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~ Broadening ,' the Base of Treatment for ~ alcohol 1 Drobi Hems Report of a Study by a Committee of the INSTITUTE OF MEDICINE Division of Mental Health and Behavioral Medicine National Academy Press Washington, D.C. 1990

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National Academy Press . 2101 Constitution Avenue, NW o Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competencies and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. The work on which this publication is based was performed pursuant to Contract No. ADM-281-87-003 with the National Institute on Alcohol Abuse and Alcoholism of the Department of Health and Human Services. Library of Congress Cataloging-in-Publication Data Institute of Medicine (U.S.) Broadening the base of treatment for alcohol problems: report of a study by a committee of the Institute of Medicine, Division of Mental Health and Behavioral Medicine. p. cm. "Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse"--P. following table of contents. "Contract no. ADM-281-87-003 with the National Institute on Alcohol Abuse and Alcoholism of the Department of Health and Human Se~vices"--T.p. verve. Includes bibliographical references. ISBN 0-309-04038-8 1. Alcoholism--Treatment--Congresses. 2. Alcoholics- -Rehabilitation--Congress. I. Institute of Medicine (U.S.). Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse. II. National Institute on Alcohol Abuse and Alcoholism (U.S.) III. Title. [DNLM: 1. alcoholism--therapy. WM 274 I585bc] RC565.I4893 1990 362.29'2-~c20 DNLM/DLC for Library of Congress First Printing, April 1990 Second Printing, August 1991 Third Printing, March 1995 Copyright ~ 1990 by the National Academy of Sciences Printed in the United States of America 90-5702 CIP

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This book is dedicated to the memory of E. MANSELL PARSON, M.D. 1933-1989 in recognition of his many contributions to the treatment of alcohol problems; and to the memory of SARAEI CAITLIN GLASER 1987-1988

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Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse ROBERT D. SPARKS, M.D.,* Chair, President Emeritus and Senior Consultant, W.K Kellogg Foundation, Battle Creek, Michigan THOMAS F. BABOR, PH.D., + Professor of Psychology, Department of Psychiatry, University of Connecticut Health Center, Farmington, Connecticut ROBERT W. BLUM, M.D., PH.D., Associate Professor of Pediatrics and Maternal and Child Health, University of Minnesota, Minneapolis, Minnesota CHAD D. EMRICK, PH.D., Assistant Clinical Professor of Clinical Psychology in Psychiatry, University of Colorado Health Sciences Center, Denver, Colorado JIM FRANCEK, M.S.W., C.E.AP., President, Jim Francek and Associates, Inc., Norwalk, Connecticut EDWARD GOTIHEIL, M.D., PH.D., Professor of Psychiatry, Jefferson Medical College, Philadelphia, Pennsylvania MERWYN R. GREENLICK, PH.13.,* + Vice President (Research), Kaiser Foundation Hospitals, and Director, Center for Health Research, Kaiser Permanente, Portland, Oregon DAVID C. LEWIS, M.D., Professor of Medicine and Community Health, Donald G. Millar Professor of Alcohol and Addiction Studies, and Director, Center for Alcohol and Addiction Studies, Brown University Medical School, Providence, Rhode Island G. ALAN MARLA1T, PH.D., Professor of Psychology, University of Washington, Seattle, Washington THOMAS F. MCGOVERN, ED.D., C.ND.A C., Associate Professor of Psychiatry, Department of Psychiatry, Southwest Institute for Addictive Diseases, Texas Tech University Health Sciences Center, Lubbock, Texas MARK V. PAULY, PH.D.,* # Robert D. Eilers Professor of Health Care Management and Economics, Professor of Public Management and Economics, and Executive Director, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania BARBARA ROSS-LEE, D.O., Professor and Chairman, Department of Family Medicine, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan. v

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HARVEY ~ SKINNER, PH.D., Professor and Chairman, Department of Behavioural Science, Faculty of Medicine, University of Toronto, and Senior Scientist Addiction Research Foundation, Toronto, Ontario, Canada CYNTHIA P. TURNURE, PH.D., Executive Director, Chemical Dependency Program Division, Minnesota Department of Human Services, Saint Paul, Minnesota ROGER DALE WALKER, M.D., Professor of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, and Chief, Addictions Treatment Center, Veterans Affairs Medical Center, Seattle, Washington CONSTANCE M. WEISNER, M.S.W., DR. P.H., Senior Scientist, Alcohol Research Group, Institute of Epidemiology and Behavioral Medicine, Medical Research Institute of San Francisco Pacific Medical Center, and Lecturer, School of Public Health, University of California at Berkeley, California STUDY STAFF FREDERICK B. GLASER, M.D., F.R.C.P.(C), Study Director HERMAN I. DIESENHAUS, PH.D., Associate Study Director LEAH MAZADE, Editor BARBARA ~ KELLEY, Project Secretary FREDRIC SOLOMON, M.D., Director, Division of Mental Health and Behavioral Medicine ELAINE LAWSON, Administrative Secretary, Division of Mental Health and Behavioral Medicine *Member, Institute of Medicine +Liaison, Committee to Identify Research Opportunities for the Prevention and Treatment of Alcohol-Related Problems #Liaison, Committee for the Substance Abuse Coverage Study . Vl

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Contents Section I: An Overview of the Study Introduction and Summary, 1 Chapter 1 - Our Vision, 13 Section II: Some Fundamental Questions Chapter 2 What is being treated?, 23 Chapter 3 What is treatment?, 42 Chapter 4-Who provides treatment?, 98 Chapter S Does treatment work?, 142 Chapter 6 Is treatment necessary?, 152 Chapter 7 Is treatment available?, 163 Chapter 8 Who pays for treatment?, 183 Section III: Aspects of Treatment Chapter 9-The community role, 211 Chapter 10-Assessment, 242 Chapter 11 Matching, 279 Chapter 12 Determining Outcome, 313 Chapter 13 Implementing the vision, 329 Section IV: Special Populations in Treatment Chapter 14-An overview and definitions, 345 Chapter IS-Populations defined by structural characteristics, 357 Chapter 16 Populations defined by functional characteristics, 381 Chapter 17 Conclusions and recommendations, 399 Section V: Aspects of Financing Chapter 18-The evolution of financing policy, 406 Chapter 19 Cost effectiveness, 455 Chapter 20 Paying for the treatment system, 464 vz'

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Section VI: Gui(ling the Ongoing Effort Chapter 21-Leadership, 485 Acknowledgements, 505 Appendixes: A. B. C. D. Index, 6:: Members of the Task Forces, 507 Treatment Modalities: Process and Outcome, 511 International Review of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse, by M. Grant and E. B. Ritson, 550 Coercion in Alcohol Treatment, by C. M. Weisner, 579 . . . v''t

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~ Treatment for ~ ~' h ~ Problems 1 r Broadening ~ the Base of

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