Bridging the Gap Between Practice and Research Forging Partnerships with Community-Based Drug and Alcohol Treatment (1998) / Chapter Skim
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Appendix D: Commissioned Paper: The Treatment of Addiction: What Can Research Offer Practice?
Appendix D: Commissioned Paper: The Treatment of Addiction: What Can Research Offer Practice?
Pages 147-185
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From page 147... ...
Finally, research findings indicate that the costs associated with the provision of substance abuse treatment provide 3- to 7-fold returns to the employer, the health insurer, and to society within approximately three years following treatment (Everingham and Rydell, 1994; Gerstein et al., 1994; Holder et al., 1991; IOM, 1990b; OTA, 1983; State of Oregon, 1996~. Supported by grants from the National Institute on Drug Abuse, the Center for Substance Abuse Treatment, and the Robert Wood Johnson Foundation.
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From page 148... ...
In this regard, we have elected not to review literature on detoxification methods in order to better focus on standard rehabilitation treatments for drug and alcohol dependence typically following detoxification. Our review does not include the adolescent drug abuse treatment literature since it is still a developing field and there is a paucity of pertinent outcome studies in this area.
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From page 149... ...
In the review that follows we first discuss some of the basic assumptions underlying rehabilitation forms of addiction treatment since they set the stage for the clinical methods currently in use and for the types of studies that are in the research literature. Next we discuss some of our considerations regarding definitions of "outcome." With these assumptions and considerations in mind, we then review the most significant patient and treatment process contributors to the outcomes of addiction treatment.
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From page 150... ...
Many of the more intensive forms of outpatient treatment (Intensive Outpatient, Day-Hospital) begin with full or half-day sessions, five or more times per week for approximately one month.
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From page 151... ...
that outcome expectations for substance abuse treatment should not be confined simply to reduction of alcohol and drug use since the public, the payers of treatment, and even the patients themselves are interested in a broader definition of "rehabilitation." Further, we have argued that for substance abuse treatments to be "worth it" to the multiple stakeholders who are involved in treatment, the positive effects of addiction treatment should be sustained beyond the end of the treatment period and carry on at least six to twelve months. Most researchers in the addiction field have taken a similar, broad view of outcome expectations in the addiction treatment field (See Anglin et al., 1989; Babor et al., 1988; Ball and Ross, 1991; De Leon, 1984; Hubbard et al., 1989, 1997; Simpson, 1981, 1997; Simpson et al., 1997a,b)
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From page 152... ...
RESEARCH ON PATIENT FACTORS RELATED TO TREATMENT OUTCOME Demographic Factors While demographic factors are typically important predictors of the development of drug abuse problems (IOM, 1990b; Wilsnack and Wilsnack, 1993) there is little evidence that race, gender, age, or educational level are consistent predictors of treatment outcome among those who begin a treatment episode.
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From page 153... ...
for treatment of primary alcohol, opiate, or cocaine dependence evaluated the contribution of demographic variables including age, ethnicity, gender, marital status, years of education, and years of problematic substance abuse (McLellan et al., 1994~. Results showed that none of the demographic measures was a significant predictor of either posttreatment substance use or posttreatment social adjustment.
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From page 154... ...
Severity of Substance Use Various measures of higher levels of severity and greater chronicity of patients' substance use patterns have been reliably associated with poorer retention in treatment and more rapid relapse to substance use following treatment. This has been true of both alcohol dependent patients (Babor et al., 1988; Finney and Moos, 1992~; opiate dependent patients in therapeutic communities and in methadone maintenance (Ball and Ross, 1991; De Leon et al., 1984, 1994; Simpson, 1981, 1997a)
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From page 155... ...
have been predictive of posttreatment drinking and posttreatment social adjustment among various samples of alcohol dependent patients. More recently, findings from the NIAAA sponsored, multisite study of patient treatment matching (Project MATCH,
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From page 156... ...
Note: While there are a number of studies relating severity of psychopathology to posttreatment outcome, it should be noted that Schuckit and his colleagues have argued cogently against "over diagnosing" psychiatric symptoms, especially among alcohol dependent patients (Brown et al., 1991; Schuckit and Monteiro, 1988~. These authors have shown that much of the serious psychopathology seen among alcohol dependent patients at treatment admission is reduced following even four weeks of abstinence.
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From page 157... ...
The second important finding from work with this measure is that the "stage of change" is apparently an important predictor of treatment response and treatment outcome across all types of substance dependent patient samples (especially alcohol and nicotine dependent patients, but it is less studied among cocaine and opiate dependent patients) , even those who are not in treatment (DiClemente et al., 1991)
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From page 158... ...
(1983a,b) found that the family relationship scale on the ASI was one of three significant predictors of posttreatment drug use and general personal and social function among opiate dependent patients in either inpatient therapeutic community or outpatient methadone maintenance treatment.
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(1994) randomly assigned alcohol dependent patients to an equal length (28-30 days)
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However, this difference was shown among employed alcohol dependent patients who were assigned to either an inpatient program plus Alcoholics Anonymous (AA) or to AA meetings only (rather than to formal outpatient treatment)
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From page 161... ...
(1992) failed to show evidence for the predictive validity of the Cleveland placement criteria at least when applied to the assignment of alcohol and drug dependent patients to day hospital or inpatient care.
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For this reason, and because of the anonymous quality of the group, not much research has been done to evaluate this important part of substance abuse rehabilitation until recently (McLatchie and Lomp, 1988; McCrady and Miller, 1993; Nowinsky and Baker, 1992; Project MATCH, 1997~. While there has always been consensual validation for the value of AA and other peer support forms of treatment, the past few years have witnessed new evidence showing that patients who have an AA sponsor, or who have participated in the fellowship activities have much better abstinence records than patients who have received rehabilitation treatments but have not continued in AA.
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From page 163... ...
There has been less research in the use of self-help organizations among cocaine and/or opiate dependent patients. However, a recent study of cocaine patients participating in outpatient counseling and psychotherapy showed that while only 34% attended a cocaine anonymous (CA)
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From page 164... ...
The Therapist or Counselor There is a growing body of research suggesting that having access to regular drug/alcohol counseling can make an important contribution to the engagement and participation of the patient in treatment and to the posttreatment outcome. Perhaps the clearest example of the role of the counselor and at least individual counseling was shown in a study of methadone maintained patients, all within the same treatment program and all receiving the same methadone dose, who were randomly assigned to receive counseling or no counseling in addition to the methadone (McLellan et al., 1993b)
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From page 165... ...
and Svikis (1991) reported significant differences in posttreatment drinking rates and several other outcomes among alcohol dependent patients assigned to different individual counselors within an alcohol treatment program.
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, LAAM has recently received FDA approval and has been accepted by 16 states for prescription only at methadone maintenance programs. Buprenorphine is a partial opiate agonist that has been widely used in Europe and in the United States.
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From page 167... ...
Alcohol dependent patients who take acamprosate have shown 30% greater posttreatment abstinence rates at six-month follow-up than those randomly assigned to placebo. Further, those who have returned to drinking while taking acamprosate report less heavy drinking (greater than five drinks per day)
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From page 168... ...
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.
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From page 169... ...
has used the CRA approach with cocaine dependent patients. Here, cocaine dependent patients seeking outpatient treatment were randomly assigned to receive either standard drug counseling and referral to AA, or a multicomponent behavioral treatment integrating contingency managed counseling, community-based incentives, and family therapy comparable to the CRA mode!
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From page 170... ...
The approach to patient-treatment "matching" that has received the greatest attention from substance abuse treatment researchers involves attempting to identify the characteristics of individual patients that predict the best response to different forms of addiction treatments (e.g., cognitive-behavioral vs.12-Step, or inpatient vs. outpatient)
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From page 171... ...
. In a third study, cocaine dependent patients who continued to use cocaine during a fourweek intensive outpatient treatment program (IOP)
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From page 172... ...
Patients who were randomly assigned to the matched services condition were also placed in one of the four treatment programs and ASI information was forwarded to that program. However, the programs agreed to provide at least three individual sessions in the areas of employment, family/social relations, or psychiatric health delivered by a professionally trained staff person to improve functioning in those areas when a patient evidenced a significant degree of impairment in one or more of these areas at intake.
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From page 173... ...
For example, despite the importance of employment related problems in predicting treatment outcome, and the range of interventions that have been developed to improve employment and self-support among substance dependent patients (see French et al., 1992) , there is little evidence that this type of specialized service is effective in improving the employment of the patients or in improving abstinence from drugs (Hall et al., 1981 is an exception)
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From page 174... ...
Our review of this research has suggested the following three points: 1. The existing literature on treatment outcomes has been disappointing with regard to informing treatment practice at the level of the community treatment program.
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From page 175... ...
participating in AA or NA following treatment. In contrast to the above findings, it was surprising that some of the treatment elements that are most widely provided in substance abuse treatment have not been associated with better outcome.
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From page 176... ...
Consider three common perspectives on the evaluation of an outpatient addiction treatment program. A quality assurance or service delivery evaluation of that treatment might conclude that the program "had very good outcomes" since there was no waiting for treatment entry and at discharge, more than 80% of the patients were "highly satisfied" with their counselor and physician.
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From page 177... ...
1988. Unitary versus multidimensional models of alcoholism treatment outcome: An empirical study.
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From page 178... ...
Journal of Substance Abuse 16: 123-131. DATOS (Drug Abuse Treatment Outcome Study)
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1997. Overview of 1-year follow-up outcomes in the Drug Abuse Treatment Outcome Study (DATOS)
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From page 180... ...
National Institute on Drug Abuse Research Monograph 106:204217. McCrady BS, Miller WR, eds.
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From page 181... ...
1983a. Predicting response to alcohol and drug abuse treatments: Role of psychiatric severity.
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1992a. A quantitative measure of substance abuse treatments: The Treatment Services Review.
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1998. The natural history of outpatient alcohol and drug abuse treatment in a private health care setting.
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1997a Program diversity and treatment retention rates in the Drug Abuse Treatment Outcome Study (DATOS)
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From page 185... ...
Journal of Substance Abuse Treatment 14(1)
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