Skip to main content

Advertisement

SpringerLink
Log in

Substance abuse treatment, what do we know?

An economist’s perspective

  • Original Papers
  • Published:
The European Journal of Health Economics Aims and scope Submit manuscript

Abstract

The literature on treating substance abuse has dealt basically with four important questions: (a) Is treatment effective? (b) Are all programs equally effective? (c) Why do programs differ in their effectiveness? (d) Which treatments are more cost-effective? This paper reviews the substance abuse treatment literature around these four questions and discusses methodological issues that hinder the interpretation and generalization of results to date. The answer to the first question is a sounding “yes,” treatment is effective but not all programs are equally effective. Researchers have moved beyond the “black box” literature that concentrated on patient and program characteristics as explanations for differences in effectiveness and search for the “active” ingredients of treatment. These include, for example, the treatment philosophy of the program’s director and staff attitudes towards patients. Cost-effectiveness studies are less common, and their conclusions are mixed. In general, it is probably safe to say that for the majority of patients, outpatient or shorter programs are more cost-effective.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

Notes

  1. References were selected from Medline, ABI-INFORM, ECONLIT and survey papers were also used as a source. Articles were also selected from the table of contents of volumens of Addiction and Journal of Studies on Alcohol. Some of the keywords used in the search were: substance abuse; drug abuse; alcohol abuse; effectiveness; cost-effectiveness; acamprosate; MATCH; self-report, economic evaluation, treatment programs.

  2. For the interested reader, there is an important economic literature on the theories of addiction. This paper deals with the treatment of substance abuse and although different theories may lead to different treatment approaches and philosophies, in this paper I only compare autcomes and do not discuss the theories that may support them.

  3. There is a new trend analyzing the effects of “brief interventions” (BI) for alcoholics, and a number of studies claim its effectiveness relative to longer treatment periods. Drummond [13], however, refutes this new literature mainly on the basis of sample selection. Trent [59] reported shorter programs to be more effective than longer ones, but this study did not randomize patients into treatment alternatives and the sample was composed of rather stable individuals.

  4. Adhering to the “black-box” type of evaluation may be not only convenient but sufficient. The latter authors analyze the problem of allocating a fixed budget among a set of programs believed to follow roughly the same treatment philosophies and goals over time and patients. Their dynamic structural model of the treatment process can detect wide differences between programs regarding observable and unobservable characteristics of patients at admission, patients’ progress through treatment, patients’ completion criteria, and programs’ capacity to hold patients until treatment completion. Joe et al. [29] also model treatment in a dynamic framework, but for their particular approach they need a truncated sample of patients in treatment for at least 3 months.

  5. Papers where treatment services such as participation in therapy sessions, Alcoholic Anonymous meetings, films, attendance to church, etc. and outcomes are associated but where no causation can be established include: Moos, Finney and Cronkite (1990) and Ball and Ross (1991).

  6. The authors acknowledge that patients were not randomized; furthermore, they note the possible unintended effects that the change in program within the same facility may have had, for instance, on staff and/or patient mood.

  7. The superior results of motivational enhancement therapy do not hold for the severely ill psychiatric patients or for patients with highly supportive network of drinking, where cognitive behavior therapy was the most cost-effective [26]. Critics of the MATCH project would probably argue that the differences in total medical costs are not really differences in cost-effectiveness but represent either differences in alternative outcome measures that the MATCH team did not care to record or is a result of patient selection in the study. For a review of some criticisms directed at the project MATCH design and methodology see [9].

  8. Although inpatient treatment programs are less common, they still account for half the funds spent in substance abuse treatment in the United States [8].

  9. Unlike other studies on the effectiveness of BI, the WHO study is probably free of sample selection because (a) it compared types of BI only with “doing nothing” and not with other programs, and (b) patients were classified according to their drinking abuse severity, and results were obtained for “hazardous” and “harmful” drinking patients separately, where the “hazardous” and “harmful” classifications were obtained from a standardized screening test.

  10. The “harm-reduction” movement in some European countries is an exception to this belief, aimed mainly at decreasing the devastating consequences of substance abuse, see [40].

  11. Lu [35] reported evidence that after the introduction of performance-based contracting between the Maine OSA and the treatment agencies, agencies changed their reporting practices in order to affect their budgets.

  12. Yates [64] describes the basic cost categories to be collected for computing treatment costs. This manual, although very useful for orienting programs regarding how to record costs, restricts the cost-effectiveness analysis to simple methods that are not capable of measuring the impact of patient and program characteristics. In particular, these methods are not able to address the probability of patient selection in calculating their cost-effectiveness ratios.

References

  1. Ackerberg DA, Machado MP, Riordan MH (2001) Benchmarking for productivity improvement: a health care application. International Economic Review, forthcoming

    Google Scholar 

  2. Aitken LS (1986) Retrospective self-reports by clients differ from ongoing reports: implications for the evaluation of drug treatment programs. Int J Addict 21:767–788

    PubMed  Google Scholar 

  3. Allen JP, Babor TF, Mattson ME, Kadden RM (2003) Matching alcoholism treatment to client heterogeneity, the genesis of project MATCH. In: Babor TF, del Boca FK (eds) Treatment matching in alcoholism. Cambridge University Press: Cambridge

    Google Scholar 

  4. Anglin MD, Hser Y (1990) Treatment of drug abuse. In: Tonry M, Wilson JQ (eds) Crime and justice: an annual review of research, vol 13. University of Chicago Press: Chicago

    Google Scholar 

  5. Apsler R (1991) Evaluating the cost-effectiveness of drug abuse treatment services. In: Economic costs, cost-effectiveness, financing and community-based drug treatment. Research monograph series 113. National Institute on Drug Abuse: Rockville, pp 17–26

    Google Scholar 

  6. Apsler R, Harding W (1991) Cost-effectiveness analysis of drug abuse treatment: current status and recommendations for future research. In: Drug abuse services research series. No 1: background papers on drug abuse financing and services research. DHHS publ no (ADM) 91-17777. National Institute on Drug Abuse: Washington, pp 58–81

    Google Scholar 

  7. Ball JC, Ross A (1991) The effectiveness of methadone maintenance treatment: patients, programs, services, and outcome. Springer: Berlin Heidelberg New York

  8. Barnett PG, Swindle RW (1997) Cost-effectiveness of inpatient substance abuse treatment. Health Serv Res 32:615–629

    CAS  PubMed  Google Scholar 

  9. Brown TG, Wood W-J (2001) Are all substance abuse treatments equally effective? Comité Permanent de Lutte à la Toxicomanie, Deuxiéme trimestre 2001, Gouvernement du Québec, Ministère de la Santé et des Services Sociaux

  10. Butler JS, Burkhauser RV, Mitchell J, Pincus TP (1987) Measurement error in self-reported health variables. Rev Econ Stat 69:644–650

    Google Scholar 

  11. Commons M, McGuire TG (1997) Some economics of performance based contracting for substance abuse services. In: Egertson JA, Fox DM, Leshner AI (eds) Treating drug abusers effectively. Milbank Memorial Fund and Blackwell Publishers, pp 223–249

  12. Commons M, McGuire TG, Riordan MH (1997) Performance contracting for substance abuse treatment. Health Sci Res 32:631–650

    CAS  Google Scholar 

  13. Drummond DC (1997) What I would most like to know about alcohol interventions: do the best things come in small packages? Addiction 92:375–379

    Article  CAS  PubMed  Google Scholar 

  14. Emrick CD (1975) A review of psychological oriented treatment for alcoholism. II. The relative effectiveness of different treatment approaches and the effectiveness of treatment versus non-treatment. J Stud Alcohol 36:88–108

    CAS  PubMed  Google Scholar 

  15. Finney JW, Hahn AC, Moos RH (1996) The effectiveness of inpatient and outpatient treatment for alcohol abuse: the need to focus on mediators and moderators of setting effects. Addiction 91:1773–1796

    Article  CAS  PubMed  Google Scholar 

  16. Fleming MF, Mundt MP, French MT, Manwell LB, Stauffacher EA, Barry KL (2000) Benefit-cost analysis of brief physician advice with problem drinkers in primary care settings. Med Care 38:7–18

    Article  CAS  PubMed  Google Scholar 

  17. French MT (2001) Economic evaluation of alcohol treatment services. Recent developments in alcoholism, vol 15. Kluwer/Pelnum, New York pp 209–228

  18. French MT, McGeary KA (1997) Estimating the economic cost of substance abuse treatment. Health Econ Lett 6:539–544

    Article  CAS  Google Scholar 

  19. French MT, Zarkin GA, Hubbard RL, Rachal JV (1991) The impact of time in treatment on the employment and earnings of drug abusers. Am J Public Health 81:904–907

    CAS  PubMed  Google Scholar 

  20. Garbutt JC, West SL, Carey TS, Lohr KN, Crews FT (1999) Pharmacological treatment of alcohol dependence, a review of the evidence. JAMA 1318–1325

    Google Scholar 

  21. Gerstein DR, Hardwood HJ (eds) (1990) Treating drug problems. Institute of Medicine, National Academy: Washington

  22. Grant KA, Arciniega LT, Tonigan JS, Miller WR, Meyers R (1997) Are reconstructed self-reports of drinking reliable? Addiction 92:601–606

    Article  CAS  PubMed  Google Scholar 

  23. Heckman JJ, Smith JA (1995) Assessing the case for social experiments. J Econ Perspect 9:85–110

    Google Scholar 

  24. Higgins ST, Budney AJ, Bickel WK, Badger GJ (1994) Participation of significant others in outpatient behavioral treatment predicts greater cocaine abstinence. Am J Drug Alcohol Abuse 20:47–56

    CAS  PubMed  Google Scholar 

  25. Holder HD, Longabaugh R, Miller WR, Rubonis AV (1991) The cost effectiveness of treatment for alcoholism: a first approach. J Stud Alcohol 52:517–540

    CAS  PubMed  Google Scholar 

  26. Holder HD, Cisler RA, Longabaugh R, Stout RL, Treno AJ, Zweben A (2000) Alcoholism treatment and medical care costs from project MATCH. Addiction 95:999–1013

    Article  CAS  PubMed  Google Scholar 

  27. Høyer G, Nilssen O, Brenn T, Schirmer H (1995) The Svalbard study 1988–89: a unique setting for validation of self-reported alcohol consumption. Addiction 90:539–544

    Article  PubMed  Google Scholar 

  28. Jaffe JH (1984) Evaluating drug abuse treatment: a comment on the state of the art. In: Tims FM, Ludford JP (eds) Drug abuse treatment evaluation: strategies, progress and prospects. Research monograph no. 51. National Institute on Drug Abuse: Rockville, pp 13–28

    Google Scholar 

  29. Joe GW, Simpson DD, Sells SB (1994) Treatment process and relapse to opiod use during methadone maintenance. Am J Drug Alcohol Abuse 20:173–197

    CAS  PubMed  Google Scholar 

  30. Kirchner JE, Booth BM, Owen RR, Lancaster AE, Smith GR (2000) Predictors of patient entry into alcohol treatment after initial diagnosis. J Behav Health Serv Res 27:339–346

    Google Scholar 

  31. Long CG, Williams M, Hollin CR (1998) Treating alcohol problems: a study of programme effectiveness and cost-effectiveness according to length and delivery of treatment. Addiction 93:561–571

    Article  CAS  PubMed  Google Scholar 

  32. Longabaugh R, McCrady B, Fink E, Stout R, McAuley T, Doyle C, McNeill D (1983) Cost-effectiveness of alcoholism treatment in partial versus inpatient settings—six month outcomes. J Stud Alcohol 44

  33. Longabaugh R, Beattie M, Noel N, Stout R, Malloy P (1993) The effect of social investment on treatment outcome. J Stud Alcohol 54:465–478

    CAS  PubMed  Google Scholar 

  34. Longabaugh R, Wirtz PW, Zweben A, Stout RL (1998) Network support for drinking, Alcoholics Anonymous and long-term matching effects. Addiction 93:1313–1333

    Article  CAS  PubMed  Google Scholar 

  35. Lu M (1999) Separating the “true effect” from “gaming” in incentive based contracts in health care. J Econ Manage Strategy 8:383–431

    Google Scholar 

  36. Lu M, McGuire TG (2002) The productivity of outpatient treatment for substance abuse. J Hum Resour 37:339–335

    Google Scholar 

  37. Machado MP (2001) Dollars and performance: treating alcohol misuse in Maine. J Health Econ 20:639–666

    Article  CAS  PubMed  Google Scholar 

  38. Maitso SA, McKay JR, Connors GJ (1990) Self-report issues in substance abuse: state of the art and future directions. Behav Assess 12:117–134

    Google Scholar 

  39. Maynard A, Godfrey C (1994) Alcohol policy-evaluating the options. Br Med Bull 50:221–230

    CAS  PubMed  Google Scholar 

  40. Marlatt GA (1996) Harm-reduction: come as you are. Addict Behav 1:779–788

    Article  Google Scholar 

  41. Mason BJ (2001) Treatment of alcohol-dependent outpatients with acamprosate: a clinical review. J Clin Psychiatry 62 [Suppl 20]:42–48

    Google Scholar 

  42. McLellan AT, Luborsky L, O’Brien CP, Woody GE (1980) An improved evaluation instrument for substance abuse patients: the addiction severity index. J Nerv Ment Dis 168:26–33

    CAS  PubMed  Google Scholar 

  43. McLellan AT, Grissom GR, Brill P, Durell J, Metzger DS, O’Brien CP (1993) Private substance abuse treatments: are some programs more effective than others? J Subst Abuse Treat 10:243–254

    Article  CAS  PubMed  Google Scholar 

  44. McLellan AT, Arndt IO, Metzger DS, Woody GE, O’Brien CP (1993) The effects of psychosocial services in substance abuse treatment. JAMA 269:1953–1959

    Article  CAS  PubMed  Google Scholar 

  45. McLellan AT, Woody GE, Metzger DS, McKay J, Durell J, Alterman AI, O’Brien CP (1997) Evaluating the effectiveness of addiction treatments: reasonable expectations and appropriate comparisons. In: Ergertson JA, Fox DM, Leshner AI (eds) Treating drug abusers effectively. Milbank Memorial Fund and Blackwell Publishers, pp 7–40

  46. McLellan TA, Hagan TA, Levine M, Gould F, Meyers K, Bencivengo M, Durell J (1998) Supplemental social services improve outcomes in public addiction treatment. Addiction 93:1489–1499

    Article  CAS  PubMed  Google Scholar 

  47. Midanik L (1982) The validity of self-reported alcohol consumption and alcohol problems: a literature review. Br J Addict 77:357–382

    CAS  PubMed  Google Scholar 

  48. Moos R, Finney J, Cronkite RC (1990) Alcoholism treatment. Oxford University Press: Oxford

    Google Scholar 

  49. Morgnstern J, Longabaugh R (2000) Cognitive-behavioral treatment for alcohol dependence: a review of evidence for its hypothesized mechanisms of action. Addiction 95:1475–1490

    Article  CAS  PubMed  Google Scholar 

  50. Overman GP, Teter CJ, Guthrie SK (2003) Acamprosate for the adjunctive treatment of alcohol dependence. Ann Pharmacother 37:1090–1099

    Article  CAS  PubMed  Google Scholar 

  51. Palmer AJ, Neeser K, Weiss C, Brandt A, Comte S, Fox M (2000) The long-term cost-effectiveness of improving alcohol abstinence with adjuvant acamprosate. Alcohol Alcohol 35: 478–492

    Article  CAS  PubMed  Google Scholar 

  52. Schädlich PK, Brecht JG (1998) The cost effectiveness of acamprosate in the treatment of alcoholism in Germany. Economic evaluation of the Prevention of Relapse with Acamprosate in the Management of Alcoholism (PRAMA) study. Pharmaecoconomics 13:719–730

    Google Scholar 

  53. Shakeshaft AP, Bowman JA, Burrows S, Doran CM, Sanson-Fisher RW (2002) Community-based alcohol counseling: a randomized clinical trial. Addiction 97:1449–1463

    Article  PubMed  Google Scholar 

  54. Shen Y (2003) Selection incentives in contracting. Health Serv Res 38:535–553

    PubMed  Google Scholar 

  55. Shepard DS et al. (2003) The ADSS cost study: costs of substance abuse treatment in the specialty sector. United States Department of Health and Human Services, Substance Abuse and Mental Health Serv Administration, Office of Applied Studies: Rockville

  56. Silverman K, Robles E (1998) Employment as a drug abuse treatment intervention. NBER working paper no 6402

  57. Strohmetz DB, Alterman AI, Walter D (1990) Subject selection bias in alcoholics volunteering for a treatment study. Alcohol Clin Exp Res 14:736–738

    CAS  PubMed  Google Scholar 

  58. Tims FM, Fletcher BW, Hubbard RL (1991) Treatment outcomes for drug abuse clients. Pickens CG, Leukefeld CG, Schuster CR (eds) NIDA research monograph 106. United States Department of Health and Human Services: Rockville

    Google Scholar 

  59. Trent LK (1998) Evaluation of a four- versus six-week length of stay in the Navy’s alcohol treatment program. J Stud Alcohol 59:270–279

    CAS  PubMed  Google Scholar 

  60. Walsh DC, Hingson R, Merrigan D, Levenson SM, Cupples A, Heeren T, Coffman G, Becker C, Barker T, Hamilton S, McGuire TG, Kelly C (1991) A randomized trial of treatment options for alcohol-abusing workers. N Engl J Med 325:775–782

    CAS  PubMed  Google Scholar 

  61. Weisner C, Matzger H (2002) A prospective study of the factors influencing entry to alcohol and drug treatment. J Behav Health Serv Res 29:126–137

    PubMed  Google Scholar 

  62. Weisner C, Mertens J, Parthasarathy S, Moore C, Hunkeler EM, Hu T, Selby JV (2000) The outcome and cost of alcohol and drug treatment in an HMO: day hospital versus traditional outpatient regimens. Health Serv Res 35:791–812

    CAS  PubMed  Google Scholar 

  63. Wutzke SE, Shiell A, Gomel MK, Conigrave KM (2001) Cost-effectiveness of brief interventions for reducing alcohol consumption. Soc Sci Med 52:863–870

    Article  CAS  PubMed  Google Scholar 

  64. Yates BT (1999) Measuring and improving costs, cost-effectiveness and cost-benefit for substance abuse treatment programs. National Institute on Drug Abuse, NIH publ no 99-4518. United States Department of Health and Human Services: Rockville

    Google Scholar 

Download references

Acknowledgements

This research was carried out in part while I was at the IAE, Barcelona, as a Marie Curie postdoctoral fellow (European Community grant #ERBFMBICT972472). I also thank the research support from the Merck Foundation. Useful comments came from Daniel A. Ackerberg, Michael H. Riordan, and two anonymous referees. Mercedes Cabañas provided invaluable assistance as a documentalist. This article was supported by an unrestricted educational grant awarded jointly to the Universities Carlos III de Madrid and Pompeu Fabra de Barcelona by The Merk Foundation, the philanthropic arm of Merck Co. Inc., White House Station, New Jersey, USA. The responsibility for all errors and omissions is mine.

Conflict of interest:

No information supplied

Author information

Authors and Affiliations

  1. Universidad Carlos III de Madrid, Spain

    Matilde P. Machado

  2. Universidad Carlos III de Madrid, Calle Madrid 126, 28903, Getafe, Spain

    Matilde P. Machado

Authors
  1. Matilde P. Machado
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Matilde P. Machado.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Machado, M.P. Substance abuse treatment, what do we know?. Eur J Health Econ 6, 53–64 (2005). https://doi.org/10.1007/s10198-004-0253-2

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10198-004-0253-2

Keywords

Search

Navigation