Elsevier

Drug and Alcohol Dependence

Volume 57, Issue 2, December 1999, Pages 167-174
Drug and Alcohol Dependence

Costs and benefits of treatment for cocaine addiction in DATOS

https://doi.org/10.1016/S0376-8716(99)00083-6Get rights and content

Abstract

Our objective was to examine the cost of long-term residential (LTR) and outpatient drug-free (ODF) treatments for cocaine-dependent patients participating in the Drug Abuse Treatment Outcome Studies (DATOS), calculate the tangible cost of crime to society, and determine treatment benefits. Subjects were 502 cocaine-dependent patients selected from a national and naturalistic nonexperimental evaluation of community-based treatment. Financial data were available for programs from 10 US cities where the subjects received treatment between 1991 and 1993. Treatment costs were estimated from the 1992 National Drug Abuse Treatment Unit Survey (NDATUS), and tangible costs of crime were estimated from reports of illegal acts committed before, during, and after treatment. Sensitivity analyses examined results for three methods of estimating the costs of crime and cost-benefit ratios. Results showed that cocaine-dependent patients treated in both LTR and ODF programs had reductions in costs of crime from before to after treatment. LTR patients had the highest levels and costs of crime before treatment, had the greatest amount of crime cost reductions in the year after treatment, and yielded the greatest net benefits. Cost-benefit ratios for both treatment modalities provided evidence of significant returns on treatment investments for cocaine addiction.

Introduction

Substance abuse has been identified as one of our nation’s primary health problems (Institute for Health Policy, 1993). In 1994, there were more than 25 million illicit drug users in the US (US General Accounting Office, 1996). Federal efforts to address this problem have included estimated public expenditures of about $3.2 billion for treatment of drug abuse, or about 20% of the US drug control budget (US General Accounting Office, 1998). The division of resources into interdiction and control (supply), and treatment and prevention (demand) indicates the ongoing policy debate over strategies for reducing illicit drug use. The greater expenditure on supply side concerns is evidence of the public’s ambivalence about the effectiveness of demand side expenditures. In part, that ambivalence can be seen as rooted in a concern as to whether treatment pays. That is, do the fiscal resources expended provide a return that justifies those expenditures. The magnitude of these expenditures confirms that illicit drug use is an important policy issue that requires significant amounts of public funds. Greater insight into the nature of drug abuse, which has been described as one of our least understood problems (Fletcher et al., 1997), may lead to more effective treatment and to lower costs for the public.

Research findings with regard to treatment effectiveness reflect no such ambivalence. A clear relationship between treatment participation, length of time in treatment, and improved outcomes has been established during the past few decades. Research has consistently demonstrated reductions in illicit drug use after treatment and improvements in other areas (Hubbard et al., 1989, Simpson and Sells, 1990, Gerstein et al., 1994, Institute of Medicine, 1996, Hubbard et al., 1997, McLellan et al., 1997, National Opinion Research Center at the University of Chicago, 1997, Simpson, 1997, Simpson and Curry, 1997). It has been confirmed that better outcomes are related to longer treatment stays (Sells and Simpson, 1980, Simpson and Sells, 1982, Hubbard et al., 1989, Hubbard et al., 1997, Simpson et al., 1997a, Simpson et al., 1997b). Cumulatively, these data demonstrate the effectiveness of treatment in the context of, and the need for, adequate treatment lengths.

While cost-benefit analysis as applied to drug abuse treatment is a relatively new area of research, findings to date support a view of treatment as producing benefits that justify its cost. Significant returns have been realized from investments in drug abuse treatment as reported in the California Drug and Alcohol Treatment Assessment (CALDATA) (Gerstein et al., 1994) and the earlier Treatment Outcome Prospective Study (TOPS) (Hubbard et al., 1989). Both CALDATA and TOPS compared the cost of treatment with savings estimated from the difference between baseline rates of crimes and subsequently lower crime rates during and after treatment. These studies defined avoided costs as benefits from treatment, and they examined costs to society and costs to taxpaying citizens.

Treatment cost estimates were developed for both TOPS and CALDATA using data reported from the National Drug and Alcohol Treatment Unit Survey (NDATUS) (US Department of Health and Human Services, 1992). Daily costs of treatment and average treatment episodes were analyzed and reported. CALDATA estimated average long-term residential (LTR) treatment costs in 1992 to be $61.47 per day, calculated an average treatment episode to be 68.9 days, and generated an average cost per treatment episode of $4405 ($61.47×68.9 days). Outpatient drug-free (ODF) costs were $7.87 per day, with an average episode of 149.5 days, and an average cost of $990 per episode. TOPS estimated average LTR costs in 1982 of $18.50 per day, with an average episode of 159 days, and an average cost of $2942 per episode. ODF costs were $6 per day, with an average episode of 101 days, and an average cost of $606 per episode. Adjusted to 1992 dollars, as reported by Rajkumar and French (1997), these TOPS estimates would have been $56.10 per day and $8920 per episode of LTR, and $28.79 per day and $2908 per episode of ODF in 1992. Overall, the ratio of benefits to costs found in both CALDATA and TOPS revealed considerable returns on drug abuse treatment investments.

The most recent cost of community-based treatment estimates from the National Treatment Improvement Evaluation Study (NTIES) (National Opinion Research Center at the University of Chicago, 1997) showed costs of $49 per day and $6800 per episode of LTR treatment, and $15 per day and $1800 per episode in ODF. Although the estimated costs vary by study (i.e. TOPS, CALDATA, NTIES), rank order of costs is the same and the relative magnitude is similar.

With cocaine use having emerged as the primary national drug problem during the 1980s, considerable effort at local, state, and federal levels has been expended to emphasize and improve treatment for cocaine abuse. Recognizing the changes in drug use patterns, the emergence of cocaine use, and the need to understand how these have affected treatment, the National Institute on Drug Abuse (NIDA) initiated the Drug Abuse Treatment Outcome Studies (DATOS). This family of studies is the first national multisite project to investigate the effect of community-based treatment on cocaine use. Outcome results from DATOS showing that treatment is effective for cocaine dependence (Simpson et al., 1999), coupled with knowledge of the cost-benefits of treatment, obtained generally from the TOPS and CALDATA studies, raise questions about the costs and benefits of treatment specific to cocaine dependence. The primary treatment benefit demonstrated in earlier studies was the reduction in cost of crime to society. A major justification for treatment has been reduced crime (Hubbard et al., 1989, Gerstein and Harwood, 1990, Flynn et al., 1999). Pursuant to these justifications and earlier cost-benefit research studies, the primary focus of this paper is on the tangible costs of crime to society among cocaine-dependent DATOS participants. Also, to better understand DATOS results in the context of the TOPS and CALDATA results, similar methodologies are used in the present paper to determine if the economic benefits from both TOPS and CALDATA can be replicated in DATOS.

The purpose of this study is to determine the value of public investments to treat cocaine dependence by calculating the economic benefits from reduced crime during and after treatment for cocaine dependence (e.g. tangible and measurable before, during, and after treatment costs of crime to society; benefits that have an accepted and explicit monetary value). Benefits, for purposes of this paper, are defined as they were in CALDATA and TOPS: costs avoided during and after treatment. Specifically, in this paper, our focus is on the cost savings produced by reduced costs of crime to society during and after treatment for cocaine dependence. DATOS costs and benefits of treatment for cocaine dependence in two major treatment modalities (LTR and ODF) are examined. Treatment benefit estimates are provided for different assumptions about the number of crimes committed by nonrespondents. Questions about whether TOPS and CALDATA results can be replicated in DATOS are answered (see Leshner, 1997). Answers to these questions are important to inform public policy development. Thus, during the same period that DATOS participants were being treated (1991–1993), less than one-half of the population in the US needing drug abuse treatment received services (Woodward et al., 1997). Should the economic benefits of treatment for cocaine addiction be found to exceed the cost of treatment, the argument for increasing support for demand side programs, and for treatment specifically, will be seen as significantly buttressed.

Section snippets

Methods

NIDA’s DATOS project was described in detail in a special issue of a journal edited by Simpson and Curry (1997). Flynn et al. (1997) presented the overall methodology and research design. DATOS, a prospective study of 10,010 admissions to 96 drug treatment programs representing four major modalities in 11 cities between 1991 and 1993, followed a sample of clients 12 months after discharge. The follow-up consisted of a 90-min face-to-face interview, for which voluntary consent was obtained.

Results

Because distinctly different clienteles are served by the different modalities of treatment, we have organized results according to the two major treatment modalities examined in this paper: LTR and ODF. Within each of the two following treatment modality sections, we present estimated treatment costs, and then show the ranges for different methods of estimating the costs of crime to society, the reductions in crime, the benefits regarding reductions in crime costs, and the benefit to cost

Discussion

A range of economic benefits from treatment for cocaine dependence, based solely on costs of crime reported by patients, was found among DATOS participants treated in both LTR and ODF modalities. These benefits, reductions in cost of crime to society during and after treatment, substantially surpass the costs of treatment and demonstrate the value of public investments to treat cocaine addiction. Even without the numerous other tangible and intangible benefits that may have occurred in addition

Acknowledgements

We gratefully acknowledge the patients and treatment programs participating in DATOS and their ongoing cooperation which continues to make this research possible. We would also like to acknowledge the contributions from an anonymous reviewer whose suggestions were invaluable. This work was supported by National Institute on Drug Abuse (NIDA) Grant U01-DA10377 as part of a Cooperative Agreement on the Drug Abuse Treatment Outcome Studies (DATOS). The project includes a Coordinating DATOS

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    More information on DATOS is available on the Internet: www.datos.org

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