Walsh D C, Hingson R W, Merrigan D M, Levenson S M, Cupples L A, Heeren T, Coffman G A, Becker C A, Barker T A, Hamilton S K
Department of Health and Social Behavior, Harvard School of Public Health, Boston, MA 02115.
N Engl J Med. 1991 Sep 12;325(11):775-82. doi: 10.1056/NEJM199109123251105.
Employee-assistance programs sponsored by companies or labor unions identify workers who abuse alcohol and refer them for care, often to inpatient rehabilitation programs. Yet the effectiveness of inpatient treatment, as compared with a variety of less intensive alternatives, has repeatedly been called into question. In this study, anchored in the work site, we compared the effectiveness of mandatory in-hospital treatment with that of required attendance at the meetings of a self-help group and a choice of treatment options.
We randomly assigned a series of 227 workers newly identified as abusing alcohol to one of three rehabilitation regimens: compulsory inpatient treatment, compulsory attendance at Alcoholics Anonymous (AA) meetings, and a choice of options. Inpatient backup was provided if needed. The groups were compared in terms of 12 job-performance variables and 12 measures of drinking and drug use during a two-year follow-up period.
All three groups improved, and no significant differences were found among the groups in job-related outcome variables. On seven measures of drinking and drug use, however, we found significant differences at several follow-up assessments. The hospital group fared best and that assigned to AA the least well; those allowed to choose a program had intermediate outcomes. Additional inpatient treatment was required significantly more often (P less than 0.0001) by the AA group (63 percent) and the choice group (38 percent) than by subjects assigned to initial treatment in the hospital (23 percent). The differences among the groups were especially pronounced for workers who had used cocaine within six months before study entry. The estimated costs of inpatient treatment for the AA and choice groups averaged only 10 percent less than the costs for the hospital group because of their higher rates of additional treatment.
Even for employed problem drinkers who are not abusing drugs and who have no serious medical problems, an initial referral to AA alone or a choice of programs, although less costly than inpatient care, involves more risk than compulsory inpatient treatment and should be accompanied by close monitoring for signs of incipient relapse.
由公司或工会发起的员工援助计划会识别出酗酒的员工，并将他们转介接受治疗，通常是住院康复项目。然而，与各种强度较低的替代方案相比，住院治疗的效果一再受到质疑。在这项以工作场所为基础的研究中，我们比较了强制性住院治疗与参加自助小组会议以及多种治疗选择的效果。
我们将227名新确定为酗酒的工人随机分配到三种康复方案之一：强制性住院治疗、强制性参加戒酒互助会（AA）会议以及多种选择。如有需要，提供住院后备治疗。在两年的随访期内，对三组在12个工作绩效变量以及12项饮酒和药物使用指标方面进行比较。
三组均有改善，在与工作相关的结果变量方面，三组之间未发现显著差异。然而，在七项饮酒和药物使用指标上，我们在几次随访评估中发现了显著差异。住院组效果最佳，分配到AA组的效果最差；允许选择方案的组结果居中。AA组（63%）和选择组（38%）比最初分配到住院治疗的受试者（23%）更频繁地（P<0.0001）需要额外的住院治疗。对于在研究入组前六个月内使用过可卡因的工人，组间差异尤为明显。由于AA组和选择组额外治疗率较高，其住院治疗的估计费用平均仅比住院组低10%。
即使对于不滥用药物且没有严重医疗问题的在职酗酒者，仅最初转介到AA组或多种选择方案，虽然比住院治疗成本低，但比强制性住院治疗风险更大，并且应该密切监测早期复发迹象。
