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INTENSIVE OUTPATIENT TREATMENT
FOR ALCOHOL AND DRUG ADDICTION:
A THREE-YEAR OUTCOME STUDY
Research site and grantee:
Gateway Rehabilitation Center,
Moffett Run Road, Aliquippa, PA 15001
Research conducted by:
Edward W. Gondolf, EdD, MPH
Mid-Atlantic Addiction Training Institute
Indiana University of Pennsylvania
1098 Oakland Ave., Indiana, PA 15705
PH: 724-357-4749; FX: 724-357-3944
E-mail:
Website:
Report submitted to:
The RICHARD KING MELLON Foundation
One Mellon Bank Center
500 Grant St., Suite 4106
Pittsburgh, PA 15217-2502
August 7, 2000
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INTENSIVE OUTPATIENT TREATMENT FOR ALCOHOL AND DRUG ADDICTION:
A THREE-YEAR OUTCOME STUDY
EXECUTIVE SUMMARY
INTRODUCTION
Treatment for alcohol and other drug addiction was significantly altered by the onset of “managed care” in the late 1980s. The standard for treatment had been a 28-day inpatient program. “Managed care” imposed limits on insurance reimbursements to contain and reduce costs. In response, treatment providers have developed alternative, less expensive methods for needed treatment, in particular “intensive outpatient treatment.” In intensive outpatient treatment, patients continue to live at home and attend counseling and educational sessions for three to five hours a day for approximately two weeks. The question for most treatment providers is: How effective is this short-term, non-residential treatment? A three-year follow-up study of the intensive outpatients at Gateway Rehabilitation Center, based in Aliquippa, Pennsylvania, was conducted to answer this question.
RESEARCH DESIGN
The intensive outpatient study is based on 215 adult patients from Gateway’s two largest outpatient treatment sites. The sample of 144 men and 71 women was recruited between July and December 1996. The characteristics of the sample were similar to those of current and previous Gateway patients.
Research assistants interviewed the outpatients by phone at six-month intervals over a three-year period. They were able to obtain information covering the entire follow-up period for 66% of the sample and contacted over 90% of the outpatients sometime during the three-year follow-up period. In order to verify the subjects’ reports, the research assistants contacted a friend or relative for 50 percent of the contacted subjects.
RESULTS
The intensive outpatient study shows substantial reduction in alcohol and other drug use:
- Three-quarters of the outpatients were not using alcohol or drugs at the end of the three-year follow-up (abstinence for 2 weeks or more).
- Nearly half of the outpatients were abstinent for at least the previous year.
- The vast majority (76%) stopped using alcohol or drugs for at least a six-month period during the 3-year follow up.
- One in five (23%) remained continuously abstinent throughout the entire study period.
Nearly 60% of the outpatients who reused alcohol or drugs during the follow-up period did so during the first six months after treatment. Nearly 90 percent did so within the first year. These results suggest that the year after treatment is a critical time for patients. Patients appear to need more extensive support beyond the short-term intensive outpatient treatment. The characteristics and extent of treatment did not meaningfully predict the reuse patterns or abstinence, and the patients most likely to “fail.”
The intensive outpatients reported a dramatic improvement in their quality-of-life and general health. Four out of 5 outpatients (82%) indicated that their life overall had “improved” or “much improved” after treatment. The majority of patients were better physically, psychologically, and socially:
- The vast majority (80%) of the patients rated their physical health as “good” (31%) or “very good” (49%)-- a 30% increase over the ratings at program intake .
- The portion of patients reporting “serious depression” in the previous six-months was reduced by 75% (52% at intake vs. 12% at follow-up).
- Nearly all the outpatients (93% to 95%) showed improvement in terms of cravings and motivation—two psychological aspects essential for long-term recovery.
- Over three-quarters reported improvement in their relationships (82%), work or school (77%), and decision-making (84%) since treatment.
- Over half (55%) had greater incomes since treatment.
Comparison to OTHER STUDIES
The intensive outpatient study was compared to a previous inpatient study conducted at the same site in 1988. This comparison helps to assess the relative effectiveness of outpatient versus treatment:
- Three years following treatment, approximately three-fours of both the inpatients and outpatients reported that they were not currently using alcohol or other drugs.
- The inpatients were much more likely to remain continuously abstinent over the three-year follow-up period—42% of the inpatients versus only 24% of outpatients.
In sum, the inpatients appeared more successful at maintaining abstinence than those treated as outpatients. The extended abstinence translates into fewer work, family, health, and criminal problems. It also heightens the prospects for long-term recovery—that is, a major change in lifestyle and outlook. Some of the difference between the inpatient and outpatient abstinence may be attributed, however, to the greater drug use among the current outpatients.
The Gateway patients appear to be doing at least as well as those patients in more extensive, “public” treatment programs. The percentage of intensive outpatients who reused alcohol or drugs one year after treatment (63%) is comparable to the rate of reuse among patients in a recent national survey of federally-funded, urban treatment programs (57%).
Conclusion
According to the most recent outcome study at Gateway, intensive outpatient treatment helps the vast majority of patients interrupt their drinking and drug use and substantially improve their quality of life. This outcome is impressive given the chronic nature of addiction and its disease-like nature. It also is an accomplishment given the substantial decrease in resources for alcohol and drug treatment, and the short duration of intensive outpatient treatment under “managed care.” Intensive Outpatient Treatment does not, however, appear to be as effective as the previous inpatient treatment in promoting continuous abstinence and would likely be improved through some form of extended treatment. Further research is needed to document this possibility.
ACKNOWLEDGMENTS
This research was made possible through a grant from the Mellon Foundation of Pittsburgh to Gateway Rehabilitation Center based in Aliquippa, Pennsylvania. Additional funding from the Hartford Foundation, for a separate study of older patients, supported a portion of the follow-up. Gateway subcontracted the Mid-Atlantic Addiction Training Center (MAATI) at Indiana University of Pennsylvania to conduct the research. The research director at MAATI, Edward Gondolf, served as the principal investigator. The research would not have been possible without the support and assistance from the administration and program staff of Gateway. Ken Ramsey, President and CEO of Gateway, conceived and initiated the research. Sharon Eakes and Jim Aiello, Vice-Presidents of Treatment Services, helped to implement the research, along with the program directors at Gateway’s Greentree and Monroeville Branches, John Massella and Frank Salotti. May Kay Snyder of the Development Office managed the funding and reporting. Data entry, management, and analysis were conducted at the MAATI offices in Indiana, Pennsylvania, under the supervision of Crystal Deemer and Jewel Lee Doherty, Project Coordinators. Chad Kimmel and Eric Bieniek were the chief data managers and assisted with analysis. Gayle Moyer and Bob Gregory, research assistants at MAATI, administered the follow-up interviews. Robert Ackerman, the Founder and Director of MAATI, also provided administrative direction and advice. A copy of the report is available through the MAATI internet site: .
TABLE OF CONTENTS
Executive Summary—i
Acknowledgments—iii
INTRODUCTION—1
CHANGES IN TREATMENT—1
Previous Research—1
METHOD—3
DESIGN—3
RESEARCH SITE—3
SAMPLE—4
DATA COLLECTION—4
RESULTS—6
SAMPLE CHARACTERISTICS—6
REUSE OUTCOMES—8
QUALITY-OF-LIFE AND HEALTH—9
OTHER OUTCOMES—11
ADDITIONAL TREATMENT AND HELP—12
Change and Recommendations—13
PREDICTING REUSE—15
Comparison to other Studies—16
DISCUSSION—18
SUMMARY—18
Implications-19
Qualifications—21
CONCLUSION—21
REFERENCES—23
TABLES
APPENDIX
INTAKE QUESTIONNAIRE (with percentages)
SUBJECT FOLLOW-UP INTERVIEWS (with percentages)
POST-TREATMENT OUTREACH (proposal)
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INTRODUCTION
CHANGES IN TREATMENT
The addiction treatment field is in crisis. Over the past eight years, treatment providers have experienced the most rapid period of change in the history of the field. Programs have been quite literally under attack in the form of imposing cost containment efforts. Many providers have adapted by developing new forms of less-expensive outpatient treatment. There is debate, however, about the effectiveness of this innovation, and whether it is a suitable replacement to the previous emphasis on extended inpatient treatment.
The conventional treatment in the 1960s through the 1980s was the 28-day, residential or “inpatient” model. Patients were physically separated from the environmental influences that contributed to their addiction in order to concentrate on their recovery. Their days were filled with educational classes about addiction, discussion groups about individual and common issues, family meetings to develop positive support, and residential supervision to keep patients on track. In the midst of increasing health costs nationwide, employers and their health insurance companies began to question the high costs of this treatment approach and created “managed care” to contain and reduce costs (Creager, 1993). The insurance companies, through “managed care,” limited the reimbursement for addiction treatment.
In response, most treatment providers developed alternative treatment approaches based primarily on outpatient treatment (Havens, 1991). The most common alternative today is “intensive outpatient treatment” in which patients continue to live at home and attend counseling and educational sessions for 3 to 5 hours a day. Insurance companies generally support only one to two weeks of such treatment. This intensive outpatient treatment may be combined with a short inpatient treatment to detoxify a patient, and weekly outpatient support following the treatment.
Addiction treatment providers unfortunately lack empirical data to support or guide the structure, costs, and efficacy of their evolving treatment systems. More extensive and more sophisticated outcome research is clearly required from addiction treatment programs in order to meet the increased demands for accountability and to adapt to the changing market. Outcome research examining the effectiveness of intensive outpatient treatment is especially needed to answer these fundamental questions: How effective is outpatient treatment? Can it be considered “successful’? Is it as effective as the previous residential “inpatient” treatment? Who is most likely to benefit from such a program? How might the outpatient treatment be improved to become more effective?
In an effort to answer these questions, Gateway Rehabilitation Center, based in Aliquippa, Pennsylvania, acquired a grant from the Mellon Foundation of Pittsburgh. The grant helped to support an extensive follow-up study of intensive outpatient treatment at Gateway to assess the effectiveness of this approach. The main objective was to determine the treatment outcome in terms of drinking and drug use and associated physical, psychological, and social problems. What portion of the intensive outpatients reduce their alcohol and drug use and experience improvements in their quality-of-life. In the process, some of the related questions about “success” and program improvement were also addressed.
PREVIOUS RESEARCH
Most studies of treatment outcomes document a substantial reduction in alcohol and drug use after treatment and across treatment approaches and modalities. The “National Treatment Improvement Evaluation Study” considered a one-year follow-up of patients from 78 treatment programs across the country (National Opinion Research Center, 1996). Approximately, 50% of the patients reused regardless of the primary drug and the treatment approach. There were some variations related to program implementation and the patients’ characteristics. The programs in the study were, however, primarily located in urban areas and federally-funded. The effectiveness of intensive outpatient treatment at a private facility, like Gateway Rehabilitation Center, remains unclear. A different assessment of alcohol and drug use might also produce different results. Long-term, longitudinal follow-up may produce different patterns of use and, as a result, different findings.
Due to costs and tracking complications, many outcome evaluations collect data once at the end of a short-term follow-up. The outcome from this procedure can be very misleading, if patients transition slowly into change. It may take sometime for the treatment to have an effect, and results to appear. An extended follow-up of patients in a one-month intensive residential treatment program for alcoholism illustrates the need for longitudinal follow-up with periodic intervals over the long-term (Shaw et al., 1997). This study found a sharp decrease in alcohol use over time. Over two-thirds (71%) of the patients were using alcohol at six months after treatment, 54% at 12-months, and 47% at the extended follow-up (i.e., an average of nine years). Similarly, a four-year follow-up of men in counseling programs for assaulting their female partners found a de-escalation of reassaults over time. In the first year, over a third of the men had reassaulted their partners, but in the third year, slightly over 10% reassaulted (Gondolf, 2000).
The effectiveness of intensive outpatient treatment versus inpatient treatment remains under researched. It is a complicated and costly comparison to make in a controlled way (i.e., with matching samples of patients in the two options achieved through random assignment to treatment). The National Institute of Drug Abuse (NIDA) has conducted a “naturalistic” study (i.e., without random assignment) of different treatment approaches (Simpson, Joe, & Brown, 1997). Their national study drew on inpatients and outpatients from 100 treatment programs in 11 cities, who entered treatment in 1991 to 1993 with cocaine-dependency. At the one-year follow-up, the drug use had declined equally across the inpatient and outpatient treatments, but those in long-term inpatient or outpatient treatment (i.e., more than three months) had better outcomes than those in short-term treatment.
The question of who benefits the most from treatment has also been a difficult one to answer. A long-standing assumption in the addiction field has been that certain types of patients do better in certain types of treatment. The large scale “Project MATCH,” funded by the National Institute on Alcohol Abuse and Alcoholism, examined the effect of different treatment modalities on outcomes (Project MATCH Research Group, 1997). The one-year follow-up showed that “there was little difference in outcomes by type of treatment.” However, those with severe psychiatric problems did better after inpatient, as opposed to outpatient, treatment.
Additionally, efforts continue to predict patients who are the most likely to do well—or conversely most likely to do poorly. A review of this research concludes that few consistent “predictors” have been identified and predictive power is weak (Edwards et al., 1988). In other words, it is difficult to select the patients most likely to succeed or fail. These predictive efforts have relied primarily on intake information and may be improved with better measurement and post-treatment information. One consistent finding of late is that at least major depression is associated with relapse, and its effective treatment improves outcomes (Bobo, McIlvain, & Leed-Kelly, 1998; Hasin et al., 1996).
METHOD
DESIGN
To examine the effectiveness of intensive outpatient treatment, we conducted a three-year longitudinal follow-up study of outpatients from Gateway Rehabilitation Center (GRC). The sample consists of 214 outpatients enrolling in the two largest GRC treatment centers during a six-month period in 1996. Each outpatient was administered an extensive background questionnaire and a depression test at enrollment. Psychiatric diagnoses, treatment plan, and treatment compliance were obtained from clinical records. (See Table 1-1.) Research assistants telephoned the outpatient subjects every 6 months over the three-year follow-up period, and interviewed them about their living situation, additional treatment and intervention, alcohol and drug use, and overall quality-of-life. They also attempted to interview a spouse, friend, or relative of each subject (i.e., “collateral”) in order to verify the subject’s reports. The outcome was assessed with several indicators for alcohol and drug use and for the patient’s quality-of-life.
Four major analyses were conducted. One, the characteristics of the patients and the extent of their treatment were summarized to describe the sample of outpatients. Second, the treatment outcome was identified in terms of alcohol and drug use and aspects of the patient’s quality-of-life. These indicators are summarized cumulatively for the full follow-up period and longitudinally for each of the 6-month follow-up periods. The cumulative summaries offer a final “success-failure” outcome, and the longitudinal summaries provide a pattern or trajectory of change. Three, the relationship of patient characteristics to the outcome is examined. This analysis attempts to identify “risk” factors for alcohol or drug reuse, or types of patients who are more likely to reuse. Four, the major outcome indicators from the intensive outpatient study are compared with those from an inpatient study conducted at GRC in 1988 and a national study of treatment programs conducted in 1996. This comparison suggests the effectiveness of intensive outpatient treatment relative to inpatient treatment.
RESEARCH SITE
The research was conducted at Gateway Rehabilitation Center, a nationally recognized private treatment facility in Western Pennsylvania. Gateway has its headquarters in Aliquippa, Pennsylvania, (near Pittsburgh), and maintains nine program sites in the area with various levels-of-care or treatment formats (e.g., detoxification, inpatient, day or night intensive outpatient, weekly outpatient). Gateway has been in operation for over 27 years, and is recognized as one of the "top twelve" alcohol treatment facilities in the country (according to Forbes Magazine, along with treatment guidebooks). It employs a conventional multi-faceted treatment approach that includes medical and psychiatric evaluations, rehabilitation counseling and education, social and family support, and recovery and spiritual growth.