Organizational Structures and the Environmental Context of Drug Abuse Treatment

Issue Paper
August, 1998

Mary Ellen Marsden, Ph.D.
Heller School
Brandeis University

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EXECUTIVE SUMMARY

The drug abuse treatment system is undergoing rapid change in response to external environmental forces such as increased expenditures for treatment, increased efforts toward cost containment, the growth of managed care, and shifts in ownership and funding. These changes are having profound effects on the structure of the treatment system and on service delivery in drug abuse treatment programs, but the nature of these changes has not been adequately studied. Perspectives from social science organizational theory could increase our understanding of these changes in the treatment system and in service delivery.

Introduction and Background

• The current drug abuse treatment system was developed largely during the 1960s and 1970s but is changing in response to increased expenditures for treatment, increased efforts toward cost containment, the growth of managed care, and shifts in ownership and funding.
• Major changes in drug abuse treatment programs include decreases in the type and intensity of services, shifts from inpatient and residential care to outpatient care, merging of programs and creation of interorganizational networks, and blurring of public and private programs.

Key Issues

• Several investigators have used organizational perspectives to portray the impact of changes in the external environment of treatment programs on their internal structure, particularly focusing on the impact of financial pressures.
• Organizational studies to date are limited and have focused largely on the impact of reductions in funding on staffing patterns and service intensity. Studies are in progress to examine the impact of managed care on service delivery.
• A number of questions remain unanswered regarding the organization of treatment, including the impact of environmental forces on service delivery, the continuum of care, linkages to other systems of care, and the impact of changes in service delivery to treatment outcomes.

Theoretical Approaches to Resolving Issues

• Social science perspectives on organizations can provide the basis for studies of the organizational structures and environmental context of drug abuse treatment.
• Organizational perspectives have been used in numerous studies of health care and mental health care, but have been less frequently applied to the study of drug abuse treatment programs.

Summary and Conclusions

• Organizational perspectives can inform the study of the changing external and internal environments of drug abuse treatment programs, particularly studies of the changing organization of treatment programs and its impact on service delivery and client outcomes.
• New types of data are needed for these studies that enable linking information about the external environment of treatment, the organization of treatment, the provision of services, and treatment outcomes.

INTRODUCTION AND BACKGROUND

The drug abuse treatment system is undergoing rapid change in response to external environmental forces such as increased expenditures for treatment, increased efforts toward cost containment, the growth of managed care, and shifts in ownership and funding. These changes are having profound effects on the structure of the treatment system and on service delivery in drug abuse treatment programs, but the nature of these changes has not been studied adequately. Despite the breadth and depth of changes in service delivery, and the importance of organizational and environmental factors in these changes, there are relatively few studies of the organization of drug abuse treatment, and these are largely descriptive. Perspectives from social science organizational theory could increase our understanding of these changes in the treatment system and in service delivery.

The Changing System: The Impact of the External Environment

The current drug abuse treatment system was developed largely during the 1960s and 1970s but is changing in response to increased expenditures for treatment, increased efforts toward cost containment, the growth of managed care, and shifts in ownership and funding.

• Methadone maintenance, therapeutic communities, and outpatient drug-free programs have been the predominant types of care for 20 years (Besteman, 1992; Gerstein & Harwood, 1990; Hubbard et al., 1989; Weisner, 1987), but the system is now changing in response to far-reaching external forces. These external forces are affecting the internal structure of treatment.
• Drug abuse treatment is delivered primarily in specialty facilities providing residential/inpatient and outpatient care but also in community mental health agencies, physicians offices, in prisons, by other social service professionals, and in a voluntary support network composed of self-help groups such as Alcoholics Anonymous, Narcotics Anonymous, and Cocaine Anonymous. About 87% of clients in specialty facilities receive care in outpatient programs (Substance Abuse and Mental Health Services Administration [SAMHSA], 1996).
• The treatment system has expanded dramatically over the past decade in response to increased federal expenditures for drug abuse treatment (Gerstein & Harwood, 1990; White House, 1994). The number of drug and alcohol treatment facilities almost doubled between 1980 and 1994 (SAMHSA, 1996, Table 5), while national and state expenditures for alcohol treatment about doubled (Huber, Pope, & Dayhoff, 1994). At the same time, increased restrictions have been placed on public spending for treatment through setasides, requirements, and cost ceilings (McCarty, 1996). These restrictions have altered who receives treatment and the types of services they receive. For example, specialized treatment for women has been mandated, increasing the numbers of women in treatment from 25% in 1980 to 30% in 1994 (SAMHSA, 1996).
• An emphasis on cost containment from all types of payers – federal, state, and local governments as well as employers – is placing increased pressures on programs to reduce costs and to provide service at set rates. Although expenditures have increased, these dollars are being used to support new initiatives and to increase the number of people who receive treatment. The result is that programs are trying to treat more clients at less cost, resulting in reductions in the quantity and quality of treatment services and in lengths of stay and a shift from more costly inpatient and residential care to less costly outpatient care.
• Managed care has introduced a variety of strategies to control the utilization, cost, and quality of health care (Mechanic, Schlesinger, & McAlpine, 1995; Wells, Astrachan, Tischler, & Unutzer, 1995). Cost savings appear to have resulted from the introduction of managed care (Callahan, Shepard, Beinecke, Larson, & Cavanaugh, 1995; Frank & McGuire, 1997), but the impact on service intensity and treatment outcomes has not been investigated fully. However, a number of research initiatives are in progress to investigate these issues, including the Brandeis/Harvard Research Center for Managed Care and Drug Abuse Treatment funded by the National Institute on Drug Abuse and the multisite Coordinating Center for Managed Care and Vulnerable Populations funded by SAMHSA.
• Although the treatment system is publicly funded through federal block grants and state and local subsidies, and state and federal legislation provides guidelines for the delivery of care, leadership of the system has shifted between federal and state governments (Horgan, 1996). The treatment system of the 1970s was largely publicly funded and treated indigent or uninsured clients (Gerstein & Harwood, 1990). The number of private-sector treatment programs that treated working-class and middle-class clients about doubled during the 1980s, but growth in the private sector began to level off during the latter part of the decade (Schmidt & Weisner, 1993).
• Changes in the client population of drug abuse treatment programs during the past 3 decades also have contributed to changes in the treatment system as it seeks to meet the needs of the clients it serves. During the 1980s, there was an increase in multiple drug abusers, a decrease in daily opioid users, more females, more mature clients, and more clients with lengthy treatment histories (Hubbard et al., 1989). In addition, cocaine replaced heroin as the major drug of abuse among clients entering treatment, crack cocaine entered the scene, and the severity of psychiatric and other problems among entering clients increased (Pickens & Fletcher, 1991). In the 1990s, there were more regular cocaine users, fewer heroin users, and more females among treatment clients than during the 1980s (Etheridge, Craddock, Dunteman, & Hubbard, 1995).

External environmental forces such as expansion of the treatment system, increased efforts toward cost containment, the growth of managed care, and shifts in ownership and funding are changing the structure and organization of the treatment system. These forces are in turn changing the internal structure of treatment.

The Internal Structure

Major changes in drug abuse treatment programs include blurring of boundaries between public and private sectors and between alcohol and drug programs, linkages to other programs and other service sectors, merging of programs and creation of interorganizational networks, decreases in the type and intensity of services, and shifts from inpatient and residential care to outpatient care.

• In the 1990s, boundaries between the public and private sectors have blurred as private programs have accepted increasing percentages of their overall funding from public sources (Schmidt & Weisner, 1993) and private programs are admitting increasing numbers of publicly funded clients (Zarkin and associates, 1995; Horgan,1996).
• The number of "combined" facilities offering more than one type of care likely has increased as treatment programs have merged for greater competitive advantage and attempt to offer a continuum of care. Many of these changes are the result of increased financial pressure on treatment programs and payers. As the pressure to contain costs has mounted, care is shifting from more costly hospital inpatient and residential care to outpatient care.
• Treatment for alcohol and drugs also has merged in many programs; the percentage of units that treated both alcohol and drug problems nearly tripled between 1982 and 1990 (Schmidt & Weisner, 1993). This shift is in response to the growing number of clients who have both alcohol and drug problems, but also to recognition of the similarities in addictions to drugs and alcohol.
• The past decade also has seen increased recognition of the interdependencies of treatment programs and the need to establish improved linkages between the treatment system and other systems of care: criminal justice agencies, health care, mental health care, and social service agencies. Drug abuse treatment has not adequately addressed the health and mental health problems of clients (Regier et al., 1990) and has largely been delivered separate from the general health care and mental health care sectors. Integrated care delivered through linked programs and services and active referrals across programs will deliver more clinically appropriate and cost-effective care than can be delivered in fragmented systems (Institute for Health Policy, 1995). Several models of coordination of substance abuse services with other types of services are possible: co-location of services, information and referral, centralized intake and referral, interagency networks, and case management (Baker, 1991).
• The system is placing increased attention on identification of drug abusing offenders and drug abuse treatment delivered to prison inmates – in short, to more effective linkages between the drug abuse treatment and criminal justice systems (Wellisch, Prendergast, & Anglin, 1993; Courtwright, 1992). The criminal justice system can help to identify persons in need of treatment and to match clients with appropriate services (Wellisch, Prendergast, & Anglin, 1995).
• There is increasing emphasis on linkages with the health care sector (Schlenger, Kroutil, Roland, & Dennis, 1992) based on the recognition of the health problems of drug abusers (Haverkos & Lange, 1990) and the utility of health providers in identifying and referring drug abusers to treatment (Bradley, 1994; Kamerow, Pincus, & Macdonald, 1986; Russo, 1991).
• Networks of providers have developed in response to financial pressures. The network would offer a broader array of services than a single program, thereby attracting a variety of types of clients. This trend will decrease the number of free-standing, isolated programs and may increase the delivery of services to those in need of specific services.
• Although these linkages and mergers may be improving the delivery of services to treatment clients, they are likely creating uncertainty for treatment providers. Service sectors differ in training and therapeutic orientation, and programs that once had been competitors now may be collaborators. Organizational perspectives may help to understand system tensions now occurring as programs merge and form networks of care.
• Drug abuse treatment is delivered in a variety of outpatient and residential settings by staff with different levels of education and training using pharmacologic and/or behavioral therapeutic approaches. Individual and group counseling constitute the backbone of treatment, although some programs provide "wraparound" services such as childcare and transportation that attempt to increase retention and assist in recovery. New pharmacologic treatments are being developed to supplement behavioral therapies.
• Many programs use recovering addicts to staff their programs. Mulligan, McCarty, Potter, and Krakow (1989), for example, found that about 46% of counselors in public and private treatment programs were recovering, and 45% had graduate degrees. Private for-profit units were more likely to have higher staff/client ratios, whereas state and local governmental units have the least intensive staffing (SAMHSA, 1993). According to the Drug Abuse Treatment System Survey, the average number of FTEs (full-time equivalents) has decreased 8% in outpatient nonmethadone units between 1990 and 1995, but increased slightly in methadone clinics (D'Aunno, 1995). This overall decrease in staffing is consistent with the increased financial pressures experienced by many programs.
• The shift to managed care, emphasis on cost containment, and growth of the private sector likely are changing the staffing of programs, but little recent information on the staffing of drug abuse treatment programs is available, nor has the impact of staff characteristics on the delivery of services been well investigated (Gerstein & Harwood, 1990). The effectiveness of recovering and nonrecovering staff, degreed and nondegreed staff, and staff whose gender and race/ethnicity match those of clients requires investigation. Major staffing problems for treatment programs are high turnover and unwillingness on the part of some professionals to work with the problems of drug abusers. These problems are likely exacerbated in the current environment of drug abuse treatment. Further, the shift to managed care may be placing more emphasis on hiring degreed staff and may be requiring that more administrative staff be hired to take care of the considerable burden placed on programs by managed care reporting requirements.
• The number and intensity of services delivered to clients have decreased over the past decade (D'Aunno, 1995; Etheridge et al., 1995), and a number of studies are indicating that treatment outcomes are linked to the intensity of treatment services. The Drug Abuse Treatment System Survey, for example, finds that the percentage of clients receiving a variety of treatment services (such as physical exams, routine health care, mental health services, employment counseling, and financial counseling) decreased during the 1990s. These decreases are likely related to an increased emphasis on cost containment and the implementation of managed care approaches.

Changes in the external environment of drug abuse treatment programs have brought about major changes in the internal structure of programs, but many issues remain uninvestigated. There are few studies of how treatment programs operate on a daily basis; how programs are managed; how decisions are made; who delivers what types of services; and how service delivery is related to recovery. Managed care likely is changing the ways work gets done in programs, and these changes in service delivery will affect treatment outcomes.

KEY ISSUES

A variety of environmental changes and financial pressures are bringing about profound changes in the drug abuse treatment system and in service delivery. These factors largely have been portrayed in descriptive terms without conceptual frameworks to depict the mechanisms by which external forces affect the organization of treatment and the delivery of treatment services. The application of organizational theory and perspectives could increase our understanding of how treatment is being delivered, the effect of financial and other pressures on the organization of treatment, and where policy attention should be placed.

Existing Information

Several investigators have used organizational perspectives to portray the impact of changes in the external environment of treatment programs on their internal structure, particularly focusing on the impact of financial pressures. D’Aunno (1994), modeled on Scott (1993), sets forth a general model of how the external environments of treatment and prevention organizations affect their internal structure and operations. D’Aunno depicts three domains in his conceptual framework: the external environment of treatment organizations, organization-environment relations, and their internal organization. Relevant aspects of the external environment include the role of social and community values; federal, state, and local regulation; market structure; and epidemiological factors such as community demographics and variation in use of services.

• D'Aunno and Price (1985) examine the development of outpatient drug abuse treatment services within the community mental health system as an instance of organizational adaptation. Focusing on changes in staffing patterns, they argue that changes in funding affect the type of staff hired: more professionals are hired as funding is increased, but professionals are dropped when funds decrease. Reductions in professional staff in turn are associated with differences in treatment goal setting.
• D'Aunno and Sutton (1992) trace the impact of decreases in drug abuse treatment funding on the delivery of services. Testing the thesis that financial threat leads to rigid responses by organizations, they find that decreases in total budgets are associated with rigid use of existing procedures, work force reduction, and competition among organization members.
• D'Aunno and Vaughn (1995) also document that changes in the external environment of treatment organizations such as decreased funding are altering the internal structure of drug abuse treatment organizations. In response to reduced funding, the percentage of clients receiving each of seven types of treatment services decreased between 1988 and 1990. Decreases in services were not consistent across all types of programs and depended to some degree on changes in the client population of treatment programs and on ownership of the facility.
• D'Aunno, Sutton, and Price (1991) depict the adaptations necessary as community mental health centers have diversified into drug abuse treatment. The two institutional environments place conflicting demands on treatment approaches and staffing.
• Price and D'Aunno (1992) provide an overview of the organization of drug abuse treatment services, arguing that the organization of treatment services determines who gets treated, what they receive, and how effective those services are. Organizational factors important in the provision of services are ownership, setting, staffing, managerial beliefs, government regulation, and payment mechanisms.
• McCaughrin and Price (1992) find that the following organizational factors predict outpatient drug abuse treatment outcomes: adequate staff levels, quality assurance efforts, client follow-up, and client selection factors that define variation across programs in client severity.
• Wheeler, Fadel, and D'Aunno (1992) document variation among private for-profit, public, and not-for-profit treatment units in the provision of care. Unit ownership defines substantial differences in clients, services, access to services, and expenditures. These differences likely have an important effect on the quality of care.
• Weisner and Room (1984) document the expansion of the alcohol treatment system, the shift from government-provided services to contracted-out services, and the growth of the private sector within this period, trends also occurring in the drug abuse treatment system. These changes are related to governmental efforts at cost containment as well as the growth and accountability of professional services.
• Schmidt and Weisner (1993) trace the movement from hospital-based care to outpatient care and the increased interdependency of alcohol treatment systems with other health and social service agencies, including health, mental health, and criminal justice. Many alcohol and drug treatment organizations have merged recently into "substance abuse treatment" organizations. This blurring of boundaries between criminal justice, drug, and alcohol treatment systems may, according to Schmidt and Weisner, be shifting attention away from therapeutic functions to the control of dangerous individuals.
• Using a conception of the "social ecology" of treatment organizations, Weisner (1987) examines how treatment cases enter community-based systems of care and the interaction and referral processes among them. Alcohol abusers are found in the caseloads of a number of health and social service agencies, and the paths and barriers to treatment are many.
• Scott (1996) discusses basic components of the alcohol treatment and prevention service delivery systems: treatment payers and programs, practitioners and staff, the client population, and the technology of service delivery. He describes organizational research on the system as being at a rudimentary level, focused to date on the structure of the specialty sector and access to care; the relationships between the specialty sector and other sectors such as general medical services and other social services; and studies of whole systems of care at the local level. Organizational research is lacking in such critical areas as the interactions among sectors, networks, and programs, and the integration of alcohol and drug abuse treatment.
• Marsden (1996) documents the impact of changes in the external environment on the internal environment of programs. External forces include efforts toward cost containment, the growth of managed care, changes in federal and state policy, public attitudes, and changes in the treatment population. Providers have adapted to these external forces by shifting from residential to outpatient treatment, decreasing the length of stay, decreasing services, and increasing linkages to criminal justice, primary care, and the workplace.
• Horgan (1996) discusses the nature of financing of alcohol treatment services that differs from other health care services in the dominant role that the public sector plays. Broader changes in health care, largely the growth of managed care, are introducing new actors in the system: purchasers (the entities that sponsor health plans) and intermediaries (managed care organizations). Little is known about these arrangements and their impacts on service delivery.
• Other investigators have examined the organizational characteristics of drug abuse treatment from a more descriptive level. Batten, Marsden, Simon, and Horgan (1992) provide an overview of findings from the 1990 Drug Services Research Survey on the type of care, setting, size, ownership, funding, staffing, and client population of drug abuse treatment facilities. D'Aunno (1995) also provides an overview of findings from the Drug Abuse Treatment System Survey conducted in 1988, 1990, and 1995. He traces the increase in multiple drug use, decrease in cocaine use, and increase in crack use. The percentage of clients receiving various services in both outpatient methadone and nonmethadone programs has decreased, and the percentage of treatment revenues from private sources is increasing relative to governmental sources. About 50% of nonmethadone units and 30% of methadone units in 1995 had some type of managed care arrangement with Medicaid, other governmental agencies, or private insurance companies. Data on the structure and organization of the drug and alcohol treatment system also are available from the National Drug and Alcoholism Treatment Unit Survey (NDATUS), now the Uniform Facility Data Set survey (UFDS) (see SAMHSA [1996]).
• The decrease in treatment services noted by D'Aunno also is found by Etheridge and associates (1995) in a comparison of findings from the Treatment Outcome Prospective Study (TOPS) of the 1980s and the Drug Abuse Treatment Outcome Study (DATOS) of the 1990s. They note that although clients are entering drug abuse treatment with more serious drug use and co-occurring problems, they are receiving fewer services in programs and in the community, resulting in a higher level of unmet need.
• McLellan and associates (1993, 1994, 1996) find that treatment services are significant predictors of outcomes and that enhanced services result in more positive outcomes.
• A host of recent studies is examining the impact of managed care on the provision of treatment services. Notably, an Institute of Medicine committee on quality improvement in behavioral health (mental health and substance abuse services) reviewed information about the effects of managed care on the structure, access, process, and outcomes of behavioral health services (Edmunds et al., 1997). The study documents the complex and often fragmented organizational and financing structures involved in providing behavioral health care services and needed reforms in systems of care. These include mechanisms to inhibit cost-shifting and to guarantee the provision of services for underserved populations.

Organizational studies to date are limited and have focused largely on examining the impact of reductions in funding on staffing patterns and service intensity. However, a number of researchers are examining what happens in the "black box" of treatment and its impact on treatment outcomes, and there is a growing body of research on the impact of managed care on treatment services.

Gaps and Unanswered Questions

A number of questions remain unanswered about the organization of treatment, including the impact of environmental forces on service delivery, the continuum of care, linkages to other systems of care, and the impact of changes in service delivery to treatment outcomes. There is increasing recognition of the interdependencies between programs and the importance of market forces in the organization of treatment. Programs are positioning themselves to improve their competitive edge. With the strength of environmental forces affecting treatment and the magnitude of changes in the organization of treatment, organizational studies can inform the processes of survival and adaptation now occurring in treatment.

Because a limited number of research studies have used organizational frameworks to study change in drug abuse treatment systems and treatment services, there remain a number of unanswered questions that could guide future research efforts on organizational structures and the environmental context of treatment. These include:

• The impact of shifts in public and private funding on the organization of treatment services
• The impact of managed care on the provision of treatment services, particularly for vulnerable populations
• The impact of system change on the continuum of care
• The provision of care outside the specialty treatment system and the relation to organizational changes within the specialty treatment system
• The provision of health and mental health services for drug abuse treatment clients as the treatment system changes
• The impact of environmental factors on program staffing and, in turn, on treatment outcomes
• The impact of program setting, ownership, and management on service delivery
• Changes in the delivery of drug abuse treatment services in response to changes in the client population
• Survival and adaptation of drug abuse treatment programs in an era of environmental change
• The development of interorganizational networks and impacts on service delivery and on meeting clients' treatment needs
• Changes in technology associated with environmental forces, including changes in systems of monitoring and reporting and in treatment approaches

These studies of the structure of drug abuse treatment programs and service delivery in those programs can effectively use organizational frameworks to contribute to a greater understanding of the provision of treatment services and the impact on treatment outcomes during a period of rapid system change. The studies link the internal workings of treatment programs to the external environment of factors such as funding, ownership, linkages to other systems of care, changes in the client population, and the growth of managed care. They will provide the foundation for policy development to improve the effectiveness of treatment.

THEORETICAL APPROACHES TO RESOLVING ISSUES

Social science perspectives on organizations can provide the basis for studies of the organizational structures and environmental context of drug abuse treatment. These perspectives portray the elements of organizations and the interrelations among those elements and the environments in which they operate.

Areas of Interest

Organizational perspectives that have guided the study of work environments, health care, and other organizations specify elements of the external and internal environments of organizations and the relationships between them.

• Following Leavitt (1965) and others, Scott (1992, pp. 16-21) specifies four internal elements of an organization: the social structure, or normative component and behaviors and interactions of participants; participants in organizations, defined in terms of demographic and other characteristics; goals or desired ends; and technology, including processes and procedures as well as knowledge and skills of participants. To these internal elements, Scott adds an external one – the environment of organizations. The organizational environment includes those physical, technological, cultural, social, and economic contexts within which the organization functions and to which it must adapt.
• Social science organizational theory is marked by a major shift beginning in the 1960s from a closed system rational view that focused on the internal elements of organizations such as management problems to more of an open system natural perspective that emphasized organization-environment relations (Aldrich & Marsden, 1988; Scott, 1992).
• Three contrasting perspectives on the nature of organizations have resulted that focus on different sets of internal and external organizational elements and processes (Scott, 1992, pp. 21-122). The organizations as rational system perspective, for example, views organizations as instruments to accomplish specified goals; the emphasis is on formalization, efficiency, and performance. The organizations as natural systems perspective focuses on the behavior of organizations and the evolution of forms; it sees organizations as collectivities engaging in survival activities informally. The more recent organizations as open systems perspective concentrates on the external environment of organizations; it sees organizations as interdependent activities engaged in by shifting coalitions of participants. The systems are dependent on and respond to their external environments.
• A number of more recent attempts have been made at integrating these three perspectives, particularly focusing on the environment of organizations and the interactions between the organization and its environment. For example, the population ecology model views the natural selection of organizations; it attempts to explain the processes by which types of organizations survive or die based on the fit between organizational forms and the environment. Whereas the population ecology model examines the replacement of one type of organization with another, the resource dependency model stresses adaptation of organizations to their environments. Organizations acquire resources through interdependencies, diversification, and merger (Scott, 1992, pp. 95-122). Interorganizational networks are one type of adaptive and survival mechanism specified by the population ecology model, whereas resource dependency defines the network's reliance on external funding and adaptations to changes in funding (Alter & Hage, 1993, pp. 25-29, 102-103). A number of these more recent formulations describe the boundary-setting strategies of organizations as they interact with their environments. These procedures concern decisions about the membership of organizations, labor market practices, and exchanges and joint ventures with other organizations (Scott, 1992, pp. 180-225).
• These organizational perspectives have been useful in describing the major changes that have occurred in the health care sector in the past half century as well as in mental health services. Scott (1993), for example, places the major trends in health care (increased scale, increased concentration, increased specialization, increased diversification, increased linkages among provider organizations, expanded role of government, increased managerial and reduced professional influence, and increased market orientation) within an integrated model that considers how the institutional and technical environments are creating new organizational forms. There has been a blurring of organizational boundaries between public and private health care agencies as well as use of vertical and horizontal integration strategies to adapt to environmental changes. Scott and Black (1986) in a collection of articles examine the organization of mental health systems, whereas Morrissey and colleagues (1994) have examined interorganizational linkages among mental health treatment providers.

Organizational perspectives have been used in numerous studies of health care and mental health care but have been applied less frequently to the study of substance abuse treatment programs and services. However, the magnitude of environmental changes faced by treatment programs suggests that these perspectives may be useful in understanding the profound changes in structure that are occurring.

Key Discussion Points

Organizational perspectives may provide the basis for organizing research on the changing drug abuse treatment system. As noted earlier, the system is undergoing rapid change in response to environmental forces such as pressures toward cost containment, the growth of managed care, and changes in ownership and funding. Organizational perspectives can aid in defining the key actors and forces in both the internal and external environments of drug abuse treatment programs and the interrelationships among these factors toward understanding the organizational adaptations that are occurring. These adaptations include mergers, networks of programs, and alterations in treatment approaches and in the scope and intensity of services delivered to clients. All these changes are likely influencing the long-term recovery of clients.

SUMMARY AND CONCLUSIONS

Although substantial changes are occurring in the organization of drug abuse treatment, relatively few studies have examined the changing environment of treatment and its impact on the internal structure and operations of treatment. The magnitude of changes confronting treatment programs is signaling a major upheaval in the ways in which treatment is provided. From treatment delivered primarily in free-standing outpatient facilities, the system is becoming one of interdependent programs in provider networks in a highly competitive environment. Several nationally based studies provide information about the structure of treatment, including the 1990 Drug Services Research Survey and the 1988, 1990, and 1995 Drug Abuse Treatment System Survey. Work is underway on the Alcohol and Drug Services Study, funded by SAMHSA, which will provide information to link the organization of treatment facilities, client populations, and treatment outcomes in programs across the nation. Studies of this type, which link the organization of treatment, service delivery, and treatment outcomes, are needed. Longitudinal designs that follow organizational changes in specific programs also are needed. Organizational perspectives can inform the study of the changing external and internal environments of drug abuse treatment programs, particularly studies of the changing organization of treatment programs and its impact on service delivery and treatment outcomes.

Organizational studies of drug abuse treatment conducted to date have focused on the impact of financial restrictions on treatment services and staffing and on describing the organization of treatment in specialty facilities. Additional studies are needed that examine the nature and intensity of treatment services delivered to clients, the characteristics of staff and their effectiveness, the management of treatment programs, and the provision of care outside the specialty sector. The impact on service delivery of newer organizational forms such as provider networks and linkages to other service systems needs to be investigated. These forms may be expanding the range of services available to clients, bringing about more positive treatment outcomes, but their impact has not been investigated. These studies can be guided effectively by organizational perspectives that suggest important variables and the linkages among them, depicting the impact of changes in the internal and external environments of treatment programs on the provision of services for clients. However, new types of data are needed for these studies that enable linking the external environment of treatment, the organization of treatment, the provision of services, and treatment outcomes.

REFERENCES

Aldrich, H. E., & Marsden, P. V. (1988). Environments and organizations. In N. J. Smelzer (Ed.), The handbook of sociology. Beverly Hills, CA: Sage Publications.

Alter, C., & Hage, J. (1993). Organizations working together. Sage library of social research 191. Newbury Park: Sage Publications.

Baker, F. (1991). Coordination of alcohol, drug, and mental health services. Rockville, MD: Alcohol, Drug Abuse, and Mental Health Services Administration, Office for Treatment Improvement.

Batten, J. L., Marsden, M. E., Simon, L., & Horgan, C. M. (1992). The organization of drug treatment. Waltham, MA: Brandeis University, Institute for Health Policy.

Besteman, K. J. (1992). Federal leadership in building the national drug treatment system. In D. R. Gerstein & H. J. Harwood (Eds.), Treating drug problems: Volume 2. Washington, DC: Institute of Medicine.

Bradley, K. A. (1994). The primary care practitioner's role in the prevention and management of alcohol problems. Alcohol Health and Research World, 18, 97-104.

Callahan, J. J., Shepard, D. S., Beinecke, R. H., Larson, M. J., & Cavanaugh, D. (1995). Mental health/substance abuse treatment in managed care: The Massachusetts Medicaid experience. Health Affairs, 14, 173-184.

Courtwright, D. T. (1992). A century of American narcotic policy. In D. R. Gerstein & H. J. Harwood (Eds.), Treating drug problems. Volume 2. Washington, DC: Institute of Medicine.

D'Aunno, T. (1994). Management and organization of drug abuse treatment and prevention services. Ann Arbor: University of Michigan, Institute for Social Research.

D'Aunno, T. A. (1995). Treating drug abuse in America. Results from a study of the outpatient substance abuse treatment system 1988-1995. Ann Arbor: University of Michigan, Institute for Social Research.

D'Aunno, T., & Price, R. H. (1985). Organizational adaptation to changing environments. American Behavioral Scientist, 28 (5), 669-683.

D'Aunno, T., & Sutton, R. I. (1992). The responses of drug abuse treatment organizations to financial adversity: A partial test of the threat-rigidity thesis. Journal of Management, 18 (1), 117-131.

D'Aunno, T., Sutton, R. I., & Price, R. H. (1991). Isomorphism and external support in conflicting institutional environments: A study of drug abuse treatment units. Academy of Management Journal, 34 (3), 636-661.

D'Aunno, T., & Vaughn, T. E. (1995). An organizational analysis of service patterns in outpatient drug abuse treatment units. Journal of Substance Abuse, 7, 27-42.

Edmunds, M., Frank, R., Hogan, M., McCarty, D., Robinson-Beale, R., & Weisner, C. (1997). Managing managed care. Quality improvement in behavioral health. Institute of Medicine Committee on Quality Assurance and Accreditation Guidelines for Managed Behavioral Health Care. Washington, DC: National Academy Press.

Etheridge, R. M., Craddock, S. G., Dunteman, G. H., & Hubbard, R. L. (1995). Treatment services in two national studies of community-based drug abuse treatment programs. Journal of Substance Abuse, 7, 9-26.

Frank, R. G., & McGuire, T. G. (1997). Savings from a Medicaid carve-out for mental health and substance abuse services in Massachusetts. Psychiatric Services, 48, 1147-1152.

Gerstein, D. R., & Harwood, H. J. (Eds.). (1990). Treating drug problems: Volume I. Washington, DC: National Academy Press.

Haverkos, H. W., & Lange, W. R. (1990). Serious infections other than human immunodeficiency virus among intravenous drug abusers. Journal of Infectious Diseases, 161, 894-902.

Horgan, C. M. (1996). Financing and reimbursement arrangements for the provision of alcohol services. Final Report. Panel on Financing and Organization. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism, National Advisory Council on Alcohol Abuse and Alcoholism.

Hubbard, R. L., Marsden, M. E., Rachal, J. V., Harwood, H. J., Cavanaugh, E. R., & Ginzburg, H. M. (1989). Drug abuse treatment: A national study of effectiveness. Chapel Hill, NC: University of North Carolina Press.

Huber, J. H., Pope, G. C., & Dayhoff, D. A. (1994). National and state spending on specialty alcoholism treatment: 1979 and 1989. American Journal of Public Health, 84, 1662-1666.

Institute for Health Policy. (1995). Integrated financing and delivery of care for alcohol, drug, and mental health disorders. Waltham, MA: Brandeis University, Institute for Health Policy.

Kamerow, D. B., Pincus, H. A., & Macdonald, D. I. (1986). Alcohol abuse, other drug abuse, and mental disorders in medical practice. Journal of the American Medical Association, 255 (15), 2054-2057.

Leavitt, H. J. (1965). Applied organizational change in industry: Structural, technological, and humanistic approaches. In J. G. March (Ed.), Handbook of organizations (pp. 1144-1170). Chicago: Rand McNally.

Marsden, M. E. (1996). A provider-level view of the delivery of alcohol treatment and prevention services. Final Report. Panel on Financing and Organization. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism. National Advisory Council on Alcohol Abuse and Alcoholism.

McCarty, D. (1996). The effects of state and federal policies on the cost and utilization of services for alcohol abuse and alcoholism. Final Report. Panel on Utilization and Cost. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism, National Advisory Council on Alcohol Abuse and Alcoholism.

McCaughrin, W. C., & Price, R. H. (1992). Effective outpatient drug misuse treatment organizations: Program features and selection effects. International Journal of the Addictions, 27 (11), 1335-1358.

McLellan, A. T., Alterman, A. I., Metzger, D. S., Grissom, G., Woody, G. E., Luborsky, L., & O'Brien, C. P. (1994). Similarity of outcome predictors across opiate, cocaine, and alcohol treatments: Role of treatment services. Journal of Consulting and Clinical Psychology, 62, 1141-1158.

McLellan, A. T., Arndt, I. O., Metzger, D., Woody, G. E., & O'Brien, C. P. (1993). The effects of psychosocial services in substance abuse treatment. Journal of the American Medical Association, 269, 1953-1959.

McLellan, A. T., Woody, G. E., & Metzger, D., McKay, J., Durell, J., Alterman, A. I., & O?Brien, C. P. (1996). Evaluating the effectiveness of addiction treatments: Reasonable expectations, appropriate comparisons. Milbank Quarterly, 74 (1), 51-85.

Mechanic, D., Schlesinger, M., & McAlpine, D. D. (1995). Management of mental health and substance abuse services: State of the art and early results. Milbank Quarterly, 73 (1), 19-55.

Morrissey, J. P., Calloway, M., Bartko, W. T., Ridgely, M. S., Goldman, H. H., & Paulson, R. I. (1994). Local mental health authorities and service system change: Evidence from the Robert Wood Johnson program on chronic mental illness. Milbank Quarterly, 72 (1), 49-80.

Mulligan, D. H., McCarty, D., Potter, D., & Krakow, M. (1989). Counselors in public and private alcoholism and drug abuse treatment programs. Alcoholism Treatment Quarterly, 6 (3/4), 75-89.

Pickens, R. W., & Fletcher, B. W. (1991). Overview of treatment issues. In R. W. Pickens, C. G. Leukefeld, & C. R. Schuster (Eds.), Improving drug abuse treatment [NIDA Research Monograph 106]. Rockville, MD: National Institute on Drug Abuse.

Price, R. H., & D'Aunno, T. A. (1992). The organization and impact of outpatient drug abuse treatment services. In R. R. Watson (Ed.), Drug and alcohol abuse reviews, Vol. 3: Treatment of drug and alcohol abuse. Totowa, NJ: Humana Press, Inc.

Regier, D. A., Farmer, M. E., Rae, D. S., Locke, B. Z., Keith, S. J., Judd, L. L., & Goodwin, F. K. (1990). Comorbidity of mental disorders with alcohol and other drug abuse. Journal of the American Medical Association, 264 (19), 2511-2518.

Russo, R. J. (1991). Primary care and intravenous drug abuse treatment. In R. W. Pickens, C. G. Leukefeld, & C. R. Schuster (Eds.), Improving drug abuse treatment [NIDA Research Monograph 106]. Rockville, MD: National Institute on Drug Abuse.

Schlenger, W. E., Kroutil, L. A., Roland, E. J., & Dennis, M. L. (1992). National evaluation of models for linking drug abuse treatment and primary care. Research Triangle Park, NC: Research Triangle Institute.

Schmidt, L., & Weisner, C. (1993). Developments in alcoholism treatment. In M. Galanter (Ed.), Recent developments in alcoholism, Volume II: Ten years of progress. New York: Plenum Press.

Scott, J. (1996). A system-level view of organizational research on the treatment and clinical prevention of alcohol-related problems. Final Report. Panel on Financing and Organization. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism, National Advisory Council on Alcohol Abuse and Alcoholism.

Scott, W. R. (1992). Organizations: Rational, natural, and open systems (3rd ed). Englewood Cliffs, NJ: Prentice-Hall.

Scott, W. R. (1993). The organization of medical services: Toward an integrated theoretical model. Medical Care Review, 50 (3), 271-303.

Scott, W. R., & Black, B. L. (1986). The organization of mental health services: Societal and community systems. Beverly Hills, CA: Sage Publications.

Substance Abuse and Mental Health Services Administration. (1993). National Drug and Alcoholism Treatment Unit Survey (NDATUS). 1991 Main findings. Rockville, MD: Author.

Substance Abuse and Mental Health Services Administration. (1996). National Drug and Alcoholism Treatment Unit Survey (NDATUS): Data from 1994 and 1980-1994. Advance report number 13. Rockville, MD: Author.

Weisner, C. (1987). The social ecology of alcohol treatment in the United States. In M. Galanter (Ed.), Recent developments in alcoholism: Vol. 5 (pp. 203-243). New York: Plenum Press.

Weisner, C., & Room, R. (1984). Financing and ideology in alcohol treatment. Social Problems, 32 (2), 167-184.

Wellisch, J., Prendergast, M. L., & Anglin, M. D. (1993, Winter). Criminal justice and drug treatment systems linkage: Federal promotion of interagency collaboration in the 1970s. Contemporary Drug Problems, pp. 611-650.

Wellisch, J., Prendergast, M. L., & Anglin, M. D. (1995). Toward a drug abuse treatment system. Journal of Drug Issues, 25, 759-782.

Wells, K. B., Astrachan, B. M., Tischler, G. L., & Unutzer, J. (1995). Issues and approaches in evaluating managed health care. Milbank Quarterly, 73 (1), 57-75.

Wheeler, J. R. C., Fadel, H., & D'Aunno, T. (1992). Ownership and performance of outpatient substance abuse treatment centers. American Journal of Public Health, 82 (5), 711-718.

White House. (1994). National drug control strategy. Washington, DC: Office of National Drug Control Policy.

Zarkin, G. A., Galinis, D. N., French, M. T., Fountain, D. L., Ingram, P. W., & Guyett, J. A. (1995). Financing strategies for drug abuse treatment programs. Journal of Substance Abuse Treatment, 12 (6), 385-399.