In this congressionally mandated study, an expert committee of the Institute of Medicine takes a close look at where treatment for people with alcohol problems seems to be headed, and provides its best advice on how to get there. Careful consideration is given to how the creative growth of treatment can best be encouraged while keeping costs within reasonable limits. Particular attention is devoted to the importance of developing therapeutic approaches that are sensitive to the special needs of the many diverse groups represented among those who have developed problems related to their use of "man's oldest friend and oldest enemy." This book is the most comprehensive examination of alcohol treatment to date.

Contents

• [Dedication]
• Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse
• Introduction and Summary
• 1 Our Vision
  • A Brief History of Treatment
  • Broadening the Base
  • Toward Treatment Systems
  • Advice to the Reader
  • REFERENCES
• 2 What Is Being Treated?
  • The Alcohol Problems Perspective
  • Other Perspectives
  • A Terminological “Map”
  • The Heterogeneity of Alcohol Problems
  • Implications of Heterogeneity for Treatment
  • Summary and Conclusions
  • REFERENCES
• 3 What Is Treatment?
  • Refining the Definition of Treatment for Alcohol Problems
  • Defining the Expanded Continuum of Care
  • Defining the Elements of Treatment in the Continuum of Care
  • Summary and Conclusions
  • REFERENCES
• 4 Who Provides Treatment?
  • Describing the System to Treat Persons with Alcohol Problems
  • A State Perspective on Treatment Providers
  • A Federal Perspective
  • A National Perspective
  • Treatment Personnel
  • Summary and Conclusions
  • REFERENCES
• 5 Does Treatment Work?
  • Reframing the Question
  • Answering the Reframed Question: Methods
  • Answering the Reframed Question: Results
  • Summary and Conclusions
  • REFERENCES
• 6 Is Treatment Necessary?
  • Improvement in Alcohol Problems Without Formal Treatment
  • Deterioration in Alcohol Problems with Formal Treatment
  • Coerced Treatment for Alcohol Problems
  • Implications for Treatment
  • Treatment Based on Knowledge of Improvement Without Treatment
  • Summary and Conclusions
  • REFERENCES
• 7 Is Treatment Available?
  • Distribution of Resources for Alcohol Problems Treatment
  • The National Drug and Alcoholism Treatment Unit Survey
  • The Distribution of Treatment Capacity
  • Expenditure Data
  • American Hospital Association Annual Survey of Hospitals
  • Relationship Between Treatment Availability and the Prevalence of Alcohol Problems
  • Summary and Conclusions
  • REFERENCES
• 8 Who Pays for Treatment?
  • Who Are the Payers?
  • Who Pays for Treatment in Specialty Programs?
  • Sources of Funding in Public-Sector Specialty Programs
  • Sources of Funding in Private Sector Specialty Programs
  • Who Pays for Treatment of All Health Care?
  • What Does Treatment of Alcohol Problems Cost?
  • Summary and Conclusions
  • REFERENCES
• 9 The Community Role: Identification, Brief Intervention, and Referral
  • An Orientation to the Community Role in Treatment
  • A Paradox and Its Implications
  • Identifying People with Alcohol Problems
  • Brief Intervention
  • Referral
  • Implementing the Community Role
  • Effects and Costs
  • Conclusions and Recommendations
  • REFERENCES
• 10 Assessment
  • What Is Assessment?
  • The Purposes of Assessment for Alcohol Problems
  • The Structure of Comprehensive Assessment
  • The Content of Comprehensive Assessment
  • Desirable Qualities of Assessment Content
  • The Administration of Assessment
  • Methods of Obtaining Assessment Information
  • Conclusions and Recommendations
  • REFERENCES
• 11 Matching
  • Studies of Matching in the Treatment of Alcohol Problems
  • Examples of Matching Programs
  • Specification of Treatment
  • Specification of Matching Guidelines
  • Some Treatment Controversies as Matching Problems
  • Conclusions and Recommendations
  • REFERENCES
  • Appendix: Excerpts From The Cleveland Admission, Discharge and Transfer Criteria
• 12 Determining Outcome
  • The Rationale for Outcome Determination
  • Some Examples of Systematic Outcome Determination
  • A Major Caveat
  • Implementing Outcome Monitoring
  • Conclusions and Recommendations
  • REFERENCES
• 13 Implementing the Vision: Toward Treatment Systems
  • Assuring Continuity of Care
  • Feedback of Outcome Information
  • An Audit of the Systems Approach
  • Evaluation of the Systems Approach
  • Conclusions and Recommendations
  • REFERENCES
• 14 The Treatment of Special Populations: Overview and Definitions
  • Defining Special Populations: A Historical Perspective
  • The Research Perspective on Special Populations
  • REFERENCES
• 15 Populations Defined by Structural Characteristics
  • Women
  • Adolescents
  • The Elderly
  • American Indians
  • Asian Americans and Pacific Islanders
  • Blacks
  • Hispanics
  • Summary and Conclusions
  • REFERENCES
• 16 Populations Defined by Functional Characteristics
  • Drinking Drivers
  • Dual-Diagnosis Psychiatric Patients
  • Homeless Persons: The New Public Inebriates
  • College Students
  • Children of Alcoholics
  • Summary and Conclusions
  • REFERENCES
• 17 The Treatment of Special Populations: Conclusions and Recommendations
• 18 The Evolution of Financing Policy
  • Development of a National Policy
  • The Establishment of the National Institute on Alcohol Abuse and Alcoholism
  • The Current Situation
  • Changes in Health Care Financing Policy: The Recent Emphasis on Cost Containment
  • Conclusions and Recommendations
  • REFERENCES
• 19 Cost-Effectiveness
  • Studies of Costs and Cost Offsets
  • Cost-Benefit and Cost-Effectiveness Analysis
  • Matching and Cost-Effectiveness
  • Conclusions and Recommendations
  • REFERENCES
• 20 Paying for the Treatment System
  • Financing the Current Treatment System
  • Financing the Ideal Treatment System
  • Financing the Vision: Paying for Specialized Treatment Services for the Poor and the Uninsured
  • REFERENCES
• 21 Leadership
  • Our Vision: The Committee's Recommendations
  • Opportunities for Leadership
  • The Challenge for the Future
  • REFERENCES
• Acknowledgments
• APPENDIXES
  • A Task Forces
  • B Treatment Modalities: Process and Outcome
  • C International Review of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse
  • D COERCION IN ALCOHOL TREATMENT

The work on which this publication is based was performed pursuant to Contract No. ADM-281-87-003 with the National Institute on Alcohol Abuse and Alcoholism of the Department of Health and Human Services.

NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competencies and with regard for appropriate balance.

This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine.

The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education.