The European Journal of Health Economics

, Volume 6, Issue 1, pp 53–64 | Cite as

Substance abuse treatment, what do we know?

An economist’s perspective
  • Matilde P. MachadoEmail author
Original Papers


The literature on treating substance abuse has dealt basically with four important questions: (a) Is treatment effective? (b) Are all programs equally effective? (c) Why do programs differ in their effectiveness? (d) Which treatments are more cost-effective? This paper reviews the substance abuse treatment literature around these four questions and discusses methodological issues that hinder the interpretation and generalization of results to date. The answer to the first question is a sounding “yes,” treatment is effective but not all programs are equally effective. Researchers have moved beyond the “black box” literature that concentrated on patient and program characteristics as explanations for differences in effectiveness and search for the “active” ingredients of treatment. These include, for example, the treatment philosophy of the program’s director and staff attitudes towards patients. Cost-effectiveness studies are less common, and their conclusions are mixed. In general, it is probably safe to say that for the majority of patients, outpatient or shorter programs are more cost-effective.


Substance abuse Alcohol misuse Survey Treatment evaluation Effectiveness 



This research was carried out in part while I was at the IAE, Barcelona, as a Marie Curie postdoctoral fellow (European Community grant #ERBFMBICT972472). I also thank the research support from the Merck Foundation. Useful comments came from Daniel A. Ackerberg, Michael H. Riordan, and two anonymous referees. Mercedes Cabañas provided invaluable assistance as a documentalist. This article was supported by an unrestricted educational grant awarded jointly to the Universities Carlos III de Madrid and Pompeu Fabra de Barcelona by The Merk Foundation, the philanthropic arm of Merck Co. Inc., White House Station, New Jersey, USA. The responsibility for all errors and omissions is mine.

Conflict of interest:

No information supplied


  1. 1.
    Ackerberg DA, Machado MP, Riordan MH (2001) Benchmarking for productivity improvement: a health care application. International Economic Review, forthcomingGoogle Scholar
  2. 2.
    Aitken LS (1986) Retrospective self-reports by clients differ from ongoing reports: implications for the evaluation of drug treatment programs. Int J Addict 21:767–788PubMedGoogle Scholar
  3. 3.
    Allen JP, Babor TF, Mattson ME, Kadden RM (2003) Matching alcoholism treatment to client heterogeneity, the genesis of project MATCH. In: Babor TF, del Boca FK (eds) Treatment matching in alcoholism. Cambridge University Press: CambridgeGoogle Scholar
  4. 4.
    Anglin MD, Hser Y (1990) Treatment of drug abuse. In: Tonry M, Wilson JQ (eds) Crime and justice: an annual review of research, vol 13. University of Chicago Press: ChicagoGoogle Scholar
  5. 5.
    Apsler R (1991) Evaluating the cost-effectiveness of drug abuse treatment services. In: Economic costs, cost-effectiveness, financing and community-based drug treatment. Research monograph series 113. National Institute on Drug Abuse: Rockville, pp 17–26Google Scholar
  6. 6.
    Apsler R, Harding W (1991) Cost-effectiveness analysis of drug abuse treatment: current status and recommendations for future research. In: Drug abuse services research series. No 1: background papers on drug abuse financing and services research. DHHS publ no (ADM) 91-17777. National Institute on Drug Abuse: Washington, pp 58–81Google Scholar
  7. 7.
    Ball JC, Ross A (1991) The effectiveness of methadone maintenance treatment: patients, programs, services, and outcome. Springer: Berlin Heidelberg New YorkGoogle Scholar
  8. 8.
    Barnett PG, Swindle RW (1997) Cost-effectiveness of inpatient substance abuse treatment. Health Serv Res 32:615–629PubMedGoogle Scholar
  9. 9.
    Brown TG, Wood W-J (2001) Are all substance abuse treatments equally effective? Comité Permanent de Lutte à la Toxicomanie, Deuxiéme trimestre 2001, Gouvernement du Québec, Ministère de la Santé et des Services SociauxGoogle Scholar
  10. 10.
    Butler JS, Burkhauser RV, Mitchell J, Pincus TP (1987) Measurement error in self-reported health variables. Rev Econ Stat 69:644–650Google Scholar
  11. 11.
    Commons M, McGuire TG (1997) Some economics of performance based contracting for substance abuse services. In: Egertson JA, Fox DM, Leshner AI (eds) Treating drug abusers effectively. Milbank Memorial Fund and Blackwell Publishers, pp 223–249Google Scholar
  12. 12.
    Commons M, McGuire TG, Riordan MH (1997) Performance contracting for substance abuse treatment. Health Sci Res 32:631–650Google Scholar
  13. 13.
    Drummond DC (1997) What I would most like to know about alcohol interventions: do the best things come in small packages? Addiction 92:375–379CrossRefPubMedGoogle Scholar
  14. 14.
    Emrick CD (1975) A review of psychological oriented treatment for alcoholism. II. The relative effectiveness of different treatment approaches and the effectiveness of treatment versus non-treatment. J Stud Alcohol 36:88–108PubMedGoogle Scholar
  15. 15.
    Finney JW, Hahn AC, Moos RH (1996) The effectiveness of inpatient and outpatient treatment for alcohol abuse: the need to focus on mediators and moderators of setting effects. Addiction 91:1773–1796CrossRefPubMedGoogle Scholar
  16. 16.
    Fleming MF, Mundt MP, French MT, Manwell LB, Stauffacher EA, Barry KL (2000) Benefit-cost analysis of brief physician advice with problem drinkers in primary care settings. Med Care 38:7–18CrossRefPubMedGoogle Scholar
  17. 17.
    French MT (2001) Economic evaluation of alcohol treatment services. Recent developments in alcoholism, vol 15. Kluwer/Pelnum, New York pp 209–228Google Scholar
  18. 18.
    French MT, McGeary KA (1997) Estimating the economic cost of substance abuse treatment. Health Econ Lett 6:539–544CrossRefGoogle Scholar
  19. 19.
    French MT, Zarkin GA, Hubbard RL, Rachal JV (1991) The impact of time in treatment on the employment and earnings of drug abusers. Am J Public Health 81:904–907PubMedGoogle Scholar
  20. 20.
    Garbutt JC, West SL, Carey TS, Lohr KN, Crews FT (1999) Pharmacological treatment of alcohol dependence, a review of the evidence. JAMA 1318–1325Google Scholar
  21. 21.
    Gerstein DR, Hardwood HJ (eds) (1990) Treating drug problems. Institute of Medicine, National Academy: WashingtonGoogle Scholar
  22. 22.
    Grant KA, Arciniega LT, Tonigan JS, Miller WR, Meyers R (1997) Are reconstructed self-reports of drinking reliable? Addiction 92:601–606CrossRefPubMedGoogle Scholar
  23. 23.
    Heckman JJ, Smith JA (1995) Assessing the case for social experiments. J Econ Perspect 9:85–110Google Scholar
  24. 24.
    Higgins ST, Budney AJ, Bickel WK, Badger GJ (1994) Participation of significant others in outpatient behavioral treatment predicts greater cocaine abstinence. Am J Drug Alcohol Abuse 20:47–56PubMedGoogle Scholar
  25. 25.
    Holder HD, Longabaugh R, Miller WR, Rubonis AV (1991) The cost effectiveness of treatment for alcoholism: a first approach. J Stud Alcohol 52:517–540PubMedGoogle Scholar
  26. 26.
    Holder HD, Cisler RA, Longabaugh R, Stout RL, Treno AJ, Zweben A (2000) Alcoholism treatment and medical care costs from project MATCH. Addiction 95:999–1013CrossRefPubMedGoogle Scholar
  27. 27.
    Høyer G, Nilssen O, Brenn T, Schirmer H (1995) The Svalbard study 1988–89: a unique setting for validation of self-reported alcohol consumption. Addiction 90:539–544CrossRefPubMedGoogle Scholar
  28. 28.
    Jaffe JH (1984) Evaluating drug abuse treatment: a comment on the state of the art. In: Tims FM, Ludford JP (eds) Drug abuse treatment evaluation: strategies, progress and prospects. Research monograph no. 51. National Institute on Drug Abuse: Rockville, pp 13–28Google Scholar
  29. 29.
    Joe GW, Simpson DD, Sells SB (1994) Treatment process and relapse to opiod use during methadone maintenance. Am J Drug Alcohol Abuse 20:173–197PubMedGoogle Scholar
  30. 30.
    Kirchner JE, Booth BM, Owen RR, Lancaster AE, Smith GR (2000) Predictors of patient entry into alcohol treatment after initial diagnosis. J Behav Health Serv Res 27:339–346Google Scholar
  31. 31.
    Long CG, Williams M, Hollin CR (1998) Treating alcohol problems: a study of programme effectiveness and cost-effectiveness according to length and delivery of treatment. Addiction 93:561–571CrossRefPubMedGoogle Scholar
  32. 32.
    Longabaugh R, McCrady B, Fink E, Stout R, McAuley T, Doyle C, McNeill D (1983) Cost-effectiveness of alcoholism treatment in partial versus inpatient settings—six month outcomes. J Stud Alcohol 44Google Scholar
  33. 33.
    Longabaugh R, Beattie M, Noel N, Stout R, Malloy P (1993) The effect of social investment on treatment outcome. J Stud Alcohol 54:465–478PubMedGoogle Scholar
  34. 34.
    Longabaugh R, Wirtz PW, Zweben A, Stout RL (1998) Network support for drinking, Alcoholics Anonymous and long-term matching effects. Addiction 93:1313–1333CrossRefPubMedGoogle Scholar
  35. 35.
    Lu M (1999) Separating the “true effect” from “gaming” in incentive based contracts in health care. J Econ Manage Strategy 8:383–431Google Scholar
  36. 36.
    Lu M, McGuire TG (2002) The productivity of outpatient treatment for substance abuse. J Hum Resour 37:339–335Google Scholar
  37. 37.
    Machado MP (2001) Dollars and performance: treating alcohol misuse in Maine. J Health Econ 20:639–666CrossRefPubMedGoogle Scholar
  38. 38.
    Maitso SA, McKay JR, Connors GJ (1990) Self-report issues in substance abuse: state of the art and future directions. Behav Assess 12:117–134Google Scholar
  39. 39.
    Maynard A, Godfrey C (1994) Alcohol policy-evaluating the options. Br Med Bull 50:221–230PubMedGoogle Scholar
  40. 40.
    Marlatt GA (1996) Harm-reduction: come as you are. Addict Behav 1:779–788CrossRefGoogle Scholar
  41. 41.
    Mason BJ (2001) Treatment of alcohol-dependent outpatients with acamprosate: a clinical review. J Clin Psychiatry 62 [Suppl 20]:42–48Google Scholar
  42. 42.
    McLellan AT, Luborsky L, O’Brien CP, Woody GE (1980) An improved evaluation instrument for substance abuse patients: the addiction severity index. J Nerv Ment Dis 168:26–33PubMedGoogle Scholar
  43. 43.
    McLellan AT, Grissom GR, Brill P, Durell J, Metzger DS, O’Brien CP (1993) Private substance abuse treatments: are some programs more effective than others? J Subst Abuse Treat 10:243–254CrossRefPubMedGoogle Scholar
  44. 44.
    McLellan AT, Arndt IO, Metzger DS, Woody GE, O’Brien CP (1993) The effects of psychosocial services in substance abuse treatment. JAMA 269:1953–1959CrossRefPubMedGoogle Scholar
  45. 45.
    McLellan AT, Woody GE, Metzger DS, McKay J, Durell J, Alterman AI, O’Brien CP (1997) Evaluating the effectiveness of addiction treatments: reasonable expectations and appropriate comparisons. In: Ergertson JA, Fox DM, Leshner AI (eds) Treating drug abusers effectively. Milbank Memorial Fund and Blackwell Publishers, pp 7–40Google Scholar
  46. 46.
    McLellan TA, Hagan TA, Levine M, Gould F, Meyers K, Bencivengo M, Durell J (1998) Supplemental social services improve outcomes in public addiction treatment. Addiction 93:1489–1499CrossRefPubMedGoogle Scholar
  47. 47.
    Midanik L (1982) The validity of self-reported alcohol consumption and alcohol problems: a literature review. Br J Addict 77:357–382PubMedGoogle Scholar
  48. 48.
    Moos R, Finney J, Cronkite RC (1990) Alcoholism treatment. Oxford University Press: OxfordGoogle Scholar
  49. 49.
    Morgnstern J, Longabaugh R (2000) Cognitive-behavioral treatment for alcohol dependence: a review of evidence for its hypothesized mechanisms of action. Addiction 95:1475–1490CrossRefPubMedGoogle Scholar
  50. 50.
    Overman GP, Teter CJ, Guthrie SK (2003) Acamprosate for the adjunctive treatment of alcohol dependence. Ann Pharmacother 37:1090–1099CrossRefPubMedGoogle Scholar
  51. 51.
    Palmer AJ, Neeser K, Weiss C, Brandt A, Comte S, Fox M (2000) The long-term cost-effectiveness of improving alcohol abstinence with adjuvant acamprosate. Alcohol Alcohol 35: 478–492CrossRefPubMedGoogle Scholar
  52. 52.
    Schädlich PK, Brecht JG (1998) The cost effectiveness of acamprosate in the treatment of alcoholism in Germany. Economic evaluation of the Prevention of Relapse with Acamprosate in the Management of Alcoholism (PRAMA) study. Pharmaecoconomics 13:719–730Google Scholar
  53. 53.
    Shakeshaft AP, Bowman JA, Burrows S, Doran CM, Sanson-Fisher RW (2002) Community-based alcohol counseling: a randomized clinical trial. Addiction 97:1449–1463CrossRefPubMedGoogle Scholar
  54. 54.
    Shen Y (2003) Selection incentives in contracting. Health Serv Res 38:535–553PubMedGoogle Scholar
  55. 55.
    Shepard DS et al. (2003) The ADSS cost study: costs of substance abuse treatment in the specialty sector. United States Department of Health and Human Services, Substance Abuse and Mental Health Serv Administration, Office of Applied Studies: RockvilleGoogle Scholar
  56. 56.
    Silverman K, Robles E (1998) Employment as a drug abuse treatment intervention. NBER working paper no 6402Google Scholar
  57. 57.
    Strohmetz DB, Alterman AI, Walter D (1990) Subject selection bias in alcoholics volunteering for a treatment study. Alcohol Clin Exp Res 14:736–738PubMedGoogle Scholar
  58. 58.
    Tims FM, Fletcher BW, Hubbard RL (1991) Treatment outcomes for drug abuse clients. Pickens CG, Leukefeld CG, Schuster CR (eds) NIDA research monograph 106. United States Department of Health and Human Services: RockvilleGoogle Scholar
  59. 59.
    Trent LK (1998) Evaluation of a four- versus six-week length of stay in the Navy’s alcohol treatment program. J Stud Alcohol 59:270–279PubMedGoogle Scholar
  60. 60.
    Walsh DC, Hingson R, Merrigan D, Levenson SM, Cupples A, Heeren T, Coffman G, Becker C, Barker T, Hamilton S, McGuire TG, Kelly C (1991) A randomized trial of treatment options for alcohol-abusing workers. N Engl J Med 325:775–782PubMedGoogle Scholar
  61. 61.
    Weisner C, Matzger H (2002) A prospective study of the factors influencing entry to alcohol and drug treatment. J Behav Health Serv Res 29:126–137PubMedGoogle Scholar
  62. 62.
    Weisner C, Mertens J, Parthasarathy S, Moore C, Hunkeler EM, Hu T, Selby JV (2000) The outcome and cost of alcohol and drug treatment in an HMO: day hospital versus traditional outpatient regimens. Health Serv Res 35:791–812PubMedGoogle Scholar
  63. 63.
    Wutzke SE, Shiell A, Gomel MK, Conigrave KM (2001) Cost-effectiveness of brief interventions for reducing alcohol consumption. Soc Sci Med 52:863–870CrossRefPubMedGoogle Scholar
  64. 64.
    Yates BT (1999) Measuring and improving costs, cost-effectiveness and cost-benefit for substance abuse treatment programs. National Institute on Drug Abuse, NIH publ no 99-4518. United States Department of Health and Human Services: RockvilleGoogle Scholar

Copyright information

© Springer Medizin Verlag 2005

Authors and Affiliations

  1. 1.Universidad Carlos III de MadridSpain
  2. 2.Universidad Carlos III de MadridGetafeSpain

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