Why and by Whom the American Alcoholism Treatment Industry is Under Siege - American Alcoholism Treatment Industry

Written by Stanton Peele

The prestigious journal Science, which has published a number of pieces that support disease models of alcoholism, published an article in 1987 that asked "Is alcoholism treatment effective?" and concluded that the best predictor of outcome is the type of patient who enters treatment, rather than the intensiveness of the treatment (Holden 1987). This article referred to Miller and Hester's work and also to Helen Annis, a researcher at the Ontario Addiction Research Foundation (ARF). ARF has for some time de-emphasized hospital treatment, preferring even to deal with detoxification in a social, rather than a medical, setting. Indeed, Annis and other researchers have reported that withdrawal is less severe when carried out in a non-medical setting (Peele 1987b).

As a result, the Canadian national health system generally does not pay for hospital care for alcoholism . Private treatment centers in Canada have thus actively begun marketing their services in America. This difference between the American and the Canadian systems is reflected even more strongly in Britain. Wallace (1989) labeled as "inappropriate" Britain's decision to de-emphasize inpatient treatment, a decision I quoted Robin Murray as saying was based on the British having found the benefits of such treatment to be "marginal." Murray and colleagues (1986: 2) commented on the sources of this difference between Britain and the United States: "It is perhaps worth noting that whether or not alcoholism is considered a disease, and how much treatment is offered, has no bearing on the remuneration of British doctors."

How Well Does Wallace Support His Claims for His Treatment Program?

As one can see from the range of negative findings about alcoholism treatment (particularly hospital treatment) both within the United States and internationally, the value and especially the cost-effectiveness of such treatment are under severe attack. For example, Medicare has attempted to impose a limitation on payment for hospital treatment for alcoholism, creating a battle that has continued to rage for more than five years and that has yet to be resolved. If one takes seriously assertions like those by Madsen (1989) and Wallace (1987c) that AA is tremendously effective, how then can the costs of inpatient treatment—which range from $5,000 to $35,000 a month—be justified? Indeed, what about Vaillant's (1983) report that his patients did no better than untreated comparison groups, or the untreated remission rate reported by Goodwin, Crane and Guze (1971) of 40% over eight years for alcoholic ex-felons?

Thus, some importance was attached to the document to which Wallace (1989) alluded in his rebuttal: the Sixth Special Report to the U.S. Congress on Alcohol and Health (Wallace 1987d), in which he made his claims about the efficacy of private treatment and his own Edgehill Newport program. Actually, the treatment chapter in this report was originally assigned to—and a first draft written by— Peter Nathan (Director of the Rutgers Center of Alcohol Studies), Barbara McCrady (Clinical Director, Rutgers Center of Alcohol Studies), and Richard Longabaugh (Director of Evaluation at Butler Hospital in Providence, Rhode Island). Nathan and colleagues found that inpatient treatment produced no greater benefits than did outpatient treatment and that intensive alcoholism treatment was not cost-effective. NIAAA asked Wallace to revise this draft, which he did by softening its major points and eliminating a number of references and key conclusions by the original authors, after which Nathan, McCrady, and Longabaugh withdrew their names from the document (Miller 1987).

Wallace (1989) mentioned specifically two studies in his rebuttal to my article that he likewise emphasized in the Sixth Special Report. The first is a 1979 study of inpatient treatment by Patton conducted at Hazelden, which reported a continuous abstinence rate of over 60% at one year following treatment. Wallace (1989: 260) indicated that he does not fully trust these results, and he revised the remission figure in this study to a more defensible "lower bound of 50%." He then cited his own published account of a 66% continuous abstinence rate six months after treatment at his Edgehill Newport program (Wallace et al. 1988). Longabaugh (1988), an outcome researcher who was originally asked to write the treatment outcome chapter for the Sixth Special Report, discussed the results from these studies along with the general conclusions of the Wallace authored Sixth Special Report at a conference titled "Evaluating Recovery Outcomes."

Longabaugh began by noting that the number of beds in private alcoholism treatment centers quintupled between 1978 and 1984. At the same time, he pointed out, there was no evidence to support the effectiveness of these for-profit units. Longabaugh (1988: 22-23) quoted Miller and Hester (1986b: 801-802): "Although uncontrolled studies have yielded inconsistent findings regarding the relationship between intensity and outcome of treatment, the picture that emerges from controlled research is quite consistent. No study to date has produced convincing evidence that treatment in residential settings is more effective than outpatient treatment. To the contrary, every study has reported either no statistically significant differences between treatment settings or differences favoring less intensive settings." He indicated that this result contrasted with the conclusions of the Wallace chapter in the Sixth Special Report, which claimed that the high relapse rate observed in the majority of the treatment programs studied made it impossible to generalize about comparative cost-effectiveness.

Longabaugh described two studies from the Sixth Special Report regarding programs that produce a 50% or higher abstinence rate, and how they differed from public programs that reported far poorer outcomes. Longabaugh (1988) indicated that "the problem in making comparisons is to use a common yardstick," and he described how "one study claiming that over 60% of patients were abstinent one year after treatment in fact had a known success rate of 27.8% when the sample was subjected to more careful and accurate examination." The study to which Longabaugh referred is the Hazelden follow-up study (Patton 1979), which is the one outcome study other than at his own treatment center that Wallace (1989: 260) described favorably. Longabaugh (1988) revised the 61% success rate reported in this study further downward—beyond the 50% at which Wallace himself placed it—based on information Patton reported on the exclusion of various groups in this research. For example, in calculating the program's success rate, the original investigators eliminated from the baseline treatment group (or denominator) patients who stayed less than five days in treatment and others who had relapsed and returned for treatment during the follow-up period. Hazelden's announced policy is that relapse and repeat treatment is an acceptable natural consequence of the disease of alcoholism that must be reimbursed by insurers.

Longabaugh (1988) concluded that it was impossible to evaluate results from "for-profit, free-standing programs with better-prognosis patients because there have been no results [based on controlled-comparison research] reported to date for those kind of treatment programs." He further noted that NIAAA has received no applications to conduct such research. Instead, the only outcome studies that can be expected from such programs "are single-program studies of doubtful value."

Longabaugh (1988) then reviewed Wallace and colleagues' (1988) study, which found that 66% of patients in the program had been continuously sober at follow-up. However, as Longabaugh noted:

. . the program report was limited to treatment of socially stable patients who were judged to have restorative potential; they had been transferred from detoxification to rehabilitation, indicating that it was expected they would participate fully in a rehabilitation program; they were married and living with a spouse with no plans to separate; they had sufficient resources to pay for treatment; they were asked to participate in the study in the third week of treatment, after any dropouts would have been removed from the sample; they had been "regularly discharged from the program" with no accounting of patients who were not "regularly'' discharged.

Longabaugh finally raised the question, "Was this population representative of the population they were treating? We don't know the answer .... More important, this treatment for this group is not compared with any alternative. It is not compared with a hospital program, an outpatient program, with AA, or no treatment whatsoever .... any other intervention [might be as effective with such a group], perhaps even including no intervention at all."