mental illness.1 Thus, the clinical complexities inherent in treating such patients has fostered a tendency to apply multiple treatment modalities without thinking through or knowing which treatments may be most effective for a specific patient, or considering the sequence in which such treatments should be applied.

This situation has major implications for the treatment of addictive disorders and, thus, for public health. The absence of an evidence-based approach to addiction treatment, coupled with a lack of valid and reliable measures of treatment outcome, has induced skepticism on the part of purchasers of care, policymakers, and consumers as to the value of treatment for drug and alcohol abuse and dependence. Skepticism and the stigma attached to these disorders, which are perceived by many as volitional and suggestive of moral weakness, has further led to discrimination in benefit design and reluctance by payers and managed care organizations to allocate resources to the care of such patients.

Community-based drug treatment organizations (CBOs) provide the backbone of drug and alcohol treatment today and their capabilities have not kept up with the rising problem of addiction, nor with the major scientific advances that have been made in understanding the biopsychosocial basis of addiction (IOM, 1996, 1997a). Such organizations receive the majority of their funding from public dollars, through state and local appropriations and federal block grants to states. In 1997 public funds accounted for two-thirds (65 percent) of the reported revenues in drug and alcohol treatment programs (Horgan and Levine—Appendix E). In the current environment of fiscal restraint and burgeoning need, there is great interest in strengthening the community-based drug treatment organizations and in helping these providers better utilize research findings on effective treatment strategies.

This report examines these issues and presents the findings and conclusions of an Institute of Medicine committee convened at the request of the Substance Abuse and Mental Health Services Administration's Center for


There are perhaps 10 million individuals who have co-occurring mental illness and substance abuse problems, including alcohol abuse and dependence. NIAAA's Ninth Special Report to Congress indicates that 13.7 million meet DSM-IV criteria for either alcohol abuse or alcohol dependence (NIAAA, 1997). And the most recent SAMHSA estimate for individuals needing treatment for drug abuse and dependence is 9.4 million (Epstein and Gfroerer, 1998). Even adjusting generously for the overlap between the two groups, it appears that co-occurring mental illness is a very large problem in treating individuals for alcohol and drug abuse. Based on recent survey data cited in Horgan and Levine (see Table 7, Appendix E), it appears that the proportion of facilities providing both substance abuse and mental health services is increasing.

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