The Effectiveness and Costs of Alcoholism

Treatment

March 1983

NTIS order #PB83-192492
HEALTH TECHNOLOGY CASE STUDY

The Effectiveness

and Costs of

22 ●

●

Alcoholism Treatment

MARCH 1983

This case study was performed as a part of OTA’S Assessment

Medical Technology and

Costs of the Medicare Program

Prepared under contract to OTA by:

Leonard Saxe, Ph. D., Boston University

with:

Denise Dougherty, Boston University

Katharine Esty, Boston University

Michelle Fine, Ph. D., University of Pennsylvania

of

OTA Case Studies are documents containing information on a specific medical

technology or area of application that supplements formal OTA assessments. The

material is not normally of as immediate policy interest as that in an OTA Report,

nor does it present options for Congress to consider.
Library of Congress Catalog Card Number 83-600708

For sale by the Superintendent of Documents,

U.S. Government Printing Office, Washington, D.C. 20402
Preface

The Effectiveness and Costs of Alcoholism

Treatments is Case Study #22 in OTA’S Health

Technology Case Study Series. It was prepared

in response to a request by the Senate Finance

Committee, Subcommittee on Health, and is part

of OTA’S project on Medical Technology and

Costs of the Medicare Program, requested by the

House Committee on Energy and Commerce and

its Subcommittee on Health and the Environment.

A listing of other case studies in the series is included at the end of this preface.

OTA case studies are designed to fulfill two

functions. The primary purpose is to provide

OTA with specific information that can be used

in forming general conclusions regarding broader

policy issues. For example, the first 19 cases in

the Health Technology Case Study Series were

conducted as part of OTA’S overall project on The

Implications of Cost-Effectiveness Analysis of

Medical Technology. By examining the 19 cases

as a group and looking for common problems or

strengths in the techniques of cost-effectiveness

or cost-benefit analysis, OTA was able to better

analyze the potential contribution that those techniques might make to the management of medical

technology and health care costs and quality.

The second function of the case studies is to

provide useful information on the specific technologies covered. The design and the funding

levels of most of the case studies are such that they

should be read primarily in the context of the associated overall OTA projects. Nevertheless, in

many instances, the case studies do represent extensive reviews of the literature on the efficacy,

safety, and costs of the specific technologies and

as such can stand on their own as a useful contribution to the field.

Case studies are selected either because they

have been specifically requested by congressional

committees or because they were chosen as part

of the analytical method in carrying out an assessment. Selection criteria were developed to ensure

that

●

●

●

●

●

●

●

●

case studies provide examples:

of types of technologies by function (preventive, diagnostic, therapeutic, and rehabilitative);

of types of technologies by physical nature

(drugs, devices, and procedures);

of technologies in different stages of development and diffusion (new, emerging, and established);

from different areas of medicine (such as general medical practice, pediatrics, radiology,

and surgery);

addressing medical problems that are important because of their high frequency or significant impacts (such as cost);

of technologies with associated high costs

either because of high volume (for low-cost

technologies) or high individual costs;

that could provide information material relating to the broader policy and methodological issues being examined in the particular

overall project; and

with sufficient scientific literature.

Case studies are either prepared by OTA staff

or are commissioned by OTA and performed

under contract by experts, generally in academia.

Each case study is subjected to an extensive review

process. Initial drafts of cases are reviewed by

OTA staff and by members of the advisory panel

to the associated project. For commissioned cases,

comments are provided to authors, along with

OTA’S suggestions for revisions. Subsequent

drafts are sent by OTA to numerous experts for

review and comment.

Case studies contain findings and conclusions

but do not include policy options. Development

and presentation of options are done only in reports of major OTA assessments,

. . .

111
Health Technology Case Study Seriesa

Case Study Case Study

Series Case study title; author(s); Series Case study title; author(s);

number OTA publication numberbnumber OTA publication numberb

1

2

3

4

5

6

7

8

9

10

11

Formal Analysis, Policy Formulation, and End-Stage

Renal Disease;

Richard A. Rettig (OTA-BP-H-9(1))C

The Feasibility of Economic Evaluation of

Diagnostic Procedures: The Case of CT Scanning;

Judith L. Wagner (OTA-BP-H-%Z))

Screening for Colon Cancer: A Technology

Assessment;

David M. Eddy (OTA-BP-H-9(3))

Cost Effectiveness of Automated Multichannel

Chemistry Analyzers;

Milton C. Weinstein and Laurie A. Pearlman

(OT’A-BP-H-9(4))

Periodontal Disease: Assessing the Effectiveness and

Costs of the Keyes Technique;

Richard M. Scheffler and Sheldon Rovin

(OTA-BP-H-9(5))

The Cost Effectiveness of Bone Marrow Transplant

Therapy and Its Policy Implications;

Stuart O. Schweitzer and C. C. Scalzi

(OTA-BP-H-9(6))

Allocating Costs and Benefits in Disease Prevention

Programs: An Application to Cervical Cancer

Screening;

Bryan R. Luce (Office of Technology Assessment)

(OTA-BP-H-9(7))

The Cost Effectiveness of Upper Gastrointestinal

Endoscopy;

Jonathan A. Showstack and Steven A. Schroeder

(OTA-BP-H-9(8))

The Artificial Heart: Cost, Risks, and Benefits;

Deborah P. Lubeck and John P. Bunker

(OTA-BP-H-9(9))

The Costs and Effectiveness of Neonatal Intensive

Care;

Peter Budetti, Peggy McManus, Nancy Barrand,

and Lu Ann Heinen (OTA-BP-H-9(1O))

Benefit and Cost Analvsis of Medical Interventions:

The Case of Cimetidin& and Peptic Ulcer Disease;

Harvey V. Fineberg and Laurie A. Pearlman

(OTA-BP-H-9(11))

12

13

14

15

16

17

18

19

20

21

22

Assessing Selected Respiratory Therapy Modalities:

Trends and Relative Costs in the Washington, D.C.

Area;

Richard M. Scheffler and Morgan Delaney

(OTA-Bp-H-9(12))

Cardiac Radionuclide Imaging and Cost

Effectiveness;

William B. Stason and Eric Fortess

(OTA-BP-H-9(13))

Cost Benefit/Cost Effectiveness of Medical

Technologies: A Case Study of Orthopedic Joint

Implants;

Judith D. Bentkover and Philip G. Drew

(o-1-A-Bp-H-9(14))

Elective Hysterectomy: Costs, Risks, and Benefits;

Carol Korenbrot, Ann B. Flood, Michael Higgins,

Noralou Roos, and John P. Bunker

(OTA-BP-H-9(15))

The Costs and Effectiveness of Nurse Practitioners;

Lauren LeRoy and Sharon Solkowitz

(OTA-BP-H-9(16))

Surgery for Breast Cancer;

Karen Schachter and Duncan Neuhauser

(OTA-BP-H-907))

The Efficacy and Cost Effectiveness of

Psychotherapy;

Leonard Saxe (Office of Technology Assessment)

(oTA-Em+-9(18)) d

Assessment of Four Common X-Ray Procedures;

Judith L. Wagner (OTA-BP-H-9(19))e

Mandatory Passive Restraint Systems in

Automobiles: Issues and Evidence;

Kenneth E. Warner (OTA-BP-H-15(20))f

Selected Telecommunications Devices for HearingImpaired Persons;

Virginia W, Stern and Martha Ross Redden

(OTA-BP-H-16(21))g

The Effectiveness and Costs of Alcoholism

Treatment;

Leonard Saxe, Denise Dougherty, Katharine Esty,

and Michelle Fine (OTA- HCS-22)

aAvailable for sale by the Superintendent of Documents, U.S. Government dBackground pawr #3 t. The Implications of Cost-Effectiveness ~alYsis of

Printing Office, Washington, D. C., 20402, and by the National Technical Medical Technology.

Information Service, 5285 Port Royal Road, Springfield, Va., 22161. Call ‘Background Paper #5 to The Implications of Cost-Effectivess Analysis of

OTA’S Publishing Office (224-8996) for availability and ordering infor- Medical Technology.

mation. fBackground paper #1 to OTA’S May 1982 report Technology and ffandiborigina] publication numbers appear in parentheses. capped People.

cNumbers I through 17 of the Case Study Series were separately published gBackground paper #Z to Technology and Handicapped people.

case studies numbers I through 17 of OTA’S August 1980 report The Implications of Cost-Effectiveness Analysis of Medical Technology.

iv
OTA Staff for Case Study #22

H. David Banta, Assistant Director, OTA

Health and Life Sciences Division

Clyde J. Behney, Health Program Manager

Anne Kesselman Burns, Project Director

Cynthia King, Analyst

Gloria Ruby, Analyst

Kerry Britten Kemp, Division Editor

Kathryn M. White, Editor’

Virginia Cwalina, Administrative Assistant

Mary Walls, Secretary

Pamela J. Simerly, Secretary and Research Assistant

OTA Publishing Staff

John C. Holmes, Publishing Officer

John Bergling Kathie S. Boss Debra M. Datcher Joe Henson

Doreen Foster Donna Young

‘OTA contract personnel.
Advisory

costs of

Panel on Medical Technology and

the Medicare Program

Stuart Altman, Panel Chair

Dean, Florence Heller School, Brandeis University

Frank Baker

Vice President

Washington State Hospital Association

Robert Blendon

Senior Vice President

The Robert Wood Johnson Foundation

Jerry Cromwell

President

Health Economics Research

Chestnut Hill, Mass.

Karen Davis

Johns Hopkins University

School of Hygiene and Public Health

Robert Derzon

Vice President

Lewin & Associates

Washington, D. C.

Howard Frazier

Director

Center for the Analysis of Health Practices

Harvard School of Public Health

Clifton Gaus

Center for Health Policy Studies

Washington, D. C.

Jack Hadley

Urban Institute

Washington, D. C.

Kate Ireland

Chairman, Board of Governors

Frontier Nursing Service

Wendover, Ky.

Judith Lave

Graduate School of Public Health

University of Pittsburgh

Mary Marshall

Delegate

Virginia House of Delegates

Walter McNerney

Northwestern University

Morton Miller

President

National Health Council

New York, N. Y.

James Mongan

Executive Director

Truman Medical Center

Kansas City, Mo.

Seymour Perry

Bethesda, Md.

Robert Sigmond

Blue Cross of Greater Philadelphia

Anne Somers

Department of Environment and

Community and Family Medicine

Rutgers University

Paul Torrens

UCLA School of Public Health

Keith Weikel

Group Vice President

AMI

McLean, Va.
Contents

—. Page

Glossary of Terms . . . . . . . . . . . . . . . . . . . . . . . . .

Glossary of Acronyms , , , . . . . . . . . . . . . . . . . . .

CHAPTER1: SUMMARY . . . . . . . . . . . . . . . . . .

The Alcoholism Problem . . . . . . . . . . . . . . . . . . .

Approaches to Alcoholism Treatment . . . . . . . .

Methodological Issues in Evaluating the

Effectiveness of Alcoholism Treatment . . .

Research on the Effectiveness of

Alcoholism Treatment . . . . . . . . . . . . . . . . .

Costs and Benefits of Alcoholism Treatment . .

Reimbursement Issues . . . . . . . . . . . . . . . . . . . . . .

Organization of the Case Study . . . . . . . . . . . . .

CHAPTER 2: THE ALCOHOLISM PROBLEM

Overview of Alcoholism . . . . . . . . . . . . . . . . . . .

Use of Alcohol.. . . . . . . . . . . . . . . . . . . . . . . . .

Effects of Alcoholism . . . . . . . . . . . . . . . . . . . .

Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Perspectives on Alcoholism . . . . . . . . . . . . . . . . .

Medical Perspective. . . . . . . . . . . . . . . . . . . . . .

Psychological Perspective. . . . . . . . . . . . . . . . .

Behavioral Approaches . . . . . . . . . . . . . . . . .

Psychodynamic Approaches . . . . . . . . . . . .

Systems Approaches . . . . . . . . . . . . . . . . . . .

Sociocultural Perspective . . . . . . . . . . . . . . . . .

Integration of Perspectives . . . . . . . . . . . . . . . .

Populations: Incidence and Treatment . . . . . . . .

Elderly People . . . . . . . . . . . . . . . . . . . . . . . . . .

Youth and Adolescents. . . . . . . . . . . . . . . . . . .

Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Blacks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hispanics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

American Indians. . . . . . . . . . . . . . . . . . . . . . . .

Other Special Groups . . . . . . . . . . . . . . . . . . .

Individual Difference Factors. . . . . . . . . . . . . .

Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CHAPTER3: APPROACHES TO

ALCOHOLISM TREATMENT . . . . . . . . . .

Treatment Modalities . . . . . . . . . . . . . . . . . . . . . .

Medical Approaches . . . . . . . . . . . . . . . . . . . . .

Detoxification. . . . . . . . . . . . . . . . . . . . . . . . .

Mood-Altering Drugs . . . . . . . . . . . . . . . . . .

Sensitizing Agents . . . . . . . . . . . . . . . . . . . . .

Psychological Treatments . . . . . . . . . . . . . . . . .

Behavioral Approaches. . . . . . . . . . . . . . . . .

Nonbehavioral Psychotherapies . . . . . . . . .

Systems Approaches . . . . . . . . . . . . . . . . . . .

Sociocultural

Combination

Approaches. . . . . . . . . . . . . . . . .

of Treatment Modalities. . . . .

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Treatment Settings and Providers. . . . . . . . . . . .

Inpatient Care . . . . . . . . . . . . . . . . . . . . . . . . . .

Detoxification/Rehabilitation Units in

General Hospitals . . . . . . . . . . . . . . . . . . .

Alcoholism Treatment Units in State

and Private Psychiatric Hospitals ., . . . .

Free-Standing Alcoholism Rehabilitation

Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Outpatient Care . . . . . . . . . . . . . . . . . . . . . . . . .

Private Physicians’ Offices . . . . . . . . . . . . . .

Community Mental Health Centers . . . . . .

Free-Standing Outpatient Clinics . . . . . . . .

Day Care Hospitalization Programs . . . . . .

Intermediate Care . . . . . . . . . . . . . . . . . . . . . . .

Other Settings . . . . . . . . . . . . . . . . . . . . . . . . . .

Utilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Treatment Providers . . . . . . . . . . . . . . . . . . . . .

Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CHAPTER 4: METHODOLOGICAL ISSUES

IN EVALUATING THE EFFECTIVENESS

OF ALCOHOLISM TREATMENT. . . . . . .

Treatment Design . . . . . . . . . . . . . . . . . . . . . . . . .

Research Design . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sampling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Outcome Measures . . . . . . . . . . . . . . . . . . . . . . . .

Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CHAPTER5: RESEARCH ON THE

EFFECTIVENESS OF ALCOHOLISM

TREATMENT. . . . . . . . . . . . . . . . . . . . . . . .

Reviews of Effectiveness Research . . . . . . . . . . .

Voegtlin and Lemere . . . . . . . . . . . . . . . . . . . . .

Emrick . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Baekeland, Lundwall, and Kissin . . . . . . . . . .

Costello . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Rand Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Studies of Treatment Settings and Specific

Modalities . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ritson. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Edwards; Edwards and Guthrie . . . . . . . . .

Wanberg, Horn, and Fairchild . . . . . . . . . .

Gallant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Baekeland . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Costello . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Rand Studies . . . . . . . . . . . . . . . . . . . . . . . . . .

Emrick . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Behavioral Therapies. . . . . . . . . . . . . . . . . . . . .

Individualized Behavior Therapy for

Alcoholics . . . . . . . . . . . . . . . . . . . . . . . . . .

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vii
Aversion Therapy . . . . . . . . . . . . . . . . . . . . . 50

Nonbehavioral Psychotherapies . . . . . . . . . . . 51

Drug Treatments . . . . . . . . . . . . . . . . . . . . . . . . 52

Sensitizing Agents . . . . . . . . . . . . . . . . . . . . . 52

Mood-Altering Drugs . . . . . . . . . . . . . . . . . . 52

SeIf-Help Groups . . . . . . . . . . . . . . . . . . . . . . . . 53

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

CHAPTER6: ANALYSES OF THE COSTS

AND BENEFITS OF ALCOHOLISM

TREATMENT . . . . . . . . . . . . . . . . . . . . . . . . . 57

Cost-Effectiveness and Cost-Benefit Analyses. . 57

Analyses of the Costs and Benefits of

Alcoholism Treatment . . . . . . . . . . . . . . . . . 59

Cost Context . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Cost-Effectiveness and Cost-Benefit Studies

of Alcoholism Treatment . . . . . . . . . . . . . . . 62

Philadelphia Police and Fire Departments. 62

General Motors . . . . . . . . . . . . . . . . . . . . . . . 63

California Pilot Program . . . . . . . . . . . . . . . 64

Group Health Association . . . . . . . . . . . . . . 64

U.S. Air Force . . . . . . . . . . . . . . . . . . . . . . . . 65

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

CHAPTER 7: REIMBURSEMENT ISSUES . . . . 69

Overview of Funding of Alcoholism Services . 69

History of Benefits for Alcoholism Treatment. 70

Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Other Coverage . . . . . . . . . . . . . . . . . . . . . . . . . 72

Current Developments in Benefits for

Alcoholism Treatment . . . . . . . . . . . . . . . . .

New Medicare Guidelines . . . . . . . . . . . . . . . . .

Other Developments in Treatment Financing

Research Developments . . . . . . . . . . . . . . . . . . . .

Implications occurrent Developments . . . . . . .

Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Appendix: Health Program Advisory

Committee and Acknowledgments . . . . . . .

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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List of Tables

Table No. Page

1.

2,

3.

4.

5.

6.

7.

Comparison of Alcoholics in NIAAA- -

Funded Treatment Programs With the

General Population . . . . . . . . . . . . . . . . . . . . . . 15

Characteristics of Treatment Settings . . . . . . 28

Estimated Treatment Utilization . . . . . . . . . . . 31

Ten General Principles of Analysis for

CEA/CBA Methodology . . . . . . . . . . . . . . . . . 58

Estimated Economic Costs of Alcoholism

in 1977 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Estimated Health Care Expenditures for

Alcohol Abuse in 1977, by Setting . . . . . . . . 60

Sources offending for Alcoholism

Treatment Units in 1979 . . . . . . . . . . . . . . . . . 70

. . . VIII
Glossary of Terms

Alcohol abuse: Drinking pattern in which, either on

a regular basis or irregular basis, alcohol consumption is above average and is associated with problems such as arrest for drinking while intoxicated

or decline in job performance.

Alcoholism: A general term used to refer to abuse of

ethanol substances. From a medical perspective, alcoholism typically refers to dependence thought to

have a physiological basis. The term is also used to

denote use of alcohol as it relates to significant social

or other problems (including problems of criminal

behavior and inability to function productively).

Antabuse 3: Brand name for the drug, disulfiram,

which is used as an adjunct in both inpatient and

outpatient treatment programs and in conjunction

with a number of therapies. Under the influence of

this drug, patients who ingest alcohol become ill.

Aversion therapy: Treatment of alcoholism and

alcohol abuse in which the ingestion of alcohol following classical conditioning is paired with an aversive stimulus or event (e.g., vomiting, electrical

shock, or thoughts of bad consequences) so that the

ingestion of alcohol itself eventually evokes aversive thoughts and/or responses. Techniques include

the use of chemicals (such as emetine) and electroshock.

Cost-benefit analysis (CBA): An analytical technique

that compares the costs of a project or technological

application to the resultant benefits, with both costs

and benefits expressed by the same measure. This

measure is nearly always monetary.

Cost-effectiveness analysis (CEA): An analytical technique that compares the costs of a project or of alternative projects to the resultant benefits, with costs

and benefits/effectiveness expressed by different

measures. Costs are usually expressed in dollars, but

benefits/effectiveness are ordinarily expressed in

terms such as “lives saved, “ “disability avoided,”

“quality-adjusted life years saved, ” or any other relevant objectives. Also, when benefits/effectiveness

are difficult to express in a common metric, they

may be presented as an “array. ”

CEA/CBA: A composite term referring to a family of

analytical techniques that are employed to compare

costs and benefits of programs or technologies. The

term as used in this assessment means “cost-effectiveness analysis/cost-benefit analysis. ”

Delirium tremens (DTs): A syndrome associated with

alcohol withdrawal that includes a clouding of consciousness, difficulty in sustaining attention, disorientation, and autonomic hyperactivity.

Drug: Any chemical or biological substance that may

be applied to, ingested by, or injected into humans

in order to prevent, treat, or diagnose disease or

other medical conditions.

Effectiveness: Same as efficacy (see below) except that

is refers to average or actual conditions of use.

Efficacy: The probability of benefit to individuals in

a defined population from a medical technology applied for a given medical problem under ideal conditions of use.

Incidence: In epidemiology, the number of cases of disease, infection, or some other event having its onset

during a prescribed period of time, in relation to the

unit of population in which it occurs. Incidence is

a measure of morbidity or other events as they happen over a period of time.

Inpatient care: Care that includes an overnight stay

in a medical facility. For alcoholism inpatient care,

settings include alcoholism detoxification units and

rehabilitation units within general hospitals, alcoholism treatment units within State and private psychiatric hospitals, and specialized alcoholism hospitals.

Intermediate care: Residential programs that provide

primarily rehabilitation services to clients. For alcoholism intermediate care, settings include halfway

houses, quarterway houses, and recovery homes

that are typically community-based, peer-group

oriented residences providing food, shelter, and supportive services in a nondrinking atmosphere.

Outpatient care: Care that does not include an overnight stay in the facility in which care is provided.

For alcoholism outpatient care, settings include (but

are not limited to) private physicians’ offices, community mental health centers, free-standing outpatient clinics, alcoholism treatment centers, and vocational rehabilitation clinics.

Prevalence: In epidemiology, the number of cases or

disease, infected persons, or persons with disabilities

or some other condition present at a particular time,

in relation to the size of the population. Prevalence

is a measure of morbidity at a point in time.

Randomized clinical trial (RCT): An experimental design by which human subjects are randomly assigned either to an experimental group (in which

subjects receive the treatment being studied) or to

a control group (in which subjects do not receive

the treatment being studied). Also referred to as

“randomized controlled clinical trial or “controlled

clinical trial. ”

Reliability: A measure of the consistency of a method

in producing results, A reliable test gives the same

results when applied more than once under the same

conditions. Also called “precision. ”

Risk: A measure of the probability of an adverse or
untoward outcome and the severity of the resultant

harm to health of individuals in a defined population and associated with use of a medical technology

applied for a given medical problem under specified

conditions of use.

Safety: A judgment of the acceptability of risk (see

above) in a specified situation.

Tolerance: The need for markedly increased amounts

of alcohol to achieve the desired effect, or the diminished effect from regular use of the same

amount.

Validity: A measure of the extent to which an observed

Glossary of Acronyms

ATC –

BAL –

CBA –

CEA

CHAMPUS =

DHHS –

DTs —

DWI –

FDA –

GAO –

Alcoholics Anonymous

Alcohol, Drug Abuse, and Mental

Health Administration (PHS)

Alcoholism Treatment Center

(NIAAA)

blood alcohol level

cost-benefit analysis

cost-effectiveness analysis

Civilian Health and Medical

Program of the Uniformed Services

(Department of Defense)

Department of Health and Human

Services

delirium tremens

driving while intoxicated

Food and Drug Administration

(PHS)

General Accounting Office (U.S.

Congress)

situation reflects the “true” situation. Internal vaMity is a measure of the extent to which study results

reflect the true relationship of a “risk factor” (e.g.,

treatment or technology) to the outcome of interest

in study subjects. Ekternal validity is a measure of

the extent to which study results can be generalized

to the population that is represented by individuals

in the study, assuming that the characteristics of that

population are accurately specified.

Withdrawal: A reaction to noningestion of alcohol;

characterized by symptoms such as morning

“shakes” and malaise relieved by drinking.

GHAA

HCFA

HMO

IBTA

NDATUS

NIAAA

OTA

RCT

PHS

VA

—

—

—

—

—

—

—

—

—

—

Group Health Association of

America

Health Care Financing

Administration (DHHS)

health maintenance organization

Individualized Behavior Therapy

for Alcoholics

National Drug and Alcoholism

Treatment Utilization Survey

National Institute on Alcohol

Abuse and Alcoholism

(ADAMHA)

Office of Technology Assessment

(U.S. Congress)

randomized clinical trial

Public Health Service (DHHS)

Veterans Administration

1 .

Summary

In recent years, mounting evidence has confirmed that alcoholism and alcohol abuse* are involved in a host of medical, psychological, and

social problems that engender major economic

costs for the country. At the same time, efforts

to treat alcoholism in the health care system have

expanded greatly—and although only a small proportion of alcoholics or alcohol abusers actually

receive treatment, the aggregate costs of treatment

have risen substantially. In 1982, Medicare alone

spent an estimated $150 million for the treatment

of alcoholism. As congressional debate over rising health care costs has intensified, questions

have been raised about whether the treatments

provided are effective. Such questions have important implications for whether Medicare and

other Government support for the existing treatment system should be expanded or be contracted.

This case study on the effectiveness and costs

of alcoholism treatment was prepared as part of

*Alcoholism is a medical/psychological term to describe particular

syndromes of alcohol use. Alcohol abuse is a more general term

used to refer to alcohol use associated with health and social problems.

THE ALCOHOLISM PROBLEM

Alcoholism constitutes a vast syndrome of medical, economic, psychological, and social problems. From 10 million to 15 million Americans

are either alcoholic or have serious problems directly related to the abuse of alcohol. Up to 35

million more individuals are estimated to be affected indirectly. Although estimates are imprecise, alcoholism and alcohol abuse have been implicated in half of all automobile accidents, half

of all homicides, and one-quarter of all suicides.

Alcohol abuse is a major factor in divorce and

accounts for perhaps 40 percent of all problems

brought to family courts.

The economic cost of alcoholism and alcohol

abuse, a major portion of which is lost work productivity, may be as high as $120 billion annually. Furthermore, alcohol abuse may be responsiOTA’S project on “Medical Technology and Costs

of the Medicare Program. ” While the overall project is being conducted in response to requests by

the House Committee on Energy and Commerce

and the Senate Committee on Finance, this particular study answers the specific request by the Subcommittee on Health of the Senate Committee on

Finance for scientifically based information on the

effectiveness of alcoholism treatments.

The goal of this case study is to provide scientific background for congressional consideration

of Medicare reimbursement for alcoholism treatment services. In addition to describing the problem posed by the abuse of alcohol, the authors

seek to assess, on the basis of scientific research

evidence, treatment programs and services developed to aid alcoholics. The primary source of information for this study has been published scientific literature. Because of the limitations of the

available literature—i. e., for some treatments, no

scientific studies are available, and for some

others, the available evidence on outcomes is not

sufficient to permit unambiguous conclusions—

the study’s conclusions are necessarily limited.

ble for up to 15 percent of the Nation’s health care

costs. Alcoholics use significantly greater amounts

of medical services than do nonalcoholics for a

wide range of physical problems caused by or

associated with excessive drinking.

Alcoholism and alcohol abuse are seen in every

socioeconomic group, although the problems may

manifest themselves differently across groups. The

proportion of people who drink alcoholic beverages has remained relatively constant, and it is

estimated that 9 percent of the U.S. adult population drink heavily on a regular basis. A significant portion of heavy drinkers are either physically or psychologically addicted to alcohol, and

their use of alcohol results in major problems for

themselves and others.

3
4 ● Health Technology Case Study .2.2: The Effectiveness and Costs of Alcoholism Treatment

APPROACHES TO ALCOHOLISM TREATMENT

The treatments for alcoholism are diverse, in cilities, such as community mental health centers

part because experts have different views about or free-standing outpatient clinics. In most treatthe causes of alcoholism. At least three major ment settings, a number of treatment modalities

views of the etiology of alcoholism can be identi- are offered. A large number of alcoholics are aided

fied: medical, psychological, and sociocultural. by Alcoholics Anonymous, a self-help organizaTreatments are generally based on one or a com- tion whose programs can be either part of or an

bination of these views. alternative to a formal treatment regimen.

Modalities of treatment for alcoholism include Despite the significance of problems relating to

the use of drugs, psychologically based treat- alcoholism and alcohol abuse and the increasing

ments, and treatments based on group and com- attention of health professionals to these probmunity efforts. Treatment settings for alcoholics lems, an estimated 85 percent of those with probinclude inpatient facilities, such as alcoholism Iems due to alcohol use receive no treatment for

units within general hospitals, and outpatient fa- their condition.

METHODOLOGICAL ISSUES IN EVALUATING THE

EFFECTIVENESS OF ALCOHOLISM TREATMENT

Much of the existing literature on the effectiveness of alcoholism treatment is not of very good

methodological quality. Scientific research on the

effectiveness of alcoholism treatment is difficult

to conduct, in part because of the complexity of

the alcoholism problem. Ethical and practical

problems have hindered the implementation of

randomized clinical trials and other controlled

research. Furthermore, the assessment of individual treatments is difficult because treatments for

alcoholism are often provided in combination.

Measuring treatment outcomes is problematic, as

well, because there is intense disagreement in the

alcoholism field about what the outcome of treatment should or must be—i.e., total abstinence

from alcohol or some other outcome such as controlled drinking. The reliability and validity of

outcome measures are also at issue. * Finally, the

interpretation of the studies that are available is

hindered because particular types of patients tend

to receive certain treatments and not others.

*Reliability is a measure of the consistency of a method in producing results. A reliable test gives the same results when applied more

than once under the same conditions. Validity is a measure of the

extent to which a situation that is observed in a study is reflective

of the true situation.

RESEARCH ON THE EFFECTIVENESS OF ALCOHOLISM TREATMENT

Despite methodological limitations, the available research evidence indicates that any treatment of alcoholism is better than no treatment.

Calculations of average success rates across

studies indicate that about two-thirds of those

treated improve. Reported success rates depend

partially on whether the outcome indicator is

abstinence, controlled drinking, or some other index of improvement. However, there is little

definitive evidence that any one treatment or

treatment setting is better than any other. Furthermore, controlled studies have typically found few

differences in outcome according to intensity or

duration of treatment.

Most treatments for which there is evidence

seem to be effective for at least some patients

under some conditions. There is some evidence

of the effectiveness of group therapy, family

therapy, and some kinds of behavior therapy.

Studies of mood-altering drugs (e.g., lithium) and

sensitizing agents (e.g., disulfiram, more commonly known as Antabuse@) indicate some positive
Ch. l—Summary

effects, but the generalizability of the effectiveness

of these treatments is limited by methodological

problems. Chemical aversion therapy (e.g., with

emetine) has been studied intensely recently, and

although there are substantial positive findings,

the interpretation of these findings is hindered by

patient selection problems—i.e., the best rates of

abstinence following this therapy seem to be

among patients who would be expected to do

well. Another problem is that chemical aversion

therapy is usually offered as part of a diverse treatment package; thus, it is difficult to attribute the

outcome of treatment directly to this therapy.

With respect to treatment setting, there is little

evidence for the superiority of either inpatient or

outpatient care alone, although some evidence exists for the importance of continuing aftercare as

an adjunct to short-term intensive rehabilitation

(usually in an inpatient setting). Further research

is needed both to specify how to match patient

to treatment and setting and to test competing

claims of effectiveness.

COSTS AND BENEFITS OF ALCOHOLISM TREATMENT

Cost-benefit analyses (CBAS) are used to develop comparisons of the benefits of treatments

against the resources they consume, with both

benefits and costs expressed in dollars. An essential qualitative conclusion from available CBAS

is that the costs of not providing treatment may

be greater than the costs of providing such treatment. Available CBAS of alcoholism treatment

services indicate significant reductions in medical

care utilization and time lost due to illness, compared to the costs of treatment.

REIMBURSEMENT ISSUES

A number of private insurance companies, employers, and the Federal Government have recently expanded benefits for alcoholism treatment because it appears that the costs of not providing

alcoholism treatment are greater than the costs

of providing such treatment. The essential question at this point seems to be not whether reimbursement for the treatment of alcoholism should

be provided, but whether current reimbursement

policy supports the provision of the most costeffective treatments.

Although reimbursement formulas are complex, reimbursement systems—particularly Medicare and Medicaid—have generally encouraged

the use of inpatient, medically based treatment

Cost-effectiveness analyses (CEAS) are used to

evaluate the relative cost of alternative treatments

per unit of effectiveness (typically specified in nonmonetary terms). It is difficult to conduct formal

CEAS of alcoholism treatment because of the lack

of sufficient data on outcomes of alternative treatments. Nevertheless, available CEAS indicate that

hospital-based inpatient care costs significantly

more for an equivalent outcome than does outpatient care or care in nonmedical settings.

for alcoholism. * Available evidence, although of

widely varying methodological quality, indicates

that medically based inpatient rehabilitation services are far more expensive, but not necessarily

more effective, than primarily nonmedical inpatient or outpatient treatment.

As of September 1, 1982, the Health Care Financing Administration had developed new Medicare guidelines that tighten criteria for reimbursement for medically based inpatient services, while

*Under the hospital insurance component of Medicare (Part A),

alcoholism can be treated as a psychiatric disorder, under the genera]

category of psychiatric health services, in either a psychiatric or general hospital. The supplementary medical insurance component of

Medicare (Part B) provides partial coverage for outpatient services.
.. .

6 ● Health Technology Case5e Studyy ,22: The Effectiveness and Costs of Alcoholism Treatment

increasing the availability of reimbursement for

outpatient treatment in hospitals and free-standing

clinics. There have been no changes in Medicaid

regulations, but because of changes in Federal

funding policies, States have more latitude in

deciding how Federal funds are spent.

Although the new Medicare regulations and

other developments in treatment financing may

increase the efficiency of the treatment system,

their impact is difficult to predict. It would seem

reasonable not to further change Medicare

eligibility standards until more information is

available concerning the effects of these evolutionary changes. It is clear that there is a need for more

systematic specification of which patients would

be best served by which of the available alcoholism treatment systems. Information pertaining to

this issue could be developed through available

research techniques.

ORGANIZATION OF THE CASE STUDY

This case study is organized into seven chapters.

Chapter 2 provides a context for the present policy

debate on alcoholism treatment, describes several

perspectives on the etiology of alcohol abuse, and

identifies various subpopulations with alcohol

abuse problems. Chapter 3 describes many of the

treatment approaches currently employed and the

settings within which alcoholism treatment is delivered.

Chapter 4 assesses various methodological

issues involved in evaluating the effectiveness of

alcoholism treatment. Chapter 5 provides an

analysis of available research evidence. It critically

examines major reviews of research on the effectiveness of alcoholism treatment and discusses

data regarding treatment outcomes in specific settings with particular modalities. The economic

costs of alcoholism and the costs and benefits of

providing alcoholism treatment services are detailed in chapter 6. In chapter 7, policy issues of

the current reimbursement system are considered

in relation to the scientific data regarding

treatment.
2

The Alcoholism Problem
2.

The Alcoholism Problem

Alcoholism constitutes a vast syndrome of medical, economic, psychological, and social problems related to the consumption of alcohol (ethanol) (144,216). The social and economic costs to

society of alcoholism, particularly to the health

care system, are staggering. From 10 million to

15 million Americans have serious problems directly related to the use of alcohol, and up to 35

million more individuals are estimated to be affected indirectly (40). Although estimates are imprecise, alcoholism and alcohol abuse have been

implicated in half of all automobile accidents, half

of all homicides, and one-quarter of all suicides

(85,216).

OVERVIEW OF ALCOHOLISM

Use of Alcohol

A substantial percentage of the American population uses alcoholic beverages, at least occasionally. The Gallup poll, which began collecting

data about alcohol use in 1939, has reported relatively stable patterns in alcohol use over the past

few decades. Consistently, about two-thirds of the

adult population (66 percent of women and 77’

percent of men) report at least occasional use of

alcoholic beverages. In recent years, the range in

use has been from 60 to 70 percent. Per capita consumption has also remained stable at about 2.6

gallons per year. In the United States, however,

about 10 percent of the population accounts for

more than half the alcohol consumed; less than

half is consumed by a large group of infrequent

drinkers and a small group of regular moderate

drinkers (168).

Most users of alcohol are not considered alcoholics, “problem drinkers,” or even “heavy drinkers.” A National Academy of Sciences panel has

estimated that among adults, only 9 percent are

problem drinkers (in some cases, this includes individuals who drink 1 ounce per day of pure alcohol) (210). Less than half of those considered

Alcoholism may be responsible for up to 15 percent of the Nation’s health care costs and for significantly lowering the productivity of workers

at all strata of the economic system. (A full discussion of the economic costs of alcohol abuse is reserved for ch. 6.) But the primary costs of

alcoholism to society are more than economic.

Alcoholism and alcohol abuse also adversely affect the health, social relations, psychological

well-being, and economic status of a large number

of individuals. The extent of these effects is difficult to determine, because an alcoholic may create

problems for many others, including family,

friends, and coworkers.

heavy drinkers—10 percent of those who regularly drink alcohol—would be consid[

Effects of Alcoholism

Reliable data on the effects of a

alcohol abuse are difficult to obta

red alcoholic.

coholism and

n, in part because of the many individuals affected and the

complexity of effects, but also because alcohol use

is widespread, and for most individuals, a normal social custom. Moreover, the absence of information about individuals with alcohol-use

problems who are not in formal treatment programs makes it difficult both to assess the pervasiveness of the alcohol abuse problem and to document the impact of current alcoholism treatment

efforts.

Alcohol (ethanol) —especially when consumed

in large quantities or habitually—is related to various health problems such as organ damage (particularly, the liver), brain dysfunction, cardiovascular disease, and mental disorders (85). It has a

significant effect on mortality rates; in general,

the life expectancy of alcoholics is 10 to 12 years

shorter than average (6,198). Cirrhosis of the

liver, a direct result of long-term alcohol con-
10 ● Health Technology Case Study 22: The Effectiveness and Costs of Alcoholism Treatment

sumption, is currently the fourth leading fatal

disease in the United States (80). When other effects of alcohol abuse are counted, alcoholism is

an even more significant mortality factor. In addition, alcoholics have significantly higher suicide

rates than do nonalcoholics (up to 58 times greater

in some groups of alcoholics) and accident rates

that are significantly greater than normal (see 85).

Each of these factors results in a significant number of deaths for individuals who abuse alcohol

at all age levels (254). In terms of morbidity, it

has been estimated that alcoholic patients comprise from so to 50 percent of all hospital admissions (120), excluding obstetrics. While these admissions are most often for other disorders,

alcoholism complicates the patients’ recovery.

Estimated to be a significant factor in up to 40

percent of all problems brought to family courts

(85), alcohol use is known to be a major factor

in divorce and has been associated with destabilization of families. In addition, automobile,

home, and industrial accidents and crimes such

as assault, rape, and wife battering have also been

associated with alcohol use (85). In recent years,

public recognition of the problems involved in

alcohol use has increased. For example, only 12

percent of families surveyed in a Gallup poll in

1966 agreed that liquor adversely affected their

family lives. In 1981, this figure rose to 22 percent, and a recent Gallup poll indicated that 33

PERSPECTIVES ON ALCOHOLISM

Although alcoholism and alcohol abuse are today acknowledged to be multifaceted medical,

psychological, and social problems, they have not

always been viewed this way. Alcohol abuse was,

historically, either accepted as normal behavior

or, in some cases, viewed as a moral problem (see

1) and treated as criminal behavior. In the 1950’s,

though, both the World Health Organization

(WHO) and the American Medical Association

gave formal recognition to alcoholism as a medical disease (see 149,150). The most prominent advocator of a medically based concept of alcoholpercent of families surveyed indicate that alcohol

use has caused serious family problems.

Governmental recognition of the problem resulted in the establishment, just over 10 years ago,

of the National Institute on Alcohol Abuse and

Alcoholism (NIAAA) and the requirement of periodic reports to Congress on progress in combating

alcoholism (216,223). Health professionals and

researchers are becoming more knowledgeable

about alcoholism as more data about the problems posed by the effects of alcoholism become

known (see, in particular, 144).

Treatment

Despite the range of problems caused by alcoholism and alcohol abuse, an estimated 85 percent of alcoholics and problem drinkers receive

no treatment for their condition (216). In 1977,

although approximately 1.6 million alcoholics and

problem drinkers received treatment from private

and public sources and over 600,000 alcoholics

participated in meetings of Alcoholics Anonymous (AA) groups, at least 8 million to 10 million

other alcoholics and problem drinkers did not

receive any treatment. In considering the effectiveness of current treatments, it should be recognized that the majority of alcoholics and problem

drinkers do not receive treatment.

ism is a physician, Jellinek (149), whose work has

been the basis of most currently used definitions.

Despite increasing emphasis on alcoholism as

a medical rather than a criminal or moral problem, experts continue to disagree about what constitutes alcoholism, and there is probably no single

best definition (199). Some definitions of alcoholism consider merely the quantity of alcohol consumed or the frequency of drunkenness (51). More

recent definitions consider the degree to which

serious medical or social dysfunctions result from

alcohol use (282) and the degree of psychological
Ch. 2—The Alcoholism Problem ● 11

dependence or physical addiction to alcohol (284).

Whatever definition is employed, however, it is

often difficult to obtain reliable diagnostic data

(118). This compounds definitional problems and

influences diagnostic decisions and treatment of

alcohol abusers.

There are degrees of alcohol use, some of which

are associated with problems and some of which

are not (49,250). Pattison has identified several

developmental patterns of alcohol use and misuse

(241). One pattern, that of the “alcohol experireenter, ” may lead to nondrinking if the experimenter’s initial experience is adverse or not pleasurable. Other patterns include “occasional drinking” (drinking only when drinking is socially expected) and “well-controlled drinking” (controlling alcohol use to avoid any adverse consequences,

the result of a personal cost-benefit calculation).

Higher alcohol use patterns include “habit” drinkers (who drink in larger amounts and may experience physical, psychological, or social effects),

and “heavier,” though still socially acceptable,

drinkers (who are psychologically vulnerable and

suffer degradation of function). Alcohol dependence can develop because drinking allays some

psychological symptom, provides escape from

chronic unhappiness, reflects social and cultural

disorganization, or is used to “treat” a physical

symptom. Depending on the sociocultural context, different patterns of “use, misuse, and abuse”

become the focus of diagnosis and treatment.

Some writers about alcoholism have taken a

dimensional approach. Polich and Orvis (249)

identified three dimensions: consumption, dependence, and adverse consequences. Marconi

(190) identified these three and also included

etiology. The key to a dimensional approach is

that a drinking problem may be defined in terms

of any one or a combination of the dimensions.

The precise time at which a drinking problem is

serious enough to be called alcoholism has not yet

been fully described, despite a range of attempts

at reaching consensus, such as that by WHO

(348,349), the National Council on Alcoholism

(214), and by various empirical attempts

(140,147,148,286). The most useful definitions of

alcoholism for treatment assessment purposes

seem to be those that evaluate the occurrence of

significant alcohol-related life problems, including

mental, legal, medical, and vocational problems

(277).

The most recent Diagnostic and Statistical A4anual (8) distinguishes between “alcohol abuse” and

“alcohol dependence. ” Diagnostic criteria for “alcohol abuse” include: drinking nonbeverage alcohol; going on binges (remaining intoxicated

throughout the day for at least 2 days); occasionally drinking a fifth of spirits (or its equivalent

in wine or beer); and having had two or more

blackouts, as well as impaired social or occupational functioning due to alcohol. In addition,

problems must have existed for a month or more.

The diagnostic criteria for alcohol dependence,

traditionally referred to as alcoholism, include the

criteria for alcohol abuse and two additional criteria: tolerance and withdrawal. Tolerance is defined as “the need for markedly increased amounts

of alcohol to achieve the desired effect, or diminished effect with regular use of [the] same

amount. ” Withdrawal includes “morning ‘shakes’

and malaise relieved by drinking. ”

The determination of the underlying causes of

alcoholism has been even more intensely debated

than the definition of alcoholism. At least three

major views of the etiology of alcoholism can be

identified: 1) medical, 2) psychological, and

3) sociocultural. Each of these perspectives is

associated with a particular set of treatment approaches. As described below, however, treatment is often based on several etiological perspectives, and practitioners often accept the view that

alcoholism is based on multiple factors.

Medical Perspective

The medical perspective focuses on biological,

chemical, and genetic etiological factors. From the

medical perspective, alcoholism is considered a

disease caused by physiological malfunctioning

and requires treatment by a physician. Jellinek

(149) posited that alcoholism represents a multifaceted syndrome. In many cases, the alcoholism

syndrome follows a particular course of progressive deterioration unless the problem is treated.

Jellinek believed that the only effective form of

treatment is that whose goal is of total abstinence

from alcoholic beverages.
12 ● Health Techology Case Study 22: The Effectiveness and Costs of Alcoholism Treatment

Alcoholism may be conceptualized as the “last

stage in a continuum of drinking that extends from

social drinking to heavy drinking to problem

drinking to alcoholism, where each population [of

drinkers] represents a subcategory of the one preceding it” (166). For present purposes, however,

the terms alcoholic, alcohol abuser, and problem

drinker will often be used interchangeably. This

usage reflects the fact that problems associated

with alcohol use and abuse may be progressive,

but that drinkers may seek treatment at any point

in the continuum and for various reasons. The

treatment literature does not always distinguish

appropriateness of treatments for patients at different points in the continuum.

From Jellinek’s perspective, “habitual symptomatic excessive drinking” was distinct from the

disease of alcoholism (149,150). Jellinek suggested

there were four primary forms of alcoholism:

●

●

●

●

Gamma alcoholism, said to produce the

greatest and most serious kinds of damage,

has five characteristics:

1. acquired increased tissue tolerance,

2. adaptive cell mechanism,

3. physical dependence (withdrawal symptoms and craving),

4. loss of control, and

S. a definite progression from psychological to physical dependence.

Delta alcoholism shares the first three characteristics of gamma alcoholism, but is

characterized by the inability to abstain

rather than loss of control; furthermore, delta

alcoholism does not include the progression

from psychological to physical dependence.

Beta alcoholism is a form of alcoholism in

which physical complications occur because

of inadequate nutrition, but without either

physical or psychological dependence on alcohol.

Alpha alcoholism represents a purely psychological continual dependence-or reliance on

the effect of alcohol to relieve pain and it does

not lead to a loss of control, nor is it considered progressive.

Jellinek maintained that only the gamma and delta

forms of alcoholism could be considered diseases.

Use of the disease concept became prevalent

and was used to refer to various alcohol-related

problems. Jellinek later encouraged the wider use

of the disease concept in order to get hospitals and

physicians involved so that alcoholics could receive some treatment (49). Through these highly

successful efforts, a medically based alcoholism

treatment system has evolved that incorporates

a range of approaches, including those that are

medically, as well as nonmedically, based.

A number of biochemical and physiological

mechanisms have been offered to explain the cause

of alcoholism. One theory postulates that alcoholism evolves from an inherited metabolic defect

that creates a need for certain substances and that

alcohol alleviates the symptoms of the deficiency (339,34 o). A second hypothesis is that alcoholism is the result of an endocrine dysfunction

(123,181,293). There is no strong empirical evidence for either of these theories (178,253).

Genetic theories of the etiology of alcoholism

have been proposed at a number of points (117,

119,280). Metabolic research with alcoholic populations, however, has been unable to distinguish

between effects caused by genetic factors and

those produced by chronic ethanol ingestion (273).

Nonetheless, evidence suggests that genetic factors may be an important predisposing factor in

the onset of alcoholism (166). Support for a genetic view is provided by carefully controlled family,

half-sibling, adoptee, and twin studies. These

studies have found that among children separated

from their biological parents at birth, the presence

of alcoholism in the biological parents was a much

better predictor of alcoholism in the child than

was the presence of alcoholism in an adoptive

parent.

In one study of twins conducted in Sweden

(161), both twins exhibited alcohol abuse in 54

percent of the pairs of identical (monozygotic)

twins but in only 28 percent of the pairs of nonidentical (dizygotic) twins. These studies strongly suggest that a predisposition to alcoholism is

inherited, but how the predisposition is transmitted remains unclear. The adoptee and half-sibling study designs cannot separate hereditary fac-
Ch. 2–The Alcoholism Problem ● 13

tors from the effects of the intrauterine environment.

Psychological Perspective

The psychological perspective views alcoholism

as arising from motivational and emotional dysfunctions in individuals. When dysfunction is preceded by, or occurs in the absence of, problem

drinking, alcoholism is considered to be a secondary diagnosis. When there are no major preexisting psychiatric problems, alcoholism is the primary diagnosis (48,277). There are actually several psychological perspectives, representing different theoretical approaches to alcoholism. These

perspectives include: 1) behavioral, 2) psychodynamic, and 3) systems approaches.

Behavioral Approaches

Behavior theorists view alcoholism as a learned

response. In their view, the drinking of alcohol

becomes “reinforcing;” i.e., the drinking of

alcohol is associated with positive, rewarding experiences, Positive reinforcers for alcohol use include tension reduction, release of inhibitions, and

facilitation of social interaction. Learning particular alcohol responses can occur through classical

conditioning (Pavlovian), operant conditioning

(Skinnerian), or modeling processes (192). Each

of these conditioning processes indicates a separate mechanism through which alcoholism develops.

A version of the behavioral approach is based

on cognitive behavior theory (191) which posits

that reinforcement lies “in the eye of the beholder.” Cognitive behaviorists hypothesize, for example, that alcoholics drink in an attempt to decrease their levels of stress, referred to as “tension reduction” (56,65), despite the fact that physiological evidence indicates that alcohol actually

increases tension (277). For example, Higgins and

Marlatt found that male subjects in a laboratory

experiment who expected to be evaluated drank

significantly more alcohol than did low-fear control subjects (134). Berglas and Jones found that

males, but not females, who were uncertain about

success on a task chose a performance-inhibiting

drug (designed to mimic alcohol ingestion), presumably to reduce tension about performance

(27,155).

Psychodynamic Approaches

From the traditional psychoanalytic perspective, alcoholism is seen as a symptom of underlying pathology resulting from unconscious conflicts. These conflicts are assumed to be the result

of early childhood experiences and an outgrowth

of interactions and fantasies about relationships

within the nuclear family. According to this application of psychoanalytic theory, once the conflict

is recognized and the patient is helped to gain insight into the problem, dysfunctional drinking behavior will stop naturally (170,329).

Several longitudinal studies have found an association between adult drinking and early pathological family experience (159,180,193,265). Lack

of control, aggressiveness, impulsivity, and disruptive family experiences (such as loss of a parent) are seen as precursors to various types of

psychopathology, including alcoholism. The immature level of development that characterizes

alcoholics is another emphasis of psychodynamic

approaches (22,287). Many studies have failed to

find specific personality traits that, prior to evidence of an alcohol problem, differentiate alcoholics from others (14,270,311). There is some evidence, however, to suggest that alcoholics, once

drinking, show similar personality traits, including low stress tolerance (179), dependency, impulsivity (5o), and feelings of isolation, insecurity,

and depression as well as poor self-image (146,

333,346).

Psychoanalytic theory, while historically very

important and influential, is no longer theoretically dominant (227). More important today is the

psychodynamic position that builds on some of

the basic assumptions of original psychoanalytic

theory, but has modified and adapted its components. From this perspective, all behavior, including alcoholism, is seen as being heavily shaped

by early experiences, but maintained by current

events.

Systems Approaches

The belief that alcoholism is sustained by a

pathological environment underlies the systems

theory approach to alcoholism. In this view, alcoholic behavior in an individual is seen as only the

tip of an iceberg, the iceberg being a continuing
14 ● Health Technology Case Study 22: The Effectiveness and Costs of Alcoholism Treatment

and immediate pathological interpersonal system

(20,97). This system is usually the family (39), but

it can also be significant other interpersonal networks in which the alcoholic participates (331).

Although the systems approach is considered here

a psychological perspective, in that the source of

the problem is seen as the individual, the systems

view shares much in common with the sociocultural perspective on alcoholism.

Sociocultural Perspective

From the sociocultural perspective, alcohol

abuse is seen as the product of living in a particular social and cultural milieu (19,51,141). Drinking behaviors may be regarded as learned, but the

sociocultural interpretation (unlike the behavioral

theory interpretation) is that these behaviors are

the result of a lifelong socialization and acculturation process. Ethnicity, age, socioeconomic class,

religion, and gender are seen as important factors

that shape an individual’s behavior. Children are

socialized in the culturally prescribed beliefs, attitudes, and behaviors toward alcohol. The variance in the occurrence of alcoholism among different groups is cited as evidence to support this

theory. Consistent reports of high rates of alcoholism among the Irish, American Indians, and

Swedes, compared to lower rates among Jews,

Mormons, and Chinese are frequently cited (59).

Zinberg and Fraser (351) have posited five sociocultural standards or cultural variables associated with the ability to control drinking behavior:

1) cultural differentiation of group drinking from

drunkenness and the association of group drinking with ritualistic or religious celebrations; 2) cultural association of drinking with food and ritualistic feasting; 3) nonsegregation of males from

females in drinking situations; 4) disassociation

of drinking from individual efforts to escape personal anxiety and disassociation of alcohol from

medicinal value; and 5) absolute cultural disapproval of inappropriate behavior when drinking,

including the disassociation of drinking from a

male or female “rite of passage. ” In the United

States, Zinberg and Fraser suggest, all the cultural

standards except those relating to drinking to alleviate anxiety have reappeared. It is possible that

the general cultural emphasis on controlled drinking may account for accelerated attempts to cure

and prevent alcoholism and alcohol abuse.

Integration of Perspectives

Each of the approaches to the etiology of alcoholism has received some empirical support, and

it is probably most reasonable to view alcoholism

as having multiple causes and a complex course

of development. Multivariant models of alcoholism have recently been proposed by a number of

alcoholism experts (e.g., 166,245). As already

noted, Pattison and colleagues contend that alcohol dependence subsumes various syndromes

defined by drinking patterns and the adverse consequences of such drinking (245). An individual’s

use of alcohol can be considered a point on a continuum from nonuse, through nonproblem drinking, to various degrees of deleterious drinking.

The development of alcohol problems follows variable patterns over time, and, according to Pattison, abstinence bears no necessary relation to

rehabilitation. Psychological dependence and

physical dependence on alcohol are separate and

sometimes unrelated phenomena, but continued

drinking of large amounts of alcohol over an extended period of time is likely to initiate a process of physical dependence. Alcohol problems are

typically interrelated with other life problems,

especially when alcohol dependence is long established.

POPULATIONS: INCIDENCE AND TREATMENT

Although alcoholism is widespread among vari- ism treatments tailored to the diverse needs of subous demographic and social groups, problems populations (306). Like Pattison, Solomon argues

with alcoholism may have different bases across that demographic characteristics such as gender,

groups and may manifest themselves differently. race, ethnicity, social class, and age, as well as

Solomon articulates the need to develop alcohol- the life situations of alcoholics, critically influence
Ch. 2–The Alcoholism Problem ● 15

both treatment selection and treatment effectiveness (240,241).

Having a job, a stable income, and a reliable

set of social and personal supports correlate positively with treatment outcomes (16). Men and

women from lower socioeconomic classes—those

most dependent on public resources, such as Medicaid and Medicare, for health services-appear

to suffer more extensive drinking problems and

respond less well to traditional treatment services

than do middle- and upper-class adults. Being

working class or poor in the United States often

involves unstable employment prospects and related disruptions of stable family relationships

(163,307,321). Such multiplicity of problems

undermines simple or inexpensive interventions

designed to reduce alcohol problems (217).

It has been consistently documented that men

across all social classes receive more alcoholism

services than do women. Armor and colleagues’

analysis of data from the NIAAA indicated that

male alcoholics in treatment tended to be unemployed, unmarried, southern, of lower socioeconomic status, and Protestant (13). Current

NIAAA data (218) are not reported by region or

religion. As shown in table 1, the population

served by NIAAA is predominantly male (81.1

percent) and middle-aged (mean age 36). Over

one-third served are racial/ethnic minorities (17.4

percent, black; 5.9 percent, Indian; 10.5 percent,

Hispanic (44). Furthermore, one-third served are

veterans. Only one-quarter are married—34.5

percent have never married, another 33 percent

are either separated or divorced, and 3.7 percent

are widowed. The mean educational level is below

high school senior. In addition, 84 percent of those

treated are potentially in the labor force, but half

of those are unemployed. Those in alcoholism

treatment programs for public inebriates, blacks,

and migrant workers are the most disadvantaged

economically (an average of almost 75 percent are

unemployed).

Table 1 .—Comparison of Alcoholics in NIAAA-Funded Treatment Programs With the General Population

Alcoholics in

NIAAA-funded treatment

programs with General population with

Characteristic characteristic Characteristic characteristic

Age:

18 and under. . . . . . . . . . . . . . . . .

19-35 . . . . . . . . . . . . . . . . . . . . . . . .

36-64 . . . . . . . . . . . . . . . . . . . . . . . .

Over 64 . . . . . . . . . . . . . . . . . . . . .

Mean age . . . . . . . . . . . . . . . . . . .

Gender:

Female. . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . .

Racelethnicity:

Black . . . . . . . . . . . . . . . . . . . . . . .

American Indian and Alaskan

Native . . . . . . . . . . . . . . . . . . . .

Hispanic . . . . . . . . . . . . . . . . . . . .

White and other minorities . . . .

Marital status:

Married . . . . . . . . . . . . . . . . . . . . .

Single. . . . . . . . . . . . . . . . . . . . . . .

Separated or divorced . . . . . . . . .

Widowed . . . . . . . . . . . . . . . . . . . .

5.2°\o

49.4

43.3

2.0

36 years

18.90/o

81.1

17.4 ”/0

5.9

10.5

65.4

25.00/o

34.5C

33.0

3.7

Under 18a . . . . . . . . . . . . . . . . . . . . .

18-34 . . . . . . . . . . . . . . . . . . . . . . . . .

35-64 . . . . . . . . . . . . . . . . . . . . . . . . .

Over 64 ..., . . . . . . . . . . . . . . . . . . .

Median age . . . . . . . . . . . . . . . . . . .

Female ... , . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . .

Black . . . . . . . . . . . . . . . . . . . . . . . . .

American Indian and Alaskan

Native . . . . . . . . . . . . . . . . . . . . . .

Hispanic . . . . . . . . . . . . . . . . . . . . . .

White and other minorities . . . . . .

Married . . . . . . . . . . . . . . . . . . . . . . .

Single . . . . . . . . . . . . . . . . . . . . . . . .

Separated or divorced . . . . . . . . . .

Widowed. . . . . . . . . . . . . . . . . . . . . .

28.1 0/0

20.7

30.9

11.3

30 years

51 .40/0

48.6

11 .7%0

0.6

6.4b

87.7

65.70/o

20.1

6.2 d

8.0

Education:

Mean school years completed. . 10.8 years Median school years completed. . 12.5 years

a~lAAA ~~~~rti~~ categories and (h_ISUS f9fIOrfhfJ Categofbs are ‘or ‘quivaient.

bper~ons of Spanish origin may be of any race; therefore, figures shown do not add to 1~ percent C~lAAA ~ategow 13 “never rnarriecf. ”

dCensu~ ~ategow is ‘(divorced.”

SOURCES: National Institute on Alcohol Abuse and Alcoholism, Alcohol, Drug Abuse, and Mental Health Administration, Department of Health and Human Services,

National Drug and A/coho/ism Treatment Utilization Survey (Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism, June 1981); and Bureau

of the Census, Department of Commerce, 7980 Census of Population; 1980 Supplementary Reports, Document No. PC 80-51-3 (Washington, D. C.: Depaflment of Commerce, 1980).

98-820 0 - 83 - 4 : QL 3
. .

lb ● Health Technology Ca5e Study 22: The Effectiveness and Costs of Alcoholism Treatment

Not much has been written about the reasons

for the apparent different rates of prevalence

among different subpopulations. Armor and colleagues (13), in trying to explain the tendency of

low socioeconomic Southern Protestant males to

present themselves for alcoholism treatment programs, invoked cultural values as an explanation.

Elderly People

Many surveys indicate an overall decline in alcohol use with age (cf. 12), indicating, perhaps,

less need for treatment services among elderly

populations. Among elderly people who drink,

however, a significant number have alcohol problems (223). In 1978, 6 1/2 percent of those served

in NIAAA-funded alcohol treatment centers were

age 60 and over (218). Schuckit and Miller (281)

report that, in recent years, approximately 10 percent of alcoholics in treatment are age 60 or older.

Two percent of elderly women are problem drinkers (13). For the late-onset alcoholics (those whose

alcohol-related problems began after age 40),

health and marital problems appear to be closely

associated factors. Stressful life situations such as

loss of a spouse, lack of purposeful employment,

and poverty, which are often connected with advanced age, contribute to alcohol use and abuse.

Despite the significant number of elderly people who receive treatment, many do not receive

treatment for alcoholism. NIAAA hypothesized

that for the elderly, reluctance of friends, relatives,

and professionals to recognize drinking problems;

incorrect diagnosis; inability of social agencies

dealing with aging to treat alcoholism; and the

orientation of treatment centers to younger clientele constitute barriers to treatment (216).

Youth and Adolescents

Surveys of alcohol use (e.g., 127) have indicated

that a substantial proportion of youths drink excessively. In 1978, youths 18 and under comprised

4.5 percent, and individuals between the ages of

19 and 24 comprised 14 percent, of those served

by NIAAA-funded alcoholism treatment projects

(100). Donovan and Jessor (82) report that approximately 5 percent of both girls and boys in

the seventh grade are problem drinkers; the proportion of problem drinkers increases steadily in

each grade, until by grade 12 almost 40 percent

of males and 20.6 percent of females are problem

drinkers. NIAAA reports that a national survey

of men aged 21 to S9 showed that the highest proportion of drinking problems are in the group

aged 21 to 24.

Donovan and Jessor (82) define problem drinking for youth and adolescents as having been

drunk five or more times and/or having two or

more life areas in which negative consequences

occurred in the past year. Although this is a liberal

standard, compared to those used to identify alcoholics, it highlights the seriousness of adolescent alcohol use. Probably the most alarming consequence of adolescent and young adult drinking

is its relationship to fatal driving accidents

(352,353). Recently, the Secretary of Transportation called for a uniform requirement that the

minimum age for those purchasing alcoholic beverages be 21 years.

The most reliable predictor of drinking among

youths is the drinking behavior of their parents

(257), although peers have an important influence

(41,151,152). In 81 percent of families in which

both parents drink, children also drink; in 72 percent of families with two abstaining parents, children do not drink (216). A number of sociocultural influences predisposes young people toward

drinking. These include residence in an urban

area, divorced or separated parents, a poor parent-child relationship, and high socioeconomic

status (34).

According to a recent review, systematic,

theory-based research on the cause of adolescent

problem drinking and the circumstances under

which it “matures out” is minimal (216). Much

as other special populations do, youths who abuse

alcohol appear to have special treatment needs.

According to some experts, it needs to be

recognized that because adolescent problem drinking is only part of the total syndrome of problem

behaviors, alcohol-specific treatment is inadequate

(216),

Women

Women comprise only 20 to 40 percent of those

served in alcohol treatment facilities, but the question of whether women are less prone to alcohol-
Ch. 2–The Alcoholism Problem ● 17

ism or are an underserved population has not yet

been answered (306).

There is evidence that women tolerate alcohol

less well than men (38). They reach a higher

blood-alcohol level faster and are more at risk for

the development of biomedical consequences.

About 16 percent of women alcoholics develop

liver disease compared to 8 percent of men, and

women appear to be at a higher risk of death from

alcoholism than are their male counterparts.

Although alcoholism typically has a later onset

in women than in men, there is evidence of “telescoping” in women, whereby medical problems

develop faster than in men.

One explanation for their relatively low rate of

treatment is that women may be less “visible” in

their need for services (e.g., the homemaker who

drinks during the day), and family members and

coworkers may be more reluctant to intervene

with women drinkers (216). Furthermore,

epidemiological surveys may be insensitive to

characteristics of female alcoholics, in part

because alcoholism is more of a stigma for women

than for men (24). It is also possible that because

women are more likely to be multiple drug

abusers, their alcohol addiction is camouflaged.

The proportion of women who drink has risen

from one-third prior to World War II to twothirds at the present time (116). As to which

women are more likely to become alcoholics, efforts to delineate a female alcoholic syndrome

have been disappointing (cf. 153). Although there

are no reliable indicators of which women will

become alcoholic, a review by Bourne and Light

(38) indicates that black women, women with

alcoholic parents (especially an alcoholic father),

and women who have a number of gynecological

problems are particularly at risk. Johnson’s recent

analysis of social factors indicates that unemployed divorced women are at greatest risk of

becoming alcoholic, although employed married

women showed significantly higher rates of consumption and number of problems than did single,

employed women or nonworking married women

(153).

It is believed that additional attention must be

paid to the needs of women alcoholics (36). This

attention seems warranted, both because of increased recognition of the problem of women

drinkers and, also, because women are childbearers primarily responsible for child care (cf.

116). The fetal alcohol syndrome, which encompasses a broad range of brain dysfunctions,

growth deficiencies, and malformations among

children born of alcoholic mothers, is believed to

represent a significant health risk (85,157).

Blacks

Although blacks are overrepresented in the

population seeking alcoholism treatment in

NIAAA-funded programs, there is evidence that

the vast majority of bIack alcoholics either do not

receive any treatment at all or receive treatment

less often than members of other groups. It has

been hypothesized that blacks may not seek treatment because of pressures in the black community

to deny that alcoholism is a problem. If it is

acknowledged as a problem, there are pressures

to treat it as a moral issue rather than a medical

one (38). It may also be, as one study found, that

black alcoholics are referred for treatment less

often despite greater prevalence because higher

levels of drinking are assumed to be normal (323).

Current social conditions, such as the high rate

of unemployment among blacks and the low level

of jobs among those who are employed, are believed to be important factors leading to the high

incidence of alcoholism (38). In support of this

view, Kane’s analysis of black and Hispanic innercity alcoholics found that the most frequently

given reason for drinking was “escape” (162). Indepth studies of such psychological factors are

few. Fine and Steers found a strong correlation

between alcoholism and depression, a finding of

special significance because of the high incidence

of depression in black males (101). One longitudinal study of 240 black males found that certain

family patterns were associated with later alcoholism: broken homes, irresponsible parents, and

parents with drinking problems.

The Third Special Report to the U.S. Congress

on Alcohol and Health (223) argued that more

research on blacks and alcoholism is imperative.

Potential causative factors have been identified,

but evidence is associative and impressionistic.

Because “the characteristics that distinguish special
18 ● Health Technology Case Study 22: The Effectiveness and Costs of Alcoholism Treatment

population groups from the dominant culture and

from each other are also frequently involved in

the development of alcohol use and abuse among

those groups, ” the report argues for research that

could lead to the development of culture-specific

treatment programs.

Hispanics

Despite the research showing that problem

drinking is relatively widespread among the Spanish-speaking population, both here and in their

native countries (187), systematic data on alcohol

use and abuse among Hispanics are sparse (162,

223). Interpretation of existing data is complicated

further by the number of different ethnic groups

included as Hispanic and by the heterogeneity of

subgroups. Most research on problem drinking

among Hispanics has focused on Mexican Americans, with less research attention being given to

the alcohol problems of Puerto Rican, Cuban,

Central American, and South American Hispanics

(223).

Problem drinking among Hispanics has been

hypothesized to be a result of acculturation stress

(188), the Latin idea of “machismo” (2), cultural

acceptance (162), and economic deprivation (313).

Machismo, in particular, contributes to denial of

the alcohol problem and, thus, creates a barrier

to seeking treatment (3,223). This also affects

alcoholic Hispanic women, whose husbands restrict their access to such treatment. Many researchers and service providers emphasize the importance of providing culturally specialized treatment programs staffed by those who can speak

Spanish and who share a cultural background

with their clients (125). Others disagree, believing that treatment should stress the nature of the

problem rather than cultural considerations (223).

American Indians

The prevalence of American Indians in NIAAAfunded alcoholism treatment programs is more

than 10 times what would be expected on the basis

of census figures. A high incidence of alcoholrelated problems among Indians has been documented, including arrests for public drunkenness

and crimes associated with alcohol; high death

rates from cirrhosis of the liver; accidents, suicide,

and homicide; and fetal alcohol syndrome (215).

These findings may be a function of the attention

given by the Federal Government to the American

Indian population and special programs established to aid the Indians. The absence of definitive

studies precludes accurate estimation of the prevalence of alcohol-related problems in American Indians. Some evidence, collected by Leland

(175,176), suggests that most Indians “drink

responsibly or do not drink at all” (223). Cultural

explanations are contradictory, but an understanding of Indian cultures has been deemed imperative for understanding the problem (174,177).

Other Special Groups

Problem drunk drivers, public inebriates, and

skid-row alcoholics are other populations that

may have special characteristics and treatment

needs for their alcohol problems. Drunk driving,

in particular, has become one of the most serious

national problems. Individuals arrested for driving while intoxicated (DWI) form a substantial

alcohol abuser population. In 1980, 29 percent of

all admissions to NIAAA-funded treatment programs were DWI-related (217). More punitive

laws are currently being implemented in many

States as a consequence of public concern about

drunk driving. Various types of compulsory treatment for this group of users have been tried in

many States for years, although their success is

questionable.

Public inebriates and skid-row alcoholics form

another special population. NIAAA’s 1981 report

(216) distinguishes between public inebriates, who

are socioeconomically heterogeneous, likely to be

working, and have a place to live, and the

stereotypical, homeless, and destitute skid-row

alcoholics. The latter population is more likely

to require specialized treatment programs, because

the individuals comprising it tend to do poorly

in any kind of treatment that is effective with

socially and economically stable individuals.

Individual Difference Factors

In addition to varying with respect to sociodemographic factors, alcoholics vary in patterns

of drinking, treatment, and severity of psycho-
Ch. 2–The Alcoholism Problem 19

logical and medical history symptoms. Although

there are few reliable indicators of the factors that

lead clients into treatment, psychological factors

of dependency/passivity, intellectual and emotional functioning, self-esteem, hostility, and

motivation have been found to relate to successful

outcomes in a variety of studies. These factors are

of weaker predictive ability than are demographic

factors. Somewhat paradoxically, good indicators

of treatment success include having had one’s first

intoxication and first alcohol-related problems at

a later age, having had a longer history of heavy

drinking, and having had a history of AA contact prior to treatment. While a longer history of

heavy drinking is a good predictor, severe symptoms at intake are not. Symptoms of a periodic

rather than a daily drinking pattern, abstinence

CONCLUSIONS

The present review of the etiology of alcoholism

and the effects of alcoholism on various subgroups

illustrates the complexity of alcoholism as a social

and health care problem. Alcoholism and alcohol

abuse have multiple origins and affect diverse

groups of individuals. That the phenomenon is

prior to treatment, and absence of delirium tremens, are particularly predictive of good outcomes

(306). These drinking behavior variables may be

more predictive of successful outcomes than are

social and psychological factors.

A recent analysis by Solomon (304) found that

patients’ exposure to outpatient therapy was greater for socially stable patients and the less alcoholically impaired. The characteristics that appear

to be associated with better treatment outcomes

are older age, Caucasian race, social stability (in

particular, a stable marriage), steady employment, higher education and income levels, and

fewer arrests. What seems clear is that particular

populations may have different prognoses and

treatment needs.

complex, however, should not deter efforts to

understand the problem and develop treatment

solutions. The problems of alcoholism and alcohol

abuse are too serious, in terms of their impact on

the Nation, for the problem to be ignored.
3.

Approaches to Alcoholism

Treatment
3.

Approaches to Alcoholism Treatment

Given the diversity of etiological understandings of alcoholism and the populations affected,

it is not surprising that there are diverse treatments. Described below are the treatment modalities, settings, and providers that comprise the

present health care system for alcoholism. It is imTREATMENT MODALITIES

The major treatments for alcoholism can be organized into three major approaches, which parallel etiological perspectives: 1) medical, 2) psychological, and 3) sociocultural. In practice, treatments often overlap, with psychologically oriented treatments using medications as adjuncts

and drug treatments being combined with psychological techniques. In fact, the approach used with

alcoholics in most treatment settings is eclectic and

multivariant, with several approaches being utilized at the same time.

Medical Approaches

The difficulty of delineating the basis of alcoholism treatments is clear in any attempt to identify medical approaches. Three types of medical

treatment are described here, one having to do

with detoxification and the others with the use

of drugs. Additional treatments that could have

been included because they are often delivered by

physicians, such as chemical aversion therapy and

psychotherapy, are discussed as psychological approaches. The classification is less important than

the nature of the treatment.

Detoxification

In the context of the present report, detoxification is not an actual alcoholism treatment, because

it is not designed to treat the underlying dependence on alcohol. However, medical intervention

may be necessary to manage withdrawal from

alcohol and may be necessary as the first step in

a treatment program. Chronic alcohol intake reportant to recognize that each of the system components to be described affects the others, that

specific modes of treatment can be offered in multiple settings, and that

use several modalities

treatment program.

treatment providers often

and settings as part of a

suits in cellular alterations to which the body

adapts, and withdrawal reactions may include

heightened sensitivity to sensory stimuli, hyperactivity of reflexes, muscular tension and tremor,

over-alertness, anxiety, insomnia, and reduced

seizure threshold. The withdrawal reaction, itself

causes additional physical stress, and problems

may be further complicated when withdrawal results from the need to recover from surgery or

serious injury. The severity of symptoms depends

on the intensity and duration of the patients’

drinking problem (285).

A recommendation of hospitalization for detoxification is made for patients with severe withdrawal symptoms, medical or surgical complications, or other evidence of moderate to severe

withdrawal such as a history of seizures during

past withdrawals (285). Detoxification can also

be handled on an outpatient basis or in a nonmedical setting (a detoxification center), although

medical backup is required in the event of emergencies. Increasingly, efforts are being made to

detoxify patients without hospitalization, although that is safe only if the patient has no complications and has available supervision.

Support services are often an important part

of the treatment for withdrawal (207). The use

of supportive services without pharmacological

treatment (e.g., reassurance, reality orientation,

and frequent monitoring of signs and symptoms)

is known as social detoxification and has been

found to be safe and effective for patients who

are not experiencing severe reactions (142,314,

334).

23

98-8 ?0 O - 83 - 5 : QL 3
14 ● Health Technology Case Study 22: The Effectjven~s and Costs of Alcoholism Treatment

Antianxiety medications are often prescribed

during the detoxification process for managing

symptoms such as disorientation, seizures, visual

and auditory hallucinations, and delirium tremens. The usual drugs of choice for managing alcohol withdrawal are the benzodiazepine derivatives: chlordiazepoxide (Librium”), diazepam

(Valium@), clorazepate (Tranxene”), and oxazepam (Serax”). Some physicians continue prescribing these tranquilizers after the detoxification

period, but such use can sometimes lead to psychological dependence on the drugs and other side

effects that inhibit recovery (108). The dosage and

the length of use of antianxiety medications vary

widely. Some experts see the drugs in later stages

as a symbolic vehicle in clinician/patient interaction, where the act of giving and receiving is seen

as more important than the actual pharmacologic

action (232,271).

Mood-Altering Drugs

Antidepressant medications have a long history

of use in the treatment of alcoholics. The logic

of their use seems persuasive, since alcoholism and

depression are often inseparable (114,186,304,

30S). Most commonly prescribed are the tricyclic

antidepressants and lithium. However, the side

effects associated with these drugs and the deleterious and, at times, fatal effects of ingesting these

drugs along with alcohol make their use questionable (165,199). Furthermore, these medications

treat the affective disorder associated with alcohol

abuse, but not alcoholism itself.

Some physicians (generally, psychiatrists) prescribe major tranquilizers or antipsychotic medications for alcoholics who are severely agitated.

Some prescribe these drugs only for people who

are both alcoholic and psychotic. Alcohol has

been considered a form of self-medication that has

been used by schizophrenics to calm themselves.

When these individuals stop drinking, they may

become severely agitated (199). Many physicians

are hesitant to prescribe these medications at all

(165). The fact that many patients do not take

their medications as prescribed is another negative

factor (262,336).

Sensitizing Agents

Disulfiram (Antabuse”) is the most commonly

used drug in alcoholism treatment. Antabuse”

does not cure alcohol craving or dependence per

se, but causes psychological effects such as respiratory difficulty, nausea, vomiting, and sweating

when alcohol is ingested while the drug is active.

The intensity of reactions depends both on drug

dosage and amount of alcohol subsequently ingested—with large doses of Antabuse@ and alcohol combined, reactions may be fatal. After taking Antabuse@

, the patient’s desire to drink will

be dulled by the thought of inevitably getting sick

(165). One disadvantage is that a person can stop

the Antabuse@ regimen at any point and shortly

thereafter (within 24 to 48 hours) be able to drink

with impunity. For patients who are motivated

to abstain, however, life is simplified by Antabuse”, as there is only one decision a day—either

to take the pill or not to take the pill. For this

reason, Antabuse”-based treatment has been described as a method of “ego-reinforcement” (30).

Antabuse” is not recommended universally for

alcoholics for several reasons. It cannot be given

to patients with other serious medical disorders

(165). For example, the use of Antabuse” with

elderly alcoholics is often contraindicated because

of the risk of cardiovascular problems (23). Furthermore, Antabuse@ has been associated with

suicide among users (303).

Psychological Treatments

The forms of psychological treatment vary

widely and, as with medical treatment, are difficult to classify. Behavioral approaches, although

based on only one of several important themes

used to explain alcoholism, have been widely employed in recent years to treat alcoholics. Other

psychological therapies (including nonbehavioral

and the related systems approaches), while extensively employed generally, have been used less frequently to treat alcoholism specifically.

Behavioral Approaches

A large number of behavioral techniques to

treat alcoholics have been developed over the last
Ch. 3—Approaches to Akoholism Treatment ● 25

30 years (cf. 208). Based on research that investigates how individuals learn and maintain habits,

behavioral approaches are supported by an extensive basic research literature and substantial evidence of their effectiveness in treating other disorders (cf. 227). Often, behavioral treatments are

used in conjunction with other psychological

treatments as part of broad-spectrum treatment

packages (15,172,301).

One type of behavioral technique used with

alcoholics is referred to as blood-alcohol level discrimination training. Based on the assumption

that alcoholics do not accurately process information about their level of intoxication, the procedure teaches alcoholics how to estimate correctly

their blood-alcohol level (182). A related technique involves confronting alcoholics with videotapes of themselves when drunk so they can

experience their drunken behavior as observers

do. In both cases, it is assumed that alcoholics

can be taught to manage their alcohol intake.

A second group of behavioral techniques is used

to train alcoholics to relax. These techniques are

based on a tension-reduction hypothesis and an

assumption that alcohol is ingested to reduce

stress. Training alcoholics to relax, by teaching

them, with biofeedback, how to alternately tense

and relax their various muscle groups is believed

to help them develop nonharmful, substitute behavior (171). Techniques of visualization and imagery are also used in relaxation and desensitization training (345).

One assumption behaviorists make about alcoholics is that they have difficulty expressing their

wants, needs, and frustrations. Various assertiveness training approaches are used to develop their

skills in self-expression. Role-playing and behavioral rehearsing of problem situations are also

used. For example, an alcoholic practices saying

“no” when offered a drink or role plays walking

away from the kind of domestic scene that usually

precipitates a drinking binge (21,298).

Cognitively oriented behaviorists assume that

if alcoholics understand the idiosyncratic thoughts,

feelings, and behaviors that precede their own

drinking, they can substitute alternative behavior

for drinking. Thus, analyses of patterns of drinking and counseling about alternative behaviors

may also be part of the behaviorists’ repertoire.

Sobell and Sobell used such an approach as part

of their Individualized Behavior Therapy for Alcoholics (296,300,301).

Chemical aversion therapy is perhaps the best

known treatment associated with behavioral theory. Its goal is to facilitate abstinence by developing a conditioned aversion to the taste, sight, and

smell of alcoholic beverages. This aversion is accomplished by injecting an alcoholic patient with

an emetic substance such as emetine hydrochloride just before serving him or her an alcoholic

drink. Nausea results in about 2 to 8 minutes.

Often, additional drinks are given over a 30-minute period as the nausea continues, and the sequence of pairing nausea with alcohol is continued. In some inpatient settings, treatment may

involve five such injections given every other day

over a l0-day period (335). By the end of the

series, the alcoholic is expected to have developed

a negative association to the sight and smell of

alcohol. The treatment is based on Pavlovian classical conditioning principles, and according to the

theory, a person who receives such treatment will

develop a long-term aversion to alcohol. In many

cases, reconditioning sessions are offered to maintain the aversion.

The advantage of chemical aversion therapy is

that it offers the potential of training alcoholics

to abstain. There are disadvantages, as well. Because nausea is repeatedly induced, the technique

is potentially hazardous and must be administered

under medical supervision (16). Chemical aversion therapy is typically provided in a hospital

setting, and with the need for multiple sessions,

it is a costly form of treatment.

A type of cognitive aversion conditioning without the dangers of chemical aversion therapy is

covert sensitization (57). Patients treated with

covert sensitization are instructed to imagine that

they are about to drink some alcoholic beverage,

experience a sensation of nausea, and vomit, In

this way, the target stimulus (alcohol) becomes

associated with an aversive stimulus (vomiting).

Feeling better becomes associated with leaving the

scene where the urge to drink occurred (escape

conditioning). The technique is called covert, because the stimuli are not present at conditioning
26 ● Health Technology case Study 22: The Effectiveness and Costs of Alcoholism Treatment

sessions. The word sensitization implies a gradual

buildup of an avoidance response. Covert sensitization is often preceded by relaxation, desensitization, and assertiveness training to treat the

anxiety component of the drinking behavior.

Depression is thereby avoided because the patient

is provided with a means of coping with his or

her environment when sober.

Nonbehavioral Psychotherapies

Various nonbehavioral psychotherapies are also

employed with alcoholics. Nonbehavioral psychotherapy can be delivered on a one-to-one basis,

in families, or in groups. The length of individual

therapy varies, ranging from short term, of 12 or

fewer sessions, to long term, from 2 to 7 years.

The kinds of approaches vary widely although the

approaches all have the goal of aiding the alcoholic (or family members) to understand and deal

with physical or psychological dependence on alcohol (227). Several forms of psychotherapy can

be employed, and speciality therapies such as

transactional analysis (115) and reality therapy

(308) are also used.

Although there is some limited use of psychoanalytic therapy, most psychotherapists who treat

alcoholics emphasize treating the contemporary

life problems of patients. They feel that alcoholism, while perhaps rooted in early experiences,

is maintained by present interactions. Therefore,

they focus their therapeutic attention on what produces stress on the job, in family interactions, and

on the role alcohol plays in the patient’s life. They

may discuss feelings, offer support, and facilitate

problem-solving. In addition, they may use some

of the behavioral techniques discussed above in

the belief that behavior change as well as insight

is important. In all kinds of psychotherapy, the

relationship between therapist and client is itself

a key factor in encouraging change (cf. 104).

Group therapy has received a good deal of attention recently as the treatment of choice for

alcohol problems (cf. 26,83). Group therapy sessions are usually held once or twice a week on

an outpatient basis or, more frequently, in inpatient settings. Therapists focus on the process of

the group as a whole, but may also work individually with patients. The group members support

and challenge one another. The feedback from the

group is supposed to be a powerful catalytic agent

in helping the alcoholic change.

It is generally assumed that nonbehavioral psychotherapies are effective because they deal with

the underlying problems of an alcoholic, rather

than the symptoms. Nonetheless, all psychotherapies have been criticized as being difficult to use

with alcoholics. Psychotherapy is especially difficult to employ if attempted while a patient is still

drinking (60). A number of experts are pessimistic

about the efficacy of psychotherapy for those who

cannot maintain abstinence or reduced drinking

during treatment (35,129,135). Other reviewers

have argued that this negative impression is not

well founded and that psychotherapy is necessary

to deal with the underlying psychological causes

of alcohol abuse, especially for heavy, habitual

drinkers (18,95,199).

Systems Approaches

As noted previously, most systems approaches

focus on family interactions, and in particular,

on family communication patterns. It is assumed

that the family has developed ways of interacting

that accommodate, if not perpetuate, the alcoholic’s drinking. If the negative family interactions

are not treated, when the alcoholic stops drinking, the family may subtly exert tremendous pressure on him or her to resume drinking.

Family therapy is related to group therapy. In

practice, family therapy can involve various psychotherapeutic techniques. In general, the goal of

such therapies is more direct expression of wishes,

needs, and feelings by family members. Families

are taught how to talk more openly about their

own family interactions and to become observers

of their interactions. It is assumed that such discussions and the development of communication

skills will aid the alcoholic member by reducing

environmental stresses and providing support to

control drinking urges.

Sociocultural Approaches

The essence of sociocultural approaches is the

assumption that the successful treatment of alcoholics requires changing the social environment
Ch. 3—Approaches to Alcoholism Treatment ● 27

within which such individuals function. Such approaches share the rationale of group and family

psychotherapies about the need to change the

alcoholic’s environment. In practice, this often

means removing the alcoholic individual temporarily from his or her home and placing that individual in a new setting, such as an alcohol treatment facility. Changing the environment may also

mean creating a whole new culture for the alcoholic, such as that which Alcoholics Anonymous

(AA) provides (351).

AA is a volunteer self-help organization, which,

although not a formal treatment provider, is perhaps the major resource for alcoholics in this

country and elsewhere (5, 173). It provides a new

ideology for members by supporting abstinence

from alcohol (351), a sense of belonging, and an

involving set of activities. Founded in 1935 by two

alcoholics (one of whom was a physician), AA

takes an approach that directly confronts the denial typical of alcoholics. At AA meetings, each

speaker announces, “I am an alcoholic.” In addition, AA incorporates a spiritual approach; as

part of the “twelve steps” of recovery, all members

submit to a “higher power. ” Although the organization has religious origins (the second founder

was a religionist), belief in God is not essential,

and many agnostics belong. At meetings, members share personal narratives about the difficulties caused by alcoholism and the positive experiences of sobriety. Members typically attend at

least one meeting a week; some attend daily. Help

for AA members is available 24 hours a day, with

fellow members willingly visiting the home of

anyone needing assistance. For those who join

AA, the group provides a network of abstainers

to replace the individual’s old social system

(128,156).

AA can also help change the family environment through parallel programs such as Al-Anon

(for spouses of alcoholics), and Alateen (for the

children of alcoholics). Using similar group support techniques, these related groups help family

members cope with the problems created by the

alcoholic family member and provide a supportive environment for sobriety. Although AA has

often been regarded as the most effective form of

help for an alcoholic (103,109) it has also been

subject to criticism (173).

Combination of Treatment Modalities

Although a variety of treatment modalities have

been described, it is important to note that alcoholics and alcohol abusers are rarely, if ever,

treated with only one method. Thus, for example, hospitals that employ aversion conditioning

may also use individual and group counseling and

participation in AA as part of the treatment regimen. Psychodynamically oriented therapists may

also use desensitization techniques and prescribe

Antabuse” or a mood-altering drug to encourage

the alcoholic to remain in treatment. Treatment

providers may refer indigent alcoholics to vocational training or those with severe psychopathology for psychiatric care. The important point is

that, in practice, no single treatment is considered

sufficient for treatment of alcoholism.

TREATMENT SETTINGS AND PROVIDERS

A major focus of research on treatment effec- Inpatient Care

tiveness is often on the setting within which treatment is provided. Recently, research has begun The distinguishing characteristic of inpatient

to assess characteristics of settings in an attempt care is overnight stay in a medical facility. * Into discover effective treatment programs and ap- patient settings include: 1) alcoholism detoxificapropnate patient-setting matches (cf. 24,42,72,73).

Differentiating between various settings, however,

is often difficult. Below, the most common treat- *This distinction follows the typology of Armor (13) and others.

ment settings for alcoholism and the providers However, the National Institute on Alcohol Abuse and Alcoholism

who deliver alcoholism services are described analyses characterize as inpatient any form of residential care (half-

(also, see table 2).

way and quarterway houses, small group homes, boarding houses,

as well as hospitals) (cf. 218).
28 ● Health Technology case Study 22: The Effectiveness and Costs of Alcoholism Treatment

Table 2.—Characteristics of Treatment Settings

Setting Treatment modalities Patients a

Inpatient

General hospitals

Short-term detoxification units

Rehabilitation stay (3 to 4 weeks)

State and private psychiatric hospitals

Free-standing alcoholism rehabilitation

facilities

Aversion-conditioning hospital

Outpatient

Private physicians’ offices

Community mental health centers

Free-standing outpatient clinics

Day care

intermediate

Halfway houses, quarterway houses,

recovery homes

Medical: frequently pharmacotherapy

Individual and group psychotherapy,

alcoholism education, AA,

Antabuse @

Nonmedical: lectures,

nonpsychodynamic group

counseling, AA, family sessions

Strong medical orientation:

detoxification, emetine or faradic

conditioning, counseling, group

therapy, education, hospital followup

programs

Medical: Antabuse@ maintenance,

symptom management, involvement

of spouse and family

Medical, psychological, social services

Medical, psychological, social services

Varied

Peer-group orientation; food, shelter,

supportive services in nondrinking

atmosphere

Socially stable, fewer years of heavy

drinking

Lower middle class, relatively socially

and vocationally disabled

Severe psychiatric condition or

opportunity to interrupt drinking

pattern or motivate a resistant

patient

Socially competent, middle class,

working

Socially competent, upper class

Usually alcoholism is not primary

complaint

Broad spectrum of patients

Broad spectrum of patients

Broad spectrum of patients

Recovering alcoholics: ambulatory and

mentally competent who usually

have no spouse or immediate family

apatlent descriptors are oniy rough charwterizations.

SOURCE: Office of Technology Assessment.

tion units and alcoholism rehabilitation units in

general hospitals, 2) alcoholism treatment units

in State and private psychiatric hospitals, and

3) free-standing alcoholism rehabilitation facilities.

Detoxification/Rehabilitation Units

in General Hospitals

In addition to providing medical services to

alcoholics not being treated primarily for their

alcoholism (241), general hospitals have recently

begun to provide services directly to alcoholics.

This practice represents a change in the long tradition of hospitals refusing to serve anyone with a

primary diagnosis of alcoholism.

Detoxification/rehabilitation units in general

hospitals typically provide an initial detoxification and/or evaluation period, followed by a 3-

to 4-week inpatient stay for rehabilitation. According to Diesenhaus (81), general hospitals

stress evaluation of medical status and frequently use pharmacotherapy. They tend to admit alcoholics who are socially stable and who have experienced fewer years of heavy drinking.

Third-party medical insurance coverage is typically provided for inpatient care in general hospitals; Medicare provides coverage for up to 3 weeks

of combined detoxification and rehabilitation in

an inpatient medical setting (130).

Alcoholism Treatment Units in State

and Private Psychiatric Hospitals

Psychiatric hospitals also provide inpatient

care, but, as Diesenhaus (81) notes, there may be

more stigma associated with “psychiatric” care

than with “medical” care, Alcoholism treatment

programs in State mental hospitals, in particular,

have in the past been underfunded, accorded low

status, staffed by untrained personnel (52) and

regarded as ineffective (184,203). Their patients

have typically been lower middle class and relatively disabled, both socially and vocationally

(241).
Ch. 3—Approaches to Akoholism Treatment ● 29

The characteristics of the State and private psychiatric hospital population may be changing,

however, as reimbursement for alcoholism treatment becomes more widely available. Private

mental hospitals provide treatment to a substantial number of patients who abuse alcohol, although alcoholism may not be the primary diagnosis. The Alcoholic Recovery Program at the

Menninger Hospital in Kansas uses a multivariant

program that addresses the psychological, biological, spiritual, and social aspects of alcoholism

(105). The 6- to 8-week treatment program consists of educational lectures, recreational activities

under the direction of a leisure therapist, family

sessions, group sessions, and nutritional advice,

as well as restricted access to alcohol. Although

physical evaluations are made, medical treatment

is not a major focus. The Menninger program follows AA philosophy but uses a treatment team

of professionals and paraprofessionals (including

psychiatrists, nurses, mental health technicians,

psychologists, social workers, alcoholism counselors, and medical internists).

Moore’s analysis of a survey of private psychiatric hospitals found that the mainstay of these

programs was individual and group psychotherapy, alcoholism education, AA, and Antabuse”

(202). Psychiatric hospitalization is believed to be

indicated when a severe psychiatric condition exists, regardless of its relationship to a drinking

problem. It is also indicated when an opportunity to interrupt a drinking pattern or motivate a

resistant patient is needed (7,201).

Free-Standing Alcoholism Rehabilitation Facilities

Free-standing alcoholism rehabilitation units are

often nonprofit organizations, affiliated with but

not necessarily located in hospitals, that provide

inpatient programs with a nonmedical orientation,

although medical and psychiatric support is also

available (241,309). In these facilities, a therapeutic milieu is created in which alcoholic patients

take some responsibility for program planning,

activities, and ongoing maintenance. AA meetings

are usually part of the community life, and family sessions are often a part of the program. Treatment includes lectures, nonpsychodynamic group

counseling, family sessions, and attendance at ~

meetings (241). Pattison (241) characterizes these

programs, of which the Hazelden Foundation in

Minnesota is a prototype, as having a “sense of

‘elan, ’ commitment, and surety of purpose. ” They

typically serve a socially competent, middle-class

working clientele in a treatment program that lasts

from 3 to 6 weeks.

Another type of free-standing rehabilitation facility has been called an aversion-conditioning

hospital (241,295). Such facilities are often proprietary and offer residential treatment from 10

to 14 days. Their programs tend to attract socially

competent, upper-class clients, and according to

Pattison have a strong medical as opposed to a

psychological orientation (241). Treatment consists first of detoxification, followed by emetine

(chemical) aversion conditioning (in some cases,

the aversive stimulus is an electric shock rather

than a drug). Counseling, along with various

forms of group therapy and education, are also

offered as part of the treatment program (295,

317). In most cases, hospitals provide followup

and continuing programs. The Raleigh Hills and

Schick-Shadel hospital systems are examples of

facilities that include aversion conditioning as an

important component of their inpatient treatment.

Outpatient Care

In addition to services provided on an inpatient

basis, some alcoholism services are provided on

an outpatient basis in nonmedically oriented residential facilities and in a variety of other settings.

Like inpatient facilities, outpatient facilities vary

in the extent of their medical orientation. The

more medically oriented outpatient facilities include: 1) private physicians’ offices, 2) community

mental health centers, 3) some free-standing outpatient clinics, and 4) day care hospitalization programs. The less medically oriented include the remaining free-standing outpatient clinics.

Private Physicians’ Offices

Alcoholics who consult private physicians usually do not present a primary complaint of

alcoholism. Nonetheless, they reportedly comprise 10 percent of general physician and internist case loads (84), with 70 percent of physicians

in private practice seeing at least 10 alcoholics per

month (197). Although general physicians do not
30 ● Health Technology Case Study 22: The Effectiveness and Costs of Alcoholism Treatment

typically refer patients to alcoholism treatment

programs (perhaps because the patients they see

are less dysfunctional), they may provide other

services. Such physicians may manage a program

of Antabuse@ maintenance, treat acute intoxication and mild withdrawal symptoms, use the doctor-patient relationship to engage patients in a

treatment program, and involve the spouse and

family in helping the patient deal with the problem (239).

Community Mental Health Centers

Community mental health centers are institutions formerly operated under guidelines of the

Community Mental Health Center Amendments

Act of 1975 (Public Law 94-63) or under State or

local legislation modeled after the act. Such centers provide a broad range of community-based

mental health services and treat alcoholism as only

one of many problems presented by patients.

For insurance reimbursement, Health Care Financing Administration guidelines distinguish between hospital- and nonhospital-based community mental health centers and free-standing outpatient clinics (see below).

Free-Standing Outpatient Clinics

As defined by the National Institute on Alcohol

Abuse and Alcoholism (NIAAA), free-standing

outpatient clinics are facilities that “one would

enter only to receive alcoholism services” (217).

These clinics provide a multiplicity of medical,

psychological, and social services to a broad spectrum of patients. Treatment services may consist

of outpatient individual, group, family, or marriage counseling; drug therapies; and vocational,

social, and recreational services.

Medicare coverage for free-standing outpatient

clinic patients is provided for services such as drug

therapy, psychotherapy, and patient education

that are reasonable and necessary and provided

incident to a physician’s professional service (130).

Marital and family therapies are specifically excluded (131).

Day Care Hospitalization Programs

Day care is treatment provided by a facility in

which the patient does not reside. In day care hospitalization programs, patients participate in a

treatment program, with or without medication,

for usually 5 or more hours per day, 5 or more

days per week. Some of these treatment facilities

are especially geared to alcoholics, while others

serve a more general psychiatric population (216).

Day hospitalization programs per se are not

covered by Medicare, although individual services

provided in these programs maybe covered under

outpatient guidelines. Meals, transportation, and

recreational and social activities are not covered.

Intermediate Care

For this study, residential programs that provide primarily rehabilitation services to patients

are considered here to be intermediate care facilities (13). Many of the patients of such programs

have formerly been treated in hospitals. Such

facilities include halfway houses, quarterway

houses, and recovery homes. Typically, intermediate care facilities are community-based and peer

group-oriented residences. They attempt to provide food, shelter, and supportive services in a

nondrinking atmosphere. Residents in these programs are considered recovering alcoholics. They

are ambulatory and mentally competent. Typically, they are without spouse or immediate family.

The facility seems to provide psychological support and help with problems such as reentry to

the work force.

Other Settings

Alcoholism treatment services are provided to

varying degrees by correctional facilities, the military, driving while intoxicated programs, business

and industry, and the so-called skid-row system

of agencies (344). Various Federal and local government agencies support alcoholism treatment

programs in correctional and military facilities,

but the contribution of these programs to alcoholism treatment, as well as the contribution of employee assistance programs, is relatively small.

Most such programs serve only as referral sources

to the kinds of programs discussed previously and

do not provide direct treatment.
Ch. 3—Approaches to Alcoholism Treatment . 31

Utilization Table 3.—Estimated Treatment Utilization

Estimating the use of treatment settings is made

difficult by the multiple sources of data and by

the tendency of patients to seek and receive treatment in multiple settings, even over the course

of relatively short time periods. Until recently,

when authority for alcoholism treatment programs was given to States with Federal assistance

through block grants, each NIAAA-funded treatment center and each project were required to collect and report data on treatment utilization.

In 1980, 460 NIAAA-funded projects reported

serving almost 250,000 people (218). The vast majority (83 percent) of patients in NIAAA projects

received outpatient treatment, sometimes in conjunction with inpatient treatment. Of the patients

who received 24-hour residential care (some of

these patients also receive outpatient care), 3 percent were hospital inpatients and 23 percent were

in other facilities. The most common inpatient

treatment was detoxification, either social (41 percent) or medical (31 percent). The most common

outpatient service was individual counseling (5o

percent), followed by group counseling (21 percent) and crisis intervention (11 percent). Approximately one-quarter of the patients received followup or aftercare.

Estimates of the number of people receiving

treatment for alcoholism in other than NIAAAfunded projects during 1976 and 1977 have been

made by Vischi and colleagues (322). According

to their data (see table 3), the largest population

is served by AA programs. As noted above, however, data such as theirs are problematic, because

some patients may receive treatment through multiple sources (this is especially so for those participating in AA programs). Furthermore, to the extent that alcoholic patients are treated under other

diagnoses, these figures underestimate the problem of alcoholism. Not known is the number of

alcoholics who receive no treatment at all; estimates of that number are as high as 85 percent

of the total population of alcoholics (216).

Treatment Providers

Another major issue in the treatment of alcoholism concerns what kind of staff would be most

effective, and, more particularly, what degree of

Population served

NIAAA-funded projects. . . . . . . . . . . . . . . 197,000a

Other than NIAAA-funded projects:

Short-stay hospitals . . . . . . . . . . . . . . . 476,000

State and county mental hospitals. . . 111,000

Private mental hospitals. . . . . . . . . . . . 11,000

Drug abuse facilities. . . . . . . . . . . . . . . 17,000

Mental health facilities. . . . . . . . . . . . . 286,000

Private physicians’ offices . . . . . . . . . . 423,000

Community mental health centers . . . 113,000

Outpatient psychiatric clinics . . . . . . . 53,000

Halfway houses . . . . . . . . . . . . . . . . . . . 36,000

Veterans Administration. . . . . . . . . . . . 133,000

Department of Defense . . . . . . . . . . . . 52,000

Department of Transportation (DWI). . 28,000

Indian Health Service . . . . . . . . . . . . . . 27,000

Alcoholics Anonymous. . . . . . . . . . . . . 671,000

Total. . . . . . . . . . . . . . . . . . . . . . . . . . . 2,634,000

%he NIAAA data are for 1980, and the other data are for 1977,

SOURCE: T. R. Vischi, K. R. Jones, E. L. Shank, et al., The A/coho/, Drug Abuse,

and h4errta/ Health Data 8ook (Rockville, Md.: Alcohol, Drug Abuse, and

Mental Health Administration, 1980); and H. Dlesenhaus, “Current

Trends in Treatment Programing for Problem Drinkers and Alcoholics,”

in Prevent/on, Irrterventlon, and Treatment: Corrcerns and Models,

Alcohol and Health Monograph No. 3 (Rockville, Md.: National Institute

on Alcohol Abuse and Alcoholism, Alcohol, Drug Abuse, and Menntal

Health Administration, 19S2),

staff professionalization is required for treatment

effectiveness. Prior to the entry of the psychology

and psychiatry professionals in the 1970’s, roles

within the alcohol treatment work force were not

distinct. Most treatment took place in nonmedical

settings where alcoholism counselors served as

primary therapists, administrators, support staff,

advocates, and outreach workers. The entrance

of professionally trained personnel diminished the

role of alcoholism counselors. Physicians, psychiatrists, psychologists, and social workers took on

supervisory roles.

According to figures compiled by the National

Drug and Alcoholism Treatment Utilization Survey (cited by 54), the three largest general categories of workers in alcoholism treatment programs are administrative and support staff, counselors, and nurses. Further, counselors without

professional degrees comprise the largest single

category (17 percent) of direct service workers in

“alcohol only” programs. Alcoholism counselors

(degree unspecified) comprise 37 percent of the

project staff in NIAAA-funded treatment centers

(100). Although alcoholism counselors dominate

the field, their distribution varies greatly by treatment setting. Halfway houses and free-standing

clinics employ proportionately more counselors

98-820 0 - 83 - 6 : ql, 3
32 ● Health Twhnology Case Study 22: The Efkctiveness and Costs of Alcoholism Treatment

without professional degrees than do community

mental health centers. Hospital programs rely

primarily on medical staff (54).

Alcoholism counselors have objected to the

over-professionalization of the treatment process,

claiming that the “functional difference between

them and professionals is unclear because both

perform many of the same functions in the treatment process, ” although

CONCLUSIONS

The treatments used for

professionals get paid

alcoholism are diverse,

including treatments based on medical and psychotherapeutic approaches, as well as treatments

based on various other approaches, such as selfhelp programs based on the AA model. Most

treatment programs combine a variety of techniques. Adding to the complex number of treatments is the fact that the settings where treatment

is delivered differ from one another on a number

of key dimensions, including outpatient versus inpatient treatments, staffing patterns, and the kinds

of populations who choose or are chosen for the

setting. Moreover, alcohol abuse is present in various population groups, although it may manifest

more (54). In addition, from the view of counselors who are themselves recovering alcoholics, professionalization actually threatens the potential

success of alcoholism services, the key ingredient

of which is self-help. There is little empirical

evidence, however, to settle the issue of the relative success rate of the various occupational

groups in the treatment of alcoholics.

itself differently and require different forms of

treatment.

In comparing reviews and studies of alcohol

treatment programs, this complexity of etiology,

treatment, settings, and patients must be kept in

mind. Many studies focus on a single aspect of

treatment or explore a particular hypothesis, making comparisons between studies extremely difficult. General statements must be offered with

great caution. The methodological issues underlying evaluation of treatment programs are reviewed in the next chapter,
Methodological Issues

Evaluating the Effectiveness ,-. -

4.

■m

of

AlcohoIism Treatment
4

Methodological Issues in Evaluating the

Effectiveness of Alcoholism Treatment

The development of a body of research on alcoholism treatment is fairly recent, having occurred

mainly during the past 20 yearn. Until the 1950’s,

treatment for alcoholism was more likely to have

been incarceration or custodial care in State mental hospitals than to have been medical or psychological therapy (cf. 325). Thus, the lag in the

development of a scientific research base is not

surprising.

Even today, despite the rapid growth of a formal treatment system, evidence of treatment effectiveness’ is often based on unsystematically collected data (46,76,135,297). Because of the limitations of available research, conclusions about the

effectiveness of treatment for alcoholism are necessarily limited, although some tentative conclusions can be drawn. Such conclusions are presented in chapter 5. The present chapter analyzes

the methodological problems in conducting and

● Effectiveness is the benefit as measured under average conditions

of use (229). Efficacy is the health benefit as measured under controlled conditions such as those in a randomized clinical trial.

TREATMENT DESIGN

Treatment design issues involve the extent to

which clarity about the “active ingredients” of the

program being tested can be achieved. Questions

such as whether the program involves a single

treatment, a combination of treatments, or a combination of treatment and nontreatment factors

must be answered. Often, because alcoholism

treatment programs are multivariant, researchers

are unable to identify separate effects (18,317).

The extent to which researchers can measure the

impact of any one component of the treatment

is limited, of course, when all patients receive or

have access to multiple components concurrently. Clarity about what the program includes is

essential for attributing outcomes to particular

treatments or treatment packages.

analyzing alcoholism treatment research. The goal

in this chapter is to place the current state of scientific knowledge about treatment alternatives into

a research perspective.

Because patient characteristics, treatment settings, services offered, and practitioner characteristics interact to affect treatment outcome, research on alcoholism treatment is complicated.

The evaluation issues, however, are parallel to

those involved in assessing other health care interventions (see, 226,227,229).

In assessing the quality of research conducted

on alcoholism treatment effectiveness, the validity

of the research evidence and the ability to generalize from it will be emphasized (229,350). For

research to be valid and permit generalizations to

be drawn, there must be clarity about what is

being tested, what is being compared, which subject populations are involved in the research, and

what is being measured. Operationally, these four

factors refer to: 1) treatment design, 2) research

design, 3) sampling, and 4) outcome measures.

One solution to these problems is to group

treatments in such a way as to be able to form

treatment packages. Few would argue that a single

treatment (e.g., psychotherapy) could alone reduce alcoholism problems (cf. 241). A single patient, especially when hospitalized or in a residential setting, may receive group therapy, antidepressants, and attend sessions of Alcoholics

Anonymous (AA). There are various problems

in analyzing treatment groupings, however.

Lumping treatment programs under umbrella

terms such as “inpatient” or “outpatient,” without

clarifying which specific services are offered or

utilized, may obscure differences between treatment components. By lumping multiple treatment

programs together, one is unable to decipher

35
36 ● Health Technology Case Study 22: The Effectiveness and Costs of Alcoholism Treatment

which treatment is effective, for whom, and under

what conditions (cf. 306).

Furthermore, even if coherent treatment packages can be developed, they may be difficult or

undesirable to administer. This is particularly

problematic if assignment of patients to treatment

packages or components is required for research

purposes. A research design that requires systematic assignment of treatment or segregation of

services might undermine a basic treatment principle—that of involving patients in decisionmaking (306). Such research-based assignment criteria may also be troublesome for practitioners

who, on the basis of clinical criteria, may want

to control treatment regimens.

RESEARCH DESIGN

A valid research design requires systematic

comparisons. At minimum, the comparisons must

involve a single group of patients measured before

and after treatment. Optimally, they will involve

two or more randomly assigned groups (an experimental group and a comparison or control

group) of patients who are tested before and after

treatment (see 350). The latter design is usually

called a “true” experiment (67), or in health care

research, a randomized clinical trial (RCT). RCTS

are considered the most definitive experimental

method for evaluating the efficacy or health benefits of a technology (229). The advantage of this

design, in comparison to a nonrandom design, is

that it allows differences in outcomes to be attributed more confidently to the treatment, and not

to preexisting differences in the samples tested.

Evaluating research on the effectiveness of alcoholism treatment poses several difficulties for researchers interested in valid conclusions. Comparative data on treatment groups are typically not

available, and most research merely tracks patients during and after treatment (135,189,297).

For example, one study documented a 38-percent

abstinence record at a l-year followup for problem drinkers who received treatment at a 4-week

residential treatment center (see 16). In the absence

of comparative data—e.g., on individuals who

did not receive treatment or who received alterThe alcoholism field is rife with intense feelings

about treatment effectiveness and safety. Individual clinicians can cite examples of patients who

have faced death, high economic costs, or health

problems because of irresponsible treatments.

Practitioners often have intense opinions, convictions, and reservations about the use of particular

treatments. Putting treatments to the test, limiting

the treatments available, withholding services, or

providing treatments presumed ineffective will be

resisted by many practitioners (46,47,189). Thus,

practitioners have had, and will continue to have,

a strong influence on the type of effectiveness research conducted.

native treatments—it is not possible to determine

if the observed 38-percent abstinence rate represents natural improvement or if a higher or lower

abstinence rate would have resulted from another

type of treatment.

Although the absence of comparative data is

the most fundamental deficit of the literature on

the effectiveness of alcoholism treatment (16,317),

other methodological problems also limit the implications that can be drawn. First, data are often

presented in aggregate form-i.e., data on patient

outcomes are often not differentiated by severity

of initial symptoms or other patient characteristics. Social class information may be lacking, and

important subpopulation differences may be obscured. In a study that does provide such sociodemographic breakdowns, patients treated at the

Raleigh Hills Fair Oaks Hospital in California

were reported (221) to have had l-year abstinence

rates that ranged from 36 percent (for Medicareeligible disabled patients) to 73 percent (for married, employed patients). Age, gender, and social

situation seem to affect significantly treatment

effectiveness.

A related issue is that multivariate analyses that

are useful for examining differences by factors

such as age, race/ethnicity, social class, employment status, sex, and disability are typically un-
Ch. 4—Methodological Lssues in Evaluating the Effectiveness of Alcoholism Treatment ● 37

available (cf.77). Although there are several important exceptions, including a study by Armor

and colleagues (13), studies that statistically control outcome data by demographic or other factors have not been conducted with many treatments. Such analyses present difficulties both in

data collection and analysis and require large patient populations. The lack of controlled research

hinders informed development of treatment strategies tailored to the needs of subpopulations.

Despite the methodological problems just discussed, alcoholism treatment researchers seek to

SAMPLING

Sampling refers to decisions concerning the subjects selected for research. Issues of sampling concern: 1) eligibility for treatment, 2) selection for

participation in research, and 3) availability for

followup research. If the general population of alcoholics is not represented in the research samples, or if certain groups (e.g., working class

adults or women; cf. 18) are underrepresented,

the ability to generalize from research findings is

limited.

Perhaps the most important sampling problem

is that individuals who receive treatment services

cannot be assumed to form a representative group

of problem drinkers (18). Many programs explicitly exclude those patients who have poor prognoses for recovery-particularly those from lower

income groups and/or the unemployed. Even

without exclusion criteria, individuals who elect

treatment undoubtedly differ from those who do

not (46,135). Those who receive treatment may

be more visible (hence, their referral to treatment),

more socially connected to others (who encourage

treatment seeking), more motivated (and so seek

treatment), and more confident of success (willing to undergo treatment). It is also possible that

those who seek treatment see themselves as more

helpless (and thus reliant on others for assistance),

more intrusive (and so referred more readily into

treatment), more troublesome (and, perhaps,

pushed into treatment), or more abusive (and so

more likely to be mandated into treatment). The

absence of data on alcohol abusers who do not

generate systematic, experimental designs with

comparison group information and multiple, longitudinal outcome measures. Practical dilemmas,

however, may undermine this aim. For example,

random assignment of patients to conditions does

not ensure that patients will accept their assigned

treatment, nor that they will remain in treatment

(18), although, in some cases, acceptance of or

dropping out of treatment is a useful outcome

measure.

seek treatment limits the ability to generalize and

the establishment of realistic spontaneous remission rates (see 290,315).

Sampling biases involve not only who constitutes the client population, but who is available

for and willing to be involved in research, especially in the case of research that involves followup and long-term commitment to a research project (cf. 18,189,272). The probability of obtaining

a representative population of alcoholics in treatment and not in treatment is remote.

Even if one were to obtain a representative population of alcoholics or problem drinkers, differences remain in terms of which patients receive

different treatments, which patients are available

for research, and which patients can be followed

up on. Mandell (189), among others, has demonstrated that middle- and upper-middle-class patients are more likely to receive treatments covered by private insurance policies and to be referred by employers. Lower-class alcoholics, in

contrast, are more likely to receive services paid

for by State and local governments. Although the

evidence is not clear cut, there appear to be differences in what types of treatments are received by

each of these groups. If, indeed, different kinds

of patient groups receive different kinds of services, merely comparing the outcomes will convey

little about the treatments’ effects across patient

populations.
38 ● Health Technology Case Study 22: The Efkctiveness and Costs of Alcoholism Treatment

Who is available for followup, and how that alcoholics who remain in treatment (and it is reaaffects the results of outcome studies, is a prob- sonable to assume that there are), followup data

Iem that has plagued much outcome research. As are limited to an understanding of those who reBaekeland, Lundwall, and Kissin (18) point out, main in treatment. There is some evidence that

mortality rates for alcoholics are high. Alcoholics those who are difficult to follow up have the

drop out, disappear, and reject treatment at nu- poorest treatment outcomes (204), although conmerous points throughout the process. If there are trary evidence is also available (cf. 250).

systematic differences between dropouts and those

OUTCOME MEASURES

Finally, the way in which treatment outcomes

are measured significantly affects the interpretation of alcoholism treatment research. Studies of

alcoholism treatment often use indirect outcomes

or a combination of outcome measures. Others

may measure the same effect differently. Selfreports on drinking behavior, interviews with

spouses, supervisor-based job productivity reports, blood-alcohol levels, psychological improvement, or even recorded attendance at a

treatment center may be used as outcome measures. The degree to which different studies use different conceptual outcomes, operational outcomes, and measurement techniques limits the

comparisons that can be made about treatments.

Much of the discussion about outcome measures has focused on self-reports. Self-reports are

often believed to be low in accuracy (96). Alcoholics may deny that they have a problem (351),

the alcohol may have affected their memory (25),

and, in general, it is socially undesirable to report

alcohol intake. Reporting high use may affect the

patient’s job and self-esteem, or maybe perceived

as unhelpful to the researcher (cf. 18). However,

despite sound reasons why self-reports should

yield unreliable results, a number of studies report

high concordance between self-reports of use-and

physiological measures (112,250), although physiological measures may be less-than-valid indicators (160).

Controversy over what should be the measure

of successful outcomes in treating alcohol problems has not really been resolved. The criteria of

abstinence from alcohol use has, traditionally,

been used as the single measure of treatment effectiveness. Some studies have also measured various

behaviors related to drinking—e.g., frequency of

drinking, number of ounces of alcohol ingested,

number of binges, days of abstinence, number of

relapses, and percentages of days without alcoholrelated problems. More recently, other outcome

measums, such as work adjustment, family adjustment, problems with the law, psychological wellbeing, and continuation of treatment, have been

utilized. Physical health has been another important criterion and relates importantly to cost-benefit assessments of treatment (see ch. 6).

A major debate in recent years has focused on

whether “controlled drinking” or “nonproblem

drinking” can be considered a successful outcome

of alcohol treatment (cf. 132). Sobell and Sobell

(302), in particular, challenge the unitary view

that alcoholism is a single syndrome whose treatment goal is abstinence (cf. 245). They argue that

the exclusive use of abstinence as the outcome obscures partial improvement, neglects improvements in other areas of life functioning, is difficult

to validate, and represents a narrow understanding of the multifaceted alcoholism syndrome. As

described in chapter 5, however, the view that

controlled drinking is the desirable outcome of

treatment has been challenged by data indicating

that the ability to learn “controlled drinking” is

unrelated to long-term remission (246).

Pattison (237) and Gerard, Saenger, and Wile

(113) present data indicating that abstinence does

not necessarily result in improvement in an alcoholic’s problems. In some cases, once abstinence

is achieved, problems in other areas increase. The

meaning of such outcome assessments is not clear.

It may reflect either longstanding health problems

or relapse. Emrick (94) reviewed 265 alcohol treat-
Ch. 4—Methodological Issues in Evaluating the Effectiveness of Alcoholism Treatment ● 39

ment studies to test the relationship of drinking The solution to these methodological problems

to other outcome measures. He found that in more would seem to be multidimensional measurements

than two-thirds of the cases, drinking outcome of outcome. Indeed, such a recommendation is

related positively to outcomes in other dimen- strongly encouraged by recent methodological

sions. reviews (47,102,297).

CONCLUSIONS

Conducting outcome evaluation research on al- urement. Nevertheless, the “whole” of available

coholism treatments is difficult. Since these diffi- research on alcoholism is probably greater than

culties are reflected in current evaluations of the the sum of its parts. By carefully considering the

alcoholism problem, many presently urgent policy results of individual studies, each of which handles

questions can probably not be answered by avail- somewhat different methodological problems,

able research. Much of this research is flawed by conclusions can be drawn from the substantial

problems in design, sampling, or outcome meas- body of literature.
5

Research on the Effectiveness

of Alcoholism Treatment
5.

Research on the Effectiveness

of Alcoholism Treatment

Despite the lack of well-controlled and generalizable research on the efficacy and effectiveness

of treatments for alcoholism, there is a vast literature that describes and analyzes treatment effects.

The literature goes back as many years as alcoholism and alcohol abuse have been problems (see

351). In recent years, the amount of work has

dramatically increased and its quality has improved (cf. 32,297). In this chapter, the research

literature on treatment effectiveness is reviewed.

An effort is made not to dismiss any body of research, but to point out inherent limitations and

inferential problems. In addition to providing

background for congressional consideration of reimbursement policies, the present review strongly suggests that consideration should be given to

ways of increasing and improving research conducted on alcoholism.

In the following section, several of the principal

reviews of available literature are described and

analyzed. These reviews cover much of the research available (except recent and ongoing studies) and summarize current wisdom about alcoholism treatments. In the succeeding section, specific

studies related to particular treatment settings and

modalities are analyzed.

REVIEWS OF EFFECTIVENESS RESEARCH

As the literature on the effects of alcoholism

treatment has developed, a number of investigators have attempted to review and summarize research evidence. Recently, the number of such

reviews has increased, and while the reviews generally arrive at similar conclusions, each focuses

on a somewhat different literature base and applies a different analytical focus. In selecting

reviews for discussion here, an effort was made

to include prominent reviews that assess the literature most comprehensively.

Voegtlin and Lemere

In the earliest comprehensive review of treatment effectiveness, Voegdin and Lemere (325)

considered over 100 studies that appeared in the

literature between 1.909 and 1940. Their review

separated psychological from physiological treatments for alcoholism and included within each

category many treatments that today would not

be considered formal psychological or medical

treatments. For example, incarceration was considered a crude psychological treatment; unscientifically based therapies, such as dietary restrictions on salt and water, were categorized as physiological.

Voegtlin and Lemere concluded that poor “statistical” evidence existed and that none of the

treatments then available for alcoholism had

proven effective. In a systematic review of each

treatment modality, however, they did suggest

that some techniques showed good effects and appeared promising. Among these were treatments

such as inpatient psychotherapy and certain drug

therapies. What seems clear from Voegtlin and

Lemere’s review, and has been partially supported

by later reviews, is that treatments for alcoholism

are differentially effective for particular populations and that treatments offered in combination

seem more effective.

Emrick

Emrick’s (93,94,95) reviews of treatment effectiveness research which appeared initially in 1974

and 1975, although not the first work to appear

43
44 ● Health Technology Case Study 22: The Effectiveness and Costs of Alcoholism Treatment

subsequent to Voegtlin and Lemere’s review are

important because of their emphases on methodologically acceptable studies. (Hill and Blanc’s

earlier review in 1967 of psychotherapeutic methods of treating alcoholics (135; see 32) found that

only 2 out of 49 available studies met minimum

methodological standards. In each of Emrick’s

reports, the goal was to review research conclusions comprehensively as to effective treatment.

In 1974, Emrick (94) reviewed 271 reports found

in the alcoholism literature published between

1952 and 1971. He noted that 67 percent of the

13,817 patients in these studies either improved

or were abstinent at followup. Emrick’s conclusion was that “once an alcoholic has decided to

do something about his drinking and accepts help,

he stands a good chance of improving.” Emrick

cautioned, however, that no evidence documents

that one treatment modality is more effective than

another. “The weight of present evidence, ” he

wrote, “is overwhelmingly against technique variables being powerful determinants of long-term

outcome.” Although Emrick seemed to indicate

that many alcoholics can stop drinking with minimal or no treatment, and that abstinence rates

do not differ between untreated and minimally

treated alcoholics, he also maintained that rate

of improvement correlates positively with amount

of treatment received: 4.2 percent of alcoholics improved with little or no treatment, and 63 percent improved with treatment.

An update (9s) of Emrick’s original review

added 126 studies of “psychologically oriented”

treatments for alcoholism to those studies previously reviewed. The focus of this review was

primarily on the effects of treatment versus those

of no treatment. However, the results are difficult

to interpret because there were relatively few

studies with no-treatment conditions and because

patient characteristics were not controlled. Emrick

also included a group of studies with minimal

treatments (fewer than five outpatient visits or

2-weeks’ inpatient treatment). He found no significant differences in either abstinence or improvement rates between the no- and minimal-treatment

studies (13 and 21 percent abstinent, respectively, and 41 and 43 percent at least somewhat improved, respectively). He did, however, find that

more than minimal treatment had an effect on abstinence and improvement rates. Twenty-eight

percent of those with more than minimal treatment were abstinent, and 63.1 percent were improved after 6 months or more after treatment.

It appears that, as Emrick stated, treatment “seems

to increase an alcoholic’s chances of at least reducing his [or her] problem. ”

Emrick’s last review (93), published in 1979, focused exclusively on randomized clinical trials of

alcoholism treatment. Such studies deal with the

most significant confounding factor in alcoholism

research—the biases that occur when patients

select their own particular forms of treatment.

Emrick documented 90 studies that used random

assignment of patients to two or more treatments.

Almost all studies he reviewed compared treatments to one another, rather than to “no treatmerit. ” In general, Emrick was able to distinguish

few differences. There seemed to be more evidence

of the efficacy of behavioral approaches (including

aversion training and systematic desensitization).

For nonbehavioral approaches (including inpatient treatment and outpatient psychotherapy),

brief interventions were as successful as longer

ones.

Although it might be concluded from Emrick’s

reviews that treatment for alcoholism is neither

efficacious nor effective, the limits of the research

considered in his analyses should be recognized.

In particular, the review of randomized clinical

trials of treatment is limited by the fact that the

studies tended to be behavioral studies with very

specific objectives. What is clear is that experimental clinical research was not available at the time

of Emrick’s reviews to answer the questions about

treatment efficacy.

Baekeland, Lundwall, and Kissin

Shortly after Emrick’s initial work appeared in

1974, Baekeland, Lundwall, and Kissin (18; see

also 16) reviewed the state of knowledge about

the effectiveness of particular treatments for

alcoholism. Their comprehensive review analyzed

research evidence for each of the treatment modalities then in use. They separately reviewed inpatient and outpatient treatments (although these

were not independent categories) along with psy -
——

Ch. 5—Research on the Effectiveness of Alcoholism Treatment “ 45

chotherapeutic, drug, and sociocultural treatments.

Their substantive conclusions are difficult to

summarize. For each of the settings and treatment

modalities, some evidence of successful outcome

was found. For example, the investigators’ analysis of 30 studies of inpatient treatment for alcoholism indicated improvement rates of almost 50

percent. When corrected for attrition from the

study sample and spontaneous remission, however, the improvement rates were somewhat lower, approximately 30 percent. In comparing inpatient treatment with outpatient care, Baekeland

and colleagues’ conclusion was similar to Emrick’s

(94,95): although methodological caveats apply,

research does not demonstrate that inpatient care

offers greater likelihood of successful treatment

than outpatient treatment.

One problem identified was that characteristics

of the patient, rather than the treatment, seemed

to affect outcome importantly. The issue is complex because one of the central differences between

patients may be their persistence in continuing

treatment. Patients with stable marital and occupational status and higher socioeconomic status

have better outcomes in that they are both better

able to help themselves and respond better to

treatment.

It is also clear from the Baekeland reviews that

there are considerable differences as to who receives or takes advantage of particular treatments.

One example is Alcoholics Anonymous (AA). According to Baekeland and colleagues, the large

membership AA has attracted is not representative of alcoholics. For various reasons, there are

many alcoholics for whom the program is not a

good option. The question, then, is whether AA’s

reported effectiveness is really a function of selfselection by potential members

noses.

Costello

Another systematic review

with the best progof the alcoholism

treatment and evaluation literature, by Costello

(71,72,73), appeared in 1975. In his first report

(71), Costello analyzed the results of 58 treatment

evaluations published between 1951 and 1973. A

followup report (72) separately analyzed 23 of

these studies that had the longest term followup

(2 years). In a 1977 update (74) of this research

base, 22 additional studies representing more recent approaches were located and compared to

the original set. Costello’s approach is similar to

that of other contemporary reviewers: although

he does not conduct a formal synthesis (350), his

goal is to compare systematically the results of

available investigations.

Costello rated studies according to outcome and

tried to determine if differences in the characteristics of the treatment programs were related

to the outcomes (71,72). Studies were grouped in

five categories, from best to poorest, on the basis

of both the percentage of successful abstainers and

the percentage of problem drinkers. The average

percentages, in Costello’s initial analysis, varied

from 12 percent successes and 60 percent problems

to 45 percent successes and 44 percent problems.

The percentage of patients who were lost to folIowup or who died were kept separately.

The findings, which were consistent for both

the initial and later samples, indicated that small

programs using a variety of intensive techniques

(e.g., inpatient care, drugs, psychotherapy) were

most successful. The findings were ambiguous,

however, and it was also the case that programs

using stringent patient selection criteria were most

successful. Although it might be viewed that the

research was designed to achieve the best outcomes, this finding may also demonstrate the

value of providing intensive therapy only when

it has a reasonable chance of success. Like other

reviewers, Costello found that patients with

characteristics such as stable marital and occupational status were more likely to benefit from

treatment.

Costello’s 1977 update (74) of his 1975 work

further validated his initial conclusions. Although

a very small increase in successful outcomes and

reduction in problem drinking can be detected

overall, the range of outcomes is about the same.

This suggests that over a relatively long period

of time approximately 45 percent of patients in

good treatment programs can be expected to

maintain sobriety (to drink without problems),

and an almost similar rate of patients can be expected to have relapses. It is difficult to know how

to interpret these rates. Compared with treatment
. .

46 ● Health Techno]ogy Case Study 22: The Effectiveness and Costs of Alcoholism Treatment

success rates for some terminal illnesses, the success rates are good; when viewed against spontaneous remission rates of perhaps 30 percent,

they appear less promising. A key question is to

what extent the outcome of treatment for alcoholism is determined by patient characteristics.

Rand Studies

The so-called Rand studies, which first appeared in 1976 and 1980 and have been a focal

point of debate and policy about alcoholism treatment, are not actually reviews of the alcoholism

literature. The studies represent followups at 6 and

18 months (13) and 4 years (250) of patients

treated at the National Institute on Alcohol Abuse

and Alcoholism (NIAAA) Alcoholism Treatment

Centers (ATCS). The importance of the Rand

studies is that they followed a large sample of

alcoholic patients, who received a wide variety

of treatments, and systematically assessed their

patterns of drinking.

In the initial study (13), a research team headed

by Armor and colleagues considered data from

almost 2,000 patients treated at eight ATCS. The

investigators analyzed data at 6 and 18 months

after treatment. At the 6-month followup, 68 percent of patients completing treatment showed improvements in their drinking behavior. At the

18-month followup, the results were similar (67

percent showed improvement): 24 percent had

been abstinent for at least 6 months, 21 percent

had been abstinent for 1 month, and the remaining 22 percent were characterized as normal drinkers. Patients were considered to be in remission

if they either abstained from drinking or engaged

in normal drinking (moderate quantities without

signs of impairment). By this criterion, 68 percent

of NIA&l patients were in remission at 6 months

and 67 percent at 18 months; furthermore, relapse

rates did not seem related to ability to abstain.

Fifty-three percent of clients who made only a

single contact with an ATC (the “untreated” population) were in remission.

The Rand studies generated intense controversy

(see, e.g., 96,213,267) because they suggested that

it was not necessary that abstinence be the central treatment goal of alcoholism therapies. Critiques of the Rand analyses indicated that the data

were not valid for several reasons: the ATC sites

were not randomly selected; about 80 percent of

the patients were lost to followup; the report relied

on self-reports; and the criteria for normal drinking were not stringent enough. The investigators

countered by presenting data indicating that the

patients lost to followup were not different from

those for whom data were available and that the

self-reports were valid. In addition, the use of

more stringent definitions of impairment would

have reduced the proportion of normal drinkers

from 22 percent to, at most, 17 percent.

In a followup to the initial survey (250), Rand

researchers (led by Polich and colleagues) collected and analyzed data from a random sample

of over 900 patients from the first study. Followup

interview data were obtained from 85 percent of

the sample. An analysis of effects of nonresponse

and sample bias seemed to indicate little distortion. Separate validity checks were conducted on

self-report data by having a random subsample

of participants take breath tests to evaluate their

blood alcohol concentration. In addition, family

members were interviewed. Finally, more stringent, empirically based definitions of normal

drinking were used. These checks yielded high

correlations between self-reports and physiological measures, although the results for reports

by significant others* were unclear. Most importantly, adjustments for overreporting “no problems” seemed to make little difference in the outcome rates reported without correction.

The principal finding of the subsequent Rand

analyses was that although a large percentage of

alcoholics go into remission for periods of time,

a substantial proportion relapse and reenter treatment. Only 7 percent of the total sample abstained

throughout the entire 4-year period, and nearly

15 percent died (mortality was 2.5 times what

would have been expected). Nonetheless, there

was a significant decrease in the percentage of individuals with very serious alcoholism problems.

At initial treatment, over 90 percent were drinking with serious problems according to NIAAA

criteria, whereas after 4 years, only 54 percent

were drinking with serious problems. The policy

*Significant others are individuals important to the alcoholic. They

can be friends or family.
Ch. 5—Research on the Effectiveness of Alcoholism Treatment 47

significance of this reduction is difficult to deter- method in particular seemed to achieve consistentmine. The results may be due to individuals enter- ly positive results. Although there are a number

ing treatment at the worst phase of their problem of diverse treatments that appear to have positive

(for these individuals, some improvement would effects, it is difficult to draw clear conclusions in

be expected). Improvement may also not be di- the absence of random assignment and deliberate

rectly attributable to treatment. No treatment treatment-patient matches.

STUDIES OF TREATMENT SETTINGS AND SPECIFIC MODALITIES

The above reviews suggest a need for providing

various treatments for alcoholism, although evidence on the superiority of particular treatments

is lacking. The important policy issue—i. e., the

extent to which alcoholism treatment should be

supported—is thus only partially addressed. The

question of which treatments have the best demonstrated effectiveness under particular conditions

for which patients remains unanswered. Below,

additional evaluative research on a number of

specific treatments and settings is reviewed. Both

the setting of treatment (most importantly, inpatient v. outpatient) is considered and the use of

treatment modalities such as psychotherapy,

drugs (including chemical aversion therapy), and

self-help treatments (AA) are considered. Although not a comprehensive review, the discussion covers treatments that are the most frequently

employed and are the current focal points of discussion about alcoholism treatment.

Setting

Perhaps the most controversial treatment issue

concerns the use of inpatient v. outpatient treatment settings. The necessity for hospitalizing alcoholics—i.e., for providing treatment over and

above that necessary for detoxification or dealing with medical complications of ethanol use, is

both a substantive problem (relating to treatment

goals and effectiveness) and a significant policy

problem (because of the high costs associated with

hospitalization). Unfortunately, assessments of the

effectiveness of particular settings are difficult to

separate from the effectiveness of treatment modalities. The setting of treatment is only one factor influencing treatment effectiveness. The review

below deals with research comparing outcomes

by setting, although a more complete analysis requires parallel consideration of evaluative data

for specific modalities.

There seems to be consensus across a number

of literature reviews that inpatient treatment is not

superior to outpatient care for alcoholism (cf. 92),

but most of the available research is flawed because the effects of treatment variables cannot be

distinguished from the effects of patient variables.

Thus, more severely impaired patients and those

of higher socioeconomic status are more typically

assigned to, or arrange to receive, inpatient treatment. Furthermore, a distinction is not often made

between hospital- and non-hospital-based inpatient (i.e., residential) treatment, although the

nature of such settings maybe very different (317).

Not making this distinction results in the aggregating of results from different types of inpatient

settings in literature reviews. Because alcoholism

treatment takes place in a variety of hospital settings it may be important to distinguish between

their effects.

Several studies have specifically addressed the

question of inpatient v. outpatient efficacy or effectiveness. Reviews by Costello (71,72,73) and

Baekeland (16) addressed the inpatient-outpatient

issue, and the Rand analyses (13,250) compared

inpatient and outpatient care. The reviews and

studies on which the the reviews’ conclusions are

based are discussed below. Length of treatment

as an outcome variable is also discussed.

Ritson

Ritson (263,264) looked at 6-month and l-year

outcomes in two groups of patients. He found no

significant group differences between the group

that received outpatient care (individual therapy)

and the one that received inpatient treatment
48 ● Health Technology Case Study 22: The Effectiveness and Costs of Alcoholism Treatment

(group therapy and AA). However, as apparent,

this study confounded treatment modalities with

settings. In addition, patients were probably not

randomly assigned to experimental groups.

Edwards; Edwards and Guthrie

A series of studies by Edwards and colleagues

(87,88,89,90) has been well received critically,

because Edwards and his associates randomly assigned socially stable patients to different settings

for the same treatment modalities. Well-matched

patients were randomly assigned to either 2

months of “intensive” outpatient care followed by

outpatient aftercare or to 8.9 weeks of inpatient

treatment followed by outpatient aftercare.

Outpatient care was found to be more efficacious with regard to global ratings but not until

12 months after treatment. The populations differed somewhat in marital status (80 percent of

the outpatients were married v. 60 percent of the

inpatients), although the differences were probably of no consequence. The findings are limited

by the exclusion of some treatment modalities

(e.g., group therapy) and of alcoholics with severe

mental or physical disease.

Wanberg, Horn, and Fairchild

In apparent contradiction to Edwards’ results,

Wanberg and colleagues (33o) found 2 weeks of

intensive inpatient treatment to be more effective

with respect to drinking indexes 90 to 100 days

after intake than three or more in-community

treatment sessions. In this study, both types of

initial treatment were followed by outpatient

group therapy. The study differed from the Edwards studies in that S1 percent of its patients were

married and the length of both intensive treatment

and evaluation in this study were longer. In addition, outpatient treatment in the Edwards studies was intensive. It is possible that any short-term

differences between the Wanberg groups might

have disappeared or changed direction at a later

point in time.

Gallant

Gallant (107) investigated a population of

chronic offenders brought before a municipal

court. Individuals convicted of an alcohol-related

offense were randomly assigned to either 1 month

of coerced inpatient treatment followed by s

months of coerced outpatient treatment or 6

months of coerced outpatient treatment. Gallant

found no differences between the inpatient and

outpatient groups on outcome measures related

to alcohol use; however, 44 percent of the offenders assigned to inpatient care received necessary medical attention.

Baekeland

Baekeland’s (16) review analyzed improvement

rates and found that uncorrected improvement

rates were essentially the same for inpatient and

outpatient settings (41.5 percent). When the rates

were corrected for sample attrition and spontaneous improvement, however, outpatient settings

(with an average improvement rate of 36 percent)

were slightly more effective than inpatient settings

(with an improvement rate of 29.9 percent).

Costello

Costello’s report (71,72) which used the statistical technique of cluster analysis to discover

the distinctions between studies reporting outcomes of very good, good, intermediate, poor,

and very poor concluded, on the other hand, that

the inpatient unit was a valuable asset to a treatment program. However, it also concluded that

an inpatient setting without an intensive community milieu and aggressive outpatient followup

would be of limited value.

Ten of the studies characterized as having very

good outcomes combined inpatient with outpatient treatment; two used outpatient only, and

two, inpatient only. The studies reporting very

good outcomes were also characterized by a variety of other characteristics associated with good

outcomes: the use of screening procedures that

eliminated high-risk clients, considerable use of

Antabuse @ or its equivalent, social casework,

family therapy, involvement of employers, and

behavioral therapy.

Costello’s analysis is limited by the inclusion

of both controlled and noncontrolled evaluation

studies (cf. 18, for a discussion of these limitations). The previously discussed Edwards (88), Edwards and Guthrie (90), and Ritson (263,264)
—

Ch. 5—Research on the Effectiveness of Alcoholism Treatment 49

studies were included in the group with very good

outcomes.

Rand Studies

The 18-month followup study of patients

treated at NIAAA ATCS by Armor and colleagues’ (initial Rand analyses, 13) found only

minor variations in outcomes among hospital, intermediate, and outpatient settings. Furthermore,

these variations virtually disappeared when the

analysis controlled for client characteristics. The

4-year followup by Polich and colleagues’ (subsequent Rand analyses, 250) found no differences

between outcomes for hospital and outpatient

settings.

In the Polich analysis, intermediate care was

combined with outpatient care. The Polich analysis found a positive correlation between the

amount of treatment and the followup status in

outpatient (but not inpatient) settings. The authors hesitated to attribute these differences to the

impact of the outpatient setting because of the

possibility that patient sdection phenomena might

have been responsible for the relationship. Better motivated patients might have remained in

treatment longer, or more favorable treatment environments might have encouraged more promising patients to stay in treatment. The authors were

unable to test this possibility with the data available.

Emrick

In general, according to Emrick (92), controlled

studies of psychotherapeutic treatments have not

found any positive effects for lengthy intensive

treatment either on an inpatient or outpatient

basis. An important methodological limitation of

available controlled studies, however, is that none

of these studies used an intensive treatment longer

than 3.5 months of inpatient care; all of these

studies used relatively brief treatments. The effects of long-term efforts, some of which are

oriented to making character changes, have not

been evaluated. In addition, research subjects who

receive differing amounts of treatment typically

receive different kinds of treatment as well, making it difficult to distinguish the type of therapy

from its intensity or duration.

Behavioral Therapies

In the last 20 years, the most developed uses

of psychotherapy for alcoholism problems have

been in the application of behavioral conditioning techniques (see 208). Most behavioral therapies rely on positive reinforcement, cognitive

change, and the development of new skills, although aversion conditioning is also employed

(see below). Behavioral techniques, as described

in chapter 3, include blood alcohol level discrimination training, use of videotapes of patients when

intoxicated, role playing, cognitive behavior therapy, and alternatives counseling. Some researchers have combined these approaches into treatment packages and have attempted to individualize the treatments to meet specific patient needs.

There has been some research interest about these

broad-spectrum approaches. Three of the most

important research efforts are reviewed below.

Individualized Behavior Therapy for Alcoholics

A treatment program called the Individualized

Behavior Therapy for Alcoholics (IBTA) was developed by Sobell and Sobell (298,301,302) and

has been extensively tested by the program designers. Their findings indicated that regardless

of whether the assigned treatment goal was “abstinence” or “controlled drinking, ” many of the

patients who received treatment were drinking in

a nonproblematic way compared to the patients

in a control group. The investigators also found,

ironically, that those patients who were assigned

“controlled drinking” as a goal had more abstinent days than those assigned “abstinence. ”

Another important aspect of this study was that

the package prescribed a thorough analysis of

each individual’s behavioral determinants for

drinking. A new repertoire of social behavior,

designed to replace the old behavioral patterns,

was carefully rehearsed. Changing attitudes toward drinking was a second major focus. Sobell

and Sobell reported successful outcomes with

IBTA (302).

Sobell and Sobell’s research on the IBTA has

been criticized because it used the treatment goal

of “controlled drinking;” recently, serious ques--

tions have been raised about the appropriateness

of this research method and its conclusions. A
50 ● Health Technology Case Study 22: The Effeciveness and Costs of Alcoholism Treatment

followup study by Pendery, Maltzman, and West

(246) of patients in the controlled drinking condition of the Sobell and Sobell 1972 study sharply contradicts the original study’s findings.

Pendery and associates report that after 10 years,

only 1 of 20 subjects was drinking “normally” and

without problems. Four of the original subjects

had died of alcohol-related causes, eight were

drinking excessively, one was not found for followup, and six were totally abstinent (although

each had had serious drinking problems since the

experiment). According to Pendery and associates, learning how to control drinking maybe impossible for an alcoholic, and abstinence is the

only workable treatment goal.

Three recent studies by Vogler and colleagues

(326,327,328) tested a package treatment program

similar to IBTA. In one Vogler study (326), an

overall success rate of about 65 percent was reported (i.e., 65 percent were not problem drinkers

after a year). There was no reported difference

between the two matched groups of hospitalized

chronic alcoholics. One group received the full

broad-spectrum package, while the second group

received only the educational component, counseling, and alternatives training.

In another Vogler study (327), four groups of

problem drinkers each received different combinations of treatments. Again, all groups showed improvements, and there were no differences between groups. In this attempt to “unpackage” the

broad-spectrum approach, Vogler found groups

with alcohol education alone did just as well as

groups with more complex treatments. There was

an 80-percent attrition rate in this study, limiting

the weight that can be given the findings.

Pomerleau’s study (252) monitored middle-class

alcoholics who were more motivated than subjects in other studies and who were functioning

at higher levels. Of 18 patients treated with

behavioral techniques, 16 continued in treatment.

Of 14 treated with “traditional” methods, only 6

remained in treatment. Because the numbers are

so small, the conclusion that behavioral techniques may have advantages over some other

therapeutic approaches can be made only tentatively.

Aversion Therapy

In the 1940’s, Voegtlin, working at the Shadel

Hospital in Seattle, described the use of chemical

aversion therapy and reported aversion as a successful treatment (324). of the 4,096 patients who

received chemical aversion therapy, 42 percent

had remained totally abstinent and 60 percent

were abstinent for at least a year. Thimann, in

a study conducted at about the same time, reported a 51-percent success rate (312). More recently, Wiens and colleagues, working at the

Raleigh Hills Portland Hospital, found that 63 percent who received the treatment were abstinent

for a year (335). These relatively positive findings

of the effectiveness of aversion therapy have been

replicated at several other Raleigh Hills and

Schick-Shadel hospitals.

The Raleigh Hills and Schick-Shadel hospitals

use a variety of methods for treating alcoholics,

including counseling and AA, but aversion counterconditioning therapy, using the drug emetine,

is a central element of their programs (see ch. 3).

Patients, who are typically hospitalized for 11 to

14 days (including detoxification), receive aversive conditioning therapy every other day (about

five times). Then, as outpatients, they return for

reconditioning aversion therapy up to seven times

a year.

Despite the relatively high rates of reported abstinence, reviews of aversion therapy are cautious

in their analysis of its effects based on nonexperimental studies. Nathan and Lipscomb, for example, maintain that positive results are probably

a function of the types of patients that enter these

treatments (209). These investigators believe that

patients at private hospitals, such as Raleigh Hills,

have better prognoses at the beginning of treatment, especially because of their higher socioeconomic status. The data of Neuberger and colleagues (220,221) provide some support for

Nathan and Lipscomb’s contention. In two samples from 1975 and 1976 (220), these investigators

found poorer results than typical (1-year posttreatment abstinence rates of 39 and 50 percent,

respectively), and they attributed these to the fact

that the samples included a larger number of Medicare, unemployed, and/or unmarried patients.
— ——.

Ch. 5—Research on the Effectiveness of Alcoholism Treatment 51

Their most recent data (221) indicate that disabled

Medicare patients have relatively poor outcomes

(36-percent abstinence rate, l-year post treatment), but validate earlier findings of good outcomes for socially stable patients (up to 73-percent

abstinence rate for married and employed patients).

The principal question about evidence on aversion therapy is whether treatment outcomes can

be attributed to demographic factors, to the use

of a broad-spectrum treatment program, or to

aversion conditioning itself. Definitive answers to

such questions will have to await controlled tests

of components of programs that use aversion therapy. It should be noted, however, that patients

who successfully abstain following treatment attribute their success to aversion therapy, while

those who continue drinking think the most valuable program component is counseling (316). In

addition, there is clear evidence that the number

of reinforcement sessions following treatment is

importantly related to abstinence. For certain patients, in particular those with socially stable

backgrounds, aversion therapy may be a useful

aid and worth the considerable discomfort it involves. For other patients, perhaps those unmotivated or for whom nausea is not a powerful aversive stimulus, it may not be effective.

There is some basic research evidence of aversion therapy’s usefulness (e.g., 55), as well as theoretical arguments to support its efficacy (343). One

theoretical problem is that the mechanism underlying its effects may be more complicated than

learned association, and cognitive factors may interfere with behavioral conditioning. The effectiveness of aversion therapy may also depend on

the technique used to develop the aversive state.

Emetine-induced nausea is the most widely used

stimulus, but there are many alternatives. Electric shocks have been used in some cases, although

not very successfully (209). Some success has been

reported with imagined aversive stimuli (s7), but

this technique is not widely used.

Various Government agencies have reviewed

chemical aversion therapy. The Food and Drug

Administration, while it has not approved the use

of emetine, does not believe that the evidence on

emetine’s hazards warrants the imposition of regulations (222). A Public Health Service review recommended that chemical aversion therapy be covered under Medicare (see 222). An Alcohol, Drug

Abuse, and Mental Health Administration/

NIAAA panel that met in January 1980 also concluded that chemical aversion therapy is probably

an effective treatment, but that the lack of controlled trials leaves the question of its safety open

(222,261). They sought new research to provide

scientific data on safety and efficacy.

Nonbehavioral Psychotherapies

Although there has been considerable research

in recent years on the effectiveness of traditional

psychotherapies (cf. 227), their use for treating

alcoholism has not been validated. In the first review of psychologically oriented treatments,

Voegtlin and Lemere (325) found little usable statistical information to indicate the success of psychoanalytically based therapy. Similarly, Hill and

Blanc, in their review of psychotherapy outcome

studies (135), found that methodological problems

made conclusions about the effectiveness of psychotherapy difficult to support. Baekeland’s

(16,18) and Emrick’s (92,93) reviews of controlled

studies found no treatment effects for a variety

of traditional outpatient psychotherapies compared with each other or with other treatments;

only one study Emrick reviewed found that traditional insight-oriented therapy resulted in better

economic and legal outcomes than did contact

with AA. Emrick found only eight controlled

studies, many of which varied aspects of treatment other than the type of therapy (e. g., abstinence v. controlled drinking as a goal of treatment).

The confounding of treatments is illustrated by

the controlled study conducted by Corder, Corder, and Laidlaw, which supported the effectiveness of couples therapy (70). In this study, experimental subjects received, in addition to 4 weeks

of treatment for alcoholism, an intensive 4-day

workshop. The workshop included a couples therapy session, videotape analysis, lectures and discussions, and meetings with AA and other followup treatment representatives. Seven months after

treatment, 55 percent of those in the couples group

were abstinent, and more experimental subjects
52 ● Health Technology case Study 22: The Effectiveness and Costs of Alcoholism Treatment

were employed and involved in aftercare than

were controls. It is difficult to determine which

aspects of treatment made the essential difference.

In addition to methodological problems with

existing studies, many approaches that are used

widely with nonalcoholics (e.g., Gestalt therapy)

have not been adequately investigated for use with

alcoholics and alcohol abusers. Research comparing different lengths of treatment, from very brief

(one to six sessions) to longer treatments (including extended aftercare), is also needed.

Drug Treatments

Pharmacological treatments for alcoholism

have a long history of use (cf. 16,23,206,325),

although the effectiveness of such drug treatments

is not widely accepted. One reason for questioning their effectiveness is that research on drug

treatments has been “careless” (16). In addition,

the effects of drugs appear to be closely tied to

patient compliance and the use of other therapies.

Despite these problems, however, drugs are widely prescribed for alcoholics (as many as 90 percent of physicians in private practice report using

medication in their treatment of alcoholism), and

the use of drug therapies has been associated with

positive treatment outcomes (13,71,72,75).

Considered below is outcome research on two

major types of drugs for treating alcoholism:

1) sensitizing agents (e.g., Antabuse”) and 2) moodaltering drugs (e.g., lithium). Excluded from consideration are drugs used in the treatment of alcohol withdrawal and drugs used to manage alcoholassociated medical disorders (e.g., vitamins for

vitamin deficiencies). A brief discussion of safety issues is included.

Sensitizing Agents

Treatment of alcoholism with drug agents that

sensitize (i.e., make ill) patients who ingest alcohol

has become the most common form of treatment.

Antabuse” treatment is used as an adjunct in

many inpatient and outpatient alcoholism treatment programs and is used in conjunction with

a number of therapies. The initial Rand report by

Armor and colleagues (13) indicated that 30 percent of all patients studied received Antabuse” at

some point in their treatment.

Although there is substantial information about

Antabuse”, Becker (23) notes that there is no consensus about its effectiveness. Studies that report

effective outcomes (e.g., patients maintaining sobriety) with Antabuse” tend to be uncontrolled.

There seems to be clear evidence that older, more

stable, and highly motivated people use Antabuse@ successfully, and this may explain positive

outcomes.

In part, the effects of Antabuse@ are difficult

to assess because of how the drug is used in alcoholism treatment. The drug makes the alcoholic

sick and unable to ingest alcohol, but these effects can be eliminated by the alcoholic’s refusing to take the medication. Within 24 to 72 hours

after stopping the drug, a user can resume drinking, apparently without having learned to control his drinking behavior. Antabuse” seems to

force the alcoholic only to delay satisfying the

urge to drink. Since Antabuse” treatment is given

in conjunction with other treatments and depends

so greatly on voluntary compliance of the patient,

its effectiveness may vary widely according to the

patient’s maturity and the effectiveness of parallel

treatments.

Antabuse” does have associated safety problems and can be lethal if ingested with sufficient

alcohol. Cardiovascular problems and other

chronic disorders are considered contraindicators

for its use. Several other drugs (e.g., tramposil,

metronidazole) have been proposed as alternatives, but Antabuse” still appears to be the drug

of choice for deterring consumption of alcohol

while in a treatment program (23). Antabuse” or

other sensitizing drugs can reduce drinking while

the patient works out his or her problems.

Mood-Altering Drugs

If it is assumed that psychological factors are

part of the alcoholism syndrome, it is reasonable

to expect mood-altering drugs to have some benefit. Obviously, these benefits will be greatest for

those patients for whom psychological problems

are most severe. Depression and anxiety are two

such problems for which drug therapies have been

widely employed.

In one large-scale and methodologically sophisticated study by Overall (235), negative findings
Ch. 5—Research on the Effectiveness of Alcoholism Treatment 53

concerning the effectiveness of chlordizepoxide

(Librium”) in reducing symptoms of anxiety and

depression were reported. Several studies, however, indicate such medications are superior to

placebos (16). After detoxification, it is common

to prescribe an antianxiety agent, although some

question this practice because the alcoholic can

also become addicted to these medications.

Studies of the efficacy of tricyclic antidepressants in the treatment of depressed alcoholics

report contradictory results: some fail to show

beneficial effects from these drugs; others suggest

a high rate of improvement with their usage (303).

The evidence regarding the use of lithium has

been inconclusive (169,200). Problems include the

length of time for the medication to take hold and

the dangers of mixing these drugs with alcohol.

In addition, lithium requires extremely careful

monitoring, which makes its safe usage a complicated process (169).

Self-Help Groups

AA was described earlier as a sociocultural

treatment regarded by some people as the most

effective form of treatment of alcoholism—more

effective than any of the approaches that profesCONCLUSIONS

Research on treatments for alcoholism and alcohol abuse seems to be in transition. The 1970’s

saw a number of attempts to summarize conclusions of piecemeal research on treatment conducted during the last several decades. The conclusion of many of these reviews is that treatment

seems better than no treatment, but that methodological problems render it difficult to conclude

that any specific treatment is more effective than

any other. Importantly, however, various treatments—such as aversion conditioning or AA—

have been shown to be effective for some patients

under some conditions. Given the diversity of

alcohol problems and patients, what seem necessary are treatments tailored to specific patients.

What is also clear is that further research must

be conducted to test competing claims (111,144).

Although some of this research can reasonably

sionals offer. Various problems, however, with

specifying the population that uses AA and a lack

of hard evidence make such conclusions regarding

AA’s effectiveness difficult to verify or discount.

Baekeland (16), in his review of literature about

AA, reports a 34-percent success rate—much

lower than some of the earlier figures. Other reviewers have reported abstinence rates from 45

to 75 percent, depending on the length of the

reporting period (173).

The problem in evaluating AA is that its members probably differ from the general population

of alcoholics, but data supporting this statement

as well as other data about AA are hard to obtain (16). Although a substantial number of regular attendees are abstinent (see s), it is unclear how

this number relates to the number who try the

program. Nonabstainers maybe subjected to ridicule and reproach by other members, so it is probably more likely than not that individuals who

remain in AA for long periods of time are those

who have achieved sobriety. It seems clear that

some aspects of AA programs have useful therapeutic roles (e.g., getting alcoholics to acknowledge their problem, and providing a support system), but AA may only be applicable to some categories of alcoholics and alcohol abusers.

be done without direct Government support (e.g.,

by proprietary organizations), a Federal role

seems needed to develop such research. Ideally,

both experimental and clinical trial research would

be supported. Such methods, although not without their own problems, offer the best hope for

providing objective and unambiguous data about

treatment effectiveness.

Aside from questions of effectiveness (and, to

a certain extent, of safety), efficiency issues must

also be addressed. It is clear from even a cursory

review of the literature, that the costs of alcoholism and alcohol abuse are very large. As the costs

for treatment increase, evidence is needed about

which treatments offer the greatest value for the

resources required. The research questions regarding such costs and benefits are described in the

next chapter.
6.

Analyses of the Costs and

Benefits of Alcoholism Treatment
6.

Analyses of the Costs and

Benefits of Alcoholism Treatment

This chapter describes the costs and benefits of

alcoholism treatment and the issues underlying

the reimbursement debate about alcoholism treatment. Its goal is to provide a framework for consideration of Medicare and other reimbursement

policy for alcoholism treatment (see ch. 7). The

methods of cost-effectiveness and cost-benefit

analysis (CEA/CBA) are described, and the costs

of alcoholism are analyzed. The present discussion of the costs and benefits of alcoholism treatments extends chapter 5’s analysis of the effectiveness of alcoholism treatments. Many of the

same methodological problems and caveats apply

to analyses of the costs of treatment. Thus, it is

necessary to indicate where reliable and valid data

are not available and which conclusions must be

tentative. Suggestions for the development of research that can assist in reducing this ambiguity

are noted.

COST-EFFECTIVENESS AND COST= BENEFIT ANALYSES

Conducting cost and outcome studies of alcoholism treatments is complex and potentially controversial. Clearly, it would be desirable to conduct formal CEAS and CBAS in order to determine definitively which of various treatment alternatives currently available are most effective at

particular resource utilization levels. As the Office of Technology Assessment (OTA) noted in

its assessment of the methods of CEA and CBA,

however, these techniques are probably most useful for structuring policy problems (228). Rarely

is it possible to develop CEA/CBAs definitively.

CEAS and CBAS are difficult to conduct with

precision, because it is almost impossible to specify comprehensively the costs and benefits of alternative treatments. This is especially true in the

area of alcoholism because of the lack of good

data directly comparing alternative treatments

and because of the difficulties in measuring and

specifying outcomes of treatment (see ch. 5). It

is also important to recognize that factors other

than those that can be quantified in a CEA should

be considered in making a policy decision (228).

The potential costs and benefits of alcoholism

treatment can be assessed with varying degrees

of comprehensiveness, and means for estimating

costs and benefits vary. In a CBA, the cost of a

treatment program includes not only the direct

costs of salaries of treatment providers, medication, administration, and overhead, but also indirect costs, such as lost productivity due to patients’ missing time from work. An analyst conducting a CBA must decide which benefits to

measure, how to measure them (if measurement

is at all possible), and what values to place on

those measurements.

Unemployment and lost productivity from alcoholism may, for example, be among the greatest

costs of alcoholism, but limiting analyses to workrelated measures would underestimate the potential benefits of a program that might aid individuals not currently in the labor force (e.g., the unemployed, full-time homemakers, adolescents in

school). For example, Cicchinelli, Binner, and

Halpern’s output-value analysis (61) (a simplified

CEA/CBA) of an alcoholism treatment program

indicated that the program was more efficient for

men than for women. This finding was due to the

average lower cost of treatment for men and the

estimated lower salary rates for women. Another

finding was that the efficiency of the program

tended to decline with severity of impairment. If

a choice had to be made concerning which program was more cost beneficial, a decision based

57
—

58 ● Health Technology Case Study 22: The Effectiveness and Costs of Alcoholism Treatment

on an analysis which valued benefits either by income gained or by degree of impairment could

foster inequities.

OTA has developed 10 principles (see table 4)

to guide the conduct, use, and evaluation of

CEA/CBA studies (228). The principles most relevant to the assessment of alcoholism treatment

programs are that all foreseeable benefits/effects

and expected costs should be defined and, if possible, measured; present-value discounting should

be performed; sensitivity analyses should be conducted to show a range of possible outcome values; uncertainties should be explicitly and clearly

stated; and ethical issues should be addressed. The

rigorous specification of data sources for quantitative analyses is another important criterion for

CBAS and CEAS. The importance of these principles in the few cost-based alcoholism treatment

studies that have been conducted will become apparent when the studies are reviewed later in the

chapter.

Despite problems, when CBA is done well, its

use aids “the complete enumeration of expected

costs and benefits as well as explicit consideration of assumptions underlying quantitative evaluations of the costs and benefits” (310). Assuming

such specification is possible, such analyses provide a solid scientific basis to aid in making deciTable 4.-Ten General Principles of Analysis

for CEA/CBA Methodology

1. Define problem.

2. State objectives.

3. Identify alternatives.

4. Analyze benefits/effects.

5. Analyze costs.

6. Differentiate perspective of analysis.

7. Perform discounting.

8. Analyze uncertainties.

9. Address ethical issues.

10. Interpret results.

SOURCE: Office of Technology Assessment, U.S. Congress, The Implications of

Cost-Effectiveness Analysis of Medical Technology, GPO stock No.

052-00340765-7 (Washington, D. C,: U.S. Government Printing Office,

OTA-H-126, August 1960).

sions. Given the substantial variance in alcoholism

program costs (e.g., inpatient v. outpatient) and

the current policy debate over reimbursement policy, such information would obviously have great

utility.

To understand what can be obtained from

CEAS and CBAS, several distinctions must be

made. A CEA implies a comparative analysis of

the costs and health effects of alternative treatments. In a CEA, a common outcome is specified

(e.g., functional status), and the costs of providing

alternative treatments are compared. Treatment

costs are typically specified in monetary terms.

A CBA, in contrast, requires that both cost and

benefits be assigned monetary values. A CBA examines the ratio of resources used (cost) to resources saved (benefits) when particular treatments or even different programs are employed

(133). The result of a CBA is usually a net costbenefit ratio. According to Swint and Nelson

(310), CBA is conceptually superior to CEA because: 1) programs with different goals (e.g., alcoholism treatment v. highway improvement) may

be compared, and 2) CBA analyzes (in a limited

way) whether an objective is worth achieving.

Even if a treatment is not cost effective (i.e., other

treatments achieve the same outcome equally as

well but at a lower cost), the same treatment may

still be cost beneficial (i.e., the benefits are greater

that the cost).

A further, perhaps technical, distinction must

be made about the term “cost.” In most CBAS,

costs are considered the value of resources used

in providing the treatment program (e.g., salaries,

overhead, medicine). The social and economic

costs incurred because treatment is not given or

is ineffective are, for these analyses, considered

negative benefits (cf. 225). Whether they are considered negative benefits or additional costs is usually not critical. It is the comprehensive assessment of such effects that is essential for making

the best comparison of resources used and saved.
Ch. 6—Analyses of the Costs and Benefits of Alcoholism Treatment 59

ANALYSES OF THE COSTS AND BENEFITS

OF ALCOHOLISM TREATMENT

Cost Context

Evaluating treatments for alcoholism must be

done in the context of what has been called the

“cost of alcoholism. ” In 1981, Cruze and associates (78) at the Research Triangle Institute prepared a report for the Alcohol and Drug Abuse

and Mental Health Administration (ADAMHA),

in which they estimated the cost of alcoholism to

U.S. society in 1977 to be nearly $50 billion. As

shown in table 5, Cruze and associates divided

total costs to society between “core costs” and

“other related costs. “ “Core costs” were those costs

most directly related to the alcoholism problem

that are borne by some component of the health

care system or are the indirect costs of mortality

and morbidity (i. e., lost productivity). “other

related costs” included the direct costs of social

programs other than those related to health, accident costs, and indirect costs of incarceration and

noninjured time loss. The distinctions arise from

Public Health Service guidelines for the cost-ofillness studies (137).

Cruze and associates also identified health care

settings involved in the treatment of alcohol

abusers and determined their alcohol-related expenditures. As shown in table 6, for example, they

estimated that to treat alcohol-abuse-specific illness (e.g., alcoholism, alcohol psychosis, cirrhosis) in 1977, alcohol specialty facilities expended

about $700 million, and general health facilities

spent $2 billion. Another $3 billion was spent for

alcohol-related illness and trauma. Cruze’s $700-

million figure for expenditures by alcohol specialty facilities for alcohol-abuse-specific illness is

close to the amount of funding for all alcoholism

treatment units reported by the National Institute

on Alcohol Abuse and Alcoholism (216).

Table 5.—Estimated Economic Costs of Alcoholism in 1977

Millions of dollars

Core costs

Direct:

Treatment (for alcoholism and causally related illness) . . . . .

Support (research, education and training, construction,

insurance administration). . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Indirect:

Lost productivity due to:

Premature mortality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $10,715

Morbidity resulting in:

Reduced productivity and lost work time . . . . . . . . . . . . . 23,593

Lost employment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,481

$36,789

Total core costs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other Related Costs:

Direct:

Motor vehicle crashes (funeral, Iegal/court, insurance

administration, accident investigation, vehicle damage) . .

Criminal justice system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Social welfare program administration . . . . . . . . . . . . . . . . . . .

Other (fire losses, fire protection, highway safety) . . . . . . . . .

Indirect:

Lost productivity due to:

Alcoholics’ incarceration . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Others’ lost worktime because of motor vehicle crashes .

Total other related costs . . . . . . . . . . . . . . . . . . . . . . . . . . .

Total economic costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$5,637

735

36,789

$43,161

$1,782

1,685

142

832

1,418

354

$6,213

$49,374

SOURCE: AdaDted from A. M. Cruze, H. J. Harwood, P. L. Kristiansen, et al., Econornlc Costs to Soc/etv of Alcohol and Drua

Abuse arrd Mental ///rress 1977, final report prepared by the Research Triangle Institute for the’ Alcohol, Drug Abus~,

and Mental Health Administration, Department of Health and Human Services, October 1981.
60 . Health Technology Case Study 22: The Effectiveness and Costs of Alcoholism Treatment

Table 6.—Estimated Health Care Expenditures for Alcohol Abuse

in 1977, by Setting (millions of dollars)

Expenditures on

Total

Setting

alcohol-abuseexpenditures specific illnesses

Alcohol specialty facilities

Hospital-based facilities:

State and county psychiatric hospitals. . . . . . . . . . . . . . .

Private psychiatric hospitals . . . . . . . . . . . . . . . . . . . . . . . .

Veterans Administration neuropsychiatric hospitals . . .

General hospitals with separate psychiatric facilities . .

Subtotal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other facilities and services:

Federally funded community mental health centers. . . .

Residential treatment centers for children . . . . . . . . . . . .

Halfway houses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Multiservice mental health facilities . . . . . . . . . . . . . . . . .

Other free-standing facilities ., . . . . . . . . . . . . . . . . . . . . .

Alcohol specialty units in correctional facilities . . . . . . .

Private practice psychiatrists . . . . . . . . . . . . . . . . . . . . . . .

Private practice psychologists . . . . . . . . . . . . . . . . . . . . . .

Subtotal . . . . . . . . . . . . . . . . . . . . ., . . . . . . . . . . . . . . . . . . .

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

General health facilities

Hospital-based facilities

Community hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Veterans Administration general hospitals and other

facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other Federal facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Subtotal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other facilities and services:

Nursing homes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Private practice physicians . . . . . . . . . . . . . . . . . . . . . . . . .

Dentists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other health professionals . . . . . . . . . . . . . . . . . . . . . . . . .

Drugs and drug sundries . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other health services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Volunteer services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Subtotal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$200

34

29

43

$200

34

29

43

$306

129 —

37

8

198

3

18

8

$401

$707

$2,274

425

149

$2,848

108

548

443

133

525

222

103

$306

129

—

37

8

198

3

18

8

$401

$707

$880

321

84

$1,285

98

16

195

62

232

90

45

$2,082 $716

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $4,930 $2,001

SOURCE: Adapted from A. M. Cruze, H.J. Harwood, P. L. Kristiansen, et al., Econornlc Costs to Soc/ety ofA/coho/andDrug

Abuse and A.ferrta/f//ness 197~flnal report prepared bythe Research Triangle lnstitutefortheAlcoho~ Drug Abuse,

and Mental Health Administration, Departmentof Health and Human Services, October 19S1.

Ascanbe seen in table 5 drawn from Cruze,

lost productivity accounted for the greatest share

of the economic costs of alcoholism, followed by

costs for treatment, motor vehicle crashes, the

criminal justice system, other, and social welfare

administration (indirect ’’other related costs’’ are

included here under productivity)—for a total of

about $49.4 billion. Using a double-digit minimum for inflation since 1977 (i.e., an average of

l0 percent per year), one can estimate that the

current cost of alcoholism and alcohol abuse is

$72 billion annually.

Although the double-digit minimum procedure

provides a rough total, a more accurate way of

assessing the impact of inflation is to make separate estimates for each market segment (e.g.,

medical costs, education and training, and earnings). If that were done, the costs of treatment

would double (both because of inflation and with

unreliability), but the costs of motor vehicle

crashes would decrease as a consequence of inflation, drinking age increases, tougher drunk

driving and safety laws (58), and lowered average

driving speeds. Productivity losses would also)
Ch. 6—Analyses of the Costs and Benefits of Alcoholism Treatment . 61

decrease slightly because wage increases have not

kept up with inflation. Whatever method is used

to estimate costs, however, the total cost of

alcoholism is substantial and has steadily increased.

The Cruze study, although it used a method

that at times significantly departed from earlier

studies, yielded a total cost of alcoholism that,

when adjusted to inflation, was similar to the

estimate of the prior principal study. That study,

by Berry, Boland, Smart, and Kanak (29), found

the costs of alcoholism to be $43 billion in 197s.

However, there were major differences in the two

studies’ costs by category; for present purposes,

the most important of these differences was

Berry’s estimate of $12 million in health care costs

owing to alcoholism and alcohol abuse compared

with Cruze’s estimate of $5 million.

Cruze and associates used a so-called illnessspecific method and thus did not include health

care costs of illnesses related to alcoholism or complicated by alcohol abuse. Berry and associates,

on the other hand, used a population-specific

method whereby they estimated all health care

costs incurred by individuals with a history of

alcohol abuse, including hospital care, physicians’

services, drugs, and nursing home care. They then

compared these costs to the per capita rate of

health care utilization for the non-alcohol-abusing

population. The difference between the two rates

was attributed to alcohol abuse and was multiplied by the estimated prevalence of alcohol abuse

to produce an estimate of total health care costs

caused by alcohol abuse. They also included government public health activities, training, and facilities construction as part of the total health care

costs, although these costs were relatively minor.

The primary difference between the Cruze and

Berry figures—and perhaps between any estimated and actual health care costs for alcohol

abuse—can be accounted for by their differing

estimates of the range of illnesses thought to be

associated with alcohol abuse (cf. 85). The Berry

analysis comes closer to including costs associated

with all such illnesses. However, the exclusion of

data for family members and victims of accidents

related to alcohol abuse, as well as the conservatism of the estimates, probably resulted in an

underestimate.

Support for the view that costs are underestimated by these analyses is provided by the Institute of Medicine’s report on alcoholism as a health

problem (144). In a chapter prepared for the report, it is argued that each of Berry’s categories

underestimate the populations affected by alcoholism (see 276). In particular, the estimate of health

costs did not include costs of related problems

(such as fetal alcohol syndrome) and of illnesses

not directly related to the abuse of alcohol. The

Institute of Medicine indicates that Berry’s estimate of the health care costs of alcoholism was

understated by 40 percent. Nevertheless, it represented 12 percent of the total national health care

expenditures by adults in 197s.

Noting the fact that various studies emphasize

the conservative biases of almost all of their estimates, the Institute of Medicine points out that

disagreements over details should not obscure “the

essential qualitative conclusion” that alcohol

abuse imposes very large costs on society (144).

The analysis of Schifrin and colleagues (276) for

the Institute of Medicine indicated that the 197s

total economic costs could be as high as $60 billion

(4o percent greater than Berry’s estimate), which

would make the 1982 economic costs of alcohol

abuse approach $120 billion. Research that could

contribute to a lessening of these costs is, in the

view of the Institute’s panel, seriously underfunded. The Institute notes by way of comparison

that cancer research receives 70 times as much

money as does alcoholism research in relation to

the costs of the illnesses (cancer costs were estimated at $19 billion in 197s; Berry’s estimate of

$43 billion was used for the costs of alcoholism).

In 1978, $627 million was spent for cancer research and only $16 million was spent for alcoholism research.

Assessment of the economic costs of alcoholism

and alcohol-related problems is obviously limited

by the inability to clearly identify problems directly caused by, rather than merely associated with,

alcohol. The prevailing view seems to be that most

estimates of these costs are too low, because alcoholism’s role in medical problems cannot be fully

explicated. The opposite position has also been

adopted by at least one analyst (194), who reported in a study for the Distilled Spirits Council

of the United States that none of the costs assigned
62 ● Health Technology case Study 22: The Effectiveness and Costs of Alcoholism Treatment

by Berry and associates could be attributed unconditionally to alcohol use. Such arguments,

however, would seem to be diluted by the potential for illnesses to be missed.

One additional type of cost to which researchers invariably allude, but which is particularly difficult to measure, are the indirect psychological

costs of alcoholism. Effects on children whose parents are alcoholic, including future losses in productivity (e.g., in children who underachieve because of low self-esteem associated with having

alcoholic parents) are also typically omitted from

CBAS (78). Even if these psychological costs were

identified, their effects on the future (e.g., for

productivity) are often exceedingly difficult to

measure.

One way of understanding the costs of alcoholism has been noted by Luce and Schweitzer (183).

On the basis of 1975 data, these analysts estimated

the yearly cost to society for each alcoholic to be

approximately $5,000. Luce and Schweitzer’s calculation of this figure was based on the assumptions that there were 9 million alcoholics and alcohol abusers and approximately $44 billion in costs

to society from alcoholism. If the figure is conservatively adjusted for inflation, the yearly cost for

each alcoholic at present is over $10,000. If only

a portion of that $10,000 could be recovered by

a moderately effective treatment system, it should

be possible to achieve significant reductions in the

economic, social, and health care costs of alcoholism and alcohol abuse.

Cost-Effectiveness and Cost-Benefit

Studies of Alcoholism Treatment

Led by State governments and private industry

employers, a number of efforts to expand alcoholism treatment benefits have been developed and

studied during the past 10 years. In 1979, Jones

and Vischi, ADAMHA staff members, reviewed

available literature with respect to alcoholism

treatment’s impact on medical care utilization and

produced a comprehensive review of cost-effectiveness and cost-benefit studies (158). Their

review, which included analyses of the dozen such

studies then available, found surprisingly consistent results across studies. Each of the investigations Jones and Vischi evaluated found that alcoholism treatment resulted in a significant reduction in medical care use and expenditures. The median reduction in sick days and accident benefits

was 40 percent.

From a technical point of view, the 12 studies

reviewed were principally cost-benefit rather than

cost-effectiveness studies. Their focus was on the

benefits of alcoholism treatment in terms of externalities (rather than a comparison of treatment

effectiveness according to cost). Not all the studies

concluded with a cost-benefit ratio, although most

could have. In several of the studies reviewed, a

benefit was established only when partial effects

(e.g., reductions in sick leave, net reductions in

health care costs or effects of improved health

status on others) were considered.

Unfortunately, methodological problems were

present in each of the studies reviewed by Jones

and Vischi. One difficulty was a treatment design

problem. Most studies were conducted in employee-based alcoholism programs or in organized

health care settings, particularly health maintenance organizations (HMOS). Such programs

and settings have particular economic incentives

and tend to emphasize treatments that are low cost

and do not take individuals away from their

work. All 12 of the studies were flawed by their

failure to identify medical utilization outside of

the study (e.g., in HMOS, by private practitioners)

because they used nonequivalent comparison

groups (i.e., quasi-experimental design). The

studies also failed to control or adjust for increases

in pretreatment medical utilization caused by the

referring visit. In general, the studies were of short

duration (1 year or less) and used limited treatment outcome measures.

Nevertheless, the existence of positive results

across 12 studies conducted by independent investigators in different settings gives added weight

to the conclusion that alcoholism treatment is cost

beneficial. Four representative studies reviewed

by Jones and Vischi and two studies completed

subsequent to their review are further described

below.

Philadelphia Police and Fire Departments

Jones and Vischi (158) reviewed two studies

conducted in Philadelphia, one with the police
Ch. 6—Ana]yses of the Costs and Benefits of Alcoholism Treatment ● 63

department (319) and one with the fire department

(318). The results of both studies illustrate not

only the potential benefits of alcoholism treatment

programs, but also the problems in developing

definitive statements about the results of such

programs.

In both programs, a counseling service was set

up for employees with alcohol and other drug,

mental health, or financial problems. An insurance program paid for hospitalization and rehabilitation where referrals were made. The studies included a relatively small number of individuals:

170 police officers and 77 firefighters. In both

groups, only a small group actually accepted and

received treatment other than brief counseling.

The findings in both studies are relatively consistent. The number of sick days and days lost

due to injury following counseling or inpatient or

outpatient care for alcoholism sharply declined.

The data indicate that the more intensive the treatment, the better: the inpatient group showed the

largest reduction in sick and injured days; the outpatient group, the next largest reduction; and the

group that only received counseling, a smaller decline (to a level below the average rate for police

and firemen).

In cost effectiveness, outpatient programs appeared to have an advantage. For the police program, the ratio of savings (savings were equated

with the dollar value of reductions in sick leave

minus the costs of counseling) for outpatient treatment to costs for outpatient treatment was 3:1;

for the fire program, the ratio was 1.5:1. For inpatient treatment, the benefit-cost ratios were

0.9:1 (police) and 0.25:1 (fire). According to Jones

and Vischi, the poor cost savings of the inpatient

fire program may be attributable to the program’s

practice of assigning only the worst cases to inpatient treatment. Overall benefit-cost ratios were

1:1 (police) and 0.4s:1 (fire).

Despite these seemingly positive results, any

conclusions from the Philadelphia studies are

clouded by the exclusion of variables on both sides

of the benefit-cost equation. On the benefit side,

savings were calculated only for the departments

involved and not for the individuals or insurance

companies. On the cost side, inpatient costs apparently included only the cost of sick leave and

not the costs of treatment beyond counseling.

Without more comprehensive data, the relative

cost effectiveness of the treatment settings cannot be determined in any definitive way.

The Philadelphia studies also lack a control

group and random assignment of participants to

treatment. It is not clear whether declines in sick

days and injured days are merely a regression

toward the mean phenomenon (extreme responses

should naturally become more average over time,

hence regression to the mean (67) or whether they

represent the direct effects of counseling and treatment. It is, of course, suggestive of the causal relation that most posttreatment rates (e.g., injured

days per year for police, both sick and injured

days per year for the fire program) were below

rates for average police and firemen. However,

statements concerning cost effectiveness are limited by the exclusion of data on the costs of inpatient care and insurance premiums on the cost side

and of posttreatment medical use on the benefit

side.

General Motors

Jones and Vischi (158) also reviewed Lunn’s

study (185) of a program for General Motors employees in Canada. This study used an untreated

comparison group. Approximately 100 employees

who were interviewed by the company doctor and

referred to treatment were compared to approximately 50 employees who were similarly referred

but did not undergo active treatment. During the

time of treatment (not specified), the experimental group’s use of sickness and accident benefits

declined by 48 percent, while the comparison (untreated) group’s use increased 127 percent.

Although the changes in utilization rates are significant, it is not clear whether the groups were

really comparable. Post hoc analyses indicated

that there was a significant difference in the level

of use of health benefits prior to entry into treatment. Differences in outcomes between groups

may just reflect the doctors having “caught” alcoholics at different stages in their illnesses. The

comparison group appears to have lagged behind

the study group by about a year in the severity

of the impact of their alcoholism.
—

64 . Health Technology Case Study 22: The Effectiveness and Costs of Alcoholism Treatment

California Pilot Program

The so-called California pilot program study

(139) reviewed by Jones and Vischi (158) was designed, in part, to investigate whether health insurance coverage for alcoholism treatment had

any impact on overall health care use and expenditures by alcoholics and their families. Although

study conclusions are limited by the failure to

present data on a comparison group of untreated

alcoholics, strengths of the study include the inclusion of costs and benefits in monetary terms

and the inclusion of treatment provided in both

organized and unorganized care settings, on both

prepaid and fee-for-service bases.

Alcoholism benefits in the California pilot program were provided through three different insurance carriers to a study group of 240 families that

had at least one alcoholic member. The benefit

consisted of a maximum of 6 days of detoxification, 21 days in a general hospital or specialized

alcoholism treatment center, 30 days in a recovery

home or other residential facility, and 45 outpatient visits. Mean monthly medical utilization

and costs for alcoholics and their family members

were collected for 12 months prior to treatment

and from 3 to 20 months after treatment. Results

differed by carriers, setting, and person treated

(alcoholics v. family members). Overall results

from reduced medical use indicated a savings of

$46 per alcoholic per month. Extrapolated to the

alcoholic population of the entire pilot program,

estimated savings equaled $280,000, or 41 percent

of the total cost of the pilot program.

Blue Cross/Blue Shield, the carrier that had

been the most restrictive in its alcoholism coverage

prior to participating in the California pilot program, experienced a 41-percent decline in posttreatment average medical costs per month. The

least restrictive carrier experienced a large (134

percent) increase in medical costs for alcoholics,

although this increase may have been attributable

to a skewed sample. Among the notable effects

for all providers was a substantial posttreatment

decrease in alcoholics’ use of inpatient treatment

and an increase in use of less expensive forms of

care, such as outpatient treatment. However, the

length and average cost per posttreatment inpatient stay across all providers increased for alcoholics (length of stay increased an average of 50

percent, from 2.3 to 3.5 days; cost increased by

34 percent, from $575 to $771). On the other

hand, these utilization rates and costs decreased

for other family members.

A followup study (138) published in 1981 indicated substantial fluctuations in costs and

utilization over a 5-year period. By the end of the

fifth year, however, medical care utilization by

alcoholics and their family members had declined,

and both utilization and costs were lower than

those of control group members. Results such as

these indicate the importance of longitudinal

studies. The problems of alcoholics and their

families are both deep-seated and longstanding,

and effects may take considerable time to appear.

When treatment becomes available, previously

hidden problems may be uncovered and presented

for treatment; however, research indicates that

eventually such treatment pays off, as less and

less care is needed over time.

An additional important finding of the California pilot program study was the posttreatment

decrease in diagnoses often reported for getting

alcoholism treatment when such treatment is not

legitimately reimbursable. Before the pilot program began, 91 persons had been diagnosed for

gastrointestinal, psychiatric, and other alcoholrelated illnesses; subsequent to treatment, the

number was 20.

Group Health Association

The most extensive study of the cost effectiveness of providing alcoholism treatment benefits

was available only in partial form at the time of

Jones and Vischi’s review (158), but has since been

completed. The study, conducted by the Group

Health Association of America (GHAA), was a

7-year study by Plotnick and associates that evaluated the feasibility of providing comprehensive

alcoholism treatment programs in four HMOS

(247). The programs were outpatient oriented, but

each attempted to provide comprehensive and

continuous treatment services. The investigators

collected and analyzed data on patient functioning, health status, and treatment use for over

2,OOO patients. Of the subjects in the study, 1,033

were alcoholics in treatment; others were spouses,
Ch. 6—Ana]yses of the Costs and Benefits of Alcoholism Treatment 65

family members, and a group of nonalcoholic

HMO members matched by age, sex, and length

of membership in the HMO.

GHAA (247) found that outpatient-oriented alcoholism treatment programs appeared to be both

effective and cost-beneficial. Patients in treatment

over a 3-year period declined in their use of alcohol by 65 percent after 6 months and by approximately 70 percent after 2 years. Alcoholic patients

also increased their length of abstinence from 8

days at intake to 19 days after 6 months, remaining at 19 or 20 days throughout the 3-year followup. Patients also showed improvement on workrelated dimensions as measured through reduction in reprimands (75 to 90 percent) and days

sick or absent from work (an average of 50 percent).

These improvements paralleled improvements

in measures of medical care use. Alcoholic patients

reduced ambulatory health care service use between 11 percent (after 6 months) to 30 percent

(after 4 years). These patients also showed an immediate decline in the percentage of emergency

care visits (from 31 to 9 percent after 6 months)

and an increase in the percentage of regularly

scheduled visits (from 59 to 78 percent after 6

months). However, alcoholics used more ambulatory care services than did the members of the

comparison group. Relative utilization went from

seven times as many encounters with health care

providers to three times as many encounters over

4 years of study.

Hospitalization experience was less positive in

the GHAA study (247). There were modest reductions relative to matched groups in three studies

and an increase in a fourth site that was cautiously

attributed to demographic characteristics of the

sample. Furthermore, there was a substantial

“peaking” phenomenon in one site at which utilization was measured frequently, with one increase

in length of stay among alcoholics at 6 months

before intake and another increase, though less

dramatic, 24 months after intake. Plotnick and

colleagues attribute this increase, and the high

utilization rates overall, to the chronic and severe

health problems generally experienced by alcoholics.

Because of methodological problems, it is unclear whether the small number of subjects or

prior patterns of hospitalization account for the

differences. The GHAA study (247) was limited

by the fact that it compared alcoholics receiving

treatment to a population of individuals who were

presumably relatively free of alcoholism problems. It also did not directly compare outpatient

alcoholism treatment with inpatient treatment,

since the HMOS had previously concluded that

outpatient treatment was more cost effective.

Finally, cost data could not be included in the

results of the study; because of their prepaid

nature, HMOS seldom focus on costs per service.

An analysis of costs by department, done by one

of the HMOS participating in the GHAA study,

was reviewed for alcoholism treatment effects by

Plotnick and associates. They found no cost savings in health care utilization. It is noteworthy,

however, that all of the HMOS involved in the

1982 study have decided to continue providing

alcoholism treatment services.

U.S. Air Force

Orvis, Armor, Williams, Barras, and Schwarzbach (234) compared the cost-effectiveness of inpatient, outpatient, and education-only treatments for U.S. Air Force personnel in a nonexperimental clinical trial. Twenty-eight days of

inpatient care at an Air Force Alcohol Rehabilitation Center cost $3,000; 10 sessions of outpatient

care cost $900; and a series of awareness seminars

cost $60 per person. Much of the inpatient cost

was attributable to lost work time. Direct costs

were $1,705 for inpatient treatment, $649 for outpatient treatment, and $28 for alcohol awareness

seminars.

The CEA consisted of estimating the annual

cost savings per capita for those severely and

moderately impaired and comparing the savings

to the cost of treatment. Using this method, it

would take 4 years for a 28-day inpatient treatment for the severely impaired to pay for itself,

compared to a little less than 2 years for outpatient

treatment to pay for itself. For nondependent alcoholics, it would take longer. These figures, based

on the equivalent effectiveness of all treatment
66 . Hea]th Technology Case Study 22: The Effectiveness and Costs of Alcoholism Treatment

contexts, result in an average 50 percentage point

reduction in problems for all participants and no

statistical differences in remission rates, which

were between 70 and 80 percent. However, while

these figures are suggestive, the fact that patients

CONCLUSIONS

There is some evidence to support the hypothesis that alcoholism treatment is cost-beneficial.

The benefits of alcoholism treatment, even if they

fall short of what maybe claimed, seem to be in

excess of the costs of providing such treatment.

It is difficult from the available evidence to determine the relative effectiveness or cost effectiveness

of inpatient v. outpatient treatment; it is also difficult to determine how changing the mix of providers or types of treatments would affect either

effectiveness or cost effectiveness. Because different groups receive different treatments, there is

an inherent methodological difficulty in interpreting most of the available research.

were not randomly assigned to treatments and

that most clients received a combination of all

types of treatment somewhat limits the usefulness

of the study.

there are less expensive ways of providing treatment than are reflected in current reimbursement

policy. However, reimbursement systems, particularly the Medicare and Medicaid programs, have

overwhelmingly emphasized the most expensive

treatment services-inpatient, medically based

treatment.

Questions about the wisdom of this approach

have resulted in recent changes in private reimbursement systems as well as clarification of Medicare policy, and an attempt to systematically evaluate whether changes in policy would result in

health care cost savings. Some of these issues are

addressed in the following chapter.

It does seem clear, however, that many alcoholism treatment services are not cost effective—i.e.,
7.
7.

Reimbursement Issue;

The development of the current system for

treating alcoholics and alcohol abusers has been

closely tied to funding and reimbursement policies

of both private and governmental insurance programs. Since the acceptance of alcoholism as a

disease over 25 years ago, an elaborate medically

based treatment system for alcoholism has

evolved. In some cases, development of treatment

services has preceded reimbursement policy; in

other cases, however, treatment seems to have

developed around what is reimbursable.

In recent years, a number of private insurance

companies, employers, and the Federal Government have expanded benefits for alcoholism treatment. Reimbursement for acute medical care as

well as inpatient treatment for alcoholism is currently available, although coverage is not universal. Non-hospital-based treatments, including outpatient care, aftercare, and non-medically-oriented

residential care, are less frequently reimbursed,

although there is a trend toward developing such

benefits (341). Thirty-three States currently mandate some form of coverage by health insurers for

alcoholism treatment (283).

Recent emphasis on expanding insurance benefits for alcoholism treatment (see, e.g., 211) stems

from a belief, supported by the evidence in chapter 6, that the costs of not providing alcoholism

treatment are greater than the costs of providing

such treatment (11,216,274). Whether alcoholism

treatment should be reimbursed at all, therefore,

does not seem to be at issue. The essential question at this point seems to be whether current reimbursement policy supports the provision of the

most cost-effective treatments. As discussed in

chapter 6, several cost analyses have been conducted that indicate the beneficial effect of alcoholism treatment, yet several issues need to be addressed in greater depth: questions about whether

ineffective treatments are being employed and

concerns about whether lower cost treatment alternatives (such as nonhospital care) are available

to treat alcoholics but are not being used.

The Nation’s health care budget has expanded

to almost 10 percent of the gross national product, and although efforts have been made to improve benefits for alcoholism treatment, increasing such benefits conflicts with needs to reduce

health care expenditures. There is an obvious need

to develop a more efficient treatment system to

treat alcoholism—with such a system, it is less

likely that services will be denied to a large number of people or that costs will be prohibitive. The

issues of reimbursement policy are complex, however, and changes in policy not only affect alcoholic patients, but have widespread implications

for the costs and treatment of all health problems.

OVERVIEW OF FUNDING OF ALCOHOLISM SERVICES

The Federal Government has a substantial stake

in the funding of alcoholism treatment services.

An estimated two-thirds of the direct costs of alcoholism treatment programs are paid for through

Federal, State, and local government programs

(217; see table 7).

Federal programs include employee-benefit insurance packages such as the Federal Employees

Health Benefit Plans; services provided by the

Armed Forces and Veterans Administration (VA)

hospitals, including the Civilian Health and

Medical Program of the Uniformed Services

(CHAMPUS); and, until recently, programs

funded by the National Institute on Alcohol

Abuse and Alcoholism (NIAAA) (now incorporated in block grants to States). In addition,

and most important for present considerations,

the Medicare program pays substantial amounts

for the treatment of alcoholism, as do most State

Medicaid programs (217).

In fiscal year 1982, Medicare paid an estimated

$150 million to treat alcoholism and alcohol-based

69
70 ● Health Technology Case Study 22: The Effectiveness and Costs of Alcoholism Treatment

Table 7.—Sources of Funding for Alcoholism

Treatment Units in 1979a

Amount

Source of funding (millions) Percent

Government

NIAAA b . . . . . . . . ... , . . . . . . . . . . . . . . . . $71

Other FederalC . . . . . . . . . . . . . . . . . . . . . . 102

Third-party (other than private):

State or local government fees for

service . . . . . . . . . . . . . . . . . . . . . . . . 38

Title XX. . . . . . . . . . . . . . . . . . . . . . . . . . 35

Public Health Insurance and

Welfare d . . . . . . . . . . . . . . . . . . . . . . . 80

State government . . . . . . . . . . . . . . . . . . . 206

Local government . . . . . . . . . . . . . . . . . . . 97

Total government . . . . . . . . . . . . . . . . .

Private

Third-party private health insurance . . . $184

Donations . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Total private . . . . . . . . . . . . . . . . . . . . . .

Other

Client fees . . . . . . . . . . . . . . . . . . . . . . . . . $94

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

7..5%

10.9

4.0

3.8

8.5

21.9

10.3

66.9%

19.6%

2.4

22.O%

10.O%

1.3

Total . . . . . . . . . . . . . . . . . . . . . . . . . . $941 100.O%

aReported by4,311 alcoholism Treatment unitsthat reported funding information

to the National Drug and Alcoholism Treatment Survey (NDATUS)

bNDATUS reportsthatNIAAA figures wereunderreported byslcoholismtreatment

units.

clnclude~ sources such as the National Institute on Drug Abuse, Bureau ‘f

Prisons, Veterans Administration, Drug Enforcement Administration, Bureauof

Community Services, Law Enforcement Administration, and National Institute

of Mental Health.

‘Includes sources such as CHAMPUS, Federal Employees Health Benefit Plan,

Medicare and Medicaid, and local general assistance programs.

SOURCE: National Institute on Alcohol Abuse and Alcoholism, Alcohol, Drug

Abuse, and Mental Health Administration, Department of Health and

Human Services, Natlona/ Drug and Alcoholism Treatment Utilization

Survey (Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism, June 1981).

disorders (99). Extrapolating from comparable

figures for 1979 suggests that approximately 90

percent of this total was spent for institutional care

alone; the remainder was paid to physicians for

their services (80). In a 20-percent sample of elderly Medicare patients, alcoholism was the 18th

most frequent discharge diagnosis (269). Persons

aged 65 and over accounted for over one-quarter

of all discharges and over one-third of patient days

of care in all non-Federal short-stay hospitals

(212). Almost 9 percent of those aged 64 and over

who used psychiatric facilities were diagnosed

with alcohol disorders (223). The percentage of

alcoholics aged 64 or over in VA hospitals is

estimated to be 16 percent (223).

Ninety-five percent of those aged 65 and over

are covered by Medicare (269). However, only

15 percent of all elderly problem drinkers appear

to be receiving any type of treatment (259). For

alcoholics receiving Medicare-funded inpatient

treatment in 1977-78, the average charge per patient day was almost $170, and the average length

of stay was over 7 days, yielding a total average

cost per discharge of nearly $1,200 (269). Thus,

the charges for alcoholism treatment under the

Medicare program have been considerable and are

potentially very large if inpatient treatment were

widely used. These figures do not include treatment for patients in noninstitutional settings or

for those with other primary disorders, although

it is clear that alcoholism plays a central contributory role in a variety of ailments that affect

the elderly, particularly cardiovascular disease,

gastrointestinal problems, and cancer (85,276,

347). Alcoholism and alcohol abuse, as noted

above, may be the primary reason an individual

comes to the hospital, may add medical complications to treatment, and may interfere with normal recovery processes. For elderly individuals,

the latter problems may be severe, and very costly

to the Medicare system.

HISTORY OF BENEFITS FOR ALCOHOLISM TREATMENT

Insurance benefits for alcoholism treatment are Medicare

increasingly being provided by private carriers

and Government insurance programs. The devel- Medicare is a nationwide, federally adminisopment of such benefits is fairly recent. A review tered health insurance program authorized in 1965

of how the current system evolved maybe useful to cover the costs of hospitalization, medical care,

for understanding the present policy debate about and some related services for eligible persons over

alcoholism treatment coverage under Medicare. age 65. Since its inception, Medicare has not spe-
Ch. 7—Reimbursement Issues ● 71

cifically provided benefits for the treatment of

alcoholism. Rather, under the hospital insurance

component of Medicare (Part A), alcoholism is

treated as a psychiatric disorder under the general category of psychiatric health services; its

hospitalization benefit for a psychiatric disorder

in a psychiatric hospital is limited to 190 days per

lifetime. For treatment of alcoholism in the psychiatric ward of a general hospital, on the other

hand, the standard (physical illness) Part A Medicare reimbursement and coverage provisions apply: 90 days of hospital care in each benefit period

with $304 deductible, and 25-percent copayment

after 60 days, as well as a lifetime reserve of 60

days with a 50-percent copayment. According to

NIAAA (223), the original limitation on psychiatric care was to avoid Medicare’s reimbursing

“custodial care, ” since Medicare was intended

only to insure against illnesses that were being actively treated.

The supplementary medical insurance component of Medicare (Part B) provides partial coverage for outpatient psychiatric services. The formula is complicated, but it results in a 50-percent

coinsurance benefit with a maximum reimbursement of $250 per year. For physical illness, however, Medicare pays 80 percent of a physician’s

reasonable charge after a $75 deductible. Although outpatient psychiatric services are limited

to a maximum reimbursement of $250 a year,

there is no limit on reimbursement for physicians’

services for medical or psychiatric care while a

patient is in a psychiatric ward of a general

hospital. The original limit on coverage of outpatient care was consistent with such limits by private insurers.

The Medicare program essentially funds providers who are physicians or are under the direct

supervision of a physician performing services incident to those of a physician. This has meant that

many non-acute-care facilities and treatment centers that offer non-physician-based care have not

been eligible for reimbursement under the generic

statutes of the Medicare program. Until recently, many such programs were funded directly by

NIAAA.

Medicaid

The Medicaid program provides medical assistance to low-income individuals and families.

Treatment costs are shared by the States and the

Federal Government. Each participating State (all

States except Arizona) must provide certain basic

health services, according to Medicaid regulations. States, however, have substantial leeway

concerning specific coverage and interpretation

of regulations.

According to NIAAA, a major limitation in the

Medicaid program (by statute) is the exclusion of

Federal financial participation for care in psychiatric institutions for persons between the ages of

22 and 64 (216). With respect to other treatment

settings, Medicaid may theoretically provide more

options for treatment, although Medicaid statutes

do not specifically mention alcoholism treatment.

For example, States have considerable latitude in

defining physician participation. Services need not

be those incident to a physician’s, and clinics may

be reimbursed for the services of paraprofessional

rehabilitation counselors (130).

In 1978, Medicaid provided 6 percent ($5 million) of the total receipts of NIAAA-funded alcoholism treatment centers (100). Information concerning how much Medicaid provided to other alcoholism treatment services is not readily available (130). 1n one study, now several years old,

the investigators found that 4 of the 45 State plans

they reviewed referred specifically to treatment

for alcoholism: 2 of the 4 allowed coverage, 1 explicitly excluded coverage, and 1 limited coverage

to detoxification (37). Eight other States were

found to have plans providing a relatively favorable environment for inpatient alcoholism treatment coverage, and 23 States were found to have

plans providing a relatively favorable environment for outpatient services. Annual levels of

reimbursement for alcoholism treatment, when

reported, were generally low (e.g., in 1978:

$45,000 in Mississippi, $800,000 in Maine,

$1409,000 in Washington), except in New York

($32.1 million). A survey conducted by NIAAA

in 1976 (215) indicated that all State Medicaid
72 ● Health Technology case Study 22: The Effectiveness and Costs of Alcoholism Treatment

agencies reimbursed for inpatient care of organic

illnesses related to alcoholism, and a majority

reimbursed for outpatient care for such illnesses.

However, a substantially lower proportion of

State Medicaid agencies reimbursed for the treatment of alcoholism itself, especially when that

treatment was not in a medical setting (130).

Other Coverage

According to the the National Drug and Alcoholism Treatment Utilization Survey (NDATUS),

State governments provided $206 million in taxderived funds to alcoholism treatment centers in

1980, or 21.9 percent of the total funds (217).

Local governments contributed $97 million, or

10.3 percent of the total. Although the States constitute the largest single source of funding for

alcoholism services, they typically do not operate

treatment programs directly; the States’ role consists of allocating resources from various funding

sources to local programs (215). In addition, some

States (e.g., California) have developed statewide

alcoholism health insurance programs for their

employees; and increasingly, State legislatures are

considering mandating, or requiring as an option,

insurance coverage for alcoholism treatment. By

September 30, 1981, such legislation had been

enacted in 33 States, had been defeated in 14, was

being considered in 2, and had not been considered in only 1 State (283).

Prior to 1972, the explicit exclusion of alcoholism treatment was standard in private insurance

policies, although treatment was often covered

under other diagnoses (341). Even though progress

has been made, very few plans cover alcoholism

on the same basis as other illnesses (341). Generally, outpatient care must be provided at a hospital,

and is subject to a 50-percent copayment provision as well as an annual maximum. There is often

a lifetime maximum as well (341). These restrictions are reflected in the fact that while 21 to 85

percent of those served in NIAAA programs in

1976 had some form of health insurance, only 10

to 45 percent had coverage for alcoholism services

(69). The demographic makeup of the NIAAA

population makes it particularly likely to~ be

underserved (332). Private health insurance provided 19.6 percent of the funding for alcoholism

treatment units in the 1980 NDATUS (215).

CURRENT DEVELOPMENTS IN BENEFITS

FOR ALCOHOLISM TREATMENT

The current reimbursement system is undergoing rather significant change, as pressures

brought about by rapidly escalating costs and

reduced revenues have forced rethinking of reimbursement policy. The Medicare program,

which is the responsibility of the Federal Government, has come under close scrutiny along with

programs funded by other Federal legislation and

programs funded by State and private agencies.

New Medicare Guidelines

Policy with respect to Medicare reimbursement

is currently undergoing change. A series of studies

found that medically based inpatient care was far

more expensive than nonmedically based inpatient

or outpatient care (see reviews by 126, 223). Furthermore, as shown in chapter 5, research evidence had not proven the superiority of the more

expensive types of care.

As of September 1, 1982, the Health Care Financing Administration (HCFA) had implemented

new Medicare guidelines specifying treatment of

alcoholism in outpatient facilities and placing

limits on inpatient treatment and treatment consultation with family members. Earlier guidelines

had not specifically referred to hospital-based outpatient treatment; the new guidelines make it clear

that such services are covered when reasonable

and necessary and incident to a physician’s services. Outpatient treatment in free-standing clinics

is also made available, with the same restrictions.

The rules for inpatient treatment were relaxed

somewhat in that patients need not be experiencing severe medical complications at the time of
Ch. 7—Reimbursement issues ● 73

admission to be eligible for inpatient medical detoxification; however, the probability of such consequences occurring is necessary for reimbursement. The new Medicare guidelines also require

that coverage of alcohol detoxification and rehabilitation are to be addressed separately (i.e., a

patient who requires the hospital setting for detoxification may not necessarily require it for rehabilitation). Presumably, this requirement will reduce

the number of patient days spent in inpatient facilities.

The guidelines also require a closer look at the

safety and feasibility of chemical aversion therapy

in individual cases, a topic of some recent controversy. Currently, electrical aversion therapy is excluded from coverage on grounds of safety and

ineffectiveness although the Public Health Service

is coordinating an assessment of what is known

about the technique (98). Family counseling is to

be limited to those cases in which the primary purpose of the counseling is the treatment of the patient’s condition. Despite the fact that inflation

has effectively halved the benefits available under

Medicare (131), no changes were made in reimbursement rates.

Other Developments in

Treatment Financing

There have been no changes in Medicaid regulations, but because of changes in Federal grants,

States have more latitude in deciding how Federal

funds are spent; at the same time, they have fewer

funds. In fiscal year 1982, 35 percent of the subblock grant for alcoholism, drug abuse, and mental health had to be allocated to alcoholism; in

1983 and 1984, funds may be transferred by the

States from alcohol and drug abuse to mental

health (53). In fiscal year 1981, block grant allocations for alcohol, drug abuse, and mental health

services were found to be 20 percent lower than

the levels of predecessor categorical programs; in

the first 6 months of the new block grant program,

15 percent of alcoholism, drug abuse, and mental health grants had been drawn by the States

(110).

An interesting development is underway with

respect to a major Federal health program,

CHAMPUS. CHAMPUS has recently proposed

rules* to alter coverage of alcoholism treatment

services. The proposals are based, in part, on several panels established by CHAMPUS to consider

its mental health benefits. Under the proposed

rules, alcoholism treatment will be reimbursed for

emergencies or for complications on an inpatient

basis. For rehabilitative care, treatment will be

authorized in approved hospital-based or freestanding clinics. Included are a variety of treatments offered in residential or outpatient settings.

Aversion therapy is specifically not authorized

under the proposed rules.

With respect to private health insurance coverage, the trend is toward increased coverage in freestanding centers, provision of treatment equal to

that for other diseases, and provision of coverage

for family counseling and care. Model legislation

to this effect has been developed by the National

Association of Insurance Commissioners, although it has not been enacted (211). Under terms

of the model legislation, coverage would be a required option rather than a mandated inclusion.

“See Federal Register, 47(179):40644-40650.

RESEARCH DEVELOPMENTS

It is obviously difficult to determine at this point Medicaid benefits to alcoholism treatment prothe impact of the new Medicare regulations and viders with the emphasis on less costly settings,

other developments in treatment financing. The such as free-standing inpatient and outpatient

developments come, however, at the same time facilities and halfway houses. The demonstration

that HCFA and NIAAA are engaged in a joint al- has also been designed to test the effectiveness of

coholism services demonstration project. The pur- using nonmedical personnel in the treatment of

pose of the project is to expand Medicare and alcoholism.
74 ● Health Technology Case Study 22: The Effectiveness and Costs of Alcoholism Treatment

The project is a 4-year demonstration, with

HCFA financing treatment costs and NM providing administrative and evaluative services.

Seven States are participating in the program, and

approximately 120 providers are treating 5,200

patients in the first year. Although the original

intent of the demonstration was to fund programs

not eligible under the Medicare and Medicaid formulas, there will be some overlap because of the

recent changes in regulations.

Independent evaluation of the demonstration

program is being conducted (see 99; 154), alnot been agreed to by NIAAA and HCFA staff

(154). Because of the way in which the demonstration projects were funded, the design will necessarily be quasi-experimental; that is, patients will

not be randomly assigned to particular facilities,

service providers, or treatment modalities. Instead, the research will track patients from their

entry in the programs for a 2- to 3-year period.

It maybe possible, as well, to collect comparison

group data. The design calls primarily for collecting cost information about the use of medical services. Program experience for 2 years prior and 2

years subsequent to the inception of the demonthough at this point the specifics of the design have stration project will be assessed.

IMPLICATIONS OF CURRENT DEVELOPMENTS

Reimbursement systems, particularly the Medicare and Medicaid programs, have emphasized

inpatient, medically based treatment for alcoholism. Although there may be some patients for

whom such intensive treatment is necessary and

appropriate, it is also true that there are many

for whom it is not appropriate. In fact, because

of the stigma and time required to be treated in

an acute care facility, many will not seek such

treatment.

The evidence does not seem strong enough,

however, to support further restricting benefits

for inpatient services. Since it would not be possible to restrict acute care admissions, the likely

result of not funding residential or free-standing

treatment settings would probably be to increase

use of acute care facilities. This situation might

result if alcoholic patients were admitted under

other primary diagnoses.

The best strategies would seem to be ones that

encourage early outpatient treatment and continuing aftercare service on an outpatient basis (260).

Given both research evidence that does not clearly

indicate the necessity of inpatient care and the

lower cost of outpatient treatment, such a strategy

might lead to better use of health care resources.

The recent changes in Medicare guidelines appear

to be consistent with this direction (see, also, 81).

Reimbursement criteria for inpatient services are

tightened, while the availability of reimbursement

for outpatient treatment is increased. The new

guidelines also allow for nonmedically trained personnel to be more involved in treatment.

Although it appears that the new guidelines will

have positive effects in making the treatment system more efficient, it may be difficult to determine, even in a crude way, the impact of these

changes. They are being introduced nationwide

and at a time when the health care system and

the economy are undergoing major changes.

There will be no comparative data on whether and

how they are effective. In addition, because the

responsibility for a majority of alcoholism treatment services has been transferred from the Federal Government to the States, national data may

no longer be available. It may be unclear whether

the new regulations simply make possible the

treatment of a larger group of alcoholics and alcohol abusers, whether their use of the benefit represents changes in the diagnostic labels given patients, and whether they achieve the intended effect of the legislation.

In light of the above, the demonstration program being carried out by HCFA/NIAAA assumes even greater importance. It is unfortunate

that this study is not being done in a more experimental way and that plans for data collection are

not further developed at this point. The demon-
Ch. 7—Reimbursement Issues ● 75

stration project represents an important opportu- this opportunity may mean an even longer delay

nity to collect data about the optimum treatment in understanding the impact of existing policy.

for alcoholism. The failure to take advantage of

CONCLUSIONS

Alcoholism treatment has evolved slowly but

steadily over the last 30 years in conjunction with

the medical system. Although the evidence is not

without methodological problems, it seems clear

that alcoholism treatment has demonstrable benefits. The hypothesis that alcoholism treatment is

cost beneficial seems more strongly supported

than alternative hypotheses. However, the Medicare system needs adjustment in order to encourage less costly and more effective forms of treatment.

The most recent changes in Medicare guidelines

seem a necessary and correct step in this process.

It is possible, if inpatient treatment were further

restricted, that alcoholic patients would be admitted to acute care hospitals under other primary

diagnoses. The additional costs of such a development are clearly impossible to estimate. It would

seem reasonable not to change eligibility standards

further, however, until more information is available to indicate the effects of recent evolutionary

changes in the reimbursement system. To the extent that research evidence can be developed (111,

144), reimbursement decisions can be made with

more confidence.
Appendix

,
Appendix.— Health Program Advisory Committee

and Acknowledments

HEALTH PROGRAM ADVISORY COMMITTEE

Sidney S. Lee, Chair

Michael Reese Hospital and Medical Center

Stuart H. Altman

Florence Heller School

Brandeis University

Carroll L. Estes

Department of Social and Behavioral Sciences

School of Nursing

University of California, San Francisco

Rashi Fein

Department of Social Medicine and Health Policy

Harvard Medical School

Melvin A. Glasser

Committee for National Health Insurance

Patricia King

Georgetown Law Center

Joyce C. Lashof

School of Public Health

University of California, Berkeley

Margaret Mahoney

The Commonwealth Fund

Frederick Mosteller

Department of Health Policy and Management

School of Public Health

Harvard University

Mitchell Rabkin

Beth Israel Hospital

New York

Dorothy P. Rice

Department of Social and Behavioral Sciences

School of Nursing

University of California, San Francisco

Richard K. Riegelman

George Washington University

School of Medicine

Walter L. Robb

Medical Systems Operations

General Electric

Frederick Robbins

Institute of Medicine

Rosemary Stevens

Department of History and Sociology Science

University of Pennsylvania

79
.

80 ● Health Technology Case Study 22: The Effectiveness and Costs of Alcoholism Treatment

—

. .

ACKNOWLEDGMENTS

The development of this case study was greatly aided by the advice and review of a number of people in

addition to the Advisory Panel for the study on “Medical Technology and Costs of the Medicare Program” and

the Health Program Advisory Panel. OTA staff and principal investigators would like to express their appreciation especially to the following individuals:

Richard Adelson, Veterans Administration

Loran D. Archer, National Institute on Alcohol

Abuse and Alcoholism; Alcohol, Drug Abuse,

and Mental Health Administration

Thomas Babour, University of Connecticut School

of Medicine

Robert J. Bednarek, St. Benedict’s Hospital, Utah

Robert Berenson, Washington, D.C,

Steven Berglas, McLean Hospital, Mass.

Sheila g. Blume, New York State Division of

Alcoholism and Alcohol Abuse

James P. Boland, Policy Analysis Inc., Brookline,

Mass.

Edward Carels, Comprehensive Care Corp.

Raymond M. Costello, University of Texas

Dale P. Dirks, Health and Medicine Counsel of

Washington, Inc.

Harley M. Dirks, Health and Medicine Counsel of

Washington, Inc.

Fritz R. Dixon, State of Idaho Department of

Health and Welfare

Mary Jean Duckett, Health Care Financing

Administration, Department of Health and

Human Services

Richard N. Ells, Seabrook House

Chad D. Emrick, Veterans Administration Medical

Center, Denver, Colo.

Michael Feinstein, The National Association of

Private Psychiatric Hospitals

Michael Q. Ford, National Association of

Alcoholism Treatment Programs, Inc.

Frederick V. Glaser, Addiction Research Foundation

Lauren Goldberg, Beth Israel Hospital, Mass.

Frederick H. Graefe, Perito, Duerk, Carlson &

Pinco, P.C.

Dick Gregory, Oklahoma State Department of

Mental Health

Meredith Hanson, Kings County Hospital, N.Y.

Tony Hausner, Health Care Financing

Administration, Department of Health and

Human Services

Richard Jaffe, Health Care Financing

Administration, Department of Health and

Human Services

James C. Kincannon, University of Minnesota

Benjamin Kissen, Brooklyn Heights, N.Y.

Philip E, Kubzansky, Boston University

Gerald L. Klerman, Harvard Medical School and

Massachusetts General Hospital

John C. Letcher, Jr., Washington, D.C.

Wendy L. Lipton, Texas Christian University

Bryan R. Luce, Health Care Financing

Administration, Department of Health and

Human Services

Gabriel O. Manasse, Veterans Administration

Medical Center, Tucson, Ariz.

Richard B. Marrin, Ford, Marrin, Esposito

& Witmeyer

Joseph D. Matarazzo, University of Oregon School

of Medicine

William Mayer, Alcohol, Drug Abuse, and Mental

Health Administration

Don A. McDonald, Eastern Washington

Alcoholism Center, Spokane, Wash.

A. Thomas McLellan, Veterans Administration

Medical Center, Philadelphia, Penn.

Roger E. Meyer, University of Connecticut

Health Center

Jack H. Mendelson, Harvard Medical School and

McLean Hospital

Sheldon I. Miller, Advanced Health Systems, Inc.

Barrie Montague, National Institute on Alcohol

Abuse and Alcoholism; Alcohol, Drug Abuse,

and Mental Health Administration

E, Mansell Pattison, Medical College of Georgia

Mary Pendrey, Veterans Administration Medical

Center, San Diego, Calif.

J. Michael Polich, The Rand Corp.

Eck G. Prud’homme, Schick Shadel

Hospital, Fort Worth, Tex.

Joseph Pursch, Comprehensive Care Corp.

Susan Solomon, National Institute on Alcohol

Abuse and Alcoholism; Alcohol, Drug Abuse,

and Mental Health Administration

Barry Stimmelf Mount Sinai School of Medicine

Stephen Stollmack, ANALOGS’ Technical

Consultants, Inc.
Appendix-Health Program Advisory Committee and Acknowlegments 81

—

Diana Tabler, National Institute on Alcohol Abuse Donald A. Young, Health Care Financing

and Alcoholism; Alcohol, Drug Abuse, and Administration, Department of Health and

Mental Health Administration Human Services

Barry S. Tuchfeld, Texas Christian University

Ray Wagner, Civilian Health and Medical

Programs for the Uniformed Services

The authors of the cast study would also like to acknowledge the assistance provided by the following individuals at Boston University:

Susan Moltz

Kuuipo Nortman

Michael Schmitz
,
References

1. Aaron, P., and Musto, D., “Temperance and

Prohibition in America: A Historical Review,” in

Alternative Policies Affecting the Prevention of

Alcohol Abuse and Alcoholism (Washington,

D. C.: National Academy of Sciences, 1981).

2. Abad, V., and Suarez, J., “Cross-Cultural

Aspects of Alcoholism Among Puerto Ricans, ”

in Proceedings of the Fourth Annual Alcoholism

Conference of the NL4AA, M. E. Chafetz (cd. )

(Rockville, Md.: National Institute on Alcohol

Abuse and Alcoholism, Alcohol, Drug Abuse,

and Mental Health Administration, 1975).

3. Alcocer, A. A., “Chicano Alcoholism, ” unpublished paper, California State University,

1975.

4. Alcohol, Drug Abuse, and Mental Health Administration, Department of Health and Human

Services, ADAMHA Data Book, DHHS publication No. (ADM) 81-662, 1980.

5. Alcoholics Anonymous, “Profile of an AA Meeting” (New York: Alcoholics Anonymous World

Service, Inc., 1972).

6. Alibrandi, T., Young Alcoholics (Minneapolis,

Minn.: Comp Care, 1978).

7. American Medical Association, Manual on AZcoholism (Chicago: AMA, 1977).

8. American Psychiatric Association, Diagnostic

and Statistical Manual of Mental Disorders (3d

cd. ) (Washington, D. C.: APA, 1980).

9. Anderson, W., and Ray, O., “Abstainers, NonDestructive Drinkers and Relapsers: 1 Year After

a 4 Week Inpatient Group-Oriented Alcoholism

Treatment Program, “ in Currents in Alcoholism

(vol. 2), F. Seixas (cd.) (New York: Grune &

Stratton, 1977).

10. Annis, H. M., and Smart, R. G., “Arrests, Readmission, and Treatment Following Release From

Detoxification Centers, ” j. Stud. Al. 39:1276,

1978.

11. Archer, L., “A Review of Progress in Development of Health Insurance Coverage for Alcoholism Treatment,” A). Health & Res. World 5:4,

1981.

12. Armor, D., Johnson, P., Polich, S., et al., Trends

in U.S. Adult Drinking Practices, contract No.

(ADNl)281-76P0020, summary report prepared by

the Rand Corp. (Santa Monica, Calif. ) for the

National Institute on Alcohol Abuse and Alcoholism, Alcohol, Drug Abuse, and Mental Health

Administration, 1977.

13, Armor, D., Polich, J. M., and Stambul, H. B.,

Alcoholism and Treatment (New York: John

Wiley & Sons, 1978).

14. Armstrong, J. D., “The Search for the Alcoholic

Personality,” Ann. Amer. Acad. Polit. Sci.

315:40, 1958.

15. Azrin, N. H. “Improvements in the Community

Reinforcement Approach to Alcoholism,” Behav.

Res. Ther. 14(5):334, 1976.

16. Baekeland, F., “Evaluation of Treatment Methods

in Chronic Alcoholism, ” in Treatment and Rehabilitation of the Chronic A]cohoZic, B. Kissin

and H. Begleiter (eds. ) (New York: Plenum Press,

1977).

17. Baekeland, F., Lundwall, L., and Kissin, B.,

“Correlates of Outcome in Disulfiram Treatment

of Alcoholism,” J IVerv. Merit. Dis. 153:1, 1971.

18. Baekeland, F., Lundwall, L., and Kissin, B.,

“Methods for the Treatment of Chronic Alcoholism: A Critical Appraisal,” in Research Advances in Alcohol and Drug Problems, vol. II,

Y. Israel (cd. ) (New York: John Wiley & Sons,

1975).

19. Bales, R, F., “Cultural Differences in Rates of

Alcoholism,” Q. J. Stud. AZ. 6:480, 1946.

20. Ballard, R. G., “The Interaction Between Marital

Conflict and Alcoholism as Seen Through

MMPI’s of Marriage Partners,” Amer. J Orthopsychiat. 29:528, 1959.

21. Bandura, A., Principles of Behavior Modifkation

(New York: Holt, Rinehart & Winston, 1969).

22. Barry, H,, “Psychological Factors in Alcoholism,”

in The Biology of Alcoholism: Clinical Pathology, B. Kissin and H. Begleiter (eds. ) (New

York: Plenum Press, 1974).

23. Becker, C. E., “Pharrnacotherapy in the Treatment of Alcoholism, ” in The Diagnosis and

Treatment of AZcohoZism, J. H. Mendelson and

N. K. Mello (eds.) (New York: McGraw-Hill

Book Co., 1979).

24. Beckman, C. J., and Kocel, K. M., “The Treatment-Delivery System and Alcohol Abuse in

Women: Social Policy Implications, ” J Soc.

Issues 38:139, 1982.

25. Begleiter, H., and Platz, A., “The Effects of Alcohol on the Central Nervous System in

Humans, ” in The Biology of Alcoholism:

Physiology and Behavior, B. Kissin, and H.

Begleiter (eds.) (New York: Plenum Press, 1972).

26. Beigel, A., and Ghertner, S., “Toward a Social

Model: An Assessment of Social Factors Which

Influence Problem Drinking and Its Treatment, ”

in The Biology of Alcoholism: Vol. 5 Treatment

and Rehabilitation of the Chronic Alcoholic, B.

Kissin and H. Begleiter (eds.) (New York: PIenum

Press, 1979).

85
86 ● Health Technology case Study 22: The Effectiveness and Costs of Alcoholism Treatment

27.

28,

29,

30.

31.

32.

33.

34.

35<

3 6

37.

38.

39.

Berglas, S., and Jones, E. E., “Drug Choice as a

Self- Handicapping Strategy in Response to Noncontingent Success, ”J. Pers. & Soc. Psychol.

36:405, 1978.

Berry, R. E., Jr., and Boland, J. P., The Economic

Cost of Alcohol Abuse (New York: Free Press,

1977).

Berry, R. E., Jr., Boland, J. P., Smart, C. N., et

al., The Economic Costs of Alcohol Abuse and

Alcoholism—1975, contract No. (ADM)

281-76-0016, final report prepared by Policy

Analysis (Boston) for National Institute on

Alcohol Abuse and Alcoholism, Alcohol, Drug

Abuse, and Mental Health Administration,

August 1977.

Billet, S. L., “The Treatment of Alcoholism:

What Do We Do About Long-Term Sedatives, ”

Med. Ann. D. C. 33:612, 1964.

Bixler, J. B., and Hathaway, J. J., Policy Directions for Alcoholism Services in Illinois: The Application of Research Fidings Concerning the Effectiveness of Treatment to Plaming and Funding

Alcoholism Services, presented at the Third National Conference on Need Assessment in Health

and Human Service Systems Louisville, Ky.,

Mar. 19, 1981.

Blanc, H. T., “Issues in the Evaluation of Alcoholism Treatment, ” Prof. Psychol. 8:593, 1977.

Blanc, H. T., The Personality of Alcoholic,

Guises of Dpendency (New York: Harper &

Row, 1968).

Blanc, H. T., and Hewitt, L. E., Mass Media,

Public Education and Alcohol: A State of the Art

Review, contract No. NIA-76-12, prepared by the

University of Pittsburgh for National Institute on

Alcohol Abuse and Alcoholism, Alcohol, Drug

Abuse, and Mental Health Administration, 1977.

Blum, E, M., and Blum, R. H., Alcoholism:

Modern Psychological Approaches to Treatment

(San Francisco: Jossey-Bass, 1967).

Blume, S. B., “Psychiatric Problems of Alcoholic

Women, ” in Alcoholism and Clinical Psychiatry,

J. Solomon (cd. ) (New York: Plenum Press,

1982).

Booz-Allen & Hamilton, Inc., Alcoholism Funding Study: Evaluation of Sources of Funds and

Barriers to Funding Alcoholism Treatment Programs (Washington, D. C.: Booz-Allen, 1978).

Bourne, P, G., and Light, E., “Alcohol Problems

in Blacks and Women, ” in The Diagnosis and

Treatment of Alcoholism, J. H. Mendelson and

N. K. Mello (eds. ) (New York: McGraw-Hill

Book Co., 1979).

Bowen, M., “Alcoholism as Viewed Through

40.

41.

42.

43.

44.

45.

46.

47.

48.

49.

50.

51.

52.

53.

54.

Family Systems Theory and Psychotherapy, ”

Ann. N. Y. Acad. Sci, 233:115, 1974.

Brandsma, J. M.Outpatient Treatment of ,

Alcoholism: A Review and Comparative Study

(Baltimore: University Park Press, 1980).

Braucht, M. G.“Problem Drinking Among ,

Adolescents: A Review and Analysis of Psychosocial Research, ”in Special Population Issues,

Alcohol and Health Monograph No. 4 (Rockville,

Md.: National Institute on Alcohol Abuse and

Alcoholism, Alcohol, Drug Abuse, and Mental

Health Administration, 1981).

Bromet, E., Moos, R., and Bliss, F., “The Social

Climate of Alcoholism Treatment Programs, ”

Arch. Gen. Psychiat. 33:910, 1976.

Bromet, E., Moos, R., Bliss, F., et al., “Treatment

Experiences of Alcoholic Patients: An Analysis

of Five Residential Alcoholism Programs, ” ht.

J. Addict. 12:953, 1977.

Bureau of the Census, Department of Commerce,

1980 Census of population; 1980 supplementary

Reports, document No. PC 80-51-3 (Washington,

D. C.: Department of Commerce, 1980).

Bureau of the Census, Department of Commerce,

Statistical Abstracts of the U. S., Library of Congress card No. 4-1-8089, 1981.

Caddy, G. R., “Problems in Conducting Alcohol

Treatment Outcome Studies: A Review,” in Evaluating Alcohol and Drug Treatment Effectiveness, L. C. Sobell, M. B. Sobell, and E. Ward

(eds.) (New York: Pergamon Press, 1978).

Caddy, G. R., “Toward a Multivariate Analysis

of Alcohol Abuse, ” in Alcoholism: New Directions in Behavior Research and Treatment, P. E.

Nathan, G. A., Marlatt, and T. Lorberg (eds. )

(New York: Plenum, 1980).

Cadoret, R., and Winokur, G., “Depression in

Alcoholism,” Ann. N. Y Acad. Ski. 233:34, 1.972.

Cahalan, D., Problem Drinkers (San Francisco:

Jossey-Bass, 1970).

Cahalan, D., and Room, R., Problem Drinking

Among American Men, Monograph No. 7 (New

Brunswick, N. J.: Rutgers Center of Alcohol Studies, 1974).

Cahalan, D., Cisin, I. H., and Crossley, H. M.,

American Drinking Practices (New Brunswick,

N. J.: Rutgers Center of Alcohol Studies, 1969).

Cahn, S., The Treatment of Alcoholics: An Evaluative Study (New York: Oxford University

Press, 1970).

Califano, J. A., Jr., The 1982 Report on Drug

Abuse and Alcoholism (New York: Warner

Books, 1982).

Camp, J. M., and Kurtz, N. R., “Redirecting
References ● 8 7

55<

56,

57<

58,

59

60.

61.

62.

63.

64.

65.

66.

67.

68.

Manpower for Alcoholism Treatment, ” in Prevention, Intervention and Treatment: Concerns

and Models, Alcohol and Health Monograph No.

3 (Rockville, Md.: National Institute on Alcohol

Abuse and Alcoholism, Alcohol, Drug Abuse,

and Mental Health Administration, 1982).

Cannon, D. S., Baker, T. B., and Wehl, C. K.,

“Emetic and Electric Shock Alcohol Aversion

Therapy: Six- and Twelve-Month Follow-Up,” J.

Cons. C]in. Psychol. 49:360, 1981.

Cappell, H., and Herman, C. P., “Alcohol and

Tension Reduction: A Review, ” Q. J. Stud. Al.

33:33, 1972.

Cautela, J. R., “The Treatment of Alcoholism by

Covert Sensitization, ” Psychotherapy: Theory,

Research, and Practice 7:86, 1970.

Centers for Disease Control, Morbidity and Wortality Weekly Report, 1982, as cited in the Boston

Globe, summer 1982.

Chafetz, M. E., and Demone, H. W., Jr., Alcoholism and Society (New York: Oxford University Press, 1962).

Chick, J., “Do Alcoholics Recover?” Z?r. Med. J.

285:3, 1982.

Cicchinelli, L. F., Binner, P. R., and Halpern, J.,

“Output Value Analysis of an Alcoholic Treatment Program, ” J. Stud. Al. 39:435, 1978.

Clare, A. W., “How Good is Treatment?” in Alcoholism: New Knowledge and New Responses,

G. Edwards and M. Grant (eds. ) (Baltimore:

University Park Press, 1976).

Clark, W. B., “Conceptions of Alcoholism: Consequences for Research, ” Addict. Dis. 1 :395,

1975.

Clark, W. B., and Midanik, L., “Alcohol Use and

Alcohol Problems Among U.S. Adults, ” in Alcohol Consumption and Related Problems, Alcohol and Health Monograph No. 1 (Rockville,

Md.: National Institute on Alcohol Abuse and

Alcoholism, Alcohol, Drug Abuse, and Mental

Health Administration, 1981).

Conger, J, J., “Alcoholism: Theory, Problem and

Challenge: Reinforcement Theory and Dynamics

of Alcoholism, ” Q. J. Stud. Al., 17:269, 1956.

Conger, J. J., “Reinforcement Theory and the

Dynamics of Alcoholism, ” presented at t~e Annual Meeting of the American Psychology Association, San Francisco, September 1955.

Cook, T. D., and Campbell, D. T., Quasi-Experimentation: Design and Analysis Issues for Field

Settings (Chicago: Rand McNally, 1979).

Cooper, A. M., Sobell, M. B., Sobell, L. C., et

al., “Validity of Alcoholics’ Self-Reports: Duration Data,” Int. J. Addict. 16:401, 1981.

69.

70,

71.

72.

73.

74.

75.

76.

77.

78.

79.

80.

81.

Cooper, M. L., Private Health Insurance Benefits

for Alcoholism Drug Abuse and Mental Illness

(Washington, D. C.: The George Washington

University, Intergovernmental Health Policy

Project, 1979).

Corder, B. G., Corder, R. F., and Laidlaw, N.

D., “An Intensive Treatment Program for Alcoholics and Their Wives, ” Q. J. Stud. AZ. 33:1144,

1972.

Costello, R. M., “Alcoholism Treatment and

Evaluation,” ht. J. Addict. 10:251, 1975.

Costello, R. M., “Alcoholism Treatment and

Evaluation: In Search of Methods, 11, Collation

of Two Year Follow-Up Studies, ” Int. J. Addict.

10:857, 1975.

Costello, R. M. “Evaluation of Alcoholism Treatment Programs, “ in Encyclopedic Handbook of

Alcoholism, E. M. Pattison and E. Kaufman

(eds.) (New York: Gardner Press, 1982).

Costello, R. M., Biever, P., and Baillargeon, J.

G., “Alcoholism Treatment Programming: Historical Trends and Modern Approaches, ” Alcoholism: Clin, Exper. Res. 1(4):311, 197’7.

Costello, R. M., Baillargeon, J. G., Biever, P.,

et al., “Second-Year Alcoholism Treatment Outcome Evaluation With a Focus on MexicanAmerican Patients, ” Am. J. Drug Alcohol Abuse

6(1):97, 1979.

Crawford, J. J., and Chalupsky, A. B., “The Reported Evaluation of Alcoholism Treatments,

1968-1971: A Methodological Review, ” Addict.

Behav. 2:63, 1977.

Cronkite, R. C., and Moos, R. H., “Evaluating

Alcohol Treatment Programs: An Integrated Approach,” J. Consult. Clin. Psychol. 46:1105,

1978.

Cruze, A. M., Hardwood, H. J., Kristiansen, P.

L., et al., Economic Costs to Society of Alcoho/

and Drug Abuse and Mental Illness, 1977 final

report prepared by the Research Triangle Institute

for the Alcohol, Drug Abuse, and Mental Health

Administration, Department of Health and Human Services, October 1981.

Davies, D. L., Shepherd, M., and Myers, E.,

“The Two-Years’ Prognosis of 50 Alcohol Addicts

After Treatment in Hospital, ” Q. J. Stud. Al.

17:458, 1956.

Department of Health and Human Services, draft

report to the U.S. Congress on Federal Activities

on Alcohol Abuse and Alcoholism, FY 1979,

1980.

Diesenhaus, H., “Current Trends in Treatment

Programing for Problem Drinkers and Alcoholics, ” in Prevention, Intervention, and Treat-
88 ● Health Technologyy Case Study 22: The Effectiveness and Costs of Alcoholism Treatment

82.

83<

8 4

85.

86.

87.

88.

89.

90.

91.

92.

93.

94.

95.

ment: Concerns and Models, Alcohol and Health

Monograph No. 3 (Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism, Alcohol, Drug Abuse, and Mental Health Administration, 1982).

Donovan, J. E., and Jessor, R., “Adolescent Problem Drinking: Psychosocial Correlates in a National Sample Study,” J Stud. Al. 39(9):1506,

1978.

Doroff, D. R., “Group Psychotherapy in Alcoholism,” in The Biology of Alcoholism: VOl. 5

Treatment and Rehabilitation of the Chonic Alcoholic (New York: Plenum Press, 1977),

Dunn, J. H., and Clay, M. L., “Physicians Look

at the General Hospital Alcoholism Service, ” Q.

J Stud. Al. 32:162, 1971.

Eckardt, M. H., Harford, T. C., Kaelber, C. T.,

et al., “Health Hazards Associated With Alcohol

Consumption, ” J. A.M.A. 246(6):648, 1981.

Edwards, D., Bucky, S., Cohen, P., et al., “Primary and Secondary Benefits From Treatment for

Alcoholism, ” Amer. J. Psychiat. 134(6):682,

1977.

Edwards, G., “Alcoholism: The Analysis of

Treatment, ” in Alcohol and Alcoholism, R. E.

Popham (cd. ) (Toronto: University of Toronto

Press, 1970).

Edwards, G., “Hypnosis in Treatment of Alcohol

Addiction: Controlled Trial, With Analysis of

Factors Affecting Outcome, ” Q. J. Stud. Al.

27:221, 1966.

Edwards, G., and Guthrie, S., “A Comparison

of Inpatient and Outpatient Treatment of Alcohol

Dependence, ” Lancet 1;467, 1966.

Edwards, G., and Guthrie, S., “A Controlled

Trial of Inpatient and Outpatient Treatment of

Alcohol Dependency,” Lancet a1:555, 1967.

Edwards, G., Orford, J., Egert, S., et al.,

“Alcoholism: A Controlled Trial of ‘Treatment’

and ‘Advice’, ” J. Stud. Al. 38:1004, 1977.

Emrick, C. D., “Evaluation of Alcoholism Therapy Methods,” in Encyclopedic Handbook of Alcohokn, E. M. Pattison and E. Kaufman (eds. )

(New York: Gardner Press, 1982).

Emrick, C. D., “Perspectives on Clinical Research: Relative Effectiveness of Alcohol Abuse

Treatment,” Fare. Comm. Health 2:71, 1979.

Emrick, C. D., “A Review of Psychologically

Oriented Treatment of Alcoholism: I. The Use

and Interrelations of Outcome Criteria and

Drinking Behavior Following Treatment, ” Q. J.

Stud. Al. 35:523, 1974.

Emrick, C. D., “A Review of Psychologically

96,

97.

98.

99.

100,

101.

102.

103.

104.

105.

106.

107.

1

Oriented Treatment of Alcoholism: II. The Relative Effectiveness of Different Approaches and

the Effectiveness of Treatment Versus No Treatmerit, ” J. Stud. Al. 36:88, 1975.

Emrick, C. D., and Stilson, D. W., “The Rand

Report: Some Comments and a Response,” J.

Stud. Al. 38(1):152, 1977.

Ewing, J. A., and Fox, R. E., “Family Therapy

of Alcoholism, ” in Current Psychiatric Therapies,

J. H. Masserman (cd.) (New York: Grune &

Stratton, 1968).

Federal Register, “Notices,” 47:38837, Sept. 1,

1982.

Feinstein, P. H., Statement on Medicare Coverage of Alcohol Treatment before the Senate

Finance Committee, Subcommittee on Health,

July 27, 1982.

Ferguson, L., and Kirk, J., Statistical Report: National Institute on Alcohol Abuse and Alcoholism-Funded Treatment Programs, Calendar Year

1978 (Rockville, Md.: National Institute on

Alcohol Abuse and Alcoholism, Alcohol, Drug

Abuse, and Mental Health Administration, 1979).

Fine, E. W., and Steers, R. A., “The Relationship Between Alcoholism and Depression in Black

Men, ” paper presented at the National Council

on Alcoholism Conference, Washington, D. C.,

May 1976.

Foster, F. M., Horn, J. L., and Wanberg, K. W.,

“Dimensions of Treatment Outcome: A Factor

Analytic Study of Alcoholics’ Response to a Follow-Up Questionnaire,” Q. J. Stud. Al 33:1079,

1972.

Fox, R., “Treatment of Alcoholism,” in Alcoholism: Basic Aspects and Treatment, H. E. Himwich (cd.), publication No. 47 (Washington,

D. C.: American Association for the Advancement of Science, 1957).

Frank, J. D., “Therapeutic Components of Psychotherapy, ” J. Nerv. Mental Disord. 159:325,

1974.

Fusillo, M., and Skoch, E. M., “The Psychiatric

Hospital Treatment of Alcoholism: A Multidisciplinary Approach, ” J. Nat. Assn. Priv. Psych.

Hosp. 12:97, 1981.

Galanter, M., and Sperber, J., “General Hospitals

in the Alcoholism Treatment System, ” in Encyclopedic Handbook of Alcoholism, E. M. Pattison and E. Kaufman (eds. ) (New York: Gardner Press, 1982).

Gallant, D. M., “Evaluation of Compulsory

Treatment of the Alcoholic Municipal Court Offender,” in Recent Advances in Studies of
References . 89

108.

109<

110,

111<

112,

113.

114,

115,

116,

117.

118.

119.

120(

Alcoholism: An Interdisciplinary Sytnposium, N.

K. Mello and J. H. Mendelson (eds.) (Rockville,

Md.: National Institute on Alcohol Abuse and

Alcoholism, Alcohol, Drug Abuse, and Mental

Health Administration, 1971).

Gallant, D. M., “Psychiatric Aspects of Alcohol

Intoxication, Withdrawal, and Organic Brain

Syndromes, ” in Alcoholism and ClinicaZ Psychiatry (New York: Plenum Press, 1982).

Gellman, G. I. P., The Sober Alcoholic: An

Organizational Analysis of Alcoholic Anonymous (New Haven, Corm.: College and University Press, 1964).

General Accounting Office, U.S. Congress, Early

observations on Block Grant Implementation,

report to the Congress by the Comptroller General of the United States, GAO IGGD-82-79

(Washington, D. C.: GAO, Aug. 24, 1982).

General Accounting Office, U.S. Congress,

“Progress and Problems in Treating Alcohol

Abusers, ” HRD-76-163 (Washington, D. C.:

GAO, 1977).

Gerard, D. L., and Saenger, G., “Outpatient

Treatment of Alcoholism: A Study of Outcome

and Its Determinants, ” Brookside Monograph

No. 4 (Toronto: University of Toronto Press,

1966).

Gerard, D. L., Saenger, G., and Wile, R., “The

Abstinent Alcoholic,” Arch. Gen. Psychiat. 6:83,

1962.

Gibson, S., and Becker, J., “Alcoholism and Depression: The Factor Structure of Alcoholics’ Response to Depression Inventories, ” Q. J. Stud Al.

34:400, 1973.

Glaser, F. B., “Anybody Got a Match?” in Alcoholism Treatment: Finding New Directions, G.

Edwards and M. Grant (eds. ) (London: Croom

Helm, 1980).

Gomberg, E. S., “Historical and Political Perspectives: Women and Drug Use,”J. Soc. Iss. 38(2):9,

1982.

Goodwin, D. W., Is Alcoholism Hereditary?

(New York: Oxford University Press, 1976).

Goodwin, D. W., Othmer, E., and Halikas, J. A.,

“Loss of Short-Term Memory as a Predictor of

the Alcoholic ‘Black-Out’,” Nature 227:201, 1970.

Goodwin, D. W., Schuksinger, F., Herrnanse, L.,

et al., “Alcohol Problems in Adoptees Raised

Apart From Alcoholic Biological Parents,” Arch.

Gen. Psychiat, 28:238, 1973.

Graham, G., Statement on Alcohol Treatment

Coverage Under Medicare before the Senate

Committee on Finance, Subcommittee on Health,

July 27, 1982.

1214

122,

123,

124,

125.

126.

127.

128.

129.

130.

Greeley, A., McCready, W., and Thiesen, G.,

Ethnic Drinking Subcultures (New York: Praeger,

1980).

Gromberg, E. S. L., “Historical and Political Perspective: Women and Drug Use, ” J Soc. Issues

38:9, 1982.

Gross, M., “The Relation of the Pituitary Gland

to Some Symptoms of Alcoholic Intoxification

and Chronic Alcoholism, ” Q. J. Stud. Al. 6:25,

1945.

Hall, S. M,, and Hall, R. G., “Maintaining

Change, ” in Comprehensive Handbook of Behavorial Medicine, J. M, Ferguson and C. B.

Taylor (eds.) (New York: Spectrum, 1980).

Hall, D. C., Chaikan, K., and Piland, B., A

Review of the Problem Drinking Behavior Literature Associated With the Spanish-Speaking Pop

u]ation Group, contract No. 281-76-0025, final

report prepared by the Stanford Research Institute, Menlo Park, Calif., for National Institute

on Alcohol Abuse and Alcoholism, Alcohol,

Drug Abuse, and Mental Health Administration,

May 1977.

HalIan, J. B., “Health Insurance Coverage for

Alcoholism: A Review of Costs and Utilization,”

Al Health. World 5(4):16, 1981.

Harford, T. C., “A National Study of Adolescent

Drinking, Behavior Attitudes, and Correlates, ”

J. Stud. Al. 37:1747, 1976,

Hayman, M., Alcoholism: Mechanism and Management (Springfield, Ill.: Charles C. Thomas,

1966).

Hayman, M., “Current Attitudes Towards Alcoholism of Psychiatrists in Southern California, ”

Am. J. Psychiat. 112:484, 1956.

Health Care Financing Administration, Department of Health, Education, and Welfare, Coverage of Alcoholism Treatment Sevices Titles XVIII

and XIX (Washington, D. C.: HCFA, Aug. 24,

1979).

131. Health Care Financing Administration, Depart132,

133.

134.

—

ment of Health and Human Services, Medicare

Intermediary Manual, Part 3—Claims Process,

transmittal No. 992, HCFA publication No. 13-3

(Washington, D. C.: HCFA, August 1982).

Heather, N., and Robertson, I., Controlled

Drinking (London: Methuen, 1981).

Hertzman, M., and Montague, B., “Cost-Benefit

Analysis and Alcoholism,’; J. Stud. Al. 38:371,

1977.

Higgins, R. L., and Marlatt, G. A., “Fear of Interpersonal Evaluation as a Determinant of

Alcohol Consumption in Male Social Drinkers, ”

1. Abnormal Psvchol. 6:644. 1975.
90 . Health Technology Case .$tudy 22: The Effectiveness and Costs of Alcoholism Treatment

135,

136,

137.

138,

139,

140,

141.

142.

143<

144.

145.

146.

147.

148.

Hill, M. J,, and Blanc, H. T., “Evaluation of

Psychotherapy With Alcoholics,” Q. J Stud. Al.

28:76, 1967,

Hill, M. J., and Blanc, H. T., “Issues in the

Evaluation of Alcoholism Treatment, ” Profess,

Psychol. 28:593, 1977.

Hodgson, T., and Meiners, M., Guidelines for

Cost-of-Illness Studies in the Public Health Service (Bethesda, Md.: Public Health Service Task

Force on Cost-of-Illness Studies, Department of

Health, Education, and Welfare, 1979).

Holder, H. D., and HalIan, J. B., Medical Care

and Alcoholism Treatment Costs and Utilization:

A Five-Year Analysis of the California Pilot Project to Provide Health lksurance Coverage for Alcoholism, contract No. ADM 281-79-0008 prepared by H-2, Inc., Chapel Hill, N. C., for National Institute on Alcohol Abuse and Alcoholism, Alcohol, Drug Abuse, and Mental Health

Administration, 1981.

Holder, H. D., and HalIan, J. B,, “A Study of

Health Insurance Coverage for Alcoholism for

California State Employees, ” unpublished report

to National Institute on Alcohol Abuse and Alcoholism, Alcohol, Drug Abuse, and Mental

Health Administration, December 1976,

Holland, R., Datta, K., and Izadi, B., et al,,

“Reliability of an Alcohol Self-Report Instrument,” J. Stud. Al. 40(1):142, 1979.

Horton, D., “The Functions of Alcohol in Primitive Societies: A Cross-Cultural Study, ” Q. J.

Stud. Al. 4:199, 1943.

Huberty, D. J., and Brandon, J. C., “Nonmedical

Alcohol Detoxification, “ in Encyclopedic Handbook of AZcohoZism, E. M. Pattison and E. Kaufman (eds. ) (New York: Gardner Press, 1982).

Imber, S., Schultz, E., Funderburk, F., et al.,

“The Fate of the Untreated Alcoholic, ” J. Nerv.

Merit. Dis. 162:238, 1976.

Institute of Medicine, National Academy of

Sciences, Alcoholism and Alcohol Abuse Related

Problems: Opportunities for Research (Washington, D. C.: National Academy Press, 1980).

Institute of Medicine, National Academy of

Sciences, Reliability of Hospital Discharge

Abstracts (Washington, D. C.: National Academy

of Sciences, 1980).

Irwin, T., “Attacking Alcohol as a Disease, ”

Today’s Health 46:21, 1968.

Jacobson, G, R., The Alcoholisms: Detection,

Diagnosis, and Assessment (New York: Human

Sciences Press, 1976).

Jacobson, G. R., Diagnosis and Assessment of

AZcohoZAbuse and Alcoholism, DHEW publication No. (ADM) 76-228 (Washington, D. C.: De149.

150.

151.

152.

153.

154.

155.

156.

157.

158.

159.

160.

161.

162.

163.

164.

partment of Health, Education, and Welfare,

1976).

Jellinek, E. M,, The Disease Concept of

Alcoholism (New Haven, Corm.: University

Press, 1960).

Jellinek, E. M., “Phases of Alcohol Addiction, ”

Q. J. Stud. Al. 13:673, 1952.

Jessor, R., and Jessor, S. L., “Adolescent Development and the Onset of Drinking, ” J. Stud. AI.

36:27, 1975.

Jessor, R., and Jessor, S. L., Problems in Behavior

and Psychosocial Development: A Longitudinal

Study of Youth (New York: Academic Press,

1977).

Johnson, P. B., “Sex Differences, Women’s Roles

and Alcohol Data, ” J. Soc. 1ss. 38:93, 1982.

Johnson & Associates, Inc., Evaluation of the

Medieare/Med”caid Alcoholism Services &monstra tion, contract No. 50-81-0049, report

prepared for the Office of Research and Demonstrations, Health Care Financing Administration,

1982.

Jones, E. E., and Berglas, S., “Control of Attributions About the Self Through Self-Handicapping

Strategies: The Appeal of Alcohol and the Role

of Underachievement, ” Pers. & Soc. Psychol.

&l]). 4:200, 1978.

Jones, K. R., “Sectarian Characteristics of

Alcoholics Anonymous, ” Sociology 4:181, 1970.

Jones, K. R., and Smith, D. W., “Recognition of

the Fetal Alcohol Syndrome in Early Infancy, ”

L.ancet 2:999, 1973.

Jones, K. R., and Vischi, T. R,, “Impact of

Alcohol, Drug Abuse and Mental Health Treatment on Medical Care Utilization: A Review of

the Research Literature,” Med. Care 17( Suppl. ):1,

1979.

Jones, M. C., “Personality Correlates and Antecedents of Drinking Patterns in Adult Males, ” J.

consult. Clin. Psychol. 32:2, 1968.

Justin, R. G., “Use of Routine Breath Alcclhol

Tests in the Diagnosis of Alcoholism in a Primary

Care Practice, ” J. Stud. AI. 40(1):145, 1979.

Kaij, L., Studies on the Etiology and Sequels of

Abuse of Alcohol (Lund: University of Lund,

1960).

Kane, G. P., I.nner-City Alcoholism (New York:

Human Sciences Press, 1981).

Kasl, S., and Colb, S., “Some Mental Health

Consequences of Plant Closing and Job Loss, ” in

Mental Health and the Economy, L. Ferman and

J. Gordus (eds.) (Kalamazoo, Mich.: W. E. UpJohn Institute, 1979).

Keller, M. A., “A Historical Overview of Alcohol

and Alcoholism, ” Cancer Res. 39:2822, 1979.
References . 91

165.

166.

167.

168.

169.

170.

171.

172.

173.

174.

175.

176.

177.

Kissin, B., and Begleiter, H. (eds. ), Treatment

and Rehabilitation of the Chronic Alcoholic (New

York: Plenum Press, 1977).

Kissin, B,, and Hanson, M,, “The Bio-PsychoSocial Perspective in Alcoholism,” in Alcoholism

and Clinical Psychiatry, J. Solomon (cd. ) (New

York: Plenum Press, 1982).

Kissin, B., Platz, A., and Su, W. H., “Social and

Psychological Factors in the Treatment of

Chronic Alcoholism,” J. Psych. Res. 8:13, 1970,

Klerman, G. L,, “Prevention of Alcoholism, ” in

Alcoholism and Clinical Psychiatry, J. Solomon

(cd. ) (New York: Plenum Press, 1982).

Kline, N. S., Wren, J. C., Cooper, T. B., et al.,

“Evaluation of Lithium Therapy in Chronic Alcoholism,” Clin. Med. 81:33, 1974.

Knight, R. P., “The Psychoanalytic Treatment in

a Sanatorium of Chronic Addiction to Alcohol, ”

J. A.M.A. 111:1443, 1938.

Kraft, T., and A1-Issa, I., “Alcoholism Treated

by Desensitization: A Case Study, ” Behav. Res.

Ther. 5:69, 1967.

Lazarus, A. A., “Towards the Understanding and

Effective Treatment of Alcoholism,” S. Afr. Med.

J. 39:736, 1965.

Leach, B., and Norris, F. L., “Factors in the Development of Alcoholics Anonymous (A. A.),” in

Treatment and Rehabilitation of the Chronic

Alcoholic, B. Kissin and H. Begleiter (eds. ) (New

York: Plenum Press, 1977).

Leatham, R. C., “A Report on the Etiology of

American Indian/Alaskan Native Alcoholism

and an Evaluation of the National Institute on

Alcohol Abuse and Alcoholism Supported American Indian/Alaskan Native Alcoholism Projects, ” paper submitted to the National Advisory

Council on Alcohol Abuse and Alcoholism, National Institute on Alcohol Abuse and Alcoholism, Alcohol, Drug Abuse, and Mental Health

Administration, Department of Health, Education, and Welfare, January 1978.

Leland, J., Firewater Myths: North American

Indian Drinking and Alcohol Addiction, Monograph No. 11 (New Brunswick, N. J.: Rutgers

Center of Alcohol Studies, 1976).

Leland, J., “North American Indian Drinking and

Alcohol Abuse, ” contract No, NIA-77-08(p), report prepared for National Institute on Alcohol

Abuse and Alcoholism, Alcohol, Drug Abuse,

and Mental Health Administration, April 1977.

Leon, R. L., “Maladaptive Interaction Between

Bureau of Indian Affairs, Staff and Clients, ” Am.

J. Qrthop. 35:723, 1965.

178.

179.

180.

181.

182.

183.

184<

185,

186.

187.

188.

189.

190.

191.

192.

193.

Lester, D., “A Biological Approach to the

Etiology of Alcoholism,” Q. J. Stud. Al 21:701,

1960.

Lisansky, E. S., “The Etiology of Alcoholism: The

Role of Psychological Predisposition,” Q. J. Stud.

Al 21:314, 1960.

Lisansky-Gomberg, E. S., “Etiology of Alcoholism,” J. Consult. & Clin. Psychol. 32:18, 1968.

Lovell, H. M., and Tintera, J. W., “Hypoadvenocorticism in Alcoholism and Drug Addiction,” ~riatrics 6:1, 2952,

Lovibond, S. H., and Caddy, G. R., “Discriminated Aversive Control in the Moderation

of Alcoholics’ Drinking Behavior, ” Behav. Ther.

1:437, 1970.

Luce, B. R., and Schweitzer, S. O., “Smoking and

Alcohol Abuse: A Comparison of Their Economic Consequences, “N. Eng. J. Med. 298:569, 1978.

Ludwig, A. M., Levine, J., and Stark, L. H., LSD

and Alcoholism: A Clinical tudy of Treatment

Efficacy (Springfield, Ill.: Charles C. Thomas,

1970).

Lunn, C. R., Remarks, unpublished paper presented at the Meeting of the Ontario Blue Cross

Symposium on Alcoholism, Toronto, May 1976.

MacAndrew, D., and Garfinkel, H., “A Consideration of Changes Attributed to Intoxication

as Common-Sense Reasons for Getting Drunk, ”

Q. J. Stud. Al. 23:252, 1962.

Maccoby, M., “Alcoholism in a Mexican Village,” in The Drinking Man, D. C. McClelland,

W. N. Davis, R. Kalin, et al. (eds.) (New York:

Free Press, 1972).

Madsen, W., “The Alcoholic Agringado, ” Am.

Anthropol. 66:355, 1964.

Mandell, W., “A Critical Overview of Evaluations of Alcoholism Treatment, ” Alcoholism:

Clin. & hper. Res. 3(4):315, 1979,

Marconi, J. T., “The Concept of Alcoholism, ” Q.

J. Stud. Al. 20:216, 1959.

Marlatt, G. A., “Craving for Alcohol, Loss of

Control, and Relapse: A Cognitive-Behavioral

Analysis, “ in Alcoholism: New Directions in Behavioral Research and Treatment, P. E. Nathan

and G. A. Marlatt (eds. ) (New York: Plenum

Press, 1978).

Marlatt, G. A., and Nathan, P. E. (eds. ), Behavioral Approaches to Alcoholism (New Brunswick, N. J.: Rutgers Center of Alcohol Studies,

1978),

McCord, W., McCord, J., and Judeman, J., Origins of Alcoholism (Stanford, Calif.: Stanford

University Press, 1960).
92 ● Health Technology case study 22: The Effectiveness and Costs of Alcoholism Treatment

194,

195.

196.

197,

198.

199.

200.

201.

202.

203.

204.

205.

206.

207.

208.

McGuire, T. G., “Measuring the Costs of Alcohol

Abuse,” in An Assessment of Statistics on Alcohol-Related Problems, prepared for The Distilled

Spirits Council of the United States, Inc. (New

York: Columbia University School of Public

Health, 1980).

McLelland, A. T., Luborsky, L., O’Brien, C. P.,

et al., “Is Treatment for Substance Abuse Effective?” J. A.M.A. 247:1423, 1982.

McLelland, A. T., O’Brien, C. P., Luborsky, L.,

et al., “Is Substance Abuse Treatment Effective?

Five Different Perspectives, ” Arch. Gen.

Psychiat. 1982.

Medical Times, “An Alcohol Abuse Manual for

Family Physicians, ” Medical Times, Special Issue,

103(6), 1975.

Medhus, A., “Mortality Among Female

Alcoholics,” Scand. J. Soc. Med. 3:111, 197s.

Mendelson, J. H., and Mello, N. K., “The Diagnosis of Alcoholism, ” in The Dagnosis and Treatment of Alcoholism, J. Mendelson and N. Mello

(eds.) (New York: McGraw-Hill Book Co., 1979).

Merry, J., Reynolds, C. M., Bailey, J,, et al.,

“Prophylactic Treatment of Alcoholism by Lithium Carbonate, ” Lancet 2:481, 1976.

Moore, R. A., “The Involvement of Private

Psychiatric Hospitals in Alcoholism Treatment, ”

in Ehcyclopedic Handbook of Alcoholism, E. M.

Pattison, and E. Kaufman (eds.) (New York:

Gardner Press, 1982).

Moore, R. A., “Ten Years of Inpatient Programs

for Alcoholic Patients,” Am. J. Psychiat. 134:542,

1977.

Moore, R. A., and Buchanan, T. K., “State Hospitals and Alcoholism: Nationwide Survey of

Treatment Techniques and Results,” Q. J. Stud.

Al. 27:459, 1966.

Moos, R. H., and Bliss, F., “Difficulty of FollowUp and Outcome of Alcoholism Treatment,” J.

Stud. Al. 39:473, 1978.

Moos, R. H., Finney, J. W., and Chan, D. A.,

“The Process of Recovery From Alcoholism: 1.

Comparing Alcoholic Patients and Matched

Community Controls,”~ Stud. Al. 42:382, 1981.

Mottin, J. L., “Drug-Induced Attenuation of

Alcohol Consumption: A Review and Evaluation

of Claimed, Potential, and Current Therapies, ”

Q. J. Stud. Al. 34:444, 1973.

Naranjo, C. A,, Chaten, K., Iversen, P., et al.,

“Importance of Nonpharmacologic Factors in the

Treatment of Acute Alcohol Withdrawal,” Clin.

Pharmacol. Ther., in press.

Nathan, P. E., “Overview of Behavioral Treatment Approaches, “ in Behavioral Approaches to

209.

210

211.

212.

213.

214.

215.

216.

217.

Alcoholism, G. Marlatt and P. E. Nathan (eds. )

(New Brunswick, N.J.: Rutgers Center of Alcohol

Studies, 1978).

Nathan, P. O., and Lipscomb, T, R., “Behavior

Therapy and Behavior Modification in the Treatment of Alcoholism, ” in The Diagnosis and

Treatment of Alcoholism, J. H. Mendelson and

N. K. Mello (eds.) (New York: McGraw-Hill

Book Co., 1979).

National Academy of Sciences, Alternative Policies Affecting the Prevention of Alcohol Abuse

and Alcoholism, Panel Report (Washington,

D. C.: NAS, 1981).

National Association of Insurance Commissioners, Alcoholism, Drug Addiction and Lnsurance Task Force (Austin, Tex.: State Board of

Insurance, May 26, 1981).

National Center for Health Statistics, Public

Health Service, Department of Health and

Human Services, “Expected Principal Source of

Payment for Hospital Discharges: U. S., 1977, ”

Advance Data, No. 62, Oct. 31, 1980.

National Council on Alcoholism/American

Medical Society Committee on Alcoholism Definitions, “Definition of Alcoholism, ” Ann. Intern

Med. 85(6):301, 1976.

National Council on Alcoholism, Criteria Committee, “Criteria for the Diagnosis of Alcoholism,” Ann. Intern. Med. 77(2):249; and An. J,

Psychiat. 129:127, 1972.

National Institute on Alcohol Abuse and Alcoholism, Alcohol, Drug Abuse, and Mental Health

Administration, Department of Health, Education, and Welfare, Excerpts: Medicare Coverage

for the Treatment of Alcoholism (Rockville, Md.:

National Institute on Alcohol Abuse and Alcoholism, Alcohol, Drug Abuse, and Mental Health

Administration, 1978).

National Institute on Alcohol Abuse and Alcoholism, Alcohol, Drug Abuse, and Mental Health

Administration, Department of Health and

Human Services, Fourth Special Report to the

U.S. Congress on Alcohol and Health (Rockville,

Md.: National Institute on Alcohol Abuse and

Alcoholism, Alcohol, Drug Abuse, and Mental

Health Administration, 1981).

National Institute on Alcohol Abuse and Alcoholism, Alcohol, Drug Abuse, and Mental Health

Administration, Department of Health and

Human Services, National Drug and Alcoholism

Treatment Utilization Survey (Rockville, h4d.:

National Institute on Alcohol Abuse and Alcoholism, Alcohol, Drug Abuse, and Mental Health

Administration, June 1981).
References . 93

218.

219

220.

221.

222.

223.

224.

225.

226.

227.

228,

National Institute on Alcohol Abuse and Alcoholism, Alcohol, Drug Abuse, and Mental Health

Administration, Department of Health and

Human Services, Statistical Report on National

Institute on Alcohol Abuse and AlcoholismFunded Treatment Programs for Calendar Year

1980: Data From NAPIS, contract No. ADM

281-81-0004 (Rockville, Md.: National Istitute on

Alcohol Abuse and Alcoholism, Alcohol, Drug

Abuse, and Mental Health Administration, 1982).

Neuberger, O. W., Hasha, N., Matarazzo, J. D.,

et al., “Behavioral-Chemical Treatment of Alcoholism: An Outcome Replication, ” J. Stud. A].

42:806, 1981.

Neuberger, O. W., Matarazzo, J. D., Schmitz,

R. E., et al., “One Year Follow-Up of Total Abstinence in Chronic Alcoholic Patients Following

Emetic Counterconditioning, ” Alcoholism: C/in.

& Exper. Res. 4:306, 1980.

Neuberger, O. W., Miller, S. I., Schmitz, R. E.,

et al., “Replicable Abstinence Rates in an Alcoholism Treatment Program,” J. A.M.A. 248:960,

1982.

Nightingale, S. L., Acting Associate Commissioner for Health Affairs, Food and Drug Administration, memorandum to Director, National

Center for Health Care Technology, on “Evaluation of Emetine for Chemical Aversion Therapy

for Alcoholism, ” Dec. 19, 1980.

Noble, E. P. (cd.), Technical Support Document:

Third Special Report to the U.S. Congress Alcohol and Health (Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism, Alcohol, Drug Abuse, and Mental Health Administration, 1978).

Oakley, S., and Holden, P. H., “Alcoholic

Rehabilitation Center; Followup Survey, 1969,”

Inventory 20(3):2, 1971.

Observer (pseudonym) and Maxwell, M. A., “A

Study of Absenteeism, Accidents and Sickness

Payments in Problem Drinkers in One Industry,”

Q. J. Stud. Al. 20:302, 1959.

Office of Technology Assessment, U.S. Congress,

Assessing the Efficacy and Safety of Medical

Technologies, GPO stock No. 052-003-00593-0

(Washington, D, C.: U.S. Government Printing

Office, OTA-H-75, September 1978).

Office of Technology Assessment, U.S. Congress,

The Efficacy and Cost Effectiveness of Psychotherapy, NTIS order No. PB 81-144610 (Washington, D. C.: National Technical Information

Service, OTA-BP-H-6, October 1980).

Office of Technology Assessment, U.S. Congress,

The Implications of Cost-Effectiveness Analysis

of Medical Technology, GPO stock No. 052-003 -

229.

230.

231.

232.

234.

235.

236.

237.

238.

239.

240.

241.

242.

243.

00765-7 (Washington, D. C.: Government Printing Office, OTA-H-126, August 1980.

Office of Technology Assessment, U.S. Congress,

Strategies for Medical Technology Assessment,

GPO stock No. 052-003 -00887-4 (Washington,

D. C.: U.S. Government Printing Office, OTAH-181, September 1982).

Ogborne, A. C., and Smart, R. G., “Halfway

Houses for Skid Row Alcoholics: Are They Rehabilitative?” Addict. Behav. 1:305, 1976.

Olson, R. P., Ganley, R., Devine, V. T., et al.,

“Long-Term Effects of Behavioral Versus InsightOriented Therapy With Inpatient Alcoholics,” J.

Consult. & Clin. Psychol. 49:866, 1981.

Ornstein, R., and Whitman, R. M., “On the

Metapharmacology of Psychotropic Drugs,”

Comp. Psychiat. 6:166, 1965.

Orvis, B. R., Armor, D. J., Williams, C. E., et

al., Efkctiveness and Cost of Alcohol Rehabilitation in the United States Air Force (Santa Monica,

Calif.: Rand Corp., 1981).

Overall, J. E., Brown, D., Williams, J. D., et al.,

“Drug Treatment of Anxiety and Depression in

Detoxified Alcoholic Patients, ” Arch. Gen.

Psychiat. 29:218, 1973.

Parloff, M. B., Wolfe, B., Hadley, I., et al.,

Assessment of Psychosocial Treatment of Mental Disorders: Current Status and Prospects

(Washington, D. C.: General Accounting Office,

1978).

Pattison, E. M. “A Critique of Alcoholism Treatment Concepts: With Special Reference to Abstinence,” Q. J. Stud. Al. 27:49, 1966.

Pattison, E, M., “Diagnosis of Alcoholism in

Relation to Treatment and Outcome,” in Prevention, Intervention, and Treatment: Concerns and

Models, Alcohol and Health Monograph No. 3

(Rockville, Md.: National Institute on Alcohol

Abuse and Alcoholism, Alcohol, Drug Abuse,

and Mental Health Administration, 1982).

Pattison, E, M., “Management of Alcoholism in

Medical Practice,” Med. Clin. N. A. 61:797,

1977.

Pattison, E. M., “The NCA Diagnostic Criteria:

Critique, Assessment, Alternative, ” J. Stud. Al.

41(9):965, 1980.

Pattison, E. M., “The Selection of Treatment

Modalities for the Alcoholic Patient, ” in The

Diagnosis and Treatment of Alcoholism, J. H.

Mendelson and N. K, Mello (eds.) (New York:

McGraw-Hill Book Co., 1979).

Pattison, E. M., “Ten Years of Change i n

Alcoholism Treatment and Delivery, ” Am. J.

Psychiat. 134(3): 261, 1977.

Pattison, E. M., and Kaufman, E. (eds.), En-
.

94 ● Health Technology Case Study 22: The Effectiveness and Costs of Alcoholism Treatment

244.

245.

246.

247.

248.

249.

250,

251,

252.

253,

254,

255

256,

cyclopedic Handbook of Alcoholism (New York:

Gardner Press, 1982).

Pattison, E. M., Coe, R., and Rhodes, R. J.,

“Evaluation of Alcoholism: A Comparison of

Three Facilities,” Arch. Gen. Psychiat. 20:478,

1969.

Pattison, E. M., Sobell, M. B., and Sobell, L. C.,

Emerging Concepts of Alcohol Dendence (New

York: Springer, 1977).

Pendery, M. L., Maltzman, I. M., and West, L.

J., “Controlled Drinking by Alcoholics? New

Findings and a Revaluation of a Major Affirmative Study, “ Science 217:169, 1982.

Plotnick, D. E., Adams, K. M., Hunter, H. R.,

et al., Alcoholic Treatment Programs Within Prepaid Group Practice HMOs: A Final Report, contract No. ADM 281-80-004, prepared by the

Group Health Association of America for National Institute on Alcohol Abuse and Alcoholism, Alcohol, Drug Abuse, and Mental Health

Administration, May 1982.

Poley, W., Lea, G., and Vibe, G., Alcoholism:

A Treatment Manual (New York: Gardner Press,

1979).

Polich, J. M., and Orvis, B. R., Alcohol Prob

lems: Patterns and Prevalence in the U.S. Air

Force, R-2308-AF (Santa Monica, Calif.: Rand

Corp., 1979).

Polich, J. M., Armor, D. J., and Braiker, H. B.,

The Course of Alcoholism: Four Years After

Treatment (New York: John Wiley & Sons, 1981).

Pomerleau, O. F., Pertschick, M., and Stennett,

J., “A Clinical Examination of Some Current Assumptions in the Treatment of Alcoholism, ” J

Stud. Al. 37:849, 1976.

Pomerleau, O. F., Pertschuk, M., Adlans, D., et

al., “A Comparison of Behavioral and Traditional Treatment Methods for Middle-Income,

Problem Drinkers,” J, Behav. Med., 1:187,1978.

Popham, R. E., “A Critique of the Genotrophic

Theory of the Etiology of Alcoholism, ” Q. J.

Stud. Al. 14:228, 1953.

Public Health Service, Office of the Assistant Secretary for Health and Surgeon General, Healthy

People: The Surgeon General’s Report on Health

Promotion and Disease Prevention, GPO stock

No. 017-001 -00416-2 (Washington, D. C.: U.S.

Government Printing Office, 1979).

Putnam, S. L., “Alcoholism, Morbidity and CareSeeking: The Inpatient and Ambulatory Service

Utilization and Illness Experience of Alcoholic

and Matched Controls in a Health Maintenance

Organization, ” Med. Care 20:97, 1982.

Putnam, S. L., “Short-Term Effects of Treating

257,

258.

259.

260,

261.

262,

263,

264.

265,

266,

267,

268,

269

Alcoholics for Alcoholism on Their Utilization

of Medical Care Services in a Health Maintenance

Organization,” Group Health Journal (Washington, D. C.: Group Health Association of

America, Inc., 1982).

Rachal, J. V., Maisto, S. A., Guess, L. L., et al.,

“Alcohol Use Among Adolescents, ” in Alcohol

Consumption and Related Problems, Alcohol and

Health Monograph No. 1 (Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism, Alcohol, Drug Abuse, and Mental Health

Administration, 1981).

Raichel, T., and Berkowitz, H., “Quality Assurance and Cost Containment in Alcoholism Services,” Al Health & Res. World 5(4):12, 1.981.

Rathbone-McCuan, E,, Lohm, H., and Levinson,

J., Community Survey of Aged Alcoholism and

Problem Drinkers (Baltimore, Md.: Levindale

Geriatric Research Center, 1975).

Regan, R. W., “The Role of Federal, State, Local

and Voluntary Sectors in Expanding Health Insurance Coverage for Alcoholism, ” AZ. Health &

Res. World 5(4):22, 1981.

Renault, P. F., Associate Director for Medical

Scientific Evaluation, National Center for Health

Care Technology, Public Health Service, Department of Health and Human Services, memorandum to Deputy Director, Office of Coverage Policy, Bureau of Program Policy, Health Care Financing Administration, Subject: Assessment of

Chemical Aversion Therapy for Alcoholism, Feb.

4, 1981.

Rickels, K., “Non-Specific Factors in Drug

Therapy of Neurotic Patients, ” in Non-Specifit

Factors in Drug Therapy, K. Rickels (cd. ) (Springfield, Ill.: Charles C. Thomas, 1968).

Ritson, B., “Personality of Prognosis in Alcoholism, ” Br. J Psychiat. 118:79, 1971.

Ritson, B., “The Prognosis of Alcohol Addicts

Treated by a Specialized Unit,” Br. J. Psychiat.

l’14:1019, 1968.

Robins, L. N., Deviant Children Grownup

(Baltimore, Md.: Williams & Wildins, 1966).

Roebuck, J. B., and Kessler, R, G., The Etiology

of Alcoholism (Springfield, Ill.: Charles C.

Thomas, 1972).

Roizon, R., “The Rand Report: Some Commerits, ” J. Stud. Al 38:170, 1977.

Roman, P. M., and Trice, H. M,, “Alcohol Abuse

and Work Organizations, ” in The Biology of

Alcoholism: Social Aspects of Alcoholism, B.

Kissin and H. Begleiter (eds. ) (New York: Plenum

Press, 1976).

Rorrie, C. G., Jr., Director, Bureau of Health
References ● 9 5

270.

271.

272.

273.

274,

275.

276.

277.

278.

279.

280.

281<

282,

Planning, Program Information Letter to State

Health Planning and Development Agencies,

Statewide Health Coordinating Councils, Health

Systems Agencies, and Centers for Health Planning, Subject: Data on the Average Charges for

the Twenty-Five Most Frequent Diagnoses for

Medicare Inpatient Discharges, Mar. 31, 1981.

Rosen, A. C., “A Comparative Study of

Alcoholics at the Washingtonian Hospital, ” Q.

j. Stud. Al. 21:253, 1960.

Rosenberg, C. M., “Drug Maintenance in the

Out-Patient Treatment of Chronic Alcoholism,”

Arch. Gen. Psychiat. 30:373, 1974.

Rothbart, G., Fine, M., and Sudman, S., “Finding the Needle in the Haystack: Multiplicity Sampling and Its Kin, ” Public Opinion Q., in press.

Rutstein, D. D., and Veech, R. I., “Genetics and

Addiction to Alcohol, ” N. Eng. J Med.

298(20):1140, 1978.

Sarvis, K. C., Insurance Cost Savings Due to an

Adequate Alcoholism Health Benefit, prepared

for the State of Florida Department of Health and

Rehabilitation Services, 1976.

Saxe, L., and Fine, M., Social Experirnents:

Methods for Design and Evaluation (Beverly

Hills, Calif.: Sage Publications, 1981).

Schifrin, L. G., Hartzog, C. E., and Brand, D.

H., “Costs of Alcoholism and Alcohol Abuse and

Their Relation to Alcohol Research,” in Alcoholism and Related Problems: Opportunities for

Research (Washington, D. C,: National Academy

of Sciences, 1980).

Schuckit, M. A., Drug and Alcohol Abuse: A

Clinical Guide to Diagnosis and Treatment (New

York: Plenum Press, 1979).

Schuckit, M. A., “Inpatient and Residential Approaches to the Treatment of Alcoholism, ” in The

Diagnosis and Treatment of Alcoholism, J. H.

Mendelson and N. K. Mello (eds. ) (New York:

McGraw-Hill Book Co., 1979).

Schuckit, M. A., and Hagh.md, R. M., “An Overview of the Etiologic Theories on Alcoholism, ”

in Alcoholism: Development Consequences and

Interventions, N. Estes and E. Heinemann (eds. )

(St. Louis: C. V. Mosby, 1977).

Schuckit, M. A., Goodwin, D. A., and

Winokeer, G., “A Study of Alcoholism in Half

Siblings,” Am. J. Psychiat. 128:1132, 1972.

Schuckit, M. A., and Miller, P. L., “Alcoholism

in Elderly Men: A Survey of a General Medical

Ward,” Ann. N. Y. Acad. Sci. 273:558, 1975.

Schuckit, M. A., Pitts, F. M., Reich, T., et al.,

“Alcoholism: I. Two Types in Women, ” Arch.

Gen. Psychiat. 20:301, 1969.

283.

284.

285.

286.

287.

289.

290.

291.

292.

293.

294.

295.

296.

297.

Science Management Corp., Status of State

Legislation and Research on Health Insurance

Coverage for Alcoholism Treatment, contract

No. ADM 281-81-0008, report prepared for the

National Institute on Alcohol Abuse and Alcoholism, Alcohol, Drug Abuse, and Mental Health

Administration, (Rockville, Md,: NIAAA, 1982).

Sellers, E. M., and Kalant, H., “Alcohol Intoxication and Withdrawal, ” N. Eng. -J. Med.

294:757, 1976,

Sellers, E. M., and Kalant, H., “Alcohol Withdrawal and Delirium Tremens,” in Encyclopedic

Handbook of Alcoholism, E. M. Pattison and E.

Kaufman (eds. ) (New York: Gardner Press,

1982).

Seizer, M. L., “The Michigan Alcoholism Screening Test: The Quest for a New Diagnostic Instrument,” Am. J. Psychiat. 127:89, 1971.

Silber, A., “The Contribution of Psychoanalysis

to the Treatment of Alcoholism, ” in Alcoholism

and Clinical Psychiat., J. Solomon (cd, ) (New

York: Plenum Press, 1982).

Smart, R. G., “Do Some Alcoholics Do Better in

Some Types of Treatment Than Others?” Drug

& Al. Depend. 3:65, 1978.

Smart, R. G., “Spontaneous Recovery in Alcoholics: A Review and Analysis of the Available

Literature,” Drug & Al. Depend. 1:227, 1976.

Smart, R. G., and Gray, G., “Minimal, Moderate

and Long-Term Treatment for Alcoholism, ” Br.

J. Addict. 73:35, 1978.

Smart, R. G., and Gray, G., “Multiple Predictors of Dropout From Alcoholism Treatment, ”

Arch. Gen. Psychiat. 35:363, 1978.

Smith, J. J., “A Medical Approach to Problem

Drinking,” preliminary report, Q. J. Stud. AJ.

10:251, 1949.

Smith, J. W., “Abstinence-Oriented Alcoholism

Treatment Approaches, ” in Comprehensive

Handbook of Behavioral Medicine, J. M.

Ferguson, and C. B. Taylor (eds. ) (New York:

Spectrum, 1980).

Smith, J. W., “Treatment of Alcoholism in Aversion Conditioning Hospitals, ” in Encyclopedic

Handbook of Alcoholism, E. M. Pattison and E.

Kaufman (eds. ) (New York: Gardner Press,

1982).

Sobell, L. C., “Alcohol Treatment Outcome

Evaluation Contributions From Behavioral Research, ” in Alcoho]ism: New Directors in

Behavioral Research and Treatment, P. E.

Nathan and G. A. Marlatt (eds. ) (New York:

Plenum Press, 1978).

Sobell, L. C., and Sobell, M, B., “Alcoholism
—

96 ● Health Technlolgyy Case Study 22: The Effectjveness and Costs of Alcoholism Treatment

298

299.

300.

301.

302.

303.

304.

305.

306,

307.

308.

Treatment Outcome Evaluation Methodology,”

in Pevention, Intervention and Treatment: Concerns and Models, Alcohol and Health Monograph No. 3 (Rockville, Md.: National Institute

on Alcohol Abuse and Alcoholism, Alcohol,

Drug Abuse, and Mental Health Administration,

1982).

Sobell, L. C., and Sobell, M. B., Individualized

Behavior Therapy for Alcoholics Rationale, Procedures, Preliminary Results, and Appendix

(Sacramento, Calif.: State of California Department of Mental Hygiene, 1972).

Sobell, L. C., and Sobell, M. B., “Outcome Criteria and the Assessment of Alcohol Treatment

Efficacy,” in Evaluation of the Alcoholic: hnplications for Research, Theory, and Treatment, Alcohol and Health Monograph No. 5 (Rockville,

Md.: National Institute on Alcohol Abuse and

Alcoholism, Alcohol, Drug Abuse, and Mental

Health Administration, 1981).

Sobell, L. C., and Sobell, M. B., “A Self-Feedback Technique To Monitor Drinking Behavior

in Alcoholics, ” Behav. Res. & Ther., 11:237,

1973.

Sobell, M. B., and Sobell, L. C., “Alcoholics

Treated by Individual Behavior Therapy: One

Year Treatment Outcome,” Behav. Res. & Ther.

?1:599, 1973.

Sobell, M. B., and Sobell, L. C., Behavioral

Treatment of Alcohol Problems (New York:

Plenum Press, 1978).

Solomon, J., “The Role of Drug Therapies in the

Context of Alcoholism,” in Ehcyclopedic Hand

book ofAlcoholism, E. M. Pattison and E. Kaufman (eds. ) (New York: Gardner Press, 1982).

Solomon, S. D., “Bias in Exposure of Outpatient

Therapy to Different Alcoholism Client Types,”

presented at the meeting of the American Psychological Association, Washington, D. C., 1982.

Solomon, S. D., “Measures of Alcoholism Treatment Outcome, ” Al. Health & Res. World

6(4):44, 1982.

Solomon, S. D., Tailoring Alcoholism Therapy

to Client Needs (Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism, Alcohol, Drug Abuse, and Mental Health Administration, 1981).

Stack, C., “Sex Roles and Survival Strategies in

an Urban Black Community, ” in Women, Culture and Society, M. Z. Rosaldo and L. Lamphere

(eds.) (Stanford, Calif.: Stanford University

Press, 1974).

Steiner, C., Games Alcoholics Play: The Analysis

of Life Scripts (New York: Grove Press, 1971).

309.

310.

311.

312.

313.

314.

315.

316.

317<

318.

319.

320.

321.

322.

323.

324.

Stuckey, R. F., and Harrison, J. S., “The Alcoholism Rehabilitation Center, “ in Eixyclopedic

Handbook of Alcoholism, E. M. Pattison and E.

Kaufman (eds. ) (New York: Gardner Press,

1982).

Swint, J. M., and Nelson, W. B., “Prospective

Evaluation of Alcoholism Rehabilitation Efforts:

The Role of Cost-Benefit and Cost-Effectiveness

Analyses,” J. Stud. Al. 38:1386, 1977.

Syme, L., “Personality Characteristics and the

Alcoholic,” Q. J. Stud. Al. 18:288, 1957.

Thimann, J., “Conditioned Reflex Treatment of

Alcoholism: II. The Risk of Its Application, Its

Indications, Contraindications and Psychotherapeutic Effects,“N. fig. J. Med. 241:408, 1949.

Torres de Gonzalez, B., Treating the Inner City

Young Spanish Speaking Alcohol Abuser, paper

presented on behalf of the East Harlem Tenants

Council, New York, and the Puerto Rican InterAgency Council, Dec. 5, 1973.

Toshney, J., “An Alcoholism and Detoxification

Centre,” Nurs. Times 74:573, 1978.

Tuchfeld, B. S., “Spontaneous Remission in

Alcoholics: Empirical Observations and Theoretical Implications, ” J. Stud Al 42:626, 1981.

Tuchfeld, B. S., and Lipton, W. L., Alcoholism

Treatment Research Study: An Evaluation of

Treatment Outcomes 18 Months Post-Adnission

to Schick-Shade/ Hospital of D/F14L Inc. (Fort

Worth, Tex.: Texas Christian University, 1982).

Tuchfeld, B. S., Marcus, M. S., and Lipton, W.

L., Salient Issues in Evaluating Alcoholism Treatment Efkctiveness (Fort Worth, Tex.: Texas

Christian University, 1982).

“Two Tales of One City: Fire Program,’” Lab.

@t. Al. J. 4:17, 1975.

“Two Tales of One City: Police Program, ” Lab.

A@. Al J. 4:1, 1975.

Vaillant, G. E., and Milofsky, E. S., “Natural

History of Male Alcoholism,” Arch. Gen.

Psychiat. 39:127, 1982.

Valentine, B. L., HustZing and Other Hard Work:

Lifestyles in the Ghetto (New York: Free Press,

1978).

Vischi, T. R., Jones, K. R., Shank, E. L., et al.,

The Alcohol, Drug Abuse, and Mental Health

National Data Book (Rockville, Md.: Alcohol,

Drug Abuse, and Mental Health Administration,

1980).

VitoIs, M. M., “Culture Patterns of Drinking in

Negro and White Alcoholics,” Dis. Nerv. Syst.

29:391, 1968.

Voegtlin, W. L., and Broz, W. R., “The Conditioned Reflex Treatment of Chronic Alcoholism:
References 97

325.

326

327.

328.

329.

330.

331.

332.

333.

334,

335,

336,

337<

338,

X. An Analysis of 3125 Admissions Over a Period

of Ten and a Half Years,” Ann. Int. Med. 30:580,

1949.

Voegtlin, W, L., and Lemere, F., “The Treatment

of Alcohol Addiction: A Review of the Literature,” Q. J. Stud. Al. 2:717, 1942.

Vogler, R. E., Compton, J. V., and Weissbach,

J. A., “Integrated Behavior Change Techniques

for Alcoholism,’f J. Consul Clin. Psych. 43:233,

1975.

Vogler, R. E., Weissbach, T. A., and Compton,

J. V,, “Learning Techniques for Alcohol Abuse,”

Behav. Res. Ther. 15:31, 1977.

Vogler, R. E., Weissbach, T. A., and Compton,

J. V., et al., “Integrated Behavior Change Techniques for Problem Drinking in the Community, ” J. Consult. Psychol. 45:267, 1977.

Wall, J. H., and Allen, E. B., “Results in Hospital

Treatment of Alcoholism, ” Am. J. Psychiat.

100:474, 1944.

Wanberg, K. W., Horn, J. L., and Fairchild, D.,

“Hospital Versus Community Treatment of Alcoholism Problems, ” Int. J. Merit. Health 3:160,

1974.

Ward, R. F., and Faillance, L. A., “The Alcoholic

and his Helpers: A Systems View, ” Q. J. Stud.

Al. 31:684, 1970.

Watts, C. D., “Health Insurance Coverage for

Underserved Populations, ” AZ. Health & Res.

World 5(4):35, 1981.

Weingold, H. P., Lechin, J. M., Bell, H. A., et

al., “Depression as a Symptom of Alcoholism:

Search for a Phenomenon,” J. Abnormal Psychol.

73: 195, 1968.

Wiens, A. N., Montague, J. R., Manaugh, T. S.,

et al., “Pharmacological Aversive Counterconditioning to Alcohol in a Private Hospital, ” J.

Stud. Al. 37:1320, 1976.

Whitfield, E, L., Thompson, G., Lamb, A., et al.,

“Detoxification of 1,024 Alcohol Patients Without Psychoactive Drugs, ” J.A. M. A. 293:1409,

1978.

Willcox, D. R., Gillan, C. R., and Here, E. H.,

“Do Psychiatric Outpatients Take Their Drugs?”

Br. Med. J. 2:790, 1966.

Willems, P. J. A., Letemendia, F. J. J., and

Arroyave, F., “A Categorization for the Assessment of Prognosis and Outcome in the Treatment

of Alcoholics, ” Br. J. Psych. 122:649, 1973.

WiI1ems, P. J. A., Letemendia, F. J. J., and

Arroyave, R., “A Two-Year Follow-Up Study

Comparing Short With Long Stay Inpatient

339.

340.

341.

342.

343.

344.

345.

346

347

348.

349.

350.

351.

Treatment of Alcoholics,” Br. J. Psych. 122:637,

1973.

Williams, R. J., Alcoholism: The Nutritional Approach (Austin, Tex.: The University of Texas

Press, 1959).

Williams, R. J., “The Etiology of Alcoholism: A

Working Hypothesis Involving the Interplay of

Hereditary and Environmental Factors, ” Q. J.

Stud. Al. 7:567, 1947.

Williams, W, G., “Nature and Scope of Benefit

Packages in Health Insurance Coverage for Alcoholism Treatment, ” Al. Health & Res. World

5(4):5, 1981.

Wilson, G. T., “Alcoholism and Aversion Therapy: Issues, Ethics and Evidence, ” in Behavioral

Assessment and Treatment of Alcoholism, G. A.

Marlatt and P. E, Nathan (eds. ) (New Brunswick,

N. J.: Rutgers Center of Alcohol Studies, 1977).

Wilson, G. T., “Alcoholism and Aversion

Therapy Approaches, “ in Behavioral Approaches

to Alcoholism, G. A. Marlatt and P. E. Nathan

(eds.) (New Brunswick, N. J.: Rutgers Center of

Alcohol Studies, 1978).

Wiseman, J. P., Stations of the Lost: The Treatment of Skid Row Alcoholics (Englewood Cliffs,

N. J.: Prentice-Hall, 1970).

Wolpe, J., Psychotherapy by Reciprocal Inhibition (Stanford, Calif.: Stanford University Press,

1958),

Wood, H. P., and Duffy, E. L., “Psychological

Factors in Alcoholic Women,” Am. J. Psychiat.

123:341, 1964.

World Health Organization, “Common AlcoholRelated Disorders, ” excerpts from Manual of the

lnternational Statistical Classification of Diseases,

Injuries, and Causes of Death, vol. I (Geneva:

WHO, 1977).

World Health Organization, Expert Committee

Report No. 48 (Geneva: WHO, 1952).

World Health Organization, Expert Committee

on Mental Health, Technical Report Series No.

273 (Geneva: WHO, 1964).

Wortman, P. M,, and Saxe, L., “Assessment of

Medical Technology: Methodological Considerations, ” in Strategies for Medical Technology

Assessment prepared by the Office of Technology

Assessment, U.S. Congress (Washington, D. C.:

U.S. Government Printing Office, 1982).

Zinberg, N. E,, and Fraser, K. M., “The Role of

the Social Setting in the Prevention and Treatment of Alcoholism, ” in The Diagnosis and

Treatment of A1coholism, J. H. Mendelson and
98 ● Health Technology Case Study 22: The Effectiveness and Costs of Alcoholism Treatment

352.

N. K. Mello (eds. ) (New York: McGraw-Hill 353. Zylman, R., “Fatal Crashes Among Michigan

Book Co., 1979). Youth Following Reduction of Legal Drinking

Zylman, R., “Collision Behavior of Young Age,” Q. J. Stud. Al. 35:293, 1974.

Drivers: Comment on the Study by Whitehead

et al.,” J. Stud. Al. 37:393, 1976. 0
-. --

ERRATA

Health Technology Case Study 22:

THE EFFECTIVENESS

AND COSTS OF

ALCOHOLISM TREATMENT

On page 79, Dr. Mitchell Rabkin, President

of Beth Israel Hospital in Boston was listed

incorrectly. He should be listed as follows :

Mitchell Rabkin

Beth Israel Hospita l

Boston