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SUMMER 2002
Sobering Times for Treatment Centers
by Judy Bolyard Purdy

A fifth of the private rehab centers that volunteered to participate in a national study have shut down since the summer of 1995.

With help from recovering alcoholic Charlie Sheen, actor Ben Affleck voluntarily checked himself into a private residential alcohol rehab center in Malibu, Calif. last summer.

When the average Joe decides to check into a private alcohol treatment center these days, though, chances are the best he’ll get is outpatient services.

Changes in health insurance coverage have put the time-honored residential programs, which may last as long as six months, out of reach for all but the privileged few – if patients can even find a private rehab center at all.

Hard hit by the trend toward “managed care,” a startling number of private rehab centers have gone belly up. Of the 450 private alcohol treatment centers that volunteered to participate in a national study led by the University of Georgia’s Paul M. Roman, one-fifth have shut down since the summer of 1995.

The ongoing, nationwide treatment center study also shows that the surviving private centers have made fundamental changes. For example, they have dumped long-term residential programs, compressed 28-day inpatient programs to a week and beefed up their lower-cost outpatient programs.

“Those that still offer the 28-day in-patient program tend to be the larger, more nationally recognized centers, and they largely rely on self-paid patients because essentially anyone covered by any sort of managed care insurance won’t qualify,” said J. Aaron Johnson, a UGA assistant research scientist who is part of Roman’s research team.

The study is providing a checkup of sorts for the nation’s private substance abuse treatment centers. Findings could help private centers avoid risky practices, increase quality and improve their chances for survival. The study also provides hard data for center managers as well as people in government and the private sector who help steer healthcare policy.

While other studies have looked into such facilities as rural hospitals — focusing on organization, adaptability and closure rates — Roman said this is the first to examine similar aspects of private substance abuse treatment centers.

“We are exploring how well their strategies are working in the volatile environment of managed care,” said Roman, a distinguished research professor of sociology who has studied issues surrounding alcohol treatment for more than three decades. “We want to see whether their management practices and organizational features are providing a competitive advantage or at least buffering them from organizational death.”

The findings are timely for the estimated 14 million Americans, or one in 13 adults, who abuse or are addicted to alcohol. Statistics from the NIH’s National Institute on Alcohol Abuse and Alcoholism, which has provided more than $3.4 million for the study’s first six years, show alcohol abuse affects more men than women and is highest among people ages 18 to 29.

Effective substance abuse treatment programs are vital to the American healthcare system, said Rex Forehand, director of the UGA Institute for Behavioral Health.

“It’s frightening where we’ve gotten ourselves in this country in terms of alcohol and drug abuse,” Forehand said. “Good treatment options are clearly important for productivity in the workplace, for family functioning and for an individual's adjustment.”

Forehand describes Roman’s work as “critical” in combining research with treatment practices. “Having research and treatment work together from the get-go will help develop and evaluate better, more effective treatment practices,” he said.

Roman also directs a graduate training program that prepares doctoral students for employee alcoholism program research. The program, now in its 14th year, has received $1.7 million in NIH grants.

Private centers: A picture of health?

Since the early days of alcohol treatment, America’s private facilities have looked like carbon copies. As recently as the early ’90s, if you checked into one in Georgia, Minnesota or California, you’d find a cookie cutter copy. That finding comes from a study of employee assistance programs and private treatment centers that Roman and his wife, Terry C. Blum, dean of Georgia Institute of Technology’s Dupree School of Management, conducted between 1988 and 1992.

“They had changed very little since they were first established. All of them were 28-day, residential programs based on the 12 Steps of Alcoholics Anonymous, period,” said Roman who, as a graduate student, met Alcoholics Anonymous’ famed co-founder Bill W., originator of the 12 Step program. “They were one-size-fits-all. They were essentially indistinguishable.”

Not any more.

To successfully navigate the choppy waters of change in the insurance industry, private rehab centers must focus on what gives them a competitive edge. For example, when the study started, 81 percent of the centers offered in-patient detoxification and 69 percent offered residential treatment. By 2001, those statistics had dropped to 57 percent and 44 percent, respectively.

“It’s analogous to what’s happening in the rest of healthcare. People are being released from hospitals after much shorter stays,” Blum said. “Innovation is important for every company — whether it’s healthcare services or not.”

Many private rehab centers have augmented AA’s 12 Step program with newer treatments and welcomed a wider range of addictive behaviors into the fold.

“Centers have had to come up with a broader range of options,” Roman said. “Right now the menus of treatment are partially out of a sense of desperation because people are not going to be reimbursed for in-patient treatment. That’s what’s driven this movement away from one-size-fits-all program.”

The move to diversify appears to be good for the health of centers and patients. The closing rate among private substance abuse treatment centers has slowed. During their 1988-1992 study, Roman and Blum discovered that nearly one in three centers closed during those four years. But only about half that number — just 15 percent — closed while the National Treatment Center Study was underway from 1995 to 1999. (See related story about risks associated with closure, Risky Business.)

Since 1995, the researchers have conducted three “waves” of on-site interviews at treatment centers scattered across 38 states. A fourth wave is planned to begin this fall.

Each wave is followed every six months by a series of phone interviews with center administrators, clinical directors, marketing directors and, more recently, substance abuse counselors. Researchers probe for information in many sensitive or confidential areas that span business, financial, organizational and treatment practices. Questions ferret out specific information on patient recruitment and referral, staff burnout, revenue sources and administrators’ abilities to spot serious financial trouble on the horizon, to name a few.

Comparing data from discreet moments in time enables the researchers to capture “freeze-frame” snapshots of private rehab centers in the midst of growth and change.

With each new wave, the team, which also includes more than a dozen research technicians and graduate students, adds new dimensions to the study. For example, third wave interviews included scrutiny of how much centers are implementing treatment innovations. Although this wave of data collection was just completed in May, Roman and Johnson are already noticing changes among the centers.

“I think if you went out into the world and asked treatment center administrators, “What’s your single most important wish?” they would say, “Give us better reimbursement so we could engage in a better menu of treatment,” Roman said.

Bigger Menus, more choices

These days, private treatment centers are improving quality and expanding services to treat other addictions: gambling, illegal and prescription drugs, sex and Internet addictions, to name a few. Centers also are adjusting to changes in their clientele, who are now more likely to have multiple addictions, Johnson said.

“Center administrators will tell you that alcoholism really doesn’t exist the way it used to,” he said. “Administrators have told me countless times that people coming into treatment now are poly-drug addicts who abuse all sorts of things, not just alcohol and not just cocaine.”

More than half of the centers studied have enhanced traditional counseling and “talk” therapies with complementary treatments, such as acupuncture and motivational enhancement therapy. The researchers found a surprising 13 percent now offer acupuncture, for example.

“There’s a whole movement at the National Institutes of Health to understand the role of complementary medicine in treatment outcomes — for example, the research on prayer, meditation, massage therapy and acupuncture,” Blum said. “And it's not just focused on substance abuse but all kinds of diseases — cancer, diabetes, etc. These don’t replace the main therapy; they are add-ons.”

But the researchers said they also found disappointments. Only 44 percent of the centers prescribed naltrexone, or ReVia®, which the FDA approved for alcohol addiction in 1995. The drug works as an alcohol antagonist, taking the pleasure out of using alcohol. People don’t get the good feelings — the “highs” — because the drug blocks the brain’s pleasure receptors.

“Why not give them some biomedical, biochemical or neurological help along the way? That's regarded as a good treatment practice,” Roman said. “And what we found is that it’s not being used very much at all.”

Their findings, published in the May issue of the Journal of Substance Abuse Treatment, show greater naltrexone use among centers with longer established programs and more experienced administrators, and among those with higher percentages of managed care coverage and higher proportions of relapsed patients in the overall caseload.

Roman said he believes prescription drugs are slow to take hold because of society’s attitudes.

“Drugs undermine the old paradigm of treatment,” he said. “They want you to take the naltrexone and keep going to AA meetings.

“(As a society) we see substance abuse as a choice behavior, so, yes, we’ll give you some help, but you're ultimately responsible to get your way out of this,” he said. “The idea of giving people a drug to help them just doesn’t fit with this notion that substance abusers have a medical problem that they're responsible for.”

Roman illustrated his point by contrasting attitudes between addiction and infections.

“If you have an infection, healthcare professionals don’t try to talk you out of it or counsel you on it,” he said. “Instead, they prescribe antibiotics to help you get better.”

The researchers are curious whether prescription drugs will lower the costs of addiction treatment.

“That’s not a question we can answer right now, but there’s certainly a hint that using drugs rather than talk to treat substance abuse is going to be cheaper in the long run,” Roman said.

The study also has turned up gender-based differences.

For example, women represent a higher proportion of Medicaid and Medicare patients, and they are more likely to be uninsured or underinsured. They also account for a higher proportion of patients at centers that offer onsite childcare and they are more likely to seek treatment at stand-alone clinics.

“Free-standing centers may offer women an increased sense of anonymity, as opposed to having to go in and out of the hospital, where there’s a bigger risk they’ll be seen,” Johnson said. “There is still, particularly for women, a major stigma attached to substance abuse treatment.”

New directions

While the researchers continue to mine data from the most recent wave of interviews, they are starting to gear up for two more waves of research with an additional $7.3 million in grants from NIH. The new studies are projected to take five years and will piggyback on the researchers’ deep reservoir of data and experience.

In one study, researchers will examine a national sample of therapeutic communities to see how structure and organizational effectiveness influence performance. Therapeutic communities essentially are long-term residential programs for people addicted to opiates. Treatment is based on the notion that many opiate addicts need habilitation, not rehabilitation, Roman said.

“They have not learned the correct rules of functioning in society,” he said. “The therapeutic community starts them like kindergartners and trains them in how to live, and in many cases, patients live in a therapeutic community for 18 months or more.

“One of the things we’ll look at is the same one-size-fits-all notion we found in private treatment centers. Nobody has looked at the variation you find across therapeutic communities,” he said.

Like their previous research, this study also will focus on overall health of therapeutic communities.

In the other new study, the UGA team will compare rates of incorporating new substance abuse treatments among three kinds of drug rehab centers: private centers, public centers and centers that participate in the NIH Clinical Trials Network for Drug Abuse Treatment.

The goal is to determine whether exposure to new treatments through intense, clinical-trial participation affects treatment offerings, treatment quality and quantity, and the overall institutional stability. The sociologists also will look for differences in practices and attitudes toward new innovations among the three groups as well as how administrators learn about the latest innovations.

“The idea is to compare the adoption and implementation of innovations within the NIH network — which has been specifically created for that purpose — to national samples of public and private centers,” Johnson said.

The study will involve 900 substance abuse treatment centers: 400 private centers from their current research, 400 public treatment centers the team is now recruiting and 100 centers affiliated with the NIH clinical trials network.

While the researchers won’t have definitive answers for five years, they predict that centers exposed to the latest, science-based treatments during clinical trials will be much more likely to adopt new treatments and will be more stable.

Their findings can’t come too soon for rehab centers or for the one million Americans who seek alcohol treatment each year.

For more information, email Paul Roman at proman@uga.edu or J. Aaron Johnson at ajohns@uga.edu or access www.niaaa.nih.gov.


THE UNIVERSITY OF GEORGIA RESEARCH MAGAZINE : www.researchmagazine.uga.edu