Effectiveness and Cost-Effectiveness of Treatment

There are many issues to be considered in evaluating whether and to what extent problems of addiction are effectively addressed through treatment. First, what results can be expected from an "effective" intervention, and are conventional treatments for substance use disorders effective in terms of these explanations? Second, is treatment better and more cost-effective than alternatives such as no treatment at all, self-help groups, community service, jail, or other options?

Thus, the seemingly simple question of whether treatment for substance use disorders is "effective" is actually one of the more complex health, social, and financial issues. In this presentation, rationales are offered for what are considered reasonable expectations for addiction treatments and, based on these, outcome criteria are proposed against which to judge the effectiveness and worth of those treatments. In the second part of the presentation, these outcome criteria are used to compare the effectiveness of addiction treatments to several alternatives, including no treatment or incarceration.

Presentation Conclusions

1. Is it possible to evaluate the effectiveness of addiction treatments? The same scientific methods and criteria that have been used to evaluate medications and medical devices have been applied with equal credibility.

2. Outcome is more than abstinence. While abstinence remains a goal of drug abuse treatment, it is not adequate for a comprehensive and meaningful evaluation of treatment. At a minimum, it is necessary to measure patients' personal health and social function for a meaningful evaluation.

3. Addiction treatment can be effective. Standard treatments have been shown to produce significant reductions in drug use and in drug-related problems of crime, family violence, unemployment, and welfare dependence. At the same time, not all treatments are effective and some are even harmful.

4. Some of the "active ingredients" of treatments that have been proven effective through controlled research include: individual sessions of drug counseling; professional sessions of employment, family, and psychiatric services; voucher-based community reinforcement; and medications such as antidepressants to reduce psychiatric symptoms, in addition to methadone and naltrexone to reduce illicit opiate use.

The Effects of Treatment on Crime

The effectiveness of a multistage therapeutic treatment system that was instituted in the Delaware correctional system has captured the attention of the National Institutes of Health, the U.S. Department of Justice, members of Congress, and the White House. Initially supported by the National Institute on Drug Abuse (NIDA), the Center for Substance Abuse Treatment (CSAT), and the Bureau of Justice Assistance (BJA), treatment occurs in a three-stage system, with each phase corresponding to the client's changing correctional status: incarceration, work release, and parole. An analysis of 18-month followup data will be presented for clients who received treatment in: (1) a prison-based therapeutic community (TC) only, (2) a work-release TC followed by aftercare, and (3) the prison-based TC followed by the work-release TC and aftercare.

1. Based on a wide body of literature in the fields of treatment and corrections, and combined with clinical and research experiences with correctional systems and populations, it would appear that the most effective treatment strategy for incarcerated, drug-involved offenders requires three stages of intervention.

2. Each stage in this continuum should be adapted to each client's changing correctional status: incarceration, work release, and parole (or other form of community supervision).

3. Treatment should be of a residential nature, that is, isolated from the drugs, violence, and prison subcultures that tend to work against positive behavioral change.

4. Although corrections-based treatment initiatives must be sensitive to the custodial demands of the prison administration, programs must have autonomy in terms of admission and release criteria and the day-to-day operations of the program.

Health Benefits of Treatment

Methadone is a mu opioid receptor-directed specific agonist that has a very long-acting pharmacokinetic and pharmacodynamic profile in humans. In the racemic form (as used in oral treatment), methadone has a half-life of over 24 hours, as sharply contrasted with heroin, which has a half-life of 3 minutes, and morphine, the major metabolite of heroin, which has a half-life of 4 hours. Thus, methadone provides steady-state profusion of the specific mu opioid receptor, whereas heroin and morphine have rapid onset and rapid offset of action. Laboratory and clinical studies have shown that rapid onset and rapid offset of drugs of abuse such as heroin disrupt many aspects of physiology, as well as specific molecular and neurochemical events. In contrast, the long-acting opioid methadone does not cause any disruption of these functions and, in fact, allows normalization of disruption caused by heroin use. L-alpha-acetylmethadol (LAAM) acts similarly to methadone and has an even longer acting pharmacokinetic and dynamic profile due to the biological activity of its two major metabolites; overall, LAAM has the duration of action of 48 to 72 hours. Thus, both methadone and LAAM allow normalization of physiology and also significantly lessen drug hunger and drug craving, thus reducing significantly or eliminating any illicit short-acting opiate use. Methadone maintenance has been used for 34 years and has been shown in numerous studies to be both medically safe and effective. LAAM, although less widely used, and, to date, for a shorter duration of time, has again been shown to be both safe and effective in maintenance treatment of heroin addiction.

Presentation Conclusions

1. Methadone is a mu opioid receptor-directed, long-acting specific agonist in humans.

2. Heroin is a short-acting opiate (half-life of 3 minutes); the major metabolite of heroin, morphine, also is a short-acting opiate (half-life of 4 hours). Both of these have a rapid onset and rapid offset of action. In contrast, methadone has a long half-life of 24 hours with slow onset and offset of action. 3. Heroin and other short-acting opiates disrupt many physiological functions, as well as related molecular and neurochemical events. In contrast, methadone allows normalization of those functions which were disrupted function cycles of heroin addiction.

4. LAAM, a second long-acting specific opioid agonist which, like methadone, acts primarily at the mu opioid receptor, is longer acting than methadone.

5. Methadone, as well as LAAM, reduces hunger and craving and eliminates any illicit short-acting opiate use.

Treatment as HIV Prevention

As the AIDS epidemic among injecting drug users (IDUs) enters its third decade, it is important to review the role drug treatment has played in reducing the spread of HIV infection. This presentation will review the research literature examining findings from studies with behavioral and serologic measures of the association between treatment participation, HIV risk reduction, and HIV infection. Numerous studies have documented that significantly lower rates of drug use and related risk behaviors are practiced by IDUs who are in treatment. These behavioral differences, based primarily on self-report, are consistent with studies that have examined HIV seroprevalence and seroincidence among drug users.

Presentation Conclusions

1. The underlying mechanism of action suggested by the collective findings of the available literature is rather simpleÑindividuals who enter and remain in treatment reduce their drug use, which leads to fewer instances of drug-related risk behavior. This lower rate of exposure results in fewer infections with HIV.

2. The protective effects of treatment can be realized only when programs are accessible and responsive to the changing needs of drug users.

3. Future research needs to be directed at developing a better understanding of the factors that enhance treatment entry and retention.

Cognitive-Behavioral Therapies and Counseling

Cognitive-behavioral therapies (CBTs), among the most frequently evaluated approaches used to treat substance use disorders, have been shown to be effective in several clinical trials of cocaine-dependent individuals and other types of substance users. The theoretical background and goals of this approach, the fundamentals of implementing CBT with substance users, and a brief review of the evidence supporting its effectiveness with drug abusers will be presented.

Presentation Conclusions

1. CBTs are based on social learning and behavioral theories of drug abuse.

2. The basic approach of CBT can be summarized as "recognize, avoid, and cope."

3. Treatment is organized around a functional analysis of substance use; i.e., understanding substance use with respect to its antecedents and consequences.

4. Skill training is focused on strategies for coping with craving, fostering motivation to change, managing thoughts about drugs, developing problemsolving skills, planning for and managing high-risk situations, identifying apparently irrelevant decisions, and cultivating drug refusal skills.

5. Basic principles of CBT are that: (a) basic skills should be mastered before more complex ones are given, (b) material presented by the therapist should be matched to patient needs, (c) repetition fosters the development of skills, (d) practice is needed for mastery of skills, (e) the patient is an active participant in treatment, and (f) skills taught are generalizable to a variety of problem areas.

Behavior Therapy

Structured behavior therapy techniques can be effective components of drug abuse treatment. Contingent incentive procedures are designed to enhance a patient's motivation to meet treatment goals by offering concrete rewards for specific performance outcomes. Two types of incentive rewards have been shown to be effective: methadone take-home doses and money-based vouchers. These incentives, when offered contingent on drug-free urines, can be used to reduce a patient's drug use during methadone treatment and to promote both retention and abstinence in outpatient drug-free programs. Strategies for practical application of research findings to real-life clinical situations will be discussed.

Presentation Conclusions

1. Drug abuse patients need motivation and skills to succeed in stopping drug use.

2. Research has shown that drug abuse behavior can be reduced by offering contingent incentives for abstinence (verified by drug-free urines).

3. Methadone take-home doses can be used effectively as a contingent incentive to increase counseling attendance and to promote abstinence.

4. The most striking successes have come from positive reinforcement programs that provide contingent incentives for abstinence using money-based vouchers as rewards.

5. Research provides examples, but treatment providers may need to be creative in discovering reinforcers that they can use for contingency management in their own clinical settings.

Family Therapy

Findings from four major family therapy research programs have shown that, by using somewhat different approaches to family therapy when working with different ethnic groups, family therapy is a highly effective treatment for drug-abusing adolescents. Data will be presented from each of these four programs that demonstrate the efficacy of family therapy and the apparent generalizability across populations, as well as intervention sites.

While most drug treatments emphasize the individual as the target of intervention, the defining characteristic of family therapy is the transformation of family interactions. Repetitive patterns of family interactions are the focus of treatment. Changing these patterns results in diminished antisocial behavior, including adolescents' drug abuse.

Presentation Conclusions

1. Family therapy is an effective treatment for adolescent drug abuse.

2. While different family therapy approaches have somewhat different emphases, the defining characteristic of all family approaches is the transformation of repetitive patterns of family interactions.

3. Because family therapy is drastically different from individual approaches, specialized training is required. It is as complex to learn family therapy as it is to learn supportive-expressive psychotherapies.

4. Family therapy can work with a broad range of family and social network configurations.

5. Family therapy approaches have developed specific interventions for engaging and keeping reluctant, unmotivated adolescents and family members in treatment.

Therapeutic Communities: Overview of Approach, Applications, and Effectiveness

A brief overview of the effectiveness of the therapeutic community (TC) approach to the treatment of substance abuse and related problems will be presented, and clinical criteria for referral to residential TCs will be reviewed. The essential elements of the treatment perspective, program model, and method will be outlined, and highlights of client profiles, retention in treatment, and post-treatment followup outcomes from 30 years of evaluation research will be presented. The current diversity, effectiveness, and cost-benefit of modified TC programs will be reported for special populations (such as women with children, the homeless, mentally ill chemical abusers, and adolescent/juvenile offenders), and for special settings (such as homeless shelters, prisons, schools, mental hospitals, and day-treatment clinics).

Presentation Conclusions

1. The TC is a unique social and psychological approach to the treatment of substance abuse and related disorders.

2. The TC serves a diversity of clients, but particularly those with serious substance abuse, social, and psychological problems. Thus the TC's treatment goals extend beyond recovery to changing lifestyles through habilitation and rehabilitation. 3. The TC model and method have been successfully modified for special populations and special settings (institutional, residential, outpatient, and day-treatment clinics).

4. The effectiveness of the TC is firmly documented by 30 years of evaluation research that demonstrates a lawful relationship between length of stay in treatment and reductions in drug use and criminality, increases in employment, and improvement in psychological status.

5. Current studies document favorable cost-effectiveness and cost-benefits for standard and modified TCs.

Detoxification: Necessary Antecedent to Treatment

Successful opioid detoxification is a function of safety and minimal discomfort as well as retention and progress to longer term treatment. Methadone withdrawal is most common, but rebound mild withdrawal symptoms lasting over 1 month are frequently associated with relapse. The -2 agonist clonidine is associated with less "rebound," but also less symptom suppression and more side effects. Combined clonidine and naltrexone produce a marked shortening of time (to 48 to 72 hours) and higher completion rate, but there is more discomfort and more intensive monitoring. Withdrawal can be reduced to 5 to 6 hours under intravenous midazolam sedation or general anesthesia (e.g., propofol) with clonidine premedication and increasing doses of naltrexone. Advantages include very high completion rates and ability to reach addicts who fear any withdrawal discomfort. Disadvantages include anesthesia risks, less elimination of postwithdrawal discomfort than claimed, and high cost. Rapid detoxification using buprenorphine, naltrexone, and clonidine may be almost as effective as the anesthesia method, but with fewer risks.

Presentation Conclusions

1. Detoxification from opiates is usually only the first step into treatment, rather than the treatment itself.

2. A variety of methods exists, each with advantages and disadvantages. Successful detoxification is a function of safety, minimal discomfort and retention, and progress to longer term treatment.

3. Newer, rapid methods using clonidine and naltrexone, preceded by buprenorphine, may ultimately prove to be easiest and most successful.

4. The psychosocial approaches with these various medications need to be improved to increase the percentage of those who continue in treatment.

Pharmacotherapy of Addictive Disorders

Over the past 25 years, scientists have made important discoveries about the mechanisms of action of drugs of abuse and the brain changes that constitute what is known as addiction. Using animal models and careful clinical studies, medications have been developed that have significantly improved the outcome of treatment for opiate addiction, alcoholism, and nicotine dependence. Several promising medication candidates are currently under study for the treatment of cocaine addiction. The focus of pharmacotherapy is on the prevention of relapse and the reduction of coexisting medical, social, and psychiatric problems. This approach is based on the medical treatment of other chronic disorders such as hypertension, diabetes, and asthma.

Presentation Conclusions

1. Drug addiction is a chronic relapsing disorder.

2. Repeated use of addicting drugs produces conditioned responses that are involuntary and persist for months and years after the last use of a drug.

3. A memory trace produced by addiction cannot be "erased" by medication or psychotherapy, but the patient can learn coping mechanisms that permit, often with the help of medication, a drug-free lifestyle.

4. Maintenance medications for opiate addiction and nicotine addiction have resulted in significant improvements in success rates.

5. Naltrexone and bupropion are two new medications that have been shown to reduce involuntary compulsive drug craving and can now be prescribed by physicians. More such medications are under study.

Combined Behavioral and Pharmacological Treatment for Drug Addiction

Both behavioral treatments and pharmacological treatments have demonstrated efficacy, but even the most powerful methods have limited success. Combining medications and behavioral treatments makes sense because each approach works on different complementary aspects of addiction. Medications treat target symptoms such as craving, drug withdrawal, and intoxication effects. Behavioral treatments attempt to change desires, goals, cognitions, habits, and interpersonal relationships. Combined treatments should have an additive effect. The empirical literature on combined treatments for substance use disorders has consistently shown that combined treatments are either superior or equivalent to behavioral or medication treatments alone. No study has shown combined treatment to be worse than either treatment alone. Despite this, combined treatments tend to be underutilized because of differences in ideology and training of substance abuse clinicians who have medical and nonmedical backgrounds.

Presentation Conclusions

1. Effective behavioral and medication treatments are available for dependence on all classes of abused substances, but even the most powerful approaches have limited success.

2. Combining medications and behavioral treatments is an optimal strategy because the two approaches work on different aspects of addiction.

3. Combined treatments tend to be underutilized because medically trained clinicians tend toward pharmacotherapies for addictions treatment, and many behaviorally trained clinicians remain ideologically opposed to them.

4. A small but growing body of empirical literature has consistently shown that combined treatments are either superior or equivalent to behavioral or medication treatments alone. No study has shown that combined treatments reduce the effectiveness of either component treatment.

5. The time has come to more aggressively incorporate medication treatments into behaviorally oriented programs and incorporate behavioral treatments into pharmacologically oriented programs.

Treatment of Individuals With Comorbid Severe Mental Illness

Recent research on co-occurring substance use disorder and severe mental illness will be reviewed, and epidemiology, correlates, the evolution of integrated treatments, and research on integrated treatment will be covered. Emphasis will be on the content of evolving integrated treatment programs and the evidence that these interventions are effective. Ten recent studies indicate that integrated treatments produce stable remissions of substance use disorder and that stable remission is associated with improvements in several other domains of adjustment.

Presentation Conclusions

1. Substance use disorder is extremely common (approximately 50 percent prevalence) in persons with severe mental illnesses such as schizophrenia and bipolar disorder.

2. Substance use disorder in persons with severe mental illness is associated with several adverse outcomes, including exacerbations of mental illness, rehospitalization, unstable housing, homelessness, disruptive behavior, legal system involvement, poor family relations, and HIV infection.

3. Patients with co-occurring severe mental illness and substance use disorder do not fit easily into traditional mental health programs or substance abuse treatment systems.

4. Integrated treatments, which combine mental health and substance abuse treatments for individuals with co-occurring disorders, have been developed over the past 15 years.

5. Several recent studies indicate that these integrated treatment programs are effective in helping dually diagnosed individuals attain stable remissions of substance use disorder.

Treatment of Women

Prior to the 1970s, psychoactive substance use and abuse research in epidemiological, clinical, and experimental forms did not focus on issues specific to women. Since that time, a number of initiatives have been developed that define gender differences: rates of initiation; distinct patterns of maintenance use common in women; rate of development and nature of consequences of chronic use; and effectiveness of outreach, intervention, and treatment using previously described models of care. Many of the initiatives critical to shaping the delivery of services to women and our understanding of women's treatment issues have been carried out through research sponsored through grants from the National Institute on Drug Abuse (NIDA) program announcements.

The antecedents shown to be associated with women's initiation of use of psychoactive substancesÑcritical life-defining events and the elements associated with critical life periods across the lifecycleÑwill be delineated. A brief overview of the epidemiology of substance use disorders among women will be presented, including a review of the utility of such data to program planning and resource allocation at the treatment delivery level. The consequences of substance use on general health, reproductive health, and mental health will be outlined. The implications of research and how research findings can improve treatment delivery will be explored.

Presentation Conclusions

1. Men and women differ in rates of initiation; maintenance; identification of abuse, dependence, and consequences of use; and cessation of chemical use.

2. Women experience a far greater ratio of health consequences to amounts of alcohol and other drugs consumed than do men.

3. Women present in a variety of settings, providing opportunities for intervention.

4. Research to define gender differences is developed sufficiently to inform clinical practice in the areas of sensitivities and services.

The Treatment of Adolescent Substance Use Disorders

The developmental etiologic factors that put children at risk for adolescent substance use disorders will be briefly reviewed, to provide the basis for understanding the need for a comprehensive assessment and a multimodal treatment approach to such adolescents. Specific empirically supported treatments that are generally effectively employed as part of a multimodal and multisystem treatment approach will then be discussed. These treatment approaches include: motivational interviewing, social skills training, evaluation and treatment of comorbidity, behavioral and cognitive-behavioral interventions, urine toxicology monitoring, community reinforcement techniques, family-based interventions, and multisystemic treatment.

Presentation Conclusions

1. Many young people have serious substance involvement with nicotine, alcohol, marijuana, and other illicit drugs. Such adolescents have high rates of conduct disorder, attention deficit hyperactivity disorder (ADHD), learning disorders, and affective and anxiety disorders. Moreover, etiologic factors are multidimensional and must be assessed and treated multimodally in the context of many interrelated systems.

2. There is growing empirical support for specific modalities that are effective in the treatment of adolescent substance use disorders. These modalities include: operant behavioral techniques, urine toxicology screening, cognitive-behavioral therapy, motivational interviewing, social skills training, structural and functional family therapy, treatment of comorbidity, and multisystemic therapy. They should be used as primary treatment modalities over other methodologies without such empirical support.

3. Common comorbid disorders, such as conduct disorder, ADHD, affective disorders, and anxiety disorders, should be addressed and treated in an integrated manner with substance treatment.

4. Urine toxicology screening is a necessary component of all effective treatment modalities for adolescent substance use disorders and must be employed in outpatient and inpatient treatment settings.

5. Although there are several promising treatments for adolescent substance use disorders, a robust research agenda is needed to replicate these treatments and develop effective new treatments. The long-term outcome of such interventions must also be investigated.