Broadening the Base of Treatment for Alcohol Problems
As an aspect of its general responsibility for the health of the American people, the U.S. Congress has been
concerned about the treatment of persons with alcohol problems. From time to time Congress has sought
information on such treatment to guide its legislative activities. In 1983, for example, the congressional Office of Technology Assessment (OTA) responded to a request from the Senate Finance Committee with a report entitled The Effectiveness and Costs of Alcoholism Treatment (Saxe et al., 1983).
During the course of its deliberations in 1986 on the extension of the expiring authorization of appropriations for alcohol and drug research programs, Congress noted (in the words of the report of the House Committee on Energy and Commerce) that the availability of these treatment services “is becoming increasingly important to the nation's health care system.” Accordingly, it authorized the present study on the treatment of alcohol problems in Section 4022 of Public Law 99-570, the Alcohol, Drug Abuse, and Mental Health Amendments of 1986, enacted on October 17 of that year. Section 4022 required the secretary of health and human services, acting through the director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA), to arrange for a study to carry out the following charge:
(a) critically review available research knowledge and experience in the United States and other countries regarding alternative approaches and mechanisms (including statutory and voluntary mechanisms) for the provision of alcoholism and alcohol abuse treatment and rehabilitative services;
(b) assess available evidence concerning comparative costs, quality, effectiveness, and appropriateness of alcoholism and alcohol abuse treatment and rehabilitation services;
(c) review the state of financing alternatives available to the public, including an analysis of policies and experiences of third-party insurers and state and municipal governments; and
(d) consider and make recommendations for policies and programs of research, planning, administration, and reimbursement for the treatment of individuals suffering from alcoholism and alcohol abuse.
Congress further specified that the study be carried out by the National Academy of Sciences. In transmitting the congressional request to the Academy, the director of NIAAA, Dr. Enoch Gordis, summarized those topics that might be viewed as having special importance for potential inclusion in the forthcoming study:
(1) the validity of outcome measures; (2) the role of minimal intervention as a treatment modality; (3) better definition of patient types and treatment modalities; (4) determining feasibility and potential benefits of matching patients with treatments; (5) defining for whom an inpatient setting is appropriate; (6) the controlled drinking issue;
(7) getting better data on the costs of alcoholism and on who pays and benefits; (8) choosing among the better of existing studies for more rigorously designed replication.
In 1987, the National Academy of Sciences accepted responsibility for conducting the study. The Academy is a private, nonprofit corporation chartered by Abraham Lincoln in 1863 to provide independent advice to the government on matters of science and technology. Over the years, components of the Academy have developed an interest in dealing with issues relating to alcohol and drug problems. For example, in 1981 the Academy's Assembly of Social and Behavioral Sciences published a report entitled Alcohol and Public Policy: Beyond the Shadow of Prohibition (Moore and Gerstein, 1981). Although concerned with prevention rather than treatment, the report detailed a number of concepts that are germane to the development of this study, including the use of alcohol problems as an inclusive framework for consideration of the subject and the importance of attending to those individuals with less severe alcohol problems as well as to those with more severe difficulties.
As the component of the Academy devoted to the improvement of health care, the Institute of Medicine (IOM) was assigned responsibility for conducting the study mandated by Congress. IOM has a history of interest in this field and in the treatment of alcohol and drug problems. At the request of a prior director of NIAAA, for example, IOM produced the 1980 report entitled Alcoholism, Alcohol Abuse and Related Problems: Opportunities for Research (IOM, 1980), which outlined a possible research agenda for the next few years.
Subsequently, the administrator of the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) asked IOM to review research opportunities in its tripartite portfolio (which includes alcohol problems); the resulting document, entitled “Research on Mental Illness and Addictive Disorders: Progress and Prospects,” was published in 1985 in the American Journal of Psychiatry (Board on Mental Health and Behavioral Medicine, Institute of Medicine, 1985).
More recently, NIAAA requested an update of the 1980 report. The initial portion of the update, which deals with basic research, was published in May 1987 as Causes and Consequences of Alcohol Problems: An Agenda for Research (IOM, 1987). The final portion of this study (IOM, 1989), which covers research opportunities in the treatment and prevention of alcohol problems, was conducted at the same time as the present study on the treatment of alcohol problems. To ensure coordination of the two efforts, a liaison member serving on both committees was appointed. That coordination did in fact occur is indicated by the appearance of a chapter of the research opportunities study as an appendix to this report (Appendix B).
In addition, during the same period, IOM conducted a third relevant study (also mandated by Public Law 99 570) on substance abuse coverage. Its overall purpose was to assess the extent and adequacy of financial coverage for the treatment of drug abuse. Again, to ensure coordination of the two studies, a liaison member belonging to both committees was appointed. Although each of the three simultaneous studies was an independent effort, a productive cross-fertilization occurred among them. Several outside experts, for example, served as consultants for more than one study. IOM staff interacted to ensure coordination of activities and the exchange of information.
Yet the three studies have had rather different emphases. The research opportunities study and this study on the treatment of alcohol problems shared a common general interest in treatment. The interest of the former, however, lay more in the area of treatment research opportunities for the future; this study concerned itself with what might be done to improve treatment in the near term and is based largely on current knowledge. In addition, the research opportunities study dealt equally with prevention and treatment. The financial aspects of treatment proved a common interest in the substance abuse coverage study and this study; nevertheless, the interest of the former focused on drugs other than alcohol and on mechanisms of insurance coverage, whereas the treatment study committee concerned itself with more general aspects of the financing of treatment.