, and S. Shawl 1986. Disulf~ram treatment of alcoholism: A Veterans Administration cooperative study. Journal of the American Medical Association 256:1449-1445. Goodwin, F. K 1988. Alcoholism research: Delivering on the promise. Public Health Repons 103:569-574. Hagen, R. E. 1986. Evaluation of the effectiveness of educational and rehabilitation efforts: Opportunities for research. Journal of Studies on Alcohol Suppl. 10:179-182. Institute of Medicine. 1980. Alcoholism, Alcohol Abuse, and Related Problems: Opportunities 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. I~wrence Johnson and Associates, Inc. 1986. Evaluation of the HCFA Alcoholism Senrices Demonstration: Final Second Analytic Repon. Prepared for the Health Care Financing Administration. Washington, D.C.
LEADERSHIP 503 Lewis, J. S. 1982. The federal role in alcoholism research, treatment, and prevention. Pp. 385401 in Alcohol, Science, and Society Revisited, E. Gomberg, H. White, and J. Carpenter, eds. Ann Arbor, Mich. and New Brunswick, NJ.: University of Michigan Press and Center of Alcohol Studies, Rutgers University. Lewis, J. S. 1988. Congressional rites of pasage for the rights of alcoholics. Alcohol Health and Research World 12:241-251. Lubran, B. G. 1987. Alcohol-related problems among the homeless: NIAAA's response. Alcohol Health and Research World 11(3):4-6, 73. Matheson, J. D. 1982. The private sector. Pp. 355-367 in Prevention, Intervention, and Treatment: Concerns and Models, J. de Luca, ed. Washington, D.C.: U.S. Government Printing Office. National Institute on Alcohol Abuse and Alcoholism (NIAAA). 1987. Request for Applications: Community Demonstration Grant Projects for Alcohol and Drug Abuse Treatment of Homeless Individuals, RFA AA~7 04. RockvilJe, Md.: NLAAA National Institute on Alcohol Abuse and Alcoholism (NLAAA). 1989. Request for Cooperative Agreement Applications: Matching Patients to Alcoholism Treatments, RFA AA-892a, Coordinating Center. Rockville, Md.: NLAAA New Jet Department of Insurance. 1988. Report of Governor's Cabinet Working Group's Ad Hoc Advisory Committee on Funding Sources for Treatment for Alcoholism and Drug Abuse. Trenton, NJ.: New Jersey Department of Insurance. Noble, J. A. 1989. Status report on the Division of Clinical and Prevention Research for the National Advisory Council on Alcohol Abuse and Alcoholism. National Institute on Alcohol Abuse and Alcoholism, Rockville, Md. May. Pisani, V. D. 1986. DUI recidivism: Implications for public policy and intervention. [no page nos.] in Zeroing-in on Repeat Offenders: A Summary of Conference Proceedings: Papers Presented at the Conference on Recidivism, September 16, 1986. Atlanta, Gal: National Commission Against Drunk Driving. Pattison, E. M. 1977. Ten years of change in alcoholism treatment and delivery systems. American Journal of Psychiatry 134:261-266. Plaut, T. F. A ., ed. 1967. Alcohol Problems: A Report to the Nation. New York: Oxford University Press. Scales, P. E., E. W. Fine, and R. ~ Steer. 1986. DUI offenders presenting with positive blood alcohol levels at presentencing evaluation. Journal of Studies on Alcohol 47:500-502. Skinner, H. A., and S. Halt. 1987. The Alcohol Clinical Index Strategies for Identifying Patients with Alcohol Problems. Toronto: Addiction Research Foundation. Saxe, L^, D. Dougherty, K Esty, and M. pine. 1983. The Effectiveness and Costs of Alcoholism Treatment. Washington: U.S. Congress, Office of Technology Assessment. Special Committee on Alcohol and Drug Abuse Policy. 1984. Report on Oregon State Programs for Alcohol and Drug Abuse Services. Prepared for the Oregon State Legislature. Portland, Oregon. U.S. Department of Health and Human Senrices (USDHHS). 1986. Toward a National Plan to Combat Alcohol Abuse and Alcoholism. Repon submitted to the United States Congress. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism. Wallen, J. Alcoholism treatment service Systems: A health services research perspective. Public Health Reports 103:605~11. Wells-Parker, E., P. J. Cosby, and J. W. Landrum. 1986. A typology for drinking driving offenders: methods for classification and policy implications. Accident Analysis and Prevention 18:443~53.
