Study Finds Significant Financial Benefits of Providing Substance Abuse Treatment. Latest study addresses policy makers’ concerns on spending public dollars on drug and alcohol treatment

Every dollar spent on substance abuse treatment generates $7 in monetary benefits for society, according to a new study from researchers at the University of California at Los Angeles (UCLA).

Published in the online early edition of the peer-reviewed journal, Health Services Research, the study finds that the average cost of substance abuse treatment is $1,583, resulting in monetary benefits of $11,487 through reduced medical expenses, reduced costs of crime and increased employment earnings.

“Policy-makers are generally more inclined to support treatment programs for substance abuse if they pay for themselves through reductions in other types of costs, such as health care, criminal justice expenses, social programs, and unemployment benefits. This study clearly demonstrates the financial benefits of providing treatment for drug and alcohol problems,” according to Susan Ettner, lead author and professor of general internal medicine and health services research at UCLA’s David Geffen School of Medicine and School of Public Health.

The researcher team used data from 2,567 clients in 43 treatment programs in 13 California counties during 2000 and 2001, through the California Treatment Outcome Project (CalTOP).

The research team estimated cost of treatment for an individual by multiplying the number of days spent in each treatment setting, such as residential or outpatient, by the average daily cost of each mode of treatment, estimated using cost data collected from treatment providers.

Monetary benefits associated with treatment were estimated using administrative records as well as data provided by each client prior to treatment and nine months after treatment began. The study examined costs of medical care, mental health services, criminal activity, earnings, and related costs of government programs such as unemployment and public aid.

The California Department of Drug and Alcohol Programs, the Center for Substance Abuse Treatment and the Robert Wood Johnson Foundation’s Substance Abuse Policy Research Program (SAPRP) provided primary support for the study.

“Substance abuse treatment is often needed by those who are indigent and are therefore dependent on services that are publicly financed. Given the stigma associated with substance abuse and the skepticism about the value of rehabilitation, financing for substance abuse treatment often runs into the question of whether or not it is beneficial in human and monetary terms. This study adds to a growing body of research showing the benefits of substance abuse treatment,” according to Ettner.

The study’s other findings:

• Treatment costs of clients who began with outpatient care totaled $838 compared to $2,791 for those who began in residential care.
• Reductions were seen in hospital inpatient, emergency room and mental health services costs, but only the $223 reduction in emergency room costs was statistically significant.
• Reduction in the cost of victimization and other criminal activities averaged $5,676.
• No significant changes were seen related to unemployment or disability costs. However, welfare payments increased slightly, perhaps due to increased referrals to public aid programs.

See full report at; http://www.rwjf.org/pr/product.jsp?id=21822

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Alcoholics Anonymous careers

BACKGROUND: Most formal treatment programs recommend Alcoholics Anonymous (AA) attendance during treatment and as a form of adjunctive aftercare, but we know very little about treatment seekers’ patterns of AA involvement over time and how these relate to abstinence.

METHOD: This paper applies latent class growth curve modeling to longitudinal data from 349 dependent drinkers recruited when they were entering treatment and were re-interviewed at one or more follow-up interviews one, three and five years later, and who reported having attended AA at least once.

RESULTS: Four classes of AA "careers" of meeting attendance emerged:

The low AA group mainly just attended AA during the 12 months following treatment entry.

The medium and high AA groups were characterized by stable attendance at the second and third follow-ups-at about 60 meetings a year for the medium group and over 200 meetings per year for the high group, followed by slight increases for the medium group and slight decreases for the high group by year five.

The declining AA group doubled its meeting attendance post baseline, to almost 200 meetings during the year following treatment entry, but by year five they were only attending about six meetings on average.

Decreases in AA meetings did not necessarily signal disengagement from AA; at the five-year follow-up, a third of the low AA group and over half of the declining AA group said they felt like a member of AA. Activities other than meeting attendance, such as having a sponsor, otherwise paralleled the meeting careers, but social networks were similar by year five.

Rates of abstinence by year five (for the past 30 days) were

• 43% for the low AA group,
• 73% for the medium group,
• 79% for the high group and
• 61% for the declining group.

Rates of dependence symptoms and social consequences of drinking did not differ between the groups at year five.

CONCLUSIONS: The prototypical AA careers derived empirically are consistent with anecdotal data about AA meetings: some never connect; some connect but briefly; and others maintain stable (and sometimes quite high) rates of AA attendance. However, contrary to AA lore, many who connect only for a while do well afterwards.

Research; Kaskutas LA, Ammon L, Delucchi K, Room R, Bond J, Weisner C. Alcoholics anonymous careers: patterns of AA involvement five years after treatment entry. Alcohol Clin Exp Res. 2005 Nov;29(11):1983-90.

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A Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals: Training Curriculum, First Edition

A Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals: Training Curriculum provides both practitioners and administrators familiarity and knowledge about the interaction between LGBT issues and substance use disorders. 

The curriculum offers skill-building knowledge enhancing practical skills to offer sensitive, affirmative, culturally relevant, and effective treatment to LGBT individuals in substance use disorders treatment. 

Based on the 2001 Center for Substance Abuse Treatment (CSAT) publication A Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals, the curriculum was developed by Prairielands Addiction Technology Transfer Center (ATTC), the Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Treatment (CSAT), and The Lesbian, Gay, Bisexual, and Transgender Community Center of New York City.

A downloadable version of the training curriculum is available at.

http://www.public-health.uiowa.edu/pattc/lgbttrainingcurriculum

Publication Year: 2007

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What are drug users looking for in treatment; abstinence or harm reduction?

Within the UK and in many other countries two of the most significant issues with regard to the development of health and social care services for drug users has been the growth of the consumer perspective and the philosophy of harm reduction.

In this paper we look at drug users’ aspirations from treatment and consider whether drug users are looking to treatment to reduce their risk behavior or to become abstinent from their drug use.

The paper is based on interviews using a core schedule with 1007 drug users starting a new episode of drug treatment in Scotland. Participants were recruited from a total of 33 drug treatment agencies located in rural, urban and inner-city areas across Scotland.

Our research has identified widespread support for abstinence as a goal of treatment with 56.6% of drug users questioned identifying ‘abstinence’ as the only change they hoped to achieve on the basis of attending the drug treatment agency.

By contrast relatively small proportions of drug users questioned identified harm reduction changes in terms of their aspiration from treatment, 7.1% cited ‘reduced drug use’, and 7.4% cited ’stabilization’ only.

Less than 1% of respondents identified ’safer drug use’ or ‘another goal’, whilst just over 4% reported having ‘no goals’.

Drug user’s desires;

• Abstinence – 56.6%
• Reduce drug use – 7.1%
• Stabilization – 7.4%
• Safer drug use or other goal (Grouped) – Less than 1%
• No goals – 4%

The prioritization of abstinence over harm reduction in drug users treatment aspirations was consistent across treatment setting (prison, residential and community) gender, treatment type (with the exception of those receiving methadone) and severity of dependence.

Neil McKeganey, Zoë Morris, Joanne Neale & Michele Robertson. What are drug users looking for when they contact drug services: abstinence or harm reduction? Drugs: Education, Prevention & Policy, Volume 11, Number 5 / October 2004, Pages: 423 – 435

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Substance abuse practitioners ask what is recovery?’

More than just abstinence, according to proposed definition

Abstinence from alcohol and drugs is just the starting point in defining “recovery” for people with substance abuse disorders, according to a paper in the October issue of the Journal of Substance Abuse Treatment.

According to an initial definition developed by a panel of experts from the Betty Ford Institute, recovery is “a voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship.” The panel’s report appears as part of a special section of Journal of Substance Abuse Treatment devoted to Defining and Measuring Recovery.

Although “recovery” is widely recognized as the goal of treatment for substance abuse disorders, there has been no widely accepted definition of what the term actually means. “Recovery may be the best word to summarize all the positive benefits to physical, mental, and social health that can happen when alcohol and other drug-dependent individuals get the help they need,” the expert panel writes.

The panel’s report outlines some of the thinking behind key components of the definition.

Sobriety—meaning complete abstinence from alcohol and all other nonprescribed drugs—is regarded as necessary, but not in itself sufficient for recovery.

The panel suggests a classification to define the duration of sobriety:

• “early” sobriety between one month and one year;
• “sustained” sobriety, between one and five years; and
• “stable” sobriety, five years or longer.

People in “stable” recovery are thought to be at lower risk of relapse.

Personal health is included as a component of recovery that may be of special importance to substance abusers and their families, as well as to society.

In this context, personal health refers not only to physical and mental health, but also to social health—ie, participation in social roles and supports.

Citizenship refers to “giving back” to community and society. While acknowledging the need refine this part of the definition, the panel felt is was important to recognize the traditional place of citizenship as a key element of recovery.

The panel members hope their definition will help in overcoming some of the remaining obstacles to substance abuse treatment—including the stigma associated with being in recovery.

They liken being “in recovery” to being a “cancer survivor”—a term reflecting research evidence that the risk of relapse is significantly reduced for patients who are cancer-free after five years.

“Public discussion of survival rates has increased the proportion of individuals willing to get early screening for [cancer] and to take preventive measures,” the experts write.

They hope that their new definition of recovery “might be the beginning of a similar course of events in the addiction field. If recovery can be effectively captured, distilled, and communicated, it can come to be expectable by those now suffering from addiction.” This in turn could promote more realistic perceptions of recovery, and its true worth from social and economic standpoint.

The articles appear in the Journal of Substance Abuse Treatment, October 2007/

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TSF ASSESSMENT

The assessment session in TSF runs 1-1/2 hours. The goals are to:

• Establish client-facilitator rapport.
• Conduct a collaborative assessment of alcohol and other drug abuse(history).
• Discuss the client’s prior efforts to stop or control use.
• Discuss negative consequences associated with use.
• Share a diagnosis with the client and attempt to have it be a collaborative decision.
• Outline the TSF program.
• Attempt to get a commitment from the client to give TSF and AA/NA and try and to keep an open mind.

Assessment within the TSF model has both an informational and a motivational goal.

It is recommended that periodic alcohol tests be done either randomly or when the facilitator suspects that the client may have been drinking or using.

Consistent with 12-step philosophy, no client is excluded from treatment as a consequence of drinking or using, although with some clients it may become appropriate to discuss inpatient treatment. Sessions with clients who are found to be (or who admit to being) drunk or high are terminated, and arrangements are made to get the client home safely.

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TSF CLIENT-COUNSELOR RELATIONSHIP

What Is the Counselor’s Role?

The facilitator’s role in TSF is broadly defined as including education and advocacy, guidance and advice, and empathy and motivation. Each of these broad goals is broken down further into a series of specific guidelines or objectives. For example, guidance and support include monitoring client involvement in AA/NA, encouraging clients to volunteer for basic service work, identifying appropriate social events the client might participate in, locating appropriate meetings, and clarifying the role of a sponsor.

Who Talks More?

Clients and facilitators talk about equally in effective TSF sessions. Since TSF is an active intervention, facilitators who are passive may not succeed in maintaining focus or accomplishing basic goals. At the same time, success in TSF is dependent on monitoring client activity and reactions, which requires soliciting active client involvement in sessions.

How Directive Is the Counselor?

TSF is similar to many cognitive-behavioral therapies in that it is focused and requires the facilitator to be fairly directive while still maintaining good rapport. The TSF facilitator is directive in the following ways:

• The focus of therapy is on early recovery. The facilitator does not allow the focus to drift onto other issues (e.g., relationship or work problems) even if these are significant. The facilitator validates other concerns and helps the client develop an overall treatment plan to deal with them but maintains the focus of TSF.
• The client’s reactions to assignments and meetings are considered very important. In TSF the facilitator needs to solicit specific feedback from the client.
• Each TSF session has a specific topic (core, elective, or conjoint) that includes a specific agenda to be covered. Although a given topic may require more than one session to cover, and while the facilitator needs to be somewhat flexible in his or her agenda, the facilitator must also take responsibility for controlling the content and flow of sessions.
• Each TSF session follows a set format that the facilitator is responsible for following. Again, there is some flexibility, but the facilitator does not simply follow the client’s agenda.
• Every TSF session ends with the facilitator making specific suggestions to the client (recovery tasks). In addition, the facilitator is expected to make specific suggestions (e.g., which meetings to attend, how to ask for a sponsor) throughout treatment.

Therapeutic Alliance

In TSF, the facilitator is seen as an expert in interpersonal counseling techniques and as knowledgeable in the principles and practicalities of 12-step fellowships.

However, in TSF the facilitator is not regarded as the primary agent of change; rather, it is the 12-step fellowship (AA or NA) that is seen as the agent of change.

Accordingly, the TSF facilitator needs to conceptualize treatment as the product of a collaborative relationship and should assume responsibility for doing the best he or she can to establish that collaborative relationship.

However, it is not the facilitator’s goal to breakdown the client’s denial, to provide all support needed to stay sober, to take the client to meetings, and so forth. Even in emergencies, the facilitator’s role and responsibilities are limited in the TSF model. For this reason the word "facilitator" was chosen rather than therapist or counselor, as it seems to describe the role better than those labels.

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AA utilization after introduction in outpatient treatment

Treatment for alcohol dependence is often provided in outpatient settings, and often includes introduction to Alcoholics Anonymous (AA). Relatively little is known about subsequent AA utilization.

Analyses of survey data collected from 72 clients of an outpatient treatment center introduced to AA revealed that, 6 months following intake, a large portion of the responding sample of 55 were still attending AA meetings.

76% were still attending AA after 6 months.

Principal components analysis of self-reports of the frequencies of 12 AA-related behaviors found three dimensions of AA utilization:

• fellowship or social involvement,
• meeting attendance and participation, and
• involvement in bureaucratic functioning and meeting production.

Results suggest it is important to consider these dimensions of utilization for those wishing to understand AA involvement.

AA utilization after introduction in outpatient treatment 16. Thomassen, L. AA utilization after introduction in outpatient treatment. Substance Use and misuse, 37(2):239-253, 2002.

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12-Step Involvement Increases Sobriety and Reduces Costs

BACKGROUND: Accumulating evidence indicates that addiction and psychiatric treatment programs that actively promote self-help group involvement can reduce their patients’ health care costs in the first year after treatment, but such initially impressive effects may wane over time. This paper examines whether the positive clinical outcomes and reduced health care costs evident 1 year after treatment among substance-dependent patients who were strongly encouraged to attend 12-step self-help groups were sustained at 2-year follow-up.

METHODS: A 2-year quasi-experimental analysis of matched samples of male substance-dependent patients who were treated in either 12-step-based (n=887 patients) or cognitive-behavioral (CB, n=887 patients) treatment programs. The 12-step-based programs placed substantially more emphasis on 12-step concepts, had more staff members "in recovery," had a more spiritually oriented treatment environment, and promoted self-help group involvement much more extensively than did the CB programs. The 2-year follow-up assessed patients’ substance use, psychiatric functioning, self-help group affiliation, and mental health care utilization and costs.

RESULTS: As had been the case in the 1-year follow-up of this sample, the only difference in clinical outcomes was a substantially higher abstinence rate among patients treated in 12-step (49.5%) versus CB (37.0%) programs. Twelve-step treatment patients had 50 to 100% higher scores on indices of 12-step self-help group involvement than did patients from CB programs. In contrast, patients from CB programs relied significantly more on outpatient and inpatient mental health services, leading to 30% lower costs in the 12-step treatment programs. This was smaller than the difference in cost identified at 1 year, but still significant ($2,440 per patient, p=0.01).

CONCLUSIONS: Promoting self-help group involvement appears to improve posttreatment outcomes while reducing the costs of continuing care. Even cost offsets that somewhat diminish over the long term can yield substantial savings. Actively promoting self-help group involvement may therefore be a useful clinical practice for helping addicted patients recover in a time of constrained fiscal resources.

Humphreys K, Moos RH. Alcohol Clin Exp Res. 2007 Jan;31(1):64-8. Encouraging posttreatment self-help group involvement to reduce demand for continuing care services: two-year clinical and utilization outcomes.

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