Morristown, New Jersey

Therapies in most areas of health care are subjected to clinical trials, e.g., an ethical drug cannot be approved for sale in the United States without having been demonstrated experimentally to be safe and effective. The ideal of the clinical trial is an experiment in which patients are randomly assigned to two or more treatment and control groups and outcomes are compared. Health care research today in addition increasingly addresses cost effectiveness, i.e., how much the cost of the therapy relative to its outcome compares with the cost and benefits of alternatives.

In the case of alcohol and drug abuse treatments, such research has been conducted (primarily in the case of alcoholism therapy). However, the results of such experiments are not funneled into any regulatory body that can approve a therapy. According to Miller and Hester [1] in the United States 'present policies. . .[entail] few conditions of accountability for quality or effectiveness'. Rather, treatment practices in the United States are based on historical traditions and folk beliefs that owe more to religion and temperance than to research. Enoch Gordis [2], the current director of the American National Institute on Alcohol Abuse and Alcoholism (NIAAA), describes the treatment environment in the United States:

In the case of alcoholism, our whole treatment system, with its innumerable therapies, armies of therapists, large and expensive programs, endless conferences. . . and public relations activities is founded on hunch, not evidence, and not on science. . . Contemporary treatment for alcoholism owes its existence more to historical processes than to science....

To determine whether a treatment accomplishes anything we have to know how similar patients who have not received the treatment fare. Perhaps untreated patients do just as well. This would mean that the treatment does not influence outcome at all....

After all [many feel], we have provided many of our treatments for years. We really are confident that the treatment approaches are sound.... Yet, the history of medicine demonstrates repeatedly that unevaluated treatment, no matter how compassionately administered, is frequently useless and wasteful and sometimes dangerous or harmful'.

Miller and Hester [3], summarized the results of their examination of controlled experimentation with alcoholism treatment:

As we constructed a list of treatment approaches most clearly supported as effective, based on current research, it was apparent that they all had one thing in common. . .: they were very rarely used in American treatment programs. The list of elements that are typically included in alcoholism treatment in the United States likewise evidenced a commonality: virtually all of them lacked adequate scientific evidence of effectiveness'.

Beneficial therapies included aversion therapies, behavioral self-control training, the community reinforcement approach, marital and family therapy, social skills training, and stress management. The standard programs that have not demonstrated their efficacy include Alcoholics Anonymous (A.A.), alcohol education, confrontation, disulfiram, group therapy, and individual counseling. For example, the two controlled experiments involving random assignment to A.A. versus other treatments (or no treatment) favoured the treatments other than A.A. or no treatment [4,5].

The importance of employing comparison groups for developing conclusions about treatment is evident in a long-term outcome study conducted by Vaillant [6]. He carefully tracked his patients in an A.A.-based hospital program for 8 years after treatment and compared their outcomes with those for comparably severe alcoholics in several community studies who had received no treatment. Vaillant reported the following startling disconfirmation of his subjective impressions of the success of his program:

'It seemed perfectly clear that. . . by inexorably moving patients from dependence upon the general hospital into the treatment system of AA, I was working for the most exciting alcohol program in the world. But then came the rub. Fueled by our enthusiasm, I and the director. . . tried to prove our efficacy. Our clinic followed up our first 100 detoxification patients. . . [and found] compelling evidence that the results of our treatment were no better than the natural history of the disease.'

Helzer et al. [7] found an extremely low remission rate for patients undergoing alcoholism treatment in a highly publicized study. Although the investigators reported as their major conclusion that few patients became moderate drinkers, they did not actually examine controlled-drinking therapy. Rather, they measured outcomes for alcoholics treated in four hospital settings, including an ordinary medical/surgical ward. Of the four settings, the alcoholism treatment ward had the lowest remission rate; only 7% in this group survived and were judged to be in remission at follow-up of from 5 to 7 years. This remission rate is actually substantially lower than that Vaillant noted for a number of untreated groups of alcoholics followed over comparable time periods.

Although Miller and Hester [3] suggest the possibility that hospital treatment "may be differentially beneficial for more severely deteriorated and less socially stable individuals," their review of all research in which inpatient and other treatments were compared concluded that more intensive treatments have not been found to offer greater benefits than those from outpatient therapy for any population. Indeed, the differences that have been discovered, for example, the likelihood the patient will be re-hospitalized following treatment, favour the outpatient setting. Obviously, if expensive inpatient treatment is ineffective, or no more effective than outpatient counseling or even no treatment, then it will certainly not be judged cost effective and deserving of reimbursement.

Despite data showing hospital treatment is no more efficacious than outpatient counseling, the U.S. Congressional Office of Technology Assessment [8] reported, 'reimbursement systems. . . have overwhelmingly emphasized the most expensive treatment services — inpatient, medically based treatment'. The situation in Canada and Britain is quite different. According to Murray [9]:

'There can be no doubt that current British and American perspectives on alcoholism differ widely . . . British clinicians have shown that the effect of treatment is only marginal, and, in contrast to their American counterparts, have decided against a major expansion of inpatient treatment.... 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'.

In the United States, inpatient care for alcoholism and drug abuse has been undergoing a boom ever since the mid-1970s. The National Institute on Drug Abuse reports that the number of drug treatment centers rose from 3018 in 1982 to 5360 in 1987; between 1978 and 1984, the number of private alcoholism treatment centers quadrupled and the patients treated in them quintupled [10]. These dramatic increases in addiction treatment occurred during a period when illicit drug use and alcohol consumption actually decreased, and such treatment continues to accelerate. According to Health Care Competition Week (July 24, 1989), 'psychiatric, chemical dependency and rehabilitative hospital care, all largely unregulated by government payment mechanisms, are booming'.

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