The Development of Medications for the Treatment of Opiate and Cocaine Addictions Issues for the Government and Private Sector (1995) / Chapter Skim
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4 Treatment Setting and Effectiveness
4 Treatment Setting and Effectiveness
Pages 95-119
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From page 95... ...
TREATMENT SETTING Opiate Addiction Methadone maintenance with counseling is the treatment of choice for opiate addiction (McLellan et al., 19931. Treatment is provided in tightly regulated programs or clinics, which, until recently have been called "methadone clinics" because methadone has been the only pharmacotherapy approved for opiate addiction.
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From page 96... ...
A typical methadone maintenance program has four functional areas: a dispensing site, counseling offices, examining rooms, and an administrative area (Ball and Ross, 1991~. Patients usually receive a daily oral methadone dose and often have the privilege of a Sunday take-home dose.
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From page 97... ...
A smaller percentage of cocainedependent patients are treated in residential settings, in which the two major treatment modalities are therapeutic communities (TCs) and chemical dependency (CD)
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From page 98... ...
ODF programs initially served as "crisis centers" but have evolved into longer term treatment programs (Hubbard et al., 1989~. They have increasing allure to patients, insurers, and policy makers because the typical course of treatment is much less expensive than that offered by inpatient and residential programs.
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From page 99... ...
The first percentage refers to the residential setting and the second refers to the hospital inpatient setting. CFigure refers to residential setting rather than treatment modality because there is no separate breakdown for chemical dependency programs or therapeutic communities (in Table 30, Batten et al., 1992~.
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From page 100... ...
It must be underscored that the demographic and financial data presented here concerns patients in specialty treatment programs, those programs dedicated to drug-abuse treatment in free-standing clinics or in a specialized wing of a
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From page 101... ...
There are no nationwide data on 3The Client Data System (CDS) is an annual and voluntary reporting system on admissions to specialty substance abuse treatment programs throughout the United States.
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From page 102... ...
TABLE 4.2 Demographics of Methadone and Cocaine-Dependent Patients in Treatment' Characteristics Methadone Cocaine-Dependent Patients Patients Patients in treatment, 1993 117,0002 C 300,000-400,0003 Admissions, 19924 112,016 385,699 Aged 2~24 years 7.6% 16.0% 25-29 years 15.2% 27.7% 30-34 years 22.5% 27.0% 35-44 years 41.6% 21.2% 45+ years 11.1% 3.3% Males 66.5% 66.6% Married 22%g 22-32%6 Employment status Not employed 31.6% 31.8% Employed full-time 18.2% 19.7% Employed part-time 5.6% 5.4% Not in labor force 44.6% 43.1% Average income 30 days prior to treatment $417a $6138 Annual NA $24,0007 Length of stay in days" 321 1098 Health insurances None 49.4% 53.9% Medicaid 16.5% 11.0% Private insurance 4.2% 5.1% Blue Cross/Blue Shield 3.2% 2.8% Medicare 1.5% 0.8% HMO 1.8% 1.7% Unknown 21.1% 22.4%
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7Average income from sample studied 198~1989, unadjusted for inflation (Rawson et al., 1993~. Figure refers to all patients in a nationally representative sample of drug and alcohol treatment programs, irrespective of primary drug of abuse.
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From page 104... ...
Attesting to the chronic, relapsing nature of opiate addiction is the finding that almost 80 percent of methadone patients admitted to and discharged from treatment have had prior treatment episodes. Those patients average 3.4 previous treatment episodes, 1.4 of which occulted in the prior year (Batten et al., 1992~.
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From page 105... ...
In comparison with methadone patients, cocaine-dependent patients tend to be somewhat younger and have shorter lengths of stay in treatment (Table 4.21. Apart from these differences, the opiate- and cocaine-dependent patient populations are very similar (although it must be remembered that CDS data are biased in favor of publicly funded programs)
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From page 106... ...
Those same patients also had the greatest reductions in opiate and cocaine use while in treatment (Strain et al., 1993~. TREATMENT EFFECTIVENESS AND COST-EFFECTIVENESS Methadone Maintenance Treatment Effectiveness There is strong consensus that methadone maintenance treatment is effective for the treatment of opiate addiction (IOM, 1990; OTA, 1990; Anglin and Hser, 1992; Prendergast et al., in press)
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From page 107... ...
The study employs random assignment to treatment groups, thereby overcoming some of the problems plaguing earlier research, which used naturalistic settings and patient self-assignments (Tims et al., 1991~. After assigning patients to three different groups with varying levels of care, McLellan and co-workers found that patients given methadone and a comprehensive array of treatment services had significantly better treatment outcomes than did those who were given methadone and counseling, and than did those given methadone alone.
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From page 108... ...
This is a multiyear, longitudinal study of 10,000 adult clients in 80 of the best treatment programs in 12 cities. In addition, SAMHSA is supporting the Services Research Outcomes Study on a cohort of clients after treatment for substance abuse.
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From page 109... ...
The California Drug and Alcohol Treatment Assessment (CALDATA) analyzed the consequences of four treatment modalities, including methadone maintenance, on a random sample of 3,000 patients in treatment or discharged in fiscal year (FY)
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From page 110... ...
That was higher than the benefit-to-cost ratio to society (2.2 to 1~. For methadone treatment, the analysis was stratified by methadone patients discharged from treatment and those continuing in treatment.
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From page 111... ...
There is growing awareness that no one treatment will work for everyone who is dependent on cocaine, and the choice of treatment could be dictated by the severity of addiction. In general, addiction treatment professionals support initial evaluation and case management to ensure that patients with more severe conditions are treated in settings with the highest intensity of services (such as
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From page 112... ...
observe that there are no well-designed studies of CD programs, but there are some limited studies showing treatment effectiveness. A study of 300 cocaine dependent males entering the West Los Angeles Veterans Administration Medical Center for inpatient, outpatient, or self-help programs found abstinence at the 12-month follow-up to be greatest among patients whose choice of treatment consisted of an initial 21-day inpatient period, an outpatient follow-up regimen, and continued involvement in self-help groups (Khalsa and Anglin, 1991~.
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From page 113... ...
The most recent study using random assignment to treatment groups found this behavioral approach superior to counseling in patient retention and abstinence (Higgins et al., 1993~. Cost-Effectiveness The average cost of an outpatient admission for cocaine addiction treatment, presented in Figure 4.3, is estimated at $762; the average cost of a residential admission is estimated at $5,107 (Rydell and Everingham, 1994~.
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From page 114... ...
To meet this objective, researchers found that the additional cost of treatment would be $34 million, an amount 7.3 times less than that needed for the next most effective strategy, domestic enforcement, and 23 times less expensive than source control (Figure 4.5~. The researchers conclude, "Our findings suggest a way to make cocaine control policy more cost-effective: cut back on supply control programs and expand treatment of heavy users," (Rydell and Everingham, 1994~.
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From page 115... ...
in direct inpatient and outpatient costs have been realized since the marketing of lithium in 1970. A new cocaine medication does hold the opportunity to reduce some, but not all' of the counseling costs, as some degree of counseling, along with pharmacotherapy, as essential ingredients of cocaine addiction treatment will continue to be necessary, as research on methadone maintenance suggests (McLellan et al., 19931.
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From page 116... ...
Given the data presented on the effectiveness and cost-effectiveness of both opiate- and cocaine-addiction treatment, and in light of the evidence that treatment is far more cost-effective than are other control strategies, such as domestic enforcement, interdiction, and source country control, the federal government should make treatment a major component of its drug control strategies. The committee strongly recommends expanding the treatment capabilities of the states for opiate- and cocaine-dependent individu als to ensure that all those seeking treatment obtain it without delay.
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From page 117... ...
In: NIDA Drug Abuse Services Research Series, No.
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From page 118... ...
1988. The costs of crime and the benefits of drug abuse treatment: a cost-benefit analysis using TOPS data.
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From page 119... ...
In: Pickens RW, Leukefeld CG, Schuster CR, eds. Improving Drug Abuse Treatment (NIDA Research Monograph 106:93-1 13~.
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