Almost all addiction treatment in this country is provided by specialty sector programs funded primarily through the State Block grant, the Department of Veterans Affairs, Medicaid, private medical insurance, and other sources (SAMHSA 2002). Most of this care is carved out from general health plans and is provided by these specialty programs through myriad reimbursement arrangements—but more than
70% of care involves government funds rather than private insurance (McKusick et al. 1998). Thus, efforts to improve addiction treatment through implementation of some of the evidence-based components of care reviewed here will be governed in a significant way by the ability of the specialty care system to absorb or adopt these new treatment methods.
In this regard, the substance abuse treatment system has been particularly affected by the general rise in costs of health care. Because of these growing costs, employers and government purchasers have turned to managed care organizations to reduce their health care expenditures. Although cost reduction and treatment streamlining efforts have affected all areas of health care, it is widely acknowledged that the addiction and mental health treatment systems have been disproportionately affected (Institute of Medicine 2006). For example, in 1990 there were more than 16,000 substance abuse treatment facilities operating in the United States; approximately 55% of those were residential or inpatient hospital, approximately 15% were methadone maintenance programs, and about 30% were outpatient programs. Figures from 2002 indicate that there are now fewer than 14,000 programs; only 10% are residential or inpatient hospital, about 12% are methadone maintenance programs, and approximately 78% are abstinence-oriented outpatient programs (SAMHSA 1997, 2002). Despite a widely perceived growth in need for substance abuse treatment, there are fewer programs in operation and fewer patients in treatment today than there were in 1990 (for a review see McLellan and Meyers 2004). In addition to outright closure, administrative restructuring is also quite prevalent, with about 20%–30% of programs undergoing some form of organizational takeover each year, leaving them under a
different administrative structure. Perhaps because of this high level of reorganization, directors of these programs also change regularly. Less than half of program directors surveyed in a recent national sample had been in their jobs for even a year (McLellan et al. 2003). This does not mean that they are new employees. Indeed, at least 80% of program directors had been working within their program prior to their appointment as director, usually in a clinical position. About 20% of those program directors had no college degree, half to two-thirds had bachelor's degrees, and about 20% had master's degrees. Less than 2% were physicians.
Beyond their administrative structures, the nature of treatment staffs and the composition of contemporary treatments are also indications of readiness to adopt and ability to provide
evidence-based treatments. In this regard, the modal treatment program in the United States employs 6–10 counselors, each treating an active caseload of 50–80 clients. Apart from counselors, there are very few other professional disciplines represented in most of these programs. For example, only about 50% of the nation's treatment programs have even a part-time physician on staff. If methadone maintenance programs are excluded from this group, the proportion drops to about 35%. In fact, only about 50% of U.S. addiction treatment programs even perform an on-site physical examination at intake (Institute of Medicine 2006). Outside of methadone programs, less than 15% of programs employ a nurse, and even fewer employ even a part-time social worker or psychologist. Annual turnover rates for these staff are in the 50% range—approximately the same as seen in the fast food industry
(McLellan et al. 2003).
Only about 30% of programs have access to well-developed clinical information systems and Internet services. Another 20% have no electronic information services of any type. The remaining 50% have some form of computerized administrative information system dedicated to billing or administrative record keeping available for the administrative staff—but very few have an integrated clinical information system for use by the majority of treatment staff (for a review see McLellan and Meyers 2004).
As might be expected from the staffing complement in these programs, the great majority of what goes on in treatment programs is some form of group counseling. Essentially all treatment programs in the United States employ group counseling but only about 40% provide individual counseling. Typical types of groups include orientation groups (in which patients introduce themselves and learn about group therapy), relapse prevention groups, and general drug education groups. Although some reports of
national surveys of drug abuse treatment program directors have suggested that a wide range of services are available through the programs, most studies of patients in treatment reveal that very few patients actually receive medical or social services beyond general counseling. In summary, these data confirm the already widely acknowledged gap between the type of evidence-based, quality services that could be delivered and the kind of care that is possible to deliver given the current infrastructure. Given the existing infrastructure, it is doubtful if any of the medications reviewed here could be prescribed or administered in most of the treatment programs. Similarly, given the level of training and background needed to effectively provide most of the evidence-based therapies reviewed here, only a minority of existing programs have the staffing and training capabilities to adopt these therapies. Thus, it is
disheartening to end this quite positive summary of promising evidence-based clinical practices with the stark but unfortunately realistic conclusion that most of them simply cannot be staffed or delivered in a sustainable manner within the contemporary treatment system.
KEY POINTS
Addiction treatment is best considered as at least three separate stages—each with distinct goals and methods: 1) detoxification or stabilization is designed to eliminate the acute effects of substance use and prepare the patient for life change; 2) rehabilitation is designed to continue the initial abstinence and to help the patient develop a life that will be enjoyable without substances; and 3) continuing care follows formal treatment and consists of mutual help groups (usually Alcoholic Anonymous [AA]), professional therapy as needed, and often telephone monitoring calls designed to prevent relapse.
Within the rehabilitation and continuing care stages of treatment there is now an impressive array of treatment components that have shown U.S. Food and Drug Administration–level evidence of
effectiveness.
Medications include naltrexone, buprenorphine, and methadone for opiate dependence; naltrexone, acamprosate, and disulfiram for alcohol dependence; and disulfiram for cocaine dependence.
Therapies include cognitive-behavioral therapy; motivational enhancement therapy, behavioral couples therapy, 12-step facilitation, community reinforcement and family training, and individual drug counseling.
Adjunctive interventions and services include voucher-based reinforcement for abstinence, clinical case management and wraparound social services, linking of patients to AA, and posttreatment monitoring (telephone, Internet, and home visit).
Despite these very promising new developments, most addiction treatment is delivered within a specialty care treatment system that does not have the personnel, information management, or administrative support to implement most of these practices. Although there will be a continuing need for new and more sophisticated treatment interventions and components, there is a pressing need for financial and organizational development to permit the treatment system to provide the kind of quality care that is now possible.
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