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.

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