Contemporary issues in the treatment of alcohol dependence.

Alcoholism treatment has certainly come of age since its inception with the founding of Alcoholics Anonymous in 1935. Although AA is a "fellowship" and is not considered "treatment" per se, the growth and proliferation of professional treatment programs has spawned a significant new sector in the health care industry, with a corresponding rise in health care cost. Because the social cost due to the destructiveness of alcoholism is enormous, however, treatment appears to be a cost beneficial investment for society, both in terms of dollars expended and in terms of the lessening of human misery. Inpatient and outpatient programs appear to be effective, but simplistic comparisons are to be avoided because their populations are frequently much different, with patients with poor prognosis indicators showing up more frequently in inpatient settings. Although outpatient treatment is undeniably cheaper initially, appreciable long-term savings may not be realized because of the greater tendency for recidivism in outpatient-treated groups. Taken as a whole, studies of treatment outcome and cost effectiveness support the view that contemporary alcoholism treatment should provide multiple levels of care, with appropriate matching of patients, depending on severity and various demographic factors. This matching may be difficult to realize in actual practice because of the wide variability among alcoholic patients. Although some patient-treatment matching criteria are now in use by insurance carriers and treatment providers, the long-term efficacy of these criteria have not been tested adequately. In the end, it may evolve that the best determinant of assignment to a particular treatment level or modality might best be done by a responsible clinician exercising good judgment based on experience and training. Appropriate legal and financial accountability for this decision should be based on standards of reasonableness, consistent with criteria used in the treatment of other medical and surgical conditions. The alcoholism clinician is performing a valuable service to humanity and to society. Social policies should support this effort by making available appropriate facilities and programs for treatment, and by promoting access through destigmatization and favorable payment and reimbursement systems.