RESEARCH ANALYSIS

and

UTILIZATION SYSTEM

Drug Abuse

Treatment Evaluation:

Strategies, Progress,

and Prospects

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service • Alcohol, Drug Abuse and Mental Health Administration
Drug Abuse Treatment

Evaluation: Strategies,

Progress, and Prospects

Editors:

Frank M. Tims, Ph.D.

Jacqueline P. Ludford, M.S.

National Institute on Drug Abuse

NlDA Research Monograph 51

A RAUS Review Report

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

Alcohol, Drug Abuse, and Mental Health Administration

National Institute on Drug Abuse

5600 Fishers Lane

Rockville, Maryland 20857
NIDA Research Monographs are prepared by the research divisions of the

National Institute on Drug Abuse and published by its Office of Science. The

primary objective of the series is to provide critical reviews of research problem

areas and techniques, the content of state-of-the-art conferences, and

integrative research reviews. Its dual publication emphasis is rapid and targeted

dissemination to the scientific and professional community.

Editorial Advisors

MARTIN W. ADLER, Ph.D.

Temple University School of Medicine

Philadelphia, Pennsylvania

SYDNEY ARCHER, Ph.D.

Rensselaer Polytechnic Institute

Troy, New York

RICHARD E. BELLEVILLE, Ph D

NB Associates Health Sciences

RockviIle, Maryland

KARST J. BESTEMAN

Alcohol and Drug Problems Association

of North America

Washington, D C

GILBERT J. BOTVIN, Ph D.

Cornell University Medical College

New York, New York

JOSEPH V. BRADY, Ph D.

The Johns Hopkins University School of

Medicine

Baltimore, Maryland

THEODORE J. CICERO, Ph.D

Washington University School Of

Medicine

St. Louis, Missouri

MARY L. JACOBSON

National Federation of Parents for

Drug Free Youth

Omaha, Nebraska

REESE T JONES, M.D.

Langley Porter Neuropsychiatric lnstitute

San Francisco, California

DENISE KANDEL, Ph D.

College of Physicians and Surgeons of

Columbia University

New York, New York

HERBERT KLEBER. M.D.

Yale University School of Medicine

New Haven, Connecticut

RICHARD RUSSO

New Jersey State Department of Health

Trenton, New Jersey

NIDA Research Monograph Series

CHARLES R SCHUSTER, Ph. D.

Director NlDA

THEODORE M PINKERT, M.D., J.D.

Acting Associate Director for Science NIDA

Parklawn Building, 5600 Fishers Lane, Rockville, Maryland 20857
Drug Abuse Treatment Evaluation:

Strategies, Progress, and Prospects
ACKNOWLEDGMENT

This monograph is based upon papers and discussion from the RAUS

Review Conference on Drug Abuse Treatment Evaluation, held May 25

and 26, 1983, in Rockville, Maryland. The conference was sponsored

by the Office of Science and the Division of Clinical Research,

National Institute on Drug Abuse.

PUBLIC DOMAIN NOTICE

All material in this volume except quoted passages from copyrighted

sources is in the public domain and may be used or reproduced

without permission from the Institute or the authors. Citation of

the source is appreciated.

Opinions expressed in this volume are those of the authors and do

not necessarily reflect the opinions or official policy of the

National Institute on Drug Abuse or any other part of the U.S.

Department of Health and Human Services.

The U. S. Government does not endorse or favor any specific

commercial product or company. Trade or proprietary names

appearing in this publication are used only because they are

considered essential in the context of the studies reported herein.

Library of Congress catalog card number 84-601075

DHHS publication number (ADM)88-1329

Alcohol, Drug Abuse, and Mental Health Administration

Printed 1984 Reprinted 1986, 1988

NIDA Research Monographs are indexed in the Index Medicus. They

are selectively included in the coverage of American Statistics

Index, BioSciences Information Service, Chemical Abstracts, Current

Contents, Psychological Abstracts, and Psychopharmacology Abstracts.

iv
Preface

The Research Analysis and Utilization System (RAUS) is designed to

serve four functions:

Collect and systematically classify the findings of all

intramural and extramural research supported by the

National Institute on Drug Abuse (NIDA);

Evaluate the findings in selected areas of particular

interest and formulate a state-of-the-art review by a panel

or scientific peers;

Disseminate findings to researchers in the field and to

administrators, planners, instructors, and other interested

persons;

Provide a feedback mechanism to NIDA staff and planners so

that the administration and monitoring of the NIDA research

program reflect the very latest knowledge gleaned from

research in the field.

Since there is a limit to the number of research findings that can he

intensively reviewed annually, four subject areas are chosen each

year to undergo a thorough examination. Distinguished scientists in

the selected field are provided with copies of reports from

NIDA-funded research and invited to add any information derived from

the literature and from their own research in order to formulate a

comprehensive view of the field. Each reviewer is charged with

writing a state-of-the-art paper in his or her particular subject

area These papers, together with a summary of the discussions and

recommendations which take place at the review meeting, make up a

RAUS Review Report in the NIDA Research Monograph series.

v
“Drug Abuse Treatment Evaluation: Strategies, Progress, and

Prospects” was chosen as a subject for one of these comprehensive

RAUS reviews in FY 1983 because a body of knowledge had evolved,

including several large treatment evaluation systems. Reports are

included on the DARP program of the seventies and on the more

recent TOPS system, both designed for treatment evaluation.

The results of these reviews and discussions are presented in this

monograph. Dr. Frank M. Tims served as a chairman of the meeting

and editor of the resulting monograph. Dr. Jerome H. Jaffe served

as the other chairman. Dr. Jaffe has subsequently accepted the

position of Director of the NIDA Addiction Research Center in

Baltimore. Ms. Jacqueline P. Ludford, coeditor of the monograph,

is coordinator of NIDA’s RAUS system.
Contents

Preface v

Executive Summary

Jacqueline P. Ludford 1

Introduction

Frank M. Tims 9

Evaluating Drug Abuse Treatment: A Comment on the State of

the Art

Jerome H. Jaffe 13

National Treatment System Evaluation Based on the Drug Abuse

Reporting Program (DARP) Followup Research

D. Dwayne Simpson 29

Treatment Outcome Prospective Study (TOPS): Client Characteristics and Behaviors Before, During, and After Treatment

Robert L. Hubbard, J. Valley Rachal,

S. Gail Craddock, and Elizabeth R. Cavanaugh . . . . . . . 42

Program-Based Evaluation Research in Therapeutic Communities

George De Leon . . . . . . . . . . . . . . . . . . . . . . . 69

Clinical Trials in Drug Treatment: Methodology

Sharon M. Hall . . . . . . . . . . . . . . . . . . . . . . . 88

Outcome of Narcotic Addict Treatment in California

M. Douglas Anglin and William H. McGlothlin . . . . . . . . . 106

Psychotherapeutic Approaches in the Treatment of Drug Abuse

Charles P. O'Brien, George E. Woody,

and A. Thomas McLellan . . . . . . . . . . . . . . . . . . . 129

Clinical Implications of Drug Abuse Treatment Outcome Research

Edward C. Senay . . . . . . . . . . . . . . . . . . . . . . 139

The State Perspective

Douglas S. Lipton and Philip Appel . . . . . . . . . . . . 151

A Treatment Evaluation Agenda:

Discussion and Recommendations

Frank M. Tims and Sherry Holland . . . . . . . . . . . . 167

List of NIDA Research Monographs . . . . . . . . . . . . . . . . 175

vii

Executive Summary

Jacqueline P. Ludford, M.S.

A considerable body of evaluative research on the treatment of drug

abuse has been generated in recent years, by clinical experience and

project research and from large evaluative studies such as the Drug

Abuse Reporting Program (DARP) of the 1970s and the more recent

Treatment Outcome Prospective Study (TOPS). Clearly, the field was

ready for a state-of-the-art review of the results of these efforts

and of what we have learned about the effectiveness of different

treatment modalities, methods, and techniques.

The RAUS review addressed not only the obvious questions regarding

treatment components and effectiveness but also such ouestions as:

To what extent should we invest in large-scale studies of

process and effectiveness vs. smaller, program-based

research?

What are the needs from the viewpoint of the providers?

From the viewpoint of the researchers?

To address these questions and the current state of the art, a RAUS

meeting was convened on May 25-26, 1983. The presentations included:

Evaluation of Drug Dr. Jerome Jaffe

Abuse Treatment: A V.A. Medical Center

Comment on the State Newington, Conn.

of the Art

National Treatment System Dr. D. Dwayne Simpson

Evaluation: Drug Abuse Texas A & M University

Reporting Program (DARP)

National Treatment System Mr. J. Valley Rachal

Evaluation: Treatment Dr. Robert Hubbard

Outcome Prospective Study Research Triangle Inst.

(TOPS) North Carolina

1
Program-Based Evaluation

Studies

Clinical Trials in

Drug Treatment

Outcome of Narcotics Addict

Treatment in California

Evaluation of Psychotherapeutic

Approaches to Drug Treatment

Clinical Implications of

Treatment Outcome Studies

Treatment Evaluation: The

State Perspective

Dr. George De Leon

Phoenix House

New York City

Dr. Sharon Hall

University of California

San Francisco

Dr. M. Douglas Anglin

University of California

Los Angeles

Dr. Charles O'Brien

VA Hospital

Philadelphia

Dr. Edward Senay

University of Chicago

Dr. Douglas Lipton

New York State Division

of Substance Abuse

Services

Dr. Jerome Jaffe, of the Veterans Administration Medical Center,

Newington, Connecticut, and Dr. Frank Tims, of the Division of

Clinical Research, NIDA, served as cochairmen for the meeting and

led the discussions.

Dr. Simpson discussed the results of the Drug Abuse Reporting

Porgram (DARP), established in 1969 to collect data on communitybased treatment services. Eventually it collected standardized data

on 44,000 clients in 52 treatment agencies. Because of a lack of

accepted criteria regarding treatment definition, classification,

and outcome, the first task under DARP was to define and document

terminology and standards to be commonly accepted. DARP then

measured treatment outcome on the basis of amount and kind of drug

use, productive activity, alcohol use, and criminality. Data on

male opioid addicts, the best represented subsample, indicate most

favorable outcomes were associated with methadone maintenance,

therapeutic communities, and outpatient drug-free treatment; the

outcome differences between the three types of treatment were not

significant. There were differences in the types of clients served

and in the dropout ratio, however. Dr. Simpson called for research

in smaller, multi-program studies to examine the effects of

differing treatments on different clients and to study process and

procedures within programs, including staff-client interaction.

Mr. Rachal and Dr. Hubbard presented data from the Treatment Outcome

Prospective Study (TOPS) which collected data on approximately

12,000 clients admitted to treatment between 1979-1981. Because the

study is so recent, followup data are necessarily limited. TOPS was

designed to analyze the association between client behavior, client

characteristics, environment, and the treatment process. Its

measures include data on drug use, alcohol consumption, mental

2
health, criminal behavior, and economic productivity. One of its

research objectives is to provide testable hypotheses regarding why

and for whom certain types of treatment do or do not work.

The TOPS study design, its advantages and limitations, were

discussed. Pretreatment and intreatment data indicate:

Outpatient drug-free programs had the biggest problem with

retention: 21 percent dropout within a week or less and 36

percent within 4 weeks or less. Methadone clients are

least likely to leave treatment early.

There is a high level of depression among clients seeking

treatment; almost half of all methadone clients reported

having been seriously depressed in the year before intake.

More than 40 percent of all clients reported some predatory

illegal activity (assault, robbery, burglary, etc.) in the

year before treatment; more than 70 percent of these

clients reported cessation of predatory illegal activity

during treatment.

Half of the methadone clients were unemployed when they

entered treatment and most remained unemployed during

treatment.

Outcomes are confounded by many factors other than treatment itself,

as described in the TOPS study (see Hubbard, this volume). Followup

of any drug treatment program is complicated by readmittance to the

same or other treatments and by incarceration which limits

opportunity to use drugs, find jobs, or commit crime. Many of the

methadone clients are still in treatment at followup. Preliminary

measures of outcome, however, indicate:

Clients improve in treatment, regardless of type, and some

of this improvement lasts after treatment. More than

one-third of clients report not using pretreatment primary

drug during followup period.

Between 20 and 30 percent of clients report predatory

illegal acts in the year after treatment, a significant

reduction from pretreatement levels.

After treatment about two-thirds of all clients report no

signs of depression.

The effect of treatment on employment trends is unclear;

data are still being analyzed.

Dr. De Leon, who is Director of Research for Phoenix House, in New

York, discussed program evaluation in a therapeutic community (TC).

The goal of a therapeutic community is to change lifestyle to

reflect abstinence from drugs, to eliminate antisocial activity, and

to develop prosocial attitudes and values. In general, when TCs are

evaluated, it is found that:

3
Clients improve significantly over pretreatment status as

measured by drug use, criminality, and prosocial behavior.

Success depends on time in treatment, with improvements for

those who spend several months in program but drop out, and

even more striking improvements for those who complete the

program.

Improvements in psychological adjustment correlate with

improvements in social adjustment and success in the

program.

Individuals who improve psychologically within the first

several months after admission show a greater likelihood of

being retained in treatment. More research is needed on

the subject of retention and its correlates.

Dr. Hall presented an evaluation of clinical trials in drug abuse

treatment. She described the strategies and procedures of various

types of clinical trials, their advantages and disadvantages. In

particular, she noted that:

Drug treatment clients will not accept random assignments

to a treatment modality.

If treatment entry differs between conditions, there tend

to be confounding variables which compromise interpretation

of outcome data.

Different modalities attract different types of clients,

and this fact further complicates comparisons.

Her review concluded that:

Well-controlled, small trials with sample size based on

power analysis yield the clearest outcomes. The best of

these have a treatment manual and well-developed followup

procedures.

Research strategies should involve some degree of

replication.

More standardization is needed in psychosocial areas, e.g.,

standardizing drug use index.

More studies or replication of findings are needed in

psychotherapy, contingency management, skill training, and

family therapy. Since the proportion of women clients

entering treatment is increasing, some emphasis needs to be

placed on treatment services geared to their needs.

Dr. Anglin reported on followup of 1,700 addicts in a study of civil

commitment vs. methadone treatment in California. He pointed out

that successful treatment in substance abuse ameliorates or relieves

the disease but rarely "cures" it in the sense of a medical model.

4
Anglin and McGlothlin measured success in terms of narcotic and

other drug use, crime, employment, and family stability.

The results of the evaluation indicate that both civil conitment

and methadone maintenance effectively reduce drug use and crime,

and, to a lesser extent, increase employment and family

responsibility. Differing policies with respect to dose of

methadone and time in treatment produced differing effects. Anglin

considers both types of treatment to involve behavior modification

techniques and offered some possible explanations for differences in

results.

Dr. O'Brien focused on psychotherapeutic approaches in the treatment

of drug abuse, reviewing eight controlled studies of psychotherapy

with opiate addicts. In six of the eight studies, the clients

improved under the psychotherapy condition as compared to controls.

Important factors influencing outcome include:

Diagnosis at entry and improved sophistication in making an

accurate diagnosis;

Taping of therapy sessions and treatment manuals to ensure

adherence to prescribed techniques; rating instruments to

measure patient-therapist interaction;

The number of sociopaths in the study, since psychotherapy

appears to be particularly unsuccessful with sociopaths;

evidence suggests, however, that psychotherapy may be

helpful with addicts when given under certain conditions,

specifically with those addicts on methadone and diagnosed

as having depression.

Dr. Senay presented a paper on the clinical implications of drug

abuse treatment evaluation research. The most important clinical

implication is that treatment for drug abuse works--clients function

more normally, reduce drug use and crime, and generally improve.

But Dr. Senay listed a number of problems and recommendations which

he feels must be addressed:

How can drug abuse treatment be coordinated with standard

mental and health care systems? In the present system

substance abusers tend to get second-class health care. We

need more 'structural" research in this area of integrating

systems rather than operating separate, parallel ones. For

example, CMHCs need to be able to use modern treatment

methods for drug abusers and develop not only knowledge and

skills but also training and tools.

How do different treatment components or phases of

treatment contribute to client outcome? This is a

complicated question, and it may be that structural

research is more likely to pay off than process research.

Substance abusers frequently need services to deal with

psychiatric problems, pregnancy, lack of job skills, and

general health.

5
Single State agencies and appropriate professional

organizations should take the lead in licensing,

credentialing, and accreditation of workers in the field.

This would involve a systematic training program for

clinicians and counselors.

Accept the fact that repeated episodes of treatment are

probably necessary for those with serious substance abuse

problems. These do not indicate failure on anyone's part,

but merely reflect the nature of the problem and the

culture.

Provide flexible scheduling, so that addicts can coordinate

treatment with work.

Evaluate from the consumer's point of view. Clients can

frequently provide information regarding the dynamics of

treament and gaps in service.

Undertake collaborative efforts with law enforcement

agencies involving the criminal justice system in

treatment-rehabilitation efforts.

Address the problem of improvement of the addict's overall

general health.

In evaluation, address clinic size (number of patients) as

it relates to success/failure in outcome measures; examine

public vs. private programs.

Reconsider the role of urinalysis in treatment and its

cost/benefit.

Link epidemiological studies with treatment studies and

outreach strategies.

Treatment programs are needed which are geared to cocaine,

marijuana, and multiple drug use. Programs are also needed

to treat females and the geographically mobile.

Dr. Lipton, who is associated with the New York State Division of

Substance Abuse Services, presented a paper on the State's interests

in drug abuse research. In a survey of nine single State agencies,

including such populous states as California, Illinois,

Massachusetts, and New Jersey, Dr. Lipton found:

NIDA materials are used in monitoring, planning, and

evaluation; DAWN, CODAP, high school and household surveys,

monographs and technical reports were mentioned.

Some agencies are making extensive use of DARP reports.

NIDA monographs describing outcome studies were considered

most useful.

6
Respondents felt a need for studies on cost-effectiveness

of treatment, "how-to" manuals for treatment evaluations,

bibliographies of treatment studies for program

administrators, formatting of reports for planners and

administrators rather than researchers, and more studies of

nonopiate abusers.

Respondents suggested routine dissemination of a list of

all treatment evaluation research projects and the reports

generated by them, including statements of implications for

treatment programs.

Several suggestions were made for dissemination strategies and

sharing of experience by evaluators, administrators, and

policymakers.

Policymakers note problems with evaluation research, in particular

lack of clear statements of practical application in the field and

the fact that frequently the research answers a somewhat different

auestion than that which the policymakers are asking. Policymakers

tend to adopt uncritically that research which supports their

existing views and to pursue what they perceive to be their

constituents' wishes, regardless of what evaluations show. The

findings of evaluation research cannot reverse popular convictions

which are upheld by policymakers. The more complex an evaluation,

the more "jargon" used, the more scientific caveats, the more the

policymaker is apt to disregard the conclusions.

Lipton proposed seven rules for successful evaluation research:

Establish a dialogue with the policymaker.

Move swiftly to produce.

Accept incremental improvement in staff, data systems, etc.

Make initial rough estimates and then refine.

Produce reports in four parts:

-Executive summary and recommendations

-Body of text with summarizing headlines

-Conclusions in "bullet" form

-All technical material in the appendix

Organize and present results by the applicable political

jurisdiction.

Evaluation should be practical, pecuniary, and political.

A number of suggestions for treatment evaluation studies were

presented.

7
AUTHOR

Jacqueline P. Ludford, M.S.

Research Analysis Branch

Office of Science

National Institute on Drug Abuse

Rockville, MD 20857

8
Introduction

Frank M. Tims, Ph.D.

The purpose of this review is to assess critically our present state

of knowledge regarding drug abuse treatment evaluation, identify

major research questions which should be the focus of future

efforts, and outline the best strategies for addressing these

questions. The National Institute on Drug Abuse has made

substantial investments in large, longitudinal studies of treated

drug abusers as well as smaller controlled studies. These have

contributed greatly to our understanding of treatment populations,

histories, and outcomes, and have made a convincing case for

treatment effectiveness. It is appropriate now that we begin a

process of consolidation of our knowledge in this area and

definition of future research priorities. Because a recent

monograph edited by Cooper et al. (1983) deals extensively with

methadone detoxification, methadone maintenance, and other

pharmacologically based drug abuse treatments, these will not be of

primary concern in this review, except as they are incidental to

more general questions of treatment evaluation.

Evaluation has been an integral part of the Federal effort to

develop and maintain a national system of community-based drug abuse

treatment programs since it began in the late 1960s. The Drug Abuse

Reporting Program (DARP), established under the auspices of the

National Institute of Mental Health and subsequently supported by

the National Institute on Drug Abuse, began as a management

monitoring system which was designed also to be of value for

treatment research. The DARP strategy has proven to be sound and

useful in describing a treatment population we knew little about in

those early days, in characterizing behavioral patterns and

treatment experiences of those clients, and in evaluating the

effectiveness of those programs and building the foundation for an

extremely productive series of treatment outcome research studies.

The DARP research, described in this volume by Simpson, provided a

substantive and methodological basis for another large-scale

treatment evaluation, the Treatment Outcome Prospective Study (TOPS)

which is described by Hubbard et al., also in this volume. At the

inception of the DARP in 1968, the treatment system was embryonic,

and concerned largely with the treatment of opioid addicts.

9
Community-based treatment was controversial, with methadone

maintenance being perhaps the most visible focus of the

controversy. Community-based treatment was unproven, and the basis

for designing the treatment for any individual was usually nothing

more than professional judgment. The TOPS was launched amid a

growing body of empirical evidence regarding the efficacy of

treatment for addiction, but when the system had undergone dramatic

changes. Large numbers of individuals not addicted to opioids, with

various nonopioids classed as their primary drugs of abuse and

perhaps no history of opioid use, began to enter residential

drug-free and outpatient drug-free programs, such that in 1979.

clients reporting opioids as the primary drug of abuse accounted for

less than half the clients in the federally funded treatment system

(NIDA 1982).

The diversity of client populations presented new challenges to the

TOPS researchers, not the least of which was the conceptual

complexity inherent in characterizing the drug dependency of those

whose drug abuse patterns might be widely varied and not explainable

in terms of physical addiction. The TOPS research strategy followed

that which had served the DARP well, a series of admissions cohorts

comprising a client population which could be followed during

treatment and sampled for followup studies after treatment.

Chapters in this volume present data from the DARP over a

considerable posttreatment period and preliminary analyses of the

available TOPS data.

Within the context of treatment outcome studies, a large number of

other studies have been undertaken with NIDA sponsorship, not to

mention the considerable body of work sponsored by other agencies,

most notably the Veterans Administration, which has supported both

large scale followup studies (e.g., Veterans Administration 1979)

and clinical investigations. NIDA-sponsored treatment research has

included a well-designed study of therapeutic community clients (see

De Leon, this volume) with measures of psychological functioning as

well as behavioral outcomes. De Leon's research typifies the

smaller scale, intensive research we have chosen to call "program

based," because it is usually conducted by investigators affiliated

with the program or cluster of programs being studied but does not

necessarily involve rigorous experimental control. Other

investigations which are in the category of controlled studies are

described by Hall in her methodologically oriented chapter, as well

as by O'Brien et al. in their discussion of studies of the efficacy

of psychotherapy in the treatment of addiction.

The work of Anglin and the late Dr. William McGlothlin represents

another of the pioneering approaches to the study of drug abuse

treatment effectiveness. While the DARP, TOPS, and De Leon's

therapeutic community studies considered the outcomes of treatment

generically, Anglin and McGlothlin examined treatment policy in

relation to outcomes. Their ability to impose quasi-experimental

designs on treatment populations affected by given treatment

policies and policy changes, such as compulsory treatment of addicts

in California, sudden changes in methadone maintenance policy

(including discontinuation of publicly funded programs), and local

variations in clinic policy provided opportunities for these

10
scientists to study the impact of treatment policy in the natural

environment.

Senay's chapter considers the clinical implications of the emerging

body of knowledge regarding treatment outcomes and examines some

treatment and research issues from his clinical perspective.

Since the Omnibus Reconciliation Act of 1981 dramatically changed

the way in which Federal support is provided to drug abuse

treatment, providing ADM block grants to individual States rather

than having NIDA administer treatment funds, there have necessarily

been changes in the relationship between NIDA and the States. The

States are now more largely responsible for making treatment

allocation decisions, and NIDA's mission is more that of a research

Institute. The changes taking place in the community based

treatment systems are in part a response to the new situation and in

part a continuation of changes which were evolvlng before this

shift. Since the States share many common concerns with NIDA where

treament evaluation research is concerned, it was felt that this

review should also provide a forum for articulation of these

concerns and interests at the State level. Lipton's chapter on "The

State Perspective" presents his impressions based on contacts with

evaluation researchers in a sample of State substance abuse

agencies, as well as his own experience in the New York Single State

Agency.

In the chapters which follow, the authors have attempted systematic

presentation of their individual research areas in a field which is

evolving and diverse in its perspectives. In the opening chapter,

Dr. Jerome Jaffe, who led the Federal treatment effort as Director

of the Special Action Office on Drug Abuse Prevention in the early

197Os, presents a succinct assessment of the state of the art in

treatment evaluation, and sets the stage for this review.

REFERENCES

Cooper, J.R.; Altman, F.; Brown, B.S.; and Czechowicz, D., eds.

Research on the Treatment of Narcotic Addiction: State of the

Art. National Institute on Drug Abuse, Treatment Research

Monograph. DHHS Pub. No. (ADM) 83-1281. Rockville, MD: The

Institute, 1983.

National Institute on Drug Abuse. "Trend Report January 1978-

September 1981: Data from the Client Oriented Data Acquisition

Process." Statistical Series, Series E., No. 24. DHHS Pub. No.

(ADM) 82-1214. Rockville, MD: The Institute, 1982.

Veterans Administration. "An Evaluation of Veterans Administration

Treatment of Drug Dependent Patients--Final Report, Phase II.”

Veterans Administration Professional Services Letter,

Washington, D.C., April 27, 1979.

11
AUTHOR

Frank M. Tims, Ph.D.

Treatment Research Branch

Division of Clinical Research

National Institute on Drug Abuse

Rockville, MD 20857

12
Evaluating Drug Abuse Treatment:

A Comment on the State of the Art

Jerome H. Jaffe, M.D.

We have been asked to address two fudamental questions at this

review. First, "What do we know about the effectiveness of

treatment of drug abuse?" Second, "Where do we go from here?" We

must keep in mind that drug abuse is a chronic illness and that

evaluating the effectiveness of treatment of chronic illness is

unlike work in biochemistry or certain other fields in natural

science, where the publication of a major finding often marks some

sharp turning point in our understanding. Evaluating the treatment of chronic illness occurs over periods of years.

preliminary analyses are described at meetings, and later more

detailed presentations (and sometimes revisions) eventually are

published. Except where radically new treatments are introduced,

the newly published must be weighed along with all previous

findings. Although the field is still relatively young, there are

now hundreds of papers on the treatment of drug abuse, and it

becomes progressively less likely that any single new study will

radically alter the inferences that have already been drawn from

these observations. It is never quite clear just when we come to

accept a given finding as valid.

Obviously, the discovery of some new medicine or some new intervention technique which represents a dramatic improvement over

previously available procedures might require a major reassessment. Twenty years ago, the evolution of the therapeutic

community and the introduction of methadone maintenance for

treating opioid addicts represented such significant changes. No

comparable dramatic changes in treatment techniques have occurred

in the last 5 years. Indeed, it would be fair to say that the

diverse interventions which we subsume under the very broad

concept of treatment have not changed fundamentally over the past

10 years. What progress we have made in understanding what

current treatment can and cannot do is based on a progressive

evolution in our methods of assessment. This evolution is, in

turn, based on progress in our understanding of the complexities

of the various addictions, of the heterogeneity of the populations

seeking treatment, and on a willingness to subject the data

obtained to ever more sophisticated analyses. Progress is also

based on a farsighted NIDA policy that continues to support

treatment evaluation as a priority rather than an afterthought.

13
Having said that there are no dramatic breakthroughs, let me now

make it clear that there have been some very significant advances

in the state of our knowledge. After more than 20 years of

systematic data collection, and after at least 10 years during

which the treatment systems for drug abusers have been relatively

stable, we are able to make some definitive statements about the

long-term effectiveness of various treatments for opioid abuse and

dependence. There are now ample data describing the probable

short-term impact of various generic types of treatment (i.e.,

methadone maintenance, therapeutic communities, short-term detoxification, and drug-free programs) on typical urban heroin

users. In general, the prognosis is far better than any one would

have predicted in the early 1970s. We can state with some

reasonable level of predictability how various background

(demographic) characteristics of the patients (or clients) will

influence the outcome at various pints in time over the first

year or two after contact with a treatment program. Not surprisingly, having a more stable family background, an intact

marriage, a job, and a history of minimal criminality predicts a

better outcome in most programs. Those with the highest levels of

criminality prior to seeking treatment continue to represent a

challenge to our capacity to alter behavior. We can make some

general statements about the value of vocational rehabilitation

efforts and other special social interventions. Over the short

run, special programs and supported work do result in more addicts

engaged in gainful activity. Over the long term, however, the

differences between controls and those offered such services

Shrink to levels where the economic value of such programs becomes

questionable, especially during times when so many people are unemployed. Having employment specialists at clinics appears to

have some positive impact on retention rates, suggesting that such

rates can be modified by changes in program content, but this

apparently has little impact on actual employment rates (see NIDA

1982).

We also have data fran studies which follow patients over long

periods after entry into a treatment system (Simpson, this volume;

Stimson and Oppenheimer 1982; Maddux and Desmond 1980; McGlothlin

and Anglin 1981b; Vaillant 1978). These studies are generally

concordant in presenting the natural history of a syndrome which

is far less incurable and unremitting than was believed as

recently as the 1960s, but is still more than sufficiently

criminogenic and lethal to justify society’s efforts to intervene

and to treat it.

For certain kinds of treatment: such as methadone maintenance, our

statements can be even more refined, and we can make general

statements while patients are in treatment about the relative

impact of varying program parameters, such as urine testing,

dosage, and take home privileges, on retention and outcome.

Additionally, we now recognize that the program and patient

factors which contribute to retention of patients in treatment are

not necessarily those which predict adjustment in the years after

leaving treatment. These general findings, along with the medical

tradeoffs involved in methadone treatment, have been summarized in

14
a recent NIDA monograph (Cooper et al. 1983). There now appears to

be a general consensus on the limited value of either outpatient

or inpatient detoxification for those addicted to opioids. For

most types of programs, we can now describe in a general way the

relationship of time spent in treatment to outcome over the next

year. We can even offer some cost benefit analysis of the value

of providing treatment compared to alternative social policies

(McGlothlin and Anglin 1981a,b).

To be able to make such statements is a significant achievement.

Yet, we are dissatisfied. We recognize that the relationships we

have found to date between patient characteristics and outcome,

while reliable, often account for only a small part of the

variance, and that in any given Case it is still not certain just

what treatment, if any, would produce the best outcome for a given

patient (see Rounsaville et al. 1982b; McLellan 1983). Equally

important, we now recognize that a significant proportion of those

seeking treatment do not stay in treatment for more than a few

weeks; that for some individuals, especially those with high

criminality and high psychopathology, treatment generally is of

limited benefit. More recently it has been suggested that some

programs are "toxic" for some patients (see McLellan et al. 1983;

O'Brien et al., this volume).

About 5 to l0 years ago, a number of researchers hypothesized that

a likely reason for our relative inability to predict treatment

outcome was our failure to measure all the relevant variables and

our tendency to analyze the data collected using one background

variable at a time, rather than using more complex, but more

appropriate, multivariate analyses. These shortcomings are being

remdied in more recent evaluations of treatment, and these

improved measures (especially of psychopathology) and more

sophisticated analytical techniques represent the major achievement of the past 5 years.

Let me offer a few examples. Recent studies have gathered

information on patients seeking treatment that goes far beyond the

demographic and drug use histories that were the major data

elements of earlier efforts. Several groups have done detailed

investigations of psychiatric symptoms and diagnoses among

patients seeking treatment. Kleber, Rounsaville, Weissman, and

their colleagues in New Haven have documented that, in addition to

drug dependence, the majority of opioid addicts seeking treatment

have other psychiatric disorders that met currently accepted

diagnostic criteria. Among the more common diagnostic entities

identified were major depressive disorders, antisocial personality, and alcoholism (Rounsaville et al. 1982d). McLellan,

O'Brien, Luborsky, Woody and their coworkers in Philadelphia have

found a very similar spectrum of formal diagnoses among veterans

with drug and alcohol problems. They have also reported that the

severity of psychological problems taken as a whole is a powerful

predictor of several outcome criteria, such as illicit drug use,

criminal activity, social productivity, and psychological adjustment, when these are measured 6 months after entry into treatment.

Furthermore, the Philadelphia group finds, as have others, that

15
these traditional dimensions of change are relatively independent

and are best predicted by past behavior on that specific dimension

(McLellan et al. 1983). More significant for our concerns about

evaluating treatment are the Philadelphia group's findings using

mulltivariate analyses of relationships among patient characteristics at intake and outcome at 6 months after entry. The broad

generalization from the early analyses of large-scale multicenter

studies such as Drug Abuse Report Program (DARP), was that

opioid-dependent patients do about equally well (on a composite

measure of overall outsome) whether they enter a therapeutic

community, a methadone maintenance program, or a drug-free outpatient program. The DARP study did not attempt to assess

severity of psychological problems or psychiatric diagnoses. The

work of McLellan and coworkers suggests that these conclusions

fran the DARP study must now be qualified and that some

opioid-dependent patients, particularly those with severe psychological problems, do quite poorly when placed in the confrontational milieu of a therapeutic community and do significantly

better in a methadone maintenance program. To what degree the

better outcome is related to the pharmacological effects of

methadone or the less demanding treatment environment is not yet

clear. An additional finding is that those patients with fewest

and least severe psychological problems did quite well in all

treatment programs while those with the most problems did poorly

in all. In the light of this work, it seems likely that the older

findings on the effectiveness of treatment, most of which did not

assess psychopathology or its severity, may have to be reevaluated.

WHY DID IT TAKE SO LONG TO FIND AN EFFECT OF PSYCHOPATHOLOGY ON

OUTCOME OF TREATMENT?

Those not familiar with the evolution of science and medicine may

well wonder why the kind of work just described was not done

sooner. Why was it necessary to spend millions of dollars on the

evaluation of treatment only to find that much of the work now may

need to be redone or, at the least, reassessed? Since policymakers may raise this question, we should be prepared to explain

why those studies were appropriate for their time, and why they

remain as important contributions. We should also explain that

even as we move to new levels of sophistication we can already see

the areas where further work will be required.

As the effort to evaluate treatment has evolved, the fundamental

questions have always been the same. What are the relevant

variables about patients, treatments, and environments that we

need to measure, how can they be measured reliably, and what conceptual and analytic frameworks are best suited to understanding

the relationships among the variables?

Even in the 19th century, researchers recognized the heterogeneity

of opiate users and postulated that treatments and outcomes might

be very different depending on who was using the drugs and for

what reasons (see Terry and Pellens 1928). Yet, it seems to have

taken almost 100 years to follow up on these early simple observations. Before offering some of the reasons why the recent

16
findings on the effects of psychopathology did not emerge 10 or 15

years ago, I should note that Kolb (1962) did report considerable

diagnostic heterogeneity among the addicts seen in the 1920s, and

there is an extensive literature on personality testing and psychopathology among addicts that dates back more than 40 years

(Sutker and Archer 1983) . Most of this work was directed toward

understanding the etiology of drug dependence rather than

accounting for differences in response to treatment. Indeed, the

few recent studies which suggested that retention in treatment or

outcome could be predicted from psychological testing or from

typologies derived from cluster analyses of patient characteristics were largely ignored.

It is fair to say that for a long time it seemed that understanding the psychodynamics of an individual in a specific situation was more important than reaching agreement on what specific

diagnostic category best matched the individual‘s symptoms and

history. Formal diagnosis was not viewed as an overwhelmingly

important issue. American psychiatry emerged fully from that era

only in the early 1970s. It would take us too far from our topic

to review the factors that brought about the deemphasis of

psychoanalytic theory and the reemergence of a descriptive phenomenologically oriented nomenclature. Suffice it to say that the

shift in emphasis permitted a revision of the American Psychiatric

Association’s Diagnostic and Statistical Manual (DSM-III) which

provided specific diagnostic criteria for each of the mental disorders. DSM-III was issued in draft form in 1978 and became

official in 1980.

Even prior to the publication of DSM-III, however, there were

research criteria for making diagnoses that could have been used

to attempt to measure psychopathology and psychiatric diagnoses

among drug abusers. Other factors retarded the measurement of

such psychopathology. I will describe a few of these factors as I

perceived them over the decade fran 1968 to 1978.

The therapeutic communities built on the model of Synanon had

developed an anti-medical, if not a broadly anti-intellectual,

attitude from their beginnings. They were pleased when outsiders

lauded their successes, but for the most part they did not look

kindly on detailed analysis of outcome. In general, they kept

minimal records, especially any that might suggest a psychiatric

orientation. It is remotely possible that more attention to a

thorough diagnostic evaluation of drug users seeking treatment

would have led to such programs being redefined as medical

facilities, with all the detailed regulation and malpractice

exposure that such a redefinition might entail. However, I doubt

if such concerns played a role in their early resistance to

evaluation. In fact, some therapeutic community programs began

using psychological testing and psychiatric evaluations more than

a decade ago, but, for a variety of reasons, the findings were

rarely utilized.

Neither were the early methadone programs overly enthusiastic

about systematic psychiatric evaluations. In part, this was

17
because sane early proponents emphasized that addicts were

psychologically normal but for their abnormal drug hunger (Dole

and Nyswander 1968). Also contributing to the lack of interest

was the then current psychiatric nomenclature which seemed to be

of little value in predicting who would respond to methadone

maintenance. Lastly, psychiatrically trained personnel were

exceedingly scarce during the rapid expansion phase of these

programs (1966-1974).

Similarly, drug-free programs were often operated by nonprofessionals who, if not antagonistic toward medically trained

personnel, often seemed threatened by researchers and evaluators.

It is also possible that many program directors came. to accept as

proven what was originally only a hypothesis: that drug dependence

causes the other problems (social and psychological) commonly

found among drug addicts. If one believes that all problems show

startling improvement when drug-related problems are successfully

controlled, then it is unnecessary to attempt to measure those

other variables, especially if drug use is easier to measure. The

advent of inexpensive urine tests that provided an objective

measure of drug use may have had the effect of devaluing the

"softer" measures of interpersonal and psychological functioning.

In any event, adding detailed psychological assessment to the

other measures would have substantially escalated the costs of

treatment evaluation.

Thus, there were at least five major factors militating against

the incorporation of an additional dimension of formal psychopathology into the assessments of treatment: (1) the lack of

agreed-upon criteria for categorizing and assessing psychopathology (as well as uncertainty about whether instruments

standardized on patients not dependent on drugs were appropriate

for those with drug dependence as a primary problem); (2) indifference or hostility of the largest treatment programs to such

detailed assessment; (3) shortages of trained personnel; (4) the

significant additional costs of adding these variables to the

already long list of drug-, work-, and crime-related variables

already deemed essential; and (5) previous work in which

standardized personality tests of addicts in treatment had not led

to the conclusion that such testing had clinical relevance.

Perhaps there was a sixth factor as well. Perhaps those of us

charged with conducting and funding evaluations did not believe

that measures of psychopathology were important enough to be given

priority over the other measures which, at the time, seemed more

likely to predict outcome. It is possible that an overemphasis on

the role of learning in the perpetuation of addiction contributed

to this belief.

It remains for others to provide a weighting for the various

factors that retarded work of this kind. For now it is sufficient

to note that most evaluations of drug abuse treatment, even some

of those recently published, pay scant attention to the possibility that the type and severity of psychopathology that is

associated with drug dependence and abuse may represent a major

variable that interacts with the kind of treatment provided to

18
determine long- and short-term outcome.

THE STATE OF THE ART: SOLIDIFYING ADVANCES

It is evident from this long explanation that I believe that the

renewed attention being given to the measurement of psychopathology among drug users in treatment represents a significant

recent advance, but not the only one. Each followup study of the

large multicentered evaluations, such as DARP and Treatment

Outcome Prospective Study (TOPS), has enlarged our appreciation of

the importance of monitoring behavior over time (not months, but

years) and of the need to measure outcome along several dimensions . Other recently published long-term outcome studies from

England provide additional support for this view (see Stimson and

Oppenheimer 1982). We should also count as significant advances

those studies which, without endorsing any specific programs,

meticulously demonstrate that crime rates among opioid addicts are

far higher than the rates estimated fran arrests or rap sheets,

but are substantially reduced when illicit opioid use is controlled (Ball et al. 1983). Such findings, taken together with

those studies of the impact of treatment programs on crime rates,

further underscore the potential benefits to society of more

effective treatment and interventions (Bowden et al. 1978;

McGlothlin and Anglin 1981b; Anglin and McGlothlin, this volume).

We must now turn to the central question: What is the state of

the art? We need to ask ourselves at the outset whether we are

interested in the state of the art of evaluating treatment or the

state of the art of treatment per se. If we are interested in

treatment, then we should not limit ourselves to those papers that

use the latest and most sophisticated evaluation methodologies,

but should use all available information to take the pulse of the

field. My overall impression is that with respect to the treatment of opioid dependence, the phase of expansion and rapid change

is over. Some of the excitement is gone, and some programs seem

more concerned with survival than self-improvement. For the

typical "street addict," we may now be at an ideal time to reexamine the relationship of treatment to short-term and longer

term outcome. I cannot recall a time when there has been such

stability of program content coupled with such interest and competence in measuring outcome.

The objectives of such a reexamination should include efforts to

resolve apparent inconsistencies in the extensive literature that

has evolved thus far, to learn more about the characteristics of

those who seem to do poorly in all of the available treatments,

and about the nontreatment events that facilitate recovery fran

drug dependence.

We should probably give our highest priority to further verification of the findings by several groups of workers that over the

Short term (i.e., 6 to 12 months) the several dimensions of outcane (drug use, alcoholism, general health, work, crime, social

and psychological well-being) are relatively independent. Relative independence of these dimensions implies that programs

19
directed primarily at treating drug dependence or drug abuse per

se may not have major influence on other important measures of

adjustment and social functioning. Such relative dependence of

outcome measures has been found among alcoholic and drug-dependent

veterans in Philadelphia by McLellan and coworkers (McLellan et

al. 1983), and among predominantly male nonveteran opioid users in

New Haven by Kleber, Rounsaville, Weissman and their coworkers

(Rounsaville et al., 1982b). More recent data fran the multicenter DARP program as analyzed by Simpson, Savage, Sells and

their coworkers (Simpson, this volume) are also supportive of this

finding of independence of outcome dimensions, although the

earlier DARP work often used composite scores to represent overall

outcome (Simpson and Sells 1982). Additional data from other

programs bearing on this question may already exist; it may be

unnecessary to conduct new studies. If this relative independence

is generally true for all programs, then the old question of which

programs are best suited to which patients becomes more complex.

It may be necessary to pay more attention to the components of

individual programs to learn which program elements influence

which outcome dimensions for which patients.

The most important implication of these findings may be for our

efforts to communicate with policymakers. They will continue to

ask, "Does treatment work?" They may be annoyed when they are

told that the question can no longer be put in such simple terms.

In our efforts to consolidate our advances, we should give equally

high priority to further independent verification of the clinical

utility of measuring severity of psychopathology among drug users

in treatment, as described by the Philadelphia group (McLellan et

al. 1983). In my view, there is already ample verification of the

high prevalence among drug abusers of psychiatric symptomatology

and diagnosable disorders in addition to drug dependence. It is

the clinical significance of this additional symptomatology that

needs further investigation (see below).

WHERE DO WE GO FROM HERE? - RESOLVING INCOSISTENCIES AND

FILLING GAPS

Given the heterogeneity of the programs and populations studied

and the varied methods, no one should be surprised that different

studies draw somewhat different conclusions from the data. Many

such apparent inconsistencies could be cited, but I would like to

focus on a select few.

In the studies by the Philadelphia group, severity of drug dependence per se, as measured by the Addiction Severity Index (ASI),

did not appear to be a powerful predictor of outcome of treatment

on any of the dimensions studied (McLellan et al. 1983). Although

this finding is consistent with results of a study of addicted

physicians (Morse et al. 1984), it is nevertheless disconcerting

for both theoretical and empirical reasons. From a theoretical

perspective, current views of drug dependence suggest that there

is a core syndrome of impaired control over drug use that varies

in severity along a continuum. One would predict on theoretical

20
grounds that the more severe the degree of dependence, the greater

the likelihood of relapse and the smaller the likelihood that the

individual could use the drug of dependence in moderation (see

Edwards et al. 1981). Data from the fields of alcohol and tobacco

dependence support this prediction about the severity of dependence. The DARP study also found evidence that among those who use

opioid drugs, those who were addicted (used every day) responded

quite differently to treatment from those who used less frequently

(i.e., were defined as nonaddicts.) Those not addicted had

better outcomes at followup (Simpson and Sells 1982). Opioid

addicted (i.e., using every day) vs. nonaddicted may be too

coarse adichotomy. One might expect that a finer differentiation

would have been even more revealing, although we must admit that

we do not have any idea of the shape of the theoretical curve of

severity of opioid addiction. In all likelihood, there is sane

level above which the severity curve flattens out and above which

further increases in severity do not affect outcome. We need to

look carefully at how these various studies defined severity. On

theoretical grounds, at least, we should not leave the matter

hanging or expect it to be resolved automatically by some future

megastudy.

One inconsistency may be more apparent than real. Heretofore, a

consistent finding from studies of therapeutic communities (see

DeLeon, this volume) and from the DARP multicenter study (see

Simpson, this volume) has been that time in treatment was reasonably well correlated with better outcome. The data from the more

recent TOPS multicenter study do not show pronounced

time-in-treatment effect (see Hubbard et al., this volume). The

differences may be a result of using differing time frames or

criteria for completion of treatment. We should resolve this as

soon as possible. The time-in-treatment effect may be telling us

something important about the dependence process per se.

As I have pointed out, given the consistency of the finding, there

appears to be little need to confirm that drug-dependent patients

seeking treatment have more than their expected share of psychiatric symptoms and diagnoses. But what is not clear is how these

findings impact upon participation in and response to treatment.

As I have already noted, the Philadelphia group (McLellan et al.

1978, 1983; O'Brien et al., this volume) found that severity of

psychopathology was a major predictor of outcome on several key

outcome variables. In studies of therapeutic communities,

depressive symptoms seem to predict early dropout which, in turn,

is correlated with poorer outcome on several dimensions (see

DeLeon, this volume). In contrast, Kleber, Rounsaville, Weissman,

and their coworkers in New Haven found that while depressive

symptoms were quite common among opioid addicts, these symptoms

appeared to show considerable spontaneous improvement (Rounsaville

et al. 1982c,d). Further, while those starting treatment during a

major or minor depression showed poorer response in terms of

illicit drug use and psychological symptoms, starting with such

symptoms was unrelated to work, crime, or remaining in treatment.

The New Haven group found that although the prevalence of depressive symptoms was high, the severity of the depression was not.

21
Indeed, the depressive mood did not seem to be clearly distinct

from subjects' usual mood. Further, the syndrome appeared to be

self-limiting (Rounsaville et al. 1982c). However, the recent

data from the TOPS project indicate that depressive symptoms among

drug abuse patients can be quite severe if thoughts of suicide are

considered a valid measure of severity (Craddock et al. 1982;

Hubbard et al., this volume). The literature over the past 20

years contains numerous papers suggesting that depression and

suicide are far more common among drug users than in the general

population (see Rounsaville et al. 1982c; Dorus and Senay 1980).

However, in Vaillant's longitudinal study of alcoholics, psychological symptoms tended to remit when the alcohol use ceased,

leading Vaillant to assert that alcohol use caused depression,

rather than the reverse (Vaillant and Milofsky 1982). It may be

important to do separate analyses according to the class of drugs

being used at entry into treatment. The TOPS data show a

clear-cut trend for those abusing sedatives to have higher levels

of depression than those using opioids only.

These comments on depression among opioid users are meant to be

illustrative of the well-established scientific principle that new

information leads to a few answers but to even more new questions.

Having found that psychopathology is prevalent, we must now find

to what degree it influences other dimensions of treatment outcome. The work of the Philadelphia group certainly suggests that,

as measured by the ASI, severity of psychological problems is a

major predictor of outcome along all dimensions, at least at the

6 month followup period. That work needs to be independently

confirmed. We also need to find out whether it is composite

severity that is critical, or if there is some significance to

specific diagnostic categories, such as affective disorders or

antisocial personality.

Related to the general topic of psychopathology are the unresolved

questions of whether current psyctrotherapeutic or psychopharmacological interventions can ameliorate the psychopathology present

and, if the pathology is influenced, whether the overall outcome

of treatment is thereby altered. With respect to depression, the

Philadelphia group appears to have positive findings for both

pharmacological (Woody et al. 1975) and psychological interventions (Woody et al. 1983; O'Brien et al., this volume), while the

group in New Haven finds little incremental benefit from either

(Kleber et al. 1983; Rounsaville et al. 1983). There does appear

to be a consensus that not only do patients who are diagnosed as

having antisocial personality have more psychopathology and a

poorer prognosis, but also that we have little to offer them in

the way of special intervention. To the best of my knowledge,

there are no effective treatments for antisocial personality.

Given the prevalence with which the diagnosis is made and the

negative implications for treatment outcome associated with antisocial behaviors, the absence of any promising approach represents

a significant gap. In sum, there is consensus that psychopathology is common, but whether we can influence its course or

whether doing so alters either short-term or long-term outcome

22
remains to be determined.

In a similar vein, I find myself puzzled by the inconsistent

findings on prognostic significance of alcohol abuse among

patients treated for drug dependence. Most studies have suggested

that patients who use alcohol excessively while in treatment for

other drug abuse problems have higher degrees of psychopathology,

tend to drop out of treatment, and have a relatively poorer prognosis (Green and Jaffe 1977). However, recent findings from the

group in New Haven show that such patients, despite having fewer

psychological assests and more liabilities, do about as well as

other patients when assessed 6 months after entry into treatment

(see Rounsaville et al. 1982e). Other groups have recently

reached similar conclusions about retention of alcoholics in

treatment (Stimmel et al. 1983). Given the frequency with which

the problem of alcoholism is encountered among opioid users, some

further clarification would be welcome.

I am particularly perplexed by our seeming inability to reach

consensus on the importance of dosage levels in the outcome of

treatment in methadone programs, but since the most recent NIDA

Treatment Research Monograph volume has been devoted to this

question (see Cooper et al. 1983), I will not elaborate further on

this point. For the same reason, I will simply note that I am

similarly perplexed by the finding that, at long-term followup,

those treated in methadone programs in New York do significantly

worse in terms of return to opioid use (see Des Jarlais et al.

1981) than do opioid addicts treated in other parts of the United

States (see Simpson, this volume; Hubbard et al., this volume) or

in England (Stimson and Oppenheimer 1982).

OTHER PERSISTENT GAPS

There are some areas where inconsistent data would be an improvement. Despite the fascinating studies that have emerged over the

past decade suggesting that there may be several genetically

transmitted types of vulnerability for alcoholism, most efforts to

evaluate drug abuse programs do not include detailed family histories of alcoholism, drug abuse, criminality, or mental illness.

Family studies (i.e., direct interviews of family members) are

rarely linked with treatment evaluation. Some of the work of

Bohman, Cloninger, and coworkers (Bohman et al. 1981, 1982)

suggests that for some forms of genetic vulnerability for alcoholism (especially that associated with having a father with severe

alcoholism and criminality), the risk of developing alcoholism in

the male offspring is increased about nine-fold, and that adoption

at an early age into a nonalcoholic family does little to lower the

risk. I think it would be useful to study family drug use histories of patients in treatment to determine whether such familial

factors influence treatment outcome. To gather such information

may not require entirely new studies. Since family history does

not change much over time, ongoing evaluations might fill in such

gaps in the baseline data during followup interviews.

There are additional areas where the tasks of evaluation are incomplete, and I will mention only a few. Despite such landmark

studies as those of O'Donnell (1969), Stimson and Oppenheimer

23
(1982), Vaillant (1978), Nurco et al. (1975), and Maddux and

Desmond (1980), we still need to know more about the long-term

natural history of the opioid dependence syndrome. In the DARP

studies, which followed a relatively recent cohort of opioid users,

each year following treatment the number of opioid addicts indicating illicit opioid use, non-opioid drug use, and arrests seemed

to go down, and the number working seemed to go up. That this was

not a tendency to minimize problems is suggested by the finding

that heavy alcohol use stayed about the same or increased (see

Simpson, this volume; Simpson et al. 1982). A tendency to improve

over time, although not quite so marked in degree, has been seen

among heroin users treated in London (see Stimson and Oppenheimer

1982). What are the pathways out of opioid addiction? Is this

general improvement across groups originally treated in different

programs a reflection of a general tendency for all symptoms to

remit? Is the improvement an artifact due to selective attrition of

those addicts with the poorest prognosis? How significant a factor

is readmission to other programs? Is improvement over the long

term a function of the degree of psychiatric impairment or diagnosis, or is it a matter of chance factors? In his work on alcoholics, Vaillant suggests that finding a caring new spouse, a

better job, Alcoholics Anonymous or renewal of faith are important

events (Vaillant and Milofsky 1982). Maddux and Desmond (1982),

studying opiate addicts in Texas, suggest that moving away from the

area where addiction developed was associated with improvement. If

there is any way our followup studies can contribute to an understanding of the process of gradual improvement among contemporary

cohorts of drug users, we should make the effort to gather the data

and conduct the analyses.

The last area I will mention is the relative paucity of information

on the non-opioid drug user. We should acknowledge from the outset

that MDA-supported treatment programs may not be seeing a representative cross-section of the individuals dependent on non-opioid

drugs. Historically, in the United States, treatment for dependence on amphetamines, sedatives and alcohol was the responsibility

of State and local governments and of the private sector. Patients

dependent on these drugs were not even eligible for treatment at

the U.S. Public Health Service hospitals at Lexington or Ft. Worth,

but they had little trouble obtaining treatment in State or private

facilites (assuming they could afford the latter.) When NIDA

opened its treatment programs to patients with these problems, the

programs were already characterized as programs for the "street

users" and, for the most part, the more conventional drug-dependent

patients found treatment elsewhere. Allowing for this fact, however, it is still vexing that we know so little about the natural

history of these patients and of their response to treatment. It

is all the more vexing because the number of patients seeking

treatment for cocaine dependence and marijuana dependence is

growing rapidly, not only in publicly supported programs, but in

the private sector as well.

Brown's review (in press) of the treatment of non-opioid dependence

is a comprehensive summary of the state of our knowledge, but that

knowledge is disturbingly incomplete and has even more inconsistencies than are found in the literature on opioid use. In

24
general, Brown's review needs to be amplified with some effort to

determine what proportion of the population with non-opioid drug

problems is seen by the "treatment system." It is my general impression that, to a very considerable degree, most non-opioid drug

users are to be found in the population of patients seen at the

offices of general practitioners, internists, mental hygiene

clinics, and alcoholism programs. Thus, it may be that the group

with whom the "drug abuse evaluation system" has the most experience is the smallest part of the population with non-opioid

problems. To the degree that certain categories of antecedent

psychopathology (i.e., antisocial personality) are major determinants of both treatment response and longer term outcome, the

prognosis for these "straight" patients may be considerably better

than for those patients for whom non-opioid drug use is but one

element of a more deviant lifestyle.

Related to this issue of non-opioid use are questions of the longer

term biological consequences of drug use and abuse over the years.

There is now a rapidly growing literature indicating that excessive

alcohol consumption may be associated with altered brain structure

and decreased performance on tests of cognitive ability. Some

workers have suggested that such cognitive impairment may adversely

affect the ability to benefit from therapy that requires retention

of verbal material. There is some data suggesting similar deficits

among barbiturate-sedative users, in contrast to the relative lack

of such findings among opioid users (see Rounsaville et al. 1982a).

Alcoholism and non-opioid abuse are problems for a high proportion

of patients in NIDA-supported programs. Eventually we will want to

know to what degree depressive symptomatology so common among drug

abusers, particularly non-opioid drug users, is related to

drug-induced anatomical or functional change, and to what degree

such changes influence participation in and outcome of treatment

and the longer term natural history. I do not underestimate the

costs of such efforts, but I do not believe that large scale

studies are required to study this question.

One last comment seems to be in order. Because NIDA was once the

major source of support for treatment, there may be a tendency to

see as its responsibility the evaluation of the programs or types

of programs it once supported. I would argue, however, that NIDA's

role should be the advancement of knowledge about the treatment

process regardless of the source of support for that treatment.

Every researcher, if asked, can prepare a long list of recommendations and can extend a wish list of studies that ought to be done

ad infinitum. Given the time and space. available, my list ends here.

25

215-494 0-88-2: QL 3
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AUTHOR

Jerome H. Jaffe, M.D.

Department of Psychiatry

University of Connecticut Medical School

Farmington, Connecticut 06032

Veterans Administration Medical Center

Newington, Connecticut 06111

28
National Treatment System Evaluation Based on the Drug Abuse

Reporting Program (DARP)

Followup Research

D. Dwayne Simpson, Ph.D.

The Drug Abuse Reporting Program (DARP) was established in 1969 as

a nationally oriented data system for the evaluation of communitybased treatment services (Sells 1975; Simpson 1983). It began with

the Federal funding of drug abuse treatment service components

(primarily for heroin addiction) in six community mental health

centers located across the United States, but it soon expanded to

include a wide variety of treatment settings and approaches for

drug abuse. Standardized data collection instruments for admission

and bimonthly during-program progress reports were developed and

later used to describe almost 44,000 clients in 52 different

agencies from 1969 to 1974. Major treatment modalities included

methadone maintenance (MM), therapeutic communities (TC),

outpatient drug-free programs (DF), and detoxification (DT).

During-treatment research, using a multiple cohort design, focused

on classification of treatment types and patient types, development

of outcome criterion scores, treatment retention and performance

evaluations, effects of community context on outcomes, and other

issues. Results of these studies have been reported in a

five-volume series of books (Sells 1974; Sells and Simpson 1976),

in a databook of descriptive tabulations (Simpson et al. 1976), and

in professional journals and NIDA Treatment Research Reports.

In 1974, the DARP posttreatment follow-up research phase began,

again using a multiple cohort design, to study outcomes associated

with various drug abuse treatment strategies and client

characteristics. A total of 6,462 clients in three separate DARP

admission cohorts were selected for follow-up from 34 treatment

agencies. These clients represented the four major treatment

modalities of MM, TC, DF, and outpatient DT; in addition, a

comparison group of intake only (IO) clients was included fran

persons who were formally admitted but who never returned to

receive treatment in the DARP agencies. Sample selection

procedures were stratified to insure adequate representation for

analytic purposes with regard to age, race-ethnicity, sex,

treatment type, length of time spent in treatment, and geographic

location of programs. Altogether, 83% (N=5,340) of this sample

were located; 73% were interviewed after granting informed consent,

5% were deceased, 1% were out of the country (mainly due to

29
military service), and 4% used their right to refuse the interview.

The other 17% could not be located. The fieldwork for the

follow-up studies was carried out under the direction of the

National Opinion Research Center.

The major focus of the studies in the 6-year DARP follow-up

research phase has been on treatment outcomes, as summarized in

overview papers by Sells and Simpson (1980) and Simpson and Sells

(1982a,b). These studies have used a variety of multivariate

analytic strategies and independent treatment samples for

replicating research findings, based on the first year, and 3 years

following DARP treatment. In addition, this research series has

also addressed related issues such as client satisfaction with DARP

treatment services, use of other types of community services needed

and received, leisure time activities, alcohol consumption,

covariations of drug use with employment and criminal activities

over a 3-to 4-year time period after DARP, effects of family and

other social relationships on posttreatment outcomes, and

long-range follow-up outcomes. (A bibliography to these papers can

be found in Simpson and Sells 1982.a.)

Currently, the DARP research is being extended to study follow-up

outcomes 12 years after entry into DARP treatment for 697 heroin

addicts who were admitted to treatment from 1969 to 1972 (and who

were also interviewed in the 6-year follow-up study). By the time

of this follow-up interview, at least 14 years will have passed

since most of the respondents first began daily use of opiate

drugs. In addition to the obvious questions about the current

status of these former addicts and the permanence of abstinence

reported in the 6-year follow-up interviews, factors involved in

the initiation, maintenance, and cessation of addiction cycles will

be addressed.

MAJOR RESULTS OF THE DARP RESEARCH PROGRAM

The original purpose of the DARP was to serve the treatment

evaluation needs of a new federally supported service delivery

system. However, the evaluation goals, procedures, and outcome

criteria were unspecified, and there were no standards or

comprehensive models for establishing a large-scale, field-based,

drug abuse treatment evaluation system. Thus, the early years of

the DARP research, reported in Sells (1974) and Sells and Simpson

(1976), dealt with fundamental issues such as criterion development

and measurement, as well as treatment definition and

classification. This work also served to describe a substantial

segment of the national drug abuse treatment clientele during the

early 1970s, and it documented some of the changes in the

treatment clientele over this time. This was an important

conceptual phase for the long-range evaluation goals for the DARP,

but the major results of the DARP research project have been based

on the posttreatment follow-up studies of treatment outcomes.

30
Treatment Effectiveness

The results of the various studies of client outcomes after DARP

treatment, are illustrated in Figure 1 (see Sells et al. 1979 and

Simpson et al. 1978a, 1979, 1980). The DARP research has included

opioid as well as nonopioid users, but most of the results

reported in this paper will center on black and white male opioid

addicts. This is the best represented subsample and it can be used

most effectively to illustrate the major treatment outcome

findings.

Since there frequently are differences of opinion on what

constitute reasonable treatment outcome expectations for opioid

addicts, two different outcome standards for the first year

post-DARP are represented in Figure 1: (1) highly favorable

outcomes are defined as no use of illicit drugs (except for

less-than-daily marijuana use) and no arrests-or incarcerations in

any 1 or more months during the year; (2) moderately favorable

outcomes are defined as no daily use of illicit drugs and no major

criminality (i.e., no more than 30 days collectively in jail or

prison, and no arrests for crimes against persons or crimes of

profit). These simplified outcome standards emphasize the major

criteria of drug use and criminal activity, and they accurately

reflect the DARP findings from other studies based on more complex

and sophisticated, empirically determined canposite outcome?

measures (with time-at-risk adjustments) which also take into

account employment, alcohol use, and return to treatment.

Comparable subsamples of black and white males (N=2,099), from all

admission cohorts in the follow-up studies, are included in the

tabulations for Figure 1.

The data demonstrate the consistent DARP research finding that

the most favorable outcomes were associated with the major

treatment modalities of MM, TC, and DF; the DT and IO groups had

significantly poorer outcomes. This same pattern of results was

found using various strategies for statistically controlling and

adjusting outcome measures with respect to client characteristics

(since clients were not randomly assigned to treatments). It was

also found that canposite outcome differences between MM, TC, and

DF treatments were not statistically significant; this finding will

be discussed in more detail later.

Prediction of Individual Client Outcomes

In addition to the between-group comparisons of treatment outcomes,

the DARP research has included studies of variables associated with

individual client outcomes within each treatment. Results based on

stepwise regression analyses have captured the primary thrust of

these findings (Simpson et al. 1978a, 1979, 1980) using client

admission and during-treatment data as predictor variables.

Analyses of individual outcome criteria showed that their

respective preadmission baseline and during-treatment measures were

generally related to posttreatment outcomes: for example. a poor

employment history before and during treatment was predictive of

unemployment after treatment. The most consistent and significant

predictors of composite outcome measures, however, were criminal

3 1
FIGURE 1. Highly favorable and moderately favorable outcomes in

the first year after DARP treatment for black and white male opioid

addicts in each DARP treatment group.

32
history and during-treatment performance; higher rates of

preadmission arrests and incarcerations were related to poorer

posttreatment outcomes, and, as expected, higher rates of criminal

activity, drug use, and unemployment during treatment in the DARP

were related to poorer posttreatment outcomes. During-treatment

performance and the length of time spent in treatment were

particularly significant predictors of outcomes. Figure 2

illustrates the relationship of tenure to the highly favorable

outcome standard defined earlier -- that is, no drug use and no

criminality (as indicated by no arrests or incarcerations). In

sane cases, up to about one-third of the variance in composite

outcome scores for individuals in the separate treatment groups was

accounted for by these predictor variables.

The association between treatment tenure and outcomes represents an

important link in the evidence for drug abuse treatment

effectiveness. Not only did the clients who remained longer in

treatment have the most favorable outcomes, but the short-term

(i.e., less than 90 days in treatment) clients in MM, TC, and DF

reported outcomes that were no different fran those of the DT and

IO clients. Furthermore, the relationships between tenure (beyond

90 days) and posttreatment outcomes in the MM, TC, and DF groups

were linear (see Simpson 1981).

These results suggest two things. First, and most obviously,

treatments which last less than about 90 days appear to be of

limited benefit, regardless of the type of treatment involved.

Beyond 90 days, however, treatment outcomes improve in direct

proportion to the length of time spent in treatment. The second

point is methodological in nature. Specifically, the lack of

significant differences between outcomes for short-term clients in

the five DARP treatment groups contraindicates any widespread

sampling bias that would have given preference to any given

treatment group in the client assignment process.

Treatments During the Post-DARP Follow-up Period

Treatments which occurred during the post-DARP follow-up period

have also been found to be associated with significant improvements

in client outcomes, and these outcomes became more favorable as the

length of the treatment contact increased (Simpson 1981, Simpson

and Savage 1980). Thus, some of the major findings associated with

DARP treatment were replicated by those from the post-DARP

treatments.

Detailed inspection and classification of long-term outcomes

throughout the entire follow-up period (i.e., ranging up to 6

years, depending on the time spent in DARP treatment) provided an

alternative method of examining treatment effects in the DARP data

base (Simpson et al. 1982). This study (based on the follow-up

sample for the 1972-73 admission cohort) showed that 61% of black

and white male addicts had achieved abstinence from opioid drugs

for the last 1 or more years before the follow-up interview. Table

1 indicates that 19% became abstinent immediately after DARP

treatment, and another 42% became abstinent later in the follow-up

period. A total of 21% continued opioid addiction throughout the

33
FIGURE 2. Highly favorable outcomes (no drug use and no criminality)

in the first year after DARP treatment by length of time spent in MM,

TC and DF treatments for black and white male opioid addicts.

34
TABLE 1

Classification of 6-Year Followup Outcomes

of Black and White Male Addicts

Outcome Patterns

Total % of

Number Total

IMMEDIATE OPIOID ABSTINENCE --

a. Without further treatment

b. With continuous treatment

DELAYED OPIOID ABSTINENCE --

180 18

5 1

c. After further treatment 134 14

d. After jail/prison 54 5

e. After treatment and jail/prison 35 3

f. With continuous treatment 119 12

g. Without treatment or jail/prison 81 8

HEAVY AND SUSTAINED OPIOID USE --

h. Without treatment or jail/prison

i. With long-term treatment

j. With short-term treatment or jail/prison

SPECIAL PROBLEMS --

k. Heavy alcohol use

1. Heavy non-opioid use

m. Continuous jail/prison

n. Periodic opioid use

o. Abstinence to relapse

TOTAL

36

47

115

45

33

51

35

20

990

4

5

12

5

3

5

3

2

100

35
follow-up period, while the last 18% had other special problems

(such as alcohol or heavy non-opioid drug use, prolonged

incarceration, or periodic relapse to heavy opioid use). Of the

clients who achieved abstinence, about 75% reportedly terminated

opioid use during DARP or a post-DARP treatment episode (i.e.,

outcome patterns a, b, c, e, and f).

IMPLICATIONS OF RESULTS

There is still an unfortunate but widespread popular belief that

drug abuse treatment is a failure and waste of public funds. The

DARP research project, and other studies reported in this volume,

however, provide convincing evidence for the effectiveness of drug

abuse treatment.

The DARP work reported in this paper has focused on treatment

evaluation, although other issues dealing with drug use, crime,

employment, death rates and causes of death, and so on have also

been studied (see Simpson and Sells 1982a). The DARP has

contributed methodologically in identifying and developing

posttreatment outcome evaluation criteria, as well as in exploring

alternative analytic strategies for dealing with evaluation issues

in applied settings. Seminal work on classification of drug abuse

treatment and patient types has been carried out, and the

posttreatment follow-up phase of the DARP research, which began in

1974, has demonstrated the feasibility of conducting such studies

-- including a sufficiently high canpletion rate in relocating

community-based drug abuse treatment samples (e.g., 83%).

The DARP results on treabnent evaluation suggest that drug abuse

treatment should continue for at least 3 months in order to achieve

positive effects; this is also consistent with studies of

therapeutic commnunity programs reported by De Leon (this volume).

Beyond that, posttreabnent outcomes tend to improve in proportion

to the length of time spent in treatment. This relationship was

also found to be consistent across opioid addict and non-addict

client subsamples, as well as across the major treatment groups,

MM, TC, and DF. Follow-up outcomes for addicts in the DT and IO

samples were significantly poorer than for those in MM, TC, and DF,

but it is important to add that the outcomes of short-term (i.e.,

less than 90 day) MM, TC, and DF treatment clients were not

different fran the DT and IO clients; all of these particular

clients received little or no treatment while in the DARP.

Approximately 60% of the DARP follow-up sample of opioid addicts

re-entered some type of drug abuse treatment within the first 4

years after leaving DARP; readmission rates within the first year

were 32% for TC, 33% for DF, 38% for MM, 40% for DT, and 43% for IO

groups (Simpson and Sells 1982a). Since each treatment readmission

reflects unsolved problems with continued drug use, this can be

considered a negative outcome with respect to DARP treatment. At

the same time, readmission to other treatments after DARP generally

leads to improvements on client behaviors -- which serves to

confound long-term evaluation efforts for DARP treatment. In other

words, effective post-DARP treatments (as well as other positive

relationships and life events) are combined with DARP treatments in

36
influencing follow-up outcomes. Indeed, this positive relationship

between treatment readmissions and outcome improvements in the

post-DARP follow-up period is documented by Simpson and Savage

(1980). Its collective influence over time is also illustrated by

a reduction in differences between DARP treatment group outcomes

measured in the last year of the follow-up period, compared to the

first year immediately after treatment (see Bracy and Simpson 1983,

and Simpson et al. 1982). Thus, long follow-up measurement periods

are especially sensitive to these uncontrolled influences, and

posttreatment follow-up studies should adopt measurement strategies

with this in mind.

Although some client characteristics (such as criminal history)

were related to posttreatment outcomes, the relationships were

generally weak, and they provided poorer outcome prediction than

the treatment performance measures (including tenure and

satisfactory completion of treatment). This result was elaborated

in a study designed to investigate categories of similar clients --

defined using sociodemographic as well as criterion-relevant

background and baseline measures -- and their relationship to

treatments (Simpson and Savage 1982). Multiple discriminant and

classification analysis yielded a set of empirically determined

client types, which were then examined with respect to treatment

types (defined on the basis of program goals, policies, and

procedures for treatment, as summarized by Cole and James 1975).

Comparisons of the posttreatment outcome criteria showed that there

was no optimal match between these client types and treatment

types.

Unfortunately, the lack of outcome differences between the MM, TC,

and DF treatment modalities, as well as between the treatment type

classifications within these modalities, provides little guidance

for identifying significant dimensions of the treatment process.

There is considerable variation between treatments, in terms of

goals, service procedures, and client expectations, but each

treatment appears to be effective in improving outcomes of its

clients. Thus, it may be the amount of treatment contact (as

reflected generally by tenure in treatment), and not so much the

type of therapeutic approach, that is important. Retention in

treatment also implies a client "treatability" factor, composed in

part by motivation and determination to change behavior. Another

consideration is the drug abuser's readiness to enter and

participate in treatment, as opposed to involuntary treatment,

usually associated with legal action or other pressures.

Preliminary data now being collected in the DARP 12-year follow-up

of heroin addicts indeed suggests that, in addition to the

prominent role that treatment plays, a personal commitment to

change after "hitting bottom," or becoming "tired of the life,"

marked the majority of recoveries from addiction. The same sort of

personal evaluation and commitment to change has been reported by

Waldorf and Biernacki (1981) in conjunction with recovered heroin

addicts who were never in formal treatment programs.

37
The importance of personal commitment to treatment for drug abuse

can hardly be denied. Nevertheless, the objective and reliable

measurement of such commitment has been met with only limited

success, probably because it represents a multidimensional and

dynamic process; a person may resolve either before or during

treatment to terminate drug use, but a personal commitment must

then be sustained, strengthened, and converted to action. Support

and guidance in this process can be seen as a major responsibility

of the treatment program counselor, and Janis (1983) has recently

discussed research on counseling procedures in dealing with such

problem behaviors. However, support for changing drug use and

other problem behaviors does not necessarily reside exclusively

with a treatment counselor; instead, it may come from family,

friends, or other social therapeutic support agents. Thus,

treatment serves as an important setting which is conducive to

client behavioral changes, but it is not necessarily the sole

causal agent.

The DARP data have not discriminated between the major modalities

of MM, TC, and DF in terms of effectiveness based on follow-up

outcomes, but it would be inappropriate to conclude that treatment

approach can be disregarded. Studies on the classification of

treatment types have documented variations in goals, policies,

procedures, etc., and these treatment differences address

differences in client needs. For instance, methadone maintenance

frequently deals with older addicts with longer histories of opioid

use and criminal involvement, and the treatment strategy is

designed to deal with these historically entrenched behavioral

Patterns in separate stages. Theoretically, drug procurement

activities are first removed through chemical maintenance, while

the therapeutic attention is devoted to developing and supporting

client commitment to behavioral change; only later are the

physiological aspects of addiction and withdrawal confronted.

Drug-free therapies (especially in therapeutic communities), on the

other hand, deal simultaneously with drug use withdrawal and

resocialization. To be effective, this form of therapy (especially

when used for opioid addicts) may require a greater initial level

of personal commitment for behavioral change than is necessary in

most methadone maintenance programs. In spite of the evidence that

they generally have limited posttreatment effects, even

detoxification programs can be argued to be beneficial as a stopgap

service that helps address acute drug use problems. At the same

time, the DT treatment group in the DARP research had the highest

percentage of clients who later returned to treatment (usually MM

programs), which suggests that detoxification efforts may help

facilitate later entries into more canplete treatments.

This more demanding requirement for client commitment may also

account in part for the relatively high early drop-out rate for

drug-free therapies. For example, 14% of MM clients left treatment

in the first 90 days, compared to 49% of TC clients (including 17%

in the first 15 days), and 43% of DF clients (Simpson et al. 1978b,

p.48). Similar differences are also reported on more recent

treatment samples in the Client Oriented Data Acquisition process

(CODAP) and the Treatment Outcome Prospective Study (TOPS).

38
CONCLUSIONS

The DARP and other treatment evaluation studies have shown that

positive behavioral outcomes are associated with treatment.

However, we still do not know why. It is suggested that three

basic factors are involved, and they should serve as the basis for

further research.

First, it is reasonable to expect that a drug abuse treatment

client should commit to changing his or her life in order to

benefit from the treatment experience. This decision does not

necessarily have to be firmly resolved at the time of entry into

treatment, but a commitment has to be made soon thereafter. In

other words, a medical model that implies that the "medicine will

heal" does not apply -- the client must accept responsibility.

Second, successful treatment requires that counselors establish

rapport with and influence over their clients. The essence of this

relationship is that the client's decision to change is made,

sustained, and translated into action. It requires guidance and

support fran the counselor, as well as a firm stand on what

constitutes acceptable behavior. Different treatment modalities

and programs may vary in the time schedule required for this

sequence of actions, but the basic therapeutic process may in fact

be very similar in all forms of effective treatment. We need to

examine that possibility; indeed, the lack of outcome differences

between the DARP MM, TC, and DF treatment types seems consistent

with this idea.

Third, the client must remain in the therapeutic relationship for a

sufficient period of time in order to benefit from the treatment

experience.

This simple framework for characterizing the therapeutic process

helps to emphasize several familiar evaluation issues. For

instance, we need to know the client's psychological and behavioral

status at intake; this includes background measures such as drug

use and criminal involvement, as well as improved assessments of

ecological considerations, perceived pressures, and motivations for

treatment. The structural and procedural features of service

delivery also need to be more clearly operationalized for treatment

evaluation purposes. We have at least made a start in some of

these areas, but we have to become more insightful and creative in

future work since current treatment variables are able to account

for only a limited amount of variance in outcomes. In addition,

more attention needs to be given to the nature of the interactions

between client and counselor.

Further procedural research should begin with the exploration,

definition, and measurement of the essential dimensions of client

characteristics, treatment structure, and counselor-client

interactions. Then posttreatment follow-up studies are necessary

to judge our success in improving outcome predictions. This sort

of research effort should begin with intensive studies of treatment

procedures within programs, and be expanded later to include

39
multiple-program comparisons for outcome evaluations.

Finally, the methodology for treatment evaluation research should

be given attention in order to improve the quality and

comparability of results across studies. Several lessons from

previous research point to the importance of selecting well-defined

treatment and comparison groups. It is also necessary to use a

follow-up time frame (preferably a l-year period) which allows

adequate representation of outcome criteria, with acceptable

statistical and distributional properties for analysis. This

follow-up period for treatment evaluation should begin immediately

after termination of treatment to avoid confounding influences --

such as other treatment episodes -- which accure over longer term

intervals. Studies of outcome status several years after treatment

are essential for our understanding of the long-range implications

of drug abuse, but their purpose and design should not be confused

with the shorter-term goals of treatment evaluation.

REFERENCES

Bracy, S.A., and Simpson, D.D. Status of opioid addicts 5 years

after admission to drug abuse treatment. Am J Drug Alcohol

Abuse, 9(2):115-127, 1983.

Cole, S.G., and James, L.R. A revised treatment typology based on

the DARP. Am J Drug Alcohol Abuse, 2(1):37-49:1975. Also see:

Sells, S.B., and Simpson, D.D., ed. Effectiveness of Drug Abuse

Treatment. Vol. III. Cambridge, MA: Ballinger, 1976 pp.

199-336.

Janis, I.L. The role of social support in adherence to stressful

decisions. Am Psychologist, 38(2):143-160, 1983.

Sells, S.B. Effectiveness of Drug Abuse Treatment. Vols. I and

II. Cambridge, MA: Ballinger, 1974.

Sells, S.B. The DARP research program and data system. Am J Drug

Alcohol Abuse, 2(1):1-14, 1975.

Sells, S.B.; Demaree, R.G.; and Hornick, C.W. Comparative

effectiveness of drug abuse treatment modalities. National

Institute on Drug Abuse Services Research Administrative Report.

Washington, D.C.: Supt. of Docs., U.S. Govt. Print. Off., 1979.

Sells, S.B., and Simpson, D.D. Effectiveness of Drug Abuse

Treatment. Vols. III, IV, and V. Cambridge, MA: Ballinger, 1976.

Sells, S.B., and Simpson, D.D. The case for drug abuse treatment

effectiveness, based on the DARP research program. Brit J

Addiction, 75:117-131, 1980.

Simpson, D.D. Treatment for drug abuse: follow-up outcomes and

length of time spent. Arch Gen Psychiatry, 38(8):875-880, 1981.

Simpson, D.D. Treatment evaluation research based on the DARP.

Paper presented at the Symposium for S.B. Sells, Fort Worth, TX,

April 1983.

Simpson, D.D.; Joe, G.W.; and Bracy, S.A. Six-year follow-up of

opioid addicts after admission to treatment. Arch Gen

Psychiatry, 39:1318-1323, 1982.

40
Simpson, D.D., and Savage, L.J. Treatment reentry and outcomes

among opioid addicts during a 4 year follow-up after drug abuse

treatment. UN Bull Nar, 32(4):1-10, 1980.

Simpson, D.D., and Savage, L.J. Client types in different drug

abuse treatments: Comparisons of follow-up outcomes. Am J Drug

Alcohol Abuse, 8(4):401-418, 1982.

Simpson, D.D.; Savage, L.J.; Joe, G.W.; Demaree, R.G.; and Sells,

S.B. DARP Data Book: Statistics on Characteristics of Drug

Users in Treatment During 1969-1974 (Report 76-4). Fort Worth,

TX: Texas Christian University, Institute of Behavioral Research,

1976.

Simpson, D.D.; Savage, L.J.: and Lloyd, M.R. follow-up evaluation

Of treatment of drug abuse during 1969 to 1972. Arch Gen

Psychiatry, 36:772-780, 1979.

Simpson, D.D.; Savage, L.J.; Lloyd, M.R.; and Sells, S.B.

Evaluation of Drug Abuse Treatments Based on the First year After

DARP: National follow-up study of admissions to drug abuse

treatments in the DARP during 1969-1972. National Institute on

Drug Abuse Service Research Monograph. DREW Pub.No. (ADM)

78-701. Washington, D.C.: Supt. of Docs., U.S. Govt. Print.

Off., 1978a.

Simpson, D.D.; Savage, L.J.; and Sells, S.B. Data Book on Drug

Treatment Outcomes: Follow-up Study of 1969-72 Admissions to the

DARP (Report 78-IV). Fort Worth,TX: Texas Christian University,

Institute of Behavioral Research, 1978b.

Simpson, D.D.; Savage, L.J.; and Sells, S.B. Evaluation of

outcomes in the first year after drug abuse treatment: A

replication study based on 1972-1973 DARP admissions. National

Information Technical Service. Pub. No. NIDA/DRD/80/05.

Springfield, VA: U.S. Dept. of Commerce, 1980.

Simpson, D.D., and Sells, S.B. Effectiveness of treatment for drug

abuse. An overview of the DARP research program. Adv Alcohol &

Substance Abuse, 2(1):7-29, 1982a.

Simpson, D.D., and Sells, S.B. Evaluation of Drug Abuse Treatment

Effectiveness: Summary of the DARP follow-up research. National

Institute on Drug Abuse Treatment Research Report. DHHS Pub. No.

(ADM) 82-1209. Washington, D.C.: Supt. of Docs., U.S. Govt.

Print. Off., 1982.

Waldorf, D.,and Biernacki, P. The natural recovery from opiate

addiction: Some preliminary findings. J Drug Issues,

11(1):61-74, 1981.

ACKNOWLEDGEMENTS

This research was supported by the National Institute on Drug Abuse

Grant R18-03419. Drs. S.B. Sells, Robert G. Demaree, and George W.

Joe supervised and conducted major portions of the research

reported; Dr. Sells provided general oversight of the research

program.

AUTHOR

D. Dwayne Simpson, Ph.D.

Behavioral Research Program, Texas A & M University

College Station, Texas 77843

4 1
Treatment Outcome Prospective

Study (TOPS): Client Characteristics and Behaviors Before,

During, and After Treatment

Robert L. Hubbard, Ph.D., J. Valley Rachal, M.S.,

S. Gail Craddock, M.S., and Elizabeth R. Cavanaugh, B.A.

The Treatment Outcome Prospective Study (TOPS) is a long

term, large-scale longitudinal investigation of the natural history

of drug abusers before, during, and after receiving services in

publicly funded drug abuse treatment programs. Funded by the

National Institute on Drug Abuse (NIDA), TOPS consists of the

Intreatment Study and the Followup Study. The Intreatment

Study included 11,750 clients in three annual admission cohorts -

1979, 1980, and 1981. To date, posttreatment studies of the 1979

admission cohort (12 and 24 months after termination) and the

1980 admission cohort (3 and 12 months after termination) have

been conducted. A followup study of the 1981 admission cohort

between 12 and 36 months after treatment will be undertaken in

1984. The TOPS research also includes studies of the outcomes

for clients involved with the criminal justice system, particularly

those referred to treatment by the Treatment Alternatives to

Street Crime (TASC) programs. These programs were developed

by the National Institute of Justice (NIJ) to identify drug users

in the criminal justice system and refer them to treatment.

TOPS was designed to provide valid, current, nationally based

information describing drug abuse treatment clients, treatment

programs, and client behavior before, during, and after treatment to help plan, refine, and assess state and local treatment

efforts. An important aspect of the TOPS design and approach

is the identification and analysis of the association of client

behaviors with client characteristics, community environments,

and the treatment process. The TOPS data base provides the

most current information from which reasonable during- and

after-treatment improvement expectations across selected behavioral measures (such as alcohol consumption, drug use, mental

health, criminal behavior, and economic productivity) can be

developed. Improvements (or change) experienced by the TOPS

clients can be viewed as the expected outcome for appropriate

groups of treatment clients. Program managers, policymakers,

and researchers can use the framework provided by TOPS to

design, conduct, and interpret studies and evaluations of individual programs, groups of programs, and the general treatment

effort.

42
TOPS was intended to expand our knowledge of treatment and its

impact on client behavior. By systematically tracking and monitoring individuals over significant periods of time, a better

understanding of the dynamics of drug treatment and client

behavior is being developed to generate new, better focused

research and to substantiate or reassess the findings of previous

research on a broader scale and enable treatment programs to

better direct their efforts to provide more meaningful, efficient,

and effective treatment. To accomplish this objective, TOPS has

employed the knowledge and useful aspects of methodologies

developed in past efforts. The multi-year cohort, longitudinal

followup design enables a comprehensive and systematic examination of many of the transitory and persisting changes in participating treatment programs, community environments, and in the

characteristics and behavior patterns of drug abusers seeking

admission to the treatment programs. One of TOPS’ research

objectives is to provide information that can be used to generate

clear, testable hypotheses about treatment effects and to identify

factors that may help determine why and for whom types of

treatment do or do not work.

The purpose of this chapter is to describe the design of the

TOPS research, summarize some of the key findings from the

Intreatment and Followup Studies, and then present recommendations for future research. The overall design of TOPS has been

the result of a systematic attempt to develop and implement

state-of-the-art methodologies in drug treatment evaluation

research, particularly in sampling, measurement, and analysis.

Many of the key elements of the design can be incorporated into

evaluation studies of different scopes and purposes. The early

results of TOPS generally support the findings of previous

evaluation research. The overall design, however, will allow researchers and policymakers to increase their understanding of

treatment effects. The recommendations presented suggest ways

to use the TOPS data and other studies to develop this understanding.

APPROACH AND METHODOLOGY

A critical element in the successful implementation of TOPS has

been the overall plan which calls for a full-scale longitudinal

study implemented in phases. The recommendations of a group

of experts in the area of drug treatment program research and

evaluation during the initial planning phase of TOPS formed the

basis for the overall plan and design. Many of these recommendations were to build upon and augment the basic design of the

Drug Abuse Reporting Program (DARP) studies conducted from

1969-1973. Work on the initial stages of TOPS began soon after

this planning meeting in 1975 (Williams 1975). After the basic

data collection instruments and field procedures were drafted, a

contract to complete the second and third stages of the TOPS

was awarded to the Research Triangle Institute (RTI) in August

1977. The 18-month intreatment study period was divided into

two phases: a comprehensive pretest data collection lasting

43
about 6 months and a pilot study data collection in 1979 lasting

12 months. The second (1980) and third (1981) years of the

Intreatment Study, and Followup Studies for the 1979 and 1980

admission cohorts were subsequently added. A grant to follow

up the 1981 admission cohort was approved and is expected to be

implemented in 1984. Advisory Committees have met several

times during the study to review the project and to recommend

the implementation of subsequent phases of the research plan.

The phased approach to the development and implementation of

TOPS has enabled NIDA and the researchers to (1) determine

the current needs TOPS can fulfill in terms of research and

policy, (2) more precisely focus the TOPS effort to meet specific

objectives, and (3) modify the design and instrumentation to

best meet current and future research and policy needs.

The magnitude of the study and the complex problems inherent

in this research required the careful consideration of a number

of important methodological issues. This section highlights the

key research design, sampling, definition and measurement, and

analysis issues in the overall planning and conduct of the TOPS

research.

Research Design

The TOPS research program is principally a descriptive and

correlational assessment of client behavior. Therefore, a survey

design was selected as the most appropriate approach for the

TOPS data collection. The 1975 Planning Group and other reviewers have generally advocated that TOPS be a large-scale,

coordinated longitudinal study rather than a series of individual

studies which might not be integrated and whose results might

not be comparable.

The use of a longitudinal, prospective cohort design has two

major advantages over other feasible designs. First, it permits

the use of measurements collected at one time to predict behaviors at a later time. Second, the cohort design can provide an

assessment of the impact of events occurring over time that

might change, including the nature of treatment, the characteristics and behaviors of clients entering treatment, and the community environments that may affect program operations and

client behaviors.

TOPS is principally a descriptive study with a prospective cohort

research design. The prospective cohort design is best described as a nonequivalent control or comparison group design. The

comparison groups that can be used in TOPS include a contact

only group, clients who stay in treatment for a short time (e.g. ,

3 months), and clients that stay 3 months or longer. In addition, treatment utilizer groups can be created among clients who

receive more or less intensive services. Clients can also be

placed in various cohorts based on date of entry into treatment,

date of discharge, chronological age, age of first addiction, or

the occurrence of other significant events. But, as is the case

44
for any single quasi-experimental, clinical trial, or correlational

study, TOPS alone cannot provide definitive evidence of causal

relationships. The information available from TOPS, coupled in a

coordinated effort with results from other studies such as DARP,

clinical trials, treatment observations, TOPS substudies, and

other related research will provide the multiple confirmation of

results necessary to confidently attribute overt client behavioral

changes to particular elements of the treatment process.

Study Programs and Client Population

Rather than a random sample of programs or clients, cities and

programs were purposively selected to reflect particular largeand medium-sized urban areas with certain types of drug problems and to include programs which were believed to have effective approaches to treatment. Stable, established programs

representing major modalities were selected to permit an assessment of treatment process as it might optimally be conducted.

Neither the cities nor the programs represent a national sample.

A listing of the cities and numbers of programs is presented in

table 1.

TABLE 1

Number of TOPS Drug Treatment Programs in Each

City, 1979-1981

Programs

Cities 1979 1980 1981 Total a

Chicago 4 3 3 (4)

Des Moines 4 4 - (4)

Detroit 4 3 (4)

New Orleans 4 4 3 (4)

New York 5 5 4 (4)

Phoenix 6 5 3 (4)

San Francisco 3 3 (3)

Total Programs 27 32 31 (41)

aTotal indicates the number of unique programs involved in

TOPS from 1979 to 1981. Seventeen programs were involved in

TOPS for all 3 years. The other 24 programs participated for

only one or 2 years. In addition to these, clients entered TOPS

through TASC programs in Chicago, Des Moines, Miami, Phoenix,

and Portland.

Intreatment Study. The first year of the full-scale Intreatment

Study began in January 1979 and involved the voluntary participation of 3,712 clients at intake to 27 treatment units (outpatient

45
detoxification, methadone maintenance, residential drug free, and

outpatient drug free) in six geographically disparate cities.

Almost 6,000 additional intreatment interviews were conducted

with these clients. The Miami and San Francisco programs were

added in January, 1980, and the Detroit and Philadelphia programs were added in January, 1981. Intreatment data collection

was terminated in December, 1981. More than 8,000 clients were

included in the study in 1980 and 1981; the total for the 3 years

was 11,750. The numbers of programs and clients participating

in TOPS are shown in table 2.

TABLE 2

Number of Drug Treatment Programs and Clients in

Each Modality, 1979-1981

1979

Admission Cohort

1980 1981 Totala

Programs

Outpatient Methadone

Residential

Outpatient Drug Free

Outpatient

Detoxification

Total Programs

Clients

Outpatient

Methadone

Residential

Outpatient Drug Free

Outpatient

Detoxification

Otherb

Total Intake

Number of Programs

8 10 10 (12)

9 10 1 1 (14)

7 10 9 (11)

3 2 1 (4)

27 32 31 41

Number of Intake Interviews

1,135 1,563 1,486

944 929 1,018

906 1,134 874

521 305 367

206 317 4 5

3,712 4,248 3,790

4,184

2,891

2,914

1,193

568

11,750

aTotal indicates the number of unique programs involved in

TOPS from 1979 to 1981. In addition to these, clients entered

TOPS through five TASC programs.

b

Includes TASC clients not assigned to TOPS programs and

clients not eligible for admission to TOPS programs.

The Intreatment Study employed a census rather than a sample

of clients in each participating program except one detoxification

program. A random sampling was used in that program which

had more than 50 intakes per month. A census permits greater

quality control, eliminates sampling error, and permits the observation of the total scope of the variety of behavior occurring in

a single treatment program. Including all clients in a program

allowed the study resources to be focused more directly and

economically by basing data collection in programs.

46
Full-time, program-based data collectors (Program Researchers)

were employed by RTI to interview clients in each participating

program. Their work was integrated with the ongoing operation

of the program. Eighty-two percent of clients were interviewed

at intake. About 5 percent refused to participate. A large

proportion of clients who contacted the program only one time

could not be recontacted for an interview. Ninety percent of

the scheduled intreatment interviews were completed.

Followup Study. The design of the followup study called for 1-

and 2-year posttreatment followups of 1,310 clients entering

TOPS programs in 1979 and 90-day and 1-year posttreatment

followups of 2,300 clients entering TOPS programs in 1980.

Twelve- to 36-month posttreatment followups of 1,380 clients in

the 1981 admission cohort are scheduled to begin in 1984. Data

collection for the 1979 and 1980 followup samples began in May

1980 and was completed in December 1982 with a completion rate

of about 80 percent for each round of interviews.

The population from which the TOPS samples were selected is

composed of all clients who entered TOPS programs and completed an intake interview in a given year of TOPS, 1979, 1980, and

1981. AU TASC clients who were assigned to one of the outpatient drug free and residential modalities and who completed an

intake interview were selected into the sample because there is

special analytical interest in this group. For a comparison

group, samples of TASC clients interviewed at TASC agencies

who were not assigned to one of the TOPS programs were also

selected (1979, n=35; 1980, n=100). Finally, 3 sample cohorts,

one for each year, were selected from the non-TASC individuals

who completed an intake interview. The total sample sizes of

1,345 clients for the 1979, 2,400 clients for the 1980, and 1,380

for the 1981 cohorts were determined by budget constraints with

a goal of achieving acceptable precision (see table 3).

TABLE 3

Followup Sample Design

Number of Clients Selected in each

Admission Cohort

1979 1980 1981

Outpatient Methadone 323

Residential 421 (135)

Outpatient Drug Free 415 (130)

Outpatient Detoxification 151

TASC Clients Not

Enrolling in

841 422

556 (49) 407 (42)

714 (186) 451 (138)

189 100

TOPS Treatment 35 ( 35) 100 (100) 0

Total 1,345 (300) 2,400 (335) 1,380 (180)

Note. Number of TASC clients in each sample is shown in

parentheses.

47
Modalities were treated as primary sample selection strata for the

sample cohorts. Secondary strata for the 1979 cohort sample

were treatment program by time-in-program (short term, long

term) categories. However, the secondary strata for the 1980

and 1381 cohort samples were simply the treatment programs.

Time in program is of interest as an analysis domain for the 1980

and 1981 samples but could not be accurately determined at the

time of sample selection.

For the 3 sample cohorts, the objective of the allocation to

primary strata has been to achieve equal variances (equal precision) for the 3 primary strata (methadone, residential, and outpatient drug free) means. A fixed sample size was allocated to

the detoxification modality in each cohort because limited numbers of detoxification programs were included in the study, and

the client populations appeared to be more homogeneous than in

the other modalities. The objective of the subsequent allocation

to secondary strata was, then, to minimize the variance (maximize the precision) of the associated primary stratum means,

subject to the restriction that a sample size of at least 25 would

be chosen for any treatment program with 25 or more eligible

subjects. This minimum sample per program provides the

opportunity to conduct individual program-based followup analysis.

Definitions

In social program evaluation it is critical to have meaningful and

practical definitions of eligibility for the program and the study,

program enrollment, and termination from the program that not

only apply to all programs but also accommodate individual program differences.

An attempt was made to interview all drug abusers when they

first physically contacted the treatment program to gain admission . Individuals were defined as eligible for an Intake interview if:

they physically visited the program (clinic) seeking

admission or readmission, and

appeared eligible for the drug treatment program, and

initiated the program intake process, and

had not previously participated in TOPS in any program, and

had not previously been contacted by a Program

Researcher (PR) in any program about participating in

TOPS.

Individuals were excluded from the Intreatment Study if they:

were clearly not eligible for the drug treatment program, or

had previously participated in TOPS and met TOPS

discharge criteria, or

had previously participated in TOPS in any program

and discontinued treatment interviews for any reason.

48
Individuals clearly not eligible for a drug treatment program

were, of course, not interviewed. For example, alcoholics with

no drug problem, individuals with overriding psychiatric problems, and those not meeting any program eligibility criteria such

as age or drug history were excluded.

In the Intreatment Study, interviews were scheduled for up to

2 years with all clients who were admitted to TOPS programs

and who completed an intake interview. Interviews were conducted until a client:

refused or missed two consecutive intreatment interviews, or

refused further participation in TOPS, or

died or was rendered permanently not capable of participating in TOPS, or

terminated treatment at the participating program.

Two criteria defined termination from treatment:

a record of discharge and no readmission to the program, or

no physical contact with program for 30 days prior to

scheduled Intreatment interview date.

For analyses and sampling purposes, the date of termination from

treatment was defined as the official program record of the date

of the client’s:

last medication or physical appearance at the treatment

center for a counseling session (for detoxification), or

last medication (for methadone maintenance), or

last night in residence (for residential), or

last physical contact for counseling (for outpatient

drug free).

Points of Interview

The longitudinal design of TOPS makes each interview point

critical both technically and operationally. The major technical

concerns in selecting the points of interview include the analytic

and conceptual problems of (1) identifying key points in the

treatment process, (2) identifying points where major changes in

behavior occur, (3) plotting trends in behavior, and (4) establishing boundaries of time periods by chronological dates or key

events. The operational concerns include (1) scheduling of

intreatment interviews, (2) the respondent’s ability to accurately

recall behavior, (3) the effects of repeated testing and respondent burden, and (4) the timely notification of treatment termination.

To determine the best points of interview, retention patterns

were examined and discussions were conducted with treatment

administrators and clinicians. The retention patterns of a variety of programs clearly showed that there is a high dropout rate

in the first month of treatment followed by a leveling off. Also,

discussions with program staff indicated that major behavioral

49
changes were most likely to occur early in treatment. The

points of interview for the Intreatment Study were designed to

best assess behaviors over these time periods.

Past studies indicated that recall of events such as arrests and

employment are reasonably accurate for up to one year. However, behavior such as drug use, criminal activity, or odd jobs

are often telescoped or forgotten. Interviews at frequent intervals, then, were considered necessary to obtain more accurate

recall of these behaviors and to assess attitudinal and evaluative

data about treatment. Based on both technical and operational

considerations, the interviewing schedule for the TOPS Intreatment Study was:

at initial contact with a program,

one month after treatment admission, and

every 3 months after treatment admission for as long

as 2 years if the client remained in treatment.

In the followup study, attempts were made to interview clients in

the 1979 cohort 3 and 12 months after treatment. For the 1980

cohort, interviews were scheduled 12 and 24 months after termination from treatment. In the followup of the 1981 cohort,

clients will be asked about the 3 months and 12 months before

the followup interview (usually 12 to 36 months after treatment

termination). The 3-month interview used in the followup of

the 1979 clients provides more detailed information surrounding

termination. The followup after one year corresponds to the

standard followup period used in a variety of evaluation studies.

The longer term followups focus on behavior in the year prior to

the followup interview.

Measurement

TOPS is designed to provide data encompassing broad-based

ecological, social, social-psychological, and socioeconomic perspectives. A large set of variables is being examined in the

basic TOPS research approach. The general categories of variables covered in the TOPS interview are outlined in figure 1.

Whenever possible, standard measures of key variables are used

such as Uniform Crime Report categories of crime and employment rates as measured and defined by the Current Population

Survey of the Bureau of Labor Statistics. Information on many

types of behavior is collected in three ways: (1) within eventor time-defined periods, such as age at first daily opiate use,

(2) status at interview or on a particular date such as labor

force participation in the week prior to treatment, and (3) within

chronological time frames such as drug use during the first

month in treatment.

In order to more fully understand the background and context of

client behaviors during and after leaving a drug treatment program, information on the treatment received in a program and

the socioeconomic and cultural system outside the program in

50
which the client must function is essential. Two TOPS substudies (not reported here) examining treatment process and

community impacts were conducted to complement the basic Intreatment and Followup phases.

Individual Background

Demographic characteristics

Life style and life changes

Drug and alcohol use and treatment experience

Illegal activities and criminal justice system involvement

Employment history and other socially approved productive behavior

Treatment

Type of treatment (modality, environment, duration,

orientation)

Client behavior during treatment (drug and alcohol use,

illegal activity, employment, participation in treatment activities)

Treatment services received (counseling, vocational,

medical, legal)

Treatment assessment (opinions about treatment, receipt

of aftercare services, behavior occurring at the time

of last program contact)

Community

Context of drug use problems (indicators of drug availability, perception of treatment resources, knowledge

of community services)

Social and economic factors affecting individual behavior (labor force participation, treatment availability,

availability of community service)

Social support (support and involvement of family and

others in treatment, family composition changes)

Community involvement (peer group relationships, community services received, involvement in the drug

culture)

Treatment Outcome

Drug and alcohol use

Illegal activity

Employment and other economic or socially approved

productive behavior

Mental health (depression, problems)

Retention in treatment and successful completion of

treatment

FIGURE 1

Types of Data Obtained in TOPS Client Interviews

51
Data Analysis Approach

The TOPS data can be used for descriptive, comparative, and

correlational purposes. Examples of specific questions that are

addressed can be organized for each type of data analysis. As

the analyses of the Intreatment and Followup Studies have progressed, information has become available to help specify questions in more precise and meaningful ways.

While the primary purpose of TOPS is to describe the characteristics and behaviors during and after treatment of cohorts of

drug abusers contacting the TOPS programs, attempts are being

made to understand differences in behaviors among clients with

different backgrounds, receiving different types of treatment

services, and facing different community environments. Models

of client behavior are being developed which encompass the many

individual and environmental factors that may influence behavior.

Emphasis is being placed on both developing and revising models

that more clearly describe the behavior of treatment clients

during and after treatment, and generating and testing hypotheses about the association of such behaviors with variables

looked at individually and within various classes.

Framework. Given the large amount of longitudinal, behavioral

data collected, a conceptual framework is necessary to provide

directions to the inquiries and to generate hypotheses that can

be examined with the data set. To better organize the data

analysis, general models are being used to indicate the general

classes of variables and the temporal relationships that should be

examined in the analyses. Four major classifications of variables

are to be investigated in TOPS: client background characteristics, client behavior, treatment program services, and community descriptors. The major analyses focus on behavior indicators in and across the various time periods - before, during and

after treatment (see figure 1).

Specifically, the major analyses are being organized around the

major individual outcome variables: drug use, employment,

mental health, and criminal behavior. Preliminary attempts were

made to develop composite outcome variables with statistical

combinations and theoretical patterns of outcomes. However,

unlike some previous studies, the major outcome variables in

TOPS did not appear to be related in a clear, systematic way.

Therefore, the use of composite measures could obscure some

important outcome results. Data books showing bivariate associations between selected predictor and outcome variables were

prepared and examined. These books provided the key information for descriptive analyses within cohort and modality. Based

on these analyses, variables are elected for multivariate analysis.

One basic technique used is logistical multiple regression for

categorical data. This approach is most appropriate for highly

skewed, nonnormal distributions common in treatment outcome

research. The models can be developed and the results presented in a form similar to a multivariate contingency table. Inter5 2
pretations are probability statements about outcomes for various

combinations of client characteristics,

Time at Risk. In considering the effects of drug abuse treatment on behavior, the opportunity to engage in the behavior of

interest must be considered. A number of drug treatment clients, especially those entering residential programs, were in

restricted environments such as jails, prisons, hospitals or other

residential treatment centers in the year prior to treatment.

Their opportunities to use illegal drugs, commit crime, or work

were limited because of these restrictions. In the first year

after treatment 9 percent of methadone, 14 percent of residential, and 5 percent of outpatient drug free clients spent more

than 9 months in restricted environments. Clearly these differences in opportunity could affect results.

A number of methods have been proposed to control for time at

risk. The principal approaches include (1) deleting cases with

little time at risk from the sample, (2) adjusting rates of behavior for time at risk, and (3) comparing behavior in time periods

when an individual was at risk with periods when an individual

was not at risk.

Restricted environment, however, does not necessarily result in

elimination of the behavior of interest; rather it more likely

limits involvement in the behavior. For example, illicit drug use

is sometimes reported among individuals in residential drug

treatment programs and inmates in jails and prisons. Other

adjustments for time at risk in effect often impute a consistent

level of high activity in crime or drug use for the period not at

risk (Ball et al. 1982). (The episodic nature of both activities

suggests that levels of behavior may have been reduced even if

the individual had remained at risk.) Thus, adjustments for

time at risk may artificially inflate the level of behavior for some

cases in the analysis. An accurate assessment of time at risk

also requires detailed and time-consuming measurement of episodic

behavior that is extremely difficult to incorporate into large-scale

surveys and data analyses. Even in the most ambitious efforts

to gauge time at risk, only some of the main elements of the

beginning and end points of time at risk episodes and the various drug use, crime, and work activities periods could be recorded. Problems in recall and data reduction for analysis limit

this approach to an even greater extent.

Both ratio and sample reduction strategies were used to assess

the impact of different strategies for controlling for time at risk

in TOPS. These analyses indicated that time at risk controls

had a major impact on the pretreatment description of residential

clients and a minimal impact on analyses of methadone and outpatient drug free clients.

53
For example, with a sample reduction approach in the residential

modality, the proportion of clients using heroin in the year prior

to treatment increased by less than 2 percent as successive

controls for time at risk were introduced; but the actual number

of clients using heroin decreased by half. Even though these

clients were in restricted environments for more than a month, a

significant proportion of them reported weekly heroin use over

the period of a year. Were individuals in restricted environments removed from the analyses, information on a substantial

number of clients who had a serious drug problem would not be

available. Similar findings hold true for the followup. Of the

almost 200 clients who reported 40 or more weeks not at risk in

the year following treatment, about one-third reported committing

a predatory illegal act during that year. This rate for a “not at

risk” group is higher than that for the TOPS followup sample

which was at risk. These results exemplify the type of tradeoff that is made when time at risk is controlled. Because one of

the major goals of TOPS is to describe the natural history of

drug use among clients before, during, and after treatment, it

seems appropriate to first describe the actual level of behavior

without adjustment for time at risk.

There are a variety of reasons why an individual uses his or her

present level of drugs (e.g., cost of drugs, availability of

drugs) in addition to time at risk. The early analyses of time at

risk demonstrate that controlling for time at risk is a very

complex theoretical and analytic issue. Alternative approaches

should be carefully considered in terms of their overall impact on

the results. Even inclusion of a time at risk control in multivariate analysis could result in spurious and misleading findings.

The impact of time at risk is being carefully considered in all

TOPS analysis, but these preliminary results indicate that adjustment for time at risk may generate greater bias than a more

straightforward presentation of descriptive data.

OUTCOMES DURING AND AFTER TREATMENT

Changes in criminal behavior, employment and other socially

productive activity, and the use of illicit drugs have repeatedly

been used to evaluate program effectiveness as has program

retention. A number of reviews of studies of treatment (Sells

1979; National Institute on Drug Abuse 1981; Quinones et al.

1979; Simpson et al. 1979; Simpson and Sells 1982) have concluded that overall there is evidence that a number of treatment

approaches for drug abusers are effective. Although important

changes in client population and treatment have occurred since

these studies were conducted, results from TOPS generally

support these conclusions. In the following sections, outcomes

during and after treatment for retention, drug use, alcohol

consumption, depression, illegal activity, and employment are

summarized.

54
Outcomes During Treatment

The analyses reported below examined behavior during treatment

on a variety of indices for all three TOPS admission cohorts.

The basic measure used was the behavior during first 3 months

in treatment. The use of the 3-month measure provides a large

sample for analysis of changes during treatment and, in general,

behavior over the first 3 months was very similar to behavior

during the first year in treatment.

Retention. Outpatient drug free clients are most likely to leave

treatment in a week or less (21%) and 4 weeks or less (36%).

By 3 months in treatment, more than 60 percent had dropped

out, transferred or completed treatment. Methadone clients are

least likely to leave treatment at any of the early stages, and 3

months after intake 65 percent remain in treatment. At 6

months, well over half remain. More than a quarter of residential clients drop out in the first month of treatment. By the end

of the third month, 56 percent of the clients entering in 1979 or

1980 had dropped out, transferred or completed treatment.

Drug Use. Almost 16 percent of all clients had either not used

drugs or had only minimally used drugs in the year before

entering treatment. This ranged from 14 percent of methadone

clients to 19 percent of outpatient drug free clients. Most of

these clients had transferred from other treatment programs or

were in jail or other institutions immediately prior to treatment.

Residential clients were most likely to reduce use of their primary drug. Ninety-nine percent of those reporting more than

minimal drug use in the year before treatment reported at least

some reduction in the first 3 months. For 95 percent, this

reduction was “large.” Nine out of 10 methadone clients reporting more than minimal use at treatment entrance experienced a

reduction in use. For more than 80 percent this reduction was

“large." Outpatient drug free clients were least successful in

reducing their drug use. About a third of those classified as

more than minimal users at entrance had continued or increased

that use at three months in treatment, though 45 percent of

users reported a large reduction in use.

Alcohol Consumption. A four category quantity-frequency index

of alcohol consumption was constructed. Heavier consumers of

alcohol were defined as those who drank 2 or more ounces of

absolute alcohol one or more times a week. More than a third of

methadone clients were nondrinkers or low level drinkers in both

the year before treatment and the first 3 months in treatment.

Of those who drank, almost a quarter of the methadone clients

increased their alcohol consumption in treatment, but 34 percent

reported at least some reduction in use.

Eighteen percent of outpatient drug free clients were nondrinkers or low level drinkers in the year before treatment and the

first 3 months in treatment. Of those who drank, 22 percent

55
of the outpatient drug free clients increased their alcohol

consumption in treatment; but 32 percent reported at least some

reduction in use.

Almost 40 percent of residential clients were nondrinkers or low

level drinkers in both the year before treatment and in the first

3 months in treatment. Of those who did drink, only 7 percent

increased their alcohol consumption to the moderate or heavier

levels in treatment and, as would be expected, almost 90 percent

reported some reduction in use.

Depression Indicators. Clients were asked if they experienced

three indicators of depression: (1) being so depressed they

could not get out of bed, (2) suicidal thoughts, and (3) suicide

attempts. Forty-six percent of all methadone clients reported

having been depressed in the year before intake. More than

60 percent of those remaining in treatment at 3 months, however, reported depression for the pretreatment and/or intreatment periods, indicating that depressed clients tend to stay in

methadone treatment. The same tendency for depressed clients

to remain in treatment holds for the other two modalities. At 3

months in treatment, more than 22 percent of all respondents

show some signs of depression. Outpatient drug free clients are

most likely to be depressed (29%) followed by those in methadone (24%) and residential (15%) programs. About 40 percent of

those remaining in treatment at 3 months report having recovered from depression. Outpatient drug free clients are least likely

to report recovery (35%) followed by methadone (39%) and

residential (50%) clients.

Illegal Activity. More than 40 percent of all clients reported

some predatory illegal activity (assault, robbery, burglary,

larceny, fraud, or stolen property) in the year before treatment . Residential clients were much more likely to report a

predatory act (62%). About a quarter of the methadone and

outpatient drug free clients (more than 70% of those who had any

predatory activity before or during treatment) reported cessation

of predatory illegal activity during treatment. The outpatient

drug free programs were less successful at reducing crime among

the clients; about one in four clients who had reported an illegal

act before treatment reported continued illegal involvement. The

reports of residential clients, of course, plummeted. Of residential clients who had reported activity, 97 percent reported cessation during treatment.

Full-time Employment (35 or more hours per week). Half the

methadone clients remained unemployed during treatment as did

more than a third of the outpatient drug free clients. At 3

months in treatment, more than 30 percent of outpatient drug

free clients worked full time or increased their work to that

level, a slight improvement over intake. The percentage of

methadone clients working full time in treatment remained about

the same as at intake (24%). Because of the design of most

56
residential programs, few clients work outside the program

during the first 3 months in treatment.

Outcomes After Treatment

How clients function in the first 12 months after terminating

treatment is a useful indicator of the impact of treatment.

Behavior patterns during the first year may also affect longer

term outcomes. Thus, this first year is a major focus of the

TOPS followup analysis.

The data presented in this section are for the merged 1979 and

1980 followup samples. Merging the samples is appropriate for a

general description of outcome. It does not imply that the two

cohorts are equivalent. Differences between the cohorts have

been found that warrant separate analyses in the future. In

this preliminary examination of the data, the followup results

were analyzed by two time-in-treatment groups for each modality:

a short-term group that stayed months 3 or less, and a longterm group that remained in treatment more than 3 months.

The analyses described in the following sections do not include

controls for a variety of factors, especially three key variables:

cohort, treatment during the followup period, and time at risk.

As described earlier, there are important differences among the

three TOPS cohorts both in terms of the programs included and

the changes that occurred in the programs. We also noted that

results are affected by treatment after TOPS and the opportunity

to engage in various behaviors.

Many clients, especially those in the methadone modality, remained in the TOPS program throughout the followup period;

many other clients left treatment but had then been admitted to

the same or another drug treatment program and were in treatment all or some of the time during the followup period. Other

clients were incarcerated or had limited opportunity to use

drugs, commit crimes, or find jobs during the followup period.

Preliminary analyses have revealed that more positive behaviors

are reported by clients who also report more involvement in

treatment during the followup period. A similar analysis for

clients with different amounts of time at risk in the followup

period indicates that opportunity does affect the level of behavior reported but in a more complex way than previously believed .

The TOPS initial descriptive followup results (see table 4) are

generally consistent with the DARP followup results. There

were major improvements in drug use and criminal activities after

treatment in all modalities, though the rates do not appear to be

as good as those found while the clients were in the treatment

program. Those clients who remained in treatment longer appear

to have more positive outcomes.

57

215-494 0-88-3: QL 3
TABLE 4

Comparisons of Behavior One Year Before and One Year After Treatment

for Clients Remaining in Treatment 13 Weeks or Less and More than 13 Weeks

Type of Weekly or

Greater Drug Use

Heroin and Narcotics

Heroin not Narcotics

Narcotics not Heroin

Multiple Nonopioids

Single Nonopiate

Alcohol/Marijuana

Minimal Use

Type of Alcohol User

Nondrinker

Infrequent/Light

Moderate

Heavier

Depression Indicators

None

Depressed

Suicide Thought/Attempts

Predatory Illegal Acts

None

1-10

11 or more

Weeks of Full-Time Work

None

1-39

4052

Sample Size n=386 n=541 n=380 n=340 n=553 n=292

Outpatient Methadone

<13 Weeks >13 Weeks

Before After Before

17.9 10.2 14.5 4.9 12.8 7.0 11 8 4.3 3.5 4.1 4.5 2.4

47.5 23.3 54.8 14.1 18.3 10.9 22.2 7.3 9.1 4.9 8.2 3.4

10.5 10.5 9.0 6.3 18.2 10.4 16.8 6.2 15.1 8.7 10.9 4.9

2.3 1.8 2.1 3.2 11.6 6.3 9.7 3.8 9.5 4.2 6.1 1.8

4.2 7.1 3.4 13 9 14.1 14.7 17.5 9.4 22.5 17.0 24.2 11.4

12.5 29.6 10.6 37.1 15.7 30.1 14.9 36.4 32.6 40.9 36.9 49.7

5.1 17.4 5.6 20.6 9.1 20.5 7.1 32.6 7.7 20.2 9.1 26.4

30.2 34.1 35.3 37.6 31.2 30.9 31.4 32.0 15.7 23.9 17.2 21.9

10.9 8.2 13.8 12.4 7.8 8.0 14.1 10.8 12.0 10.0 13.3 13.9

37.1 39.6 25.8 26.5 15.4 23.2 18.7 27.3 30.8 29.8 36.0 36.7

31.9 28.1 25.1 23.5 45.5 37.9 35 7 30.0 41.5 36.3 33.5 27.5

43 I 68 4 42.5 64.9 36.9 61.6 42.1 71.9 36.8 61.4 34.0 65.5

25.0 17.6 26.8 22.8 20.3 17.8 17.1 12.9 12.2 13.7 19.4 12.3

31 9 14 0 30.7 12.2 42.8 20.5 408 15.1 51.0 24.8 46.6 22.2

58.2 72.8 67.7 80.3 39.7 57.0 39.6 70.5 61.6 74.8 66.2 80.9

27.7 16.3 19.5 13.3 32.6 28.3 29.6 19.8 27.7 18.1 24.4 13.3

14.1 10.9 12.8 6.4 27.7 14.7 30.8 9.7 10.6 7.1 9.4 5.7

44.5 50.4 47.5 59.7 39.2 41.8 38.8 33.3 30.8 32.1 30.8 29.2

29.4 29.7 29.5 21.3 47.3 43.3 48.8 41.9 43.0 40.0 44.0 32.1

26.1 19.9 23.0 19.0 13.5 14.9 12.4 24.8 26.2 27.8 25.2 38.7

After

Residential

<13 Weeks >13 Weeks

Before After Before After

Outpatient Drug Free

<13 Weeks >13 Weeks

Before After Before After
Post-TOPS Drug Treatment. Consistent with DARP findings, a

substantial proportion of TOPS clients were in treatment during

the followup period (see table 5). Forty percent of short-term

and 60 percent of long-term methadone clients were in treatment

during the TOPS followup period. Most of the long-term clients

who reported 40-52 weeks of post-TOPS treatment were methadone maintenance clients who remained in the original TOPS

program throughout the followup period. These clients were

interviewed with a Long-term Interview form, and their data

were included in the long-term sample. The proportions of

clients from residential and outpatient drug free programs returning to treatment were much lower than for methadone clients. About 30 percent of short-term and 40 percent of longterm residential clients reported treatment in the followup period.

About one of 4 outpatient drug free clients reported treatment.

TABLE 5

Number of Weeks in Drug Treatment in the Year

After Leaving TOPS Treatment by Modality and

Time in TOPS Treatment

Outpatient Outpatient

Number Methadone Residential Drug Free

of <13 >13 <13 >13 <13 >13

Weeks Weeks Weeks Weeks Weeks Weeks Weeks

None

1-13

14-39

40-52

59.7% 38.9% 71.3% 61.9% 76.2% 78.5%

11.1 6.2 14.5 9.7 12.2 5.9

10.1 8.9 7.5 13.6 6.2 5.1

19.1 45.9a

6.8 14.9a5.5 10.6a

aCIients who remained in the TOPS treatment program throughout

the followup period are included in the calculation of these

percentages.

Clearly, treatment in the followup period must be considered as

an important covariate of behavior in the followup period. The

preliminary results reveal a nonlinear relationship for methadone

clients. For example, long-term clients who report no treatment

or 40-52 weeks of treatment report less heroin use (32%) and

predatory crime (18%) than clients who report 1-39 weeks of

treatment (60% heroin use and 32% predatory crime). Similar

patterns of predatory crime and treatment were found for longterm residential and outpatient drug free clients. These curvilinear relationships can be taken into account in multivariate

analyses with the use of dummy or categorical indices of postTOPS treatment.

59
Drug Use. There is a dramatic reduction in the use of the client’s primary drug. In all modalities more than one-third of the

clients report not using their pretreatment primary drug during

the followup period.

After methadone treatment, daily or weekly use of heroin and

other narcotics was decreased by 50 percent for short-term clients, and by 70 percent for clients remaining in methadone

treatment for 3 to 24 months. Only one of 10 clients who

remained in methadone treatment throughout the TOPS followup

period reported weekly or greater use of heroin or narcotics.

About 20 percent of all methadone clients reported no weekly use

of alcohol or any other drug in the year after treatment.

Over 20 percent of the short-term residential clients and onethird of the long-term clients reported no weekly use of any

substance in the year after treatment. Another third of these

former clients reported weekly use of marijuana and/or alcohol

only. These findings are even more impressive considering that

pretreatment multiple use patterns were reported by three of

four residential clients.

For the outpatient drug free modality, one in five short-term

clients reported no weekly use of any substance in this year

after treatment, and 36 percent reported weekly or greater use

of only marijuana or alcohol after treatment. One-fourth of the

long-term clients reported no weekly use of any substance in the

year after treatment, and half reported weekly use of alcohol

and/or marijuana only.

Alcohol Use. Although the proportions of residential and outpatient drug free clients reporting heavier alcohol use after treatment were 5 to 10 percent lower than before treatment, drug

treatment did not appear to have much impact on drinking.

About 3 in 10 clients could still be described as heavier drinkers

after treatment.

Illegal Activity. Reports of illegal activity were much lower

after treatment, especially for clients remaining in treatment

more than three months. Only 20 percent of long-term methadone clients, 30 percent of long-term residential clients, and

20 percent of long-term outpatient drug free clients reported

illegal acts in the year after treatment.

The largest changes in predatory illegal activity occurred for

residential clients. Where 60 percent reported at least one act

in the year before TOPS treatment, only about one-third reported activity in the year after treatment. Smaller decreases in

illegal activity were reported for methadone and outpatient drug

free clients. There still appeared to be a group of about 5-10

percent of the clients in all modalities who commit a high number

of predatory crimes. Many appear to be the same clients who

report committing high numbers of predatory criminal acts before

and during treatment.

60
Depression Indicators. Clients in all modalities reported a substantial decrease in indicators of depression. After treatment,

about two-thirds of all clients reported no signs of depression.

Reports of suicidal thoughts or attempts fell from about 30 percent before treatment to 13 percent after treatment for both

long- and short-term methadone clients, from about 40 percent

before to 20 percent after for residential clients, and from

49 percent before to 24 percent after for outpatient drug free

clients. There did not appear to be major differences between

the 2 time-in-treatment groups. Despite the improvements in

reports of depression indicators after treatment, suicidal

thoughts and attempts still appeared to be a significant problem

for 10-25 percent of clients.

Full-time Employment. The results for employment are mixed in

the three modalities, Fewer methadone clients worked in a

full-time job in the year after treatment than the year before

treatment. A troubling decrease of about 10 percent was also

found in the proportion of clients who reported working full time

40 or more weeks. This result may, in part, be accounted for

by the poorer economic conditions after treatment.

A more positive picture emerges for residential and outpatient

drug free clients who remained in treatment more than three

months. For these clients there was a marked increase in the

proportion who worked full time for 40 or more weeks (12.4%, to

24.8% in residential and 24.7% to 38.7% in outpatient drug free).

We hypothesize that clients who increase their full-time employment are those who worked full time for at least a few weeks in

the year before treatment. There is little change in the percentages of clients who report no full-time work. Many of these

clients may be housewives, the disabled, or students who did

not seek full-time work. Besides employment, other socially

productive activities are being considered in analyses to measure

social and economic improvements after treatment.

RECOMMENDATIONS FOR RESEARCH

The conduct of the TOPS research, the nature of results to

date, and questions raised about the results by State planners,

as well as researchers, have generated a number of new issues

and questions.

Many new research questions involve moving beyond the basic

question of whether treatment “works." We must focus more on

how treatment influences behavior, what types of clients benefit

most, and how long after treatment and under what conditions

behavioral changes persist. Policy questions involving costeffectiveness, organization and focus of treatment systems, and

provision of different types of services for different types of

clients need to be continually modified to reflect new knowledge

emerging from studies of treatment effectiveness. Many of the

questions can be addressed with existing data from TOPS or

other studies. However, a number would require additional

further study.

61
We have organized our recommendations for future research into

four areas. The first is centered on the need for studies of

three general issues:

characteristics or types of clients,

nature and components of treatment process, and

persisting direct and indirect effects of treatment.

The second area involves the analysis approaches that can be

used to investigate these issues. We stress the need for

clear variable definitions and basic model construction,

utilization of existing data sets, and

replication and generalization of findings.

The third recommendation is the development of a useful, detailed plan for future data collection efforts including:

continuing program-based data collection,

long term followup, and

linkages and integration of clinical trials and individual

program-based studies with a more representative data

base.

A final recommendation is for studies to determine how to best

organize the drug treatment and other health service delivery

systems, including alcohol and mental health systems. Budget

constraints and increasing health service delivery costs must be

included as a parameter in defining how best to organize health

service delivery systems to meet the needs of clients:

who enter drug treatment programs with multiple problems, including alcohol-related and mental health problems .

who contact other service delivery agencies such as

alcoholism treatment programs and mental health centers .

These recommendations have been based on our work in the area

and incorporate many of the suggestions and recommendations of

TOPS review committees. Many of these recommendations reflect

issues raised in discussions with treatment professionals in

alcohol, drug, and mental health treatment programs, and with

state and local decisionmakers. We have integrated our ideas

and others into the following discussions of each area. These

recommendations are presented as a basis for further discussion.

Issues

An awareness and understanding of the diverse types of drug

treatment clients and treatment processes are fundamental to

increasing our knowledge of treatment outcomes, the client, and

the program. Of importance, too, is the more general question

of the persistence of treatment effects first identified in the

recent followup analyses of Simpson and Sells (1982).

Client Typologies. Some important initial work has been done on

client typologies by Sells and Simpson (1976) focusing on demographic and other client characteristics. We think another key

approach is to classify clients according to drug use patterns.

62
Unlike the DARP clients, most clients now entering treatment

present one of a variety of multiple substance abuse patterns.

Anecdotal accounts from treatment personnel and analysis of the

TOPS data indicate clients abusing multiple substances have more

problems and a poorer treatment prognosis. We think that

analyzing outcomes for users with various characteristics will

generate important findings for clinical and research areas. The

7-category drug use pattern index developed for TOPS, for

example, could be used for such classification.

Another method is to classify clients according to their problems.

McLellan et al. (1980) have pioneered this effort with the Addiction Severity Index which was constructed for each individual

based on clinical judgment. TOPS uses a similar measure of

drug- and alcohol-related problems based on clients’ attribution

of problems to drug abuse. Further work on the objective and

subjective severity of problems and their attribution to drug use

needs to be conducted. The work of McLellan clearly shows that

treatment outcomes differ for clients with different levels of

severity. We think problem-based typologies should be one of

the key methods of describing clients.

Treatment Process. The complexity of treatment is difficult to

conceptualize and even harder to define and quantify. In TOPS.

important advances have been made in assessing the many levels

and components of treatment. Among the components to be

studied are type of service or methods used and general indicators of treatment such as strength and integrity of treatment

(Sechrest et al. 1979). However, the task of collating and linking components into a comprehensive description of treatment

tied to treatment outcome remains.

Two key aspects of treatment process need to be explored.

First, are services focused on the clients in need of particular

services? Second, given limited treatment resources, is treatment (or are particular treatments) rendered to the clients who

will benefit most from the service? The latter approach can be

assessed in part from a cost-benefit or cost-effectiveness framework. We think that a careful assessment of the treatment

process and individual components of this process can help

greatly in developing a body of knowledge clarifying how treatment works to provide the practitioner with information on how

treatment might be rendered most effectively and efficiently.

Persistence of Treatment Effects. It is generally acknowledged

that treatment works well while clients remain in a program.

The results of DARP, Phoenix House, and TOPS followups indicate that, while treatment efforts do persist, other factors

become important after the client leaves treatment. The most

recent analysis of the DARP data suggests that 5 years after a

particular treatment, the effects of the treatment experience may

be obscured by intervening events such as a subsequent treatment experience and normal maturation (Simpson et al. 1982).

63
The theoretical framework of Moos (1981) incorporates consideration of environmental influences following treatment that may

supplant or override treatment effects.

A fruitful area of research traces the posttreatment behavior

pattern of the client. What are the direct and indirect effects of

treatment on long-term success? Do some treatment clients

move, get jobs, or receive other community services immediately

after leaving treatment that contribute to long-term success?

Are these lifestyle changes a result, in part, of the treatment

experience? To ascertain these effects we need analyses of data

collected soon after treatment which are then linked with longer

term followups. These studies should provide important information for the development of reentry and aftercare efforts.

Analysis Approaches

Different approaches to the analysis of treatment outcome data

have been developed. These include simple descriptive tables of

survey data, detailed multivariate statistical analyses, and carefully controlled clinical trial designs. We think all approaches

are essential, and more effort needs to be directed toward the

integration and generalization of the findings derived from each

of these approaches. We propose three fundamental efforts:

development and presentation of clear, meaningful, and useful

concepts and basic models; secondary analysis of existing data;

and concentration on the replication and generalization of results.

Concepts and Models. We believe that clear, direct results

which can readily be interpreted are essential to advancement of

knowledge and improvement of treatment efficiency. The TOPS

review panels, NIDA representatives, and State, local and individual program administrators have urged us to provide data that

can be useful to them. They have consistently cited the monies

spent on previous research and the limited utility of those studies to treatment programs for clinical, administrative, and other

purposes. An additional objective or concern is the development

of a research base that is useful to the research community and

that will stimulate additional research. For this purpose, the

clear specification of measures, composite variables, and models

is paramount.

Clearly, the techniques for sophisticated multivariate searches

for structure such as factor analysis, discriminant function

analysis, and stepwise multiple regression are available. We,

however, propose that these tools be used more as a method to

test hypotheses and develop theoretical frameworks than to

create statistically elaborate models which may lack a firm conceptual or theoretical base. Our analysis and model construction

approach for TOPS emphasized, first, the creation of readily

interpretable, conceptually sound measures and, second, the

need to understand how these variables are related to other

variables.

64
Only after these first steps are completed do we think it is

efficient to proceed to basic model development. With the basic

data and models, we can then begin to develop more sophisticated and elaborate models.

Secondary Data Analysis. A vast store of valuable data has

been collected. We strongly recommend that data bases such as

DARP, TOPS, therapeutic community followups, and individual

program studies such as those for Phoenix House and the Philadelphia VA Medical Center be mined to their fullest extent.

Researchers should be encouraged to submit grants to conduct

additional analysis for these data sets. For example, a program

could be initiated for secondary analysis of these data, replications or expansion of the results from these studies, or additional data collection on supplementary samples of clients.

Such a program should emphasize how analyses of data from a

particular study could complement other existing data bases.

Most of the studies have numerous measures in common. For

example, the TOPS questionnaires include all CODAP items, many

DARP measures, and data that could be used to develop Addiction Severity Index scores. In the reports prepared by RTI,

TOPS aggregate data are compared to DARP and CODAP results.

The analyses conducted under this program could compare results from other data sets with findings from the CODAP, TOPS,

and DARP data bases and vice versa.

Replication and Generalizability. The data now available for

secondary analysis lead us to stress the need for replication of

results. We have previously pointed out that DARP and TOPS

cohorts of drug treatment clients differ in many ways. Treatment programs and systems evolve. Therefore, it is essential

that findings be carefully replicated in different client populations, programs, and points in time to determine the limits to the

generalizability of results of individual studies. We now have

two general data bases, TOPS and DARP, that offer the opportunity for such replication and generalization. We think researchers should be encouraged to submit grants designed to replicate

to the extent possible their results in the TOPS and DARP data

bases. Research findings that can be replicated and generalized

provide the firmest foundation for the orderly progress in the

development of knowledge and the design of effective treatment.

Need for Additional Data Collection

Data collection of sufficient scope to effect research advances

and practical improvements in treatment are costly in terms of

time, money, and effort. Therefore, any future data collection

efforts should be carefully considered in terms of their potential

utility. We think that the three types of data collection efforts

discussed below deserve such careful consideration.

65
Long-Term Followup Studies. The long-term followup studies

such as those initiated in the DARP research should be continued and others encouraged. They provide important information

on the development and maturation of addicts and drug abusers.

Five- and 10-year followup studies could be conducted with

carefully selected samples from existing data sets. In a long

term followup study, the focus should be more on a natural

history of addict careers rather than on the impact of a particular treatment episode. In the followup studies, the focus should

be on issues such as episodic and persisting changes in behavior, the history of treatment since the initial treatment episode,

and the changes in the relationships among various conditions,

treatments and behaviors, and mental health and psychological

status.

Multipurpose Treatment-Based Research Program. The past,

current, and potential utilization of the DARP and TOPS data

bases, and to a more limited extent CODAP, shows that a treatment-based research program can serve a variety of purposes

for NIDA researchers and the drug treatment community. Unfortunately, for the first time in the past 15 years, no such data

base exists. We have fragmented information on what has happened in treatment since 1981 and what kinds of clients are

entering treatment. The reestablishment of a treatment data

base can:

provide updated descriptions of drug abuse patterns

and service needs of clients seeking drug abuse treatment,

identify administrative and treatment-related changes

in the treatment system and individual program organizations, services rendered, and effects on client

outcomes,

continue the important aspects of the CODAP epidemiological data base and augment the National Drug Abuse

Treatment Utilization Survey (NDATUS) treatment

management information system,

provide samples for followup, and

develop information about treatment/clinical and administrative/ management issues for knowledge transfer to

State and local agencies.

More specifically, four major needs that a treatment-based research such as TOPS or DARP can fulfill are:

monitor changes in the population of drug abusers

seeking entry to drug abuse treatment,

develop in-depth information on the nature and extent

of treatment received, especially under the block grant

funding mechanism,

collect followup data after treatment termination, and

provide a population base for clinical trials, individual

program studies, special studies, or special issues

analyses.

6 6
Linkage with Clinical Trials, Special Studies, and Program-Based

Studies. The need for more generalizable research findings can

be fulfilled by linking various types of data collection efforts

with similar instruments and samples. During TOPS, a number

of programs, researchers, and doctoral students supplemented

the TOPS data collection with special studies and used TOPS

data for secondary data analysis. TOPS data collection forms

were used by Daytop in their mini-university followup and in a

community mental health center study of appropriate diagnoses of

drug use by physicians and mental health practitioners. The

emphasis on linkages would promote assessment of how individual

study results can be integrated into the existing body of knowledge.

Studies of the Drug Treatment System Organization

Perhaps the major change which has taken place in drug abuse,

alcohol, and mental health treatment systems recently has been

the switch to State-directed block grant funding. Clearly, there

is a need to develop knowledge about the types of organizations

and treatment services which may be efficient and effective

under this system. It is likely that in many States and localities

at least some drug abuse treatment services will become more

closely associated with alcohol and mental health services, and it

is important to assess the outcome of these changes from a

clinical or treatment effectiveness point of view, particularly for

clients with multiple problems.

FOOTNOTE

1

It should be noted that TOPS defines termination as the last

physical contact with the OPDF program for counseling. Official

records used for reporting to NIDA’s Client Oriented Data Acquisition Process (CODAP) management information system could

show a discharge date up to 30 days after the last contact.

Therefore, compared to CODAP, TOPS data would indicate shorter retention.

REFERENCES

Ball, J.C.; Rosen, L.; Flueck, J.A.; and Nurco, D.N. Lifetime criminality in heroin addicts in the United States.

J Drug Issues, 12(3): 225, 1982.

McLellan, A.T.; Luborsky, L.; Woody, G.E.; and O’Brien,

C.P. An improved diagnostic evaluation instrument for substance abuse patients: The Addiction Severity Index,

J Nerv Ment Dis, 168: 26-33, 1980.

Moos, R.H.; Cronkite, R.C.; and Finney, J.W. A conceptual

framework for alcoholism treatment evaluation. In: Pattison,

E.M., and Kaufman, E., eds. The American Handbook of

Alcoholism. New York: Gardner Press, 1981.

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National Institute on Drug Abuse. Effectiveness of Drug Abuse

Treatment Programs. DHHS Pub. No. (ADM) 81-1143.

Washington, DC: Supt. of Docs., 1981.

Quinones, M.A.; Doyle, K.M.; Sheffet, A.; and Louria, D.B.

Evaluation of drug abuse rehabilitation efforts: A review.

Am J Pub Health, 69(11): 1164-1169, 1979.

Sechrest, L.; West, S.G.; Phillips, M.A.; Redner, R.; and

Yeaton, W. Some neglected problems in evaluation research:

Strength and integrity of treatments. In: Sechrest and

Associates, eds. Evaluation Studies Review Annual (Vol. 4).

Beverly Hills, CA: Sage Publications, 1979.

Sells, S.B. Treatment effectiveness. In: DuPont, R.L.,

Goldstein, A., and O’Donnell, J., eds. Handbook on Drug

Use. Rockville, MD: National Institute on Drug Abuse,

1979.

Sells, S.B.; and Simpson, D.D., eds. Effectiveness of Drug

Abuse Treatment (Vol. 3). Further studies of drug users

treatment typologies and assessment of outcome during treatment in the DARP. Cambridge, MA: Ballinger Publishing

Company, 1976.

Simpson, D.D.; Joe, G.W.; and Bracy, S.A. Six-year followup

of opioid addicts after admission to treatment. Arch Gen

Psychiatry, 39(11): 1318-1323, 1982.

Simpson, D.D.; Savage, L.J.; and Lloyd, M.R. Followup evaluation of treatment of drug abuse during 1969 to 1972. Arch

Gen Psychiatry, 36: 772-780, 1979.

Simpson, D.D., and Sells, S.B. Evaluation of Drug Abuse

Treatment Effectiveness: Summary of the DARP Followup

Research. Rockville, MD: National Institute on Drug

Abuse, 1982.

Williams, J.R. Prospective Cohort Study of Drug Abusers Admitted to Treatment: Developing a Research Protocol. Prepared for the National Institute on Drug Abuse by the

Research Triangle Institute. Rockville, MD: National

Institute on Drug Abuse, 1975.

AUTHORS

Robert L. Hubbard, Ph.D.

J. Valley Rachal, M.S.

S. Gail Craddock, M.S.

Elizabeth Cavanaugh, B.A.

Center for Social Research and Policy Analysis

Research Triangle Institute

P.O. Box 12194

Research Triangle Park, NC 27709

68
Program-Based Evaluation

Research in Therapeutic

Communities

George De Leon, Ph.D.

There are four major treatment modalities addressing the problem of

substance abuse: detoxification, methadone maintenance, drug-free

outpatient settings, and therapeutic communities (TCs). Each modality

has its view of drug abuse; each impacts the abuser in different ways:

and the effectiveness of each must be evaluated in terms of its own

principal aims.

The primary aims of therapeutic communities are to achieve the

following: a global change in lifestyle reflecting abstinence from

illicit substances, elimination of antisocial activity, increased

employability, and prosocial attitudes and values. A critical assumption

in TCs is that stable recovery depends upon a successful integration of

these social and psychological goals. The rehabilitative approach,

therefore, requires multi-dimensional influences and training that, for

most clients, can occur after an extended period of living in a 24-hour

residential setting.

The effectiveness of therapeutic communities has been evaluated primarily through followup studies. Many of these have been executed by

investigating teams engaged in large scale modality comparisons that

include therapeutic communities. Others have been conducted on and

by individual TCs. This chapter selectively reviews these programbased studies to assess the effectiveness of the TC. The emphasis of

this research has been on treatment outcome, although there has been

some investigation of retention and treatment process. Illustrative

findings and conclusions from these studies are summarized briefly.

The literature is not surveyed exhaustively, nor is it reviewed

critically. Three criteria guided the selection of research to be

reviewed. First, studies involved therapeutic communities whose

planned duration of treatment exceeded 12 months in residency.

Studies of hospital-based and shorter term TCs were excluded on the

assumption that these constituted departures from the traditional TC

model either in treatment goals or in the procedures. Although

evaluation of these modified TCs is important, their findings would not

fairly reflect the effectiveness of the traditional approach. Second,

the studies were conducted by research teams that were affiliated

69
with, or based in, therapeutic community settings. Third, the studies

have been published, were in press, or were technical reports of

completed projects. Finally, findings from externally based research

(multimodality) are also cited to highlight corroboration or disagreement

with the conclusions drawn from the program-based evaluations.

TREATMENT OUTCOME

The program-based followup studies surveyed varied with respect to

sample size, length of followup period, number of variables observed

and complexity of data analysis. However, all observed at least one of

three separate outcome variables: illicit drug use; criminality and

unemployment; and several constructed composite measures of individual

social adjustment (success or favorable outcome status). Most of the

studies utilized self-report which was considered reliable, although

several also contain corroborating information from outside agencies.

Separate Outcome Variables

All of the studies revealed that immediate and long-term outcome

status of the clients followed improved significantly over pretreatment

status. Drug use and criminality declined while measures of prosocial

behavior (employment and/or school involvement) increased (Aron et al.

1976; Barr and Antes 1981; Brook and Whitehead 1980; De Leon 1984;

De Leon et al. 1979; Holland 1978, 1983; Pin et al. 1976; Pompi et al.

1979; Romond et al. 1975; Wilson 1978; Wilson and Mandelbrote 1978).

Studies which examined differences between clients who complete

(graduate) and those who drop out of treatment indicated that the

graduates were significantly better than dropouts on all measures of

outcome. The investigations that analyzed time-in-program reported a

positive relationship between favorable outcome and length of stay in

treatment among dropouts (Barr and Antes 1981; Coombs 1981; De Leon

1984; De Leon et al. 1979; Holland 1978, 1982; Wilson and Mandelbrote

1978). None of the recent studies yielded contrary results, although

the magnitude of the changes varied, and several with positive findings

failed to obtain time-in-program differences (Brook and Whitehead

1980).

Success Rates

A few studies utilized a composite index of outcome, based upon selfreported employment, opiate use or primary drug use, and criminal

activity. In these studies, maximally or moderately favorable outcome

occurs in approximately half of the clients followed (De Leon 1984).

Figure 1 illustrates the stability of therapeutic community success

rates in relation to length of stay. Two cohorts of male opioid

abusers, drawn from different admissions populations, were compared at

followup. Success rates by time-in-program for both cohorts were

virtually indistinguishable, ranging from zero percent for those who

remained under one month to approximately 50 percent among dropouts

beyond a year in treatment (De Leon et al. 1982).

7 0
FIGURE I

Success & Improvement Rates

Comparisons between the 1970-71 and 1974 cohorts through 2 years of

followup for male opioid abusers. Success (group 4) and improvement

rates by time-in-program (TIP) are shown by the 1974 TIP

classifications. There are no significant cohort differences at any

point on the curve, revealing a striking replication of the time-inprogram function.

7 1
These social adjustment findings have been obtained in large-scale

multimodality efforts that included therapeutic communities. For

example, in the Drug Abuse Reporting Program (DARP) samples of

therapeutic community dropouts and completed clients, the direction

and magnitude of results obtained on outcome variables and composite

indices vary little from those obtained in the program-based evaluations. Moreover, the DARP studies also substantiated the significant

relationship between time-in-program and outcome (Simpson and Sells

1982). In general, other multimodality evaluations report similar

findings for the traditional TCs studied (Bale et al. 1980; Sheffet et

al. 1980), although one investigation didn’t obtain length-of-stay

differences (Burt et al. 1979).

Psychological Adjustment

Although a primary goal of therapeutic communities is psychological

adjustment, this domain appears in few outcome studies (Brook and

Whitehead 1980; De Leon 1984; De Leon and Jainchill 1981; Kennard

and Wilson 1979). In these, psychological scores or profiles

significantly improved at followup-a finding obtained in all of the

investigations reviewed, including those outside of the U.S.A. The

Phoenix House studies have demonstrated a direct correlation between

social adjustment (success rate) and psychological adjustment at twoyear followup (De Leon 1984; De Leon and Jainchill 1981).

Factors Associated with Successful Outcome

Does success or improvement relate to treatment or to client factors?

This question still requires research answers. Added to these factors

are the apparent influences of maturation and intercurrent life events

upon long-term, posttreatment status.

Only a few studies, program-based or otherwise, have systematically

examined factors that are associated with successful outcome.

Primarily, these studies have focused upon predicting outcome status

from client and background characteristics, pretreatment variables, and

treatments after discharge from TCs (De Leon 1984; Holland 1978;

Simpson and Sells 1982).

Significant correlations have been obtained between demography,

primary drug, and successful outcome; although these findings were not

stable and tended to vary across studies. For example, in the Phoenix

research, females and opioid abusers showed higher success rates, and

females revealed significantly better psychological adjustment than did

males at followup (De Leon and Jainchill 1981). Although the difference in psychological outcome by sex was impressive, it remains to

be replicated in other programs.

Regression studies have identified several predictors of the separate

outcome measures, e.g., lifetime criminality, pretreatment educational

level, opioid drug use, and reentry into treatment within the first postdischarge year (De Leon 1983a; Simpson and Sells 1982). Though

significant, these associations were small when compared with the

effects of time in program. Moreover, they failed to predict

72
successful status when measured with the composite index (De Leon

1983b).

Finally, program-based studies have assessed nontreatment hypotheses in

explaining positive outcome. In these, behavioral cycle, statistical

regression, social climate factors, maturation, and other influences have

been rejected as valid alternatives to treatment effectiveness (De Leon

et al. 1982; De Leon 1984; Holland 1984).

In summary, the findings from the program-based followup research

provide convincing evidence for the effectiveness of the TC approach

for drug abuse. Significant improvements occurred on the separate

outcome measures of social adjustment (drug use, criminality, and

employment), and on composite indices for measuring individual status.

With few exceptions, followup studies reported a positive relationship

between time-in-program and posttreatment outcome status. Generally,

these findings were obtained in larger scale, externally based followup

studies that included therapeutic communities.

In the few program-based studies that investigated psychological

outcome, results uniformly showed significant improvement at followup.

Recent Phoenix House studies have demonstrated a direct relationship

between success status and psychological adjustment at followup.

Univariate and multivariate investigations revealed relatively few

significant predictors of successful outcome other than length of stay

in treatment. Finally, several program-based studies have advanced

persuasive arguments and data that reject various nontreatment

hypotheses offered as alternatives to treatment effectiveness.

RETENTION

The most consistent predictor of successful outcome has been length of

stay in treatment. This finding stresses the importance of understanding retention as a phenomenon in its own right. Notwithstanding

the importance of this issue, research has not systematically

investigated the three main retention questions: What are the retention rates? Who are the dropouts? And, why do they leave treatment?

Reviews of retention studies have been published (Baekland and

Lundwall 1975; Brook and Whitehead 1980; Cole et al. 1981). The

main findings and conclusions from the few program-based investigations on retention can be summarized briefly.

Correlates of Retention

Most of the dropout studies, program-based or otherwise, have focused

upon client characteristics and selected pretreatment variables that

correlate with retention. In these studies, typical client profiles in

relation to retention have not been delineated. While some variables

have consistently correlated with length of stay, their predictive power

has not been corroborated in replicational study designs.

73
The variables studied in relation to retention may be grouped into

several categories which assess demography, client background

characteristics, or client status prior to entry into treatment: (1)

Demography and primary drug: these variables have not consistently

related to retention, although Hispanics and non-opioid abusers have

revealed significantly shorter length of stay (De Leon 1983a); (2)

Previous treatment history: the number and type of previous treatment

experiences have not related to retention in TCs, although a few

studies report somewhat longer retention in those with more previous

treatment admissions. Specifically, among readmissions to the same

programs, the number of days before initial dropout has been found to

be a significant predictor of long-term retention in subsequent

admissions (De Leon 1983b; De Leon and Schwartz 1984); (3)

Background (lifetime characteristics): family background, criminal

history and social relations generally have not related to retention in

treatment, although those with longer and more severe lifetime criminal

histories reveal shorter durations of stay in therapeutic communities

(De Leon 1983a); (4) Current status (pretreatment): variables

describing the client’s status in the days or months prior to entry into

treatment generally do not relate to retention. However, younger

clients with legal pressure, admissions with prior attempts at ceasing

drug use, clients who are less defensive about their problems, or those

who desire to change their deviancy remain somewhat longer in TCs

(De Leon 1983a; Holland 1982); and (5) Psychological adjustment:

several investigations indicate that early dropouts reveal higher levels

of psychological dysfunction measured with standard paper and pencil

instruments (Sacks and Levy 1979; Wexler and De Leon 1977).

Although significant, the magnitude of the correlations between

psychological scores at admission and length of stay is moderate, indicating their relatively low predictive power. One impressive finding,

however, obtained in a recent investigation involving a consortium of

therapeutic communities, revealed a striking relationship between

psychological change during treatment and overall retention. Individuals who improved psychologically within the first several months

after admission showed a significantly greater likelihood of continuing

their stay in treatment (De Leon 1980). This finding has obvious implications for clarifying the relationship between client progress and retention.

Retention Rates

Retention rates in therapeutic communities have received some

attention in the program-based literature (Brook and Whitehead 1980;

De Leon and Schwartz 1984; Glaser 1974; Sansone 1980). Generally,

these studies agree in revealing a rather high dropout rate in

therapeutic communities, although interpretation of these rate studies

is clouded by the method of analyzing and reporting retention data.

For example, a summary statistic is usually provided of either the

percentage of those who failed to complete treatment or 12 month

retention rates. These single values ignore differences in residential

programs such as planned treatment duration. The units of analysis

vary (days, weeks, months, quarters) as do the methods of calculating

rates (i.e., based upon all admissions, dropouts, surviving admissions).

74
Moreover, the temporal pattern, or critical points of dropout, have not

been well described.

Several of these difficulties have been overcome in a recently

completed, program-based, research project in which retention rates

and the temporal pattern of dropout were compared among drug-free

residential programs in several data sets (De Leon and Schwartz 1984).

The main results show: (a) across seven traditional therapeutic

community programs, the 12-month retention rate ranged from 9% to

15%; and (b) based upon rates adjusted for those who left treatment

(“survivor rates”), estimates indicated that the likelihood of continued

retention increased significantly with longer stay in treatment. Figure

2 shows, for example, that almost 70 percent of clients remaining in

treatment 180 days continue through 9 months’ residency.

Analysis of other data sets revealed that attrition is the rule in all

drug treatment modalities. For example, among 1979 admissions to all

federally funded treatment programs in the CODAP system, 12-month

75
retention rates averaged 22% in methadone maintenance, 9% in drugfree ambulatory programs, and 7% in drug-free residential programs (De

Leon and Schwartz 1984). Yearly analyses have reliably documented a

decline in annual retention rates across all modalities from 1964

through 1980 (Bayer and Koenigsberg 1981; Simpson and Joe 1976).

Some recent evidence, however, suggests a reversal of this trend in a

number of traditional TCs.

Finally, the temporal pattern of dropout is remarkably stable. Figure

3, for example, presents retention curves for the residential drug-free

modality in several data systems. Though not shown, this pattern of

dropout is the same for nonresidential settings, methadone, and

outpatient drug-free programs. While the absolute levels of dropout

may vary (higher retention for methadone maintenance), the shape of

the retention curve is the same as that depicted in Figure 3.

FIGURE 3

Retention in Several Data Systems (DARP admissions, 1969-71; TCA,

1979; CODAP, 1979; Phoenix House, 1979)

Reasons for Dropout

Why clients drop out of treatment is a question that has not been

investigated adequately, although several research teams are currently

exploring this aspect of retention (De Leon 1983a). Hypotheses concerning client reasons for dropout have been offered mainly from

76
clinical impressions, with some preliminary research, and remain to be

empirically tested (Baekland and Lundwall 1975; De Leon 1980; De

Leon and Rosenthal 1979; Heit and Pompi 1977; Sansone 1980).

In summary, program-based research on retention reveals only sporadic

and weak correlates of dropout with demographic factors, primary drug,

background characteristics, pretreatment status, and psychological adjustment. No client profile has emerged that predicts length of stay in

treatment. This conclusion is confirmed in multimodality investigations of client predictors of dropouts (Burt et al. 1979; Sheffet et

al. 1980; Simpson and Joe 1976). For example, the DARP studies conclude that patient characteristics are not strong predictors of retention

in any treatment modality (Joe 1976).

Research on some quantitative aspects of retention, however, has

yielded lawful and predictable patterns of retention in long-term

therapeutic communities. Dropout is highest within the first 15 days

of admission and declines sharply thereafter in such a way that the

likelihood of dropout decreases with length of stay itself. Although

overall retention rates differ across programs and modalities, the shape

of their retention remains uniform. Thus, attrition is the rule in drug

treatments, substantiating the observation that retention is a lawful

phenomenon. Finally, little is known of the client’s reasons for leaving

or remaining in treatment.

TREATMENT PROCESS

Treatment process has been the least investigated problem in drug

abuse treatment research. Ironically, the first process studies in TCs

appeared more than a decade ago, but their importance receded in

favor of the need to establish firm information concerning treatment

effectiveness and cost effectiveness.

To facilitate review, the relatively few process related studies in the

literature were classified into three categories: studies of treatment

change, direct investigations of treatment process elements, and client

attribution of treatment influences. A departure from the previous

sections is that published studies in the last 12 years were included

along with data from several unpublished efforts.

Treatment Change

These studies examined psychological measures of client change during

their stay in programs without assessment of treatment components.

They are reviewed as process studies since many of the psychological

scores measured change as reflecting program goals, e.g., attitudes, ego

strength, emotional control, responsibility, self-esteem, etc. Together

with behavioral changes in drug use and antisocial behavior,

psychological change during residency strengthens inferences concerning

the specific influences of treatment elements.

The program-based studies employed standardized psychological

inventories such as the Minnesota Multiphasic Personality Inventory

(MMPI), the Tennessee Self Concept (TSC), as well as specific scales

assessing I.Q., moods, or psychological symptoms. The studies vary

77
with respect to design, number of variables measured, and the number

of observations during the treatment (Brook and Whitehead 1980; De

Leon 1974, 1976, 1980, 1984; De Leon et al. 1971, 1973, 1984; Kennard

and Wilson 1979; Sacks and Levy 1979; Zuckerman et al. 1975).

The results are quite uniform in showing significant improvement on

most psychological scales during treatment. Most apparent is the fact

that the entry profile or pattern of psychological scores is also similar

across programs and even cultures. For example, the signs of

character disorder, personality inadequacy, mood disorder, poor selfesteem and dull-normal intellectual level are prominent. At second

testing, overall psychological status improves significantly across most

measures but generally does not attain normative or healthy levels.

Larger improvements occur in self-esteem, ego strength, socialization,

and depression. Relatively small changes occur in the more enduring

personality features, e.g., the character disorder elements. Thus, drug

abusers in the TC show significant improvement in most psychological

domains, although long-standing character traits are more resistant to

change.

Several studies contained multiple measurement points of psychological

change during treatment and at followup (Brook and Whitehead 1980;

De Leon 1984). The results are fairly uniform in showing that

psychological improvement posttreatment generally exceeded the gains

made during treatment, although one study obtained no further gains at

four year followup beyond those obtained in the first posttreatment

year (Brook and Whitehead 1980).

The studies completed at Phoenix House further correlated social

adjustment (success status) with psychological improvement during

treatment and at followup. Clients with an unfavorable success index

at followup showed little psychological change during treatment or at

followup. In contrast, clients who obtained a favorable success index

revealed significant psychological improvement during treatment and

continued psychological gains at followup. This important finding

offered indirect, but positive, evidence for the influence of treatment

factors in the change process (De Leon 1984).

Studies of Process Elements

These studies addressed the relationship between specific treatment

elements and client change during residential treatment. Two early

studies at Phoenix House evaluated the immediate effects of the

encounter group experience upon emotional and physiological changes in

group participants. When compared with baseline measures, results

showed significant reductions in self-rated emotionality (depression,

hostility, anxiety) and in physiological “upset” (systolic blood pressure)

immediately following participation in encounter therapy sessions (Biase

and De Leon 1969; De Leon and Biase 19751.

Research in progress at Daytop Village therapeutic community has

experimentally evaluated the effects of a specific educational

intervention (college credit courses) upon clients in a therapeutic

community during the primary treatment stage of their residency.

78
Eligible clients were matched on a number of variables and were

randomly assigned to one group, those who received college courses in

addition to their usual treatment, or to a second group, those who only

received the usual TC treatment. Significant longitudinal changes in

self-concept occurred for both groups, but gains were larger in the

college clients. These findings support the TC assumptions concerning

process and role changes. The student role significantly enhanced selfesteem over that expected from treatment effects alone in the TC

(Biase 1981).

The design of the above studies evaluated clients under various

controlled or comparative conditions (e.g., no college, discussion groups,

work activities). This design strengthens conclusions concerning the

effects of the specific treatment interventions (e.g., encounter group

or college). Thus, though limited, these investigations affirm the

feasibility of studying treatment process with acceptable methodology.

Treatment process has also been examined in several program-based

studies which measured client and staff perception of the therapeutic

community environmental elements, using an instrument based upon

empirically derived dimensions which assess aspects of social and health

environments such as prisons, hospitals, and community oriented

programs. The respondents completed two forms of the instrument,

expressing their opinions concerning the actual state of the

environment and the way the respondent would like to see the

environment if it were the best possible treatment program.

Despite the preliminary investigative status of this area, the research

has provided a considerable amount of information from several programs, with apparent consistent results. First, all TC programs in the

research revealed environmental profiles that were similar and positive

compared with profiles obtained from prisons and hospitals. Thus, the

assumption that common philosophy and practices underlie the

traditional TCs, which generate a unique treatment environment, is not

contradicted by the staff’s and residents’ perceptual data provided in

the studies. Second, client perceptions of the environment were in

accord with expectations concerning the treatment process associated

with length of stay (De Leon et al. 1980).

Attribution

These studies have investigated client perceptions of their experiences

in TCs (Browne 1980; Simpson and Lloyd 1979; Wexler and De Leon

1983; Winick 1980). Generally, on measures of satisfaction, clients

reported a favorable experience in the therapeutic community and

would recommend their particular residential program to others. Other

analyses have yielded findings clarifying the specific relationship

between program components and client status during and after

treatment. One study of in-treatment change obtained a positive

association between time-in-program, client insight, and participation in

encounter groups (Browne 1980).

A large scale, program-based study assessed the relationship between

clients’ status at followup and their retrospective perceptions of the

7 9
treatment experience (Wexler and De Leon 1983). Successful status

and length of stay in treatment were directly related to client ratings

of their satisfaction with treatment, the relevance of specific program

components to their status, and their weighting of the relative

importance of treatment and nontreatment influences upon their

lifestyles since leaving Phoenix House. Although clear, these findings

must be interpreted cautiously, given their retrospective nature.

Possible halo effects, or dissonance factors, might have influenced

client perception of treatment experience and their own followup

status. Nevertheless, the results firmly support hypotheses concerning

the relationships between treatment experience, treatment elements,

and outcome status.

In summary, there is relatively little published research on the

treatment process in therapeutic communities. The small program-based

literature has, for the most part, indirectly examined process through

longitudinal studies of treatment change, and clients’ retrospective

perceptions of their treatment experience. Only a handful of studies

directly investigated the relationship between program components and

client change.

In general, the findings from all these studies support inferences

concerning the process of client change, although the process itself

remains to be studied directly. This conclusion is not contradicted by

the findings of the few multimodality studies which contain measures

of clients’ perceptions of the treatment experience.

SOME IMPLICATIONS FOR FUTURE RESEARCH

The treatment research reviewed, both program and externally based,

appears to have converged upon several conclusions, issues of

interpretation, and implications for future research directions. These

are discussed in relation to the three main areas of inquiry reviewed.

Treatment Outcome

A substantial followup literature indicates that drug treatments are

effective when evaluated in terms of their principal aims. Programbased followup studies, for example, have firmly established the

effectiveness of the TC approach in terms of its principal aim of

modifying both social and psychological adjustment.

Nevertheless, conclusions concerning treatment effectiveness remain

tentative in light of familiar methodological considerations, the most

serious of which is the lack of control groups. The followup samples

studied may be self-selected to seek, remain in and benefit from the

TC; or, perhaps, to improve without any treatment. Thus far,

however, solutions to these selection problems have eluded research

design strategies. Assembling untreated matched controls or

comparative treatment groups through random assignment has not been

feasible. There are ethical problems in withholding treatment; and

random assignment to modalities has resulted in high and differential

attrition rates, presumably arising from client-treatment mismatch. (As

80
noted below, however, random assignment within treatment programs

can be implemented).

These difficulties stress the need for a revised perspective on the

interpretation of treatment outcome research that would reflect the

multivariate complexity of individual change. One such perspective has

been outlined for therapeutic communities in other writings (De Leon

et al. 1982). Briefly, successful outcome emerges from an interaction

of client, treatment, and nontreatment influences. The specific impact

of the treatment experience is most apparent during and immediately

following residency; thereafter, though less recognizable, treatment

effects may integrate with (or perhaps alter) the contribution of other

experiences in maintaining successful status.

This perspective emphasizes several assumptions that are relevant for

the design of outcome studies. First, drug abusers can be classified

according to differences actually observed in relation to their

treatment involvement. This suggests that the universe of drug abusers

can be quadrisected by definition: Those who come to treatment and

those who do not, and within each, those who make positive changes

and those who do not.

The differential outcomes among the four groups reflect each group’s

unique membership. For example, those untreated drug abusers who

mature out of their addiction lifestyle are simply different people from

those who enter treatment and change. This assumption avoids the

dead end criticism of the no-treatment control since the four groups

do not serve as controls for each other, although they can be usefully

compared.

Second, among those who enter treatment, change reflects an

interaction between the individual and the treatment. This implies a

mutual, bidirectional exchange between the person and the treatment

environment. Thus, treatment influences, as unique measurable events,

are not readily extractable. Furthermore, the treatment experience

itself is an episode, one of many experiences in the individual’s

continually changing status. Thus, “proving” a treatment influence is

less relevant than identifying its contribution to a continuing process

of individual change.

From this perspective, treatment effectiveness should be assessed for

those clients who seek, or perhaps remain in, treatment settings.

Comparisons among the clients in the other quadrants, however, could

reveal much about individual differences and the many influences that

contribute to the change process.

Finally, the primary source of information about this process is the

client’s own view of the relevant influences. External corroboration of

client change through records or other evidence validates the fact of

change, but does not reveal the reason for change. In the last

analysis, it is the client who evaluates the relevant influences in his

or her life.

81
Retention

Dropout is the rule across all drug treatment modalities. The programbased retention findings reviewed contain several implications for

directing research on this problem. First, although factors have been

shown to correlate with retention, the consistency and magnitude of

their predictive power has been relatively low. This finding was substantiated in the externally based studies of the number of programs,

modalities, or variables surveyed.

The fact that retention is difficult to predict from client characteristics suggests that the populations studied (drug abusers seeking

treatment) are, not unexpectedly, more similar than different. Hence,

measures of their characteristics tend to show relatively low variability, evident in the generally small to moderate multiple correlations

obtained in regression analyses predicting time in program.

Nevertheless, even those who seek treatment could be diverse in ways

that have not yet been fully explored. These presumed differences

reflect not who clients are, in terms of fixed background characteristics, but how they perceive themselves, their circumstances, and their

life options at the time of treatment contact.

Assessment of these differences could focus upon at least four domains

of client perception variables which alone, or in combination. affect

dropout:

(1) Motivation (intrinsic pressures): This refers to the severity of the

problem and the need for personal change;

(2) Circumstances (extrinsic pressures): These refer to influences from

family, personal relationships, health and legal conditions, employment,

educational, and fiscal matters;

(3) Readiness: This refers to the perceived need for any treatment to

assist in personal change, compared with alternative options such as

self-change or other offerings; and

(4) Suitability: This refers to the client’s understanding and

acceptance of particular treatment approaches.

The specific variables within each domain remain to be elaborated, and

their relevance to the orderly retention curve must be investigated

empirically.

Second, the pattern of retention is lawful and quantitatively

predictable, but the phenomenon itself remains to be explained. Not

unlike the perspective on outcome, however, retention can be viewed

as a complex interaction of client diversity and treatment influences.

Shifts in the relative contribution of each component may be reflected

in the different segments of the retention curve. Within this

interactional context, however, a constant proportion of dropout is

82
expected when homogeneous procedures (e.g., treatment) are imposed

upon a diversity of clients.

Nevertheless, the stable temporal characteristics of retention can be

utilized by researchers and program managers in several ways. For

example, these permit analyses of factors that may alter expected

dropout rates. The critical points of termination are particularly

relevant for treatment planning and for enhancing retention. Finally,

the relatively invariant temporal pattern provides a reliable dependent

variable in evaluating efforts to reduce dropout.

Treatment Process and Program-Based Research

The importance of treatment process studies is evident to most

investigators. To a large extent, the conclusions concerning treatment

retention and effectiveness highlight the need to clarify the treatment

process. Although impressive, the relationship between length of stay

and treatment outcome only indirectly implies the influence of

treatment elements upon client status. Process studies can render

explicit the correlation between actual events in treatment and change

in client status. It is this interplay between treatment elements and

client change which defines process.

The study of drug treatment can best be advanced by a complementarity between externally- and program-based research efforts.

Much has been learned from program-based research as to the

implementation of studies in treatment settings (see, for example, De

Leon 1979, 1980). An important lesson from these efforts is that

treatment process is perhaps the one investigative area that is uniquely

suitable for program-based or affiliated research teams. This is

evident in the following points.

First, as noted earlier, some of the treatment process studies of

therapeutic communities employed rather rigorous research designs

involving control conditions or random assignment procedures. The

implementation of these designs is possible only in treatment settings

that involve the complete cooperation of staff and clients. The

likelihood of obtaining this cooperation of staff and clients is greater

with program-based research personnel.

Second, the successful completion of process studies will vary directly

with the degree to which programs view their utility. Clinical and

management personnel appreciate outcome studies since these are

relevant to issues of funding, program marketability, and staff morale.

Moreover, these studies exert relatively little demand on program

activities. Treatment process research, however, imposes heavy strains

upon program activities, and it is understandably resisted by staff

unless they can see its benefits. Thus, acceptance and utilization of

treatment process research is more likely to be facilitated by programbased research teams who serve in educative roles.

More generally, treatment process studies should be designed to solve

problems rather than test theories. Human services programs

experience practical, everyday problems concerning staff turnover and

83
training, client dropout, and inconsistent treatment outcomes. Thus,

treatment process studies present the strongest challenge to

researchers, program-based or otherwise, to provide relevant answers

for pressing clinical and administrative questions.

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MMPI patterns in drug abusers before and after treatment

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286-296, 1975.

AUTHOR

George De Leon, Ph.D.

Director of Research & Evaluation

Phoenix House Foundation

164 West 74th Street

New York, New York 10023

87
Clinical Trials in Drug Treatment:

Methodology

Sharon M. Hall, Ph.D.

The most common form of clinical trial is the between-group

comparison study. Subjects are randomly assigned to one or more

innovative treatment conditions or to a control condition. Variants of

between-group designs are the most powerful tools available for

determining the effects of treatment. An optimally designed, betweengroup, clinical trial can control for time in treatment, therapist

attention and qualifications, client and therapist expectations, and

client characteristics. Multiple examples of this design are in the drug

treatment literature (for example, Hall et al. 1981a, 1981b; Stanton et

al. 1980).

The within-subject design is less common. Here, different treatment

conditions are sequentially presented to the same subject or to a small

group of subjects. Comparisons are then made across different

treatment conditions for the same subject(s). The best example of the

within-subject design in drug treatment is the systematic work of

Stitzer and her colleagues on contingency contracting (Stitzer et al.

1980).

No matter which design is used, two groups of factors are important in

evaluating a controlled trial: Experimental design and treatment

design.

EXPERIMENTAL DESIGN

Experimental design includes factors which are central in determining

the internal validity of the study. Internal validity refers to the

degree to which the results of a study can be interpreted unambiguously (Campbell and Stanley 1963).

Design survival is a necessary, but not sufficient, criterion for a

controlled trial’s usefulness. This term refers to whether the

treatment design survived the study so that the outcome can be

interpreted as an experiment. A second factor is outcome

measurement. Since drug abuse affects many aspects of a client’s life,

multifocal measures are usually preferable to single-focus measures.

As in any research endeavor, measures should be reliable and valid.

88
The issue in evaluating sample size is usually whether the experiment

includes enough subjects to detect significant differences in the

population. Occasionally, however, the rationale for unusually large

sample sizes is not clear. Attrition is related to sample size; high

attrition rates can reduce an originally acceptable sample size to a

final sample that is too small to detect differences. It can also result

in inadvertently testing only the most highly motivated subjects.

Differential attrition can produce treatment conditions which become

confounded on crucial variables. Finally, in the ideal experimental

design, nonspecific factors can be ruled out, and any outcomes can be

attributed to the specific aspects of the treatment. That is,

differences between conditions cannot be attributed simply to different

amounts of time in treatment, or different amounts of attention from

therapists. Similarly, treatments can be presented so that client

expectations of success differ. This can occur independently of actual

treatment efficacy. Expectations of success and actual success are

probably related; thus, in the ideal designs, subjects in all conditions

enter treatment with identical expectations of success.

TREATMENT DESIGN

Treatment design refers to the adequacy of the experiment as a test

of a particular treatment; that is, whether the findings can be

generalized and applied to actual clinical practice.

Credibility and representativeness of change agents are part of

treatment design. For example, a psychiatrist and a drug counselor

are perceived differently as health providers. While it is difficult to

say which class of provider is most effective (LoScuito et al. 1979),

clear cut differences between them may well confound provider

differences with treatment differences. Also, atypical change agents

may produce non-replicable findings, and subject representativeness

must be a factor when considering the treatment population for which

results can be generalized. This is particularly crucial in drug

treatment, since client characteristics vary widely across and within

modalities. Both the number and representativeness of different

settings must also be considered in generalizing results. Studies

replicated in multiple facilities are less likely to be confounded by

characteristics unique to a single facility than studies completed in one

facility.

Some followup is usually necessary for results to be clinically useful.

The standard length for followups is 6-12 months, since relapse usually

happens immediately after treatment termination (Hunt et al. 1971).

Protocol adherence is another aspect of treatment design; treatments

can change subtly as therapists gain experience or lose enthusiasm.

Therefore, studies which use a treatment manual or some other method

of formally standardizing treatment are more likely to produce

treatments which are consistent over time. Thus, what is being

evaluated is clearer.

Factors in this review were addressed only if they affected the

interpretation of the study.

89

215-494 0 - 88 - 4 : QL 3
STRATEGY AND CLINICAL TRIALS

The value of a clinical trial rests not only on its individual

characteristics, but also on the research strategy in which it is

embedded. Three strategies have been used in evaluating drug

treatments: single trials; multiple-site, partial replications; and series

of partial replications.

Single Trials

Most controlled studies are single trials completed in isolation from

other research. An example is the large-scale, family therapy trial

completed by Stanton et al. (1980). The advantages of single trials

center around the great degree of possible control; because single

trials are executed by a single investigator or investigative team on

one subject sample, confounding variables can be tightly controlled or

eliminated. Also, the protocol can be explicitly developed. On the

other hand, single trials have no built-in replication mechanism, as do

the other research strategies. Single trials do not provide estimates of

the parameters of conditions under which a particular treatment is

effective. Further, they do not allow convergent validation; that is,

they do not indicate whether conceptually similar therapies applied in

slightly different ways produce a given result. Single trials are

potentially the most dangerous in terms of risk/benefit ratios; there is

always the risk that, despite considerable effort, a controlled trial will

collapse and fail to yield useful information.

Multiple Site, Partial Replications

In partial replications at different sites, studies are completed at more

than one site by different investigative teams. This category does not

include studies completed at different treatment facilities by the same

team, where the goal is to use exactly the same procedures at each

facility. In that case, treatment facility is simply an independent

variable in a single trial. For partial replications at multiple sites,

independent and dependent variables may be drawn from the same

universe but need not be used in exactly the same fashion. This

strategy gives a broad picture of the efficacy of a particular

intervention and is especially informative if general outcomes are

replicated, since the strategy provides information about the conditions

under which treatments are useful, as well as the convergent validity

of a particular treatment. Also, differences in outcome between sites

help develop preliminary hypotheses. The risk of not having useful

information is lower, since failure at one site does not prevent useful

information being obtained from another site.

The multiple-site study is logistically more difficult to control. Also,

if outcomes at different sites are the same, the case for validity is

established. If they vary, however, the source of differences is hard

to detect, although hypotheses may be generated.

90
Series of Partial Replications

The final strategy in this type of drug treatment research uses a

series of partial replications. The replicates are partial because some

aspects of the procedure vary, but the general questions asked and

major aspects of the procedures overlap. This strategy usually involves

a series of studies completed at the same site. Examples in drug

treatment include the series of three Job Seekers’ Workshop studies

(Hall et al. 1977; Hall et al. 1981a, 1981b), and the series of

contingency management studies completed by Maxine Stitzer and her

associates at Baltimore City Hospital (Stitzer et al. 1977; Stitzer and

Bigelow 1978; Stitzer et al. 1979a, 1979b, 1980). When properly

designed, such studies have all the advantages of a single trial. They

may also allow a more precise definition of the range of factors that

determine effectiveness. These studies are less risky than the single,

large-scale trial, because, even if one study is defective, others in the

series may yield useful information. Series of partial replications are

generally completed over a considerable time period. Thus, failures to

replicate can be the result of weak and variable effects, or the result

of changes that occur because of the passage of time. An example of

the latter is changes in characteristics of clients attracted to a

particular treatment.

For this review, controlled trials are broken down into three classes:

1) major drug treatment modalities; 2) psychotherapeutic interventions,

including contingency contracting, relaxation training, and biofeedback;

and 3) vocational rehabilitation interventions. Because of the scope of

the literature, studies were eliminated which, even if they had been

executed perfectly, would not have yielded clinically useful

information. These generally had one or more of the following

characteristics: 1) They did not include followups (under conditions

when followups were necessary for results to be clinically meaningful);

2) They had a sample size too small to allow any conclusions; or 3)

They were so incompletely reported that they could not be evaluated.

Also, one or two well-controlled studies (for example, Havassy and Hall

1981) were omitted, primarily because they addressed areas without

sufficient research to draw any useful conclusions.

COMPARISONS OF MAJOR DRUG TREATMENT MODALITIES

An early, ambitious comparison of methadone maintenance and

therapeutic communities was reported recently by Bale et al. (1980).

Five hundred and eighty-five male veterans were randomly assigned

either to methadone maintenance or to one of three therapeutic

communities. Subjects were interviewed, at 6, 12, and 24 weeks

following treatment assignment. A cross check of interview and urine

data indicated fairly good validity. Data was collected on drug use,

criminal behavior, and work and school attendance. However, only 108

of the subjects accepted the random assignment, and spent as long as

1 week in their assigned program. Most subjects dropped out early in

treatment, especially in the therapeutic community condition.

Because of this high dropout rate, and despite an exemplary followup

rate and sophisticated data analyses, the outcome was virtually

uninterpretable.

91
The only other comparison of major treatment modalities which was not

solely a drug trial was the Heroin Antagonist and Learning Therapy

(HALT) project, which began as a trial of behavior therapy, naltrexone,

and naltrexone and behavior therapy combined. This study had a

unique recruiting procedure: Subjects had to “earn” their way into

treatment by completing phone calls to the treatment facility, avoiding

drug use, and performing other prosocial behaviors. The most recent

report (Callahan et al. 1980) presented only data from the naltrexone

condition and the combined condition. Of the 104 potential male

subjects in this condition, 40% earned their way into the naltrexone

therapy condition, and 34% into the combined condition. Dependent

variables were days on naltrexone, time in program, illicit drug taking,

and reported side effects. These variables were assessed during three

7-month periods. The combined group showed more days on naltrexone,

greater time in treatment, and reported fewer side effects during the

initial assessment period. However, these differences disappeared

during the second and third assessment periods.

An earlier report (Rawson et al. 1979) revealed the fate of the

behavioral treatment condition. Of the 71 subjects assigned to this

condition, only 15 (21%) completed the requirements necessary for

entering treatment. Even the behavioral subjects who entered

treatment had worse outcomes, including treatment completion,

completion of therapeutic assignments, and illicit drug use than did the

other groups.

Perhaps the behavioral treatment was so unattractive that only the

most highly motivated clients persisted if they were assigned to that

condition and the behavioral condition greatly worsened their outcome.

Or perhaps only the least functional clients persisted and the

behavioral treatment was potentially as effective, but the subjects

enrolled in it were so impaired that the treatment could not bring

them to the level of the rest of the sample. The latter possibility is

less likely. However, as these considerations illustrate, the cause of

any differences between conditions cannot be attributed to treatments

since subjects may have differed prior to treatment entry.

Summary: Comparison of Major Drug Treatment Modalities

These early studies were basic, and I believe sophistication in design

has increased greatly since their execution. Still, we can learn at

least three lessons from them. First, drug treatment clients will not

accept assignments to widely varying treatments, especially if they

have a stake in one treatment or another.

Second, designs in which treatment entry differs between conditions

are risky and will probably confound variables obtained later in the

study. Both entrance and exit from treatment are clinically interesting

variables, but they should not be studied through random assignment;

any differences between conditions will compromise the interpretation

of the remaining outcome data.

Finally, different drug modalities may attract different client groups.

Therefore, comparisons between modalities are probably not possible

92
since no two modalities approach equal attractiveness for any one

subject pool.

EVALUATIONS OF PSYCHOTHERAPIES

Psychotherapy

Perhaps the best controlled, single study of a psychotherapeutic

intervention was the family therapy study completed by Stanton and his

associates (1980). To be eligible for this Veterans Administration (VA)

study, male applicants for methadone maintenance had to meet a

restrictive set of criteria, including regular contact with parents or

surrogates, and both parents living together in the same household.

Over 25% of the clients screened met these criteria. Eligible subjects

were assigned to family treatment if an opening existed. Otherwise,

they were assigned to a standard treatment control. Family treatment

subjects were randomly assigned to either paid family therapy, unpaid

family therapy, or a paid family movie therapy condition. In the latter

condition, families were paid for attendance at movies and for drugfree urines produced by the subjects. This condition controlled for

time in treatment and for payment. Interview data obtained for two 6-

month blocks following family treatment indicated different patterns of

outcome. In the initial 6 months, both paid and unpaid family

conditions had more drug-free days than the movie group or the

nonfamily group. Differences were stronger for the paid than for the

unpaid group; no differences in alcohol use or in days spent working in

school were found. In the second 6 months, differences between the

conditions were less.

This study was characterized by moderate rates for both pretreatment

drop out (30%) and refusal to participate among family therapy

assignees (21%). Analyses of the data did not indicate that the

legitimacy of the comparisons was compromised by pre-existing

differences between treatment conditions. Also, the nonrandom

assignment probably introduced some unknown bias. However, if this

bias existed, it was not evident. Attrition at followup was moderate

and was not differentially distributed across treatments (11% at 6

months; 17% at 1 year).

This study is strong. The design, subject sample, length of followup,

and verifiability of drug measures all provide reasonable conclusions

about treatment efficacy. The paid family movie condition is an

interesting innovation. However, it does not appear equal in credibility

or expectations of success to the family treatment conditions. Also,

since the treatment was conducted by a drug counselor, therapist

status and expectations about change may have helped determine

outcome. Thus, while the paid family movie condition controls for

amount of contact and for use of contingencies without other

therapeutic intervention, therapist variables are confounded with

treatment variables. Also, the effects of differences in therapeutic

attention and client expectations are unknown. Finally, this study

should be replicated with women, for whom family dynamics may be

quite different.

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Apparently, the only studies in this category using multiple-site, partial

replication in drug treatment were the psychotherapy studies in New

Haven and Philadelphia. The impetus for these studies grew out of a

series of conferences sponsored by The National Institute on Drug

Abuse (NIDA) which considered the issue of psychotherapy-particularly

psychoanalytic therapy-in drug treatment (Woody 1977).

The Philadelphia study indicated that psychotherapy might help addicts

(Woody et al. 1983). On entrance into treatment, male methadone VA

clients were randomly assigned to one of three conditions: 1) supportive expressive therapy, a psychodynamic therapy; 2) cognitive

behavioral therapy; or 3) drug counseling. In the first two conditions,

subjects received psychotherapy from a paraprofessional counselor in

addition to drug counseling. In the third condition, only drug

counseling was provided. AU conditions were conducted according to

detailed treatment manuals. Subjects could continue treatment with

their therapists for up to 6 months. Clients were assessed on a

battery of psychological tests, including the Addiction Severity Index

(ASI) (McLellan et al. 19801, a multi-scale index which taps medical,

legal, drug and alcohol abuse, employment, family and psychiatric

problem severity; on the Schedule for Affective Disorders and

Schizophrenia-Lifetime and -Change versions (SADS-L and SADS-C); and

on urine test results, methadone dose, and licit prescription drug use.

According to study criteria, 60% of the clients were eligible for

treatment. About 60% of these clients entered treatment and

completed three sessions. From the beginning of the study to the

7-month followup, subjects who received psychotherapy in addition to

drug counseling made more and larger gains than those who received

counseling alone. They also were maintained on lower doses of

methadone and ancillary medications, without increases in illicit drug

use.

This study is sound. The experimental manipulations were successfully

completed. The study provides data which indicate that the addition

of psychotherapy to drug counseling may be valuable, especially for

patients in some diagnostic classes (Woody, personal communication,

May 1983).

The primary criticism of this study is that the treatment conditions

differ on time in treatment. The investigators acknowledge this, and

note that their aim was to study efficacy of adding psychotherapy to

drug counseling, not replacing drug counseling with psychotherapy.

Another factor is the possibility (unmeasured) that the conditions

differed in treatment expectations, especially since the therapists

differed in status.

The companion study in New Haven did not find a treatment effect

(Rounsaville et al. 1983). This study evaluated short-term,

interpersonal psychotherapy-a brief psychodynamic therapy for

methadone clients with apparent psychiatric disorders. Subjects were

72 clients diagnosed as having current psychiatric disorders, such as

anxiety or depression. Clients doing poorly in treatment or having

significant psychopathology were especially encouraged to attend. In

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the psychotherapy condition, subjects received 1 hour per week of

individual therapy with a professional therapist. The control condition

did not receive individual psychotherapy, but met with a psychiatrist

once per month for 20 minutes. Treatment manuals were used as

guides. Both conditions received access to all clinical services and the

standard 90-minute group therapy provided all clients. Treatment was

available for 6 months. The multiple outcome measures included

treatment attrition, number of urines positive for illegal drugs, number

of arrests, psychiatric symptomatology, personal and social functioning,

and attainment of individual goals. Attrition was high in both

conditions; only 38% of the subjects completed the psychotherapy

condition, and 54% completed the control condition. The results

indicated few differences between the two groups.

The authors discussed several factors which might have obscured

differences between conditions. They included the large amount of

counseling provided for all subjects, the selection of only

psychopathological subjects, and the restriction that subjects be

recruited into the study only after spending 6 weeks in methadone

treatment (when motivation to change may be less than earlier in

treatment). Two other factors warrant consideration. First, the 90-

minute group sessions and the individual sessions may have provided

conflicting therapeutic directives. Second, by encouraging clients who

were not doing well in methadone treatment to enter psychotherapy,

the most noncompliant clients may have been included in the study.

This could explain the extremely high dropout rates.

These two studies of psychotherapy, taken individually, are clearly

among the strongest in the drug treatment literature. They provide

comparisons of standardized treatments, use treatment manuals, and use

reliable and valid measures with clinically appropriate populations and

therapists. The Philadelphia study controlled attrition sufficiently for

interpretation of results. However, neither study addressed nonspecific

effects or exceptional factors.

These two trials imply that further research is needed on

psychotherapy. They also suggest two methodologies for such research.

One, the measures used may provide the basis for assessing drug

treatment. Both used standardized measures which were sensitive to

therapeutic change in drug treatment clients. Two, the contrast

between outcomes of the two studies suggests that the recruiting and

implementation strategies of Woody et al. (1983) should be considered

in designing additional treatment trials. These strategies include

induction of a broad range of clients early in treatment, as well as

the close integration of drug treatment and psychotherapy staff.

Despite the costs, these two studies illustrate the potential benefits of

multiple-site studies. First, the studies alone are of value. Second,

comparisons between them on the limited set of variables on which

they differ provide some clear hypotheses for further study. Finally,

had the brief analytic therapy been effective in both sites (as it might

in possible future trials), the therapy would be established as a

generally useful tool.

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Contingency Contracting

Contingency management is a behavior change intervention in which

reinforcers and punishers are provided depending on adaptive behavior.

Drug treatment clinics-especially methadone clinics-have control over

several reinforcers which could be used, including methadone dose and

take-home privileges.

A series of partial replications on contingency management were

completed by Maxine Stitzer and her colleagues at Baltimore City

Hospital. Stitzer and Bigelow (1978) demonstrated that take-home

doses can be used on chronic nonattenders to increase attendance at

counseling sessions. Weekend take-home doses, which were either

contingent on or independent of session attendance, were given to 16

subjects during five successive 2-month periods. During contingent

delivery periods, attendance increased significantly above levels

observed during noncontingent periods, when attendence rates did not

return to the same low level observed during the baseline phase.

Stitzer et al. (1980) assessed the effects of a limited contingency

“menu” on heroin use The participants were seven male clients who .

consistently produced morphine-positive urines during a baseline period.

Reinforcement was available during randomly selected weeks for clients

with morphine-free urines. Reinforcers were a choice between $15,

two methadone take-home privileges, or two opportunities to selfregulate dose. During contingent reinforcement, the rate of morphinepositive urines declined significantly. However, the morphine-positive

rate also declined during study periods when no reinforcement was

available.

Two other studies from this group addressed the use of illicit

benzodiazepines among methadone maintenance clients. In the first

study, eight chronic benzodiazepine abusers were given prescriptions

for 20 mg diazepam daily. If they refused their dose, they were given

the opportunity for one take-home dose, or self-regulation of their

methadone dose for a day. During baseline, 95.6% of available

diazepam was requested. Only 11.2% of diazepam was requested when

refusal resulted in take-home doses, and 69.7% when refusal resulted in

methadone dose self-regulation opportunities. Unlike counseling session

attendance and heroin use, requests for the diazepam prescription

rapidly returned to baseline levels when reinforcers were terminated.

This methodology was extended in a subsequent study (Stitzer et al.

1982) to out-of-clinic benzodiazepene self-administration. The ten

subjects were selected on the basis of a history of benzodiazepine

abuse. Benzodiazepine-free urines were reinforced by a choice of two

methadone take-home doses, $15 cash, or two single-day opportunities

to self-regulate dose. The efficacy of the contingencies was evaluated

in an A-B-A (baseline-treatment-baseline) design. Clear effects were

evident in five of the ten subjects; benzodiazepine use decreased

during treatment, and returned to baseline levels during the second

baseline. During the intervention period, three other clients showed

runs of five to eight consecutive clean urines which were not present

during the baseline period.

96
The small-scale, well-controlled studies of Stitzer’s group suggest that

contingencies can control problem behaviors in methadone maintenance

clients. However, these behaviors are sometimes found not to return

to baseline levels when a repeat baseline is included as the final phase

of the study. Since some therapeutic effects occur during

noncontingent periods, nonspecific effects may result from participation

in an experiment.

Similar positive results were reported by Hall et al. (1979) in a study

completed in 21-day outpatient detoxification. Unfortunately, the

methodology of this study did not control for attention-related effects.

The 81 subjects were randomly assigned to receive either standard

treatment, or contingent payment and information feedback for opiate

free urines and treatment completion. A single experimenter

administered both contingent and noncontingent conditions. Contingent

payment increased the rate of drug-free urines on days when subjects

were paid (but not on unpaid days) and did not affect treatment

completion.

Any treatment effect in 21-day outpatient detoxification is important

since this modality may have little therapeutic impact (Sheffet et al.

1976; Wilson et al. 1975). However, this short-term treatment effect

could result from payment, feedback, increased attention, or other

nonspecific factors regulated by this design.

The only negative results from contingency management were those

reported by Havassy et al. (1979) and Havassy and Hargreaves (1981).

The 116 subjects from two methadone maintenance clinics were

randomly assigned to either dose self-regulation, self-regulation with

take-home incentives for dose reduction, or to a standard treatment

control for 48 weeks. No reinforcement effect was found in this

study, even among the subset of clients on voluntary detoxification.

This study may have failed to find a positive outcome because of

factors unique to the setting. Shortly after the initiation of the

study, the clinics became involved in long-term political and

administrative turmoil which lasted throughout the study. Although the

delivery of treatment was monitored by research staff, such chaos may

have swamped experimental effects.

Relaxation Training and Biofeedback

Three controlled studies of relaxation response are notable, primarily

because of the convergence of their findings and the disagreement of

these findings with uncontrolled clinical reports. After completing a

small (n=20) pilot study which showed weak positive results, Khatami et

al. (1982) assigned 37 male, VA methadone clients to either a

biofeedback condition or to a noncontingent, “pseudobiofeedback”

control. Pseudobiofeedback control subjects received feedback matched

to an experimental subject, independent of their own response.

Subjects were assessed on patient self-report, including measures of

depression, anxiety, withdrawal symptoms, drug references, and

psychiatrist rated depression. Information was also obtained from

patients and their counselors on job or school status, social adjustment,

97
and illegal activity. Subjects were evaluated at the end of the

treatment and at 1-month followup. Data were only obtained for the

subjects who completed 15 sessions (n=19).

The two groups had no meaningful differences. The control condition

in this study is particularly noteworthy; it controlled for all attentionand expectation-related factors which might be correlated with

biofeedback. However, the sample sizes were sufficiently small

-especially after attrition--that even clinically interesting differences

were statistically insignificant, and therefore overlooked. For example,

the experimental group showed positive changes in several self-report

measures, and showed less opiate relapses. But the sample size was so

small that differences did not reach traditional levels of statistical

significance.

However, negative findings were also reported in a larger scale study

of relaxation training--a therapy considered by many practitioners to

be similar to biofeedback. Our group completed a study of relaxation

training as an adjunct to methadone detoxification (Hall et al. 1983).

The 53 subjects recruited from seven methadone maintenance clinics

were randomly assigned to either a relaxation information condition or

to a standard treatment control. Treatment followed a manual

(Kushner et al. 1981). Two therapists each led half the treatment

groups. Clients were assessed at weeks 0, 5, 12, 24, and 52.

Assessments included measures of general and detoxification-specific

anxiety, mood state, withdrawal symptomatology, and self-reported

alcohol and drug use. Methadone dose and urine test results were

collected throughout the 1-year followup period. Seventeen of the 27

experimental clients completed treatment.

The data indicated little difference over the year between the

experimental and control subjects in methadone dose reduction or

complete detoxification. Experimental subjects reported less alcohol

use and fewer withdrawal symptoms immediately following treatment,

but these differences were not evident at later followup periods. No

differences in other psychometric measures were found. This study did

not control for therapist expectations or attention. Further, the

attrition in the experimental group was great enough that it could

have prevented a fair treatment assessment.

Summary: Psychotherapy, Contingency Management, and Relaxation

Training

The conclusion is that random assignment studies are feasible if the

subjects are all drawn from the same drug treatment modality. The

success of these trials at methadone maintenance clinics suggests the

importance of embedding psychosocial interventions in other modalities

with “bonds” to reduce attrition. Informative trials have been

completed. Many of these studies are characterized by clear

descriptions of the treatments delivered, or, even better, by use of a

treatment manual. In most instances, the only conclusion which can be

drawn, however, is that a specific treatment is better than a standard

treatment. Such designs are appropriate in a new field. However,

designs which control for therapist- and attention-related factors are

98
the next step. Also, the studies provide little, if any, information

about treatment processes; that is, what factors in the treatment are

correlated with change. Contingency contracting and psychotherapy

show some promise; relaxation therapy and biofeedback do not.

VOCATIONAL REHABILITATION

Three large- scale, random- assignment, controlled studies were

completed on vocational rehabilitation in drug treatment. The earliest

of these was the Wildcat Demonstration Program (Friedman 1978) which

evaluated the effects of supported work on 604 drug treatment clients,

80% of whom were from methadone programs. The intervention was

compared with a standard treatment control condition. Criteria for

acceptance into the study varied across time. The exact intervention

also varied; some subjects were placed with work crews, others were

not. At the end of the supported work period, efforts were made to

place participants in nonsupported jobs. These efforts also varied.

Clients were interviewed at intake and during the following 3 years.

Interview information was verified against other data sources. About

one-third of the original sample was lost. Included in this one-third

were 30 experimental clients who failed to take the job assigned to

them. Differences in employment, use of public assistance, and stable

relationships occurred during the year of supported work, but mostly

disappeared during followups. No differences were found in drug

abuse.

Any interpretation of the results is weak with such a large proportion

of the sample lost-particularly since 30 of the experimental subjects

lost had removed themselves from the sample by never appearing for

work. These were the least motivated clients, and their exclusion

artificially increased the differences between the two groups. Also,

even if the differences between the groups are “real,” the

interventions are so diffuse and poorly spelled out that it is difficult

to describe the experimental conditions which may have caused the

differences.

TREAT (Training, Rehabilitation, and Employment for Addicts in

Treatment; Bass and Woodward 1978) recruited subjects from a single,

large, multimodality drug treatment program, and randomly assigned

them to either Comprehensive Employment and Training Act (CETA)

training or to a control condition. Experimental clients were more

likely to decrease drug use (as indicated by urine analysis) and to show

better outcome on a multicomponent measure of treatment outcome,

but showed no differences in treatment retention or criminal behavior.

Experimental subjects worked full time more often and earned higher

salaries than controls, but showed no differences in the number of

weeks worked.

Again, confidence in these results is diminished by the procedure used

for experimental dropouts; results were reported for the entire control

condition. But, in the experimental condition, early dropouts were

replaced and not included in the data, thus biasing the data in favor

of the experimental condition. Later dropouts were not replaced.

99
Also, perhaps differences between the conditions existed prior to the

intervention; 21% of the experimental subjects and 35% of the controls

had not worked in the 2 years prior to the study. Other research

(Hall et al. 1981b) showed that lack of recent employment history is a

powerful predictor of failure in job seeking.

In the random assignment, supported work project of the Manpower

Demonstration Research Corporation, approximately 1,200 (12%) of the

10,043 participants were ex-addicts (Board of Directors, Manpower

Demonstration Research Corporation 1980). Over half the ex-addict

sample (54.5%) was drawn from methadone maintenance clinics; the

remainder were primarily from drug free treatments. Subjects in three

cohorts were followed for 1, 2, and 3 years, respectively. At the end

of the 12-month, supported work period, clients were assisted in

finding employment. All subjects who completed random assignment

and who could be located were included in the final data analyses.

One-year followups-which were completed for all available

subjects-provided data on only 974 subjects. However, differential

attrition between conditions was not evident.

During the supported work period, experimental subjects worked more

hours than controls and had higher employment rates. Interpretation of

the followup data was difficult because of differences between cohorts

entering the program at different time periods. In general, differences

were only significant for early entrants, primarily because of lower

employment rates among early controls. Supported work did not

influence drug and alcohol use. However, arrest rates for the

conditions differed, especially during the period immediately following

supported work. Methadone clients benefited more from the program

than did other drug treatment clients.

Why such large sample sizes were needed is unclear. Monitoring

experimental procedures to prevent significant deviations over time and

across sites is difficult with a large sample; deviations increase

variance and could attenuate the findings. A second problem concerns

precise specifications of the interventions themselves, especially in

staff contact and peer group support. This problem mostly affected

multisite studies that had significant variations across time and from

site to site. Also, the handling of dropouts and missing subjects was

often vague enough that legitimate conclusions could not be drawn.

An investigation of change mechanisms and a better link between

actual intervention content and outcome are needed. Differences in

outcome as a function of intervention leaders have rarely been

addressed, and no studies comparing different treatments or attention

controls exist.

We have completed a series of small-scale studies to test the

usefulness of a job-finding intervention for drug treatment clients.

The Job Seekers’ Workshop (Hall et al. 1977, 1981a, 1981b) is a

behaviorally based, skill training program designed to help ex-heroin

addicts increase job interviewing and job skills. Treatments were

based on a manual. In the initial study, 49 methadone maintenance

clients (recruited from several clinics) seeking either jobs or placement

in a competitive skill training program were randomly assigned to the

100
workshop or to a minimal treatment control. At the end of the

workshop, an interviewer who was “blind” to experimental conditions

rated subjects on employability/acceptability as trainees. Three months

after the interview, subjects were contacted and asked whether they

had found a job. Of the experimental subjects, 50% had been placed;

only 14% of the controls had found employment or placement in a

training program. Also, Job Seekers’ Workshop clients were rated more

favorably than the controls on both interview skills and completed

application forms.

In a second study, 60 job seeking, methadone maintenance clients were

assigned to either the workshop or the minimal contact (information

only) control. The program, which was streamlined from the initial

effort, was presented in 11 hours over 4 days. At treatment

termination, subjects were assessed by two "blind" interviewers on a

multi-item scale tapping specific interview behaviors. Experimental

subjects were rated more positively than controls, particularly in

general interview competence and manner of presentation. By the end

of 3 months, 52% of the experimental subjects were employed, as

compared with 30% of the controls.

In a final study, 55 probationers and parolees with heroin abuse

histories were randomly assigned to the workshop or to the control

condition. The workshop content and format were modified to suit the

needs of this population. Measures were identical to the previous

study. The two groups differed on scales measuring interview skills

and rate of employment. By 3-months posttreatment, approximately

86% of experimental subjects had found employment, as compared to

54% of controls.

Considerable similarity in outcome exists between the two methadone

maintenance studies. In both, employment rates at the end of 3

months were approximately 50%. Some variation in control group data

existed between the two studies (14% vs. 30%), but, in fact, when

subjects seeking placement in training programs were removed from the

data of the first study, these differences lessened. Further, the data

indicated a sharp difference between methadone maintenance and

criminal justice subject pools. Interventions were essentially identical

among the three studies. The methadone maintenance samples had

similar overall employment rates; both groups had considerably lower

overall employment rates than the criminal justice sample.

The studies did not control for time in treatment or for expectations.

Leader differences were noted in the only study which evaluated

them-the second methadone maintenance study; but characteristics

which described successful and unsuccessful leaders could not be

determined.

Summary: Vocational Rehabilitation Interventions

In many ways, the research strategy for vocational rehabilitation

interventions has been less rigorous than that of psychotherapy studies.

The treatment protocols are vague, changing with time and varying

from site to site. In some instances, dropout rates may have

101
compromised the random assignment. Despite these many faults, a

surprising convergence emerges from the data: in effect, supported

work projects, independent of their precise content, decrease

dependence on public assistance and increase employment. These work

projects may not have much long-term effect, and they do not directly

affect drug abuse.

Even though these studies were not designed for replication, they

accomplished that purpose better than might be expected. However,

small-scale, well-controlled studies have been successfully conducted in

this area, and seem to yield more conclusive results. These results

indicate that skill training is a promising modality for enhancing

vocational effectiveness. However, further research on nonspecific

factors in skill training is desirable.

CONCLUSIONS AND RECOMMENDATIONS

1. Well-controlled, small trials with sample size based on power

analyses have been the most successful in yielding clear outcomes and

comprehensible data. The best of these trials are characterized by use

of a treatment manual or a standardized treatment, and by welldeveloped procedures for tracking patients over a long time span.

Further research of this kind should be completed and is preferable to

large, national attempts at controlled outcome trials where variations

are so great, and the size of the projects so large, that findings are

difficult to interpret.

2. Research strategies which are planned with some degree of replication are preferable to isolated single trials for several reasons.

First, if such trials are relatively small scale, the risk associated with

one trial is less because several studies can be built into the research

plan. Second, replication quickly provides clear hypotheses for further

study. Finally, such strategies determine the situations and parameters

under which an intervention is effective.

3. Developing a basis for measuring drug use might help in evaluating

treatments. The core of such measures lies in drug screens from

urines and in treatment attendance data. However, more

standardization in psychosocial areas would be useful. The ASI could

provide part of this battery. Again, this standardization would

facilitate replications and comparisons between studies.

4. Promising strategies have emerged from controlled research.

Clearly, more studies are needed on psychotherapy, contingency

management, and skill training. In psychotherapy, the findings of

Woody et al. (1983) need replication in a different site. Also, the

positive results of family therapy warrant more research, especially

since, next to medical service, psychological and family services are

among the most frequently offered treatments. The proportion of

women clients in treatment seems to be increasing, so the inclusion of

women seems even more crucial-especially in family therapy studies.

Two directions are important in contingency management. One is

controlled studies which partial out any placebo factors from specific

102
treatment effects. The other is larger scale studies which evaluate

the effectiveness of contingencies in one or more “typical” drug

treatment clinics. This point is important, because the best work to

date has been completed at one site in a small research clinic. Skill

training appears to be valuable, and is appropriate and acceptable to

the drug treatment clients. Studies evaluating its use outside the

vocational area seem warranted.

5. Many valid studies have demonstrated differences between innovative treatments and standard treatment controls. Refinements in

intervention design are needed. Factors such as time in treatment,

placebo, and expectational effects have been neglected. Often these

factors can be controlled or measured without sacrificing clinical

generalizability.

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Stitzer, M.L.; Bigelow, G.E., and Liebson, I. Supplementary

methadone self-administration among methadone maintenance

clients. Addict Behav, 4:61-66, 1979a.

104
Stitzer M.L.; Bigelow, G.E.; and Liebson, I. Reducing benzodiazepine self-administration with contingent reinforcement.

Addict Behav, 4:245-252, 1979b.

Stitzer, M.L.; Bigelow, G.E.; and Liebson, I. Reducing drug

use among methadone maintenance clients: Contingent reinforcement for morphine-free urines. Addict Behav,

5:333-340, 1980.

Stitzer, M.L.; Bigelow, G.E.; and Liebson, I.; and Hawthorne,

J.W. Contingent reinforcement for benzodiazepine-free

urines: Evaluation of a drug abuse intervention. Unpublished,

1982.

Wilson, B.K.; Elmo, R.R.; and Thompson, C.P. Outpatient vs.

hospital methadone detoxification: An experimental comparison.

Int J Addict, 10:13-21, 1975.

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and therapeutic issues. In: Blaine, J.D., and Julius, D.A.,

eds. Psychodynamics of Drug Dependence, National Institute on

Drug Abuse Research Monograph 12. DHHS Pub. No. (ADM) 77-470.

Washington, D.C.: Supt. of Docs., U.S. Govt. Print. Off., 1977.

Woody, G.E.; Luborsky, L.; McLellan, A.T.; O’Brien, C.P.; Bech,

A.T.; Blaine, J.; Herman, I.; and Hale, A. Psychotherapy for

opiate addicts. In: Harris, L.S., ed. Problems of Drug Dependence 1982: Proceedings of the 44th Annual Scientific Meeting,

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Institute on Drug Abuse Research Monograph 43. DHHS Pub. No.

(ADM) 83-1264. Washington, D.C.: Supt. of Docs., U.S. Govt.

Print. Off., 1983.

ACKNOWLEDGMENT

Preparation of this manuscript was supported by ADAMHA Research

Scientist Development Award DA00065 from the National Institute on

Drug Abuse.

AUTHOR

Sharon M. Hall, Ph.D.

University of California, San Francisco

1454 Fifth Avenue

San Francisco, CA 94143

105
Outcome of Narcotic Addict

Treatment in California

M. Douglas Anglin, Ph.D., and

William H. McGlothlin, Ph.D.

INTRODUCTION

Society has attempted for many years and in many ways to control and

rehabilitate the narcotic addict. Where all methods of social

intervention have achieved less than desired results, methods which

incorporate some concept of treatment have generally been more

effective than those that have not. In particular, solely criminal

sanctions have proven relatively ineffective. The theory underlying the

preceding statements is based partially upon interviews with more than

400 heroin addicts of both sexes, diverse ethnic backgrounds, and

heterogeneous personality types. These interviews were conducted in

the course of several treatment followup studies of some 1,700 narcotic

addicts in which their entire addiction careers (from 12 months prior

to their first use of a narcotic up to the time of interview) were

chronologically recorded. The data collection procedures allowed a

determination of quantifiable changes over time in addiction related

patterns of behavior. The analyses of the addict career histories

further substantiate this theory. These results are presented in detail

elsewhere (Anglin 1980; Anglin et al. 1983; McGlothlin and Anglin

1981a; McGlothlin and Anglin 1981b; McGlothlin et al. 1977). Some

highlights of this research and their implication in assessing the overall

efficacy of drug abuse treatment will be presented here.

Our research group at UCLA has conducted a number of followup

studies of narcotic addicts in two types of long term treatment: civil

commitment and methadone maintenance. Civil commitment was

virtually the only major publicly supported program for addicts during

the 1960s. Methadone maintenance became a major treatment

modality for the State beginning in 1970.

Some comments about the use (or misuse) of the word "treatment"

when applied to narcotic addicts are in order. The word is borrowed

directly from medicine, where it is applied to any course of action

designed to cure, ameliorate, retard, or provide symptomatic relief

from a physical disease or condition. Generally, desirable results are

obtained from a medical course of treatment. Thus, the term has most

often become associated with its highest level application: cure.

Although the use of the term in the area of drug abuse is appropriate,

106
the level to which it can be applied is typically much lower:

amelioration, retardation, temporary relief, or no effect. A rational

evaluation of treatment efficacy in drug abuse has to deal with the

general public’s expectation of treatment as a cure. Given the

multiple determinants of a complex physio-psycho-social behavior such

as addiction, the generally poor premorbid characteristics of those who

become addicted, and the lengthy time course of the addiction, it is

not surprising that cures, in the usual sense of the word, are relatively

rare. They should not even necessarily be expected.

Three considerations are important in evaluating treatment outcomes.

The first is a clear description of the characteristics of the target

population to be treated. Addicts are a very heterogeneous group and

the etiology of addiction is complex. This renders the goal held by

public health administrations of providing a comprehensive system of

services much more difficult to implement. Second, the proportion of

patients meeting the various treatment outcome levels mentioned above

must be considered. What proportion are “cured” of their addiction?

What proportion experience amelioration vis-a-vis society and

themselves? For what proportion is the treatment ineffective at that

time? It should be expected that those proportions would not

favorably compare to those resulting from treatments for most physical

diseases. Finally, the consideration of treatment effects over time is

an important one. Unlike the physical diseases, most character

disorders can be expected to be chronic. Since long term-addiction

may often have more psychological components associated with it that

physiological ones, it should be expected to be a chronic condition in

the majority of cases.

The general question then becomes a probabilistic one: “What is the

time-related probability that the outcome of treatment will be

desirable for a group of addicts with defined characteristics?” Timerelated means the proportion of addicts showing the desired outcomes

at stated intervals (in years, probably) during or after treatment.

Desirable would mean some demonstrated amelioration for society or

for the individual in the expected nontreated course of the addiction.

The phrase “defined characteristics” emphasizes the understanding that

premorbid characteristics of the individual addict are important in

determining outcome of treatment.

Having these distinctions made explicit leads to very different

evaluation questions from those typically asked in the drug abuse field.

The stereotypical question has been: “How many patients become

completely drug free (cured) after treatment?” It is more appropriate

to ask, “How has the course of the behavior been changed for the

betterment of society and the individual from what it probably would

have been had treatment not been available?” A corollary question is,

“What is the overall benefit of the treatment compared to the cost to

society for providing it?” This question is not as unhumanitarian as it

seems; it is a necessary consideration in any society with limited

resources. Cost benefit analysis, usually determined by the traditional

economic weightings of reduced criminal costs and increased treatment

costs, can be appropriately augmented by humanitarian considerations

such as the quality of life improvement envisioned for the addict.

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Presented below is an overview of the results our research group

obtained from evaluations of the California Civil Addict Program (a

civil commitment program hereafter abbreviated as CAP) and of several

methadone maintenance programs in the Southern California area

(hereafter abbreviated as MM). Full descriptions of these studies may

be found in McGlothlin et al. (1977), Anglin (1980), McGlothlin and

Anglin (1981a), McGlothlin and Anglin (1981b), and Anglin et al. (1983).

Background

Since 1973, we have conducted research on heroin addiction and

treatment in California. The greater part of our research has been

directed toward evaluating the effectiveness of civil commitment

and/or methadone maintenance for chronic heroin addicts. Measures

used were narcotic and other drug use. incidence of crime and/or drug

trafficking, employment, and family stability. Evaluations included

assessments of the cost/benefits of these programs. During the past 10

years, we have conducted four major studies involving ten chronic

addict samples (primarily male) for a combined sample size of 1784

(McGlothlin et al. 1977; Anglin et al. 1981; McGlothlin and Anglin

1981a; Anglin et al. 1983). Each sample was drawn from a different

program or from multiple programs. Thus, we have sampled a

reasonable number of long term California treatment programs

(including some of the largest) from various geographical areas, serving

different client populations, and, with Federal and State guidelines,

having diverse administrative policies. We have been able to address

questions concerning what effect treatment entry and treatment

termination had on addict behavior, and what specific subgroups of

addicts responded differently to treatment efforts. Our followup

interview was designed to take retrospective longitudinal data covering

the entire addiction history, from 12 months prior to first narcotics

use to the time of interview. This approach allows for time series

analyses of behaviors for extended periods before and after entry into

treatment. The self-report data obtained from the interview are

supplemented by the official arrest and incarceration history as

detailed in the California Criminal Investigation and Identification

record (CII or “rapt’ sheet) and by urinalysis results from a voluntarily

obtained specimen requested, without prior notification, from a

volunteer at the time of interview.

Samples

The research data were obtained from samples of heroin addicts

identified from three general sources: 1) admission records of the

California Civil Addict Program (CAP), a compulsory treatment

approach operated by the Department of Corrections and the major

treatment program available during the 1960s; 2) admission records of

various Southern California county methadone programs; and 3) active

client lists of Southern California county methadone programs. In

some instances the samples were representative of the populations of

their respective programs; other samples were matched to these

representative samples for comparison purposes and are themselves not

necessarily representative.

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Table 1 summarizes the geographical and chronological characteristics

of the ten samples. Sample sizes of interviewed subjects are

reasonably large and represent from 83% to 97% of the originally

selected samples. The median dates of the first daily use for the 10

samples range from August, 1958, to February, 1970. Median interview

dates range from January, 1975, to March, 1979. For those entering

methadone maintenance, the post-methadone entry followup periods

range from 20 months to 82 months, The samples are generally

representative of addicts from many areas in the State. The time

periods for which data were obtained cover two decades, the 1960s

and the 1970s.

Interview Procedures

The interview was adapted in part from a schedule developed by Nurco

and colleagues (1975), and has been described in detail in an earlier

monograph (McGlothlin et al. 1977). Briefly, a schematic time sheet is

prepared prior to the interview showing all known arrests and intervals

of incarceration, legal supervision, and methadone treatment. The

interviewer establishes the date of first narcotic use on the time

chart, then proceeds chronologically to the point where narcotic use

changes from less than daily use to daily use, or vice versa, or the

respondent’s legal status changes. Data is then collected on narcotic

use, employment, criminal behavior, and certain other variables for that

interval. The interviewer then proceeds to the next interval, and so

on until the interview date. Each interval is uniform in terms of

narcotic use, legal status, and drug treatment enrollment. This method

of segmenting the interview into intervals which are meaningful to the

respondent has proven quite successful in collecting retrospective data.

Typically, the respondents appear to have little difficulty recalling, for

the specific period, whether they were employed, how frequently they

were using narcotics, their costs, and how they were obtaining funds

for drug purchase. The procedure requires the interviewer to work

closely with the respondent to structure the period of concern.

Extensive interviewer training is necessary. The authors participated

as interviewers for all samples and were responsible for training and

supervising the interviewing staff. Graduate students in psychology,

sociology, and education served as interviewers.

RESEARCH RESULTS

The accumulated data base collected for the 10 samples provides

sufficient information to answer questions concerning many aspects of

civil commitment and methadone maintenance treatment. Immediate

and long-term outcomes of these two treatment approaches are

summarized below.

Perhaps the best evidence for the efficacy of both civil commitment

and methadone maintenance treatment comes from evaluation of the

California Civil Addict Program (McGlothlin et al. 1977). For this

study we were able to construct a pre/post time series design with a

matched comparison group. The treatment groups came from two

different time periods: early admissions to the program, in the years

1962-1964, and later admissions, from the year 1970. The size of the

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1964 admissions sample was 225, and the 1970 sample size was 251.

The comparison sample came from a group of 1962-1963 program

admissions who were released after nominal exposure to the inpatient

phase of the program because of technical errors committed by the

courts. A sample of 214 was chosen from this group to match the

characteristics of the treatment groups.

TABLE 1

Characteristics of UCLA Folowup Samples of Heroin Addicts

Entering Treatment

The Effects of Civil Commitment

Figure 1 is a time series presentation of the effects of the civil

addict program on the daily narcotic use of the two treatment samples

and the comparison sample. The percentage of precommitment and

postcommitment nonincarcerated time during which the respondents

reported that they were using narcotics daily is represented. During

the precommitment period, the comparison sample (minimally exposed to

the CAP) shows a somewhat higher percentage of daily use than that

for the early treatment (maximally exposed to the CAP) sample. The

rate of daily use is relatively low for the late treatment sample during

the early precommitment years, perhaps as a result of more polydrug

use and less commitment to the opiates. An interesting aspect of the

precommitment graphs is the sharp rise in daily usage which occurs

during the two years prior to admission for all three samples. This

rise in usage is undoubtedly closely related to the initiation of the

commitment proceedings. A similar rise in usage very likely occurs

during the period preceding volunteering for, or being coerced into,

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treatment programs generally. Thus, followup evaluations which utilize

relatively short pretreatment baseline periods are likely to ensure a

spurious improvement in the postadmission behavior by virtue of this

self-selection phenomenon.

The postcommitment graphs of daily narcotic use show a marked

improvement in behavior for the early treatment sample over the

comparison sample for the first four years, and a moderate

improvement during the remaining time until the interview. The

percentage of postcommitment daily narcotic use for the late treatment

sample begins substantially above the early treatment sample level, but

then falls below the latter curve by the time of the interview. As

will be discussed later, a considerable portion of the sharp drop in the

late treatment sample graph is attributable to the increasing

percentage enrolled in methadone maintenance programs. Another

reason for the drop in daily use in this sample is the higher rate of

exclusions from the CAP and their subsequent prison sentences.

The comparison and early treatment sample graphs both show a gradual

decline in daily use over time. This decline is in accord with the

“maturing out” hypothesis (Winick 1962), but part of the decline in the

later years is also due to increasing enrollment in methadone

FIGURE 1

Percent of Nonincarcerated Time

Reported as Daily Narcotic Use: CAP Admission

111
programs. It should be kept in mind that the postadmission period for

which methadone treatment was available varies for the different

samples in figure 1. Methadone treatment became available about year

9 for the comparison sample, about year 7 for the early treatment

sample, and year 1 for the late treatment sample. This may account

for some of the difference between the rate of daily narcotic use for

the comparison and early treatment samples during the years

immediately prior to the interview.

Figure 2 presents the precommitment and postcommitment level of selfreported criminal activity. With the exception of the late treatment

sample, the precommitment level is relatively stable until the rise in

the last two years preceding the commitment (the period corresponding

to a sharp increase in daily narcotic use). There are no notable

differences between the precommitment levels of criminal activity

reported by the comparison and early treatment samples. During the

postcommitment period, the pattern is quite similar to that for the

percentage of daily narcotic use for all three samples (figure 1).

Figure 3 shows the combined full- and part-time-employment levels for

the precommitment and postcommitment periods. During the

precommitment period, employment generally declines over the time

corresponding to the heavier involvement in daily narcotic use. The

precommitment employment level for the comparison sample is more

uniform than that for early treatment group. In the

postcommitment period, the comparison and early treatment graphs

show a mirrow image of the daily narcotic usage pattern (figure 1);

For example, the figure shows much higher employment for the early

treatment sample for the first four years, declining to only slightly

FIGURE 2

Percent of Nonincarcerated Time Involved

in Crime Other than Drug Offenses: CAP Admissions

112
higher employment thereafter. The postcommitment employment level

for the late treatment sample is substantially lower than that for the

early treatment sample, and shows a rise over time corresponding to

the drop in daily narcotic use.

Successive Effects of Civil Commitment and Methadone Maintenance

A second analysis allows an examination of the successive effects of

the Civil Addict Program and methadone maintenance. Of the 439

combined comparison and early treatment samples used to evaluate the

CAP, 118 (29%) subsequently entered methadone treatment when it

became available in California in the early 1970s. By this time, nearly

all the sample had completed the commitment period and were no

longer under the supervision of the CAP. Thus, they were essentially

“free agents” and could maintain their rehabilitated status (if it had

been achieved), continue in an addicted life style, or enter a different

type of treatment (methadone maintenance) for another try at

controlling their drug use. The data showed that all three outcomes

occurred for this combined sample.

Two populations could be differentiated from those who did not enter

methadone treatment. One type, inactive addicts, consisted of

individuals who, in the initial years of methadone maintenance

availability in California, showed minimal drug use, and whose lifestyle

gave little indication of a return to daily involvement with narcotics.

This group may be considered, in Winick’s terms, to have “matured out”

of addiction (Winick 1962). The second type, active addicts, were

individuals who, like methadone entrants, showed continued daily use of

narcotics, but who had not chosen or had not been coerced into

entering methadone treatment. This is the more appropriate reference

group. It is composed of active addicts who supposedly would benefit

from treatment, while inactive individuals have no need for methadone

maintenance.

FIGURE 3

Percent of Nonincarcerated Time Employed: CAP Admissions

113
An examination of the overall personality and behavioral patterns of

those who entered methadone maintenance revealed that they had not

responded well to any effort by society to control their addiction and

had not themselves been able to achieve the control shown by a

certain proportion of the addict population (the inactive subsample)

(Anglin 1980). Generally they showed less antisocial behavior than the

other chronic users, who did not enter maintenance (the active

subsample).

Time series data were constructed to demonstrate the effects of the

CAP and methadone maintenance on a comparative basis for the three

subsamples. Figures 4, 5, and 6 present the data for daily drug use,

criminal involvement, and employment for periods before CAP

admission, during the CAP, after the CAP, as well as before and after

methadone maintenance. In examining the implications of figures 4, 5,

and 6, it is important to recall that two major social interventions

have occurred for the sample: CAP commitment and methadone

treatment entry. For this combined sample, the two events were well

separated in time. These two interventions show clear effects in the

time series graphs-both for the variables presented, and for other

variables affected by addiction (Anglin and McGlothlin, in press).

During the pre-CAP period, the inactive subsample shows more

employment and somewhat less incarceration, daily drug use, and crime

involvement than the active subsample. The methadone subsample is

FIGURE 4

Percent of Nonincarcerated Time Reported as Daily Narcotic Use:

CAP Inactive, Active and Methadone Subsamples

114
FIGURE 5

Percent of Nonincarcerated Time in Crime:

CAP Inactive, Active, and Methadone Subsample

FIGURE 6

Percent of Nonincarcerated Time Employed:

CAP Inactive, Active, and Methadone Samples

115
intermediate, although a few fluctuations do occur in which values for

the methadone sample exceed those of the active or inactive

subsamples.

CAP commitment at premethadone entry, year 8, produces an

immediate effect in all three subsamples, and this continues for the

duration of commitment (years 8 through 14). The inactive group

shows the greatest amount of improvement for the three behaviors

(daily drug use, crime involvement, and employment) while the active

group shows the least improvement. Except for criminal involvement,

where their behavior resembles that of the active group, the

methadone subsample is again intermediate.

The postcommitment, premethadone period (years 1 through 3) shows a

continuation of these gains for the inactive subsample, illustrating

moderate further improvement in behavior. The active and methadone

subsamples exhibit marked increased in daily drug use and crime

involvement, and a sharp drop in employment for the period. Part of

this increase can be attributed to the termination of CAP supervision

and a resulting “bounce back” effect. However, at this same time

(1968-1971), heroin addiction was at epidemic levels in the United

States (NIDA 1981). The increased availability of heroin appears to

have resulted in higher levels of use by both the methadone and active

groups. The inactive group had achieved enough control to not be

affected.

Figure 4 compares the postmethadone period to the premethadone

period. The active and inactive subsample data maintain nondisjunctive

patterns. Note, however, the sharp decline in daily drug use for the

active subsample, which corresponds to the end of the heroin epidemic

period. In strong contrast, the methadone subsample data demonstrate

marked and immediate reductions in daily drug use and crime

involvement. A moderate increase in employment is also evident. The

variables remain relatively constant for the three year followup period.

Data presented in this section confirm that, for considerable number of

narcotics addicts, civil commitment and methadone maintenance produce

substantial reductions in antisocial behavior and moderate improvement

in prosocial activities (employment).

EARLY METHADONE MAINTENANCE ADMISSIONS

Another series of followup studies provides compelling evidence for the

efficacy of MM alone in producing desirable outcomes in chronic

addicts. In the first of these, a sample of 347 was drawn from the

male first admissions in three multiple clinic county methadone

programs in Southern California during the years 1971-1973 (McGlothlin

& Anglin 1981b). The number of addicts selected from the Los

Angeles, San Bernardino, and Orange County programs were 138, 99,

and 110, respectively. The samples were selected to study the impact

of civil commitment parole status on methadone patient behavior, and

they are not necessarily representative of the overall methadone

admissions to the programs (Anglin et al. 1981). Figures 7-10 are time

series presentations which plot percent time in methadone maintenance,

116
daily narcotic use, crime involvement, and employment. The graphs

show the immediate beneficial outcomes of treatment on these

behaviors. Comparing the performance of clients from the three

programs also shows distinct interprogram differences in level of

desirable outcomes achieved. A brief synopsis of the policies of the

three programs will provide a context for interpreting the results.

The Los Angeles program was initiated in October 1970, and generally

employed a high-dose blockade policy. There was about an 18-month

waiting list throughout the time period sampled, and preference was

given to persons with a long history of addiction-hence the greater

mean age at admission. There was no firm date at which clients were

expected to detoxify, and, except for cases involving violence,

involuntary terminations for program violations were employed only as

a last resort after a series of probations and appeals. In April 1973,

the State mandated a maximum dose of 80 mg per day unless State

permission for an increase was received on a case-by-case basis. This

resulted in some drop in dose levels.

The San Bernardino program began in September 1971, and the original

protocol listed the stabilization dose at 80-160 mg. One year later,

the dose was lowered to a maximum of 100 mg. This was further

FIGURE 7

Percent Time on Methadone Following Entry

for Los Angeles, San Bernardino and Orange

County Methadone Admissions

117
reduced in April 1973 under the new State regulations. There was an

initial waiting list of about 6 months, and admission was on a first

come, first served basis. San Bernardino was also flexible with respect

to involuntary terminations, and there was no firm expectation for a

maximum time in the program.

The Orange County program differed considerably in policy from the

other two. This program began in September, 1969, and initially

employed stabilization doses of 80-120 mg. However, in October 1971,

the maximum dose for incoming patients was set at 50 mg. Thus, a

low-dose policy prevailed during most of the period in which patients

were selected for this study. In May 1972, there was a two-year

waiting period for admissions, but this had been reduced by 1974. In

addition to the low-dose regimen adopted in 1971, the program imposed

a fairly strict policy of termination for program violations, as well as

an expectation of treatment graduation after two years on

maintenance.

Effects of Treatment Entry

Of the three programs, Los Angeles and San Bernardino counties fit

the MM-A (adaptive) type, and Orange County fits the MM-CO (changeoriented) type described by Gorsuch and associates (1976). While

Gorsuch and associates’ evaluation of the Drug Abuse Reporting

Program (DARP) sample indicated similar improvements for clients in

both types of maintenance programs, our data show considerable

differences. Figures 7-10 are time series graphs for the three program

FIGURE 8

Percent of Nonincarcerated Time Reported as Daily Narcotic Use: Los

Angeles, San Bernardino, and Orange County Methadone Admissions

118
FIGURE 9

Percent of Nonincarcerated Time Involved

in Crime: Los Angeles, San Bernardino, and Orange

County Methadone Admissions

FIGURE 10

Percent of Nonincarcerated Time Employed

Los Angeles, San Bernardino, and Orange County

Methadone Admissions

119
samples beginning 8 years prior to admission and extending 6 years

after admission. Variables plotted are: daily narcotics use, crime

involvement, and employment. Two features are noted. First, there is

a distinct postmethadone entry improvement for these variables for all

three programs. Second, while there are no consistent patterns of

premethadone differences among the three programs, the postmethadone

results tend to correspond to the proportions of time on methadone,

which are strongly related to the policies of the three programs.

Except for employment, Los Angeles county shows the greatest

improvement, San Bernardino is next, and Orange County shows the

least improvement. In general, Orange County measures are roughly

equivalent to those of the other two programs in the premethadone

period, but are substantially lower in the postmethadone entry period.

These results remain after controlling for race and age. Also, a

similar pattern is found for other variables not shown here:

incarceration, arrest rate (particularly for property and drug-related

crimes), and employment (McGlothlin and Anglin 1981b).

The Southern California findings provide substantial support for

arguments that methadone maintenance programs are not as effective

as they might be because of excessive regulation and a misplaced

emphasis on minimizing dosage levels for moral or political reasons,

rather than choosing a dosage appropriate to the legitimate needs of

the client (Anglin and McGlothlin, in press).

CROSS-SECTION SAMPLES

Of the ten major samples described in table 1, the last four to be

discussed differ from the first six in that they represent not

admissions, but cross-section samples of their respective clinic

populations. In addition, these four samples were not utilized to

determine the effects of treatment entry, but to demonstrate the

effects of the termination of entire treatment programs. One sample

was from the only methadone program in Bakersfield, California, which

closed in September 1976. For the purposes of the followup, all 99

(60 males and 39 females) who were enrolled in the clinic as of June

30, 1976, were included. The second sample, chosen to be comparable

to the Bakersfield sample, was obtained from the Tulare clinic. The

Tulare sampling population was defined as those enrolling after January

1, 1971, and still in the program as of June 30, 1976. A stratified

sample of 59 males was selected, controlling for age and race so that

these characteristics would match the Bakersfield male sample. Since

there were only 29 females in the Tulare program who met the

sampling criteria, the total population was included.

The third and fourth samples were drawn to assess the effects of the

closure of the San Diego County methadone maintenance program (in

December 1978) on client’s drug use, and criminal and social behavior.

The research was also designed to allow an evaluation of the overall

costs and benefits of the substitution of fee-for-service methadone

programs for those supported by public funds. A detailed report of

the findings of this study is available elsewhere (Anglin et al. 1983).

120
The San Diego sample was drawn from the 561 enrolled in the County

program as of September 30, 1978. The 50 Veterans Administration

and 11 pregnant female clients who enrolled in the private programs,

but whose fees were paid from public funds, were excluded. A random

sample of 195 males was selected, and the total population of females

(168 after exclusions) was included.

The comparison samples of 129 males and 131 female; were selected

from the combined populations of the continuing Orange, Riverside, and

San Bernardino County programs. All persons selected were enrolled in

their respective programs as of September 30, 1978. The comparison

samples were matched for age and race, but otherwise were randomly

drawn from the combined Orange, Riverside, and San Bernardino

County programs.

Effects of Treatment Entry

The pre- to post- treatment increase in desirable outcomes previously

shown for the early admissions to the Southern California methadone

maintenance programs is duplicated by these four samples and specific

results can be obtained from the original reports (McGlothlin and

Anglin 1981a; Anglin et al. 1983). These replications, for samples

drawn from other geographical regions and programs and representing

different populations of addicts, provide strong confirmatory evidence

for the general effectiveness of methadone maintenance in the

treatment of chronic addiction.

Effects of Treatment Termination

The more important information from the Bakersfield and Tulare

samples, and the San Diego and its comparison sample, partially

answers the corollary question concerning the effects of program

termination. To assess these effects, the date of discharge from the

Bakersfield and San Diego programs just prior to their closing

(September 1976, and December 1978, respectively) was used as the

reference point. Dummy discharge dates of August 31, 1976, and

October 1, 1978, were chosen for the respective comparison samples.

Table 2 compares the status and behavior of the Bakersfield and

Tulare samples for the period from closure to interview. The data are

displayed in terms of the percent of the sample involved in the status

or behavior at some time during the interval. In addition, the mean

percent time of the interval that behavior is involved is given for all

measures except for mean number of arrests. The latter is the mean

of the individual percentages, including those with zero time involved.

Except for the incarceration item, percentages are based on the

individual’s nonincarcerated time during the interval. Arrest data were

obtained from the California Criminal Investigation and Identification

Record. Overall, the percentage of Bakersfield respondents arrested,

incarcerated, or on parole or probation, is about twice that for Tulare.

With respect to arrests, most of the difference is accounted for by

drug and minor offenses (warrants for failure to appear in court, drunk

in public, traffic violations resulting in arrest, and miscellaneous

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misdemeanors). Since the Bakersfield police had an especially active

narcotics task force in operation at the time, it is possible this was

partially responsible for the high percentage arrested in the Bakersfield

sample.

TABLE 2

Status on Behavior from Methadone

Program Closure to Interview (a)

Probably the most relevant variables in table 2 are the number of

Bakersfield clients who became readdicted to heroin, and the percent

of time addicted. Slightly over one-half reported addiction at some

time after termination. Of the eight Bakersfield respondents who

transferred directly to another methadone program after the clinic

closing, only one became readdicted to illicit narcotics. If these eight

transfers are excluded, nearly 60% of the sample became readdicted

subsequent to discharge. Overall, the mean nonincarcerated time

addicted was 26%. Of the Tulare sample, only 26 (31%) reported

readdiction, and the mean nonincarcerated time addicted was 12%. Of

these 26, 22 were discharged from the methadone program prior to

interview, and, for 13, all daily use was subsequent to discharge.

122
Alcohol abuse and drug dealing were substantially higher for the

Bakersfield sample than for the Tulare samples. The percentage of

those interviewed who reported engaging in property crime was similar

in both groups. This is consistent with the arrest rates for property

crime. Of the 19 Tulare clients reporting property crime, 14 had been

discharged prior to interview. Seven reported that all property crime

was subsequent to discharge.

Table 3 presents similar information for the San Diego and comparison

sample. The results here must be interpreted with the knowledge that

private methadone programs were made available in San Diego

immediately after the closure of the County program. Some 40% of

the County program clients transferred immediately to these programs.

The cost to these clients was $100 per month at this time. Table 3

shows the status, or behavior, for the period from program closure (or

pseudo-closure for the comparison groups) up to the interview.

Regarding the differences in the male samples, it is significant that

the proportion of San Diego males arrested (60%) is 12% higher than

the comparison group, a reversal of the criminal justice system

involvement evident prior to methadone treatment entry (Anglin et al.

1983). This rise in arrest rates is primarily due to drug offenses.

Increased criminal justice system contact is also indicated by the

greater proportion (and percent time) of the San Diego sample under

legal supervision.

The proportion of subjects using heroin daily and the percent time

involved in daily use are similar for the San Diego and comparison

samples. The greater involvement in dealing apparent in the

pretreatment entry data is also evident in this period for San Diego

males. The property crime data do not indicate any significant

differences, but the reduced involvement for San Diego noted in the

premethadone period continues to be apparent. Other than for percent

time on methadone maintenance, the female samples do not differ for

the postclosure period.

Generally, because of the higher percentage of clients who arranged

fro private methadone maintenance treatment, the clients terminated

from the San Diego program appear not to be substantially different in

behavior for the period from closure to interview from the comparison

group, except in those areas where pretreatment differences existed.

The exception to this is in the level of legal supervision, which is

significantly higher for the San Diego males.

However, one of the most interesting items overall is the percent not

incarcerated, not in treatment, and not “using” daily at the time of

interview. If this is used as a measure of success, the San Diego

clients tend to show poorer outcomes. When the male and female

samples are combined, 47% of the comparison samples meet this

criterion, while 37% of the San Diego sample do so. This difference

achieves statistical significance (p < .05) and is notable, given the

overall better pretreatment characteristics of the San Diego samples.

In addition, the disruption of the treatment process produced by the

program’s closure resulted in an increased personal cost of treatment

which was beyond the means of some addicts. Further, it may have

123
TABLE 3

Status on Behavior from Methadone

Program Closure to Interview (b)

prolonged the addiction status for some who would otherwise have

reduced their drug use and involvement in an addict lifestyle at a

faster rate. For the 60% of the San Diego sample who did not

transfer immediately to private programs, outcomes were much poorer

than for the sample overall (Anglin et al. 1983).

It must be emphasized that the San Diego data represent the effects

of program termination on enrolled clients who had had sufficient

124
exposure to methadone maintenance to determine its importance in

their lives. At closure, they had some experiential basis to choose, if

financially possible, to continue receiving treatment on a fee-forservice basis, unlike the Bakersfield terminated clients, who had no

opportunity to do so. The private clinics thus had a pool of

methadone-sophisticated individuals who either made a commitment to

continue treatment (those who transferred without an interruption in

treatment), or who subsequently chose to re-enter a treatment with

which they were already familiar (the 76 who entered private

methadone treatment after an interruption). An important question

which cannot be answered by these data concerns the extent to which

treatment entry by methadone-naive addicts is rejected or delayed

because of the cost of private treatment. The San Diego and

comparison samples show, respectively, 40% and 37% decreases in mean

annual costs to society for their addiction after entering MM. The

sharp declines in social costs associated with treatment entry are not

realized, of course, until an addict enters treatment. To the extent

that the payment requirements of private programs prevent or delay

“new” addicts from entering treatment, or “oldf’ addicts from reentering, addiction periods are prolonged. Also, methadone-naive

addicts may be less likely to enter private programs or once admitted,

be less likely to stay, given the lower level of ancillary services

private clinics can provide for the fee charged. The rehabilitation

process, which may be enhanced by ancillary services, would also be

slowed, and problem behaviors in clients expressed for a longer period

of time. While it is by no means clear that counseling or other

ancillary services are particularly effective in the rehabilitation of

narcotic addicts (especially in light of the expense of these services).

these issues must be given consideration. Consequently, the degree to

which rejection or delay of treatment increases property crime and

criminal justice system costs, which might have been reduced had nocost treatment been available, is unanswerable at present. Presumably,

the social and individual pressures which motivate entry to methadone

maintenance treatment would have to be higher when treatment is $100-

$150 per month than when it is at a nominal level. This is

particularly true if an addict couple (where costs are doubled) seeks

treatment.

CONCLUSIONS AND DISCUSSION

The results of our evaluations indicate that both civil commitment (as

represented by the California Civil Addict Program) and methadone

maintenance effectively reduce drug use, dealing, income-generating

crime, and arrests, and, to a lesser extent, increase employment and

family responsibility. While civil commitment can be applied to any

identified addict, methadone maintenance seems to appeal to a portion

of the addict population that has not been amenable to other social

intervention strategies. Although the majority of the socially

beneficial improvements in behavior occur during treatment for both

types of programs, there is evidence of some retention of improvement

after treatment. Furthermore, the strength of the effect is probably

related positively to time in treatment.

125
Program policy also seems to be an important element. The policies of

the California Civil Addict Program seemed to produce better outcomes

than did those employed by either the New York Civil Commitment

Program, or the Federal Narcotic Addict Rehabilitation Act. The

policies of the Los Angeles and San Bernardino methadone

maintenance programs produced better outcomes than did those of

Orange County. The higher dosage level and flexible policies regarding

dose changes of the former programs produced more desirable outcomes

than did the relatively low dose level and inflexible policies toward

dose changes of the latter program. Further, termination of treatment,

by program closure prior to a discharge point chosen by the client,

generally produces a “bounce back” effect on behavior toward

pretreatment levels.

Clearly, civil commitment was, and methadone maintenance is now, an

important component of the treatment network for heroin addiction.

Neither has produced the results anticipated by early researchers and

policy planners, but disappointed expectations should not detract from

their real and beneficial contribution to reducing the social and

individual costs associated with addiciton.

It is apparent that overall results are determined, in part, by program

administration and policy, including dosage policies in the case of

methadone maintenance, and that some improvement in the proportion

of desirable outcomes would result from relatively simple administrative

changes. High-dose, relatively flexible MM programs were more

effective than low-dose, inflexible ones.

The elements of the Civil Addict Program which were most effective

were the behavioral ones. First, the behavioral goal was clear and

unambiguous: abstinence. (This goal may have been modified at the

application level [parole officer supervision] to the more practical one

of non-addicted use). Second, behavior was monitored by parole

officers and urine testing. This relatively strict supervision typically

revealed relapse to an addicted state soon after it had occurred

(McGlothlin and Anglin 1977). Finally, if readdiction or other failure

to meet parole requirements occurred, a return for a period of

incarceration was imnmediate. Although this model of monitored

behavior and punishment is not the best behavioral one for modifying

undesirable behavior, it is effective when the period of monitoring is

sufficiently long (three years at a minimum). It must also be noted

that the program included elements of the better behavioral

modification model of substituting more appropriate behaviors for

undesirable ones, and reinforcing the substitutions. During the

incarceration period, educational and vocational training were available

and inpatients were encouraged to utilize them. During the outpatient

phase, parole officers referred addicts under their supervision for

further educational and vocational assistance, and also provided

assistance with other social service agencies, such as medical care or

public assistance.

Methadone maintenance can also be described as a behavioral

modification model, but one with a basically different approach from

civil commitment. Methadone maintenance provides addicts with a

126
substitute source of meeting their addiction needs, and negates the

otherwise necessary involvement in income-generating activities (crime,

dealing, and the sexual black market) and with other aspects of the

addict lifestyle. Continued involvement in these activities often

occurs, typically at a much reduced level, as addicts continue to

generate a subsistence level of income or maintain a social involvement

with active addicts. Some elements of the behavioral monitoring and

punishment model exist in methadone maintenance programs, such as

urine testing and disciplinary actions for inappropriate behavior.

Simultaneously, more appropriate social behavior is encouraged via

counseling and referral to vocational training, or to other social

service resources.

Since the etiology of addiction has multiple components, and the

population of heroin abusers is heterogeneous, a number of issues

remain to be resolved. It is not yet clear what percentage of the

total addict population would be amenable to these modalities or which

treatment would be most beneficial at different points in the addiction

process. Civil commitment may be more effective in reducing the

frequency and duration of addicted periods and may promote an earlier

“maturing out” for addicts with shorter addiction histories. Methadone

maintenance may be the treatment of choice for long-term addicts who

have not responded to other attempts at intervention. Additionally, it

has not been established what the characteristics are of those most

responsive to each, and if these characteristics change over time.

Finally, the questions of the effective duration of treatment and what

the ancillary rehabilitation components should be for each are still

unanswered. While the treatments described are generally effective

for substantial numbers of chronic addicts, it is unlikely that any major

improvement in their outcomes, above those already demonstrated, can

be achieved without answers to these questions.

REFERENCES

Anglin, M.D. A follow-up of Civil Addict Program methadone

maintenance admissions. Unpublished doctoral dissertation,

University of California, Los Angeles, 1980.

Anglin, M.D.; McGlothlin, W.H.; and Speckart, G.R. Effect of parole

on methadone patient behavior. American Journal of Drug and

Alcohol Abuse, 8:153-170, 1981.

Anglin, M.D.; McGlothlin, W.H.; Speckart, G.R.; and Ryan, T.M.

Shutting off methadone: The closure of the San Diego Methadone

Maintenance Program. Unpublished report, 1983.

Anglin, M.D., and McGlothlin, W.H. Methadone maintenance in

California: A decade’s experience. In Brill, L., and Winick, C.,

eds. The Yearbook of Substance Use and Abuse. New York: Human

Sciences Press, in press.

Gorsuch, R.L.; Butler: M.C.; and Sells, S.B. Evaluation of treatment

for drug users in the DARP: 1972-1973 admissions. In Sells, C.B.,

and Simpson, D.D., eds. Studies of the Effectiveness of Treatments

for Drug Abuse, Vol. 5. Cambridge: Ballinger Publishing Co., 1976.

McGlothlin, W.H., and Anglin, M.D. Shutting off methadone: Cost and

benefits. Archives of General Psychiatry, 38:885-892, 1981a.

127
McGlothlin, W.H., and Anglin, M.D. Long-term followup of clients of

high- and low-dose methadone programs. Archives of General

Psychiatry, 38:1055-1063, 1981b.

McGlothlin, W.H.; Anglin, M.D.; and Wilson, B.D. An Evaluation of

the California Civil Addict Program. National Institute on Drug

Abuse Services Research Monograph Series. DHEW Pub. No. (ADM)

78-558. Washington, D.C.: Supt. of Docs., U.S. Gov’t Print. Off.,

1977.

National Institute on Drug Abuse. Statistical Series (Series E, Number

20). Washington, D.C.: National Institute on Drug Abuse, April

1981.

Nurco, D.N.; Bonito, A.J.; Lerner, M.; and Balter, M.B. The natural

history of narcotic addiction: A first report. Presented at the 37th

Annual Meeting of the Committee on Problems of Drug Dependence,

Washington, D.C., May 19-21, 1975.

Winick, C. Maturing out of narcotic addiction. Bulletin on

Narcotics, 14:1-7, 1962.

ACKNOWLEDGMENTS

This work was supported in part by National Institute on Drug Abuse

grants DA01146, DA01890, DA02577 and DA03541, and by contract 77-

61245 from the California Department of Health.

AUTHORS

M. Douglas Anglin, Ph.D.

William H. McGlothlin, Ph.D. (deceased)

Department of Psychology

University of California, Los Angeles

Los Angeles, California 90024

128
Psychotherapeutic Approaches in

the Treatment of Drug Abuse

Charles P. O’Brien, M.D., Ph.D., George E. Woody, M.D.,

and A. Thomas McLellan, Ph.D.

ADVANCES IN PSYCHOTHERAPY RESEARCH

The effectiveness of talk therapy has been debated for decades.

Some authors have contended that patients treated by psychotherapy

are no better off than waiting list controls and that experienced

therapists are no more effective than inexperienced ones. While

there have been substantial numbers of studies which have found

psychotherapy to be effective, there is agreement that the process

of therapy has been difficult to control and the outcome has been

exceedingly difficult to characterize and quantltate.

In recent years, however, the science of psychotherapy research has

advanced considerably. Controlled studies now include better

patient selection, use reliable diagnostic instruments, specify and

identify therapies using manuals, and include valid, comprehensive

outcome measures. These techniques have permitted a more precise

analysis of the effects of psychotherapy and are leading to clearer

concepts of the benefits and liabilities of psychotherapy.

Perhaps the most important development which has advanced

psychotherapy research has been the improved classification of

patients. The standard use of structured diagnostic interviews as

well as standardized diagnostic criteria (e.g., RDC or DSM III) has

permitted greater homogeneity in subject populations selected for

study.

This in turn has allowed more fine-grained analysis of therapy

effects by enabling patients with similar prognosis to be randomly

assigned to control groups and competing treatments. Of course,

current diagnostic instruments have not been in use long enough to

have satisfactory validity testing by showing that they predict

natural history or course of illness. Also, the diagnoses have not

always shown stability over time. However, the instruments have

shown excellent reliability in that multiple clinicians

independently rating the same patient in the same time period have

obtained similar results.

There have also been improvements in techniques used to investigate

the process of psychotherapy through analysis of taped therapy

sessions. Rating instruments have been developed to measure such

129
complex phenomena as patient-therapist interaction and the degree of

direction versus support provided by the therapist. Although

measurement of these phenomena is not easy, results have shown

significant reliability when independent raters review the same

sessions. Taped sessions have also permitted the verification of

the specific type of therapy that is actually being administered.

All of these techniques lead to greater objectivity and precision in

controlled comparisons of types of psychotherapy.

Psychotherapy in Addiction

Clinicians have noted the high degree of psychopathology displayed

by opiate addicts, and that the use of illicit substances frequently

occurs in response to psychiatric symptoms (Khantzian et al. 1974).

In this context, addiction itself has been viewed as self-medication

in an attempt to avoid depression, anxiety, and other psychiatric

symptoms (Wurmser 1979). Recent studies indicate that the types of

psychiatric problems observed in addicts are similar to illnesses

which are often treated with psychotherapy when they occur in

nonaddict populations (Rounsaville et al. 1982). Yet many workers

both within and outside the addiction field have been pessimistic

that professional psychotherapy could make a meaningful contribution

to the treatment of the addicted patient (Bourne 1975; Karkus

1973). This opinion may originate from two lines of experience.

First, there have been numerous attempts to do psychotherapy with

addicts in private practice settings. Here, the patient's need for

drugs and the acting out behaviors that develop around this need

have commonly undermined the chance for a therapeutic relationship.

Second, there has been the perception that all addicts are simply

sociopaths, and that psychotherapy would not work for sociopathy.

Part of this perception appears to have its roots in studies

originating from the Addiction Research Center in Lexington, which

may have involved particularly high levels of sociopathic behavior

because the treatment setting was a Federal penitentiary.

However, there is some evidence to suggest that psychotherapy may be

both practical and helpful with addicts if given under certain

conditions. For example, the development of methadone maintenance

treatment programs has provided a means to reduce much of the

addict's intense, impulsive, and daily search for illicit

substances. Stabilizatlon with methadone has permitted the

development of therapeutic, long-term relationships and thus, in

theory at least, methadone programs might provide a medium in which

psychotherapy could be employed effectively. In addition, the most

recent studies on psychopathology in methadone-maintained patients

showed that depression and not sociopathy is the most commonly

diagnosed psychiatric disorder, though sociopathy is certainly well

represented (Rounsaville et al. 1983). Further, about half of those

patients with a diagnosis of sociopathy also have other psychiatric

problems. Thus, there is reason to believe that psychotherapy may

be capable of providing benefits to addicts, especially if it is

delivered in a methadone treatment program.

130
Review of Controlled Studies

No published studies on the effectiveness of psychotherapy with this

population appear to have been done prior to 1970. The one

exception was the work done by Nyswander et al. (1958) which was

completed before the development of methadone treatment. In this

study, professional psychotherapy was advertised as available and

offered to any interested addicts in New York City. Only seventy

people responded by contacting the clinic and only 13 of these

became regularly engaged in therapy. These engaged patients had an

average of 35 appointments with psychotherapists over a period of

approximately 1 year. They were compared with a control group of 22

minimally treated patients who kept an average of 8 appointments.

Although the treated patients showed more benefits than the

minimally treated patients, the investigators decided that the role

of psychotherapy in treating opiate addiction was minimal because so

few patients applied for therapy and because only a small proportion

of those who applied actually became engaged.

Since 1970 there have been other studies of psychotherapy with

addicts, and most of these were done with methadone-treated

patients. In eight of these studies, opiate-dependent patients were

randomly assigned to psychotherapy or to a treatment control

condition, usually drug counseling. Six of the studies (75%) showed

a better outcome in the psychotherapy condition than in the control

condition (table 1). The overall conclusion reached from a review

of these few studies is that there is evidence to indicate that

psychotherapy can be helpful for opiate-dependent patients. This

type of review and conclusion is similar to that reached by Luborsky

et al. and others in their overviews of many diverse psychotherapy

studies of treatment efficacy for psychiatric patients in general

(Luborsky et al. 1975; Smith et al. 1980; Andrews and Harvey 1981).

TABLE 1

Controlled Studies of Psychotherapy with Addicts

No

Authors Psychotherapy Better Difference

Willett 1973 X

LaRosa et al. 1974 X

Abrahms 1979 X

Connett 1980 X

Resnick et al. 1981 X

Stanton et al. 1982 X

Rounsaville et al. 1983 X

Woody et al. 1983 X

SUGGESTIONS FOR FUTURE RESEARCH

Practical Issues

Although the overall conclusions from both past studies and recent

research indicate the benefits of psychotherapy, recent experience

131
with conducting controlled comparisons of different types of

psychotherapy has highlighted several practical issues which must be

considered in any future research. First, the research program

should be considered a central part of the treatment program.

Research studies encounter great difficulties when they are

structured as add-ons to a busy treatment program. There is a

natural tension between clinical and research staff which tends to

be exploited in such situations. Ideally there should be an overlap

between clinical and research staff and the principal investigator

or one of the central figures in the research should also be the

clinical director of the treatment program.

Another important issue in conducting psychotherapy outcome research

in a substance abuse population is that the therapists themselves

should be at least part-time members of the treatment staff.

Therapists who are paid by the hour and who give patients

appointments in the private practice model at-e at a distinct

disadvantage to those who are in the clinic for large blocks of

time. The latter staff member/therapists are able to see patients

who drop in at unscheduled hours. Substance abuse patients tend not

to lead orderly, structured lives and thus they have a poor record

of keeping appointments. While improved life organization may be an

important goal of therapy, it is unrealistic to expect patients to

have such independent and organized behavior and to keep

appointments at the beginning of treatment.

Data Collection Instruments

In 1975 the National Institute on Drug Abuse held a drug treatment

efficacy conference in Reston, Virginia. One of the facts which

became obvious during this conference was the need for a generally

agreed-upon measure of the severity of the addiction syndrome. It

was clear that addiction was a multi-dimensional condition which

could not be accurately described by measures taken in only one

domain. The Addiction Severity Index (ASI) was developed by a group

of clinical researchers to fill this need (McLellan et al. 1980).

The ASI is a structured clinical interview which may be administered

by a technician in 30-40 minutes, producing 10-point problem

severity ratings in each of six areas commonly affected by

addiction. The ASI has been found to be useful not only as a

clinical tool for evaluating patients but also as a research

instrument for categorizing patients and for measuring change in the

six outcome areas following treatment. Future research comparing

treatment outcomes should include a comprehensive evaluation

instrument such as the ASI in order to adequately describe the

patient population, to study the relationships between various areas

of disability, and to provide a standardized and comprehensive

assessment of treatment effects.

Another issue that is potentially important in designing and

conducting research in this area is the presence of a psychiatric

diagnosis and the measure of its severity. Patients all tend to

have serious substance abuse problems at the time of admission to

treatment, but there is great variability In the severity of their

132
psychiatric problems. Consequently, future research should focus on

the severity of different types of psychopathology found among

addicts. The Schedule for Affective Disorders and SchizophreniaLifetime (SADS-L) has been found to have a high degree of

reliability in psychiatric populations including drug-abusing

populations. Recently, however, it has been shown that even SADS-L

diagnoses change significantly over time. Thus Rounsaville and

colleagues (1981) found 6-month and l-year repeat SADS-L diagnostic

interviews to show marked changes from the lifetime diagnoses made

at the initial evaluation. Future research, therefore, should be

directed at a closer examination of this phenomenon. Perhaps it is

the severity of psychiatric problems rather than the type of

psychiatric problems which is the best predictor of treatment

outcome.

Finally, psychotherapy outcome studies in substance abuse patients

should utilize all of the sophisticated techniques of psychotherapy

research which have been developed over the years. These include

the use of treatment manuals, the use of regular supervision of

therapists, the audio-taping of sessions, and the independent rating

of sessions by external observers. Such techniques insure quality

control and enable a more precise analysis of the factors leading to

the observed results.

Natural History

An area of treatment research which has been neglected because of

the great difficulties in doing such studies is that of the natural

history of untreated addiction. Available data on the consequences

of addiction are obtained from those individuals who apply for

treatment. In the best studies, treatment dropouts are followed as

well as those patients who remain in treatment. However, this does

not provide us with information on those individuals who never apply

for treatment. We do not know whether users who do not seek help

are qualitatively different, or whether they are just in a

preliminary stage which will eventually lead them to reach a stage

requiring treatment.

Treatment Outcome Studies

There have now been three large-scale national studies of the

treatment of drug abuse during the past 10 years. These are the

Veterans Administration study (Lorei et al. 1978), the DARP study

(see chapter in the volume), and the TOPS study (see chapter in this

volume). All of these had a basically similar design in that they

collected demographic data on patients at the time of admission to

treatment, using a variety of social and psychological measures.

They also included a series of intreatment measures and

posttreatment measures. These large studies all provided useful

information, and they were unanimous in showing substantial changes

in those patients who remained in treatment, with longer treament

generally being correlated with better outcome. Individuals who

dropped out of treatment early generally showed much less

improvement over time. It is now appropriate to move from such

large studies to more focused studies of particular patient types

and particular treatments.

133

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SPECIFIC THERAPIES

TABLE 2

MAJOR MODALITIES

Meth. Therapuetic

Maint. Detox. Antagon. Community

Psychotherapy

Cognitive

Supportive-Expressive

Behavioral

Group

Family

Vocational Counseling

Psychoactive Medication

Anti-Depressant

Anti-Manic

Neuroleptlc

Anti-Anxiety

A typical patient may receive more than one major

modality (columns), in any sequence, although usually

only one at a time, and several specific therapies (rows)

in any order and in different columns.

Future treatment outcome studies should include random assignment of

homogeneous groups of patients to different treatment modalities. On

the basis of past attempts, it seems apparent that random assignment

between major treatment modalities such as therapeutic community and

methadone maintenance is not feasible (Bale et al. 1980). In a

well-designed, energetic attempt to accomplish such a random

assignment, Bale and colleagues found that the majority of patients

went to the modality which they desired rather than the one to which

they had been randomly assigned. However, it is possible to

accomplish random assignment within a major modality (table 2). Good

examples of this are found in the two NIDA-sponsored psychotherapy

outcome studies (Woody et al. 1983; Rounsaville et al. 1983) in which

all patients received methadone maintenance, but patients were

randomly assigned to different types of control or psychotherapy

modalities.

134
Genetic Studies

Another area for future data collection should include family

history. Future studies of treatment efficacy should all include a

standard assessment of family history, not only of substance abuse

problems but also of other illnesses, particularly psychiatric

illnesses. The important findings on genetic aspects of alcoholism

make such studies in other areas of substance abuse imperative.

Biological Factors

At the present time it is not feasible to collect biological

measures in most treatment outcome studies. Longitudinal measures

of endorphins in patients undergoing treatment, however, are

currently being conducted in one center (O'Brien et al. 1982).

Eventually, such biological measures may become an important

component of diagnostic assessment and assignment to appropriate

treatment.

CONCLUSIONS

Drug abuse treatment has been extensively evaluated. It has been

the subject of three large-scale studies and several focused,

controlled studies. All of the large-scale followup studies and

most of the controlled studies have found the treatment of drug

abuse to produce substantial positive results, though no treatment

has been developed that offers a high probability of cure. Future

research should involve greater specificity. Patients should be

categorized in more detail and randomly assigned to comparison

groups within a large treatment modality. Recent work indicates

that severity of psychopathology may be a reliably measured variable

which is highly predictive of outcome.

The following specific recommendations should be considered by NIDA:

1. There should be an attempt to obtain some degree of consensus as

to the appropriate battery of testing devices to be included in

treatment outcome studies. Improved diagnosis has been very helpful

in other areas of medicine and psychiatry, such as that of affective

disorders. All treatment outcome studies should include a minimum

battery of tests which should have at least one multi-dimensional

measure such as the Addiction Severity Index. In addition, studies

should include other more focused measures such as the SADS-L or a

social functioning scale, depending on what questions are being

asked in the study. Having a minimum battery for each study,

however, would help to standardize treatment outcome studies in the

field of substance abuse.

2. Future studies should be designed not so much to compare one

treatment with another but rather to determine which patient best

responds to which type of treatment. Although sequential treatments

involving multiple interventions are difficult to study

experimentally, clinical evidence indicates that such complex

studies may be necessary. For example, some patients respond to the

sequence of methadone maintenance, detoxification, and naltrexone,

135
with ongoing psychotherapy throughout (O'Brien et al. 1983). A

diagram of the ways in which major treatment modalities interact

with specific therapies is shown in table 2. Psychotherapy or

chemotherapy may cut across major modalities.

Random assignment between major modalities may be impractical, but

random assignment between specific therapies has been effective and

informative. Thus future studies could utilize specific types of

patients (e.g., high severity on ASI) in a specific major modality

(e.g., methadone maintenance).

3. Many of the clinicians providing excellent treatment in the

field of substance abuse are inexperienced in the methodology of

treatment outcome studies. NIDA could provide a service to the

field by making technical information available concerning minimal

requirements of controlled treatment studies. This would include

recommendations regarding the battery of tests to be used in

describing the patient population and the scales to be used in

measuring changes in response to treatment. It would also include

the recommendation of publications describing treatment outcome

methodology, such as that published by the National Academy of

Sciences, Committee on Substance Abuse and Habitual Behavior

(Guidelines for Studies in Substance Abuse Treatment, NAS, 1981).

REFERENCES

Abrahms, J.L. A cognitive behavioral versus nondirective group

treatment program for oploid addicted persons: An adjunct to

methadone and maintenance. Int J Addict 14:503-511, 1979.

Andrews, G., and Harvey, R. Does psychotherapy benefit neurotic

patients? Arch Gen Psychiatry, 38:1203-1212, 1981.

Bale, R.N.; VanSton, W.W.; Kuldow, J.M.; Engelsing, T.M.J.;

Elashoff, R.M.; and Zarcone, V.P. Therapeutic communities vs.

methadone maintenance, design and l-year follow-up of narcotic

addiction treatment. Arch Gen Psychiatry 37:179-194, 1980.

Bourne, P.G. Methadone: Benefits and Shortcomings. Drug Abuse

Council, Inc. Washington, D.C.: Publication MS-12, 11-12, 1975.

Connett, G. Comparison of progress of patients with professional

and paraprofessional counselors in a methadone maintenance

program. Int J Addict 15:585-589, 1980.

Karkus, H.D. Methadone vs. psychotherapy in the treatment of

addiction. Int J Addict 8:427-434, 1973.

Khantzian, E.J.; Mack, J.E.; and Schatzberg, A.F. Heroin use as an

attempt to cope: Clinical observations. Am J Psychiatry,

131:160-164, 1974.

LaRosa, J.C.; Lipsius, J.H.; and LaRosa, J.H. Experiences with a

combination of group therapy and methadone maintenance in the

treatment of heroin addiction. Int J Addict, 9:605-617, 1974.

Lorei, T.W.; Francke, G.N.; and Harger, P.S. Evaluation of drug

dependence treatment in VA hospitals. Am J Pub Health, 68:39-43,

1978.

Luborsky, L.; Singer, B.; and Luborsky, L. Comparative studies of

psychotherapies: Is It true that "everybody has won and all

must have prizes?" Arch Gen Psychiatry, 32:995-1008, 1975.

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McLellan, A.T.; Luborsky, L.; O'Brien, C.P.; and Woody, G.E. An

improved diagnostic evaluation instrument for substance abuse

patients: The addiction severity index. J Nerv Ment Disease,

168:26-33, 1980.

National Academy of Sciences. Guidelines for Studies In Substance

Abuse Treatment, Washington, D.C.: Academy Press, 1981.

Nyswander, M.; Winick, C.; Bernstein, A.; Brill, L.; and Kaufer, G.

The treatment of drug addicts as voluntary outpatients: A

progress report. Am J Orthopsychiatry, 28:714-729, 1958.

O'Brien, C.P.; Terenius, L.; Wahlstrom, A.; McLellan, A.T.; and

Krivoy, W. Endorphin levels in opioid-dependent human

subjects: A longitudinal study. Ann NY Acad Sci, 38:377-387,

1982.

O'Brien, C.P.; Woody, G.E.; and McLellan, A.T. Modern treatment of

substance abuse. Drug Alcohol Depend, 11:95-97, 1983.

Resnick, R.B.; Washton, A.M.; and Stone-Washton, N. Psychotherapy

and naltrexone in opioid dependence. In Harris. L.S.. ed.

Problems of Drug Dependence, 1980. National Institute on Drug

Abuse Research Monograph 34. DHHS Pub. No. (ADM) 81-1058.

Washington, D.C.: Supt. of Docs., U.S. Govt. Print. Off., 1981.

pp. 109-115.

Rounsaville, B.J.; Cacciola, J.; Weissman, M.M.; and Kleber, H.D.

Diagnostic concordance in a follow-up study of opiate addicts.

J Psychiatric Res, 16:191-201, 1981.

Rounsaville. B.J.: Weissman. M.M.: Kleber. H.D.: and Wilber. C.H.

Heterogeneity of psychiatric diagnosis in treated opiate

addicts. Arch Gen Psychiatry, 39:161-166, 1982.

Rounsaville B.J.; Glazer, W.; Wilber, C.H.; Weissman, M.M.; and

Kleber, H.D. Short-term interpersonal psychotherapy in

methadone maintained opiate addicts. Arch Gen Psychiatry,

40:629-638, 1983.

Stanton, M.D., and Todd, T. The Family Therapy of Drug Abuse and

Addiction. New York: Guilford Press, 1982.

Smith,M.; Glass, G.; and Miller, T. The Benefits of Psychotherapy

Baltimore: The Johns Hopkins University Press, 1980.

Willett, E.A. Group therapy in a methadone treatment program: An

evaluation of changes in interpersonal behavior. Int J Addict,

8:33-39, 1973.

Woody, G.E.; Luborsky, L.; McLellan, A.T.; O'Brien, C.P.; and Beck,

A.T. Psychotherapy for opiate addicts. Arch Gen Psychiatry,

40:639-648, 1983.

Wurmser, L. The Hidden Dimension: Psychopathology of Compulsive

Drug Use. New-York: Jason Aronson, 1979.

ACKNOWLEDGMENTS

This report grew out of work supported by the Veterans

Administration Medical Research Service and by Grant DA 02554 from

the National Institute on Drug Abuse.

AUTHORS

Charles P. O'Brien, M.D., Ph.D., Chief, Psychiatry Service, VA

Medical Center, Philadelphia, PA 19104 and Associate Professor,

Department of Psychiatry, University of Pennsylvania, Philadelphia,

PA 19104

137
George E. Woody, M.D., Chief, Drug Dependence Treatment Unit, VA

Medical Center, Philadelphia, PA 19104 and Associate Professor,

Department of Psychiatry, University of Pennsylvania, Philadelphia,

PA 19104

A. Thomas McLellan, Ph.D., Director, Clinical Research, Drug

Dependence Treatment Unit, VA Medical Center, Philadelphia, PA

19104 and Associate Professor, Department of Psychiatry, University

of Pensylvania, Philadelphia, PA 19104

138
Clinical Implications of Drug

Abuse Treatment Outcome

Research

Edward C. Senay, M.D.

The most important fact established by the scores of outcome

studies conducted in the past 15 years is that drug abuse treatment

works (NIDA 1982; Bray et al. 1982; Craddock et al. 1982; Simpson

and Sells 1982; De Leon et al. 1982). The number and quality of

studies carried out demonstrate, as well as can be realistically

expected from any set of studies, that positive changes in client

functioning occur during and after drug treatment. While there

have been programs that have been poorly run and have encountered

serious credibility problems, there can be little question that,

from a public health and national point of view, many people have

been helped by drug treatment.

There are numerous issues relating to treatment outcome, structure,

process, and the changing nature of the drug abuse field and its

treatment populations. I will limit the range of issues to be

considered in this paper to a few of these, based on my impressions

of existing treatment evaluation research and my experience as a

clinician and program director involved in the treatment of drug

dependency. The clinical implications presented here have largely

to do with how and by whom treatment is delivered, and in what

context; how do they affect treatment outcome, and what aspects

should we study in future evaluations? Specifically, I wish to

address the following areas: (1) the structure of treatment

programming and treatment process as they presently exist; (2) the

changing structure of treatment systems, and ways in which change

should be guided; (3) qualifications, training, credentialing,

licensing, and role definition for counselors in an emerging drug

treatment system; (4) the need for special training for those

outside the drug abuse field who are involved in service

delivery/referral of drug abusers; (5) the need for both

professionals and clients to better understand the nature of drug

dependency and the variety of factors which have a bearing on

outcomes; (6) the need for new strategies to improve retention;

(7) improving clinic organization and operation; (8) the need to

better disseminate research findings to the field; and (9) the need

for special studies to better understand emerging drug use

patterns, special needs of treatment populations, and promising

interventions.

139
There are two distinct drug abuse treatment issues that have not

been adequately addressed in evaluation efforts but are of crucial

importance to the future success of drug treatment. One is

structural; that is, how drug abuse treatment can be coordinated

with existing service systems. For example, attention must be

given to the relation between drug treatment and standard health

care systems such as mental health and medical health care

institutions and agencies. Drug abuse programs are supposed to

have links wlth hospitals and other community-based service

systems, but these links are generally honored more on paper than

in practice. Drug clients are often too poor for the private care

system and too well off for the public care system. This factor,

combined with negative attitudes toward the problems of substance

abuse, perpetuates parallel systems of care which, in effect,

create second class care for many of the substance abusers'

problems, especially thelr medical and psychiatric problems.

Agencies charged with the future course of drug abuse treatment

must closely examine the feasibility of linking drug treatment with

hospitals in a meaningful way. In such experiments, hospital

administrators will need training in administration of drug clinics

located near or on hospital grounds. Hopefully, the establishment

of Employee Assistance Programs in hospitals will help pave the way

for acceptance of substance abuse treatment in hospital outpatient

facilities. The possible benefits to patients far outweigh the

costs (which are largely attributable to negative attitudes) of

such programs.

The second issue of importance to the future success of treatment

concerns process--how different treatment components or phases of

treatment contribute to client outcome. What are the best modes of

therapeutic interaction in individual or in small group

situations? There are many process questions to be explored; how

should we prioritize this research in relation to research on

structural questions? My bias is that structural experiments are

much more likely to pay off than process experlments. This

judgment is based partially on a conclusion that resources are

limited for either kind of exploration. Even a brief reading of

process therapy research (Smith and Glass 1980; Garfield and Bergin

1978) should convince anyone that process research is extremely

complicated and requires an extensive investment of time and

resources. The report of patients' satisfaction with treatment

summarized in the TOPS data (e.g., Bray et al. 1982) indicates that

programs are doing well clinically. I believe that much more can

be gained from structural changes in the treatment system.

It is far more important to train the staff of a community mental

health center (CMHC) to accept and to use modern treatment methods

for drug abusers than it is to explore counselor-patient exchanges

in the current drug treatment network. CMHCs constitute a

potentially important but underutilized resource for treating drug

abuse clients. CMHCs treat many drug abusers, perhaps in greater

numbers than are treated ln the drug abuse treatment system,

although most do not have drug treatment programs. Therefore,

there is an urgent need to organize systematically and provide

140
training support for staff in CMHCs. Given current training and

attitudes in psychiatry, social work, psychology, and nursing, it

would be an error simply to charge the CMHCs with offering drug

abuse treatment without offering training support. Research is

needed to assess the capability of different CMHCs to deliver

treatment to specific kinds of drug abusers, to identify the

knowledge and skills required, and to determine the usefulness of

different training methods and tools. The results of this research

will help prepare the CMHCs for this role.

While the competition for third-party funds is inducing some CMHCs

to add drug abuse services to those routinely provided, preliminary

and fragmentary evidence suggests that this is far from common in

CMHCs (Burke et al. unpublished). Moreover, the incentive of

third-party payment may lead hospitals and CMHCs to be more

selective. Thus, they are more likely to treat patients who have

better social resources (e.g., the employed drug abuser) suggesting

a better prognosis, while shifting the more problematic and needy

client onto the free-standing drug abuse treatment programs. Yet

these clients are likely to be in need of the range of services

which are more readily available in CMHCs and hospitals. For

example, the pregnant addict is in need of both drug treatment and

prenatal health care, as well as other services, but she is far

more likely to receive these services if they are provided in the

same facility. In an integrated setting, she has the benefit of

coordinated care and is spared unnecessary travel.

Research in the past decade has established that substance abuse

populations have significant rates of psychiatric problems, i.e.,

personality disorders, depression, and phobic disorders (Bray et

al. 1982; Rounsaville et al. 1983); and it is the exception rather

than the rule that the schizophrenic addict gets appropriate care.

The mental health system rejects the schizophrenic addict because

he or she is an addict, while the drug abuse treatment system

rejects the schizophrenic addict because he or she is schizophrenic. This is part of a larger mosaic which suggests a need to

reevaluate the treatment system and develop policies and

forward-looking leadership to bring about a better integration of

services. The ideal model treatment system to explore would be one

in which drug treatment facilities (therapeutic communities,

methadone maintenance, and outpatient drug-free programs) are

linked clinically and administratively to community-based service

systems that provide job skills training, mental health and general

health care, etc.

The outcome research of the past 15 years provides a solid basis

for legitimizing and standardizing substance abuse treatment. An

important next step is for single State agencies to take the lead

in the licensing, credentialing, and accreditation of workers in

the field. Hopefully, there would be coordination between the drug

and alcohol fields in this regard. There is, of course, a need for

a systematic training program through which substance abuse

clinicians would receive training in different modalities. For

example, clinicians might work in a therapeutic community for a

141
year, the following year in a methadone maintenance program, and

the following year in a drug-free outpatient program. The purpose

of this type of training would be to broaden the horizons and,

consequently, the expertise of workers in the field. Such a

cooperative program could also include clinical experiences which

would span alcoholic and mental health treatment modalities as well

as drug abuse treatment modalities. The training program might be

modeled on the Career Teacher program, with the single State

agencies providing the necessary administrative support. "Lead

clinicians" could be attached to single State agencies to provide a

much-needed link between clinical and administrative functions.

Third-party payers would welcome such a training program. Once

licensing standards and mechanisms for accreditation and credentialing are established, the drug treatment system will be in a

better position to develop formal linkages with the general health

care delivery system. If licensing and credentialing are

established by State/government agencies with the cooperation of

groups such as the Association of Labor and Management

Administrators and Consultants on Alcoholism (ALMACA) and the

National Association of Alcohol and Drug Abuse Directors (NASADAD),

programs can become eligible for third-party payment and, as a

result, have much-needed financial stability.

The multipurpose counselor who works with substance abusers should

have a wide range of skills and should be experienced in particular

clinical methods and techniques, i.e., conducting self-help groups

like Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). By

being exposed to a variety of treatment modalities, drug clinicians

will be seen as having particular skills and knowledge to offer

rather than being identified with a particular service modality. A

concerted effort should also be made to bring mainstream health and

mental health professionals into this program for cross-training

and certification, to improve their ability to provide appropriate

treatment or referral, and to enhance the quality of services

provided to drug abuse clients.

In addition to the need to legitimatize the field by licensing,

there is a need to upgrade the training of professionals and

nonprofessionals in other fields who come into contact with drug

abusers, including physicians and nurses. Prior to being permitted

to work in a drug abuse program, all clinicians should undergo

basic introductory training in addition to their residency.

Counselors, social workers, psychologists, and others involved in

substance abuse programs need similar training to get them out of

the one-channel treatment mode and to realize that there are many

more similarities than differences between treatment methods. It

should be clear from the foregoing that the old division between

alcohol and drugs no longer has much meaning clinically. As

suggested above, efforts should be made to create a broad treatment

role such as substance abuse counselor, chemical dependence

specialist, or whatever term is most appropriate. The name is not

as important as the ability to deliver a range of services for all

problems that people create for themselves with intoxicants.

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The treatment outcome research conducted in the past two decades

has other important implications for clinical practice in the drug

field. Evidence has been produced that just as substance abuse

tends to become a career, so does substance abuse treatment;

studies show that drug abusers tend to have multiple treatment

episodes (Simpson and Sells 1982). There is some disjunction

between this apparent reality and the perception of many, both

inside and outside the treatment community. Many researchers,

practitioners, and clinicians have assumed that treatment should

occur once and should result in cure if it is to be termed

effective. Substance abuse does not appear to be the kind of

problem that makes this orientation pragmatic. When the community

in which people live is so strongly pro-intoxication, it is not

surprising that treated persons are recruited back into the drug

lifestyle. Steps should be taken to orient people to the fact

that, while treatment does not need to be applied forever, repeated

episodes of treatment are probably necessary for most who develop

serious problems with intoxicants. It should be accepted that

repeated episodes are necessary for some and do not indicate

failure on anyone's part, but merely reflect the nature of the

problem and the culture in which we live.

If clinicians in the field are confused about such matters, imagine

the plight of the patients or clients. They come to the treatment

experience with the notion that they are seeking a cure, and they

receive reinforcement for this unrealistic expectation. It makes

better sense to acknowledge that some clients will experience

repeated treatment episodes unless cultural and community

conditions change dramatically. Treatment may be more or less

intensive. For the more fortunate, it may only require one or a

few episodes. But it is reasonable to expect that treatment of

substance abuse is likely to require a sustained commitment, as is

found in other treatment approaches. People in Alcoholics

Anonymous are forever "recovering," not recovered. This concept

applies to the treatment of most intoxicant-related problems.

Outcome research findings suggest that the longer we can retain

people in treatment, the less pathologic the substance abuse career

(National Institute on Drug Abuse 1981). Therefore, both access to

treatment and reentry into treatment should be easy. To accomplish

this objective, we should provide for keeping people in the

treatment system when they are excluded from a particular element

of that system. Outcome research indicates that administrative

discharge is a frequent end to treatment episodes. Those clients

who are administratively discharged from a treatment program but

need further treatment often represent a loss to themselves and to

society. To the extent that we can retain them in some treatment,

albeit under changed circumstances, both the client and society are

likely to benefit. The Illinois Treatment Program had considerable

experience with this problem. Instead of excluding patients who

had to be discharged from regular units because of threats of

violence or misbehavior of some kind, clients were transferred to a

"Losers Unit." As a result, the Illinois program was able to

143
maintain well over 50 percent of such patients in the treatment

system. This was both to their advantage and society's (Senay

1981).

Another problem with the organization and delivery of treatment

services in the drug field is scheduling. If programs were

coordinated better, it would be possible to stagger admission times

so that working addicts could obtain treatment in the early morning

or late evening or whenever it would fit their working schedules.

Weekend admissions could be increased by utilizing treatment units

as part of a treatment system. There is a need to have studies

comparing the success rates of communities that utilize isolated

drug treatment units with communities that have implemented

multimodality concepts. To date, most single State agencies have

failed to view treatment units as a system, with the result that

there is much duplication of weekend coverage and no specialization

of treatment units to deal with special problems such as pregnancy

or severe psychiatric problems. Consequently, there is an

unnecessary duplication of services and loss of resources.

In future attempts to evaluate the treatment system, it will be

important to focus more attention on the consumer. Not only can

clients provide data on which aspects of treatment are efficacious,

but they can also provide insight regarding the dynamics of

treatment and the gaps in service.

Studies (McGlothlin 1979; Simpson and Sells 1982; Bray et al. 1982)

show that crime rates of addicts drop substantially during and

after treatment. Further research is needed on the kinds of crimes

that decrease during treatment. The long-term success of the

Treatment Alternatives to Street Crime efforts suggests that

substantial gains can be made through collaborative efforts

involving the criminal justice systems (National Institute of Law

Enforcement and Criminal Justice 1979; Collins et al. 1982). The

fact is that mandatory treatment has benefited both society and the

addicts. So, efforts like those reported by Brill and Lieberman

(1969), which examined the role of rational authority and coercion

In treating addicted probationers, should be applied to addicts

with significant criminal involvement. It would be useful to have

more data on specific changes in criminal behavior to determine

possible correlations with intervention strategies.

FUTURE RESEARCH

To understand the benefits of treatment to clients, researchers

must look beyond the outcome measures that have been used thus

far. Evaluators must consider the value inherent in the ideal

concept of health or total well-being. If the addict survives

heroin addiction to only to die of a carcinoma of the lung, is

that a triumph? Treatment outcome data show that illicit drug use

is reduced by treatment. However, while people in treatment may

have decreased their use of illicit substances such as heroin or

other non medically prescribed drugs, their use of legal

144
intoxicants sometimes increases substantially. Researchers at

the University of Chicago (Senay et al. 1983) have just completed a

3-year study evaluating the effectiveness of comprehensive health

programming. More specifically, the study was designed to assess

the benefits of health-oriented counseling in which clients made a

conscientious effort to improve their overall health through

exercise and good eating habits and to confront their cigarette

and/or marijuana smoking as well as their heroin addiction. New

knowledge was gained through this study which can be applied to

future attempts to create rational treatment. It was learned that

many addicts share the general population's concerns about the

health consequences of intoxicants such as alcohol and nicotine and

can be persuaded to do something about them. Once again, the goals

of treatment and, consequently, of outcome research need to be

examined.

Studies are needed on the relative success or failure of programs

as a function of program size. In the early days of building a

treatment system in Illinois, large clinics were built on the basis

of clinical experience (some had a census of 150 patients or

more). It was felt that therapeutic communities should have no

more than 50-75 clients in any one unit. It would be important to

know from a therapeutic effectiveness point of view whether large

clinics with 100 or more clients are as effective in rehabilitating

drug clients as are smaller clinics. Because of implications for

resource management, these research questions should be of

particular interest to single State agencies.

The idea of a large mother clinic with satellite clinics for

special needs (e.g., advanced patients who are working, have years

of clean urines, and no arrests) also merits exploration. This

kind of arrangement could spread resources more effectively, and

perhaps enable programs to increase treatment slots or add

specialized services.

There is a need for studies comparing public with private programs

because clinical experience indicates final outcomes are

different--probably because public and private populations are

different. Ideally, of course, we should have a system in which

private treatment efforts function in concert with public

programming.

Old research questions regarding the usefulness of urinalysis have

not been adequately answered. Many clinicians feel that urinalysis

only confirms signs that are otherwise communicated. It is usually

obvious to a clinician that a person is not doing well, and routine

urines are not needed to confirm this. Havassy and Hall (1982)

found no difference in outcome as a function of using clinical

urinalysis. Such assays are expensive, and their exact role for

clinical purposes should be studied. The role of urinalysis in

treatment outcome studies is extremely important, but the focus on

clinical use can be kept separate from the focus on evaluation

use.

145
Researchers should also consider evaluating outreach, in

conjunction with a multiservice system that includes services

provided by drug, mental health, and health agencies in a

coordinated, community-based effort. A variety of outreach

strategies are available and it would be useful to know which are

most (and least) effective for different treatment populations and

service configurations.

Another aspect of the treatment process which needs study is the

initial phase when the client makes the decision to seek

treatment. Both Beck Depression Index and Hamilton Depression

Scale scores have been found to be elevated at the point when a

client comes into treatment and seem to recede whether people stay

in treatment or leave. These scores also recede whether or not

they receive treatment for depression (Dorus and Senay 1980).

After decreasing, the scores are still elevated in comparison to

norms. There is a need to understand these phenomena much better

than we do. It would also be useful to study patients with high

scores on the Beck or Hamilton Scales who are treated with standard

psychiatric techniques. This is the kind of study which could be

carried out more easily in the comprehensive treatment model

previously suggested in this paper.

There are indications that both drug clients and drug treatment

programs have been changing. Drug abuse patterns of 1983 are not

the same as those of 1973, and the changes are significant for

treatment. The drug abuser of 1983 is much more involved with

multiple drugs, some of them relatively new (insofar as treatment

is concerned), such as phencyclidine, cocaine, and marijuana. This

produces serious clinical problems, with implications for

management that are still unclear. The drug abuser of today is

much younger, is more often female, and is more geographically

mobile than the drug abuser of 1973. Retention in treatment is not

as long as it was in the 1970s. In many communities, methadone

treatment is not as acceptable as it once was, and consequently

success rates are not as good as they once were. One can always

expect a lag between institutional arrangements and the appearance

of new social problems; this appears to be what has happened in the

drug field. The problems are changing faster than the treatment

approaches, so we need continued macro studies like DARP and TOPS

as part of a coordinated strategy which employs a mix of macro

studies and micro studies. The kinds of micro studies which would

be an appropriate part of such a strategy are exemplified by that

of Newman and Whitehill (1979) in their clinical study of methadone

maintenance in Hong Kong.

People who work on line in the field need new knowledge. How

should they respond to the new problems with cocaine free-basing or

with young people who say that they are dependent upon marijuana

but that this (drug use) is not a problem? Therapeutic communities

and methadone maintenance, as well as AA, are having trouble

responding to some of the contemporary substance abuse problems.

People in the front lines need to know what others are learning

about these problems.

146
The morale of workers in the field is obviously important to their

clinical effectiveness; unfortunately the message that treatment--

at least some of the classical forms of treatment such as therapeutic communities and methadone maintenance--has proven to be

effective has not been adequately communicated to those in the

field. Instead, they are exposed to many negative stories about

methadone in the media. For example, a newspaper account which

concluded that methadone led to reduced motivation in people was

actually based on experimental animal studies. One would get the

impression that methadone treatment did not work and that the drug

is harmful to patients. This kind of false extrapolation from

animal data to humans neglects the massive amount of data gathered

in scores of evaluation studies involving humans. Counselors read

these accounts in newspapers and ask questions about them, as do

patients, and both are sometimes confused and concerned as a

result.

We need to continue disseminating information to the field and to

get across the message that: (1) we have built a treatment system

that works for many people, and (2) we have to continue to build

upon our knowledge and skill because clinical problems are

changing. These messages, presented in the right way, could be an

extremely important unifying agent, and hopefully would reduce

factionalism in the field.

A growing number of studies (Willett 1973; Longwell et al. 1978;

LaRosa et al. 1974) indicate that formal psychotherapy may have

something to offer addicts. With the increasing recognition that

many clients are multiply impaired, that treatment of addicts is

frequently complicated by major depressive illness, alcoholism, and

other disorders, it behooves those charged with treating addicts

(and other drug abusers) to delineate and provide appropriate

interventions. McLellan and his colleagues (1979) have had some

degree of success in Philadelphia in improving outcomes for the

severely disturbed client, and have specified some conditions under

which the psychotherapeutic intervention is more effective. The

use of talking therapies and pharmacological agents (e.g., antidepressants) to improve outcomes and increase client retention

(which may itself improve outcomes) should be further explored,

systematically tested, and elaborated.

Findings from such studies as the DARP research (Simpson and Sells

1982) might lead some to suggest less emphasis on detoxification

strategies and more emphasis on those treatment approaches that

have proven to be effective and economical (e.g., methadone

maintenance, residential). Detoxification programs have been less

effective in achieving subtantial lasting positive gains. But

again, there is a tendency to regard separate treatments as

unrelated one to the other. From a clinical point of view, we need

detoxification programs to treat episodes, reduce the length and

severity of "runs," and to attract addicts into the treatment

system. Thus, it is important that the field appreciate the place

of detoxification in a system of treatment service delivery.

147
Studies should be designed to evaiuate the unique contributions

that detoxification programs make rather than comparing

detoxification results with the results of other treatment

modalities.

Further studies en treatment outcomes for females are also in order

for the future (Beschner et al. 1932). Micro studies of this type

should be high on the evaluation agenda. Micro studies should also

focus on issues such as take-home policy. Do restrictive policies

have an impact on diversion beneficial enough to offset the

decrease in acceptability of treatment? In a similar vein, a focus

of other micro studies should be the question of what duration of

poor performance programs will tolerate. For example, staff at the

University of Chicago Clinic will not really "crack down" until a

client has about a 6-month record of poor performance. At that

point, improvements are expected or the patient is threatened and,

in fact, discharged if performance does not change. Micro studies

are also needed to determine whether clients who have a high

frequency of past criminal behavior require special programmlng.

Studies such as the DARP (Simpson and Sells 1982) have shown

criminal background to be a a powerful predictor of outcome.

Another area in which the drug abuse treatment system can benefit

is from outpatient self-help groups. Unfortunately, AA and NA tend

to be ideological about methadone. There is a need to develop and

evaluate the effectiveness of self-help groups which do not

discriminate against those taking medically prescribed drugs.

To summarize, future evaluation policy should continue macro

studies such as DARP and TOPS with the provision that new clinical

problems be included in the assessment, e.g., cocaine free-basers

and marijuana-dependent patients. A supplementary set of micro

studies would complement macro level studies. Studies at both

levels should focus on a range of issues which the research of the

past decade has indicated are important in treatment outcome, e.g.,

criminal history, pyschlatrlc status, and the length of time poor

progress in treatment should be tolerated. Policymakers should

rank issues and then articulate a coherent policy of evaluation.

As was the case with the TOPS research, the consumer should

continue to be included in evaluatlon studies. Finally, a decision

should be made vis-a-vis structural studies vs. process studies.

Perhaps a balance could be achieved, depending on resources. As I

have indicated above, my bias is for a major allocation of

treatment resources to structural studies.

Such an evaluation strategy should seek to resolve the many open

questions I have described above, with specific attention given to

improving treatment and increasing retention. As the activist

orientation to treatment improvement research suggests, there is a

need to make changes in the organization of drug abuse treatment,

bringing it more into the mainstream of the health establishment,

and to provide a better integration of services for our clients.

Finally, we should redouble our efforts almed at spreading the good

news about drug abuse treatment effectiveness and the findings of

148
our considerable investment in treatment research to the drug abuse

field, the medical and allied health professions, and to those

decision makers who will determine the future shape of drug abuse

treatment programming.

REFERENCES

Beschner, G.M.; Reed, B.G.; and Mondanaro, J. Treatment Services

for Drug Dependent Women. DHHS Publication No. (ADM)82-1219.

Rockville, MD: National Institute on Drug Abuse, 1982.

Bray, R.M.; Cavanaugh. E.R.; Craddock, S.F.; Hubbard, R.L.; and

Rachal, J.V. Client Characteristics, Behaviors and Intreatment

Outcomes, 1979 TOPS Admission Cohort. Treatment Outcome

Prospective Study. Research Triangle Institute Contract Report

No. RTI/l500/04-04F. Rockville. MD: National Institute on

Drug Abuse, May 1982.

Brill. L., and Lieberman L., Authority and Addiction. London:

J&A Churchill. Ltd., 1969.

Burke, C.; D'Aunno, T.; and Price, R.H. "Outpatient Drug Abuse

Treatment: Organizational Environment and Patterns of Care."

unpublished draft 1983 (cited with permission of authors).

Collins. J.J.; Hubbard, R.L.: Rachal J.V.; Cavanaush, E.R.: and

Craddock, S.G. Criminal Justice Clients in Drug Treatment.

Research Trianqle Institute Contract Report No.

RTI/l901/01/02S. Rockville. MD: National Institute on Drug

Abuse, February 1982.

Craddock. S.G .; Hubbard, R.L.; Bray, R.M.; Cavanaugh, E.R.; and

Rachal, J.V. Client Characteristics, Behaviors, and Treatment

Outcomes, 1980 TOPS Admission Cohort. Research Triangle

Institute Contract Report No. RTI/l901/01-OlF. Rockville, MD:

National Institute on Drug Abuse, May 1982. May 1982 *

Craig R.J. Personality characteristics of heroin addicts: A

review of the empirical literature with critique, part II. Int

J Addict 14:607, 1979.

DeLeon, G.; Wexler, H.; and Jainchill, N. "The therapeutic

community: Success and improvement rates 5 years after

treatment." Int J Addict 17(4) 703-747, 1982.

Dorus, W., and Senay, E.C. Depression, demographic dimensions and

drug abuse. Am J Psychiatry 137:6, June 1980.

Garfield, S.L., and Bergin, A.E. Handbook of Psychotherapy and

Behavior Change 2nd Ed. New York: John Wiley and Sons, 1978.

Havassy, B.E., and Hall, S.M. Urine monitoring of methadone

maintenance clients: Does it prevent illicit drug use? In:

Harris, L.S. ed. Problems of Drug Dependence, 1981.

Proceedings of 43rd Annual Scientific Meeting of the Committee

on Problems of Drug Dependence: National Institute on Drug

Abuse Research Monograph 41. Rockville, MD: The Institute,

1982. pp: 276-281.

LaRosa, J.C.; Lipsius, S.H.; and LaRosa, J.H. Experiences with a

combination of group therapy and methadone maintenance in the

treatment of heroin addiction. Int J Addict 9(4):615-617,

1974.

149

215-494 0 - 88 - 7 : QL 3
Longwell, B., and Miller, J. Counselor effectiveness in a

methadone maintenance program. Int J Addict 13(2):307-317,

1978.

McGlothlin. W.H. Drugs and crime. In DuPont, R.I.; Goldstein, A.;

and O'Donnell, J.; eds. Handbook on Drug Abuse. National

Institute on Drug Abuse. Washington, D.C.; Supt. of Docs.,

U.S. Govt. Print. Off., 1979.

National Institute on Drug Abuse. Treatment Research Report:

Effectiveness of Drug Abuse Treatment Programs. DHSS

Publication No. (ADM)81-1143. Rockville, MD: The Institute,

1981.

National Institute of Law Enforcement and Criminal Justice.

Evaluation of Treatment Alternatives to Street Crime.

Washington, D.C.: Supt. of Docs., U.S. Govt. Print. Off.,

1979.

Newman, R.G., and Whitehill. W.B. Double-blind comparison of

methadone and placebo maintenance treatments of narcotic

addicts in Hong Kong. Lancet, 8141:485-488, Sept. 8, 1979.

Rounsaville, B.J.; Glaser, W.; Wilber. C.H.; Weissman, M.M.; and

Kleber, H. Short-term interpersonal psychotherapy - methadone

maintained addicts. Arch Gen Psychiatry

Senay. E.C., "Multimodality Progamming in Illinois: Evolution of a

Public Health Concept" Lowinson J.H.. and Ruiz P. eds.

Substance Abuse: Clinical Problems and Perspectives.

Baltimore: Williams and Wilkins 1981 pp 396-402.

Senay, E.C. Substance Abuse Profiles and Treatment Strategies,

Final report of The National Institute on Drug Abuse, Research

Grant R-18-DA-03326-03, February 1983.

Simpson, D.D., and Sells, S.B. Evaluation of Drug Abuse Treatment

Effectiveness: Summary of the DARP Followup Research. DHHS

Publication (ADM) 82-1194. Rockville, MD: National Institute

on Drug Abuse. 1982.

Smith, M.L.:. and Glass, G.V. The Benefits of Psychotherapy.

Baltimore: The Johns Hopkins Press. 1980.

Willett, E.A. Group therapy in a methadone treatment program: An

evaluation of changes in Interpersonal behavior. Int J

Addict, 8(1):33-39, 1973.

Woody, G.E.; Luborsky, L.; McLellan, A.I.; O'Brien, C.P.; Beck,

A.T.; Blaine, J.; Herman, I.; and Hole, A. Psychotherapy for

opiate addicts. Arch Gen Psychiatry, 40:639-645, 1983.

AUTHOR

Edward Senay, M.D.

Department of Psychiatry

University of Chicago

950 E. 59th Street

Chicago, IL 60637

150
The State Perspective

Douglas S. Lipton, Ph.D., and Philip Appel, Ph.D.

The meeting upon which this monograph is based presented a rare

opportunity to convey the State's interests in a forum specifically

designed to review treatment research efforts supported by the

National Institute on Drug Abuse (NIDA). In part, NIDA's focal

concerns overlap the State's concerns. NIDA is basically

interested in utility, productivity, knowledge, and future

directions; and so are the States. This paper has been written to

review and consider the concerns and recommendations that States

have regarding drug abuse treatment evaluation: dissemination,

utilization, and research directions.

DISSEMINATION

To understand the special interests of States regarding NIDA's

treatment evaluation efforts, it was felt that it would be useful

to solicit opinions and suggestions from a sample of States. This

brief survey had two purposes: (1) to get a sense of how extensively NIDA treatment evaluation materials are used by States; and

(2) to get suggestions for new materials and the best means of

disseminating them.

Nine single State agencies, responsible for coordinating drug

activities in their respective States, were contacted by

telephone. The persons contacted were involved in planning,

research, and evaluation for their State drug abuse agencies. By

virtue of their work performed for a State agency, all of the

respondents were aware of how the National Institute's evaluation

materials were used in their respective States. Respondents were

from the States of California, Colorado, Florida, Illinois,

Louisiana, Massachusetts, Minnesota, New Jersey, and Washington.

The following six questions were asked of all respondents: (1)

What materials from NIDA have you used to evaluate and assess

treatment? (2) Specifically, have you used DARP and TOPS

material? (3) How did NIDA disseminate these materials to you?

(4) If used, which were the most useful? (5) What guidance might

you give NIDA on the mater-ials it develops for treatment

evaluation? and, (6) As far as your State is concerned, should

there be a narrow focus on modality?

151
Data were obtained from all nine States, and responses were

tabulated to derive their range and their general thrust. The

results are summarized below, question by question.

RESULTS

Question #1. What materials from NIDA have you used to evaluate

and assess treatment?

Responses ranged from reading and use of NIDA-sponsored outcome

studies to no use of NIDA materials for evaluation or assessment of

drug treatment. Two points emerged from the replies with

particular force: (1) Many NIDA materials are used in monitoring,

forming policy, treatment planning, and in treatment evaluation.

DAWN, CODAP, surveys of high school students and household

populations, monographs and technical reports, manuals, etc.. are

used extensively. (2) State agencies' responsibility for managing

and maintaining drug agency budgets needed to support drug programs

has grown significantly in the past 1 to 2 years, to the extent

that keeping abreast of treatment evaluation and related findings

is no longer as salient as that activity had been.

Question #2. Specifically, have you used treatment evaluation

reports?

Responses ranged from little use of treatment evaluation reports

and materials to thorough familiarity and extensive use. Some

extensive use of DARP materials and a number of contacts with the

principal investigators were reported. There was greater

familiarity with DARP and its associated reports and materials than

with other large-scale evaluation study reports.

Question #3. How did NIDA disseminate these materials to you?

This question was broadly interpreted by the respondents. As a

result it is not evident precisely how those respondents who

reported using evaluation reports and materials got them from

NIDA. Some respondents suggested that a regular, personal contact

within NIDA was helpful in getting various kinds of materials.

Virtually all respondents are on NIDA mailing lists. Some

respondents said that, except for Clearinghouse materials, they

have to call and shop around within NIDA to get specific items.

Two of the respondents explicitly suggested that the dissemination

system needed improvement.

Question #4. If used, which were most useful?

Those NIDA publications described as most useful were monographs

involving outcome studies, such as the following:

Robins' study of post-Vietnam drug use by veterans of that

war (1973);

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Studies from the DARP followup research published by NIDA,

such as the first-year posttreatment outcome monograph

(Simpson et al. 1978); and

Nurco's study of heroin addiction over a 25-year period in

Baltimore (1980).

Thus, NIDA treatment evaluation materials, including selected DARP

items produced by NIDA, were considered by a majority of the

respondents to be among the most useful NIDA materials. It is not

clear from the replies, however, which DARP materials/reports were

most useful, except for the mention of the first-year followup

study.

Question #5. What guidance might you give NIDA on the materials it

develops for treatment evaluation?

All of the respondents were able to offer suggestions about

treatment evaluation materials that would be useful to them.

Responses to this question were diverse. For example:

One respondent who is familiar with the various other

followup studies felt that while, cumulatively, they

clearly establish the efficacy of drug treatment, what is

needed in the current fiscal climate are studies of the

cost effectiveness of treatment.

A few of the respondents felt "how-to" manuals for

conducting treatment evaluations would be useful, if they

were geared to treatment administrators. In the same

vein, it was suggested that a detailed set of case

histories of "good" evaluations would provide models that

could be adapted locally.

Another recommended resource was an edited bibliography of

treatment studies which would be sent to program

administrators.

Another class of suggestion concerned processing and

packaging existing treatment evaluation data so that it

could be more useful for program administrators and

clinicians.

Some respondents felt that treatment evaluation data were

not "accessible" and were somewhat difficult to

interpret. Data presentations were seen to be sometimes

directed to researchers rather than at a level useful to

policymakers.

More studies of nonopiate abusers, especially cocaine

abusers, were suggested, as were more studies of programs

outside large metropolitan areas.

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Question #6. As far as your State is concerned, should there be a

narrow focus on modality?

A majority felt that the conventional focus on evaluating

treatment modalities was acceptable and should be

continued, but that there was little to be gained from

cross-modality comparisons.

Some expressed a desire, however, for greater

differentiation within modalities to capture the

considerable variations in services, procedures,

philosophy, etc., between programs of the same type.

There was, in addition, a strong minority view which held

that modality-based data were only useful for

administrative or regulatory purposes.

An alternative model asserts that NIDA and other

researchers should work toward developing typologles of

drug users, the stages in their careers, and under what

circumstances specific interventions were effective (or

ineffective) in favorably modifying those careers.

With respect to dissemination of treatment evaluation written

reports, it was suggested that NIDA produce and routinely

disseminate:

A listing of all treatment evaluation research projects

funded by NIDA. and reports and articles generated by them;

and

A digest or summary of the clinical, cost effectiveness,

and methodological implications derived from the research

NIDA supports.

A dissemination mechanism that NIDA might consider establishing

would be twice- or three-times-a-year l-day multiple city

teleconferences with video. The presentations to be made would

consist of summaries or digests of the results and implications of

clinical and treatment evaluation projects. The audience in each

city, perhaps 30 to 50 people, could comment on the research and

question the presenter. Regional centers could be used, such as San

Francisco, Los Angeles, Chicago, Dallas, Atlanta, Washington, D.C.,

and New York. Travel costs and time spent for the participants

would be reduced and evaluation research results would be more

accessible and more usable (in light of the digesting and short

presentation format). Video tapes of the proceedings could also be

made available for reshowing to selected State audiences, viz:

policymakers, program administrators, and service providers.

Another feature might be an overlay as the presenter speaks, showing

where and to whom to write to obtain a full report.

A compendium of clinical experiences based on successful and

unsuccessful management of common clinical problems that treatment

154
personnel encounter was recommended. Case studies written so as to

show other clinicians how and how not to deal with a patient's

avoidance of responsibility, resistance to group therapy, and

refusal to get a job, as some examples, would be useful. Such

compendia could be disseminated as clinical case manuals, each

focused on a related set of clinical problems such as unemployment,

alcohol use, etc. Dissemination by teleconferencing is also

possible for this kind of information.

UTILIZATION

Clearly related to the issue of dissemination is the usefulness of

the evaluation materials that are disseminated to the States. As

seen from the survey, a majority of the respondents wanted NIDA to

know that its evaluation products were frequently difficult to

interpret and to utilize directly. Recently, Davis and Salasin

(1979), Deutschner and Gold (1979), Ianni and Orr (1979), Rossi

(1979), Lawrence and Cook (1982), and Schneider (1982) have all

noted the shift in emphasis away from the rigorous methodology in

evaluation research to making evaluation findings useful to

policymakers and program administrators. NIDA should, to the

extent possible, move in this direction.

There has been a constant call to make evaluation products more

utilizable, beginning with Weiss (1972), through Love (1982), and

Strasser et al. (1983). Evaluation researchers as well as

policymakers (Koretz 1982) and Congressmen (Doty 1982) recognize

this. Unfortunately, historically there has been poor

communication between evaluators and the consumers of evaluation.

Havelock (1981) refers to it as a "dialogue among the hearing and

speaking impaired." This lack of communication is based on several

things: different kinds of training, different world views,

different expectations and frames of reference, different

constituencies, and different languages. The drug abuse research

agency in New York has learned to bridge these differences over the

past 15 years, but not without some pain and frustration. One key

to achieving successful utilization of evaluation results lies in

understanding the perceptions of policymakers. The following

general statements (drawn loosely from Brandl 1980 and others)

typify the policymaker's perceptions and frame of reference

regarding evaluation, its uses, and its limitations.

Policymakers know that evaluations do not always yield

"truth" (Rutman 1977); they sense there is some

arbitrariness to all scientific work, especially

evaluations. Policymakers are aware of holes in

methodology, and they know that much of the logic in

evaluation research rests on unverifiable assumptions.

They believe that evaluations mix objective analysis with

political judgments which politicians are better equipped

to make on their own. For example, the evaluation

research-produced contention that some methadone patients

are not suited for abstinence is rejected by those

155
policymakers who believe methadone treatment simply

substitutes one evil narcotic for another.

2. Policymakers note that evaluation almost always answers a

somewhat different question than the policymakers are

asking (Scanlon et al. 1977). For example, it may be true

that methadone maintenance treatment reduces crime and

improves social functioning, but how many addicts are

really "cured"?

3. Policymakers have neither the time nor inclination to

assess the quality of an evaluation (Carlson 1979; Messina

1982). If the basic finding is in agreement with their

existing views, they will include the report in their

armamentarium and wave it high in support of their

argument. If the basic finding is antithetical to their

views, they will reject it as biased, serving the

opposition's cause, and/or shelve it. The quality,

methodology, and skill used are irrelevant.

4. Partly in response to criticisms that evaluators did not

come to grips with the "black box" of treatment, and that

evaluators were too detached from real world problems,

formative evaluation has emerged to occupy increasing

numbers of evaluation researchers in recent years. This

kind of evaluation determines what the program administration and staff want their program to do, observes the

process of treatment, and assists the staff in modifying

the program during the course of the evaluation as

necessary. This often yields an insightful understandlng

of the treatment program as well as a mutually respectful

partnership between evaluator and program. As the

evaluator becomes directly involved in policymaking,

however, he trades his independence for influence (Weiss

and Bucuvalas 1980). Thus, the policymaker suspects the

evaluator of advocacy, and is convinced that truth is no

longer the evaluator's sole objective.

5. Policymakers believe that "truth" does not determine what

is "right and proper." It may be true that drug abuse

treatment clients receive better care and that more recover

faster in smaller clinical caseloads, but that does not

imply that small caseloads should be mandated, or paid for,

by the State. Also, it may be true that substantial

numbers of persons seeking drug abuse treatment have

serious alcohol or psychological problems, but this does

not mean that State or Federal agencies responsible for

those problem areas should help pay for treatment.

6. Policymakers believe their job is to carry out their

constituents' wishes, regardless of what evaluations show.

If a methadone clinic is stirring up a neighborhood because

of loitering, and the neighborhood brings their legislator

in as a contingent ally, no positive evaluation of the

156
program, or of methadone in general, will be sufficient to

overcome the larger "political" judgment. Likewise, the

findings of evaluation research cannot reverse wellestablished, popular convictions which are usually upheld

by policymakers. For example, methadone maintenance is

still controversial in many communities, and this

controversy finds expression through elected officials and

the press, a fact which cannot be lost on policymakers and

which evaluation itself cannot change.

7. Policymakers face myriad desiderata with any decision. An

evaluation is only one contending judgment. The more

complex the evaluation, the more jargon in the language,

the more hidden or equivocated the conclusion, the more

caveats in the preamble, the thicker the report, the more

obscure the evaluator, the more sensitive the issue--the

more apt the policymaker is to discard, ignore, or attack

the evaluation. If he attacks it, the evaluator at least

has a fighting chance to defend it, but usually the

policymaker ignores the report, which is the worst possible

outcome for the researcher.

8. Evaluators other than ourselves have recognized these

perception problems and have suggested various solutions,

such as the Evaluability Assessment (Kay 1978; Rutman 1980;

Wholey, 1977, 1979, 1981), the Stakeholder Survey (Lawrence

and Cook 1982), and the Developmental Evaluation Sequence

(Love 1982).

Our experience in this regard comes from having served

simultaneously in policymaking and evaluation roles. We

have evolved seven rules for maximizing the utilization of

evaluation research.

Establish a dialogue with the primary potential

user--the policymaker (Cox 1977 and Kennedy 1978).

Identify the critical questions and the critical

audiences the user has. From the critical questions,

develop a mission statement for the evaluation with

which the policymaker can agree. With knowledge of

the critical user's audiences, one can tailor the

presentation of the findings appropriately. Remember

that the policy implications of evaluation reports are

singularly paramount, and forget the research paper

style learned in graduate school--that style turns off

policymakers immediately. Provide a clear-cut policy

rationale for the document; researchers without a

policy rationale are viewed by policymakers as

self-aggrandizing. That is, the report will be

perceived as serving no other purpose than to enhance

the evaluator's resume.

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2. Move swiftly to produce; only a researcher is patient

enough to wait 2 or 3 years for an answer to a

question. Long-term evaluation projects are

tolerable only when short-term products are

available. In addressing important questions, even

partial answers are useful, and they create momentum

for more support.

3. Accept incremental improvement; the search for

perfection in evaluation is always fruitless. If one

follows these rules and is patient, incremental

improvement can be expected in data quality, data

systems, definitions, levels of cooperation, and

quality and quantity of staff.

4. Move with progressive refinement. This means that,

initially, researchers must be willing to make crude

or rough estimates. In order to respond swiftly to

information requests, general questions must be

divided into specific ones that can be answered

rapidly by available data systems and staff.

5. Produce reports in four parts.

The executive summary and recommendations must

come first. They should be no longer than two

pages (remember that policymakers receive 40 or

more reports a day). They should cite the main

points clearly in English, not jargon. These

main points should respond to the user's critical

questions and audience;, not necessarily the

evaluator's. Avoid at all costs burying a

critical point (i.e., the answer to a critical

question) in the middle or the end of the

document.

The body of the report should be presented like a

table of contents with summarizing headlines. If

you include tables, they should be clearly

understood by lay persons, and the numbers from

table to table should never contradict each

other. There is always someone who checks these

numbers, and if the numbers do not agree, he or

she will call to question the credibility of the

entire document. If the data permit, include an

analysis of the cost effectiveness of the program

and include a cost effectiveness or cost benefit

statement in the conclusions. Provide legislators with conclusions, not with recommendations

unless they are asked for. Making recommendations and policies is the legislature's job.

158
Agency directors and senior administrators or

advisors, on the other hand, may appreciate

recommendations as well as conclusions.

Write conclusions in short paragraphs,

preferably in "bullet" form. This saves wading

through ponderous rhetoric to find the

conclusions, and they can then be used

immediately by decisionmakers as announcements

for press purposes. Recommendations should also

be "bulleted" and incorporated into the

Executive Summary. Prepare the bullets with the

"stand-alone principle," using oversimplified

statements which can be quoted in legislative or

cabinet-level debates, or in interviews with the

public media. They should be written for

multimedia impact.

Put all technical material in the appendix.

This includes all technical and complex tables,

technical caveats, statistical procedures,

cost-benefit calculations, and methodological

details. Such material is useful to other

researchers, but disconcerting and annoying to

policymakers.

6. Organize the results by political jurisdiction before

presenting them by census tract. Policymakers cannot

relate to problem estimates for areas that have no

political reality. This implies that the evaluator

has an obligation to understand something about the

political dynamics of the questions he or she

investigates. In the same light, NIDA evaluation or

epidemiological products that cannot be related to a

single State have very limited use (if any) for the

State. And, if the potential audience includes

legislators, the evaluator should try to present data

by assembly and senatorial districts. Remember that

politicians always have the needs of their

constituents uppermost in their minds.

7. The purpose of evaluation and social science research

in government can easily be remembered as three "P"s

and three "A"s:

It should be PRACTICAL--that is, it should

ANSWER the critical questions.

It should be PECUNIARY--that is, it should

provide ACCOUNTABILITY for critical dollars.

It should be POLITICAL--that is, it should

recommend ACTION for critical audiences.

159
RESEARCH DIRECTIONS

The section that follows is a potpourri of treatment evaluation

ideas. They are viewed as guidelines and seeds for thought and

possible future directions. The ideas are the fruit of brainstorming among evaluation researchers and, as such, vary in levels

of development.

1 . Numerous studies have shown that time in treatment is

correlated with outcome. Yet, there has been very little

research on factors that might lead to higher retention

rates among programs. If the specific factors leading to

higher retention rates could be identified, this might

lead to relatively inexpensive methods of retaining

clients in treatment and significantly improving treatment

outcomes. Conversely, cases of those persons who leave

programs prematurely as a result of external pressures

could be studied; then researchers could identify the

pressures and other problems patients are likely to

encounter and develop program elements to counteract

them.

2. We also need to study ways of recruiting detoxified and

untreated drug users. Research has shown that there are

many such people who are not motivated to enter

treatment. Using ethnographic techniques, factors that

breed resistance to treatment and those that foster entry

can be identified. Then, in turn, specific methods can be

tested to overcome the source of resistance and augment

those factors that boost entry.

3. Usually treatment is thought of as restricted to within

the program; external influences on treatment outcome are

rarely considered in any type of treatment planning,

though some attention recently has been given to family

therapy. There is a need for more studies of how external

influences have an impact on treatment outcomes. In

particular, studies of external economic influences are

needed. The illicit drug business is very large and

profitable. Thus part of the difficulty in getting

clients to stop using illicit drugs is undoubtedly due to

the economic forces involved in the illicit drug business,

but the exact nature and impact of these forces have never

been studied. Our ability to counter these external

limitations on treatment effectiveness will remain limited

if we do not increase our understanding of them. We also

need to explore what external factors encourage or result

in patient amenability and cooperation during treatment,

and then develop techniques to enhance them.

4. Examining the drug abuse treatment evaluation literature,

one is struck by the emphasis on fine tuning of existing

160
5.

6.

7.

modalities. With the exception (in recent years) of

antagonist therapy, no new methods for the treatment of

drug abusers have been explored. In the late seventies,

efforts were made to investigate techniques such as

acupuncture (for detoxification), hypnosis, biofeedback,

transcendental meditation, nutrition therapy,

transactional analysis, and other "therapies" in vogue at

that time. These studies should be reviewed

systematically and findings communicated, together with

limitations on their use, to evaluation audiences.

There is a need for studies on the effectiveness of

short-term early intervention treatment for young drug

users. In particular, holistic approaches dealing with a

broad range of services to reach a broad range of problems

among such youth need investigation. These methods, if

effective, would add low-cost treatment altenatives to

dealing with the bulk of the youthful drug users in the

country. Similarly, studies are needed of the effectiveness of employee assistance programs. These programs have

been initiated and are being advocated all over the

country, but remain unevaluated.

Studies of treatment failure using case study techniques

could inform the process of treatment. And, in this vein,

case studies of persons who ceased drug use without

treatment, such as those conducted by Waldorf (1983), could

be equally informative. Recent studies of weight loss and

smoking cessation show that self-treatment efforts may be

much more effective than previously thought. But the

research on self-treatment for illicit drug use is

relatively scarce, and mostly confined to heroin use. Much

can potentially be learned from studies of how people stop

using a variety of illicit drugs without formal treatment.

Such studies should also examine why some self-treatment

efforts fail, and whether the factors that lead

self-treatment to fail are repeated in formal treatment

programs.

Formal drug treatment programs almost exclusively proclaim

abstinence as the only suitable goal for treatment of

illicit drug abuse. This goal is rarely achieved in any

single episode of treatment, which suggests two lines of

treatment evaluation research. First, the effects of

multiple episodes of treatment need to be coherently

explicated. Second, the utility of less-than-total

abstinence goals should be explored. It is quite likely

that many clients and staff actually share such treatment

goals, but there is almost no information on how frequently

this occurs and what effect it has on treatment processes

and outcomes.

161
8. One concern expressed repeatedly has been that treatment is

largely a "black box." The people, events, and

interactions subsumed by labels such as "therapy,"

"counseling," "referral for services," and "remediatlon"

remain largely undescribed in drug programs. As a result,

variations in delivery and efficacy, which are crucial to

treatment evaluation, are also unspecified. NIDA should

support research on these processes as they occur in

programs--call it applied microsociology or preevaluatlve

research. To us, knowledge of these processes appears

essential for understandng and improving treatment.

9. The current treatment paradigms were originally designed

for the treatment of opiate abusers. The patients we often

encounter now, however, consist of cocaine, marijuana, and

polydrug abusers. These persons are not necessarily suited

to opiate treatment, and much of the "fine tuned" research

done on opiate users needs to be repeated for them.

10. NIDA should consider competitive awards for new treatment

approaches. For such an award, NIDA would issue a problem

analysis focusing on a specific problem such as the cocaine

user, the psychotic self-meditator, the young heavy

marijuana/alcohol user, or prescription drug misusers, and

request treatment evaluators to submit proposals of new

techniques tailored to the specific population.

11. In the same vein, NIDA could encourage grants assessing the

effectiveness of acupuncture in treatment of heroin

addiction, for example, and receive highly focused

evaluation proposals for specific methods.

12. A serious problem affecting all treatment effectiveness is

the social stigma which current drug users and former drug

users bear. Studies into stigma management and methods for

changing the public's and employers' attitudes are needed.

Just as important, if more general, are studies of how to

build community support for treatment. Antagonistic

communities prevent treatment programs from opening and

inhibit their operation. Supportive communities, on the

other hand, can facilitate job placement and social

reintegration, while encouraging treatment recruitment and

cooperation.

13. NIDA should consider studies of systematic shifts in

service delivery, such as private physician/pharmacy

dispensation of methadone, and short-term intensive

residential treatment for marijuana or cocaine abusers.

14. NIDA should consider an evaluation of a vocational program

designed for the drug abusers who have never worked. This

162
15.

16.

SUMMARY

program could provide for testing, guidance, training,

guaranteed placement, and followup support during

employment, plus pay a profit based on success as an

incentive to the training company, which would also provide

followup support.

NIDA should fund a meta-evaluation of all treatment

evaluation research performed over the last 25 years.

This compendium of treatment effectiveness should be

classified by treatment method and outcome. It would be

the state-of-the-art document for all treatment.

NIDA should fund studies of treatment effectiveness for

the following special populations:

The multiply handicapped, e.g., deaf drug abusers

Violent drug abusers

New immigrant groups, e.g., Southeast Asians, Cubans,

Haitians

Abuser families

Alcoholic drug abusers

Athletes, musicians, entertainers and other

professional groups

Our survey showed that State agencies make use of NIDA materials of

all sorts, including NIDA treatment evaluation materials. A

majority of the respondents indicated that NIDA treatment

evaluation materials were among the most useful of its products;

most frequently mentioned was DARP, then Nurco's and Robins' work,

and TOPS. That DARP was most frequently mentioned is not a

contradiction, since the responses were stated in a general sense,

not in terms of a specific report or material.

In the past 1 to 2 years, many State drug abuse agency budgets have

been substantially reduced due to declines in Federal funding. As

a result, treatment evaluation reports and related materials are

viewed somewhat differently than they were in the past. The fiscal

climate in various States may thus be another factor contributing

to the greater familiarity and reported use of reports such as

DAWN, CODAP, and case management and monitoring manuals published

by NIDA.

A number of suggestions were made about the kinds of evaluation

materials needed by States. It was generally agreed that attempts

should be made to produce treatment evaluation findings/new

knowledge in a format where it would be more accessible to

administrators (e.g., "how-to" manuals, evaluation case studies,

163
dissemination of treatment evaluation bibliographies) and should

assist in making existing treatment evaluation results more

accessible (divide results for modalities into subtypes, provide

data on the effectiveness of specific interventions with specific

conditions, diversify the settings of programs in which evaluations

are done, etc.). The theme of these various suggestions is to make

evaluations more available, usable, and specific, especially now in

view of the reduced ability of many States to carry on their own

evaluation activities.

The general sense of the respondents regarding dissemination was

that right now, in view of other problems such as the financial

crunch, NIDA's system of distribution cannot be a salient concern.

Nevertheless, from a State perspective, NIDA's dissemination of

treatment evaluation materials is particularly important in the

light of the paucity of resources States have to conduct their own

research. Thus, having access to NIDA's usable evaluation data is

all the more crucial to improving service delivery and its cost

effectiveness. Another factor to bear in mind at the present time

is the absence of opportunities to share evaluation results at

national conferences which formerly were, of course, major

mechanisms for formal dissemination.

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AUTHORS

Douglas S. Lipton, Ph.D.

Philip Appel, Ph.D.

Bureau of Research and Evaluation

New York State Division of Substance Abuse Services

2 World Trade Center

New York, New York 10047

166
A Treatment Evaluation Agenda:

Discussion and Recommendations

Frank M. Tims, Ph.D., and Sherry Holland, M.S.

INTRODUCTION

This review, as stated in the Introduction to this volume, had two

purposes: (1) to assess critically the state of the art of

treatment evaluation--i.e., where we are in our knowledge regarding

treatment evaluation and treatment effectiveness, and (2) to assess

the most important needs of the field, both in terms of research

areas or questions and methodological issues which should be

resolved. A panel of nationally recognized experts was convened to

review the state of the art and to develop a body of

recommendations for future research.

In response to these questions, a number of themes emerged.

Prominent among these were (1) the need for a synthesis of prior

research. (2) the opportunities afforded by existing data bases for

secondary analysis, and (3) development of an agenda for new

research, Including continuing examination of drug abuse treatment

systems and populations, studies of treatment process, assessment

of treatment for nonopioid abuse, continued study of drug abuse

careers, and studies of untreated drug abuse populations. Also of

concern was the need to disseminate treatment research findings

widely, both to researchers in drug and alcoholism treatment, and

to treatment providers.

DISCUSSION

To return to the first question of this review, "What do we know

today about the effectiveness of drug abuse treatment?", today's

state of knowledge represents a stage of an evolutionary sequence,

as we confirm treatment effectiveness in general terms, and turn to

the task of being more specific about how and for whom what aspects

of treatment are effective. Our answers have tended to raise many

more questions. The field has now developed a knowledge base from

which to apply increasingly sophisticated methodologies to

treatment studies. Because the drug abuse evaluation field may be

characterized as evolving, both in terms of knowledge advancement

and methodological aspects, and involving a multiplicity of

167
disciplines, our present knowledge contains not only gaps but also

inconsistencies. Resolving the apparent conflicts in research

findings represents a major task for treatment evaluation at this

point. Two principal approaches which make use of existing data

are suggested: A synthesis of existing studies, and secondary

analysis of available treatment research data.

Synthesis of Existing Studies

Although the evidence for the effectiveness of drug abuse treatment

is impressive, there are questions, problems and issues of

interpretation that remain to be clarified. A systematic review

and synthesis of treatment outcome studies which has as its major

objective the clarification and, where possible, resolution of

treatment issues could be of great benefit to the field. Such a

synthesis should provide an estimate of the magnitude of treatment

effects across studies. In addition, a cross-study summary of

observed relationships among client, treatment, and outcome

variables might usefully distinguish among client variables

associated with positive outcomes irrespective of type/setting of

services, treatment variables associated with positive outcomes

irrespective of client variables, and client-treatment

interactions. The research synthesis should include a critical

examination of methodologies used, with a view to identifying the

strongest studies and sources of inconsistency in findings.

Secondary Analysis and Modification of Existing Studies

Other possible sources of new knowledge and clarification of

research findings may be found in existing data bases and ongoing

studies. During the past decade, a large and rich body of data has

been developed in a variety of drug treatment studies. With regard

to resolving or clarifying apparently conflicting results of

different studies, consideration should be given to reexamining the

analytic approaches and, where possible, reanalyzing study data

itself. Several issues meriting reanalysis were identified,

including the interdependence of outcome behaviors; the ability of

psychopathology to predict outcomes; the nature of the relationship

between time in program and changes in criterion behaviors; and the

relationship between severity of drug and alcohol dependence and

posttreatment outcomes.

Some investigators have found relatively low correlations among

posttreatment outcome behaviors (e.g., drug use, employment,

criminality). This finding suggests that treatment procedures may

cause positive changes in some behaviors and not others. Thus the

question of client-treatment matching--"What procedures work best

for what types of clients"--needs more thorough consideration of

the nature and degree of the anticipated changes.

Pretreatment severity of psychopathology is associated with poorer

posttreatment outcomes in some studies but not in others. Some

programs screen out psychiatrically disturbed clients. This

restriction on within-program variance may place a ceiling on the

correlation between psychopathology and outcome. A "state-trait"

168
problem may also exist. Clients with long-term psychiatric

disorders may have outcomes which differ from those whose

symptomatology is a transient condition associated with the

circumstances of their treatment admission. Data for these two

subgroups should be examined separately.

Several major drug treatment evaluations have found that time in

program predicts posttreatment outcomes. This has provided

critical support for the treatment hypothesis in studies without

controlled assignment. However, in the TOPS data time in program

and posttreatment outcomes are weakly related. Such an apparent

conflict with previous research findings suggests that the data be

carefully examined and reanalyzed to explain or resolve the lack of

a significant time-in-treatment effect. Possible explanation of no

such finding would include differences in the populations being

studied, and measurement artifacts which tended to obscure

differences in response to treatment between subgroups.

Unpublished analyses of TOPS data conducted since this review have

controlled for selected covariates and found what appears to be a

time-in-treatment effect, but the meaning of the effect is not yet

clear. The time-in-treatment effect, which is among the most

significant findings in treatment evaluation, needs to be further

explored, clarified, and tested.

Gaps in knowledge may also be at least partially filled by

secondary analysis of existing data, and adding or reorienting

questions in ongoing research to capture variables not previously

identified, to address questions which have emerged as our state of

knowledge has evolved. For example, new insights into the

importance of the role of psychopathology in determining treatment

outcome suggest that prospective studies should have more detailed

information in this area on clients entering treatment, to enable

appropriate classification into subgroups for which outcomes may be

differentiated. The TOPS has obtained some limited depression

indicators for clients at admission, as well as alcohol use and

pretreatment criminal involvement. It may be possible retrospectively to develop life history data in future followup

interviews which could be used to develop subgroups of clients who

had been violent, frequently depressed, or who may have been

dysfunctional in particular areas of life with problems in

childhood, adolescence, and/or adulthood. Family health history

could also provide valuable data.

Future Treatment Assessment Research

Turning to the shape of future studies, it is clear that some

periodic large-scale or medium-scale followup studies will be

needed at intervals, (1) to assess the changing nature of

treatment populations and services, (2) to provide sufficiently

large data bases on contemporary client samples for multivariate

analysis, and (3) to provide replications where needed to confirm

or clarify previous research findings. Such prospective studies

probably should not reasonably be expected to involve the large

numbers of clients tracked in DARP and TOPS, although the

169
information available on the client population base should be

sufficient to permit appropriate sampling. These studies should be

effectively coordinated with smaller, program-based studies. The

program-based studies, in which investigators affiliated with

treatment programs or larger treatment organizations are involved,

could address highly focused questions related to treatment process

and outcome issues.

Large-scale studies have made a point of comparing outcomes across

modalities. The general pattern of findings suggests that few

meaningful differences are likely to be found in outcomes among

opioid addicts in methadone maintenance, residential drug-free, and

outpatient drug-free treatment that are not either a function of

client differences or of time in treatment. Future studies can

more appropriately examine how given treatments work for

well-defined subgroups of clients within a particular modality or

program. When we better understand the dynamics of treatment

services or therapies for such well-defined client types, the

assignment of those clients to a particular regimen can be made

more meaningful. A convincing case has been made for the

usefulness of controlled studies to test hypotheses regarding

client-treatment matchings. While attempts to randomly assign

well-defined, homogeneous client pools to modalities have been

frustrated by clients crossing over to their treatment of choice,

random assignment within modalities to service configurations and

to more satisfactory control groups has proved feasible.

Whether we speak of medium-scale prospective studies or

program-based studies, naturalistic or controlled, such studies

must include better client data at admission. In particular, a set

of core variables and measures whose validity and reliability are

reasonably well established should be developed and used in all

future treatment evaluation studies which involve clients entering

treatment. Such "minimum research criteria" would provide the

well-defined subgroups of clients for better analysis and would

enable comparability across studies, which has been problematic in

the past. The minimum research criteria would include specified

Information on drug and alcohol use over specific pretreatment

intervals, employment, criminal history, and treatment history, as

well as measures of psychopathology and social functioning.

Consideration should also be given to including family history

data, with particular reference to health and genetic variables.

There are, of course, a number of existing instruments which could

be used. These would have to be carefully evaluated and a set

chosen which would be methodologically satisfactory, appropriate to

key research issues, and which would not pose insurmountable

obstacles to acceptance by clinicians who would, In many cases, be

asked to use them. The practical issues of acceptance of the

be considered. Greater

in co-principal investigator

ingness to use the prescribed

measures at the clinical level must

involvement of clinicians, perhaps

roles, may result in increased will

instruments.

170
Treatment process studies are clearly needed. While the DARP,

TOPS, and other studies have recognized the eventual questions of

process, research priorities have focused largely on outcome

studies, with process very much the junior partner. As suggested

above, program-based studies offer the best opportunitles for

testing specific variations in services or therapies, although it

Is also possible that larger scale, externally based research

efforts could make contributions in this area, given appropriate

program involvement and an imaginative design. One much-needed

process study would test approaches for increasing retention by

modifying program content in the critical early weeks of

treatment. For therapeutic communities, especially, where

attrition is high In the first 4 - 6 weeks, it is suggested that

while some clients are not suited to a high-intensity treatment

involving confrontation, others who drop out of treatment could

benefit, given proper support and clarification of treatment

content. Such a program of treatment improvement research is

activist In orientation, and may provide an important contribution

to our understanding of the role retention plays in improving

outcomes.

Research on treatment effectiveness for those clients who are

primarily involved with nonoploid drugs has been largely

neglected. Because the community-based treatment system was

developed to deal primarily with opioid addiction, and because so

many researchers and clinicians have had a primary interest in

oploid addiction, this area has received most attention. Attempts

to deal with nonopioid abusers in the DARP and TOPS have been

problematic, owing largely to difficulties in conceptualization and

having insufficient numbers of clients involved primarily with

particular nonopioid abuse patterns. The lack of treatment

evaluation research focused on clear subtypes in well-defined

treatments suggests a need for special efforts to develop such

studies.

In treatment evaluation studies which have attempted to impose

quasi-experimental research designs on treatment systems, controls

or comparison groups have always been a problem. The usual

compromise is to take some group which is presumably similar to the

treated groups but which has not itself received treatment, and

consider them a "no treatment comparison group." The argument

against using these "no treatment" comparison groups is that they

usually turn out to be something else. They drop out of treatment

but many of them re-enter treatment. Analysis of the DARP data

suggests that, while as a group they have less satisfactory

outcomes, substantial numbers of these comparison group subjects

are doing well at followup.

It is also widely recognized that substantial numbers of addicts

carry on long addiction careers, remaining outside the treatment

system. We do not know how similar or different these untreated

addicts are from those who make their way into treatment, but

existing natural history studies are hampered by the fact they have

only involved addicts captured by the treatment system or the

criminal justice system. Natural history studies should, of

171
course, include studies of clients from treatment populations such

as DARP and TOPS over the longer term, but there should also be

efforts to ascertain what happens to people who leave treatment

after only minimal contact, and those who are never treated. The

"minimal treatment" and "never treated" groups could be explored

from the standpoint of what the natural history is in the absence

of treatment, as well as what the potential is for bringing these

individuals into treatment by various strategies.

In any event, this expanded version of the natural history of drug

abuse/addiction would be useful in enabling us to understand

important aspects of drug abuse careers. It is also important to

note that our concern with natural history over the longer term has

understandably been with opioid addiction, since these are the

client populations which have been around long enough to mature

sufficiently for such studies. The large client populations never

addicted to opioids, but involved primarily in the various

nonopioid abuse patterns, should be similarly followed up over

time. An important first step in this regard is to examine closely

the data already available from such studies as DARP and TOPS.

This provides the opportunity to begin accumulating a knowledge

base with regard to defining the different subgroups,

characterizing them in terms of client background characteristics,

their treatment and/or criminal histories, and exploring outcome

patterns over whatever time period is available in the data.

Subsequent long-term followups could be initiated once the nature

and availability of suitable samples are assessed.

Dissemination

A variety of research consumers have a need for current information

on treatment research findings, including researchers, clinicians,

administrators, and others who are charged with the responsibility

for decisions affecting treatment programming. NIDA's treatment

research dissemination strategy has included publication of

scientific reports and monographs, as well as short summaries of

research findings, both in Clinical Research Notes and as

individual publications. These have been directed to clinicians.

researchers, and a more general audience. Dissemination of these

publications has been through the National Clearinghouse for Drug

Abuse Information (NCDAI) and through other distribution channels.

Several of the participants in this review suggested that, in

addition to continuing to provide such timely summaries, NIDA

explore alternative strategies for using research findings to

stimulate appropriate programmatic change.

RECOMMENDATIONS

The following recommendations resulted from the review. While

consensus was evident on most of these points, the order of

presentation does not imply priority. Specifically, it was

172
recommended that research be supported and encouraged in the

following areas:

A comprehensive review and synthesis of findings from

existing studies. This should include comparison across

studies and, where appropriate, reanalysis of data bases,

to resolve apparent inconsistencies in the overall pattern

of findings in the literature.

Continued large- to medium-scale studies such as DARP and

TOPS, coordinated with smaller scale studies to extend and

clarify findings.

Program-based studies to investigate treatment process,

clarify program differences, and foster utilization of

findings by treatment programs.

Controlled studies designed to produce reliable data on

outcomes for specific treatment interventions, e.g.,

long-term vs. short-term programs, brief therapy vs.

routine treatment, aftercare initiatives vs. no such

services.

Studies evaluating treatment for nonopioid clients.

Natural history studies to better characterize and

understand the complex of events and influences

experienced by drug abusers before, during, and after

their periods of abuse, including those for primarily

nonopioid abusers.

Studies evaluating psychodiagnostic and other strategies

for subclassifying clients and exploring more appropriate

client-treatment matching. The question of "what

treatment works best for what type of client" has not been

adequately addressed. Studies should focus on better data

for classifying clients (e.g., biologic, psychiatric, and

pyschosocial, as well as drug use patterns) to permit

studies of matching.

Studies of the feasibility of using standardized

instrumentation in treatment evaluation. NIDA should

support and encourage the use of standardized research

criteria in order to identify client subpopulations and

develop useful measures of client change during

treatment.

Systematic studies of interventions (outreach strategies)

with untreated drug abusers and of interventions with

early dropouts from treatment to determine the most

appropriate forms of treatment for these populations.

In addition, it was recommended that NIDA continue its

efforts to provide up-to-date summaries of research

findings (such as the DARP summary and review papers

173
published by the Institute) and disseminate these to the

field in a timely manner. Study should be made of

different strategies for using research findings to guide

programmatic change.

AUTHORS

Frank M. Tims, Ph.D.

Treatment Research Branch

Division of Clinical Research

National Institute on Drug Abuse

Rockville, Maryland 20857

Sherry Holland, M.S.

Gateway Houses Foundation

624 S. Michigan Ave.

Chicago, Illinois 60605

174
While limited supplies last, single copies of the monographs may be

obtained free of charge from the National Clearinghouse for Alcohol

and Drug Information (NCADI). Please contact NCADI also for

information about availability of coming issues and other

publications of the National Institute on Drug Abuse relevant to

drug abuse research.

Additional copies may be purchased from the U.S. Government Printing

Office (GPO) and/or the National Technical Information Service

(NTIS) as indicated. NTIS prices are for paper copy. Microfiche

copies, at $6.50, are also available from NTIS. Prices from either

source are subject to change.

Addresses are:

NCADI

National Clearinghouse for Alcohol and Drug Information

P.O. Box 2345

Rockville, Maryland 20852

GPO

Superintendent of Documents

U.S. Government Printing Office

Washington, D.C. 20402

NTIS

National Technical Information

Service

U.S. Department of Commerce

Springfield, Virginia 22161

For information on availability of NIDA Research Monographs l-24

(1975-1979) and others not listed, write to NIDA Office for Research

Communications, Room lOA-54. 5600 Fishers Lane, Rockville, MD 20857.

25 BEHAVIORAL ANALYSIS AND TREATMENT OF SUBSTANCE ABUSE. Norman A.

Krasnegor, Ph.D., ed. NCADI out of stock

GPO out of stock NTIS PB #80-112428 $24.95

26 THE BEHAVIORAL ASPECTS OF SMOKING. Norman A. Krasnegor, Ph.D.,

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Health.)

GPO out of stock NTIS PB #80-118755 $18.95

30 THEORIES ON DRUG ABUSE: SELECTED CONTEMPORARY PERSPECTIVES. Dan

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31 MARIJUANA RESEARCH FINDINGS: 1980. Robert C. Petersen, Ph.D., ed.

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32 GC/MS ASSAYS FOR ABUSED DRUGS IN BODY FLUIDS. Rodger L. Foltz,

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38 DRUG ABUSE AND THE AMERICAN ADOLESCENT. Dan J. Lettieri, Ph.D.,

and Jacqueline P. Ludford, M.S., eds. A RAUS Review Report.

GPO out of stock NCADI out of stock

NTIS PB #82-148198 $18.95

40 ADOLESCENT MARIJUANA ABUSERS AND THEIR FAMILIES. Herbert

Hendin, M.D., Ann Pollinger, Ph.D., Richard Ulman, Ph.D., and

Arthur Carr, Ph.D. NCADI out of stock

GPO out of stock NTIS PB #82-133117 $18.95

42 THE ANALYSIS OF CANNABINOIDS IN BIOLOGICAL FLUIDS. Richard L.

Hawks, Ph.D., ed.

GPO out of stock NTIS PB #83-136044 $18.95

44 MARIJUANA EFFECTS ON THE ENDOCRINE AND REPRODUCTIVE SYSTEMS.

Monique C. Braude, Ph.D., and Jacqueline P. Ludford, M.S., eds. A

RAUS Review Report. NCADI out of stock

GPO out of stock NTIS PB #85-150563/AS $18.95

45 CONTEMPORARY RESEARCH IN PAIN AND ANALGESIA, 1983. Roger M.

Brown, Ph.D.; Theodore M. Pinkert, M.D., J.D.; and Jacqueline P.

Ludford, M.S., eds. A RAUS Review Report. NCADI out of stock

GPO out of stock NTIS PB #84-184670/AS $13.95

46 BEHAVIORAL INTERVENTION TECHNIQUES IN DRUG ABUSE TREATMENT. John

Grabowski, Ph.D.; Maxine L. Stitzer, Ph.D., and Jack E.

Henningfield, Ph.D., eds. NCADI out of stock

GPO out of stock NTIS PB #84-184688/AS $18.95

47 PREVENTING ADOLESCENT DRUG ABUSE: INTERVENTION STRATEGIES.

Thomas J. Glynn, Ph.D.; Carl G. Leukefeld, D.S.W.; and

Jacqueline P. Ludford, M.S., eds. A RAUS Review Report.

GPO Stock #017-024-01180-1 $5.50 NTIS PB #85-159663/AS $24.95

176
48 MEASUREMENT IN THE ANALYSIS AND TREATMENT OF SMOKING BEHAVIOR.

John Grabowski, Ph.D., and Catherine S. Bell, M.S., eds.

GPO Stock #017-024-01181-9 $4.50 NCADI out of stock

NTIS PB #84-145184/AS $18.95

50 COCAINE: PHARMACOLOGY, EFFECTS, AND TREATMENT OF ABUSE. John

Grabowski, Ph.D., ed.

GPO Stock #017-024-01214-9 $4 NTIS PB #85-150381/AS $18.95

51 DRUG ABUSE TREATMENT EVALUATION: STRATEGIES, PROGRESS, AND

PROSPECTS. Frank M. Tims, Ph.D., ed. NCADI out of stock

GPO Stock #017-024-01218-1 $4.50 NTIS PB #85-150365/AS $18.95

52 TESTING DRUGS FOR PHYSICAL DEPENDENCE POTENTIAL AND ABUSE

LIABILITY. Joseph V. Brady, Ph.D., and Scott E. Lukas, Ph.D., eds.

GPO Stock #017-024-01204-1 $4.25 NTIS PB #85-150373/AS $18.95

53 PHARMACOLOGICAL ADJUNCTS IN SMOKING CESSATION. John Grabowski,

Ph.D., and Sharon M. Hall, Ph.D., eds.

GPO Stock #017-024-01266-1 $3.50 NCADI out of stock

56 ETIOLOGY OF DRUG ABUSE: IMPLICATIONS FOR PREVENTION. Coryl LaRue

Jones, Ph.D., and Robert J. Battjes, D.S.W., eds.

GPO Stock #017-024-01250-5 $6.50

57 SELF-REPORT METHODS OF ESTIMATING DRUG USE: MEETING CURRENT

CHALLENGES TO VALIDITY. Beatrice A. Rouse, Ph.D., Nicholas J.

Kozel, M.S., and Louise G. Richards, Ph.D., eds.

GPO Stock #017-024-01246-7 $4.25

58 PROGRESS IN THE DEVELOPMENT OF COST-EFFECTIVE TREATMENT FOR DRUG

ABUSERS. Rebecca S. Ashery, D.S.W., ed.

GPO Stock #017-024-01247-5 $4.25

59 CURRENT RESEARCH ON THE CONSEQUENCES OF MATERNAL DRUG ABUSE.

Theodore M. Pinkert, M.D., J.D., ed.

GPO Stock #017-024-01249-1 $2.50

60 PRENATAL DRUG EXPOSURE: KINETICS AND DYNAMICS. C. Nora Chiang,

Ph.D., and Charles C. Lee, Ph.D., eds.

GPO Stock #017-024-01257-2 $3.50

61 COCAINE USE IN AMERICA: EPIDEMIOLOGIC AND CLINICAL PERSPECTIVES.

Nicholas J. Kozel, M.S., and Edgar H. Adams, M.S., eds.

GPO Stock #017-024-01258-1 $5

62 NEUROSCIENCE METHODS IN DRUG ABUSE RESEARCH. Roger M. Brown,

Ph.D., and David P. Friedman, Ph.D., eds.

GPO Stock #017-024-01260-2 $3.50

63 PREVENTION RESEARCH: DETERRING DRUG ABUSE AMONG CHILDREN AND

ADOLESCENTS. Catherine S. Bell, M.S., and Robert J. Battjes,

D.S.W., eds.

GPO Stock #017-024-01263-7 $5.50

177
64 PHENCYCLIDINE: AN UPDATE. Doris H. Clouet, Ph.D., ed.

GPO Stock #017-024-01281-5 $6.50

65 WOMEN AND DRUGS: A NEW ERA FOR RESEARCH. Barbara A. Ray, Ph.D.,

and Monique C. Braude, Ph.D., eds.

GPO Stock #017-024-01283-1 $3.25

66 GENETIC AND BIOLOGICAL MARKERS IN DRUG ABUSE AND ALCOHOLISM.

Monique C. Braude. Ph.D., and Helen M. Chao, Ph.D. eds.

GPO Stock #017-024-01291-2 $3.50 NCADI out of stock

68 STRATEGIES FOR RESEARCH ON THE INTERACTIONS OF DRUGS OF ABUSE.

Monique C. Braude, Ph.D., and Harold M. Ginzburg, M.D., J.D., M.P.H.,

eds.

GPO Stock #017-024-01296-3 $6.50 NCADI out of stock

69 OPIOID PEPTIDES: MEDICINAL CHEMISTRY. Rao S. Rapaka, Ph.D.;

Gene Barnett, Ph.D.; and Richard L. Hawks, Ph.D., eds.

GPO Stock #017-024-1297-1 $11

70 OPIOID PEPTIDES: MOLECULAR PHARMACOLOGY, BIOSYNTHESIS, AND

ANALYSIS. Rao S. Rapaka, Ph.D., and Richard L. Hawks, Ph.D., eds.

GPO Stock #017-024-1298-O $12

71 OPIATE RECEPTOR SUBTYPES AND BRAIN FUNCTION. Roger M. Brown,

Ph.D.; Doris H. Clouet, Ph.D.; and David P. Friedman, Ph.D., eds.

GPO Stock #017-024-01303-O $6

72 RELAPSE AND RECOVERY IN DRUG ABUSE. Frank M. Tims, Ph.D., and

Carl G. Leukefeld, D.S.W., eds.

GPO Stock #017-024-01302-1 $6

73 URINE TESTING FOR DRUGS OF ABUSE. Richard L. Hawks, Ph.D., and

C. Nora Chiang, Ph.D., eds.

GPO Stock #017-024-1313-7 $3.75

74 NEUROBIOLOGY OF BEHAVIORAL CONTROL IN DRUG ABUSE. Stephen I.

Szara, M.D., D.Sc., ed.

GPO Stock #017-024-1314-5 $3.75

75 PROGRESS IN OPIOID RESEARCH. PROCEEDINGS OF THE 1986 INTERNATIONAL NARCOTICS RESEARCH CONFERENCE. John W. Holaday, Ph.D.;

Ping-Yee Law, Ph.D.; and Albert Herz, M.D., eds.

GPO Stock #017-024-01315-3 $21

76 PROBLEMS OF DRUG DEPENDENCE, 1986. PROCEEDINGS OF THE 48TH

ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS OF DRUG

DEPENDENCE, INC. Louis S. Harris, Ph.D., ed.

GPO Stock #017-024-1316-1 $16 NTIS PB #88-208111/AS $44.95

178
78 THE ROLE OF NEUROPLASTICITY IN THE RESPONSE TO DRUGS

David P. Friedman, Ph.D., and Doris H. Clouet, Ph.D., eds.

GPO Stock #017-024-01330-7 $6

79 STRUCTURE-ACTIVITY RELATIONSHIPS OF THE CANNABINOIDS

Rao S. Rapaka. Ph.D., and Alexandros Makriyannis, Ph.D., eds.

GPO Stock #017-024-01331-5 $6

IN PRESS

77 ADOLESCENT DRUG ABUSE: ANALYSES OF TREATMENT RESEARCH.

Elizabeth R. Rahdert, Ph.D., and John Grabowski, Ph.D., eds.

80 NEEDLE-SHARING AMONG INTRAVENOUS DRUG ABUSERS: NATIONAL AND

INTERNATIONAL PERSPECTIVES. Robert J. Battjes, D.S.W., and Roy W.

Pickens, Ph.D., eds.

81 PROBLEMS OF DRUG DEPENDENCE, 1987. PROCEEDINGS OF THE 49TH

ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS OF DRUG

DEPENDENCE, INC. Louis S. Harris, Ph.D., ed.

82 OPIOIDS IN THE HIPPOCAMPUS. Jacqueline F. McGinty. Ph.D., and

David P. Friedman, Ph.D. eds.

179

U.S. GOVERNMENT PRINTING OFFICE : 1988 0 - 215-494 : QL3
DHHS Publication No. (ADM)88-1329

Alcohol, Drug Abuse, and Mental Health Administration

Printed 1984 Reprinted 1986, 1988