INSURERS

Ensuring Access to Treatment: A Guide for Private Insurers

Substance use disorders affect people of all ages, all income levels, and all walks of life. Substance use disorders encompass both dependence on and abuse of alcohol and illicit drugs. Dependence on and abuse of alcohol and illicit drugs, which include nonmedical use of prescription-type drugs, are defined using the American Psychiatric Association's criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Dependence reflects a more severe substance problem than abuse; individuals are classified with abuse of a particular substance only if they are not dependent on that substance.¹

It is estimated that 21.6 million Americans in 2003 were classified with substance dependence or abuse (9.1 percent of the total population aged 12 or older).² In addition, substance use disorders can have a negative effect on the children of people who have these disorders.³ Yet as many as 20.3 million people with substance use disorders who needed treatment in 2003 did not receive it. Approximately 33 percent of people who needed but did not receive treatment and felt they needed treatment cited cost or insurance problems as barriers.⁴

With the overwhelming number of Americans living with substance use disorders relying on health insurance to help pay for the cost of treatment, the nation's private insurers face significant challenges in providing adequate coverage.⁵ In 2002, the average cost of treatment of substance use disorders in an outpatient setting was estimated at $1,433 per course of treatment; more aggressive in-patient treatment options and methadone (medication-assisted treatment) services can cost nearly $8,000 per admission.⁶ Clearly, the cost of treatment is significant; however, the cost of not treating these disorders is even higher.

Central to the challenges private insurers face when deciding which treatment options to cover are concerns about whether employers will want to invest their money in treatment plans that may not be used, as well as concerns about the cost-effectiveness of those treatments. Unfortunately, studies show that the stigma related to alcohol and drug use often prevents people from actively seeking out and using the treatment services available to them. A national poll commissioned by Faces & Voices of Recovery recently found that nearly 20 percent of people in recovery and their family members cited fear of being fired or facing discrimination at work as barriers to accessing treatment services.⁷

Additionally, in an economy where employers look to cut costs, providing additional covered services may not appear cost effective for private insurers. In the long term, however, the opposite is often true.^{8, 9} In some cases, integrating addiction treatment with medical treatment can cut the cost of medical treatment in half.¹⁰

Also, recent data now reveal that providing private insurance coverage for treatment services is not only effective in helping people return to work, it also reduces health care costs overall. This is clearly a benefit for employers, who are likely to invest in treatments that save money while strengthening their workforce, as well as a benefit for private insurers.^{11, 12}

• In a program implemented by Chevron Texaco, three-fourths of employees who entered treatment for alcohol problems were able to stay employed. In comparison, the national turnover rate for employees with untreated alcohol use disorders is 40 percent. Chevron Texaco's cost-effective approach allowed the company to treat its employees while avoiding costs related to terminating and re-training new hires-costs that would amount to much more than the cost of alcohol treatment.^{13, 14}



• Another landmark study spanning 14 years at a Midwest manufacturing plant revealed that workers and their families had lower health care costs when they were offered treatment for alcohol use disorders. After 6 months, alcoholism treatment had begun to reduce health care costs by as much as 55 percent. Even 3 years later, the employer continued to see a substantial return on its investment: the health care costs of people who received treatment were 24 percent lower than those of problem drinkers who were not treated.^{15, 16}

For these reasons, U.S. employers are beginning to understand the importance of offering comprehensive treatment coverage to their employees. Some are favoring private insurers who can provide such options. In turn, some private insurers are actively seeking ways to meet the needs of employers and employees through innovative alcohol and drug treatment services.¹⁷ For example, Mohawk Valley Physicians' Health Plan Inc. (MVP Healthcare), one of the largest health insurance companies in Vermont, recently became the first in that state to cover methadone treatment.¹⁸ Citing the need to treat heroin addiction as well as to erode the stigma often attached to it, state officials lauded MVP Healthcare and expressed hope that other private insurers would follow suit.

The following information may help you, as a private insurer, understand the need for com­prehensive coverage and develop avenues for extending access to treatment services.

Types of Treatment

Without adequate insurance coverage, people with substance use disorders may be able to access some treatment services, but not necessarily the specific programs they need to fully recover. Recovery is a personal process, and each person's treatment plan should be based on his or her individual needs.^{19, 20, 21} According to a Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Improvement Protocol titled Integrating Substance Abuse Treatment and Vocational Services: A Treatment Improvement Protocol TIP 38, treatment providers must attempt to match a client's individual needs to an appropriate level of care, and intervention strategies should incorporate treatment along with vocational counseling and employment services.²² This SAMHSA publication is available online at http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.68228 and hard copies can be ordered free of charge from SAMHSA's National Clearinghouse for Alcohol and Drug Information (NCADI) at 1-800-729-6686.

Treatment is offered in different settings, and types of treatment greatly depend on the type of substance misused, as well as the person's needs and characteristics. Treatment is often offered in residential and day care programs, as well as outpatient settings. Some people require medical detoxification (detox), a process administered under the care of a physician that helps manage physical withdrawal symptoms. Treatment also includes counseling or other behavioral therapy, medication, or a combination of both.²³ Counselors and therapists have found that brief interventions can be used as a method of providing more immediate attention to clients waiting for specialized programs.²⁴

A new focus has been placed on the use of medications such as buprenorphine and methadone as a component of treatment for addiction to opiates. SAMHSA recently published the first practical guide for physicians who want to use the medication buprenorphine to treat patients who are addicted to opiate pain medications or heroin.²⁵ The guide, titled Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction: A Treatment Improvement Protocol TIP 40, is available online at www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.72248, and hard copies can be obtained free of charge from NCADI at 1-800-729-6686. SAMHSA also is engaged with treatment experts, state and other Federal officials, and patient representatives to develop guidelines and other educational materials on the use of medications such as methadone in the treatment of addictions.²⁶

Different populations often have very distinct methods of treatment that work best for them. Family-based treat­ments are currently recognized as among the most effective approaches for adolescent drug abuse.²⁷ Involving the entire family reduces the trauma families experience when faced with multiple systems, policies, and competing timelines. Older adults with substance use disorders have been shown to respond well to age-specific, supportive, and non-confrontational group treatment that aims to build or rebuild self-esteem. Older adults also work best with staff members who are interested and experienced in working with older adults.²⁸

Based on findings such as these, experts agree that treatment for substance use disorders should be personalized to each patient and based on standards of care that significantly increase the likelihood of success.²⁹ The American Society of Addiction Medicine (ASAM) has developed a set of standards, the Patient Placement Criteria for Treatment of Substance-Related Disorders, which assists providers in selecting the appropriate level of service for both adolescents and adults.³⁰

Access to Treatment

Just as personalized treatment can improve the chances of success, a person's private insurance coverage (or lack thereof) can determine how-or even if-he or she will be treated. While health plans normally cover some treatment services, they may not cover a full range.

When private insurers cover treatment for substance use disorders, they do not always cover it the same way they do other medical conditions, despite the benefits of doing so.³¹ Many private health plans charge higher co-payments for alcohol treatment than they do for the treatment of other illnesses. One-fourth set maximum dollar amounts that they will pay for alcohol treatment, and a small number of private health plans cover only one or two episodes of treatment.³²

All of these coverage limitations can become barriers, affecting peoples' ability to access the specific treatment programs they need to achieve recovery.³³ As an alternative, brief interven­tions and therapies are less costly, yet have proven effective in substance abuse treatment; however, barriers also apply. While SAMHSA recognizes that “brief therapy is a valuable approach, it should not be considered a standard of care for all populations.”³⁴

Support Services

In addition to the professional treatment programs available to those seeking recovery from substance use disorders, other resources exist to augment these services. For example, the Recovery Community Services Program (RCSP) is a grant program of SAMHSA. In RCSP grant projects, peer-to-peer recovery support services are provided to help people initiate and/or sustain recovery from substance use disorders. Some RCSP grant projects also offer support to family members of people needing, seeking, or in recovery. Peer support services are not treatment or post-treatment services provided by professionals, but rather support services from people who share the experiences of addiction and recovery. Peer-to-peer services help prevent relapse and promote long-term recovery, thereby reducing strain on the overburdened treatment system.³⁵

The Importance of Health Care Coverage

Research has repeatedly shown that the societal benefits of investing in alcohol and drug use treatment are substantial. This includes improved societal functioning for individuals and families, reduced health care costs, and significant decreases in crime.^{36, 37} Therefore, it makes sense for health plans to cover a full range of adequate and comprehensive treatment:

• For every $1 invested in treatment, there is a return of between $4 and $7 in reduced drug-related crime, criminal justice costs, and theft. When savings related to health care are included, total savings exceed costs by a ratio of 12 to 1.³⁸



• However, private health plan spending on treatment is relatively limited. The total cost to society of substance use disorders is nearly 25 times what the United States spends on treatment.³⁹

To minimize financial risks to the private insurance industry, health plans can structure coverage to offer reimbursement for the types of treatment that have been proven most effective. This method is beginning to take hold, and national experts are recommending that private insurers take steps to shift to a coverage system that recognizes, rewards, and drives improved treatment outcomes.⁴⁰

In fact, the Ensuring Solutions to Alcohol Problems initiative at The George Washington University Medical Center has released a new report that highlights a performance measurement tool called the Health Plan Employer Data and Information Set (HEDIS). In 2004, the nation's leading health accredita­tion group asked health care providers to use tools such as HEDIS to measure and report their success in engaging people with alcohol and other drug problems in treatment.⁴¹

Ongoing research is continuing to reveal new information about the most effective types of treatment, so it is important for private insurers to stay informed about the latest developments in the treatment field. Resources for learning about these developments are provided at the end of this document.

Making a Difference: What Can I Do?

• Get the Facts. Work collaboratively with employers, treatment service providers, people in recovery, and the scientific community to learn about substance use disorders. Talk to these different groups and find out the needs of people in recovery, as well as the needs of providers. Stay current on the science of treatment and what treatments work best. For example, take advantage of the National Institute on Drug Abuse's Brain, Behavior, Health Initiative: Multidisciplinary Exploration of the Brain. This effort harnesses the recent data made available by scientific advances during the past decade to develop effective treatment strategies.



• Take Action. Adjust private insurance policies based on key learnings from your information-gathering efforts. Use the latest science to make informed decisions about how best to allocate resources and make private insurance plan offerings cost effective.

Making a Difference: How Can I Contribute to Recovery Month?

Each September, National Alcohol and Drug Addiction Recovery Month (Recovery Month) is celebrated by hundreds of organizations across the country to highlight the importance of treatment for substance use disorders. The theme for this year's Recovery Month is “Join the Voices for Recovery: Healing Lives, Families, and Communities.” As a member of the private insurance industry, your company can make a difference by taking part in outreach efforts to promote and observe Recovery Month.

• Collaborate with treatment programs and other organizations in your community that are participating in Recovery Month. Assist in their efforts by donating time or funds (if donations are accepted) or other resources to help make their events a success. Actively participating with these groups during Recovery Month can promote the private insurance industry's reputation in the community by showing it is committed to helping people in recovery.



• Consider funding (or partially funding) a study to document the cost effectiveness of local treatment programs.



• Hold an educational workshop for purchasers/employers to demonstrate the value of providing a full range of treatment services to their employees, while still protecting their employees' privacy and confidentiality.

For additional Recovery Month materials, visit our Web site at www.recoverymonth.gov or call 1-800-662-HELP.

Insurer Resources

Federal Agencies

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS)
This government agency provides information and resources on alcohol and drug use disorders and health insurance/Medicaid issues.
200 Independence Avenue SW
Washington, D.C. 20201
877-696-6775 (Toll-Free)
www.hhs.gov

HHS
National Institutes of Health (NIH)
The National Institutes of Health is the steward of medical and behavioral research for the nation. It is an agency under the U.S. Department of Health and Human Services.
9000 Rockville Pike
Bethesda, MD 20892
301-496-4000
www.nih.gov

HHS, NIH National Institute on Alcohol Abuse and Alcoholism (NIAAA)
This institute provides leadership in the national effort to reduce alcohol-related problems by conducting and supporting research in a wide range of scientific areas.
5635 Fishers Lane, MSC 9304
Bethesda, MD 20892-9304
301-443-3885
www.niaaa.nih.gov

HHS, NIH
National Institute on Drug Abuse (NIDA)
This government institute supports more than 85 percent of the world's research on the health aspects of drug abuse and addiction and carries out a broad range of programs to ensure rapid dissemi­nation of research information and its implementa­tion in policy and practice.
6001 Executive Boulevard Room 5213 MSC 9561
Bethesda, MD 20892-9561
301-443-1124
Telefax fact sheets: 888-NIH-NIDA (Voice) (Toll-Free)
Or 888-TTY-NIDA (TTY) (Toll-Free)
www.nida.nih.gov

HHS, Substance Abuse and Mental Health Services Administration (SAMHSA)
This Federal agency improves the quality and avail­ability of prevention, treatment, and rehabilitative services in order to reduce illness, death, disability, and cost to society resulting from alcohol and drug use disorders and mental illnesses.
1 Choke Cherry Road, 8th Floor
Rockville, MD 20857
240-276-2130
www.samhsa.gov

HHS, SAMHSA
Center for Substance Abuse Treatment (CSAT)
This government organization provides information on treatment programs, publications, funding opportunities, and resources and sponsors Recovery Month.
1 Choke Cherry Road, 5th Floor
Rockville, MD 20857 240-276-2750
www.samhsa.gov/centers/csat/csat.html

HHS, SAMHSA
National Helpline
This national hotline offers confidential information on alcohol and drug use disorder treatment and referral.
800-662-HELP (800-662-4357) (Toll-Free)
800-487-4889 (TDD) (Toll-Free)
877-767-8432 (Spanish) (Toll-Free)
www.samhsa.gov

HHS, SAMHSA National Mental Health Information Center
This center supplies publications and information about mental health.
P.O. Box 42557
Washington, D.C. 20015
800-789-2647 (Toll-Free)
www.mentalhealth.samhsa.gov

HHS, Center for Medicare and Medicaid Services (CMS)
This Federal Agency provides health insurance for over 74 million Americans through Medicare, Medicaid, The Health Insurance Portability and Accountability Act (HIPAA) and several other health-related programs.
7500 Security Boulevard
Baltimore, MD 21244
877-267-2323 (Toll-Free)
410-786-3000
www.cms.hhs.gov

Alcohol and Drug Services

The Ensuring Solutions to Alcohol Problems Initiative
George Washington University
This program is designed to increase access to treatment for individuals with alcohol problems by collaborating with policymakers, employers, and concerned citizens.
2021 K Street NW, Suite 800
Washington, D.C. 20006
202-296-6922
www.ensuringsolutions.org

Hazelden Foundation
This non-profit, private treatment organi­zation offers publications and programs for individuals, families, professionals, and communities to prevent and treat alcohol and drug use disorders.
P.O. Box 11
Center City, MN 55012
800-257-7810 (Toll-Free)
www.hazelden.com

Public Policy and Research

Johnson Institute
This national organization works to identify and eliminate barriers to recovery, while promoting the power and possibility of recovery by enhancing awareness, prevention, intervention, and treatment practices for alcohol and drug use disorders.
D.C. Office:
613 Second Street NE
Washington, D.C. 20002
202-662-7104
MN Office: 10001 Wayzata Boulevard
Minnetonka, MN 55305
952-582-2713
www.johnsoninstitute.org

Join Together
This national resource for communities working to reduce alcohol and drug use disorders offers a comprehensive Web site, daily news updates, publications, and technical assistance.
One Appleton Street, Fourth Floor
Boston, MA 02116-5223
617-437-1500
www.jointogether.org

Specialty Treatment Providers

American Association of Health Plans
This is a health plan association representing more than 1,000 health plans throughout the country. It provides information on managed care organization educational programs, health care delivery, research, services, and products.
129 Twentieth Street NW
Washington, D.C. 20036-3421
202-778-3239
www.ahip.org

Employee Health Programs
This group, a subsidiary of First Advantage Corporation, designs and manages drug-free workplace programs, Employee Assistance Programs, and other services that benefit employers and employees.
P.O. Box 2430
Bethesda, MD 20817
800-257-7051(Toll-Free)
www.ehp.com

Kaiser Family Foundation
This organization is a non-profit, private operating foundation focusing on the major healthcare issues facing the nation. The Foundation is an independent voice and source of facts and analysis for policymakers, the media, the health care community, and the general public.
2400 Sand Hill Road
Menlo Park, CA 94025
650-854-9400
www.kff.org

National Association of State Medicaid Directors (NASMD)
This is a bipartisan, professional, non-profit organization of representatives of state Medicaid agencies, affiliated with the American Public Human Services Association (APHSA). The primary purposes of NASMD are: to serve as a focal point of communication between the states and the federal government, and to provide an information network among the states on issues pertinent to the Medicaid program.
810 First Street NE Suite 500
Washington, D.C. 20002
202-682-0100
www.nasmd.org/

This list is not exhaustive of all available resources. Inclusion does not constitute endorsement by the U.S. Department of Health and Human Services, the Substance Abuse and Mental Health Services Administration, or its Center for Substance Abuse Treatment.

Sources

1 Results from the 2003 National Survey on Drug Use and Health: National Findings. DHHS Publication No. (SMA) 04-3964. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, September 2004, p. 57.

2 ibid, p. 4.

3 West, M.O., Printz, R.J. Parental alcoholism and childhood psychopathology. Psychological Bulletin, 102, 1987, pp. 204-218.

4 Results from the 2003 National Survey on Drug Use and Health: National Findings, p. 5.

5 Current Population Reports: Health Insurance Coverage: 2000. U.S. Census, September 2001, pp. 60-215.

6 The DASIS Report: Alcohol and Drug Services Study (ADSS) Cost Study. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, June 18, 2004, p.1.

7 Faces & Voices of Recovery Web site: http://facesandvoicesofrecovery.org/pdf/hart_research.pdf, section entitled “The Face of Recovery,” p. 10. Accessed September 22, 2004.

8 Goplerud, E., Cimons, M., et al. Workplace Solutions: Treating Alcohol Problems Through Employment-Based Health Insurance. Ensuring Solutions Research Report. Washington, D.C.: The George Washington University Medical Center, Ensuring Solutions to Alcohol Problems, December 2002, p. 7.

9 Strunk, B.C., Reschovsky, J.D., et. al. Trends in U.S. Health Insurance Coverage, 2001-2003. Washington, D.C.: Center for Studying Health System Change, Tracking Report, August 2004, p. 1.

10 “NIDA NewsScan for July 30, 2003,” U.S. Department of Health and Human Services, National Institutes of Health, National Institute on Drug Abuse Web site: www.drugabuse.gov/newsroom/03/NS-07-30.html, section entitled “Individuals With Medical Conditions Related to Alcohol or Drug Abuse Benefit From Integrating Medical and Substance Abuse Treatment.” Accessed September 23, 2004.

11 Rewarding Results: Improving the Quality of Treatment for People with Alcohol and Drug Problems. Recommendations from a National Policy Panel. Boston, MA: Join Together, a project of the Boston University School of Public Health, 2003, p. 7.

12 Chalk, Mary Beth. Telephone Substance Abuse Treatment: The Next Generation of Care. Employee Benefit Plan Review (58) 2, August 2003, p. 19.

13 National Household Survey on Drug Abuse, 2001. DHHS Publication No. (SMA) 02-3758. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, September 2002, Ensuring Solutions to Alcohol Problems' analysis of data.

14 Cummings, C.R., testimony on workplace substance abuse prevention programs before the Subcommittee on National Security, International Affairs and Criminal Justice of the U.S. House of Representatives, 1996. (Cummings manages labor relations and employment compliance at ChevronTexaco, formerly known as Chevron Corporation.)

15 Holder, H.D., Blose, J.O. The reduction of healthcare costs associated with alcoholism treatment: A 14-year longitudinal study. Journal of Studies on Alcohol 1992, 53(4), pp. 293-302.

16 Holder, H.D., Lennox, R.D., Blose, J.O. The economic benefits of alcoholism treatment: A summary of twenty years of research. Journal of Employee Assistance Research, 1992, 1(1), pp. 63-82.

17 Rewarding Results: Improving the Quality of Treatment for People with Alcohol and Drug Problems, p. 5.

18 Join Together Online Web site, May 10, 2004, section entitled “Vermont Insurer to Pay for Methadone Treatment,” p.1. Accessed September 23, 2004.

19 Mark, T.C. Mental Health and Substance Abuse Treatment Expenditures, 1987-1997. Health Affairs 19(4), 2000, pp. 107-120.

20 The National Drug Control Strategy. 1999. ONDCP 1999b. Washington, D.C.: Office of National Drug Control Policy.

21 Treatment for Addiction: Advancing the Common Good. Boston, MA: Join Together Policy Panel, January 1998, pp. 3-7.

22 Integrating Substance Abuse Treatment and Vocational Services: A Treatment Improvement Protocol TIP 38. DHHS Publication No. (SMA) 00-3470. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, 2000, section entitled “Executive Summary and Recommendations.”

23 Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction: A Treatment Improvement Protocol TIP 40.DHHS Publication No. (SMA) 04-3939. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Treatment, 2004, pp. 51 and 58-59.

24 Treatment Improvement Protocol (TIP) Series 34: Brief Interventions and Brief Therapies for Substance Abuse. DHHS Publication No. (SMA) 99-3353. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 1999, p. 1 of Executive Summary.

25 Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction: A Treatment Improvement Protocol TIP 40, pp. 51 and 58-59.

26 “Patient Education.” Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, Division of Pharmacologic Therapies Web site: http://dpt.samhsa.gov/, para. 1. Accessed October 1, 2004.

27 Rowe, C.L., Liddle, H.A. Substance Abuse. Journal of Marital and Family Therapy 29 (1), January 2003, pp. 97-120.

28 “Clinical Guidelines for Alcohol Use Disorders in Older Adults.” The American Geriatrics Society Web site, November 2003: www.americangeriatrics.org/products/positionpapers/alcoholPF.shtml, Position statement, section entitled “Features of pre­ferred treatment options for abuse/dependence among older adults.” Accessed October 1, 2004.

29 Ending Discrimination Against People with Alcohol and Drug Problems. Recommendations from a National Policy Panel. Boston, MA: Join Together, a project of the Boston University School of Public Health, 2003, p. 7.

30 American Society of Addiction Medicine Web site: www.asam.org/ppc/ppc2.htm, section entitled “Patient Placement Criteria, Second Edition Revised,” para. 4. Accessed July 29, 2004.

31 Treatment for Addiction: Advancing the Common Good, p. 3.

32 Goplerud, E., Cimons, M., et al. Workplace Solutions: Treating Alcohol Problems Through Employment-Based Health Insurance. Ensuring Solutions Research Report. Washington, D.C.: The George Washington University Medical Center, Ensuring Solutions to Alcohol Problems, December 2002, p. 5.

33 Results from the 2003 National Survey on Drug Use and Health: National Findings, p. 5.

34 Treatment Improvement Protocol (TIP) Series 34: Brief Interventions and Brief Therapies for Substance Abuse, p. 5 of Executive Summary.

35 U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, Recovery Community Services Program Web site: http://rcsp.samhsa.gov, sections entitled “The Recovery Community Services Program,” “About the RCSP Program,” and “Peer Services: Peers Helping Peers.” Accessed November 16, 2004.

36 Holder, H.D., Blose, J.O. The reduction of healthcare costs associated with alcoholism treatment: A 14-year longitudinal study, pp. 293-302.

37 Holder, H.D., Lennox, R.D., Blose, J.O. The economic benefits of alcoholism treatment: A summary of twenty years of research, pp. 63-82.

38 Principles of Drug Addiction Treatment: A Research Based Guide. NIH Publication No. 99-4180. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Institute on Drug Abuse, printed October 1999/Reprinted July 2000, p. 21.

39 Coffey, R.M., et al. National Estimates of Expenditures for Substance Abuse Treatment, 1997. DHHS Publication No. (SMA) 01-3511. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, Medstat Group, February 2001, section entitled “Key Findings,” para. 1.

40 Rewarding Results: Improving the Quality of Treatment for People with Alcohol and Drug Problems, p. 5.

41 The State of Health Care Quality: Industry Trends and Analysis 2004. Washington, D.C.: National Committee for Quality Assurance, 2004.

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