Low-Cost Clinics: Best Way to Treat Substance Abuse
If sensible treatment for drug abuse and alcoholism were to be offered in every U.S. neighborhood, it also could improve the health of some people who have never touched drugs or taken a drink, and do this more dramatically than any research now in progress. It also could lower medical-care costs more effectively than will all the arbitrary cost-cutting that is now shaving most everyone's medical care down to the grimly skinny. The overdue task is to properly define what sensible substance-abuse treatment is.</br></br>Given the current obsession with controlling medical-care costs, what's sensible should bear some relation to what's affordable. Yet at the most publicized of alcohol- and drug-abuse treatment centers, the Fair Oaks hospital group (which sponsors the famous 800-COCAINE hotline), the current cost of a hospital day is $1,000, which exceeds the price of a day in the coronary-care unit of Massachusetts General Hospital. The cost of a full inpatient term of treatment at these centers -- four weeks to six months -- ranges from $28,000 to $160,000, with an average of $56,000. This is a spread whose lower end is higher than the cost of bypass surgery and all its attendant expense and whose upper end is more than double the average cost -- $70,000 -- of treating an AIDS patient. Most other middle-class centers cost $10,000 per term of inpatient treatment, while the Betty Ford Center charges $5,000, and Hazelden in Minnesota charges $4,000.</br></br>The reason no one questions these prices, not even the insurance companies who pay them, is that the alternative expense in addiction-related disease, lost productivity and crime is reckoned at $170 billion a year. With treatment success rates reported as high as 85% to 92% at (for instance) the Fair Oaks hospital group, the treatment prices have appeared eminently cost-effective, and the success rates miles ahead of those recorded over the past 50 years by public substance-abuse programs. The hitch, according to Dr. Chad Emrick of the University of Colorado (the only researcher to review all the literature on this subject), is that those success rates are more fantasy than fact. Both Dr. Emrick and Dr. George Vaillant, professor of psychiatry at Dartmouth Medical School, say that, even when addressed in these same expensive treatment centers, alcoholism and drug abuse remain notoriously prone to relapse -- which confuses the meaning of "success." Many of those treated need retreatment two or three or more times.</br></br>Given prices of $160,000 or $56,000 or even $4,000 per term of treatment, how can we afford care for those who are habitual and excessive users of drugs and/or alcohol? There are an estimated 40 million people who regularly abuse these substances. Were all of them to be treated only once at even the lowest-priced outpatient center (Hazelden, at $1,800 per term of treatment) the cost would be on the order of $72 billion. That's one-fifth of annual current medical expenses in the U.S. If, against high odds, half of these heavy users could break their habits by themselves, the remainder would still cost some $36 billion to treat -- once. What is the answer?</br></br>To begin with, Drs. Emrick and Vaillant and others have not found a scintilla of evidence to show that expensive treatment works any more effectively than less expensive kinds. Mr. Vaillant, author of the classic book "The Natural History of Alcoholism," says, "What's important is that treatment be available for everyone as often as they need it." On just this precept, the Cambridge and Somerville Program for Alcohol Recovery in Massachusetts, developed by Harvard Medical School physicians, has for the past 16 years treated about 20,000 patients a year at an annual cost of $1 million. Its bywords are easy accessibility and versatility of approach. The program includes a 24-hour walk-in clinic, outpatient groups, groups for families, women's groups, a detoxification unit and three halfway houses. It boasts no amazing statistics or new wonder therapies, but in its humdrum and unpretentious way it weans a great many people from their injurious addictions, some permanently, others only for a while at a time. Its "success" rate, in short, is as good as any.