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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: [email protected]
Website: www.iup.edu/maati
Report submitted to:
THE RICHARD KING MELLON FOUNDATION
One Mellon Bank Center
500 Grant St., Suite 4106
Pittsburgh, PA 15217-2502
August 7, 2000
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”
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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.
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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: www.iup.edu/maati/publications .
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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)
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
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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, & LeedKelly, 1998; Hasin et al., 1996).
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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 levelsof-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.
The structure of alcohol and drug treatment has changed dramatically in the last ten years
due largely to greater emphasis on cost containment and managed care. Patients currently
receive some combination of detoxification, inpatient treatment, intensive outpatient treatment,
and aftercare outpatient treatment. The primary treatment for the majority of patients is,
however, some configuration of intensive outpatient treatment (all day or evenings, 3-5 days a
week) lasting for approximately 2 weeks. This treatment contrasts to the 28-day inpatient care of
the past. The current intensive outpatient treatment offers education about alcoholism and the
requirements for recovery through group discussion and counseling. An individual treatment
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plan, based on a comprehensive psychosocial assessment, provides direction, skills, and support
for a person to attain sobriety. A multi-disciplinary treatment staff of physicians, nurses,
therapists and specialized counselors, is involved in a given patient’s treatment as needed.
SAMPLE
The response rate for the outpatient sample was nearly 60% (124 of the initial 214) for
the full three-year follow-up period (see Table 1-2). A relative or friend (i.e., a “collateral”
interviewee) was interviewed for 60% of the responding subjects to verify their reports (i.e., a
subject and collateral were interviewed). The subject or a collateral was interviewed for 70% of
the cases. Nearly all the subjects (90%) were interviewed for at least one of the follow-up
intervals (every six months) during the three-year follow-up period.
“Reuse” (or relapse) was measured as alcohol or drug use by either the subject or the
verifying interview. The verifying interviews raised the rate of alcohol and drug reuse during the
three-year follow-up from 66% to 73%--or 7 percentage points. Information was collected for
75% of the subjects (subjects and/or collaterals) for at least two years.
The possible bias caused by subjects who were not interviewed appears to be minimal.
The rate of alcohol and drug use during the follow-up period was only a few percentage points
lower for the group of “partial” respondents than for those who responded for the full three-year
period. Also, the characteristics of those who responded for the full period and any interval were
nearly equivalent. Therefore, we might assume that the respondents for the full three-year period
are representative of the initial sample recruited at program enrollment.
NOTE: The influence of the verification interviews with collaterals is illustrated in the
alcohol and drug use reported for the final follow-up interview at three-years after program
intake (covering 30 to 36 months). The collaterals plus subjects together increase the response
rate from 57% for subjects to only 65% for subjects or collaterals. Forty four percent of the
subjects reported reuse during the past six-months. There was a corresponding collateral
interview for approximately half of the responding subjects. These collateral interviews
increased the drinking rate to 49%. Only 4% of the subjects reported no use in the previous six
months when the collaterals reported use. That is, they “underreported.” Nearly 10% of the
subjects said that they had used, when a collateral said “no use.” In sum, some collaterals helped
offset underreporting by the subjects; however, there were many collaterals who were apparently
not aware of, or did wish to report, reuse admitted by the subjects. The reuse would likely to be
even higher, if there were collateral interviews corresponding to all the responding subjects
rather than only about half of them.
DATA COLLECTION
Patient Characteristics
Patient characteristics were assessed through an extensive background questionnaire with
a list of responses for each question (see Appendix). The questionnaire asked about the aspects
of the patient’s life identified by professional associations (i.e., American Society of Addiction
Medicine or ASAM; (Hoffman et al., 1991; Shulman, 1994) as relevant to alcohol and drug
treatment. The questionnaire included a series of questions about:
 past alcohol and drug abuse,
 current drinking patterns and prescriptions,
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 physical and mental health,
 treatment-seeking in the past and present,
 living arrangements and social support, and
 employment and income.
The written questionnaire was administered as part of the program intake process. A staff person
was present to assist patients in interpreting and reading the questionnaire. (See Appendix for
“Intake Questionnaire.”)
The Beck Depression Inventory (BDI) was also administered at intake. Additional
information was obtained through clinical records maintained by Gateway: the psychiatric
diagnosis at program intake, the number of treatment days completed by each person, and any
prior admission to Gateway. A staff psychiatrist determined the diagnosis during an interview
near the time of program intake.
Program Outcome
The program outcome was assessed using a follow-up questionnaire administered by
telephone every six-months over the three-year follow-up period (see Appendix). The questions
apply to the previous six-month period to maximize recall. Research staff tracked and
interviewed the subjects, and a designated relative or friend to help verify the response of the
subject. Verifying interviews with relatives or friends (i.e., collateral interviews) have been
shown to increase the accuracy of subjects’ self-reports (Sobell et al., 1997; Tucker et al., 1991).
The questionnaire asked categorical questions and inventories about alcohol and drug
use, physical health, psychological and behavioral issues, relationship development, legal and
arrest history, treatment acceptance, social support, relapse potential, and recovery environment
(e.g., living arrangements, social support, employment). These areas represent the main outcome
areas designated by treatment professionals (e.g., American Society of Addition Medicine;
Hoffman et al., 1991; Shulman, 1994) and addiction assessment instruments (e.g., Addiction
Severity Index; McLellan et al., 1985). The principal outcome of interest, for the purpose of this
study, is the use of alcohol or drugs during any of the six-month follow-up intervals, according to
the patient’s or relative’s report. The patients and their designated relatives were asked, “Did
you drink any alcohol since our last interview?” and separately “Did you use any drugs since our
last interview?” A series of questions followed about the number of times, the use pattern, the
kind of alcohol or drugs, the place or circumstances of the use, and the reasons for the use.
There was also a separate set of questions about use of prescription drugs. (See Appendix for
“Subject Follow-up Interview.”)
The longitudinal follow-up enables consideration of both cumulative reuse and patterns
of reuse over the follow-up. (“Longitudinal” refers to the periodic interviewing—every six
months—over the course of the three-year follow-up.) The cumulative reuse is any reuse or
“relapse” at any time during the three-years. The pattern of reuse considers when, during the
three-year period, the reuse occurred. Did the person reuse continually, use only a short time
after treatment, or use only long after treatment? Additionally, we are able to consider
“abstinence” (or no reuse) retrospectively—that is, how long the person has not used alcohol or
drugs at the time of the final interview. Rather than measure the reuse of alcohol or drugs from
treatment forward through the follow-up, reuse is measured backward from the last follow-up to
treatment. This approach accounts for the inevitable “slips” that patients encounter as part of
recovery, and for the time it sometimes takes for the treatment to have an impact.
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RESULTS
SAMPLE CHARACTERISTICS
Summary
The demographics of the subjects in our intensive outpatient sample are similar to those
of patients in other private programs. The current demographics have, also, remained fairly
constant over the years. They are comparable to those of an inpatient sample drawn ten years
earlier at Gateway, when inpatient treatment was the primary treatment modality. The current
patients are, however, slightly older and higher in socio-economic status than patients in other
current addiction treatment programs from around the country (National Opinion Research
Center, 1996). Our sample demographics are influenced, in part, by the substantial number of
referrals from Employment Assistant Programs and the insurance coverage needed for most
patients. Public assistance monies are available for only a small portion of the patients at
Gateway.
The vast majority of the current subjects were diagnosed with alcohol dependency or
addiction as opposed to drug use, have long histories of alcohol or drug use, and have previously
been treated for their addiction. The patients bring a variety of emotional, physical, and social
problems, but only a small portion tested positive for severe depression. These problems have
intensified during the year prior to treatment, and apparently prompted many of the patients to
seek treatment or led their family members to encourage them to do so. Despite the extent and
severity of their problems, the patients on average received two weeks of intensive outpatient
treatment—half as many days as the conventional month-long inpatient treatment of ten years
ago.
Demographics and Diagnosis
The patients in our sample were on average 38 years old, but the age distribution was
fairly broad (sd=15). Over two thirds were male (67%) and most were white (83%). Only half
of the patients had completed high school (48%) and a quarter (23%) were unemployed. About
a third (36%) of the patients were currently married, as opposed to separated (13%), divorced
(18%), or never married (34%). Two thirds (66%) had children, but only a third (36% or half of
those with children) had children living with them. Half (49%) were living with a spouse or
partner, and a fifth (17%) were living alone. (See Table 2-1 and “Intake Questionnaire” in
Appendix.)
The primary diagnosis for nearly two-thirds (63%) of the current intensive outpatient
sample was alcohol dependence, and for about one-third (31%) was cocaine addiction. The use
of cocaine was substantially lower in the previous inpatient sample—only 6%. (See Table 2-2.)
Also, nearly two-thirds (59%) of the outpatient sample had a relative who had alcohol or drug
problems. The intensive outpatients typically had long histories of drinking or using drugs.
According to the patients, they started using an average of 21 years prior to treatment (sd=10.8)
and had been using heavily (more than 3 days a week) for an average of 14 years (sd=9.7). They
realized that they had an alcohol or drug problem an average of 7.7 years prior to treatment
(sd=8.8). The consequences of their use are also extensive. Over a third (36%) reported tremors,
shakes, or D.T.s in the previous year, and over a third (38%) had missed work or school for two
or more days.
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The portion of patients with evidence of depression was lower than expected and
equivalent across the primary diagnoses. In other words, the levels of depression were similar
among those diagnosed with alcohol addiction and those addicted to other drugs. A quarter of
the patients (25%) showed evidence of mild or severe depression, according to the Beck
Depression Inventory administered at program intake. Only 6% of the sample had scores
indicating “severe depression.” A fifth of the patients (21%) admitted threatening or attempting
suicide sometime in the past. However, nearly half (42%) reported experiencing “serious
depression” during the previous year, a fifth (20%) had thoughts of suicide, and almost twothirds (62%) noted “mood swings.” The portion of patients with these recent problems was twice
that of those reporting such problems in the past (i.e., prior to the year previous to intake).
A substantial portion of the patients also had interpersonal problems. Nearly half (47%)
had been hostile or aggressive toward family members or close friends, and nearly a third (32%)
admitted pushing, shoving, or assaulting someone in the previous year. The main target for these
assaults was the patient’s spouse or partner (52% of those who assaulted someone).
Approximately 1 in 6 (15%) had been previously arrested for domestic violence or had a
protection order filed against him or her. Half of the patients (49%) had been arrested for any
crime in the past and half of these previously arrested patients had been arrested two or more
times (25% three times or more). (See Table 2-3).
Treatment
The questions about prior treatment addressed how and why the subjects sought their
current alcohol and drug treatment and also what other forms of treatment they previously had
obtained. The patients appeared to have worsening problems prior to their current treatment, and
to be reaching out more for help, as a result. Equal portions of patients had experienced the
stressful events of separation or divorce (25%), injury or death of a loved one (26%), physical
problems or illness (24%), and work or financial problems (26%) in the previous year. Nearly
half (54%) considered their life overall worsening during the past year, as compared to about a
quarter (23%) who indicated it was “about the same” and another quarter (23%) who saw it as
“improved.” Most of the patients had talked about their drinking or drug problems to either
family members (79%), friends or acquaintances (61%), or professionals (46%) in the past year,
but only a small portion had done so in the past (family 35%, friends 23%, and professionals
15%).
The majority of the patients had previously been in treatment. More specifically, twothirds (66%) of the patients had attended Alcoholics Anonymous, the same portion (64%) had
received psychological counseling, and over a third (37%) had been in addiction treatment (on
average 3 times). Relatives (23%) and employers (17%) were the main referral source to the
current treatment for nearly half of the patients, but nearly a quarter of the patients indicated that
they sought treatment on their own. The main reasons that the patients came to treatment were
because of “they were determined to make a change” (28%), problems at work (25%), emotional
or physical problems related to drinking (19%), and family encouragement or problems (16%).
The current treatment for the sample was intensive outpatient treatment. According to
clinical records, the average length of intensive outpatient treatment was 15 days (sd=5.7). This
average includes both those patients who dropped out of the program and those who were
granted a longer treatment. Some of the intensive outpatients also received some prior inpatient
treatment (in the form of detoxification) and some additional outpatient sessions after intensive
outpatient treatment. Nearly a quarter of the patients (23%) received an average of 9.0 days
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(sd=4.5) of inpatient treatment prior to their intensive outpatient treatment. The average number
of days in weekly outpatient sessions after intensive outpatient was 7.7 days (sd=6.3). The
combined forms of treatment amounts to an average of 17.5 days of treatment (sd=7.4). (See
Table 2-4.)
REUSE OUTCOMES
Summary
The main goal of the treatment is to help addicted patients stop using alcohol and drugs
altogether or become “abstinent.” The reuse of alcohol or drugs was assessed in different ways
in an attempt to capture not only the cumulative prevalence of reuse, but also the patterns of
reuse during the follow-up period. The majority of the patients did reuse alcohol or drugs
sometime during the three year follow-up after treatment, but only 1 in 5 reportedly used
continuously. In other words, most of the patients interrupted their drinking for at least one 6month follow-up interval and at least half were abstinent for the previous 6 months or longer at
the end of the three-year follow-up. At the three-year follow-up, three-quarters were not
currently using and nearly half of the patients had been abstinent for a year. Most of those who
did reuse did so shortly after treatment. It appears that the post-treatment period is a crucial time
in which patients need more support or extended treatment. Smaller portions of patients either
stopped after that early post-treatment use or drank again after that and stopped again. In other
words, there are a variety of patterns of reuse.
The interruption of continuous alcohol use might be considered an accomplishment,
given the chronic nature of the addiction and “disease” quality of it. The treatment field
generally acknowledges that patients may reuse or “relapse” sporadically after treatment.
Occasional relapse may be a part of the “recovery” process or pathway to total abstinence. The
vast majority of intensive outpatients, in this light, are moving toward total abstinence, and a
substantial portion has already achieved abstinence.
Cumulative Reuse
The majority of patients (77%) used alcohol or drugs sometime during the three-year
follow-up, according to the reports of patients and collaterals combined. (See Table 3-1.) This
cumulative measure of reuse, however, fails to represent the interruption of alcohol and drug use
and low level of reuse at the end of the three-year follow-up period. At the three-year follow-up,
74% of the patients indicated that they were not currently drinking or using drugs (within the last
two weeks or longer). Nearly half of the men (45%) had been abstinent for at least a year, and a
third (33%) for a full two years. One in four (24%) had been abstinent for the full three-year
follow-up, according to the patients’ reports. (See Table 3-2.) When this rate is adjusted for the
collateral verifications, the rate of abstinence falls slightly to one in five or a fifth of the patients
(21%). (See table 2-2).
Most of those who reused alcohol or drugs did so by 18-months after treatment (71% by
18 mos. vs. 77% for the full 36 mos.) That is, the number of patients reusing for the first time is
very small after 18 months. The reuse rate increases by only 6% from 18 months to 36 months
(or in the next 1½ years). (See Table 3-3). Roughly half of the patients had been using alcohol or
drugs during any of the 6-month follow-up intervals; conversely, approximately half of the
patients were abstinent for at least 6-months. Those patients using during any six-month follow-
9
up interval fluctuated between 47% and 55% in the first three follow-up intervals and around
50% during the remainder of the follow-up intervals (49% to 51%). (See Table 3-4.) At the end
of the 3-year follow, 51% had not used in the previous six-months, and 74% had not used in the
previous 2 weeks. (See Table 3-2). Two-thirds (66%) of those who reused during the follow-up
did so during the first 6-month interval—that is, shortly after treatment (49% reuse during first 6
mos. / 74% reuse during three-year follow-up).
Almost all of those patients who reused during the follow-up used alcohol (74% of the
sample). When other drugs are included with alcohol, the reuse rate increases only about 3%
(77% vs. 74%). Yet 41% of the sample also used other drugs (25% used marijuana, 20% used
crack, cocaine, crank, or heroin, 5% used other pills or drugs). Therefore, most of those who did
use drugs also drank alcohol. (See Table 3-5.)
Patterns of Reuse
The pattern of reuse during the follow-up period can be sorted into four main types of
fairly equal proportions: continuous, current, intermittent, and abstinent. About a fifth of the
patients drank continuously through the follow-up—from the first follow-up interval to the last.
The current users were drinking or using drugs at the time of the last follow-up, but had
interrupted their use for at least one of the 6-month intervals. (See Table 4-1 & 4-2).
Approximately, two-thirds of this type of user drank or took drugs two years out of a three-year
period. Nearly a third of the patients drank or used intermittently; that is, they used during only a
portion of the follow-up intervals and abstained during others. A third of these intermittent users
drank or used drugs during only one six-month follow-up period, and another third used during
three or more 6-month intervals. Finally, about a quarter (23%) of the patients did not use
alcohol or drugs at any time during follow-up. They remained abstinent. The continuous users
were more likely to drink or use drugs “steadily,” whereas the intermittent users were more
likely to revert to binges.
Over half of those who did reuse did so sporadically rather than return to regular constant
drinking or drug use. The frequency of reuse was relatively constant across the follow-up
intervals. About a third of those who reused alcohol or drugs did so 1-3 times during the 6month follow-up interval. Approximately a quarter did so 2-3 times per month, and between a
third and half used at least weekly or more. (See Table 4-3.) The reuse most often occurred at
social events (43%) or alone (34%). The use at social events was lower during the follow-up
than prior to treatment intake (61%), and higher for drinking alone (15%). There was also an
apparent shift to more social drinking from immediately after treatment to the end of the followup. In sum, the patients who were reusing were more likely to do so privately after treatment
than before treatment, but they began to shift back to more social drinking during the course of
the follow-up. (See Table 4-4).
QUALITY-OF-LIFE AND HEALTH
Summary
Another goal of treatment is to improve the patients’ quality-of-life and reduce problems
associated with alcohol and drug use. The outpatients reported a dramatic improvement in their
quality-of-life and especially their physical health. They also were less likely to report serious
depression at the three-year follow-up, compared to program intake. In fact, three-fifths of the
10
patients experienced “improvement” in their overall quality-of-life. Patients additionally reported
that their major activities and recovery issues “improved” since treatment. The majority saw
improvements in their relationships, work or school, and decision-making. In other words, the
outpatients were functioning much better in the social realm of their lives. Nearly all the patients
showed improvement in terms of cravings and motivation—two psychological aspects essential
for long-term recovery.
Quality-of-Life
As a global indicator of quality-of-life, the patients were asked, “How has your life
changed overall--for the better, worse, or about the same?” By the end of the three-year followup, the vast majority of patients (82%) indicated their lives had changed for the better since
treatment (60% “much better” and 22% “better”). (See Table 5-1). This portion represents a
nearly threefold increase from similar reports at program intake (23% reporting “much better” or
“better”). At program intake, less than a quarter (23%) of the patients said their lives had
improved in the previous year. Almost a third (31%) rated their lives as “worse” and a quarter
(24%) reported “much worse.” Over 80% were “much better” or “better” at 6-months after
treatment, and nearly two thirds (57% to 61%) reported being “much better” or ‘better” at the
subsequent follow-up periods. (See Table 5-2.) In other words, a substantial portion of patients
not only improved, but also kept improving over the course of the follow-up. There was a small
percentage (6%) whose lives had worsened since treatment. Nearly all of these individuals had
been drinking heavily since treatment and had increased psychological or physical problems, as a
result.
Similarly, the vast majority (80%) of the patients rated their physical health as “good”
(31%) or “very good” (49%). (See Table 5-1.) These ratings were improved by 30% over the
ratings at intake (62% “good” or “very good” at intake). The health ratings improved to 76%
(very good or good) at the 6 month follow-up, peaked at 87% at the 12-month follow-up, and
remained at approximately 80% through the two- and three-year follow-up interviews. (See
Table 5-3.) The patients who considered their health to be “poor” or “very poor” were fairly
consistent from intake through the follow-up (4%-6%). Half (51%) of the outpatients reported
having a “major” health problem sometime during the three-year follow-up period.
Approximately a quarter of the patients reported a major health problem both at the six-month
follow-up (23%) and at the three-year follow-up (28%). There were a great variety of problems.
The most common problems were those related to the brain (e.g., headaches, memory loss,
migraines, seizures), those related to muscles and joints (e.g., body pains, arthritis, muscle
spasms), and those related to sleep and anxiety.
Emotional Problems
There was also a marked decrease in emotional problems. Most notably, the patients
overwhelmingly reported no “serious depression” at the end of the three-year follow-up period
(88%), as compared to nearly half indicating serious depression at program intake (48%).
(Conversely, the portion of patients reporting “serious depression” in the previous six-months
was reduced by 75% [52% at intake vs. 12% at follow-up].) (See Table 5-3.) Only a few patients
(1%) had thoughts of suicide during the last 6-months of the three-year follow-up, whereas a
fifth (21%) of them did at program intake. Other emotional problems similarly decreased from
before to after treatment and over the follow-up. At intake, most of the patients (81%) reported
some emotional problems in the past year; three-quarters (76%) reported such problems between
11
treatment and the six-month follow-up; and only half (53%) indicated any such problems in the
previous six months at the three-year follow-up interview. For instance, almost two-thirds (59%63%) of the patients reported anxiety or tension at program intake, as opposed to over a third
(38%) at the three-year follow-up.
There was substantial improvement in the psychological aspects of recovery—
specifically, cravings for alcohol or drugs, desire to be clean and sober, and faith in a higher
power. Almost all of the patients noted “improvement” or “much improvement” in these aspects
sometime during the follow-up period (cravings 86%, desire 90%, faith 77%) (See Table 5-4.)
The portion indicating an improvement in their desire to be clean and sober was 81% at the sixmonth follow-up, and 64% at the three-year follow-up. Only 2% reported a decrease in their
desire at the three-year follow-up.
OTHER OUTCOMES
Social Activities and Employment
The patients lives improved in several social areas of their lives. Over three-quarters
reported improvement in their relationships (82%), work or school (77%), and decision-making
since treatment (64%). (See Table 6-1.) This improvement was sustained over the follow-up for
nearly half of the patients. That is, they reported improvement at each follow-up interval over
the previous follow-up period, which had also shown improvement. For instance, 56% of the
patients indicted that their relationships were “better” at the six-month follow-up interview, and
43% reported better relationships at the three-year follow-up interview. The other areas showed
almost identical trends.
The patients appeared to be doing relatively well economically by the end of the followup. The majority (83%) of the patients were employed at the end of the three-year follow-up;
only 17% were unemployed as compared to 23% at program intake. Three quarters (73%) were
working full-time and 10% were working part-time. A very small portion (8%) reported having
any problems at work in the form of disagreements or reprimands. Over half (55%) had greater
incomes since treatment, with about 20% the same and 25% less income.
Aggression and Arrest
Those involved in interpersonal violence was relatively low. While 20% reported being
shoved or hit during the first two-years after treatment, only 4% had been hit in the previous
year. Similarly, 23% reported shoving or hitting others (mostly their spouses or partners), but
only 6% did so the previous 6 months. About a third admitted to being abused and a third to
abusing others in the year prior to intake. A small portion of women (7%) reported being
sexually assaulted during the follow-up, even though nearly a fifth of the women (19%)
indicated they were sexually abused sometime prior to treatment. (See Table 6-2.) The
percentages of abuse during follow-up are comparable to those in the population at large.
The portion of patients arrested decreased by 50% during the follow-up. One in five
patients (22%) were arrested during the three-year follow-up, according to the patients’ and
collaterals’ reports, compared to half (49%) of the patients being arrested sometime prior to
program intake. Between 3% and 6% of the patients were arrested during each of the 6-month
follow-up intervals, indicating no notable trend in those being arrested and few being arrested
more than once over the three-year follow-up.
12
ADDITIONAL TREATMENT AND HELP
Summary
The majority of patients turned to other treatment or treatment support during followup—mostly AA or NA. The percentage receiving additional treatment decreased over the
follow-up period, however. A smaller portion of patients also obtained other kinds of assistance
(i.e., job training, legal aid), but at least half regularly attend church—more than three times as
many at program intake. Family, AA, and oneself are the most helpful in trying to stay “clean
and sober” during the follow-up.
Additional Treatment
Most of the patients do obtain some form of additional treatment after the intensive
outpatient treatment for drug and alcohol abuse. (See Table 7-1.) Nearly all the patients attended
Alcoholics Anonymous (AA) at sometime during the follow-up period. Nearly 80% attended
AA during the six months after treatment, but that percentage decreased to less than half (50%)
by the three-year follow-up interview. Less than a fifth returned for drug and alcohol treatment.
The percentage of patients rose to 19% toward the end of the first year of treatment (6-mos. to
12-mos.) and gradually decreased to 8% in the last 6 months of the three-year follow-up (24 mos.
to 36 mos.). This treatment was primarily in response to relapse or continued drinking. Some
patients also obtained psychological treatment mostly in the form of counseling for emotional
problems. Approximately half (51%) received psychological treatment during the follow-up
period with a third (33%) getting treatment during the first 6-months and 18% during the last 6
months of the follow-up, according to patients or collaterals.
Many of the patients also received other kinds of assistance and support. Approximately
a third had contacted social services, legal aid, job training, or housing assistance over the threeyear follow-up. At the first 6-month follow-up interval, 13% of the patients had additional
assistance. This amount declined during the follow-up to 5% during the last follow-up interval
(24 mos. to 36 mos.). About half (50% to 42%) of the patients attended church, on at least a
monthly basis, through the follow-up. Only 15% indicated that they were attending church
monthly prior to program intake.
Most Helpful
The patients were also asked who or what was the “most helpful in trying to stay clean
and sober.” There was a great range of help sources including other counseling, church
attendance, exercise programs, a higher power, and AA sponsor. Family members and AA or
NA were the most frequently cited, with “oneself” being the third most cited. Approximately,
40% of the patients said their family members “help the most” throughout the course of the
three-year follow-up. About a third (31% to 35%) indicated AA was the most helpful
consistently through the follow-up. Also, a quarter (28% to 25%) of the patients consistently
cited themselves as the most important source of help. At six-months after treatment, over a
quarter (27%) of the patients pointed to the Gateway treatment program as the most helpful, but
that percentage decreased to only 2% by the end of the follow-up.
13
CHANGE AND RECOMMENDATIONS
Summary
The patients interrupted alcohol and drug use and their improved quality-of-life are
reflected in the patients’ description of their overall change and general support of the treatment
program. Most of the patients described their increased awareness of addiction’s consequences
and pointed to the positive aspects of not drinking or using drugs. Their lives were
psychologically and socially better as a result of decreased use. Most of the patients had only a
positive response to the program. They remarked most often, positively or negatively, about the
counselors’ personality or attitude. In the patients’ point of view, the counselors as “people”
seem to be the most noteworthy component of the program. Those with suggestions also pointed
to a need for more structure in the sessions and a separation of voluntary and court-referred
patients. They also mentioned the need for more aftercare, supervision, or continued support
beyond the short-term intensive outpatient treatment.
Overall Change
To explore further the broad impact of treatment, we asked the outpatients to describe the
nature of change during the follow-up. They were asked: “How have you changed since going
to the treatment program three years ago?” This open-ended question allowed the subjects to
summarize changes they experienced and considered most important. Nearly two-thirds (64%)
of the patients mentioned a change in their attitude or outlook, suggesting the treatment’s impact
on the patients’ general well-being and perspective. The next most common topic was actually a
set of topics related to reductions in alcohol and drug use. Patients noted increased awareness of
the effect of addiction on themselves and others, and increased efforts to stop using alcohol and
drugs. (See Table 8-1.) Many patients discussed seeing the connection between stopping
drinking and improvement in many other part of their lives. Other major topics related to
positive social and psychological changes. Patients talked of better relationships, improved
family life, caring more for others, a more positive outlook, increased self-esteem, greater calm
and poise, and more self-reliance (i.e., taking better care of oneself). The emphasis was clearly
on more than just a change in alcohol and drug use, but the relationship between stopping the use
and well-being were usually acknowledged. The collaterals’ accounts echoed these topics. (See
Table 8-2 for examples of responses.)
The responses to these open-ended questions appeared to corroborate the answers to more
direct questions about alcohol and drug use and quality-of-life. As the previous questions about
other aspects associated with drinking suggest, over two thirds (64%) of the patients described
changes in attitude and outlook, and over 40% (42%) mentioned being more focused or clearheaded. The next most frequently cited item was stopping drinking with a third of the patients
(33%). Nearly a quarter (23%) of the patients reported stopping drug use. These two percentages
correspond to previous questions indicating no drug or alcohol use in the previous six months.
Additionally, another 15% of the patients reported reducing their alcohol usage and 5% said they
had reduced drug usage. Those who stopped and those who reduced use total approximately
75% and correspond to those who reported not using at the time of the three-year follow-up
interview. Nearly a third (29%) reported improved support from family and friends and a fifth
talked about a change in their own will-power, motivation, or determination to change. These
reflect the “main reason” for change responses that showed family and friends and “my own
self” as the most commonly sighted reasons.
14
Program Recommendations
The patients were asked for their appraisal of the treatment program at the six months
after treatment and again at three years. At six-months, they were asked what they liked best and
least about the program. Over half (53%) of the patients indicated the counselors’ personality or
attitude is what they “liked best” about the program. A much smaller portion noted the group
process (18%) or program content (12%). Others were either not sure, had nothing they liked, or
mentioned program structure, counselor skills, other participants, or family involvement. Nearly
half had anything negative to say about the program (i.e., what they liked least). About a quarter
(24%) did not like the personality or behavior of the counselor, and another quarter (28%) did
not like the program content or structure. (See Table 8-3.) Half (52%) of the collateral
interviewees did not have any suggestions or recommendations for the program. Those who did
offered a wide range of suggestions dealing with the counselors and program structure.
We asked the patients again at the end of the three-year follow-up: Do you have any
suggestions for the Gateway program? The three major topics reflected those from the previous
six-month follow-up. Many patients spoke about the need for a stricter program structure in
terms of more regulations and requirements, such as homework, non-smoking policy, urine tests,
and continued follow-up. They recommended more supervision and less idle time. Patients also
spoke of a need for separate groups, especially for court-ordered versus voluntary patients. They
felt that that those patients who did not want to be there held back the other patients. Other
suggestions were to improve the counselor-patient ratio, lessen the concern about money, add
more medical and detoxification help, and extend outreach after treatment. The collaterals
similarly spoke of the need for stricter programs with more intensive supervision, and also the
need for longer programs and extended after care.
PREDICTING REUSE
Summary
It would be helpful to know which patients are most likely to reuse alcohol or drugs after
treatment. These patients might receive more extensive or different treatment to address their
distinguishing characteristics or problems. We explored for patient characteristics associated
with reuse. Female, younger, unemployed, and lower educated patients were more likely to
reuse during the follow-up. There was no difference in reuse for race or occupation. Moreover,
the type of treatment (inpatient plus outpatient vs. outpatient only) and number of treatment days
did not affect the reuse outcome.
Our attempt to identify predictors for different measures of reuse (i.e., any reuse,
continual reuse, and patterns of reuse) produced, however, an inconsistent set of predictors and a
very weak prediction (i.e., the correct classification of cases was very low). Despite some
modest tendencies, it is very difficult to identify who is most at risk for reuse after treatment.
Characteristics
We cross-tabulated any cumulative reuse of alcohol or drugs by patient characteristics for
each of the 6-month follow-up interviews during the first two years after treatment. Nearly all of
the cumulative reuse had occurred within this two-year period. (“Cumulative reuse” refers to
any use of alcohol or drugs since treatment.) Differences that were statistically significant
(according to Chi Square p<.05) were identified. (All of the demographic results appear in Table
15
9-1.) Nearly twice (65% vs. 35%) as many of the younger patients (18-29) than older patients
(50 and over) had reused by six months after treatment. While the margin of difference decreases
over time to 16%, the younger patients are still more likely to have reused by two years after
treatment (89% vs. 73%). The trend is similar for education with twice (83% vs. 40%) as many
patients having less than a twelfth grade education, as compared to those with some college
education, reusing by six months after treatment. All of the less educated patients had reused by
two years, as compared to three-quarters (73%) of those with some college. Significantly more
women and more part-time or unemployed patients reused by six months after treatment, but the
reuse differences disappeared by three years.
There was no significant difference in reuse for race or occupation. The difference in
reuse outcomes was also not substantial or significant for primary diagnosis (alcohol vs. drug
addiction) or depression (normal/mild vs. moderate/severe on the BDI) over the course of the
follow-up. One of the program sites did have a substantially higher percentage of patients
reusing than the second site. (See Table 9-2.) However, this site had more patients who were
male, had higher education, and had more previous inpatient treatment.
Treatment
We also examined the relationship of treatment type and number of treatment days to any
reuse during the follow-up. The reuse outcomes across the follow-up intervals did not
significantly differ for combination of treatment (inpatient and intensive outpatient vs. outpatient
only) or the number of days in treatment. There is a trend in the expected direction, however, for
treatment days. For instance, those with 1 to 14 total days of treatment were more likely to reuse
than those with 22 or more days of treatment (88% vs. 67%; 15 to 21 days=75% reuse). (See
Table 9-3.) While the difference is substantial, it is not statistically significant because of the low
number of patients in the category of “22 or more days.” (“Not significant” means that the
difference could be by chance and may be unreliable.) The differences for treatment type and
days are, moreover, confounded by the fact that the more seriously addicted or impaired patients
are likely to be assigned to and complete more extensive treatment, and some of these patients
are more likely to drop out than other patients. In other words, the slightly higher reuse for 1 to
14 days could be the result of problematic patients dropping out or of an inadequate length of
treatment for compliant patients.
Predictors of Reuse
We also conducted multi-variate analyses of any reuse, only continual reuse, and
different patterns of reuse. Multi-variate analysis determines the influence of a particular factor
when controlling for other factors. It helps determine the influence of a factor separate from
other influences that might be combined with it when using only the bi-variate cross-tabulations
above. A combination of demographics, prior use, psychological and physical health, additional
treatment, and social supports (e.g., family, friends, church, exercise) in the six-month follow-up
were used as “predictors” in a stepwise logistic regression for any reuse and continual reuse
(binary: yes or no). (A significance level p<.1 for the entry criteria was used to accommodate for
the relatively small sample size with respect to the number of predictors). A stepwise linear
regression was used to predict the pattern of reuse (ordinal: no, intermittent, current, and
continual use).
The significant predictors for “any reuse” during two years after treatment were women,
long previous use, previous alcohol-related arrests, and increased cravings and additional
16
treatment during follow-up. For “continual reuse,” the predictors were prior unemployment,
long previous use, and low AA or NA attendance. Younger age, unemployment during the
follow-up, low AA/NA attendance, and additional treatment predicted “patterns” of increasing
reuse. There is a slightly different set of predictors for each different type of reuse (any reuse,
continual reuse, or pattern of reuse). The most common predictors were long previous use, low
AA or NA attendance, and additional treatment. The additional treatment is a positive predictor
partly because those most likely to reuse are the one’s most likely to end up returning to
treatment. Interestingly, none of the social support items were predictive. (See Table 9-4 for list
of predictors and results)
Besides no consistent predictors for the different reuse types, the predictors were very
weak. That is, they correctly identified only a small portion of reuse cases or non-reuse cases.
The predictors correctly identified 81% of all the cases for any reuse, but only 37% of the
abstinent or non-use cases (which were about 25% of the overall cases). The overall correct
classification rate for continual reuse was 73% with a 51% rate for the continual cases (about
25% of the cases). The power of the predictors in the linear regression for pattern of use is
measured with an adjusted R2 . The R2 was only .18 suggesting that the predictors account for
only 20% of the variance across the pattern of use.
In sum, we were not able to effectively predict reuse of alcohol or drugs during the
follow-up. This may be because prediction is simply difficult or our measures were imprecise.
The reuse outcomes are particular problematic for this sort of analysis. For instance, broad
categories of “use versus non-use” may not be sufficiently precise or calibrated to detect
differences. Also, it is difficult to sequence additional treatments or supports with reuse during
the follow-up. That is, additional treatment, in some cases, may be preventative and precede
potential relapse, and in other cases it may be a reaction to a relapse. A larger sample size is,
furthermore, needed to effectively analyze the large number of predictors employed in the
analysis.
COMPARISON TO OTHER STUDIES
Summary
We compared our outcomes with two previous studies to assess the relative “success” of
the intensive outpatient treatment. First, we compared the outcome to a national study of
addiction treatment programs and, second, to an inpatient treatment study at the same site. The
alcohol and drug reuse among the intensive outpatients appears comparable to the national
programs and to the inpatients at the same site, except that the rates of continuous abstinence are
higher for the inpatients. These comparisons need to be weighed with some caution, however,
since differences in subject characteristics may have influenced the results.
National Comparison
Substance Abuse and Mental Health Services Administration of the U. S. Department of
Health and Human Services sponsored an extensive national study of treatment reported in 1996
(National Opinion Research Center, 1996). Over 5,000 patients in 78 treatment programs across
the country were contacted one year after treatment (83% response rate). The programs were
primarily in urban areas and received federal funding. Urine tests were also administered to a
subsample of the patients to verify self-reports. (See Table 10-1.) Over half (57%) of the
17
patients reused alcohol or drugs by one year after treatment. The rate of reuse was consistent
across the modalities, and similar across drugs used except for heroin. The re-arrest rate was
17% and the assault rate was 11% during the one-year follow-up. The reuse and re-arrest rates
for our outpatient study are comparable to these: 63% reused within the first year, 9% were
rearrested, and 16% assaulted someone.
The comparison suggests that the outcomes for the intensive outpatient treatment are as
good as outcomes in other programs across the country. The comparison has some limitations,
however. The programs in the national study were “public” programs in urban areas, as
opposed to the “private” facility used in our study. They are likely to have a greater range of
patients demographically and possibly have more problematic patients referred to them. In sum,
we do not know for sure how comparable our sample is to the national sample.
Inpatient Comparison
A three-year follow-up of patients in conventional residential treatment was conducted at
Gateway Rehabilitation Center in 1988 (Crabtree, 1988). The 1988 study consisted of 250
patients who completed the inpatient treatment with a 75% response rate for the full three-year
follow-up. When this study was conducted, the vast majority of patients stayed in a residential
facility for approximately 28 days. They received supervision, counseling, education, and
support away from the distractions of their home, neighborhood and family. In more recent
years, insurance companies have increasingly limited reimbursement for treatment and forced
treatment programs to rely almost entirely on the less costly intensive outpatient treatment that
lasts about 14 days. The outpatients receive similar counseling and education, but live at home
with less supervision and support.
We compared the results of the 1988 inpatient study to our 1996 study of intensive
outpatient treatment to draw some indication of the relative effectiveness of inpatient versus
outpatient treatment. Three years following treatment, approximately three-quarters of both the
1988 inpatients and 1996 outpatients were not currently using alcohol and other drugs (for at
least the previous two weeks or more). The rates of continuous abstinence, however, were twice
as high for the inpatients compared to the outpatients. (See Table 10-2.) Forty-two percent of the
inpatients remained continuously abstinent over the three-year follow-up period, compared to
only 23% of the outpatients. In the second to third year after treatment, the percentage of
subjects in both studies reporting abstinence remains fairly constant.
Some of the reuse difference may be attributable to differences in the patients’
characteristics. The current outpatients are much more likely to be addicted to cocaine or heroin
(31%), compared to the outpatients (6%). This sort of drug addiction is generally much more
difficult to treat. The inpatient study, moreover, only included patients that completed the 28day program, whereas the outpatient study included both dropouts and completers of what was
on average a two-week program. The demographics of the two samples were very similar,
suggesting a consistent—and comparable—composition of patients over the years. (See Table
2-1)
18
DISCUSSION
SUMMARY
This study examined the outcomes of intensive outpatient treatment at Gateway
Rehabilitation Center through a three-year follow-up of 214 patients. (See Table 11-1 for a
summary of research questions and answers.) The main objective was to assess the patient’s
reuse of alcohol and drugs after treatment and changes in their overall quality-of-life. In terms of
reuse, we found that while the majority of patients did reuse alcohol or drugs sometime during
the three-year follow-up, most interrupted their use for a substantial period of time. Moreover,
nearly three-quarters of the patients were not currently using at the time of the three-year followup, and over half had been abstinent for at least a year. Approximately one-in-four patients were
abstinent throughout the three-year follow-up. Only about a fifth of the patients used alcohol or
drugs continuously during the follow-up period. Interestingly, the majority of those who reused
began doing so during the first six-months after treatment. This may be the reason so many
patients recommended longer treatment or extended support beyond the intensive outpatient
treatment. We identified some familiar risk markers for different types of reuse, including
attendance at Alcoholics Anonymous. However, prediction of reuse in a clinically useful way
remains very weak.
The improvements in the patients’ quality-of-life were dramatic. There were marked
improvements in the patients’ physical and psychological health. The vast majority noted
reduced cravings and increased motivation—both of which are fundamental to recovery from
addiction. Most all of the patients also identified substantial improvements in social and family
relationships, and in their income and work situation. There was some decrease in arrests and
interpersonal violence, as well. The patients not only had an increased awareness of addiction
and its consequences, but also saw the relationship of alcohol use and their quality-of-life.
While these improvements correspond to alcohol reuse, they are not necessarily based on total
abstinence. In other words, the patients reported improvements in their quality-of-life overall
even if they had reused sometime during the follow-up. Those who did report getting worse
were typically those patients who were using drugs or alcohol continuously.
These findings appear comparable to those of a recent national survey of federallyfunded, urban treatment programs, and an inpatient study conducted at the same site in 1988.
The reuse rate in the one-year follow-up of the national survey was approximately the same as
the reuse for the same period in our current outpatient study. The re-arrest rate was slightly
higher, but the reassault rate was slightly lower. In the inpatient comparison, the rates of current
use at the end of a three-year follow-up were equivalent for both the inpatients and outpatients.
The portion of inpatients that was abstinent throughout the follow-up was, however, nearly twice
that of the outpatients. In sum, the intensive outpatient treatment at Gateway appears to be
doing nearly as well as and other national urban programs and the previous inpatient program.
This comparison must be weighed with some caution, however, since the characteristics of
subjects in the national survey and in the inpatient study may not be equivalent to those in our
intensive outpatient study.
19
IMPLICATIONS
Measuring Success
These findings raise the question of “success.” Do the level of abstinence and quality-oflife after treatment represent “successful” treatment? Unfortunately, this question is a
complicated one to answer. It involves an agreed standard or comparison to make what is
basically a “judgment call.” The notion of “success” all depends on how success is defined.
There are two ways to define it. One is in terms of the program in and of itself. How does the
output compare to the “input”—that is, the characteristics of the patients and the nature of the
problems they bring to treatment. The other way is comparing the outcome to other programs
and treatment alternatives. We also have two related but distinct outcome categories to consider:
one, the reuse of alcohol and drugs during the follow-up and, two, the patients’ quality-of-life
and personal change. Treatment might be more “successful” in some of these areas and less so
in others.
Outcomes vs. Inputs
In comparing the outcomes to the inputs, the intensive outpatient treatment appears to be
successful. It is “fairly” successful if success is defined in terms of the reuse outcomes, and
“very” successful if the focus is on quality-of-life. The high level of cumulative reuse presents a
somewhat discouraging picture on the surface. The vast majority of patients reused sometime
during the three-year follow-up. However, the trend and pattern of reuse present a more positive
picture. Firstly, less than a quarter of the patients reused continually throughout the follow-up.
That means that three-quarters of the patients interrupted their addictive use of alcohol or drugs
for six-months or more during the follow-up. Secondly, most of those who reused began doing
so in the first several months after treatment. It may take some time for treatment to take hold
and recovery to have an effect on usage. Thirdly, nearly half of the patients had not used for at
least a year at the three-year follow-up, and three-quarters were not currently using drugs or
alcohol. It would seem that the majority was on their way towards total abstinence.
Compared to the characteristics of the patients, these reuse outcomes are impressive. The
patients brought a complexity of compounding physical, psychological, social, and economic
problems with them. These make especially short-term treatment, focused on primarily alcohol
and drug use, a challenge. Moreover, the patients had chronic use and diagnosed addictions. To
interrupt even alcohol and drug use with short-term treatment, therefore, must be considered an
accomplishment. Moreover, experts in the field acknowledge while “abstinence” is the goal,
relapse is the reality. In other words, recovery from alcohol and drug addiction involves a series
of relapses for most patients, but increased periods of sobriety between the periods of relapse.
The “disease” nature of alcohol or drug addiction makes this so. According to our study, the
treatment has brought such periods of sobriety, and moved most of its patients ahead toward
recovery.
If the main criteria for “success” is the patients’ quality-of-life, then the intensive
outpatient treatment appears very successful. As mentioned above, the patients reported
substantial improvements physically, psychologically, and socially. Their ratings of their
physical and psychological well-being were higher during the follow-up than at program intake,
along with their perceptions that they had improved in specific areas. The more objective
indicators, such as arrests, assaults, and employment, showed less improvement, but change was
still evident. The patients, moreover, a broader composite of change that included awareness of
20
addiction, interruption of their use, and changes in other aspects of their lives. Many also
acknowledged additional help from family and friends, support groups, and counseling. In sum,
our indicators appear to point to a more complex process of “recovery” than a static final
outcome. Most of the patients describe some process of change that, while not complete, is
positive—and treatment appears to have activated or furthered this process.
The main limitation with the quality-of-life outcomes is that they are primarily subjective
and relative. That is, they are based on the patients’ perceptions or impressions, which may be
distorted or inflated by their expectations and desire for change. These outcomes are also
relative to the patients’ past experiences. Their lives may have been so bad, that a little change
represents something substantial in their eyes. The question remains, therefore, whether the
extent of the “improvements” is sufficient to be considered successful. The answer may depend
on how we define and measure the process of change or what we expect “recovery” from
addiction to look like.
Comparison to Other Studies
In comparing these outcomes to those in other studies, the “success” looks at least
comparable to other programs and approaches. The current reuse rates at our research site are
similar to those in the national multi-site survey with a one-year follow-up. Many of these
programs involved more inpatient treatment days and patients with different characteristics, but
the exceptionally large sample in the national study presents a suitable outcome norm. A
comparison to the inpatient outcome of ten years ago shows similar rates of low current use at
the end of three-years. However, the overall abstinence rate was higher for the inpatients. In
other words, the inpatients achieve similar levels of low current use with fewer relapses.
The later comparison raises some important implications about “managed care” and the
advent of intensive outpatient treatment. On the one hand, the intensive outpatient treatment
appears relatively successful in terms of the interruption of alcohol and drug use and the
dramatic improvements in the patient’s quality-of-life. One could argue that the outpatient
program appears to be accomplishing a great deal and at a much lower cost than the conventional
28-day inpatient programs of the past. This conclusion, however, may be more the result of the
particular program’s innovation, commitment, and sacrifice to compensate for substantial
reduction in compensation under managed care, rather than to the effectiveness of the new
format alone.
On the other hand, one could also argue that many patients would benefit from more
residential treatment or longer treatment in general. The lower level of relapse among inpatient
treatment patients, in our comparison study, suggests a much smoother and safer pathway to
recovery. A lower rate of relapse may also indicate more long-term abstinence and fewer health
and social complications. There is likely to be less “peripheral damage” and more “lasting
peace.” This is especially a concern when the treatment objective is expanded to the well-being
of family, friends, and employers potentially affected by the patients.
A related implication is that, minimally, short-term intensive outpatient treatment should
be extended. The bulk of the relapse begins in the first few months following treatment.
Additional case management of patients during the first several months following outpatient
treatment may help reduce the relapse and extend the impact of the intensive outpatient treatment
overall. Case managers might weekly contact and periodically visit patients to assess their
progress and add support. They might also refer individuals to additional treatment and services
as a preventive measure, rather than wait until individuals relapse again for a reactive return to
21
treatment. The costs of this sort of treatment extension would be modest, and the active outreach
would be appreciated. A recurring recommendation in our follow-up interviews was for more
follow-up contact from the program. Many patients seem reluctant to initiate the contact
themselves, because it represents some sort of weakness on their part, but they felt reinforced by
the care and support the follow-up call represented. (See Appendix for proposal for “PostTreatment Outreach.”)
QUALIFICATIONS
Clinical studies of this sort carry inevitable limitations and qualifications. The most
notable is that the findings may not apply to other programs and sites. They are drawn from one
particular and, in some ways, exceptional program. Gateway Rehabilitation Center is a large
private treatment facility with a national reputation for quality care. The appropriateness and
effectiveness is likely to be better there than at other less experienced and less funded programs.
Moreover, the findings do not necessarily represent all of Gateway, since they are based
primarily on two intensive outpatient sites among the nine total sites maintained by Gateway.
Additionally, the findings are based on information from one particular period of time. Patient
demographics, type of drug use, and severity of problems, however, tend to vary over time. Our
subjects drawn from the year 1996 appear to have more severe problems than those admitted in a
1988 study at Gateway. As drug use patterns and availability change, so do the problems of the
patients. The advent of managed care and welfare cuts also effect the extent of treatment and the
social status of the patients.
There are several methodological limitations that must be considered, as well. Another
challenge that faces most program evaluations is measuring the outcome. First, our focus on
relapse during a three-year follow-up admittedly slights the complex process of recovery. We do
examine a number of addiction-related problems to broaden the outcome, but combining those to
represent a pattern of recovery would be the ideal. Second, the relapse is based on the patients’
self-reports that are susceptible to the denial associated with addiction and some distortion
caused by recall. The longitudinal design of repeated interviews and verification from friends or
relatives, no doubt, reduce this problem, but they do not solve it. Urinalysis tests throughout the
follow-up would have offered a more objective measure, but they are costly and difficult to
administer, and become an intervention in themselves.
In sum, the findings of this study ultimately need to be replicated at other treatment
programs, at other times, with more patients, and using further verification. They do raise
important issues and alternative possibilities that warrant further research and programmatic
attention. Our current study suggests that the current outpatient treatment may not be as effective
as the past inpatient treatment, in terms of continuous abstinence. This possibility needs to be
addressed in a “clinical trial” of equivalent and current samples of inpatients and outpatients. We
also found that reuse for most patients began shortly after treatment and surmise that extended
treatment or outreach might alleviate this. A demonstration project that implemented posttreatment outreach or case management would be the logical way to explore this possibility.
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. Despite a high
percentage of relapse, nearly three-fourths are not currently using at the end of a three-year
follow-up period. Even more encouraging is the fact that the vast majority of patients report
22
improvements in their quality-of-life, physical and mental health, and social and work activity.
This outcome is comparable to more extensive federally-funded programs and to previous
inpatient treatment at the same site. It is particularly impressive considering 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 shorter duration of intensive outpatient
treatment under “managed care.”
23
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TABLES
RESEARCH DESIGN AND
PATIENT CHARACTERISTICS
REUSE OUTCOMES
PATTERNS OF REUSE
QUALITY-OF-LIFE AND HEALTH
OTHER OUTCOMES
CHANGE AND RECOMMENDATIONS
PREDICTING REUSE
COMPARISON TO OTHER STUDIES
APPENDIX:
QUESTIONNAIRES AND PROPOSAL
INTAKE QUESTIONNAIRE (with percentages)
SUBJECT FOLLOW-UP INTERVIEWS
Six-Month Interview (with percentages)
Three-Year Interview (with percentages)
POST-TREATMENT OUTREACH (proposal)
NOTE: Contact [email protected] for a copy of the Tables and
Appendix