Treating Drug Problems Volume 1 (1990) / Chapter Skim
Currently Skimming:
5 The Effectiveness of Treatment
5 The Effectiveness of Treatment
Pages 132-199
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 132... ...
Drug treatment is not a single entity but a variety of different approaches to different populations and goals. Response to treatment is not a matter of all or nothing, complete success versus total failure, but of degrees of improvement.
|
From page 133... ...
In light of the frequent use of other psychotropic medications during outpatient treatment, the committee views the term "nonmethadone" as more accurate than "drug free." The lumping together of all outpatient nonmethadone treatment is testimony to the prominence and distinctive nature of methadone maintenance and the fact that the population it serves is sufficiently homogeneous and different from the populations served by other outpatient programs. It should also be noted that methadone may be used in modalities other than maintenance, which technically refers to a planned treatment duration of 180 days or longer.
|
From page 134... ...
national admission sample cohort and the Treatment Outcome Prospective Study, or TOPS, which involved a 10,000-person national sample of 19791981 admissions to 41 drug treatment programs in 10 cities. The Drug Abuse Treatment Outcome Study (DATOS)
|
From page 135... ...
Because drug-related Anonymous groups have been meeting in most cities longer than drug treatment programs have been present, and because they generally welcome individuals who are in treatment as well as those who are not (except that many Anonymous groups are antipathetic to individuals in methadone maintenance) , they are in essence a part of the environmental baseline over which the incremental effects of the more formal treatments must be measured.
|
From page 136... ...
Methadone maintenance is a treatment specifically designed for dependence on narcotic analgesics, particularly the narcotic of greatest concern in the United States, heroin.3 The controversies surrounding methadone maintenances have made it the subject of literally hundreds of studies. From these studies, including a few vitally important clinical trials, strong evidence has accumulated about the safety and effectiveness of methadone.
|
From page 137... ...
Goals Methadone maintenance cannot be understood apart from the correct stipulation of the major goals of treatment, primarily to reduce illicit drug consumption and other criminal behavior and secondarily to improve productive social behavior and psychological well-being. It is critical that methadone is a legally prescribed drug for the purpose of treating dependence.5 Yet even more critical is that individuals who receive methadone maintenance treatment should reduce their use of illicit drugs and their commission of other crimes (e.g., selling drugs, stealing money, using weapons to obtain funds to support their drug consumption)
|
From page 138... ...
Then the methadone dose is tapered down to zero. Individual responses vary, but usually this method does not completely suppress withdrawal symptoms during and after the tapering period; rather, it keeps them mild for a time until the tapering procedure does not provide enough methadone to prevent the more discomfiting withdrawal symptoms.
|
From page 139... ...
Overall, during the trials, methadone was more successful than IAAM in retaining clients in treatment (by 20 percentage points) , largely because more LAAM recipients felt that the medication was not "holding," that is, not keeping opiate withdrawal symptoms from beginning to emerge between doses, a result that Goldstein and Judson (1974)
|
From page 140... ...
Recurrent withdrawal symptoms stimulate drug seeking during heroin dependence, and the ability of methadone maintenance to keep them at bay is a major attraction and benefit. In its initial clinical trials, which began in inpatient settings and then were extended to outpatient sites, methadone maintenance proved capable of stabilizing the psychological functioning of the heroin-dependent
|
From page 141... ...
The clinicians conducting the trials observed that clients on methadone were not obsessed with acquiring the next dose, became interested in the prospects for improving the conventional strands of their lives, and were generally functioning without notable drug impairment or side effects. An individual on methadone was capable of participating in counseling, psychotherapy, and remedial education and training (most of the same rehabilitative services delivered in therapeutic communities and outpatient treatment)
|
From page 142... ...
How Well Does Methadone Work? The goals of methadone maintenance—to reduce illicit consumption of heroin and other opiates, to reduce other criminal activity, and to help clients become more socially productive and psychologically stableconstitute a continuum that can be cut at various points to designate "success" versus "failure." At the outset of its use, the modality was specifically targeted toward those who were most severely dependent, as judged by substantial histories of relapse from earlier detoxification episodes (frequently in jail)
|
From page 143... ...
The steadiness of employment increased somewhat, but a much more dramatic change was the sustained reduction in criminal behavior, especially drug trafficking crimes.7 The most convincing results about the efficacy of methadone maintenance the capacity of the treatment to induce client changes independent of initial selection or motivational effects come from a handful of clinical experiments that are widely separated in time and place but that consistently yield very distinctive findings. In these studies, heroin-dependent, heavily criminally involved populations who were randomly assigned to methadone maintenance or a control condition (an outpatient nonmethadone modality)
|
From page 144... ...
Five still had drug problems, and of these, 2 had been discharged from treatment for severe abuse of sedative-hypnotic drugs. Of the 17 individuals who went into the outpatient nonmethadone program, only 1 was doing well; 2 were dead, 2 were in prison, and the rest had returned to taking heroin.
|
From page 145... ...
(0 done maintenance treatment; the right half represents the controls who will not be given methadone maintenance. Leo years after acceptance or decline: white circles = no drug abuse; H = abuse of heroin or (in the experimental group)
|
From page 146... ...
. Drug consumption and criminal involvement in this study population were high just prior to the introduction of methadone, despite the fact that all members of the population had been incarcerated and supervised for several years in the 1960s by the state's Civil Addict Program (CAP)
|
From page 147... ...
The strongest treatment retention and outcomes (measured as improved social functioning) were seen in the initial methadone clinical trials (Dole and Nyswander, 1965, 1967)
|
From page 148... ...
The Treatment Outcome Prospective Study, for example, showed a large degree of variation in clinically important client outcomes across nine
|
From page 149... ...
There is solid, experimentally grounded evidence (see the major review by Hargreaves, 1983, and the associated conclusions of the expert consensus conference; reported in Cooper et al., 1983) that higher dose levels are fundamentally more successful in controlling a client's illicit drug consumption while he or she is in treatment.
|
From page 150... ...
The programs with the highest illicit drug consumption among clients not only had low methadone doses but also had high rates of staff turnover and poor relationships between staff and clients. Knowledge of and sensitivity to the clinical significance of appropriate dose levels is probably one sizable element in a constellation of clinical competencies and strategies that contribute to the greater or lesser effectiveness of methadone maintenance programs.
|
From page 151... ...
examined the cost-effectiveness of three major treatment modalities (methadone maintenance, TCs, and outpatient nonmethadone) based on an analysis of the DARP data base (Sells, 1974a,b)
|
From page 152... ...
In this instance, a private methadone program picked up a large proportion of the clients on a self-pay basis. The most comprehensive examination of economic benefits and costs of drug treatment was performed with data from the TOPS (Harwood et al., 1988~.
|
From page 153... ...
and whether poorly performing programs can be improved. The extensive evaluation literature on methadone maintenance yields the following conclusions: There is strong evidence from clinical trials and similar study designs that heroin-dependent individuals have better outcomes on average (in terms of illicit drug consumption and other criminal behavior)
|
From page 154... ...
The profile of TC clients is also more demographically diverse than that of the heroin-dependent population. Generally, on average, TC clients in the early 1970s, when there was a national counting system, were several years younger and predominantly white by a modest margin, a pattern that has continued in later, more partial statistics (e.g., the 1979-1981 Treatment Outcome Prospective Study sample; Hubbard et al., 1989~.12 The TC's group-centered methods encompass the following, all of which are grounded in an interdependent social environment with a direct link to a specific historical foundation: 12TC clients were 57 percept white, 34 percent black, and 9percent Hispanic.
|
From page 155... ...
De Leon (1986:5,7~) has summarized the approach as follows: The TC views drug abuse as a deviant behavior, reflecting impeded personality development and/or chronic deficits in social, educational and economic skills.
|
From page 156... ...
How Well Do Therapeutic Communities Work? Conclusions about the effectiveness of TCs are limited by the difficulties of applying standard clinical trial methodologies to a complex, dynamic treatment milieu and a population resistant to following instructions.
|
From page 157... ...
The early success stories from the therapeutic communities S,rnanon and Daytop Village, in contrast to most treatment modalities' gloomy prior experience with heroin addiction, were positive and convincing enough that many clinicians and policymakers backed the establishment of TCs in the late 1960s and early 1970s. The scientific community paid them relatively little attention (a notable exception was Yablonsky, 1965)
|
From page 158... ...
. Less than half of the randomly assigned subjects entered and spent as long as a week in any of the VA treatment programs, and only half of those entered the specific programs they had been assigned to (the others waited out at least a 30-day exclusion period to enter their own preferred program)
|
From page 159... ...
with Assignment, Combining Therapeutic Communities (TCs)
|
From page 160... ...
Other Significant Follow-up Studies Beyond the efforts of Bale and colleagues, there is a significant controlled observational literature on therapeutic communities. The bulk of these studies have focused on clients admitted to particular programs such as Phoenix House and Daytop Village in New York; in addition, the DARP (Simpson et al., 1979)
|
From page 161... ...
studied a sample of 230 graduates and dropouts and found that before admission the two groups were very similar with respect to criminal activity and drug use but that dropouts had somewhat greater employment. After treatment, the status of both groups was much better than before, but graduates had dramatically superior posttreatment outcomes compared with dropouts (Table 5-3~.~7 The Drug Abuse Reporting Program provided further important controlled observational findings about the effectiveness of therapeutic communities (Sells, 1974a,b)
|
From page 162... ...
Alcohol problems were not related to treatment retention. In summary, multisite evaluations of the DARP (Simpson et al., 1979; Simpson, 1981)
|
From page 163... ...
Even in the absence of clinical trials, it is difficult to credit any explanation of these results other than the following: TCs can strongly affect the behavior of many of the drug-dependent individuals who enter them, and retention in treatment after some minimum number of months how many seems to vary with the program is positively and significantly related to improved outcomes as measured by illicit drug consumption, other criminal activity, and economically productive behavior. Why Do the Results of Therapeutic Communities Vary?
|
From page 164... ...
and rising competition with private-tier outpatient and chemical dependency treatment providers for credentialed, experienced staff. Yet there are no studies that specifically investigate how TC staffing relates to the effectiveness of treatment.
|
From page 165... ...
Source: National Institute on Drug Abuse (1981~. Costs and Benefits of Therapeutic Community Treatment Most evaluations of TCs indicate that they are cost-effective or costbeneficial, or both.
|
From page 166... ...
analyzed the TOPS data base, examining the reduced crime-related impacts on society that result from drug treatment. A particularly important finding was that TC treatment, as with methadone treatment (see the section above entitled "Costs and Benefits of Methadone Treatment")
|
From page 167... ...
OUTPATIENT NONMETHAI) ONE TREATMENT What Is Outpatient Nonmethadone Treatment?
|
From page 168... ...
How Well Does Outpatient Nonmethadone Treatment Work? The major conclusion that can be offered about the effectiveness of outpatient treatment is a familiar one: clients who remain in treatment longer have better outcomes at follow-up than shorter term clients.
|
From page 169... ...
~ _ ::::: ::::: :,::,::.: _ .~ 'at l ~ Alcohol Crime Work OUTCOMES FIGURE 5-5 Outcomes and retention in outpatient nonmethadone programs based on data from the Treatment Outcome Prospective Study and shown as odds ratios derived from multivanate analyses. The odds that members of the intake-only group will report a successful outcome at follow-up are compared with the odds for those who were in treatment for 1-13 weeks, 1~26 weeks, and more than 26 weeks.
|
From page 170... ...
Unlike the results of TC treatment, crime-related benefits of OPNM after discharge were not discernible. CHEMICAL DEPENDENCY TREATMENT What Is Chemical Dependency Treatment?
|
From page 171... ...
CD treatment practices represent a blending of the Alcoholics Anonymous model of recovery, certain insights and prescriptions of somatic medicine, and psychiatric and behavioral science principles. Chemical dependency treatment is usually an intensive, highly structured three- to six-week inpatient regimen.
|
From page 172... ...
, these origins continue to shape the CD approach. How Well Does Chemical Dependency Treatment Work?
|
From page 173... ...
31~.~9 Why Do the Results of Chemical Dependency Treatment Vary? There are no useful studies that distinguish the reasons why some clients in CD programs recover and others do not.
|
From page 174... ...
Benefits and Costs of Chemical Dependency Treatment There are no studies available on the costs and benefits or costeffectiveness of this modality. There is some discussion of cost data, however, in Chapters 6 and 8.
|
From page 175... ...
There has been some success in the management of cocaine withdrawal symptoms and craving in ambulatory clinical trials using desipramine hydrochloride (Gawin et al., 1989a) , amantadine (Tennant and Sagherian, 1987)
|
From page 176... ...
CORRECTIONAL TREATMENT PROGNOSIS The overall record of research on prison-based drug treatment programs is moderate in scope, and the findings mostly correspond to the largely negative results observed in the treatment of criminals during incarceration in hopes of reducing their recidivism (Vaillant, 1988; Besteman, 1990; Chaiken, 1989~. Yet Falkin and colleagues (1990)
|
From page 177... ...
With the proper program elements in place, treatment programs could achieve a significantly greater reduction in recidivism than by continuing a policy of imprisonment without adequate treatment. Their list of the elements necessary for a successful prison drug treatment program22 is succinct: a competent and committed staff; adequate administrative and material support by correctional auseparation from the general prison population; · incorporation of self-help principles and ax-offender aid; · comprehensive, intensive therapy aimed at the entire lifestyle of a client and not just the substance abuse aspects; and · an absolute essential—continuity of care into the parole period.
|
From page 178... ...
were compared with similar groups of drug-abusing and dependent prisoners. The comparison groups received either regular drug abuse counseling (N = 576)
|
From page 179... ...
179 ._ ._ Cal Cal _t sit o A o v o o 50 is: EM o U
|
From page 180... ...
the poorest responders. The California Civil Addict Program A different type of correctional treatment program combines treatment in a penal institution with specialized parole supervision, including access to a variety of community-based treatment opportunities.
|
From page 181... ...
As discussed earlier, this expansion of treatment coincidentally presented a research opportunity to compare the results of the correctional treatment program and methadone maintenance. CAP permitted adjudication of heroin-dependent individuals through a civil commitment procedure rather than regular criminal sentencing.24 The first (repeatable)
|
From page 182... ...
~ CAP 1 1 1 1 1 1 1 1 1 1 1 1 8 6 4 2 A 2 4 6 8 10 12 YEARS FIGURE 5-6 Effects of the California Civil Addict Program on daily narcotics use. The percentage of nonincarcerated time during which subjects reported using narcotics daily is shown for 8 pre- and 13 postadmission yeam.
|
From page 183... ...
U] at: =~< 80 6 in Z ~ Go Z <( ~ Z OcD 40 LL at — oh LL, UJ 20 0 G LD o Premethadone ,,f/~ 1 Postmethadone non-CAP ,~ ~ CAP 1 1 4 6 8 6 4 183 2 M 2 YEARS FIGURE 5-7 The effect of methadone maintenance on daily narcotics use in the California Civil Addict Program and control groups.
|
From page 184... ...
Boot camps vary in nature. Some are entirely militaristic environments with few if any therapeutic staff or procedures; others incorporate many drug treatment elements that the more successful prison treatment efforts display but lack still other requirements particularly continuity of care when the individual returns to the community.
|
From page 185... ...
Of the four major modalities, methadone maintenance has received the most extensive study, using all of the main types of treatment evaluation research techniques. Therapeutic communities have received the next most extensive assessment; outpatient nonmethadone treatments have been evaluated at a
|
From page 186... ...
Chemical dependency treatment has the least extensive useful body of knowledge concerning its e~ectiveness.25 Yet according to the committee's analysis of a 1987 national survey of drug treatment providers (detailed in Chapter 6) , the order of expenditures for these modalities is exactly the reverse of the order of knowledge about their effectiveness.
|
From page 187... ...
Research on methadone has demonstrated the following: · There is strong evidence from clinical trials and similar study designs that, on average, heroin-dependent (or other opiate-dependent) individuals have much better outcomes in terms of illicit drug consumption and other criminal behavior when they are maintained on methadone than when they are not treated at all, when they are simply detoxified and released, or when methadone is tapered down and terminated arbitrarily.
|
From page 188... ...
Therapeutic communities are designed for individuals with major impairments and social deficits, including histories of serious criminal behavior. The results of research on the effects of TC treatment are as follows: · TC clients end virtually all illicit drug taking and other criminal behavior while in residence and perform better (in terms of reduced drug taking and other criminal activity and increased social productivity)
|
From page 189... ...
· Retention in outpatient nonmethadone programs is poorer than for methadone maintenance and therapeutic communities. The benefits of OPNM treatment are fewer than for methadone or TCs, but the cost of the treatment, at about $1,350 for six months (about $1,800 for a model program)
|
From page 190... ...
There are no cost/benefit analyses for chemical dependency treatment. Detoxification Detoxification is therapeutically supervised withdrawal to abstinence over a short term that is, up to several months but usually five to seven days, often employing pharmacological agents to reduce client discomfort or the likelihood of complications.
|
From page 191... ...
Correctional Treatment Treatment of drug-involved prisoners is fairly common, but at least two-thirds of prison treatment programs are equivalent to outpatient nonmethadone treatment that is, periodic individual or group therapy sessions. This level of intervention is probably not intensive enough to do much for this group.
|
From page 192... ...
RECOMMENDATIONS FOR RESEARCH ON TREATMENT SERVICES AND METHODS Rebuilding the Research Base Federal support for drug research, including research on treatment methods and seIvices (alternatively, clinical and services research) , surged during the early 1970s, declined steadily in real terms for the next decade, and began to surge again as a result of the Anti-Drug Abuse Acts of 1986 and 1988 and recent initiatives for AIDS-related research (Figure 5-8~.
|
From page 193... ...
To evaluate and improve the adequacy and effectiveness of treatment plans and expenditures, the national services research program in particular needs rebuilding. The prospects for maintaining and improving treatment quality as well as continuing to develop more effective treatment methods depend to a great extent on treatment services research.
|
From page 194... ...
The results of earlier treatment enterprises tell an enlightening and reasonably heartening tale, and there is little possibility of improving current therapeutic practices further without careful study of outcomes, not only in research units, with their limited patient protocols and cadre of university-based researchers, but also in all other treatment programs. Most importantly, the advances in knowledge that came out of clinical and services research in the 1970s have not been followed up, and as a result analysts today are not better prepared to answer questions about the effectiveness, costs, and benefits of current treatment than they were a decade ago.
|
From page 195... ...
NIDA, in conjunction with its sister agency, the Office of Treatment Improvement, needs to give more adequate, focused attention to the drug treatment delivery system as a whole. Stronger services research programs at NIDA are a critical complement to the research and service responsibilities of the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA)
|
From page 196... ...
study of a 196~1971 national admission cohort, which included a 12-year follow-up, and TOPS (the Treatment Outcome Prospective Study) , which involved a 10,000-person national sample of 1979-1981 admissions to 41 drug treatment programs in 10 cities.
|
From page 197... ...
A services research issue worth noting here is the difficulties that drug treatment programs experience in securing zoning approval for clinical facilities, a problem usually summarized as "not in my back yard" (NIMBY)
|
From page 198... ...
The federal block grant for alcohol, drug abuse, and mental health services mandates that 10 percent of the grant be set aside to provide special services for women. According to the Institute of Medicine analysis of the 1987 National Drug and Alcoholism Treatment Utilization Suney, about one-third of the more than 80,000 women in drug treatment were in programs that had at least some special services for women, although there is no further specification of the nature or extent of these services.
|
From page 199... ...
The committee recommends that a special study initiative be undertaken by the National Institute on Drug Abuse, in conjunction with other relevant agencies of the Public Health Service, on the treatment of drug abuse and dependence among adolescents and women who are pregnant or rearing young children. The initiative should review and summarize all available sources of evidence and insight from research and clinical experience, provide as much guidance as possible for current treatment efforts, and develop a comprehensive research agenda.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.