Addiction treatment, like many other aspects of health care, does not entail a standard, paint-by-number approach. There exists a wide spectrum of treatment options. On one end lies the medical approach, such as cognitive-behavioral treatment. On the opposite end are "faith-based" initiatives such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). A study in the May issue of Alcoholism: Clinical & Experimental Research evaluates the post-discharge health-care utilization and associated costs of these two very different types of approaches.
Inpatient treatment costs and clinical outcomes are approximately the same notwithstanding which of the two approaches is chosen, said Keith Humphreys, assistant professor of psychiatry at Stanford University School of Medicine, and the study’s lead author. "We found that the staffing levels, three-to-four week lengths of stay, and costs were fairly similar regardless of the specific nature of the two types of treatment we examined," he said. Clinical outcomes - defined as whether or not the patients stopped using drugs and alcohol, stopped having addiction-related problems such as conflicts at work and/or with their families, and/or enjoyed good mental health (such as the absence of depression, worries, nervousness, emotional upset) - were likewise comparable.
The focus of Humphreys’ study, however, was on the care provided in the year after discharge from inpatient treatment, when costs are very different. "Patients with serious drug and alcohol problems who are treated in programs based on the approaches of spiritually oriented self-help organizations like AA," he said, "are more likely to abstain from drugs and alcohol after treatment, and also have much lower health-care costs than do patients treated in programs that do not emphasis AA-style principles." The study showed that the faith-based approach lowers post-treatment costs by about two-thirds, or about $5000 per year per patient.
Alcoholics Anonymous, founded in 1935 by Bill W. (AA members use first names only), requires its members to follow 12 steps of behavior that are based on 12 spiritual principles. Twelve-step oriented treatment programs strongly encourage patients to attend self-help groups after treatment is completed. As a result, these individuals tend to rely on their AA and NA groups for support, and much less on professional counseling services, after they leave the hospital. Cognitive-behavioral treatment, on the other hand, uses more professional and scientific activities such as cognitive skills training and cognitive-behavioral psychotherapy to teach people how to contend with situations that may tempt them to drink, cope with negative moods that may lead to drinking, etc. Once treatment is completed, these patients tend to rely more on professional services for support.
"There has always been debate about AA," noted Lee Ann Kaskutas, a research scientist with the Alcohol Research Group at Berkeley. "Medical people have been suspicious more often than not, because they feel AA is unproven, and also because AA has a ‘god component’ that doesn’t make it seem very scientific. Members of AA, people who have become sober there, are at the other end of the spectrum. They are total believers, and they can be heard saying ‘there is no easier, softer way’ than AA."
Yet despite skepticism by the medical establishment, said Kaskutas, studies such as this one show that treatment methods that emphasize AA methods do not result in high rates of hospitalization or psychiatric visits after treatment. In fact, she said, another of the study’s key findings is that patients in programs with a 12-step orientation had a higher rate of abstinence, in addition to much lower health-care costs, following treatment completion.
"You might not think it would have that effect," she said, "because of the non-medical and non-psychiatric flavor of 12-step methods. Dr. Humphreys suggests one thing that may contribute to this effect: during treatment, people make connections with each other, and get advice from one another. So later, if they feel sick or worried, and talk to someone they met in treatment about this, they will likely send that person back to the same type of program where they met. When people who were in cognitive treatment need help, they immediately think of going to the doctor. People [who were] in 12-step treatment immediately think of going to a meeting. Whether or not he is right about [the effects of fellowship] is an area for future research. His study has set up a lot of important questions to pursue next."
"We as a society are fortunate to have a developed system of self-help organizations that do not cost the taxpayer or the health-care system a dime," said Humphreys. "Organizations like AA not only reduce human misery, they also take a big burden off of our increasingly resource-strapped health-care system. Hence, it is important for health care professionals to learn about these organizations and develop connections with them."