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7 THE SOCIAL AND HISTORICAL CONTEXT OF ALCOHOL TREATMENT RESEARCH A variety of factors, many of them outside the academic scientific community, have influenced the course of alcohol treatment research during the past few years. These historical factors and trends need to be understood before considering new research directions because they will continue to influence future research efforts. Some of the factors that affect treatment research priorities include (a) changing federal involvement in alcohol treatment; (b) emerging trends in the size, financing, and public/private ownership of alcohol treatment services; (c) demographic trends in the general population; and (d) popular movements in treatment and referral. FEDERAL INVOLVEMENT IN ALCOHOL TREATMENT The foundation of a federal alcoholism effort was laid during the late 1960s through a series of policy studies, court decisions, and congressional initiatives (Lewis, 1982~. The 1967 and 1969 amendments to the Economic Opportunity Act created the first federally funded alcoholism treatment programs. In 1970, amendments to the Community Mental Health Centers Act authorized direct grants for special alcohol treatment projects. Around this time, separate treatment systems were also established at the federal level within the Veterans Administration (VA) and the military. Despite these initiatives, however, alcohol treatment services in the United States were administered primarily through state, local, and voluntary efforts. This situation changed dramatically with the enactment of the Hughes Act in late 1971. Officially known as the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act, this legislation created the National Institute on Alcohol Abuse and Alcoholism from a section of the National Institute of Mental Health and charged the new agency with responsibility for education, training, research, and planning in the areas of alcohol treatment and prevention. One year after its inception, NIAAA inherited nearly 200 alcohol treatment programs from the Office of Economic Opportunity. Under the leadership of Morris Chafetz, its first director, NIAAA launched a major effort to alter the public's perception of alcoholism and encourage people to see it as a treatable disorder (Chafetz, 1975~. During this time, high priority was given to the development of a comprehensive system of treatment services at the state and community levels, primarily through the mechanism of formula grants (NIAAA, 1977~. By 1981, NIAAA had distributed $654.4 million in project grants and contracts and $468.3 million in formula grants to the states (Lewis, 1982~. In choosing grant recipients the agency placed special emphasis on the development of innovative treatment services, especially those that were accessible to undersexed populations such as women, racial and ethnic minorities, the disabled, the elderly, young persons, and the families of alcoholics (NIAAA, 1980~. In contrast to its role in the development of treatment services, however, only a small portion of NIAAA's total budget was spent to support research and training. -141

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During this period, the agency initiated several innovative programs in the areas of treatment evaluation and reimbursement policy. In 1977, NIAAA contracted for a study of the barriers to third-part~r reimbursement for alcohol treatment and initiated a National Alcoholism Program Information System (NAPIS). By monitoring categorical community treatment programs in terms of client characteristics, services provided, and treatment outcomes, NIAAA created a valuable data base for the influential Rand Corporation study, the first comprehensive evaluation of treatment effectiveness (Armor, Polich, and Stambul, 1978~. During this period, NIAAA also initiated special cost and utilization studies of various federally and state-mandated programs to provide health insurance coverage for alcohol treatment (NIAAA, 1980, 1985; Plotnick et al., 1982~. In addition to its direct support of treatment services and program evaluation research, the agency promoted early intervention activities directed at high-risk groups. NIAAA gave impetus to the development of occupational alcohol programs, drinking driver education programs, the federal employees alcohol program, and criminal justice programs, as well as efforts to educate pregnant women about the risks of excessive alcohol consumption (NIAAA, 1977, 1980~. In the early l9&0s, NIAAA's pivotal role in the dramatic expansion of treatment services came to an end. Direct service grants were curtailed as third-party insurance expanded to cover the costs of alcohol treatment services. Congress then eliminated project formula grants, and funds were henceforth distributed directly to the states as Dart of the block grant mechanism. This action coincided with a shift in NIAAA's priorities away from treatment services to the support of biomedical and psychosocial research and the development of a basic science infrastructure through the agency's intramural research program, investigator-initiated grants, and the National Research Centers Program. Despite its recognized expertise in the area of alcohol treatment and the continued support of NIAAA by influential constituency groups, NIAAA's treatment efforts were rapidly eclipsed by other initiatives, creating a leadership vacuum that has been filled only recently through the agency's renewed commitment to treatment research. This renewed interest has been signaled by the creation of the new Division of Clinical and Prevention Research within the institute and by the congressional appropriation of funds specifically to support treatment research. EMERGING TRENDS IN TREATMENT SERVICES Coincident with the shift in NIAAA's role from treatment provider to research institute, chances have occurred in the organization and ownership of alcohol treatment services in the United States (Lowman, 1983; U. S. Department of Health and Human Sen~ic~es, 1983; Korcor, 1985~. Alterations in reimbursement policy for treatment of alcohol problems, the expansion of inpatient treatment, an increase in the number of for-profit treatment providers, the growth of Alcoholics Anonymous (AA) (Robertson, 1988), and the emergence of nontraditional sources of recruitment into treatment (e.g., media advertising, employee assistance programs, drinking driver programs) have all been part of these changes. According to a survey by the federal government, in 1984 there were 6,963 alcoholism units providing treatment services to more than a half-million patients (Reed and Sanchez, 1986~. (Compared with 1982, 6,963 units is an increase of 64 percent in the number of service units.) Of the 540,231 patients in treatment on the date of the survey, 82.9 percent were being treated as active outpatients, whereas smaller proportions were receiving treatment -142

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in inpatient (7.6 percent) or residential (9.6 percent) settings. Almost half of the alcoholism treatment units were freestanding facilities; 21 percent were based in community mental health centers; and 19 percent were allocated to general, specialized, or VA hospitals. Compared with previous surreys, this study showed a large increase in the number of proprietary programs, especially in the proportion being run on a profit-making basis. For-profit units had increased almost 200 percent from 1982 and constituted 12 percent of all alcoholism treatment units. Another more recent study has documented the emergence of two separate treatment systems within the United States: one is privately owned and serving middle- and upper-income clients, while the other is publically owned and senring uninsured lower-income patients (Yahr, 1988~. Within both of these treatment systems, there has been a marked trend toward diversification and specialization. Early counseling or referral to specialized treatment is becoming increasingly prevalent in employment settings and health maintenance organizations (HMOs). Both inpatient and outpatient programs are directing their services toward special population groups (e.g., the military, adolescents, children of alcoholics, employee groups, professionals, women, homosexuals, and drunk drivers). Media advertising Is being used to promote program utilization in many parts of the country (Korcor, 1985~. Alongside the tremendous increases in the availability and scope of alcohol treatment services, there has also been a trend to organize therapeutic approaches around a single inpatient rehabilitation model consisting of detoxification, alcohol education, group confrontational therapy, AA meetings, and disulfiram therapy (Miller and Hester, 1986~. This treatment package is typically delivered to all types of patients in the course of a standard three- to four-week residential program. What is surprising about this trend is the relative lack of empirical data that could serge as a rational basis for the selection of these or other treatment components or to justify the duration of intensive care (Saxe, 1983; Miller and Hester, 1986~. Lee trend toward rapid expansion, standardization, and integration of alcohol treatment services creates special challenges and opportunities for research. The emergence of a complete continuum of services from detoxification to aftercare makes it imperative to investigate how best to assign a patient to the least expensive, yet therapeutically appropriate, alternative. The broad range of available services makes it possible to study the relative efficacy of different therapeutic modalities and treatment programs. For example, Social model" detoxification and rehabilitation programs were developed in California during the 1970s (Borkman, 1986~. They feature community-based facilities, variable lengths of stay, and treatment of clients by nonprofessional staff. These programs apparently treat clients at a fraction of the cost of standard, medical-model private programs. A fundamental and as yet unanswered research question concerns the relative effectiveness of these programs for similar types of clients. DEMOGRAPHY, EPIDEMIOLOGY, AND THE DELIVERY OF TREATMENT SERVICES Recent demographic trends in the American population, coupled with changing patterns of alcohol and drug abuse, may have important implications for the demand for alcohol-related health services in the future. These trends may also affect the need for more carefully evaluated treatment interventions that go beyond the specialized treatment systems that have developed in recent years. National and regional surveys of the adult U.S. population -143

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(Regier et al., 1984) have indicated that alcohol abuse and dependence are among the most prevalent psychiatric conditions. Survey data and hospital records have consistently shown that alcohol dependence reaches its peak prevalence among persons 35 to 45 years old (Hilton, 1987~. The maturing of the postwar baby boom population, which encompasses the 1945-1960 birth cohorts, means that an increasingly larger proportion of the population is passing through this period of greatest risk for alcohol-related consequences (Williams et al., 1987~. Other demographic trends that have the potential to influence the nature and availability of treatment services are increases in the Hispanic population, changes in the configuration of the nuclear family, increases in the number of homeless persons, the aging of the population, and the deinstitutionalization of psychiatric patients. Epidemiological data point to a broad diversity of alcohol-related problems, only some of which overlap with the continuum of alcohol dependence symptoms. For example, a 1979 survey estimated that there were 10 million adult men and women who consumed four or more drinks per day, a common criterion for heavy drinking (U. S. Department of Health and Human Services, 1981~. Although heavy or frequent drinking is not necessarily indicative of alcoholism, it is an important risk factor and can lead to health problems even in the absence of alcohol dependence (Babor, Kranzler, and I~uerman, 1987~. The findings of a 1982 study showed that the prevalence of alcohol-related problems and heavy drinking in patients seeking treatment for other health problems in general hospital settings ranged from 15 to 20 percent of male patients and from 4 to 10 percent of female patients (MacIntosh, 1982~. Epidemiological surveys indicate that the baby boom cohorts of younger heavy drinkers are also frequent users of other psychoactive substances (e.g., marihuana, cocaine) and are more likely than primary alcoholics to have other psychiatric comorbidities (especially depression or antisocial personality disorder). These trends toward multiple substance-use patterns, greater numbers of individuals at risk, and the pervasiveness of alcohol-related problems in general medical patients not only should be taken into consideration in the planning of health services but also should guide the design of health services research For example, the high prevalence of heavy drinking and alcohol abuse among general medical patients suggests that attempts should be made to integrate the identification and management of alcohol abuse into general medical practice and to evaluate the impact of this practice change on the health of the primary care population. Similarly, the high concordance of tobacco dependence, alcohol dependence, and dependence on other psychoactive substances means that alcohol-specific treatments may have to be broadened to include the remediation of multiple substance-use disorders. Finally, the projected increase in the absolute numbers of persons at risk, as well as the anticipated changes in patterns of substance abuse, argues for the development of a more empirically based approach to estimations of the need for treatment services. These estimation techniques should rely on current social indicators, census data, or other readily available information sources. They may also rely on extrapolation or "synthetic. estimates drawn from well-executed population surveys such as the Epidemiologic Catchment Area Study (Regier et al., 1984) or the National Health Interview SuIvey. These techniques must be sensitive to variations in those demographic variables (e.g.,age, sex, ethnicity, education, socioeconomic status) that are related to the prevalence of alcohol problems and to the conditions that promote efficacious treatment. The development of these techniques may involve research on uniformly coded data bases to help reduce the variability of current social indicator data. It may also involve the comparative evaluation of these techniques in a variety of field settings. -144

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The assessment of a community's need for alcohol treatment services consists of an accurate estimate of three factors: (1) the actual need for treatment in the community; (2) the total treatment resources available to the community at all levels of care; and (3) the demand for those resources from the community. Once these components are known, they can be analyzed to see how need, resources, and utilization compare; where the gaps of unmet need are located; what types of resources are required; and where the new resources ought to be placed. Although considerable progress has been made since the 1950s in assessing the need for treatment services, more work should be done to refine the needs assessment methods that are currently used. These methods are vital to local, state, and national planners who are attempting to allocate limited resources in the most efficient way. POPULAR TRENDS IN TREATMENT AND REFERRAL Popular trends in treatment and referral may have a profound effect on the treatment-seeking population as well as on the treatments being delivered. Researchers must be prepared to describe, investigate, and interpret these trends. For example, the emergence during the 1980s of public interest groups devoted to the prosecution and prevention of drunk driving has placed special demands on treatment services (see Chapters 3 and 4~. Legally mandated treatment has raised questions about the appropriateness of using the same conventional approaches that in other contexts rely heavily on individual motivation. Another trend that is affecting the design of treatment services is the increasing health consciousness of the American public, combined with changing norms about the advisability and appropriateness of heavy drinking. As noted in Chapter 4, during the past decade there has been a sharp decline in the public's preference for distilled beverages and a concomitant switch to beers and liquors with lower alcohol contents (Kling, in press). Public awareness of the possible hazards of heavy drinking may increase the acceptability of minimal or brief interventions targeted at the large population of heavy drinkers who are at high risk for alcohol dependence (Babor, Kranzler, and Lauerman, 1987~. Within the alcohol field itself, there have been significant changes in the acceptance of different ideas and concepts. Adult children of alcoholics have received a great deal of attention in the media, which has been fueled in part by advocates of the need for special therapeutic approaches to this population. Similarly, the concept of "codependence~ of family members has gained popularity as a clinical entity that is assumed to be partly responsible for maintaining the alcoholic's self-defeating behavior (Cermak, 1986~. Little research attention has been devoted to the implications of these new ideas for the improvement of treatment services. The treatment field has also seen a growing professionalism among alcoholism counselors, as well as an increasing tendency to monitor and coordinate services through managed care systems. These trends will place special demands on the research community, which increasingly is being asked to provide the answers to such complex questions as the relative effectiveness of credentialed versus noncredentialed counselors or the cost savings that can be realized from managed care approaches. -145

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POLICY-ORIENTED SERVICES RESEARCH Although other sections of this report address the more traditional types of research opportunities, it is appropriate to begin this discussion of the treatment research agenda with the following recommendations for policy-oriented services research to set the stage for the future: Research is needed on the multiple economic forces that shape the demand for, and provision of, treatment services for alcohol-dependent persons and problem drinkers. More research is needed, especially at the local level, on the geographic distribution of alcohol treatment. Some of the questions to be answered in this area concern the appropriate and efficient distribution of resources and the social, economic, and geographic factors that affect the development of treatment services. Reliable and valid techniques of prevalence assessment that are sensitive to local conditions are needed for health services planning. Researchers should be encouraged to use national sample surreys (e.g., Clark and Midanik, 1982), as well as psychiatric epidemiological methods (e.g., Regier et al., 1984), to develop forecasting models to estimate the need for treatment services. The importance of emerging trends in patient characteristics, population demographics, alcohol-use patterns, and service utilization has revealed a need for systematic health services data to describe these trends. Vigorous support should be -provided to the national survey of alcoholism, drug abuse, and combined treatment units, which has been conducted for NIAAA and the National Institute on Drug Abuse (NII)A) since 1979. These surveys could be fruitfully expanded with the use of a more intensive data collection procedure and the identification of a representative sample of facilities. In addition, other data bases are needed to assess alcohol-related general service and specialty service utilization in ambulatory settings. This research should span a wide range of services such as community mental health centers, family service agencies, prisons, HMOs, primary care clinics, and general hospitals. The development of data bases on ambulatory services will allow more precise estimates of the scope, severity, and cost effects of alcohol use on mental health and general medical problems. Both the alcohol and the drug abuse fields have benefited from longitudinal cohort studies of clients sampled from multiple facilities (Armor, Polich, and Stambul, 1978; Hubbard, Marsden, and Allison, 1984~. The NIAAA should support major outcome monitoring studies, preferably covering a representative sample of units drawn from the national survey census. Researchers should be encouraged to investigate popular trends and concepts in the treatment field--for example, the need for special treatment services for adult children of alcoholics and codependents, and the efficacy of such services once they have been established and marketed. Greater attention should be devoted to comparing alternative treatment systems, both in the United States and in other countries. (For example, California's social model program could be compared with other public and private systems in terms of costs and efficacy of both detoxification and rehabilitation treatment.) Detailed historical analyses, contrasting case studies, and large-scale statistical studies are now needed to provide a knowledge base to guide health planning and treatment policy. In a world of great diversity among health systems, all of which seem to be affected by similar economic problems, the promise of comparative treatment systems research both within the United States and internationally is substantial. Policy studies should be undertaken tO evaluate the impact of recent changes in training, credentialing, and licensing of personnel who treat alcohol problems. -146

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REFERENCES Armor, D. J., J. M. Polich, and H. B. Stambul. Alcoholism and Treatment. New York: John Wiley and Sons, 1978. Babor, T. F., H. R. Kranzler, and R. J. Lauerman. Social drinking as a health and psychosocial risk factor: Anstie's limit revisited. Pp. 373-402 in Marc Galanter, ed. Recent Developments in Alcoholism, vol. 5. New York: Plenum Press, 1987. Bork~nan, T. A Social-Exper~ential Model in Programs for Alcoholism Recovery: A Research Report on a New Treatment Design. Washington, DC: NtAAA, 1986. Cermak, T. L. Diagnosing and Treating Co-Dependence: A Guide for Professionals Who Work with Chemical Dependents, Their Spouses, and Children. Minneapolis, MN: Johnson Institute Books, 1986. Chafetz, M. From program to people: Toward a national policy for alcoholism services. Alcohol Health and Research World, Summer:14-19, 1975. Clark, W., and L. Midanik. Alcohol use and alcohol problems among U.S. adults: Results of the 1979 national survey. Pp. 3-52 in National Institute on Alcohol Abuse and Alcoholism. Alcohol Consumption and Related Problems. Alcohol Health Monograph No. 1. USDHHS Publ. No. (ADM)82-1190. Washington, DC: Government Printing Office, 1982. Hilton, M. E. Drinking patterns and drinking problems in 1984: Results from a general population survey. Alcoholism: Clinical and Experimental Research 11~2~:167-175, 1987. Hubbard, R., M. E. Marsden, and M. Allison. Reliability and Validity of TOPS Data. Research Triangle Park, NC: Research Triangle Institute, April 1984. Treatment Outcome Prospective Study: Kling, W. Measurement of ethanol consumed in distilled spirits. J. Stud. Alcohol, in press. Korcor, M. Alcoholism treatment, a growing "product line." American Medical News, October 11, 1985. Lewis, J. The federal role in alcoholism research, treatment and prevention. Pp. 385-401 in E. L. Gomberg, H. R. White, and J. ~ Carpenter, eds. Alcohol, Science and Society Revisited. Ann Arbor: University of Michigan Press, 1982. Lowman, C. Changes in alcoholism treatment services, 1979-1982. Alcohol Health and Research World 8:2, 1983. Macintosh, I. D. Alcohol-related disabilities in general hospital patients: A critical assessment of the evidence. International Journal of Addictions 17~4~:609-639, 1982. Miller, W. R., and R. K Hester. Matching problem drinkers with optimal treatments. Pp. 175-203 in W. R. Miller and N. Heather, eds. Treating Addictive Behaviors: Processes of Change. New York: Plenum Press, 1986. -147

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National Institute on Alcohol Abuse and Alcoholism. Sixth Annual Report to the U.S. Congress, Fiscal Year. Rockville, MD: NLAAA, 1977. National Institute on Alcohol Abuse and Alcoholism. Report to the U.S. Congress on Federal Activities on Alcohol Abuse and Alcoholism, Fiscal Year. Roclorille, MD: NIAAA, 1980. National Institute on Alcohol Abuse and Alcoholism. Alcoholism Treatment Impact on Total Health Care Utilization and Costs. Washington, DC: U.S. Department of Health and Human Services, February 1985. Plotnick, D. E., K M. Adams, H. R. Hunter, and I. C. Rowe. Alcoholism Treatment Programs Within Prepaid Group Practice HMOs: A Final Report. Rockville, MD: NIAAA, 1982. Reed, P. G., and D. S. Sanchez. Characteristics of Alcoholism Services in the United States--1984. Rockville, MD: U.S. Department of Health and Human Services, 1986. Reaer, D. A, J. K Myers, M. Kramer, et. al. The NIMH epidemiologic catchment area program. Arch. Gen. Psych. 41:934-941, 1984. Robertson, N. The changing world of Alcoholics Anonvmous. New York Times Magazine 4~45, February 21, 1988. ~O Saxe, I-, D. Dougherty, K Esty, and M. Fine. The Effectiveness and Costs of Alcoholism Treatment. Health Technology Case Study 22. Office of Technology Assessment, U.S. Congress. Washington, DC: Government Printing Office, 1983. U.S. Department of Health and Human Services (OHHS). Fourth Special Report to the U.S. Congress on Alcohol and Health. Washington, DC: National Institute on Alcohol Abuse and Alcoholism, 1981. U.S. Department of Health and Human Services (OHHS). Fifth Special Report to the l].S. Congress on Alcohol and Health. Washington, DC: National Institute on Alcohol Abuse and Alcoholism, 1983. Williams, G. D., F. S. Stinson, D. ~ Parker, et. al. Demographic trends, alcohol abuse and alcoholism: 1985-1995. Alcohol Health and Research World 2:80-83, 1987. Yahr, H. T. A national comparison of public and private-sector alcoholism treatment delivery system characteristics. I. Stud. Alcohol 49:233-239, 1988. -148