Norman G. Hoffmann, Ph.D.
Methodological Issues
Research Results
Effective
treatment of alcohol and drug addiction has been available in the
Many
physicians do not routinely identify or refer patients who need treatment to
abstinence‑based programs for alcohol and drug addiction. Less than 12%
of almost 20,000 alcoholics and drug addicts were referred by physicians to
treatment programs similar to those described here (Chappel, in press). Given
the fact that addicted individuals are disproportionately represented in health
care populations, such a statistic is problematic. The estimated prevalence
rate of alcoholics and drug addicts in medical and psychiatric populations
ranges from 25 % to 80 % (Schuckit, 1978). The wide range of prevalence
estimates are accounted for by the nature of the populations under
consideration and the methods used to identify addictions. For example, one
would expect higher rates in psychiatric populations than in general medical
populations. Further, prevalence estimates based on chart reviews, are likely
to be lower than if patients are actually screened while on the units.
Ironically, simple and effective screening is not only possible but practical
in most medical settings.
A
multi‑site study using a structured diagnostic interview determined a
prevalence of addictive disorders of approximately 20% among general medical
patients. For males under the age of 71, 35% were alcoholics, while for women
the prevalence was 14 % (Hoffmann et al, 1989). The same study found four
items, identified by the acronym BONS, that correctly identified almost all
active alcoholics while holding the false positive rate to less than 10 % for
patients with no history of addictions. Those four items were: (1) Have you
even drunk enough so that the next day you could not remember what you had said
or done? (Blackouts); (2) Have your family or friends
ever told you they objected to your drinking? (Objections); (3) Have you ever
neglected some of your usual responsibilities when drinking? (Neglect); and (4)
Have you ever had the shakes after stopping or cutting down on drinking, or
shakes the morning after drinking? (Shakes). Such a
simple inquiry based on events and behaviors could be included in any medical
examination.
However,
identification and referral of patients is moot if no effective treatments can
be identified. Not only do the majority of patients benefit from these
programs, significant benefits are also provided to society as a whole. In
particular, general health care costs are reduced substantially by addiction
treatment. Immunology and addictions treatment are two of the few areas of
medicine which can consistently demonstrate the potential for saving more
health care dollars than are expended for their respective services.
The
data presented here are from CATOR (the Comprehensive Assessment and Treatment
Outcome Research), which is the largest independent evaluation service for
addictions treatment programs in the
Most
of the abstinence‑based programs monitored by CATOR are outpatient and
inpatient variations of the Minnesota Model based on an integration of
professional services and Twelve Step support systems (Laundergen, 1982). This
treatment is structured in form and content involving both group and individual
therapies. The primary, or intensive, phase provides group and individual
sessions daily for inpatients and at least nine hours of sessions per week for
outpatients. This is followed by a less intensive and tapered continuing care
of weekly outpatient services for a period of months to a year or two.
Educational and family components are part of the typical content. In addition,
services for other physical and psychiatric conditions may be included in some
programs for those who suffer from more than just the addictions and their
consequence
Although
the programs monitored by CATOR tend to be variations of the Minnesota Model,
psychiatrically based programs and aversion therapy programs are included as
well. The common element to all of these programs is that the ideal goal is
assisting the patient to remain abstinent from all mood altering drugs of
abuse. To be admitted to these programs one must have a diagnosable addictive
disorder. Thus, problem drinkers and drug misusers should not be admitted to
these programs, nor included in this patient registry system.
The
patient data to be presented here is from the current version of the general
registry system and contains data from 49 inpatient and 33 outpatient programs
serving clients from all over the
Most research falls into one
of three levels of inquiry: survey, evaluation or experimental. Epidemiology
utilizes survey research to assess the prevalence of certain phenomena and
their relationships to various factors. Evaluation research is more focused in
that it involves naturalistic research without modifying the existing practices
and procedures, and attempts to provide baseline standards to specified
existing practices in routine clinical settings. Experimental research employs
the classical research designs which involve the manipulation of the
environment and/or clinical practices and testing whether one condition is
superior to the other. In a sense, as one moves from
survey to evaluation to experimental research, one focuses in on a narrower and
narrower perspective with increasing external control over the target of study.
Evaluation
research, as a naturalistic research activity, seeks to explore relationships
without experimental manipulation. This frequently results in a
misunderstanding of the nature of the work by those schooled in traditional
experimental procedures. In some cases, quasiexperimental designs must be
employed (Campbell & Stanley, 1986; Cook & Campbell, 1979). In others,
one must control for the lack of randomized assignment of subjects by using
statistical approaches to partial out baseline differences or to match subjects
on key parameters. The differences in approach between evaluation and
experimental research work reflect differences in purpose more than
differentials of scientific rigor
One
of the perennial questions in evaluation research is the validity of self‑report
data. This has engendered much controversy, but the mounting evidence is that
self report data can be reliable if the proper care is taken in formulating the
data gathering instruments and strategies (Babor, Stephens & Marlatt, 1986;
Hoffmann & Harrison, 1988; O'Farrell et al, 1984; Verinis, 1983).
Research
by CATOR has shown reasonable agreement between patients' and significant others'
reports. A recent analysis of 625 cases revealed that when patients reported
abstinence the family member contacted agreed in 88 % of the cases. Analyses
also revealed that the level of agreement appeared to be related primarily to
the salience of the event and concreteness of the question. (Salience refers to
how memorable the event is; in general, arrests are more memorable than visits
to a doctor for an illness.) Questions requiring subjective inference, such as
interpretation of mood, had lower agreement than those involving observable
behavior. The possible sensitivity of the item did not appear to be a factor.
In short, self report can provide a good indicator of outcome if questions are
clear and focus on behavior rather than subjective interpretations (Hoffmann
& Ninonuevo, in press).
Another
controversial issue is how to deal with cases which are lost to follow‑up
during the post‑treatment period. Many researchers have simply declared
these to be relapsed cases. However, this may be an overly pessimistic and
simplistic assumption for the middle class individuals served by private
programs.
More
appropriate estimate of overall outcome can be presented as a range analogous
to a confidence interval (Hoffmann & Miller, 1992). This provides a recovery
range in which the outcomes for entire population would be expected to fall.
The extremes of the projected recovery range are defined at the top by the
observed outcomes of contacted cases and at the bottom by the estimate based on
the assumption of relapse for all non‑contacted individuals. A narrower
projected recovery range can be
defined by estimating the upper bound of the outcome
range by using prognostic indicators of the non‑contacted Table 1.
Demographics
cases or partial data cases to estimate the outcome
of
those cases who were not contacted at all. The lower
bound of this narrowed recovery range can be defined
by INPATIENTS OUTPATIENTS
assuming that the non‑contacted cases have a
sobriety rate N
= 6508 N = 1572
at a specified rate lower than the projection. VARIABLE % %
For example, if one wishes to estimate
the outcome
of all cases at one year after treatment, the following Sex:
procedure might be employed. The cases contacted at six
months, but lost at a later interval, have been found
in Male 69 73
our previous work to have a recovery rate lower than Female 31 27
those who continue to be followed. The recovery rate
of
these single contact cases might be used to estimate
the Age:
outcome of those not contacted at all, and would yield
a Under 20 6 3
more conservative estimate of the upper bound of the 229 27 35
projected recovery range than the overall observed
recovery rate at one year. One could then assume that
the 30‑39 32 35
recovery rate of the non‑contacted cases might be
only 40‑49 14 19
half that of these single contact cases. This could be used 50+ 18 8
as a lower bound for the projected recovery range.
A more sophisticated strategy would be
to develop a Ethnicity:
prognostic index based on contacted cases. Such an Whit 87 90
index would take into account differential
probabilities of
recovery based on client characteristics. Non‑contacted Black 7 6
cases could then be assigned a recovery probability
to Other 6 4
estimate the overall projected recovery rate for all non
contacted case. This estimate would be the upper bound Marital Status:
of the narrowed projected recover range. One might Never Married 29 34
reduce the projected recovery of non‑contacted
cases by a Separated / Divorced 22 24
specified amount to allow for any unrecognized factors
that might result in lower recovery rates for these sub‑ Widowed 3 1
jects.
This adjusted estimate would then be the lower Married 46 41
bound of the narrowed projected recovery range.
Data are reported here only on followed
cases; when Degree:
outcomes are discussed, only the observed data rather None 15 12
than projections to non‑contacted patients are used. High school only 56 56
The sample consists of 6,508 ASAM Level
III patients
(inpatients) and 1,
572 ASAM Level II patients (out‑ Vocational
/ Associate 15 17
patients). The primary focus of the analyses will be on College Graduate 14 15
the nature of the treatment populations, factors which
influence recover and benefits of treatment. Work Status:
Full
time 62 71
Part
time 10 9
DEMOGRAPHIC CHARACTERISTICS.
Demographically, the
inpatient and outpatient populations are relatively
similar Not working by choice 11 6
except for age and work status. As seen in Table 1, Unemployed 17 14
outpatients are much more likely to be in their 20s, with
few persons over 50 or under 20. The fact that slightly
fewer outpatients are married and more have never
married may be related in part to the younger age of
the
outpatients. The inpatients also include more minorities,
but
educational attainment is essentially identical for the two groups.
Table 2. Personal and Family Incomes for Inpatients and
Outpatients
INCOME
RANGE INPATIENTS N = 6508 OUTPATIENTS N.‑
1572
PERSONAL INCOME FAMILY
INCOME PERSONAL INCOME FAMILY INCOME
<
$10,000 29
% 13 % 28 % 14 %
$10,001‑$20,000 25 17 28 18
$20,001-30,000 19 19 20 20
>
$30,000 18 36 19 36
Won't
say 9 15 5 12
More
of the outpatients are employed full time. However, this possible indicator of
higher vocational functioning does not yield substantially higher incomes, as
seen in Table 2. Over half of all the patients had personal incomes of $20,000
or less, but only about a third had family incomes in that range. Among both inpatients
and outpatients, 36% reported family incomes in excess of $30,000. (Of all
items in the CATOR database, personal income remains the question patients are
most likely to refuse to answer. Even questions about sexual abuse or arrests
have lower refusal rates. In the case of family incomes, the patient may be
unable or unwilling to indicate the incomes of others in the family.)
In
summary, inpatients and outpatients are similar in their demographic
characteristics. Both populations are composed largely of white males, between
the ages of 20 and 40, high school educated, employed and from middle to lower
middle class households.
CLINICAL CHARACTERISTICS. In
contrast, substantial differences are seen in the clinical characteristics of
the two groups (Table 3).
Table 3. Clinical Characteristics
INPATIENTS OUTPATIENTS
N = 6508 N = 1572
VARIABLE % %
Diagnosis
of dependence for:
Alcohol 82 80
Prescription
medications 12 5
Marijuana 23 19
Stimulants 7 3
Cocaine 19 15
Opiates 3 1
Number
of drugs used at least
weekly (alcohol not included):
1 26 22
2 10 6
3+ 5 2
Number
of substances, including alcohol,
used within 24 hours
of admission:
1 32 17
2 9 3
3+ 4 1
Although a comparable number
of patients in both treatment groups are alcoholics, more than twice as many
inpatients are dependent on prescription drugs, stimulants and opiates. Cocaine
and marijuana dependence are much higher in the inpatient group.
Of
the inpatients, 15 % admitted using at least two drugs other than alcohol on a
weekly basis, but only 8
of the
outpatients admitted such heavy drug use. Further, 45 % of the inpatients had
used alcohol or other drugs within 24 hours of admission as contrasted to 21 %
of the outpatients; 14 % of inpatients and 4 % of outpatients had used multiple
drugs
within a day of admission. In summary, the inpatients were dependent on more
drugs and were much more likely to have ingested such drugs just prior to
admission.
A
global clinical severity index was developed from the number of symptoms for
alcohol and other drug dependence, the patterns of symptoms and frequency, and
the recency of use. The results of this index are presented in Table 4. While
over one third of the outpatients
Table 4. Clinical Severity Index
CLINICAL
SEVERITY INPATIENTS OUTPATIENTS
SCORE % %
0‑2 15 36
3‑4 24 28
5‑6 28 18
7‑8 19 10
9‑12 14 6
fell in
the lowest ranges of this index, only about one in seven inpatients shows such
low indications of severity. In contrast, over 40 % of inpatients scored in the
higher ranges, as compared to only 20% of outpatients.
Other
differentials can also be noted in subsequent discussion of outcome correlates.
Inpatients have higher levels of medical care and vocational functioning problems
prior to treatment. These indications suggest a greater scope of involvement or
later stage of illness for the inpatients. Therefore, when considering the
outcome findings to follow, one must remember that these are not comparable
populations. The placement issue is not which type of treatment is superior,
but rather which patients require the structured control of an inpatient
program to begin the recovery process and which patients can initiate that
journey with intensive outpatient services.
CONTINUUM OF CARE. Previous
analyses have revealed that the general observed one‑year abstinence
rates tend to be in the 60 % to 65 % range. When the projected outcomes for all
cases, including non‑contacted individuals, are computed, the results
tend to fall within the range of 45% to 60% (Hoffmann & Miller, 1992). The
observed abstinence rates for these samples under discussion are slightly over
60 % . In addition, more than 25 % report at least six
months of complete abstinence in the year after treatment. Thus, the current
data are in conformity with earlier estimates that treatment affords
improvements for the majority of cases.
However,
global recovery rates are relatively meaningless in light of the relationship
to continuing care and involvement in self‑help support groups. The
analogy here is to the diabetic who does not receive regular medical attention
following titration of insulin levels or to the cardiac patient who does not
receive routine care following stabilization of hypertension. Addictions are
chronic conditions that require a reasonable continuum of care for maximum
benefit. Unfortunately, many health care coverages do
not provide for such a continuum. Self-help groups can provide some needed
support and, to an extent, can substitute for continuing care, but the real
solution is to afford patients the continuum of care which appears to be
required.
Previously
published findings show that individuals who attend Alcoholics Anonymous (AA)
after treatment are more likely to be sober than non‑attendees (Hoffman,
Harrison & Belille, 1983; Hoffmann & Miller, 1992). The observation
that patients who remain active in self-help groups are more likely to be
recovering has been extended to a two‑year follow‑up of inpatients
and outpatients (Hoffman & Harrison, 1988; Harrison & Hoffmann,
1988). The current findings presented in Table 5 support these earlier reports.
Both inpatients and outpatients who attend either AA or the continuing care
provided by the treatment program are more likely to remain abstinent than non‑attendees.
More
detailed analyses of the interplay between AA and aftercare reveals that each
appears to provide an additive contribution to continuing recovery. Only 45
of
patients who received less than six months of continuing care and did not
attend AA for the entire year remained abstinent. One year of AA attendance in
the absence of at least six months of aftercare yields outcome of 69 % . One year of continuing care in the absence of continuous
AA attendance yields and abstinence rate of 77 % .
However, 90 % of those who attended both AA on a weekly basis and went to
aftercare for the entire year maintained their abstinence. Clearly, addictions
need to be addressed as chronic, not acute, conditions.
Table 5. One‑Year Abstinence Rates, by Continuum
of Care and Self‑Help Support
INPATIENTS
N = 6508 OUTPATIENTS
N = 1572
VARIABLE ATTENDING ABSTINENT ATTENDING ABSTINENT
Months of continuing care attended in year:
0 42 % 53
% 34 % 48 %
1‑5 32 55 33 61
6‑11 19 71 18 68
12 8 88 14 89
AA
attendance:
Non‑attendee 54 47 43 49
Regular attendee 46 74 57 80
Previous reports have presented evidence of the association between a variety of stressors and risk of relapse (Harrison & Hoffmann, 1989; Hoffmann & Miller, 1992). Analysis of those who relapsed after the first six months were found to have significantly higher stress levels during their first six months of abstinence than those who maintained their abstinence during the second six months (Harrison & Hoffmann, 1989). One might hypothesize that the greater the level of stress, the greater the probability of relapse. Continuing care services may be more appropriate to address some of these stressors, while AA might be as good or better at addressing issues of craving or other stressors. This could help account for the apparent additive effects of AA and continuing care.
MEDICAL CARE. Cost offset issues
have been an interest of CATOR for the past decade. The evidence clearly
indicates that treatment has the ability to offset much, if not all, of its
costs (Holder, 1987). The data on medical care utilization from Table 6 are
compatible with earlier work (Hoffmann, Harrison & Belille, 1984; Rode
(DeHart), Hoffmann & Fulkerson, 1990; Hoffmann, DeHart & Fulkerson,
1993).
The
inpatient utilization rates are consistently higher than the outpatient, both
before and after treatment. Over one‑fourth of the inpatients had been
admitted to a hospital for medical, psychical or detoxification admissions
within the past year as compared to approximately one‑fifth of the
outpatients. Almost one in four inpatients had a medical admission compared to
one in six of the outpatients. Emergency room and outpatient clinic visits
showed no significant differentials. The data suggest that a larger portion of
the inpatients had serious medical problems. Some of these may be related to
consequences of addiction. This again addresses the differences between the two
treatment groups.
Nevertheless,
both inpatients and outpatients show significant decreases in post‑treatment
medical care utilization for expensive hospital services. Admissions for
medical conditions are reduced by over 50 % . Previous
studies have demonstrated that for recovering patients reductions are stable
over a two‑year period. Relapsed patients, however, show a significant
rise in hospitalizations in the second year after treatment (Hoffmann, DeHart
& Fulkerson, 1993). This suggests that medical cost offsets are directly
proportional to the recovery rate. Clinic visits showed little change before
and after treatment suggesting no shift of cost from hospital to ambulatory
services.
VOCATIONAL FUNCTIONING. Even
more striking changes are noted in the improvements in vocational functioning
as indicated by a decrease in work problems, absenteeism and working while
under the influence. Table 7 shows two‑ to five‑fold decreases in
job problems for both the inpatients and outpatients employed before and after
treatment. As with medical care utilization, inpatients show grater prevalence
of problems. Both absenteeism and tardiness are about 50% higher in the
inpatient population as compared to the outpatients. Only for conflicts with
superiors and accidents do the prevalence rates for the inpatients approach outpatient
rates. Thirty percent of inpatients missed at least three days of work in the
months prior to treatment compared to 16
of the
outpatients.
Despite
the initial differentials, both the inpatient and outpatient population show
similar problem levels after treatment. The most pronounced drops occur in
areas where the patient has control of the situation such as being late,
completing work, etc. Problem areas involving others such as conflict with
superiors and chance events such as injuries show less of a reduction.
Table
6. Medical Utilization One Year Before and After 'treatment
INPATIENTS
N = 6508 OUTPATIENTS N =1572
VALUABLE Before AFTER BEFORE After
Hospitalizations: Medical 23 % 10
% 16 % 7 %
Psychiatric 5 2 4 1
Detoxification 16 4 9 2
Any Admission 28 14 21 9
Emergency
room use: Medical 31 22 29 22
Psychiatric 3 1 3 1
Any ER use 30 24 29 23
Table
7. Vocational Issues for Employed Patients One Year
Before and After Treatment
Inpatients
N = 3429 Outpatients N =1016
VARIABLE BEFORE AFTER BEFORE AFTER
Problems
with
Missing
work 42 % 6 % 26 % 4
%
Being
late for work 35 6 26 6
Making
mistakes 29 5 22 4
Completing
work 22 4 15 5
Boss/supervisor
conflict 27 13 24 10
On‑the‑job
injury 10 5 7 5
Days of work missed during month before treatment and
month before one year follow‑up:
0 46 79 61 83
1‑2 24 14 22 13
3‑5 17 4 10
2
6+ 13 3 7
2
OTHER
COST AREAS. Moving traffic violations and other arrests show
dramatic declines as well (Table 8). In addition, motor vehicle accidents are
also significantly reduced the year after treatment. These events also involve
cost issues to individuals and society. Accidents increase insurance rates, and
arrests result in added costs for law enforcement, judicial procedures and
corrections.
More
than 20 % of these patients had at least one motor vehicle accident in the year
prior to treatment. One‑fourth of those who had accidents report more
than one. These are extremely high accident rates which affect all drivers.
Even if one is not involved in an auto accident with an addicted person,
insurance rates are still affected by these accidents. The post‑treatment
reduction in accidents suggest that this may be another
area where cost affects can be attributed to the treatment effort.
Moving
violations and criminal arrests also provide evidence that treatment may be
beneficial to law enforcement. If we are to develop effective measures to
address crime, we must carefully consider the role of treatment. These data
suggest that treatment may make a greater contribution to the control of crime
than aggressive law enforcement makes to controlling
the alcohol and drug problems in this country.
TREATMENT CAF DUI OFFENDERS. One
of the more interesting aspects of treatment outcomes concerns persons arrested
for driving while under the influence (DUI). Previous reports of the treatment
of addicted DUI offenders have shown no difference in outcome between persons
who had a DUI and were court‑referred and other outpatients. (Hoffmann, Ninonuevo et al, 1978; Hoffmann & Ninonuevo, in
press).
A
series of items in the CATOR forms now cover several possible forms of
coercion, such as DUI conviction, other court actions or ultimatums from
employers.
Comparison
of 469 DUI offenders who were admitted to outpatient
treatment and 709 non‑coerced outpatients, revealed that the DUI
offenders actually had a better outcome than the non‑coerced patients.
One year abstinence was reported by 68 % of the DUI offenders as compared to
60% of the non‑coerced outpatients.
Comparisons
of data on AA attendance revealed that almost half of the DUI offenders
attended weekly meetings during the year after treatment as compared to 43
of the
other patients. The DUI offenders were also somewhat more likely to attend
continuing care throughout the hear than the non‑coerced
patients. Given the strong relationship between continued abstinence and both
AA attendance and continuing care, the superior outcome of the DUI offenders
appears reasonable.
Similar
data are obtained from 669 DUI offenders who entered inpatient programs.
Overall, their outcomes were comparable with other non‑coerced
inpatients, and they were also at least as likely to utilize regular AA meetings
and continuing care as their treatment peers. Thus, the evidence from over
1,000 DUI offenders who entered treatment suggests that treatment should be
carefully considered in the adjudication of DUI offenders.
Evaluative
studies can be used to estimate general outcome of addictions treatment as
delivered in typical clinical settings. More importantly, such studies can
demonstrate relationships between treatment components such as continuing care
and the probability of recovery. In addition, such studies can also provide
indications of cost offsets relevant to the determination of public policy and
the selection of benefits in the private sector. These studies may further
suggest clinical innovations to improve treatment efficacy. Naturalistic
studies can help
focus
experimental research on those areas with the highest potentials.
Several definite conclusions can be drawn from these
data on over 8,000 patients who have entered treatment programs throughout the
Table
8. Other Comparison for One Year Before
and After Treatment
INPATIENTS
N = 6508 Outpatients N = 1 72
BEFORE
% AFTER % BEFORE % AFTER, %
VARIABLE
Motor
vehicle accidents 1 16 7 16 7
2+ 6 1 4 2
Moving
traffic violation: 1 19 8 30 7
2+ 4 3 7 1
Criminal arrest: 1 10 4 11 3
2+ 3 1 3 1
The
evaluation data provide valuable guidelines about how we as a society, as
individuals and companies may wish to invest our health care dollar. Addictions
treatment has the potential to be one of the best investments to reduce health
care costs. Cost containment cannot be achieved only by restricting care. We
must also spend money wisely in order to produce the desired impact on the
needs for health care services. Immunizations and other prevention efforts
should be at the forefront of our efforts. Yet, the
The
effective treatment of addictions can save billions of dollars for all segments
of society. Improved vocational functioning is a benefit to management and
labor. Reduced absenteeism and increased productivity benefit business.
Retention of active and productive workers benefits labor unions. Helping to
contain the health care costs is relevant to the public as well as private
sectors. Potentials for reducing crime should get the attention of local, state
and federal leaders. Removing drunk drivers through treatment and appropriate
sanctions will make the roads safer for all. Finally, reducing auto accidents
provides savings to every driver in the
If
one should ask, "Who cares about treating alcoholics or other drug
addicts?" The answer should be that everyone who works, pays for health
care, drives a car or pays taxes should care about addictions treatment.
Promoting improvements in the treatment of addictions
may be one of the best investments we can make for our future and the
generations to come.
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