promising work is currently being tested in animal models, but there are no treatment relevant medications available for cocaine rehabilitation at this time.

Although the use of opiate and alcohol antagonists or blocking agents is increasing as addiction physicians are more comfortable with the prescription of adjunctive medications and as more substance dependence is treated by primary care physicians in office settings (see Fleming and Barry, 1992), there are still relatively few patients that receive—or practitioners that prescribe—these medications (Institute of Medicine, 1995). Furthermore, the available literature in this area still does not provide an unambiguous conclusion regarding the parameters that are most effective when using antagonist or ''blocking" pharmacotherapy. For example, a recent cautionary article by Moitto and colleagues warned about an unusually high rate of deaths (particularly suicides) among opiate dependent individuals who were transferred to naltrexone (Moitto et al., 1997). The appropriate use of these antagonist or blocking medications in "real world" treatment of substance dependence disorders may be among the most important topics for future research in the treatment field. These medications are often expensive and managed care companies have been slow to permit these medications to reach formularies (see Institute of Medicine, 1995; O'Brien, 1996; O'Brien and McKay, in press). In addition, there is a need for long-term studies of patients who have been prescribed these medications as well as studies examining the most appropriate and efficient mix of psychosocial and pharmacological services to maximize rehabilitation for various types of substance dependent patients.

Provision of Specialized Services—The majority of patients admitted to substance abuse treatment have significant "addiction related" problems in one or more areas such as medical status, employment, family relations, and/or psychiatric function (McLellan and Weisner, 1996). As has been indicated above, the severity of these problems at the time of treatment admission is generally a good negative predictor of posttreatment outcome. Studies have documented that strategies designed to direct and focus specialized services to these "addiction related" problems can be applied in standard clinical settings and can be effective in improving the results of substance abuse treatment. Again, this conclusion follows more than a decade of research showing that the addition of professional marital counseling (Fals-Stewart et al., 1996; McCrady et al., 1986; O'Farrell et al., in press; Stanton and Todd, 1982), psychotherapy (Carroll et al., 1991, 1993, 1994a,b; Woody et al., 1983, 1984, 1987, 1995) and medical care (Fleming and Barry, 1992) produces clinically and significantly better outcomes from substance abuse treatment.

It should be noted that in some cases, these adjunctive forms of therapy