1
Introduction

Drug abuse remains one of our nation's most intractable problems. Only a small proportion of the approximately 9.4 million addicted and dependent individuals receive treatment in a given year. In fact, almost 80 percent go untreated, a figure that has changed little in the 1990s while the number needing treatment has increased (Epstein and Gfroerer, 1998). The stigma of drug abuse and the political and financial barriers encountered at all levels impede efforts to increase treatment. The care of patients with addictive disorders is characterized by a high degree of variability in the application of treatment methodologies and patient placement decisions. In addition, the field has been plagued by approaches to treatment that have not been based on evidence beyond anecdotal reports and belief systems. Dogmatic thinking about etiology and treatment of addictive disorders, as well as changes in the financing environment, has led to the application of treatment concepts without reference to their appropriateness or efficacy for particular classes of patients.

At the same time, however, there is a paucity of data on the efficacy of specific treatments and their short- and long-term outcome, as well as on the relationship between clinical and demographic characteristics of patients with addictive disorders and their responses to particular treatment modalities. These difficulties are greatly complicated by the fact that patients often have a limited ability to comply with treatment regimens, a high incidence of relapse, and high levels of other coincident psychiatric, psychosocial, and medical problems. Perhaps as many as half of those needing treatment for drug and alcohol abuse also need treatment for co-occurring



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1 Introduction Drug abuse remains one of our nation's most intractable problems. Only a small proportion of the approximately 9.4 million addicted and dependent individuals receive treatment in a given year. In fact, almost 80 percent go untreated, a figure that has changed little in the 1990s while the number needing treatment has increased (Epstein and Gfroerer, 1998). The stigma of drug abuse and the political and financial barriers encountered at all levels impede efforts to increase treatment. The care of patients with addictive disorders is characterized by a high degree of variability in the application of treatment methodologies and patient placement decisions. In addition, the field has been plagued by approaches to treatment that have not been based on evidence beyond anecdotal reports and belief systems. Dogmatic thinking about etiology and treatment of addictive disorders, as well as changes in the financing environment, has led to the application of treatment concepts without reference to their appropriateness or efficacy for particular classes of patients. At the same time, however, there is a paucity of data on the efficacy of specific treatments and their short- and long-term outcome, as well as on the relationship between clinical and demographic characteristics of patients with addictive disorders and their responses to particular treatment modalities. These difficulties are greatly complicated by the fact that patients often have a limited ability to comply with treatment regimens, a high incidence of relapse, and high levels of other coincident psychiatric, psychosocial, and medical problems. Perhaps as many as half of those needing treatment for drug and alcohol abuse also need treatment for co-occurring

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mental illness.1 Thus, the clinical complexities inherent in treating such patients has fostered a tendency to apply multiple treatment modalities without thinking through or knowing which treatments may be most effective for a specific patient, or considering the sequence in which such treatments should be applied. This situation has major implications for the treatment of addictive disorders and, thus, for public health. The absence of an evidence-based approach to addiction treatment, coupled with a lack of valid and reliable measures of treatment outcome, has induced skepticism on the part of purchasers of care, policymakers, and consumers as to the value of treatment for drug and alcohol abuse and dependence. Skepticism and the stigma attached to these disorders, which are perceived by many as volitional and suggestive of moral weakness, has further led to discrimination in benefit design and reluctance by payers and managed care organizations to allocate resources to the care of such patients. Community-based drug treatment organizations (CBOs) provide the backbone of drug and alcohol treatment today and their capabilities have not kept up with the rising problem of addiction, nor with the major scientific advances that have been made in understanding the biopsychosocial basis of addiction (IOM, 1996, 1997a). Such organizations receive the majority of their funding from public dollars, through state and local appropriations and federal block grants to states. In 1997 public funds accounted for two-thirds (65 percent) of the reported revenues in drug and alcohol treatment programs (Horgan and Levine—Appendix E). In the current environment of fiscal restraint and burgeoning need, there is great interest in strengthening the community-based drug treatment organizations and in helping these providers better utilize research findings on effective treatment strategies. This report examines these issues and presents the findings and conclusions of an Institute of Medicine committee convened at the request of the Substance Abuse and Mental Health Services Administration's Center for 1   There are perhaps 10 million individuals who have co-occurring mental illness and substance abuse problems, including alcohol abuse and dependence. NIAAA's Ninth Special Report to Congress indicates that 13.7 million meet DSM-IV criteria for either alcohol abuse or alcohol dependence (NIAAA, 1997). And the most recent SAMHSA estimate for individuals needing treatment for drug abuse and dependence is 9.4 million (Epstein and Gfroerer, 1998). Even adjusting generously for the overlap between the two groups, it appears that co-occurring mental illness is a very large problem in treating individuals for alcohol and drug abuse. Based on recent survey data cited in Horgan and Levine (see Table 7, Appendix E), it appears that the proportion of facilities providing both substance abuse and mental health services is increasing.

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Substance Abuse Treatment (CSAT) and the National Institute on Drug Abuse (NIDA).2 This committee was asked to accomplish the following tasks (see Appendix A): 1.   identify relevant treatment strategies and promising research approaches, including the development of a typology linking specific treatment strategies with amenable research approaches; 2.   identify mechanisms by which community-based treatment programs are participating in research, including subsequent use of that research; 3.   identify mechanisms for technology transfer; 4.   identify barriers that may hinder conduct of research within or the application of research results in the treatment setting; 5.   identify barriers that hinder the communication of treatment practices back to the researchers; and 6.   identify innovative yet practical strategies for overcoming these barriers. The committee hopes that its findings and recommendations will foster increased bidirectional communication, interaction, and activities aimed to enhance knowledge transfer between CBOs and the research community. Committee members believe a bidirectional flow of information will enhance the quality of treatment-based research, increase treatment effectiveness, and help CBOs to thrive in an increasingly challenging and complex environment. The participation of policymakers will be essential if this is to happen. Thus, the audience for this report is quite broad and includes federal, state, and local policymakers, drug treatment researchers, community-based treatment providers (including their professional organizations), and consumers, as well as sponsors of research and treatment programs. Others with interest in this report may include managed care programs, professionals involved with employee assistance programs (EAPs), behavioral health researchers, behavioral health providers, and those involved with criminal justice and social welfare programs. And finally, there is an important role for foundations, because, while many of the needs identified in this report are interstitial with regard to the missions of the agencies to 2   CSAT is the federal agency mandated by Congress to expand the availability of effective treatment for alcohol and drug problems. As one of the National Institutes of Health, NIDA's mission is to provide the research and add to the knowledge of drug abuse and addiction and its effective treatment, including educating the public and broadening the dissemination of research findings to improve drug abuse treatment practice and policy.

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whom these recommendations are addressed, they are areas of significant interest for a number of foundations. THE STUDY PROCESS AND REPORT ORGANIZATION To accomplish its task, the committee met four times between April and December 1997. Through these meetings and other activities summarized below, the committee obtained information from a rich variety of sources. For example, roundtable and workshop discussions with providers, researchers, and policymakers were held and site visits made by the committee and staff to solicit a broad base of input from representative stakeholders. The workshop and roundtable discussions, held in Washington, D.C., and Albuquerque, New Mexico, yielded data of critical interest to the committee. These workshops were designed to allow researchers, providers, and policymakers to discuss the issues with each other and with members of the committee. A list of participants and the topics discussed are included in Appendix B. The first workshop was held in Washington, D.C., with participants from 14 states. Providers, researchers, and policymakers presented in separate panels, each hosted by a member of the committee. Providers spoke of the gap between research and practice, as well as the language and culture barriers that hinder collaboration. They expressed concern that research findings were sometimes misinterpreted and misused in the search for lowest-cost alternatives, but they also expressed their need for relevant and practical research, conducted and disseminated in ways that would help them improve treatment and demonstrate cost effectiveness. Other major concerns of this group were the changing policy and regulatory environment, shrinking treatment options and capacity, and growing need for infrastructure and training resources. Examples included, a state where providers were given only ten days to implement new legislation requiring screening and evaluation for all DUI (driving while under the influence) arrestees and another state where a facility was facing the requirement to work with multiple HMOs with one outdated computer and just one person who knew how to use it. Policymakers, as well as providers, spoke of the long lag time for research findings to reach them and the need for better strategies for translating research information to meet their needs. It was suggested that policymakers and researchers take lessons from business: design audience-specific information and market it aggressively. Policy panelists stated that federal and state policymakers needed to know what worked, and that Congress wanted evidence to support community-based treatment organizations as the front-line of prevention and treatment. Researchers and providers spoke of financial and political barriers to

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the implementation of proven research findings. For example, behavioral incentive programs proven highly effective in treatment of cocaine addiction are not very practical for a mid-west CBO receiving $340 per case per year, about a third of the cost of the incentive program. Researchers talked of the difficulty getting funded for community-based research, the special pitfalls of the NIH grant review process for applied research proposals, and the challenge of doing research in a nonacademic treatment setting. Providers and researchers agreed on the difficulties of getting funding to cover the true costs of participating in research. This workshop concluded with a discussion focused on the impact of stakeholder interactions and how these interactions—or their lack—affected treatment of drug abuse, the need for more and different collaborative research and better strategies to translate results into findings relevant to the intended audience. The second workshop, held in Albuquerque, New Mexico, was co-hosted by the Center on Alcoholism, Substance Abuse and Addiction (CASAA) at the University of New Mexico and provided input from stakeholders in western states. Participants described successes and failures in research collaboration and dissemination of research findings, as well as the challenges of integrating clinical experience with research design. This meeting provided an opportunity to obtain an overview of community-based drug treatment in a richly multicultural and mostly rural state containing a very large Hispanic population and 26 Indian nations. In addition to researchers from CASAA, participants included representatives of the state substance abuse agency, the state legislature, the city of Albuquerque, Albuquerque public schools, New Mexico drug courts, the Navajo Nation, and the regional representative of the National Association of Alcohol and Drug Abuse Counselors. Participants from Arizona, California, Colorado, Texas, and Washington attended the Albuquerque workshop, representing providers, researchers, and counselor organizations and the Window Rock Navajo Reservation. Additional input from drug treatment providers and policymakers in the District of Columbia was obtained through two meetings attended by committee staff. The first was a special meeting of the District of Columbia Health Policy Council to discuss drug abuse and mental health needs where it was reported that less than 10 percent of the estimated 76,000 substance abusing individuals in D.C. received any form of treatment. The second was a meeting for District providers of drug abuse treatment held at Seton House of Providence Hospital. The discussion focused on the dilemma faced by treatment providers in an area of shrinking social as well as treatment services. The lack of social services is a special concern to providers with clients who may never have held a job, perhaps do not speak English or have not learned to read, and do not have family or community support to ''wraparound" their treatment. At the earlier D.C. committee

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workshop, this issue was also raised as an area where research could help funding and regulatory agencies understand the difference between habilitation needs and rehabilitation needs "and perhaps, thank us, instead of penalizing us, for taking these difficult patients." Finally, to supplement these meetings, individual committee members made site visits to treatment programs and state agencies in their area to explore issues relevant to the study. Site visits were also made by members of the committee staff (see Acknowledgments for list of sites visited). Another important source of information was invited presentations to the committee on special topics. These topics included: diffusion of innovation and dissemination; models of collaboration; research agenda building; drug services survey data; requirements of federal and state policy; and, finally, the implications of the current research grant review process for efforts to form and maintain research collaborations with community-based treatment organizations. Four additional activities completed the major data gathering phase of the study: 1.   preparation of commissioned papers (Appendices C, D, and E); 2.   review of journals and other publications that disseminate drug abuse research findings; 3.   review of research literature and relevant websites; and 4.   review of survey and other data sources (e.g., State Alcohol and Drug Abuse Profile Data, CSAT's Uniform Facility Data Set, and NIDA's Drug Abuse Treatment Outcome Study). This report is organized into six chapters including this introductory chapter, which provides an overview of the major issues and study process. The second chapter examines the gaps between research, treatment, and policy in detail. Chapter 3 describes approaches for closing these gaps. The potential benefits and challenges confronting community-based treatment providers are the subject of Chapter 4. Chapter 5 discusses these benefits and challenges from the researcher perspective and presents models of successful collaboration. The committee's findings and recommendations are presented in Chapter 6. HISTORICAL BACKGROUND To understand the current state of community-based drug treatment, it is useful to consider key aspects of the development of the drug treatment system in the United States. Prior to the 1960s, community-based, noninstitutional services for drug abuse were almost nonexistent. Drug dependent individuals who received treatment were most likely to receive limited and

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ineffective care in state mental hospitals, county jails, federal hospitals, and penal facilities. Alternatives developed during the 1960s and 1970s in response to state legislation that decriminalized public intoxication and federal legislation that permitted community services for the treatment of drug addiction. Stimulated by federal initiatives, such alternatives accompanied the trend to deinstitutionalize the mentally ill from state mental hospitals, develop community mental health centers, and fund alcoholism and drug abuse treatment programs (Besteman, 1992; IOM, 1990a,b). Historically, access to treatment for drug abuse was more limited than for alcohol treatment. Prior to the 1960s, treatment for opiate, cocaine, and marijuana dependence was generally restricted to two federal public health hospitals located in Lexington, Kentucky, and Fort Worth, Texas (IOM, 1990b, 1997b; Jaffe, 1979). The first therapeutic community for drug addiction, Synanon, opened in 1958 and demonstrated that a program using group confrontation and staff in recovery could promote stable recovery from heroin addiction. Second generation therapeutic communities developed during the early 1960s and incorporated public funding and professional staff into the model. Methadone and methadone maintenance treatment, first implemented in New York City, also developed during the early 1960s (Courtwright et al., 1989; IOM, 1990a, 1997b). In 1966 a system of community-based treatment centers was authorized by the Narcotic Addict Rehabilitation Act of 1966 (P.L. 89-793) (Besteman, 1992). Two years later, a 1968 census of drug treatment programs identified 183 agencies located primarily in states with major metropolitan areas (New York, California, Illinois, Massachusetts, Connecticut, and New Jersey) (Jaffe, 1979). Most of the facilities had opened recently; over 75 percent were less than five years old and only two (the federal hospitals) had been operational for more than 20 years (Jaffe, 1979). In 1971, President Nixon created the Special Action Office for Drug Abuse Prevention (SAODAP), predecessor to the Office of National Drug Control Policy, to coordinate his "war on drugs." The first director of SAODAP, Dr. Jerome Jaffe, was determined to improve access to treatment by shifting services from prisons and hospitals to community-based services, primarily because institutional services were too expensive and it was impossible to meet the demand for care (Jaffe, 1979). These initiatives, and the funding authorized to implement their requirements, resulted in two critical shifts in the delivery system of care for addiction. First, groups of men and women in recovery were encouraged to incorporate as private not-for-profit entities and to open detoxification centers, halfway houses, therapeutic communities, and outpatient treatment centers. Thus, the recovering community was empowered to participate fully in the development of the continuum of care and to draw upon their personal experiences with recovery in the design and implementation

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of services. Second, by 1995, more than 8,000 facilities were providing drug or combined alcohol and drug treatment in the 50 states and the District of Columbia. All of these facilities receive some funding from their state alcohol and drug abuse agencies, and in most cases fully 80 percent of their revenue came from public sources (Gustafson et al., 1997). DEFINITIONS AND CURRENT CONTEXT This committee was funded by CSAT and NIDA to study community-based drug treatment. While the committee focused its data collection primarily on drug abuse treatment and research, it recognized that alcohol is also a drug and one that plays a large part in community-based drug treatment. Hence recommendations are included for the National Institute on Alcohol Abuse and Addiction (NIAAA), and the term drug abuse as used in this report should be interpreted to include alcohol abuse when that is appropriate in the context. The first challenge for the committee was the need to define community-based organization in order to frame the study. The committee reviewed several approaches for doing this, including the approach taken by a previous IOM committee that emphasized the multifaceted nature of community-based care and need to pay special attention to the needs of community groups that are vulnerable and underserved (IOM, 1994). An earlier monograph from NIDA, defined a community-based organization as, "a noninstitutional provider located in the community where its user population resides" (Cartwright and Kaple, 1991). This latter definition seemed overly restrictive to the committee in light of the current environment in which increasing numbers of providers of community drug treatment are associated with medical and other institutions. Ultimately, there was a consensus among committee members that program accountability may come the closest to capturing the essence of social identity in the definition of "community based." The extent to which a program is accountable to major elements of a specific community defines the program's interests, mission, and the social setting it serves. So, in an important sense, the community itself may define community-based.3 An important aim of this study is to increase bidirectional interaction and knowledge exchange between the research community and the drug treatment community. In considering definitional issues, then, the committee believed that this aim would not be well served by a highly restrictive definition of community-based treatment programs. Consequently, in the 3   A paper by committee member Benjamin P. Bowser, reflecting the work of a subcommittee formed to address this problem is included as Appendix C. This paper discusses the importance of community, the many ways of defining community, and the meaning of "community-based" in the context of drug abuse treatment programs.

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inquiry underlying its recommendations, this committee sought to include the widest range of drug and alcohol treatment programs possible and was careful not to exclude from discussions and consideration those programs that defined themselves as community-based. Likewise, the committee was cautious not to exclude, a priori, any significant programs of interest by a determination that they were not "community-based." Thus, the public workshops included representatives from a diverse group of treatment programs, ranging from small programs who would be considered community-based by the most restrictive definition, to large and complex programs sponsored by larger entities, such as the Department of Veterans Affairs, academic medical centers, state court systems, and managed care organizations. One of the important cultural elements that differentiates among community-based treatment programs is the set of beliefs that each uses to define the knowledge base about how to deliver effective drug treatment. There are at least two main types of programs in this regard. First, there are programs in which treatment models are based largely on the experiential knowledge of staff, especially those in recovery from drug abuse problems. This is the tradition of the "twelve-step" programs, following the model of Alcoholics Anonymous (AA). Such treatment providers have confidence in their knowledge because it has been tested in a most important test—their own recovery. Also in this category are programs that are identified with religious organizations and bring an element of faith to their treatment approach. Since faith is built into the foundation of their treatment approach, their religious beliefs fuel their organizational culture, including, to some extent, their fundamental "knowledge" about the nature of appropriate treatment for drug abuse problems. On the other hand, there is a set of organizations more closely related to the general health care system or to the traditions of the behavioral sciences. Because these treatment programs share much of the culture of medicine and the behavioral sciences, their organizational cultures include more of their scientific beliefs and values about the nature of treatment. Such a perspective suggests that, in programs in this second category, the therapist's knowledge about what is appropriate in treatment is defined by the fruits of scientific medical or behavioral research.4 4   Some of this argument follows a perspective put forth by Edward Suchman. In discussing different world views among consumers of health care, Suchman argued that some people had, what he called, a "cosmopolitan" view of the world, while others had a "local" view. And he proposed ways to differentiate those approaches to and explanations of life. He proposed that those views also led to unique and different orientations toward health and illness. He suggested that people with a "cosmopolitan'' view of the world were more likely to have, what he referred to as, a "scientific" orientation to health and disease. Those with a "local" life view would be more likely to have a "parochial" orientation to health and illness (Suchman, 1966).

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It was not, however, the a priori assumption of this committee that one or the other kind of program is "better" in some fundamental way, although many might agree that a close link to medical sciences—especially in the current environment—is most desirable. In fact, there is very little scientific data available on relative treatment effectiveness by categories of treatment programs. Yet, this categorization does provide the opportunity to consider different models of relationship between researchers and the treatment programs, depending on the specific orientation and organizational culture of the different types of programs. In the environment today, all community-based drug treatment programs have seen an increase in drug use, an exploding epidemic of HIV and AIDS, an increase in tuberculosis, hepatitis, and other infectious diseases, an increase in comorbid psychological and psychiatric problems, and high levels of unemployment. However, treatment length, intensity, and service mix have decreased due to payor restrictions, despite increases in the acuity and complexity of multiple problems drug abuse patients experience. Community-based organizations are challenged to meet demand in this environment of rapid changes, with dwindling resources and uncertainty about the future. Most community-based organizations will survive, but some will not, and indeed some have already closed their doors. To remain viable, community-based organizations must learn to adapt and navigate in this new and uncertain environment. To do this they must have new tools, new skills, new incentives, and new partnerships. SUMMARY Community-based services for drug and alcohol addiction developed in response to many factors: poor care in state mental hospitals, discrimination and prejudice in general hospitals and private facilities, inhumane conditions in "drunk tanks," the expense of providing institutional services, and the need to rapidly expand the nation's capacity to provide treatment for drug abuse and alcoholism. The services that developed and served the nation during the 1970s and 1980s have shrunk during the early 1990s, and the organizations that provide them are challenged to survive as the nation approaches the twenty-first century. Competition for funding has increased, the financing of care has changed, and demands for accountability and efficiency are forcing free-standing community-based agencies to seek mergers with hospitals and health plans or to integrate with mental health and community health programs. Over 60 percent now report they are part of another organization (Appendix E, Table 1). One of the major threats to the survival of this system is the widening gap between knowledge gained from basic scientific and treatment research and knowledge gained from clinical experience. This is accompanied by

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growing isolation of the clinical-provider communities from the research communities. Within this context, it is clearly critical to examine closely all elements of the community-based drug abuse treatment system with the goal of facilitating new strategies for partnership and increasing synergy among those working in a variety of settings to reduce the individual and societal costs of drug addiction. REFERENCES Besteman KJ. 1992. Federal leadership in building the national drug treatment system. In: Institute of Medicine Treating Drug Problems. Vol. 2. Washington, DC: National Academy Press. Cartwright WS, Kaple JM, eds. 1991. NIDA Research Monograph 113: Economic Costs, Cost-Effectiveness, Financing, and Community-Based Drug Treatment. Rockville, MD: National Institute on Drug Abuse. Courtwright D, Joseph H, Des Jarlais D. 1989. Addicts Who Survived: An Oral History of Narcotic Use in America, 1923-1965. Knoxville, TN: The University of Tennessee Press. Epstein J, Gfroerer J. 1998. Changes Affecting NHSDA Estimates of Treatment Need for 1994-1996: OAS Working Paper. Rockville, MD: Office of Applied Studies, Substance Abuse and Mental Health Services Administration. Gustafson JS, Reda JL, McMullen H, Sheehan K, McGencey S, Rugaber C, Anderson R, DiCarlo M. 1997. State Resources and Services Related to Alcohol and Other Drug Problems: Fiscal Year 1995. Washington, DC: National Association of State Alcohol and Drug Abuse Directors, Inc. IOM (Institute of Medicine). 1990a. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: National Academy Press. IOM. 1990b. Treating Drug Problems. Washington, DC: National Academy Press. IOM. 1994. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: National Academy Press. IOM. 1996. Pathways of Addiction: Opportunities in Drug Abuse Research. Washington, DC: National Academy Press. IOM. 1997a. Dispelling the Myths About Addiction: Strategies to Increase Understanding and Strengthen Research. Washington, DC: National Academy Press. IOM. 1997b. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: National Academy Press. Jaffe JH. 1979. The swinging pendulum: The treatment of drug abusers in America. In: Dupont RI, Goldstein A, O'Donnell J eds. Handbook on Drug Abuse. Washington, DC: U.S. Government Printing Office. Pp. 3-16. NIAAA (National Institute on Alcohol Abuse and Alcoholism). 1997. Ninth Special Report to the U.S. Congress on Alcohol and Health. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism. Suchman E. 1966. Health Orientation and Medical Care. American Journal of Public Health 56:97-105.