Cost and Benefits of Therapeutic Communities

Cost and Benefits of Therapeutic Communities by Martien Kooyman, MD, PhD Paper presented at the National Conference on Drug Abuse Treatment and Rehabilitation Sofia on May 13 th 2006

Cost and Benefits of Therapeutic Communities by Martien Kooyman, MD, PhD Introduction Today in The Netherlands there is heroin distribution in addition to methadone. The costs of this heroin distribution are around 25.000 Euro per person year. Recently also a program of two years enforced treatment in prisons has been established for addicts who have been arrested three times. The costs of this enforced treatment are around 200 Euro a day per person. For persons in other countries it is often a surprise to know that there is enforced treatment for heroin addicts in The Netherlands. It seems to be a tolerant country: you can use drugs, visit prostitutes, kill yourself, however: as long as you are not a nuisance to other persons. Recently a survey was done to estimate the numbers of regular users, those who are addicted and the percentage of the addicted persons who come for treatment in The Netherlands (population: 16 million). Not all users use regularly and not all regular users are addicted. Only a relative small number of addicts are in treatment. From the estimated number of 350,000 persons addicted to alcohol 10 % are in treatment, 3000 from the estimated 500.000 cannabis users are in treatment, less than 30% of the cocaine addicts and 70 % of the heroin addicts ( Parnassia Addiction Research Center, The Hague). The treatment of heroin addicts mainly consists of harm reduction programs, in which methadone is distributed without further support. The figures are difficult to compare with other countries. For instance the average age of the heroin addicts in the Netherlands is estimated to be over 40 years, much different from for instance East European countries. After cannabis, cocaine is now the most frequent used drug in the Netherlands (approximately 65.000 users). Its use is increasing especially among the younger users. Also the use of extacy (XTC) is popular especially among visitors of house parties. Figures published by the Center of Drug Research of the University of Amsterdam showed that the use of cocaine is increasing from 2,1% ever used in 1997 to 2,9 % ever used in 2001. Recent use is also increasing from 0,2 % to 0,4 %. The percentages for Amsterdam differ greatly from the Netherlands as a whole: ever used in 2001: 10 % and recent use: 1.2 %. Only one in ten of the cocaine users is a regular user. One can expect that persons coming for treatment only are from the regular users group. They are the users who lost the control on their use and who are responsible for most of the costs for society. Costs and benefits The costs of a person addicted to-day to society are considerable; the costs of health care, apprehension, courts, incarceration, lost employment and social welfare allowances. Treatment with abstinence as a goal means investing. There are however not just costs, but also benefits. When we take in consideration the long term benefits of addiction treatment we see, that the benefits are greater than the costs. When we look at the success of treatment of 2

addiction several measures are used. Lasting abstinence, no illegal drug use, diminished drug use or drug free days. Other measures are: improved physical heath, prevention of infections ( hepatitis, HIV) and improved liver function. Improved mental health ( improved SCL score, clients satisfaction with results of the treatment). Improved social integration: no ( or diminished) crime, useful daily activities, work/education and contacts with non users. When we look at cost and benefits in health we find the costs of treatment and additional health care and a reduction in costs of addiction treatment and general health care ( doctors visits and hospitalization). When we consider cost and benefits in crime we find no costs during inpatient treatment and as benefits of all treatment modalities reduced costs of police, justice system and prisons. Looking at work and income we find no or reduced income from work during in-patient treatment as costs and as benefits reduced social allowances during and after in-patient treatment and tax-income from work after treatment. In review of the literature of eighteen cost-benefit studies of various drug treatment services Cartwright, showed that a persistent finding is that benefit exceeds costs. ( Cartwright, 2000) There were great differences in results between the studies even within comparable treatment modalities. The criteria differ especially in measuring the costs of the behaviour consequences of addiction. Theft is sometimes regarded as costs while it should be seen as a transfer of resources (except when properties are damaged). One can nevertheless draw conclusions as often large numbers are studied using American evaluation programs such as DARP (Drug Abuse Reporting Program), TOPS (Treatment Outcome Program Study) and DATOS (Drug Abuse Outcome Study). NIDA states in its guidelines that each dollar invested in treatment results in 4 dollars reduction of crime costs and up to 10 dollars in health costs. In the overview of the studies by Cartwright the benefit-cost ratio of residential programs is usually around two. When comparing costs, one has to consider that the samples of drug addicts may differ a lot in costs to society. For instance clients of drug free outpatient programs usually have fewer criminal records, while the majority of the residents of therapeutic communities have prior prison sentences. John Berg did a study on the benefits and costs of therapeutic communities in Norway. He found a 200% profit when money was invested in treatment, which is not bad at all nowadays( Berg, 2002). James Pitts, reported at the Melbourne conference of the World Federation of Therapeutic Communities in 2002 of a research in therapeutic communities in Australia. The costs per day of an addict in the year before admission for drug use, court, hospitalization, doctors visits, crime and government benefits was found to be $ 738,59. The sample of persons in the study did cost the society $77.964.494,- in total in the year before admission. The saving in costs of clean days during treatment, when all these costs are non-existent were in the sample: $ 24.895.235,-. The savings are even greater when we look at the post treatment benefits ( Pitts, 2002). The success of therapeutic communities We can attribute the following qualities to residential treatment in Therapeutic communities: -we can speak of stepped care (residential, when out-patient treatment has failed). -beds of therapeutic communities are inexpensive. -30-50 % of all admissions have a successful outcome. -longer time in program improves outcome success. -with a stay in the program of at least a year the success rate is more than 70%. 3

-the residents in which most costs are invested (those who stay longer) give most benefits after treatment. -parent participation improves successful outcome. -treatment can be an alternative to prison. Thirty years ago a follow up research of the Emiliehoeve Therapeutic Community in the Hague, the Netherlands was established. The criteria for success were rather strict (after leaving the program: no use of hard drugs, only occasional use of cannabis or prescribed drugs such as sleeping pills or tranquillizers, no alcohol abuse, no treatment for addiction, no drug-related arrests or convictions and no admissions to psychiatric institutions. At the two year follow-up of the first 172 first admissions the success for all ex residents was 32 %, compared with 4,5 % for a detox-only group. It was clear that the longer the residents had stayed, the better were the results. When they stayed less than one month: 0% success, staying one year 70 % success, completions (graduates): 80 % (Kooyman, 1992). It also was apparent that persons leaving the program prematurely often started to use for a short time and than stopped again for good. When we look at the last six months before the interview at the two year follow-up, we see that 50% of the persons that had left the Emilihoeve program were no longer addicted to drugs or alcohol and 42 % of the other therapeutic community Essenlaan, a similar program of which the results were compared. This research was repeated 10 years later with similar outcome results (van der Meer, 1997). Longer time spent in the program is related to better results. This is a common finding in evaluation studies of therapeutic communities. Participation of parents in parent groups improved the success considerably. The clients who had parents attending at least two meetings had more than two times better results ( Kooyman, 1992). Statistical analysis of the Emiliehoeve-data showed that this was an indirect effect: parent participation correlate with longer stay in the program what lead to a better treatment outcome. It became also apparent that some ex residents had used drugs only for a short period after discharge. When considered the last half year before the interview of the sample in the research the results showed almost half of the ex- residents being a success ( Kooyman, 1992). The successfully treated persons were no longer showing addictive behaviour. Most of them found jobs and became tax-paying citizens. Recently more promising results were found in new programs derived from the original therapeutic community in The Hague, such as Triple-Ex. The program Triple-ex is a therapeutic community for ex-convicts, ex-addicts and ex-jobless persons with does emphasize on training in on skills and education. The clients could choose to go to this program instead of prison or could spent the last half year of their prison sentence in this program. Of the clients ( 92 % male) with an average age of 33 years, 28 % were more than10 years in a methadone program, 31 % had a parent born in a non western country. They had an average time spent in jail of more than four years. The main drug of 69 % was heroin with an average duration of the use of 11 years, of!9 % the main drug was cocaine with an average duration of the use of 8 years. After nine months 50% were still in the program ( average time in program: 218 days). The follow-up study one year after leaving the program showed the following results: no hard drugs ever used: 41%, there was no heroin use last month before the interview in 74% of the sample. As to social integration the following was found: employed in a job: 47 %, studying full time: 7 %. There was also a considerable reduction in crime after discharge: It was also clear that the longer the time spent in the program the better were the results. 4

Cost-benefits analysis To convince policy makers that therapeutic communities is worth while to invest in it is important to show that the therapeutic communities are cost effective. Drug free treatment does not only costs money but generates also profits. The costs of drug free programs rehabilitating addicts is less than the profits due to a decrease in public spending for the clients over time. No treatment or only reducing harm to the addicted individual without the goal to try for reaching abstinence means the continuation of spending money for these persons. Half of the ex residents of therapeutic reach a drug free life. Most of them find jobs and become tax-payers. Those who did not make it spent less time in the programs and used less money for treatment. Berg in Norway calculated the return on investment in treatment of drug addicts above 200% (Berg, 1992). In the Netherlands were all addicts are getting monthly allowances from the state when they are not in-patients and all medical care is paid for the profits of treatment are considerable. Keeping a person in treatment inside a therapeutic community is cheaper than no treatment or harm reduction programmes. The estimated total daily costs, social, medical and crime related costs for police, justice, prison, for an individual are in Euro : 100 for a person not in treatment; 115 for a person in a heroin distribution program 105 for a person in a harm reduction (methadone distribution) program; 75 for a person in a methadone maintenance (methadone as a substitute for heroin with urine controls and additional treatment) program and 75 for a person in a therapeutic community. The benefits are respectively: 0, -15, -5, 25 and 25 Euro per person per day. After three years the benefits of individuals who entered a therapeutic community (assuming that 50 % of the ex-residents are no longer addicted) are far greater compared with those in programs where almost all participants are still addicted to (heroin and /or methadone) and depending on funds from the society. Most of the successful treated ex-residents of therapeutic communities do not have any social allowance, they have jobs and pay taxes. Van der Meer did a cost-benefits analysis of the Emiliehoeve Therapeutic Community and the Triple-Ex programs. He used the analysis of the costs to society from 1997 (of the KPMG), accepted by the Council for Public Health in The Netherlands (Raad voor de Volksgezondheid). The costs for society of a hard drug addict in The Netherlands of health care, social allowances and crime are an average of 50.000 Euro a year, per person. For the addicts who are admitted to residential treatment this is a modest estimate. For both modalities The Emiliehoeve Therapeutic Community and Triple-Ex, the total of yearly admissions is 60 persons each on a capacity of 30 beds each. Based on the earlier mentioned research, we assume to discharge of these 60 persons from the Emiliehoeve at least 20 success cases of each 6o persons who are admitted each year. We assume a modest number of 12 persons who will stay a long term success (at least seven years) We take the cost of treatment of a year in the Emiliehoeve, and the cost of after-care in the re-entry program and deduct the costs saved by the successes. The total costs invested in the residents are 1.800.000 Euro. The benefits are 5.280.000 Euro. The conclusion is that the benefit-cost ratio is 2.9. For the Triple-Ex program a similar table can be made. The benefit-cost ratio is here also 2.9. The yearly savings for each program are more than.5 million Euro to society (van der Meer, 2002). 5

Conclusion In conclusion can be said that the financial benefits of drug addict treatment exceed the costs greatly. This is also the case for therapeutic communities. To compare the cost and benefits of different program standard procedures should be developed to estimate the costs and benefits for society before during and after treatment. Investing in treatment is saving money for the society with more than a 200% profit. Therapeutic communities are successful treatment modalities for drug addicts, if the clients can stay long enough in the program and are relatively inexpensive. The benefits are greater than the costs. Besides that treatment has other benefits such as reducing the suffering of the addicts and their relatives. References: Aron, W.S. (1975). Family background and personal trauma among drugaddicts in the U.S.A.: implications for treatment. Brit. J.of Addiction, 70, 295-305. Berg, J.E. (2002). Behandeling en economie: kosten-baten analyse van de therapeutische gemeenschap. Voordracht gehouden op het symposium tgv. 30 jaaar therapeutische gemeenschap Emiliehoeve op 28-11-2002.. Cartwrigt, W.S. (2000) Cost-Benefit Analysis of Drug Treatment Services: Review of the Literature. Journ. Mental Health Policy Econ, 3, 11-26. Cramer, E.A.S.M. & Schippers G.M. ( 1994) Zelfcontrole en ontwenning van hard drugs. University of Nijnegen Research Group on Addictive Behaviours, Nijmegen Kooyman, M. (1992). The Therapeutic Community for Addicts. Intimacy, Parent Involvement and Treatment Outcome, Dissertatie. Univ. Drukkerij Erasmus Universiteit Rotterdam. Meer, Chr. van der (1997) Evaluatie onderzoek van de Emiliehoeve. Voordracht gehouden op het symposium tgv het 25 jarig bestaan van de Emiliehoeve in 1997. Meer, Chr. van der (2002). Verslavingszorg, een maatschappelijke belegging. Voordracht gehouden op het symposium tgv.30 jaaar therapeutische gemeenschap Emiliehoeve op 28-11- 2002. Pitts, J.A. (2002). Cost Benefits of Therapeutic Community Programming, Results of a National Survey. Paper presented at the 21th World Conference of Therapeutic Communities, 17-21 February 2002, Melbourne. 6