Psychotherapy

Volume 25/Fall 1988/Number 3

This document is copyrighted by the American Psychological Association or one of its allied publishers.
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DETERMINANTS OF CHEMICAL DEPENDENCY

TREATMENT PLACEMENT: CLINICAL, ECONOMIC,
AND LOGISTIC FACTORS
PATRICIA A. HARRISON
NORMAN G. HOFFMANN

C. DAVID HOLLISTER
University of Minnesota

Ramsey Clinic, St. Paul, Minnesota

LEONARD GIBBS
University of WisconsinEau Claire
Logistical, political, and economic
factors frequently combine to preempt
clinical considerations in chemical
dependency treatment placement. A
study of 319 alcoholics with or without
concurrent drug use disorders was
conducted to determine the relative
efficacy of inpatient, outpatient, and
inpatient-to-outpatient treatment and to
identify patient characteristics
associated with differential outcome by
treatment type. Successful 6-month
follow-up of 73% of the patients
revealed a 67% abstinence rate with no
significant differences by treatment
setting. The routine use of standardized
instruments and procedures for
diagnosis and assessment is
recommended along with changes in
This research was funded by the Chemical Dependency
Program Division, Minnesota Department of Human Services,
and administered through St. Paul-Ramsey Foundation. Computer support was provided by Academic Computing Services
and Systems at the University of Minnesota. Participating
treatment sites were Abbot-Northwestern Hospital, Minneapolis,
ARC/Parkview Treatment Center, St. Louis Park, and St.
Paul-Ramsey Medical Center, St. Paul, Minnesota.
The authors gratefully acknowledge the assistance with data
collection of Donna Dregger, Richard E. Selvik, Leslie Levine
Adler, and Janice Mozey.
Correspondence regarding this article should be addressed
to Patricia A. Harrison, CATOR, 17 West Exchange Street,
Suite 420, St. Paul, MN 55102.

356

MICHAEL G. LUXENBERG
Minneapolis, Minnesota
service delivery systems and insurance
coverage as steps toward optimal
treatment placement.
Increasing emphasis on cost containment has
led to concern, if not outright alarm, that economic
factors will eventually override clinical judgment
as the primary determinant of placement in the
appropriate level of patient care. Nowhere is the
wariness about current trends more apparent than
in the field of chemical dependency. Advocates
of mandatory health insurance coverage and governmental assistance for treatment of alcohol and
drug dependence, having fought long and hard
for the gains they have accomplished, now fear
these advances will get blown away in a whirlwind
of new health care systems.
Such fear is well founded even though alcoholism
is indisputably the number one health problem in
the country. The economic costs associated with
alcoholism each year have been estimated at $117
billion with an additional $60 billion in costs associated with drug abuse (Harwood et al., 1984).
Yet, only $4.4 billion of this cost is actually spent
on the detoxification and treatment of individuals
suffering from alcohol and other drug dependence
(U.S. Department of Health and Human Services/
NIAAA, 1986). If one considers only rehabilitation, treatment costs account for only 1% of all
health care expenditures (H. J. Harwood, personal
communication, 1987). The notion that medical
necessity or clinical wisdom is now, or ever was,
the primary determinant in selecting level of care
for alcoholics and drug abusers is a myth. Logistical, political, and economic factors frequently

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Determinants of Treatment Placement

combine to preempt clinical considerations. Ironically, these factors frequently result in greater
costs than if clinical guidelines had been followed.
Past and most current attempts at treatment cost
containment have not focused on early detection
followed by the least intensive treatment necessary.
Rather, they have generally restricted access to
treatment for all but the most seriously affected
through stringent admission criteria and limitations
on the providers who are eligible to receive reimbursement. Employers, including the federal government, have purchased health insurance which
does not include treatment for one of the most
prevalent and now treatable conditions affecting
their employees.
A penny-wise-pound-foolish approach to chemical dependency treatment has long dominated the
health insurance industry and government policies.
For instance, Medicare has had a long-standing
policy of providing coverage for hospital-based
inpatient treatment but not free-standing residential
treatment or outpatient treatment. Health insurance
policies often provide for 100% reimbursement
of inpatient treatment but only 50% or 80% of
outpatient treatment. In the case of Ohio and Massachusetts, the legislated minimum mandates of
$550 and $500 for the reimbursement of outpatient
treatment in effect became the ceiling of insurance
providers. The net result may be that some patients
are receiving expensive round-the-clock care they
do not need while others are forgoing treatment
altogether.
When confronted with the question of appropriateness of inpatient treatment, economic issues
aside, most chemical dependency practitioners will
agree that some people need it and some people
do not. However, there the agreement ends. There
is no consensus as to how many need it or how
to identify them. In order to make a strong case
that clinical factors should indeed be the primary
determinant of treatment placement, empirical
evidence must be adduced to support such decisions.
Methods
Faced with cost-effectiveness/quality-of-care
issues, the State of Minnesota funded a three-year
study to assist in policymaking decisions with
respect to chemical-dependency treatment placement and reimbursement.
The purpose of the Minnesota study was to
determine the relative efficacy of inpatient treatment, outpatient treatment, and combination in-

patient-to-outpatient treatment for alcoholism, and

to identify patient characteristics associated with
differential outcome by treatment type. The randomly selected study population included 157 inpatients from one hospital-based and one freestanding residential program and 134 outpatients
from the same sites as well as another hospitalbased program serving a more indigent population.
Only 28 combination program patients were included due to the infrequent utilization of this
program option.
For inclusion in the study patients had to be
Minnesota residents between the ages of 18 and
70 and meet DSM-III criteria for a diagnosis of
alcohol abuse or dependence with or without concurrent drug use disorder diagnoses. Participants
granted informed consent for interviews and neuropsychological testing while in treatment and three
follow-up contacts at one, three, and six months
after discharge. Patients were enrolled in the study
between May 1983, and January 1985. Of 380
randomly selected individuals, 319 (84%) agreed
to participate.
The treatment programs at the participating
sites were relatively homogeneous in philosophy
and methods, with differences between inpatient
and outpatient programs related chiefly to setting and time involvement rather than content
or format. The recovery program of Alcoholics
Anonymous was the philosophical base for treatment and the disease concept of chemical dependency was the educational model. Multidimensional aspects of treatment included attention to
physical, mental, social, emotional, behavioral,
and spiritual processes. Involvement of significant
others when possible was considered crucial to
the recovery process. Typical lengths of stay for
inpatients were three to four weeks and for outpatients 20 evening sessions of three hours each.
Combination program patients were transferred
to outpatient settings after an inpatient stay of one
to three weeks.
Results
The study population was predominantly white
(92%) and male (70%). The mean age was 36
and the median age was 34. The majority of patients
were employed at admission to treatment (63%)
and had at least a high school education (76%).
The majority were unmarried (30% separated or
divorced, 2% widowed, and 28% never married).
More than half (57%) were in treatment for the
first time. Thirty percent met DSM-III criteria for

357

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Patricia A. Harrison et al.

a diagnosis of drug abuse or dependence in addition
to alcohol abuse or dependence.
Inpatients differed from outpatients in several
key respects. Inpatients were older and significantly
more likely to drink daily. Alcoholism and drugdependence symptoms, especially those associated
with late-stage disorders, were reported with significantly greater frequency by inpatients. There
were no significant differences between the two
groups, however, with respect to sociodemographic
variables other than age, neuropsychological testing
results, prior treatment history, or previous hospitalizations for detoxification, medical illness,
or psychiatric care in the past year. All but 35
(11%) of the subjects completed treatment with
very little difference between the completion rate
of inpatients (91%) and outpatients (88%). Treatment dropout was significantly associated with
unemployment, severe alcoholism symptoms such
as DTs, and the absence of some alcoholism
symptoms such as blackouts and tolerance. Patients
who dropped out of treatment during the first week,
however, are not represented in the study sample
because patients were not approached for consent
until approximately one week after admission.
Such early terminations involve approximately 10%
of all admissions. Follow-up contacts at one, three,
and six months postdischarge were completed for
73% of the subjects.
For all analyses presented here, posttreatment
sobriety was the dependent variable, dichotomized
as either total abstinence for the six months following discharge or any use of alcohol or drugs
during that period. Two thirds (67%) of the patients
reported total abstinence. Although the sobriety
rate for outpatients (74%) was higher than that
for inpatients (61%) and combination program
patients (64%), the differences were not statistically
significant (see Table 1). Sex, age, ethnicity, marital status, and employment status did not predict
outcome for this sample. Treatment dropout was
a strong predictor of relapse.
Only two alcohol-related symptoms were significantly associated with outcome; shakes and
not drinking more than planned were associated
with a higher likelihood of relapse. Drug-related
symptoms, however, were consistently associated with outcome at a statistically significant level,
with drug symptoms predicting a higher likelihood
of relapse (see Table 2).
Contingency table analyses were conducted to
test for significant differences in sobriety rates for
inpatients and outpatients matched on a variety

358

of characteristics or scale scores. Combination

program patients were not included in these analyses because of their small sample size. Scales
were also subjected to analyses of variance to
determine whether observed differences in patient
group sobriety rates were attributable to a single
independent variable or to interactions among independent variables. Logistic regression analyses
were performed to evaluate the effects of independent variables and interactions among predictors
when sobriety/nonsobriety was used as the outcome

criterion.

The search for interactions between patient

characteristics and treatment type with respect to
posttreatment sobriety did not support the hypothesis that inpatients with serious impairment
or a history of low social stability would do better
than outpatients with these characteristics (see Table
3). These patients had comparable outcomes regardless of treatment setting. However, several
subgroups actually did worse in inpatient treatment:
younger persons, those with "high" job status,
and those with high cognitive functioning. Differences were attributable more specifically to much
lower than average sobriety rates among inpatients
with these characteristics than to higher sobriety
rates for outpatients. Similarly, outpatients who
reported daily drug use, drug tolerance, drugrelated erratic behavior, or drug-related memory
problems had significantly better outcomes than
inpatients with the same symptoms.
Discussion
The poorer outcomes among drug-abusing
alcoholics overall, and notably among those in
inpatient treatment, merit examination. Some unidentified factors may have moderated these outcomes. Even with attempts to control for the inpatient/outpatient treatment selection bias, factors
not measured in the study may have contributed
to the disproportionate placement of lower-prognosis patients in inpatient settings. However, it
may be that outpatient settings are in fact superior
for some persons. The pattern that younger persons,
those with high cognitive functioning, and those
abusing drugs along with alcohol did better in
outpatient treatment than in inpatient treatment
suggests the possibility that outpatient settings
may have been in some way more appropriate for
them. One possibility is that ideology and peer
interaction may play a role, since the inpatient
populations contained more later-stage alcoholics.
Drug abuse, especially in Minnesota, has been

Determinants of Treatment Placement

TABLE 1. Abstinence/Substance Use 6 Months Posttreatment Based on Contacts with 73% of Patients
or Their Significant Others
Returned to
Substance Use

Maintained Total
Abstinence

Male
Female

n %fl
(76) 33
(49) 30
(27) 40

n %a
(157) 67
(116)70
(41) 60

Age

18-29
30-39
40-49
50-70

(28)
(24)
(13)
(11)

Ethnicity

White
Black
Amerindian
Other

(73) 36
(2)25
(0)
(1)34

Marital status at intake

Married
Separated
Divorced
Widowed
Never married

(32) 32
(7)30
(15) 34
(0)
(22) 35

Employment status at intake

Employed
Unemployed
Homemaker
Retired
Student

(49) 33
(13) 29
(3)25
(3)43
(2)33

(100) 67
(31)71
(9)75
(4)57
(4)67

ns

Treatment type

Inpatients
Outpatients
Combination program patients

(41) 39
(27) 26
(8)36

(65) 61
(78) 74
(14)64

ns

Discharge status

Completers
Noncompleters

(63) 29
(13) 72

(152) 71
(5)28

.0005

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All Interviewed Patients

Gender

33
35
32
27

(56)
(45)
(27)
(29)

67
65
68
73

(145) 67
(6)75
(4) 100
(2)66
(67)
(16)
(29)
(4)
(41)

68
70
66
100
65

X2 p value

ns
ns

ns

ns

"Row percentages.
Note, ns = not significant.

conceptualized under the umbrella of "chemical

dependency." In the evolution of Minnesota's response to alcoholism, drug abuse was a late entry.
A separate treatment model did not emerge to
respond to drug abuse. Instead, the traditional
disease concept of alcoholism was extended to
drug abuse/dependency, and the recovery model
of Alcoholics Anonymous was applied to everyone
diagnosed as "chemically dependent." The Minnesota model of treatment capitalized on the similarities of the chemical dependencies, and overlooked the differences.
The findings that multiple-substance-use problems predict a poorer outcome raise questions

about two common assumptions associated with

an umbrella model of treatment. These assumptions
are 1) that there are no significant differences
between people who drink and people who also
use drugs, and 2) that there are no significant
differences between alcohol abuse and drug abuse.
Both assumptions are challenged by the findings
of our study.
The distinction between the legality of drinking
and the criminality of drug use is not based on
their mood-altering effects or propensity to cause
harm. Yet because of this distinction, a parallel
cannot be drawn between appropriate alcohol use
and appropriate drug use. Because society does

359

Patricia A. Harrison et al.

TABLE 2. DSM-III Symptoms and Substance Use Variables with Significant Relationship to Outcome
6-Month
Posttreatment
Abstinence
(JV = 233)

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Alcohol-related symptoms
Shakes
Drank more than planned
Drug-related symptoms
Daily use
Failure to reduce drug use
Tolerance
Withdrawal symptoms
Health problems
Family/friends object to use
Job/school absenteeism
Impulsive behavior
Arrest for possession/sale
Emotional problems
Barbiturate use
Nonheroin opiate use

(%)

No
Yes
No
Yes

80/107
77/126
9/21
147/211

75
61
43
90

.05

No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes

115/160
42/73
137/193
20/40
120/165
37/68
137/190
20/43
141/195
16/38
125/170
32/63
134/183
23/50
118/164
39/69
148/208
9/25
119/164
38/69
133/193
18/40
141/201
13/32

72
58
71
50
73
54
72
47
72
42
74
51
73
46
72
57
71
36
73
55
69
45
70
41

.05

not sanction drug use, people who might be using

drugs in contexts or amounts analogous to social
drinking are not visible.
Since drug use is criminal behavior, obtaining
and using drugs frequently involves association
with a deviant subculture. Giving up drugs then
may entail giving up a peer group and a lifestylelosses that may be experienced more acutely
by drug users than by drinkers. Especially for
young drug users, their emerging identities may
be closely bound to their peer group; reentry into
a straight society may bring with it a sense of
alienation. Recovery groups which are not sensitive
to the different experiences of drug users may
compound these feelings. Drug users may be en-

360

X2 p value

Patient Response

.025

.025
.01
.005
.001
.005
.0005
.05
.001
.025
.025
.01

couraged to attend AA meetings but find that they

are not always welcome. Alternatives such as
Narcotics Anonymous and Cocaine Anonymous
are not as numerous and geographically widespread
as AA.
In treatment itself, educational examples and
the recovery model of Alcoholics Anonymous focus
on alcohol, with analogies drawn to marijuana,
cocaine, and other drugs. Persons with dual dependencies are in the minority in many Minnesota
treatment centers, and if they perceive drug use
as their primary problem, they may fail to identify
with the recovery model as presented. They may
believe that in order to recover they have to accept
a model which does not seem tofittheir experiences

Determinants of Treatment Placement

or their perceptions. Furthermore, their disclaimers
may be seen by staff as resistance rather than as
an attempt to forge a recovery model that is a
better fit for their needs.
At least three possible explanations of these
findings and their corollary implications can be
raised:

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1. Factors associated with drug use not measured

in the study may have influenced treatment

placement and/or sobriety. For example, drug

abusers may be more likely to manifest personality disorders or antisocial lifestyles. Such
factors might account for some of the differences
observed in the results.
2. A unitary model of treatment for substance
abuse may be inappropriate for some or all
drug abusers. This argument suggests that since
the pharmacodynamic properties of some
classes of drugs differ from alcohol, as do the

TABLE 3. Posttreatment Sobriety by Treatment Modality: Diagnostic Questions with Statistically Significant Results
6-Month Sobriety

Alcohol-related arrest (nondriving)

No
Yes
Alcohol-related liver disease
No
Yes
Alcohol-related injury
No
Yes
Daily drug use for a month or more
No
Yes
Subjective feeling of drug dependence
No
Yes
Failure to reduce drug use
No
Yes
Drug tolerance
No
Yes
Drug-related health problems
No
Yes
Drug-related unusual behavior
No
Yes
Drug-related memory problems
No
Yes
Acknowledgment that drugs have interfered with life"
No
Yes
Acknowledgment of problems with marijuana in past year
No
Yes

Inpatients
(%)

Outpatients
(%)

56
67

78
65

60
70

77
33

60
83

58
66

69
44

74
76

71
37

75
71

67
33

75
70

69
44

75
72

69
29

76
67

71
39

73
77

69
44

73
79

71
36

73
77

68
36

72
83

X2 p value
.025

.05

.025

.025

.005

.01

.025

.001

.005

.01

.001

.01

"Not a diagnostic criterion.

361

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Patricia A. Harrison et al.

contexts of use, alternative treatment models
are needed to respond to these differences.
3. The unitary model of treatment may be adequate, but the specific techniques or focal points
of treatment may need to be modified for some
subgroups of patients. This hypothesis is suggested by the relatively consistent outcomes
of outpatients. Since these inpatient programs
serve a larger proportion of persons with chronic
alcohol symptoms, drug users may not relate
as well to the inpatient program or to their
fellow inpatients.
Study results regarding low-symptom alcoholics
who nevertheless meet diagnostic criteria also raise
the question of the advisability of traditional treatment settings for borderline diagnostic cases. Patients who did not report blackouts or tolerance
were significantly more likely to drop out of treatment. Patients who denied excessive drinking or
drinking more than planned had a significantly
higher likelihood of returning to drinking. Treatment noncompletion and relapses may indicate
for some of these patients not so much an inability
to refrain from drinking, but the lack of conviction
that it is necessary. Perhaps programs populated
by chronic and severely affected alcoholics actually
contribute to the capacity of more moderately impaired alcoholics to minimize their own problems.
While low-symptom alcoholics certainly require
intervention of some kind, they may require a
treatment tailored more specifically to their earlystage disorders and consequences in order that
they not fail to appreciate the seriousness of their
own problems because they compare favorably to
worst-case scenarios.
Results of the study overall, however, must be
considered in light of its limitations. The design
was quasiexperimental and the populations were
limited to patients already admitted to the participating sites. Excluded from the study were persons
without a means to pay for treatment (insurance,
Medicaid, or Medicare) which include some of
those most severely impaired by their chemical
dependency. The sample is also limited by its
narrow geographic scope and the preponderance
of whites and males. The patients who refused
participation, who left treatment before being approached for consent, and the proportion who
were not successfully contacted after treatment
all provide potential for sample bias.
The quasiexperimental design was a concession
to clinical concerns and pragmatic realities that
became insurmountable barriers to a random as-

362

signment design. Our inability to conduct a random

assignment study as originally planned in itself
points to some key issues surrounding the utilization
of treatment settings. Before acknowledging defeat,
project staff randomly selected and considered
107 patients for random assignment, but only three
were so placed. The greatest single barrier to random assignment was the distance of patient residence from the treatment site: 36 (34%) lived
too far to commute daily to outpatient treatment,
at least at the site selected. Whether an outpatient
treatment option was available closer to home for
these persons is not known. For 14 (13%) patients'
work schedules precluded one or the other option
and for 11 (10%) differential insurance coverage
for treatment setting dictated their choice. Two
patients were court-ordered into an inpatient setting.
Thus, for almost 60% of the patients, logistic,
economic, legal, or other considerations preempted
the clinical decision.
In addition to these obstacles, the other major
barrier to the random assignment was the refusal
of clinical staff to consider outpatient as a clinically
sound alternative for many patients. Clinical approval was necessary to allow the patient into the
random assignment pool. Clinical staff refused to
allow random assignment of 29 patients due to
psychological symptoms or environmental stressors
that they believed warranted an inpatient placement.
For an additional five patients, the determination
was made that a medical condition warranted inpatient treatment. Patient refusals constituted the
remaining seven cases.
In this small sample then, treatment placement
was based on nonclinical factors for 63 (59%)
patients and on clinical judgment for 34 (32%).
It must be noted that in the hierarchy of decisionmaking, logistic impediments precluded clinical input. Thus, if the nonclinical factors had not
come into play, exclusions based on clinical decisions may have accounted for a greater proportion
of ineligible patients.
Even in the face of accumulating evidence that
outpatient treatment is appropriate for many adults
with alcohol and drug dependencies, outpatient
settings will probably continue to be underutilized.
The impediments to the growth of the outpatient
modality can be categorized as environmental obstacles, economic barriers or disincentives, and
the inertia of tradition.
The primary environmental obstacle to outpatient
treatment is the distance of available programs
from a patient's residence. In many communities,
particularly in rural areas, no outpatient program

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Determinants of Treatment Placement

exists within 100 miles or more. Other logistic
problems associated with daily commuting are the
lack of a driver's license or lack of access to a
vehicle coupled with inadequate public transportation. Outpatient programs, when available, are
most commonly offered in the evenings, and thus
are not a beneficial option for second shift or other
evening workers. Evening programs are not necessarily attractive to homemakers with schoolaged children or single parents who have no one
to stay with their families in the evening. If outpatient treatment were more universally available,
commuting difficulties and scheduling conflicts
could be overcome through the flexibility afforded
by a greater variety of options.
Economic barriers include the failure of many
insurance providers to provide adequate reimbursement for outpatient treatment, the requirement
of a substantial copayment by the patient when
outpatient care is chosen, or the stipulation of
restrictive admission criteria requiring multiple
and/or late-stage symptoms if the treatment provider
is to receive payment. The cost-effectiveness of
policies that discourage the use of low-cost alternatives may seriously undermine early intervention efforts and drive up the ultimate costs
associated with alcohol and drug dependencies.
Overcoming the inertia of tradition for inpatient
treatment is yet another challenge. When inpatient
programs became the vanguard of alcoholism rehabilitation, both the clientele and staff were quite
different from those in programs today. By the
time they entered treatment, most alcoholics were
older than those admitted today, with late-stage
symptoms, serious physical and mental deterioration, and loss of family, jobs, and other social
supports. Long-term residential rehabilitation was
seen as the only way to restore severely incapacitated alcoholics to physical and mental stability.
Staff were, for the most part, themselves recovering
alcoholics with little if any professional training.
Today, more and more alcoholics and drug abusers
are being identified and admitted into treatment
when they are younger and at less advanced stages
of their substance abuse disorders. Staffs include
physicians, psychologists, social workers, nurses,
and counselors with specialized training in treating
alcohol and drug dependence. Family members
and significant others are brought into the treatment
process to understand the dynamics of their behavior that have enabled the identified patient to
continue drinking or using drugs. Aftercare programs are available to provide long-term support
after the patient has completed a primary treatment

sequence.
For many patients, the structured environment
of inpatient treatment is apparently not required
for successful recovery. Other studies comparing
the results of inpatient and outpatient programs
also have not found significant differences attributable to the effects of treatment setting (Cole et
al., 1981; Longabaugh et al., 1983; McLachlan
& Stein, 1982). In another study, although "psychiatric severity" was the strongest predictor of
treatment outcome overall, it did not predict differentially by treatment type (McLellan et al.,
1983); low-severity patients did better, regardless
of treatment type, and high-severity patients did
worse, also regardless of treatment type.
Despite the lack of empirical support in this
study and others for the hypothesis that more severely ill and socially unstable patients would
have better outcomes if treated in inpatient settings,
this possibility cannot yet be ruled out. Quasiexperimental designs cannot control for all the patient
characteristics involved in selection or referral to
treatment type. Heterogeneous patient populations
may obscure as yet unidentified subgroups for
whom inpatient settings may offer superior outcomes. Comparative outcome studies systematically exclude patients for whom outpatient treatment is judged too risky. Thus, whenever ethical
concerns result in the exclusion of severely impaired
patients from random assignment studies, the most
these results can establish is that persons who can
safely be treated in outpatient settings do not have
better outcomes when treated as inpatients. Furthermore, the promising alternative of short-term
inpatient stays for evaluation and stabilization followed by outpatient treatment at the same site has
not been explored adequately, although it may
offer the advantages of both settings.
Recommendations
The routine use of standardized instruments and
procedures for diagnosis and assessment of alcohol
and drug abuse and dependence could reduce the
apparent inconsistency of current practice which
leaves the chemical dependency treatment industry
open to charges offinancialself-interest in treatment
placement decisions. Diagnostic instruments such
as the Substance Use Disorder Diagnostic Schedule
(SUDDS), a refinement of the interview used in
the Minnesota study, or the Addiction Severity
Index (ASI) (McLellan et al., 1980) have been
found to be efficacious and comprehensive methods
of substantiating and documenting the scope and
severity of alcohol and drug problems.

363

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Patricia A. Harrison et al.

Even with improved identification of patient
needs and objectively defined decision guidelines,
the systems of service delivery and insurance coverage must be changed in order to ensure that the
level of treatment needed by each individual is
available within each community and that financial
obstacles will not preclude optimal treatment
placement. Such changes will require the coordinated and cooperative efforts of providers, insurers, and regulators. Providers must develop
clinically sound and cost-effective treatment options, and insurers must develop realistic and economically justifiable premium and reimbursement
rates for a broader range of coverage. Together
they must educate the corporate and governmental
consumers of group insurance, benefits managers,
and personnel directors about the economics of
adequate coverage for alcohol and drug-dependency
treatment.
References
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(1981). Inpatient vs outpatient treatment of alcohol and

364

drag abusers. American Journal of Drug and Alcohol Abuse,

8, 329-345.
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