Alcohol and drug treatment among HMO patients

December 13, 2000

Until approximately a decade ago, alcohol and drug treatment programs in the United States were separate. Each type of program had its own patients, policies and methods of treatment. Yet many individuals who were dependent on alcohol also used, and were often dependent on, other drugs. This might explain why numerous alcohol and drug treatment programs were merged in the early 1990s. The effectiveness of these combined treatment programs, however, remains unclear. A study in the December issue of Alcoholism: Clinical & Experimental Research is one of the first to attempt to understand how the needs and problems of alcohol and drug patients may differ even though they are now usually treated in the same program.

Researchers interviewed more than 700 people seeking treatment in a program operated by their health maintenance organization (HMO). Clients were divided into two samples: those who were dependent only on alcohol (491 or 69%) and those who were dependent on both alcohol and other drugs (217 or 31%). The objectives were to identify both treatment needs as well as risk factors for developing substance abuse-related problems among the two types of clients.

"The two groups of clients in this HMO treatment population can be distinguished by demographic characteristics," explained Tammy Tam, a scientist with the Alcohol Research Group and lead author of the study. "Those with combined alcohol-and-drug dependence were more likely to be younger, male, less educated, and African American."

Conversely, said Keith Humphreys, assistant professor of psychiatry at Stanford University School of Medicine, those who had problems with alcohol only "were much more likely to be older, to be women, to be Caucasian, and to be college educated than were those individuals who had problems with both alcohol and drugs."

"In terms of substance use and initiation of use," said Tam, "those with a combined dependence were more likely to initiate use of a substance at an earlier age, start with multiple substance use, and initiate heavy drinking before the age of 18. They also tended to have more severe psychiatric and family/social problems and fewer social resources. A major finding of this study," she added, "is that many of the differences between the two groups of clients were related to the younger age of the combined dependence group. It suggests that there may be generational differences in treatment needs for different age cohorts that the merged alcohol-and-drug treatment programs fail to address." It also suggests that, as this generation ages, treatment programs will have an increasing number of clients with multiple alcohol and drug dependencies.

Further commenting on the study, Humphreys noted that its findings also speak to the cliché of who a drug user may be. "This study shows that, contrary to the stereotype of who the typical middle-class substance abuser is," he said," say maybe a middle manager who drinks himself to sleep each night, there is a lot of serious, illegal drug use among middle-class people who have HMO coverage. In other words, it is not just poor people who get into serious trouble with substances like cocaine and heroin. Even among 'nice' middle-class people who have HMO coverage, just like the average American, many people with alcohol problems are using 'hard' drugs like cocaine and heroin, and these people have different needs for treatment than do people who are 'just' alcoholics."

Tam pointed out that most of the research on treatment populations has been conducted on "public populations" (those without private insurance), and populations where substances other than alcohol were the focus. "This is a managed care population," she said, "most of whom are insured through their own or a family member's employer. It gives us the opportunity to see how, even in such a population, treatment needs, and the development of problems, can differ among those there to be treated. However, the homogeneity of the population and the managed care setting of the study - while it moves the field forward in studying new populations - does mean that the results cannot necessarily be generalized to different kinds of treatment populations." Tam said that several future studies will address this 'lack of generalization' by examining different populations: problem drinkers who have entered treatment programs in both the public and private sectors; those who are dependent on drugs only; and a treatment population aged 13 to 18 years (to address the generational aspects brought up in this study).

"Another important finding," said Humphreys, "is that race really seems to shape the substances that people use. We have known for a long time that when Caucasians get into trouble with substances, it is usually alcohol, and when African-Americans get into trouble with substances, it is usually drugs. This pattern is usually attributed to social class differences, meaning that because African-Americans have higher rates of poverty, it is assumed that it is the poverty that drives the difference between Caucasians' and African-Americans' substance use problems. This study shows that this explanation is probably not true, because almost everyone in the sample was a middle-class person. Even within the middle class, we can see that Caucasian substance abusers tend to get in trouble with alcohol, and African-American substance abusers tend to get into trouble with drugs. So, a substance abusers' race seems to change their 'substance of choice' beyond what can be explained by social class."

"Yet another important finding," added Humphreys, "is that men are more likely than women to have problems with both alcohol and drugs. This may explain why women, on average, have better treatment outcomes, because they are often only struggling with one kind of substance instead of multiple kinds."

"If I had a family member who needed treatment," concluded Tam, "I would want to be sure that the program had an individualized assessment and could provide for their differential needs. Some programs by their very nature emphasize alcohol, some don't address alcohol as much as other drugs, and some do address both. If I were a clinician, I would remember that, although there are many commonalities among those with alcohol and drug disorders, even in a primarily middle class population in outpatient treatment, there are large differences in treatment needs. Finally, if I were doing prevention work, or was a teacher or someone else working with adolescents, I would pay attention to the kinds of substance use, including tobacco, that I observed."

"One final point," said Humphreys, "is that I hope people who operate HMOs read this study because it will give them some important guidance on what services should be covered when they design their benefit packages."
Co-authors of the Alcoholism: Clinical & Experimental Research paper included: Constance Weisner of the Department of Psychiatry at the University of California-San Francisco, and the Division of Research at Kaiser Permanente Medical Care Program; and Jennifer Mertens of the Division of Research at Kaiser Permanente Medical Care Program. The study was funded by the National Institute on Alcohol Abuse and Alcoholism.

Alcoholism: Clinical & Experimental Research

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