Sustained increases in personal health and social function. Improvements in the medical/psychiatric health and social function of addicted patients are important from a societal perspective in that these improvements reduce the problems and expenses produced by the addiction. In addition, improvements in these areas are important for maintaining reductions in substance use. Within the review, we accepted evidence from measures such as general health status inventories, psychological symptom inventories, family function measures, and simple measures of days worked and dollars earned, collected either directly from the patient via confidential self report or from independent medical/psychiatric evaluations and employment records.


    Sustained reductions in public health and public safety threats. The threats to public health and safety from substance abusing individuals come from behaviors that spread infectious diseases and from behaviors associated with personal and property crimes. With regard to infectious disease, the sharing of needles, unprotected sex, and trading sex for drugs are serious behaviors that have clearly been linked to addiction and are significant threats to public health. Within the review, we accepted evidence of improved public health from confidential self reporting techniques or (rarely) through laboratory tests. Public safety threats were measured in the studies reviewed either by confidential interviews and questionnaires or by objective records of arrests and incarcerations.

    In our view, the first two domains are quite consistent with the "primary and secondary measures of effectiveness" typically used by the Food and Drug Administration to evaluate new drug or device applications in controlled clinical trials (FDA) and quite consistent with the mainstream of thought regarding the evaluation of other forms of health care (Stewart and Ware, 1989). The final outcome dimension we believe is more specific to the treatment of substance use disorders since it acknowledges the significant public health and public safety concerns associated with addiction.


    Demographic Factors—While demographic factors are typically important predictors of the development of drug abuse problems (IOM, 1990b; Wilsnack and Wilsnack, 1993) there is little evidence that race, gender, age, or educational level are consistent predictors of treatment outcome—among those who begin a treatment episode. An inspection of a wide range of treatment outcome studies in the substance abuse rehabilitation field suggests that demographic factors such as age, education, race, and even treatment history are relatively poorly related to the three out-

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