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Treatment for Alcohol Problems
Treatment EffectivenessAccording to the Substance Abuse and Mental Health Services Administration (SAMHSA), alcohol abuse was involved in over 70 percent of substance abuse treatment admissions in 1997, and about half of people entering treatment reported alcohol as their primary drug of abuse. Opiates, the next most commonly used drugs, accounted for 16 percent of admissions, followed by cocaine at 15 percent.181
The 1997 National Treatment Improvement Evaluation Study of addiction treatment effectiveness found a 70 percent reduction in the number of clients reporting problems with alcohol in the year following treatment.182 The study also found that arrests among treatment clients decreased by nearly two-thirds, alcohol and other drug-related medical visits decreased by over 50 percent and suicide attempts decreased by 40 percent.183
Treatment also reduces social costs.184 Treatment accounts for only 13 percent of the $167 billion in annual alcohol-related costs. However, the 1994 California Drug and Alcohol Treatment Assessment (a statewide evaluation of treatment outcomes and cost-effectiveness) found that $1 invested in alcohol and other drug treatment saved taxpayers $7 in future spending associated mainly with criminal justice and health care costs.185 In 1996, a statewide study of the costs and benefits associated with treatment in Ohio found a $4 return for every $1 spent, even when treatment achieved only a 50 percent abstinence rate.186 Reductions in criminal justice costs accounted for the bulk of cost savings in both studies.
Community-based, self-help programs designed to serve alcoholics are widely available; the most well known is Alcoholics Anonymous (AA).187 An estimated 6 million people have attended AA. Many intensive treatment programs require participation in a self-help group. AA consists of fellowship meetings, an one-to-one sponsor system and the 12-step philosophy, with no ties to any formal counseling. In addition to self-help programs for alcoholics, related organizations, like Al-Anon and Alateen, support families and friends of alcoholics.
It is difficult to study AA's effectiveness in part because of the anonymity of its members; however, a 1990 study of alcohol treatment outcomes found AA participation to be the only significant predictor of sobriety during long-term follow up.188 Becoming an AA sponsor was an even greater indicator of success, with 91 percent of sponsors reporting sobriety.
The development of medications to reduce relapse and to increase abstinence has evolved substantially over the past several years.189 Naltrexone was originally approved in 1984 to treat heroin addiction. In 1994, the Food and Drug Administration approved naltrexone to treat alcoholism. Patients treated with both naltrexone and outpatient therapy are twice as likely to abstain from any drinking and from reverting back to heavy drinking than patients only receiving outpatient therapy.190/191 Naltrexone was originally approved in 1984 to treat heroin addiction.192
However, naltrexone is not widely prescribed, in part because some treatment providers are reluctant to treat a drug problem with a drug. In addition, naltrexone has not been extensively marketed to primary care providers, the major point of treatment contact for most alcoholics.193
Naltrexone is the first medication approved to treat alcohol dependence since the 1940s 194. In contrast, the last two decades have seen development of dozens of medications to treat clinical depression.195
In addition to naltrexone, research trials on new drugs show promise for future success. A study of nalmefene, for example, found that alcoholic patients who received the drug were 58 percent less likely to relapse than patients who received a placebo.196 And while findings from U.S. trials on acamprosate have not yet been published, the drug has been found effective in various European trials and has been approved in France since 1989.197
The next step in pharmacological advancements will be combining medications which act on different brain receptors in order to improve outcomes. In 2000, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) plans to launch Project Combine to test whether these combinations, along with counseling, can significantly improve alcoholism treatment.198
Alcohol and Nicotine Addiction
An estimated 80 to 95 percent of alcoholics are heavy smokers— three times the rate in the general population.199 Studies of the links between drinking and smoking suggest smoking may trigger relapse among alcoholics who have completed treatment.200 According to NIAAA, smoking and alcohol dependence can be treated simultaneously without endangering alcoholism recovery.201 In addition, treating both dependencies can significantly reduce risks for hypertension and certain forms of cancer.202
Approximately 14 million Americans have alcohol abuse problems serious enough to require treatment.203 However, only one in ten individuals who need treatment have sought it.204 Financial, geographic and cultural barriers to treatment; denial that treatment is needed; and concern about the stigma of alcoholism are primary reasons.205
Women are also less likely than men to receive treatment for alcohol problems.206 Doctors are more likely to identify men than women with drinking problems. One possible explanation is that men more often exhibit public signs of problem drinking, while women may experience less obvious symptoms, such as depression.207 In addition, police are less likely to arrest women than men for drunk driving, which means fewer women face court-ordered treatment.208
One of the most significant barriers to alcohol treatment is the cost. As cost containment has become a national priority, significant changes have occurred in the financing of alcohol treatment services.209 The field has seen reductions in inpatient care; increases in outpatient care, including outpatient detoxification; fewer individual therapy sessions and more group therapy sessions; and use of less costly providers.210 One of the greatest challenges facing alcohol treatment providers is maintaining the quality of care in the face of these constraints. Many physicians have little confidence in the effectiveness of treatment. According to a 1998 Peter Hart Poll conducted for the Recovery Institute, doctors believe that fewer than one-third of alcoholics in treatment are able to achieve lifelong recovery. In addition, treatment approaches known to be effective in reducing alcohol use, such as use of medications combined with counseling, are underutilized partly because of their higher cost.
Parity for alcohol and other drug treatment— insurance coverage on par with other medical services—would make treatment more accessible. Typically, health plans and third-party payers provide less coverage for alcohol and other drug abuse treatment than for other medical services. Some insurance companies provide none. Federal parity legislation would not only increase access to treatment but would also help stimulate developments of treatment medications and protocols, which the current system discourages.
Many fear parity because of the anticipated cost to third-party payers. However, a series of studies published in 1998 and 1999 showed that the costs of parity are small, while the benefits to individuals, employers and society are significant. 211/212 One report conducted by SAMHSA 213 found that parity would increase insurance premiums by only 0.2 percent. Nonetheless, no Federal parity legislation has been passed, and only five states have passed parity laws. President Clinton has called for all Federal employee health plans to include substance abuse and mental health treatment parity by 2001, which may help spur Congress and states to follow suit.
Increasing access to treatment services may lead to small increases in up-front costs, but the long-term savings make it cost-effective. Health care costs for treated alcoholics are nearly 25 percent lower than for untreated alcoholics.214 General health care costs for families of alcohol abusers can be as much as three times higher than those for other families. However, these costs also drop substantially after successful treatment.215
Although nearly half of adult treatment participants report alcohol as their primary drug of abuse, only one-third of adolescents in treatment report major alcohol problems. The number of youth in alcohol and other drug abuse treatment programs rose by more than one-third between 1992 and 1997. However, adolescents continue to be underserved.
According to the 1998 National Household Survey on Drug Abuse, only 16 percent of 12-17 year olds dependent on alcohol or marijuana had received any treatment.
Adolescents have unique treatment needs. Concurrent mental illness; legal problems; family and community environment; and emotional, intellectual and physical development must all be considered in planning effective treatment. It is also critical to meet the educational needs of youth in treatment.216 Treatment for adolescents should encourage family involvement, incorporate a wide range of social services, and provide aftercare services to reinforce progress achieved in treatment.217
In addition to developing more youth-specific treatment approaches, SAMHSA recommends screening youth to identify those most likely to have addiction problems. This includes teens who exhibit warning signs of abuse, including substantial behavioral changes, significant changes in academic performance, trauma injuries, and contact with the juvenile justice system or the child welfare system. Homeless and runaway teens in shelters, and all teens who receive mental health assessments should also be screened for addiction treatment needs. According to SAMHSA, adolescents with severe emotional and behavioral problems are significantly more likely to have alcohol and other drug abuse problems than other adolescents.
181. Treatment Episode Data Set 1992-1997. Substance Abuse and Mental Health Services Administration, Office of Applied Studies, 1999.
182. National Treatment Improvement Evaluation Study. Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, 1997.
183. National Treatment Improvement Evaluation Study. Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, 1997.
184. The Economic Costs of Alcohol and Drug Abuse in the United States, 1992. National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism, May 1998.
185. Evaluating Recovery Services: The California Drug and Alcohol Treatment Assessment (CALDATA) Executive Summary. Sacramento, CA: Department of Alcohol and Drug Programs, 1994.
186. Initial Cost-Offset Findings: Cost Effect Study Executive Summary. Columbus, OH: Division of Alcohol and Drug Addiction Services, 1996.
187. Ninth Special Report to the U.S. Congress on Alcohol and Health. U.S. Department of Health and Human Services, National Institute on Alcohol Abuse and Alcoholism, June 1997. Nine percent of American adults have attended AA, one-third of them for drinking problems of their own. Three percent of 202,916,000 (1999 Census of Americans over age 18) is just over 6 million.
188. G.M. Cross, C.W. Morgan, A.J. Mooney, C.A. Martin and J.A. Rafter, "Alcoholism treatment: A ten-year follow-up study." Alcoholism: Clinical and Experimental Research, 14(2):169-173, 1990. Cited in: Mary E. McCaul and Janice Furst, "Alcoholism Treatment in the United States." Alcohol Health and Research World, National Institute of Alcohol Abuse and Alcoholism, 18(4):253-260, 1994.
189. Naltrexone and Alcoholism Treatment, Treatment Improvement Protocol (TIP) Series. HHS, SAMHSA, 1998.
190. J.R. Volpicelli, A.I. Alterman, M. Hayashida, C.P. O'Brien, "Naltrexone in the Treatment of Alcohol Dependence." Archives of General Psychiatry, 49:876-880, 1992.
191. S.S. O'Malley, A.J. Jaffe, S. Rode and B. Rounsaville, "Naltrexone and Coping Skills Therapy for Alcohol Dependence." Archives of General Psychiatry, 49:881-887, 1992.
192. Naltrexone and Alcoholism Treatment, Treatment Improvement Protocol (TIP) Series. HHS, SAMHSA, 1998.
193. This is all from a personal communication with Dr. Barbara Mason of the University of Miami on October 7, 1999.
194. Enoch Gordis, "What We Know: Conceptual Advances in Alcoholism Research." Introduction for Principles of Addiction Medicine Second Edition. Washington, DC: American Society of Addiction Medicine, 1998.
195. Physicians' Desk Reference. Montvale, NJ: Medical Economics Company, 1996.
196. Barbara J. Mason, Fernando R. Salvato, Lauren D. Williams, Eva C Rivo and Robert B. Cutler, "A Double-blind, Placebo-Controlled Study of Oral Nalmafene for Alcohol Dependence." Archives of General Psychiatry, 56:719-724, 1999.
197. Pharmacotherapy for Alcohol Dependence. HHS, AHCPR, 1999.
198. Richard A. Knox, "Medications may reduce alcohol cravings." Boston Globe, p.C1, 8/30/99.
199. "Alcohol and Tobacco." Alcohol Alert, National Institute on Alcohol Abuse and Alcoholism. No. 39, January 1998.
200. Ninth Special Report to the U.S. Congress on Alcohol and Health. U.S. Department of Health and Human Services, National Institute on Alcohol Abuse and Alcoholism, June 1997.
201. "Alcohol and Tobacco." Alcohol Alert, National Institute on Alcohol Abuse and Alcoholism, No. 39, January 1998.
202. Ninth Special Report to the U.S. Congress on Alcohol and Health. U.S. Department of Health and Human Services, National Institute on Alcohol Abuse and Alcoholism, June 1997.
203. Bridget F. Grant, "The Influence of Comorbid Major Depression and Substance Use Disorders on Alcohol and Drug Treatment: Results of a National Survey." Paper presented at the National Institute on Drug Abuse Technical Review Meeting: Comorbid Mental and Addictive Disorders: Treatment and HIV-Related Issues, Rockville, MD, September 1994.
204. Bridget F. Grant, "The Influence of Comorbid Major Depression and Substance Use Disorders on Alcohol and Drug Treatment: Results of a National Survey." Paper presented at the National Institute on Drug Abuse Technical Review Meeting: Comorbid Mental and Addictive Disorders: Treatment and HIV-Related Issues, Rockville, MD, September 1994.
205. Improving the Delivery of Alcohol Treatment and Prevention Services: A National Plan for Alcohol Health Services Research. National Institutes of Health, National Institute of Alcohol Abuse and Alcoholism, 1997.
206. Substance Abuse and the American Woman. New York: Center on Addiction and Substance Abuse at Columbia University, June 1996.
207. Substance Abuse and the American Woman. New York: Center on Addiction and Substance Abuse at Columbia University, June 1996.
208. Substance Abuse and the American Woman. New York: Center on Addiction and Substance Abuse at Columbia University, June 1996.
209. Ninth Special Report to the U.S. Congress on Alcohol and Health. U.S. Department of Health and Human Services, National Institute on Alcohol Abuse and Alcoholism, June 1997.
210. Improving the Delivery of Alcohol Treatment and Prevention Services: A National Plan for Alcohol Health Services Research. National Institutes of Health, National Institute of Alcohol Abuse and Alcoholism, 1997.
211. R. Sturm, W. Zhang and M. Schoenbaum, "How Expensive are Unlimited Substance Abuse Benefits Under Mananged Care?" The Journal of Behavioral Health Services and Research, 26(2):203-210, 1999.
212. Premium Estimates for Substance Abuse Parity Provisions for Commercial Health Insurance Products. Seattle, WA: Milliman & Robertson, Inc., 1997.
213. The Costs and Effects of Parity for Substance Abuse Insurance Benefits. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 1998.
214. Mary E. McCaul and Janice Furst, "Alcoholism Treatment in the United States." Alcohol Health and Research World, 18(4):253-260, 1994.
215. R. Lennox, J. Scott-Lennox, H. Holder, "Substance Abuse and Family Illness: Evidence from Health Care Utilization and Cost-Offset Research." The Journal of Mental Health Administration (Special Issue: Substance Abuse Services), 19(1):83-95, 1992.
216. Oscar G. Bukstein, "Treatment of Adolescent Alcohol Abuse and Dependence." Alcohol Health and Research World, National Institute on Alcohol Abuse and Alcoholism, 18(4):296-301, 1994.
217. Oscar G. Bukstein, "Treatment of Adolescent Alcohol Abuse and Dependence." Alcohol Health and Research World, National Institute on Alcohol Abuse and Alcoholism, 18(4):296-301, 1994.
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