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5 The Effectiveness of Treatment The question that people ask drug treatment experts most often and most insistently is a simple one: Does treatment really work? In the committee's judgment, and that of most experts, the available clinical experience and research data add up to a similarly short and pointed answer: It varies. This answer should be no surprise, as the question is naive. Virtually everything in Chapters 2, 3, and 4 of this report leads one to expect the effectiveness of treatment to be a complicated matter to understand and assess. Drug treatment is not a single entity but a variety of different approaches to different populations and goals. Response to treatment is not a matter of all or nothing, complete success versus total failure, but of degrees of improvement. Moreover, the setting for evaluation is not the quiet purity of a controlled laboratory experiment but the tangled complexity of real lives and programs under pressure from many directions. The committee's strategy under the circumstances has been to put forward a line of questioning that is straightforward but somewhat more elaborate and revealing than "Does treatment really work?" These ques- tions, which are listed below, cannot all be fully and confidently answered at present. Consequently, they must continue to be asked about each kind of treatment. What are the basic concepts or modalities of treatment? That is, what are the underlying designs or theories of treatment, what specific types of drug problems or population groups are being addressed by each 132

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THE EFFECTIVENESS OF TREATMENT 133 design, and what are the best results that have been obtained under ideal conditions? How well does each modality work in practice? How adequate in terms of methodology are the evaluations of real programs, and what do the best of these evaluations reveal? If a modality Is not working as well as might be expected, what are the reasons? For example, is the implementation or replication of the modality flawed or incomplete? Are the wrong kinds of clients being treated? Are there unexpected side effects? Does the environment interfere with the effectiveness of the treatment? Do the benefits of the treatment justify its costs? In other words, is treatment a sound investment of scarce public and/or private resources? In addition to these questions about treatment as it presently exists: How might further research help to improve treaornent? In responding to the first of these questions, this chapter considers serially the four major types or modalities of drug treatment: outpatient methadone maintenance, residential therapeutic communities (TCs), outpa- tient nonmethadone (OPNM) treatment, and inpatient/outpatient chemical dependency (CD) treatment. As indicated in the brief description of these modalities in Chapter 2, each type of drug treatment has developed since the 1950s. TCs derived largely from Synanon, which began in California in 1958. Methadone maintenance developed from studies on a hospital ward In New York in 1964; CD programs grew out of hospital-based ap- proaches to treating alcoholism in Minnesota In the 1960s. Outpatient nonmethadone treatment) goes back at least to psychoanalytic treatment of "toxicoman~a" In the 1930s, but the community mental health move- ment, youth crisis counseling, "drop-in centers," and "free clinics" of the 1960s adopted quite different orientations that have substantially shaped the OPNM programs seen today. Although every modality has specific roots, all have continued to evolve since their introduction. The most extensive usable results of research on the effectiveness of 1 Because methadone maintenance programs are virtually always conducted on an outpatient basis but are set apart by the specific reference to methadone, all other outpatient programs are conventionally lumped together as outpatient nonmethadone or outpatient drug free. In light of the frequent use of other psychotropic medications during outpatient treatment, the committee views the term "nonmethadone" as more accurate than "drug free." The lumping together of all outpatient nonmethadone treatment is testimony to the prominence and distinctive nature of methadone maintenance and the fact that the population it serves is sufficiently homogeneous and different from the populations served by other outpatient programs. It should also be noted that methadone may be used in modalities other than maintenance, which technically refers to a planned treatment duration of 180 days or longer. (Shorter periods usually 3 weeks to 2 months are considered methadone detoxification.) Planned methadone-to-abstinence tapers of longer than 180 days are also incorporated into some program plans.

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134 TREATING DRUG PROBLEMS drug treatment are from several moderately sized clinical experiments and natural or quasi-experiments and from prospective longitudinal studies in- volving thousands of clients. There have been two large-scale, multisite, federally sponsored studies of publicly supported programs: the 12-year follow-up of a 1969-1971 Drug Abuse Reporting Program (DARP) na- tional admission sample cohort and the Treatment Outcome Prospective Study, or TOPS, which involved a 10,000-person national sample of 1979- 1981 admissions to 41 drug treatment programs in 10 cities. The Drug Abuse Treatment Outcome Study (DATOS), a third large-scale national prospective study, is scheduled to begin in 1990. The committee addresses the paradigmatic questions separately within each modality. Although many treatment seekers try more than one treat- ment modality over the course of their drug careers (they build up a "treatment career" as well), the average profiles of clients admitted to the major modalities are quite different. Both treatment seekers and treatment programs engage in a great deal of individual selection into which many factors enter. For example, programs are geographically and economically differentiated in their accessibility to various types of potential clients; methadone clinics are relatively low in cost and typically located in inner- city areas; chemical dependency units are generally expensive and found in affluent suburbs. The typical demographic and drug-taking patterns of the different modalities' populations (a reflection of who starys in treatment from among those who are admitted) are quite distinctive. As a result, one cannot simply compare the performance or results of each modality with the others as if their client populations were interchangeable. Moreover, because some clients move between programs and there is evidence that treatment effects may, in part, be delayed and cumulative, it is hazardous to ascribe all the effects of a treatment episode to that episode alone; adjustments must be made to take prior treatments into account. The most extensive and scientifically best developed evidence con- cerns methadone maintenance. A lower although still suggestive level of evidence is available concerning therapeutic communities and outpatient nonmethadone treatment. The lowest level of evidence is available for chemical dependency. Where the evidence on treatment effectiveness ap- proaches adequacy, its overall tendencies are clear. . Treatment reduces the drug consumption and other criminal behav- ior of a substantial number of people. Clients exhibit their best behavior while actively enrolled in treatment; their behavior is often poorer following treatment than during it, although still better than before admission. There are large variations in effectiveness across programs, which seem to be related to the varying quality of clinical management and com- petence. Practices in methadone maintenance dosing are a clear instance

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THE EFFECTIVENESS OF TREATMENT 135 of this variation; there is also variance owing to differences in the char- acteristics of the populations being treated, such as the severity of their problems at admission. The length of time in treatment is a very important correlate of outcome; that is, longer treatment episodes yield better outcomes than shorter ones. Retention is presumably related to general program quality and specific client motivation to remain in treatment; however, no pre- dictive treatment motivation test is available, and the role of treatment in facilitating motivation or averting impulsive decisions to "split" from treatment is not yet well understood. The benefits of treatment programs on the whole outweigh their costs, but variations in cost-benefit methodologies and results are great. It should be noted that, except to describe the model, there are virtually no data to answer critical questions regarding independent self-help fellowship groups such as Narcotics Anonymous and Cocaine Anonymous or the Oxford Houses. Although the ideas underlying the Anonymous fellowships were incorporated at the outset into the clinical approaches2 of TCs and CD programs and clients in these modalities are encouraged to participate in Anonymous meetings, the fellowships have shied away from involvement in formal evaluation protocols. Because drug-related Anonymous groups have been meeting in most cities longer than drug treatment programs have been present, and because they generally welcome individuals who are in treatment as well as those who are not (except that many Anonymous groups are antipathetic to individuals in methadone maintenance), they are in essence a part of the environmental baseline over which the incremental effects of the more formal treatments must be measured. Ho special topics are set slightly apart from the main lines of the chap- ter: the role of detoxification, which is often carried out in hospital settings, and the effects of treatment that occurs within correctional institutions. In the committee's view, it is not tenable to consider detoxification a treatment modality for the rehabilitation of drug abuse and dependence. Rather, it Is a way of moderating some of the effects of overdose or withdrawal, and it may serve as a gateway to treatment. Correctional programs seem to fall largely into one of three types: they are either therapeutic communities, outpatient-type programs whose clients happen to live in prison, or drug law education programs carrying the name of treatment. 2Although CD programs incorporate numerous therapeutic components in addition to Alco- holics Anonymous-type meetings, the 12 steps of the Anonymous creed are so fundamental to the CD modality that the latter has been referred to as the "professionalization of Alcoholics Anonymous." There is no scientific literature on the Oxford House approach, which combines residential proximity with the fellowship principles.

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136 TREATING DRUG PROBLEMS The committee considers the need and opportunity for research rele- vant to treatment effectiveness to be so important that this chapter presents several recommendations for research on treatment methods and services. With recent budget increases for research, there is no overall lack of re- sources that could be devoted to such studies. Rather, the challenges of treatment-oriented research are arduous and demand certain kinds of com- mitments that are altogether too easy to slight in the rush to distribute cascades of research funding to more glamorous (e.g., high-technology) research ventures. METHAI)ONE MAINTENANCE What Is Methadone Maintenance? Methadone maintenance is a treatment specifically designed for depen- dence on narcotic analgesics, particularly the narcotic of greatest concern in the United States, heroin.3 The controversies surrounding methadone maintenances have made it the subject of literally hundreds of studies. From these studies, including a few vitally important clinical trials, strong evidence has accumulated about the safety and effectiveness of methadone. 3There are three main types of narcotic analgesics: those derived from opium, such as morphine, heroin (diacetylmorphine), and codeine, and the two major synthetics, meperidine (best known as Demerol) and methadone. There are numerous congeners of each major narcotic type that have varying degrees of activity. The natural and synthetic compounds have dissimilar chemical bases but share certain critical structural properties that result in their penetrating and affecting the "endogenous opioid" neurotransmitter system in similar ways. There are significant differ- ences, however, in how the major narcotic types are absorbed and metabolized outside the brain; these difference affect the duration and rate of their central nervous system effects. 4There continue to be widespread negative beliefs among the general public and some policy- makers about methadone (see, for example, the results of focus group discussions reported by the Technical Assistance & Gaining Corporation [1989~. The drug is suspected, for example, of being unsafe even in clinically controlled usage; it is said to "rot" the bones (or the brain, or the liver) and to create lassitude or stupefaction among individuals who take it for any length of time or at any dose except a minimal one. It is also said that indefinite maintenance is "just substituting one addiction for another," so the most important clinical goal should be to "get off methadone" as soon as possible. It is thought that most of the people enrolled in methadone maintenance programs sell some or all of their daily methadone dose and use the proceeds to buy heroin and other drugs. Putting all of these beliefs together, methadone can be portrayed as an assault on the well-being of communities in which methadone maintenance clinics are lo- cated, rather than a therapeutic response to local drug problems. This set of beliefs about methadone is based partly on shards of experience (often reported by journalists), partly on philosophical or ideological premises that may be impervious to evi- dence, and partly on frank skepticism about the existence of a therapeutic rationale or base of evidence underpinning methadone maintenance treatment. This section should at least be useful in addressing the last of these sources of belief.

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THE EFFECTIVENESS OF TREATMENT 137 The idea is not unfamiliar that a treatment for a chronic health disor- der could involve long-term, even permanent pharmacological maintenance using a powerful drug that is nevertheless safe if properly administered. Perhaps the most obvious examples are treatments for endocrine prob- lems: insulin for diabetes, thyroxine for thyroid deficiency. A treatment for chronic mood disorders (manic-depressive cyclothymia) using lithium chloride for long-term maintenance is a psychiatric example. Although methadone maintenance was viewed as revolutionary when it was first de- veloped in the United States, the historical sketches in Chapter 2 and in Courtwright (1990) point toward early twentieth century instances in U.S. cities of morphine maintenance as a treatment for opiate dependence. In Great Britain, heroin maintenance was also practiced, although it has largely been replaced there by methadone maintenance. The application of maintenance concepts to the treatment of drug dependence therefore is not medically unusual. But to understand how methadone maintenance operates as a treatment for heroin dependence, three aspects must be stressed: the significance of clinically defined goals, the pharmacological basis of drug substitution, and the embedding of substitution in a broader clinical behavioral strategy. Goals Methadone maintenance cannot be understood apart from the cor- rect stipulation of the major goals of treatment, primarily to reduce illicit drug consumption and other criminal behavior and secondarily to improve productive social behavior and psychological well-being. It is critical that methadone is a legally prescribed drug for the purpose of treating depen- dence.5 Yet even more critical is that individuals who receive methadone maintenance treatment should reduce their use of illicit drugs and their commission of other crimes (e.g., selling drugs, stealing money, using weapons to obtain funds to support their drug consumption) ideally to zero but at least by an appreciable amount. Improved social productivity and well-being would be important further measures of the effectiveness of methadone maintenance. The goal of ending the licit dependence on methadone itself is well down the listso that the risk of increased crime or illicit drug use weighs heavily against arbitrary limitation on the duration of methadone maintenance. Nevertheless, this goal has been given much higher priority in many programs, as discussed later in the chapter. 51be argument has been made that even illegally marketed methadone represents a significant public health improvement over street heroin. Although this result is theoretically plausible, an opposite result is equally plausible, and there is little evidence to support either theory. There- fore, in policy terms, street methadone sales are a negative effect.

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138 Substitution TREATING DRUG PROBLEMS At the base of methadone maintenance is an empirical observation that was made before the biological reasons for it were well understood: all of the effective narcotic analgesics may be substituted for one another with adjustments in dose and route of administration. Substitution is possible because there are basic similarities in their objective and subjective effects; in particular, in dependent individuals there is parallel or cross-tolerance to elevated doses and cross-suppression of respective withdrawal effects. Key differences involve how quick how strong, and how long-lasting these actions are; they are also apparent in the precise mixture of effects for each drug. Cross-dependence is particularly important in detoxification. Most drugs of widespread abuse and dependence (heroin, cocaine, alcohol) act quickly and dramatically and wear off in a matter of hours. By the same token, the associated primary withdrawal syndromes tend to be striking but short; there is usually, however, a somewhat more protracted but less dramatic phase of sustained withdrawal symptoms such as sleep disturbance, agitation, or mild depression. The general approach to detoxification is to moderate the more severe symptoms, often by substituting a long-acting drug, which can then be tapered down to zero, leaving only the lesser symptoms. Methadone may be prescribed not for maintenance purposes but for a shorter period three weeks was once standard, although the period may legally extend up to six months to moderate withdrawal symptoms. Detoxification generally begins with an escalating dosage to reach a point such that the patient stops using other opiates and withdrawal symptoms are not evident. Then the methadone dose is tapered down to zero. Individual responses vary, but usually this method does not completely sup- press withdrawal symptoms during and after the tapering period; rather, it keeps them mild for a time until the tapering procedure does not provide enough methadone to prevent the more discomfiting withdrawal symptoms. It is common for individuals to drop out of methadone detoxification some time during the second week of a typical three-week planned detoxifica- tion period. Sometimes other medications are given during methadone detoxification to manage particular symptoms. As shown by the long record of experience with detoxification of heroin dependence, those detoxified were universally found to have a very high susceptibility to relapse usually well in excess of 90 percent of followed cases (see Vaillant, 1973~. After detoxification, and often before its proce- dures had been completed, there was a resumption of craving for opiates. Dole (1988) and others have theorized that the extensive use of opiates may bring on alterations in the brain neurotransmitter/receptor systems affected

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THE EFFECTIVENESS OF TREATMENT 139 by opiates, leaving many individuals with a virtually permanent craving that can only be assuaged by drugs of the opiate family. Methadone has several unusual pharmacological properties that have made it especially suited to a maintenance approach. Unlike many opiates, it is effective orally, a significant advantage in that oral dosing is more hygienic than the needle and more easily titrated than smoke. Because of methadone's particular pattern of absorption, metabolism, and elimination, a single dose within a train of level doses, in the typical maintenance range of 30 to 100 milligrams per day (mg/day), takes effect gradually and wears off slowly, yielding a fairly even effect across a period of 24 hours or longer. Methadone is thus conducive to a regime of single daily maintenance doses, eliminating dramatic subjective or behavioral changes and making it easy for clinician and client to fit into a routinized clinic schedule.6 This pattern is very different from the shorter action and more dramatic highs and lows of heroin, morphine, and most other opiates. The long-term toxic side effects of methadone, as of other opiates if taken in hygienic conditions in controlled doses, are notably benign. The short-term clinical effects of methadone were first studied at the Lexington addiction research center In the l950s, and research continued there and elsewhere into the 1960s. Since the mid-1960s, about 1.5 million person-years of methadone maintenance have accumulated In the United States. Not all clients have been closely observed for medical side effects, but the thousands of research cases that have been carefully observed yield a well-documented conclusion: Physiological and biochemical alterations occur, but there are minimal side effects that are clinically detectable in patients during chronic methadone maintenance treatment. Toxicity related to methadone during chronic treatment is extraordinarily rare. The most important 6There was extensive research from the late 1960s to the late 1970s on a longeracting methadone congener, levo-alpha-acetylmethadyl (LAAM), that requires less frequent doses~very two or three days instead of daily. LAAM has been studied in a series of phased clinical trials but has not yet been approved for nonexperimental use, although its safety and freedom from toxic side effects appear comparable to those of methadone (Savage et al., 1976; Ling et al., 1978; Blaine et al., 1981~. Overall, during the trials, methadone was more successful than IAAM in retaining clients in treatment (by 20 percentage points), largely because more LAAM recipients felt that the medication was not "holding," that is, not keeping opiate withdrawal symptoms from beginning to emerge between doses, a result that Goldstein and Judson (1974), after a double- blind study, judged to be more psychological than physiological in origin. LAAM recipients who stayed in treatment used less heroin and performed better on other clinical measures than methadone clients, particularly those on lower methadone doses. Some clinicians reported a substantially improved therapeutic climate in LAAM clinics owing to the more relaxed three- days-per-week visiting schedule (Goldstein, 1976~. There are probably clients who would do better on LAAM than on methadone, and vice versa, with results for both likely to improve with better dose optimization and counseling about differences between the two drugs. A revival of interest in LAAM and an attempt to restore the initiative toward approval by the Food and Drug Administration for nonexperimental use are under way.

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140 TREATING DRUG PROBLEMS medical consequence of methadone during chronic treatment, in fact, is the marked improvement in general health and nutritional status observed in patients as compared with their status at the time of admission to treatment. (Kreek, 1983:474) The most common physical complaints during methadone maintenance are insomnia and weight gain, but these are clinically related both to the consumption of other drugs and alcohol (consumption that continues and sometimes increases among a fraction of clients, the size of which varies from program to program) and to preexisting or coexisting abnormalities common in this population and in the general population. Clinical Behavioral Strategy In terms of the social history and individual model of drug-seeking behavior reviewed in Chapters 2 and 3, a program of controlled methadone maintenance at an appropriate dose level could have recovery-inducing effects on heroin dependence. These effects may be felt through two paths corresponding to the two most common motivational processes that operate during heroin dependence: pleasure seeking and withdrawal avoidance. With regard to pleasure seeking, methadone is an effective analgesic. Yet the effect of an accustomed (tolerated) dose is merely a dim echo or reminder of heroin's most intense effects, not so much a "rush" as a reassurance which may wear better in the long run and is certainly less disruptive in the short run than the euphoric heroin high with its associated itchiness and dreamy nods. There is also a more subtle and perhaps equally valuable effect: if heroin and methadone are both in the body, their active metabolites compete with each other for access to sites of action in the brain. If the methadone dose is high relative to the heroin dose, the latter will not have a very distinctive effect, and the individual taking methadone will find heroin less rewarding. As a result, the shooting of heroin "over" the methadone may become self-extinguishing. On the other side of the pharmacological fence, methadone main- tenance prevents symptoms of heroin withdrawal, which, although not life-threatening or excruciating, are immiserating (a good parallel is a head cold or a bout of influenza). The critical condition is that the dependent person feeling withdrawal symptoms knows that all of these unwelcome sen- sations can be banished within minutes with a dose of an opiate. Recurrent withdrawal symptoms stimulate drug seeking during heroin dependence, and the ability of methadone maintenance to keep them at bay is a major attraction and benefit. In its initial clinical trials, which began in inpatient settings and then were extended to outpatient sites, methadone maintenance proved capa- ble of stabilizing the psychological functioning of the heroin-dependent

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THE EFFECTIVENESS OF TREATMENT 141 individual at a near normal state. Methadone in effect eliminated the alter- nating phases of euphoria, somnolence, and agitated concern characteristic of the incipient stage of withdrawal from heroin dependence. The clini- cians conducting the trials observed that clients on methadone were not obsessed with acquiring the next dose, became interested in the prospects for improving the conventional strands of their lives, and were generally functioning without notable drug impairment or side effects. An individual on methadone was capable of participating in counseling, psychotherapy, and remedial education and training (most of the same rehabilitative ser- vices delivered in therapeutic communities and outpatient treatment). This capability was partly the result of the intrinsic pharmacological effects of methadone and partly because, unlike street heroin, it was provided reliably, in legitimate clinical settings, and in reliable doses. Methadone maintenance was originally defined as the administration of methadone together with rehabilitative and counseling services, and this definition, along with many detailed specifications about facilities and staffing, was built into federal regulations as a required protocol for a licensed methadone maintenance program. These regulations permit methadone to be dispensed only by licensed maintenance or detoxification programs or by hospital pharmacies. (In hospitals, methadone is prescribed mainly for severe postoperative or cancer pain and occasionally for short- term inpatient detoxification.) Methadone programs are nearly always ambulatory, with daily visits to swallow the methadone dose (usually provided in a 3- to 4-ounce plastic bottle of sweetened, orange-flavored water) in the clinic, except for the traditional Sunday take-home dose. After several months in the program with a "clean" drug-testing record and good compliance with other program requirements such as counseling appointments, clients may regularly take home one or more days' doses between every-other-day, twice-weekly, or even weekly visitsa revocable range of privileges. Some methadone clients voluntarily reduce their doses to abstinence and conclude treatment after some time; others remain on methadone indefinitely. The role of counseling is multifold. In the first instance, the design of methadone maintenance programs includes numerous monitoring and adjustment features that stress the need for clients to wean themselves away from street drug seeking. Program clinics have specific hours for dispensing, counseling, and medical appointments; there are codes of proscribed behavior (e.g., no violence or threats of violence), and monitored drug tests are conducted at random intervals at least monthly and as often as weekly, although the cost of the tests have led financially strained programs to cut them back to the minimum. Counseling includes the assessment of client attitudes and appearance (important in themselves and as clues to drug behavior) and the gathering of information about

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142 TREATING DRUG PROBLEMS employment, family, and criminal activities; counselors offer psychotherapy and individualized social assistance and recognition, depending on their caseloads and their training for such tasks. In most clinics, counselors participate in staff decisions with regard to changing dose levels, requirements for therapeutic contacts, award and re- vocation of take-home privileges, and decisions regarding termination from the program. Clinical experiments have studied methadone dosage and behavioral techniques (contingent rewards and sanctions for "dirty" urines and missed and late counseling appointments) as part of the modality's repertoire. The clinical trial literature has demonstrated important success in the use of methadone dosage supplements or decrements and take-home privileges to punish or reward clients for noncompliance with such clinical rules as the proscription on continued drug use and the requirement of cooperation by timely attendance for dispersing, participating in counseling, and paying required fees (Stitzer et al., 1983~. The drawbacks to methadone maintenance have been well recognized since its inception: the client is still at least mildly dependent; the drug reduces heroin craving and stabilizes the individual psychologically but does not necessarily modify or rehabilitate other behavior; clients often still use or abuse and sometimes become dependent on other drugs including alcohol; and it is possible for take-home methadone to be diverted from therapeutic uses and sold to permit the client to buy heroin or other drugs. Moreover, methadone has no direct pharmacological bearing on abuse or dependence on alcohol or other drugs, especially cocaine, which has become such a serious and widespread problem in the 1980s. The important question is this: Does the modality reach its primary goals in enough cases to outweigh these limitations and drawbacks? How Well Does Methadone Work? The goals of methadone maintenanceto reduce illicit consumption of heroin and other opiates, to reduce other criminal activity, and to help clients become more socially productive and psychologically stable- constitute a continuum that can be cut at various points to designate "success" versus "failure." At the outset of its use, the modality was specifically targeted toward those who were most severely dependent, as judged by substantial histories of relapse from earlier detoxification episodes (frequently in jail); this commitment was built into the early regulations requiring documentation of at least two vears of heroin use and two prior . ~ , relapses. Early trials of methadone maintenance in New York (Dole and Nyswan- der, 1965, 1967; Dole et al., 1966, 1968, 1969) noted two striking findings: the majority of clients would remain in treatment for as long as it was

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THE EFFECTIVENESS OF TREATMENT 189 of outcomes at follow-up, with graduates having the best outcomes at that point. Attrition from TCs is typically highabove the rates for methadone maintenance but below the rates for outpatient nonmethadone treatment. Typically, about 15 percent of admissions will graduate after a continuous stay; the figure is higher (20 to 25 percent) once later readmissions are considered. The minimum retention necessary to yield improvement in long- term outcomes seems to be several months, which covers one-third to one-half of a typical program's admissions. Improvements continue to be manifested for full-time treatment of up to one year in length. The benefits of TO treatment are substantial and they virtually repay the costs on a day-by-day basis, although the per diem costs are higher than for methadone maintenance: generally, about $13,000 per year- probably $20,000 for a model progra~yielding somewhat lower benefit/cost ratios than for methadone but ones that still favor the use of this treatment. Outpatient Nonmethadone Programs Outpatient nonmethadone programs display a great deal of hetero- geneity in their treatment processes, philosophies, and staffing. Their clients generally are not opiate dependent but otherwise vary across all types of drugs. Usually, OPNM clients have much less serious criminal histories than methadone or TC clients and include more nondependent individuals. Outpatient nonmethadone programs generally provide one or two visits per week for individual or group psychotherapy/counseling, with an expected course averaging about six months. Despite the heterogeneity of programs and their clients, the limited number of outcome evaluations of OPNM programs have generated con- clusions qualitatively similar to those from studies of TCs: outpatient nonmethadone clients during and following treatment exhibit better behavior than before treatment. Those clients who are actu- ally admitted to programs have better outcomes than clients who contact but do not enter programs (and clients who only undergo detoxification). Outcome at follow-up is positively related to length of stay in treatment, and completers have better outcomes than dropouts. Retention in outpatient nonmethadone programs is poorer than for methadone maintenance and therapeutic communities. The benefits of OPNM treatment are fewer than for methadone or TCs, but the cost of the treatment, at about $1,350 for six months (about $1,800 for a model program), is low. As a result, the yields are favorable

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190 TREATING DRUG PROBLEMS for those who stay longer than three months, and the aggregate program ratios are mildly favorable. Chemical Dependency Programs Chemical dependency programs generally are residential or inpatient, with a three- to six-week duration, followed by up to two years of attendance at self-help groups or a weekly outpatient therapy group. CD programs are based on an Alcoholics Anonymous (12-step) model of personal change, a belief that dependence is a permanent but controllable disability, and goals of total abstinence and lifestyle alteration. The proportion of the CD population who are drug involved is similar to the outpatient nonmethadone population in that the primary drugs are cocaine and marijuana. The modal CD client, however, is an older, socially well-supported, alcohol-dependent individual. CD programs are often located in hospitals, but the core therapeutic elements of this modality do not require the presence of acute care hospital services. There is little evidence on whether hospital-based CD programs are more or less effective for drug problems than CD programs that are not sited in hospitals, or whether they are more or less effective than no treatment at all. Chemical dependency programs treat mainly primary alcoholism and have not been adequately evaluated for treatment of drug problems. A few follow-up studies of individuals who have completed CD treatment indicate that primary drug clients have poorer outcomes than primary alcohol clients. There are no cost/benefit analyses for chemical dependency treatment. Detoxification Detoxification is therapeutically supervised withdrawal to abstinence over a short term that is, up to several months but usually five to seven days, often employing pharmacological agents to reduce client discomfort or the likelihood of complications. Detoxification is seldom effective in itself as a modality for bringing about recovery from dependence, although it can be used as a gateway to other treatment modalities. Clinicians generally advocate that detoxification not be considered a modality of treatment in the same sense as methadone, TCs, outpatient counseling, and CD units because of its narrow, short-term focus and poor outcomes in terms of relapse to drug dependence. Detoxification episodes are often hospital based and may begin with emergency treatment of an overdose. Much drug detoxification (an esti- mated 100,000 admissions annually) is now taking place in hospital beds. It is doubtful whether hospitalization (especially beyond the first day or

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THE EFFECTIVENESS OF TREATMENT 191 two) is necessary in most cases, except for the special problems of addicted neonates, severe sedative-hypnotic dependence, or concurrent medical or severe psychiatric problems. For clients with a documented history of com- plications or highs from detoxification, residential detoxification may be indicated. Detoxification may, in the committee's judgment, be undertaken successfully in most cases on a nonhospital residential, partial day care, or ambulatory basis. Correctional Treatment Treatment of drug-involved prisoners is fairly common, but at least two-thirds of prison treatment programs are equivalent to outpatient non- methadone treatment that is, periodic individual or group therapy ses- sions. This level of intervention is probably not intensive enough to do much for this group. The other prison treatment programs are similar to stays in a therapeutic community, including separation from the general prison population for the expected 6- to 12-month duration of the program. Most of the prison drug treatment programs that have been studied, in- cluding specialized "boot camp" or "shock incarceration" facilities, have not been shown to reduce the typically very high postrelease rates of recidivism to drug seeking and other criminal behavior that occur among untreated prisoners. Nevertheless, a small number of well-designed controlled stud- ies, involving prison TCs and residential programs that have strong linkages to community-based supervision and/or treatment programs, indicate that prison-initiated treatment can reduce the treated group's rate of rearrest by one-fourth to one-half; clear correlations are observed between positive outcome rates and length of time in treatment, just as in studies of entirely community-based modalities. The results have some anomalies and there have been difficulties in sustaining the integrity of prison-based treatment programs, but the results argue that these programs should be carefully encouraged. * * * * * If a single phrase could succeed in capturing most of the findings in this chapter, it would be an expression that much like the current treatment modalitiesdates from the 196Os: different strokes for different folks. No single treatment "works" for a majority of the people who seek treatment. Each of the treatment modalities for which there is a baseline of adequate studies can fairly be said to work for many of the people who seek that treatment; and enough of them do find the right treatment, and stay with it long enough, to make the current aggregate of treatment programs worthwhile. Selection of the most appropriate treatment modality by clients or

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192 TREATING DRUG PROBLEMS others (e.g., judges, probation officers, employee assistance counselors, family members) is constrained by poor information about programs, lo- cation/transportation issues, waiting lists at some portals and aggressive recruitment at others, and cost questions. In most locations, there is no comprehensive intake (assessment and referral) unit or agency to advise or assign applicants. (This triage feature, which was relatively common in the multimodality programs and municipal treatment agencies of the 1960s or 1970s, was often abandoned in the cost-cutting of the early 1980s.) Most of all, the search for the right program is bedeviled by variations in program quality. The signs of poor program performance (particularly of poor response to the prospective client's specific set of problems) are not readily apparent, and the general lack of reliable information about program outcomes does not offer incentives for programs to change for the better. There is a great deal of room for improvement, and there are in- dications in the research literature on how to bring that about. Much of Chapters 7 and 8 is informed by the committee's reading of those in- dications. Before moving to the final third of the report, however, the committee considers it vital to lay out a plan for restocking and expanding the limited store of knowledge it has had to draw on so that if another group is charged with studying the treatment system 5 or 10 years from now, they will not have to be as disappointed as this body was about the knowledge gains in the intervening years. The last section of this chapter therefore presents a brief but systematic template of recommendations for a national program of treatment research. RECOMMENDATIONS FOR RESEARCH ON TREATMENT SERVICES AND METHODS Rebuilding the Research Base Federal support for drug research, including research on treatment methods and seIvices (alternatively, clinical and services research), surged during the early 1970s, declined steadily in real terms for the next decade, and began to surge again as a result of the Anti-Drug Abuse Acts of 1986 and 1988 and recent initiatives for AIDS-related research (Figure 5-8~. Unfortunately, but quite predictably, the base of capable researchers declined during the decade-long period of stagnation, as scientists moved on to other fields and very few new ones entered the drug research area. The number of centers of excellence in treatment-oriented research active programs generating sound new results on current data" declined substantially; where there were formerly close to two dozen, located in

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THE EFFECTIVENESS OF TREATMENT 193 all parts of the country, there are now just a handful in a few major metropolitan centers. The national research infrastructure must be rebuilt and the number of local centers of excellence in research on treatment methods and services increased to reverse the shortage of experienced investigators. Current funding increases are sufficient to rebuild the needed base of treatment research excellence but only if the current level is sustained for at least four or five years and expenditures are patterned during that time to ensure attention to the perennial questions that face clinicians and policymakers responsible for the system. It is critical that this base be maintained through a program of steady incremental funding changes and not be dismantled once again, a course that would leave the nation unprepared to respond quickly to whatever new epidemic of drug use might arise in the futureand the lesson of history is that some new wave will arise. To evaluate and improve the adequacy and effectiveness of treatment plans and expenditures, the national services research program in particular needs rebuilding. The prospects for maintaining and improving treatment quality as well as continuing to develop more effective treatment methods depend to a great extent on treatment services research. The National Insti- tute on Drug Abuse (NIDA), the agency most responsible for maintaining 260 240 220 200 180 160 140 120 100 80 60 40 20 73 75 77 79 81 83 FISCAL YEAR 206 (est.) / / Real $ 1 2^ _ 34 84 Nominal $ - 34 1 1 1 1 I I I I 85 87 89 FIGURE 5-8 Annual research obligations of the National Institute on Drug Abuse (in both nominal [current] and real [1989-equivalent] dollars) for fiscal years 197~1990. Source: National Institute on Drug Abuse, unpublished data, 1989.

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194 TREATING DRUG PROBl EMS treatment research, is, of course, not autonomous. Its budget and priori- ties are proposed by the President and disposed by Congress. Moreover, providers of drug treatment services are very much at fault for permitting and in some cases tacitly encouraging the paucity of treatment research over the past decade. Programs have been characterized too much by a fear of failure and too little by the courage of their convictions. The results of earlier treatment enterprises tell an enlightening and reasonably heartening tale, and there is little possibility of improving current therapeutic practices further without careful study of outcomes, not only in research units, with their limited patient protocols and cadre of university-based researchers, but also in all other treatment programs. Most importantly, the advances in knowledge that came out of clinical and services research in the 1970s have not been followed up, and as a result analysts today are not better prepared to answer questions about the effectiveness, costs, and benefits of current treatment than they were a decade ago. Data systems and analytic capabilities that were designed to answer policy questions have not been well maintained. It would be a travesty of prudent governance if once again the federal government and the states were to proceed to build, or rebuild, a major instrument of national drug control policy without assuring themselves and the taxpayers that there would be timely, necessary research and evaluation to understand that instrument's performance and facilitate its improvement. One more note needs sounding in this context. A critical longer term role is played by basic epidemiological, behavioral, biological, and neurochemical research to address such issues as the role of genetic pre- dispositions in addiction, the factors that contribute to the plasticity of addictive behavior, the effects of social factors, and methods for reducing drug craving. The goal of such work should be to integrate the biological and behavioral sides of the drug problem. This integration will remain difficult so long as a continuing imbalance persists between substantial investments in high-quality biomedical research and meager ones in high- quality biobehavioral and psychosocial research. Major Research Questions The core questions that need to be addressed for the various modal- ities of public treatment are the following: What client and program fac- tors influence treatment-seeking behavior, treatment retention and efficacy, and relapse after treatment? How can these factors be better managed? ~eatment-seeking factors include community outreach, health promotion and disease prevention efforts such as experimental needle-exchange pro- grams, family and employer interventions, and program intake and triage

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THE EFFECTIVENESS OF TREATMENT 195 procedures. Retention and efficacy factors include optimal treatment dura- tions and schedules, pretreatment motivations, counselor or therapist be- havior, incentives and conditions of employment, clinic procedures, criminal justice contingencies, and ancillary services. Posttreatment factors include relapse prevention interventions, abstinence monitoring, and environmental reinforcement. The questions need to be attacked in a variety of ways. Despite the difficulties of maintaining the integrity of controlled experiments in treat- ment programs, these studies provide the most incontrovertible endence about comparative treatment effects, and efforts to conduct them should be strongly encouraged. A more detailed understanding of treatment pro- cesses through ethnographic and case study methods is also badly needed. This work is the basis for the design and interpretation of survey instru- ments. Studies should be initiated within as well as across each major treatment modality to answer the following question: What are the rela- tions of treatment performance (that is, differential outcomes, taking initial client characteristics into account), the content and organization of treat- ment (specific site arrangements, service offerings, therapeutic approaches, staffing practices), and the costs of treatment? Services Research Health services research is a critical element in building treatment systems. An important foundation for services research as well as program accountability is the development, maintenance, and analysis of a system of data acquisition on treatment programs, client performance, and costs. Results from studies that use these kinds of data will permit better and more cost-effective decisions about facility characteristics, staff salary and training levels, services coordination methods, intensity of services, reason- able charges, and other components. Systems of this sort were established in the 1970s but were effectively disassembled as a matter of federal policy in the 198Os. Treatment data acquisition systems must be rebuilt and ef- fectively managed and utilized if the improvement of treatment knowledge and practice is to be evaluated and facilitated in the 1990s. Data on treat- ment effectiveness and costs should become the cornerstone of decisions about treatment coverage by public and private programs. NIDA, in conjunction with its sister agency, the Office of Treatment Improvement, needs to give more adequate, focused attention to the drug treatment delivery system as a whole. Stronger services research programs at NIDA are a critical complement to the research and service respon- sibilities of the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA). Fulfilling this responsibility requires close linkages to practice

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196 TREATING DRUG PROBLEMS and thus some responsibility to and for service delivery. Existing legislative authority directing these linkages should be implemented fully. The responsibilities for research coordination, however, do not stop at the boundaries of ADAMHA Collaborative and coordinative arrange- ments with the National Institute of Justice, the Bureau of Justice Statistics, the National Institute of Corrections, and other relevant agencies in the Department of Justice and other federal departments should be extended beyond current levels. More extensive relationships would encourage crit- ical technical improvements, such as the inclusion in epidemiological and treatment surveys of "linkage" items to facilitate syntheses with data from criminal justice populations. For example, treatment applicants should be asked how many emergency room admissions and arrests they have under- gone during the year prior to treatment, which would not only serve to build baseline data for outcomes research but also provide calibrations with respect to the Drug Abuse Warning Network and Drug Use Forecasting data systems. Some of the most compelling results of treatment research have come from large longitudinal studies involving thousands of clients: the DARP (Drug Abuse Reporting Program) study of a 196~1971 national admission cohort, which included a 12-year follow-up, and TOPS (the Treatment Out- come Prospective Study), which involved a 10,000-person national sample of 1979-1981 admissions to 41 drug treatment programs in 10 cities. There is reason to believe that some findings about the treatment modalities- such as the importance of time in treatment will prove robust in the face of changing drug markets, but others may not. Another such national treatment sample study (DATOS, or the Drug Abuse Treatment Outcome Study) is beginning in 1990, and some smaller scale studies, such as the Drug Services Research Survey, are in process. Intervals of 10 years between entry cohorts to major studies as important as these are far too long. New study panels composed of 3-year entry cohorts (an efficient period of admission to a multiwave design) should begin at no greater than 5-year intervals. The responsibility to study treatment services in the field generally is not met by demonstration grant programs. Demonstrations have histori- cally functioned as a stop-gap measure to provide a new kind of service for which there seemed to be a need but no certain knowledge about how to fill it knowledge lacking at least in part because adequate research systems were not already in place to generate it. Demonstrations are not a reasonable substitute for a strong program of treatment services research. Demonstration grants should be made only when objectives are carefully specified and independently designed and performed collaborative evalua- tions are funded. Collaborative clinical trials are the basis for developing

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THE EFFECTIVENESS OF TREATMENT 197 standardized protocols in other forms of treatment and should be imple- mented as models for demonstration programs. Such a plan would allow effective programs or program components to be adequately described, replicated, and, if found useful, incorporated into certification standards. A services research issue worth noting here is the difficulties that drug treatment programs experience in securing zoning approval for clinical facilities, a problem usually summarized as "not in my back yard" (NIMBY). This problem, of course, is not confined to siting community drug treatment programs but confronts public utilities and services of many kinds. There is currently a NIDA-sponsored market research project (Technical Assistance & Raining Corp., 1989) to create technical assistance materials to overcome this "barrier" to treatment. Research support for more definitive studies of program site effects for example, on local real estate values and criminal victimization rateswould provide a better foundation for this work. Chemical Dependency Chemical dependency programs are the least well studied of the drug treatment modalities. The aggressive marketing deployed by many such programs has created suspicions about them in many quarters that cannot be allayed without investments in objective treatment research and evalua- tion. The optimal site of delivery and length of programming, including the duration of intensive treatment and aftercare periods, and the specific ther- apeutic elements necessary for an effective program should be investigated more closely. Only a few chemical dependency treatment providers have played positive roles in providing data and research opportunities for effectiveness studies. Many more need to do so to answer these questions: What is the effectiveness of chemical dependency treatment for drug-impaired clients of varying characteristics? Are there variations in program effectiveness and if so, why? What are the actual costs and benefits of the most effective components of chemical dependency treatment? Cocaine Treatment The major efforts to date to investigate cocaine treatment efficacy occurred prior to the epidemiological reemergence of cocaine In the 1980s. There Is reason to believe that some findings about treatment modalities such as the importance of time in treatment will prove robust in the face of changing drug markets, but others may not. The infrastructure of treatment research centers decayed during the stagnation of drug research funding, and as this capability is rebuilt, it should specifically address the following questions about cocaine treatment: What are the most effective treatment elements for cocaine dependence and abuse? To what degree can

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198 TREATING DRUG PROBLEMS current modalities be effective for crack-cocaine? What new or existing pharmacological and nonpharmacological treatment elements can improve the clinical picture? Women, Children, and Adolescents The majority of individuals in treatment are adult males who are 20 to 40 years old, and their responses dominate treatment research statistics. The major findings of research to date on the effectiveness of different modalities and elements of treatment seem to apply roughly as well to ado- lescents and women with young children as they do to the more prevalent demographic groups (Hubbard et al., 1989~. Yet the potential significance of child-bearing and child-rearing women and adolescent clients in terms of the future benefits of present treatment (or the future costs of present nontreatment) is great. Research plans in all areas need to devote spe- cial attention to differentiated knowledge about the two populations of adolescents and women with young children (including pregnant women). It seems clear from earlier studies that women in treatment who are pregnant or have young children are especially likely to bring particular needs to the treatment system (Beschner et al., 1981; Reed et al., 1982~. For example, drug-abusing or dependent women on average have poorer self-esteem than men and suffer from greater anxiety, depression, and detachment; as a result, therapists who rely too heavily on confrontative techniques may worsen such problems rather than help reduce them. Be- cause of their child care responsibilities, long-term residential treatment in TCs may be ruled out for many women unless there are special pro- visions for child care. In many states, long-term TC treatment becomes doubly problematic because extended residential treatment may jeopardize family eligibility for Aid to Families with Dependent Children (welfare) or threaten the mother's custody of the children. The federal block grant for alcohol, drug abuse, and mental health services mandates that 10 percent of the grant be set aside to provide special services for women. According to the Institute of Medicine analysis of the 1987 National Drug and Alcoholism Treatment Utilization Suney, about one-third of the more than 80,000 women in drug treatment were in programs that had at least some special services for women, although there is no further specification of the nature or extent of these services. Both clinical and services research are needed to gain an understanding of the nature and efficacy of current practices and the potential of innovations. The state of knowledge about adolescent treatment is, if anything, even less satisfactory. The number of useful studies of adolescents is small, and most work in this area is based too heavily on studies of treatment in much earlier periods (e.g., Friedman and colleagues [1986] analyze data

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THE EFFECTIVENESS OF TREATMENT 199 on adolescents in the Drug Abuse Reporting Program of the early 1970s). There are major obstacles to research on adolescents, including conceptual issues, such as discordant terminology for adolescent treatment service components, and logistical constraints, such as unmanageable requirements for obtaining parental consent. The committee recommends that a special study initiative be under- taken by the National Institute on Drug Abuse, in conjunction with other relevant agencies of the Public Health Service, on the treatment of drug abuse and dependence among adolescents and women who are pregnant or rearing young children. The initiative should review and summarize all available sources of evidence and insight from research and clinical experience, provide as much guidance as possible for current treatment efforts, and develop a comprehensive research agenda. The agenda in turn should be pursued by research agencies of the federal government and other sources of research support and carried forward by the community of clinicians and scientists.