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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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