Optimizing the cost-effectiveness of alcohol treatment: a rationale for extended case monitoring

There has been much research on and debate about the appropriate length of acute treatment for alcohol problems. In the United States, the lengthy and costly treatment programs of only a few years ago have been supplanted by ever-shorter and less intensive protocols, with little evidence that this trend will end soon. In this paper, we argue that, because of the chronic, recurrent nature of alcohol problems, an optimal system for delivering treatment services to alcoholics needs to focus on long-term engagement with clients. There is evidence from studies on research reactivity and telephone follow-up protocols that a low-intensity long-term protocol for maintaining contact with clients over time spans measured in years may result in better long-term clinical outcomes and reduced long-term health care utilization and costs. We describe a flexible long-term low-intensity follow-up protocol for alcohol abusers we call "case monitoring." This protocol is specifically designed to minimize long-term health-care use. We predict that such an intervention should be especially efficacious for women, persons with comorbid Axis I disorders, and persons lower in sociopathy. The design of a study to determine the clinical and health service effects of this intervention is also described.