Targeted Outreach

Substance use disorders affect millions of Americans of all ages and backgrounds. Insurance providers play an integral role in ensuring that people who need treatment have access and can begin a path of recovery. Substance use disorders can cause a variety of related illnesses, such as heart or liver disease, and directly contribute to an increase in health care and insurance-related costs.¹ However, recognizing that substance use disorders are treatable and covering treatment options will help insurance providers defray more costs in the long run. It also will help improve the health and well-being of those affected.

Picture your average girl next door from a middle class suburban family in the midst of a major crisis. Add a genetic disposition to addiction and a 16-year-old girl searching for an escape from the chaos in all the wrong placesyou have me. I spent 2 years running the streets lying, cheating, and manipulating my way to my next fix. A run-in with the law forced me to take a look at my options in life: keep going and end up in jail, or seek help. The option of treatment seemed the obvious choice, but that hope died when my insurance denied funding for in-patient treatment. I decided to follow choice number two. I continued my self-destructive behavior for two more months before run-ins with the law turned into handcuffs, leading to three days in county lockup. Following desperate attempts to get me treatment, my parents received news that I was eligible for a scholarship at the local treatment facility. I was bailed out on the condition that I attend a full 31-day program and complete it successfully. Treatment provided me with a safe environment to remove myself from the people, places, and things that are so dangerous for me. I was taught basic principles for living life sober and how to become a productive member of society. If I hadnt gotten the scholarship to fund my treatment, I can only imagine where I would be today.

Carrie Lee Schwartz

Person in Recovery

A substance use disorder* (See Glossary near the end of this page for definitions of bolded and starred terms) involves the dependence on, or abuse of, alcohol and/or drugs, including the nonmedical use of prescription drugs. Substance use disorders can affect people regardless of their age, race, ethnicity, class, employment status, or community.² Therefore, like other chronic physical and mental disorders, substance use disorders are medical conditions that can be treated effectively.^{3, 4}

Insurance providers play a large part in determining whether someone who needs treatment actually receives it. With that in mind, this document will provide an overview of the value of investing in treatment*, as well as the costs of untreated substance use disorders. Later in this piece, you will find specific examples of employers and policies that have effectively provided more access to treatment services.

Investing in treatment makes financial sense, and perhaps most importantly, helps people on a path of recovery. Research shows that substance use disorders are medical conditions that can be effectively treated, just as many illnesses are treatable.^{5, 6} A major study published in 2000 in the Journal of the American Medical Association is one of several that demonstrate the effectiveness of treatment for substance use disorders. The study found that treatments for drug use disorders are just as effective as treatments for other chronic conditions, such as high blood pressure, asthma, and diabetes.⁷

Many studies show a positive return on investment when money is spent on treatment. Research suggests at least a 2:1 benefit-to-cost ratio, with other studies allowing for a return of $7 for every dollar spent on treatment.^{8, 9} Another study discovered as much as a $23 return for every dollar spent on treatment.¹⁰ While the return on investment varies from state to state and program to program, evidence supports the overall positive financial gain to businesses when investing in the treatment of people with substance use disorders. Ensuring Solutions to Alcohol Problems offers an online tool that assists employers in determining the return-on-investment ratio when investing in alcohol screening and treatment for employees. This tool, titled The Alcohol Cost Calculator for Business, is available online at www.alcoholcostcalculator.org/roi/.

Offering adequate health care coverage that provides people with access to treatment programs is cost effective. A Substance Abuse and Mental Health Services Administration (SAMHSA) study found that covering mental health and/or substance use disorder treatment at the same level as other medical care in private health insurance plans that strictly manage the offering would only increase family insurance premiums by less than 1 percent.¹¹ This nominal increase is a small price to pay when considering the amount of savings at stake.

In fact, while providing extensive coverage might be challenging in today’s economic climate, studies have repeatedly shown that investing in treatment offsets any costs. Integrating treatment for substance use disorders with medical treatment can actually cut the cost of medical treatment in half.^{12, 13, 14}

Aside from the large economic benefits, treatment reduces alcohol and/or drug use, improves mental and physical health, and contributes to a healthier family. Providing treatment for people with substance use disorders is directly related to improvements in the public’s health and safety, as well as a reduction in health costs.^{15, 16} Following treatment, alcohol- and drug-related medical visits decline 53 percent.¹⁷

Coverage options should also be taken into account for serious psychological distress* (SPD), or mental illness, which is associated with substance use disorders. People with a substance use disorder and SPD at the same time are said to have a co-occurring disorder. Co-occurring mental and substance use disorders are fairly prevalent, with 21.3 percent of adults with SPD also having a substance use disorder. Therefore, ensuring that treatment is available and accessible for both disorders is essential to providing a successful path of recovery*.¹⁸ According to SAMHSA's Report to Congress on the Prevention and Treatment of Co-Occurring Substance Abuse Disorders and Mental Health Disorders, the treatment of both mental health and substance use disorders can help prevent the exacerbation of other health problems, including cardiac and pulmonary diseases.¹⁹ Preventing additional diseases will, therefore, help reduce the insurance provider’s costs for additional coverage.

Despite the benefits of treating substance use disorders, treatment costs continue to hinder access for many people, ultimately increasing other health costs for insurers. Combined data from 2004 and 2005 state that among people who needed treatment for a substance use disorder, didn’t receive it at a specialty facility*, and felt they needed it, 35 percent said they did not receive it because of cost and insurance barriers.²⁰ In fact, nearly 44 percent of people who received treatment for alcohol or illicit drug use in the past year paid at least a portion of the cost with their own savings or earnings, more than any other reported source.²¹

The burden on both public and private insurers is clear. People with substance use disorders rely on public sources of financing to a much greater degree than people with other diseases. In 2001, 76 percent of total spending for treatment for substance use disorders nationwide was by public sources—primarily state and local governments, as well as Medicaid, Medicare, and other federal funding. In contrast, 45 percent of overall health care spending was by public sources. Furthermore, private insurance represented only 13 percent of treatment expenditures, while it covered 36 percent of all health care expenditures.²²

Employer health plans are a large source of financing for treatment. Most people with substance use disorders are employed, costing businesses financially through increased medical claim costs.²³ In 2005, of the 20.2 million adults classified with substance dependence or abuse, 15.5 million (or 76.7 percent) were employed.²⁴ Some insurance policies require people with substance use disorders to cover some of the cost themselves. They may need to pay higher deductibles and copayments, experience annual or lifetime dollar limits for treatment, or receive less coverage or limits on the allowed number of visits or days of coverage.²⁵

Regardless of how treatment is funded, there are great costs to society. Health-related substance use disorder costs in 2002 were projected to total $16 billion for drug use, representing an increase of $5.1 billion since 1992.²⁶ The overall costs of substance use disorders are comparable to those of other devastating, and often treatable diseases, many of which are likely covered by insurance. Based on 1990s' estimates that employed comparable methodologies, the total economic cost of the consequences of drug abuse (about $180.9 billion in 2002) and alcohol abuse (about $184.6 billion in 1998) was equivalent, if not higher than:

People with untreated substance use disorders have a greater risk of suffering from additional diseases, which increases health-related costs, and have a greater chance of death. In fact, heavy drinking contributes to illness in each of the top three causes of death: heart disease, cancer, and stroke. The 10th leading cause of death—liver disease—is largely preventable, as nearly half of all cirrhosis deaths are linked to alcohol.³² Drinking also causes accidents and other bodily injuries.^{33, 34, 35} Illicit drug use is associated with hepatitis, tuberculosis, and indirect causes of death, such as falls and motor vehicle crashes.³⁶ Lastly, there are substantial health care costs for people who do not have substance use disorders, but are harmed by the behavior of those who do, such as motor vehicle accidents caused by individuals operating under the influence.³⁷ In 2000, the costs of alcohol-related crashes in the United States were estimated at $51 billion.³⁸

Dependence on alcohol and/or drugs is a disease that deserves the same treatment coverage as for other chronic, relapsing disorders such as diabetes and hypertension.³⁹ Untreated, it can drain health care resources that could be used to provide insurance coverage for treatment. It is important for insurance providers to understand the landscape of treatment coverage, the positive outcomes of treatment and recovery services, and the cost benefit to people who are insured, their families, their employers, and the community.

Managers of company insurance plans who view treatment for substance use disorders as comparable to other medical illnesses can set good examples for insurance providers and businesses in the community.

For example, the Ohio State Employee Program was one of the first employee-sponsored health plans to cover mental health and substance use disorder treatment on the same level as other medical care, starting in 1991. The level of coverage has remained constant over a 10-year period and there was no evidence of a sudden increase in costs.^{40, 41}

Two West Coast employers implemented similar policies in January 2001, substantially increasing the generosity of plan benefits. For one employer, costs in the first quarter under this improved coverage policy were identical to the two previous quarters and slightly lower than the prior year. For the other employer, costs in the first quarter were slightly higher, at about $1.50 per member per month compared to prior quarters. This corresponds to an increase of less than 1 percent of the premium.⁴²

More than 1,400 federal and state laws affect health insurance companies and their offerings. These laws set standards for items such as consumer protection and coverage requirements.^{43, 44} Currently, seven states require equal coverage for treatment for substance use disorders as compared to other medical illnesses. In states where insurance laws require that treatment coverage be the same as that for other illnesses, people are more likely to get the services they need.⁴⁵

In 1998, Vermont enacted a law to require that mental health and substance abuse treatment be on par with other medical coverage. The law was widely viewed as one of the most comprehensive in the country and applied to all employers, regardless of size. In a study of both large and small employers, two-thirds reported that they were satisfied with this law. Many valued the treatment coverage, and others had seen their employees’ need for this type of coverage firsthand. Some employers thought equal coverage of treatment might make their employees even more productive.⁴⁶

Some employers voluntarily offer their employees equal coverage for treatment even though they are not located in the states that require it. Large companies that write and administer their own health plans and are exempt from state insurance laws, and some individual health plans, already provide equal coverage for treatment services, most commonly for alcohol dependence.⁴⁷ This sets an important precedent for other businesses that self-regulate their insurance plans. When insurance providers offer companies the opportunity to provide equal coverage for treatment, even if they are not required to do so, they are sending the message that they care about the well-being of local businesses and their employees, while also increasing cost efficiency.

Without adequate, well-rounded, and comprehensive coverage, people with substance use disorders may be able to access some treatment services, but not necessarily the specific program that best suits their needs. Recovery is a personal process, with each individual finding his or her own path, and ideally a treatment and recovery plan should be based on a person’s individual needs.^{48, 49, 50} To increase the likelihood of success, and ultimately reduce subsequent health care costs, insurance providers can promote multiple avenues of treatment.

Treatment is offered in different settings. Types of treatment greatly depend on the substances misused, as well as a person’s individual needs and characteristics. Treatment is offered in residential and outpatient programs and can include counseling or other behavioral therapy, family therapy, medication, or a combination of these services.^{51, 52}

Different groups of people are often provided with distinct methods of treatment that may work better for them. For example, a family-oriented approach to treatment can be most effective among adolescents with substance use disorders.⁵³ Older adults may respond well to age-specific, supportive, and nonconfrontational group treatment that aims to build or rebuild self-esteem.⁵⁴

Using performance measurement* tools to assess and improve the quality of treatment for people with substance use disorders is one way insurance providers can help. For example, the National Committee for Quality Assurance, a nonprofit accreditor for managed care organizations, developed and maintains a tool to measure health care value and improve quality—the Health Plan Employer Data and Information Set (HEDIS). Almost 90 percent of America’s health plans use HEDIS to measure performance on important elements of care and services for many different health conditions.⁵⁵

Another resource is available through the National Business Coalition on Health (NBCH), which represents more than 7,000 employers—including several of the nation’s largest—who provide insurance for an estimated 34 million workers and their families. Since 1999, the NBCH has offered a Web-based tool called eValue8 that enables its members to conduct a uniform, annual assessment of the quality of care for a wide range of health conditions. This tool includes an alcohol module that incorporates several performance quality recommendations made by a panel funded by SAMHSA. It found that health plans should be held accountable for the entire process of addiction care, including educating patients about substance use disorders.

Insurance providers should recognize that employers select their plans partly based on accountability. About half of the participating employers offer financial rewards to high-performing plans or provide employees with financial incentives to choose these plans for their health care needs. Employers use these rewards and incentives to drive quality improvement in substance use disorder treatment within their health plans.⁵⁶ Insurance providers, likewise, can use these tools to help employers purchase plans that provide the most effective care.

This September, National Alcohol and Drug Addiction Recovery Month (Recovery Month) will be celebrated by hundreds of organizations and communities around the country to highlight the value of investing in treatment for substance use disorders. As part of Recovery Month 2007’s theme, “Join the Voices for Recovery: Saving Lives, Saving Dollars,” you can take the following steps:

Much has been written about substance abuse, dependence, and addiction; many studies have used different terminology to explain their findings. To foster a greater understanding and avoid perpetuating any stigma associated with these conditions, the phrase “substance use disorders” is used as an umbrella term to encompass these concepts.

Below you will find extensive definitions of substance use disorders, other terms that are highlighted throughout this document, and additional concepts that you may find useful. Unless otherwise noted, more detailed definitions and criteria can be found in the 2005 National Survey on Drug Use and Health: National Findings at www.oas.samhsa.gov/nsduh.htm.

Substance use disorders – Substance use disorders involve the dependence on or abuse of alcohol and/or drugs. Dependence on and abuse of alcohol and illicit drugs, which include the nonmedical use of prescription drugs, are defined using the American Psychiatric Association’s criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Dependence indicates a more severe substance problem than abuse; individuals are classified with abuse of a certain substance only if they are not dependent on it.⁵⁸

Treatment – Treatment is a path of recovery that can involve many interventions and attempts at abstinence. It is offered in different settings, and types of treatment greatly depend on the substances misused, as well as a person’s individual needs and characteristics. Treatment is offered in residential and outpatient programs and can include counseling or other behavioral therapy, family therapy, medication, or a combination of services._{59, 60, 61} For more information, please refer to “A Guide To Treatment: Methods To Help People With Substance Use Disorders” in this planning toolkit.

Serious psychological distress/mental health problems – These problems occur in people who exhibit high levels of distress due to any type of mental problem, which may include general symptoms related to phobia, anxiety, or depression.⁶² A national organization, Mental Health America, provides greater detail about the types of mental health problems that correlate with substance use disorders. Mental health problems often predate substance use disorders by 4 to 6 years; alcohol and/or drugs may be used as a form of self-medication to alleviate the symptoms of a mental disorder.

Recovery – Recovery from alcohol and drug problems is a process of change through which an individual achieves abstinence and improved health, wellness, and quality of life. Individuals from the recovery community and treatment-related service providers developed this definition through the National Summit on Recovery process sponsored by SAMHSA’s Center for Substance Abuse Treatment (CSAT).

Specialty facility – Specialty facilities include alcohol or drug rehabilitation facilities (inpatient or outpatient), hospitals (inpatient services only), and mental health centers.⁶³

Performance measurement – Performance measurements offer standard, measurable formulas that can be consistently applied across various health care delivery systems. Measurements are based on established clinical guidelines, clinical evidence, and/or expert consensus.⁶⁴

¹ Substance Abuse: The Nation’s Number One Health Problem. The Schneider Institute for Health Policy, Brandeis University and the Robert Wood Johnson Foundation, February 2001, p. 58.
² Results From the 2005 National Survey on Drug Use and Health: National Findings. DHHS Publication No. (SMA) 06-4194. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, September 2006, pp. 69-72, 141, 146, 170.
³ Kleber, H.D., O’Brien, C.P., Lewis, D.C., McLellan, A.T. “Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation.” Journal of the American Medical Association, 284(13), Chicago, IL: American Medical Association, October 4, 2000, p. 1689.
⁴ Pathways of Addiction: Opportunities in Drug Abuse Research. National Academy Press. Washington, D.C.: Institute of Medicine, 1996.
⁵ Ibid, p. 9.
⁶ Kleber, H.D., et. al. “Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation.” Journal of the American Medical Association, p. 1689.
⁷ Ibid.
⁸ “Cover treatment through health insurance.” Ensuring Solutions to Alcohol Problems Web site: www.ensuringsolutions.org/solutions/solutions_list.htm?cat_id=982 . Accessed November 28, 2006.
⁹ Ettner, S., Huang, D., Evans, E., Ash, D.R., Hardy, M., Jourabchi, M., Hser, Y. “Benefit-Cost in the California Treatment Outcome Project: Does Substance Abuse Treatment Pay for Itself?” Health Services Research, 41(1), January 2006, pp. 192-213.
¹⁰ French, M.T., Salome, H.J., Krupski, A., McKay, J.R., Donovan, D.M., McLellan, A.T., Durrell, J. “Benefit cost analysis of residential and outpatient addiction treatment in the State of Washington.” Evaluation Review, 24(6), 2000, pp. 609-634.
¹¹ Sing, M., Hill, S., Smolkin, S., Heiser, N. The Costs and Effects of Parity for Mental Health and Substance Abuse Insurance Benefits. DHHS Publication No. MC99-80. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, 1998, section entitled “Executive Summary.”
¹² Ettner, S., et. al. “Benefit-Cost in the California Treatment Outcome Project: Does Substance Abuse Treatment Pay for Itself?” Health Services Research, pp. 192-213.
¹³ Sing, M., et. al. The Costs and Effects of Parity for Mental Health and Substance Abuse Insurance Benefits, section entitled “Executive Summary.”
¹⁴ “NIDA NewsScan for July 30, 2003.” U.S. Department of Health and Human Services, National Institutes of Health Web site: www.drugabuse.gov/newsroom/03/NS-07-30.html , section entitled “Individuals With Medical Conditions Related to Alcohol or Drug Abuse Benefit From Integrating Medical and Substance Abuse Treatment.” Accessed August 1, 2006.
¹⁵ Substance Abuse: The Nation’s Number One Health Problem, p. 108.
¹⁶ Harwood, H., Malhotra, D., Villarivera, C., Liu, C., Chong, U., Gilani, J. Cost Effectiveness and Cost Benefit Analysis of Substance Abuse Treatment: A Literature Review. National Evaluation Data Services, June 2002, p. iii.
¹⁷ The National Treatment Improvement Evaluation Study (NTIES): Highlights. DHHS Publication No. (SMA) 97-3156. Rockville, MD: Office of Evaluation, Scientific Analysis and Synthesis, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1997, table 4.
¹⁸ Results From the 2005 National Survey on Drug Use and Health: National Findings, p. 84.
¹⁹ Report to Congress on the Prevention and Treatment of Co-occurring Substance Abuse Disorders and Mental Health Disorders. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 2002, p. ix.
²⁰ Results From the 2005 National Survey on Drug Use and Health: National Findings, p. 77.
²¹ The NSDUH Report: Sources of Payment for Substance Use Treatment. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, 2006, p. 1.
²² Mark, T.L., Coffey, R.M., McKusick, D.R., Harwood, H., King E., Bouchery, E., Genuardi, J., Vandivort, R., Buck, J., Dilonardo J. National Estimates of Expenditures for Mental Health Services and Substance Abuse Treatment, 1991-2001. SAMHSA Publication No. (SMA) 05-3999. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005, pp. 28, 32.
²³ “The Impact of Addiction in the Workplace.” Hazelden Web site: www.hazelden.org/web/public/mrab_impact.page . Accessed July 26, 2006.
²⁴ Results From the 2005 National Survey on Drug Use and Health: National Findings, p. 72.
²⁵ “Ensure Equal Coverage for Treatment.” Join Together Web site: www.jointogether.org/keyissues/coverage/equal-treatment-readmore.html . Accessed September 28, 2006.
²⁶ The Economic Costs of Drug Abuse in the United States: 1992-2002. Pub. No. 207303. Washington, D.C.: Executive Office of the President, Office of National Drug Control Policy, 2004, p. ix.
²⁷ Harwood, H. Updating Estimates of the Economic Costs of Alcohol Abuse in the United States: Estimates, Updated Methods, and Data. [Based on data in Harwood et al., 1998.] Report prepared for the National Institute on Alcohol Abuse and Alcoholism, 2000.
²⁸ Harwood, H., Fountain, D., Livermore, G. The Economic Costs of Alcohol and Drug Abuse in the United States 1992. Report prepared for the National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism. NIH Publication No. 98-4327. Rockville, MD: National Institutes of Health, 1998.
²⁹ The Economic Costs of Drug Abuse in the United States: 1992-2002, p. vi.
³⁰ Ibid, p. xiii.
³¹ Ibid.
³² Substance Abuse: The Nation’s Number One Health Problem, p. 50.
³³ Anderson, P., Cremona, A., Paton, A., Turner, C., Wallace, P. “The risk of alcohol.” Addiction, 88, 1993, pp. 1493-1508.
³⁴ Andreasson, S., Allebeck, P., Romelsjo, A. “Alcohol and mortality among young men-longitudinal study of Swedish conscripts.” BMJ, 296, 1988, pp. 1021-1025.
³⁵ Dawson, D.A. “Alcohol consumption, alcohol dependence, and all-cause mortality.” Alcoholism, Clinical and Experimental Research, 24, 2000, pp. 72-81.
³⁶ Substance Abuse: The Nation’s Number One Health Problem, p. 58.
³⁷ Ibid.
³⁸ Blincoe, L., Seay, A., Zaloshnja, E., Miller, T., Romano, E., Luchter, S., et. al. The Economic Impact of Motor Vehicle Crashes, 2000. Washington, D.C.: U.S. Department of Transportation, National Highway Safety Administration Web site, 2002.
³⁹ “Ensure Equal Coverage for Treatment.” Join Together Web site: www.jointogether.org/keyissues/coverage/equal-treatment-readmore.html . Accessed September 28, 2006.
⁴⁰ Sturm, R. The Costs of Covering Mental Health and Substance Abuse Care at the Same Level as Medical Care in Private Insurance Plans. Santa Monica, CA: RAND Health, July 2001, p. 3.
⁴¹ Sturm, R., Goldman, W., McCulloch, J. “Mental Health and Substance Abuse Parity: A Case Study of Ohio’s State Employee Program.” The Journal of Mental Health Policy and Economics, 1998, pp. 129-134.
⁴² Sturm, R. The Costs of Covering Mental Health and Substance Abuse Care at the Same Level as Medical Care in Private Insurance Plans. Santa Monica, CA: RAND Health, July 2001, p. 3.
⁴³ Goplerud, E., Cimons, M. Workplace Solutions: Treating Alcohol Problems Through Employment-Based Health Insurance. Washington, D.C.: George Washington University Medical Center, Ensuring Solutions to Alcohol Problems, December 2002, p. 8.
⁴⁴ Issue Brief: Mandated Health Insurance Benefits: Tradeoffs Among Benefits, Coverage and Costs? California Health Policy Roundtable, 2002.
⁴⁵ Goplerud, E., Cimons, M. Workplace Solutions: Treating Alcohol Problems Through Employment-Based Health Insurance, p. 8.
⁴⁶ Rosenbach, M. “Mental Health and Substance Abuse Parity in Vermont: Employer Perspectives.” Issue Brief. Mathematica Policy Research, Inc., Number 2, September 2003, pp. 1, 2.
⁴⁷ Goplerud, E., Cimons, M. Workplace Solutions: Treating Alcohol Problems Through Employment-Based Health Insurance, p. 5.
⁴⁸ Mark, T.C. “Mental Health and Substance Abuse Treatment Expenditures, 1987-1997.” Health Affairs , 19(4), 2000, pp. 107-120.
⁴⁹ The National Drug Control Strategy. 1999. ONDCP 1999b. Washington, D.C.: Office of National Drug Control Policy.
⁵⁰ Treatment for Addiction: Advancing the Common Good. Boston, MA: Join Together Policy Panel, January 1998, pp. 3-7.
⁵¹ Treatment Improvement Protocol (TIP) Series 40: Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. DHHS Publication No. (SMA) 04-3939. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, 2004, pp. 51, 58-59.
⁵² Treatment Improvement Protocol (TIP) Series 39: Substance Abuse Treatment: Group Therapy. DHHS Publication No. (SMA) 04-3957. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, Printed 2004, Chapter 1.
⁵³ Rowe, C.L., Liddle, H.A. “Substance Abuse.” Journal of Marital and Family Therapy , 29(1), January 2003, pp. 97-120.
⁵⁴ “Clinical Guidelines for Alcohol Use Disorders in Older Adults.” The American Geriatrics Society Web site, November 2003: www.americangeriatrics.org/products/positionpapers/alcoholPF.shtml , section entitled “Features of preferred treatment options for abuse/dependence among older adults.” Accessed September 26, 2005.
⁵⁵ Using Performance Measurement to Improve the Quality of Alcohol Treatment. Washington, D.C.: George Washington University Medical Center, Ensuring Solutions to Alcohol Problems, January 2003, p. 1.
⁵⁶ Ibid, pp. 6, 8.
⁵⁷ Ibid, p. 10.
⁵⁸ Results From the 2005 National Survey on Drug Use and Health: National Findings, p. 67.
⁵⁹ Daley, D.C., Marlatt, G.A. “Relapse prevention: Cognitive and behavioral interventions.” Substance abuse: A comprehensive textbook, Lowinson, Ruiz, Millman, Langrod (eds), 1992, pp. 533-542.
⁶⁰ Treatment Improvement Protocol (TIP) Series 40: Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction, pp. 51, 58-59.
⁶¹ Treatment Improvement Protocol (TIP) Series 39: Substance Abuse Treatment: Group Therapy, Chapter 1.
⁶² Results From the 2005 National Survey on Drug Use and Health: National Findings, p. 165.
⁶³ Ibid, p. 167.
⁶⁴ Using Performance Measurement to Improve the Quality of Alcohol Treatment, p. 2.