permanent abstinence may not a realistic goal of any single round of treatment for heavy long-term users. From this perspective, drug dependence requires long-term management comparable to those of other chronic relapsing disorders, such as hypertension, diabetes, and asthma. Drug treatment is a fairly modest intervention relative to the history of conditioned associations, situational stressors, and peer supports that reinforce a pattern of drug use. Thus, without major neuropharmacological breakthroughs, it is unrealistic to expect treatment to provide dramatic short-term results.

At the same time, claims for the effectiveness of drug treatment are sometimes based on misleading or ambiguous results. Many authors have cited observational studies comparing pretreatment and posttreatment drug use consistently find that between a quarter and a half of clients show significant reductions in their frequency of drug use. These reductions are interpreted as evidence for the effectiveness of drug treatment. The U.S. General Accounting Office (1998) has argued persuasively that the heavy reliance on self-report outcome measures in treatment outcome research may inflate estimates of the effectiveness of drug treatment. In this chapter, we argue that these estimates are often vulnerable to various other methodological biases.

A common argument is that even if drug treatment has less than perfect success rates, it is still a good investment. Many authors have cited the CALDATA estimate (Gerstein et al., 1994) that drug treatment has a benefit-cost ratio in the $3 to $7 range, or RAND’s analysis (Rydell and Everingham, 1994) suggesting that it is considerably cheaper to reduce cocaine use using drug treatment than to use source-country interventions, interdiction, or drug law enforcement. The committee agrees that drug treatment should not be evaluated according to a standard of perfect abstinence, but rather by its ratio of benefits to costs, and its cost-effectiveness relative to other interventions. Unfortunately, the CALDATA benefit-cost ratio and the RAND cost-effectiveness estimates are based on problematic estimates of treatment effectiveness drawn from uncontrolled observational studies. At present, there is little firm basis for estimating the benefit-cost ratio or relative cost-effectiveness of drug treatment.

We begin by articulating a philosophy of constant treatment improvement through the use of successive randomized controlled clinical trials. We then offer several illustrative examples of compelling experimental research programs. We note the inferential limitations of controlled trials that lack a no-treatment control group. We describe potential opportunities for supplementing existing treatment versus treatment trials with treatment versus no-treatment experiments. We then examine one such domain of opportunity—treatment as an alternative or adjunct to criminal justice sanctions. Finally, we note the potential loss of clinical utility in



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