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CHAPTER 5. EVALUATIONS OF ALCOHOL ABUSE TREATMENT 5.1 Introduction Our original goals for this chapter were straightforward. Based on a review of the existing literature, we hoped to learn the answers to the following questions: (1) What treatments are being used to treat alcoholic abuse? (2) Are these treatments effective? (3) What are the costs of these treatments? (4) Which treatments are the most cost-effective? (5) What are the benefit/cost ratios for these treatments? In addition to learning the answers to these questions for the population of alcohol abusers as a whole, we had hoped to learn which treatments are cost-effective for different subgroups of patients. Unfortunately, we were only able to find partial answers to some of the questions. The outline of the chapter is as follows. Section 5.2 discusses the major types of alcoholism treatments. In the next section, we discuss some important methodological problems involved in estimating the effectiveness of alcoholism treatments. In Section 5.4, we review the literature on the effectiveness of alcoholism treatments. While it is generally recognized that some treatments are more effective than others, at least for some types of alcoholics, a consensus has not been reached on the relative effectiveness of the different treatments. Section 5.5 explains the lack of cost-effectiveness studies of alcoholism treatments. While some information is available on the costs of treating alcoholism by setting or modality, and many researchers have investigated the relative effectiveness of different treatments, no one has estimated the cost-effectiveness of such treatments. A few studies have attempted to indirectly measure the cost effectiveness of alcoholism treatments. As we shall see, this research area is new and relatively unsettled. Some agreement, however, has been reached on the cost effectiveness of alcoholism treatments by settings (i.e., inpatient vs. outpatient) and we shall review this literature in Section 5.6. To date, no full-fledged cost/benefit analysis of alcoholism treatment has been published. There are, however, a growing number of partial cost/benefit studies called “cost-offset” studies of alcoholism treatments. Theses studies will be reviewed in Section 5.7. In the following section, we shall examine the studies of state alcoholism treatment programs cost-offsets. Section 5.9 summarizes our findings and conclusions on alcoholism treatment evaluations. 5.2 Alcohol Abuse Treatments Today alcoholism and alcohol abuse are acknowledge to be multifaceted medical, psychological, and social problems (Saxe 1983). The medical, psychological, and sociocultural views of the causes of alcoholism are associated with a number of alternative treatment approaches. Miller and Hester (1986) set forth nine major classes of alcoholism treatments, although they recognized that these methods frequently overlap or are combined. These include the following: (1) Pharmacotherapy The conception of alcoholism as a disease has fostered investigations of a large number of medications as potential therapeutic agents including: (a) antidipsotropic drugs, (b) psychotropic medications, and (c) hallucinogens. (2) Psychotherapy and Counseling Various types of counseling and psychotherapy have been proposed as appropriate for alcoholics. (3) Alcoholics Anonymous Some experts regard the AA as a non-professional self help group and not a treatment, per se. (4) Alcoholism Education Usually consists of a series of lectures, films, readings, or discussions on the topic of alcohol and alcoholism. (5) Marital and Family Therapy Recognizing that alcohol problems both influence and are influenced by the family, programs have increasingly included the spouse and other family members in the treatment process. (6) Aversion Therapies The aversion therapies have as their common goal the altering of an individual’s attraction for alcohol. Through counter-conditioning procedures, alcohol is paired with any of a variety of unpleasant experiences. If the conditioning is successful, the individual shows an automatic negative response when later exposed to alcohol alone. (7) Controlled Drinking Controlled drinking is not a treatment method, per se, but rather an outcome or goal of a treatment. Treatments are designed to teach moderate and non-problem drinking.
(8) Operant Methods Operant conditioning techniques alter behavior through modification of its consequences. With alcoholics, reinforcement and punishment contingencies have been used to influence drinking and drinking related behaviors. (9) Broad-Spectrum Approaches The premise of this approach is that drinking behavior is functionally related to other problems in the person’s life, and that an approach addressing this broader spectrum of problems is more effective than one that focuses on drinking alone. Under this approach individuals are provided social skills training, stress management, and other training. The community reinforcement approach (CRA) is included in the broad-spectrum approach. Based on their review of controlled outcome research, Miller and Hester concluded that the following treatment methods are effective in reducing alcoholics drinking: (1) aversion therapies, (2) behavioral self-control training, (3) community reinforcement approach, (4) marital and family therapy, (5) social skills training, and (6) stress management. Unfortunately, according to Miller and Hester these are not the treatments most widely used in America. The most widely used techniques are, in fact, not very effective. These include: (1) AA, which many experts do not regard as a treatment technique, (2) alcoholism education, (3) confrontation, (4) disulfiram, (5) group therapy, and (6) individual counseling. Miller and Hester do not attempt to explain why this is true. In a subsequent analysis Holder, Longabaugh, Miller and Rubonis (1991) devised a scheme to rank the relative effectiveness of 33 different treatment modalities in terms of abstinence and reduced use outcome. They reviewed the literature of controlled studies with drinking outcome measures to assess the cumulative evidence for effectiveness of specific modalities of treatment for alcohol abuse problems. Each treatment within a controlled study was classified as yielding either a positive or a negative finding. Positive findings were counted whenever a modality was observed to produce incremental effectiveness over (1) no treatment, (2) minimal alternative intervention, (3) a placebo intervention or (4) another treatment modality. In additive designs, a positive finding was counted when a treatment package including a specific modality improved outcomes relative to the same treatment package without the additional modality. Results were counted as negative when incremental effectiveness was not observed. They were not satisfied with a simple plus or minus frequency measure of positive or negative results, so they devised a weighted evidence index (WEIn). The WEIn was calculated by subtracting the number of negative (N) from the number of positive studies (P), then adding an extra point for each positive finding greater than two. Their WEIn rankings of treatment models grouped by the extent of evidence are presented in Table 5.2. The Holder et al. study has been criticized by Howard (1993) for failing to account for the fact that the treatment modules being compared were applied to persons with alcohol problems of widely varying severity. Also the length of the follow-up periods varied across the studies making comparisons difficult. Finally, Howard objected to the selection of studies reviewed and the interpretation of their results. Finney and Monahan (1996) extended the work of Holder, et al. (1991) by creating an alternative index to rank the relative effectiveness of alcoholism treatments. They examined 41 comparative treatment studies and determined whether or not each found at least one statistically significant positive effect on a drinking outcome variable for the modalities examined in a paired contrast with one another. Next they calculated the predicted probability of each study yielding at least one statistically significant treatment effect based on the number of tests for treatment effects conducted. Following that, for each treatment evaluated, the strength of the “weakest competitor” against which the modality had been compared was determined. For each modality, they used the average predicted probability of the relevant study finding a significant effect and the average
Table 5.2 Ranking of Alcoholism Treatment Modality Effectiveness
Source: Holder, Longabaugh, Miller, Rubonis (1991, p. 526). effectiveness of the weakest competitor to predict the modality’s effectiveness. Their Adjusted Effectiveness Index (AEIn) for each modality was the difference in predicted and actual effectiveness score. Table 5.3 compares Finney and Monahan’s. AEIn rankings of treatment effectiveness with Holder et al.’s rankings for 24 common treatments. Some of the same treatment modalities rank high on both indexes (e.g. social skills training, the community reinforcement approach, behavioral marital therapy and stress management training). These modalities were also rated highly by Miller and Hester (1986), so we can have some confidence in their relative effectiveness in reducing drinking problems. Some treatments are rated as relatively unaffected on both indexes (residential milieu treatment, general counseling, and metronidazole). The relative effectiveness of the other treatments continues to be in doubt. 5.5 Cost Effectiveness Analysis of Alcoholism Treatments As noted in Section 2.2, the central purpose of cost effectiveness analysis (CEA) is to compare the relative efficiency of different interventions (i.e., alcoholism treatments) in creating better outcomes. CEA can help government decision makers decide how to allocate their scarce resources across different treatment programs to get more value for their money. CEA analysis of treatment program components helps managers to redesign programs to improve its overall efficiency. For meaningful comparisons of alcoholism treatment CEAs to be made, the studies must use the same methodology, have the same analysts perspective, define and measure costs and outcomes similarly, and treat similar groups of patients.
Table 5.3 Comparative Rankings of Alcoholism Treatment Modality Effectiveness
Source: Finney and Monahan (1996, p. 239).
5.3 Methodological Problems in Evaluating Alcoholism Treatments This Section discusses nine major methodological problems the authors faced while trying to interpret the literature on evaluations of alcoholism treatments. The problems are discussed in no particular order. 5.3.1 Problem 1. Standardizing Treatment Protocols. As noted in Section 3.4, for meaningful economic evaluations to be made both the primary program and the alternative must be fully described in terms of who does what to whom, where, and how often. As of yet, there is little agreement among researchers or clinicians as to what the common active ingredients of alcoholism treatments are. Many studies only briefly describe the treatments provided in a general way. For our understanding of the effectiveness of alcoholism treatments to advance, a required next step would be the codification of procedures necessary to provide protocols for treatment implementation (Holder, Longabaugh, et al. (1991). 5.3.2 Problem 2. Standard Outcome Measures. Alcoholism treatment does not have a commonly accepted standard of effect or output measure. In many treatment situations, the treatment goal is abstinence, but there is no uniform agreement of what constitutes abstinence, how it should be reliably measured or over what time period it should be measured (Holder, Longabaugh, et al. 1991). It is not unusual for a study to report six to ten different measures of alcohol use, health care utilization or expenditure measures, and various social outcomes. Since the reported effectiveness of the treatment varies over these alternative measures, it is difficult to draw any conclusions on its overall effectiveness. 5.3.3 Problem 3. Patient Variation. Until very recently, research on alcoholism treatments assumed that alcoholics are all alike. In recent years, we have become aware that alcoholics are heterogeneous and that subgroups may differentially respond to different treatments (Holder, Longabaugh, et al. 1991). Researchers have begun tracking the types and amounts of treatments provided to different types of alcoholics to determine what works best for whom under the so-called “patient-treatment matching hypothesis”. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) conducted research that addressed the “patient-treatment matching hypothesis” (PROJECT MATCH RESEARCH GROUP 1997). In this study, clients were randomly assigned to one of three 12-week, manual-guided, individually delivered treatments: Cognitive Behavioral Coping Skills Therapy, Motivational Enhancement Therapy or Twelve-Step Facilitation Therapy. Clients were then monitored over a 1-year post-treatment period. Individual differences in response to treatment were modeled as a latent growth process and evaluated for 10 primary matching variables and 16 contrasts specified a priori. The primary outcome measures were percent days abstinent and drinks per drinking day during the 1-year post-treatment period. Significant and sustained improvements in drinking outcomes were achieved from baseline to 1-year post-treatment by clients assigned to each of the three treatments. Importantly, there were no significant findings in 15 of the 16 matching hypotheses tested. The one significant finding was that clients with little or not psychopathology were more likely to maintain abstinence in the Twelve Step Facilitation treatments than in the Cognitive Behavioral Coping Skills Therapy. This is only a single study and more research needs to be conducted on the patient-treatment matching hypothesis in the future. In the interim, we need to be aware of differences in the client populations, when discussing the relative effectiveness of alcoholism treatments and settings. 5.3.4 Problem 4. Costs of Treatments. Treatment costs are typically reported in unit costs by the type of facility, setting, or provider. They are not broken down by the types of treatments provided and they are not reported on an individual client basis. It is assumed that all clients use the same resources and thus have the same costs of treatments. In fact, we know that some clients receive more treatments than others and outcomes should reflect this (see Section 3.5). It should not be surprising to learn that outcomes improve with the length of the treatment period.
5.3.5 Problem 5. Research Design Problem. As noted in Section 3.7, the preferred research design for determining the effectiveness of alcoholism treatments is a randomized clinical trial (RCT). Under an RCT, patients are randomly assigned to an “experimental group” which receives treatment services and to a “control group” which does not receive treatment services. The advantage of this research 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 pre-existing differences in the samples tested. Due to the random assignment process, the “experimental” and “control” groups of alcoholics should be nearly identical in terms of motivation (i.e., they both applied for treatment), severity of drinking problems, and other personal characteristics that might affect outcomes. Random assignment designs including “no-treatment” control groups have not been used in evaluations of alcoholism treatments for ethical reasons (Holder, 1987 and McLellan, Woody, and Metzger, 1996). Thus, as Holder (1987) concludes with respect to the effects of alcoholism treatments, “we have not had in practice the basis for determining directly what total health care costs would have been under a no-treatment condition.” There have been a number of evaluations of alcoholism treatments that utilize the treatment group as its own control group and time series pre-/post-treatment generated data to measure the effectiveness of the treatments. As we shall see in our discussion of the “ramp-up” effect and the “regression-to-the-mean” problem below, there are limits to the use of own control groups. Another group of studies use matched samples drawn from the non-alcoholic population as a control group. The outcome measures used to measure treatment effectiveness with this control group is health care utilization or health care expenditures rather than measures of alcohol use. From these studies, we learn that alcoholics spend considerably more money on health care than non-alcoholics in the period prior to treatment, whereas the ratio of health care spending of alcoholics to non-alcoholics is greatly reduced in the post-treatment period. Although this result is consistent with the argument that alcoholism treatments are effective, it is not conclusive. It is always possible that alcoholic patients would have reduced their health care expenditures over this same period of time without treatment. In fact, we shall see that such a reduction is likely when we discuss the problem of the “ramp up effect” and associated “regression-to-the-mean problem” presented below. These so-called “cost-offset” studies will be reviewed in Section 5.6. Finally, a number of studies have developed control groups of either “low to minimum” treatment to measure the effectiveness of different treatments (Holder 1987). Such studies may help us to understand the relative effectiveness of alcoholism treatments, but they do not measure the absolute effectiveness of such programs. Some treatments may work better for some types of patients than for others. To determine the absolute effectiveness of an alcoholism treatment, treated patients must be compared to patients randomly assigned to a no-treatment option as noted above. In comparative treatment studies, patients are sometimes randomly assigned to the different treatment groups and sometimes they are not. Random assignment is the preferred research design for measuring the relative effectiveness of alcoholism treatments. If patients are randomly assigned to treatment groups, it is likely that the treatment groups are similar in terms of motivation, the severity of the drinking problem and other personal characteristics that might affect outcomes. Thus, differences in the outcomes can be attributed to treatments rather than some confounding factors. The comparative treatment studies will be reviewed in the next section. Finally, it should be noted that the early alcoholism treatment literature included a large number of uncontrolled case studies and group designs. We have ignored these studies in our review because as Miller and Hester (1986) point out, positive uncontrolled reports can be found for virtually every treatment that has ever been tried for alcoholism. The observed effects of such studies may be attributable not only to the treatment offered, but to a host of confounding factors including patient selection criteria, expectancies, additional treatment components and post treatment factors. 5.3.6 Problem 6. The “Ramp Up Effect” and “Regression-to-the-Mean” Problem It has been observed that alcoholic’s health care costs tend to rise rapidly just prior to treatment (the so-called “ramp up effect”) and then fall rapidly following treatment. As Holder (1987, p. 66) explains, the difference between untreated alcoholics and non-alcoholics’ health care spending increases over time prior to alcoholism treatment. During the 25-36-month pretreatment period, the alcoholic on the average incurs costs that are about 130% higher than those incurred by comparable non-alcoholics. In the 13-24 month period before treatment, the alcoholic’s costs are around 180% higher, and in the last 12 months before treatment, the alcoholic’s costs are close to 300% higher than costs of comparable non-alcoholics. Most of this difference is attributable to inpatient utilization resulting from substantially higher inpatient days per month per person for alcoholics. Most studies show a statistically significant reduction of health care costs following treatment, usually in the first 12 months after treatment. Does this constitute proof of the effectiveness of alcoholism treatments? The answer is not necessarily. As Holder (1987) notes, the observed expenditure pattern can occur as a result of natural cyclic patterns or the random behavior of a time series. That is, it is natural, all other things equal, for a high level of a measure to be followed by a lower level or vice versa. The sharp up-and-down pattern of health care utilization and costs around the point in time when alcoholism treatment begins could be a consequence of this “regression-to-the-mean” phenomenon rather than the effects of treatments. We shall return to this point below. 5.3.7 Problem 7. Follow-Up Analysis Problems Outcome data are usually obtained through follow-up interviews with patients that have undergone treatments. There are a number of potential problems associated with such interviews. The first is the issue of who is included in the follow-up sample. It has long been recognized that a high rate of patient follow-up contact is necessary to ensure representative information from the treated sample (McLellan, Woody and Metzger, 1996). Studies have shown that the patients who are more difficult to find at follow-up typically have worse outcomes. For this reason, the Food and Drug Administration requires a minimum of 70 percent contact at follow-up in their studies. Many of the alcoholism treatment studies in the literature contain follow-up samples of far less than 70 percent. These studies are likely to overestimate the effects of treatment and therefore should be regarded critically. A second problem in evaluating alcoholism studies is that the time interval at which outcomes are compared also varies widely across studies. According to Holder, Longabraugh et al. (1991), follow-ups conducted shortly after treatment are more likely to indicate treatment effects than follow-ups conducted at more extended points. Holder (1987) recommends extended follow-ups as a way of minimizing the “regression-to-the-mean” problem. He says that in the typical study, which includes a 12 month pre- and 12 month post-period, differences may only be the result of “regression-to-the-mean” and not treatment. Extended pre-periods (24 months or longer) will reduce the “ramp-up effect” and extended post-periods (24 months or longer) will minimize the “regression-to-the-mean problem.” Unfortunately, as we shall see in Section 5.6, only a few studies have used such extended pre- and post-periods. 5.3.8 Problem 8. The Relapse Issue We know that a significant number of alcoholics who successfully complete treatments will relapse at some point in the future. Furthermore, many of these will reenter treatment at a later date. Because so many relapsed patients return to treatment, later follow-up evaluations of a single treatment episode may become contaminated by the effects of previous treatments (McLellan, Woody, and Metzger, 1996). As noted in Section 3.7, if first-time patients and readmitted patients use different amounts of treatments and have different expected outcomes, then treatment evaluations could be a function of their mix of patients. Most evaluations of alcoholism treatments ignore the issue of readmission so we have no idea what effect it has on the estimated effectiveness of treatments. Clearly the long-term effectiveness of treatments depends on future relapse rates. Undoubtedly, some treatments have longer-term effects than others. Extrapolating long-term outcomes from short (one year or less) follow-ups is impossible unless we model relapse rates and this has not been done to our knowledge. Most authors either ignore the relapse issue and simply note that the long-term benefits of treatments must be greater than the short-term benefits captured by the short follow-up period (unless, of course, the relapse rate is 100 percent). 5.3.9 Problem 9. Spontaneous Recovery As discussed in Section 3.8, an unknown number of treated alcoholics would have recovered spontaneously from their addiction without treatment, and therefore their benefit should not be counted in the effectiveness of treatment (Cartwright 1998). We have almost no data on alcoholics who do not seek treatments, so it is hard to judge the significance of the spontaneous recovery problem. A recent study by Estee and Nordlund (2001) of SSI recipients in the State of Washington sheds some light on this issue. In that study SSI recipients were placed in three separate groups for purposes of comparison. First, based on their medical diagnoses and procedures, receipt of alcohol or drug abuse (AOD) treatment, and arrests for drug- or alcohol-related offenses, individuals were placed into “need” and “do not need” treatment groups. The need treatment group was divided into two groups: those who were treated and those who remained untreated. The authors tracked the average monthly medical costs (including treatment costs) for the No Need, Treated, and Untreated groups in the pre- and post-identification periods. The identification period for the Treated and Untreated groups refers to the point in time when it first became known that the recipient needed AOD treatment. The length of the pre- and post-treatment identification periods varies for individuals in the Treated and Untreated groups depending on when they were identified as needing AOD treatment. The identification month for No Need recipients was arbitrarily set at the midpoint of their observation period. On average, the Treated group had 12.0 months in the pre-period and 25.6 months in the post identification period. The Untreated had an average of 15.1 months in the pre-period and 20.7 months in the post-period. The No Need group had an average of 18.5 months in both the pre- and post-period. Table 5.1 presents the average medical costs in pre- and post-identification periods for the three groups of SSI recipients. For both the treated and untreated groups, their costs after need for AOD treatment was identified were substantially higher than their medical costs before that seminal event. From the pre- to post-identification periods the average monthly medical costs rose from $387 to $740 for Treated recipients and from $648 to $1,445 for Untreated recipients. No Need recipients experienced only a small increase from $453 to $525 over the two periods. Since these figures are in constant December 2000 dollars, this increase suggests a growth in their medical expenses due to either general worsening of their medical conditions over time or rises in medical costs over and above inflation (measured by the CPI). The numbers reported in Table 5.1 are a bit misleading. Both the Treated and Untreated alcoholic groups experienced a sharp rise in medical costs right before they were identified as needing AOD treatments as shown in Figure 5.1. This sharp rise in medical costs is consistent with the so-called “ramp-up effect” discussed above. Figure 5.1 indicates that both the Treated and Untreated groups experienced a sharp decline in spending in the post-identification period almost to the pre-identification spending levels. The sharp decline in spending by the Untreated group cannot be attributed to treatments since they did not receive any. One interpretation of the data is that individuals in both the Treated and Untreated groups were more or less out of control
Table 5.1 Average Medical Costs in Pre- and Post-Event Periods for SSI Recipients July 1997 – December 2000a
aIncludes only cases with at least one month on SSI/Medicaid in the pre and post periods. Medical Costs equal Medicaid payments plus estimated chemical dependency treatment costs.
Source: Estee and Nordlund (2001)
at the time they were identified as needing AOD treatments. This caused the sharp increase in health care spending. It appears that this out of control behavior and associated high rates of health care spending were not sustainable. Some alcoholics sought treatment to help them change their behavior. Others changed their behavior without the benefit of treatment. These behavioral and spending patterns make it difficult to measure the true effectiveness of AOD treatment programs. In the early studies of alcohol/drug abuse programs, researchers often evaluated such programs on the basis of participant outcomes in the pre- and post-treatment periods with no control group present. Given the tendency toward out of control behavior and sharp increases in spending in the period just prior to entering the treatment program, it is not surprising that almost all of these simple pre/post outcome studies concluded that the treatment programs are highly successful. To isolate the “true” effectiveness of a treatment program, one needs the “ideal” control group. The No Need group identified above is not a “good” control group. As shown in Table 5.1 and Figure 5.1, the pre-identification medical costs for the No Need group were higher ($453) than for the Treated group ($387), but post-identification costs for the No Need group ($525) were lower than for the Treated group ($740) because of the sharp increase in Treated group spending at the time of identification. Because spending on medical and treatment costs declined for the Treated group after treatment as compared to little or no change in costs for the No Need (i.e., control) group, the treatments would be regarded as highly effective. Note, however, that medical and treatment costs declined sharply for the Untreated group as well, even though members of this group did not receive treatments. If the No Need (i.e. non-abuser) group is used as
Figure 5.1 Average Monthly Medical and Chemical Dependency Treatment Costs Before and After Need for Treatment Identified Washington State SSI Recipients, July 1997 – December 2000 (3-Month Rolling Averages)
Source: Estee and Nordlund (2001).
the control group, then the sharp decline in spending for the Treated group will be regarded as a treatment effect and the treatment program will be regarded as highly effective. The Untreated group would be a better control group to use when attempting to evaluate the effectiveness of treatment programs. However, for the Untreated group to serve as the optimal control group, alcoholics need to be randomly allocated to the Untreated and Treated groups as discussed above. In this study, the members of each group were identified after the fact. As a consequence, the Treated and Untreated groups differ in unknown ways in addition to having and not having treatments. This is evidenced by the fact that Untreated medical spending exceeded Treatment group spending in both the pre- ($648 vs. $387) and post- ($1,445 vs. $740) identification periods. The fact remains, however, that health care expenditures for the Untreated group declined sharply after they “ramped-up” even in the absence of treatments. Undoubtedly, this would also have been true for some members of the Treated group. Therefore, the pre/post decline in health care spending for the Treatment group must overstate the “true” effectiveness of alcoholism treatments by a significant amount. In the absence of randomly selected “no treatment” control groups, we shall never know the “true” effectiveness of alcoholism treatments. 5.4 The Effectiveness of Alcoholism Treatments As noted above, very rarely is an alcoholism treatment modality compared against a no-treatment condition because it is considered unethical to deny treatment to an alcoholic. Most treatment modalities are therefore either compared against other modalities or are treated as “add-ons” to ongoing treatment. In the methodologically stronger studies, the patients are randomly assigned to the treatment modalities being considered. A finding of equal clinical effectiveness may simply mean that both treatments are effective, rather than that neither is effective since the no-treatment option has not been considered (Holder, Longabaugh, et al., 1991). In the case of add-ons, the question is whether the add-on has any incremental effectiveness, not whether it is more effective than no treatment. There have been more than 600 studies of the effectiveness of alcohol treatments (Miller and Hester, 1986). We have made no attempt to read all of these studies. Rather, we have relied on the surveys of the effectiveness of alcoholism treatments provided by Emrick (1975), Jones and Vischi (1979), Saxe (1983), Miller and Hester (1986), and Holder, Longabough, et al. (1991). According to Saxe (1983), the earliest comprehensive review of treatment effectiveness was conducted by Voegtlin and Lemere. They received over 100 studies that appeared in the literature between 1909 and 1940. Voegtlin and Lemere concluded that poor “statistical” evidence limited conclusions but that none of the treatments then available had proven effective. They believed that some treatments such as inpatient psychotherapy and certain drug therapies showed promise. Emrick (1974) reviewed 271 alcoholism studies published between 1952 and 1972. He noted that a high percentage of the patients at follow-up reported being abstinent or at least using less alcohol. 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.” It must be remembered that most of these studies had no control group and were methodologically flawed in other ways (Saxe 1983). Even then, Emrick cautioned that no evidence documents that one treatment modality is more effective than another. He did report that the rate of improvement correlates positively with the amount of treatment. This finding has been continuously reported in the literature. Emrick could find no evidence that treatments had significant long-term effects. Later, Emrick (1975) reviewed an additional 126 studies of “psychologically oriented” treatments not included in his first study. He found that patients receiving minimal treatments (fewer than five outpatient visits or two weeks inpatient treatment) did no better than patients that received no treatments. Patients with more than minimal treatment did improve: 2.8 percent were abstinent and 63.1 percent drank less than before. Most of these studies, however, did not use a control group and most did not control for patient characteristics (Saxe 1983). Shortly after Emrick’s initial study, Baekeland, Lundwall and Kissin (1976) separately reviewed alcoholism treatment studies by setting (inpatient and outpatient) and by treatment modality (psychotherapeutic, drug, and sociocultural). According to Saxe (1983), it is difficult to summarize their findings. For each of the settings and treatment modalities, some evidence of successful outcome was found. Saxe (1983) points to three notable findings from their review. First, the research does not demonstrate that inpatient care offers greater likelihood of successful treatment than outpatient treatment. We shall return to this issue in Section 5.5. Next, Baekeland, Lundwall and Kissin noted that characteristics of the patient had an important effect on treatment outcomes. Patients with stable marital and occupational status and higher socioeconomic status tend to remain in treatment longer and have better outcomes. As noted above, when trying to measure the relative effectiveness of alcoholism treatments it is necessary to control for patient variation. Along these same lines, the Baekeland et al. review showed that there are considerable differences as to who receives or takes advantage of particular treatments. They noted that Alcoholics Anonymous (AA) membership is not representative of alcoholics. It is possible that AA’s reported effectiveness is really a function of who selects this type of treatment rather than the treatment itself. Subsequent reviews by Costello (1975 and 1977) confirmed that programs using stringent patient selection criteria were the most successful and that patients with characteristics such as stable marital and occupational status were more likely to benefit from treatment (Saxe 1983). Two other findings of Costello are worth noting. First, small programs using a variety of intensive techniques (e.g., inpatient care, drugs, and psychotherapy) were the most successful. Second, over a relatively long period (i.e., two years), both the number of patients remaining abstinent or relapsing in good treatment programs is about equal at 45 percent. Saxe (1983) notes that a 45 percent success rate sounds good unless you compare it to spontaneous remission rates of perhaps 30 percent. It is not at all clear where Saxe derived his spontaneous remission rate of 30 percent. He cites no references. Cartwright (1998) refers to a possible 10 percent spontaneous remission rate, but he also cites no references. It is also not clear whether they are referring to a temporary or permanent change in drinking behavior. As noted below, there is some evidence that indicates that some alcoholics who receive little or no treatments do periodically reduce their consumption of alcohol, at least temporarily. Two studies conducted at Rand, Armor et al. (1976) and Polich, et al. (1981), have been a focal point of debate and policy about alcoholism treatments for years. These are not reviews but large scale 6 and 18 month and 4 year follow-ups of patients treated at the National Institute on Alcohol Abuse and Alcoholism’s (NIAAA) Alcohol Abuse Treatment Centers. These studies generated intense controversy because they suggested that it was not necessary that abstinence be the central treatment goal of alcoholism therapies. The Rand studies considered patients 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 patients were in remission at 6 months, 67 percent at 18 months, and 46 percent after 4 years (Saxe 1983). Prior to treatment, over 90 percent of the patients had a serious drinking problem so it was concluded the treatments were effective. However, the Rand studies did not include a control group so one is left wondering how much of this success is due to a regression-to-the-mean effect and how much is due to spontaneous recovery. Jones and Vischi (1979) reviewed 12 studies that focused on the impact of alcoholism treatment on medical care utilization. These studies consistently reported reductions in medical care utilization ranging from 26 to 69%, with a median of 40%. Most of these studies were conducted in association with employee alcoholism programs or in prepaid health care programs or HMOs. The studies had methodological problems. They used the “own-control” group research design and the pre- and post-periods were of short duration, usually 12 months each. As such, a significant portion of the 40% decline in medical care utilization is probably due to the regression-to-the-mean phenomenon and to spontaneous recovery. After reviewing a wide range of studies on the effectiveness of alcoholism treatment, Saxe, et al. (1983) was highly critical of the methodology employed in these studies. Nevertheless, he concluded, “the benefits of alcoholism treatments, even if they fall short of what may be claimed, seem to be in excess of the costs of providing such treatment” (p. 66). The most extensive review of the literature on the relative effectiveness of alcoholism treatment was conducted by Miller and Hester (1986). They placed four major restrictions on their review. First, they only included controlled research; that is studies including either random or matching assignment designs with control or comparison groups. Second, they focused on studies evaluating the impact of treatment on drinking behavior. Third, they only considered treatment interventions with problem drinking populations; they did not include preventive interventions. Finally, they attempted to draw reasonable and accurate conclusions from the studies without getting bogged down in detailed discussions of methodological issues. Their review focused on nine major classes of intervention even though they recognize that these methods frequently overlap or are combined. (1) Pharmacotherapy They noted that drug therapy studies are plentiful, but few are controlled studies. These tend to have short follow-up periods and high dropout rates (i.e. >50%) so conclusions from these studies are limited. They considered three major alternative strategies of pharmacotherapy for alcoholism. (a) antidipsotropic drugs. They concluded that disulfiram (trade name Antabuse) performed only slightly better than a placebo so they question using it as a therapeutic agent. They also reported that citrated calcium carbimide (CCC) performed no better than disulfiram and that these treatments should also not be used. Lastly, they concluded that the evidence indicates that metronidazole (trade name Flazyl) produces no significant reduction in drinking behavior. (b) psychotropic drugs. They find no evidence for using antianxiety drugs (e.g. Librium) to treat alcoholics. Miller and Hester also found that antipsychotic drugs such as thiothixene and trifluoperazine performed no better than a placebo in treating alcoholics. They found that while antidepressant drugs might be helpful in treating alcoholics’ mood disorder, these drugs should not be used as primary agents to bring about sobriety. Miller and Hester reported that two controlled studies found that lithium reduced drinking problems but another found that this drug performed no better than a placebo. They suggest further research on this drug. They concluded that no psychotropic drug has yet been shown to produce reliable changes in drinking behavior. (c) hallucinogens. They reported that early controlled studies showed that lysergic acid diethylamide (LSD) reduced drinking activity. Later controlled studies failed to replicate the earlier results so that LSD is no longer used to treat alcoholism.
(2) Psychotherapy and Counseling Miller and Hester reported that in outpatient and inpatient settings, controlled evaluations have failed to demonstrate benefit from adding psychotherapy or counseling to more minimal interventions. As an add-on therapy, psychotherapy and counseling had no incremental effect on alcoholics drinking. But two studies showed that psychotherapy yielded modest short-term gains relative to no treatment at all. Overall, they concluded there is no consistent and substantive evidence that psychotherapy and counseling approaches are effective. While there are no controlled evaluations of confrontational counseling with alcoholics, Miller and Hester cite non-controlled studies that suggest that this form of therapy may be effective. (3) Alcoholics Anonymous (AA) Many uncontrolled studies have targeted the effectiveness of AA. Miller and Hester could not find a single controlled evaluation supporting the effectiveness of AA so they concluded that at the present time the alleged effectiveness of AA remains unproved. In a recent study (PROJECT MATCH RESEARCH GROUP 1997), it was shown that the Twelve Step Facilitation approach was equally effective as Motivational Enhancement and Cognitive Behavior in the treatment of alcoholism. The Twelve Step Facilitation approach included in the study facilitates client transition into the 12-step program of AA. (4) Alcoholism Education Miller and Hester report that controlled studies employing random assignment have failed to support the efficacy of alcohol education in changing drinking behavior and problems.
(5) Martial and Family Therapy The authors reported that all of the studies reviewed showed that marital or family therapy when added to other treatment increases the level of improvement observed at short-term follow-up (6 months). (6) Aversion Therapies Miller and Hester concluded that aversion conditioning strategies appear to be effective in suppressing drinking behavior and urges to drink, at least for a few months. They generally favor the use of nausea, electrical aversion, and covert sensitization. (7) Operant Methods They concluded that reinforcement and punishment contingencies can be used to enhance program compliance, but that ultimate impact on drinking behavior depends on the effectiveness of the program itself. (8) Controlled Drinking They reviewed evaluations of treatment programs intentionally designed to teach moderate and non-problem drinking. Miller and Hester concluded that controlled drinking works for moderate problem drinkers, but is not an effective treatment for chronic alcoholics who are severely dependent. (9) Broad-Spectrum Approaches This approach believes drinking behavior is functionally related to other problems in the person’s life and that an approach addressing these other problems is more effective than one that focuses on drinking alone. Miller and Hester reported that social skills training are an effective addition to alcoholism treatments. They found mixed evidence with respect to stress management training. Miller and Hester also reported that systematic desensitization and the community reinforcement approach (CRA) appear to be successful treatments for alcoholism.
As explained in the previous section, there are more than 600 studies that attempted to measure the effectiveness of alcoholism treatments. Unfortunately, these studies differed in terms of methodology, types of outcomes, and types of patients treated so that we can make only gross estimates of their relative effectiveness. Almost none of these studies provided information on the cost of treatments. As a result, there are virtually no CEAs of alcoholism treatments to be found in the published literature. Holder, Longabaugh, Miller, and Rubonis (1991), hereafter referred to as HLMR, tried to fill this gap in the literature through an analysis of cost effectiveness of alcoholism treatment modalities based upon (1) findings from clinical trials on the relative effectiveness of treatment modalities, (2) costs for treatment in settings and/or by providers and (3) recommendations from treatment experts about appropriate settings, providers and treatment events. We discussed HLMR’s methods and rankings of treatment modality effectiveness in the previous section. They compiled an extensive database of the average costs of alcoholism treatment from providers, insurance carriers, state alcohol and drug abuse authorities, and self-insured employers. Table 5.4 presents their estimated treatment costs in 1987 dollars for the following four general types of settings and providers. (1) Inpatient – the provision of medical services and the supporting services, including board, laundry and housekeeping, for patients who require 24-hour supervision in a hospital or other suitably equipped and licensed medical setting for treatment of alcoholism and other problems related to alcohol use. (2) Residential – the provision of 24-hour care and/or support for patients or residents who live on the premises of the program.
Table 5.4 Typical Costs Per Unit For Alcoholism Treatment By Facility, Setting And Provider In Dollars (inflation-adjusted to 1987)
Source: Holder, Longabaugh, Miller and Rabonis (1991, p. 527).
(3) Intermediate – the provision of care and/or support in a partial (<24-hour) treatment or recovery setting for patients or clients, who have need for more intensive care, treatment and support than is available on an ambulatory setting or who can benefit from supportive social arrangements during the day. (4) Ambulatory – the provision of nonresidential evaluative and treatment services on both a scheduled and nonscheduled basis. As shown in Table 5.4, costs per unit are highest in inpatient facilities, where they might reach $487 per day for general acute care hospitals, and lowest in ambulatory care. HLMR were unable to directly determine the relative cost/effectiveness of one treatment modality versus another since a specific modality may be used in a variety of settings. For this reason, they conducted a survey of treatment experts to estimate treatment cost for a modality on the basis of the least expensive setting in which it could be delivered. Based on expert opinion, they were able to differentiate those modalities that could only be provided in inpatient and residential settings from those that could also be delivered in less costly outpatient settings. HLMR did not believe that their treatment modality least cost estimates should be taken literally; so they placed each modality into one of five cost categories: minimum $99 or less; low, $100-199; medium-low, $200-599; medium high, $600-999; and high, $1,000 or more. They used their categories of relative effectiveness and cost categories to produce a 5 by 5 table (Table 5.5) in which each treatment modality is placed according to its cost and effect combination and in comparative position relative to other modalities. The numbers in Table 5.5 provide good evidence that more costly treatments are not
Table 5.5 Treatment Modalities Classified By Costa And Effectivenessb Categories
aFive categories of cost range are provided. The derived dollar values of estimated cost for each modality are given in Table 6. bFive categories of effectiveness range are provided. The calculation of the Weighted Evidence Index (WEIn) is described in the text. The derived WEIn values of estimated effectiveness for each modality are given in Table 3.
Source: Holder, Longabaugh, Miller, Rabonis (1991, p. 532).
necessarily more effective treatments and that more effective treatments are not necessarily more costly. In fact, the numbers suggest there might be a negative relationship between alcoholism treatment effectiveness and cost. HLMR calculated a Pearson product-moment correlation between the estimated low cost for each modality and its effectiveness score (WEIn). This analysis reflected a significant negative relationship (r = -.385, 26 df, p < .05). When Finney and Monahan (1996) estimated a Pearson correlation for the 26 modalities that had 3 or more relative studies between their effectiveness index rating and HLMR’s low cost estimate they obtained (r = -.29, p < .16). Although Finney and Monahan’s estimated relationship is not statistically significant and not as strong as that of HLMR, the two studies combined indicate that there is no positive relationship between alcoholism effectiveness and cost as one might suppose. One can only speculate as to why high cost/low effectiveness treatments are still widely in use. If we had more cost effectiveness studies where both cost and effectiveness are carefully measured as recommended by HLMR, it is likely that high cost/low effectiveness treatments would be eliminated and high effectiveness/low cost treatments would proliferate. 5.6 Cost Effectiveness of Alcoholism Treatment Settings There have been a number of studies published in the literature on the relative effectiveness and cost-effectiveness of alcoholism treatment in inpatient or outpatient settings. Since inpatient treatments are generally more costly than outpatient treatments, a finding of no difference in the effectiveness between settings is generally interpreted to imply that outpatient treatment is more cost-effective than inpatient treatment. A number of studies have rightly noted that inpatient clients are often more difficult to treat than outpatient clients, which may explain (partly or entirely) why inpatient programs do not show better outcomes (Saxe 1983, Miller and Hester, 1986,and French 2001). Also, the types of treatments offered in the two settings often differ so that studies may be confusing treatment effects and setting effects and the intensity of treatments given may vary across settings (Saxe 1983). Most of the studies have relatively short follow-up periods (usually 6 or 12 months), and it is possible the effectiveness of inpatient and outpatient treatments is different in the long-run than in the short-run. It is possible that relapse rates differ by treatment setting (French 2001). One other factor should be noted. Most studies are presented from a program manager’s point of view. As such, they ignore the costs of foregone work income, which are important from the individual and society’s viewpoint. In residential, inpatient, and intensive day treatment, patients cannot hold employment so the cost of these settings is higher than indicated in most studies (Cartwright 1998). With these qualifications let us review the literature. Saxe (1983) reviewed the existing literature through 1983. He noted that most of the existing studies were methodologically flawed for reasons just discussed, but that the consensus of the literature seems to be that inpatient treatment is not superior to outpatient care for alcoholism. Saxe noted that inpatient treatments continue to be dominant in practice because they are reimbursable and that practitioners have been slow to react to the scientific evidence on the cost-effectiveness of alternative, outpatient, and non-hospital-based services. The conventional wisdom that alcoholism outpatient treatment is more cost-effective than inpatient treatment drew further support from Miller and Hester (1986). They reviewed 12 controlled evaluations of inpatient treatment versus nonresidential alternatives and not a single study found superior outcome for inpatient settings and several found that existing differences favored nonresidential settings. Almost all of these studies employed random assignment to the inpatient or outpatient setting so that the problem of patient variation was eliminated. Subsequent studies have continued to find that alcoholism outpatient treatment is more cost-effective than inpatient treatment. Longabaugh et al. (1983) compared the post-treatment costs of 60 extended inpatients with 114 partial hospital treatment patients and found the partial hospital group to have lower costs but that there was no difference in clinical effectiveness. As French (2001) noted, their analysis did not control for patient severity and patient-treatment matching so their results need to be cautiously interpreted. McCrady et al. (1986) follows the treatment groups from Longabaugh et al. through 12-month outcomes. They reported that the 12 month results are the same as the 6 months outcomes reported earlier. Hayashida et al. (1989) compared the costs of detoxification and outcomes of patients having mild-to-moderate alcohol withdrawal syndrome. The patients were randomly assigned to the two settings. The authors reported that significantly more inpatients completed detoxification (72% vs. 95%) and that the costs were substantially greater for inpatients ($3,331 to $3,665 per patient vs. $174 to $388). The 6 month follow-up revealed no difference in the subsequent use of other alcohol-treatment services. Walsh et al. (1991) randomly assigned 227 workers who were identified as abusing alcohol to one of three treatment alternatives: (1) compulsory inpatient treatment, (2) compulsory attendance at AA, and (3) a choice of options. Of the 71 workers who selected the choice option, 29 chose inpatient hospital treatments, 33 chose AA attendance, and 6 chose no treatment. While there was no difference between the groups in job performance measures, the hospital group did best on substance use outcomes and the AA group did least well. Also, the AA group and choice group required more subsequent hospitalization than the hospital group. This study had a longer follow-up (2 years) than the other studies. Their results raise the issue of whether inpatient treatments have greater long-term effects as well as higher costs than outpatient treatments. We need more longer follow-up studies to address this issue. 5.7 Cost Benefit and Cost Offset Studies of Alcoholism Treatments As noted in Section 2.3, cost-benefit analysis (CBA) is a formal method for the monetary valuation of incremental benefits and costs of alternative interventions. In theory, CBA can be used to ascertain whether the beneficial consequences of alcoholism treatments justify their costs. Under CBA all relevant costs and benefit must be valued in money terms. This is a difficult task in the case of alcoholism treatments. Section 3.5 identified three main categories of costs of health care programs (i.e., alcoholism treatments): Healthcare sector costs (C1), Patients and family costs (C2), and other sector costs (C3). The relevant costs to be included in any given evaluation depend on the viewpoint of the analyst (see Table 3.1). Section 3.6 identified the major benefits associated with health care interventions such as alcoholism treatments. If treatments are effective the individual enjoys immediate health benefits and reduced risk of future ill-health. Improved health status could lead to greater periods of employment and higher earnings for the individual and more tax revenue for government. There may be improved social functioning and family relations and benefits to third parties as well, such as (1) reduced future health care costs, (2) productivity gains for employers, (3) reduced criminal activity and criminal justice costs, (4) reduced social care, and (5) reduced automobile and other accidents. Because of the difficulties involved in measuring and valuing these costs and benefits, most of the CBA in health care published to date are limited to a comparison of those costs and consequences that can easily be expressed in money terms. For these reasons, there have been no complete CBAs of alcoholism treatments published in the literature. There are a number of partial CBAs or so-called “cost-offsets” studies, which compare the costs of alcoholism treatments with the dollar value of avoided future health care costs (for a review of the recent literature see Holder 1998). 5.7.1 Reviews of Cost-Offset Studies There have been a number of cost-offset studies of alcoholism treatment published over the past 40 years. Four major reviews of these studies have been published and they will serve as the basis for our analysis. (1) Jones and Vischi (1979) In 1979, Jones and Vischi reviewed the available literature with respect to alcoholism treatment’s impact on medical care utilization. Each of the studies reviewed found that alcoholism treatment results in a significant reduction in medical care use and expenditures. The median reduction in sick days and accident benefits was 40 percent. The studies reviewed by Jones and Vischi were flawed by a number of methodological problems (Saxe 1983). First, is the issue of censored samples. The studies focused on employee-based alcoholism programs or organized health care settings that have particular economic incentives and tend to emphasize low cost treatments that do not take individuals away from their work. It is not clear to what extent their findings will hold up on an economy wide basis. Second, the studies only considered medical utilization inside the organizational unit. They ignored personal expenditures. Third, most of the studies lacked a control group and if they had one, assignment was non-random. So these studies were subject to the regression-to-the-mean and spontaneous recovery issues discussed above. These effects were accentuated by the relatively short follow-ups (1 year or 6 months). (2) Saxe (1983) In 1983, Saxe reviewed four of the studies considered by Jones and Vischi (1979) plus two more studies completed after their review. He noted that in a 5 year follow-up to one of Jones and Vischi’s studies, medical care utilization by alcoholics and their family members had declined, and both utilization and costs were lower than those of control group members. Long-term effects like this are not consistent with regression-to-the-mean behavior and spontaneous recovery. Saxe stressed the value of longitudinal studies. After discussing the methodological problems as well as the findings in the studies reviewed Saxe concluded: “there is some evidence to support the hypothesis that alcoholism treatment is cost-beneficial. (3) Holder (1987) Holder reviewed the alcoholism treatment cost-offset studies that had been completed since Jones and Vischi (1979). Holder divided his research into two types of studies. Controlled studies use a well-defined patient group and a specific form of treatment under regulated and carefully monitored conditions. These studies can indicate whether a specific type of treatment can reduce overall health care utilization for alcoholic patients. Naturalistic studies examine the actual experience of a diverse population of alcoholic patients in a naturally occurring research situation. Specific treatments are unknown and the control group typically consists of non-alcoholics. Data are usually based on existing medical records or health insurance claims. Naturalistic studies can indicate whether the provision of varied forms of alcoholism treatments in a large population (usually enrolled in a specific health insurance plan) result in a reduction of total health care utilization and cost. Holder (1987) makes the argument that the studies he reviewed are methodologically stronger than those reviewed by Jones and Vischi (1979). Most of Holder’s studies use pre/post longitudinal research design, they are larger, and they use better control groups (i.e., usually matched samples of non-alcoholics. But no study employed the ideal control group (i.e., a randomly selected non-treatment control group from the same populations as the treated population, i.e., alcoholics). Based on his literature review, Holder made the following observations or conclusions. During the 25-36-month pretreatment period alcoholics incur costs about 130% higher than those incurred by comparable non-alcoholics. First, in the 13-24-month period before treatment, the alcoholic’s costs are around 180% higher, and in the last 12 months before treatment, the alcoholic’s costs are close to 300% higher than costs of comparable non-alcoholics. Most of this last difference is attributable to inpatient utilization resulting from substantially higher inpatient days per month per person for alcoholics. Of course, this pattern establishes the likelihood of regression-to-the-mean and spontaneous recovery effects in the immediate post-treatment period. Second, Holder noted that in comparative treatment studies, where patients are randomly assigned to treatment groups, no significant differences in medical care cost reductions have been shown. He interprets this to suggest that alcoholism treatment approaches may be equally likely to be associated with reduction in total health care costs. It is also possible that much of the cost reductions observed in the studies are due to regression-to-the-mean and spontaneous recovery effects rather than treatment effects, which we learned earlier are not uniform. With respect to cost offsets, Holder reported that most studies have shown a statistically significant reduction of health care costs following initial alcoholism treatment comparing the 12 months before treatment with annual values after treatment begins. He noted that longer pre-periods would have been preferred because of the “ramp-up effect” in costs and the likelihood of a regression-to-the-mean problem. Holder noted that the few studies that had longer pre-periods (i.e., 2 years) and longer post-periods (i.e., 2 years) have also shown a downward trend in costs providing stronger evidence of cost-offsets. He says it is less likely that sustained reductions in utilizations and costs after the “crisis has subsided” are attributable only to statistical regression or spontaneous remission. It is difficult to argue that all cost reduction is simply a statistical artifact. Finally, he reported that four studies found that post-treatment initiation costs converged to the level of a comparable group of non-alcoholics. (4) Holder (1988) In a subsequent paper, Holder (1998) summarized some of the salient research of the past 20 years concerning cost-offsets of alcoholism treatment. Most of his discussion is a rehash of Holder (1987), but here is an important new discussion of whether the cost-offset results generated from studies of working employees covered by private insurance or organized health care plans are generalizable to lower socioeconomic alcoholics. He reviewed several studies by Booth and colleagues, Booth, Yates, and Petty, et al. (1990 and 1991) and Booth, Blow, and Cook, et al. (1992). These studies analyzed changes in medical care utilization before (i.e., 3 year pre-period) and after (i.e., 3 year post period) alcoholism treatment for Veterans Administration (VA) patients, who tend to have lower socioeconomic status and more disability than patients in other medical care situations. In contrast to most alcoholism cost offset studies, Booth et al. found a significant increase in the number of inpatient days and outpatient visits for all types of medical care and for all groups of alcoholics who received treatment services, even for individuals who completed inpatient treatment. The authors suggested several explanations for their findings, but the most compelling reason may derive from the fact that relapse is common even for those who complete treatment and the VA system is more apt to provide follow-up services compared to other public and private clinics (French 2001). Holder (1998) reviewed two other alcoholism cost-offset studies dealing with non-traditional populations. Lo and Woodward (1993) examined whether Medicare patients had lower health care utilization after they received treatment in free standing residential alcoholism treatment facilities. Their control group was formed of a randomly selected population of Medicare patients who were not treated directly for alcoholism but for the physical health consequences of heavy chronic alcohol use. The control group was treated in the hospital. Lo and Woodward found that both groups experienced a decline in overall health care costs following treatments, but those treated in freestanding facilities had the greater decline in costs. Holder (1998) also reviewed a study by Lawrence Johnson and Associates (1985), who examined the health records for alcoholics and a general cohort of Medicaid and Medicare patients. They used a two year pretreatment period, but only had post-treatment data available for one year. Both the Medicaid and Medicare alcoholism clients showed a decline in post-treatment costs while costs for the Medicaid and Medicare general control groups increased. These findings are similar to the findings of most alcoholism cost-offset studies. But given the short post-treatment period and lack of a randomly selected non-treated alcoholic control group, this study also suffers from the possibility of regression-to-the-mean and spontaneous recovery effects. Holder (1998) also reviewed several studies that estimated the cost-offset hypothesis by gender and age groups. He reported there are no apparent gender differences in pre/post spending patterns for alcoholics. The pre- and post-treatment patterns of alcoholic males and females are virtually identical. There are, however, differences that support the value of early intervention. Older (say 55 or older) workers have higher pre-treatment costs than younger workers and they respond less well to treatments. The older treated alcoholic is unlikely to experience lower health care costs following treatment initiation than before treatment. Holder concluded on the basis of his review that “the results of research provide consistent support for the cost effectiveness of alcohol treatment. That is, we find support if we define cost effectiveness in terms of treatment’s ability to offset its own cost by reducing future health expenses” (p. 370). One other study is worth mentioning with respect to alcoholism treatment cost-offsets. Holder and Shachtman (1987) attempted to estimate the actual values of offset in the absence of an untreated control group. They used pre-treatment cost trends of the treated alcoholic population to estimate what “no treatment” costs might have been for that group. Forecasts of “no treatment” costs were derived using Markov chains and ordinary least squares regression. They compared the predicted “no treatment” costs to the actual costs after treatment to determine the level of cost-offsets by the end of the third year after treatment. A positive net savings was found for all the models, but the extent of cost-offsets varied dramatically – ranging from $405 to $9,400 per person. 5.8 State Alcoholism Treatment Programs’ Cost-Offsets Particularly germane to the current study are the findings of studies of state alcoholism treatment programs’ cost-offsets. Holder (1987) reviewed studies of Oklahoma and Illinois. Gregory et al. (1981) studies a sample of 2,362 clients who received alcoholism treatment in 1974-1978 under Federal formula grant-supported alcoholism treatment programs in the State of Oklahoma. No information was given on the sampling method or treatments provided. Based on self-reported information on hospital admissions, the authors estimated the total health care cost for the year prior to treatment to be $1,883 per client and for the year after treatment the cost was estimated to be $1,391, resulting in a statistically significant reduction of $492 per client. These conclusions were validated by utilizing the actual hospital utilization records of 433 clients. The total medical costs for this group was estimated at $1,929 in the pre-period and only $945 in the post-treatment period, yielding a cost-savings of $984 per client. Without a “no treatment” control group and a short pre- and post-treatment period, this study suffers from regression-to-the-mean and spontaneous recovery effects being counted as treatment effects. Becker and Sanders (1984) and Sanders and Becker (1985) analyzed Medicare clients who received services under the Illinois Medicare/Medicaid Alcoholism Services Demonstration. During the 22 month demonstration period the average monthly total health care cost per alcoholic client was $188.33 compared to $85-$90 for all Medicaid clients statewide. Health care use and costs for Medicaid demonstration clients substantially increased during the 6-month period before treatment began and then gradually dropped over the follow-up period. Holder (1987) provided no more information on this study. The pre/post expenditure pattern is similar to that reported in other cost-offset studies. As in the Gregory (1981) study, the Illinois studies also suffer from regression-to-the-mean and spontaneous recovery effects being counted as treatment effects. There have been a number of additional studies completed on the cost-savings of Drug and Alcohol Treatment programs for other states. These studies do not separate the alcohol and drug treatment effects on the total cost-savings so we shall postpone our discussion of these studies until the next chapter. 5.9 Summary and Conclusions on Alcoholism Treatment Evaluations Over the past half century it has become recognized that alcoholism is a multifaceted problem involving many dimensions including medical, psychological, and sociological. As a consequence, the number of alternative treatments for alcoholism has greatly expanded during this period. Nine methodological problems make it difficult to interpret the studies of alcoholism treatment evaluations. These include: (1) the lack of standardized treatment protocols, (2) the lack of standard outcome measures, (3) the lack of control for patient variation, (4) the failure to report or lack of consistency in reporting treatment costs, (5) the failure to use the “ideal” research design where alcoholics are randomly assigned to experimental treatment groups and to a no-treatment control group, (6) the so-called “ramp-up effect” just prior to treatments leads to a potential “regression-to-the-mean problem,” (7) follow-up analysis is plagued by censored samples, reliance on self-reported data and varying post-treatment periods most of which are too short to capture the long run effects of treatment and to minimize the effects of “regression-to-the-mean” and spontaneous recovery, (8) the high relapse rate among successfully treated alcoholics makes it difficult to measure both the short-run and long-run effects of single episodes of treatment, and (9) there is no way to separate the effects of spontaneous recovery from treatment effects in the absence of the “ideal” research design. The absolute effectiveness of alcoholism treatments has yet to be determined in the absence of the “ideal” research design (with random assignment of alcoholics to experimental groups and a “no-treatment” control group) being used. There is, however, a growing and methodologically improving literature on the relative effectiveness of alcoholism treatments that has developed over the last half century. During the past twenty years, the comparative treatment studies have used larger samples and random assignment of patients to the different control groups so we can have greater confidence in their estimates of the relative effectiveness of different alcoholism treatments. The literature seems to be moving toward agreement that social skills training, the community reinforcement approach, behavioral marital therapy and stress management training are relatively effective whereas residential milieu treatment, general counseling, and metronidazole are not. The relative effectiveness of the other alcoholism treatments remains in debate. Currently there are no cost-effectiveness studies of alcoholism treatments in the published literature. Holder et al. (1991) and Finney and Monahan (1996) attempted to fill this gap in the literature indirectly by merging the separate literatures on the relative effectiveness of alcoholism and the cost literature by setting and provider with survey data from clinical experts about appropriate treatment settings and length of treatment. Whether they have done so is debatable. In any case, they found evidence of a negative relationship between alcoholism treatment effectiveness and cost. In the absence of cost-effectiveness, it should not be surprising that a number of low effectiveness/high cost treatments continue to be used. One of the major purposes of cost-effectiveness analysis is to weed out relatively inefficient treatments. In this regard, there is a growing literature on the cost-effectiveness of treating alcoholism in an outpatient or inpatient setting. Most studies have concluded that outpatient treatment is more cost-effective than in-patient treatments. Many of these studies have failed to account for patient variation and differences in the types of treatment provided. The more recent studies have used random assignment of patients to inpatient and outpatient groups so that the problem of patient variation is eliminated. Most of these studies continue to find outpatient alcoholism treatments to be more cost-effective than inpatient treatments, but there are a few notable exceptions. There have been no cost-benefit studies of alcoholism treatments from the society viewpoint, which requires that all relevant costs and benefits to all parties be included in the analysis, published to date. A number of partial cost-benefit studies or so-called cost-offset studies have estimated whether alcoholism treatments have led to a reduction in future health care costs sufficient to cover the costs of treatments. The pre-1979 studies suffered from the same methodological flaws that marred early studies of the relative effectiveness of alcoholism treatments. The samples were small, patient variation was ignored, and control groups were inadequate. Most of these studies showed significant reductions in health care utilization and costs in relatively short follow-up periods (6 months or one year). For these reasons, the problems of “regression-to-the-mean” and “spontaneous recovery” almost certainly caused the estimates of medical care cost-savings to be overstated. Post-1979 studies, which included larger samples and better control groups have consistently found a statistically significant reduction in health care costs following treatments. Significantly, the few studies that have used longer follow-up periods (2 or more years) have reported ongoing reductions in health care costs, which indicates declining health care expenditures are due to treatments and not just due to “regression-to-the-mean” or spontaneous recovery effects. Recent contributions to the literature suggest that cost-offsets are problematic when dealing with VA patients and patient groups aged 55 and older. On the other hand, studies of Medicaid and Medicare alcoholism patients have reported cost-offsets comparable to those of working employees covered by private insurance. Admittedly, these studies are not methodologically strong. Also, there are no differences in the cost-offsets generated by providing alcoholism treatments to males or females. Finally, several studies have investigated the cost-offsets associated with State alcoholism treatment programs. These studies found that these state programs produced health care cost-savings similar to those found in the private sector. Unfortunately, the studies of the state programs were methodologically weak. They made no attempt to control for “regression-to-mean” and spontaneous recovery effects.
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