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An expensive private treatment system in the United States encourages and rewards expensive treatments and has no mechanisms in place to evaluate outcomes. This system is very closely aligned with a powerful "recovering alcoholics" lobby and builds on the naive American acceptance of the efficacy of Alcoholics Anonymous and medical treatment. John Wallace [11], clinical director of the Edgehill Newport hospital, issued a rallying cry to alcoholism counselors to fight those who question whether intensive alcoholism treatment is cost beneficial:
'These forces of disunity tried first to divide the alcoholism field over the issue of controlled drinking and then, through various attacks upon sobriety, on the disease model of alcoholism, on recovered people, on the concepts, principles, and activities of Alcoholics Anonymous. Now it appears that the target has become the still emerging and fragile comprehensive system of alcoholism treatment services....
We must recognize and resist the various tactics and strategies of the anti-traditionalist lobby to divide us. We must stand shoulder to shoulder in solidarity. Otherwise, alone and divided we will be weak and easy targets for those who do not want to pay for alcoholism services. The most costly outcomes of the current debate over the cost-effectiveness of alcoholism treatment would be the blind and mindless destruction of the comprehensive system of treatment services that benefits so many desperately ill people and took so many years of struggle to build. We cannot, must not let this happen'.
Wallace authored the treatment section of the Sixth Special Report to the U.S. Congress on Alcohol and Health [12]. This report was originally written by Peter Nathan (Director of the Rutgers Center of Alcohol Studies), Barbara McCrady (Clinical Director at the Rutgers Center), and Richard Longabaugh (Director of Evaluation at Butler Hospital in Providence, RI). Nathan et al.'s draft indicated that inpatient treatment produced no greater benefits than did outpatient treatment and that intensive alcoholism treatment was not cost effective. The NIAAA submitted the draft for review by Wallace, who revised it, after which Nathan, McCrady and Longabaugh withdrew their names from the document [13].
Wallace's argument is that, while comparative evaluations of hospital treatment have shown disappointing results (like those presented by Vaillant and Helzer et al.), this is only because the treatments involved were poor ones. Instead, he points to an outcome study he conducted at his Edgehill Newport Hospital which found 66% of patients were continuously abstinent at 6 months following treatment to show that appropriate treatments can lead to tremendously high remission rates. Wallace [14] characterizes his study as methodologically rigorous and representative in which "patients were randomly selected from a pool of socially stable patients". Longabaugh [10] put the study's methodology in a different light, however, in the following analysis:
'[Wallace's] program report was limited to treatment of socially stable patients who were judged to have restorative potential; they had been transferred from detox 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 had 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.'
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....'.
'What can we generalize?' Longabaugh asked. He said we can't generalize about 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. Are such evaluations likely in the near future? He said no applications had been received by the NIAAA for research studies in that area. All that can be expected are single-program studies of doubtful value for such purposes.
On a nationally televised program, Nightline, Wallace made even greater claims for his research [15]:
'There are other intensive inpatient programs like Edgehill Newport that show a dramatically higher recovery rate [than hospitals used in comparison studies]. In our latest randomly assigned study of socially stable alcoholics treated in a middle-class alcoholism treatment program, 66 percent of our people are continuously abstinent from both alcohol and drugs. . . at six months following treatment'.
Here, unfortunately, we have a cheapening of the research dialogue, where Wallace has redefined the term 'randomly assigned' from its usual meaning of assignment to independent treatment groups in a clinical trial to apply to his highly selected group of patients from his unmatched private hospital treatment population. Ultimately some groups may be shown to be helped by inpatient treatment as part of a panoply of alcoholism services. The target population for hospital treatment, however, is unlikely to be the socially stable, middle-class alcoholics included in the Edgehill Newport study, who are those most likely to overcome drinking problems under any regimen or even without treatment.
In the meantime, the failure to subject treatment approaches to systematic evaluation will not benefit alcoholics in the way advocates of private hospital treatment seem to hope, but will only make it harder to discover which treatments are best for which patients. Only when private treatment centers are motivated to participate in actual clinical trials will an effective alcoholism treatment system be possible in the United States.
references
next: What We Now Know About Treating Alcoholism and Other Addictions
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