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Economic costs of Oxford House inpatient treatment and incarceration

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Economic costs of Oxford House inpatient treatment and incarceration

Abstract

The Oxford House model for substance abuse recovery has potential economic advantages associated with the low cost of opening up and maintaining the settings. In the present study, annual program costs per person were estimated for Oxford House based on federal loan information and data collected from Oxford House Inc. In addition, annual treatment and incarceration costs were approximated based on participant data prior to Oxford House residence in conjunction with normative costs for these settings. Societal costs associated with the Oxford House program were relatively low, whereas estimated costs associated with inpatient and incarceration history were high. The implications of these findings are discussed.
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Chapter 6
Bradley D. Olson
a
, Judah J. Viola
a
, Leonard A.
Jason
a
, Margaret I. Davis
b
, Joseph R. Ferrari
a
&
Olga Rabin-Belyaev
a
a
DePaul University , USA
b
DePaul College , USA
Published online: 08 Oct 2008.
To cite this article: Bradley D. Olson , Judah J. Viola , Leonard A. Jason , Margaret
I. Davis , Joseph R. Ferrari & Olga Rabin-Belyaev (2006) Chapter 6, Journal
of Prevention & Intervention in the Community, 31:1-2, 63-72, DOI: 10.1300/
J005v31n01_06
To link to this article: http://dx.doi.org/10.1300/J005v31n01_06
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Chapter 6:
Economic Costs of Oxford House
Inpatient Treatment and Incarceration:
A Preliminary Report
Bradley D. Olson
Judah J. Viola
Leonard A. Jason
DePaul University
Margaret I. Davis
Dickinson College
Joseph R. Ferrari
Olga Rabin-Belyaev
DePaul University
SUMMARY. The Oxford House model for substance abuse recovery
has potential economic advantages associated with the low cost of open
-
Address correspondence to: Bradley D. Olson, DePaul University, Center for Com
-
munity Research, 990 West Fullerton Avenue, Suite 3100, Chicago, IL 60614-2458.
The authors appreciate the financial support from the National Institute on Drug
Abuse (Grant # DA13231) and the National Institute on Alcohol Abuse and Alcohol
-
ism (Grant # AA12218).
[Haworth co-indexing entry note]: “Chapter 6: Economic Costs of Oxford House Inpatient Treatment and
Incarceration: A Preliminary Report.” Olson, Bradley D. et al. Co-published simultaneously in Journal of Pre
-
vention & Intervention in the Community (The Haworth Press, Inc.) Vol. 31, No.1/2, 2006, pp. 63-72; and: Cre
-
ating Communities for Addiction Recovery: The Oxford House Model (ed: Jason et al.) The Haworth Press, Inc.,
2006, pp. 63-72. Single or multiple copies of this article are available for a fee from The Haworth Document De
-
livery Service [1-800- HAWORTH, 9:00 a.m. - 5:00 p.m. (EST). E-mail address: docdelivery@
haworthpress.com].
Available online at http://www.haworthpress.com/web/JPIC
2006 by The Haworth Press, Inc. All rights reserved.
doi:10.1300/J005v31n01_06 63
Downloaded by [DePaul University] at 20:05 30 May 2015
ing up and maintaining the settings. In the present study, annual program
costs per person were estimated for Oxford House based on federal loan
information and data collected from Oxford House Inc. In addition, an
-
nual treatment and incarceration costs were approximated based on par
-
ticipant data prior to Oxford House residence in conjunction with normative
costs for these settings. Societal costs associated with the Oxford House
program were relatively low, whereas estimated costs associated with
inpatient and incarceration history were high. The implications of these
findings are discussed.
[Article copies available for a fee from The Haworth
Document Delivery Service: 1-800-HAWORTH. E-mail address: <docdelivery@
haworthpress.com> Website: <http://www.HaworthPress. com> 2006 by The
Haworth Press, Inc. All rights reserved.]
KEYWORDS. Economic, cost, substance abuse, mutual-help, Oxford
House
A central concern associated with providing effective social services
involves locating the best and most comprehensive forms of therapeutic
support within the realistic confines of public and private cost
(Drummond, O’Brien, Stoddart, & Torrance, 1997). Addiction-related
services, in particular, are strongly dependent on such cost consider-
ations (Cartwright, 2000; French, Salomé, Sindelar, & Mclellan, 2002;
Yates, 1994; Zarkin, 1998). The national monetary figures associated
with substance abuse are in the hundreds of billions of dollars annually.
They include treatment, legal and incarceration costs; property damage;
victim harm; employment attrition and loss of productivity; and medi
-
cal care for sexually transmitted diseases, alcohol-induced cirrhosis, fe
-
tal alcohol syndrome, cardiovascular disease, and a variety of cancers
(NIDA, 1998; Ponitz, Olson, Jason, Davis, & Ferrari, 2006; Zarkin;
Robert Wood Johnson Foundation, 1999). Treatment alone has the po
-
tential to significantly decrease these societal costs. However, the eco
-
nomic benefits to be gained through treatment can be maximized by
retaining program efficacy while reducing base program costs.
The most commonly chosen approach in the U.S. to lowering tax
-
payer investment associated with program costs has been to reduce the
duration of services (Jason, Olson, Ferrari, & Davis, 2004). The brief
intervention, for instance, attempts to target problematic use early
through an intense intervention often occurring within a single session
(Zweben & Fleming, 1999). The recovery management checkups
64 Creating Communities for Addiction Recovery: The Oxford House Model
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model is another innovative method to increase long-term maintenance
and monitoring through brief visits following traditional (or shortened)
treatment stays (Dennis, Scott, & Funk, 2003). While distinct advan
-
tages exist in utilizing these brief methods, the commonly severe and
chronic nature of substance abuse dependence more often than not re
-
quires them to be used in conjunction with more comprehensive and
therefore more costly services, thus curbing their ultimate economic
value.
Duration of services is often associated with higher program costs,
yet also more successful forms of recovery (Yates, 1994). Length of
time within a therapeutic community, for instance, has been associated
with more effective recovery outcomes (see Jason et al., 2004). The
therapeutic community, one of the most comprehensive and therefore
most costly forms of care for substance abuse addiction, has neverthe
-
less demonstrated impressive overall cost-effectiveness estimates (French,
Sacks, DeLeon, Staines, & McKendrick, 1999). Cost-benefit ratios can
increase further if services are provided that are of equivalent duration
as the therapeutic community and similar in other benefits but imple-
mented at lower costs.
One recovery option that has extended the duration of support and re-
quires little to no taxpayer investment is the mutual-help group, such
as Alcoholics Anonymous (AA) (McCrady & Miller, 1993). Twelve-
step programs require little other operational costs than gathering ex-
penses (e.g., photocopying, refreshments), all donated by members
themselves. Despite the low societal program costs, little research has
been attempted to obtain precise cost effectiveness estimates associ-
ated with AA attendance. Such research may be uncommon because
social scientists perceive the difficulties associated with studying a
group that values self-protection from external influences, and is not
likely to be interested in policy changes should economic research sug
-
gest them. Therefore, while 12-step programs have, and likely will al
-
ways, play a significant role in low-cost recovery, challenges will
continue to exist for gaining in-depth economic understanding and en
-
gaging in subsequent policy strategies with this recovery option.
The Oxford House model of mutual-help recovery homes possesses
many advantages of the above programs: the comprehensive and long-
term support of the therapeutic community, the reduced tax-burden ele
-
ment of AA, and yet, nevertheless has demonstrated an openness to
state and federal involvement. Oxford Houses are democratic, self-run
homes based on the 12-step model, functioning without professional
staff. The primary operational costs are associated with rent paid by the
Olson et al. 65
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residents (Jason et al., 1997). The opening and expansion of the model
furthermore has led to approximately 1000 houses in the United States,
and also requires minimal costs, often having been developed through
funds provided by existing houses. Oxford House has also grown
through federal/state initiatives with revolving loan funds distributed
to states according to the Federal Anti-Drug Abuse Act of 1988.
Whereas these policy initiatives cost more in tax-payer funds than the
grassroots forms of expansion, the amounts are still minimal compared
to traditional interventions. The majority of such costs are invested in
the allocation of furniture, security deposit/down payment of rent and in
the hiring of outreach workers to set up and initially stabilize a collec
-
tion of houses (Braciszewski, Olson, Jason, & Ferrari, 2006; Jason,
Braciszewski, Olson, & Ferrari, 2005; Molloy, 1993).
While the ideal form of research in this area is represented by pro
-
spective economic evaluations investigating the relationship of cost to
benefit, it is important to establish the societal cost of programs like Ox-
ford House. In the present study, we attempt to establish the annual, per
person estimates of societal program costs associated with Oxford
House (i.e., the opening and maintaining of houses). We also derive
conservative estimates of societal inpatient treatment costs and incar-
ceration costs based on national data of individuals prior to entering Ox-
ford House and ranges of normative costs associated with these settings
(i.e., inpatient treatment, jail, and prison). Data were obtained from
90-day data on the inpatient treatment and incarceration history of
residents prior to entering Oxford House.
METHOD
Societal Oxford House Program Costs. To obtain annual, per person
societal cost estimates associated with the opening and maintenance of
an Oxford House, loan fund information was obtained and verified from
several state and federal sources (e.g., SAMSHA) in addition to Oxford
House Inc. (Molloy, personal communication, February 2004). Addi
-
tional estimates were obtained from various development grants and
contracts funded to open Oxford Houses (e.g., Veterans Affairs fund
-
ing). Estimates from several of the sources include operational costs for
larger organizations, and while these costs are rarely necessary for the
successful opening of Oxford Houses, the inclusion of these estimates
contributes to the conservative goals of this analysis. The base figures to
open an Oxford House, as described, generally include funds for secu
-
66 Creating Communities for Addiction Recovery: The Oxford House Model
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rity deposit, first month’s rent, furniture and amenities, and, in broader
state-wide efforts, the hiring of outreach workers (Molloy, 1993). The
present system of revolving loan funds are repaid by house residents,
but again are nevertheless included in the estimates to contribute to the
conservative approach. Rent beyond one month, however, which is pro
-
vided by the residents, cannot be interpreted as tax-base related costs
(i.e., societal costs), and therefore are not included within the estimates.
Societal Inpatient Treatment and Incarceration Program Costs. For
cost estimates of societal inpatient and incarceration costs, information
was used from a national dataset of Oxford House residents. The total
dataset was of 900 participants from over 200 houses, and collected
from five primary regions within the U.S., including Washington/Ore
-
gon, Texas, Illinois, Pennsylvania/New Jersey, and the Carolinas. The
majority of participants completed the baseline battery in their Oxford
Houses and a minority filled out the inventories at an Oxford House
convention. Significant differences by house, region, or method of col-
lection were not found. Participants had been given $15 for their
participation.
The 90-day Timeline Follow-back measure (Carter-Sobell, Agrawal,
Sobell, Leo, Young, Cunningham, & Simco, 2003) provided data on
past inpatient treatment history and incarceration time of participants,
and its use is consistent with that of the Addiction Severity Index to ob-
tain sample-derived societal costs in prior economic studies (French et
al., 2002). While the database consisted of information on a sample of
900, 269 of these participants provided the investigators at least 30-90
days of data available on their incarceration and inpatient treatment
experiences prior to entering the Oxford House. Only the data from
this sample of 269 participants was included in the present analyses,
providing an average of 63.9 days (range 30-90) of pre-Oxford House
data. The average number of inpatient treatment days for this resi
-
dence-time differentiated sample was 17 days (range: 0 to 90 days),
3.70 days for jail (range 0 to 75), and 1.87 days for prison (range: 0 to
90 days).
Additional necessary information for estimates required normative
figures reflecting average societal costs (facility and operational) for in
-
patient treatment, jail, and prison, making them comparable to the soci
-
etal program cost estimates of Oxford House. This data was gathered
from archival public sources (e.g., U.S. Department of Justice, 2003).
Based on these estimates, costs were extrapolated for all 269 partici
-
pants. Number of days for inpatient treatment, jail, and prison were
transformed into single day figures and then annualized. The financial
Olson et al. 67
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estimates of treatment and incarceration costs were finally adjusted for
inflation at a conservative 3% rate of growth from the year reported in
the source to 2004 (Levy, 1995).
RESULTS
Estimates of annual per person costs first required house costs, which
ranged from $4,000 to $22,000 per Oxford House. The higher end of the
range reflects the attempt to remain conservative because the modal
cost is more likely to reflect the lower end of the range (i.e., $4,000).
Based on a national average of seven residents per house, the annual es
-
timates per person ranged from $571.43 to $3,142.86, the latter figure
reflecting the upper end of larger statewide-scale initiatives.
Societal inpatient treatment costs were based on the Oxford House
sample, estimates from prior research sources (French, Salomé, Sindelar, &
Mclellan, 2002), and subsequent adjustments for inflation increases.
Average yearly approximations of societal costs of inpatient care for
this sample ranged from $3,929.57 (French, Salomé, & Carney, 2002)
to $16,964.58 (Schinka, Francis, Hughes, LaLone, & Flynn, 1998).
To obtain final incarceration costs, jail, and prison costs were combined
into a single set of estimates. A collection of normative jail costs were first lo-
cated, and it was evident that the range of figures in the pool were restricted
enough to choose one annual, per person, median figure of $17,635 (U.S.
Department of Justice, 2003). This jail cost, was averaged with both the
lower and higher prison estimates. Because jail costs are consistently lower
than prison costs, this approach provided a more conservative overall incar
-
ceration estimate. The annual prison cost estimates per inmate ranged from
$22,344 (Drug Policy Alliance Ohio, 2002) to $62,927 (Rosten, 2003). Av
-
eraging the jail and prison figures, the annual societal program incarceration
cost estimate per participant ranged from $19,989 to $40,281.
DISCUSSION
In general, data suggest that low annual, per person costs are involved
in the opening and maintaining of an Oxford House. Findings from the
present study also suggest that annual, per person inpatient treatment and
incarceration costs derived from a pre-Oxford House sample are high.
The findings presented are preliminary, despite the conservative ap
-
proach taken throughout the estimation process. There are substantial
68 Creating Communities for Addiction Recovery: The Oxford House Model
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limits to taking a retrospective approach when conducting economic
analyses, and the procedures are no substitute for prospective economic
investigations designed to assess cost-effectiveness using measures ex
-
plicitly created for this purpose (e.g., French et al., 2002).
One advantage of this study is that it represents a first effort to estimate
Oxford House costs, in addition to inpatient treatment and incarceration
costs based on a relatively large sample of individuals who naturally
choose to reside in an Oxford House. Past studies have suggested that the
severity and chronic nature of drug use and crime among Oxford House
residents are comparable to most treatment samples in the U.S. (Jason et
al., 2001; Olson, Jason, Davis, Alvarez, & Ferrari, 2003). Nevertheless,
until there is a substantial body of literature demonstrating the compara
-
bility of these populations, the use of sample-specific derivations is the
most prudent approach to approximate these costs.
As stated above, the present analysis investigated societal program
costs–not the cost and benefits derived from the Oxford House or any
other program. Past economic studies in the substance abuse arena that
have investigated benefits have shown substantial societal savings from
a variety of treatment forms (French et al., 1999; Yates, 1994; Zarkin,
1998). Past studies using other treatment modalities have ranged from
societal savings of one dollar for every dollar invested in treatment to
$18 dollars for every dollar invested (see Salomé, French, Scott, Foss, &
Dennis, 2003). A combined examination of cost and benefits is a sensi-
ble next step for future Oxford House research. Moreover, comprehen-
sive investigations are needed that examine traditional benefits (e.g.,
reductions in substance use/crime, and increases in employment) and
less traditional benefits (e.g., reductions in victimization from crime, in
-
cidence of fetal alcohol syndrome).
There exists a general need to better understand the high costs of in
-
patient treatment and incarceration, and to investigate a variety of
strategies that have the potential to reduce the societal burden. Oxford
House can be utilized in conjunction with other recovery options
within a continuum of care, as a diversion opportunity for offenders or
community-based transition for ex-offenders (Olson et al., 2003).
Much of the societal potential of Oxford House in these areas and others
is expanded through its openness to federal and state policy involve
-
ment (Braciszewski et al., 2006; Jason et al., 2005). More rigorous and
comprehensive economic investigations of such community-based op
-
tions will allow investigators and public policy officials to better under
-
stand the possible role of self-run recovery homes within a more
comprehensive and integrated substance abuse treatment system.
Olson et al. 69
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... OH research has found that people who live in an OH are less likely to relapse, be incarcerated, and be without employment as compared to individuals that are not provided OHs [21]. Recovering people from various backgrounds report positive experiences in OH, including: residents who live with both mental illness and substance abuse, Caucasians, African Americans, and both biological sexes [21,22]. ...
... OH research has found that people who live in an OH are less likely to relapse, be incarcerated, and be without employment as compared to individuals that are not provided OHs [21]. Recovering people from various backgrounds report positive experiences in OH, including: residents who live with both mental illness and substance abuse, Caucasians, African Americans, and both biological sexes [21,22]. In addition to studies on the effectiveness of OH, other research has explored mechanisms through which recovery is gained in these settings [19]. ...
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Oxford Houses (OH) are a peer-run sober living homes that are the largest network of recovery homes with over 2,000 in the US. They are self-run without any professional staff. The current study focused on better understanding the facilitators and barriers to OH entry for transgender individuals. The study explored ways in which transgender people found entry into the OHs and the experiences of transgender residents in OHs in comparison to cisgender residents. We conducted semi-structured interviews of 7 transgender women and 7 cisgender men, using grounded theory methodology. Participants reported fear and apprehensions upon entry into OH due to participants initially feeling that OHs may be similar to past settings that were not sensitive to their needs and gender identity. However, the participants reported diminished fear and comfort shortly after transitioning into OHs. Though discrimination was brought up, it appears that participants could work through minor issues by means of discussion and boundary setting. Both groups of participants followed similar paths in addiction and recovery. Salient themes including familial connections within the house are discussed.
... That issue also contained smaller-scale studies of Oxford Houses as well as qualitative and quantitative data regarding intrapersonal variables (Davis, Dziekan, et al., 2006;Kim, Davis, Jason, & Ferrari, 2006). Those studies also included both local and national residents (d 'Arlach et al., 2006) and contextual characteristics and policy implications (Braciszewski, Olson, Jason, & Ferrari, 2006;Ferrari, Jason, Blake, Davis, & Olson, 2006;Olson et al., 2006). ...
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Substance abuse disorders (SUDs) create significant and pervasive health and economic burdens in the U.S. and the world. After primary treatment has ended, supportive social environments are critically important to prevent relapse and to sustain long-term sobriety. Although approaches to SUDs and treatment vary internationally, studies in the United States indicate that a major risk factor for SUD relapse are lack of social environments to support sustained remission from substance use after primary treatment has ended. Evidence suggests that abstinence is enhanced when individuals are embedded in drug-free settings that support abstinence. Longabaugh, Beattie, Noel, and Stout proposed a theory of social support that engages two processes: general social support, which affectspsychological functioning, and abstinence-specific social support, which supports ongoing abstinence from substance use.
... A key question is whether community-based recovery supports can have an effect on the high costs of substance abuse to our society. Olson et al. (2006) found that costs associated with the OH program were relatively low, whereas costs associated with inpatient and incarceration history prior to entering OHs were high. This study, however, did not compare the costs and benefits of those in OHs with those in a comparison condition. ...
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... Service may also be a positive social role through which one may gain access to other social resources (Wolfensberger 2011). Such service is also essential for the maintenance of mutual-help systems, which are typically run by volunteers and funded mostly by members with relatively little taxpayer financing needed to support or maintain the organizations (McCrady and Miller 1993;Olson et al. 2006). For example, committed leaders and member helping behaviors have been found to be essential to the continuance and success of mutual-help groups (King et al. 2000;Wituk et al. 2002). ...
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This highly successful textbook is now available in its third edition. Over the years it has become the standard textbook in the field world-wide. It mirrors the huge expansion of the field of economic evaluation in health care, since the last edition was published in 1997. This new edition builds on the strengths of previous editions, being clearly written in a style accessible to a wide readership. Key methodological principles are outlined using a critical appraisal checklist that can be applied to any published study. The methodological features of the basic forms of analysis are then explained in more detail with special emphasis of the latest views on productivity costs, the characterisation of uncertainty and the concept of net benefit. The book has been greatly revised and expanded especially concerning analysing patient-level data and decision-analytic modelling. There is discussion of new methodological approaches, including cost effectiveness acceptability curves, net benefit regression, probalistic sensitivity analysis and value of information analysis. There is an expanded chapter on the use of economic evaluation, including discussion of the use of cost-effectiveness thresholds, equity considerations and the transferability of economic data. This new edition is required reading for anyone commissioning, undertaking or using economic evaluations in health care, and will be popular with health service professionals, health economists, pharmacand health care decision makers. It is especially relevant for those taking pharmacoeconomics courses.
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