Promoting Self Change Taking the Treatment to the Community

Linda Carter Sobell and Mark B. Sobell

As discussed in detail in Chapter 1, the vast majority of people with alcohol and drug problems are unlikely to enter traditional substance abuse or addiction treatment programs (Harris & Mckellar, 2003). Several major U.S. surveys have concluded that only a small percentage of individuals with alcohol problems ever seek and enter into treatment (Dawson, Grant, Stinson, et al., 2005; Raimo, Daeppen, Smith, Danko, & Schuckit, 1999). For example, of 4,422 adults 18 years or older classified with prior-to past-year DSM-IV alcohol dependence in the 2001-2 National Epidemiologic Survey on Alcohol and Related Conditions (Dawson, Grant, Stinson, et al., 2005), only 25.5% reported ever receiving treatment (12-Step programs: 3.1%; Formal treatment: 5.4%; both 12-Step and treatment: 17.0%). Another national survey found "only 16% of those with an alcohol use disorder (AUD) had received any treatment in 2001. Similarly, a recent report on utilization of AUD treatment in the Veterans Administration found that only 23% of individuals with an identified disorder received treatment" (Harris & McKellar, 2003, p. 1). Clearly, such figures underscore the need to seriously develop and evaluate alternative, minimally intrusive interventions that will appeal to such individuals.

For close to three decades, treatment for individuals with alcohol and drug problems has been provided almost exclusively at traditional specialty substance abuse agencies. If individuals with substance use and abuse problems are unwilling to come into treatment, the key question is "What can be done to motivate them to change their substance use outside of treatment or as a result of a very brief encounter?" One suggestion has been that we should take the treatment to the people (Sobell, Cunningham, Sobell, et al., 1996; Sobell, Sobell, Leo, et al., 2002). Alternative interventions need to be provided in settings other than traditional substance abuse agencies, such as physicians' offices, primary care settings, or nontraditional ways such as on the Internet or by mail.

Interestingly, effective January 2007, the U.S. Centers for Medicare and Medicaid Services added two new reimbursement codes for use by Medicaid, Medicare, and other third-party payers. These codes allow providers to be reimbursed for alcohol and drug screenings and brief interventions (SBIs)

in clinical settings. Bertha Madras (2006), Deputy Director of Demand Reduction from the White House Office of National Drug Control Policy, reported that the "impetus behind the Medicaid decision to reimburse for alcohol and drug screening services was the recognition of the number of people who go unidentified who are in need of an intervention or treatment" (Medscape Medical News, 2006). In addition to the fact that so few substance abusers seek treatment, the other compelling reason behind these two new codes appears to be financial. It is estimated that conducting alcohol and drug SBIs in clinical settings will save the federal Medicaid budget $520 million annually. Given scarce medical resources and health care cost containment, such savings could be used in a stepped-care manner where the first intervention is minimal, of low intensity, least costly, likely to be effective, and has consumer appeal (Sobell & Sobell, 2000). For those where such interventions are successful, their further progress need only be monitored. For those where it was not effective, their care could be stepped up (i.e., more intensive treatment) using some of the savings from the SBIs. Such thinking is consistent with a stepped-care model of treatment (Davison, 2000; Foulds & Jarvis, 1995; Sobell & Sobell, 2000). In summary, successful methods of promoting self-change would allow for widespread impact on substance use problems and at a much lower cost than traditional treatment.

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