hearing from many experts the consensus panel concluded that opiate addiction met the criteria of having effective medical treatment and established diagnostic criteria, and it made recommendations for improving treatment access and identified future research areas and training needs. The consensus statement from this conference is included as Appendix F.

Another example of this gap between research and practice is the underuse of naltrexone, a pharmacologic treatment (opiate-antagonist) which has long been shown to be effective in preventing relapse to opiate addiction in highly motivated patients (Brahen et al., 1978). Several well-controlled studies have also shown naltrexone to be effective as an adjunct to a variety of psychosocial rehabilitation interventions in the treatment of alcohol dependence (Volpicelli et al., 1992). In 1994, naltrexone received Food and Drug Administration (FDA) approval for use in the treatment of alcohol dependence.

However, naltrexone is not widely used in alcohol treatment outside of medical centers and some specialized treatment settings. The manufacturer of naltrexone estimates that approximately 80,000 individuals were treated with naltrexone in 1996 for all indications. Even allowing for a large margin of error, these figures indicate that naltrexone is prescribed for less than one percent of the persons who might benefit. The reasons for this low utilization are unclear, but they likely relate to some of the organizational constraints described above, including lack of available medical expertise, lack of cost reimbursement coverage, and lack of information concerning the cost-effectiveness of adding this medication to current treatment strategies.

A final example of an established research finding that has not been adopted widely in clinical practice is the integration of contingency management strategies in community-based treatment settings. The knowledge that positive reinforcement can increase desired behaviors has been empirically demonstrated in both laboratory and clinical settings. Over the years, these principles have been applied to drug abuse treatment in several ways. In a study of cocaine users, Higgins and colleagues used a system of vouchers which could be traded for material goods which individuals received when the routine urine testing proved negative (Higgins et al., 1994). This research, when compared to noncontingent vouchers, demonstrated a very beneficial effect of the voucher system in increasing drug-free urines. This study has since been replicated (Silverman et al., 1996) in a number of different treatment settings. Despite this, the use of positive reinforcement or a voucher-based system has not been widely implemented in treatment settings. Again, the barriers are multiple, including lack of information concerning the efficacy of these strategies as well as implementation difficulties due to payer policies. Several workshop participants expressed concern about these barriers and one provider reported that the average total



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